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Leaving a lasting legacy: A scoping review of ethical wills

Published online by Cambridge University Press:  05 May 2022

Sarah A. Neller
Affiliation:
College of Nursing, University of Utah, Salt Lake City, UT
Mary M. McFarland
Affiliation:
Spencer S. Eccles Health Sciences Library, University of Utah, Salt Lake City, UT
Linda S. Edelman
Affiliation:
College of Nursing, University of Utah, Salt Lake City, UT
Gail L. Towsley
Affiliation:
College of Nursing, University of Utah, Salt Lake City, UT
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Abstract

Objectives

Palliative care guidelines recommend an interdisciplinary approach to address patients’ awareness of mortality and need for end-of-life preparation. An ethical will is a nonlegal way to address mortality by communicating a lasting and intangible legacy of values to others. The aim of this scoping review is to clarify the operationalization of ethical wills across disciplines and map the purposes and outcomes of creating an ethical will.

Methods

We followed the Joanna Briggs Institute methodology for scoping reviews. We searched 14 databases in November 2019 and January 2021 without filtering publication date or type. Two reviewers independently screened 1,948 publications. We extracted frequently used terms describing content, audience, format, purpose, and outcomes identified in ethical will creation.

Results

Fifty-one publications met inclusion criteria. Six (11.7%) were research articles. Twenty-four (47.1%) were lay literature published within law, estate, and financial planning. Collectively, our included studies defined an ethical will as a nonlegal way to express values, beliefs, life lessons and experiences, wisdom, love, history, hope for the future, blessings, apology, or forgiveness using any format (e.g., text, audio, video) that is meant to be shared with family, friends, or community. The most common purposes were to be remembered, address mortality, clarify life's meaning, and communicate what matters most. Creation provided opportunity to learn about self, served as a gift to both writer and recipient, and fostered generativity and sense of symbolic immortality.

Significance of results

Our findings highlight interdisciplinary utilization and a lack of research of ethical wills. This review provides supportive evidence for ethical wills as a way for patients to address mortality, renew intergenerational connections, solidify self, and promote transcendence before their final days. Ethical wills have potential to be incorporated into interdisciplinary palliative care in the future to address psychological symptoms for patients anticipating the end of life.

Type
Review Article
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2022. Published by Cambridge University Press.

Individual legacy has been broadly defined as what one leaves behind after death, making a lasting impression, leaving a mark on the world, personally contributing to the future, or leaving a portion of oneself (Kearl, Reference Kearl1989; Newton et al., Reference Newton, Herr and Pollack2014). Though legacy is often thought of in a material context, these definitions expand the potential for a legacy to be more than wealth or possessions. Legacy can be shared beyond material forms, including biological legacy (genetics and health) and a legacy of values (faith and culture) (Hunter and Rowles, Reference Hunter and Rowles2005). When planning for the end of life, older adults view values and life lessons as the most important things to pass on through a legacy to loved ones (Merrill and Age Wave, 2019). However, planning for the end of life has traditionally been viewed as a very formal process that involves creating legal documents designed to bequeath material possessions or convey the individual's treatment care preferences (e.g., last will and testament or living will). While these processes are very practical, the resulting documents are filled with legalese and often lack personal expression. Many individuals are now wanting to supplement their legal wishes with nonbinding expressions of values, guidance, and love for the recipients. This legacy of values can be written through documents such as a legacy letter or an ethical will. An ethical will is a formal method of documenting a legacy of values usually signifying a moral, rather than material, legacy (Hicks, Reference Hicks2008; Stanton and Peyser, Reference Stanton and Peyser2010). Ethical wills are completed by the individual rather than an attorney and are meant to be shared with family, friends, or the community (Martin, Reference Martin2015). They provide a way for individuals to reflect about the life they have lived, the meaning that they have derived from it, and the significance of their life experiences and pass on an intangible, rather than material, legacy to future generations.

Ethical wills have been utilized for centuries. There are multiple examples in the Christian Bible of ethical wills being left by leaders (e.g., Moses and Joshua) to the people of Israel on how to follow God's commands (Deuteronomy 33, Joshua 23) and by fathers (e.g., Jacob, David, and the writer of Proverbs) to instruct their children on how to live (Genesis 49, 1 Kings 2, Proverbs). In medieval times, ethical wills were documented by Christians and Muslims (Keeva, Reference Keeva2005). In the Jewish tradition, ethical wills are letters written from parents to children; individuals may choose to leave an ethical will to share the way they have lived and hope future generations will live, pass on what they do not want to be forgotten, ask for forgiveness, leave something special behind for friends or family, and so forth (The Jewish Theological Seminary, n.d.). While ethical wills were originally passed down orally from one generation to another, the modern ethical will can take many forms (e.g., letters, audio-visual formats) (Gessert et al., Reference Gessert, Baines and Kuross2004; Hicks, Reference Hicks2008; The Jewish Theological Seminary, n.d.). Current literature documenting the use of ethical wills comes from heterogeneous sources across multiple disciplines including law, estate planning, religion, and Jewish rabbinic tradition and uses a variety of terms including “ethical will,” “legacy statement,” “spiritual legacy,” and “ethical capital” (Hicks, Reference Hicks2008; Williams et al., Reference Williams, Woodby and Drentea2010; The Jewish Theological Seminary, n.d.). Thus, there is a lack of consistent terminology and conceptual parameters that ascertain the context and outcomes of creating and transmitting an ethical will, which may depend on the individual's life, health, and relational circumstances.

Significance

The importance of individuals communicating a legacy of values, through documents such as an ethical will, has been discussed in the literature for more than 20 years as a way to pass on what matters most (Kivnick, Reference Kivnick1996; Sapp, Reference Sapp1996; Meuser et al., Reference Meuser, Mthembu and Overton2019). Current palliative care practice guidelines underscore the importance of clinical providers being aware of their patients’ existential concerns and highlight the need to identify interventions clinicians can employ that help patients address their mortality and process these concerns as they navigate the end of life (National Consensus Project for Quality Palliative Care, 2018). Though several legacy-creation interventions have been researched among patients with a life-limiting illness or receiving palliative care or hospice as a way to foster meaning-based coping, quality of life, dignity, and end-of-life preparation and completion (Chochinov et al., Reference Chochinov, Hack and Hassard2005; Allen et al., Reference Allen, Hilgeman and Ege2008; Steinhauser et al., Reference Steinhauser, Alexander and Byock2008; Akard et al., Reference Akard, Dietrich and Friedman2015), there is very little research on creating a legacy of values in a self-directed manner. While ethical wills are recognized and utilized in the lay community as a way to create a legacy of values, ethical will research in health, social, or behavioral sciences is sparse. The lack of supportive evidence prevents providers in the clinical setting from recommending ethical will completion to patients as they age and anticipate the end of life.

