Advance Care Planning in Chinese Seniors: Cultural Perspectives

The coping experiences in patients with hepatocellular carcinoma and their spouses following postoperative recurrence: A dyadic qualitative study

Objective

Dyadic coping practices can vary depending on cultural contexts, socioeconomic factors, and the stages of the cancer journey. This study aimed to explore the dyadic coping experiences of hepatocellular carcinoma (HCC) patients and their spouses following postoperative recurrence in the Chinese cultural context, where cancer recurrence is frequently seen as a death sentence, and family-centered care is prioritized.

Methods

A descriptive qualitative research design was used, involving face-to-face, in-depth semi-structured interviews with 13 pairs of hepatocellular carcinoma patients and their spouses at a tertiary cancer hospital from July to October 2023. The interview guide was designed based on the Actor-Partner Interdependence Model (APIM) framework. Data were analyzed using thematic analysis, and the study adhered to the COnsolidated criteria for REporting Qualitative research (COREQ) checklist.

Results

Three themes were identified: (1) active coping strategies, (2) negative coping tendencies, and (3) the need for systematic coping support. The majority of couples perceived hepatocellular carcinoma recurrence as a death sentence, which prompted them-especially the spouses-to adopt proactive strategies, such as striving to seek advanced treatments and concealing unfavorable information. In contrast, patients, particularly those with a hereditary hepatocellular carcinoma background, often exhibited passivity, withdrawal, and contemplation of treatment abandonment. Spouses frequently felt overwhelmed and unable to alleviate their partners' anxiety about recurrence and death, particularly in the absence of support from health care professionals. They expressed a strong need for professional guidance and targeted interventions to address end-of-life concerns, emphasizing the need for increased financial support, empowerment through knowledge, and access to peer support networks.

Conclusions

This research emphasizes the importance of recognizing the interdependent coping experiences of recurrent HCC patients and their spouses. Health care professionals are encouraged to implement culturally sensitive, dyadic interventions that foster collaborative coping, address death-related anxiety, and empower couples in managing recurrence together, thereby enhancing their coping strategies and confidence.

Acceptance of advance care planning among older adults in Mainland China: a national cross-sectional study

BACKGROUND

Acceptance of advance care planning (ACP) among older adults is important for the promotion of ACP. It is of great importance to explore the acceptance of ACP and associated influencing factors among older adults in China based on the health ecology model (HEM).

METHODS

Based on a national cross-sectional study in 2022, 4,180 older adults were included. Stepwise linear regression was used to analyze factors associated with acceptance of ACP using SPSS 26.0, based on the HEM. Acceptance scores were calculated based on a self-assessment visual analog scale (range, 0 ~ 100, with higher scores indicating higher acceptance of ACP).

RESULTS

50.05% (2,092) of 4,180 participants were female. The median acceptance of ACP score was 64, and the range was (49, 81). In addition, the study found higher well-being index (β = 0.086; 95% CI, 0.199 to 0.535; P < 0.001) and health literacy (β = 0.054; 95% CI, 0.07 to 0.423; P = 0.006) scores, broader media use behaviors (β = 0.064; 95% CI, 0.127 to 0.419; P < 0.001), and a higher per capita monthly household income (β = 0.086; 95% CI, 1.827 to 3.825; P < 0.001) were associated with a higher acceptance of ACP, while participants with higher depression scores (β = -0.06; 95% CI, -0.435 to -0.129; P < 0.001), larger social network (β = -0.054; 95% CI, -3.289 to -0.937; P < 0.001), and health insurance (β = -0.04; 95% CI, -7.294 to -1.027; P = 0.008) demonstrated a lower acceptance of ACP.

CONCLUSIONS

For the first time, this study revealed basic personal information, economic status, media use, social networks, health knowledge, and mental health as the main factors associated with acceptance of ACP among older adults in mainland China. These findings were of great significant for enhancing healthcare quality and the overall quality of life for older adults in China.

Factors influencing advance care planning among cancer patients: A qualitative study

PURPOSE

The study aims to explore the factors influencing advance care planning among cancer patients, recognizing the importance of understanding these factors to enhance patient outcomes and ensure that patients' preferences are honored.

METHODS

Conducted from May to November 2023, this qualitative descriptive study employed a phenomenological research approach. In-depth face-to-face interviews and observations were utilized to gather insights into the factors influencing participation in advance care planning, guided by a semi-structured interview outline based on social ecosystem theory. Content analysis and thematic analysis were applied to identify and interpret key themes from the data.

RESULTS

A total of 17 cancer patients participated in the interviews. The analysis revealed four main themes. Facilitating factors included optimistic health views and positive attitudes toward advance care planning, which encouraged engagement. Conversely, barriers such as a lack of understanding of advance care planning, misconceptions, and negative attitudes hindered participation. Family dynamics played a significant role; trust in family decisions facilitated discussions, while family pressure created challenges. Economic burdens and cultural taboos surrounding death, along with reliance on healthcare providers, impeded open conversations. These findings highlight the necessity for targeted strategies to enhance patient involvement in advance care planning.

CONCLUSION

Cancer patients' advance care planning is influenced by positive factors like optimistic health views and supportive family dynamics, as well as obstacles such as misconceptions, cultural taboos, and economic burdens. Targeted interventions are needed to empower patients and better align care with their values.

Hindering Factors and Perceived Needs for the Decision Making of Advanced Directives Among People with Dementia and Their Families

Making advanced directives is challenging in Asia. The hindering factors and perceived needs for advanced directives for people with dementia and their families have not been fully explored in Taiwan. In this study, we aimed to identify the barriers and perceived needs of people with mild dementia and the families of people with dementia within the cultural context of Taiwan for advanced directives. A qualitative descriptive design with purposive sampling and content analysis was used to collect and analyze the data. Thirteen people with mild dementia and thirty-two families of people with dementia were recruited. Our findings indicated that the hindering factors for people with mild dementia and the families of people with dementia to make advanced directives included "talking about death is a taboo", "the timing is not right", "cultural values of filial piety", "male protagonist's social status", and "insufficient information on advanced directive". The perceived needs for participants in making advanced directive decisions were "a wish to die without suffering", "wanting to rely on others to make a decision", and "an increased awareness of information". This research offers valuable insights into the barriers and needs related to advanced directives for people with mild dementia and the families of people with dementia in Taiwan. These findings address the identified challenges and needs to develop effective solutions to help healthcare providers to better facilitate the decision-making process for advanced directives.

The mediating role of family cohesion in the relationship between death anxiety and readiness toward advance care planning among Chinese community-dwelling older adults: A cross-sectional study

OBJECTIVE

To determine the mediating role of family cohesion in the relationship between death anxiety and readiness toward advance care planning (ACP).

METHODS

This study included 965 Chinese community-dwelling older adults. Pearson correlation coefficient was conducted to assess the relationship between readiness toward ACP, death anxiety, and family cohesion. Structural equation model was used to examine the study hypothetical model.

RESULTS

965 valid questionnaires were collected. Death anxiety is significantly related to the readiness toward ACP (r = -0.437, P < 0.01) and family cohesion (r = -0.444, P < 0.01), and family cohesion exhibited a positive correlation with readiness toward ACP (r = 0.499, P < 0.01). Family cohesion partially mediated the effect of death anxiety on readiness toward ACP, accounting for 35.94 % of the total effect.

CONCLUSIONS

Family cohesion mediates the relationship between death anxiety and readiness toward ACP. Healthcare professionals should implement measures to alleviate death anxiety and promote family cohesion in older adults, thereby enhancing their readiness toward ACP.

Factors Influencing Knowledge, Attitudes and Behaviour Towards Engaging with Advance Care Planning: A Cross-Sectional Survey of Chinese Diaspora

OBJECTIVE

Advance care planning (ACP) is increasingly recognized as a public health priority globally, with cultural aspects influencing people's knowledge, attitudes, and behaviours toward ACP. Despite being one of the largest diaspora groups, the Chinese community remains under-researched in this area. This study aims to examine the knowledge, attitudes, and health behaviours related to ACP among Chinese diaspora within a region in the United Kingdom.

METHOD

A cross-sectional online survey based on the Theory of Planned Behaviour was conducted with 284 Chinese adults recruited from four social and voluntary organisations in the United Kingdom.

RESULTS

The study found low awareness (15%) and knowledge (mean score: 2.26 ± 1.78) of ACP, with less than 5% of the participants engaging with ACP. This contrasted with participants' attitudes (17.24 ± 2.57) and behavioural intention (14.93 ± 3.26) toward ACP, which were generally positive. Behavioural intention was the strongest predictor of engaging with ACP (OR 3.29, 95% CI: 1.35-8.02, p = 0.01). Participants with previous end-of-life care experience had a better understanding of ACP; older age and higher knowledge of ACP were associated with more positive attitudes. Cultural beliefs associated with the level of family involvement, legal aspects, and the availability of information in one's first language was significant influences on engagement with ACP.

