Archives of Gerontology and Geriatrics 74 (2018) 155–161

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Archives of Gerontology and Geriatrics

journal homepage: www.elsevier.com/locate/archger

Factors influencing attitudes toward advance directives in Korean older MARK

adults☆
Ji Eun Leea, Dong Wook Shind, Ki Young Sona, Hyun Jung Parka, Jae-Young Lime, Mi Soon Songf,
⁎ ⁎⁎
Yeon-Hwan Parkf, , BeLong Choa,b,c,
a
Department of Family Medicine, Center for Health Promotion and Optimal Aging, Health Promotion Center for Cancer Survivor, Seoul National University Hospital, 101
Daehak-ro, Jongno-gu, Seoul 03087, Republic of Korea
b
Advanced Institute of Convergence Technology, Seoul National University, 145 Gwanggyo-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16229, Republic of Korea
c
Institute on Aging, College of Medicine, Seoul National University, 71 Ihwajang-Gil, Jongno-gu, Seoul 03087, Republic of Korea
d
Department of Family Medicine, Samsung Medical Center, 81 Irwon-Ro, Gangnam-gu., Seoul 06351, Republic of Korea
e
Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Republic of Korea
f
College of Nursing, The Research Institute of Nursing Science, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: We aimed to determine the factors influencing attitudes toward advance directives in Korean older adults
Advance care planning with consideration of an Asian cultural background.
Advance directives Methods: We recruited community-dwelling older adults aged 60 years or older at a regional senior welfare
End-of-life center in Korea. Demographic factors and mental and physical health status were examined using questionnaires
Family discussion
and a physical examination. The questionnaire also assessed perceived necessity of advance directives and re-
Personal experience
lated experiences.
Results: Most participants (79.32%) agreed that advance directives were necessary. Older adults with high
education levels (odds ratio [OR] 2.31, 95% confidence interval [CI] 0.84–6.34), low economic status (OR 2.09,
95% C.I. 0.60–7.27), and poor cognitive function (adjusted odds ratio [aOR] 2.10, 95% CI 0.89–4.97) had a
greater odds of agreeing that advance directives are necessary. All participants with self-care problems (9/9) and
most participants with at risk status of physical functioning (13/14) reported agreement. Death-related ex-
periences were also associated. Notably, individuals who had discussions on end-of-life care with family
members showed a greater odds of agreeing that advance directives are necessary (aOR 2.12, 95% CI 0.88–5.11).
Conclusions: The factors associated with increased agreement that advance directives are necessary were high
education level, low economic status, poor cognitive function, problems in self-care, poor physical functioning,
death-related experiences. Especially, discussions of end-of-life care with family members increased the agree-
ment. Thus, discussion on end-of-life care should be encouraged and the factors influencing older adults’ atti-
tudes toward advance directives should be considered in developing policies for such discussion.

1. Introduction planning (ACP) increasingly important.

The age at death is currently increasing, which has led to changes in
the most common causes of death. Currently, chronic diseases such as
cancer, stroke, and dementia are the highest ranking causes of death in
most countries (Korea, 2013). These chronic diseases cause disability
and long-term suffering from pain at end-of-life, thereby increasing the
burden of patients and caregivers. This change has made advance care
ACP refers to the process of formal decision making regarding future
care that takes effect when patients lose the capacity to make decisions
(Mullick, Martin, & Sallnow, 2013). Advance directives (ADs) are
documents detailing patients’ wishes for life-sustaining treatment, their
choice of a surrogate decision maker, or both (Silveira, Kim, & Langa,
2010). ADs are critical for ACP because they are considered written
proof of the plan. As shown in previous studies, ADs enable people to

☆
This study protocol and interim results of this study was presented at the Korean Geriatrics Society 2015 Autumn Conference, which was held on 28th–29th Nov 2015 at Seoul, South
Korea.
⁎
Corresponding author.
⁎⁎
Corresponding author at: Department of Family Medicine, Center for Health Promotion and Optimal Aging, Health Promotion Center for Cancer survivor, Seoul National University
Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03087, Republic of Korea.
E-mail addresses: hanipyh@snu.ac.kr (Y.-H. Park), belong@snu.ac.kr (B. Cho).