Purpose

To address this research gap and add conceptual clarity, the aim of this scoping review is to categorize the terms used to define how “ethical will” is operationalized within the literature and map the conceptual boundaries of ethical wills, including uses and outcomes. The primary research question is: How are ethical wills utilized and operationalized across disciplines? Secondary research questions include: What terms are being used to describe ethical wills? and How, by whom, and for what purposes are ethical wills created and employed?

Conducting a scoping review is appropriate in this context as the working definition of ethical wills is vague and a comprehensive review on the topic has not been conducted (Peters et al., Reference Peters, Godfrey and Khalil2015). Scoping reviews can clearly and rigorously map the state of the research (Arksey and O'Malley, Reference Arksey and O'Malley2005). A scoping review is necessary to survey the breadth of published information available to define and clarify the role of ethical wills and to map their purpose and outcomes across disciplines, which will inform the scientific literature and provide a platform for expanded research. No scoping or systematic reviews on this topic were identified by our team in the CINAHL, PubMed, Scopus, or Cochrane Library databases.

Methods

We conducted the scoping review with guidance from The Joanna Briggs Institute (2015) using Arksey's five stages: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting the results (Arksey and O'Malley, Reference Arksey and O'Malley2005; Peters et al., Reference Peters, Godfrey and Khalil2015; The Joanna Briggs Institute, 2015). An unpublished a priori protocol was completed in November 2019. To ensure transparency and reproducibility, we followed the PRISMA-ScR reporting guideline, Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (Tricco et al., Reference Tricco, Lillie and Zarin2018). We used EndNote X9 (Clarivate Analytics) to manage citations and remove duplicates. Covidence (Veritas Health Innovation), an online systematic reviewing platform, was used to screen and select articles. In line with scoping review methodology, no quality assessment of selected articles was conducted (Arksey and O'Malley, Reference Arksey and O'Malley2005; Peters et al., Reference Peters, Godfrey and Khalil2015). We are using the terms articles or publications for our included “studies” to more accurately reflect the pool of publications which met our inclusion criteria.

Literature search

Searches were developed by the information specialist on our team (MMM) and peer-reviewed with the Peer Review of Electronic Search Strategies (PRESS) guidelines by library colleagues (McGowan et al., Reference McGowan, Sampson and Salzwedel2016). We conducted a two-phased literature search. In the first phase, conducted in November 2019, we searched a few priority databases, Medline, CINAHL, and Embase, to screen results for additional terms synonymous with “ethical will.” The second phase, conducted in January 2020, built upon the first and included those additional terms in the fuller search for all databases. Finally, we repeated the second-phase search in January 2021 to identify any additional literature published since the last search. The database searches did not filter date, language, or publication type. Sensitive search strategies were composed primarily of keyword phrases harvested for ethical wills through preliminary literature searches and the first phase of the systematic search. Search terms included “ethical will,” “legacy statement,” “ethical capital,” and “spiritual legacy.” Database subject headings were utilized when appropriate. See Supplementary material for search histories. As the focus of the review is on ethical wills, we did not include search terms to identify legacy interventions. In total, we searched 14 databases: Medline (Ovid), Embase (embase.com), CINAHL Complete (Ebscohost), Cochrane Library (wiley.com), including CENTRAL (wiley.com), Academic Search Ultimate (Ebscohost), Business Source Premier (Ebscohost), Dissertations & Theses Global (ProQuest), PsycINFO (Ebscohost), Religion & Philosophy Collection (Ebscohost), Scopus (scopus.org), Sociological Abstracts (ProQuest), HeinOnline (heinonline.org), Legal Collection (Ebscohost), and Web of Science Core Collection (Clarivate Analytics).

Study selection

Two reviewers (SAN, GLT) independently screened the results by title/abstract and then full text. The reviewers discussed any conflicts during the team meetings. A third reviewer (LSE) on the team was available if consensus could not be reached with the two reviewers; all conflicts were resolved by the first two reviewers.

Inclusion criteria

Our inclusion criteria were modeled on The Joanna Briggs Institute's research question elements of participants, concept, and context (The Joanna Briggs Institute, 2015). Participants included anyone creating an ethical will with the purpose of sharing with recipients (e.g., family, friends, community) before or after the creator's death. Family was defined as “any person(s) who plays a significant role in an individual's life. This may include a person(s) not legally related to the individual” (The Human Rights Campaign, 2019). The concept of ethical will was defined as a nonlegal expression of values, guidance, or love as a way for individuals to pass on an intangible rather than material legacy to the next generation, regardless of how imminent their death is. We included a global context of ethical will creation within published literature written in English encompassing multiple formats (written, audio, or visual). As this scoping review focused on the breadth of literature within a variety of disciplines, publications were included from lay and scientific literatures, as well as qualitative and quantitative research studies.

Exclusion criteria

We excluded publications if they focused on a standard legal will or used the words “ethical” and “will” in succession outside of the context of our definition (e.g., “issues that are ethical will be discussed”), legacy documents created by a surrogate (e.g., parent, caregiver, obituary, memoir, etc.), or documents completed solely for the benefit of the creator without clearly addressing intent to share or communicate with others through oral or written means (e.g., life review interventions). We also excluded books, conference abstracts without additional publication information, and articles that briefly mentioned ethical wills as an option for clients to create without providing definition of concept or use. Publications of interventions with a legacy component or that solely referenced the concept of legacy in theoretical or developmental discussion without identifying a means or importance of sharing it were excluded.

Data extraction and charting

The first author extracted the data from the included publications and discussed extraction findings with the senior author (GLT) in team meetings. The outline for charting data extraction is found in Table 1. Extracted data were analyzed and sorted into categories of like terms describing the content, audience, format, purpose, and outcomes of ethical will creation. The categories were further analyzed across the data to identify central elements of ethical wills.

Table 1. Outline for data extraction: planned versus final data extraction

Note. Only six research articles were identified in the included articles. As such, extraction criteria including study population, age, measurement, and key findings were not applicable or insufficient for the majority of the final extracted publications. Though we intended to identify the motive of creation based on a framework of end-of-life preparation identified in the literature (Emanuel et al., Reference Emanuel, Bennett and Richardson2007; Gawande, Reference Gawande2014), there was insufficient evidence to chart this information. To avoid speculation, motivation was excluded from the final extraction criteria. The final extraction table was simplified to only include the criteria applicable to the majority of included publications.

