Attitude Toward Family Involvement in End-of-Life Care Among Older Chinese Americans: How Do Family Relationships Matter?

Abstract

Family involvement is critical to end-of-life (EOL) care among older adults. This study aims to examine the association and pathways between family relationships and older Chinese Americans’ attitude toward family involvement in EOL care discussions. Data were collected from 260 Chinese Americans aged 55 years and above. Structural equation modeling was used to examine the total and indirect effects of family relationships on attitude toward family involvement in discussing EOL care plans. Family relationships had a significant positive total effect on attitude toward family involvement in EOL care. Indirect effects of family relationships on attitude toward family involvement in EOL care through self-efficacy, perceived benefits, and perceived barriers of discussing EOL care with family members were all significant. Findings provide empirical evidence of how family relationships affect older Chinese Americans’ attitude toward family involvement in EOL care and underline the need for family-centered EOL interventions for this population.

Keywords

end-of-life care planning family relationship family involvement older Chinese Americans

Introduction

Advance care planning (ACP) is defined as the process of deciding medical treatment preferences ahead of time when patients have life-threatening diseases and are not able to speak for themselves (Weathers et al., 2016). While the completion of an advance directive (AD), defined as legal documents that allow individuals to communicate medical decisions about end-of-life (EOL) care in advance (Wang et al., 2021), is considered the optimal ACP outcome, discussing EOL care plans with significant others has become increasingly important before completing an AD (Volandes & Volandes, 2015). Successful communication of EOL care plans has been associated with improved quality of life among patients (Wright et al., 2008), less aggressive medical care (Mack et al., 2012), and lower stress and anxiety of family members (Detering et al., 2010). Furthermore, discussing EOL care can increase patients’ AD completion rate (Houben et al., 2014).

There are approximately five million Chinese Americans in the United States (Pew Research Center, 2017), many of whom have not been actively involved in ACP. Research shows that the completion rate of AD is only 14% among older Chinese Americans (Wang et al., 2021). Despite the strong evidence of benefits, older Chinese Americans tend to refrain from discussing EOL care plans with their family members (X. Gao et al., 2015). One commonly cited reason is that older Chinese Americans perceive the discussion of EOL care plans as an unnecessary burden to their loved ones and should be delayed until their health conditions decline (Yonashiro-Cho et al., 2016). Such beliefs contribute to low awareness and engagement of early discussion of EOL care among older Chinese Americans. To develop culturally sensitive interventions to facilitate EOL care planning with family members, it is crucial to identify factors associated with older Chinese Americans’ attitudes toward family involvement in discussing EOL care.

The Influence of Family Relationships

Family relationship is a primary source of social support for older Chinese Americans, which includes both family cohesion and family conflict (Cox & Brooks-Gunn, 1999). Family cohesion is defined as “the emotional bonding that family members have toward one another” (Olson, 1986), whereas family conflict refers to “active opposition between family members” (Marta & Alfieri, 2014). Because of the dynamic nature of family relationships, especially among older adults (Suitor et al., 2015), it is important to include both positive (family cohesion) and negative (family conflict) aspects of older adults’ family relationship.

Chinese culture prioritizes the values of family relationships when individuals make important life decisions (Wang et al., 2020). Research has shown that the impact of both family cohesion and family conflict on older Chinese Americans across outcome domains (Sun et al., 2018). For example, one study that focused on how family relationships impact older Chinese adults’ health reported that older Chinese Americans with high family cohesion were more likely to report excellent or good health than those with low family cohesion (Wang et al., 2020). In addition, studies have found that family conflict is associated with poor health among older Chinese Americans, with one study reporting that greater family conflict and lower family support is associated with increased depressive symptoms among older Chinese Americans (Sun et al., 2018).

