Communication with older Chinese patients on advance directives: real life experience and predictive factors of successful acceptance

Abstract

Background: Advance directive (AD) is based upon the principle of a patient’s autonomy in making their own decisions about end-of-life care ahead of time. In Chinese culture, death is a sensitive issue, and overt reference to the end of life can be regarded as disrespectful. In this pragmatic hospital-based study of the real-life experience of communicating with older Chinese patients about AD, we examined the acceptance rate and the predictive factors for successful acceptance of the AD. Methods: We recruited 60 Chinese patients over 65 years of age, who were medically and mentally stable with no history of active cancer or end-stage organ diseases, from the Acute Geriatric Unit at the Grantham Hospital. The geriatrician educated and interviewed the patient and their families, and used a locally-designed AD document to declare the patient's preferences, and the refusal of futile treatment in case they suffered from terminal disease, persistent vegetative state or irreversible coma. We documented baseline socio-demographic, medical, functional and cognitive factors, and the reasons for accepting or rejecting the AD. The reasons for accepting and rejecting the AD were documented. Results: Amongst the 60 patients, 35% accepted and 65% rejected the AD. Factors that predicted AD acceptance included: higher education level (p=.046), single or widow marital status (p<.001) and poor health status (p=.028). Factors that predicted AD rejection included: independent functioning (p=.039), having children (p=.007), good social support (p=.001) and have family as the main carer (p=.008). The commonest reasons for accepting the AD were to avoid suffering (67%) and upholding quality of life above longevity (33%). Commonest reasons for rejecting the AD were the belief that their family would make the decision (67%) and nature would take its course (31%). 23% remained unfamiliar with the concept of AD and 23% were not ready to discuss or accept it. Conclusion: Only 1-in-3 older Chinese patients accepted AD even after discussion with a geriatrician. We identified several factors that could predict acceptance and rejection, which may help to shape future policy making and clinical practice. Much more intergenerational public education on end-of-life issues is needed before AD can be widely adopted.