Introduction
The end-of-life stage is a critical juncture for both patients and their caregivers, representing a time of vulnerability and considerable challenge. The certainty of life’s finitude underscores the imperative to maintain dignity throughout the end-of-life process. Living wills, also known as ‘advance directives,’ are legal instruments executed by individuals with clear mental faculties and good physical health. These individuals thoughtfully consider and articulate their preferences for end-of-life care, encompassing choices between allowing natural death or accepting a state of permanent unconsciousness [1]. The medical decisions for the individual are made collectively by a multidisciplinary team of healthcare professionals [1], comprising physicians, nurses, volunteers, psychologists, legal and social workers, and other specialists [2‐4]. This team offers comprehensive support and care to both the terminally ill patient and their grieving loved ones. Studies [5, 6] have evidenced that adept pain and symptom management, in conjunction with access to high-quality palliative care, can preserve patients’ dignity. Living wills, as a key aspect of hospice care, reflect respect for the sanctity of life and death by preventing unnecessary medical interventions, alleviating physical and emotional suffering, reducing excessive medical expenses, and ultimately improving the quality of life for patients [7]. They can assist in resolving the dilemmas faced by family members in decision-making and foster a proper understanding of the natural cycle of life and death [8, 9]. Primarily, it prevents disagreements among hospitalized individuals and their relatives, as well as between families and healthcare professionals [6]. As crucial members of the clinical operations team, Master’s degree nursing students, who possess a comprehensive understanding of living wills and cultivate a positive perspective on mortality, can significantly contribute to their professional growth. This study aims to thoroughly explore the perceptions, beliefs, and anticipations of nursing master’s students in China regarding living wills, addressing the knowledge gap among nursing students in the implementation of living wills. By doing so, it seeks to offer comprehensive guidance for the effective implementation and further development of living wills within China’s unique cultural context. The findings are expected to serve as a benchmark for improving end-of-life care in countries with deeply rooted Confucian traditions that emphasize filial piety.
Background
The concept of living wills originated from the United States’ "Natural Death Act" in 1976, which was the first law in the world to propose the legal protection of living wills [10]. In 1990, the United States enacted the "Patient Self-Determination Act," which required all hospitals and healthcare providers to incorporate advance directives as part of medical services [11]. This legislation has laid a crucial foundation for the advancement of living wills. Currently, a multitude of nations and territories across Europe, Latin America, and Asia have enacted legislation to govern living wills, ensuring their rational and efficient execution [12]. This indicates a growing recognition of the importance of advance care planning and the legal protection of patients’ autonomous choices in end-of-life care decisions. However, in the majority of developing countries, such legislative development remains in its infancy [13‐15].
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Perceptions of death differ significantly among various social and cultural contexts. In China, the cultural taboo surrounding death is profound [16], leading many Chinese individuals to consider discussions of death as inauspicious and a topic to be avoided. This belief system, deeply ingrained within the collective psyche, often results in a reluctance to engage in advance care planning or to articulate end-of-life preferences. Such cultural hesitancy can pose challenges for healthcare providers seeking facilitate informed decision-making processes in end-of-life care [15]. A substantial number of individuals, particularly among the elderly population, exhibit a reluctance to engage in advance decision-making regarding end-of-life care. This reticence may stem from cultural norms and personal beliefs that shy away from discussing mortality, thereby impacting the documentation of advance care plans and the expression of preferences for palliative and end-of-life treatment options [17]. Filial piety, as a cornerstone of ethical principles, has been revered as the paramount guiding rule within many cultural frameworks. It dictates the primary code of conduct and responsibilities towards one’s parents, often extending its influence to broader societal interactions and expectations [18]. Furthermore, the cultural emphasis on filial piety in China often dictates that family members should shield a sick relative from the full extent of their illness. This practice is rooted in a desire to protect and is accompanied by a commitment to exert all possible efforts to ensure the recovery of the afflicted family member. Such cultural norms can significantly influence the approach to communication and decision-making within the healthcare context, particularly at the end of life [19]. Despite potential futility in treatment, the norm in China is for patients to remain hospitalized until their passing. Consequently, the authority to make critical healthcare decisions during severe illness typically rests with the family. This cultural norm is propelled by a deeply ingrained belief that prioritizes life extension, even if it may cause additional suffering to the ill. Family members often seek emotional reassurance by prolonging life, sometimes at the expense of the patient’s comfort, thus potentially neglecting the patient’s right to medical autonomy [20]. According to research [21], over 70% of patients with advanced cancer experience pain, rely on life-support equipment to prolong their lives, and undergo distressing treatments until their final moments. This reality underscores the critical need for comprehensive pain management strategies and the importance of patient autonomy in end-of-life care decisions. It is essential to overcome the limitations of traditional filial piety culture to promote the implementation of advance directives in end-of-life care planning, enhance patient satisfaction, and ensure that the quality of symptom management, family communication, and awareness of death remain unaffected.