In addition to health and mental health outcomes, family relationship significantly influences other life aspects among older Chinese Americans, including older adults’ medical decision-making (Ho et al., 2010). Previous studies have shown that family involvement can increase the likelihood of older Chinese patients’ acceptance of EOL care communication and AD completion (Mok et al., 2010; Wong et al., 2012). Although ACP was originally developed to improve patients’ self-determination and autonomy in making health care decisions (Sabatino, 2010), many older Chinese adults prefer support from family members during ACP. More importantly, individuals with high-quality family relationships were more likely to discuss EOL care plans with family members (Blackford & Street, 2016; Boerner et al., 2013).

Having successful EOL care planning depends greatly on people’s attitudes toward family involvement. Attitude (i.e., a latent disposition to express favorableness or unfavorableness to a psychological object) is among the most significant indicators used to predict and explain intentions and behaviors (Fishbein & Ajzen, 2010). Having previously established that family relationship (including attitude toward family involvement) poses significant influence on older adults’ medical decision such as EOL care planning (Gjerberg et al., 2015; Huang et al., 2020), it is then logically compelling to associate older adults’ attitude toward family involvement with successful EOL care planning. This is especially true for older adults of Asian descendants given the significant role of family relationship in Asian cultures. For example, research has identified a positive association between attitudes and intentions toward family discussions about ACP among Korean Americans (Hong et al., 2019). Given the important influence of attitudes toward family involvement, this study will explore the association between family relationship and attitudes toward family involvement in EOL care planning among older Chinese Americans.

In addition to the abovementioned association, this study also intends to explore how individual beliefs about themselves (self-efficacy) and about involving family members in EOL care (perceived benefits and barriers) may be influenced by one’s family relationship and, consequently, impact Chinese older adults’ attitudes toward family involvement in EOL care planning, that is, mediation.

Self-Efficacy

Self-efficacy is defined as “people’s beliefs about their capabilities to exercise control over their own level of functioning and over events that affect their lives” (Bandura, 1991, p. 257). A previous study found that individuals with a higher perceived ability to discuss EOL care plans were more likely to involve family members in EOL care communication (Chung et al., 2016). Another study suggested that older adults with higher self-efficacy were more likely to have higher ACP engagement (David et al., 2018). Building on the existing evidence, this study explores the potential mediating effect of self-efficacy on the association between family relationships and older Chinese Americans’ attitudes toward discussing EOL care plans with their family members.

Perceived Benefits and Barriers

Perceived benefits refer to the advantages of adopting a health-related behavior, whereas perceived barriers refer to negative aspects that hinder someone from taking such actions (Champion & Skinner, 2008). Literature suggests that perceived benefits and barriers have counterbalanced interactions with each other to influence individuals’ health-related behaviors, including medical decision-making (Janz et al., 2002). More specifically, both perceived benefits and barriers can mediate social determinants and older adults’ health-related behaviors (Jones et al., 2015; Weathers et al., 2016). For example, Ko and Lee (2010) found that perceived benefits and barriers mediated the relationship between ethnicity and the completion of ADs among Korean American and non-Hispanic White older adults. Another study found that one’s perceived benefits mediates the relationship between age and social support seeking (Jiang et al., 2018). Older adults are less likely to seek social support because they report lower perceived benefits of doing so. Given the crucial mediating role of perceived benefits and barriers in ACP, their potential mediating effects are examined to understand how family relationships impact Chinese older adults’ EOL care decisions through one’s perceived benefits and barriers.

Taken together, to investigate the influence of family relationships on EOL care communication, the objectives of this study are to (a) examine the association between family relationships and older Chinese Americans’ attitudes toward family involvement in EOL care and (b) test whether self-efficacy, perceived benefits, and perceived barriers mediate the association. Figure 1 shows the conceptual model of the study.

Figure 1.

Conceptual model.