CONCLUSIONS

Despite low awareness and engagement with ACP among the Chinese diaspora, positive attitudes and behavioural intention suggest potential for increased engagement. This could be achieved through culturally tailored interventions that address cultural influences and complexity surrounding legal requirements. Further research is needed to develop and test such interventions.

Qualitative analysis of concordance in advance care planning discussions between patients with advanced cancer and their surrogate decision makers

OBJECTIVES

This study aimed to explore the concordance in advance care planning (ACP) discussions between patients with advanced cancer and surrogate decision makers within an oncology ward.

DESIGN

Purposive and snowball sampling methods were used in this qualitative study, which involved conducting semistructured interviews to gather patients with advanced cancer and their surrogate decision makers. Interpretative phenomenological analysis was performed on the interview data to identify commonalities and differences in ACP discussions and to explore the factors influencing these differences.

SETTING

The research was conducted in the oncology ward of a tertiary hospital located in Foshan, China.

PARTICIPANTS

Participants included a total of 15 pairs of patients with advanced cancer and their surrogate decision makers in oncology wards.

RESULTS

Interpretative phenomenological analysis yielded three main themes and fourteen subthemes. The identified themes were: (1) personal factor; (2) family intrinsic factors and (3) external factor.

CONCLUSION

This study revealed the consistency of ACP between patients with advanced cancer and their surrogate decision makers in China and its influencing factors. Future research should further explore family-centred ACP practices, delve into how family factors influence the implementation of ACP for patients and develop conceptual frameworks and implementation strategies for ACP that align with Chinese cultural values and healthcare systems. These efforts will contribute to enhancing understanding in clinical practice, advancing scientific research and guiding policy formulation. ACP holds promise as a crucial intervention to improve the quality of end-of-life care for patients with advanced cancer in China, playing a central role in the field of palliative care in the country.

Reliability and validity of the Self-Efficacy in Palliative Care Scale among nurses

OBJECTIVES

To provide appropriate palliative care, nurses should have appropriate level of self-efficacy in palliative care, but the levels among nurses were low. To improve the levels effectively, self-efficacy in palliative care should be assessed using reliable and valid instruments. The purpose of this study was to examine the reliability and validity of the Self-Efficacy in Palliative Care Scale in Korean nurses.

METHODS

In this cross-sectional, observational study, 272 nurses (mean age: 30 years) were enrolled from 6 university-affiliated medical centers or community hospitals in South Korea. Data on self-efficacy and demographic characteristics were collected. Validity was assessed by exploratory and confirmatory factor analyses (SPSS and Mplus). Reliability and homogeneity were assessed by Cronbach's alpha and item analyses (SPSS), respectively.

RESULTS

The exploratory and confirmatory factor analyses supported the 4-factor structure (communication, assessment and symptom management, psychosocial and spiritual management of patient and family, and multiprofessional teamworking) with factor loadings >.60 and with good model fit: root mean square error of approximation =.07, Tucker-Lewis index =.94, comparative fit index =.95, and standardized root mean square residual =.04. Cronbach's alphas for the total scale and each of the subscales ranged from .883 to .965. The corrected item-total correlation coefficients of all items ranged from .61 to .90.

SIGNIFICANCE OF RESULTS

The findings of this study supported the reliability and validity of this instrument among Korean nurses. This instrument can be used to assess nurses' self-efficacy in palliative care and to test intervention effects on it.

Chinese and Belgian pediatricians' perspectives toward pediatric palliative care: an online survey

BACKGROUND

As pediatricians play a vital role in pediatric palliative care (PPC), understanding their perspectives toward PPC is important. PPC is established for a long time in Belgium, but has a shorter tradition in China, although it is growing in the last decade. Sampling and comparing the perspectives of these pediatricians could be insightful for both countries. Therefore, we sampled and compared perspectives of pediatricians in China and Belgium toward PPC, and explored factors influencing their perspectives.

METHODS

We conducted a cross-sectional online survey using the validated Pediatric Palliative Care Attitude Scale (PPCAS). Over a five-month period, we recruited pediatricians practicing in China (C) and Flanders (F), Belgium. Convenience sampling and snowballing were used. We analyzed data with descriptive statistics, and evaluated group differences with univariate, multivariate and correlation tests.

RESULTS

440 complete surveys were analyzed (F: 115; C: 325). Pediatricians in both regions had limited PPC experience (F: 2.92 ± 0.94; C: 2.76 ± 0.92). Compared to Flemish pediatricians, Chinese pediatricians perceived receiving less unit support (F: 3.42 ± 0.86; C: 2.80 ± 0.89); perceived PPC less important (F: 4.70 ± 0.79; C: 4.18 ± 0.94); and faced more personal obstacles while practicing PPC (F: 3.50 ± 0.76; C: 2.25 ± 0.58). Also, select socio-demographic characteristics (e.g., experiences caring for children with life-threatening condition and providing PPC) influenced pediatricians' perspectives. Correlational analyses revealed that pediatricians' PPC experiences significantly correlated with perceived unit support (ρF = 0.454; ρC=0.661).

CONCLUSIONS

Chinese pediatricians faced more barriers in practicing PPC. Expanding PPC experiences can influence pediatricians' perspectives positively, which may be beneficial for the child and their family.

'Only to reconcile with it'. The coping experience amongst middle-aged and older cancer survivors: A qualitative study

BACKGROUND

Cancer threat is relevant to age, and the threat of a foreshortened life coupled with a lengthy treatment process negatively affects middle-aged and older adults. Understanding the coping throughout the cancer experience in middle-aged and older cancer survivors will help develop supportive care to promote their physiological and psychological coping effects.

OBJECTIVES

To explore the cancer coping experiences of middle-aged adults aged 40-59 and older adults over 60.

DESIGN

A descriptive phenomenological study was employed.

METHODS

Face-to-face, in-depth, semistructured interviews were conducted with 22 oncology patients in a tertiary university hospital aged 40 or above from August to October 2023. The interview data were analyzed using thematic analysis procedures.

RESULTS

Five themes and 13 subthemes were formed through analysis: acceptance of cancer (considering cancer as chronic, believing in fate and attributing cancer to karma); having different information needs (desired to be truthfully informed, information-seeking behaviour, information avoidance behaviour); getting families involved (developing dependent behaviours, feeling emotional support, family members suffering worse); striving to maintain positive psychological state (positive thinking, seeking peer support) and negative experience (undesirable, low self-esteem).

CONCLUSION

Our study reveals that cancer survivors' attitudes towards having cancer have changed from a death sentence to a more positive perception of a chronic disease. Supportive programmes for developing coping strategies should consider the cultural traditions and religious beliefs, different information needs, involvement of family and promoting a positive psychological state while avoiding negative factors.

PATIENT OR PUBLIC CONTRIBUTION

Participants with experience of coping with cancer were involved in the semistructured interview.

Advance care planning as perceived by marginalized populations: Willing to engage and facing obstacles

BACKGROUND

Health disparities exist in end-of-life (EOL) care. Individuals and communities that are marginalized due to their race, ethnicity, income, geographic location, language, or cultural background experience systemic barriers to access and receive lower quality EOL care. Advance care planning (ACP) prepares patients and their caregivers for EOL decision-making for the purpose of promoting high-quality EOL care. Low engagement in ACP among marginalized populations is thought to have contributed to disparity in EOL care. To advance health equity and deliver care that aligns with the goals and values of each individual, there is a need to improve ACP for marginalized populations.

AIM

To describe how patients from marginalized populations experience and perceive ACP.

METHODS

We used an interpretive phenomenological approach with semi-structured qualitative interviews. Participants were recruited from four primary care clinics and one nursing home in a US Pacific Northwest city. Thirty patients from marginalized populations with serious illness participated in individual interviews between January and December 2021. Participants were asked to describe their experiences and perceptions about ACP during the interviews.

RESULTS

The mean age of 30 participants was 69.5; 19 (63%) were women; 12 (40%) identified as Asian/Pacific Islanders, 10 (33%) as Black; and 9 (30%) were non-native English speakers. Our three key findings were: 1) patients from marginalized populations are willing to engage in ACP; 2) there were multiple obstacles to engaging in ACP; and 3) meaningful ACP conversations could happen when clinicians listen. Although participants from marginalized populations were willing to engage in ACP, a fragmented and restrictive healthcare system and clinicians' biased behaviors or lack of interest in knowing their patients were obstacles. Participants who felt their clinicians took time and listened were encouraged to engage in ACP.

