Factors Influencing Attitude toward Advance Directives of Older Cancer Patients

Min Hye Lee; Yeon-Hwan Park

doi:10.7475/kjan.2015.27.4.449

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Factors Influencing Attitude toward Advance Directives of Older Cancer Patients

Min Hye Lee¹, Yeon-Hwan Park²

Korean Journal of Adult Nursing 2015;27(4):449-458.
Published online: August 31, 2015

DOI: https://doi.org/10.7475/kjan.2015.27.4.449

¹College of Nursing, Seoul National University, Seoul

²College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, Korea

Corresponding author: Park, Yeon-Hwan College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 110-799, Korea. Tel: +82-2-740-8803, Fax: +82-2-765-4103, E-mail: hanipyh@snu.ac.kr

• Received: June 8, 2015 • Accepted: August 16, 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
REFERENCES

Abstract

Purpose
The aims of this study were to identify the reported attitudes of older patients with cancer toward advance directives (ADs) and the factors associated with their attitudes toward ADs.
Methods
The design was a cross-sectional survey. The age mean of the 130 participants were 70.8, and 66.2% of the participants were male. The data were collected at one university hospital in Seoul, South Korea during the period from October 1^st to December 5^th in 2013. The data collecting instruments were the Advance Directives Attitude Survey (ADAS) and questionnaires including socio-demographic and disease-related characteristics, family function.
Results
30.0% of the participants were aware of ADs, only 9% of them had been informed by healthcare providers. Most participants (93.1%) intended to complete ADs. The mean score of ADAS was 48.29. The stepwise linear regression analysis indicated that family function, perceived health status, period of education, and age accounted for a significant percentage (52.0%, p<.001) of the variance in participants’ ADAS. The variable with the greatest effect was family function.
Conclusion
The findings suggest that family function and attitude of older cancer patients need to be considered for adapting ADs to Korean health care systems. Healthcare providers should include family members in advanced care planning discussions.
Key Words: Advance directives; Advance care planning; Aged; Cancer; Family

Table 1.

Characteristics of the Subjects (N=130)

Characteristics	Categories	n (%) or M±SD
Gender	Male	86 (66.2)
Gender	Female	44 (33.8)
Age (year)		70.75±5.09
	65~74	98 (75.4)
	≥75	32 (24.6)
Spouse	Having	114 (87.7)
Spouse	Not having	16 (12.3)
Level of education	None	10 (7.8)
	Elementary school	18 (13.8)
	Middle school	23 (17.7)
	High school	38 (29.2)
	University	41 (31.5)
Religion	Yes	97 (74.6)
Religion	No	33 (25.4)
Living with	Alone	14 (10.8)
	Spouse	71 (54.6)
	Spouse & children	35 (26.9)
	Children	6 (4.6)
	Others	4 (3.1)
Medical expenses payment	Self	73 (56.2)
	Children	32 (24.6)
	Self + Children	25 (19.2)
Cancer site	HPB	98 (75.4)
	Gastroenteric	21 (16.1)
	Urinary	11 (8.5)
Period since cancer diagnosis (month)		48.36±55.40
	0~11	35 (27.0)
	12~35	32 (24.6)
	36~59	18 (13.8)
	60~83	19 (14.6)
	≥84	26 (20.0)
Period of medical treatment (month)		46.96±54.43
	0~11	36 (27.7)
	12~35	32 (24.6)
	36~59	17 (13.1)
	60~83	20 (15.4)
	≥84	25 (19.2)
Perceived health status		6.18±1.78
	0~3	7 (5.4)
	4~7	98 (75.4)
	8~10	25 (19.2)
Listen about ADs	Yes	43 (33.1)
Listen about ADs	No	87 (66.9)
Route of informed about ADs (N=43)	Healthcare provider	4 (9.0)
	Broadcast media	27 (61.4)
	Surrounding people	8 (18.2)
	Others	5 (11.4)
Awareness of ADs	Yes	39 (30.0)
Awareness of ADs	No	91 (70.0)
Intention to ADs	Yes	121 (93.1)
Intention to ADs	No	9 (6.9)
Preferred type of decision about ADs	Make one's own decision	24 (18.5)
	Discuss with family	81 (62.3)
	Discuss with family when	25 (19.2)
	necessary
Family member to discuss about ADs^†	Spouse	61 (44.5)
	Children	35 (25.5)
	Brother and Sister All family	1 (0.8) 38 (27.7)
	Others	2 (1.5)

ADs=Advance Directives; HPB=Hepatopancreaticobiliary;

^†Duplicated answer.