Living wills serve a dual purpose: they preserve the dignity of the patient while also easing the emotional and financial burden on family members and healthcare professionals. Furthermore, they encourage a compassionate and competent approach among medical staff, promoting a standard of care that is both respectful of patient wishes and considerate of the challenges faced by those involved in end-of-life care [22, 23]. In the realm of healthcare, the execution of living wills not only safeguards the dignity of patients but also alleviates the emotional and financial burden on family members and healthcare professionals [24]. This practice fosters a compassionate and proficient approach among medical staff [25], ensuring that end-of-life care is delivered in a manner that respects the patient’s wishes and autonomy [26]. Consequently, there is a pressing need to recognize the profound influence of traditional Chinese values, particularly those surrounding filial piety, on end-of-life care decisions. It is essential to understand that blind adherence to aggressive life-saving measures may not align with the principles of filial respect. Instead, true filial duty is reflected in honoring the patient’s wishes for a peaceful and dignified passing, devoid of unnecessary suffering. This approach prioritizes the patient’s autonomy and comfort, ensuring that their final moments are marked by tranquility and respect. Encouraging the establishment of living wills may cultivate a more profound respect for death as an inherent aspect of life, honoring the autonomous wishes of patients. Furthermore, it can instill new dimensions into the traditional concept of filial piety [18], thereby reconciling contemporary end-of-life care with cultural values [27].
Upon completing their postgraduate education, the majority of nursing students embark on careers in clinical practice. As the frontline caregivers, the perceptions, beliefs, and anticipations of Master’s-level nursing students wield considerable influence over the attitudes and experiences of patients. Their educational background equips them with advanced knowledge and skills that are pivotal to shaping the landscape of patient care and outcomes. An affirmative perspective on life and death, in conjunction with a comprehensive understanding of living wills, can significantly facilitate the implementation and progression of such directives. To date, research on living wills has predominantly focused on medical professionals, individuals with chronic medical conditions, and other pertinent groups, highlighting the need for a broader exploration of these issues within different populations and contexts [28].
Aim
This study aims to meticulously investigate the perceptions, beliefs, and expectations regarding living wills among Chinese nursing students at the Master’s level. Through this exploration, it seeks to provide a comprehensive guide for the effective implementation and advancement of living will practices within China’s unique cultural context.
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Method
To address the research objective, an exploratory qualitative descriptive approach was employed, utilizing semi-structured face-to-face interviews [29]. This method allowed for a deep understanding of the participants’ experiences and perspectives. Subsequently, an inductive content analysis was conducted to systematically analyze the data [30], enabling the identification of patterns and themes that emerged from the interview narratives. This process facilitated a rich and nuanced interpretation of the findings related to living wills among nursing students.
