Attitudes of Critically Ill Filipino Patients and Their Families Toward Advance Directives

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Filipino American and Korean American Patients

As of 2019, there are 4.2 million Filipino Americans (FAs) and 1.9 million Korean Americans (KAs) in the United States, largely concentrated in New York, California, Texas, Illinois, and Washington. In both populations, similar to the broader U.S. culture, one can find health literacy gaps around understanding and utilizing palliative care. In this article, we provide 10 cultural pearls to guide clinicians on how to sensitively approach FA and KA groups when addressing palliative and end-of-life (EOL) discussions. We fully celebrate that every person is an individual and care should be tailored to each person's goals, values, and preference. In addition, there are several cultural norms that, when appreciated and celebrated, may help clinicians to improve serious illness care and EOL discussions for members of these populations.

End-of-life care for Filipino patients with cancer

Providing end-of-life care within the cultural context of a Filipino patient in the United States is a complex process for clinicians, patients, and their families. An inclusive approach is crucial, especially because a significant proportion of patients belong to minority groups such as Filipinos, who represent the fourth largest group of immigrants in the United States as of data available in 2019. The case provided in this paper highlights the importance of family, religion, and finances in guiding the best possible way of providing end-of-life care for Filipino patients with cancer. At the end of this review, we discuss concrete action points that may give a non-Filipino physician a deeper understanding of end-of-life care for Filipinos.

Perceptions of Patients and Their Families Regarding Limitation of Therapeutic Effort in the Intensive Care Unit

OBJECTIVE

Our objective was to determine and describe the opinion and attitudes of patients and their families regarding the limitation of therapeutic effort and advanced directives in critical patients and whether end-of-life planning occurs. Religious affiliation, education level, and pre-admission quality of life were also evaluated to determine whether they may influence decisions regarding appropriate therapeutic effort.

METHODS

A prospective, observational and descriptive study, approved by the center's ethical committee, was carried out with 257 participants (94 patients and 163 family members) in the intensive care unit (ICU). A questionnaire regarding the opinions of patients and relatives about situations of therapeutic appropriateness in case of poor prognosis or poor quality of life was used. The questionnaire had three sections. In the first section, sociodemographic features were investigated. In the second section, information was collected on the quality of life and functional situation before ICU admission (taking as a reference the situation one month before admission) assessed by the Karnofsky scale, Barthel index, and the PAEEC scale (Project for the Epidemiological Analysis of Critical Care Patients). The third section aimed to determine whether the family knew the patient's opinion regarding his/her end of life.

RESULTS

Of those interviewed, 62.2% would agree to limit treatment in case of poor prognosis or poor quality of future life. In contrast, 37.7% considered that they should fight for life, even if it is irretrievable. Only 1.6% had advanced directives registered, 43.9% of the participants admitted deterioration in their quality of life before ICU admission, 18.2% with moderate-severe deterioration. Our study shows that the higher the educational level, the lower the desire to fight for life when it is irretrievable and the greater the agreement to limit treatment. Besides, those participants not affiliated with a religion were significantly less likely to fight for life, including when irretrievable, than Catholics and were more likely to agree to limit treatment.

CONCLUSIONS

More than half of the participants would agree to limit treatment in the case of a poor prognosis. Our results indicate that patients do not prepare for the dying process well in advance. Religion and educational level were determining factors for the choice of procedures at the end of life, both for patients and their families.

Palliative Care for the Asian American Adult Population: A Scoping Review

BACKGROUND

The Asian American (AA) population is rapidly becoming one of the largest racial/ethnic groups in the United States. Despite this growth and advances in palliative care (PC) programs in the United States, the scope and nature of the literature regarding PC for AAs remains unclear. This review provides an overview of existing research on PC for AAs, identifies gaps in the research with recommendations for future research and delineates practice implications.

METHODS

A scoping review of studies published in English was conducted. Electronic Databases (PubMed, Embase, CINAHL, and PsycINFO databases) were searched up to December 2019. No starting date limit was set. Arksey and O'Malley's methodological framework was followed for scoping reviews.

RESULTS

Of 2390 publications initially identified, 42 studies met our inclusion criteria for this review. Southeast AA subgroups remain understudied compared to East and South AAs. Most studies were descriptive; a few (n = 3) evaluated effectiveness of PC interventions for AAs. Research synthesized in this review addresses the following topics and includes considerations in PC related to care recipients and their relatives: treatment choice discussions (73%), coordination of care with health care providers (26%), symptom management (14%), and emotional support (10%). This review identified various factors around PC for AAs, specifically the influence of cultural aspects, including levels of acculturation, traditional norms and values, and religious beliefs.

CONCLUSION

A culturally inclusive approach is vital to providing appropriate and accessible PC for AAs. Further research is needed concerning core PC components and effective interventions across diverse AA subgroups.