The reported percentages for the categories were tallied by adding the number of times the terms were referenced across the articles, then dividing by the total number of references in each category; therefore, the results are reported at the category level rather than at the article level unless specified. For example, within the content category, there were 100 references to values, beliefs, and principles out of the 376 total references to content.

Results

The literature search resulted in 1,948 articles, as outlined in the PRISMA diagram (Figure 1). After removing 429 duplicates, 1,328 were excluded at the title and abstract level, and 140 were excluded during full-text review. Of these, a total of 51 articles related to ethical wills were included in the data extraction and are presented in the extraction table (see Table 2). The research team included one conference abstract (Wynn and de Vries, Reference Wynn and de Vries2005) as we had personal communication with the senior author to obtain the results from the conference presentation. All extracted articles were published in the US between 1997 and 2020 across diverse disciplines. The majority of the articles (47.1%, n = 24) were published within law, estate, and financial planning. Additional disciplines included religion/ministry (9.8%, n = 5), gerontology/long-term care (9.8%, n = 5), medicine (7.8%, n = 4), psychology/sociology (7.8%, n = 4), general public (7.8%, n = 4), nursing (5.8%, n = 3), and business (3.9%, n = 2). We identified six research publications (11.8%) related to ethical wills (Barnes et al., Reference Barnes, Taylor-Brown and Wiener1997; Gessert et al., Reference Gessert, Baines and Kuross2004; Wynn and de Vries, Reference Wynn and de Vries2005; Cohen-Mansfield et al., Reference Cohen-Mansfield, Regier and Peyser2009; Williams et al., Reference Williams, Woodby and Drentea2010; Grewe, Reference Grewe2017).

Fig. 1. PRISMA flowchart outlining literature search.

Table 2. Ethical will data extraction table

Defining ethical wills

Ninety-four percent (n = 48) of the articles used the term ethical will alone or in addition to other terms for legacy of values. Twelve percent (n = 6) of the articles also used the term legacy letter, the second most frequently used term; 6% (n = 3) of the articles only used an alternative term (e.g., ethical capital, personal legacy declaration, and legacy video). We identified 84 different words or phrases used to define ethical will content, which were organized into six categories of like terms. The percentage of each category is presented in Figure 2. The most common terms used to describe the content included in ethical wills related to (1) values, beliefs, and principles and (2) life lessons, wisdom, and experiences, which combined accounted for more than half of the terms used to describe the content included in ethical wills. The least common terms used to describe ethical will content included personal characteristics, personality traits, and quirks. In addition, we identified terms used to describe how an ethical will is differentiated from a legal will; 47% (n = 24) of the articles referenced the nonlegal nature of ethical wills, and 37% (n = 19) referenced bequeathing intangible or nonmaterial information rather than possessions.

Fig. 2. The 84 unique terms describing ethical will content were grouped into like categories. The percentage for each category was calculated by tallying the number of times the terms were used and dividing by the total term count (n = 376).

Audience and format

Of the 78 references of terms describing the intended audience of an ethical will, 49.4% (n = 38) were biological family. Other recipients included younger or future generations (19.2%, n = 15), friends (10.3%, n = 8), community (10.3%, n = 8), loved ones (5.1%, n = 4), heirs or recipients of a legal will (2.6%, n = 2), and others (3.8%, n = 3). There was no set format for creation (e.g., medium or outline of questions that need to be addressed) identified in the articles. Of the 90 references to format, the most commonly cited format was written (e.g., letter or handwritten; 57.8%, n = 52). Other categories used to describe common formats included digital or video (17.8%, n = 16), creative arts (e.g., photos, songs, drawings, paintings; 12.2%, n = 11), oral or audio (10%, n = 9), and others (2.2%, n = 2).

Purpose of creating an ethical will

Many unique purposes of ethical will creation were identified (n = 175 references). The most common purposes were categorized as a way to be remembered, to preserve, or pass on an intangible legacy (26.3%, n = 46), communicate to others (e.g., exhortation, forgiveness, blessings; 23.4%, n = 41), cope with transitions or mortality (13.7%, n = 24), compliment the legal or estate planning process (11.4%, n = 20), address failures, barriers, and conflicts (10.9%, n = 19), clarify the writer's meaning and purpose in life (8.6%, n = 15), and foster intergenerational connection (5.7%, n = 10).

Potential outcomes

One of the initial aims of the review was to identify the validated outcomes of completing an ethical will. Though the literature included few validated outcomes, we identified many potential outcomes of completion that were not necessarily researched or measured (n = 93 references). We grouped the terms describing potential outcomes into the categories of self-growth, personal satisfaction, and transformation (25%, n = 23), comfort for self and others (18.5%, n = 17), connection with others (16.3%), gift for the writer and recipient (14.1%, n = 13), developing acceptance of mortality or a sense of life completion (13.0%, n = 12), achieving symbolic immortality or transcendence (9.8%, n = 9), and others (3.3%, n = 3).

When and how to create and share

Multiple articles noted that ethical wills are often created during or around a transition or milestone for the writer (e.g., birth of a child or grandchild, wedding, retirement, anticipating the end of life) (Baines, Reference Baines2003; Pagano, Reference Pagano2006; Williams et al., Reference Williams, Woodby and Drentea2010; Kaslow and Benjamin, Reference Kaslow and Benjamin2015; Martin, Reference Martin2015; Ziff, Reference Ziff2016; Tugend, Reference Tugend2020). Only 53% (n = 27) of the articles mentioned the timing of when to share the ethical will; of these, 63% recommended sharing while alive and 37% noted that writers may wish to share after death. Ethical wills do not need to be completed with a facilitator or guide, though they may help the creator get started or act as a sounding board for life reflection. Several articles warned that the ethical will could be potentially damaging for recipients if written to be punitive or as a weapon of control or retaliation and cautioned writers to avoid using the ethical will as a way to rule from the grave (Kahn, Reference Kahn2001; Alexander, Reference Alexander2006; Vizzard, Reference Vizzard2012; Gustke, Reference Gustke2014). Ethical wills are not the place to rehash family feuds or work out family conflict and should be written in a kind tone, especially if shared after the writer's death when there is no longer an opportunity to facilitate discussion (Lynch, Reference Lynch2008; Vizzard, Reference Vizzard2012; Federer, Reference Federer2013).

