LAUSR

Dear Editor: It is well known that Asians and Pacific Islanders utilize hospice at very low rates (3.1%) compared with whites and other minority groups despite being the fastest growing racial group in the United States between 2000 and 2010. Research on Japanese Americans’ attitudes toward hospice, advance care planning, and end-of-life care discussion is limited and a greater understanding of their knowledge and attitudes is important for increasing access to and utilization of end-of-life care. Therefore, the purpose of this study was to explore Japanese Americans’ knowledge of and attitudes toward hospice care, advance care planning, communicating preferences, and developing advance directives. Two qualitative focus groups were conducted (one each in English and Japanese) among community-dwelling Japanese American adults aged 65 years or more. Participants were from a social service agency serving Japanese older adults in a large metropolitan city (n = 20). Focus groups were guided by an open-ended research protocol. Predominant themes were (1) misconceptions/misinformation about hospice, (2) attitudes toward hospice and endof-life care, and (3) cultural characteristics and traditions at end of life (Table 1). Findings indicate not only a need to increase hospice education among Japanese Americans but also suggest an interest in and acceptance of this type of information. Relatedly, participants affirmed a cultural shift among the current generation of older Japanese Americans as open and willing to discussing end-of-life care whereby previous generations were not. Cultural considerations included not wanting to be a burden, preference for family/ group decision making, and mixed preferences around disclosure of prognosis. Results suggest one reason Japanese Americans utilize hospice at low rates may be lack of knowledge and misconceptions about hospice and end-of-life care in the United States, creating a barrier to informed decision making when navigating care options. However, our results also identified pervasive interest in learning about hospice and openness to information, highlighting an opportunity for education. Despite cultural stereotypes held, many older Japanese Americans in our focus groups appeared willing to engage in prognostic and advance care planning conversations, particularly when accompanied by diagnoses of serious illness. Yet despite recognized cultural shifts in conversations, traditional values persist in the inclusion of family members in care discussions and decisions, and concern about limiting burden to family members and caregivers. This finding directly opposed results in a study of Chinese Americans that suggested hospice care may be perceived as bringing a greater burden to family members. Nevertheless, hospice care may serve as a culturally parallel response to relieving family burden among Japanese Americans. Finally, results of this study and two others point to an attitudinal shift toward greater acceptance of hospice and Western values among Japanese Americans. Although some researchers have attributed this shift to acculturation level, others have found age cohort (>70 years) to be associated with generational values. Regardless of the reason, these results underline the importance of acknowledging withingroup differences and caution against stereotyping, resulting in assumptions about what people within an ethnic or cultural group think or how they will behave. This is especially important for healthcare providers caring for older adults and those with serious illness.