Preferences for Long-Term Care: What Does Love and Culture Have to Do with It?
Article Outline
Dr. Barbara Resnick
With the increasing number of older adults nationally and internationally, there has been an expansion in care alternatives at the later stages of life, including continuing-care retirement communities (CCRCs)—both the traditional CCRC settings and the naturally occurring continuing-care communities (NORCS)—assisted living communities, group homes, and alternatives within nursing home settings to include those that are smaller and more homelike versus the tradition institutional type home. Alternatively, the individual may decide simply to stay at home either alone, with a partner (cohabitation is increasingly an option!), or with family caregivers. With so many options, choices become more difficult. Understanding what influences the choice of care site for older individuals is important information to help ensure optimal life satisfaction for these individuals.
Recently, we published the article titled “Factors Affecting the Long-Term Care Preferences of the Elderly in Taiwan,” in Geriatric Nursing. This article focused specifically on explaining what some of these influential factors are, at least among older adults in Taiwan. The survey that was performed within this study included 562 elderly Taiwanese residents from 7 counties/cities in northern Taiwan who were asked to identify what influenced their choices for long-term care. The results indicated that ethnic background and the requirement for additional medical care services had significant effects on these decisions. This article stimulated some interesting thoughts on the part of Jong-Ni Lin, RN, a doctoral student at the University of Washington, School of Nursing.
Although Ms. Lin identified some of the strengths of the work, she raised several important issues. She wrote,
It is interesting that both ethnic origin and the need for medical care services are contributing factors to an individual's long-term care preferences. I am afraid, however, that several points in the article need to be clarified and discussed further. It has previously been noted that relocation or milieu change is an important event in an elder's life, and there is a common belief that relocation results in a breakdown of family unity.1 In Chinese culture, parents and children share close bonds, and most elders want to die in their homes surrounded by their families rather than in institutions.2 Chiu and her colleagues have also found that older adults who live alone and have no caregivers are more inclined to use nursing homes.2 The study findings, however, indicated that day care was the least preferred of long-term care services, although the majority of individuals (77.9%) had never heard of day care. I would argue, therefore, that individual preferences' for long-term care services may be moderated by resources, access and knowledge of the many options that are available with regard to long term care, rather than simply culture. Moreover, family preferences may affect the choice of location.2
The relationship between cultural values and overall preferences of older adults for long-term care services does make logical sense, however, and was substantiated by this work. Moreover, it was particularly interesting to note that the preference for institutional care was greater among Mainlanders than Taiwanese Hakkas. The authors indicated that this was likely because Hakkas maintain a stronger emphasis on Confucian filial piety than the other groups and thus elect to remain in the home setting. As far as I know, Mainlanders are also Chinese who may be influenced by Confucian filial piety. Was the value of filial piety the major determinant that resulted in this finding? If yes, the sampling might be biased by recruiting the subjects from northern Taiwan including Hsinchu City/County and Taoyuan County. According to the demographic data from Taiwanese government (2007), it has been estimated that only 20.4% of residents in Taiwan are Hakkas,3 but they are concentrated in those regions. It may not be appropriate, therefore, to generalize these results to all Taiwanese.
In conclusion, I argue that the preference for home care service may be influenced by many factors beyond culture and health care needs, such as financial and caregiving resources, family preferences, and policy. Decisions around long-term care preferences are complex for older adults and their families and both researchers and clinicians need to be aware of not only the individual (e.g., cultural values and elderly living patterns) and family variables (e.g., family preferences) but also the sociopolitical context in which these decisions are made.
Kudos to Ms. Jong-Ni Lin for raising these issues and helping to explain the findings of this research. Personally, I found the significance of health care issues to be of greater interest than the cultural impact of the decisions. Baby boomers today are scrambling to arrange their homes, or buy new homes, that will be easy to manage and live in as they age. I might add a point here that easy is not always the best way to optimize and maintain function. I wonder—to myself usually—how many of those individuals will change their minds and their preferences in the face of illness and the presence of multiple comorbid conditions. When daily life is a challenge, you have pain, shortness of breath, or simply feel alone and isolated, do you really want to be sitting by yourself in your lovely little home? You don't know for sure until you are there. How often we hear from families about their angst over placing a loved one in a long-term care facility and then observe that individual as he or she blossoms following the move. Some individuals are comforted by having the security of a wonderful and loving nurse nearby, having others to talk to and see, and having people tell them how to manage their medical and daily life challenges. These are the important quality-of-life choices we need to make. Personally, this hit me when I was immobilized following knee surgery through several dark, cold, winter months. I began to think that giving up my independence would be worth the social stimulation that an assisted living facility could provide. Preferences and decisions about moving to any long-term care facility are complex and individual based. Culture is important, health care needs are important, as are social and economic factors. Long-term care facilities are not bad places; rather these are facilities in which some older adults enjoy many happy years of comfort and care at the end of their lives. As health care providers, what is most important is that we set aside our own beliefs and biases and that we help individuals make these decisions by matching what is wanted, needed, and possible.
References
- . Milieu change and relocation adjustment in elders. Western J Nurs Res. 2008;30:113–129
- Consistency between preference and use of long-term care among caregivers of stroke survivors. Public Health Nurs. 1998;15:379–386
- My E Government. World Yearly Book 2007: the population of Hakkas in Taiwan. 2007. Available at www7.www.gov.tw/todaytw/2007/intestine/ch01/2-1-15-0.html. Cited November 23, 2008.
PII: S0197-4572(09)00036-6
doi:10.1016/j.gerinurse.2009.01.002
© 2009 Mosby, Inc. All rights reserved.