Table 2.

Attitude toward ADs and Family Function of the Subjects (N=130)

Variables	Items	M±SD
Attitude toward ADs	Having an ADs would make my family feel left out of caring for me.	3.32±0.56
	It is better to make an advance directive when you are healthy.	3.32±0.58
	Having an ADs would make sure that my family knows my treatment wishes.	3.30±0.55
	Making my end of life treatment wishes clear with an ADs would keep my family from disagreeing over what to do if I were very sick and unable to decide for myself.	3.19±0.64
	Having an ADs would make sure that I get the treatment at the end of my life that I do want.	3.18±0.61
	If I could not make decisions, my family would be given choices about the treatment I would receive.	3.17±0.64
	Having an ADs would prevent costly medical exposures for my family.	3.15±0.65
	I trust one of my family or friends to make treatment decisions for me if I cannot make them myself.	3.13±0.66
	Making my end of life treatment wishes clear with an ADs would help to prevent guilt in my family.	3.12±0.70
	My doctor would include my concerns in decisions about my treatment at the end of life.	3.08±0.70
	I am not sick enough to have an ADs.^†	2.97±0.74
	I would be given choices about the treatment I would receive at the end of my life.	2.96±0.71
	I think my family would want me to have an ADs.	2.69±0.85
	My family wants me to have an ADs.	2.64±0.79
	Making my end of life treatment wishes clear with an ADs would have no impact on my family.^†	2.60±0.84
	I have choices about the treatment I would receive at the end of my life.	2.48±0.95
	Total Mean	3.02±0.75
	Total Sum	48.29±5.57
Family function	Cohesion	39.36±6.84
	Adaptability	36.15±5.74
	Total Sum	75.51±11.13

ADs=advance directives;

^†Reverse score.

Table 3.

Differences of Attitude toward ADs according to Characteristics of the Subjects (N=130)

Characteristics	Categories^†	M±SD	t or F	p
Gender	Male	48.52±5.31	0.66	.511
Gender	Female	47.84±6.08	0.66	.511
Age (year)	65~74	49.47±5.29	4.52	＜.001
Age (year)	≥75	44.69±4.86	4.52	＜.001
Spouse	Having	48.09±5.38	-1.12	.265
Spouse	Not having	49.75±6.82	-1.12	.265
Level of education	None^a	41.70±4.92	9.45	＜.001
	Elementary school^a,b	45.56±5.14	a＜b＜c
	Middle school^b,c	48.39±4.77
	High school^b,c	48.08±4.34
	University^c	51.24±5.50
Religion	Yes	48.37±5.72	0.28	.783
Religion	No	48.06±5.19	0.28	.783
Living with	Alone	46.86±5.35	2.16	.078
	Spouse	48.69±5.57
	Spouse&Children	47.63±4.61
	Children	46.33±7.34
	Others	55.00±8.37
Medical expenses payment	Self^a	49.29±5.34	5.77 a＞b	.004
	Children^b	45.50±5.39
	Self + Children^a	48.96±5.47
Cancer site	HPB	48.77±5.92	1.52	.222
	Gastroenteric	46.57±4.59
	Urinary	47.36±3.04
Period since cancer diagnosis	0~11	47.40±4.68	2.04	.093
	12~35	46.69±5.49
	36~59	49.83±5.32
	60~83	48.63±5.16
	≥84	50.15±6.69
Period of medical treatment	0~11	47.47±4.63	1.53	.198
	12~35	46.88±5.70
	36~59	49.47±5.25
	60~83	49.05±5.36
	≥84	49.88±6.68
Perceived health status	0~3^a	39.29±3.40	16.66	＜.001
	4~7^b	48.11±5.10	a＜b
	8~10^b	51.52±4.93	a＜b
Listen about ADs	Yes	47.95±4.73	0.53	.600
Listen about ADs	No	48.46±5.96	0.53	.600
Route of informed about ADs	Healthcare provider	50.75±6.50	0.56	.725
	Broadcast media	47.19±4.53
	Surrounding people	49.13±5.57
	Others	47.80±2.49
Awareness of ADs	Yes	48.49±4.50	-0.29	.771
Awareness of ADs	No	48.21±5.60	-0.29	.771
Intention to ADs	Yes	48.40±5.65	0.85	.400
Intention to ADs	No	46.78±4.27	0.85	.400
Preferred type of decision about ADs	Make one's own decision	49.43±41.71	1.21	.300
	DWF	48.21±26.90
	DWF when necessary	46.92±33.21

