Development and psychometric properties of the general public’s attitudes toward advance care directives scale in Portugal

  • Carlos Laranjeira
    School of Health Sciences of Polytechnic Institute of Leiria; Research in Education and Community Intervention (RECI), Piaget Institute; Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Portugal.
  • Maria dos Anjos Dixe
    School of Health Sciences of Polytechnic of Leiria; Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria , Portugal.
  • Luís Gueifão
    Intensive Care Unit, Leiria Hospital Center, Leiria, Portugal.
  • Lina Caetano
    Leiria Hospital Center, Leiria, Portugal.
  • Rui Passadouro
    ACES do Pinhal Litoral, Leiria; Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Portugal.
  • Tiago Gabriel
    ACES do Pinhal Litoral, Leiria, Portugal.
  • Ana Querido
    School of Health Sciences of Polytechnic of Leiria; Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Center for Research in Health and Information Systems (CINTESIS), NursID, University of Porto, Portugal.


Background: To date, no instrument in Portugal has evaluated the attitudes of the population about advance care directives. This paper describes the development and testing of the General Public's Attitudes Toward Advance Care Directives (GPATACD) Scale.

Design and Methods:
 Methodological study.  The development of the instrument was based on a literature review, updated in 2018. Face and content validity were verified by an expert panel and piloted among six participants. Data were collected in an online survey of 1024 Portuguese adults. The obtained data were analyzed using Varimax rotation, while the reliability was evaluated by calculating Cronbach’s alpha.

 The scale achieves good Item-Content Validity Index (I-CVI) values, between 0.89 and 1.00, and scale-CVI values of 0.91. A principal component analysis generated four dimensions with 26 items as a final scale, with overall Cronbach’s alpha of 0.848.

 The findings demonstrate that the scale is valid and reliable as a vehicle for assessment of the general public's attitudes toward advance care directives.


Permanyer I, Scholl N. Global trends in lifespan inequality: 1950-2015. PLoS One 2019;14:e0215742. DOI:

Fan SY, Wang YW, Lin IM. Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision. BMC Palliat Care 2018;17:114. DOI:

Hall A, Rowland C, Grande G. How should end-of-life advance care planning discussions be implemented according to patients and informal carers? A qualitative review of reviews. J Pain Symptom Manage 2019;58:311-35. DOI:

Nunes R. [Diretivas antecipadas de vontade].[Thesis in Portuguese]. Brasília, DF: CFM/Faculdade de Medicina da Universidade do Porto; 2016.

Meeussen K, Van den Block L, Echteld M, et al. Advance care planning in Belgium and The Netherlands: a nationwide retrospective study via sentinel networks of general practitioners. J Pain Symptom Manage 2011;42:565-77. DOI:

Mei Ching L, Hinderer KA, Kehl KA. A systematic review of advance directives and advance care planning in Chinese people from Eastern and Western cultures. J Hosp Palliat Nurs 2014;16:75-85. DOI:

Chan CWH, Wong MMH, Choi KC, et al. Prevalence, perception, and predictors of advance directives among Hong Kong Chinese: A population-based survey. Int J Environ Res Public Health 2019;16:365. DOI:

Chung RY, Wong EL, Kiang N, et al. Knowledge, attitudes, and preferences of advance decisions, end-of-life care, and place of care and death in Hong Kong. A population-based telephone survey of 1067 adults. J Am Med Dir Assoc 2017;18:367.e19-27. DOI:

Gao X, Sun F, Ko E, Kwak J, Shen HW. Knowledge of advance directive and perceptions of end-of-life care in Chinese-American elders: The role of acculturation. Palliat Support Care 2015;13:1677-84. DOI:

Panfilis L, Rossi P, Mazzini E, et al. Knowledge, opinion and attitude about the Italian law on advance directives: a population-based survey. J Pain Symptom Manage 2020;60:P906-14. DOI:

Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665-73. DOI:

Brinkman-Stoppelenburg A, Rietjens JA, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med 2014;28:1000-25. DOI:

Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010;340:c1345. DOI:

Carr D, Luth EA. Advance care planning: contemporary issues and future directions. Innov Aging 2017;1:igx012. DOI:

Alves R. Has end-of-life decisions or Advance Directives become an economic strategy to contain health care costs has much as a way to respect patient’s informed consent and private autonomy rights? Master of Transnational Law Degree Thesis, Católica Global School of Law; 2018.

