Barriers to good end-of-life care: a physician survey.

Surveyed about barriers to good end-of-life care were 804 Hawaii physicians in specialties most likely to care for dying patients. Responses were received by 367 (46%). The majority attended terminally ill patients within the past year and felt that the physician should be the first to tell a patient that he/she is dying. Yet 86% identified barriers to talking about end-of-life preferences and 94% identified barriers to providing good end-of-life care. Perceived as major barriers were family conflict about the best course of action, patient/family discomfort with or fear of death, and cultural/religious beliefs of the patient or family. Since relatively few respondents supported the concepts of physician-assisted suicide (32%) or physician-assisted death (18%), the alternative is for physicians to join with other concerned entities to help overcome the attitudinal, behavioral, educational, and economic barriers to providing appropriate, humane, and compassionate care for the dying.

Support for physician-assisted suicide: exploring the impact of ethnicity and attitudes toward planning for death.

The authors interviewed adults in five ethnic groups, used factor analysis to quantify attitudes toward planning for death, and used path analysis to test the relative influence of respondent characteristics, including ethnicity, and attitude factors (Advocacy to Discuss/Document Wishes, Trust in Family and Physician to Make Decisions, Reliance on Religious Guidance, Fears and Anxiety About Life's End, and Fatalism About Death's Timing) on support for physician-assisted suicide (PAS). Findings verified that attitude factors had a direct effect on PAS support but that, contrary to the hypothesis, ethnicity had a direct effect on support for PAS as well.

Roles for the church in improving end-of-life care: perceptions of Christian clergy and laity.

Although faith communities may seem to be logical places to discuss death and dying, few churches are engaged in extensive efforts to improve end-of-life care. To explore the meaning of a good death and potential roles for faith communities in this effort, the authors held focus groups involving 121 clergy and congregants affiliated with Christian churches in Honolulu. Participants' definitions of a good death were similar to those articulated in other studies, for example, pain is managed, inappropriate prolongation of dying is avoided, the family is present and supportive, conflicts are resolved, and spiritual/existential issues are addressed. Participants identified a number of roles for the church: (a) to help congregants prepare for death, both spiritually and practically; (b) to facilitate resolution of conflict and forgiveness; (c) to clarify if or how church theology should guide attitudes and practices related to death and dying; (d) to administer the appropriate rituals; and (e) to provide outreach to sick, dying, and bereaved members. A number of participants noted that attention to spiritual issues at life's end would be important to all people, and churches wanting to increase membership should expand offerings in this area. These findings suggest that faith communities can have a major impact on improving end-of-life care and that pastoral education include attention to these issues.

Ten-year changes in breast cancer knowledge, attitudes, and practices in Native Hawaiian women.

Compared to women in other ethnic groups, Native Hawaiian women have the highest breast cancer mortality rates in the state of Hawai'i. Nationally, the five-year relative survival rate for Native Hawaiian women is 9% shorter than for Caucasians and all races. This poor outcome has been attributed, in part, to late-stage detection of cancer in Native Hawaiians, and data suggest that breast cancer screening rates for Native Hawaiian women are relatively low. This study examined breast cancer knowledge, attitudes, and practices (KAP) among Native Hawaiian women, reached through their friendship, community, and organizational networks. Response to an initial KAP survey in 1989-1990 was rewarded by a voucher for a free mammogram. Participation in both the survey (n = 903) and mammogram offer (n = 496) was high. The initial, Time 1 participants were resurveyed in 1999-2000, yielding a sample of 117 women who completed KAP surveys at both time points. After 10 years, changes in women's knowledge and attitudes were minimal. However, remarkable improvements in breast health practices were seen, with 62% of women reporting compliance with American Cancer Society guidelines for mammogram screening in 1999-2000, compared to only 14% in 1989-1990. Findings suggest that breast health practices can be improved through appropriate outreach; encouragement by health professionals; and policies and programs that increase access and affordability.

'Imi Hale: establishing an inheritance for Native Hawaiians on cancer awareness, research and training.

Native Hawaiians experience disproportionate rates of cancer incidence and mortality both nationally and in their homeland, Hawai'i. 'Imi Hale--the Native Hawaiian Cancer Awareness, Research, and Training Project, a five-year project funded by the National Cancer Institute, is aimed at reducing the burden of cancer among Native Hawaiians. The project's overall goal is to reduce cancer incidence and mortality among Native Hawaiians through the establishment of a sustainable infrastructure to 1) promote cancer awareness within Native Hawaiian communities, and 2) initiate cancer research, training, and control activities. A community-based project, 'Imi Hale emphasizes community participation, respect for cultural values, and the sharing of information, as we believe that a commitment to involve Native Hawaiians in all activities of the project will help assure that the community's awareness, training, and research priorities are addressed. In the first year of operation, cancer awareness activities included the development of culturally sensitive booklets on breast cancer and the provision of cancer education and screening for members of the Association of the Hawaiian Civic Clubs. Research and training activities included focus groups to explore the perceptions and experiences of cancer survivors, surveys to assess research priorities, the identification of Native Hawaiian researchers and the development of pilot research projects. The work of 'Imi Hale is guided by the hope that Native Hawaiians can reverse the negative effects of cancer and leave a powerful legacy and inheritance for future generations based on good health and well-being. 'Imi Hale means "to establish, as a dynasty; to acquire authority, power; to seek and establish an inheritance for one's children; and to form a friendship so close that one feels welcome in the house of the other." "By using our language for a name, we are invoking and honoring our ancestors, our culture, language and restoration as a nation."

