Attitudes and Beliefs Toward Advance Care Planning Among Underserved Chinese-American Immigrants

Life-Sustaining Treatment and Advance Care Documentation among Chinese American ICU Decedents

CONTEXT

Despite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings.

OBJECTIVES

To compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents.

METHODS

In this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis.

RESULTS

We identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99-3.40) and DNI completion (OR 1.81; 95%CI, 1.07-1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55-1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03-41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%).

CONCLUSIONS

During terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.

Attitudes of the Portuguese population towards advance directives: an online survey

BACKGROUND

Advance directives (ADs) were implemented in Portugal in 2012. Although more than a decade has passed since Law 25/2012 came into force, Portuguese people have very low levels of adherence. In this context, this study aimed to identify and analyse the attitudes of people aged 18 or older living in Portugal towards ADs and to determine the relationships between sociodemographic variables (gender/marital status/religion/level of education/residence/whether they were a health professional/whether they had already drawn up a living will) and people's attitudes towards ADs.

METHODS

An online cross-sectional analytical study was conducted using a convenience sample. For this purpose, a request (email) that publicized the link to a -form-which included sociodemographic data and the General Public Attitudes Toward Advance Care Directives (GPATACD) scale-was sent to 28 higher education institutions and 30 senior universities, covering all of mainland Portugal and the islands (Azores and Madeira). The data were collected between January and February 2023.

RESULTS

A total of 950 adults from completed the online form. The lower scores (mean 1 and 2) obtained in most responses by applying the GPATACD scale show that the sample of the Portuguese population has a very positive attitude towards ADs. The data showed that women, agnostics/atheists, health professionals and those who had already made a living will had more positive attitudes (p < 0.001) towards ADs. There were no statistically significant differences in the attitudes of the Portuguese population sample towards ADs in relation to marital status, education level, and residence.

CONCLUSION

The results obtained enable us to confirm that this sample of the Portuguese population has a positive attitude towards ADs. We verify that there are certain fringes of this sample with certain sociodemographic characteristics (women, agnostics/atheists, health professionals and those who had already made a living will) that have a more positive attitude towards ADs. This data could facilitate the implementation and adjustment of relevant measures, particularly in the field of health education and aimed at groups with less favourable attitudes, to increase the effectiveness of voluntary exercise of citizens' autonomy in end-of-life care planning.

Advance Directives in Portugal: A Qualitative Survey

(1) Background: Advance directives (ADs) in Portugal have been legalized since 2012. What has been observed over time, from the few studies carried out, is that despite the positive attitudes in the population, there is a low level of adherence to ADs. To try to understand the reasons for these data, the current study aimed to explore and describe the experiences of the Portuguese population regarding AD. (2) Methods: For this exploratory and descriptive qualitative study, the researchers conducted open (unstructured) interviews with a convenience sample aged over 18 years until data saturation was achieved. (3) Results: A total of fifteen interviews were conducted-eight with women and seven with men. The following four categories emerged from the content analysis of the interviews: (1) AD literacy, (2) AD relevance, (3) AD attitudes, and (4) conditionalities for compiling the ADs. (4) Conclusions: The study pointed out the good receptivity of the participants to the ADs; however, literacy on this subject was low, and identifying the conditionalities in the development of ADs could contribute to improvements in implementation in the population. The data from this study suggest the need to implement measures to increase the literacy of the Portuguese population on ADs and review the legal framework for improving the accessibility of the citizen population. There is also a need to continue researching and obtain more evidence about the ways in which the Portuguese population perceives ADs; thus, in this way, a society can better respond to its citizens' right to freely exercise their prospective autonomy at the end of their lives.

A Systematic Review of Non-Seriously Ill Community-Dwelling Asians' Views on Advance Care Planning

OBJECTIVES

To systematically synthesize the views of community-dwelling Asians on Advance care planning and to summarize the factors and reasons affecting their uptake of ACP.

