Efficacy of a Church-Based, Culturally Tailored Program to Promote Completion of Advance Directives Among Asian Americans

Healthcare Provider's Culture and Its Impact on End-Of-Life Discussions

To examine the openness to communication in end-of-life care of three major ethno-cultural groups of healthcare providers (HCPs) (in Israel: Israeli Arabs (Arabs), Israeli Jews (Sabras), and Immigrants from the Soviet Union (Russians). An anonymized set of three questionnaires was distributed among 240 physicians and nurses (HCPs) from the three ethno-cultural groups, yielding a response rate of 91% (and 82% when including hospital division). Sabra ethno-cultural group was more open to communicating about and relating to end-of-life with terminally ill patients. While recent exposure to death and external locus of control decreased the effect of ethno-cultural background, the latter remained statistically significant. Gender, age, marital status, and specialty were not found to be influential factors.This research highlights the importance of increasing awareness and responses to the effects of HCPs' culture on end-of-life care as varied cultures and medico-legal requirements come into contact in society.

Examining Utilization of Formal Supports and Related Impacts on Overall Well-Being Among East Asian American Family Caregivers of Persons With Dementia: A Mixed-Methods Study

BACKGROUND AND OBJECTIVES

Although East Asian American family caregivers are known to underutilize formal support services, there is a lack of evidence regarding the associations of formal service utilization with caregivers' well-being. This study examined the prevalence of different types of home-and community-based formal service utilization among Korean and Chinese American family caregivers of persons with dementia and how utilization of such services was associated with their well-being. We also explored their overall experience in accessing and utilizing formal dementia support services and programs.

RESEARCH DESIGN AND METHODS

We employed a convergent mixed-methods study design. In a convenience sampling method, we recruited 62 family caregivers. Logistic regression and thematic analysis were utilized to analyze data.

RESULTS

The results showed in-home services were mostly utilized among family caregivers of these ethnic groups. Out of 9 different support services, those who utilized nutrition programs and case management were more likely to report higher overall well-being. Four themes were developed: (1) awareness of formal support services but uncertainty on how to access them, (2) language barriers imposing additional challenges in accessing formal support services, (3) traveling to access culturally appropriate services, and (4) desire for culturally tailored medical and long-term care services.

DISCUSSION AND IMPLICATIONS

Findings from this study suggest the importance of case management services to overcome barriers to accessing and utilizing a wide range of formal support services and provision of culturally appropriate food in formal support services to increase East Asian American family caregivers' utilization of long-term care services.

A model for community-led peer-facilitated advance care planning workshops for the public

Background

The core to successful advance care planning (ACP) facilitation is helping people determine their values, beliefs and wishes, and understand substitute decision-making. Recognizing the potential for community members to support public awareness and education we developed a model of ACP education, whereby peer facilitators associated with community organizations host workshops that educate and assist members of the public with ACP.

Objectives

Describe the development and evaluation of the model for community-led peer-facilitated ACP workshops for the public.

Design

Descriptive mixed methods.

Methods

A training curriculum and program model were co-developed with two community organizations that had been successful in delivering ACP workshops independently in their communities. Herein we describe a mixed-methods evaluation of three cycles of implementation and improvement of the model.

Results

The model centers on three key concepts; the right content (based around three steps Think, Talk, Plan), the right facilitator, and the right approach. A suite of tools was designed to support the three groups involved in the delivery of the ACP workshops: the public participants, the peer facilitators, and the community-based organizations. The peer-facilitator training addresses the facilitator's learning needs of ACP content knowledge, facilitation skills, and understanding change behavior. Training evaluation data from 106 facilitators confirmed that the curriculum prepared them to facilitate the workshops. Qualitative data revealed that support from organizations with established reputations in their community is critical, with mentoring from more experienced facilitators beneficial.

Conclusion

Our model demonstrates the potential of community-led, peer-facilitated ACP initiatives to enhance the capacity of community to upstream ACP conversations. Reaching a broader audience and creating a supportive, inclusive environment for individuals to comfortably learn about ACP can drive the much-needed culture shift to normalize ACP. Meaningful community engagement, empowerment, and partnerships are essential for the successful development and widespread impact of these initiatives.

Family Involvement in Asian American Health Interventions: A Scoping Review and Conceptual Model

Family members play a crucial role in the health of Asian American communities, and their involvement in health interventions can be pivotal in optimizing impact and implementation. To explore how family members can be effectively involved in Asian American health interventions and develop a conceptual framework of methods of involvement at the stages of intervention development, process, and evaluation, this scoping review documented the role of Asian American family members in interventions (across any health objective). Of the 7175 studies identified through database and manual searches, we included 48 studies in the final analysis. Many studies focused on Chinese (54%) or Vietnamese (21%) populations, were conducted in California (44%), and involved spouses (35%) or parents/children (39%). We observed involvement across 3 stages: (1) intervention development (formative research, review process, material development), (2) intervention process (recruitment, receiving the intervention together, receiving a parallel intervention, enlisting support to achieve goals, voluntary intervention support, agent of family-wide change, and participation gatekeepers), and (3) intervention evaluation (received evaluation together, indirect impact evaluation, and feedback during intervention). Impact of family member involvement was both positive (as sources of encouragement, insight, accountability, comfort, and passion) and negative (sources of hindrance, backlash, stigma, obligation, and negative influence). Suggestions for future research interventions include (1) exploring family involvement in South Asian or young adult interventions, (2) diversifying types of family members involved (eg, extended family), and (3) diversifying methods of involvement (eg, family members as implementation agents).

"At the End I Have a Say": Engaging the Chinese Community in Advance Care Planning

CONTEXT

Despite the association of advance care planning (ACP) with improved patient and caregiver outcomes, Chinese American elders have low rates of ACP.

