A Family-Oriented Confucian Approach to Advance Directives in End-of-Life Decision Making for Incompetent Elderly Patients

Terminally Ill Cancer Patients' Concordance Between Preferred Life-Sustaining Treatment States in Their Last Six Months of Life and Received Life-Sustaining Treatment States in Their Last Month: An Observational Study

“…22 In western cultures, individual autonomy is highly valued, including at EOL. 33 By contrast, in a Confucian doctrineeinfluenced society such as Taiwan, where family power is strongly exercised in medical care decision making, including EOL care, 34 Taiwanese families have the authority to make medical decisions on behalf of terminally ill relatives even when they are physically capable or consciously competent. 35 Respecting patients' autonomy in Asian countries is further impeded by physicians' infrequently disclosing prognosis to cancer patients 35,36 and EOL care seldom being discussed between patients and their families.…”

A Decade of Changes in Family Caregivers' Preferences for Life-Sustaining Treatments for Terminally Ill Cancer Patients at End of Life in the Context of a Family-Oriented Society

“…Taiwanese people feel culturally obliged to provide every possible means, especially nourishment, to keep a parent (patient) ''alive'' at EOL. 26,48 This obligation reflects the most fundamental moral duty in Confucianism, as outlined in the Xiao Jing (Book of Filial Duty), of caring for one's aging/ill parents to repay for the life they bestowed and their gracious care when the adult children were young. 48 Fulfilling one's filial duty is a step toward personal integrity and perfection of the self, whereas ignoring filial duty is considered a serious sin worthy of social blame and punishment.…”

“…48 Fulfilling one's filial duty is a step toward personal integrity and perfection of the self, whereas ignoring filial duty is considered a serious sin worthy of social blame and punishment. 26,48 Providing food, hydration, and nutrition is recognized by Taiwanese people as necessary not only to stave off physical deterioration, but also for humanistic EOL care by not abandoning dying patients and honoring filial piety 49,50 because a person who dies hungry is believed to become a ''starving soul'' or ''hungry ghost/spirit'' in hell. 49 However, the Xiao Jing also advises that children should respectfully care for their elderly parents not only by nourishing their physical bodies, but also by preserving their human dignity.…”

“…25 Taiwanese families have the authority 12 to make medical decisions on behalf of their members even for physically capable or consciously competent patients. 26 This policy intentionally avoids emotionally harming dying patients by forcing them to confront their poor prognosis and forthcoming death.…”

Family-Oriented Informed Consent

“…11 Perhaps, as Wenqing Zhao (2014), argues, it would be beneficial to turn to the family as a whole to help assure proper medical decision-making. Moreover, as Yaning Yang (2014), argues, familybased accounts of advanced directives would likely benefit the elderly. For insights into the situation in Taiwan see Lee (2014b, pp.…”