DESIGN

Mixed-methods systematic review (PROSPERO: CRD42018091033).

SETTING AND PARTICIPANTS

Asian adults (≥18 years old) living in the community globally.

METHODS

Medline (Ovid), Web of Science, CINAHL (EBSCO), Open Grey, and Google Scholar were searched from inception to June 30, 2022. Qualitative, quantitative, or mixed-methods studies reporting on the views of non-seriously ill community-dwelling Asian adults on ACP or the factors influencing their ACP uptake were included. Secondary research, studies not published in English, or studies not available as full text were excluded. Two independent teams of researchers extracted data, assessed methodologic quality, and performed the data analysis. Data analysis was conducted using the multistep convergent integrated approach based on Joanna Briggs Institute methodology for mixed-methods systematic review.

RESULTS

Fifty-eight studies were included. Non-seriously ill community-dwelling Asians were willing to engage in ACP (46.5%-84.4%) although their awareness (3.1%-42.9%) and uptake of ACP remained low (14.0%-53.4%). Background factors (sociodemographic factors, and health status, as well as experience and exposure to information) and underlying beliefs (attitude toward ACP, subjective norm, and perceived behavioral control) were found to affect their uptake of ACP. A conceptual framework was developed to facilitate a proper approach to ACP for this population.

CONCLUSIONS AND IMPLICATIONS

A flexible approach toward ACP is needed for non-seriously ill community-dwelling Asians. There is also a need to raise end-of-life and ACP literacy, and to explore ways to narrow the gap in the expectations and implementation of ACP so that trust in its effective execution can be built.

Medical Travel for Immigrant Patients With Cancer-Returning Home

This Viewpoint describes motivations for and barriers to travel to the country of origin among immigrant patients with cancer and recommends strategies to address these motivations and barriers.

Perceptions, Attitudes, and Knowledge toward Advance Directives: A Scoping Review

(1) Background: Advance directives are an expression of a person's autonomy regarding end-of-life care. Several studies have shown that the level of completion in countries where advance directives are legalised is low. To better understand this phenomenon, it is important to know the perceptions, attitudes, and knowledge that the population has about this instrument. The aim of this article was to explore a population's perceptions and/or attitudes and/or knowledge toward advance directives. (2) Methods: A search was conducted in March 2023 in the ISI Web of Knowledge, Scopus, and PubMed databases using the following keywords: "advance care directives", "advance care planning", "perceptions", "attitudes", and "knowledge". Two hundred and twenty-four (224) articles were identified, and thirteen (13) were included for analysis. (3) Results: The selected articles point to a low level of knowledge toward advance directives: they recognise a strong positive attitude of the population toward the implementation of advance directives but a low level of achievement. (4) Conclusions: Studies on perceptions/attitudes/knowledge toward advance directives are important to understand the real needs of the population regarding this issue and to implement more adequate and effective promotion and dissemination measures.

The role of acculturation in the process of advance care planning among Chinese immigrants: A narrative systematic review

BACKGROUND

Acculturation is the process of two different cultures coming into contact. It is unclear how acculturation influences Chinese immigrants' engagement in advance care planning due to the complexity and multifaceted nature of both acculturation and advance care planning.

AIMS

To synthesize evidence regarding the role of Chinese immigrants' acculturation in their engagement in advance care planning.

DESIGN

Systematic mixed-method review, registered in PROSPERO (CRD42021231822).

DATA SOURCES

EMBASE, MEDLINE, Web of Science, and Google Scholar were searched for publications until January 21, 2021.

RESULTS

Twenty-one out of 1112 identified articles were included in the analysis. Of those 21 articles, 17 had a qualitative design and 13 originated from the United States. Three of four quantitative studies reported that higher acculturation levels were associated with better knowledge or higher rate of engagement in advance care planning. Analysis of qualitative studies showed that Chinese immigrants' engagement in advance care planning was associated with their: (1) self-perceived cultural identity (native or non-native); (2) interpretation of filial piety (traditional or modern); and (3) interpretation of autonomy (individual or familial). To facilitate their engagement, Chinese immigrants prefer an implicit approach, non-family-related initiators, contextualization advance care planning in Chinese culture and using Chinese language.

