Perspectives of Elderly People on Advance Directives in Japan

Assessing family function: older adults vs. care nurses: a cross-sectional comparative study

BACKGROUND

This study aimed to assess family function in home care for older adults. Understanding family dynamics is essential for providing quality care to older adults choosing to age in place.

METHODS

In a cross-sectional study, 53 patients aged 65 or older receiving home care were evaluated, along with four home care nurses. The General Function of Family Assessment Device (FAD-GF) was used for self-assessment to examine family resources.

RESULTS

Only 5.7% of older adults reported good family function. Strong correlations were found between assessments by nurses and older adults. Among the six aspects of family function, "problem solving," "communication," "affective responsiveness," and the overall results showed no disparities between the evaluations of older adults and nurses.

CONCLUSIONS

Home care nurses can effectively assess family function using the FAD-GF, particularly after six months of care. This assessment can help identify family issues and enhance home care quality through nurse training in FAD-GF application.

The Characteristics of Withdrawal or Withholding of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Single Japanese Institutional Study

OBJECTIVES

There is little evidence on the factors influencing the decision to withdraw or continue life-sustaining treatment in the setting of severe traumatic brain injury in Japanese institutions. We investigated the factors associated with the withdrawal or withholding of life-sustaining treatment (WLST) for severe traumatic brain injury at a single Japanese institution.

METHODS

A total of 161 patients with severe traumatic brain injury were retrospectively reviewed. Patient characteristics and injury types were compared between patients with and without the WLST.

RESULTS

Of the 161 patients, 87 (54%) died and 52 (32%) decided to undergo WLST. In 98% of the WLST cases, the decision was made within 24 h of admission. The mean duration between WLST and death was 2 days. The predicted probabilities for mortality and unfavorable outcomes were highest in patients with WLST within 24 h. Patients with WLST were older and had a higher frequency of falls on the ground, ischemic heart disease, and acute subdural hemorrhage than those without WLST.

CONCLUSIONS

The decisions of almost all WLST cases were made within 24 h of admission for severe traumatic brain injury in a Japanese institution because of Japanese patients' religious and cultural backgrounds.

Factors associated with preferred place of death among older adults: a qualitative interview study in Tama City, Tokyo, Japan

OBJECTIVES

To analyse the cognitive processes involved in the decision-making of older adults who are not in the end-of-life stage regarding the selection of a preferred place of death.

DESIGN

A qualitative cross-sectional study based on semistructured in-depth interviews. The interview scripts were sectioned by context, then summarised, conceptualised and categorised. Post-categorisation, the relationships between the conceptual factors were examined.

SETTING

Tama City, Tokyo, Japan, from November 2015 to March 2016.

PARTICIPANTS

20 long-term care users and their families or care providers were interviewed about their preferred places of death and the factors behind their decisions.

RESULTS

Three categories based on the preferred place of end-of-life care and death were extracted from the interview transcripts: (A) discouraging the decision of a preferred place of death, (B) enhancing the desire for home death and (C) enhancing the desire for a hospital/long-term care facility death. Category A consists of concerns about the caregiver's health, anxiety about solitary death, and constraints of and concerns about the household budget. Both categories B and C consist of subcategories of reinforcing and inhibiting factors of whether to desire a home death or a hospital/long-term care facility death. If their previous experiences with care at home, a hospital or a care facility were positive, they preferred the death in the same setting. If those experiences were negative, they tend to avoid the death in the same setting.

CONCLUSIONS

One's mindset and decision regarding a preferred place of death include the consideration of economic factors, concerns for caregivers, and experiences of care at home or in a hospital/long-term care facility. Furthermore, health professionals need to be aware of the ambivalence of senior citizens to support their end-of-life decisions.

