Determinants of Advance Directive Completion Among Older Chinese Americans

Abstract Advance Directive (AD) allows older adults to communicate preferred care at the end of life. Numerous studies reported that ethnic minorities were less likely to complete AD then non-Hispanic Whites. However, determinants of AD completion among older Chinese Americans remain unknown. The present study aims to address this knowledge gap. Data came from a survey of 439 Chinese Americans aged from 51 to 103 living in two metropolitan areas in 2018. Participants’ average year was 75 (SD=9.37). About 63% were women and 93% were born outside the US. Approximately 14% of participants completed an AD. Guided by the Andersen’s Service Use Model, we used logistic regression to examine determinants of AD completion. Results show that older age (OR = 1.06, p < 0.01), being employed (OR = 2.63, p < 0.05), acculturation (OR = 2.09, p < 0.001), having US citizenship (OR = 3.57, p < 0.01), and expectation of intergenerational support (OR = 1.84, p < 0.05), were positively associated with AD completion. Physical and mental health needs were not significantly associated with AD completion. This is among the first studies focusing on AD completion among Chinese Americans, one of the fastest growing older minority populations in the US. Findings highlight the influence of socioeconomic and cultural factors on AD completion and illustrates the importance of developing culturally sensitive interventions to promote end-of-life care decision-making among older Chinese Americans.

improving the health and well-being of older adults. This approach can be especially helpful for older adults who are experiencing mental health conditions as it focuses on strengths, resilience and recovery comprehensively. Few clinical interventions have addressed wellness in older adults with mental health conditions (Zechner et al., 2019).The authors reviewed two existing wellness frameworks: 1) grounded in extensive practical interventions for people living with mental health conditions (Swarbrick, 1997;2006;2012;2017), and 2) a theoretical framework informed by a systematic literature review (Fullen, 2019). The two frameworks were compared for usefulness in older adults living with mental health conditions using the concept analysis strategies of analyzing the overlap and contrasting characteristics of concepts with related ideas, and then proposing a merged operationalized definition and practical implementation suggestions based on the characteristics of the original dimension (Mackeroff et al., 2016). The two wellness models described similar dimensions, but also represented distinct areas. We propose a synthesized framework combining the models to best serve older persons living with mental health conditions. The framework holds eight distinct areas 1) Developmental 2) Cognitive/ Intellectual, 3) Physical 4) Emotional 5) Social/ Relational, 6) Occupational/Vocational 7) Spiritual and 8) Contextual/Environmental/Financial. Inter-professional practical clinical strategies and policy suggestions will be presented for consideration. More work is underway to understand the salience of the proposed model for stakeholders and to empirically test how the proposed framework impacts outcomes.
were positively associated with AD completion. Physical and mental health needs were not significantly associated with AD completion. This is among the first studies focusing on AD completion among Chinese Americans, one of the fastest growing older minority populations in the US. Findings highlight the influence of socioeconomic and cultural factors on AD completion and illustrates the importance of developing culturally sensitive interventions to promote end-of-life care decision-making among older Chinese Americans.

DISPARITIES IN EOL CARE BY DEMENTIA STATUS AND RACE Joann Reinhardt, The New Jewish Home, New York, New York, United States
Prior research shows that minority and dementia status are associated with suboptimal end-of-life (EOL) care quality; care that is more aggressive, invasive, and futile. We conducted a retrospective study of EOL care for 300 decedents of varied race/ethnicity in a skilled nursing facility. The purpose of this secondary analysis was to test whether the EOL experience (medical orders in place, treatments, distressing symptoms, discussions with providers) differed by dementia status for different race/ethnic groups (Black, White, Hispanic). Chi-square tests were used to examine the relation between these four sets of EOL variables and dementia status (yes/no) separately for the three groups. Findings showed that for White decedents, PWD were less likely to have had a DNR or a DNI discussion with a provider in the nursing home. Also for White decedents, PWD were less likely to have had shortness of breath or pain. For Black decedents, PWD were more likely to have a DNR order. Also, for Black decedents, PWD were less likely to have been hospitalized. For Hispanic decedents, EOL variables and dementia status were not significantly associated. Overall, findings showed differences by race/ethnic groups in EOL experience based on dementia status. Black decedents with dementia were more likely to have escaped the acute care default. Findings for White decedents with dementia were mixed for aggressive versus comfort care. The EOL experience did not differ by dementia status for Hispanic decedents. Thus, efforts to promote positive EOL care for persons with dementia need to account for differences by race/ethnicity.