CONCLUSION

Patients from marginalized populations are willing to engage in ACP conversations despite a common belief otherwise. However, obstacles to meaningful ACP conversations with healthcare providers exist. Clinicians need to be aware of these obstacles and listen to build trust and engage marginalized patients in mutually meaningful ACP conversations.

Stages of readiness for advance care planning: Systematic review and meta-analysis of prevalence rates and associated factors

BACKGROUND

Advance care planning has been widely recommended to respect the medical care preferences of patients in the final stages of life. However, uptake of advance care planning in healthcare settings remains suboptimal. It may be beneficial to take into account individuals' readiness for advance care planning based on the stages to change identified in the Transtheoretical Model.

OBJECTIVE

To identify the measurements used to assess readiness of advance care planning based on the Transtheoretical Model, to pool the prevalence of readiness stages, and to summarize the factors affecting people's readiness for advance care planning.

DESIGN

Systematic review and meta-analysis.

METHODS

We systematically searched the databases of PubMed, EMBASE, The Cochrane Library, CINAHL, and Web of Science for relevant studies from inception to February 2023. A random effects model was used to estimate the pooled prevalence. And a narrative review on the factors associated with stages of readiness was conducted.

RESULTS

This meta-analysis included 25 studies involving a total of 4237 individuals. The precontemplation stage was the most commonly identified stage of readiness among advance care planning behaviors (26-72 %). The prevalence of readiness stages for advance care planning varied among different types of behavior. The behavior of "talking to health care proxy/family/loved ones about thoughts on quality versus quantity of life" had the highest level of readiness among all listed behaviors, followed by "talking to health care proxy/family/loved ones about living will", "signing a health care proxy form" and "signing a living will", "signing an advance directive", as well as "talking to doctors about living will". Regarding to influencing factors, a majority of sociodemographic and clinical factors did not show consistent associations with readiness, but some studies did suggest potential links with age, health status, countries, type of assessment, core structures of the Transtheoretical Model, and intervention modalities.

CONCLUSIONS

A majority of individuals were unaware of advance care planning. There is an urgent need to promote readiness for such planning. Starting with preliminary activities such as "talking to health care proxy/family/loved ones about thoughts on quality versus quantity of life" can help initiate advance care planning. Better integration of the Transtheoretical Model and interventions into the research of advance care planning readiness are needed.

REGISTRATION

Not registered.

Co-designing a culturally-sensitive theory-driven advance care planning game with Chinese older adults and healthcare providers

BACKGROUND

Advance care planning can be challenging because discussing end-of-life care often has negative connotations. Gamification is a novel approach to encourage advance care planning conversations in Western culture.

AIM

To co-design a game with multiple stakeholders to promote advance care planning in Chinese communities.

DESIGN

A two-phase design guided by the Medical Research Council framework for developing complex interventions was adopted between May 2019 and August 2020. In phase I, a game prototype was developed based on literature review, expert consultation and end-user consultation. In Phase II, the game prototype was tested among end-users and refined according to their feedback and expertise of a multi-disciplinary team through an iterative process.

SETTING/PARTICIPANTS

Experts in the field of aged care, palliative care, life education and game development and Chinese community-dwelling adults aged 60 years or older.

RESULTS

A board game called 'The Five Tastes Found in a Grocery Store' was developed. The game design was shaped by Bandura's Self-efficacy theory and feedback from experts and end-users. The participants generally found the gaming experience enjoyable and appreciated the opportunity to discuss end-of-life care openly.

CONCLUSIONS

This study is the first to develop an evidence-informed, theory-based, culturally sensitive game for promoting advance care planning in the Chinese community using a co-design approach.

Barriers to initiate a discussion about advance care planning among older Taiwanese residents of nursing homes and their families: A qualitative study

BACKGROUND

In Taiwan, the Patients' Right to Autonomy Act was enacted in 2019. However, advance care planning (ACP) implementation rates remain low in long-term care facilities.

AIM

This study explored the barriers to initiate a discussion about ACP among older Taiwanese residents of nursing homes and their families.

METHODS

A descriptive qualitative design was used. Face-to-face interviews were individually conducted with 38 participants (residents: 18; family members: 20), and data were analyzed through content analysis.

RESULTS

Five themes were identified: (1) having cultural or spiritual concerns (both groups), (2) prioritizing the bigger picture (family) (both groups), (3) waiting for the right time (both groups), (4) feeling unsure (residents), and (5) following the pace of the residents (family members).

CONCLUSION

The results indicate that discussing ACP with Chinese people and their families clashes with traditional Chinese culture. To implement ACP in long-term care facilities based in regions with ethnically Chinese populations, medical professionals must ensure that the residents and their family members understand advance directives and their role in ensuring a good death and must act as a bridge between residents and their family members to assist them in making consensual end-of-life-care decisions with residents.

Reliability and Validity of the Chinese Version of Advance Care Planning Self-efficacy Scale for Physicians

Background: Chinese patients prefer physicians to initiate advance care planning (ACP) conversations, but there is no appropriate tool to evaluate physicians' ACP self-efficacy level in mainland China. This study aimed to translate the ACP self-efficacy scale into Chinese (ACP-SEc) and measure its psychometric properties among clinical physicians. Method: The original scale was translated by literal translation, synthesis, and reverse translation, according to Brislin's translation model. Seven experts were invited to further revise the scale and evaluate the content validity. 348 physicians were conveniently sampled to evaluate the reliability and validity of the scale from May to June 2021 in 7 tertiary hospitals. Results: The ACP-SEc contained 17 items, 1 dimension, with a total score of 17 to 85 points. In this study, the critical ratios of the items ranged from 12.533 to 23.306, the item-total correlation coefficients ranged from 0.619 to 0.839. The item-content validity index ranged from 0.86 to 1.00, and the average scale-level content validity index was 0.98. In total, 75.507% of the total variance was explained by 1 common factor. The results of confirmatory factor analysis showed that the fitting indices of the modified model were desirable. The ACP-SEc was moderately correlated with General Self-Efficacy Scale (r = 0.675, P < .001), and it differentiated between physician groups based on the knowledge level of ACP, palliative care or ACP-related training experience, attitude toward ACP, willingness to initiate ACP discussions with patients, and experience of discussing ACP with family and friends, willingness to initiate ACP discussions with family and friends (P <.05). The total Cronbach's α and test-retest reliability of the scale were .960 and .976, respectively. Conclusion: The ACP-SEc shows good reliability and validity, and it can be used to assess the ACP self-efficacy level of physicians.

Association Between Primary Decision-Maker and Care Intensity Among Patients With Advanced Cancer in Mainland China

Purpose: In China, decisions regarding the treatment of seriously ill patients are usually made by family caregivers. This study aimed to explore the association between the primary decision-makers and the intensity of care given to patients with advanced cancer in China. Methods: We conducted a survey of family members and other caregivers representing 828 cancer patients who died between July 2013 and July 2016. The survey asked: "After the physician conveyed that the disease is incurable, what treatment did the patient and caregiver prefer?" and "Who was the primary decision-maker?" We compared the treatment intensity with locus of decision-making using multivariable logistic regression, adjusting for socio-demographic and clinical covariates informed. Results: Of the 792 patients in our sample, the majority were male (67·2%), 60 years or older (64·0%), married (82·2%), lived with family (98·2%), had medical insurance (94·8%), earned below-average income (53·5%), lived rurally (61·5%), had a gastrointestinal cancer diagnosis (50·8%), experienced moderate or severe pain (86·3%), never received palliative care (80·4%) and had caregivers as primary decision-makers (70·6%). We found that patients were more likely to receive intensive disease-modifying treatments when the primary decision-maker were their children (adjusted odds ratio [AOR] = 1·86, 95% CI:1·26-2·74), spouse (AOR = 2·04, 95% CI:1·26-3·30), or other caregivers (AOR = 3·46, 95% CI:1·24-9·69). Conclusions: When patients with advanced cancer in China did not make their own medical decisions, they were more likely to receive intensive disease-modifying treatments at the end-of-life. Actions should be taken to better understand and ensure that caregivers' decisions reflect the values and presence of patients.