ADs=advance directives, DWF=discuss with family; HPB=hepatopancreaticobiliary;

^†Mean followed by same letter do not differ significant at post hoc test.

Table 4.

Correlation among Variables related to the Attitude toward ADs (N=130)

Variables	X2	X3	X4	X5	X6	X7	X8	X9	X10	X11
X1	.63**	.60**	.60**	-.35**	.47**	.54**	.00	.23*	.22*	.21*
X2		.95**	.94**	-.24**	.41**	.50**	.11	.14	.13	.13
X3			.79**	-.25**	.40**	.53**	.11	.10	.09	.08
X4				-.21*	.36**	.41**	.10	.17	.16	.16
X5					-.20*	-.18*	-.19*	-.07	-.07	-.07
X6						.38**	.19*	.12	.12	.12
X7							.03	.13	.13	.13
X8								.01	.01	-.01
X9									1.00**	.99**
X10										99**

X1=attitude toward advance directives; X2=family function; X3=cohesion; X4=adaptability; X5=age; X6=period of education; X7=perceived health status; X8=no. of living together family; X9=period since cancer diagnosis; X10=period since informed about illness; X11=period of medical; ADs=Advance Directives;

*p＜.05,

**p＜.01.

Table 5.

Associations of Attitude toward Advance Directives with Variables by Stepwise Linear Regression Analysis (N=130)

Variables	B^†	SE	β	R²	t	p
(Constant)	39.69	5.98			6.64	＜.001
Family function (FACE III)	0.20	0.04	.39	.39	5.30	＜.001
Perceived health status	0.78	0.23	.25	.46	3.41	.001
Period of education (year)	0.24	0.09	.18	.50	0.18	.010
Age (year)	-0.20	0.07	-.18	.53	-2.80	.006
		R²=.53, Adjusted R²=.52, F=35.29, p＜.001

SE=standard errors;

^†Unstandardized coefficients.

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Factors Influencing Attitude toward Advance Directives of Older Cancer Patients

Korean J Adult Nurs. 2015;27(4):449-458. Published online August 31, 2015

DOI: https://doi.org/10.7475/kjan.2015.27.4.449

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Factors Influencing Attitude toward Advance Directives of Older Cancer Patients

Korean J Adult Nurs. 2015;27(4):449-458. Published online August 31, 2015

DOI: https://doi.org/10.7475/kjan.2015.27.4.449

Factors Influencing Attitude toward Advance Directives of Older Cancer Patients

Table 1.

Characteristics of the Subjects (N=130)

