The Life Design Programme: Promoting Advance Care Planning in Elderly Schools

Introduction

Elderly schools were initially established with four main objectives:

1. To promote quality of life and lifelong learning among older adults
2. To support self-development, personal care, protection, and advocacy for the rights of older people
3. To enhance physical and mental health
4. To encourage seniors to contribute positively to their communities and society

Despite ongoing activities in various regions, including the elderly school in Mae Suai District (อำเภอแม่สรวย), Chiang Rai Province, there remain gaps in addressing physical and mental health, particularly around advance care planning (ACP). Many older adults still lack the necessary awareness and skills to prepare for illness and the end of life.

To respond to this gap, the Chiang Rai compassionate communities has developed a 3-hour learning programme titled “The Nature of Life and Death in 3 hours (หลักสูตรการเรียนรู้ธรรมชาติชีวิตและความตาย 3 ชั่วโมง)” to introduce ACP and palliative care concepts to older adults. This article shares insights and lessons learned from implementing the Life Design programme (โปรแกรมออกแบบชีวิต) at the Mae Suai Hospital Elderly School between 2019 and 2024. It highlights the importance of advance care planning, outlines programme content and learning processes, and offers recommendations for scaling up this approach.

Why Should Older Adults Learn About Advance Care Planning?

According to Thailand’s National Health Act B.E. 2550 (2007), Section 12 grants individuals the legal right to refuse medical interventions that only prolong the dying process or add to suffering at the end of life. It states:

A person has the right to make a living will to refuse public health services that merely prolong life in the final stage, or that serve only to delay death or prolong suffering from illness…

However, 17 years since the law was enacted, public awareness (especially among older adults in local communities) remains low. Many do not realise they have the right to make such decisions or engage in advance care planning. Furthermore, knowledge of palliative care, which focuses on enhancing quality of life during serious illness, is often limited. As a result, elderly in the community frequently receive excessive or unwanted medical treatment at the end of life. Additionally conflicts of interest may arise between healthcare professionals and family members over the appropriate course of care

Elderly School Curricula and the Missing Piece

Elderly schools generally provide knowledge in three areas:

1. Life Skills (50%) – covering useful everyday knowledge to help seniors live happily and independently
2. Vocational Skills (30%) – focusing on work or income-generating skills suited to older adults
3. Academic Learning (20%) – including physical and mental health knowledge, discussions, and relaxation activities

Some elderly schools have also added content on ageing-related changes, fall prevention, and cognitive decline. However, many still lack crucial components related to preparing the body and mind for illness and death, topics that are essential for older people to understand and reflect upon.

Recognising this gap, the Chiang Rai compassionate communities developed the Life Design programme – a 3- hour workshop inviting older adults to explore the nature of life, identify personal needs, and create an ACP plan aligned with their values and preferences.

The Life Planning Programme

The Designing Life Programme is a 3-hour educational initiative that guides older adults in exploring, understanding, and accepting the natural course of life. It provides a foundation for advance care planning (ACP) that aligns with their values and life stage. The programme consists of six structured learning activities:

Activity 1: Building Relationships

The session begins by inviting participants to understand the goals of the Life Design Programme. A visual timeline called “Life Stages” (Image 1) is used to prompt reflection on where participants see themselves now and how they wish to shape their remaining years. This activity helps older adults realise they can design their lives at any stage.

Participants are also encouraged to co-create a respectful, safe, and open space for shared learning, one where everyone can listen, speak, and reflect without fear or judgment.

To warm up the group, facilitators may use ice-breakers like Brain Gym or simple question-based games. Participants raise their hands if they identify with a prompt, followed by short, voluntary interviews. Example questions include:

• Who is under 40? Aged 41–50? 51–60? 61–70? 71–80? Over 80?
• Who has 1, 2, 3, or 4 children? Who lives with a spouse? With children? Why?
• Who feels strong? Somewhat strong? Not very strong? Why?

These prompts foster connection and open dialogue.

Activity 2: Designing Life in Old Age

This reflective session explores how participants view ageing. Key prompts include:

• “What is your attitude toward being an elderly?”
• “What kind of elderly do you wish to be?”

Participants write their thoughts on sticky  notes and place them on a board. The goal is to build a shared understanding of what it means to be an “ideal elderly” across three domains:

1. Physical: Healthy, disease-free, good sleep, appetite, mobility, and financial independence
2. Emotional: Positive mindset, cheerful, calm, not easily offended or frustrated
3. Relational: Loved by others, a role model, helpful, accepting of differences

Activity 3: Designing Life During Illness

This session invites participants to reflect on what brings them joy and meaning. Facilitators highlight the importance of cherishing good memories and how they can support mental and physical well-being, especially at the end of life.