Advance Care Planning Among Older Adults with Cognitive Impairment

In this study, we used data from the Health and Retirement Study (HRS) to investigate factors associated with older adults' engagement with advance care planning (ACP) across varying levels of cognitive functioning status. Our analysis used a sample of 17,698 participants in the HRS 2014 survey. Survey descriptive procedures (Proc SurveyMeans, Proc SurveyFreq) and logistic regression procedures (Proc SurveyLogistic) were used. Race, ethnicity, level of cognition, education, age, and number of chronic diseases consistently predicted ACP. Participants with lower levels of cognition were less likely to have a living will and durable power of attorney for healthcare (DPOAH). African American and Hispanic participants, younger participants, and those with lower cognition and education levels were less likely to engage in ACP. Marital status and loneliness predicted ACP engagement. Some results varied across the cognition cohorts. Our results indicated that sociodemographic status, together with health and cognitive status, has a significant role in predicting ACP. The results can provide valuable insights on ACP for older adults with or at risk of Alzheimer's disease and related dementia and other cognitive impairments, caregivers, families, and healthcare providers.

A serious game for engaging older adults in end-of-life care discussion: A mixed method study

OBJECTIVE

To examine the acceptability of a board game newly developed through a co-design process for promoting end-of-life care discussion among Chinese older adults.

METHODS

A multi-centre mixed method study, including a one group pre-test post-test study and focus group interviews, was conducted. Thirty older adults participated in a one-hour game session in a small group format. Acceptability was assessed by attrition rate and satisfaction with the game. Participants' experiences with the game were explored qualitatively. Within-subject changes in self-efficacy and readiness for advance care planning (ACP) behaviours were also examined.

RESULTS

The players generally had positive experiences with the game, giving a low attrition rate. A significantly higher level of self-efficacy in sharing end-of-life care preferences with surrogates was reported after the game session (p = 0.008). There was a slight increase in the proportion of players indicated that they would complete ACP behaviours in the coming months immediately after the intervention.

CONCLUSION

A serious game is acceptable by Chinese older adults to raise discussions regarding end-of-life matters.

PRACTICE IMPLICATIONS

A game can be an ice-breaking tool to increase self-efficacy towards communicating end-of-life care preferences with surrogates, but follow-up support is needed to facilitate the uptake of ACP behaviours.

Information disclosure to cancer patients in Mainland China: A meta-analysis

OBJECTIVE

This study aims to systematically examine Chinese cancer patients' and families' preferences for information disclosure to the patient, patient awareness, and predictors of patient awareness.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. Web of Science, Scopus, Proquest, Taylor & Francis Online, and China National Knowledge Infrastructure were searched in April 2022 and Chinese Biomedical Literature Database in July 2022 for quantitative studies. The Mixed Methods Appraisal Tool was used for quality assessment.

RESULTS

A total of 22 studies were included, and the average quality score was 0.65/1. Meta-analyses showed that 89.6% and 81.8% of cancer patients wanted to know their diagnosis and prognosis, respectively. Meanwhile, 50.0% and 32.4% of families prefer diagnosis disclosure and prognosis disclosure to the patient, respectively. Significantly more patients than families favored disclosure to the patient. In reality, only 59.3% of cancer patients know their diagnosis, and 19.9% know their prognosis. For predictors, while patients' gender, cancer type (breast cancer or not), treatment method (operation or other), or complications (yes or no) do not influence diagnosis awareness, being younger, being married, having higher educational attainment, having early-stage rather than late-stage cancer, and being in a higher-grade hospital all predict better chances of knowing a diagnosis. No study explored predictors of patients' prognosis awareness. The findings did not vary according to publication time or sample size.

CONCLUSIONS

Chinese cancer patients are eager to know their diagnosis and prognosis, but families are hesitant about disclosure to the patient, and patients' awareness is low. While cultural, legal, and medical backgrounds lay the foundation for information disclosure in Mainland China, case-by-case practical factors also make a difference.

A dyadic advance care planning intervention for people with early-stage dementia and their family caregivers in a community care setting: a feasibility trial

BACKGROUND

Advance care planning (ACP) is highly relevant for people with early-stage dementia to communicate their care preferences for serious illness conditions with their family caregivers before they become mentally incapacitated.

METHODS

A multi-centre, quasi-experimental study was conducted to test the feasibility and acceptability of a theory-guided, dyadic ACP intervention ('Have a Say' programme) among participants with early-stage dementia-family caregiver dyads. The feasibility of the trial design, intervention procedures, subject recruitment and retention, and study instruments were assessed. Study outcomes were measured at baseline (T0), immediately after the intervention (T1), and at 1 month (T2) and 3 months post-intervention (T3). Acceptability of the intervention was determined by the satisfaction score, completion rate and qualitative interviews as process evaluation with a purposive sample of participants and ACP facilitators. Generalised estimating equations were performed to examine differential changes between groups over time, with covariates adjusted.

RESULTS

Subject recruitment from five elderly community centres yielded a recruitment rate of 60% and resulted in 36 client-caregiver dyads. The intervention was acceptable to the dyads, with a mean satisfaction score of 4.4 out of 5 and completion rate of 94.4%. The attrition rates at T1, T2, and T3 were 8.3%, 13.9%, and 19.4%, respectively. The intervention group reported a significantly greater improvement in the readiness for ACP at T1, self-efficacy for ACP at T3, and dyadic concordance on end-of-life care preferences at all time points than the control group, but not on depressive symptoms. Family caregivers in the intervention group reported a significantly higher caregiving burden at T2 than the control group. The qualitative findings revealed that triadic involvement of and trusting relationships among the dyads and ACP facilitators, and documentation of clients' views are the programme strengths, while the structured format and discussion about medical issues posed implementation challenges.

CONCLUSIONS

This ACP intervention and trial design were feasible and acceptable to the dyads. Several refinements were identified, including adding a nurse-led group-based session for information giving, allowing flexibility in arrangement, and adding measure of ACP engagement of family caregivers. A rigorous trial to test the effects of the ACP intervention is warranted.

TRIAL REGISTRATION

Retrospectively registered on 14/08/2020 at clinicaltrials.gov (Identifier: NCT04513106).

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.

The effect of Chinese culture-adapted dignity therapy on advanced cancer patients receiving chemotherapy in the day oncology unit: A quasi-experimental study

PURPOSE

To examine the effects of Chinese culture-adapted dignity therapy on dignity-related and psychological, spiritual distress and family function for advanced cancer patients receiving chemotherapy in the day oncology unit.

METHOD

This is a quasi-experimental study. Patients were recruited from a day oncology unit at a tertiary cancer hospital in Northern China. A total of 39 patients agreeing to participate were assigned to receive Chinese culture-adapted dignity therapy (intervention group, n = 21) or supportive interview (control group, n = 18) according to their admission time. Patients' dignity-related, psychological, spiritual distress, and family function were assessed at baseline (T0) and after completing the intervention (T1) and the scores were compared between and within the groups. Besides, the interviews were conducted with patients at T1 to obtain their feedback, which were analyzed and integrated with the quantitative results.

RESULTS

There was no statistical significance in all outcomes at T1 between the two groups, as well as in most outcomes between T0 and T1 in the intervention groups except for the relieved dignity-related distress (P = 0.017), especially the physical distress (P = 0.026), and the improved family function (P = 0.005), especially the family adaptability (P = 0.006). The synthesized quantitative and qualitative results showed that the intervention could relieve physical and psychological distress, enhance the sense of dignity, and improve the spiritual well-being and family function of patients.

CONCLUSIONS

The Chinese culture-adapted dignity therapy showed positive effects on the life experiences of patients receiving chemotherapy in the day oncology unit and their family, and it might be a suitable, indirect communication prompt for Chinese families.

Intern nursing students’ perceived barriers to providing end-of-life care for dying cancer patients in a death taboo cultural context: A qualitative study

Objective

Internationally, intern nursing students' experiences with dying patients and death are an area of great concern. However, barriers to providing end-of-life care for dying cancer patients have not been extensively investigated in mainland China, where death remains a taboo issue. Therefore, this study aimed to elucidate intern nursing students' perceived barriers to their performance in providing end-of-life cancer care in the Chinese cultural context.

Methods

This was a descriptive, qualitative study. Twenty-one intern nursing students from three cancer centers in mainland China were interviewed between January 2021 and June 2022. A thematic analysis method was used to analyze the data. The theory of planned behavior was adopted to design the study and identify themes.

Results

A range of barriers related to attitudes, subjective norms, and perceived behavioral control that hindered intern nursing students from acquiring abilities to deal with patient dying and death were identified in the Chinese cultural context.

Conclusions

Chinese intern nursing students encountered many barriers that affected their provision of end-of-life care to dying cancer patients. Strategies to improve their ability to provide appropriate end-of-life care should focus on helping them develop appropriate attitudes toward dying and death and how to overcome subjective norms and behavioral control barriers.

