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

Background and Purpose: Advance care planning is intended to prevent individuals from receiving unwanted treatments which, when honored, promote the individuals' quality of life. Existing national studies have found that only 15 to 25% of the U. S. general population has completed an advance directive (Braun, Onaka, & Horiuchi, 2001; Salmon & David, 2005). Moreover, the use of advance directives has mostly been identified among White Americans. Korean Americans are the fastest growing subgroup of Asian Americans which constitutes one of fifth largest Asian American group. Despite this, there is only one quantitative study examining advanced directives with Korean Americans (Murphy et al., 1996). The purposes of this study were to: 1) examine ethnic differences in the completion of advance directives among Korean American and non-Hispanic White older adults, and 2) to identify the factors impacting the completion of advance directives.

Methods: A two-stage sampling method with stratification by ethnicity was used. In the first stage, a non-probability method of purposive sampling was used to select senior centers. Inclusion criteria were senior centers located in five boroughs of New York City that had at least 100 enrolled seniors. At stage two, a non-probability convenience sampling method was used to select participants. Inclusion criteria were Korean American older adults who were born in Korea and who primarily spoke Korean, and non-Hispanic Whites; age 65 or older who were cognitively intact. The total sample size was 217 (112 Korean Americans and 105 non–Hispanic Whites). Face-to-face interviews were conducted using a structured questionnaire which consisted of behaviors in completion of advance directives, knowledge, health beliefs including perceived susceptibility, severity, benefits and barriers, and other socio-demographic variables. Data analysis included descriptive statistics and binary logistic regression analysis.

Results: Overall, about one third (30.7%) of the participants completed advance directives. About 21% had both a living will and health care proxy, and 9% had only one type of advance directive. As compared to non-Hispanic Whites, Korean Americans were less likely to complete advance directives (56.2% vs. 5.4%) and had less knowledge about advance care planning. Korean Americans were also less likely to have susceptibility, severity and benefits but more likely to perceive barriers about advance care planning than non-Hispanic Whites. The results of logistic regression showed that ethnicity, knowledge, income and perceived barriers were significant predictors for completion of advance directives. Among those, ethnicity was the strongest factor (exp [B] = .02, p < .05). Knowledge and income had positive effects, while perceived barriers and number in household had negative effects on completion of Advance Directives.

Conclusion and Implications: Consistent with the existing literature, this study found ethnic disparities in the completion of advance directives. A knowledge gap, along with perceived barriers about advance care planning also negatively influenced individuals' likelihood of completing advance directives. It is imperative that social workers explore the barriers older adults encounter in completing advance directives and develop culturally appropriate resources and interventions in this area. In addition, educational interventions need to be provided beyond health care settings to the larger community.