CONCLUSION

Chinese immigrants' willingness to engage in advance care planning varied with their acculturation level. To engage them in advance care planning, we recommend adapting the introduction of advance care planning to address people's perceptions of their cultural identity, filial piety, and autonomy, as well as their preference for certain approach, initiator, context, and language.

Experiences of Medical Interpreters During Palliative Care Encounters With Limited English Proficiency Patients: A Qualitative Study

Background: There are many challenges in communication and cultural barriers for patients with limited English proficiency (LEP) who suffer from serious illnesses. Palliative care utilization among this population remains limited and the experiences of medical interpreters during palliative care encounters remain understudied. Methods: We conducted semistructured video interviews with interpreters working at an academic medical center. Interview questions explored interpreters' observations and experiences during palliative care encounters with LEP patients. We performed thematic analysis of the interview contents. Results: Our study included 20 interpreters who interpret in 9 languages with a mean experience of 16.3 years. We identified four themes from the interviews that shed light on the challenges of incorporating palliative care into the care of patients with LEP: (1) lack of a verbatim interpretation for the term "palliative care," (2) poor patient understanding of their treatment goals, (3) suboptimal timing of palliative care involvement, and (4) fears and misconceptions related to palliative care. Owing to challenges in word choice, the timing of palliative care involvement, and poor understanding of palliative care, interpreters observed that many patients with LEP declined palliative care involvement in their treatment plan. Conclusions: In this study, we identified several actionable barriers interpreters noted to incorporating palliative care into care of patients with LEP. Interventions directed toward providing LEP patients with standardized culturally appropriate information on palliative care are needed.

The Association of Chinese Ethnicity and Language Preference with Advance Directive Completion Among Older Patients in an Integrated Health System

BACKGROUND

Little is known about possible differences in advance directive completion (ADC) based on ethnicity and language preference among Chinese Americans on a regional level.

OBJECTIVE

To understand the association of ethnicity and language preference with ADC among Chinese Americans.

DESIGN

Retrospective cohort analysis with direct standardization.

PARTICIPANTS

A total of 31,498 Chinese and 502,991 non-Hispanic White members enrolled in Kaiser Permanente Northern California during the entire study period between 2013 and 2017 who were 55 or older as of January 1, 2018.

MAIN MEASURES

We compared the proportion of ADC among non-Hispanic White and Chinese patients, and also analyzed the rates according to language preference within the Chinese population. We calculated ADC rates with direct standardization using covariates previously found in literature to be significant predictors of ADC such as age and utilization.

KEY RESULTS

Among Chinese members, 60% preferred English, 16% preferred another language without needing an interpreter, and 23% needed an interpreter. After standardizing for age and utilization, non-Hispanic Whites were more than twice as likely to have ADC as Chinese members (20.6% (95% confidence interval (CI): 20.5-20.7%) vs. 10.0% (95% CI: 9.6-10.3%), respectively). Among Chinese members, there was an inverse association between preference for a language other than English and ADC (13.3% (95% CI: 12.8-13.8%) if preferring English, 6.1% (95% CI: 5.4-6.7%) if preferring non-English language but not needing an interpreter, and 5.1% (95% CI: 4.6-5.6%) if preferring non-English language and needing an interpreter).

CONCLUSIONS

Chinese members are less likely to have ADC relative to non-Hispanic White members, and those preferring a language other than English are most affected. Further studies can assess reasons for lower ADC among Chinese members, differences in other Asian American populations, and interventions to reduce differences among Chinese members especially among those preferring a language other than English.