Characteristics	Categories	n (%) or M±SD
Gender	Male	86 (66.2)
Gender	Female	44 (33.8)
Age (year)		70.75±5.09
	65~74	98 (75.4)
	≥75	32 (24.6)
Spouse	Having	114 (87.7)
Spouse	Not having	16 (12.3)
Level of education	None	10 (7.8)
	Elementary school	18 (13.8)
	Middle school	23 (17.7)
	High school	38 (29.2)
	University	41 (31.5)
Religion	Yes	97 (74.6)
Religion	No	33 (25.4)
Living with	Alone	14 (10.8)
	Spouse	71 (54.6)
	Spouse & children	35 (26.9)
	Children	6 (4.6)
	Others	4 (3.1)
Medical expenses payment	Self	73 (56.2)
	Children	32 (24.6)
	Self + Children	25 (19.2)
Cancer site	HPB	98 (75.4)
	Gastroenteric	21 (16.1)
	Urinary	11 (8.5)
Period since cancer diagnosis (month)		48.36±55.40
	0~11	35 (27.0)
	12~35	32 (24.6)
	36~59	18 (13.8)
	60~83	19 (14.6)
	≥84	26 (20.0)
Period of medical treatment (month)		46.96±54.43
	0~11	36 (27.7)
	12~35	32 (24.6)
	36~59	17 (13.1)
	60~83	20 (15.4)
	≥84	25 (19.2)
Perceived health status		6.18±1.78
	0~3	7 (5.4)
	4~7	98 (75.4)
	8~10	25 (19.2)
Listen about ADs	Yes	43 (33.1)
Listen about ADs	No	87 (66.9)
Route of informed about ADs (N=43)	Healthcare provider	4 (9.0)
	Broadcast media	27 (61.4)
	Surrounding people	8 (18.2)
	Others	5 (11.4)
Awareness of ADs	Yes	39 (30.0)
Awareness of ADs	No	91 (70.0)
Intention to ADs	Yes	121 (93.1)
Intention to ADs	No	9 (6.9)
Preferred type of decision about ADs	Make one's own decision	24 (18.5)
	Discuss with family	81 (62.3)
	Discuss with family when	25 (19.2)
	necessary
Family member to discuss about ADs^†	Spouse	61 (44.5)
	Children	35 (25.5)
	Brother and Sister All family	1 (0.8) 38 (27.7)
	Others	2 (1.5)

ADs=Advance Directives; HPB=Hepatopancreaticobiliary;

^†Duplicated answer.

Table 2.

Attitude toward ADs and Family Function of the Subjects (N=130)

Variables	Items	M±SD
Attitude toward ADs	Having an ADs would make my family feel left out of caring for me.	3.32±0.56
	It is better to make an advance directive when you are healthy.	3.32±0.58
	Having an ADs would make sure that my family knows my treatment wishes.	3.30±0.55
	Making my end of life treatment wishes clear with an ADs would keep my family from disagreeing over what to do if I were very sick and unable to decide for myself.	3.19±0.64
	Having an ADs would make sure that I get the treatment at the end of my life that I do want.	3.18±0.61
	If I could not make decisions, my family would be given choices about the treatment I would receive.	3.17±0.64
	Having an ADs would prevent costly medical exposures for my family.	3.15±0.65
	I trust one of my family or friends to make treatment decisions for me if I cannot make them myself.	3.13±0.66
	Making my end of life treatment wishes clear with an ADs would help to prevent guilt in my family.	3.12±0.70
	My doctor would include my concerns in decisions about my treatment at the end of life.	3.08±0.70
	I am not sick enough to have an ADs.^†	2.97±0.74
	I would be given choices about the treatment I would receive at the end of my life.	2.96±0.71
	I think my family would want me to have an ADs.	2.69±0.85
	My family wants me to have an ADs.	2.64±0.79
	Making my end of life treatment wishes clear with an ADs would have no impact on my family.^†	2.60±0.84
	I have choices about the treatment I would receive at the end of my life.	2.48±0.95
	Total Mean	3.02±0.75
	Total Sum	48.29±5.57
Family function	Cohesion	39.36±6.84
	Adaptability	36.15±5.74
	Total Sum	75.51±11.13

ADs=advance directives;

^†Reverse score.

Table 3.

Differences of Attitude toward ADs according to Characteristics of the Subjects (N=130)

