Objective To analyze the attitudes of older patients receiving head and neck cancer surgery on decision making towards preoperative advance care planning (ACP), informing the development of preoperative ACP interventions for older patients with head and neck cancer. Methods Semi-structured interviews were conducted with 13 elderly patients undergoing head and neck can-cer surgery, and Q statements were generated based on the literature review, summarized, organized, numbered and randomly ranked for backup; another 18 elderly patients undergoing head and neck cancer surgery were selected to rank the Q statements according to the Q methodology, and the resulting data were subjected to a factor analysis in order to clarify the patients′ attitude towards decision-making. Results A total of 3 factors were extracted. The types of decision-making attitudes of elderly head and neck cancer surgery patients toward preoperative ACP could be categorized into 3 types: shared decision-making, professional decision-making, and self decision-making. All 3 types of participants believed that preoperative ACP discussions should be conducted before surgery, and they were opposed to the idea that it was inauspicious or ungrateful to discuss this topic before surgery. There were also some differences among the 3 types. Conclusion It is feasible to conduct preoperative ACP discussions with elderly patients undergoing surgery for head and neck cancer, whose attitudes toward participation in preoperative ACP vary. The medical staff should screen patients for different types of decision-making and target preoperative ACP interventions.