Method

Data Source

Data were collected from a convenience sample of 260 community-dwelling older Chinese Americans aged 55 years and older in Arizona and Maryland through community partners in 2018. Participants were recruited from multiple community settings, including Chinese senior centers, subsidized senior housing apartments, religious sites, community events, and senior social clubs. Face-to-face interviews were conducted using participants’ preferred languages (i.e., English, Mandarin, or Cantonese). All study materials, including survey questions, the consent form, and recruitment scripts were created in English. To develop Chinese-written questionnaire packets, the English-written materials were translated into Chinese and back translated into English by two Chinese scholars outside of the research team to assure accuracy. About 95.8% of participants completed the survey in Chinese, whereas the rest (4.2%) completed the survey in English. Two thirds of the sample (66.7%) was living at subsidized senior housing facilities, whereas the rest were living either in public neighborhoods (31.0%) or retirement communities (2.3%). All participants completed written consent forms to be enrolled in the study. This study received the approval from the Michigan State University’s Institutional Review Board (No. i053829).

Definition of Variables

Attitude toward family involvement in discussing EOL care plan

Participants were first provided with the explanation of EOL care planning (“End-of-life care planning helps us before we encounter a medical crisis and are not able to speak for ourselves. It includes discussing your end-of-life care preferences with family members”). Attitude toward family involvement in discussing EOL care plan was measured by one single survey statement: “Discussing my end-of-life care plan with family members is . . .” Responses included 1 = “very bad,” 2 = “bad,” 3 = “neutral,” 4 = “good,” and 5 = “very good.”

Family relationships

“Family relationships” was constructed as a latent variable constructed from family cohesion and family conflict. Family cohesion was measured using five Likert-type scale questions adapted from Olson’s Family Cohesion Scale (Olson, 1986). Participants were asked to indicate to what degree they agreed with these statements: (a) Family members respect one another, (b) We share similar values and beliefs as a family, (c) Family members feel loyal to the family, (d) We can express our feelings with our family, and (e) Family members like to spend free time with each other (Cronbach’s α = .88). Responses to each item included 1 = “strongly agree,” 2 = “somewhat agree,” 3 = “somewhat disagree,” and 4 = “strongly disagree.” All responses were reverse-coded and averaged to create a family cohesion score, ranging from 1 (indicating lowest family cohesion) to 4 (indicating highest family cohesion). Family cohesion was calculated using the mean of all those responses. Family conflict was measured using five Likert-type scale questions adapted from the Hispanic Stress Inventory (Cervantes et al., 1990). Participants were asked to rate the extent to which they experienced five items: (a) You have felt that being too close to your family interfered your own goals, (b) Because you have different customs, you have had arguments with other members of your family, (c) Because of the lack of family unity, you have felt lonely and isolated, (d) You have felt that family relations are becoming less important for people that you are close to, and (e) Your personal goals have been in conflict with your family. Responses to each item included 1 = “rarely or never,” 2 = “sometimes,” and 3 = “often” (Cronbach’s α = .80). Family conflict was calculated using the mean of all those responses.

Self-efficacy of family involvement in discussing EOL care plan

Self-efficacy of involving family in discussing an EOL care plan was measured using the Witte’s 4-Item Self-Efficacy Scale (Witte et al., 2001). Participants were asked to indicate the degree to which they agreed with the following statements: (a) I am confident that I can discuss my EOL care plan with family members, (b) I have the ability to discuss my EOL care plan with family members, (c) It would be easy for me to discuss my EOL care plan with family members, and (d) I have enough knowledge to be able to discuss my EOL care plan with family members. Responses to each item included 1 = “completely disagree,” 2 = “mostly disagree,” 3 = “neither agree nor disagree,” 4 = “mostly agree,” and 5 = “completely agree” (Cronbach’s α = .93).

Perceived benefits of family involvement in discussing EOL care plan

Perceived benefits of family involvement in discussing EOL care plan was measured by Vandecreek and Frankowski’s (1996) five-item Perceived Benefits Scale. Participants were asked to indicate the degree to which they endorse the following statements: (a) Discussing my EOL care plan with family members will help my doctor know about my medical treatment preferences in advance, (b) Discussing my EOL care plan with family members will help me get the wanted medical treatments in the future, (c) Discussing my EOL care plan with family members will help me relieve family burdens, (d) Discussing my EOL care plan with family members will help me reduce family conflicts, and (e) Discussing my EOL care plan with family members will increase the quality of my life in my last days. Responses to each item included 1 = “completely disagree,” 2 = “mostly disagree,” 3 = “neither agree nor disagree,” 4 = “mostly agree,” and 5 = “completely agree” (Cronbach’s α = .92).