OBJECTIVES

Assess ACP facilitators/barriers in the San Francisco (SF) Chinese community and codesign, implement, and test community-based ACP-promoting pilot events.

METHODS

A Chinese Community Committee (N = 19 community-based organization leaders, health system representatives, community members) conducted focus groups in Cantonese and English with Chinese older adults (age ≥55), caregivers, and community leaders. The Committee designed and implemented pilot events in-person and online. We analyzed focus group data using thematic analysis; assessed pre-to-post-event readiness to engage in ACP (validated survey; 14 scale, 4 = most ready); and assessed event acceptability.

RESULTS

A total of 34 people participated in six focus groups. Themes described Chinese community-specific importance of ACP (e.g., reduces family burden), barriers (e.g., younger generations lack tools to discuss ACP with elders and vice versa), and facilitators (e.g., intergenerational events, culturally/linguistically appropriate materials). Based on focus groups findings, the Committee developed a novel ACP tool and designed intergenerational events. A total of 195 participants attended 10 events; 95% were Chinese, 90% spoke Chinese languages, 80% were women. ACP readiness increased significantly (1.66 [SD 0.84] vs. 2.03 [SD 0.85]; P < 0.001); 94% of participants were comfortable attending and 96% would recommend events.

CONCLUSION

Community-developed intergenerational events that highlight the value of ACP and address barriers are acceptable and increase ACP engagement in the Chinese community.

Perceived Barriers and Social Cultural Factors Associated With Advance Care Planning Conversations Among Chinese American Older Adults

Despite the well-documented benefits of advance care planning (ACP), persistent racial and ethnic disparities continue to exist in ACP engagement. Guided by a social ecological model, this study examined perceived barriers and sociocultural factors associated with informal ACP conversations among Chinese American older adults. A purposive sample of 281 community-dwelling older Chinese Americans aged 55 years or older in Arizona and Maryland completed a survey in 2018. Hierarchical logistic regression models were conducted. There were 26.5% of participants who engaged in advance care planning. Lower perceived barriers and sociocultural factors (i.e., length of stay in the U.S. and English language proficiency) were positively associated with ACP conversations. Social support had a significant moderation effect. Findings highlighted the importance of language services and social support in facilitating ACP discussions among older Chinese immigrants. Effective strategies are needed to reduce the barriers to ACP at various levels for older Chinese American populations.

Church Matters: Education About Advance Care Planning and End-of-Life Care in Black Churches

For many African American adults, the church has the potential to be a place to receive education about advance care planning (ACP). The current study was conducted to (1) identify the frequency of ACP conversations and caregiving and (2) evaluate interest in church-placed end-of-life (EOL) care education. Data were collected from parishioners in 2 African American churches in an urban city in the mid-Atlantic region of the United States. Individuals older than 50 years reported a higher frequency of caregiving ( P < .001) and were more likely to have talked to someone about EOL care ( P < .001) than individuals younger than 50 years. Nearly all respondents considered EOL conversations "important" or "very important" (99.1%) and wanted more information about EOL conversations available via the church (95.8%). Our findings suggest EOL conversations are happening within families and with health care providers, but they are not documented in ways (eg, in writing) that research has focused on previously. Future EOL education will focus more on the importance of documenting and sharing EOL care wishes with family and health care professionals.

Racial Disparities in Health Beliefs and Advance Care Planning Among Patients Receiving Maintenance Dialysis

CONTEXT

Among people receiving maintenance dialysis, little is known about racial disparities in the occurrence of prognostic discussions, beliefs about future health, and completion of advance care planning (ACP) documents.

OBJECTIVES

We examined whether Black patients receiving maintenance dialysis differ from White patients in prognostic discussions, beliefs about future health, and completion of ACP-related documents.

METHODS

We surveyed adult patients receiving maintenance dialysis from seven dialysis units in Cleveland, Ohio, and hospitalized patients at a tertiary care hospital in Cleveland. Of the 450 patients who were asked to participate in the study, 423 (94%) agreed. We restricted the current secondary analyses to include only Black (n=285) and White (n=114) patients. The survey assessed patients' knowledge of their kidney disease, attitudes toward chronic kidney disease (CKD) treatment, preferences for end-of-life (EoL) care, the patient-reported occurrence of prognostic discussions, experiences with kidney therapy decision making, sentiments of dialysis regret, beliefs about health over the next 12 months, and advance care planning. We used stepwise logistic regression to determine if race was associated with the occurrence of prognostic discussions, beliefs about future health, and completion of an ACP-related document, while controlling for potential confounders.

RESULTS

We found no significant difference in the frequency of prognostic discussions between Black (11.9%) versus White patients (7%) (P=0.15). However, Black patients (19%) had lower odds of believing that their health would worsen over the next 12 months (OR 0.22, CI 0.12, 0.44) and reporting completion of any ACP-related document (OR 0.5, CI 0.32, 0.81) compared to White patients CONCLUSION: Racial differences exist in beliefs about future health and completion of ACP-related documents. Systemic efforts to investigate differences in health beliefs and address racial disparities in the completion of ACP-related documents are needed.

The Association of Chinese Ethnicity and Language Preference with Advance Directive Completion Among Older Patients in an Integrated Health System

BACKGROUND

Little is known about possible differences in advance directive completion (ADC) based on ethnicity and language preference among Chinese Americans on a regional level.

OBJECTIVE

To understand the association of ethnicity and language preference with ADC among Chinese Americans.

DESIGN

Retrospective cohort analysis with direct standardization.

PARTICIPANTS

A total of 31,498 Chinese and 502,991 non-Hispanic White members enrolled in Kaiser Permanente Northern California during the entire study period between 2013 and 2017 who were 55 or older as of January 1, 2018.