Participants are prompted to consider:

• What do you want to be remembered for when you’re nearing death?
• What kind of memories do you want to recall when you’re dying? Would you prefer to recall joyful or painful memories at life’s end?
• If your heart feels unsettled when you’re dying, what might be the consequences?

Participants are also invited to discuss their current health conditions. A visual tool, “Life’s Journey” (Image 2), illustrates possible trajectories of chronic illness and dying. It highlights that while we may not choose the path, we can still make choices about how we navigate it, especially to avoid unnecessary hospitalisations.

Discussion continues with:

• How do you feel about the word “death”?
• At what age would you like to die?
• What do you fear most: aging, illness, being bedridden, or death? Why?
• What are the causes of death?
• Can we prepare for death or loss? How might preparation change outcomes?

These questions naturally lead into the next session, which focuses on palliative care and advance care planning.

Activity 4: Understanding Physical Decline and Palliative Care

Participants use visuals like “Changing Strength” (Image 3) and “Choose for Me” (Image 4) to explore how the body changes with age and what types of care align with those changes.

Discussion points include:

• If you’re still strong—use your time well and begin preparing.
• If you’re managing illness—learn to live well with it; consider writing a living will.
• If you’re becoming weaker—how can you stay comfortable? What should you let go of? Who can help—family, neighbours, healthcare providers?
• If you’re nearing death—can you choose where to die? What would a “good death” look like for you?

Facilitators should remind that there is no right or wrong answer. What matters is knowing your own preferences and communicating them ahead of time.

The group is introduced to palliative care as a holistic approach to support people with serious illness: addressing physical, emotional, social, and spiritual needs. It neither hastens nor prolongs death. Everyone is entitled to access palliative care services in hospitals across Thailand. The ultimate goal of palliative care is to ensure comfort in body and peace of mind, allowing both the patient and their family to face the end of life with readiness and dignity.

From a palliative care perspective, community members can play a vital role in supporting one another. This might include helping patients resolve unfinished emotional matters, fulfilling their last wishes, or providing types of care that healthcare professionals may not be able to offer, simply because they are not as close to the patient or as familiar with their life stories as people in the community are. This kind of shared responsibility for care is the essence of the Compassionate Communities model. In many communities, there are real-life examples of neighbours and local residents stepping in to care for patients and help them achieve what they hope for before they die. At this point in the session, facilitators invite participants to share community stories that reflect these values, helping to bring the concept of a compassionate communities to life.

Activity 5: Advance Care Planning (ACP)

This session introduces ACP as a legal right under Section 12 of Thailand’s National Health Act B.E. 2550. The law allows individuals to refuse life-prolonging treatments or interventions that cause suffering at the end of life.

Participants learn how to express their wishes using the Baojai Booklet (สมุดเบาใจ): a Thai ACP tool that encourages self-reflection and the communication of end-of-life preferences with family.

Writing in the booklet is optional. For some, simply reflecting on its content or discussing it with family members may be enough. Facilitators recommend submitting a copy to a local health centre or hospital to ensure that healthcare teams are aware of one’s preferences in advance.

Activity 6: Summary and Reflection

The final session invites participants to reflect on their learning:

• What did they learn from this activity?
• Was the programme useful?
• Is it appropriate to talk about death and dying in this community?

Participants are encouraged to continue the conversation at home—perhaps by visiting someone in their neighbourhood who is ill or by sharing their own wishes with loved ones.

Summary and Recommendations

The Designing Life Programme is a 3-hour session designed to help older adults reflect on ageing, illness, and end-of-life care. Through five interactive learning activities, it promotes awareness of:

• Life’s natural changes
• Positive ageing attitudes
• Understanding palliative care
• Communicating about death
• Planning ahead with dignity

It empowers older adults to recognise that everyone has the right to plan their final chapter and access appropriate care.

Key Recommendations for Scaling Up:

1. Language sensitivity: The word “death” may cause discomfort. Facilitators should be attentive to the group’s emotional readiness and offer alternatives or opt-out opportunities as needed.
2. Timing: Activities should not exceed 3 hours and are best scheduled in the morning, when older adults are most alert.
3. Memory aids: Use visual tools and keywords like “palliative care” or “Baojai Booklet” to help with recall. Repetition reinforces learning.

Promoting advance care planning (ACP) among older adults is essential and should be scaled up across all regions. In particular, the Life Design programme should be considered a foundational learning activity for every elderly school. Moreover, involving local networks such as hospitals, subdistrict administrative organisations, temples, community health volunteers (อสม.), and community caregivers, can strengthen the programme’s impact. These stakeholders could support by providing venues, refreshments, lunch, or participating as activity mentors.

Gradually, the Life Design Programme can become a key mechanism for advancing the vision of a compassionate communities, where every sector plays a part in improving the quality of life for older adults at the community level.