UNRAVELING THE EFFECTS OF SOCIAL CLASS AND SYSTEMIC RACISM ON ADVANCE CARE PLANNING Jenny McDonnell, Emory University, Roswell, Georgia, United States
While advance care planning (ACP) is recognized as a key facilitator of high-quality, goal-concordant end-of-life care, black Americans are less likely to participate in ACP than non-Hispanic whites (Carr 2011;Detering et al. 2010). There are divided explanations for why these disparities persist. Some scholars attribute racial disparities in end-of-life care to socioeconomic (SES) differences between black and white Americans citing blacks' and whites' differentiated access to, control over, and use of material resources (Wilson 1978;Yearby 2011). Others assert that health care preferences do not solely reflect lack of resources or health literacy, but that the larger social context frames care preferences differently across racial and ethnic groups in American society (Alegria et al. 2011; Sewell and Pingel forthcoming). By turning the analytical lens to class-privileged black Americans, I investigate whether racism overflows the margins of class disadvantage. Using data from the Health and Retirement Study, I ran logistic regression and moderation models. I found that class-privileged blacks are less likely to engage in ACP than both high-SES and low-SES whites. The interaction of race and SES was negatively and significantly associated with ACP (OR=0.91; P<0.05), indicating that SES has a stronger effect on the probability of ACP among whites than among blacks. Predicted probabilities show that 51% of low-SES whites are likely to engage in ACP compared to 32% of high-SES blacks. These findings indicate that racialized disparities in ACP exist independent of SES, and that the effects of SES and race are intersectional rather than simply additive. Older adults with comorbid dementia and cancer is an increasing phenomenon with the aging population worldwide. Caregivers of these older adults might have a totally different and unique end-of-life caregiving experience. This is because all physical and behavioral signs and symptoms of dementia and cancer may interact with each other and complicate the caregiving experience. The aims of this study was to understand and examine the end-of-life caregiving experiences for older adults with comorbid dementia and terminal cancer from the perspective of family caregivers. Twenty-one caregivers were invited to participate in a semi-structured interview that examined the end-of-life caregiving experiences, its impact and how they coped with the challenges they faced. The interviews were transcribed and analyzed using interpretative phenomenological analysis. The essential meaning of the phenomenon is understood as "grieving thrice, suffering dually and becoming one", characterized by how caregivers understood the meaning of togetherness after going through the time of recurring losses from dementia through cancer to death and experiencing ambiguous sufferings dually with their loved one. Ambiguous sufferings were not "there" before the diagnosis of cancer but emerge in the context of comorbid dementia and cancer and in the connection with the caregivers making interpretation and appraisal of their internal and external resources. These important findings fill in the knowledge gap in the literature related to end-of-life caregiving experience for older adults with comorbid dementia and cancer; and may guide the development of appropriate interventions to support the older adults and their caregivers in a holistic approach.

RISK OF MILD COGNITIVE IMPAIRMENT AND DEMENTIA
DECREASING SOCIAL SUPPORT ASSOCIATED WITH RISK OF MCI AND DEMENTIA IS PARTIALLY MEDIATED BY HIPPOCAMPAL VOLUME Tara Gruenewald, 1 Andrew Petkus, 2 Xinhui Wang, 3 Diana Youan, 2 Margaret Gatz, 3 Mark Espeland, 4 and