Differences in the Advance Care Planning Activities and End-of-Life Treatment Preference Among Immigrant Older Adults in the U. S.: Moderation Effects of Race/Ethnicity and Acculturation

Purpose

Studies reported low engagement in advanced care planning (ACP) among ethnic minorities, yet limited empirical research is available to inform our understanding of foreign-born immigrants’ ACP, who would experience more challenges of language and culture. Based on ethnicity-oriented race theory that emphasizes cultural factors and variations among ethnic groups, this study examined differences in ACP activities and preference of end-of-life (EOL) treatment among immigrant older adults with different races/ethnicities in the U.S. Research questions include: (1) how are the ACP activities and EOL treatment preference differ by race/ethnicity? and (2) how race/ethnicity and acculturation are associated with ACP activities and EOL treatment preference among immigrant older people? 

Method

The National Health and Aging Trends Study, a nationally representative longitudinal study that sampled Medicare beneficiaries ages 65 years and older was used. The analytic sample included immigrant respondents who participated in the surveys in 2011 and 2012 and were randomly selected for the ACP survey in 2012 (N=232). ACP activities were measured by three elements of ACP: (a) having an EOL discussion with others, (b) having a power of attorney (POA) for the EOL treatments, and (c) having a written living will (LW). The EOL treatment preference was measured by the desire to receive treatments when they are terminally ill with severe pain or cognitive/physical disabilities. The effects of race/ethnicity (Hispanic, non-Hispanic White, Asians, Black) and acculturation (proficiency of English and lengths of living in the U.S.) were tested, controlling for a health condition (subjective physical health status, number of chronic medical conditions, and number of help for ADLs) and socio-demographic characteristics. Using Stata 15.0, chi-square and logistic regression analysis methods were used.

Results

A majority of Blacks (76.74%) and Hispanics (71.91%) had significantly less discussion on EOL (p<.01). Most Black (76.19%), Asian (74.07%), and Hispanic (70.11%) immigrants did not have POA (p<.01) and living will (p<.001). Most Asians desired aggressive EOL treatments (72.22%) (p<.01) whereas around ¾ White desire to stop treatments (73.81%). Comparing with White immigrants, Hispanics tended to have fewer conversations about EOL (OR= .29, p<.05). English proficiency worked differently by race/ethnicity. Whereas White immigrants with higher English proficiency have higher chance to have POA (OR=27.39, p<.05), Blacks (OR=.02, p<.05), Asians (OR=.04, p<.05), and Hispanics (OR=.05, p<.05) with high proficiency were less likely to have POA. Similarly, Hispanics with higher English proficiency showed less chance to complete their LW as compared with their counterparts (OR=.06, p<.05). Asian immigrants tended to have more preference for the aggressive EOL treatments (OR=5.33, p<.05).

Conclusions and Implications

This study found that there were gaps in ACP activities and preferred EOL treatment by race/ethnicity. Especially, as compared with White immigrants, those from diverse countries showed lower participation in ACP even though they had high proficiency in English. These findings may imply the effects of a culture embedded in different ethnicities or discrimination/microaggressions which may cause barriers for them to take part in mainstream of this society. Aging policymakers and gerontological social workers should develop more culturally sensitive approaches for those with diverse ethnicities.