Introduction
Chinese Americans, numbering ∼5 million, are the fastest-growing racial/ethnic minority in the United States (Jia et al. Reference Jia, Stokes and Pan2021). Compared to non-Hispanic White Americans, Chinese Americans experience significant disparities at the end of life (EoL), including higher healthcare costs, lower quality of care due to less utilization of advance care planning (ACP), and greater reliance on intensive care services (Jia et al. Reference Jia, Leiter and Yeh2020). Due to ACP’s potential impact on EoL care utilization and quality, its engagement among U.S. racial and ethnic minorities, including Chinese Americans, has become a growing concern, especially considering their unique cultural traits (Jia et al. Reference Jia, Leiter and Yeh2020; Suk et al. Reference Suk, Kozachik and Cotter2021).
ACP is a communication process that helps individuals of any age or health status to consider and share their personal values, life goals, and preferences for future medical care. To document and trace ACP, advance directive (AD) is essential for capturing relevant information (Sudore et al. Reference Sudore, Lum and You2017; Zwakman et al. Reference Zwakman, Jabbarian and van Delden2018; Wolff et al. Reference Wolff, Scerpella and Giovannetti2025). As a key component of palliative care (Institute of Medicine Committee on Care at the End of Life Reference Field and Cassel1997), ACP is associated with improved quality of life at EoL, reduced physical and emotional suffering from excessive medical treatment, and decreased consumption of medical resources (Hein et al. Reference Hein, Knochel and Zaimovic2020; Rainsford et al. Reference Rainsford, Hall Dykgraaf and Kasim2021).
Although ACP has been shown to improve quality of life at EoL, align care with patient preferences, and reduce unnecessary interventions, its adoption remains particularly low among Chinese Americans (Nouri et al. Reference Nouri, Li and Huang2023). This might suggest that existing ACP communication may not be effective in dealing with the special cultural and contextual challenges that could impact Chinese Americans’ ACP engagements. As Morrison et al. (Reference Morrison, Meier and Arnold2021) mentioned, EoL planning is a complicated communication process, especially during highly uncertain and emotionally charged times in one’s life. For example, factors such as patients’ and families’ hesitation due to fear or feeling unprepared, along with physician-related obstacles – such as resistance to having difficult conversations, or even an unwillingness to discontinue care – can make these ACP conversations challenging among Chinese Americans (Kim and Flieger Reference Kim and Flieger2023). In addition to the above factors, complexity is increased for Chinese Americans by cultural beliefs that discourage open discussions about death and EoL care planning. For example, filial piety – a representative virtue of respecting parents and elders – can potentially contribute to families’ discomfort with having intergenerational ACP conversations (Nouri et al. Reference Nouri, Li and Huang2023). Influenced by filial piety and collectivism, many individuals of Chinese cultural backgrounds express concerns that ACP engagement and signing ADs may lead to family conflict, insufficient support from relatives, or difficulties in exercising autonomous medical decision-making (Chen et al. Reference Chen, Young and Shayya2025). These culturally rooted concerns may hinder effective ACP communication and engagement among Chinese populations, including Chinese Americans, ultimately affecting ACP completion.
Recent reviews have examined ACP knowledge and involvement, barriers and facilitators in specific cultural contexts, and the impact of acculturation in ACP practice among the Chinese diaspora (Jia et al. Reference Jia, Leiter and Yeh2020; Li et al. Reference Li, Beck and McIlfatrick2023; Zhu et al. Reference Zhu, Martina and Heide2023). However, a critical gap remains that none of these reviews specifically explored the individual elements or factors of ACP communication among Chinese Americans and the relationships of these factors to each other. ACP attitudes and communication processes among Chinese Americans can be shaped by traditional Chinese cultural values such as collectivist orientation, which focuses on the interactions between individuals, their families, and society (Nouri et al. Reference Nouri, Li and Huang2023; Ahn et al. Reference Ahn, Sebok-Syer and Maniate2025). In contrast, the United States is a highly individualistic society, with loosely connected social structures in which people are expected to have individual rights to make medical decisions (Jiang et al. Reference Jiang, Wei and Zhang2022; Ahn et al. Reference Ahn, Sebok-Syer and Maniate2025). Within this context and considering language environments and communication preferences (Yonashiro-Cho et al. Reference Yonashiro-Cho, Cote and Enguidanos2016), Chinese Americans may hold distinctive patterns of ACP engagement compared with other populations. Furthermore, given that ACP research and practice remain in the early stages among Chinese residents and that death education is relatively limited (Yao et al. Reference Yao, Zhang, Li, Xia, Jiang, Chen, Li, Wu and Song2025), Chinese Americans may face barriers to ACP communication and engagement due to insufficient prior experience and cultural contextual differences in the United States. Accordingly, identifying potential influencing factors is critical to addressing their unique ACP communication needs. Therefore, the purpose of this integrative review is to identify the key factors influencing culturally congruent ACP communication among Chinese Americans and to develop a conceptual framework to guide ACP conversations within this population. Given the underutilization of ACP among Chinese Americans, this framework may help tailor culturally sensitive communication strategies for this community.
