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Korean J Adult Nurs : Korean Journal of Adult Nursing

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Original Article

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

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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

Copyright © 2015 Korean Society of Adult Nursing

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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  • 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 1st to December 5th 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)
Female 44 (33.8)
Age (year)   70.75±5.09
65~74 98 (75.4)
≥75 32 (24.6)
Spouse Having 114 (87.7)
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)
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)
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)
No 91 (70.0)
Intention to ADs Yes 121 (93.1)
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
Female 47.84±6.08
Age (year) 65~74 49.47±5.29 4.52 ＜.001
≥75 44.69±4.86
Spouse Having 48.09±5.38 -1.12 .265
Not having 49.75±6.82
Level of education Nonea 41.70±4.92 9.45 ＜.001
Elementary schoola,b 45.56±5.14 a＜b＜c
Middle schoolb,c 48.39±4.77
High schoolb,c 48.08±4.34
Universityc 51.24±5.50
Religion Yes 48.37±5.72 0.28 .783
No 48.06±5.19
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 Selfa 49.29±5.34 5.77 a＞b .004
Childrenb 45.50±5.39
Self + Childrena 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 0~3a 39.29±3.40 16.66 ＜.001
4~7b 48.11±5.10 a＜b
8~10b 51.52±4.93
Listen about ADs Yes 47.95±4.73 0.53 .600
No 48.46±5.96
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
No 48.21±5.60
Intention to ADs Yes 48.40±5.65 0.85 .400
No 46.78±4.27
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
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    Factors Influencing Attitude toward Advance Directives of Older Cancer Patients
    Factors Influencing Attitude toward Advance Directives of Older Cancer Patients

    Characteristics of the Subjects (N=130)

    Characteristics Categories n (%) or M±SD
    Gender Male 86 (66.2)
    Female 44 (33.8)
    Age (year)   70.75±5.09
    65~74 98 (75.4)
    ≥75 32 (24.6)
    Spouse Having 114 (87.7)
    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)
    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)
    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)
    No 91 (70.0)
    Intention to ADs Yes 121 (93.1)
    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.

    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.

    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
    Female 47.84±6.08
    Age (year) 65~74 49.47±5.29 4.52 ＜.001
    ≥75 44.69±4.86
    Spouse Having 48.09±5.38 -1.12 .265
    Not having 49.75±6.82
    Level of education Nonea 41.70±4.92 9.45 ＜.001
    Elementary schoola,b 45.56±5.14 a＜b＜c
    Middle schoolb,c 48.39±4.77
    High schoolb,c 48.08±4.34
    Universityc 51.24±5.50
    Religion Yes 48.37±5.72 0.28 .783
    No 48.06±5.19
    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 Selfa 49.29±5.34 5.77 a＞b .004
    Childrenb 45.50±5.39
    Self + Childrena 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 0~3a 39.29±3.40 16.66 ＜.001
    4~7b 48.11±5.10 a＜b
    8~10b 51.52±4.93
    Listen about ADs Yes 47.95±4.73 0.53 .600
    No 48.46±5.96
    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
    No 48.21±5.60
    Intention to ADs Yes 48.40±5.65 0.85 .400
    No 46.78±4.27
    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.

    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.

    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)

    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)

    SE=standard errors;

    Unstandardized coefficients.

    Table 1.

    Table 2.

    Table 3.

    Table 4.

    Table 5.

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