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 decisional balance, attitudes, and practice behaviors, its predicting factors, and related experiences of advance care planning in Taiwanese patients with advanced cancer

Background

Patients with advanced cancer are prone to experience burdensome physical, psychological, and financial consequences. Healthcare providers may not fully appreciate advanced cancer patients’ medical care autonomy, such as at that emboded by Advance Care Planning (ACP), and by doing so may compromise their quality of end-of-life (EOL). Hence, it is essential for healthcare providers to effectively assess and communicate with patients’ regarding their medical decisions before their patients are incapacitated by their disease progression. The purpose of this investigation was to describe the decisional balance, attitudes, and practice behaviors of ACP and its predictors of ACP-related experiences in Taiwanese patients with advanced cancer.

Methods

This cross-sectional, descriptive study employed a mixed-methodsquantitative and qualitative design with a sample of 166 patients that were purposely recruited from in-patient oncology units at a regional teaching hospital in southern Taiwan. Study data consisted of patient replies to a 34-item self-report tool, Decisional Balance, Attitudes, Practice Behaviors of ACP (DAP-ACP) and 4 semi-structured questions.

Result

Findings indicated that, in general, study participants exhibited favorable ACP-decisional balance and positive ACP-attitudes & practice behaviors. The results also indicated that gender, educational level, and cancer diagnosis were associated with significant differences on the “ACP-decisional balance” and “ACP-attitudes” scales. In addition, our findings documented that the participants’ gender and educational level were significant predictors of both ACP-decisional balance and ACP-attitudes. Furthermore the participants’ ACP-practice behaviors were predicted by ACP-decisional balance, but not with their ACP-attitudes. The qualitative analysis of the semi-structured questions identified six themes in responses to current medical decision making (e.g., compliance with physician instructions, family engagement in treatment decision-making); and eight themes pertaining to future ACP-related concerns were identified (e.g., family conflict, effectiveness of time-limited trials).

Conclusion

To promote patients’ engagement in ACP, the healthcare professional need to assess and advocate patients’ concerns or attitudes regarding ACP in a timely manner. In addition, factors or concerns that might influence patients’ responses to ACP derived from both the quantitative and qualitative findings of this current study need to be considered especially in initiating the dialogue regarding ACP with patients with advanced cancer.

Trial registration

No. CYCH 2,019,072, Date of registration 5 Dec 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01073-5.

Knowledge, attitudes, and behavioral intentions of elderly individuals regarding advance care planning: Questionnaire development and testing

Background

Studies have indicated that the advance care planning knowledge and attitudes of elderly individuals strongly affect their implementation of advance care planning. A measurement with a theoretical base for evaluating elderly individuals’ knowledge, attitudes, and behavioral intentions regarding advance care planning is lacking.

Objectives

To develop a questionnaire and understand elderly individuals’ knowledge, attitudes, and behavioral intentions regarding implementing advance care planning.

Methods

A cross-sectional questionnaire survey was conducted. The content validity index, and statistical methods, including discrimination, factor, and reliability analysis, were adopted for psychometric testing. Descriptive statistics mainly presented data analysis.

Results

401 elderly individuals were recruited from a medical center and one senior activity center. The content validity index was approximately 0.71–0.92 for the developed questionnaires, the Kuder–Richardson formula 20 was 0.84 for advance care planning knowledge, and the Cronbach’s alpha was 0.86, 0.94, 0.76, and 0.92 for attitudes, behavioral intentions, influencing factors, and subjective norms, respectively. The average score for advance care planning knowledge for elderly individuals was 4.42, with a correct answer rate of 49.1%. They lacked knowledge of advance care planning-related legislation. The mean score for attitudes and behavioral intentions was 14.32 and 3.48, respectively. Elderly individuals agreed that advance care planning has benefits but were worried about the emotional distress caused by advance care planning discussions. Elderly individuals with positive behavioral intentions tend to implement advance care planning. Spouses, children, doctors, and nurses are significant reference people for elderly individuals.