Capelas M, Coelho S, Silva S, et al. [Os portugueses e o Testamento Vital]. [Article in Portuguese]. Cadernos Saúde 2017;9:44-53.

Ferreira C, Nunes R. Living will: information verification and sharing in a Portuguese hospital. Rev Bioetica 2019;27:691-8.

Pereira SM, Fradique E, Fialho R, et al. Advance directives: Portuguese palliative care professionals' views. Int J Palliat Nurs 2011;17:373-80. DOI:

Arruda LM, Abreu KPB, Santana LBC, Sales MVC. Variables that influence the medical decision regarding Advance Directives and their impact on end-of-life care. Einstein (São Paulo) 2019;18:eRW4852. DOI:

Leitão P. [Os alunos de Enfermagem do 4º Ano da Faculdade Ciências da Saúde – Universidade Fernando Pessoa perante a aplicação do Testamento Vital]. [Degree Thesis in Portuguese]. 2015.

Colton D, Covert R. Designing and constructing instruments for social research and evaluation. Chichester: J. Wiley & Sons; 2007.

Streiner D, Norman G. Health measurement scales: A practical guide to their development and use. Oxford: University Press; 2008.

Heyland DK, Cook DJ, Rocker GM, et al. The development and validation of a novel questionnaire to measure patient and family satisfaction with end-of-life care: the Canadian Health Care Evaluation Project (CANHELP) Questionnaire. Palliat Med 2010;24:682-95. DOI:

Nolan MT, Bruder M. Patients' attitudes toward advance directives and end-of-life treatment decisions. Nurs Outlook 1997;45:204-8. DOI:

Polit DF, Beck CT. The content validity index: are you sure you know what's being reported? Critique and recommendations. Res Nurs Health 2006;29:489-97. DOI:

Kyriazos T. Applied psychometrics: Sample size and sample power considerations in factor analysis (EFA, CFA) and SEM in general. Psychology 2018;9:2207-30. DOI:

Pestana M, Gageiro J. [Análise de dados para ciências sociais: a complementaridade do SPSS].[Book in Portuguese] 6th ed. Lisboa: Edições Sílabo; 2014.

Coluci M, Alexandre N, Milani D. Construction of measurement instruments in the area of health. Ciênc Saúde Colet 2015;20:925-36. DOI:

Burns N, Grove S. The practice of nursing research: Conduct, critique and utilization. Elsevier Saunders; 2005.

Blackwood DH, Vindrola-Padros C, Mythen MG, Walker D. Advance-care-planning and end-of-life discussions in the perioperative period: a review of healthcare professionals' knowledge, attitudes, and training. Br J Anaesth 2018;121:1138-47. DOI:

Hamilton IJ. Barriers to advance care planning in primary care. Br J Gen Pract 2016;66:512-3. DOI:

Nedjat-Haiem FR, Cadet TJ, Amatya A, Mishra SI. Healthcare providers’ attitudes, knowledge, and practice behaviors for educating patients about advance directives: A national survey. Am J Hosp Palliat Care 2019;36:387-95. DOI:

Patel P, Lyons L. Examining the knowledge, awareness, and perceptions of palliative care in the general public over time: A scoping literature review. Am J Hosp Palliat Care 2020;37:481-7. DOI:

Andrés-Pretel F, Navarro Bravo B, Párraga Martínez I, et al. [Conocimientos y actitudes de los mayores hacia el documento de voluntades anticipadas].[Article in Spanish]. Gac Sanit 2012;26:570-3. DOI:

Aguilar-Sánchez J, Cabañero-Martínez M, Fernández F, et al. [Grado de conocimiento y actitudes de los profesionales sanitarios sobre el documento de voluntades anticipadas].[Article in Spanish]. Gac Sanit 2017;32:339-45. DOI:

Macedo JC. Contribution to improve advance directives in Portugal. MOJ Gerontol Ger 2020;5:27‒30. DOI: