title: Knowledge, Attitudes, and Preferences of Advance Decisions, End-of-Life Care, and Place of Care and Death in Hong Kong. A Population-Based Telephone Survey of 1067 Adults.
abstract: OBJECTIVE
  According to the 2015 Quality of Death Index published by the Intelligence Unit of the Economist, Hong Kong is ranked 22nd in terms of quality of palliative care in the world, behind many other major developed countries in Asia, including Taiwan, Singapore, Japan, and South Korea. The objectives of the present study were to describe the knowledge, attitude, and preferences of the general Hong Kong adult population across different age groups regarding end-of-life (EOL) care decisions, place of care and death, as well as advance directive (AD).
  
  
  METHODS
  This was a population-based cross-sectional survey conducted by telephone. A total of 1067 adults over 30 years old were contacted through residential telephone lines using a random sampling method and were interviewed. Information on sociodemographic factors, general health status, chronic diseases, knowledge, attitude and preferences of advance decisions, EOL care, and place of death were collected.
  
  
  RESULTS
  A total of 85.7% had not heard of AD, but 60.9% would prefer to make their own AD if legislated after explanation; and for those who did not prefer to have an AD, the predominant concern was the possible change of mind afterward. Adjusted logistic regression suggested that female participants were less willing to make an AD, whereas those with prior knowledge of do-not-attempt-cardiopulmonary-resuscitation significantly increased the chance of making an AD. In terms of life-sustaining treatments, a predominant 87.6% preferred to receive appropriate palliative care that gives comfort rather than to prolong life if being diagnosed to be terminally ill; 43% disagreed that doctors should generally try to keep patients alive for as long as possible; and 86.2% agreed that the patient's own wishes should determine what treatment he/she should receive. Adjusted logistic regression showed that palliative care was more preferred by age groups 50 years or above but was less preferred by those who did not care for their family members with chronic diseases. Regarding place of death, 31.2% of the participants would choose to die at home, and among those, 19.5% would still prefer to die at home even if they did not have sufficient support. Adjusted logistic regression showed a decreased trend for all older age groups from 40-49 years to 80+ years, as well as having poor self-rated health, to prefer to die at home. Being a female participant and having education level of tertiary or above, however, had higher preference for death at home.
  
  
  CONCLUSIONS
  This is the first population-representative survey of the general Hong Kong adult population on the knowledge, attitude, and preferences of AD, EOL care, and place of care/death. The main implication of this study was that preferences to have autonomy over own EOL care, to receive palliative care, and to die at home were greater than the actual practice currently, highlighting the service gaps for better EOL care in the future.
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong. Electronic address: rychung@cuhk.edu.hk.
authors.forename: Roger Yat-Nork
authors.initials: RY
authors.lastname: Chung
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Eliza Lai-Yi
authors.initials: EL
authors.lastname: Wong
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Nicole
authors.initials: N
authors.lastname: Kiang
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Patsy Yuen-Kwan
authors.initials: PY
authors.lastname: Chau
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Janice Y C
authors.initials: JYC
authors.lastname: Lau
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Samuel Yeung-Shan
authors.initials: SY
authors.lastname: Wong
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Eng-Kiong
authors.initials: EK
authors.lastname: Yeoh
authors.affiliation: CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Jean W
authors.initials: JW
authors.lastname: Woo
mesh_terms: D000328:Adult; D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D003643:Death; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006723:Hong Kong; D006801:Humans; D008297:Male; D008875:Middle Aged; D057240:Patient Preference; D011795:Surveys and Questionnaires; D013727:Terminal Care
keywords: Chinese; End-of-life; advance directive; dying in place; palliative; telephone survey