http://dx.doi.org/10.1016/j.archger.2017.10.008
Received 3 June 2016; Received in revised form 25 September 2017; Accepted 11 October 2017
Available online 31 October 2017
0167-4943/ © 2017 Elsevier B.V. All rights reserved.
J.E. Lee et al.
receive the care of their choice and can thus improve the quality of their
end-of-life care (Silveira et al., 2010). Some studies have also revealed
that they can reduce healthcare expenditures (Nicholas, Langa,
Iwashyna, & Weir, 2011; Starr, 2008).
Currently, the use of ADs varies across countries. In the US, the
Patient Self-Determination Act took effect in 1990, mandating that all
Medicare-certified institutions provide patients with written informa-
tion regarding their right to formulate ADs. Recently, it is estimated
that up to 70% of community-dwelling older adults have completed
ADs (Starr, 2008). In addition, on January 1, 2016, the Centers for
Medicare & Medicaid Services (CMS) began reimbursing for ACP.
In contrast, in South Korea, ACP and ADs are not well known among
general people. ADs are fulfilled by non-government organizations and
some hospitals; however, they have no standardized format. In the past
two decades, two events have sparked public interest in ACP and re-
lated end-of-life issues. First, at Boramae Hospital in 1997, physicians
discontinued life-sustaining treatment and discharged a patient at his
wife’s request. The physicians were found guilty even though further
therapy was deemed futile. Over ten years later, in 2009, the Korean
Supreme Court recognized a patient’s previously stated intention for
care and permitted withdrawal of life-sustaining treatment. The two
conflicting incidents generated social discourse on ACP and end-of-life
issues in South Korea, and encouraged some policymakers to attempt to
enact legislation. After all, a law so-called ‘well-dying act’ which re-
cognizes the legal validity of ACP and ADs has been passed the con-
gress, in January 2016. This law is due for implementation in 2018.
However, there is still a lack of research on the perceptions and factors
that affect ACP and ADs. Knowledge of such factors is needed for proper
discussion of the activation of ACP.
To date, most investigations on end-of-life issues have taken place in
Western, Anglo-Saxon societies. Furthermore, most of the studies were
descriptive and focused solely on socioeconomic factors (Randén,
Helde-Frankling, Runesdotter, & Strang, 2013; Rao, Anderson,
Lin, & Laux, 2014). There is a lack of research in Asian countries, par-
ticularly in South Korea. Additionally, other factors including health
status, physical functioning, and personal experiences of older adults
may affect their opinions about ACP and end-of-life care.
Thus, the objective of this study was to determine the factors in-
fluencing attitudes toward ADs in Korean older adults so as to con-
tribute to the activation of ACP and ADs.
2. Materials and methods
2.1. Study population and data collection procedure
The present study was part of a prospective cohort study called
“Health Status of Community Dwelling Older Adults: Community-Based
Prospective Cohort Study” on older adults aged 60 years or older living
in the region of Jongnogu in South Korea. This comprehensive study
aimed to examine medical problems, socioeconomic factors, and phy-
sical functioning in community-dwelling older adults. All participants
were recruited from a senior welfare center and a total of 512 older
adults participated. An optional part of the questionnaire administered
to participants asked them their perspectives on ADs and related per-
sonal experiences. Participants who responded to that part of the
questionnaire were included in the present analysis. Ultimately, 295
(57.62%) older adults completed the questionnaire. This study was
approved by the Institutional Review Board of Seoul National
University Hospital.
2.2. Measures
The questionnaire comprised items assessing physical and mental
health status and health-related quality of life. Self-rated health was
assessed using response choices of “very healthy,” “ordinary,” and “not
healthy,” which were relabeled “good,” “fair,” and “poor” for the