Conclusions

The developed questionnaire exhibits good validity and reliability for understanding elderly individuals’ knowledge, attitudes, and behavioral intentions concerning advance care planning. Advance care planning materials or decision aids suitable for elderly individuals must be developed to increase their understanding of advance care planning. Additionally, the role of nurses is indispensable in promoting advance care planning among elderly individuals.

Lessons learned from a social worker's approach to advance care planning discussions with Chinese-immigrant oncology outpatients

PURPOSE

To examine Chinese-immigrant cancer patients' openness to advance care planning (ACP) in an outpatient oncology setting.

DESIGN

Retrospective review of social work assessment data.

SAMPLE

150 Chinese-immigrant patient charts were reviewed (55% Cantonese, 45% Mandarin).

METHODS

Data were summarized descriptively and with logistic regression analyses.

FINDINGS

Sixteen percent of patients had completed ACP prior to meeting with the oncology social worker (OSW). Twenty percent of patients agreed to complete a health care proxy (HCP) after receiving culturally-tailored education in their language of origin from the OSW, while 75% remained open to ongoing consideration of ACP and HCP completion.

CONCLUSIONS

This study illuminates how Chinese immigrants engage in ACP discussions in an oncology setting.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDER

OSWs can play an integral role in advocating, educating, and intervening with this population and can assist the interdisciplinary team in understanding the importance of the cultural differences, even if the OSW's primary language differs from that of a patient's.

Modeling and analysis of Chinese culture and communication

Along with many other Asian countries, China's communication differs from, and at times, conflicts with, the United States, which is considered more collectivist and low-contact than that of the United States. The topic of the chapter is mental, physical, and behavioral health. This ancient society is one of the world's oldest, with a history spanning many thousand years. These aspects of Chinese culture have significant weight in the Chinese community and society. Chinese participants care deeply about the cultural context, whether social scientists, humanists, or clinical psychiatrists. Based on several studies, Chinese culture influences various aspects of health, including physical and mental well-being, parent-child interactions and social connections, goals for individuals and groups, and health care delivery models. According to research on the subject, traditional Confucian cultural norms have influenced Chinese communication features. To maintain harmonious ties, the Chinese rely heavily on indirect communication. For them, the way you stand, your attitude, and even the tone of your voice all communicate a lot more than just words. They use imprecise language and may understate the significance of what they say. For the MA-CCC model, a brand-new approach has been presented. As long as this Confucian-influenced Chinese communication style persists, it will significantly impact Chinese society and communication between Chinese professionals and their western counterparts. However, the frequency of attachment terms was lower in Chinese literature; the findings showed a rising tendency for AC (affectionate communication) in recent decades. In addition, the frequency of love terms in Chinese novels was linked positively to individuality. As a result of societal shifts, affection sharing becomes more common in individualistic metropolitan settings, as these findings showa performance of 94.2% enhancement.

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.

Development and Pilot Test of a Culturally Relevant Toolkit to Enhance Advance Care Planning With Chinese American Patients

BACKGROUND

First-generation Chinese American patients have low engagement in advance care planning (ACP). Among the causes may be clinician uncertainty about traditional cultural values.

AIM

Based on a survey identifying barriers to ACP among older ethnic Chinese American patients, we created a toolkit to support clinicians in culturally relevant ACP practices and conducted a pilot test to evaluate usability, acceptability, and preliminary outcomes.

DESIGN/SETTING/PARTICIPANTS

The toolkit includes culturally relevant information and an ACP guideline with a prompt list of questions. Six clinicians (three physicians, two nurse practitioners, and one physician assistant) in two New York City-based practices piloted the toolkit through discussions with 66 patients.

RESULTS

Patients' age averaged 70.2 years (SD=12.4); 56.1% were women. Almost two-thirds had not finished high school and 53.0% spoke only Cantonese. More than three-quarters (78.8%) did not understand the purpose of ACP before the discussion. During the discussion, 58 patients (87.9%) completed a new proxy naming a health care agent, 21 (31.8%) requested a nonhospital DNR order, and two (3%) completed a living will. Topics discussed included treatment preferences (discussed with 80.3% of patients); health care values (77.3%); treatment decisions (72.7%); goals of care (68.2%), and hospice (1.5%). Five of the six clinicians expressed satisfaction ("very" or "somewhat") with the toolkit, four were "very" comfortable using it, and three stated that it helped them "a lot" with effective discussions.