Methods
Data sources and search strategy
Following the PRISMA guidelines (Shamseer et al. Reference Shamseer, Moher and Clarke2015), 5 electronic databases (PubMed, CINAHL, Web of Science, PsycINFO, and Embase) were used to systematically search and identify potential publications published before July 1, 2025, that matched the inclusion criteria. With the guidance of a health science librarian, a comprehensive list of MeSH terms and relevant keywords and search strategy was developed (Table 1). The terms “Advance Care Planning,” “Advance Directives,” or “living wills” combined with “Chinese Americans,” “Chinese Diaspora,” or “Chinese Immigrants” were used.
MeSH terms, relevant keywords, and databases used for literature search
Table 1 Long description
Search strategy elements are listed for databases, search terms, targeted information, example syntax, and limitations. Databases searched were PubMed, Embase, Web of Science, PsycInfo, and CINAHL. Search terms include advance care planning and related phrases such as advance directives, medical power of attorney, living wills, and end of life planning, conversation, and decision making. Population terms include East Asian People, Chinese, Asian continental ancestry group, Chinese immigrant, migrant, diaspora, Chinese American, Chinese speaking, Asian American, and Chinese immigrant health. Targeted information is listed as advance care planning, communication, culture, factors, and end of life. An example PubMed syntax combines the advance care planning term set with the population term set using MeSH and title or abstract fields. Limitations are English written only and peer reviewed primary research with investigators reported data only.
Inclusion and exclusion criteria
The inclusion criteria for this review are as follows: (1) studies that focused on any type of ACP describing any cultural barriers and facilitators of communication; (2) the study sample was entirely Chinese Americans or included a majority (>50%) of Chinese Americans, with results reported by racial/ethnic group; (3) participants were ≥18 years old; (4) peer-reviewed primary research with investigators reported data; and (5) any study design without publication date limitation. The exclusion criteria for this review are as follows: (1) studies that focused on the topic of euthanasia and physician-assisted dying with insufficient information about ACP; (2) studies that focused only on racial disparities in ACP utilization or life-sustaining treatment preferences, without considering cultural, linguistic, or other relevant factors influencing Chinese American engagement in ACP conversations; (3) publications of reviews, letters, editorials, comments, case reports, chapters, protocols, and conference abstracts; (4) articles published in non-English; and (5) articles with no access to the full text of studies. Figure 1 summarizes the steps in the search process.
Quality appraisal
The Mixed Methods Assessment Tool (MMAT) was used to conduct the critical quality assessment for included studies (Pace et al. Reference Pace, Pluye and Bartlett2012). Two authors independently assessed the quality of included studies through full-text review. Then the results were compared using an Excel sheet, and any discrepancies were resolved through further review by a third reviewer. The MMAT is a scoring system used to evaluate article quality for various research designs, including qualitative, quantitative randomized controlled trials, quantitative nonrandomized, quantitative descriptive, and mixed-methods studies. The purpose of the article, research design, methodology, recruitment, data collection procedure, description of results, discussion, and conclusion was evaluated according to the MMAT guideline. Each element of every article was rated as either high, moderate, or low quality, and a total quality score was calculated (Afaya et al. Reference Afaya, Konlan and Kim Do2021). In this review, studies that did not meet the minimum quality threshold (i.e., scoring <60% on the predefined appraisal criteria) were excluded to ensure methodological rigor.
Data extraction and analysis
For each article, the following information was extracted: authors and year published, aim, study design, sample and settings, characteristics of participants (e.g., mean age, percentage of female participants), and main findings. The first author conducted the data extraction using a Microsoft Excel table by focusing on the necessary information reported in the results sections of included articles. Extracted data highlighted the factors influencing Chinese Americans’ engagement in ACP communication, such as knowledge, attitudes, English proficiency, and communication preferences (Abad et al. Reference Abad, Shah and Daack-Hirsch2024). To ensuremethodological rigor, all articles were reviewed frequently to improve the completeness and accuracy during the data extraction process (Abad et al. Reference Abad, Shah and Daack-Hirsch2024). After data extraction, qualitative techniques were used (Lubbe et al. Reference Lubbe, Ham-Baloyi and Smit2020). A directed content analysis approach was applied to guide data synthesis. The process for generating categories about the elements of ACP communication involved combining outcomes from mixed-methods studies, or summarizing crucial variables or results in quantitative research, or categorizing data from qualitative studies. To make sure these categories appropriately represent the data, they were iteratively refined through analysis and cross-comparison (Whittemore and Knafl Reference Whittemore and Knafl2005). The initial coding was based on the shared patterns derived from included articles. Through an iterative process of coding, comparison, and refinement, these categories were further refined into more specific subcategories (Abad et al. Reference Abad, Shah and Daack-Hirsch2024).
PRISMA flow diagram of the study selection process.
Figure 1 Long description
The process of identifying studies via databases and registers is outlined in a flowchart. It begins with ′Identification′ where records are identified from PubMed (154), Embase (170), Web of Science (98), CINAHL (82), PsycINFO (27), totaling 531. Records removed before screening include duplicates (226), ineligible by automation tools (0) and other reasons (40), totaling 266. ′Screening′ follows with 265 records screened. Records excluded are 232, with reasons: Not about ACP (22), Not Chinese Americans or data not separable (140), Measurement studies (11), Review/Conference/Editorial/Letter/Thesis (38), Not English (1), Duplicates (20). Reports sought for retrieval are 33, with 4 not retrieved. Reports assessed for eligibility are 29. Reports excluded are 9, due to not addressing factors influencing ACP conversations (2) and not being Chinese Americans or predominantly Chinese American (7). ′Included′ shows 20 studies included in the review, with 19 reports of included studies.