Characteristics	Categories^†	M±SD	t or F	p
Gender	Male	48.52±5.31	0.66	.511
Gender	Female	47.84±6.08	0.66	.511
Age (year)	65~74	49.47±5.29	4.52	＜.001
Age (year)	≥75	44.69±4.86	4.52	＜.001
Spouse	Having	48.09±5.38	-1.12	.265
Spouse	Not having	49.75±6.82	-1.12	.265
Level of education	None^a	41.70±4.92	9.45	＜.001
	Elementary school^a,b	45.56±5.14	a＜b＜c
	Middle school^b,c	48.39±4.77
	High school^b,c	48.08±4.34
	University^c	51.24±5.50
Religion	Yes	48.37±5.72	0.28	.783
Religion	No	48.06±5.19	0.28	.783
Living with	Alone	46.86±5.35	2.16	.078
	Spouse	48.69±5.57
	Spouse&Children	47.63±4.61
	Children	46.33±7.34
	Others	55.00±8.37
Medical expenses payment	Self^a	49.29±5.34	5.77 a＞b	.004
	Children^b	45.50±5.39
	Self + Children^a	48.96±5.47
Cancer site	HPB	48.77±5.92	1.52	.222
	Gastroenteric	46.57±4.59
	Urinary	47.36±3.04
Period since cancer diagnosis	0~11	47.40±4.68	2.04	.093
	12~35	46.69±5.49
	36~59	49.83±5.32
	60~83	48.63±5.16
	≥84	50.15±6.69
Period of medical treatment	0~11	47.47±4.63	1.53	.198
	12~35	46.88±5.70
	36~59	49.47±5.25
	60~83	49.05±5.36
	≥84	49.88±6.68
Perceived health status	0~3^a	39.29±3.40	16.66	＜.001
	4~7^b	48.11±5.10	a＜b
	8~10^b	51.52±4.93	a＜b
Listen about ADs	Yes	47.95±4.73	0.53	.600
Listen about ADs	No	48.46±5.96	0.53	.600
Route of informed about ADs	Healthcare provider	50.75±6.50	0.56	.725
	Broadcast media	47.19±4.53
	Surrounding people	49.13±5.57
	Others	47.80±2.49
Awareness of ADs	Yes	48.49±4.50	-0.29	.771
Awareness of ADs	No	48.21±5.60	-0.29	.771
Intention to ADs	Yes	48.40±5.65	0.85	.400
Intention to ADs	No	46.78±4.27	0.85	.400
Preferred type of decision about ADs	Make one's own decision	49.43±41.71	1.21	.300
	DWF	48.21±26.90
	DWF when necessary	46.92±33.21

ADs=advance directives, DWF=discuss with family; HPB=hepatopancreaticobiliary;

^†Mean followed by same letter do not differ significant at post hoc test.

Table 4.

Correlation among Variables related to the Attitude toward ADs (N=130)

Variables	X2	X3	X4	X5	X6	X7	X8	X9	X10	X11
X1	.63**	.60**	.60**	-.35**	.47**	.54**	.00	.23*	.22*	.21*
X2		.95**	.94**	-.24**	.41**	.50**	.11	.14	.13	.13
X3			.79**	-.25**	.40**	.53**	.11	.10	.09	.08
X4				-.21*	.36**	.41**	.10	.17	.16	.16
X5					-.20*	-.18*	-.19*	-.07	-.07	-.07
X6						.38**	.19*	.12	.12	.12
X7							.03	.13	.13	.13
X8								.01	.01	-.01
X9									1.00**	.99**
X10										99**

*p＜.05,

**p＜.01.

Table 5.

Associations of Attitude toward Advance Directives with Variables by Stepwise Linear Regression Analysis (N=130)

Variables	B^†	SE	β	R²	t	p
(Constant)	39.69	5.98			6.64	＜.001
Family function (FACE III)	0.20	0.04	.39	.39	5.30	＜.001
Perceived health status	0.78	0.23	.25	.46	3.41	.001
Period of education (year)	0.24	0.09	.18	.50	0.18	.010
Age (year)	-0.20	0.07	-.18	.53	-2.80	.006
		R²=.53, Adjusted R²=.52, F=35.29, p＜.001

SE=standard errors;

^†Unstandardized coefficients.

Table 1. Characteristics of the Subjects (N=130)

ADs=Advance Directives; HPB=Hepatopancreaticobiliary;

†

Duplicated answer.

Table 2. Attitude toward ADs and Family Function of the Subjects (N=130)

ADs=advance directives;

†

Reverse score.

Table 3. Differences of Attitude toward ADs according to Characteristics of the Subjects (N=130)

ADs=advance directives, DWF=discuss with family; HPB=hepatopancreaticobiliary;

†

Mean followed by same letter do not differ significant at post hoc test.

Table 4. Correlation among Variables related to the Attitude toward ADs (N=130)

*p＜.05,

**p＜.01.

Table 5. Associations of Attitude toward Advance Directives with Variables by Stepwise Linear Regression Analysis (N=130)

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