Perceived barriers of family involvement in discussing EOL care plan

Perceived barriers of family involvement in discussing EOL care plan was measured by Vandecreek and Frankowski’s (1996) nine-item Perceived Barriers Scale. Participants were asked to indicate the degree to which they agreed with the following statements: (a) It makes me sad to discuss my EOL care plan with family members, (b) Discussing my EOL care plan with family members will increase my family conflicts, (c) It is difficult to discuss my EOL care plan because I do not know what my medical treatment preferences will be in the future, (d) I feel uncomfortable to discuss my EOL care, (e) Discussing my EOL care plan with family members will cause anxiety around my death, (f) I am not used to considering my EOL care plan in advance, (g) I am not sick enough to discuss EOL care plan with family members, (h) Discussing my EOL care plan with my family members is bad luck, and (i) It will make my family members sad if I discuss my EOL care plan with them. Responses to each item included 1 = “completely disagree,” 2 = “mostly disagree,” 3 = “neither agree nor disagree,” 4 = “mostly agree,” and 5 = “completely agree” (Cronbach’s α = .93).

Other covariates

Covariates included age, gender (0 = “male,” 1 = “female”), marital status (0 = “not married/partnered,” 1 = “married/partnered”), education (1 = “6th grade or lower,” 2 = “7th–9th grade,” 3 = “9th–12th,” 4 = “vocational or trade school,” 5 = “college graduate,” and 6 = “postgraduate or higher”), household annual income (intervals of US$5,000), employment status (0 = “not employed,” 1 = “employed”), daily function, expectation for intergenerational support, religiosity, and acculturation. Daily function was measured by the 15-item Katz Activities of Daily Living (ADL; each item ranging 1–3, Cronbach’s α = .95; Katz, 1983). Expectation for intergenerational support was measured by four items from the Popular Support for Filial and Parental Obligations Scale (each item ranging 1–5, Cronbach’s α = .77; Daatland et al., 2011). Religiosity was measured by the Duke University Religion Index (each item ranging 1–5 or 1–6, Cronbach’s α = .93; Koenig & Büssing, 2010). Acculturation was measured by Gupta and Yick’s (2001) 10-item 5-point Acculturation Scale (each item ranging 1–5, Cronbach’s α = .83). All items of the abovementioned scales for covariates are displayed in Table 1.

Table 1.

Participants’ Characteristics (N = 260).