Conceptual framework development
Through the collaborative process of undertaking regular discussions and consultations among the research team, the conceptual framework was iteratively developed and refined to ensure close alignment with the emerged categories and subcategories. This collaborative process enables our research team to consistently evaluate the relationships between emerged categories and subcategories. Meanwhile, through ongoing reflection and incorporation of the included studies, the conceptual framework was adjusted and improved to ultimately reflect the patterns and connections emerging from the synthesized findings instead of merely providing a visual summary of emerged data.
Results
Out of a pool of 531 papers, a total of 19 articles from 18 studies were included in this review. The details can be found in the PRISMA diagram (Figure 1). The synthesis of the 19 articles that met the quality threshold is reported below. Table 2 provides a detailed description of the included articles.
Summary of study characteristics
See Table 2 for the summary of the table characteristics. The study sample size ranged from 14 to 18,794 participants. The included articles were published between 2015 and 2025, with the majority published in 2021 (n = 5), followed by 2023 (n = 3), and 2018 and 2022 (n = 2 each). Fourteen articles were quantitative studies, 4 were qualitative studies, and only 1 was a mixed-methods study. The settings for recruiting the participants included hospital (n = 4), community (n = 13), and community-based organization (n = 2). A majority of included studies were conducted in large metropolitan areas across the United States, with San Francisco most frequently represented (n = 3).
Quality of included studies
The quality assessment of the 20 articles revealed that the majority were either good (n = 3) or very good quality (n = 16). Based on the MMAT criteria, only 1 article (Zhou et al. Reference Zhou, Bressler and Weinberg2023) was excluded from the review. Figure 2 illustrates the specific ratings of all included articles.
Synthesis of the findings
The ACP factors included across studies fell into the following domains: (1) Psychosocial factors including knowledge, attitudes, and family dynamics; (2) Acculturation factors including language preference and length of U.S. residency; (3) Cross-cultural communication context including optimal timing and communication skills; and (4) Outcomes: ACP readiness or AD completion. Table 3 depicts the distribution of each domain from the 19 included articles. Figure 3 illustrates the conceptual framework derived from the synthesized findings.
Psychosocial factors (N = 16)
Knowledge (n = 8)
ACP knowledge refers to the Chinese Americans’ individual understanding of ACP, including its purpose, goal, legal documents, and treatment choices. Existing studies showed that only a small percentage of Chinese Americans had heard of ACP-related documents such as healthcare proxy, living will, or Do Not Resuscitate order (Gao et al. Reference Gao, Sun and Ko2015; Dhingra et al. Reference Dhingra, Cheung and Breuer2020). Although some of them had already completed AD or had previous experience as a surrogate or made EoL decisions (Hinderer and Lee Reference Hinderer and Lee2019; Ye et al. Reference Ye, Champion and Fry2021), they confused ACP with other concepts such as a will, euthanasia, making a funeral arrangement, or property distribution (Yonashiro-Cho et al. Reference Yonashiro-Cho, Cote and Enguidanos2016; Mei Ching et al. Reference MeI Ching, Ha Do and Hinderer2017). Notably, in 1 study, some Chinese American participants perceived palliative care services, including ACP, as the cessation of medical treatments instead of a personalized treatment plan to increase their quality of life (Jia et al. Reference Jia, Yeh and Lee2022). In addition, several studies indicated that participants felt it was hard to discuss ACP based on limited understanding of ACP due to the absence of culturally appropriate materials related to ACP information, Chinese language support, appropriate translated forms, and counseling services (Mei Ching et al. Reference MeI Ching, Ha Do and Hinderer2017; Jia et al. Reference Jia, Yeh and Lee2022). To address this gap, Dhingra et al. (Reference Dhingra, Lam and Cheung2021) implemented a toolkit to support clinicians in culturally informed ACP practices among Chinese Americans. They found that 78.8% of patients did not understand the purpose of ACP before the discussion. Following the ACP discussion, 97.0% of patients showed better understanding of ACP, which is consistent with Ye et al. (Reference Ye, Champion and Fry2021).
Summary of characteristics of included studies (N=19)
Table 2 Long description
Rows list 19 studies by author and year, with columns for objective, location and setting, participants, research design, and main findings about advance care planning and end of life discussions. Settings include community sites in San Francisco, Phoenix, Chicago, Honolulu, Central Texas, Atlantic, Arizona and Maryland, and Washington, DC, plus hospitals in Boston, a primary care practice in New York City, a nonprofit coalition, and electronic health records in Northern California. Sample sizes range from 14 to 18,974, with mean ages commonly in the 60s to 70s and female percentages from 33 percent to 79.8 percent. Two qualitative ethnographic studies in San Francisco with 14 participants report initiating end of life discussions during routine check ins, using indirect and depersonalized approaches, and that discussions occurred after triggering events, health changes, or advanced age. Quantitative studies report advance directive completion or ownership at 15.1 percent in a New York City primary care sample of 179, 10 percent completion and 21 percent awareness in a Phoenix sample of 385, 29.5 percent having an advance directive in a Washington, DC sample of 72, 14 percent completion in an Arizona and Maryland sample of 435, and 10.0 percent completion in Northern California electronic health records of 18,974 with language groups at 13.3 percent for English preference, 6.1 percent for non English with no interpreter, and 5.1 percent for non English needing an interpreter. Unfamiliarity and understanding gaps are reported, including 56.8 percent unfamiliar with any type of advance directive in the New York City primary care study and 78.8 percent not understanding the purpose of advance care planning before discussion in a New York City community pilot of 66. Willingness and intentions are reported, including 74.4 percent willing to complete an advance directive in the future in the New York City primary care study and 86.5 percent intending to complete advance directives after heart to heart cards in a nonrandomized study of 2,267. Several studies report associations with acculturation and time in the United States, including greater awareness linked to higher acculturation and more than 20 years in the United States in Phoenix, and U. S. born participants having higher odds of advance care planning contemplation and discussion and burial planning than foreign born in Honolulu. A Boston hospital study of 63 advanced cancer patients compares Chinese American and White patients on goals of care and end of life care discussions, timing in median days before death, interpreter use at 97 percent among Chinese American patients, and higher family presence percentages for Chinese American patients in both discussion types. Mixed method community work in San Francisco reports themes of reducing family burden, barriers such as lack of intergenerational tools, and a readiness score increasing from 1.66 to 2.03 with a reported p value less than 0.001.
