Background: The East Asian population in the United States (US) and Canada is heterogeneous and there is no agreed upon definition for ‘East Asian’ in the published literature. This Fast Fact (FF) will use “East Asian” to refer to patients who self-identify as Chinese, Taiwanese, Japanese, or Korean; and/or have cultural or familial ties to these associated locations (1). According to the 2020 US Census more than 9 million people in the US identify as East Asian (2). Since language and cultural barriers lead to health disparities in East Asian populations, this Fast Fact will assimilate published evidence and expert opinion to foster patient-centered care for patients with serious illness who self-identify as East Asian (3-5).

Importance of cultural humility and respect: While this Fast Fact discusses cultural values and trends among East Asians, there will certainly be differences among individuals and families. Avoid assumptions. East Asians living in the US and Canada may speak English fluently, prefer detailed prognostic discussions with clinicians, and have a different sense of filial obligation (6-8).

Medical interpreters: For patients or families who do not speak English as a primary language, using a professional medical interpreter is a patient right (See Fast Fact #154). Interpreters act as cultural liaisons to help clinicians understand the cultural context of the illness and nonverbal cues between family members (9). Include the interpreter in the pre-family meeting huddle to prepare them emotionally and to review culturally sensitive language (See Fast Fact #368). For example, Chinese Mandarin and many Chinese dialects have translations for hospice and palliative care that may not accurately reflect the meaning (10,11).

Common cultural values: 

• Caring for one’s elderly parents is a prevalent East Asian cultural value (12). It stems from a combination of, “filial piety” (duty to one’s parents), “saving face,” (one’s actions being influenced by how others perceive oneself), and “doing what is accepted,” (conforming to the cultural norm) (12-14). These values may lead to friction with clinicians– e.g., a child requesting nondisclosure of disease to a parent, seeking life-prolonging treatments longer than the clinical team feels are appropriate (10,15).   
• Respecting the patient and family unit is a cornerstone to building trust. Show respect by acknowledging everyone in the room and eliciting the concerns of both the patient and the family. Incorporate nonverbal behaviors such as sitting down, giving documents with two hands, nodding, smiling when appropriate, and mirroring (10,14).    
• “Trusted clinicians”, Having a trusted clinician is a key component to good end-of-life (EOL) care for East Asians (7,10,14-16). Becoming a “trusted clinician” often requires multiple encounters of respectful interactions eliciting the patient’s and family’s concerns.

Serious illness care tips for patients who self-identify as East Asian 

• Communication: Patients and families may expect trusted clinicians to initiate serious illness discussions and make recommendations on EOL decisions (7,10,14,17). This is because many East Asians avoid communication about EOL issues. Reasons include discussing death is a “cultural taboo”, fears surrounding bad luck, and/or burdening the patient with difficult information (10,13-15,17-21).  
  • Clearly state clinician’s dedication to the patient: “I am here to advocate for you.”  
  • Identify the key decision-maker in the patient-family unit, especially if the patient does not wish to make decisions themself. 
  • Ask permission to make a clinical recommendation: “I hear that [ABC goal] is important to you, may I make a recommendation?” 
  • For those unfamiliar with the health system, make clear what is possible: “Based on your goals, our health care system can offer [XYZ benefit]. Here is how this helps you achieve your goal…”  
• Advance care planning (ACP) may be a sensitive subject for many East Asians. Ask for permission to initiate an ACP discussion and consider framing it to promote filial piety.  It may be helpful to utilize an indirect approach when bringing up ACP (10,14,19-21): 
  • Share your clinical experience to explain why ACP discussions can help.  “I see many patients with dementia.  Some never get to share their preferences and that’s why I want to talk about it now.” 
  • Utilize hypothetical situations or well-publicized events to begin an ACP discussion (i.e.., Terri Schiavo). Show respect by asking for the patient’s perspectives. 
  • Normalize the completion of advance directives (ADs). ADs may not be a familiar concept to East Asians. Stress the importance of having an established surrogate if needed for familial harmony.  
• Medical decision making (MDM): The clinician must balance Western values of individualized, autonomous MDM with Eastern values of collective, familial MDM (10,14,17,19-21). Identify how involved the patient wants each family member to be in their MDM (10,14,18). If the family does not want the clinician to disclose medical information or a diagnosis to a patient, utilize the explanatory model of illness to explore their reasoning (22, See Fast Fact #26).      

The concept of a “good death”:  Being free from pain and suffering, discontinuation of futile life-sustaining treatments, being with family, and not being a burden to family are common elements of a “good death” among East Asians (7,15,16,23,24). Yet, Asian Americans are more likely to experience high-intensity EOL care and less likely to utilize hospice compared to Caucasian decedents (25).  

• Clarify patient/family’s goals of care (GOC) within the context of the underlying illness: “Given your medical condition, what is most important to you right now?”   
• Share your clinical experience when helping patients and families weigh their options: “In my experience, patients who choose path [ABC] experience [XYZ]…” 
• Make a recommendation based on the discussed GOC and utilize the patient/family’s terminology when possible. For example, if the patient/family said they wanted, “everything done,” clarify what “everything” means to them. If “everything” means to manage symptoms aggressively, consider this sample language: “I recommend that we do everything to make sure your pain is under control and that you are able to spend quality time with your family.” 