Practitioner accounts of end-of-life communication in Hong Kong, Mainland China and Taiwan: A systematic review

OBJECTIVE

Communication at the end-of-life (EOL) is complex and multidimensional. Although culture is acknowledged as a key influence, there remains a gap in knowledge about intracultural aspects of EOL communication in the Chinese context. This review presents a synthesis of practitioners' accounts of communication at the EOL in Hong Kong, Mainland China and Taiwan.

METHODS

This review was registered prospectively on PROSPERO (CRD42021297052). Five databases were systematically searched using the terms 'communication', 'End-of-Life', 'Hong Kong', 'China' and 'Taiwan'. Empirical research published between 2015 and 2021 was downloaded and appraised. Fifteen articles were included in the review.

RESULTS

Findings highlight the influence of Chinese culture and philosophy, inadequate communication skills training and psychological support for practitioners and legislative and organisational factors.

CONCLUSION

Education and training for practitioners and public education about the EOL needs strengthening. Enhanced understanding of how culture influences EOL communication will strengthen service delivery and enhance awareness in multicultural communities.

PRACTICE IMPLICATIONS

EOL workers need practical and workplace-based support to engage in meaningful communication practices. The influence of culture and the readiness of patients and families to engage in communication are also important considerations.

Cultural impediments to frank communication regarding end-of-life care between older nursing home residents and their family members in Taiwan: a qualitative study

BACKGROUND

When older nursing home residents and their families are faced with end-of-life care decisions in Taiwan, they make them in the context of traditional cultural norms and socioeconomic changes. Both parties (residents and their family members) are often unwilling to broach the topic, leading to a decisional impasse. The aim of this study was to understand difficult-to-raise issues related to end-of-life care by investigating the perspectives of older nursing home residents and their family members.

METHODS

This qualitative descriptive study was conducted using content analysis based on the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to select the participants, and sampling continued until data saturation. Data were collected using semi structured interviews, and related analyses were conducted using an inductive approach.

RESULTS

Ten residents and twelve family members were interviewed individually. Six main themes were identified: (1) the inevitability of a goodbye; (2) a good death; (3) going with or against traditional culture; (4) better a good death than a bad life; (5) abiding by the residents' decisions; and (6) being willing but unable to take care of residents.

CONCLUSION

Nursing home residents and their family members' thoughts on end-of-life care shifted toward the concept of a good death, and they even regarded death as a form of liberation. Health care providers may serve as mediators to counsel a resident and their family members separately, enabling them to speak up and understand each other's thoughts on end-of-life care before a decision is made so that neither party has regrets.

Willingness of patients with cancer pain to participate in end-of-life decisions: a multi-center cross-sectional study from three coastal provinces in southern China

BACKGROUND

Little is known about patients' intention for participation in end-of-life decisions (EOLD) in three coastal provinces in southern China. This study aimed to explore the willingness of patients with cancer pain to participate in EOLD and potential influencing factors.

METHODS

A multi-center cross-sectional study was performed in three coastal provinces in southern China. Two hundred and thirty patients with cancer pain were recruited and consented to fill out the questionnaires. The patients' willingness to participate in EOLD, demographic and disease-related data was surveyed.

RESULTS

In total, 223 patients completed and returned the survey (response rate = 96.95%). One hundred four cases (46.64%) were willing to participate in EOLD. 119 (54.36%) cases not willing to participate in EOLD, respectively. Multivariate logistic regression analysis shows that educational level (OR: 0.683, 95% CI: 0.482-0.966), history of alcoholism (OR: 8.353, 95%CI: 2.535-27.525), Eastern Cooperative Oncology Group (ECOG) score (OR: 0.645, 95% CI: 0.450-0.925) and experience of explosive pain (OR: 6.367, 95% CI: 3.103-13.062) and clinical rescue (OR: 3.844, 95% CI: 1.722-8.577) had significant effects on EOLD intention (P <  0.05). Finally, a predictive model combined above five factors was established, which showed a good discrimination (area under receiver operating characteristic curve: 0.849, 95% CI: 0.796-0.899, P <  0.001) and calibration (Hosmer-Lemeshow Test: Chi-square = 10.103, P = 0.258) for which patients more willing to participate in EOLD.

CONCLUSIONS

The willingness of patients with cancer pain to participate in EOLD is at a modest level in three coastal provinces in southern China. Patients with lower educational level, history of alcoholism, better health status and experience of explosive pain and clinical rescue may be more prone to participate in EOLD.

Factors Influencing Older Adults' End-of-Life Care Preferences

The objective of this study was to explore factors influencing Taiwanese older adults' end-of-life (EOL) care preferences. A cross-sectional questionnaire survey was conducted in 2 geriatric wards of a veterans' hospital. Fifty-five older adults aged 65 years or older were included. Structured questionnaires were used to collect data regarding demographic characteristics, EOL care preferences, stages of change for advance care planning behaviors, and reluctance to burden others. The study revealed that nearly 60% of the participants preferred to let their spouses, adult children, or health care professionals make the decisions. Furthermore, 83.6% of the participants lived with their family members and were moderately to severely disabled with a certain degree of dependence on their family members. Sex, independence, discussion of advance care planning with family members, and completion of advance directives were significantly correlated with EOL care preferences. The regression model showed that the participants' discussion of advance care planning with their family members influenced their EOL care preferences. The results demonstrate that family is an essential consideration for older adults choosing EOL care. Accordingly, because Chinese culture focuses on family harmony, improving communication between older adults and their family members is crucial for promoting advance care planning.

The Effect of Advance Care Planning Intervention on Hospitalization Among Nursing Home Residents: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effect of advance care planning (ACP) interventions on the hospitalization of nursing home residents.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Nursing homes and nursing home residents.

METHODS

A literature search was systematically conducted in 6 electronic databases (Embase, Ovid MEDLINE, Cochrane Library, CINAHL, AgeLine, and the Psychology & Behavioral Sciences Collection), in addition to hand searches and reference list checking; the articles retrieved were those published from 1990 to November 2021. The eligible studies were randomized controlled trials, controlled trials, and pre-post intervention studies describing original data on the effect of ACP on hospitalization of nursing home residents; these studies had to be written in English. Two independent reviewers appraised the quality of the studies and extracted the relevant data using the Joanna Briggs Institute abstraction form and critical appraisal tools. A study protocol was registered in PROSPERO (CRD42022301648).

RESULTS

The initial search yielded 744 studies. Nine studies involving a total of 57,180 residents were included in the review. The findings showed that the ACP reduced the likelihood of hospitalization [relative risk (RR) 0.54, 95% CI 0.47-0.63; I² = 0%)], it had no effect on emergency department (ED) visits (RR 0.60, 95% CI 0.31-1.42; I² = 99), hospice enrollment (RR 0.98, 95% CI 0.88-1.10; I² = 0%), mortality (RR 0.83, 95% CI 0.68-1.00; I² = 4%), and satisfaction with care (standardized mean difference: -0.04, 95% CI -0.14 to -0.06; I² = 0%).

CONCLUSION AND IMPLICATIONS

ACP reduced hospitalizations but did not affect the secondary outcomes, namely, ED visits, hospice enrollment, mortality, and satisfaction with care. These findings suggest that policy makers should support the implementation of ACP programs in nursing homes. More robust studies are needed to determine the effects of ACP on ED visits, hospice enrollment, mortality, and satisfaction with care.

Advance Care Planning Engagement Among Family Members of Community-Dwelling Elderly Patients With Chronic Diseases in China: A Mixed-Methods Study

In China, traditional culture advocates family consensus, and the advance care planning (ACP) engagement of family members is crucial to the implementation of ACP. However, there is still a lack of research on family members' engagement in ACP in mainland China. This study investigated the ACP engagement of family members of community-dwelling elderly patients with chronic diseases and provided evidence for further ACP intervention research. We conducted a mixed-methods sequential explanatory study, 273 family members were surveyed, and semistructured interviews were conducted. Following that, 12 family members were selected after statistical analysis to supplement the quantitative results. The results showed that the ACP engagement of family members of elderly patients with chronic diseases in the community was low, but the self-efficacy was higher. The age of family members, severity, and duration of patients' diseases were the main influencing factors for family members' ACP engagement. Traditional cultural, clinical decision-making mode, lack of understanding of ACP, and factors within the family may impede family members' engagement. This study showed that family-centered ACP practice has significant advantages in China and that future research should focus on the Chinese culture and medical system and highlight the role of families.