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Archives of Gerontology and Geriatrics 74 (2018) 155–161
analysis. Comorbidities assessed included hypertension, stroke, dysli-
pidemia, angina or myocardial infarction, diabetes mellitus, thyroiditis,
arthritis, osteoporosis, lumbar pain, chronic bronchitis or emphysema,
asthma, tuberculosis, cataract, chronic otitis media, duodenal ulcer or
gastritis, hepatitis, liver cirrhosis, chronic kidney disease, benign
prostate hyperplasia, urinary incontinence, sexually transmitted dis-
ease, anemia, skin disease, depression, any cancer, and any fracture or
its sequelae. The comorbid diseases were grouped into none/hy-
pertension, diabetes or dyslipidemia/stroke, angina, myocardial in-
farction or cancer/other diseases. For instrumental activities of daily
living (IADL), obtaining a score of over 10 was regarded as being de-
pendent. Loneliness and social support were assessed using the social
domain of the Comprehensive Frailty Assessment Instrument (De Witte
et al., 2013). Depressive mood was assessed by the Geriatric Depression
Scale Short Form Korean version; a score of 5 or more indicated de-
pressive symptoms (Jee & Lee, 2013; Lee, Kim, & Jung, 2009). The EQ-
5D, Mini-Cog test, and Mini-Nutritional Assessment Short Form Korean
version were used to assess health-related quality of life, cognitive
function, and nutritional status, respectively. For the 5 subscales of the
EQ-5D, individuals with scores of > 1 were categorized as having
problems (Cheung, Oemar, Oppe, & Rabin, 2009). Physical functioning
was assessed with a short physical performance battery by trained re-
search assistants. Participants with scores of ≥10, 7–9, ≤6 were re-
garded as normal, frail, and at-risk, respectively.
The assessment of attitudes toward ADs and related experiences
were also included in the questionnaire. Prior to the assessment, a short
explanation about ADs was given as ‘the form of a document that allows
the patient’s opinions to be written in advance and reflected in the
treatment decision in the event the patient loses consciousness and is
unable to choose treatment by himself or herself’. Then, participants
were asked if they were in favor of ADs using the following question:
“Do you think these documents are necessary?”. For experiences related
to ADs, in order to assess the recent medical care received by the
subjects, we asked whether they have had outpatient or inpatient care
over the past six months. We also assessed personal experiences of
discussions on end-of-life care with family members or health profes-
sionals. For death-related experiences, we asked if the participant had
experienced the following events during the past five years:
Hospitalization – self; hospitalization – family members; observed a
family member dying; taken care of someone who was dying; experi-
enced cardiopulmonary resuscitation; witnessed another person re-
ceiving cardiopulmonary resuscitation; and death of a family member,
relative, or friend.
2.3. Statistical analyses
Participants were grouped into agreement and disagreement groups
according to whether they agreed or disagreed that ADs were necessary,
respectively. Then, we compared the demographic characteristics,
physical and mental health status, and individual experiences between
the two groups; for categorical variables, this was done by chi-square
tests, while for continuous variables, we used the Mann-Whitney U test.
To investigate the associations between each variable and attitudes
toward ADs, odds ratios (ORs), and P-values for trend were calculated
using univariate and multivariate logistic regression analysis. P-values
of < 0.10 were considered statistically significant. STATA (ver. 14.0;
STATA Corp., Houston, TX, USA) was used for all statistical analyses.
3. Results
3.1. Study population characteristics
A total of 295 participants were included in the analysis. Their mean
age was 73.55 years old and they were primarily women (71.53%).
About half (49.83%) had not been educated past middle school. For
self-reported economic status, only 4.75% considered themselves as
J.E. Lee et al. Archives of Gerontology and Geriatrics 74 (2018) 155–161