Variable	M/SD	Frequency (%)
Age	73.70/9.44
Female		166 (63.85)
Married/partnered		184 (70.77)
Employed		43 (16.54)
Education	3.65/1.52
Income	2.84/2.30
ADL	2.68/0.44
Living alone		63 (24.23)
Religiosity
Experiencing presence of divine (item range: 1–5)	3.58/1.00
Religious beliefs are approaches to life (item range: 1–5)	3.34/1.61
Carrying religion over into all dealings in life (item range: 1–5)	3.23/1.56
Attending church or other religious meetings (item range: 1–6)	2.97/1.90
Spending time in private religious activities (item range: 1–6)	2.55/1.86
Acculturation (item range: 1–5)
Speaking Chinese more often than English	1.67/1.21
English is more fluent than Chinese	1.80/1.38
Celebrating more Chinese holidays and Americans holidays	2.29/1.18
Watching more Chinese TV programs than English ones	2.11/1.47
Reading more Chinese books or newspapers than English ones	1.76/1.26
Writing in English more often than Chinese	2.11/1.55
Eating mostly Chinese food	1.60/1.03
Most activities attended are sponsored by Chinese communities	1.74/1.03
Mainly shopping at Chinese or Asian stores	2.11/1.17
Feeling at home in the United States	3.97/1.00
Expectation for intergenerational support (item range: 1–5)
Parents should provide financial help to adult children	3.86/1.16
Parents should live with adult children when children have difficulty living on their own	3.61/1.29
Adult children should provide financial help to older parents	4.08/1.15
Adult children should live with older parents when parents have difficulty living on their own	3.50/1.24
Family relationships
Family cohesion (item range: 1–4)	3.46/0.48
Family conflict (item range: 1–3)	1.54/0.41
Self-efficacy of family involvement in EOL care (item range: 1–5)
Confident to discuss EOL care plan	3.61/1.24
Having ability to discuss EOL care plan	3.78/1.34
Would be easy to discuss EOL care plan	3.63/1.26
Having knowledge to discuss EOL care plan	3.53/1.27
Perceived benefits of family involvement in EOL care (item range: 1–5)
Helping doctors know treatment preferences	3.90/1.27
Helping me get the wanted medical treatment	3.95/1.25
Helping me relieve family burden	3.85/1.25
Helping me reduce family conflicts	3.68/1.34
Increasing quality of life	3.92/1.23
Perceived barriers of family involvement in EOL care (item range: 1–5)
Making me sad to discuss EOL care	2.29/1.43
Increasing my family conflicts	2.00/1.22
I don’t know my future treatment preferences	2.72/1.45
Feeling uncomfortable to discuss EOL care	2.40/1.49
Causing anxiety around my death	2.20/1.37
Not used to considering EOL care in advance	2.70/1.56
Not sick enough to discuss EOL care with family	3.16/1.62
Discussing EOL care is bad luck	2.23/1.40
Making family members sad to discuss EOL care	2.47/1.47
Attitude toward family involvement in EOL care (item range: 1–5)	3.58/1.00

Note. ADL = Activities of Daily Living; EOL = end-of-life.

Analytical Approach

We used descriptive statistics to summarize sample characteristics. We used structural equation modeling (SEM) to test the relationships proposed in this study. For the measurement component, previous research shows that ordinal variables with five or more categories can be treated directly as continuous manifest variables in SEM estimation (Rhemtulla et al., 2012), whereas item parceling, that is, aggregating individual items into “parcel(s)” and using parcel(s) as manifest variable(s), can be applied to ordinal variables with fewer than five categories (Matsunaga, 2008). Therefore, considering that items for family cohesion and family conflict had fewer than five categories, we obtained the mean scores for all items, respectively, for family cohesion and family conflict and used the two mean scores as manifest variables for the latent variable family relationships. Similarly, we obtained the mean score for all items in daily function and used this score as a covariate. As items in all other scales in this study had at least five categories, we used those items as individual manifest variables to estimate the corresponding latent variable. For the structural component, paths were constructed (a) from family relationships and each covariate simultaneously to three mediators (self-efficacy of family involvement, perceived benefits of family involvement, and perceived barriers of family involvement) and (b) from family relationships, three mediators, and each covariate simultaneously to attitude toward family involvement. We used the Satorra–Bentler correction in the model to address the violation of multivariate normality of manifest variables (Satorra & Bentler, 1994). After the estimation of the SEM model, we applied the delta method and obtained the nonlinear combination of structural coefficients to estimate the total effect of family relationships on attitude toward family involvement and the indirect effect of family relationship on attitude toward family involvement through three mediators, respectively, and together (Oehlert, 1992). All data analyses were performed in STATA SE 15.

Results

Descriptive Statistics

Table 1 displays the descriptive statistics for the sample. The average age of participants was 74 years (SD = 9.44 years). Most participants were females (63.85%) and married/partnered (70.77%). A total of 16.54% of participants were employed. The mean scores of education, income, and daily function were 3.65 (SD = 1.52), 2.84 (SD = 2.30), and 2.68 (SD = 0.44), respectively. Nearly a quarter (24.23%) of the participants was living alone. The ranges of means of items for religiosity, acculturation, and expectation for intergenerational support were, respectively, 2.55 to 3.58, 1.60 to 3.97, and 3.50 to 4.08. The means of family cohesion and family conflict were, respectively, 3.46 (SD = 0.48) and 1.54 (SD = 0.41). The ranges of means of items for self-efficacy, perceived benefits, and perceived barriers of family involvement in EOL care were, respectively, 3.53 to 3.78, 3.68 to 3.95, and 2.00 to 3.16. The mean of attitude toward family involvement in EOL care is 3.58 (SD = 1.00).