ACP = advance care planning; AD = advance directive; EoL = end of life; GoC = goals of care; OG = older generation; YG = younger generation; Qual = qualitative; Quan = quantitative; OR = odds ratio; AOR = adjusted odds ratio; CI = confidence interval; SD = standard deviation; b: regression coefficient (unstandardized beta).
Attitudes (n = 8)
Attitudes regarding ACP represent Chinese Americans’ emotional and psychological disposition about ACP and related topics such as EoL care, death, which may be shaped by cultural and religious beliefs as well as perceived risks about future medical care. Across 2 studies, Chinese Americans tended to have neutral attitudes toward ACP (i.e., neither strongly positive nor negative), with mean scores ranging from ∼47.31 to 49.96 (Hinderer and Lee Reference Hinderer and Lee2019; Ye et al. Reference Ye, Champion and Fry2021). In 2 different studies, authors reported that some participants recognize the role of ACP in reducing family burden and guiding surrogates in decision-making (Mei Ching et al. Reference MeI Ching, Ha Do and Hinderer2017; Nouri et al. Reference Nouri, Li and Huang2023). In addition, participants stated that past experiences such as witnessing the suffering of others who lacked EoL care plans shaped their attitudes and beliefs related to ACP in a positive and favorable way (Mei Ching et al. Reference MeI Ching, Ha Do and Hinderer2017). However, cultural taboos remain a significant barrier. In the included studies, Chinese Americans mentioned that talking about topics around death was seen as potentially cursing someone to death or even killing them (Yonashiro-Cho et al. Reference Yonashiro-Cho, Cote and Enguidanos2016; Mei Ching et al. Reference MeI Ching, Ha Do and Hinderer2017; Dhingra et al. Reference Dhingra, Cheung and Breuer2020; Kim et al. Reference Kim, Jiang and Duberstein2025). Participants mentioned that the future is uncontrollable, and some of them treated the unpredictability as hope, while others felt that it brought acceptance and resignation (Jia et al. Reference Jia, Yeh and Lee2022). However, attitude alone may not predict positive ACP behaviors among Chinese Americans. Hinderer and Lee (Reference Hinderer and Lee2019) found that in those individuals who did not have an AD before, there was no relationship between ACP discussion and Advance Directive Attitude Survey scores at 1-month post-discussion (p = 0.189).
This risk of bias plot shows the detailed information about the results of quality appraisal based on Mixed Methods Appraisal Tool (MMAT) criteria.
Figure 2 Long description
This risk of bias plot shows the detailed information about the results of quality appraisal based on Mixed Methods Appraisal Tool criteria. The heat map displays study types and citations along the vertical axis and items A1 to A5, S1, S2 along the horizontal axis. The legend indicates that dark gray represents ′Can′t tell′ and light gray represents ′Yes′. Most items are marked ′Yes′ across studies. ′Can′t tell′ appears mainly in A4 and in Zhou et al. 2023 across A1, A2 and A4. Quantitative non-randomized studies show multiple ′Can′t tell′ entries in A4. All other studies have no ′Can′t tell′ cells.
This conceptual framework depicts the proposed mechanism of various culturally tailored factors toward Chinese Americans’ advance care planning (ACP) conversations.
Distribution of domains of included studies (N=19)
Table 3 Long description
Checkmarks indicate which studies addressed seven factors grouped as psychosocial factors, acculturation factors, and cross cultural communication strategies. Psychosocial factors include knowledge and attitude, each labeled with n equals 8, and family dynamics, labeled with n equals 9. Acculturation factors include language preferences, labeled with n equals 8, and length of U. S. residency, labeled with n equals 9. Cross cultural communication strategies include optimal timing, labeled with n equals 4, and communication skills, labeled with n equals 6. By study, Chi et al. 2018b marks optimal timing and communication skills, and Chi et al. 2018a marks family dynamics and optimal timing. Dhingra et al. 2020 marks knowledge, attitude, language preferences, and length of U. S. residency, and Dhingra et al. 2021 marks knowledge and language preferences. Gao et al. 2015 marks knowledge, family dynamics, length of U. S. residency, and communication skills; Glover et al. 2022 marks family dynamics, language preferences, and optimal timing; Hinderer and Lee 2019 marks knowledge, attitude, and optimal timing. Jia et al. 2021 marks language preferences and length of U. S. residency, and Jia et al. 2022 marks knowledge, attitude, family dynamics, length of U. S. residency, and communication skills. Kim et al. 2025 marks attitude and length of U. S. residency; Mei Ching et al. 2017 marks knowledge, attitude, family dynamics, and communication skills; Nouri et al. 2023 marks attitude, language preferences, and communication skills; DHW et al. 2023 marks language preferences. Pei et al. 2021 marks family dynamics and length of U. S. residency; Wang et al. 2021 marks family dynamics and length of U. S. residency; Wang et al. 2024 marks family dynamics only; Ye et al. 2021 marks knowledge, attitude, and length of U. S. residency; Yonashiro-Cho et al. 2016 marks knowledge, attitude, language preferences, and communication skills; Zhang et al. 2023 marks family dynamics, language preferences, and length of U. S. residency.