CONCLUSIONS

An ACP toolkit may facilitate culturally relevant ACP discussions by increasing clinician competency and patient engagement. Further studies of this approach are needed.

Evaluation of a Large Scale Advance Care Planning Co-Design Education Program for Chinese-Speaking People in Australia

BACKGROUND

Advance care planning (ACP) is important, however ethnic minorities have half the completion rates in the United States compared to Caucasian counterparts, and in Australia only 3.5% of advance directives were completed by those overseas-born.Educational intervention improves ACP knowledge and subsequent uptake. We evaluated immediate and longer-term outcomes of a co-designed ACP education toolkit in Chinese-speaking people in Victoria, Australia.

METHODS

We conducted a cross-sectional survey of Chinese-speaking community members who participated in a co-designed Chinese ACP educational workshop. A self-selected subgroup were subsequently contacted 6 months later to determine longer-term outcomes.

RESULTS

Of 519 attendees across 17 workshops, 325 (63%) completed the evaluation. The majority (63%;n = 206) were previously unaware of ACP. Perception of receipt of useful information positively correlated with motivation to undertake ACP (r = 0.3486, p < 0.001). Of the 70 participants who consented to follow up, 36% (n = 26) agreed to participate in structured telephone interviews. English speakers were more likely to have undertaken ACP (n = 6 vs n = 3). ACP completion was not associated with being a carer or suffering from cancer or chronic illness.

CONCLUSIONS

This first Australian study evaluating ACP co-design education implementation outcomes in Chinese-speaking people supports that motivation to undertake ACP is related to knowledge, albeit a modest ACP uptake in a small follow up sample. Clinicians should note that this assists with ACP uptake, with likely downstream improved health outcomes. This co-designed toolkit could be helpful in increasing ACP uptake. Future engagement by Chinese language societies to overcome further barriers to ACP is needed.

Heart to Heart Cards: A Novel, Culturally Tailored, Community-Based Advance Care Planning Tool for Chinese Americans

CONTEXT

A paucity of literature describes the growing Chinese American community's end-of-life (EOL) priorities and preferences.

OBJECTIVE

Develop a culturally-tailored advance care planning (ACP) tool to understand the EOL preferences of this underserved minority group.

METHODS

Informed by the Cultural Appropriateness Theory, the Chinese American Coalition for Compassionate Care (CACCC) developed Heart to Heart (HTH) Cards using a 3-step approach. First, CACCC created and refined a list of bilingual, culturally relevant EOL issues. Next, CACCC organized the EOL issues into a card deck. Finally, CACCC developed a unique playstyle of the cards-the HTH Café. From 2014-2019, CACCC recruited Chinese American volunteers and participants for HTH Cafés. Following each Café, participants completed an anonymous survey describing their sociodemographics, top 3 cards, and café evaluation.

RESULTS

The 54 HTH Cards were organized into 4 suits (spiritual, physical, financial/legal, and social). Each card displayed a culturally-tailored EOL issue in English and Chinese. Playstyles included one-on-one and group formats (ie. HTH Café). CACCC volunteers conducted 316 HTH Cafés for 2,267 Chinese American adults. Most participants were female (61.6%), between 18-50 years old (56.7%), lived in California (80.2%) and born in Asia (74.3%). The top priority (25.5%) was "If I'm going to die anyway, I don't want to be kept alive by machines." Participants thought the session was pleasant (99.5%) and expressed intent to complete advance directives (86.5%).

CONCLUSION

HTH Cards represents the first, theory-driven, culturally-tailored ACP tool for Chinese Americans. More research is needed to establish its impact on ACP conversations and outcomes.