While writing an ethical will is a powerful exercise, it is not recommended or beneficial for everyone. One article (Kaslow and Benjamin, Reference Kaslow and Benjamin2015) addressed reasons individuals might not want to complete an ethical will, such as being uncomfortable expressing subjective and emotional feelings in documents that are traditionally distant and couched in legalese or perceiving writing the ethical will as daunting or frightening. Kaslow and Benjamin (Reference Kaslow and Benjamin2015) also stated that ethical wills should not be created if the writer fears rejection or backlash from sharing with others or is too ill to deal with recipients’ reactions. Additional barriers to completion included feelings of self-doubt or inadequacy (Baines, Reference Baines1999).

Discussion

For this review, we mapped the evidence of ethical will utilization and operationalization across disciplines by charting the terms used to describe ethical will content and detailing the intended audience, format, purposes, and potential outcomes of creating an ethical will. Based on the extracted terms from the included studies, an ethical will is defined as a nonlegal way to express values, beliefs, life lessons and experiences, wisdom, love, history, hope for the future, blessings, apology, or forgiveness using any format (e.g., text, audio, video) that is meant to be shared with family, friends, or community. This composite definition confirms yet expands the definition used in the a priori search criteria. We only extracted six research publications, indicating that the lay community may be more familiar with ethical wills than the research community.

Ethical will creation and generativity

One common theme appeared in our extracted data: an ethical will is intended as a way of sharing one's life for the sake of another — a distillation of oneself, experiences, and lessons learned to benefit someone else. It should not be controlling but is meant to be an influential document which can be used by the recipients as a form of guidance to help them navigate the rest of their lives. It can also foster intergenerational connection (Baines, Reference Baines2003; Alexander, Reference Alexander2006; Shultz, Reference Shultz2006; Gaudiani, Reference Gaudiani2007; Cohen-Mansfield et al., Reference Cohen-Mansfield, Regier and Peyser2009; Kaslow and Benjamin, Reference Kaslow and Benjamin2015). Thus, generativity is a central component of ethical will creation. Generativity is linked with the desire for immortality and is described as a developmental stage that involves contributing to the next generation, living intentionally, and planning to construct one's legacy that has been studied across mid-to-late adulthood (McAdams and de St Aubin, Reference McAdams and de St Aubin1992; Maxfield et al., Reference Maxfield, Greenberg and Pyszczynski2014). It has been identified among older adults as a coping mechanism to address awareness of mortality and buffer existential anxiety (Maxfield et al., Reference Maxfield, Greenberg and Pyszczynski2014). Furthermore, generativity contributes to the sense of life completion and addresses a primary need of individuals nearing the end of life through guidance, instruction, or finalizing a legacy (Steinhauser et al., Reference Steinhauser, Clipp and McNeilly2000, Reference Steinhauser, Bosworth and Clipp2002; Kehl, Reference Kehl2006; Emanuel et al., Reference Emanuel, Bennett and Richardson2007; Gawande, Reference Gawande2014).

A related purpose in creating an ethical will is to be remembered or preserve what was most important to the writer. This desire for preservation can lead to the outcome of symbolic immortality, which is a way for individuals to live on in the minds of others after their death and is a way to address existential concerns (Lifton, Reference Lifton1979; Newton and Jones, Reference Newton and Jones2016). Creating and sharing an ethical will is an intentional way to be remembered and provide an enduring link connecting generations, which may offer writers a sense of transcending death or remaining connected to those left behind (Barnes et al., Reference Barnes, Taylor-Brown and Wiener1997; Gessert et al., Reference Gessert, Baines and Kuross2004; Cohen-Mansfield et al., Reference Cohen-Mansfield, Regier and Peyser2009; Kaslow and Benjamin, Reference Kaslow and Benjamin2015). Receiving a letter from a loved one after death can modify the grief experience for survivors and provide family members and caregivers with a sense of consolation, solace, feeling the presence of the loved one with them, and encouragement in the midst of loss (Hicks, Reference Hicks2008; Martin, Reference Martin2015).

The process of creating an ethical will is also beneficial to the writer (Gaudiani, Reference Gaudiani2007; Cohen-Mansfield et al., Reference Cohen-Mansfield, Regier and Peyser2009; Falkner, Reference Falkner2009; Streit, Reference Streit2012). An ethical will may be used as a way to address mortality, clarify life's meaning, communicate what matters most, or supplement formal end-of-life planning documents. Telling one's personal and family stories helps make sense of life experiences and has the power to shape meaning and deepen family relationships (Thompson et al., Reference Thompson, Kellas and Soliz2009; Meuser et al., Reference Meuser, Mthembu and Overton2019). Creating an ethical will can offer the writer an opportunity to learn about themself, provide a sense of growth and meaning, and leave part of themself behind for others.

Facilitating end-of-life preparation

Additionally, creating an ethical will can help facilitate end-of-life preparation for patients. A new paradigm has emerged in end-of-life care which seeks to not only provide excellent patient care in the final days but also promote “a good life to the very end” (Gawande, Reference Gawande2014, p. 245). Current palliative care practice guidelines recommend the interdisciplinary care team be prepared to assess patients’ existential concerns as they navigate chronic illness and prepare for the end of life and address any unmet needs (National Consensus Project for Quality Palliative Care, 2018). Comprehensive palliative assessment explores the patient's spiritual and existential views of their meaning and purpose in life, spiritual beliefs and practices, relationships, concerns or fears of quality of life or death and dying, and life completion tasks (National Consensus Project for Quality Palliative Care, 2018), which could be addressed through ethical will creation. Through this review, we identified 14 articles that discussed using the ethical will to address mortality or attitudes about death, which indicate that reflecting on meaning in life and articulating values may provide the writer a sense of life completion (Barnes et al., Reference Barnes, Taylor-Brown and Wiener1997; Wheeler and Farnsworth, Reference Wheeler and Farnsworth2000; Baines, Reference Baines2003, Reference Baines2004; Cole and Kloberdanz, Reference Cole and Kloberdanz2003; Frank, Reference Frank2003; Gessert et al., Reference Gessert, Baines and Kuross2004; Alexander, Reference Alexander2006; Shultz, Reference Shultz2006; Hicks, Reference Hicks2008; Falkner, Reference Falkner2009; Williams et al., Reference Williams, Woodby and Drentea2010; Martin, Reference Martin2015; Grewe, Reference Grewe2017). The Dying in America report recommends patients, families, and providers prepare for death by having conversations throughout the life cycle, not just near the end of life (Pizzo, Reference Pizzo2016). As the ability to plan and communicate effectively in the final days is not a guarantee, it is beneficial for individuals to begin planning for the end of life once they have an awareness of their mortality, which often occurs through the process of aging (Doka, Reference Doka2015).