Family dynamics (n = 9)
Family dynamics in ACP refers to the intergenerational communication patterns and decision-making processes within Chinese American families regarding EoL care planning. There are consistent findings that Chinese Americans preferred to have face-to-face and in-depth EoL care conversations occur within their family, preferably between spouses, before disclosing their EoL care decisions to their adult children and nonfamily members (Chi et al. Reference Chi, Cataldo and Ho2018a; Glover et al. Reference Glover, Schroeder and Ernst2022; Jia et al. Reference Jia, Yeh and Lee2022). To be specific, participants most preferred daughters (55.1%) as decision-makers, followed by sons (49.1%), spouses (45.5%), and, to a much lesser extent, doctors (15.8%) and others (6.5%) (Gao et al. Reference Gao, Sun and Ko2015). While some participants, especially younger generations, found it easier to talk about ACP with their children (Mei Ching et al. Reference MeI Ching, Ha Do and Hinderer2017), many Chinese Americans still had concerns about causing a burden on families (Gao et al. Reference Gao, Sun and Ko2015). Notably, family conflict appears to be a double-edged factor. For example, Pei et al. (Reference Pei, Zhang and Wu2021) found that higher levels of family conflict were linked with a higher likelihood of ACP contemplation (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.07–1.38), ACP discussion (OR 1.22, 95% CI 1.07–1.39), and preference in burial planning (OR 1.22, 95% CI 1.04–1.42). Conversely, Wang et al. (Reference Wang, Sun and Liu2024) reported that family conflict was negatively associated with self-efficacy in EoL care planning with family after adjusting for all covariates (b = −0.472, p < 0.05, 95% CI [−0.922, −0.063]). To understand this scenario, several studies showed that positive ACP behaviors, such as having ACP conversations and completion of AD, require intergenerational support. Consistent with Zhang et al. (Reference Zhang, Sun and Hirsch2023), Wang et al. (Reference Wang, Liu and Sun2021) found that 1 additional unit of expectation of intergenerational support was significantly associated with 52% increase in the odds of AD completion (OR 1.52, 95% CI 1.02–2.27).
Acculturation factors (N = 14)
Language preferences (n = 8)
Language preferences play a key role in Chinese Americans’ ACP communication. A consistent pattern across papers is identified in first-generation Chinese American immigrants, who primarily speak various Chinese dialects and less frequently English (Dhingra et al. Reference Dhingra, Cheung and Breuer2020; Zhang et al. Reference Zhang, Sun and Hirsch2023). For example, in the studies that reported language or dialect, Cantonese was the most frequently reported dialect, followed by Mandarin, Fuzhounese, and Toisanese (Yonashiro-Cho et al. Reference Yonashiro-Cho, Cote and Enguidanos2016; Dhingra et al. Reference Dhingra, Cheung and Breuer2020, Reference Dhingra, Lam and Cheung2021; Nouri et al. Reference Nouri, Li and Huang2023). Glover et al. (Reference Glover, Schroeder and Ernst2022) found that 97% of Chinese American patients (n = 63) in their study required an interpreter for the EoL care conversations, which demonstrates the need to assess English proficiency among Chinese Americans before any discussions. Furthermore, limited English proficiency may be associated with AD completion. In 1 study, participants who indicated English as their primary language had more than 10 times greater odds of having an ACP conversation than those who indicated Chinese as their primary language (OR = 11.85, p < 0.01) (Zhang et al. Reference Zhang, Sun and Hirsch2023), which is consistent with Oh et al. (Reference Oh, Conell and Lyon2023). In other words, the ability to speak English was positively associated with the completion of AD (χ 2 = 11.5, p < 0.001) (Yonashiro-Cho et al. Reference Yonashiro-Cho, Cote and Enguidanos2016). Finally, limited English reading and writing capacity can potentially further complicate ACP communication when the English-based ACP materials are used (Jia et al. Reference Jia, Stokes and Pan2021).
