Cultural and ethical barriers to implementing end-of-life advance care planning among oncology nursing professionals: a content analysis of open-ended questions

Yi-An Shih; Cheng Wang; Jiahui Ding; Yuhong Zhou; Qian Lu

doi:10.1186/s12910-025-01261-x

Cultural and ethical barriers to implementing end-of-life advance care planning among oncology nursing professionals: a content analysis of open-ended questions

BMC Med Ethics. 2025 Jul 11;26(1):96. doi: 10.1186/s12910-025-01261-x.

Authors

Yi-An Shih^#^{1

2}, Cheng Wang^#^{3

4}, Jiahui Ding⁵, Yuhong Zhou⁶, Qian Lu⁷

Affiliations

¹ School of Nursing, Inner Mongolia Medical University, Hohhot, China.
² School of Nursing, Peking University, Beijing, China.
³ Department of Rheumatology and Immunology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China.
⁴ Inner Mongolia Key Laboratory for Pathogenesis and Diagnosis of Rheumatic and Autoimmune Diseases, Hohhot, China.
⁵ Hohhot Customs Port Outpatient Department, Hohhot International Travel Health Care Center, Hohhot, China.
⁶ China Fire and Rescue Institute, Beijing, China.
⁷ School of Nursing, Peking University, Beijing, China. luqian@bjmu.edu.cn.

^# Contributed equally.

Abstract

Background: Advance care planning (ACP), a cornerstone of ethical end-of-life care, upholds patient autonomy. However, its practice in Confucian-influenced societies, like China, is significantly shaped by cultural norms where family preferences often precede individual choice. This study explored cultural and ethical barriers to ACP implementation among oncology nursing professionals, focusing on tensions between patient-centered care and deeply rooted social norms.

Methods: A qualitative thematic analysis was conducted on open-ended responses from oncology hospitals across 22 provinces, 4 municipal cities, and 5 autonomous regions in China. Data were collected via a cross-sectional online survey and analyzed using Braun and Clarke's framework to identify patterns in cultural, ethical, and communicative challenges.

Results: A total of 838 oncology nursing professionals participated in the study. Three main interdependent barriers emerged: (1) Cultural norms, including filial piety (15.6% of codes) and death-related taboos (11.0%), often led to family-mediated decision-making (33.1%) over patient autonomy; (2) Ethical dilemmas involved neglecting patient preferences (24.3%) and conflicts between life-prolonging treatments and quality-of-life considerations (8.1%); (3) Communication challenges arose from information asymmetry (7.9%) and power imbalances, which often silenced patient voices. These factors collectively created systemic obstacles to ACP implementation.

Conclusions: Context-specific ACP strategies in China should integrate Confucian ethics into nursing education, support ethics consultation, and develop culturally sensitive communication models. Future research must assess these interventions' impact on balancing cultural values and patient autonomy, advancing equitable end-of-life care in culturally diverse healthcare systems.

Trial registration: Not applicable.

Keywords: Advance care planning; Cultural sensitivity; Ethical communication; Family decision-making; Nursing ethics; Patient autonomy.

MeSH terms

Adult
Advance Care Planning* / ethics
Attitude of Health Personnel
China
Cross-Sectional Studies
Decision Making / ethics
Female
Humans
Male
Middle Aged
Oncology Nursing* / ethics
Patient Preference
Patient-Centered Care / ethics
Personal Autonomy
Qualitative Research
Surveys and Questionnaires
Terminal Care* / ethics

Abstract

MeSH terms

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