MAIN MEASURES

We compared the proportion of ADC among non-Hispanic White and Chinese patients, and also analyzed the rates according to language preference within the Chinese population. We calculated ADC rates with direct standardization using covariates previously found in literature to be significant predictors of ADC such as age and utilization.

KEY RESULTS

Among Chinese members, 60% preferred English, 16% preferred another language without needing an interpreter, and 23% needed an interpreter. After standardizing for age and utilization, non-Hispanic Whites were more than twice as likely to have ADC as Chinese members (20.6% (95% confidence interval (CI): 20.5-20.7%) vs. 10.0% (95% CI: 9.6-10.3%), respectively). Among Chinese members, there was an inverse association between preference for a language other than English and ADC (13.3% (95% CI: 12.8-13.8%) if preferring English, 6.1% (95% CI: 5.4-6.7%) if preferring non-English language but not needing an interpreter, and 5.1% (95% CI: 4.6-5.6%) if preferring non-English language and needing an interpreter).

CONCLUSIONS

Chinese members are less likely to have ADC relative to non-Hispanic White members, and those preferring a language other than English are most affected. Further studies can assess reasons for lower ADC among Chinese members, differences in other Asian American populations, and interventions to reduce differences among Chinese members especially among those preferring a language other than English.

Chinese Diaspora Communities' Knowledge of and Engagement with Advance Care Planning: A Systematic Integrative Review

OBJECTIVES

To synthesize evidence regarding Chinese diasporas' understanding, experience, and factors influencing engagement with advance care planning. Methods: A systematic integrative review using content analysis. Seven electronic databases (Embase, CINAHL, SCOPUS, Web of Science, Medline (OVID), PsycINFo, and The Cochrane Library) and gray resources were searched for studies from January 1990 to March 2022. Study quality appraisal was undertaken. Results: 27 articles were identified and rated as moderate to good. Two overarching and interrelated themes were identified, "Awareness and knowledge" and "Engagement with advance care planning." There are low levels of awareness, knowledge and engagement with advance care planning for Chinese diaspora. Findings highlight that this is influenced by two key factors. First, the geographic context and legal, cultural, and social systems within which the Chinese diasporas are living act as a potential catalyst to enhance awareness and engagement with advance care planning. Second, aspects of Chinese diasporas' original culture, such as filial piety and a taboo surrounding death, were reported to negatively affect the promotion and engagement of advance care planning. Significance of Results: Chinese diasporas are intermediaries between two divergent cultures that intertwine to strongly influence engagement with advance care planning. Hence, a bespoke culturally tailored approach should be accommodated in future research and practice for Chinese communities in multicultural countries to further advance palliative and end-of-life care awareness among this group.

Community workshops increase advance care planning knowledge, appointment of legal proxies and completion of end-of life written plans

Advance Care Planning involves having conversations, completing documents detailing individuals' end-of life treatment and care preferences, and appointing legal proxies who make health, lifestyle, or financial decisions. Although beneficial outcomes have been demonstrated, community rates of Advance Care Planning remain low. We developed a theoretically based workshop to increase knowledge and change behaviors in relation to Advance Care Planning; 347 participants completed the workshop. Advance Care Planning knowledge and action significantly improved three months post workshop. The intervention increased Advance Care Planning knowledge and changed behaviors.

The effect of end-of-life decision-making tools on patient and family-related outcomes of care among ethnocultural minorities: A systematic review

Background

End-of-life decision-making tools are used to establish a shared understanding among patients, families and healthcare providers about medical treatment and goals of care. This systematic review aimed to understand the availability and effect of end-of-life decision-making tools on: (i) goals of care and advance care planning; (ii) patient and/or family satisfaction and well-being; and (iii) healthcare utilization among racial/ethnic, cultural, and religious minorities.

Methods

A search was conducted in four electronic databases (inception to June 2021). Articles were screened for eligibility using pre-specified criteria. We focused on adult patients (aged ≥18 years) and included primary research articles that used quantitative, qualitative, and mixed-methods designs. Complementary quality assessment tools were used to generate quality scores for individual studies. Extracted data were synthesized by outcome measure for each type of tool, and an overall description of findings showed the range of effects.

Results

Among 14,316 retrieved articles, 37 articles were eligible. We found that advance care planning programs (eleven studies), healthcare provider-led interventions (four studies), and linguistically-tailored decision aids (three studies) increased the proportion of patients documenting advance care plans. Educational tools (three studies) strongly reduced patient preferences for life-prolonging care. Palliative care consultations (three studies) were strongly associated with do-not-resuscitate orders. Advance care planning programs (three studies) significantly influenced the quality of patient-clinician communication and healthcare provider-led interventions (two studies) significantly influenced perceived patient quality of life.

Conclusion

This review identified several end-of-life decision-making tools with impact on patient and family-related outcomes of care among ethnocultural minorities. Advance care planning programs, healthcare provider-led interventions and decision aids increased documentation of end-of-life care plans and do-not-resuscitate orders, and educational tools reduced preferences for life-prolonging care. Further research is needed to investigate the effect of tools on healthcare utilization, and with specific patient population subgroups across different illness trajectories and healthcare settings.

End-of-Life Preparedness Among Japanese Americans: A Community Survey

The purpose of this study was to investigate the level of preparedness among Japanese American older adults for life's end by examining their knowledge, preferences, and arrangements for end-of-life issues. A total of 248 community dwelling Japanese Americans aged 50 and older participated in the study. The cross-sectional survey results indicated that participants believed they were well-informed about end-of-life issues and well-prepared for their lives' end. While most participants were in favor of making end-of-life arrangements, particularly with regard to making a will/living trust, creating an advance health care directive, appointing a health care agent, and funeral planning, relatively few favored life-prolonging treatment or planning for organ donation. They placed a high value on natural death and family-centered decision-making processes. These findings highlight the importance of awareness and cultural humility for social workers when providing culturally informed services at life's end to diverse Americans, including Japanese American older adults and their families.