Participants and recruitment
In this study, a purposive sampling method was utilized to maximize the sample size, ensuring a diverse array of participants’ responses and a comprehensive interview process that captures a breadth of demographic characteristics. Participants were carefully selected to ensure diverse demographic characteristics, such as gender and years of clinical experience, in order to broaden the range of perceptions on living wills. This diversity helps to deepen the understanding of the various factors that shape Master’s degree nursing students’ views on living wills, thereby providing a strong foundation for the study’s objectives [31]. A snowball sampling method was used to recruit eligible Master’s degree nursing students, who were referred by their classmates [32]. Nursing master’s students refer to those who have previously undergone clinical internship experience but are currently enrolled in full-time master’s degree programs in nursing. They possess a certain level of clinical nursing experience and are also beneficiaries of higher education. Upon graduation, they are expected to engage in either clinical nursing practice or nursing education. The study was conducted at a university in Tianjin from September to December 2023, applying specific inclusion and exclusion criteria to ensure a targeted participant group. Eligibility for Master’s degree nursing students was determined by the following criteria: being 30 years of age or younger; possessing no communication barriers and the ability to accurately articulate their views; and demonstrating a willingness to participate voluntarily. We set the age limit to ensure the homogeneity of the study population and the generalizability of the findings. This strategic selection process aimed to yield a sample of participants who could offer insightful perspectives on living wills, contributing to a focused and relevant study outcome.
Ethical consideration
This study was granted approval by the Research Ethics Committee, ensuring adherence to ethical standards and participant protection. Prospective participants were provided with detailed information about the study’s objectives through a Participant Information Sheet, which was meticulously explained by a professional researcher via e-mail. Upon receiving and understanding the information, those who voluntarily consented to participate were asked to sign an informed consent form before commencing their involvement in the study. This process was designed to ensure that all participants entered the research with full knowledge and consent, upholding the principles of autonomy and informed decision-making.
Data collection
The researcher conducted individual semi-structured interviews using an interview guide developed by the authors, all of whom possess expertise in palliative care [33]. The guide was meticulously crafted following a comprehensive literature review and was refined through collaborative discussions among research group members, comprising three professors and ten postgraduate nursing students. To ensure the guide’s relevance and clarity, the researcher conducted a preliminary validation process.
The interview guide was designed to explore several key areas: the introspective thoughts on end-of-life care prompted by unexpected losses of loved ones or patients during clinical practice; the understanding and acceptance of living wills, along with any suggestions or questions participants might have regarding these documents; and the perceived clinical benefits of living wills, as well as the factors that could influence their wider promotion. This systematic approach aimed to elicit in-depth insights into the nuances of living wills from the perspective of nursing students, thereby enriching the study’s findings. The interview guide was pre-tested on five nursing graduate students prior to the main data collection to assess its clarity and scope. Necessary adjustments were made to the guide based on the feedback obtained during this process. The researcher, serving as a teaching assistant at a medical school, had established rapport with the students through core courses prior to the start of the study, making the interviews appropriate. The interview was conducted in a relaxed atmosphere at the university lecture hall that is frequently used by students.
Prior to each interview, the researcher briefed the participants on the study’s objectives and significance, selecting a tranquil classroom environment to ensure comfort and minimize distractions. All interviews were conducted with the participants’ consent and were audio-recorded, with the researcher also taking field notes to capture immediate observations. The researcher utilized adept communication skills to probe for further details while maintaining a focus on the central theme of living wills. Attention was given to the interviewees’ non-verbal cues, such as facial expressions, body language, and vocal intonation, to gain a comprehensive understanding of their perspectives. Each interview was scheduled to last between 30 to 60 min, allowing for a thorough exploration of the topic at hand.