Length of U.S. Residency (n = 9)
The length of U.S. residency, another indicator of Chinese Americans’ acculturation levels, is potentially linked with ACP engagement. Based on the results from multiple studies, it is evident that the majority of Chinese Americans participating were long-term residents, with an average duration in the United States varying from 10 to 25 years (Jia et al. Reference Jia, Stokes and Pan2021, Reference Jia, Yeh and Lee2022; Zhang et al. Reference Zhang, Sun and Hirsch2023; Kim et al. Reference Kim, Jiang and Duberstein2025). A longer residency in the United States seems to be a facilitator of ACP behaviors. For example, Zhang et al. (Reference Zhang, Sun and Hirsch2023) found that each additional 1-year increase in the length of stay in the United States increased the odds of having ACP conversations with family by 4% (OR = 1.04, p < 0.05). Similarly, Gao et al. (Reference Gao, Sun and Ko2015) reported that older Chinese Americans with higher acculturation levels and those living more than 20 years in the United States were more likely to have an awareness of ADs. However, inconsistent with the above findings, Ye et al. (Reference Ye, Champion and Fry2021) showed that there were weak or no significant correlation between years in the United States and ACP knowledge scores unless there was other evidence of greater acculturation. Notably, low levels of acculturation among Chinese Americans, even those with long-term residency, impacts ACP behaviors (Dhingra et al. Reference Dhingra, Cheung and Breuer2020; Jia et al. Reference Jia, Yeh and Lee2022). However, in contrast, U.S.-born Chinese Americans and those with higher acculturation were significantly more likely to have ACP contemplation and discussion (Pei et al. Reference Pei, Zhang and Wu2021), and even to complete AD (Wang et al. Reference Wang, Liu and Sun2021).
Cross-cultural communication context (N = 9)
Optimal timing (n = 4)
Optimal timing is recognized as a crucial factor influencing cross-cultural ACP communication among Chinese Americans. Optimal timing refers to the most ideal and effective period to initiate conversations related to EoL care among stakeholders, including Chinese Americans, family members, and healthcare professionals. In a qualitative study, Chi et al. (Reference Chi, Cataldo and Ho2018a) introduced the concept of a “temporal window” – a period during which opening ACP conversations is regarded as most appropriate and effective. Optimal timing or a “temporal window” typically occurs during triggering events, such as the older adult’s health-care encounters, hospitalization, falls, retirement, or changes in health status (Chi et al. Reference Chi, Cataldo and Ho2018a, Reference Chi, Cataldo and Ho2018b). Though these triggering events can be acknowledged, optimal timing can still be challenging to determine in the moment, as it requires sensitivity to both emotional and relational cues (Mei Ching et al. Reference MeI Ching, Ha Do and Hinderer2017). Mei Ching et al. (Reference MeI Ching, Ha Do and Hinderer2017) found that participants struggled to find the right moment to initiate conversation about ACP, and being in a good mood was felt to help with these discussions. In addition, optimal timing seems to be different across racial groups. Glover et al. (Reference Glover, Schroeder and Ernst2022) demonstrated that Chinese American and non-Hispanic White patients had comparable rates of ACP conversations; however, Chinese American patients tended to have ACP discussions earlier than the day of death for all 3 types of conversations (i.e., prognosis, goals of care, and EoL care conversations) with a median of 34.0, 15.5, and 34.0 days, respectively. Chi et al. (Reference Chi, Cataldo and Ho2018b).
Communication skills (n = 6)
Across 6 studies, the evidence demonstrated that the ideal ACP communication strategies among Chinese Americans can be characterized as clinician-initiated dialogs in a culturally appropriate approach. Although most of the participants felt comfortable talking about EoL care preferences with physicians, several authors noted the importance of the conversations being initiated by clinicians after the clinician first acknowledges cultural taboos related to death by using indirect, respectful, concise communication styles (Gao et al. Reference Gao, Sun and Ko2015; Yonashiro-Cho et al. Reference Yonashiro-Cho, Cote and Enguidanos2016; Chi et al. Reference Chi, Cataldo and Ho2018b; Jia et al. Reference Jia, Yeh and Lee2022). In addition, effective communication skills also include the application of anecdotal cases, standardized policy framing, successful experiences, or symbolic gestures (e.g., culturally longevity wishes) when it relates to sensitive death topics (Mei Ching et al. Reference MeI Ching, Ha Do and Hinderer2017; Chi et al. Reference Chi, Cataldo and Ho2018b). Furthermore, nonverbal cues and sympathetic tone, such as patting the shoulder or compassionate vocal expressions, were described as supportive approaches during ACP communication (Jia et al. Reference Jia, Yeh and Lee2022). From their mixed-method study, Nouri et al. (Reference Nouri, Li and Huang2023) reported that intergenerational and community-based events to both facilitate discussion between older and younger generations, with good access to culturally, linguistically, and literacy-appropriate ACP materials would be beneficial for the success of ACP conversations. The above findings highlighted the significance of culturally informed as well as relational communication strategies among Chinese Americans.