Advance Care Planning Among Chinese Americans Through a Web-Based Culturally Tailored Education Program

At any time, a medical crisis could result in an individual too sick to make one's own health care decisions. Advance care planning (ACP) is an important step to ensure that each person receives the medical care desired. Despite its significant importance and proven benefits, the completion rate for advance directive is approximately one-third among the general population in the United States and lower among Chinese Americans. This study explored Chinese Americans' knowledge and attitudes about ACP following completion of a web-based culturally tailored health education program. Ninety-six individuals completed the study between October 1 and December 31, 2020. Prestudy-poststudy outcomes measured included the Advance Directive Knowledge Survey and Advance Directive Attitude Scale administered before and after completion of the education program. Each measure has 9 questions and 16 questions, respectively. Participants' Advance Directive Knowledge Survey scores (pre: mean, 6.04 [SD, 2.28]; post: mean, 8.75 [SD, 0.53]; P < .01) and Advance Directive Attitude Scale scores (pre: mean, 47.31 [SD, 5.69]; post: mean, 53.59 [SD, 4.37]; P < .01) increased significantly following program completion. Findings indicated feasibility for integration of web-based technology and culturally tailored approaches to promote ACP knowledge and attitudes among Chinese Americans.

Advance Care Planning, Palliative Care, and End-of-life Care Interventions for Racial and Ethnic Underrepresented Groups: A Systematic Review

CONTEXT

Persons from underrepresented racial and ethnic groups experience disparities in access to and quality of palliative and end-of-life care.

OBJECTIVES

To summarize and evaluate existing palliative and end-of-life care interventions that aim to improve outcomes for racial and ethnic underrepresented populations in the United States.

METHODS

We conducted a systematic review of the literature in the English language from four databases through January 2020. Peer-reviewed studies that implemented interventions on palliative care, advance care planning, or end-of-life care were considered eligible. Data were extracted from 16 articles using pre-specified inclusion and exclusion criteria. Quality was appraised using the modified Downs and Black tool for assessing risk of bias in quantitative studies.

RESULTS

Five studies were randomized controlled trials, and the remainder were quasi-experiments. Six studies targeted Latino/Hispanic Americans, five African Americans, and five, Asian or Pacific Islander Americans. The two randomized control trials reviewed and rated "very high" quality, found educational interventions to have significant positive effects on advance care planning and advance directive completion and engagement for underrepresented racial or ethnic groups.

CONCLUSION

The effectiveness of advance care planning, end-of-life, and palliative care interventions in improving outcomes for underrepresented racial and ethnic populations remains uncertain. Randomized controlled trials and educational interventions indicate that interventions targeting underrepresented groups can have significant and positive effects on advance directives and/or advance care planning-related outcomes. More high-quality intervention studies that address racial and ethnic health disparities in palliative care are needed, particularly those that address systemic racism and other complex multilevel factors that influence disparities in health.

Extending Advance Care Planning to Black Americans in the Community: A Pilot Study of the PREPARE Program

CONTEXT

Advance care planning (ACP) is underutilized, especially among Black Americans. Yet, no ACP interventions have been tested at the community level.

OBJECTIVES

Within an established academic and community partnership, we sought to determine whether ACP is a community-identified need and if so, to conduct a pilot study of an evidence-based ACP program, PREPARE (PrepareForYourCare.org).

METHODS

We conducted open discussions and in-depth interviews to determine the relevance of ACP to the community. We then conducted a pre- to 3-week postpilot study of a virtual peer facilitated brief session to introduce ACP and encourage participants to engage with PREPARE. We conducted thematic content analysis for qualitative data and used paired t-tests to assess within-participant changes in the validated ACP Engagement Survey measured on a 1-5 scale (5 = greatest engagement).

RESULT

We conducted two discussion groups with community leaders (n = 12) and key informant interviews (n = 6), including leaders in aging, public health, health care and faith. We concluded that ACP is a community priority. In the pilot study, we enrolled 13 Black Americans; 85% were women and the mean age was 59.7 years (SD 15.1). There was a trend toward increased ACP engagement after the peer facilitated PREPARE (mean 3.2 (SD 0.6) pre vs. 3.5 (SD 0.6) post, paired t-test P = 0.06). All participants found the intervention to be acceptable and were satisfied with it.

CONCLUSION

Community members identified ACP as important for their community. Peer facilitated PREPARE program is a promising community-based strategy to increase engagement in ACP and may promote health equity.

Increasing Advance Care Planning Conversations Among Korean Americans Through a Faith Community Nurse Intervention

ABSTRACT

Minority populations have lower rates of advance care planning (ACP) than the general population. Faith community nurses (FCNs) can facilitate ACP training to improve end-of-life care outcomes for patients and caregivers. A nurse-led ACP training delivered to a primarily Korean American faith community increased the number of families who discussed end-of-life care values and wishes. Considerations for ACP outreach to Korean Americans and implications for FCNs are discussed.

Evaluation of a Large Scale Advance Care Planning Co-Design Education Program for Chinese-Speaking People in Australia

BACKGROUND

Advance care planning (ACP) is important, however ethnic minorities have half the completion rates in the United States compared to Caucasian counterparts, and in Australia only 3.5% of advance directives were completed by those overseas-born.Educational intervention improves ACP knowledge and subsequent uptake. We evaluated immediate and longer-term outcomes of a co-designed ACP education toolkit in Chinese-speaking people in Victoria, Australia.

METHODS

We conducted a cross-sectional survey of Chinese-speaking community members who participated in a co-designed Chinese ACP educational workshop. A self-selected subgroup were subsequently contacted 6 months later to determine longer-term outcomes.