Structural Equation Model

Table 2 displays key standardized measurement coefficients, whereas Table 3 displays standardized structural coefficients of key direct effects, indirect effects, and total effect. As an important assumption of mediation, 1 SD increase in family relationships was significantly associated with 0.32 SD increase in self-efficacy of family involvement (95% confidence interval [CI] = [0.18, 0.46]), 0.25 SD increase in perceived benefits of family involvement (95% CI = [0.11, 0.40]), and 0.36 SD decrease in perceived barriers of family involvement (95% CI = [–0.46, –0.22]) after adjusting for all covariates. One SD increase in self-efficacy, perceived benefits, and perceived barriers of family involvement was significantly associated with 0.47 SD increase (95% CI = [0.36, 0.58]), 0.13 SD increase (95% CI = [0.02, 0.27]), and 0.11 SD decrease (95% CI = [–0.21, –0.01]), respectively, in attitude toward family involvement in discussing EOL care plan after adjusting for all covariates.The standardized indirect effects of family relationships on attitude toward family involvement in discussing EOL care plan through self-efficacy, perceived benefits, and perceived barriers of family involvement were, respectively, 0.15 (95% CI = [0.07, 0.22]), 0.03 (95% CI = [0.00, 0.07]), and 0.04 (95% CI = [0.00, 0.08]), all of which were statistically significant. Self-efficacy of family involvement in EOL care shows the strongest mediation effect on the association between family relationships and attitude toward discussing EOL care plan than the other two mediators. The total effect of family relationships on attitude toward family involvement was statistically significant (β = .31, 95% CI = [0.16, 0.45]); however, the direct effect of family relationships on attitude toward family involvement was not statistically significant (β = .08, 95% CI = [–0.08, 0.24]), indicating that self-efficacy, perceived benefits, and perceived barriers of family involvement fully mediated the relationship between family relationships and attitude toward family involvement (β = .22, 95% CI = [0.11, 0.33]).

Table 2.

Key Standardized Measurement Coefficients (N = 260).

Variable	Coefficient	95% CI
Family relationships
Family cohesion (FR1)	0.74***	[0.69, 0.80]
Family conflict (FR2)	−0.65***	[−0.71, −0.59]
Self-efficacy of family involvement in EOL care
Confident to discuss EOL care plan (SE1)	0.87***	[0.84, 0.91]
Having ability to discuss EOL care plan (SE2)	0.90***	[0.89, 0.93]
Would be easy to discuss EOL care plan (SE3)	0.84***	[0.80, 0.88]
Having knowledge to discuss EOL care plan (SE4)	0.80***	[0.74, 0.85]
Perceived benefits of family involvement in EOL care
Helping doctors know treatment preferences (BE1)	0.81***	[0.73, 0.90]
Helping me get the wanted medical treatment (BE2)	0.80***	[0.72, 0.88]
Helping me relieve family burden (BE3)	0.88***	[0.82, 0.94]
Helping me reduce family conflicts (BE4)	0.86***	[0.79, 0.93]
Increasing quality of life (BE5)	0.85***	[0.80, 0.90]
Perceived barriers of family involvement in EOL care
Making me sad to discuss EOL care (BA1)	0.78***	[0.72, 0.83]
Increasing my family conflicts (BA2)	0.70***	[1.17, 1.77]
I don’t know my future treatment preferences (BA3)	0.68***	[0.61, 0.75]
Feeling uncomfortable to discuss EOL care (BA4)	0.90***	[0.86, 0.94]
Causing anxiety around my death (BA5)	0.87***	[0.84, 0.91]
Not used to considering EOL care in advance (BA6)	0.73***	[0.66, 0.80]
Not sick enough to discuss EOL care with family (BA7)	0.48***	[0.40, 0.57]
Discussing in EOL care is bad luck (BA8)	0.84***	[0.79, 0.88]
Making family members sad to discuss EOL care (BA9)	0.78***	[0.73, 0.83]
Attitude toward family involvement in EOL care	1	—

Note. CI = confidence interval; EOL = end-of-life.

