OBJECTIVE: Culture may have an important impact on a patient’s decision whether to perform advance care planning. But the cultural attitudes
influencing such decisions are poorly defined. This hypothesis-generating study begins to characterize those attitudes in
3 American ethnic cultures.
DESIGN: Structured, open-ended interviews with blinded content analysis.
SETTING: Two general medicine wards in San Antonio, Texas.
PATIENTS: Purposive sampling of 26 Mexican-American, 18 Euro-American, and 14 African-American inpatients.
MEASUREMENTS AND MAIN RESULTS: The 3 groups shared some views, potentially reflecting elements of an American core culture. For example, majorities of all
groups believed “the patient deserves a say in treatment,” and “advance directives (ADs) improve the chances a patient’s wishes
will be followed.” But the groups differed on other themes, likely reflecting specific ethnic cultures. For example, most
Mexican Americans believed “the health system controls treatment,” trusted the system “to serve patients well,” believed ADs
“help staff know or implement a patient’s wishes,” and wanted “to die when treatment is futile.” Few Euro Americans believed
“the system controls treatment,” but most trusted the system “to serve patients well,” had particular wishes about life support,
other care, and acceptable outcomes, and believed ADs “help staff know or implement a patient’s wishes.” Most African Americans
believed “the health system controls treatment,” few trusted the system “to serve patients well,” and most believed they should
“wait until very sick to express treatment wishes.”
CONCLUSION: While grounded in values that may compose part of American core culture, advance care planning may need tailoring to a patient’s
specific ethnic views.
Key words culture - cross-cultural comparison - advance directives - terminal care - attitude toward death
These data were presented at the Tenth Annual Bioethics Summer Retreat, Brewster, Mass, June 17–21, 1998; the national meeting
of the American Society for Bioethics and Humanities, Houston, Tex, November 18–22, 1998; and the southern regional meeting
of the Society of General Internal Medicine, New Orleans, La, February 18, 19, 2000. The data were also accepted for presentation
at the national meeting of the Society of General Internal Medicine, Boston, Mass, May 4–6, 2000.
Susan Bagby and Andrew K. Diehl, MD, made helpful suggestions about earlier drafts of this article. The Mexican-American Medical
Treatment Effectiveness Research Center and the Aging Research and Education Center at the University of Texas Health Science
Center at San Antonio funded this project in part.