RESULTS

Of 519 attendees across 17 workshops, 325 (63%) completed the evaluation. The majority (63%;n = 206) were previously unaware of ACP. Perception of receipt of useful information positively correlated with motivation to undertake ACP (r = 0.3486, p < 0.001). Of the 70 participants who consented to follow up, 36% (n = 26) agreed to participate in structured telephone interviews. English speakers were more likely to have undertaken ACP (n = 6 vs n = 3). ACP completion was not associated with being a carer or suffering from cancer or chronic illness.

CONCLUSIONS

This first Australian study evaluating ACP co-design education implementation outcomes in Chinese-speaking people supports that motivation to undertake ACP is related to knowledge, albeit a modest ACP uptake in a small follow up sample. Clinicians should note that this assists with ACP uptake, with likely downstream improved health outcomes. This co-designed toolkit could be helpful in increasing ACP uptake. Future engagement by Chinese language societies to overcome further barriers to ACP is needed.

Community-Based Advance Care Planning Interventions for Minority Older Adults: A Systematic Review

Racial/ethnic minority older adults in the United States often experience access, language, and cultural barriers to advance care planning. For the current study, a systematic review was conducted to summarize and appraise the current science on community-based interventions aimed at increasing advance care planning in racial/ethnic minority older adults. Five articles met the inclusion criteria, which represented four unique interventions in Asian American (n = 2) and Hispanic (n = 2) communities. Two interventions were nurse-led workshops and two were one-onone social worker-led sessions. Outcomes measured were intention to or completion of advance directive or advance care planning discussion; and improvement in advance directive knowledge, beliefs, attitudes, and comfort related to advance care planning. Interventions increased intention to or completion of advance directives and improved advance care planning knowledge, beliefs, and attitudes. Results were inconclusive regarding promoting advance care planning discussions. Further research is needed to address the diverse needs of racial/ethnic minority older adults and barriers to advance care planning. [Journal of Gerontological Nursing, 47(5), 26-36.].

Exploratory Study of Advance Care Discussions Among Chinese American and White Stage IV Cancer Patients at an American Tertiary Medical Center

PURPOSE

Timely advance care discussions are essential components of quality care for diverse populations; however, little is known about these conversations among Chinese American cancer patients. This exploratory study describes differences in advance care discussions and planning between Chinese American and White advanced cancer patients.

METHODS

We collected data for 63 Chinese American and 63 White stage IV cancer patients who died between 2013 and 2018. We compared: frequency and timing of prognosis, goals of care (GOC), and end-of-life care (EOLC) discussions in the final year of life; family inclusion in discussions; healthcare proxy (HCP) identification; do not resuscitate (DNR) order, do not intubate (DNI) order, and other advance directive (AD) completion. We did not conduct statistical tests due to the study's exploratory nature.

RESULTS

Among Chinese American and White patients, respectively, 76% and 71% had prognosis, 51% and 56% had GOC, and 89% and 84% had EOLC discussions. Prognosis, GOC, and EOLC discussions were held a median of 34.0, 15.5, and 34.0 days before death among Chinese American and 17.0, 13.0, and 24.0 days before death among White patients. Documentation rates among Chinese American and White patients were 79% and 76% for DNRs, 81% and 71% for DNIs, 79% and 81% for HCPs, and 52% and 40% for other ADs.

CONCLUSIONS

Findings suggest that Chinese Americans had similar rates of advance care discussions, completed conversations earlier, and had similar to higher rates of AD documentation compared to White patients. Further studies are needed to confirm our preliminary findings.

Evaluation of Neighborhood Socioeconomic Characteristics and Advance Care Planning Among Older Adults

IMPORTANCE

Advance care planning (ACP) is low among older adults with socioeconomic disadvantage. There is a need for tailored community-based approaches to increase ACP, but community patterns of ACP are poorly understood.

OBJECTIVE

To examine the association between neighborhood socioeconomic status (nSES) and ACP and to identify communities with both low nSES and low rates of ACP.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study examined University of California San Francisco electronic health record (EHR) data and place-based data from 9 San Francisco Bay Area counties. Participants were primary care patients aged 65 years or older and living in the San Francisco Bay Area in July 2017. Statistical analysis was performed from May to June 2020.

EXPOSURES

Patients' home addresses were geocoded and assigned to US Census tracts. The primary factor, nSES, an index combining area-level measures of income, education, poverty, employment, occupation, and housing or rent values, was divided into quintiles scaled to the distribution of all US Census tracts in the Bay Area (Q1 = lowest nSES). Covariates were from the EHR and included health care use (primary care, outpatient specialty, emergency department, and inpatient encounters in the prior year).

MAIN OUTCOMES AND MEASURES

ACP was defined as a scanned document (eg, advance directive), ACP Current Procedural Terminology code, or ACP note type in the EHR.

RESULTS

There were 13 104 patients included in the cohort-mean (SD) age was 75 (8) years, with 7622 female patients (58.2%), 897 patients (6.8%) identified as Black, 913 (7.0%) as Latinx, 3788 (28.9%) as Asian/Pacific Islander, and 748 (5.7%) as other minority race/ethnicity, and 2393 (18.3%) self-reported that they preferred to speak a non-English language. Of these, 3827 patients (29.2%) had documented ACP. The cohort was distributed across all 5 quintiles of nSES (Q1: 1426 patients [10.9%]; Q2: 1792 patients [13.7%]; Q3: 2408 patients [18.4%]; Q4: 3330 patients [25.4%]; Q5: 4148 patients [31.7%]). Compared with Q5 and after adjusting for health care use, all lower nSES quintiles showed a lower odds of ACP in a graded fashion (Q1: adjusted odds ratio [aOR] = 0.71 [95% CI, 0.61-0.84], Q2: aOR = 0.74 [95% CI, 0.64-0.86], Q3: aOR = 0.81 [95% CI, 0.71-0.93], Q4: aOR = 0.82 [95% CI, 0.72-0.93]. A bivariable map of ACP by nSES allowed identification of 5 neighborhoods with both low nSES and ACP.