Differences in ethical wills and interventions with a legacy component

In our search, we excluded 27 articles that related conceptually to leaving a legacy or legacy interventions as they were not specifically about creating an ethical will or legacy of values, and we did not specifically search for interventions. However, we separately reviewed these articles and discuss them here to provide a comparison to ethical will creation. The excluded articles discussed the concept of legacy in a broad context (n = 16) (e.g., qualitative studies examining legacy in the context of family, understanding older adults’ perspective of legacy) or interventions with a legacy component (n = 11). The interventions were primarily based upon reminiscence and life review therapy, and 73% (n = 8) were conducted among patients with a terminal illness.

Ethical wills differ from other closely aligned methods of preserving self, including reminiscence, life review therapy, and Dignity Therapy (Chochinov et al., Reference Chochinov, Hack and Hassard2005) in three fundamental ways. First, though they all share a component of reflection and self-evaluation of life experiences, a key attribute of ethical will creation is the intent to transmit information to survivors to help them live more fulfilling lives (Gessert et al., Reference Gessert, Baines and Kuross2004; Stanton and Peyser, Reference Stanton and Peyser2010). Writers of ethical wills communicate how they want to be remembered, personal history, and content to benefit others (e.g., values, beliefs, guidance, traditions, life lessons learned), which promotes generativity. All of the ethical will articles (n = 51) identified in this scoping review discussed sharing, transmitting, or communicating to recipients or survivors, and 84.3% (n = 43) specifically identified the intended audience for the legacy document. This is unlike articles that discussed legacy conceptually without creating a legacy document (Schultz-Krohn, Reference Schultz-Krohn2002; Morgan, Reference Morgan2003; Hunter and Rowles, Reference Hunter and Rowles2005; Hunter, Reference Hunter2007; Manoogian et al., Reference Manoogian, Walker and Richards2007; Meuser et al., Reference Meuser, Mthembu and Overton2018) or legacy interventions used for individual or group therapy that can be optionally shared with others (Barber, Reference Barber2008; Ho et al., Reference Ho, Leung and Tse2013; Allen et al., Reference Allen, Harris and Burgio2014; Franklin and Cheung, Reference Franklin and Cheung2017; Robinson and Murphy-Nugen, Reference Robinson and Murphy-Nugen2018). Second, the timeline for ethical will creation is broader than the final days, which provides individuals the opportunity for reflection and revision over time. Within the excluded legacy intervention articles (n = 11), 73% (n = 8) were conducted with patients with a terminal illness. However, only 27% (n = 14) of the ethical will articles discussed using ethical wills to address mortality or attitudes about death, suggesting ethical wills may be appropriate for patients early in their palliative care journey. Third, ethical will creation is a self-directed exercise anyone can complete independently without assistance from a trained member of the healthcare team or a specific number of sessions, making it accessible to a wide audience with a flexible timeline of completion. The process of writing an ethical will is not a prescriptive intervention and may be unstructured or prompted by questions to allow the creator to write from the heart (Baines, Reference Baines2003).

Limitations and strengths

Limitations

The results of this scoping review should be considered in light of several limitations. In accordance with scoping review methodology, we did not formally review the methodological quality of the included sources; thus implications for practice may be limited (Arksey and O'Malley, Reference Arksey and O'Malley2005). However, these results can be used to inform continued research on leaving a legacy of values (The Joanna Briggs Institute, 2015). Because of the multiple terminologies used for the concept of ethical wills, our review may have missed relevant studies. Notably, 31/51 (61%) of the articles cited the work of Dr. Barry Baines, a board-certified family, hospice and palliative medicine physician and expert on ethical wills who has been influential in popularizing awareness of ethical will creation through his foundational writings, workshops, and trainings for individuals in the community. This likely led to redundancy in the terms used to describe and define ethical wills. Including books and conference abstracts in the analysis may have identified additional authors; nevertheless, we were able to identify a breadth of purposes and outcomes by including articles across disciplines. These findings highlight the need for continued research to expand the knowledge base of ethical will utilization and outcomes.

Strengths

To our knowledge, this is the first scoping review conducted to explore the utilization of ethical wills across disciplines as a way to communicate a legacy of values. It was guided by an a priori protocol reviewed by an expert in conducting scoping reviews (available upon request) and included a broad literature search across 14 databases. Results were presented according to the PRISMA-ScR guidelines to reduce bias and enhance transparency and reproducibility. As there were no limits on document type or date of publication, the review includes publications from a broad array of disciplines and intended audiences.

Implications for palliative care practice and research

The Institute of Medicine recognizes the need for improvement in end-of-life care, including increasing clinicians’ awareness that patients and families may have existential and spiritual concerns in addition to the need for clinical care (Institute of Medicine, 2015). Ethical wills have been proposed as a way for clinicians to positively influence end-of-life planning and discussions through holistically addressing the needs of patients (Baines, Reference Baines2003; Brown, Reference Brown2007; Cohen-Mansfield et al., Reference Cohen-Mansfield, Regier and Peyser2009; Martin, Reference Martin2015) recommends clinicians (1) be educated on the value of leaving a legacy and the impact communicating it can have on patients and their families and (2) participate in self-reflection about their own legacy in order to be able to discuss ethical will creation with patients. The fact that ethical will creation does not need to be facilitated by a trained professional expands the opportunity for it to be used in a number of scenarios and increases access for its use among the broader population, not only to patients nearing the end of life. More research is needed to understand the similarities and differences in psychotherapy interventions that are delivered by trained individuals compared to the experiences of those who complete an ethical will in the community setting. Similarly, comparing the experiences of individuals who create an ethical will near the end of life versus throughout the life course would identify if there is an optimal timepoint of creation that is most beneficial to individuals.

Interest in research examining ways to enrich the lives of patients anticipating the end of life continues to expand beyond relief of physical symptoms to incorporate psychological symptoms as well (Bernard et al., Reference Bernard, Strasser and Gamondi2017; National Consensus Project for Quality Palliative Care, 2018). Given the dearth of research on ethical wills, future research validating outcomes of ethical will creation would inform and hold promise for utilization and promotion of ethical wills in the clinical setting. Research exploring individuals’ motivations for creating ethical wills would help identify the population best suited for ethical will creation and optimal contexts or timing of completion. Finally, future research can build upon the findings of this review to explore the intergenerational and family effects of sharing an ethical will on mental health, perceived family closeness, and the bereavement process.