Psychometric Testing of the Korean Version of the Attitudes toward the Advance Directives in Low-Income Chronically Ill Older Adults

The purpose of this study was to examine the psychometric properties of the Advance Directive Attitude Survey in Korean (K-ADAS), a measure of attitudes toward advance directives (ADs). A total of 118 low-income, community-dwelling older adults (mean age, 75.09 years) participated. An exploratory factor analysis (EFA) was conducted to determine the factor structure of the K-ADAS. Validity was further assessed by known associations of the K-ADAS with perceived susceptibility and severity using part of the Advance Care Planning surveys. Its reliability was examined by calculating alpha coefficients. EFA determined a three-factor structure model with good model fit. Validity was further supported with significant correlations between the K-ADAS and susceptibility and severity. Reliability was supported by adequate level of Cronbach’s alpha. The K-ADAS was a valid and reliable measure for assessment of AD attitudes with a sound model fit. Thus, the K-ADAS can be used to assess AD attitudes among community-dwelling elders.

Associations of Advance Directive Knowledge, Attitudes, and Barriers/Benefits With Preferences for Advance Treatment Directives Among Patients With Heart Failure and Their Caregivers

BACKGROUND

Patients with heart failure (HF) have not been considered as major beneficiaries of advance directives (ADs). We analyzed factors affecting the preferences for the adoption of ADs by patients with HF and their caregivers.

METHODS AND RESULTS

Seventy-one patient (mean age: 68 years)-caregiver (mean age: 55 years) dyads were enrolled during clinic visits for routine care at a single institution and completed questionnaires during in-person visits. Cohen's kappa coefficients and generalized estimating equation models were used to analyze the data. The agreement on dyadic perspectives for aggressive treatments was poor or fair, whereas agreement relative to hospice care was moderate (k = 0.42, 95% confidence interval = 0.087-0.754). Both patients and caregivers demonstrated poor knowledge of ADs and similar levels of perceived benefits and barriers to advance care planning. However, the caregivers had more positive attitudes toward ADs than patients. Patients and caregivers who were older and/or males had greater odds of preferring aggressive treatments and/or hospice care. Further, those with depressive symptoms had lower odds of preferring hospice care.

CONCLUSION

The dyadic agreement was moderately high only for hospice care preferences. Both patients and caregivers demonstrated knowledge of shortfalls regarding ADs. Timely AD discussions could increase dyadic agreement and enhance informed and shared decision-making regarding medical care.

The factor structure of a short acculturation scale for Filipino Americans in an adult U.S.-born sample

The influx of non-European immigrants since 1965 ushered the development and use of acculturation measures in immigrant health studies. A Short Acculturation Scale for Filipino Americans (ASASFA) represents a validated, unidirectional ethnic-specific measure used with first-generation FAs. ASASFA's psychometric properties with adult U.S.-born children-the second generation-remain unexplored. This study determined (a) the factor structure of ASASFA with adult U.S.-born FAs and (b) the predictors of their acculturation scores. A secondary analysis was conducted on ASASFA data from a mental health survey of 116 U.S.-born FAs. Exploratory factor and parallel analyses showed a two-factor solution: language use and preference (Factor 1) and ethnic social relations (Factor 2). Ordinary least squares regression indicated gender and ethnic self-identification predict Factor 1 scores; self-identification solely predicts Factor 2 scores. Results demonstrate ASASFA's validity and parsimony, supporting its use in FA health studies when lengthy bidirectional acculturation measures become impractical.

The Knowing–Doing Gap in Advance Directives in Asian Americans: The Role of Education and Acculturation

Objectives:

The purposes of the present study were (1) to explore the completion rate of advance directives (ADs) in a sample of Asian Americans and (2) to examine the direct and moderating effects of knowledge of AD, education, and acculturation in predicting AD completion. Education and acculturation were conceptualized as moderators in the link between knowledge and completion of ADs.

Methods:

Using data from 2609 participants in the 2015 Asian American Quality of Life survey (aged 18-98), logistic regression analyses on AD completion were conducted, testing both direct and moderating effects.

Results:

The overall AD completion rate in sample was about 12%. The AD knowledge and acculturation independently predicted AD completion. No direct effect of education was found; however, it interacted with AD knowledge. The AD knowledge was more likely to be translated into completion in the group with higher education.

Conclusions:

The AD completion rate observed in the present sample of Asian Americans was much lower than that of the US general population (26%-36%). The interactive role of education helps to explain the gap between AD knowledge and completion and suggests intervention strategies.

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.

Level of acculturation, food intake, dietary changes, and health status of first-generation Filipino Americans in Southern California

PURPOSE

This exploratory descriptive study investigates the acculturation level, food intake, dietary changes and practices, health status perceptions, and diet-related health indicators-body mass index (BMI), waist and hip circumferences, and waist-to-hip ratio-of first-generation Filipino Americans (FAs) in Southern California.

DATA SOURCES

Healthy FA adults-20 women and 10 men-were interviewed. Acculturation level was obtained using A Short Acculturation Scale for Filipino Americans. A 24-h dietary recall elicited their food intake. Survey questions revealed dietary changes and practices, health status perceptions, and sociodemographic characteristics. Height, weight, waist and hip circumferences were measured.