Advance Care Planning Preferences in Hong Kong: A Cross-Sectional Study in a Community

(1) Background: Hong Kong is experiencing population aging, but there is little research on advance care planning. This research asks for community-dwelling older adults’ views on advance care planning in order to provide a different angle to the results collected from nursing homes and hospitals. (2) Methods: The targeted respondents were people aged 55 or above. A total of 282 questionnaires were collected using the random sampling method. Respondents were asked whether they would make an advance care plan, whether they would prepare for their death, and whether they had received any death education; they were also given eight statements related to treatments and decision making. (3) Results: The study found that only 17% of the respondents would like to use advance care planning, even after it was explained to them. Advance care planning favorers would be more likely to insist on having wills and would be more likely to trust doctors rather than family members. (4) Conclusions: The results also suggested that the medical care and social support for end-of-life patients should be improved. The results also showed the importance of medical professionals as they showed that respondents wanted advice on end-of-life decision-making from medical professionals.

Advance directives and end-of-life care preferences among adults in Wuhan, China: a cross-sectional study

Background

Little is known about advance directives (ADs) and end-of-life (EOL) care preferences among the general population in Mainland China. This study aimed to describe knowledge and attitudes of ADs and EOL care preferences, and to explore factors related to preferences for ADs among Chinese adults.

Methods

The sample included 1114 adult participants in Wuhan, Mainland China. A brief message including the link to the online survey was sent to local residents who were registered at household registration management centers in Wuhan. The questionnaire included information regarding demographics, self-rated health, views on ADs and EOL care. Bivariate analyses and binary forward logistic regression were conducted to examine factors related to ADs preferences of Chinese adults.

Results

The average age of the sample was 48.0 years and more than half of the sample was female. 81.8% had never heard of ADs, but 86.6% indicated that they might create one after learning what ADs were. 58% would choose hospice care if they were terminally ill whereas 48.7% of the participants wanted to die at home. 92.3% would want to know their diagnosis and prognosis if ill; however, if their family members were diagnosed with an incurable disease, 50.5% would not tell their ill family member the actual diagnosis and prognosis. Those who had heard of ADs (OR = 1.567, p < 0.001), earned an associate’s degree (OR = 2.448, p < 0.001) or a bachelor’s degree or higher (OR = 2.382, p < 0.001), and self-rated their health as very poor/poor (OR = 1.002, p = 0.001) were more likely to be willing to make an AD than their counterparts. However, those who were single (OR = 0.149, p < 0.001) or widowed /divorced/separated (OR = 0.405, p = 0.001) were less likely to be willing to make an AD than the married ones.

Conclusions

Chinese adults showed positive attitudes towards ADs. There is an urgent need to promote more educational initiatives and raise awareness on the importance of ADs. It is important to develop more policies and legislation about ADs to improve the quality of EOL care in Mainland China.

Investor Activity in Chinese Financial Institutions: A Precursor to Economic Sustainability

One requirement for sustainable economic development is established, trusted, and utilized financial institutions to facilitate investment. The rapid development of financial markets in China, combined with the recency and magnitude of middle-class wealth, has resulted in a rapidly changing investment landscape, as well as changes in people’s investing activities. The extent to which economic growth is sustainable will depend, at least in part, on how financial institutions are perceived, as well as the extent to which they are utilized. The objective of this study was to examine the investment behaviors of individual investors as a way to ascertain the perceived level of trust and stability in the relatively recently developed financial institutions. The influence of market information acquisition on asset allocation and value investment in China was analyzed. This study used secondary data from a China securities corporation from previous research. The analyses utilized the general decision-making style test to assess respondents’ decision-making models and quantitative research methodology culminating in the use of correlation analysis. The results indicated that the acquisition of market information had a positive correlation with the number of assets and investment portfolios. Practical implications and suggestions for future research are provided. The results may be of interest to individual and institutional investors in China, as well as those with an interest in current trends in market information acquisition, asset allocation, and value investment in China.

How Acculturation Influences Attitudes about Advance Care Planning and End-of-Life Care among Chinese Living in Taiwan, Hong Kong, Singapore, and Australia

Background: Understanding attitudes towards life and death issues in different cultures is critical in end-of-life care and the uptake of advance care planning (ACP) in different countries. However, existing research suffers from a lack of cross-cultural comparisons among countries. By conducting this comparative study, we hope to achieve a clear understanding of the linkages and differences among healthcare cultures in different Chinese societies, which may serve as a reference for promoting ACP by considering cultural differences. Methods: Our researchers recruited Chinese adults who could communicate in Mandarin and lived in metropolitan areas in Taiwan, Hong Kong, Singapore, and Australia. Focus group interviews were conducted, and the interview contents were recorded and subjected to thematic analysis. Results: Between June and July 2017, 14 focus groups with 111 participants were conducted in four regions. With traditional Chinese attitudes towards death as a taboo, many participants felt it would be challenging to discuss ACP with elderly family members. Most participants also desire to avoid suffering for the self and family members. Although the four regions’ participants shared a similar Chinese cultural context, significant regional differences were found in the occasions at which participants would engage in end-of-life discussions and select settings for end-of-life care. By contrast, participants from Singapore and Australia exhibited more open attitudes. Most participants from Taiwan and Hong Kong showed a preference for end-of-life care at a hospital. Conclusions: The developmental experiences of ACP in Western countries, which place a strong emphasis on individual autonomy, cannot be directly applied to family-centric Asian ones. Healthcare professionals in Asian societies should make continuous efforts to communicate patient status to patients and their family members to ensure family involvement in decision-making processes.

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 for older people in mainland China: An integrative literature review

BACKGROUND

Recently, the attempts to promote advance care planning (ACP) and advance directives (ADs) have appeared in mainland China. However, anecdotal evidence suggests that the concept of ACP and ADs is not widely known to the public and healthcare professionals.

AIM

To examine and synthesise currently available research about ACP and ADs for older people in mainland China, and to discuss implications for future nursing practice and research.

DESIGN

An integrative literature review.

METHODS

A systematic search was conducted in seven English electronic databases (CINAHL, MEDLINE, ProQuest, Cochrane, JBI, Scopus and Wiley) and four Chinese electronic databases (CNKI, Wanfang, VIP and CBM). Eligible articles were critically appraised using the Mixed Methods Appraisal Tool (MMAT).

FINDINGS

From various groups including older people, families and healthcare professionals, low levels of knowledge and awareness about ACP and ADs are reported. Demographic characteristics such as age, gender, education and clinical conditions were related to positive or negative attitude towards ACP. The main reason people cited for being 'reluctant/fairly reluctant' to make an AD was that they were 'Not familiar with it'.

CONCLUSIONS

Given that older people showed positive attitudes towards ACP, policy support and practice guidelines about ADs and ACP are necessary to respect their wishes and to guide healthcare professionals in mainland China.

Cultural implications for disclosure of diagnosis and prognosis toward terminally ill cancer patients in China: A literature review

OBJECTIVE

Health professionals in China tend to avoid open communication with terminally ill cancer patients concerning their diagnosis and prognosis. This review aims to explore Chinese cultural beliefs and attitudes concerning disclosure and death among health professionals and cancer patients in China and to investigate preferences of terminally ill cancer patients for a "good death."

METHOD

A narrative literature review was conducted in May 2020 on MEDLINE, EMBASE, and WEB OF SCIENCE to include all studies with clear study design which presented its own study data or referred to data within underlying studies, published between January 2000 and May 2020, having cancer patients and/or healthcare professionals as participants, conducted in Mainland China, Hong Kong, or Taiwan and containing relevant data concerning "medical disclosure" or "good death." Quality assessment of publications was conducted using the NIH and CASP checklists.

RESULTS

Primary database search revealed a total of 108 papers of which 9 were ultimately included. The additional hand search led to the inclusion of eight further papers. In total, there were 11 quantitative studies, 4 qualitative studies and 2 literature reviews included in this review. Our findings indicated that most terminally ill cancer patients in China want to know the truth about their diagnosis and prognosis and preferred to be informed by their doctors. Terminally ill cancer patients valued a good relationship with family and medical staff as well as being respected as an individual and wanted to be able to prepare for death.

SIGNIFICANCE OF RESULTS

Terminally ill cancer patients in China often have a substantial need for information about their condition while their preferences are widely consistent with those in Western societies. Training for health professionals needs to focus on communication skills in order to overcome barriers in patient interaction.

Exploratory Study Comparing End-of-Life Care Intensity between Chinese American and White Advanced Cancer Patients at an American Tertiary Medical Center

Background: Understanding ethnic disparities in end-of-life care (EOLC) intensity is central to improving outcomes for diverse populations. Although Chinese Americans represent one of the fastest growing ethnic groups in the United States, little is known about their EOLC intensity.