Conclusion

Our scoping review results indicate that creating an ethical will is a way for individuals to address mortality, renew intergenerational connections, solidify self, and promote transcendence before their final days. Many disciplines promote legacy of values creation, including law, health and social sciences, business and finance, and religion, which suggests ethical wills can be incorporated into interdisciplinary care to help individuals achieve their goals. This review provides supportive evidence for ways ethical wills are utilized and a foundation for understanding how they may be incorporated into interdisciplinary palliative care in the future. Ethical will creation holds promise as an intervention palliative care teams can use to promote holistic care and fulfill the recommendation to address the spiritual and existential concerns of patients as they prepare for the end of life.

Supplementary material

The supplementary material for this article can be found at https://doi.org/10.1017/S1478951522000451.

Conflict of interest

We have no known conflicts of interest to disclose.

References

REFERENCES

Akard, TF, Dietrich, MS, Friedman, DL, et al. (2015) Digital storytelling: An innovative legacy-making intervention for children with cancer. Pediatric Blood & Cancer 62(4), 658665. doi:10.1002/pbc.25337CrossRefGoogle ScholarPubMed
Alexander, RG (2005) Beyond death and taxes: Discovering values-based planning. Journal of Practical Estate Planning 7, 3942.Google Scholar
Alexander, RG (2006) Ethical wills: The gift of a heart. Journal of Practical Estate Planning 8, 2761.Google Scholar
Allen, RS, Hilgeman, MM, Ege, MA, et al. (2008) Legacy activities as interventions approaching the end of life. Journal of Palliative Medicine 11(7), 10291038. doi:10.1089/jpm.2007.0294CrossRefGoogle ScholarPubMed
Allen, RS, Harris, GM, Burgio, LD, et al. (2014) Can senior volunteers deliver reminiscence and creative activity interventions? Results of the legacy intervention family enactment randomized controlled trial. Journal of Pain and Symptom Management 48(4), 590601. doi:10.1016/j.jpainsymman.2013.11.012CrossRefGoogle ScholarPubMed
Alshech, E (2008) Egoistic Martyrdom and Hamās' success in the 2005 municipal mlections: A study of Hamās Martyrs' ethical wills, biographies, and eulogies. Die Welt des Islams 48(1), 2349. doi:10.1163/157006008X294918.CrossRefGoogle Scholar
Arksey, H and O'Malley, L (2005) Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology 8(1), 1932. doi:10.1080/1364557032000119616.CrossRefGoogle Scholar
Baines, BK (1999) The ethical will: Reviving a biblical tradition and applying it to retirement planning focus. Journal of Retirement Planning 2, 4448.Google Scholar
Baines, BK (2003) Ethical wills: Creating meaning at the end of life. Home Health Care Management & Practice 15(2), 140146. doi:10.1177/1084822302239301CrossRefGoogle Scholar
Baines, BK (2004) Writing an ethical will. Minnesota Medicine 87(1), 2628. Available at: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med5&AN=14977266Google ScholarPubMed
Barber, JR (2008) Nursing Students’ Perception of Spiritual Awareness after Participating in a Spirituality Project (Publication Number 3315149) (Doctoral dissertation, College of Saint Mary). ProQuest Dissertations & Theses Global.Google Scholar
Barnes, DB, Taylor-Brown, S and Wiener, L (1997) “I didn't leave y'all on purpose”: HIV-infected mothers’ videotaped legacies for their children. Qualitative Sociology 20(1), 732.CrossRefGoogle Scholar
Bernard, M, Strasser, F, Gamondi, C, et al. (2017) Relationship between spirituality, meaning in life, psychological distress, wish for hastened death, and their influence on quality of life in palliative care patients. Journal of Pain and Symptom Management 54(4), 514522.CrossRefGoogle ScholarPubMed
Blum, ME and Selby, AK (2015) Creating a family legacy committee report: The modern practice. Trusts and Estates 154, 2028.Google Scholar
Brown, J (2007) A note on ethical wills. Physician's Money Digest 14(9), 33.Google Scholar
Chochinov, HM, Hack, T, Hassard, T, et al. (2005) Dignity therapy: A novel psychotherapeutic intervention for patients near the end of life. Journal of Clinical Oncology 23(24), 55205525.CrossRefGoogle ScholarPubMed
Clarivate Analytics. EndNote X9.Google Scholar
Cohen-Mansfield, J, Regier, NG, Peyser, H, et al. (2009) Wisdom of generations: A pilot study of the values transmitted in ethical wills of nursing home residents and student volunteers. Gerontologist 49(4), 525535. doi:10.1093/geront/gnp045CrossRefGoogle ScholarPubMed
Cole, W and Kloberdanz, K (2003) Leaving your values behind. TIME Magazine 162(1), 91. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=asn&AN=10124446&site=ehost-liveGoogle Scholar
Colgan, M (2008) Get practical and personal with estate planning – It is not just the money that matters. Journal of Practical Estate Planning 10, 3748.Google Scholar
Collins, V and Shafron, J (2014) Legacy planning in the digital age: Help clients preserve their histories and life lessons feature: High-net-worth families & family offices. Trusts and Estates 153, 2125.Google Scholar
Doka, KJ (2015) The awareness of mortality: Continuing Kastenbaum's developmental legacy. OMEGA-Journal of Death and Dying 70(1), 6778.CrossRefGoogle Scholar
Emanuel, L, Bennett, K and Richardson, VE (2007) The dying role. Journal of Palliative Medicine 10(1), 159168.CrossRefGoogle ScholarPubMed
Falkner, CE (2009) Happily ever after: An ethical will may be a step on that journey. Thomas M. Cooley Journal of Practical and Clinical Law 12, 451468.Google Scholar
Federer, DP (2013) Guiding a client's moral legacy. On Wall Street 23(2), 3940. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=85403017&site=ehost-liveGoogle Scholar
Frank, JA (2003) The human legacy: Using ethical wills to enhance estate planning. Thomas M. Cooley Journal of Practical and Clinical Law 6(2), 6582.Google Scholar
Franklin, FC and Cheung, M (2017) Legacy interventions with patients with co-occurring disorders: Legacy definitions, life satisfaction, and self-efficacy. Substance Use and Misuse 52(14), 18401849. doi:10.1080/10826084.2017.1316290CrossRefGoogle ScholarPubMed
