Improving Patient Preparedness and Confidence in Discussing Advance Directives for End-of-Life Care with Health Care Providers in the United States and Japan

Abstract

Background The low completion rate of advance directives (ADs) has received attention in Japan and the United States, as policy makers and health care professionals face aging populations with multiple comorbidities. Among the barriers to AD planning, cultural values and attitudes appear to be particularly influential. A comparison of culturally distinct societies provides a deeper understanding of these barriers. Through such an approach, this study identifies strategies for increasing AD planning among late-middle-age Japanese and US individuals. Methods After giving informed consent for the Institutional Review Board–approved study, Japanese and US respondents (45–65 y; 50% female) without ADs completed a language-appropriate online survey. Participants were asked to review a decision aid as part of a scenario-based physician consultation regarding artificial nutrition and hydration (ANH). Hypotheses were analyzed using multigroup structural equation modeling. Results Important similarities were identified across the 2 groups. After reviewing the decision aid, both samples strongly preferred “no ANH.” Respondents who strongly valued either self-reliance or interpersonal relationships experienced greater preparedness for AD planning. In both countries, greater decision preparedness and positive death attitude predicted greater confidence to discuss care options with a provider. Finally, cultural values predicted preference for family participation: respondents with a strong interdependent self-concept desired more family involvement, whereas high independents preferred less. Conclusions Findings indicate the importance of documenting care preferences and accounting for individual differences. To increase AD adoption, providers should identify patient segments likely to benefit most from the interventions. Targeting individuals in both countries who value self-reliance and interpersonal relationships appears to be a good place to begin. Such individuals can be identified clinically through administration of validated measures used in this study.

Geographic variation in inpatient medical expenditure among older adults aged 75 years and above in Japan: a three-level multilevel analysis of nationwide data

“…However, in the context of Japan, where the surplus of psychiatric and chronic care beds seems to be a key driver for prolonging hospitalisation and increasing IMEP75, spending on outpatient care may contribute little to reducing IMEP75. Furthermore, while more primary care visits in the preceding year is linked to reduced end-of-life hospital utilisation and costs in the US (44), the low adoption of advance directives in Japan may be associated with avoidable emergency transfers and hospital admissions (45)(46)(47).…”

Improving health service design and delivery for men: does gender targeting matter?

“…Health-care research also suggests that interdependent and independent self-construal may be made salient by the decision aid experience (Alden et al, 2014;Friend and Alden, 2021).…”

“…As part of the scenario, respondents were presented with the possible harms and benefits of each treatment option followed by patient narratives and a value clarification exercise. Scenario design followed similar vignette-based research on treatment decision-making (Friend and Alden, 2021). Due to their ability to increase both internal and external validity in experimental designs, vignettes are widely used in health-care research (Evans et al, 2015;Sheringham et al, 2021).…”

“…Therefore, it is important that transformative health service interventions match patients' value cocreation practice styles (McColl-Kennedy et al, 2012). Health-care providers should consider implementing a two-step framework that involves targeting men with health communications that fit their preferred communication styles and, then, tailoring decision aid content to individual-level differences (Alden et al, 2014), such as selfconstrual type (Friend and Alden, 2021) and/or masculine traits (McGraw et al, 2024). For example, providers could determine the patient's self-construal type prior to the consultation from a brief survey linked to the electronic medical record system.…”

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record

“…Dunn et al [6] found that only 26% of patients older than 65 years undergoing surgery for hip fractures had advanced care planning documents uploaded into their EMR. Although factors associated with engaging in endof-life care planning such as higher income, higher levels of education, and having strong interpersonal relationships have been established [9,13,14,25,26,29], to the best of our knowledge, the association of patient demographics and economic well-being on the presence of advanced care planning documents in the EMR for patients older than 65 years undergoing repair of a hip fracture has not been explored. Additionally, the research by Dunn et al [6] was a single-institution study, so further study is warranted to explore the generalizability of their results.…”