Dealing With Death Taboo: Discussion of Do-Not-Resuscitate Directives With Chinese Patients With Noncancer Life-Limiting Illnesses

Am J Hosp Palliat Care. 2019 Sep;36(9):760-766. doi: 10.1177/1049909119828116. Epub 2019 Feb 11.


Background: Noncancer patients with life-limiting diseases often receive more intensive level of care in their final days of life, with more cardiopulmonary resuscitation performed and less do-not-resuscitate (DNR) orders in place. Nevertheless, death is still often a taboo across Chinese culture, and ethnic disparities could negatively affect DNR directives completion rates.

Objectives: We aim to explore whether Chinese noncancer patients are willing to sign their own DNR directives in a palliative specialist clinic, under a multidisciplinary team approach.

Design: Retrospective chart review of all noncancer patients with life-limiting diseases referred to palliative specialist clinic at a tertiary hospital in Hong Kong over a 4-year period.

Results: Over the study period, a total of 566 noncancer patients were seen, 119 of them completed their own DNR directives. Patients had a mean age of 74.9. Top 3 diagnoses were chronic renal failure (37%), congestive heart failure (16%), and motor neuron disease (11%). Forty-two percent of patients signed their DNR directives at first clinic attendance. Most Chinese patients (76.5%) invited family caregivers at DNR decision-making, especially for female gender (84.4% vs 69.1%; P = .047) and older (age >75) age group (86.2% vs 66.7%; P = .012). Of the 40 deceased patients, median time from signed directives to death was 5 months. Vast majority (95%) had their DNR directives being honored.

Conclusion: Health-care workers should be sensitive toward the cultural influence during advance care planning. Role of family for ethnic Chinese remains crucial and professionals should respect this family oriented decision-making.

Keywords: Chinese; Hong Kong; advance care planning; advance directive; death education; do-not-resuscitate (DNR); end-of-life; palliative.

MeSH terms

  • Adult
  • Advance Directives / ethnology*
  • Age Factors
  • Aged
  • Aged, 80 and over
  • Asian Continental Ancestry Group / psychology*
  • Attitude to Death / ethnology*
  • Cardiovascular Diseases / psychology
  • Cultural Competency
  • Decision Making
  • Family
  • Female
  • Hong Kong
  • Humans
  • Kidney Failure, Chronic / psychology
  • Male
  • Middle Aged
  • Motor Neuron Disease / psychology
  • Palliative Care / psychology*
  • Resuscitation Orders / psychology*
  • Retrospective Studies
  • Socioeconomic Factors
  • Terminal Care / psychology
  • Time Factors