Gage, D, Gromala, J and Kopf, E (2004) Holistic estate planning and integrating mediation in the planning process. Real Property, Probate and Trust Journal 39, 509540.Google Scholar
Gambone, JV (2003) LEGACY what we leave to future generations. Clergy Journal 80(2), 1819.Google Scholar
Gaudiani, C (2007) Transferring the intangible philanthropy. Trusts and Estates 146, 3236.Google Scholar
Gawande, A (2014) Being Mortal: Medicine and What Matters in the End. New York, NY: Metropolitan Books.Google Scholar
Gessert, CE, Baines, BK, Kuross, SA, et al. (2004) Ethical wills and suffering in patients with cancer: A pilot study. Journal of Palliative Medicine 7(4), 517526.CrossRefGoogle ScholarPubMed
Grewe, F (2017) The soul's legacy: A program designed to help prepare senior adults cope with end-of-life existential distress. Journal of Health Care Chaplaincy 23(1), 114. doi:10.1080/08854726.2016.1194063CrossRefGoogle ScholarPubMed
Gustke, C (2014) The ethical will, an ancient concept, is revamped for the tech age. New York Times 164(56672), B4. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=asn&AN=99149228&site=ehost-liveGoogle Scholar
Hacker, D (2010) Soulless wills. Law and Social Inquiry 35, 957984.CrossRefGoogle Scholar
Hicks, ZM (2008) Is your (ethical) will in order? ACTEC Journal 33, 154168.Google Scholar
Ho, AH, Leung, PP, Tse, DM, et al. (2013) Dignity amidst liminality: Healing within suffering among Chinese terminal cancer patients. Death Studies 37(10), 953970.CrossRefGoogle ScholarPubMed
Hube, K (2005) Life's lessons. Wall Street Journal – Eastern Edition 246(127), R12.Google Scholar
Hunter, EG (2007) Beyond death: Inheriting the past and giving to the future, transmitting the legacy of one's self. OMEGA - Journal of Death & Dying 56(4), 313329.CrossRefGoogle Scholar
Hunter, EG and Rowles, GD (2005) Leaving a legacy: Toward a typology. Journal of Aging Studies 19(3), 327347. doi:10.1016/j.jaging.2004.08.002CrossRefGoogle Scholar
Institute of Medicine (2015) Dying in America: Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Press.Google Scholar
Kador, J (2014) The Rep's guide to ethical wills. REP 38(3), 5861.Google Scholar
Kahn, J (2001) Where there's an (ethical) will, there's a Way. FSB: Fortune Small Business 11(8), 91.Google Scholar
Kaslow, FW and Benjamin, GAH (2015) Ethical wills: The positives and the perils for the family. Journal of Family Psychotherapy 26(3), 163177. doi:10.1080/08975353.2015.1067530CrossRefGoogle Scholar
Kearl, MC (1989) Endings: A Sociology of Death and Dying. New York, NY: Oxford University Press.Google Scholar
Keeva, S (2005) A legacy of values. ABA Journal 91(10), 8888.Google Scholar
Kehl, KA (2006) Moving toward peace: An analysis of the concept of a good death. American Journal of Hospice and Palliative Medicine® 23(4), 277286.CrossRefGoogle ScholarPubMed
Kivnick, HQ (1996) Remembering and being remembered: The reciprocity of psychosocial legacy. Generations: Journal of the American Society on Aging 20(3), 4953.Google Scholar
Langer, N (2018) Your grandchildren may inherit your wealth. But, will they inherit your values? An ethical will to my grandchildren. Educational Gerontology 44(8), 535536. doi:10.1080/03601277.2018.1521617.CrossRefGoogle Scholar
Lifton, RJ (1979) The Broken Connection: On Death and the Continuity of Life. Washington, DC: American Psychiatric Press.Google Scholar
Lynch, JT (2008) Life insurance enables intangible legacies. Journal of Financial Service Professionals 62(2), 2628.Google Scholar
Manoogian, MM, Walker, AJ and Richards, LN (2007) Gender, genocide, and ethnicity: The legacies of older Armenian American mothers. Journal of Family Issues 28(4), 567589. doi:10.1177/0192513X06297605CrossRefGoogle Scholar
Martin, CA (2015) Promoting advance directives and ethical wills with the HIV-aging cohort by first assessing clinician knowledge and comfort level. The Journal of the Association of Nurses in AIDS Care 26(2), 208214. doi:10.1016/j.jana.2014.09.001CrossRefGoogle ScholarPubMed
Maxfield, M, Greenberg, J, Pyszczynski, T, et al. (2014) Increases in generative concern among older adults following reminders of mortality. The International Journal of Aging and Human Development 79(1), 121.Google ScholarPubMed
McAdams, DP and de St Aubin, E (1992) A theory of generativity and its assessment through self-report, behavioral acts, and narrative themes in autobiography. Journal of Personality and Social Psychology 62(6), 1003.CrossRefGoogle Scholar
McGowan, J, Sampson, M, Salzwedel, DM, et al. (2016) PRESS peer review of electronic search strategies: 2015 guideline statement. Journal of Clinical Epidemiology 75, 4046.CrossRefGoogle ScholarPubMed
Merrill and Age Wave (2019) Leaving a Legacy: A Lasting Gift to Loved Ones. https://www.ml.com/content/dam/pbig/articles/how-do-you-want-to-be-remembered/pbig_LegacyStudy_Final.pdfGoogle Scholar
Meuser, TM, Mthembu, TG, Overton, BL, et al. (2018) Legacy beliefs across generations: Comparing views of older parents and their adult children. International Journal of Aging and Human Development. doi:10.1177/0091415018757212Google ScholarPubMed
Meuser, TM, Mthembu, TG, Overton, BL, et al. (2019) Legacy beliefs across generations: Comparing views of older parents and their adult children. International Journal of Aging and Human Development 88(2), 168186. doi:10.1177/0091415018757212Google ScholarPubMed
Morgan, JE (2003) The Experience of the Transfer of Psychosocial Legacy from Older Adults to the Next Generation (Publication Number 3109026) (Doctoral dissertation, Saybrook University). ProQuest Dissertations & Theses Global.Google Scholar
Murphy, K (2002) The virtues and values of an ethical will. BusinessWeek (3777), 8383.Google Scholar
National Consensus Project for Quality Palliative Care (2018) Clinical practice guidelines for quality palliative care. Available at: https://www.nationalcoalitionhpc.org/ncp/Google Scholar
Newton, N and Jones, BK (2016) Passing on: Personal attributes associated with midlife expressions of intended legacies. Developmental Psychology 52(2), 341353. doi:10.1037/a0039905CrossRefGoogle ScholarPubMed