Outcomes: ACP readiness or AD completion (N = 4)
A limited number of studies reported outcomes of Chinese Americans’ ACP communication, which included the following: (1) the intent to have EoL care discussions (Hinderer and Lee Reference Hinderer and Lee2019; Jia et al. Reference Jia, Stokes and Pan2021; Ye et al. Reference Ye, Champion and Fry2021; Nouri et al. Reference Nouri, Li and Huang2023); and (2) the completion of ACP discussions and AD (Hinderer and Lee Reference Hinderer and Lee2019). In the 4 intervention trials, Chinese American attitudes toward and likelihood to complete ACP increased in response to the interventions. For example, Hinderer and Lee (Reference Hinderer and Lee2019) found that their nurse-driven intervention improved the attitude toward ADs among 72 Chinese Americans, and this subsequently facilitated their AD completion and ACP discussions. After developing a culturally tailored ACP tool, heart to heart (HTH) Cards, Jia et al. (Reference Jia, Stokes and Pan2021) conducted 316 HTH Cafés, inspired by the death café model. The results showed that almost every participant (99.5%) felt positive about the HTH Café and expressed intent to complete ADs (86.5%). Similarly, Nouri et al. (Reference Nouri, Li and Huang2023) developed a novel ACP tool and designed intergenerational events, finding that ACP readiness among 195 participants increased significantly after the community-based ACP-promoting pilot events (1.66 [SD 0.84] vs. 2.03 [SD 0.85]; p < 0.001). Finally, Ye et al. (Reference Ye, Champion and Fry2021) reported consistent findings in their web-based culturally tailored education program. They found that culturally tailored educational intervention increased the ACP knowledge scores (pre: mean, 6.04 [SD, 2.28]; post: mean, 8.75 [SD, 0.53]; p < 0.01) and attitude scores (pre: mean, 47.31 [SD, 5.69]; post: mean, 53.59 [SD, 4.37]; p < 0.01) among Chinese Americans.
Conceptual framework for culturally tailored ACP conversation among Chinese Americans
Guided by synthesized findings from included studies, this review developed a conceptual framework to depict the factors influencing the quality of ACP communication among Chinese Americans (Figure 3). From this conceptual framework, psychosocial factors – such as knowledge, attitudes, and family dynamics – influence how individuals process ACP information and respond to family interactions within their cultural context. Acculturation factors, including language preferences and length of residence in the United States, equally affect their capacity to have smooth and informational communication with healthcare professionals, as well as their trust in and familiarity with the U.S. healthcare system. The cross-cultural communication context emphasizes 2 considerations, including optimal timing and culturally sensitive communication skills. Specifically, determining the optimal timing to begin, choosing culturally appropriate content, and applying a sensitive and respectful tone are critical components to be considered. These factors are critical in facilitating meaningful and effective EoL conversations. Finally, the outcomes of delivered ACP communication are reflected in Chinese Americans’ increased readiness to participate in ACP, which in turn facilitates proactive behaviors such as the completion of ACP conversations and AD. All domains interact dynamically, collectively shaping ACP communication between Chinese Americans and key stakeholders, including healthcare providers.
Discussion
This review identified the unique needs of Chinese Americans in ACP communication and how those culturally tailored factors can improve the quality of EoL communication. Furthermore, this review found that there is a need for more studies to pay attention to the cross-cultural communication context, focusing on optimal timing and communication skills. A significant trend identified in the included studies is the accumulating body of knowledge on the significance of ACP knowledge, attitude, and family dynamics in having ACP conversations. Open communication, considering individual acculturation levels, is key to delivering transparent information related to ACP for Chinese Americans. Based on the synthesized findings, a conceptual framework was developed, which provides actionable insights for culturally appropriate communication guidelines and future research aimed at promoting ACP engagements in Chinese American communities.
Referencing the prior research question, existing research has emphasized familial roles in EoL communication among Chinese Americans (Chi et al. Reference Chi, Cataldo and Ho2018a; Glover et al. Reference Glover, Schroeder and Ernst2022; Jia et al. Reference Jia, Yeh and Lee2022). To be specific, rooted in Confucian norms, Chinese culture emphasizes harmonious interpersonal relationships as a crucial foundation for societal obligations and personal meaning, and they are often embedded in collective bargaining and place a high value on avoiding face-to-face disputes and preserving family harmony (Lam et al. Reference Lam, Fielding and McDowell2012; Xu et al. Reference Xu, Wen and Zuo2023). Given that many Chinese Americans prefer deep ACP conversations to take place within the family circle (Chi et al. Reference Chi, Cataldo and Ho2018a; Glover et al. Reference Glover, Schroeder and Ernst2022; Jia et al. Reference Jia, Yeh and Lee2022) – and considering their preference for clinicians to initiate such dialogs (Gao et al. Reference Gao, Sun and Ko2015; Yonashiro-Cho et al. Reference Yonashiro-Cho, Cote and Enguidanos2016; Chi et al. Reference Chi, Cataldo and Ho2018b; Jia et al. Reference Jia, Yeh and Lee2022) – healthcare professionals must proactively engage them in ACP discussions and ensure the joint participation of key family members. However, considering the potential for family conflict (Wang et al. Reference Wang, Sun and Liu2024), healthcare professionals need to inquire about the patient’s need for the participation of family members and their specific requirements. Furthermore, it is crucial to provide patients with comprehensive information regarding ACP – including the designation of a surrogate decision-maker – in order to facilitate family-centered decision-making, reduce uncertainty in communication, and enhance the consistency and effectiveness of ACP conversations.
