Factors Affecting the Completion of Advance Care Planning and End-of-Life (EOL) Care Decisions Among Older Korean Americans in Rural America

Background and Purpose: Despite existing studies, more research is needed on the factors influencing advance directives preferences among older Korean Americans, particularly focusing on cultural aspects like acculturation and filial piety. Additionally, little research has targeted older Korean Americans in rural communities. Consequently, this study explored possible factors, including knowledge and attitudes toward advance directives and cultural factors, influencing the completion of advance directives (ADs) among older Korean Americans in a rural Midwestern community. The research question addressed was: What factors influence Korean elderly Americans' advance care planning, and how do cultural factors impact these decisions?

Methods: A mixed methods approach was used, combining open-ended and closed-ended questions. One-hour, face-to-face interviews were conducted with 10 older Korean Americans aged 60 and above, recruited through posted fliers, with interviews conducted in Korean. Four participants were male, with a mean age of 66.5 years (SD=12.6), and an average U.S. residency of 34.2 years (SD=12.6). Despite residing in the U.S. for over 30 years, all participants self-identified as Korean. Knowledge of ADs was assessed with a 10-item tool, attitudes toward ADs were measured using Nolan and Bruder's scale, and filial piety attitudes were gauged with Gallois et al.'s six-item scale. Acculturation was determined via language preference and self-identification. Qualitative data were collected on factors affecting AD completion, timing, and the influence of cultural factors on the completion of ADs. Analysis involved quantitative descriptive and bivariate methods and qualitative thematic analysis.

Results: None of the participants had completed advance directives or received education about them. However, their knowledge of advance directives yielded overall high scores (M=6.2 points, SD=0.97 points). Attitudes toward advance directives were moderately positive, with scores ranging from 35 to 56 (M=46.5, SD=7.13). Despite high knowledge scores and moderately favorable attitudes among the participants, there was no link to advance directive completion. Also, all the participants had no intention to complete them soon. Qualitative interviews revealed that factors such as advancing age, health condition, treatment choices, family wellbeing, and financial considerations influenced the completion of ADs, surpassing mere knowledge and attitudes. This qualitative finding aligned with the quantitative finding that all participants strongly agreed with the statement "I am not sick enough to create advance directives" on the attitudes toward AD scale. None of the cultural factors, including acculturation and filial piety, were linked to completing ADs. This conclusion was supported by qualitative interviews, where participants did not cite filial piety as a factor in their decision-making about completing advance directives.

Conclusions and Implications: This study has important implications for enhancing the welfare of racial and ethnic minority older adults, especially those in rural areas, who are frequently overlooked. The findings provide essential guidance on timing and approach for discussing end-of-life care with Korean immigrant older adults in rural areas. Identifying factors influencing end-of-life care planning will aid in crafting culturally tailored interventions, enabling informed decisions that improve their end-of-life quality of life and ease family burden and emotional stress.