CONCLUSIONS AND RELEVANCE

In this study, lower nSES was associated with lower ACP documentation after adjusting for health care use. Using EHR and place-based data, communities of older adults with both low nSES and low ACP were identified. This is a first step in partnering with communities to develop targeted, community-based interventions to meaningfully increase ACP.

Advance care planning information intervention for persons with mild dementia and their family caregivers: Impact on end-of-life care decision conflicts

Persons with dementia are at high risk for loss of decision-making ability due to increased cognitive decline as the disease progresses. Participation in advance care planning (ACP) discussions in the early stages of dementia is crucial for end-of-life (EoL) decision-making to ensure quality of EoL care. A lack of discussions about ACP and EoL care between persons with dementia and family caregivers (FCGs), can lead to decisional conflicts when persons with dementia are in the later stages of the disease. This study explored the effects of a family-centered ACP information intervention among persons with dementia and FCGs. The study was conducted in outpatient clinics in Taiwan. Participants were dyads (n = 40) consisting of persons diagnosed with mild cognitive impairment or mild dementia and their FCGs. A one-group, pretest–posttest, pre-experimental design was employed. The intervention was provided by an ACP-trained senior registered nurse and was guided by ACP manuals and family-centered strategies. Outcome data were collected with four structured questionnaires regarding knowledge of end-stage dementia treatment, knowledge of ACP, attitude towards ACP, and EoL decisional conflict about acceptance or refusal of cardiopulmonary resuscitation, ventilators, and tracheostomy. Paired t tests compared differences between pre-intervention data and 4-weeks’ post-intervention data. The intervention resulted in significant improvements among persons with dementia and FCGs for knowledge of end-stage dementia treatment (p = .008 and p < .001, respectively), knowledge of ACP (both p < .001), and significant reductions in decisional conflicts (both p < .001). Scores for positive and negative attitude toward ACP did not change for persons with dementia; however, there was a reduction in negative attitude for FCGs (p = .001). Clinical care for persons with dementia should incorporate ACP interventions that provide knowledge about EoL dementia care using family-centered care strategies that facilitate regular and continuous communication between FCGs, persons with dementia, and medical personnel to reduce decisional conflicts for EoL care.

Toward Culturally Tailored Advance Care Planning for the Chinese Diaspora: An Integrative Systematic Review

Background: The Chinese diaspora experiences disparate end-of-life (EOL) care outcomes. Advance care planning (ACP) may be an effective intervention to improve EOL care, but its reception and uptake in the Chinese diaspora are unknown. Objective: Review and synthesize current literature to develop a culturally tailored ACP framework for the Chinese diaspora. Design: A systematic integrative review framed by Whittemore and Knafl's method was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Data Sources: PubMed, Embase, CINAHL, Web of Science, Cochrane Library, and University of York Center for Reviews and Dissemination were systematically searched for articles published before February 2020. All English, peer-reviewed quantitative, qualitative, and mixed-method literature studying ACP in Chinese adults living outside China and Taiwan were included. A mixed-method appraisal tool was utilized for quality assessment. Results: The search yielded 836 unique articles, from which we included 30. Integrative synthesis resulted in a novel framework to guide culturally tailored ACP among the Chinese diaspora. The framework highlights the importance of an authority-initiated, indirect approach to ACP that maximizes individual and collective harmony. Furthermore, due to evolving sociodemographic and acculturation factors, the perception of harmony may differ between individuals and generations. Conclusion: The Chinese diaspora population is willing to engage in ACP. An individualized, culturally sensitive approach that captures and maximizes harmony will be central to the success of ACP in this population. Further work is required to understand the influence of serious illness, spirituality, and family on ACP.

Dialysis Decision Making and Preferences for End-of-Life Care: Perspectives of Pakistani Patients Receiving Maintenance Dialysis

CONTEXT

Previous studies from the U.S. and Canada report deficiencies in informed decision making and a need to improve end-of-life (EoL) care in patients undergoing dialysis. However, there is a paucity of literature on these issues in Pakistani dialysis patients, who differ from Western patients in culture, religion, and available health care services.

OBJECTIVES

To study informed dialysis decision-making and EoL attitudes and beliefs in Pakistani patients receiving dialysis.

METHODS

We used convenience sampling to collect 522 surveys (90% response rate) from patients in seven different dialysis units in Pakistan. We used an existing dialysis survey tool, translated into Urdu, and backtranslated to English. A facilitator distributed the survey, explained questions, and orally administered it to patients unable to read.

RESULTS

Less than one-fourth of the respondents (23%) felt informed about their medical condition, and 45% were hopeful that their condition would improve in the future. More than half (54%) wished to know their prognosis, and 80% reported having no prognostic discussion. Almost 63% deemed EoL planning important, but only 5% recalled discussing EoL decisions with a doctor during the last 12 months. Nearly 62% of the patients regretted their decision to start dialysis. Patients' self-reported knowledge of hospice (5%) and palliative care (7.9%) services was very limited, yet 46% preferred a treatment plan focused on comfort and symptom management rather than life extension.

CONCLUSION

Pakistani patients reported a need for better informed dialysis decision making and EoL care and better access to palliative care services. These findings underscore the need for palliative care training of Pakistani physicians and in other developing countries to help address communication and EoL needs of their dialysis patients.

