Advanced care planning (ACP) can improve healthcare outcomes for patients, their families, and care teams. However, to be effective, ACP should reflect and respect the culture of each country where it is implemented. Unfortunately, most ACP research and guidelines reflect a distinctly Western perspective.
So said Sun-Hyun Kim, MD, PhD, a professor at the International St. Mary’s Hospital College of Medicine, Catholic Kwandong University, at the 2022 Asia Conference on Lung Cancer, which took place in October in Nara, Japan. Dr. Kim summarized the benefits of advanced care planning and how it could be effectively implemented across Asia.
Advanced care planning increases autonomy, peace, and the quality of end-of-life care for patients, Dr. Kim said. Additionally, it typically lessens the impact of grief and the likelihood of developing post-traumatic psychiatric conditions for patients’ family members. From a broader economic perspective, these advanced planning practices also lead to decreased resource utilization and costs across a nation’s healthcare system.
“Although ACP had been implemented in many fields, [historically] there were no guidelines or recommendations for the definition or uses of ACP,” Dr. Kim explained.
In 2017, Judith Rietjens, PhD, and a team supported by the European Association for Palliative Care (EAPC) published a study that included a definition and recommendations for advanced care planning.1 These guidelines defined the roles and tasks of providers, policy and regulatory considerations, and evaluation metrics. In the US, Rebecca L. Sudore, MD, led a similar effort that led to a consensus definition of ACP from a multidisciplinary Delphi Panel.2
“Most regions have unique cultures and religious characteristics,” Dr. Kim said. “So advanced care planning recommendations, including Dr. Rietjens’, should reflect local customs and cultures.”
She noted that Asian cultures tend to have a greater emphasis on family-oriented autonomy and values like filial piety versus the focus on individual freedom more prominent in Western society.
Dr. Kim explained that diagnosis non-disclosure to patients with terminal conditions has traditionally been widespread in clinical practice in Eastern culture because providers and families did not want to place unwanted stress upon the patient. She cited a study from Korea that showed that out of 143 patients with a do-not-resuscitate directive, only one of these discussions took place directly with the patient.3 However, some practices across Asian countries may be evolving.
“As technology and the ways of communication improve repeatedly, younger generations are sensitive to these changes,” Dr. Kim stated. “They have less heterogeneity to other countries’ culture compared to older generations.”
Individual autonomy is slowly becoming more important in Asian cultures. Dr. Kim said this gradual evolution is reflected in recent legislation from Taiwan, including The Natural Death Act (2000) and the Patient Right to Autonomy Death Act in Taiwan (2019). These trends could facilitate more active and shared decision-making processes with patients.
Recently, The Asia Pacific Hospice Palliative Care Network conducted a study that was very similar to the EAPC’s to determine if advanced care planning could be effectively implemented in Asia. To account for cultural differences between Asian countries, 23 experts from six unique sectors (Hong Kong, Japan, Korea, Singapore, Taiwan, and Indonesia) were included. Dr. Kim was one of the experts representing Korea. When the results are officially published, this study will be the first to reflect Asian culture’s approaches and attitudes regarding advanced care planning.
“The biggest difference from the EAPC guidelines is the emphasis on a person-centered and family-based approach,” Dr. Kim said. “Times are changing, but the concept of family is still important in Asia.”
- 1. Rietjens JAC, Sudore RL, Connolly M, et al. Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care. Lancet Oncol. 2017;18(9):e543-e551. doi:10.1016/S1470-2045(17)30582-X
- 2. Sudore RL, Lum HD, You JJ, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017;53(5):821-832.e1. doi:10.1016/j.jpainsymman.2016.12.331
- 3. Oh DY, Kim JE, Lee CH, et al. Discrepancies among patients, family members, and physicians in Korea in terms of values regarding the withholding of treatment from patients with terminal malignancies. Cancer. 2004;100(9):1961-1966. doi:10.1002/cncr.20184