Our data suggest that ACPs can be effectively constructed in family-centric societies so long as healthcare professionals continue to update and educate families on the patient's situation. Collusion and familial intervention in the decision-making process are part of efforts to protect the patient from distress and are neither solely dependent on cultural nor an "all-or-nothing" phenomenon. The response of families are context-dependent and patient-specific, weighing the patient's right to know and prepare and the potential distress it is likely to cause. In most cases, the news is broken gently over time to allow the patient to digest the information and for the family to assess how well they cope with the news. Furthermore, the actions of families are dependent upon their understanding of the situation, highlighting the need for continued engagement with healthcare professionals.

In family-centric societies, maintenance of hope amongst ill family members is a pivotal duty of the family. Meeting this duty often takes the form of continuing treatment even when such options may be futile. This makes efforts to maximize quality-of-life options challenging. We explore Singaporean perceptions surrounding quality-of-life advocates who advice quality-of-life measures over potentially life-prolonging treatment in terminal illness using a novel video vignette based semi-structured interviews. Findings suggest that quality-oflife advocates are viewed as failing in their filial obligations and perceived as 'selfish', 'money-minded' and 'immoral'. These findings highlight the need to educate patients and caregivers about quality-of-life approaches.