So Help Me, God: Religiosity and End-of-Life Choices in a Nationally Representative Sample

Background: Studies show significant associations between the various dimensions of religiousness and end-of-life (EOL) decisions, such as individuals with high religiosity are more likely to choose aggressive care at EOL. However, these studies focused largely on smaller cancer populations. To our knowledge, there is no existing literature about the association between religiosity and EOL decisions within a national sample of older adults. Objective: The objective of this study was to investigate the association between religiosity and advance directive (AD) completion, and among those with an AD, documented EOL care preferences, using a nationally representative sample. Methods: This was an observational study. Descriptive statistics and logistic regression were conducted with 6051 decedents from the Health and Retirement Study using self-reported frequency of religious service attendance, importance of religion, and religious affiliation. Measurements: The dependent variables were AD completion and care preference. The independent variables were self-reported frequency of religious service attendance, importance of religion, and religious affiliation. Results: Protestants and Catholics had significantly lower odds of AD completion, compared with those with no religious preferences. Decedents who reported religion as very important had significantly lower odds of AD completion than decedents who said religion is not too important. Furthermore, decedents who attended religious services at least once a week, compared with those who do not attend, had significantly higher odds of completing an AD. Among those who completed an AD, neither religiosity nor religious affiliation was significantly associated with preference for prolonged care. Conclusions: Our study demonstrates the influence religiosity has on the development of ADs, prompting seriously ill patients' religious needs to be recognized and supported. It further suggests that religious services may provide a good opportunity for promoting knowledge and completion of ADs.

A Faith-Based Intervention to Reduce Blood Pressure in Underserved Metropolitan New York Immigrant Communities

Minority populations, including Asian Americans, face disparities in hypertension compared with non-Hispanic whites. This underscores the need for culturally adapted programs in settings that reach Asian American communities, such as faith-based organizations. We worked collaboratively with community partners to culturally adapt and implement an evidence-based community blood pressure monitoring program for Asian Americans (Asian Indians, Koreans, Filipinos, and Bangladeshis) in metropolitan New York during 2015 and 2016. The program included regularly scheduled volunteer-led screening and counseling events with congregants at faith-based organizations. Among participants with complete 6-month data (n = 348), health-related self-efficacy significantly improved after 6 months, and systolic and diastolic blood pressure was significantly reduced in some subgroups; reductions were highest in participants who self-reported a previous diagnosis of hypertension. Among Asian Americans, faith-based programs may be a replicable, low-cost, sustainable way to increase health-related self-efficacy and decrease blood pressure, specifically among individuals with self-reported hypertension.

Does Acculturation Matter? End-of-Life Care Planning and Preference of Foreign-born Older Immigrants in the United States

Background and Objectives

Advance care planning (ACP) is a critical component of health care affecting the quality of later life. Responding to the increase in the older immigrant population in the United States, this empirical study explored the racial/ethnic gaps in ACP behaviors among older immigrants and examined the end-of-life (EOL) care planning and preferences of foreign-born immigrant older adults focusing on race/ethnicity, acculturation, health need factors, and enabling social factors (financial capability, public assistance, and informal supports) after controlling predisposing factors (sociodemographic characteristics).

Research Design and Methods

Using a subsample from the National Health and Aging Trends Study 2011 and 2012, hierarchical logistic regression models of the EOL plan and preferences were examined with 50 multiple imputation data sets (n = 232).

Results

Descriptive statistics reveal lower ACP engagement of immigrants from racial/ethnic minority groups. In logistic models, however, only Black immigrants were less likely than Whites to have EOL conversations. Among acculturation factors, age at immigration was only negatively associated with having a durable power of attorney for health, but not significantly associated with other ACP behaviors. Instead, health and social factors, primarily need in health and informal support (i.e., number of coresidents and receiving financial help from family members), were associated with different types of ACP components. Receiving public assistance (i.e., receiving Medicaid and SSI) were positively associated with EOL treatment preferences.

Discussion and Implications

Older foreign-born immigrants, in general, showed lower ACP engagement than the overall older population. Moreover, minority immigrants were lower on ACP engagement than both White immigrants. This study highlights the need for formal and informal assistance for enhancing EOL planning for older immigrants. Adding to the culturally competent approach, policy efforts should address social and health factors that accrued throughout individuals’ life spans and affect older immigrants’ EOL preparation and care.

Chinese Americans' attitudes toward advance directives: An assessment of outcomes based on a nursing-led intervention

BACKGROUND

The process of advance care planning (ACP) encompasses learning about and planning for end-of-life (EOL) decisions, documenting preferences through legal forms known as Advance Directives (ADs), and having discussions with loved ones to share these preferences. While most ethnic minority groups have low ACP engagement and AD completion rates, Chinese Americans face additional challenges related to cultural beliefs and ACP.

PURPOSE

The purpose of this study was to estimate the impact of a culturally tailored nurse-driven educational intervention on the relationship between attitudes toward ADs and AD completion and ACP discussions.

DESIGN

Pre-posttest, repeated measures non-experimental design.

METHODS

A convenience sample of Chinese Americans participated in a culturally tailored nurse led AD and ACP workshop in English and Mandarin in a Chinese Community Center. Participants completed surveys before and after the workshop and at one-month follow-up.

RESULTS

Seventy-two Chinese Americans participated in this study. Most were female and born in China. Attitudes toward ADs improved after participating in the workshop and remained consistent at one-month follow-up. There was a significant positive relationship between attitudes and AD completion and ACP discussions.

CONCLUSIONS

Nurse-driven interventions improved engagement in the ACP process in Chinese Americans, a population thought to be averse to discussing death and dying and one with lower than average AD completion rates. Using culturally tailored interventions improves engagement in the ACP process.