Important Factors Influencing Willingness to Participate in Advance Care Planning among Outpatients: A Pilot Study in Central Taiwan

Advance care planning (ACP) and advance directives (ADs) ensure patient autonomy in end-of life care. The number of ADs made and followed in Taiwan is still lacking. This study aimed to determine the factors that influence the willingness to participate in ACP among outpatients in Taiwan. In this study, we conducted a cross-sectional survey based on convenient sampling methods. The questionnaire included questions about participants' basic sociodemographic information, knowledge of ACP, and awareness of ACP. A total of 198 adults who were outpatients of a family medicine clinic in an affiliated hospital in Taiwan were recruited. The associations between each variable were evaluated using the χ2 test. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the logistic regression method to examine the influence of each variable on willingness to participate in ACP. Being happy and being a healthcare professional were positively correlated with ACP participation. A lack of ACP knowledge (OR = 0.30 in model A and OR = 0.42 in model C), valuing "Reducing families' end-of-life decision-making burden" (OR = 2.53 in model B and OR = 2.65 in model C), and a "Belief in a good death" (OR = 4.02 in model B and OR = 4.10 in Model C) were the main factors affecting subjects' willingness to participate in ACP. Knowing which factors influence willingness to participate in ACP helps in the promotion of ACP. Continuously educating both the general public and healthcare professionals strengthens knowledge about the right to autonomy, about its associated laws, and about the ACP process, and thus, programs should be created to provide this education. Additionally, taking into account the differences between cultures can be helpful.

End-of-life decision making in critical illness: Perspectives of Asian parents

OBJECTIVE

To explore parents' perspectives regarding end-of-life (EOL) decisions, factors and possible barriers that influence the EOL decision making process, and to understand parental preferences for communication about EOL care in an Asian population.

METHOD

A prospective questionnaire cohort study conducted in a university-based tertiary care hospital. 30 parents of children who had been admitted to general pediatric wards for acute ailments and/or were being followed up in general pediatric outpatient clinics after inpatient admissions or emergency department visits completed 30 interviewer-administered questionnaires. With the first 10 completed questionnaires, we sought feedback on the design of the four case vignettes and related questions. Responses to specific questions related to each case vignette were rated on a Likert scale.

RESULTS

The majority of parents were able to comprehend and identify with the issues in the case vignettes, which allowed them to respond appropriately. Parents tended to avoid active withdrawal or withholding of life-sustaining treatment. The top three priorities for parents making EOL decisions for their children were: the chance of improvement, the presence of pain or discomfort, and information provided by healthcare staff. Parents reported that they would prefer to know immediately if their child is at risk of dying; they also preferred to get as much information as possible from the healthcare team and thought that meeting with the healthcare team before making EOL decisions was pivotal.

SIGNIFICANCE OF RESULTS

Parents place highest priorities on their child's likelihood of improvement, perception of their child's pain, and information provided by healthcare professionals in making EOL decisions.

Experience as an Informal Caregiver and Discussions Regarding Advance Care Planning in Japan

CONTEXT

Advance care planning (ACP) is vital for end-of-life care management. Experiences as informal family caregivers might act as a catalyst to promote ACP.

OBJECTIVES

We investigated the association between ACP discussions and caregiving experiences.

METHODS

A nationwide survey in Japan was conducted in December 2016 using a quota sampling method to select a sample representative of the general Japanese population. The responses of 3167 individuals aged 20-84 years (mean age: 50.9 ± 16.8) were analyzed. The outcome was measured by asking if respondents had ever engaged in ACP discussions. The exposure was measured by asking whether and for how long respondents had experience as informal caregivers for family members. We analyzed informal caregiving experience related to the occurrence of ACP discussions using multivariable logistic regression models that adjusted for possible covariates.

RESULTS

Respondents with informal caregiving experience had significantly higher odds of having ACP discussions than those without caregiving experience (adjusted odds ratio: 1.93, 95% CI = 1.63, 2.29). Stronger effects were identified in younger adults (aged 20-65 years) and those with a higher education level (education duration > 12 years) than in older adults (aged ≥65 years) and those with a lower education level, respectively.