Table 1 3.4. Association between ADs attitudes and personal experiences

General characteristics.
All participants who had visited the emergency room within the
Total (N = 295)
n % previous 6 months (n = 14) were in the agreement group. Furthermore,
all participants who had experienced CPR (n = 5) and most of those
Age, mean (SD) 73.55 (6.23) who had witnessed it (n = 20/22) within the previous 5 years were in
Gender the agreement group. Those who had discussed end-of-life care (i.e.,
Male 84 28.47 ACP) with family members had a greater odds of being in the agreement
Female 211 71.53 group compared to those who had not discussed it (OR 2.15, 95% CI
Education level 0.92–5.01). This tendency remained after adjusting for possible con-
Less than middle school 147 49.83 founders (age, gender, education level, economic status, marriage, self-
Less than high school 46 15.59
rated health, comorbidities, and depression; adjusted OR 2.12, 95% CI
Less than college 60 20.34
College and above 42 14.24 0.88–5.11). However, only 58 of the 295 participants had had such a
discussion. Only 24 participants had experienced a discussion on end-
Economic status (self-reported)
High 14 4.75 of-life care with health professionals; among them, most (n = 20) were
Middle 144 48.81 in the agreement group (Table 4).
Low 137 46.44

Marriage
Unmarrieda 153 51.86
Married 142 48.14
Religion
Do not have 70 23.73
Have 225 76.27
a
Unmarried participants included those who were divorced, widowed, and never
married.
being “high”. Furthermore, 48.14% were married, while the rest were
divorced, widowed, or never married (Table 1).
3.2. Association between ADs attitudes and demographic factors
The distributions of age and gender did not significantly differ be-
tween the agreement and disagreement groups. The agreement group
had more highly educated participants than that of disagreement group
([college and above] 15.81% vs. 8.20%). Furthermore, highly educated
participants had a greater odds of being in the agreement group (OR
2.31, 95% confidence interval [CI] 0.84–6.34) than did less educated
participants. Regarding economic status, in the agreement group, more
participants had a low economic status than in the disagreement group
(49.15% vs. 36.07%). Participants with low economic status had a
greater odds of being in the agreement group (OR 2.09, 95% CI
0.60–7.27). Finally, married participants had a greater odds of being in
the agreement group than did unmarried participants (OR 1.71, 95% CI
0.96–3.05) (Table 2).
3.3. Association between ADs attitudes and physical and mental health
status
Nine participants, all of whom were in the agreement group, re-
ported problems with self-care. Regarding comorbidities, participants
with “other diseases” had a greater odds of being in the agreement
group compared with participants without comorbidities (aOR 3.62,
95% CI 1.11–11.82). This category includes diseases other than meta-
bolic diseases or cancers. In terms of nutritional status, 10 persons were
categorized as malnourished and all of them were in the agreement
group. Participants who showed poor cognitive function had a greater
odds of being in the agreement group (aOR 2.10, 95% CI 0.89–4.97)
then participants with normal cognitive function after adjustment for
age, gender, education level, economic status, marital status, religious
status. In terms of physical performance, 14 subjects were categorized
as at-risk, most of whom (n = 13) were in the agreement group. Other
factors, such as self-rated health, fall experience, IADL score, social
support and depression were not significantly different between the two
groups. Furthermore, none of these factors affected the odds of being in
the agreement group (Table 3).
4. Discussion
A major strength of this study is its comprehensive investigation of
the associations of attitudes toward ADs with socioeconomic factors,
physical and mental health status, physical functioning, and personal
experiences. To date, most studies on this topic were descriptive and
focused on socioeconomic and cultural factors (Randén et al., 2013; Rao
et al., 2014). For older adults, other factors such as health status,
physical functioning, and self-care ability may have considerable effects
on their attitudes towards end-of-life issues.
Until now, in South Korea, ACP and ADs have not been well known
among the general population (Yu, Chae, Choi, & Kim, 2013), especially
among older adults. In the current study, only 29.15% had heard of a
“proxy-designation,” and none had reported completing an AD (not
shown in tables). However, most respondents agreed that ADs were
necessary (n = 234, 79.32%) after receiving a short explanation about
them; thus, providing exposure to ACP and ADs via education (e.g.,
media campaigns) would likely help increase positive attitudes toward
ACP. Indeed, exposure to educational media initiatives has been found
to contribute to increased completion of ADs (Alano et al., 2010).
Participants with low economic status were more likely to be in the
agreement group. In previous studies, many elderly patients expressed
anxiety about the future and expected ACP to determine their future
care (Davison & Simpson, 2006; Kass-Bartelmes & Hughes, 2004;
Seymour, Gott, Bellamy, Ahmedzai, & Clark, 2004). Thus, it is possible
that participants who considered themselves to have low economic
status feel more anxious about the future and desire ACP to relieve that
anxiety. Similarly, all participants who had visited the emergency room
within 6 months and most respondents who had experienced or wit-
nessed CPR expressed agreement that ADs were necessary. These ex-
periences would likely aggravate older adults’ anxiety about the future.
Although directly asking about depressive mood or anxiety did not
reveal any relation between anxiety/depression and AD attitudes, non-
clinical anxiety about the future might still affect older adults’ per-
ception of ADs.
From the health-related quality of life assessment, all participants
who had problems with self-care were in the agreement group, as were
most participants categorized as “at-risk” in terms of physical function.
The observed relations between poor self-care and physical functioning
and AD agreement can be explained by perception of burden, especially
in the context of an Asian cultural background. Having a poor physical
condition make older adults’ more dependent, thereby increasing the
burden on family caregivers as well as self-perceived burden, which
refers to care recipients’ feelings of dependence and the resulting
frustration (Chan, 2007). Older adults in many cultures profess not
wanting to burden their family members (McPherson,
Wilson, & Murray, 2007). Furthermore, previous surveys of older
adults’ perspectives on ACP have shown that older adults believed that
ACP would help relieve family burden (McPherson et al., 2007). In the