***

p < .001.

Table 3.

Standardized Structural Coefficients of Key Direct Effects, Indirect Effects, and Total Effect (N = 260).

Major paths	Coefficient	95% CI
Direct effects
Family relationships → Self-efficacy in family involvement	0.32**	[0.18, 0.46]
Family relationships → Perceived benefits of family involvement	0.25**	[0.11, 0.40]
Family relationships → Perceived barriers of family involvement	−0.36**	[−0.49, −0.22]
Self-efficacy in family involvement → Attitude toward family involvement	0.47**	[0.36, 0.58]
Perceived benefits of family involvement → Attitude toward family involvement	0.13*	[0.02, 0.27]
Perceived barriers of family involvement → Attitude toward family involvement	−0.11*	[−0.21, −0.01]
Family relationships → Attitude toward family involvement	0.08	[−0.08, 0.24]
Indirect effects
Family relationships → Self-efficacy in family involvement → Attitude toward family involvement	0.15**	[0.07, 0.22]
Family relationships → Perceived benefits of family involvement → Attitude toward family involvement	0.03*	[0.00, 0.07]
Family relationships → Perceived barriers of family involvement → Attitude toward family involvement	0.04*	[0.00, 0.08]
Family relationships → All three mediators → Attitude toward family involvement	0.22**	[0.11, 0.33]
Total effect
Family relationships → Attitude toward family involvement	0.31**	[0.16, 0.45]

Note. All parameters were estimated after adjusting for covariates. CI = confidence interval.

p < .05. **p < .001.

Figure 2 summarizes key measurement and structural coefficients after adjusting for covariates. The Satorra–Bentler-corrected relative χ² of the model was 1,384.99 (p < .001). The Satorra–Bentler-corrected root mean square error of approximation (RMSEA) was 0.04. The Satorra–Bentler-corrected Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) were, respectively, 0.93 and 0.92. All of those indicated good model fit (Arbuckle, 1995).

Figure 2.

Diagram of key structural and measurement coefficients.

Discussion

Family relationship is an important factor associated with mental and physical well-being of older Chinese Americans (Wang et al., 2020). The present study highlighted the importance of family relationships in older Chinese Americans’ attitude toward family involvement in EOL care discussions. Results of total effect revealed that better family relationships were associated with more positive attitude toward family involvement in discussing EOL care plan in this population.

Older Chinese Americans with positive family relationships are more likely to involve family members in ACP, which generally leads to positive outcomes, such as the completion of AD (Mok et al., 2010). For ethnic minorities, patient-centered, family focused, and culturally sensitive ACP is a goal that cannot be realized without the involvement of family members (Otis-Green et al., 2019). Because EOL care is a sensitive topic in Chinese culture, family members are better positioned than health professionals to initiate the conservation with older Chinese Americans (Cheng, 2018). Positive family relationship, as affirmed in this study, is essential to facilitate older adults’ discussion of ACP. Consistent with the findings from Boerner et al.’s (2013) study, this study confirms that cohesive and supportive family relationships are associated with a higher likelihood of discussing EOL care plans with family members. In contrast, conflicting or malfunctioned family dynamics, a known risk factor for poor mental health among older Chinese Americans (Sun et al., 2018), reduces the likelihood of ACP discussions with family members.