CONCLUSION

Experiences as informal caregivers for family members may facilitate ACP discussions among Japanese adults, especially younger adults with higher educational attainment. Our findings may help health-care providers screen those at risk for inadequate ACP discussions, and informal caregiving experience should be considered when health-care providers initiate discussions of end-of-life care.

Association between direct interpersonal involvement with a dying family member and discussions regarding advance care planning among Japanese older adults

AIM

There is growing recognition of the need to hold advance care planning discussions. Older adults who have direct interpersonal involvement with dying family members might begin to consider their own end-of-life care. This study examined the associations between experiences of being with a dying family member and advance care planning discussions among Japanese older adults.

METHODS

This study examined data from a previous self-administered questionnaire survey carried out among outpatients aged ≥65 years. All participants were visitors of a community hospital in Japan, with data being collected over a 1-week period in July 2016. The main exposure was experiences of being with dying family members, while the outcome was advance care planning discussions with the family members and/or their physician. We analyzed the associations between experiences of being with dying family members and advance care planning discussions through log-binomial regression models adjusted for possible sociodemographic confounders.

RESULTS

Of the 302 respondents included for analysis, 96 (32%) had experiences of being with dying family members, while 179 (59%) held advance care planning discussions. Respondents with said experiences were more likely to have discussions than those without experiences (fully adjusted prevalence ratio 1.31, 95% confidence interval 1.04-1.65). Subgroup analyses showed no significant interaction effects between experiences of being with dying family members and the covariates.

CONCLUSIONS

Direct interpersonal involvement with dying family members might facilitate advance care planning discussions among Japanese older adults. Our results should help healthcare providers recognize individuals who are unlikely to have discussions. Geriatr Gerontol Int 2021; 21: 197-202.

Advance care planning and advance directive awareness among East Asian older adults: Japan, Hong Kong and South Korea

AIM

Population aging is a global phenomenon, and East Asian countries are no exception. However, the use of advance care planning (ACP) and advance directives (ADs) are not widespread in East Asia. This study aimed to examine the awareness of ACP/ADs and its related factors among community-dwelling older persons in Japan, Hong Kong and South Korea.

METHODS

This was a cross-sectional, cross-cultural questionnaire conducted among a convenience sample of community-dwelling persons. The questionnaire included information regarding awareness of ACP/ADs and personal information. Multiple logistic regression was used assess relationships between awareness of ACP/ADs and potential related factors.

RESULTS

The sample consisted of 404 community-dwelling older adults: 174 (43.0%) from Japan, 132 (32.7%) from Hong Kong and 98 (24.3%) from South Korea. In total, 122 participants (30.2%) had heard of ACP/ADs. Multiple logistic regression analysis revealed that an educational level >12 years was significantly associated with increased ACP/ADs awareness (adjusted odds ratio [AOR]: 2.19, 95% confidence interval (CI): 1.18-4.07, P = 0.01). The rate of those who have heard of ACP/ADs was significantly higher among Japanese than South Koreans were (AOR: 4.54, 95% CI: 1.64-12.58, P < 0.01), those from Hong Kong than South Korea (AOR: 5.15, 95% CI 1.89-14.0, P < 0.01) after some variables with significant differences among the three countries were controlled.

CONCLUSIONS

In particular, support tailored to the targets' educational levels will be required. It is also suggested that support is needed to enhance awareness of ACP/ADs in East Asia, although there is a difference in degree of awareness among the three countries. Geriatr Gerontol Int 2021; 21: 71-76.

Patients' preferences and factors influencing initial advance care planning discussions' timing: A cross-cultural mixed-methods study

BACKGROUND

Although advance care planning discussions are increasingly accepted worldwide, their ideal timing is uncertain and cultural factors may pertain.

AIM

To evaluate timing and factors affecting initiation of advance care planning discussions for adult patients in Japan and Taiwan.

DESIGN

Mixed-methods questionnaire survey to quantitatively determine percentages of patients willing to initiate advance care planning discussions at four stages of illness trajectory ranging from healthy to undeniably ill, and to identify qualitative perceptions underlying preferred timing.