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Table 2
Comparison of demographic characteristics by attitudes toward advance directives.

Attitudes toward advance directives

Disagreement (n = 61) Agreement (n = 234)

n % n % P-value OR (95% CI)c P for trend

Age, mean (SD) 74.11 (5.06) 73.40 (6.50) 0.155 0.98 (0.94–1.03) 0.426

Gender
Male 13 21.31 71 30.34 0.164 1.00 0.167
Female 48 78.69 163 69.66 0.62 (0.32–1.22)

Education level
Less than middle school 35 57.38 112 47.86b 0.183 1.00 0.052
Less than high school 12 19.67 34 14.53 0.89 (0.41–1.89)
Less than college 9 14.75 51 21.79 1.77 (0.79–3.96)
College and above 5 8.20 37 15.81 2.31 (0.84–6.34)

Economic status (self-reported)

High 4 6.56b 10 4.27 0.176 1.00 0.068
Middle 35 57.38 109 46.58 1.25 (0.37–4.22)
Low 22 36.07 115 49.15 2.09 (0.60–7.27)

Marriage
Unmarrieda 38 62.30 115 49.15 0.067 1.00 0.069
Married 23 37.70 119 50.85 1.71 (0.96–3.05)

Religion
Do not have 16 26.23 54 23.08 0.606 1.00 0.606
Have 45 73.77 180 76.92 1.19 (0.62–2.26)

a
Unmarried participants included those who were divorced, widowed, and never married.
b
Total percentages may not equal 100% because of rounding off.
c
OR = odds ratio, CI = confidence interval.