This study further sheds light on the mediating mechanisms through which family relationships influence attitudes toward family involvement in discussing EOL care plans among older Chinese Americans. The three identified mechanisms are perceived benefits, perceived barriers, and self-efficacy. The positive effect of family relationships on health behaviors and outcomes may be exerted through social support or social control provided by family members (Lewis & Rook, 1999; Thoits, 2011). The support or monitoring from family members can help older adults better grasp the benefits of ACP, reduce their perceived barriers, and enhance their self-efficacy. One study on attitude toward ACP among different generations of Chinese Americans found that the older group needed tangible support from family members to complete ACP (Lee et al., 2017). Such support includes information about ACP, interpretations of implications of the ACP in older adults’ native language, and the facilitation of ACP.

Perceived benefits of involving family members in discussing EOL plan are related to more favorable attitudes toward family involvement in EOL, whereas perceived barriers of involving family members in discussing EOL care plan are associated with less favorable attitudes toward family involvement in EOL. Such findings highlight the importance of family values when making EOL care plan decisions in Chinese culture (X. Gao et al., 2015; Ho et al., 2010). Older Chinese Americans, when considering benefits and barriers of involving family members in EOL planning, are not limited to their own quality of life or future care, but also weigh the impact of their decisions on family members and the whole family. If they perceive an overwhelming negative impact on family members’ well-being or projected high family burden and conflict, they are less likely to initiate EOL care discussions with family members, despite some perceived benefits for their own well-being. In addition, the positive effect of family relationship is internalized to older people’s perceived ability in discussing EOL care plans with family members as well as reinforced positive projections of consequences of discussing EOL care plans with family members.

When combined, the three mediators (self-efficacy, perceived benefits, and perceived barriers) explain away the direct association between family relationship and attitude toward family involvement, that is, full mediation. Such findings suggest that strong family ties and/or positive family relationships are internalized with older Chinese Americans’ perception on their self-perceived efficacy as well as their evaluated benefits and barriers regarding EOL care planning. It is also important to note that each of the three mediators reported statistically significant indirect effect, highlighting the importance of simultaneously considering all three factors in enhancing family involvement in older Chinese Americans’ EOL care planning.

Our findings have significant implications for practice. As one of the first quantitative inquiries of older Chinese Americans’ attitude toward ACP, this study presented empirical evidence highlighting the importance of family in ACP among older Chinese Americans. Our findings indicate that a family-centered approach has the potential to promote effective ACP for older Chinese Americans. As older Chinese Americans are mostly foreign-born immigrants with low acculturation levels, they may need to rely on their adult children to navigate the health and social care systems and plan for EOL care. ACP programs in primary care, hospitals, or long-term care facilities should incorporate adult children of older Chinese Americans. Older Chinese Americans with poor family relationships or limited family support warrant attention from social services and community support programs.

Several limitations of the study should be recognized. The cross-sectional design of this study precludes our ability to make causal inferences in the mediation model. Future longitudinal research needs to elucidate mechanisms underlying the association between positive family relationships, self-efficacy, perceived benefits and barriers, and attitudes toward family involvement in EOL care planning. Furthermore, this study used only a small sample of participants selected through convenience sampling, which limited the generalizability of findings to older Chinese Americans in other geographic areas. In addition, data for this study were self-reported, which may have caused biased results. This is particularly relevant to the underestimation of family conflict, as revealing family conflict to outsiders is condemned in traditional Chinese culture (G. Gao, 1998). Finally, attitude toward family involvement was measured with one single item, the reliability and validity of which could be improved in future research using multidimensional measures.

Despite these limitations, this study enhanced the understanding of the relationship between family relationships and attitude toward family involvement in discussing EOL care among older Chinese Americans. Study findings suggest that positive family relationships can enhance self-efficacy, increase perceived benefits, and reduce perceived barriers associated with EOL planning, which thereby contribute to a positive attitude toward family involvement in ACP. Such findings call for family-based ACP strategies for health and social service providers serving older Chinese Americans.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

IRB Approval

This study received the approval from the Michigan State University’s Institutional Review Board (No. i053829).

ORCID iDs

Kaipeng Wang

Dexia Kong

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