SETTING/PARTICIPANTS

Patients aged 40-75 years visiting outpatient departments at four Japanese and two Taiwanese hospitals were randomly recruited.

RESULTS

Overall (of 700 respondents), 72% (of 365) in Japan and 84% (of 335) in Taiwan (p < 0.001) accepted discussion before illness. In Japan, factors associated with willingness before illness were younger age and rejection of life-sustaining treatments; in Taiwan, older age, stronger social support, and rejection of life-sustaining treatments. Four main categories of attitudes were extracted: the most common welcomed discussion as a wise precaution, responses in this first category outnumbered preference for postponement of discussion until imminent end of life, acceptance of the universal inevitability of death, and preference for discussion at healthcare providers' initiative.

CONCLUSION

The majority of patients are willing to begin discussion before their health is severely compromised; about one out of five patients are unwilling to begin until clearly facing death. To promote advance care planning, healthcare providers must be mindful of patients' preferences and factors associated with acceptance and reluctance to initiate advance care planning.

Prevalence and related factors of depression and falls among the elderly living in rural communities of Guangzhou

Few studies have concentrated on the prevalence and related factors of depression and falls among the elderly living in rural communities of Guangzhou. A total of 335 participants aged ≥60 years were recruited by simple random sampling method. A structural equation model was applied to determine interrelationships between depression, falls and other variables. As high as 27.5% and 23.3% participants had reported depressive symptoms and falls, respectively. The path analysis showed the total effect (β = -0.58) of depression on quality of life (QOL) consisted of a direct effect (β = -0.51) and an indirect effect (β = -0.07), which was mediated by family function and number of falls, and the R ² was 0.36. The model fit indices were χ ² /df = 1.096, P > 0.05, Root Mean Square Error of Approximation (RMSEA) = 0.017, Tucker-Lewis Index (TLI) = 0.998 and Comparative Fit Index (CFI) = 0.999. Depression and falls were prevalent among the elderly living in rural communities of Guangzhou city. Pay attention to strengthen family function and prevent falls may prevent depression and improve the QOL among the elderly.

Rebuilding and guiding a care community: A grounded theory of end-of-life nursing care practice in long-term care settings

AIMS

To investigate the end-of-life (EOL) nursing care practice process in long-term care (LTC) settings for older adults in Japan.

DESIGN

A qualitative study based on grounded theory developed by Corbin and Strauss.

METHODS

Sampling, interviewing, and analysis were performed cyclically, with results for each stage used as the basis for data collection and next-stage analysis decisions. Semi-structured interviews were conducted from March 2015-March 2019 with 22 nurses from eight LTC settings. Analysis was performed using coding, constant comparison, and emerging categories.

RESULTS

The core category, "guiding the rebuilt care community to assist the dying resident" comprised five categories: "assessing the resident's stage," "harmonizing care with the dying process," "rebuilding a care community," "helping community members care for the resident," and "encouraging community members to give meaning." The participants were described as "traditional village elders" who were the integral members of the care community, as well as guides who helped and encouraged the community.

CONCLUSION

Results revealed the holistic process of EOL nursing-care practice in Japan. Nurses aimed to allow LTC residents to die as social human beings, surrounded by people, and not just responding physical and psychological distress. Such practice requires nursing expertise, healthcare skills, and leadership qualities to build and serve care communities. Nurses must also consider residents' uncertainties and vulnerabilities as well as their cultural backgrounds.

IMPACT

This study showed that the nurses hold unique roles in providing dying people with care from a community. These findings can potentially be applied for developing a universal model for LTC nurses in many aging populations, to modify their EOL care practice, educate new LTC nurses, and collaborate with other healthcare professionals.

Action research study on advance care planning for residents and their families in the long-term care facility

Background

Research in Taiwan has indicated that advance care planning is rarely undertaken in long-term care facilities. The purpose of this study was to develop an advance care planning interview guideline and care model to facilitate the process of advance care planning for residents and their families in long-term care facilities.