Newton, N, Herr, J, Pollack, J, et al. (2014) Selfless or selfish? Generativity and narcissism as components of legacy. Journal of Adult Development 21(1), 5968. doi:10.1007/s10804-013-9179-1Google Scholar
Odom, RC (2012) Statements of wealth transfer intent. Trusts & Estates 151(5), 5662.Google Scholar
O'Donnell, P (2005) Something to remember me by. Science & Spirit 16(4), 2627.Google Scholar
Pagano, D (2006) Helping clients leave a lasting legacy with the family love letter. Journal of Practical Estate Planning 8, 4355.Google Scholar
Parmar, N (2005) Willing your way. Smart Money 14(11), 144144.Google Scholar
Peters, DJM, Godfrey, MC, Khalil, BH, et al. (2015) Guidance for conducting systematic scoping reviews. International Journal of Evidence-Based Healthcare 13(3), 141146. doi:10.1097/XEB.0000000000000050CrossRefGoogle ScholarPubMed
Pizzo, PA (2016) Thoughts about dying in America: Enhancing the impact of one's life journey and legacy by also planning for the end of life. Proceedings of the National Academy of Sciences 113(46), 1290812912.CrossRefGoogle ScholarPubMed
Raphael, LW (1999) The teaching of writing an ethical will. Judaism: A Quarterly Journal of Jewish Life and Thought 48(2), 174.Google Scholar
Rehl, KM (2003) Help your clients preserve values, tell life stories and share the voice of their hearts through ethical wills editor's choice. Journal of Practical Estate Planning 5, 1749.Google Scholar
Robinson, JT and Murphy-Nugen, AB (2018) It makes you keep trying: Life review writing for older adults. Journal of Gerontological Social Work 61(2), 171192. doi:10.1080/01634372.2018.1427645CrossRefGoogle ScholarPubMed
Sapp, S (1996) Religious views on legacy and intergenerational transfers. Generations 20(3), 3136.Google Scholar
Schultz-Krohn, WA (2002) A Qualitative Investigation of the Engagement in Meaningful Family Activities and Routines by Homeless Parents (Doctoral dissertation, Saybrook University). ProQuest Dissertations & Theses Global.Google Scholar
Scroggin, JJ (2003) The changing nature of estate planning part II – Influencing the legacy. Journal of Practical Estate Planning 5, 3760.Google Scholar
Sheridan, J (2009) The ethical will: A modern approach to an ancient tradition. LLI Review 4, 114120.Google Scholar
Shultz, JA (2006) Ethical wills: A tool for resolving unfinished business [corrected] [published erratum appears in AGING TODAY 2006 May-Jun;27(3):6]. Aging Today 27(2), 1112.Google Scholar
Stanton, J and Peyser, H (2007) Sharing wisdom and building community: The ethical will project. Nursing Homes: Long Term Care Management 56, 2932.Google Scholar
Stanton, J and Peyser, H (2010) The use of ethical wills to engage future Jewish leaders. Religious Education 105(5), 536548. doi:10.1080/00344087.2010.516217CrossRefGoogle Scholar
Steinhauser, KE, Clipp, EC, McNeilly, M, et al. (2000) In search of a good death: Observations of patients, families, and providers. Annals of Internal Medicine 132(10), 825832.CrossRefGoogle ScholarPubMed
Steinhauser, KE, Bosworth, HB, Clipp, EC, et al. (2002) Initial assessment of a new instrument to measure quality of life at the end of life. Journal of Palliative Medicine 5(6), 829841.CrossRefGoogle ScholarPubMed
Steinhauser, KE, Alexander, SC, Byock, IR, et al. (2008) Do preparation and life completion discussions improve functioning and quality of life in seriously ill patients? Pilot randomized control trial. Journal of Palliative Medicine 11(9), 12341240. doi:10.1089/jpm.2008.0078CrossRefGoogle ScholarPubMed
Streit, M (2012) Share your values in an ethical will. Kiplingers Retirement Report 19(9), 1818. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=79326064&site=ehost-liveGoogle Scholar
The Human Rights Campaign (2019) LGBTQ-Inclusive definitions of family. Available at: https://www.hrc.org/hei/lgbtq-inclusive-definitions-of-familyGoogle Scholar
The Jewish Theological Seminary (n.d.) Why create an ethical will?. Available at: http://www.jtsa.edu/the-jewish-ethical-wills-projectGoogle Scholar
The Joanna Briggs Institute (2015) The Joanna Briggs Institute reviewers’ manual 2015: Methodology for JBI scoping reviews, pp. 1–24. Available at: https://doi.org/10.1017/CBO9781107415324.004CrossRefGoogle Scholar
Thompson, B, Kellas, JK, Soliz, J, et al. (2009) Family legacies: Constructing individual and family identity through intergenerational storytelling. Narrative Inquiry 19(1), 106134.CrossRefGoogle Scholar
Tricco, AC, Lillie, E, Zarin, W, et al. (2018) PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Annals of Internal Medicine 169(7), 467. doi:10.7326/M18-0850CrossRefGoogle ScholarPubMed
Tugend, A (2020) Pass along life lessons With an ethical will. Kiplingers Retirement Report 27(6), 6. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=143212811&site=ehost-liveGoogle Scholar
Veritas Health Innovation. Covidence systematic review software. Available at: http://www.covidence.orgGoogle Scholar
Vizzard, AR (2012) The ethical will: A loving legacy. American Nurse Today 7(9), 1618.Google Scholar
Wheeler, KB and Farnsworth, SM (2000) Living legacy planning. Journal of Practical Estate Planning 2, 3140.Google Scholar
Williams, B, Woodby, L and Drentea, P (2010) Ethical capital: ‘what's a poor man got to leave?’. Sociology of Health & Illness 32(6), 880897. doi:10.1111/j.1467-9566.2010.01246.xCrossRefGoogle ScholarPubMed
Wynn, M and de Vries, B (2005) Bequeathing values, hopes and meaning: A content analysis of ethical wills. Gerontologist 45, 356357.Google Scholar
Ziff, A (2016) Leading groups in a senior center. Group: Journal of the Eastern Group Psychotherapy Society 40(4), 343356. doi:10.13186/group.40.4.0343Google Scholar
Figure 0

Table 1. Outline for data extraction: planned versus final data extraction

Figure 1

Fig. 1. PRISMA flowchart outlining literature search.

Figure 2

Table 2. Ethical will data extraction table

Figure 3

Fig. 2. The 84 unique terms describing ethical will content were grouped into like categories. The percentage for each category was calculated by tallying the number of times the terms were used and dividing by the total term count (n = 376).

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