Cross-cultural similarities and differences in attitudes about advance care planning

Abstract

OBJECTIVE: Culture may have an important impact on a patient's decision whether to perform advance care planning. But the cultural attitudes influencing such decisions are poorly defined. This hypothesis‐generating study begins to characterize those attitudes in 3 American ethnic cultures. DESIGN: Structured, open‐ended interviews with blinded content analysis. SETTING: Two general medicine wards in San Antonio, Texas. PATIENTS: Purposive sampling of 26 Mexican‐American, 18 Euro‐American, and 14 African‐American inpatients. MEASUREMENTS AND MAIN RESULTS: The 3 groups shared some views, potentially reflecting elements of an American core culture. For example, majorities of all groups believed “the patient deserves a say in treatment,” and “advance directives (ADs) improve the chances a patient's wishes will be followed.” But the groups differed on other themes, likely reflecting specific ethnic cultures. For example, most Mexican Americans believed “the health system controls treatment,” trusted the system “to serve patients well,” believed ADs “help staff know or implement a patient's wishes,” and wanted “to die when treatment is futile.” Few Euro Americans believed “the system controls treatment,” but most trusted the system “to serve patients well,” had particular wishes about life support, other care, and acceptable outcomes, and believed ADs “help staff know or implement a patient's wishes.” Most African Americans believed “the health system controls treatment,” few trusted the system “to serve patients well,” and most believed they should “wait until very sick to express treatment wishes.” CONCLUSION: While grounded in values that may compose part of American core culture, advance care planning may need tailoring to a patient's specific ethnic views.

“Knowing is Better”: Preferences of Diverse Older Adults for Discussing Prognosis

“…21 They, and others, have shown that Latinos' attitudes in particular may differ notably from those in other ethnic groups. 27,28,39,40 Latinos in our study described feeling more comfortable with the idea of discussing prognosis with a clinician from their same ethnic background, and were also more likely to express considerable concern over the emotional burdens associated with knowing prognosis. Published studies similarly show that older Asian-Americans may not want to discuss a poor prognosis and that many would prefer that family members take the lead in communicating with doctors.…”

“…25,26 A limited number of studies from the advance planning literature also point to Latinos' unique perspectives on patient-doctor discussions around the end of life. 27,28 Additional studies have addressed how best to discuss prognosis given patients' preferences and perceived needs, 17,29,30 but we could find no deep, qualitative investigations of the reasons behind patient preferences for prognosis in a diverse elderly population. An in-depth understanding of the factors that motivate patients to desire or decline prognostic information, however, could enable clinicians to provide individualized and patient-centered care for diverse older adults in late life.…”

Interpreting Advance Directives: Ethical Considerations of the Interplay Between Personal and Cultural Identity

“…Perkins et al [22], also found in their qualitative interview survey that MexicanAmerican and European-American patients more often than African-Americans voice the wish not to receive life-sustaining treatment. The observation that AfricanAmericans more often wish to receive high tech medicine and life-sustaining treatment is explained among others with the collectively shared self-conception as a group that is often disadvantaged in the system [9].…”

“…It is known that in some religions illness is considered a divine trial that one has to face with discipline (among others in Islam) or as fate decided by God that one must accept (rather a Christian, but partially also a Jewish perspective). However, according to Perkins et al [22] religious affinity might be less relevant than ethnicity.…”

“…Only 3-23% of people hold an advance directive according to studies in USA, Israel, Netherlands and Germany (see [21,22,26]). Why is this?…”