Advance directive completion rates and end-of-life preferences in Hawaii.

To estimate rates of advance directive completion, preference for in-home death and hospice services at life's end, and support for physician assistance in dying, questions were added to two statewide, random-sample telephone surveys-the 1998 Behavioral Risk Factor Surveillance System (N=2,153) and the 1999 OmniTrak health survey (N=700). Data were compared across age, ethnic, and gender groups. Overall, 29% of Hawaii residents had a living will, 22% had a healthcare power of attorney, 65% said they would prefer a home death, 60% would want hospice services, 64% believed a person had a moral right to end his or her life when faced with an incurable illness, and 63% felt doctors should be allowed by law to end a patient's life if the patient and his or her family requested it. Advance directive completion rates increased with age, desire for an in-home death varied by gender and ethnicity, and support of assisted-death options varied by ethnicity. Despite a large minority population, end-of-life preferences among the general population in Hawaii are similar to those of U.S. mainlanders. However, age, gender, and ethnic differences exist. Clinicians are encouraged to ask patients directly about their preferences as a first step toward improving end-of-life care.

End-of-life preferences in Hawaii.

Questions on end-of-life preferences were included in two statewide, random-sample telephone surveys. Findings suggest that Hawaii residents are similar to mainlanders on their rates of advance directive completion, their preference for dying at home, their desire for hospice care when dying, and their support for legalization of aid in dying. Physicians are encouraged to ask these questions directly of their patients as a first step to improving end-of-life care.

Perceptions of dementia, caregiving, and help seeking among Asian and Pacific Islander Americans.

The United States is becoming more ethnically diverse, and Asian and Pacific Islanders (APIs) are one of the most rapidly growing ethnic minority groups. Of interest to social workers is how the traditional values and practices of these cultures affect their perceptions of disease and use of health services. This article presents information on perceptions of dementia, caregiving, and help seeking for the API group as a whole, with additional information on five of the major API subgroups--Chinese, Japanese, Filipino, Vietnamese, and Hawaiian. Implications for practice, policy, and research are discussed.

Do Hawaii residents support physician-assisted death? A comparison of five ethnic groups.

Surveyed were 250 adults in five ethnic groups--Caucasian, Chinese, Filipino, Hawaiian, and Japanese--on questions about physician-assisted death. When asked if there were any conditions under which physician-assisted death should be allowed, 52% said yes, 19% said perhaps, and 29% said no. Differences in response were seen, however, by ethnicity (with less support among Filipinos and Hawaiians), by religious affiliation (with less support among Catholics), and by educational attainment (with greater support among college graduates). Given the controversial nature of this topic, more public education and debate are needed. Meanwhile, physicians are urged to expand discussions with patients on their expectations about and options for end-of-life care.

Asian and Pacific Islander cultural values: considerations for health care decision making.

As the United States becomes more ethnically diverse, health care practitioners must learn about the perspectives and values of a variety of cultural groups. Of interest is how these cultural values intersect with those of the dominant culture, especially in the health care arena. This article explores the values that influence decision making among Asian and Pacific Islander cultures, with specific illustrations from six of these cultures. The literature, along with our observations as health professionals and researchers working in Hawaii, suggest potential areas of conflict between the more collectivist values of Asian and Pacific Islander cultures and the more individualist orientation of the U.S. health care system. Implications for practice and research are presented.

Death and dying in four Asian American cultures: a descriptive study.

Among ethnic minorities, the Asian and Pacific Islander (API) American group is the fastest growing, and, as a whole, is quite longevous. Although there is a significant literature on the history and religious traditions of API cultures, little has been published on death rituals and beliefs of the American descendants of these groups. The purpose of this study was to begin to explore cultural variations in response to the process of dying and grieving among four Asian American populations--Chinese, Japanese, Vietnamese, and Filipino. To this end, key informants and focus group interviews were conducted with members of these ethnic groups, and significant differences among, and within, groups were found. The small size and Hawaiian base of the sample preclude generalization of findings to the United States as a whole. However, this study provides health care workers with information that can increase their awareness of and sensitivity to Asian American approaches to death and dying.

Asian and Pacific Islander mortality differences in Hawaii.