Objective: To explore differences in indicators of high-intensity EOLC in the final 30 days of life, place of death, and hospice utilization between Chinese American and White advanced cancer patients.

Methods: In this exploratory review, we collected data on 48 Chinese American and 48 White stage IV solid tumor patients who died during 2013–2018. Indicators of high-intensity care from the final 30 days of life included ≥2 hospital, ≥1 intensive care unit (ICU), and/or ≥2 emergency department admissions; cardiopulmonary resuscitation administration and mechanical ventilation (MV); place of death; and whether patients were on hospice at death.

Results: Among Chinese American and White patients, respectively, 49% and 36% died in the hospital, 15% and 7% died in the ICU, 17% and 8% received MV, and 6% and 13% had ≥1 hospital admission lasting >14 days. Seventeen percent of Chinese American and 43% of White patients died at home. Hospice enrollment was similar between groups. Seventeen percent of Chinese American and 8% of White patients died within 30 days of diagnosis.

Conclusion: Results suggest that fewer Chinese Americans died at home, whereas more died in the ICU, received MV, and died within 30 days of cancer diagnosis, indicating possible disparities in EOLC. Further studies are needed to explore findings from this exploratory investigation.

Attitude Toward Family Involvement in End-of-Life Care Among Older Chinese Americans: How Do Family Relationships Matter?

Family involvement is critical to end-of-life (EOL) care among older adults. This study aims to examine the association and pathways between family relationships and older Chinese Americans' attitude toward family involvement in EOL care discussions. Data were collected from 260 Chinese Americans aged 55 years and above. Structural equation modeling was used to examine the total and indirect effects of family relationships on attitude toward family involvement in discussing EOL care plans. Family relationships had a significant positive total effect on attitude toward family involvement in EOL care. Indirect effects of family relationships on attitude toward family involvement in EOL care through self-efficacy, perceived benefits, and perceived barriers of discussing EOL care with family members were all significant. Findings provide empirical evidence of how family relationships affect older Chinese Americans' attitude toward family involvement in EOL care and underline the need for family-centered EOL interventions for this population.

A research agenda for ageing in China in the 21st century (2nd edition): Focusing on basic and translational research, long-term care, policy and social networks

One of the key issues facing public healthcare is the global trend of an increasingly ageing society which continues to present policy makers and caregivers with formidable healthcare and socio-economic challenges. Ageing is the primary contributor to a broad spectrum of chronic disorders all associated with a lower quality of life in the elderly. In 2019, the Chinese population constituted 18 % of the world population, with 164.5 million Chinese citizens aged 65 and above (65+), and 26 million aged 80 or above (80+). China has become an ageing society, and as it continues to age it will continue to exacerbate the burden borne by current family and public healthcare systems. Major healthcare challenges involved with caring for the elderly in China include the management of chronic non-communicable diseases (CNCDs), physical frailty, neurodegenerative diseases, cardiovascular diseases, with emerging challenges such as providing sufficient dental care, combating the rising prevalence of sexually transmitted diseases among nursing home communities, providing support for increased incidences of immune diseases, and the growing necessity to provide palliative care for the elderly. At the governmental level, it is necessary to make long-term strategic plans to respond to the pressures of an ageing society, especially to establish a nationwide, affordable, annual health check system to facilitate early diagnosis and provide access to affordable treatments. China has begun work on several activities to address these issues including the recent completion of the of the Ten-year Health-Care Reform project, the implementation of the Healthy China 2030 Action Plan, and the opening of the National Clinical Research Center for Geriatric Disorders. There are also societal challenges, namely the shift from an extended family system in which the younger provide home care for their elderly family members, to the current trend in which young people are increasingly migrating towards major cities for work, increasing reliance on nursing homes to compensate, especially following the outcomes of the 'one child policy' and the 'empty-nest elderly' phenomenon. At the individual level, it is important to provide avenues for people to seek and improve their own knowledge of health and disease, to encourage them to seek medical check-ups to prevent/manage illness, and to find ways to promote modifiable health-related behaviors (social activity, exercise, healthy diets, reasonable diet supplements) to enable healthier, happier, longer, and more productive lives in the elderly. Finally, at the technological or treatment level, there is a focus on modern technologies to counteract the negative effects of ageing. Researchers are striving to produce drugs that can mimic the effects of 'exercising more, eating less', while other anti-ageing molecules from molecular gerontologists could help to improve 'healthspan' in the elderly. Machine learning, 'Big Data', and other novel technologies can also be used to monitor disease patterns at the population level and may be used to inform policy design in the future. Collectively, synergies across disciplines on policies, geriatric care, drug development, personal awareness, the use of big data, machine learning and personalized medicine will transform China into a country that enables the most for its elderly, maximizing and celebrating their longevity in the coming decades. This is the 2nd edition of the review paper (Fang EF et al., Ageing Re. Rev. 2015).

Discussion of Advance Care Planning on end of life decisions with lung cancer patients in Wuhan China: Attitude, Timing, and Future Directions

Background

Progress in advance care planning (ACP) in China has been hindered for decades compared with other countries.

Aims

To describe knowledge of ACP, end‐of‐life (EOL) care preferences and the predictors of patients' preference for ACP, as well as who should mention ACP among Chinese lung cancer patients.

Methods

Questionnaire‐based interviews were carried out. Two hundred and fifty‐eight lung cancer patients were recruited when first admitted to Tongji Hospital from October 2017 to November 2018. Social‐demographic factors, which might influence patients' preference on ACP decisions and who should mention ACP, were evaluated using multivariate logistic regression analysis.

Results

A total of 91.1% (n = 235) of patients favoured ACP on EOL issues. One hundred and sixty (60%) patients wanted to make EOL decisions on their own. Only 10% of patients were familiar with advance directions. Eighty‐two (31.8%) patients were familiar with do not resuscitate/do not intubate (DNR/DNI) directions. ACP was not mentioned in 92.2% of patients. Gender (male, OR = 4.87 (2.16–5.83)), tumour stage (Stage III, OR = 0.108 (0.06–0.51); Stage IV, OR = 1.780 (1.02–2.11)) and number of children (every increase in the number of children, OR = 0.267 (0.09–0.93)) were the significant predictors of preference for autonomous ACP. Female patients and patients currently receiving treatment are 2.743 and 1.8 times, respectively, more willing to need ACP initiated by doctors.

Conclusions

Chinese patients showed preferences towards ACP, but with inadequate knowledge. More assistance is needed with ACP for those patients, especially for females, patients with one child and those with early stage lung cancer. For female patients and patients receiving treatment, doctors may initiate ACP dialogue first.

Association of advance care planning with place of death and utilisation of life-sustaining treatments in deceased patients at Taipei City Hospital in Taiwan

OBJECTIVE

Evidence is mixed regarding the impact of advance care planning (ACP) on place of death. This cohort study investigated the effect of ACP programmes on place of death and utilisation of life-sustaining treatments for patients during end-of-life (EOL) care.

METHODS

This prospective cohort study identified deceased patients between 2015 and 2016 at Taipei City Hospital. ACP was determined by patients' medical records and defined as a process to discuss patients' preferences with respect to EOL treatments and place of death. Place of death included hospital or home death. Stepwise logistic regression determined the association of ACP with place of death and utilisation of life-sustaining treatments during EOL care.

RESULTS

Of the 3196 deceased patients, the overall mean age was 78.6 years, and 46.5% of the subjects had an ACP communication with healthcare providers before death. During the study follow-up period, 166 individuals died at home, including 98 (6.59%) patients with ACP and 68 (3.98%) patients without ACP. After adjusting for sociodemographic factors and comorbidities, patients with ACP were more likely to die at home during EOL care (adjusted OR (AOR)=1.71, 95% CI 1.24 to 2.35). Moreover, patients with ACP were less likely to receive cardiopulmonary resuscitation (AOR 0.36, 95% CI 0.25 to 0.51) as well as intubation and mechanical ventilation support (AOR 0.54, 95% CI 0.44 to 0.67) during the last 3 months of life.

CONCLUSION

Patients with ACP were more likely to die at home and less likely to receive life-sustaining treatments during EOL care.

Disparities in end-of-life care, expenditures, and place of death by health insurance among cancer patients in China: a population-based, retrospective study

Background

Disparities in the utilization, expenditures, and quality of care by insurance types have been well documented. Such comparisons have yet to be investigated in end-of-life (EOL) settings in China, where public insurance covers over 95% of the Chinese population. This study examined the associations between health insurance and EOL care in the last six months of life: outpatient visits, emergency department (ED) visits, inpatient services, intensive care unit (ICU) admissions, expenditures, and place of death among the cancer patients.