Methods

This study follows an action research design. Cycles of planning, action, observation, and reflection were planned and modified based on the results of interviews with residents and their families as well as meetings with staff. To establish the interview guideline and care model through this action research study, residents and their families were interviewed separately. The researcher subsequently held meetings with staff members to evaluate the results and identify problems during each advance care planning process. This information was synthesised and used to modify the care model for implementation with the next resident–family pair. This process was performed a total of ten times.

Results

This study included residents (N = 10), their families (N = 20), and medical staff (N = 4) at a long-term care facility. The interviews and meetings were audio recorded, transcribed, and subjected to a simple thematic analysis together with the field notes and reflection logs. Four themes emerged from the data related to: opening the conversation with the interview guidelines about the life story of residents; continuing life stories to the quality of remaining years of the residents; gradually changing the topic to the end-of-life care issues; and concluding the conversation by explaining the content of advance directives and hospice care.

Conclusions

The advance care planning care model was implemented following logical thinking from a Chinese perspective. This consisted of opening, developing, changing, and concluding through the views of Confucianism, Buddhism, and Taoism. The research findings indicate that the model successfully facilitated the process of advance care planning for residents and their families.

A Population-Based Study on Advance Directive Completion and Completion Intention among citizens of the Western Canadian province of Alberta

Determining what proportion of the public has completed an advance directive and which population subgroups complete or do not complete such a directive is crucially important for planning purposes. Our research objective was to examine and compare advance directive completion, intention to complete, and noncompletion rates among citizens of one Canadian province. A telephone survey was conducted with 1,203 Albertans who met gender, age, and other requirements for a representative sample. When asked, “Do you have a living will or personal directive?” 43.6 percent reported having completed a directive and 42.1 percent indicated that they planned or intended to complete one. Completion rates increased with age. Widowed, self-employed, and retired people, and those who had lost a family member or friend and had other select end-of-life experiences and viewpoints were significantly more likely to have completed one. Although older people more often had an advance directive, personal life-and-death experiences should be recognized as major influences on directive completion.

Advance Care Planning: Contemporary Issues and Future Directions

Advance care planning (ACP) is widely considered an essential step toward achieving end-of-life care that is consistent with the preferences of dying patients and their families. ACP comprises a living will and a durable power of attorney for health care (DPAHC); these tools enable patients to articulate and convey their treatment preferences when they are still cognitively intact. In this article, we describe the strengths, weaknesses, and correlates of ACP in the United States, with attention to race and socioeconomic disparities therein. We then discuss other public policies and community programs designed to increase both the number of older adults who articulate their preferences for end-of-life care, and efficacy of ACP for ensuring that patients' end-of-life treatment preferences are met. We describe the characteristics, strengths, and limitations of Physician Orders for Life Sustaining Treatment (POLSTs), and describe community programs, educational interventions, and public policies aimed toward increasing the prevalence and efficacy of end-of-life preparations. A key policy advance in the early 2010s has been Medicare coverage of one doctor-patient consultation session regarding end-of-life issues; we highlight the potentials and possible pitfalls of this policy. We conclude by identifying areas for future research, and highlighting practices from other nations that may help improve quality of end-of-life care in the United States.

Chronic Illness with Complexity

The present study examines how different chronic illnesses and mental illness comorbidity (chronic illness with complexity [CIC]) associate with components of advance care planning (ACP). We also explore the role self-perceived burden plays in the relationship between illness and ACP. Data were gathered from a cross-sectional survey of 305 elderly participants from the New Jersey End-of-Life study. Participants with diabetes and those with cardiovascular disease (CVD) are less likely, while participants with CIC are more likely, to plan for the end-of-life. Participants with diabetes are less likely to make formal plans, whereas those with CVD are less likely to hold informal discussions. CIC is associated with increased odds of having an advance directive, but no other form of ACP. Self-perceived burden did not appear to be the gateway by which illness groups differentially engaged in ACP. Future research should investigate what aspects of illnesses drive ACP.

