Background To examine the underpinnings of Asia’s first national Advance Care Planning (ACP) programme, and to identify the dynamics, mechanisms and systemic factors that influence the implementation of ACP in Singapore.

Methods A qualitative interpretive-systemic focus group study with 4 professional stakeholder groups who played critical roles in the ACP programme. Study included 63 physicians, nurses, medical social worker and allied health workers from 7 public hospitals and specialist center that incorporated ACP into clinical practice.

Results Framework analysis revealed 19 themes, organized into 5 categories including: (1) Life and Death Culture (social perception of death, biomedical model, health system hierarchy, health seeking behaviors), (2) ACP Coordination (institutional leadership, programme receptiveness, interdisciplinary trust, preparatory training), (3) ACP Administration (practice diversity, work flow, operation clarity), (4) ACP Outcomes (care preferences, medical-social dissonance, performance measures, intrinsic values), and (5) Sustainability Shift (public life and death education, holistic end-of-life care training, governance and service alignment, empowered citizenry). These further formed an interpretive-systemic framework of sustainable ACP, reflecting the social, cultural, political, operational and spiritual contexts that support national ACP development.

Conclusion This research provides insights on developmental and implementation challenges of Asia’s first national ACP programme. ACP should be supported by public health strategy for enhancing individual, professional, and institutional readiness for end-of-life conversation before programme commencement. It emphasizes the importance of health policy, organizational structure, social discourse, and shared meaning in planning and delivery of ACP to aid care decision making among Asian patients and their families facing terminal illness and mortality.