Confucian cultures of Eastern Asia, burdening others is considered
highly discourteous. This is called meiwaku in Japan, which means
causing trouble to others, and should be avoided (Bito et al., 2007). A
study on end-stage cancer patients and their family caregivers in South
Korea showed that patients who perceived themselves as burdens to
their families were more likely to prefer palliative care over life-sus-
taining treatment (Lee et al., 2015). Therefore, in end-of-life decision-
making, burden on family seems to be very important factor for older
adults. The high agreement on ADs among respondents with poor
physical functioning and problem in self-care could be understood in
this context.
Both in this study and in previous studies (Alano et al., 2010), more
married people agreed on ADs than did unmarried people. Again, not
wanting to burden spouses could explain the result. In addition, as in
other studies, patients appear to consider ACP as means of avoiding
placing undue responsibility for end-of-life decision-making on loved
ones (Alano et al., 2010; Chan, 2007).
This study revealed that discussion of end-of-life issues with family
members would help older adults agree on ADs. The older adults who
had discussed their end-of-life care with family members had a greater
odds of being in the agreement group compared to participants who
had not had such a discussion. A similar trend, albeit not as strong, was
observed for discussion with health professionals. Thus, discussions
with older adults on end-of-life care may improve their attitudes toward
ADs. This accords somewhat with an earlier intervention study on
community-dwelling older adults, wherein provision of educational
material increased use of ADs, and the increase was greater when
education was provided in a face-to-face meeting (High, 1993).
However, in the present study, very few participants had experi-
enced a discussion on end-of-life care with family members or health
professionals. In South Korea, conversations about death can be con-
sidered an assault on a person’s wellbeing (Blank, 2011). Thus, care-
givers and health professionals may feel it to be disrespectful to discuss
end-of-life care. However, as shown in this study, many older adults
have positive attitudes towards ADs. Thus, ACP should be supported so
that older adults can openly express their hopes about end-of-life care.
To encourage end-of-life discussions, educational materials or
media campaigns might be helpful (Alano et al., 2010; High, 1993).
However, in some studies, using written materials without direct
counseling was relatively ineffective for increasing AD completion
(Ramsaroop, Reid, & Adelman, 2007). Indeed, provision of oral in-
formation over multiple sessions was found to be the most successful
intervention (Bravo, Dubois, & Wagneur, 2008). Thus, face-to-face dis-
cussion should be encouraged. To support such discussion, specific
education for family members and health professionals might be
needed.
On the other hand, to ensure active end-of-life discussion, the de-
velopment of policies supporting it would be required. Additionally,
reimbursement for ACP consultation would be helpful. Recently in
South Korea, a law recognizing the validity of ACP and ADs has been
legislated, however, sufficient discussion is required before acting the
law. In such discussions, it should be considered that older adults’
education level, economic status, physical functioning, and self-per-
ceived burden can affect their perspectives on ACP. In other words,
efforts enabling older adults to frankly express their hopes for ADs and
end-of-life care, not based on such conditions, are needed.
This study had some limitations. First, there were inequalities in
general characteristics of the subjects included in the agreement and
disagreement groups, such as educational level, economic level, marital
status, and religion. These differences may have affected the relation-
ship between other factors and attitudes toward ADs. On the other
hand, however, differences in the characteristics may also be con-
sidered as important factors affecting the attitudes toward ADs. Second,
although the question of necessity of ADs was most important, it was
evaluated with only one question. ADs may include diverse options and
the format can be varied. In future studies, it is expected that attitudes
toward such varied options of ADs could be studied using more detail
questions on ADs. Third, participants were recruited from one region of
South Korea, so the results may not be generalizable. Korean culture
and the economic status of the region might have affected the results.
Fourth, participants were recruited from a senior welfare center, so
their physical function might be better than that of other older adults.

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Table 3
Comparison of physical and mental health status by attitudes toward advance directives.

Attitudes toward advance directives

Disagreement (n = 61) Agreement (n = 234)