Willingness to complete advance directives among low-income older adults living in the USA

This study explored low-income older adults' willingness to (i) complete advance directives, legal documents, whereby an individual designates decision-makers in the event that they cannot make their own decisions about end-of-life treatment preferences, and (ii) the role of social support and other predictors that impact their willingness. This study was conducted as part of a larger study exploring behaviours of advance care planning among low-income older adults. Out of a total of 255 participants from the original study, this study included 204 participants who did not complete an advance directive for data analysis. A cross-sectional study using probability random sampling stratified by ethnicity was used. Older adults residing in two supportive housing facilities or who were members of a senior centre in San Diego, California, USA, were interviewed in person between December 2010 and April 2011. Hierarchical logistic regression analysis revealed that the majority of participants (72.1%) were willing to complete advance directives and the factors significantly predicting willingness to complete included self-rated health, attitudes towards advance decision-making and social support. Participants with a poorer health status (OR = 1.43, 95% CI = 1.07-1.90) were more willing to complete advance directives. Conversely, participants with higher positive attitudes (OR = 1.18, 95% CI = 1.00-1.39) and greater social support (OR = 1.07, 95% CI = 1.00-1.15) were also more willing to complete advance directives. The findings suggest the importance of ongoing support from healthcare professionals in end-of-life care planning. Healthcare professionals can be a source of support assisting older adults in planning end-of-life care. Initiating ongoing communication regarding personal value and preference for end-of-life care, providing relevant information and evaluating willingness to complete as well as assisting in the actual completion of advance directives will be necessary.

Evaluating family function in caring for a geriatric group: Family APGAR applied for older adults by home care nurses

AIM

Family function is an essential factor affecting older adults' health. However, there has been no appropriate method to assess the family function of most older adults with fragility or poor health status. The present study aimed to explore the differences and relevance of family function estimated by home care nurses and the older adults, and to determine if nurses could represent older adults to provide the estimation.

METHODS

Study participants were 50 older adults who were aged older 65 years and were taken care of at home by well-trained nurses. The present study used the Family APGAR as the questionnaire. We compared the results evaluated by the older adults and their home care nurses. The results included the level of dysfunction and the total scores of the questionnaire. The paired t-test and McNemar-Bowker test were used for the analysis.

RESULTS

Family function could be leveled as "good," "moderate dysfunction" and "severe dysfunction" according to the scores. The family function levels estimated by nurses showed no significant differences to the patients' condition (P = 0.123 > 0.05). Comparing the total scores of the older adults with those of their own home care nurses, the results showed a moderate to nearly high correlation (R = 0.689/P < 0.001). Caring time might be the factor affecting the result.

CONCLUSIONS

The present study provides a way of helping physicians to ascertain older adults' family problems much earlier and to improve the their health status by enhancing family support. Geriatr Gerontol Int 2015; ●●: ●●-●●.

Relationship of social support and decisional conflict to advance directives attitude in Korean older adults: A community-based cross-sectional study

AIM

The aim of this study was to clarify the relationship between social support, decisional conflict, and attitude towards advance directives, and determine whether decisional conflict mediates the relation between social support and advance directives attitude among older adults in South Korea.

METHODS

In total, 209 community-based older adults (mean age, 74.82 years) participated in this cross-sectional study. Demographic characteristics, self-perceived health status, social support, decisional conflict, and advance directives attitude were investigated via a structured questionnaire. Data analysis was carried out using Pearson's correlation and path analyses.

RESULTS

The mean score of advance directives attitude was 48.01 (range, 35-61). Decisional conflict and social support were both significantly related to advance directives attitude (P < 0.001). Additionally, decisional conflict was a mediator between social support and advance directives attitudes.

CONCLUSION

The results confirmed the importance of social support for reducing decisional conflict and encouraging positive attitudes toward advance directives. Future studies are needed to support the development of culturally sensitive educational approaches regarding advance directives for older adults in Korea.