In the United States, national health status data pertaining to Asian and Pacific Islander (API) Americans are rarely disaggregated. By aggregating API data, however, the poor health status of some API groups is often masked by the favorable health status of others. The purpose of this paper is two-fold: (1) to compare mortality rates of the five major ethnic groups in Hawaii (Caucasians, Chinese, Filipinos, Japanese, and Hawaiians) and (2) to explore methodological issues related to comparative studies of API health indicators. Standardized and age-specific mortality rates and 95 per cent confidence intervals for major causes of death were estimated for 1990 based on Hawaii vital records and population data. In general, death rates were highest for Hawaiians and lowest for Japanese and Chinese, illustrating the importance of API data disaggregation and suggesting that special attention be paid to improving the health of Hawaiians. Methodologically, the study demonstrated that, while some compromises in analysis are required, legitimate comparisons across API groups can be made if data sets are available.

Cultural issues in death and dying.

Although all of us experience death, not all of us think about death or respond to death the same way. This study begins to explore how cultural traditions, education, and tenure in Hawaii impact views of advanced directives, organ donation, suicide, and euthanasia. This information is useful to physicians who need to engage patients and families in discussions about death and end-of-life decision making.

Life and death in Hawaii: ethnic variations in life expectancy and mortality, 1980 and 1990.

Life expectancy in Hawaii is among the highest in the nation. Past research, however, found significant ethnic differences in longevity. This study presents life expectancy estimations for 1980 and 1990, along with ethnic differences in mortality rates for specific causes of death. The findings suggest that ethnic differences continue, with Chinese and Japanese having the longest life expectancy and Native Hawaiians having the shortest.

Protection against amebic liver abscess formation in the severe combined immunodeficient mouse by human anti-amebic antibodies.

We have used serum from patients with amebic liver abscess to investigate the role of antibody in the prevention of invasive amebiasis using the severe combined immunodeficient (SCID) mouse model of Entamoeba histolytica infection. The SCID mice were passively immunized with serum or purified antibody from patients with amebic liver abscess 24 hr prior to the direct intrahepatic challenge with 10(6) virulent E. histolytica trophozoites. This treatment reduced the mean abscess size in these animals from 24.5% to 3.5% (P < 0.0001). These results demonstrate that human anti-amebic antibodies are capable of exerting a protective effect in an animal model of amebic liver abscess formation.

Perceptions of dementia, caregiving, and help-seeking among recent Vietnamese immigrants.

Using qualitative methods, perceptions of dementia, caregiving, and help-seeking were obtained from three groups of Vietnamese immigrants - adult men, adult women, and youth - and from Vietnamese American professionals working with or studying this cultural group. Vietnamese culture and the history of immigration for Vietnamese Americans help explain and contextualize these perceptions. Of interest to practitioners are: (1) the importance of hierarchy within the family and the community, (2) the low priority of dementia and eldercare in a list of problems facing this group, (3) the variety of Vietnamese words and phrases that can be used to describe symptoms associated with mental illness and dementia, and (4) a willingness to use services. Findings can be used to increase the cultural competence of workers and services for Vietnamese Americans.

High mortality rates in Native Hawaiians.

Native Hawaiians continue to have higher mortality rates than do other ethnic groups in Hawaii. This discrepancy becomes even more pronounced when rates are calculated separately for full-Hawaiians versus part-Hawaiians versus all races. In an exploratory discussion of these data, a group of Native Hawaiian physicians recommend greater attention be given to Native Hawaiian values and participation in health care delivery, increasing access to services, and further research.

HealthScope: a model for a low cost health education program using commercial television.

HealthScope is a health education based on the Health Belief Model that uses television and print materials. It was designed for a number of agendas--(a) a desire by health educators to provide health information to a broad audience at a reasonable cost (b) a desire by the local medical association to promote its role in prevention and primary care, and (c) a desire by commercial television to expand its coverage of local health issues in a cost-effective way. In its summer series, HealthScope included 10 weekly television programs that focused on various aspects of disease prevention and health promotion and answered viewers' questions on the air. Each program was followed by a bank of physicians answering questions on the telephone for 90 minutes. Corresponding fact sheets were distributed through a local pharmacy chain. A "healthy weekend" sweepstakes contest also was held. Intermediate outcome measures indicated that HealthScope had a broad reach and stimulated viewers to seek additional information about health. At the same time, the program generated revenue for the commercial television station.

Developing and testing outreach materials on Alzheimer's disease for Asian and Pacific Islander Americans.

Compared to whites, minorities have similar rates of dementia but are less likely to use services. Native language videos and brochures that incorporated culturally specific perceptions of dementia, caregiving, and help-seeking for seven Asian and Pacific Islander American (APIA) groups were developed and tested. Findings suggested that these tools were culturally appropriate and, when used in combination with discussion, helped increase awareness of Alzheimer's disease and sources of help.