CORE VALUE INFLUENCES ON ADVANCED DIRECTIVE DECISION MAKING IN JAPAN

Purpose: Advanced care directives (ACD) can improve shared decision making, help avoid unwanted, aggressive care, and decrease caregiver bereavement at the end-of-life (EOL). However, research suggests that a very small percentage of the Japanese population has an ACD. Since ACDs involve preselecting preferred EOL treatment, low rates of adoption pose significant problems for patients, families, and healthcare providers in Japan. Seeking to understand positive ways to enhance diffusion of ACDs in Japan, a multinational research team pilot tested an ACD planning decision aid (DA) and measured individual difference effects on participants’ decisional conflict, confidence, and preparedness.  

Method: 224 Japanese participants (age 45-65, x̄=56; 50% female) without ACDs were recruited from an online panel.  Using a scenario study design, participants were told they were meeting with their physician in the near future to discuss whether to adopt an ACD regarding preference for tube feeding, intravenous nutrition, or palliative care only at EOL. In preparation, their physician has asked them to review an online DA. Thereafter, they responded to questions measuring readiness to participate in the consultation as well as their cultural values and death-related attitudes.   

Result: Participants evaluated the DA positively (x̄=3.46/5). Regression models with relevant gender/age controls tested hypothesized relationships between individual difference predictors and relevant outcome measures. Participants who valued self-independence and group-interdependence reported significantly lower decisional conflict (β=-.372; p<.001/ β=-.160; p=.008), higher preparedness (β=.309; p<.001/ β=.226; p=.001), and higher confidence (β=.389; p<.001/ β=.226; p<.001). Furthermore, having more positive attitudes toward death predicted lower decisional conflict (β=-.169; p=.010), while preferring life sustaining technologies predicted lower confidence regarding consultation participation (β=-.251; p<.001).  

Conclusion: Results point to the importance of targeting for early ACD adoption segments of Japanese 45-65 year olds with strong individual identities and strong relationships with family/ partners. Individuals within this segment who hold more positive death attitudes and lower EOL sustaining technology preferences appear particularly likely as early adopters. These constructs can be measured within the clinic before consultation. Japanese middle age patients who hold core values at the other end of the spectrum may benefit from additional decision support (e.g., use of patient navigators with the DA) as they are likely to have higher decisional conflict and feel less prepared/confident to participate in advanced directive decision making.