End-of-life considerations in the ICU in Japan: ethical and legal perspectives

In Japan, the continuation of critical care at the end of life is a common practice due to the threat of legal action against physicians that may choose a palliative care approach. This is beginning to change due to public debate related to a series of controversial incidents concerning end-of-life care over the last decade. In this review we contrast and compare the history and evolution of end-of-life care in Japan vs. the USA and other Asian countries. Efforts by the Japanese Society of Intensive Care Medicine (JSICM) to establish better end-of-life care systems, as well as future directions in palliative care in Japan, are discussed.

Cultural and Ethical Considerations for Cardiopulmonary Resuscitation in Chinese Patients With Cancer at the End of Life

End-of-life (EOL) decision making is based on the values and wishes of terminally ill patients. However, little is known on the extent to which cultural factors affect personal attitudes toward life-sustaining treatments (LSTs) such as cardiopulmonary resuscitation (CPR) in China. This study evaluated the cultural and ethical considerations during EOL decisions and assessed the factors that affect pursuing LSTs in China. We used a case–control study design and compared their baseline characteristics with the provided EOL care and treatments. The CPR treatment among patients with cancer at EOL was affected by Chinese family traditions and Western influences. Our results reflect the need to improve EOL care and treatment in China.

Attitudes regarding life-sustaining measures in people born in Japan, China, and Vietnam and living in Texas

Cultural beliefs about and preferences for care at the end of life are diverse and unique in many respects. This descriptive qualitative study presents findings about the attitudes and preferences of people born in Japan, China, and Vietnam and living in the southern part of the USA regarding life-sustaining measures. In-depth personal and focus group interviews were conducted with 46 participants and thematic analysis completed. The findings reflected some similarities and differences among the three groups concerning initiation and discontinuance of artificial nutrition and mechanical ventilation. They also demonstrated the requirement for sensitivity to individual needs when honouring the wishes of patients and surrogate decision makers. Interventional studies should follow that test educational strategies to improve practice outcomes for health-care providers who care for these populations at this vulnerable time of life.

Factors influencing preferences of Korean people toward advance directives

Although Korean society has begun to seek a way of utilizing advance directives, there is not much known about the factors influencing the average Korean person's preference toward advance directives. The purpose of this study was to examine factors, in addition to demographic variables, influencing preferences regarding advance directives. These include: to what extent people's awareness of advance directives, preferences of extending their life at the end of life, experience of illness and medical care, and family functioning independently influence the preferences toward advance directives. The participants were 382 community-dwelling Korean people. The data analysis was performed using hierarchical multiple logistic regression analysis. The findings showed that a majority of Korean people had a positive preference on advance directives and the factors influencing their preferences for advance directives were the preferences against the use of life-sustaining treatment at the end of life, a good self-rated heath status, and an unsatisfactory family functioning.

Cross-cultural communication and use of the family meeting in palliative care

Terminally-ill patients and their families often report poor communication and limited understanding of the patient's diagnosis, prognosis, and treatment plan; these deficits can be exacerbated by cross-cultural issues. Although family meetings are frequently recommended to facilitate provider-family communication, a more structured, evidence-based approach to their use may improve outcomes. Drawing on research and guidelines from critical care, palliative care, and cross-cultural communication, we propose a framework for conducting family meetings with consideration for cross-cultural issues.