Factors Associated With Designation of a Substitute Decision-Maker in Older Asian Americans: The Role of Cultural Factors

The present study examined the prevalence of and factors associated with the designation of a substitute decision-maker (SDM) in a sample of older Asian Americans. Particular emphasis was placed on cultural factors (ethnicity, time in the United States, English proficiency, acculturation, and cultural belief) that might influence on one's attitudes toward death and dying or end-of-life decision-making. Data were drawn from the 499 participants aged 60 years and older using the 2015 Asian American Quality of Life survey. Twenty-two percent of the sample had completed a legal document identifying a SDM. Results of a hierarchical logistic regression indicated that ethnicity, time in the United States, English proficiency, and acculturation were significant predictors. By examining the role of cultural factors in predicting SDM designation, the present study provided implications for culturally tailored strategies to help older Asian Americans plan their end-of-life care.

Perceived knowledge of palliative care among immigrants to the United States: a secondary data analysis from the Health Information National Trends Survey

BACKGROUND

Immigrants to North America receive more interventions at end of life potentially due to knowledge gaps. The primary objective of this study was to measure and describe levels of perceived knowledge about palliative care among immigrants to the United States (US) compared to those born in the US. Our secondary objective was to identify trusted sources for seeking information about palliative care among immigrants and compare these trusted sources with those born in the US. We hypothesized that immigrants would have less knowledge of palliative care than those born in US and would trust different sources for information about palliative care.

METHODS

We analyzed data from the nationally representative 2018 Health Information National Trends Survey (HINTS 5, cycle 2). Questionnaires were administered via mail between January and May 2018 to a population-based sample of adults. The primary outcome of interest was assessed using the item "How would you describe your level of knowledge about palliative care?" The secondary outcome of interest was determined using the item "Imagine you had a strong need to get information about palliative care, which of the following would you most trust as a source of information about palliative care?" Descriptive statistics were calculated, and bivariate analyses run between the outcomes of interest and sociodemographic characteristics (age, sex, education, race/ethnicity, nativity, fluency with English). Multivariable logistic regressions were conducted to assess the role of nativity, controlling for relevant sociodemographic variables. Jackknife weighting was used to generate population-level estimates.

RESULTS

About 70% of those born in the US and 77% of immigrants (weighted) responded that they had "never heard of palliative care." Trusted sources of palliative care were very similar between the groups (all P>0.05). Both groups' preferred trusted source of palliative care knowledge was "health care provider," with over 80% of respondents in each group selecting this option. Printed materials and social media were the least popular trusted sources among both groups. After adjusting for relevant sociodemographic characteristics, we found no association between poor knowledge of palliative care and nativity (P=0.22). Female respondents had 2.5-fold increased odds of reporting low levels of perceived knowledge of palliative care (OR =2.58, 95% CI, 1.76-3.78; P<0.001). Education was an important predictor of perceived knowledge of palliative care; as education level increased, so did perceived knowledge of palliative care (P<0.001).

CONCLUSIONS

Perceived knowledge of palliative care is poor generally, regardless of birthplace. Trusted sources for palliative care are similar between immigrants and those born in the US. Education is important and is a strong predictor of perceived knowledge of palliative care. Women perceive they have lower levels of knowledge of palliative care (PC) than men. Differences in end of life care between immigrants and non-immigrants cannot be explained by knowledge differences.

Facilitators and Barriers for Advance Care Planning Among Ethnic and Racial Minorities in the U.S.: A Systematic Review of the Current Literature

Growing evidence suggests a low engagement in advance care planning (ACP) among ethnic minorities in the U.S. The purpose of this study was to synthesize findings from prior research about ACP among ethnic minorities. An extensive literature search was conducted using multiple electronic databases. After applying inclusion criteria, 26 studies were included. Four categories of facilitators and barriers to ACP were identified: (1) Socio-demographic factors, (2) health status, literacy and experiences, (3) cultural values, and (4) spirituality. Socio-demographic factors showed inconsistent findings regarding their association with ACP engagement. Worse health status and knowledge about ACP are common facilitators across ethnic minority groups, whereas mistrust toward the health care system was a barrier only for Blacks. Collectivistic cultural values influenced ACP engagement among Latinos and Asian Americans; however, spirituality/religion played an important role among Blacks. The implications for culturally competent approaches to promote ACP and future research directions are discussed.

Implementing health promotion activities using community-engaged approaches in Asian American faith-based organizations in New York City and New Jersey

Faith-based organizations (FBOs) (e.g., churches, mosques, and gurdwaras) can play a vital role in health promotion. The Racial and Ethnic Approaches to Community Health for Asian Americans (REACH FAR) Project is implementing a multi-level and evidence-based health promotion and hypertension (HTN) control program in faith-based organizations serving Asian American (AA) communities (Bangladeshi, Filipino, Korean, Asian Indian) across multiple denominations (Christian, Muslim, and Sikh) in New York/New Jersey (NY/NJ). This paper presents baseline results and describes the cultural adaptation and implementation process of the REACH FAR program across diverse FBOs and religious denominations serving AA subgroups. Working with 12 FBOs, informed by implementation research and guided by a cultural adaptation framework and community-engaged approaches, REACH FAR strategies included (1) implementing healthy food policies for communal meals and (2) delivering a culturally-linguistically adapted HTN management coaching program. Using the Ecological Validity Model (EVM), the program was culturally adapted across congregation and faith settings. Baseline measures include (i) Congregant surveys assessing social norms and diet (n = 946), (ii) HTN participant program surveys (n = 725), (iii) FBO environmental strategy checklists (n = 13), and (iv) community partner in-depth interviews assessing project feasibility (n = 5). We describe the adaptation process and baseline assessments of FBOs. In year 1, we reached 3790 (nutritional strategies) and 725 (HTN program) via AA FBO sites. Most AA FBOs lack nutrition policies and present prime opportunities for evidence-based multi-level interventions. REACH FAR presents a promising health promotion implementation program that may result in significant community reach.