Theoretical Issues Associated with Cultural Readiness for End-of-Life Care Planning in Taiwan

By Hsiung, Yvonne | Social Behavior and Personality: an international journal, September 15, 2015 | Go to article overview

Theoretical Issues Associated with Cultural Readiness for End-of-Life Care Planning in Taiwan


Hsiung, Yvonne, Social Behavior and Personality: an international journal


As medical technology advances, clinicians who work with people with terminal illnesses and their families may find it difficult to provide end-of-life (EOL) treatment decisions that are consistent with the wishes of the individual. Efforts made in previous decades to promote advance directives in the hospital context (Perkins, 2007) achieved only modest effects (Ramsaroop, Reid, & Adelman, 2007) and it was found that actual EOL care that was consistent with patient preference could not be ensured (Briggs, 2004). Although a new objective of procedural planning is being encouraged, wherein patients and their family members participate with the health care providers to contemplate and articulate EOL goals with their loved ones (Sudore & Fried, 2010), in real life, significant discrepancies remain between planned and received EOL care (Moskop, 2004), particularly among those from cultural backgrounds where the idea of advance care planning (ACP; Blackhall et al., 1999; Bonner, 1996; Braun, 1998) is relatively unfamiliar.

A growing interest in EOL research in which health behavioral theories are utilized to conceptualize and foster ACP has emerged (Foti & Hanrahan-Boshes, 2010), in which efforts were specifically made to understand EOL decision making in populations of various ethnicities (Blackhall et al., 1999; Bonner, 1996; Braun, 1998). Comprising an overlapping set of traditional behavioral theories, the transtheoretical model (TTM; Prochaska, Velicer, DiClemente, & Fava, 1988) has been widely used since the 90s for the development of intervention strategies. Several descriptive and intervention studies using the TTM to assess individuals' readiness in making advanced EOL decisions have been published (Fried, Bullock, Iannone, & O'Leary, 2009; Schickedanz et al., 2009; Sudore, 2009). However, to date, there has been little research directly examining the cultural fit of those constructs to behavioral change among people of Chinese ethnicity. Recent theoretical applications of the TTM have also been focused mainly on barriers to planning, rather than on other constructs of equal importance, such as self-efficacy and processes of change.

The Taiwanese government implemented a new Palliative Care Act in 2014, in which ACP was recognized as a national health goal to honor the autonomy of the individual as a patient and improve quality of EOL care, yet Taiwanese studies published in this area have not usually been based on behavioral theories (Chen, Wang, & Wang, 2011; Hsieh & Wang, 2011; Hu et al., 2010). A remaining fundamental task is to analyze whether or not the TTM is adequate to characterize Taiwanese individuals' EOL decision making in the context of the culture of this country. My purpose was to raise basic theoretical concerns relating to culture in the application of the TTM. To the best of my knowledge, this is the first attempt to explore the full range of TTM constructs when they are applied to Taiwanese individuals' internal intention and external behavioral change regarding ACP.

The Need to Design Stage-Based ACP Interventions for Individual Patients in Taiwan

To date, issues associated with the operationalization of the TTM in an ACP context have not been fully discussed. Previous researchers have argued that stage-based interventions are ineffective for promotion of nonaddictive health (i.e., physical activity and dietary) behaviors (Adams & White, 2003). In the case of Taiwan, this might also be true because ACP, as a nonaddictive health behavior, is a lengthy process involving deliberate decision making about a series of difficult and specific actions. One fundamental difficulty when applying the TTM is accurately defining and classifying each individual into one of the six stages of precontemplators (believers and disbelievers), contemplators, preparers, actioners, and maintainers (Prochaska et al., 1988). Categorizations of the general readiness outcomes in TTM research are usually determined by analyzing individuals' responses to a self-report measure with an algorithm based mostly on outward behavioral performance (Velicer, Prochaska, Rossi, & Snow, 1992). …

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