Researching the end-of-life in old age: cultural, ethical and methodological issues

Increased life expectancy has strengthened the association between old age and death, with significant implications for gerontology and for the generation of knowledge through research. The global rise in chronic disease has had a significant impact on the duration and shape of dying trajectories in old age and their variations. This development poses ethical and methodological challenges for researchers, not least because it is often difficult to establish whether an older person is ‘dying from’ as opposed to ‘living with’ one or more diseases. This paper reports a comprehensive literature review of empirical research on the end-of-life in old age, and has two inter-related themes. It explores the social and cultural contexts of death and critically analyses the methods and ethical approaches adopted by researchers. Cross-cultural studies and studies in which cultural factors were of prime interest were selected with a view to examining the concept of a ‘good death’ in old age. The paper discusses the evidence of cultural similarities and differences and the impact of social and cultural change on ideas concerning a good death. It identifies contemporary influences and pressures on end-of-life care for older people and discusses the significance of communication and the roles of families and service providers. The paper concludes by identifying substantive and methodological lessons for researchers in gerontology and suggests ways in which the impact of research might be enhanced.

Effectiveness of end-of-life education among community-dwelling older adults

The purpose of this study was to evaluate the effectiveness of an educational intervention regarding end-of-life discussion directed at older Japanese adults and their attitude to and acceptance of this intervention. A quasi-experimental design was used. A total of 121 older adults, aged 65 years and over, consented to participate. Data from 55 intervention and 57 control participants were used for the analysis. The intervention consisted of an education program comprising a video, a lecture using a handout, and discussion among participants. The control group received only the handout. Both groups were followed up after one month. The intervention group’s attitude became more favorable towards advance directives, especially living wills (P = 0.024). In addition, their expression of preference for life-sustaining treatment by means of artificial nutrition was less at follow up, demonstrating that these older adults had become more autonomous (P = 0.008). There was greater acceptance of the intervention as a whole by the intervention group compared with the control group (P = 0.011). Although few participants overall completed living wills, at follow up twice as many in the intervention group had discussed end-of-life matters with family members and/or their physician.

Design of the Advance Directives Cohort: a study of end-of-life decision-making focusing on Advance Directives

Background

ADs are documents in which one can state one's preferences concerning end-of-life care, aimed at making someone's wishes known in situations where he/she is not able to do so in another manner. There is still a lot unclear about ADs. We designed a study aimed at investigating the whole process from the formulating of an AD to its actual use at the end of life.

Methods/Design

The study has mixed methods: it's longitudinal, consisting of a quantitative cohort-study which provides a framework for predominantly qualitative sub-studies. The members of the cohort are persons owning an AD, recruited through two Dutch associations who provide the most common standard ADs in the Netherlands, the NVVE (Right to Die-NL), of which 5561 members participate, and the NPV (Dutch Patient Organisation), of which 1263 members participate. Both groups were compared to a sample of the Dutch general public. NVVE-respondents are more often single, higher educated and non-religious, while amongst NPV-respondents there are more Protestants compared to the Dutch public. They are sent a questionnaire every 1,5 year with a follow-up of at least 7,5 years. The response rate after the second round was 88% respectively 90% for the NVVE and NPV. Participants were asked if we were allowed to approach close-ones after their possible death in the future. In this way we can get insight in the actual use of ADs at the end of life, also by comparing our data to that from the Longitudinal Aging Study Amsterdam, whose respondents generally do not have an AD.

Discussion

The cohort is representative for people with an AD as is required to study the main research questions. The longitudinal nature of the study as well as the use of qualitative methods makes it has a broad scope, focusing on the whole course of decision-making involving ADs. It is possible to compare the end of life between patients with and without an AD with the use of data from another cohort.

Ethics and Advance Care Planning in a Culturally Diverse Society

Emerging international research suggests that in multicultural countries, such as Australia and the United States, there are significant disparities in end-of-life care planning and decision making by people of minority ethnic backgrounds compared with members of mainstream English-speaking background populations. Despite a growing interest in the profound influence of culture and ethnicity on patient choices in end-of-life care, and the limited uptake of advance care plans and advance directives by ethnic minority groups in mainstream health care contexts, there has been curiously little attention given to cross-cultural considerations in advance care planning and end-of-life care. Also overlooked are the possible implications of cross-cultural considerations for nurses, policy makers, and others at the forefront of planning and providing end-of-life care to people of diverse cultural and language backgrounds. An important aim of this article is to redress this oversight.