n % n % P-value OR (95% CI)l aOR (95% CI)m

Health-related quality of lifea

Mobility
No problems 48 78.69 198 84.62 0.268 1.00 1.00
Problems 13 21.31 36 15.38 0.67 (0.33–1.36) 0.72 (0.34–1.50)
Self-care
No problems 61 100.00 225 96.15 0.120 1.00 1.00
Problems 0 0.00 9 3.85 N/Aj N/Aj
Usual activity
No problems 55 90.16 218 93.16 0.427 1.00 1.00
Problems 6 9.84 16 6.84 0.67 (0.25–1.80) 0.76 (0.27–2.11)
Pain/discomfort
No problems 32 52.46 122 52.14 0.964 1.00 1.00
Problems 29 47.54 112 47.86 1.01 (0.58–1.78) 1.01 (0.55–1.84)
Depression/anxiety
No problems 48 78.69 175 74.79 0.527 1.00 1.00
Problems 13 21.31 59 25.21 1.24 (0.63–2.46) 1.14 (0.56–2.33)
Self-rated health
Good 18 29.51 81 34.62k 0.564 1.00 1.00
Fair 24 39.34 95 40.60 0.88 (0.45–1.73) 0.70 (0.34–1.44)
Poor 19 31.15 58 24.79 0.68 (0.33–1.40) 0.57 (0.26–1.24)
Comorbidities
None 12 19.67 30 12.82k 0.208 1.00 1.00
Hypertension, diabetes, or dyslipidemiab 36 59.02 138 58.97 1.53 (0.71–3.29) 1.61 (0.73–3.54)
Stroke, angina or cancer 8 13.11 25 10.68 1.25 (0.44–3.54) 1.16 (0.39–3.48)
Other diseases 5 8.20 41 17.52 3.28 (1.04–10.30) 3.62 (1.11–11.82)
IADLc
Independent 50 81.97 203 86.75 0.341 1.00 1.00
Dependent 11 18.03 31 13.25 0.69 (0.33–1.48) 0.58 (0.26–1.28)
Social supportd
Loneliness, mean (SD) 10.69 (3.39) 10.24 (3.18) 0.329 0.96 (0.87–1.05) 0.96 (0.87–1.05)
Social network, mean (SD) 1.82 (1.64) 1.62 (1.25) 0.309 0.90 (0.74–1.10) 0.89 (0.73–1.10)
Depressive moode
Not depressive 34 55.74 138 58.97 0.648 1.00 1.00
Depressive 27 44.26 96 41.03 0.88 (0.50–1.55) 0.77 (0.42–1.43)
Cognitive functionf,i
Normal 52 86.67 188 80.34 0.259 1.00 1.00
n
Poor 8 13.33 46 19.66 1.59 (0.71–3.58) 2.10 (0.89–4.97)*
Nutritiong,i
Normal 47 77.05 179 76.82k 0.221 1.00 1.00
Risk of malnutrition 14 22.95 44 18.88 0.83 (0.42–1.63) 0.91 (0.44–1.85)
Malnutrition 0 0.00 10 4.29 N/Aj N/Aj
Physical performanceh
Normal 47 77.05 190 81.20k 0.151 1.00 1.00
Frail 13 21.31 31 13.25 0.59 (0.29–1.21) 0.68 (0.31–1.50)
At-risk 1 1.64 13 5.56 3.22 (0.41–25.20) 4.09 (0.50–33.29)
Fall in previous 6 months
No 48 78.69 198 84.62 0.268 1.00 1.00
Yes 13 21.31 36 15.38 0.67 (0.33–1.36) 0.60 (0.28–1.27)

a
Health-related quality of life was assessed by the 5 subscales of the EQ-5D questionnaire; scores of greater than 1 were categorized as “problems”.
b
Participants with stroke, angina, myocardial infarction, or cancer were excluded.
c
IADL = instrumental activities of daily living; scores of > 10 indicated dependency.
d
Social support was measured by the social domain of the Comprehensive Frailty Assessment Instrument; higher scores indicate greater social support.
e
Depressive symptoms were measured by the Geriatric Depression Scale Short Form Korea Version; participants with a score of 5 or more were considered as having depressive
symptoms.
f
Cognitive function was measured by Mini-Cog test.
g
Nutritional status was measured by using the Mini-Nutritional Assessment Short Form Korea version.
h
Physical performance was assessed by a short physical performance battery.
i
There was one missing response in each of cognitive function and nutrition assessment.
j
Calculation of odds ratios was not possible because some categories did not contain a value.
k
Total percentages may not equal 100% because of rounding off.
l
OR = odds ratio, CI = confidence interval.
m
aOR = adjusted odds ratio; these ORs were adjusted for age, gender, education level, economic status, marital status, religious status.
n
For odds ratios with asterisk (*), p-values were < 0.10.