Methods

A total of 398 patients diagnosed with cancer who survived more than 6 months after diagnosis and died from July 2015 to June 2017 in urban Yichang, China, were included. Descriptive analysis and multivariate regression models were used to investigate the bivariate and independent associations, respectively, between health insurance with EOL healthcare utilization, expenditures and place of death.

Results

Urban Employee Basic Medical Insurance (UEBMI) beneficiaries visited EDs more frequently than Urban Resident-based Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS) beneficiaries (marginal effects [95% Confidence Interval]: 2.15 [1.81–2.48] and 1.92 [1.59–2.26], respectively). NRCMS and UEBMI beneficiaries had more hospitalizations than URBMI beneficiaries (1.01 [0.38–1.64] and 0.71 [0.20–1.22], respectively). Compared to URBMI beneficiaries, NRCMS beneficiaries and UEBMI beneficiaries had ¥15,722 and ¥43,241 higher expenditures. Similarly, UEBMI beneficiaries were most likely to die in hospitals, followed by NRCMS (UEBMI vs. NRCMS: 0.23 [0.11–0.36]) and URBMI (UEBMI vs. URBMI: 0.67 [0.57–0.78]) beneficiaries.

Conclusions

The disproportionately lower utilization of EOL care among NRCMS and URBMI beneficiaries, compared to UEBMI beneficiaries, raised concerns regarding quality of EOL care and financial burdens of NRCMS and URBMI beneficiaries. Purposive hospice care intervention might be warranted to address EOL care for these beneficiaries in China.

Measuring Self-Efficacy and Readiness for Advance Care Planning in Chinese Older Adults

CONTEXT

Self-efficacy and readiness for advance care planning (ACP) is underresearched in the Chinese population given that these are novel concepts in the culture.

OBJECTIVES

To translate the self-efficacy and readiness subscales of the ACP Engagement Scale into Chinese using the Brislin's Model and test its psychometric properties in Chinese older adults.

METHODS

Content validity and face validity were established based on the views of a group of experts and older adults. Then, a survey was conducted with a convenience sample of 204 community-dwelling older adults. Convergent validity was evaluated using Pearson's correlation coefficients with the SURE test, a decisional conflict scale. The scores between older adults who had hospitalization experience in the previous year and those who did not have were compared to examine discriminant validity.

RESULTS

The findings showed that the Chinese subscales had good internal consistency (Cronbach's α 0.94-0.97) and acceptable one-week test-retest reliability (intraclass correlation coefficient 0.66-0.70). There was a significantly high correlation between the self-efficacy and the readiness subscales (r = 0.809; P < 0.01) and moderate correlation between the two subscales and the SURE test (r = 0.509-0.587; P < 0.01). Discriminant validity was supported by significant differences between older adults who had hospitalization experience in the last year and those who did not have (P < 0.05).

CONCLUSION

The Chinese readiness and self-efficacy subscales of the ACP Engagement Survey are valid and reliable tools for assessing the preparedness of the Chinese older adults for ACP.

Effects of a Death Education Intervention for Older People with Chronic Disease and Family Caregivers: A Quasi-Experimental Study

PURPOSE

To investigate the effectiveness of a structured death education program for older adults with chronic illness and their family caregivers.

METHODS

This study adopted two-group, nonrandomized quasi-experimental design. Patient-caregiver dyads in the intervention group (N = 40 dyads) engaged in the death education program at the bedside once a week for 5 weeks, and were compared with participants (N = 40 dyads) in the control group who received usual health education. The program consisted of five sessions based on the Interaction Model of Client Health Behavior. Death attitude, death competence, well-being, family function, and satisfaction were measured at baseline (T0), immediately after the intervention (T1), and 1 month later (T2). Data collection was conducted from July 30, 2019, to December 30, 2019.

RESULTS

The intention-to-treat analysis The intention-to-treat analysis of between groups at 1-month follow-up revealed that the intervention group had greater decreases in the fear of death (p=.002, 95% CI -2.53, -0.47; p<.001, 95% CI -3.61, -1.65) and death avoidance (p<.001, 95% CI -3.46, -1.84; p<.001, 95% CI -3.89, -2.43), had greater increases in the neutral acceptance (p=.032, 95% CI 0.05, 1.38; p<.001, 95% CI 0.99, 2.56) and death competence (p<.001, 95% CI 4.10, 8.01; p<.001, 95% CI 7.80, 12.11) in patients and caregivers, respectively. There were significant intergroup differences over time for patient well-being of (p<.001, 95% CI 3.06, 9.74) and satisfaction of (p<.001, 95% CI 2.01, 4.59). Results were consistent with the results from the sensitivity analysis.

CONCLUSION

This study demonstrated the feasibility and benefits of death education in hospitals and provided an implementation plan for nursing professionals. Nurses should consider providing death education for older adults with chronic diseases and their families to promote the development of palliative care and the quality of end-of-life.

Advance Care Planning and Decision-Making in a Home-Based Primary Care Service in a Canadian Urban Centre

Background

Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future, and has been shown to reduce hospital-based interventions at the end of life. Our goal was to describe the current state of ACP in a home-based primary care program for frail homebound older people in Vancouver, Canada. We did this by identifying four key elements that should be essential to ACP in this program: frailty stage, documentation of substitute decision-makers, and decision-making with regard to both resuscitation (i.e., do not resuscitate (DNR)) and hospitalization (i.e., do not hospitalize (DNH)). While these elements are an important part of the ACP process, they are often excluded from common practice.

Methods

This was a cross-sectional, observational study of data abstracted from 200 randomly selected patient electronic medical records between July 1 and September 30, 2017. We describe the association between demographic characteristics, comorbidities, and four key elements of ACP documentation and decision-making as documented in the clinical record using bivariate comparison, a logistic regression model and multiple logistic regression analysis.

Results

In 73% (n=146) of the patient records, there was no explicit documentation of frailty stage. Sixty-four per cent had documentation of a substitute decision-maker. Of those who had their preferences documented, 90.6% (n=144/159) indicated a preference for DNR, and 23.6% (n=29/123) indicated a preference for DNH. In multiple regression modeling, a diagnosis of dementia and older age were associated with documentation of a DNR preference, adjusted odds ratio (AOR) = 4.79 (95% CI 1.37, 16.71) and AOR = 1.14 (95% CI 1.05, 1.24), respectively. Older age, male sex, and English identified as the main language spoken were associated with a DNH preference. AOR = 1.17 (95% CI 1.06, 1.28), AOR = 4.19 (95% CI 1.41, 12.42), and AOR = 3.42 (95% CI 1.14, 10.20), respectively.

Conclusions

Clinician documentation of some elements of ACP, such as identification of a substitute decision-maker and resuscitation status, have been widely adopted, while other elements that should be considered essential components of ACP, such as frailty staging and preferences around hospitalization, are infrequent and provide an opportunity for practice improvement initiatives. The significant association between language and ACP decisions suggests an important role for supporting cross-cultural fluency in the ACP process.

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.

Dealing With Death Taboo: Discussion of Do-Not-Resuscitate Directives With Chinese Patients With Noncancer Life-Limiting Illnesses

BACKGROUND

Noncancer patients with life-limiting diseases often receive more intensive level of care in their final days of life, with more cardiopulmonary resuscitation performed and less do-not-resuscitate (DNR) orders in place. Nevertheless, death is still often a taboo across Chinese culture, and ethnic disparities could negatively affect DNR directives completion rates.

OBJECTIVES

We aim to explore whether Chinese noncancer patients are willing to sign their own DNR directives in a palliative specialist clinic, under a multidisciplinary team approach.

DESIGN

Retrospective chart review of all noncancer patients with life-limiting diseases referred to palliative specialist clinic at a tertiary hospital in Hong Kong over a 4-year period.

RESULTS

Over the study period, a total of 566 noncancer patients were seen, 119 of them completed their own DNR directives. Patients had a mean age of 74.9. Top 3 diagnoses were chronic renal failure (37%), congestive heart failure (16%), and motor neuron disease (11%). Forty-two percent of patients signed their DNR directives at first clinic attendance. Most Chinese patients (76.5%) invited family caregivers at DNR decision-making, especially for female gender (84.4% vs 69.1%; P = .047) and older (age >75) age group (86.2% vs 66.7%; P = .012). Of the 40 deceased patients, median time from signed directives to death was 5 months. Vast majority (95%) had their DNR directives being honored.

CONCLUSION

Health-care workers should be sensitive toward the cultural influence during advance care planning. Role of family for ethnic Chinese remains crucial and professionals should respect this family oriented decision-making.