CONCLUSIONS

FAs consider themselves more Filipino than American, but their acculturation level reflects transitioning into biculturalism. FAs relinquish, maintain, and adapt elements of both Philippine and U.S. cultures in food intake, dietary changes, and practices. Although FAs perceive their health status as very good to excellent, many exceed the cut-off points for BMI, waist circumference, and waist-to-hip ratio.

IMPLICATIONS FOR PRACTICE

This study underscores the importance of nurse practitioners and other healthcare givers conducting cultural dietary assessment as a basis for culturally appropriate dietary counseling. The inclusion of waist measurement to regularly monitor abdominal obesity-a predictor of cardiovascular disease and diabetes-is highly recommended.

Testing theoretical relationships: factors influencing positive health practices (PHP) in Filipino college students

OBJECTIVE

To examine variables influencing the positive health practices (PHP) of Filipino college students to gain a better understanding of health practices in this ethnic/racial group. Cross-sectional study tested theoretical relationships postulated among (a) PHP, (b) social support (SS), (c) optimism, and (d) acculturation.

PARTICIPANTS

A sample of Filipino college students (N = 226) aged 18 to 21 was obtained in June 2009.

METHODS

Participants completed 4 instruments. Statistical analyses were performed using SPSS 16.0.

RESULTS

Positive correlations were found between PHP and SS (r = .39, p = .01) and optimism and PHP (r = .36, p = .01). No correlation was found between PHP and acculturation. Optimism and SS predicted performance of PHP (R (2) = .18, F[2, 221] = 24.927, p < .001). A difference was found in acculturation levels between participants who grew up in the United States (t[223] = 4.5, p < .001) and those who did not.

CONCLUSIONS

Findings help health practitioners and educators to better understand the underlying factors that influence PHP in this population.

Knowledge of and preference for advance care planning by adults with congenital heart disease

Congenital heart disease (CHD) is a chronic illness. Few adults with CHD are cured and those with disease of moderate or great complexity remain at risk of premature death. Current adult CHD guidelines recommend that providers encourage their patients to complete advance directives. We evaluated the prevalence of completed advance directives by and the preference for information about life expectancy of outpatients at a large adult CHD program. Two hundred patients with CHD (52% men, 35 ± 15 years old, range 18 to 79, 81% with disease of moderate or great complexity) completed a survey that assessed knowledge of advance directives and nature of and preferences for advance care planning. Only 5% of patients reported that they had completed advance directives; 56% had never heard of them. However, most patients (87%) reported that they would prefer to have an advance directive available if they were dealing with their own dying and were unable to speak for themselves. Patients who had formally identified substitute decision makers (n = 34) were typically older (47 ± 16 vs 33 ± 13 years, p <0.001) and more likely to have partners (30% vs 6%, p <0.001). Most patients (70%) reported that they wanted general information about the average life expectancy for patients with their heart condition. In conclusion, in contrast to recommendations from published guidelines, advance care planning documents are infrequently completed by outpatients. Health care providers caring for patients with CHD should educate their patients about advance directives and assist them in preparing formal end-of-life-planning documents.

Concept analysis of acculturation in Filipino immigrants within health context

Although acculturation has been widely used as a health research variable among other immigrant populations, it is nonexistent to the Filipino immigrant population. Accurate assessment, measurement, and exploration of acculturation of Filipinos in the United States can help improve the overall health care of this population. The work of Walker and Avant is used as a guide to analyze and clarify the operational definition of acculturation of this group within the context of health.

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.

Factors influencing older adults to complete advance directives

Objective:

The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults.

Method:

Direct interviews of hospitalized and community-dwelling cognitively intact patients >65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables.

Results:

Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3,p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2,p < 0.0001), having undergone major surgery (OR 6.3,p < 0.0017), female gender (OR 11.1,p < 0.0001) and increasing age (76–85vs.59–75: OR 3.4,p < 0.0543; <85vs. 59–75: OR 6.3,p < 0.0263).

Significance of results:

This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.

Completion of Advance Directives Among Korean American and Non-Hispanic White Older Adults

This study examines completion of advance directives, highlighting ethnic differences between Korean and non-Hispanic White older adults in relation to health beliefs and knowledge. In this study, 217 community-dwelling older adults (112 Korean Americans and 105 non-Hispanic Whites) were interviewed using structured questionnaires. As compared to only 5.4% ( n = 6) of Korean American older adults, more than half of non-Hispanic White older adults (59.2%, n = 61) had completed advance directives. Health beliefs, but not knowledge, significantly mediated the relationship between ethnicity and completion of advance directives; Korean Americans had lower levels of health beliefs toward advance care planning than non-Hispanic Whites, and this in turn led to relatively lower rates of completing advance directives. Thus, it is advised that health care practice needs to encompass older adults’ health beliefs, which may be uniquely represented among different ethnic groups.

Communication Strategies and Cultural Issues in the Delivery of Bad News

Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.