Childlessness influences Chinese adults' end-of-life care preferences

Chinese adults who have children prefer to receive end-of-life care from family members at home, while those who lost their only child prefer to be cared for in hospice or palliative care institutions, finds a new study led by an international team of researchers and published in the November issue of The Journal of Palliative Medicine. Income, property ownership, and support from friends also influenced individuals' end-of-life care preferences.

"Childlessness greatly influences adults' end-of-life care preferences, as children play an important role in traditional Chinese family-based end-of-life care," said Bei Wu, PhD, Dean's Professor in Global Health at NYU Rory Meyers College of Nursing and co-director of NYU Aging Incubator. She is the study's senior author.

Filial piety, or respect for one's parents, is a core value in traditional Chinese culture, and children play a critical role in caring for aging parents and providing end-of-life care. End-of-life care is the support and medical care provided during the days, weeks, or months leading up to one's death.

China's one-child policy has led to a unique situation in caring for aging parents. As of 2010, one million Chinese parents had lost their only child, a number projected to grow to 11.8 million in 2050. Chinese adults who lose their only child are particularly disadvantaged when it comes to family-based end-of-life care.

In Western society, the end-of-life care model relies less on family members, instead using hospice and palliative care institutions and professional health care providers to provide support, reduce pain, and improve comfort. Hospice and palliative care systems are underdeveloped in China and face many structural and cultural challenges, including traditional views toward death, limited public funding, and a shortage of end-of-life care professionals at all levels.

In this study, Wu and her colleagues used data from a survey of 1,400 older adults in Shanghai to explore their end-of-life care preferences. The majority (1,200) were adults aged 60 years and older; the researchers also surveyed 200 adults aged 45 years and older who lost their only child. Participants were coded as having children who live with them, having children who do not live with them, or having lost their only child.

The researchers asked participants to share how they would want to be cared for at the end of their lives: by family, by visiting health care professionals, or in a specialized hospice or palliative care institutions.

They also measured factors related to end-of-life care, including sociodemographic characteristics such as gender, age, marital status, education, income, and property ownership; whether they have a support network of relatives and friends; health status, including chronic diseases, recent hospitalizations, mental health, and limitations in performing daily tasks; and whether they have health insurance.

The researchers found that adults who lost their only child prefer end-of-life care provided by a specialized hospice or palliative care institution (58 percent), while adults with children prefer family care at home (47 percent for adults whose children do not live with them and 49 percent for those whose children live with them).

Additional analyses show that adults with higher incomes and property tend to opt for family care at home. Conversely, those with a supportive network of friends prefer end-of-life care provided by visiting health care professionals or in end-of-life care institutions over family care at home. Health status was not associated with end-of-life care preferences; nor were other demographic factors (age, gender, marital status, and education).

"Our findings demonstrate a need to develop hospice and palliative care in China, both at-home care and care in hospitals and other clinical settings. Health care professionals and policymakers should recognize the particular preferences of those who have lost their only child and should develop tailored care accordingly," said Wu, who is also the director of research for the Hartford Institute of Geriatric Nursing at NYU Meyers.