Data analysis
The audio-recorded interview data were transcribed within 24 h of each session’s completion, subsequently translated into English, and meticulously reviewed for accuracy by two bilingual team members. To safeguard the confidentiality of the participants, the interviews were assigned codes, ensuring that the data could not be traced back to individual participants. Access to this sensitive data was strictly limited to the authors of the study, maintaining the privacy and security of the information gathered. This rigorous process upheld the ethical standards of the research and protected the rights of the participants [31]. Inductive content analysis was utilized to systematically examine and distill the predominant themes from the interview data. This approach facilitated an autonomous exploration of the data, allowing for the emergence of patterns and insights without preconceived categories. At the inception of the analytical process, the textual data were reviewed iteratively to fully comprehend the core elements and contextual nuances of the participants’ narratives. This methodological rigor ensured a deep and unbiased understanding of the perspectives on living wills as expressed by the nursing students [30]. To ensure the credibility of the study, rigorous cross-verification of transcripts against their translated interpretations was conducted throughout the analysis. Concurrently, an open coding technique was applied to the textual data using Excel software. This involved highlighting segments of each transcript that pertained to the research objectives, thereby shedding light on the diverse dimensions of the content.
To ensure the credibility and validity of the coding process, the highlighted data were independently coded by two researchers. The reliability of the coding consistency was tested by calculating Cohen’s Kappa coefficient between the two coders. After computation, evaluation, and adjustment, the Cohen’s Kappa coefficients exceeded 0.75, indicating substantial agreement between the coders and demonstrating good reliability of the coding results. In order to increase the reliability of the data analysis, the codes and themes were reviewed by an independent third researcher and a final coding structure was created that was agreed upon.
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The subsequent phase involved the comparative analysis of codes to form themes. This process integrated data related to specific concepts, revealing patterns and connections within the dataset. The abstraction phase identified the central theme and its subordinate categories, which were then organized into a coherent structure.
Finally, the primary and secondary themes were determined from these headings, attributing meaning to the phenomenon under study. This meticulous analytical process was designed to enhance the trustworthiness of the findings and to provide a comprehensive understanding of the participants’ perspectives on living wills.
Findings
In this study, a total of thirteen Master’s degree nursing students were interviewed, with their demographic information presented in Table 1. The analysis of the interview data uncovered three primary themes and eight sub-themes, as follows:
Table 1
The demographic Information of the respondents
Group | Number (total 13) |
|---|---|
Gender | |
Male | 3 |
Female | 10 |
Age (years) | |
< 25 | 9 |
≥ 25 | 4 |
Grade | |
1 | 4 |
2 | 6 |
3 | 3 |
Single child | |
Yes | 4 |
No | 9 |
Birthplace | |
Rural | 7 |
Urban | 6 |
Monthly consumption (in CNY) | |
< 800 | 1 |
800–1500 | 8 |
1500–2500 | 3 |
> 2500 | 1 |
Have you ever worked in clinical practice | |
Yes | 7 |
No | 6 |
Whether engaged in clinical care | |
Yes | 11 |
No | 2 |
1.
Perceptions of Living Wills:
-
High Attention: Participants demonstrated a significant level of interest in living wills.
-
Knowledge Deficit: There was a recognized gap in the participants’ knowledge about living wills.
-
Lack of Education: A deficiency in educational resources and training on living wills was identified.
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2.
Beliefs of Living Wills:
-
High Acceptance: The participants generally held positive attitudes towards living wills.
-
Positive Clinical Significance: Living wills were seen as having beneficial implications for clinical practice.
3.
Anticipations of Living Wills:
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High Expectations of Improved Knowledge: There was a strong desire among participants for increased knowledge on living wills.
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Factors Influencing Promotion: Various factors that could affect the promotion of living wills were discussed.
-
Suggestions for Improvement: Participants offered recommendations for enhancing the understanding and application of living wills.
These findings provide a structured overview of the nuanced perceptions, beliefs, and anticipations that nursing students have regarding living wills, offering valuable insights for educational and policy development in the field of end-of-life care (Table 2).
