Engaging Chinese-Americans in Advance Care Planning: A Pilot Study

Purpose:

Implement a culturally sensitive seminar to engage community-dwelling Chinese Americans in advance care planning (ACP). The aims of the study were to examine the effectiveness of a culturally sensitive ACP seminar on (1) Advance directive (AD) knowledge and (2) engagement of Chinese Americans in ACP and AD completion.Advance care planning is the process through which individuals consider the types of medical treatments and decisions they would want if they were no longer able to speak for themselves.¹ Advance directives, an element of ACP, allow individuals to document their treatment preferences when they are no longer able to speak for themselves.² In the United States (US), overall AD completion is approximately 18-36%. This rate is even lower in ethnic minority groups including Asian Americans.³ Identified barriers to ACP and AD completion are lack of knowledge about ACP and AD^4-5 and cultural values. Minority groups, including the Chinese Americans, were found to have significantly less ACP knowledge and were less engaged in ACP.³ Chinese culture embraces collectivism and a family-centered approach to decision-making; autonomy, a central principle in the ACP process, is not highly valued in Chinese culture.⁶ In the US, the Chinese American population is quickly increasing, thus emphasizing the need for ACP engagement in this population.⁷

Methods:

This study was a quasi-experimental, repeated-measures, pre-test, post-test design. After institutional review board approval, a convenience sample of community-dwelling Chinese Americans was recruited. A culturally sensitive bilingual (English and Mandarin) educational seminar on ACP and AD was conducted. The nurse-led seminar included an overview of the ACP process, definitions of terms commonly used on ADs, and a step-by-step guide to completing an AD. Participants were asked to complete a background survey, the Advance Directive Knowledge Survey (ADKS), and the Advance Directive Questionnaire (ADQ) before and after the seminar. Data were collected immediately before (time 1), immediately after (time 2) and one month after (time 3) the seminar.  Data were analyzed using SPSS version 19.0.  Descriptive statistics were used to describe sample characteristics, AD knowledge scores, AD completion rates, and engagement in ACP conversations with family and loved ones. Pearson correlations and Chi-square tests were used to explore the relationship between demographic variables and engagement in ACP. Inferential statistics were used to examine the effectiveness of the seminar on AD knowledge and engagement in ACP.

Results:

The sample size was 72.  We had a 99% (n= 71) response rate at time 1, a 100% (n= 72) response rate at time 2, and an 88% (n= 63) response rate at time 3. Participant age ranged from 32 to 87 with mean age of 61 years (SD = 12.2). The majority of participants were female (63.9%, n=46) and were born in China (65.3%, n= 47). Many participants (44.44%, n=32) were college educated. Prior to the seminar (time 1), mean knowledge scores, as assessed by the ADKS, were 7.11(SD = 1.98).  Immediately after the seminar (time 2) knowledge scores increased to 9.20(SD = 1.07), and at one-month follow-up (time 3), they were about the same at 9.22 (SD = 1.17).  When comparing time 1 and time 2 ADKS scores, there was a significant increase in mean knowledge scores [t (70) = -8.380, p < 0.000]. Advance directive completion and ACP discussions were significantly higher one month (time 3) after the seminar as compared to pre-seminar (time 1) [t (49) = -3.5, p = 0.01] and [t (37) = -5.187, p = 0.000] respectively. Several variables were significantly related to ACP at time 3. Age was positively related to AD completion and ACP discussions (r =.397, p=0.001; r=.295, p=0.019). Sex was related to ACP discussion only (χ² =4.67, p=.031).

Conclusion:

It is feasible to conduct a nurse-led educational seminar on ACP in a community-dwelling population of Chinese. Chinese in this study were open to the topic and showed a willingness to learn about ACP. This study supported previous research that found age and female gender was positively related to engagement in ACP.⁸ Research is needed to examine the reasons for differences in AD completion and ACP discussions. This culturally sensitive educational seminar significantly increased participants’ AD knowledge. Knowledge levels remained high 1 month after attending the seminar. Participants’ engagement in ACP significantly increased after the seminar as evidenced by reported AD completion rates and ACP discussions on the time 3 follow up survey. Our results have global implications for the importance of developing culturally sensitive nurse-led educational interventions.  Future research could incorporate similar models to improve the ACP engagement in different cultural and ethnic groups.