Preferences for Long-Term Care: What Does Love and Culture Have

to Do with It?

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.

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, 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.