References 

1. United States Census Bureau. Detailed Race and Ethnicity Crosswalk: 2010 to 2020. 2023.  Available from:  https://www.census.gov/programs-surveys/decennial-census/technical-documentation/complete-technical-documents.html#dhc-and-dp.  Accessed November, 2023
2. United States Census Bureau. Census Bureau Releases 2020 Census Data for Nearly 1,500 Detailed Race and Ethnicity Groups, Tribes and Villages. 2023.  Available from: https://www.census.gov/newsroom/press-releases/2023/2020-census-detailed-dhc-file-a.html.  Accessed November, 2023
3. Kindig, D. A., Panzer, A. M., & Nielsen-Bohlman, L. (Eds.).  Health Literacy: A Prescription to End Confusion. National Academies.  2004.  Available from: https://www.nap.edu/catalog/10883/health-literacy-a-prescription-to-end-confusion  Accessed November, 2023
4. Jang Y, Yoon H, Park NS, Chiriboga DA. Health Vulnerability of Immigrants with Limited English Proficiency: A Study of Older Korean Americans. J Am Geriatr Soc. 2016;64(7):1498-1502. doi:10.1111/jgs.14199
5. Sentell T, Braun KL. Low health literacy, limited English proficiency, and health status in Asians, Latinos, and other racial/ethnic groups in California. J Health Commun. 2012;17 Suppl 3(Suppl 3):82-99. doi:10.1080/10810730.2012.712621  
6. Yoo GJ, Kim BW. Remembering sacrifices: attitude and beliefs among second-generation Korean Americans regarding family support. J Cross Cult Gerontol. 2010;25(2):165-181. doi:10.1007/s10823-010-9116-8
7. Mori M, Kuwama Y, Ashikaga T, et al. Acculturation and Perceptions of a Good Death Among Japanese Americans and Japanese Living in the U.S. J Pain Symptom Manage. 2018;55(1):31-38. doi:10.1016/j.jpainsymman.2017.08.010
8. Guo M, Kim S, Dong X. Sense of Filial Obligation and Caregiving Burdens Among Chinese Immigrants in the United States. J Am Geriatr Soc. 2019;67(S3):S564-S570. doi:10.1111/jgs.15735
9. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476-480.
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11. Chinese American Coalition for Compassionate Care. Glossary of End-of-Life Care Terms. April 2022.  https://www.caccc-usa.org/en/educationmat.html  Accessed February, 2024
12. Lim AJ, Lau CYH, Cheng CY. Applying the Dual Filial Piety Model in the United States: A Comparison of Filial Piety Between Asian Americans and Caucasian Americans. Front Psychol. 2022;12:786609. Published 2022 Feb 3. doi:10.3389/fpsyg.2021.786609
13. Glass AP, Chen LK, Hwang E, et al. A cross-cultural comparison of hospice development in Japan, South Korea, and Taiwan. J Cross Cult Gerontol. 2010;25(1):1-19. doi:10.1007/s10823-009-9108-8
14. Chung JE, Karass S, Choi Y, et al. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Filipino American and Korean American Patients. J Palliat Med. 2024;27(1):104-111. doi:10.1089/jpm.2023.0255
15. Lee MC, Hinderer KA, Alexander CS. What Matters Most at the End-of-Life for Chinese Americans?. Gerontol Geriatr Med. 2018;4:2333721418778195. Published 2018 Jul 17. doi:10.1177/2333721418778195
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17. Pun J, Chow JCH, Fok L, et al. Role of patients’ family members in end-of-life communication: an integrative review. BMJ Open. 2023;13(2):e067304. Published 2023 Feb 21. doi:10.1136/bmjopen-2022-067304
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19. Turnbull M, Yu C, Wu XI. Practitioner accounts of end-of-life communication in Hong Kong, Mainland China and Taiwan: A systematic review. Patient Educ Couns. 2023;106:31-41. doi:10.1016/j.pec.2022.10.007
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21. Liu TW, Wen FH, Wang CH, et al. Terminally Ill Taiwanese Cancer Patients’ and Family Caregivers’ Agreement on Patterns of Life-Sustaining Treatment Preferences Is Poor to Fair and Declines Over a Decade: Results From Two Independent Cross-Sectional Studies. J Pain Symptom Manage. 2017;54(1):35-45.e4. doi:10.1016/j.jpainsymman.2017.02.013
22. Periyakoil, VS. Psychosocial and Cultural Considerations in Palliative Care. In: Yennurajalingam, S and Bruera, E. Oxford American Handbook of Hospice and Palliative Medicine and Supportive Care. Second Edition. Oxford University Press, 2016: P252- 253
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24. Jia Z, Stokes SC, Pan SY, et al. Heart to Heart Cards: A Novel, Culturally Tailored, Community-Based Advance Care Planning Tool for Chinese Americans. Am J Hosp Palliat Care. 2021;38(6):650-657. doi:10.1177/1049909121989986
25. Jia Z, Leiter RE, Sanders JJ, et al. Asian American Medicare Beneficiaries Disproportionately Receive Invasive Mechanical Ventilation When Hospitalized at the End-of-Life. J Gen Intern Med. 2022;37(4):737-744. doi:10.1007/s11606-021-06794-6 

Authors’ Affiliations: Matthew Kwong, MD: Asian Network Pacific Home Care and Hospice, Oakland, CA; Cynthia X. Pan, MD: NewYork-Presbyterian, Queens and Weill Cornell Medical College, New York, NY.
Conflicts of Interest: None.
Version History: originally edited by Sean Marks MD; first electronically published in August 2024.