Advance Care Planning Among Chinese-Speaking Cancer Patients: Sociodemographic Predictors and Response to Social Work Intervention

Background and Purpose: Advance care planning (ACP), including healthcare proxy (HCP) appointment, is critical for ensuring patient-centered cancer care. Chinese-speaking cancer patients represent a growing yet underserved population facing unique linguistic and cultural barriers to ACP engagement. Although disparities in ACP completion among Asian Americans are well-documented, most studies focus on community-dwelling older adults. Little is known about factors associated with HCP documentation among cancer patients and/or younger populations. This study examined:(RQ1) sociodemographic and clinical characteristics associated with having an HCP prior to meeting with a social worker among Chinese-speaking cancer patients across age groups; and (RQ2) decision-making styles and barriers associated with HCP appointment following social work intervention among these patients without a prior HCP designation.

Methods: This retrospective chart review from 2019 to 2023 included 275 Chinese-speaking adult cancer patients (age 24+) at a comprehensive cancer center in New York City, of whom 237 patients without an HCP received a social worker-led ACP intervention. For RQ1, bivariate analyses and multivariable logistic regression identified sociodemographic, clinical, barrier types and decision-making style predictors of HCP documentation prior to the social work encounter. For RQ2, bivariate and multivariable logistic regression was used to examine decision-making styles and barriers of HCP appointment on HCP appointment following intervention among the 237 patients without a prior HCP.

Results: Only 38 patients (13.8%) had an HCP prior to meeting with the social worker. In bivariate analyses, Cantonese-speaking patients were more likely to have an HCP than Mandarin-speaking patients (p=0.017), as were patients aged 65 and older (p<0.023), patients with late-stage cancer (p=0.024), and those who deferred decisions to family (p<0.001). In multivariable logistic regression, self-deciding patients had significantly lower odds of having an HCP before the social worker’s intervention compared to patients who deferred decisions to family (OR=0.08, 95% CI=0.02–0.40, p=0.002). Among the 237 patients without a prior HCP, 93.2% cited lack of awareness as their primary barrier. Following social work intervention, 40.9% appointed an HCP, 43.0% remained open to future discussion, and 16.1% declined further discussion. Barrier type was the strongest predictor of response to the intervention: none of the 12 patients citing social or cultural barriers appointed an HCP, compared to 43.1% of those citing lack of awareness (p=0.002). Among patients whose barrier was lack of awareness, self-deciding patients had significantly lower odds of appointing an HCP following intervention compared to patients who deferred to family (OR=0.15, 95% CI=0.03–0.72, p=0.018).

Conclusions and Implications: This study highlights a substantial gap in HCP documentation among Chinese-speaking cancer patients, especially among younger patients and patients diagnosed with early-stage cancer, with lack of awareness as the predominant barrier. Social work intervention was highly effective in addressing knowledge-based barriers. However, patients with social or cultural barriers and autonomous decision-makers showed significantly lower engagement. These findings underscore the need for educational outreach targeting Mandarin-speaking and younger patients, and culturally tailored, family-inclusive ACP interventions. Social workers are uniquely positioned to identify barrier type, decision-making style, and age and cancer stage factors to advance health equity for this underserved population.