Beyond family dynamics, clear ACP information that helps distinguish ACP from related but distinct concepts such as AD and living wills, in conjunction with individuals’ prior knowledge, is critical in shaping engagement (McMahan et al. Reference McMahan, Knight and Fried2013; Li et al. Reference Li, Beck and McIlfatrick2023). Similar to findings from Martina et al. (Reference Martina, Geerse and Lin2021), these studies demonstrated that there are several prevalent misconceptions about ACP, which include that ACP solely involves financial planning (Yonashiro-Cho et al. Reference Yonashiro-Cho, Cote and Enguidanos2016), is simply about filling out official paperwork (Dhingra et al. Reference Dhingra, Cheung and Breuer2020), or is only relevant to the cessation of treatment (Jia et al. Reference Jia, Yeh and Lee2022). This phenomenon represents a critical gap that must be addressed to ensure consistent and accurate implementation of ACP in clinical settings. Within the broader literature focusing on ACP, there are ongoing challenges as to how to best ensure that healthcare professionals possess a clear and consistent understanding of ACP and related concepts such as AD and POLST, as well as how their understanding can translate into more effective communication of ACP information to patients. Recognition that ACP is a dynamic, ongoing communication process instead of a one-time static documentation completion (Riley et al. Reference Riley, Voisin and Stevens2024) may yield positive results for Chinese Americans and their families as they reevaluate and modify their preferences over time. This approach may be particularly effective, as it aligns the ACP process with the dynamic nature of care decision-making and may help reduce their psychological resistance.
In the context of immigration, acculturation would contribute to Chinese Americans’ understanding of ACP, underscoring the importance of clear communication to reduce language-related misunderstandings. Consistent with the findings from Zhu et al. (Reference Zhu, Martina and Heide2023), our review highlighted several critical barriers to effective ACP conversations among Chinese Americans, which are limited English proficiency and low levels of acculturation. These barriers potentially impact their ability to receive, interpret, and process information related to ACP (Pandey et al. Reference Pandey, Maina and Amoyaw2021). Yet, the mechanisms through which these cultural and linguistic factors shape ACP engagement remain poorly understood, indicating a significant gap that warrants further empirical investigation. From a clinical practice perspective, linguistically appropriate educational materials developed and validated with bilingual clinical experts are crucial to guide the ACP conversations among Chinese Americans (Tsai et al. Reference Tsai, Zhang and Park2021). In addition, it is recommended that healthcare professionals, with the assistance of professional interpreters as needed, use illustrative scenarios to convey the ACP information further, paying close attention to Chinese Americans’ reactions and confirming that patients have adequate comprehension (Chan et al. Reference Chan, Nhy and Chan2019; Silva et al. Reference Silva, Tsai and Sobota2020).
Notably, our review specifically incorporates the consideration of cross-cultural communication in delivering effective ACP conversations among Chinese Americans. In terms of specific communication strategies, Chinese Americans believe that healthcare professionals should take the lead in initiating ACP conversations, as this approach is consistent with the cultural norm of respecting authority like doctors (Glover et al. Reference Glover, Jia and Waybill2024). Healthcare professionals could incorporate ACP conversations into standard medical visits and transfer them into regular components of care management and treatment planning by identifying the optimal timing for those conversations (Chi et al. Reference Chi, Cataldo and Ho2018a, Reference Chi, Cataldo and Ho2018b). In addition, storytelling may be an effective technique to share examples of positive experiences with previous patients as a way to deliver key information to Chinese Americans in need and boost their self-efficacy to discuss deeper thoughts about future EoL care (Yonashiro-Cho et al. Reference Yonashiro-Cho, Cote and Enguidanos2016; Chi et al. Reference Chi, Cataldo and Ho2018b). Furthermore, building trust and fostering positive interpersonal connections are essential to accomplishing professional interactions crucial for effective collaboration and reaching goals (Tsai et al. Reference Tsai, Zhang and Park2021).
There are several limitations in this study. The generalizability of findings can be limited as most included studies were conducted in community-based settings in large metropolitan areas, such as San Francisco. The predominance of community settings also limits in-depth understanding of ACP communication in real-world clinical practice. Additionally, interpreting the results from included studies using qualitative methods may introduce some degree of researcher bias.
Future implications
According to the findings from the 19 included articles, educational and community-based programs should be recommended for facilitating ACP conversations among Chinese Americans. Meanwhile, future studies should focus on the development of culturally and linguistically appropriate materials to promote effective ACP conversations for Chinese Americans. The findings also suggested the importance of optimal timing and communication skills for ACP conversations. The specific communication guidelines should also be built up in clinical settings to better guide healthcare professionals in leading the EoL care conversations. More qualitative studies are also needed to explore the communication styles or preferences tailored to EoL care among Chinese Americans.
Conclusions
In this review, we synthesized 19 studies to collect the evidence that can be useful for facilitating the ACP conversations among Chinese Americans. Informed by those findings, a conceptual framework highlights the key interplay between psychosocial factors, acculturation factors, and cross-cultural communication context in contributing to high-quality and effective ACP conversations between Chinese Americans and healthcare professionals. By determining those actionable pathways for culturally appropriate ACP conversations, this synthesis highlights that ACP conversations require communication competence (e.g., optimal timing and indirect communication styles), as well as cultural and systematic considerations to foster a more welcoming environment for EoL care communication within Chinese Americans.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1478951526103800
Acknowledgments
During the preparation of this work, the first author (Y. J.) used prompted ChatGPT for advice on tone, clarity, and the flow of our ideas between sentences, paragraphs, and sections. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.
Author contributions
Y.J.: Conceptualized the study, conducted the literature search, data extraction, and analysis, and drafted the initial manuscript. H.G.B.: Contributed to the research design, shared critical feedback on the research topic and conceptual framework, and reviewed and revised the manuscript in depth. S.G.W.: Reviewed the full manuscript meticulously, guiding the writing process based on the plan and journal selection, and provided substantial editorial feedback to proofread the language and contents. All authors approved the final version of the manuscript.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors have no known conflicts of interest to disclose.
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