How Acculturation Influences Attitudes About Advance Care Planning and End-of-life Care Among Chinese Living in Taiwan, Hong Kong, Singapore, and Australia

Abstract

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.

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

“…Compared to the sparse studies undertaken in geographical locations such as Australia, 32,45 Singapore, 29,39,46 and Malaysia, 35 thirteen of the retrieved studies were conducted in the United States 30,31,33,34,37,38,[40][41][42]44,47,49,52 where the authors recognized the underpinning legal, financial, and policy frameworks supporting engagement with advance care planning. This is echoed in an international qualitative study by Chiang et al 36 undertaken with Chinese diasporas located across Taiwan, Hong Kong, Singapore, and Australia which reported significant regional variances in participants' understanding and experience of advance care planning that were attributed to the legal, financial, and policy frameworks in different regions and the culture of westernization.…”

“…A total of 27 studies comprised twelve qualitative studies, 18,[27][28][29][30][31][32][33][34][35][36][37] fourteen quantitative [38][39][40][41][42][43][44][45][46][47][48][49][50][51] and one mixed-method study. 52 Qualitative research design used a combination of in-depth interviews, 18,28,29,[32][33][34][35]37 focus groups, 18,27,30,31,36 and informal field observation. 34 Quantitative studies adopted cross-sectional, [38][39][40][41][42][43][44] longitudinal 45 and non-randomized experimental designs.…”

“…While studies were internationally spread they mainly represented the United States (n = 18), 27,30,31,33,34,37,38,[40][41][42][43][44][47][48][49][50][51][52] followed by Singapore (n = 4), 18,29,39,46 Australia (n = 2), 32,45 Canada (n = 1), 28 Malaysia (n = 1) 35 and cross-country included Taiwan, Hong Kong, Singapore, and Australia (n = 1). 36 No studies were undertaken in the UK. 3566 participants were included within the 27 papers, of whom 378 were patients, 39 caregivers of people with life-limiting conditions, and 40 were healthcare professionals.…”

“…Two different but overlapping main themes were identified which reflect Chinese diaspora engagement with advance care planning; namely, awareness and knowledge were identified in 10 studies, 18,[30][31][32]39,41,45,47,50,51 and engagement with advance care planning in 20 studies. [29][30][31][32][33][34][35][36][37][38][39][40][41][42][44][45][46][47]49,52 Theme 1: Awareness and Knowledge Ten studies 18,[30][31][32]39,41,45,47,50,51 reported on the levels of awareness and knowledge regarding advance care planning among Chinese diasporas. Combined findings indicate levels of advance care planning ranged from low 18,[30][31][32]39,41,45,…”

“…Of the 27 papers, 20 [29][30][31][32][33][34][35][36][37][38][39][40][41][42][44][45][46][47]49,52 reported on the levels of engagement among Chinese diasporas and found low levels regardless of socio-demographic factors. 30,38,39,41,42,45,47,49 However, geographical location of the studies, where the legal, cultural, and social system acted as a catalyst, had a significant bearing on engagement with advance care planning.…”