Background The ACTION trial evaluated the effect of a modified version of the Respecting Choices' advance care planning programme in patients with advanced cancer in six European countries. For this purpose, an advance directive acceptable for all six ACTION countries to be used for documenting the wishes and preferences of patients and as a communication tool between patients, their caregivers and healthcare staff, was needed. Aim To describe the development of a multinational cancer specific advance directive, the 'My Preferences form', which was first based on the 2005 Wisconsin 'Physician Orders of Life Sustaining Treatment' Form, to be used within the ACTION trial. Methods Framework analysis of all textual data produced by members of the international project team during the development of the ACTION advance directives (e.g. drafts, emails, meeting minutes. . .). Setting/participants ACTION consortium members (N = 28) with input from clinicians from participating hospitals (N = 13) and 'facilitators' (N = 8) who were going to deliver the intervention. Results Ten versions of the ACTION advance directive, the 'My Preferences form', were developed and circulated within the ACTION consortium. Extensive modifications took place; removal, addition, modification of themes and modification of clinical to lay terminology. The result was a thematically comprehensive advance directive to be used as a communication tool across the six European countries within the ACTION trial. Conclusion This article shows the complex task of developing an advance directive suitable for cancer patients from six European countries; a process which required the resolution of several cross cultural differences in law, ethics, philosophy and practice. Our hope is that this paper can contribute to a deeper conceptual understanding of advance directives, their role in supporting decision making among patients approaching the end of life and be an inspiration to others wishing to develop a disease-specific advance directive or a standardised multinational advance directive.