In fact, the prevalence of dependency according to an IADL assessment Lastly, the part of the questionnaire asking about end-of-life care and
was much lower among the present participants than among the gen- ADs was optional, so only participants who agreed to respond to that
eral population (Jung, Kim, Choi, Lee, & Park, 2009). Thus, partici- part were included in the analysis. Such patients may have had more
pants’ responses might have been affected by their physical condition. positive attitudes toward end-of-life issues, which in turn might have

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J.E. Lee et al. Archives of Gerontology and Geriatrics 74 (2018) 155–161

Table 4
Comparison of personal experiences by attitudes toward advance directives.

Attitudes toward advance directives

Disagreement (n = 61) Agreement (n = 234)

n % n % P-value OR (95% CI)d aOR (95% CI)e

Hospital service use for last 6 months

Outpatient visit
No 8 13.11 36 15.38 0.658 1.00 1.00
Yes 53 86.89 198 84.62 0.83 (0.36–1.89) 0.84 (0.36–1.98)
Emergency room visit
No 61 100.00 220 94.02 0.050 1.00 1.00
Yes 0 0.00 14 5.98 N/Af N/Af
Death-related experiencesa
Hospital admission
No 23 50.00 98 60.87 0.187 1.00 1.00
Yes 23 50.00 63 39.13 0.64 (0.33–1.24) 0.65 (0.32–1.33)
Hospital admission of family member members
No 30 65.22 99 60.74 0.581 1.00 1.00
Yes 16 34.78 64 39.26 1.21 (0.61–2.40) 1.21 (0.59–2.49)
Caregiving of patient at EOLa,c
No 33 71.74 118 72.39 0.930 1.00 1.00
Yes 13 28.26 45 27.61 0.97 (0.47–2.00) 0.94 (0.43–2.05)
Experienced CPRb
No 46 100.00 158 96.93 0.229 1.00 1.00
Yes 0 0.00 5 3.07 N/Af N/Af
Witnessed CPRb
No 44 95.65 143 87.73 0.122 1.00 1.00
Yes 2 4.35 20 12.27 3.08 (0.69–13.68) 4.22 (0.89–20.13)*g
Witnessed death of an acquaintance
No 27 58.70 103 63.19 0.579 1.00 1.00
Yes 19 41.30 60 36.81 0.83 (0.42–1.61) 0.71 (0.35–1.43)
Experienced discussion
With family members
No 54 88.52 183 78.21 0.071 1.00 1.00
Yes 7 11.48 51 21.79 2.15 (0.92–5.01)* 2.12 (0.88–5.11)*
With health professionals
No 57 93.44 214 91.45 0.613 1.00 1.00
Yes 4 6.56 20 8.55 1.33 (0.44–4.05) 1.13 (0.35–3.62)

a
Experience was within the previous 5 years. There were 88 missing responses for experience of hospital admission and 86 missing. responses for the other questions on death-related
experience.
b
CPR = cardiopulmonary resuscitation.
c
EOL = end-of-life.
d
OR = odds ratio, CI = confidence interval.
e
aOR = adjusted odds ratio; these ORs were adjusted for age, gender, education level, economic status, marital status, self-rated health, comorbidities, and depression.
f
Calculations of odds ratios were not possible because some categories did not contain values.
g
For odds ratios with asterisk (*), p-values were < 0.10.

introduced bias into the results. University as part of a joint research project of the College of Medicine
and College of Nursing [grant number 800-20150098]. And we ap-
5. Conclusion preciate the advice and assistance of The Korean Geriatrics Society.

In conclusion, many community-dwelling older adults in South References

Korea agreed that ADs were necessary. The factors associated with
agreement were high education level, low economic status, being
married, poor cognitive function, having problems in self-care, having
poor physical functioning, having experiences of emergency room visits
and CPR, and having had discussions about end-of-life care with family
members. Thus, end-of-life discussion should be encouraged and edu-
cational programs and policies for it should be prepared. The above-
mentioned factors affecting the older adults’ attitudes should be con-
sidered in developing such programs and policies.
Disclosure statement
No potential conflicts of interest were disclosed.
Acknowledgments
This study was supported by the College of Medicine, Seoul National
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