Spiritual factors associated with ACP broadly involve existential issues regarding the purpose and meaning in life as well as other highly valued concerns. For example, a meta-study on qualitative literature across international populations identified a spectrum of spirituality encompassing: spiritual despair (alienation, loss of self, dissonance), spiritual work (forgiveness, self-exploration, search for balance), and spiritual well-being (connection, self-actualization, consonance) (Williams, 2006). However, in a review on preferences for care at the EOL, the Agency for Healthcare Research and Quality has found that many persons are unaware of their desires, that desires change in the course of illness, and that discussions with providers and others can facilitate a better understanding of personal values and goals for future care (Kass-Bartelmes, Hughes, & Rutherford, 2003). Helpful approaches to discern spirituality can be found in the prolific work of David Hodge (2001, 2005).
Medical circumstances represent perhaps one of the most important considerations in ACP. For example, ACP preferences have been found to change over time due to health (Hawkins et al., 2005) and are related to declining health manifestations (Fried et al., 2006). Research on patients in the latter stages of a terminal disease course identified several coping concerns dealing with physical changes and managing financial demands (Farber, Egnew, Herman-Bertsch, Taylor, & Guldin, 2003). Therefore, ACP is typically conducted at several times during a person's illness so that needs can be continually reassessed (Byock, 2001).
To best meet comprehensive ACP needs, it is critically important to consider physical aspects of the person's life, such as the match between their current degree of functioning and projected needs. This involves assessing the physical environment of the home as well as the fit between the older person and his or her residential setting (Pynoos, 1990). That is, it is important to ensure the right balance between the demands of the person's ability to deal with their environment (Lawton & Nahemow, 1977). Moreover, physical needs, as well as one's physical environment, are further compounded by psychological, social, medical, and financial circumstances that affect future
and end-of-life care plans. That is, the physical environment is the result of the dynamic interaction between people, social processes, and relationships (Yen & Syme, 1999). Therefore, though identified as a distinct domain here, physical needs must be viewed within a comprehensive context.
Financial considerations represent a critical, yet often under-considered, aspect of planning. Understanding one's finances is important to best plan for the costs of future care needs. In most cases, a variety of factors converge with financial issues to impact ACP. For example, factors influencing plans for future nursing home care included affordability and insurance availability, as well as health and functional status and the availability of formal and informal support (Mitsuko, Chapin, Macmillan, & Zimmerman, 2004). Helpful resources to assess future care costs can be found at the National Clearinghouse for Long-Term Care Information at longtermcare.gov, which provides detailed costs throughout the continuum of care by geographical location (U.S. Department of Health and Human Services, 2012).