The dynamic interactions for initiation of advance care planning in Hong Kong Chinese : a tripartite perspective

Abstract

Modern medical advancements have made life-sustaining and life-prolonging interventions possible over the past decades. People nowadays must make health and social decisions more often when facing health challenges. Advance Care Planning (ACP), a facilitated communication process discussing end-of-life care in advance, has been increasingly recognized by healthcare professionals and service recipients as achieving concordant care at the end of life. Empirical studies indicated this recognition did not transit to action in ACP, resulting in a relatively low uptake rate. Moreover, research indicated that many factors affecting ACP could not be differentiated as barriers or facilitators but interweaved with intrapersonal, interpersonal, and socio-environment. Unfortunately, there were scant explorations on the dynamic interactions in ACP, and a tripartite perspective has rarely been adopted. ACP initiation involves multi-dimensional interactions between the person and others. This research is an attempt to unveil this special terrain. Sequential mixed-method research was adopted and comprised two phases. Because of the scant knowledge of the dynamic interactions in ACP, this research began with an exploratory qualitative study using triadic semi-structured interviews in Phase I to gain a broader and deeper understanding of the dynamics experienced by the three parties in ACP initiation. Twelve natural trios, the patient, the patient’s family caregiver, and the patient’s healthcare professional were interviewed to explore their experience of elements of others in the tripartite interactions of ACP initiation. Their narratives illustrated the elements of others in three major categories, including the elements of basic beliefs toward persons in the tripartite, the elements of interpersonal resistance, and the elements in tripartite interactions. The qualitative study led to the formulation of the questionnaire in Phase II of the research. Phase II involved a quantitative study using a questionnaire to examine the relative importance and relationships of the elements of others in the tripartite in ACP initiation identified in Phase I. Findings from the 421 participants illustrated the relative importance of the preferences of the parties on the basic belief towards others in the tripartite, the importance of the signs of interpersonal resistance to different parties, and the determinants of trustful relationships as the core elements in the tripartite. It also unfolded the dynamics of handling the resistance of others in the tripartite for ACP initiation. Based on the findings, this thesis proposed a conceptualization of a tripartite dynamism in ACP initiation. It suggested ACP initiation is a tripartite phenomenon and introduced the concept of the elements of others to each party in the tripartite interactions. This thesis also reported the advancement in the research methodology by extending dyadic interviews to triadic interviews to address the research objectives, the limitations and challenges encountered in the whole research process, the implications to clinical practice, and the future research direction.