Table 2
Themes identified by major subject
Themes | Subthemes |
|---|---|
Knowledge of living will | High attention |
Knowledge deficit | |
Lack of education | |
Attitude towards living will | High acceptance |
Positive clinical significance | |
Expectations of the living will | High expectation of improvement knowledge |
Factors influencing promotion | |
Promotion suggestions |
Perceptions of living wills
High attention
In a survey inquiring about their contemplation of end-of-life scenarios and reflections, it was revealed that four participants have not given thought to end-of-life concerns or considered decisions regarding end-of-life treatment. In certain situations, they may consider such issues.
“Body function is not so good, will consider this question. ”(Participant 4).
“When the family is sick (will consider this question) ”(Participant 7).
“If my heart disease develops to the end stage, I will think about this question. ”(Participant 13).
In contrast, nine participants have explicitly stated that they have deeply reflected upon their mortality, with two of them having considered the possibility of organ donation, affirming that such decisions should be within their domain:
“Seeing a lot of videos about sudden death, I will consider my own dying situation. ”(Participant 3).
“A relative died of cancer at home, I thought of this problem. ”(Participant 9).
“Injured when participating in school sports training, from the leg injury to the leg can ‘ t even be kept or lifelong impact, and then think of the accident led to death. ”(Participant 2).
“When living is not wonderful, I think that there is no meaning in living, and I think of the end of life. ”(Participant 11).
Participants who had reflected upon end-of-life concerns overwhelmingly expressed a preference to forgo treatment in the event of incurable, severe illness or when nearing the end of life. The underpinnings of this preference are multifaceted and include: 1) perceiving life as lacking significance, 2) a desire to alleviate the decision-making burden on family members, 3) the presence of excruciating pain, 4) a lack of dignity, 5) the futility of treatment that wastes medical resources, 6) a diminished quality of life, and 7) the desire to mitigate the economic burden:
“There is a consensus that it is unnecessary to relive the ordeal of exhaustion, being tethered to a multitude of tubes, or experiencing the helplessness of being in an ICU, where one is incapable of meeting their own basic needs. ” (Participant 12).
Knowledge deficit
The majority of participants demonstrated a superficial understanding of living wills. Those Master’s degree nursing students who had not undergone end-of-life education exhibited ambiguous and erroneous perceptions of living wills. Even among participants who had completed courses in end-of-life care, there was a discernible yet incomplete grasp of the concept. Their comprehension of the fundamental principles was found to be deficient and occasionally misleading. There was a propensity to confuse living wills with traditional last wills and testaments.
“It is frequently observed that individuals often encounter difficulty in explicitly formulating their preferences and tend to merely acknowledge them in a cursory fashion, failing to engage with the depth of their true desires. ” (Participant 5).
Lack of education
Participants primarily gained knowledge about living wills through educational courses, online videos, television programs, literature searches, and online resources. Notably, a participant (Participant 12) who had proactively sought learning was still uninformed about the existence of websites dedicated to living wills and was unaware of how to access them. This pattern was observed among individuals with medical knowledge and is anticipated to be more pronounced among the general public.
“The online domain does not provide a feasible pathway for acquiring this skill. ”(Participant 12).
Beliefs of living wills
High acceptance
When confronted with delicate subjects such as mortality, all participants exhibited a calm and sincere attitude. They showed no aversion to the concept of death and instead displayed an open and accepting view of living wills. They were keen to sign, actively advocated for their implementation and advancement, and conveyed optimism regarding their future evolution. Following a brief overview of the content of living wills, the majority of participants showed a positive belief. Specifically, four respondents indicated their readiness to sign living wills immediately after being introduced to them, while nine others planned to do so in the future. The participants unanimously recognized the importance of living wills.
“Rather, I prefer to execute the document when the need arises, as this approach lends a heightened sense of authenticity to the act. ”(Participant 11).
Positive clinical significance
Twelve participants held the view that acquiring knowledge about living wills is advantageous for clinical practice, citing the following reasons: 1) It offers support in end-of-life care situations. 2) As healthcare professionals interacting with patients, clinical nurses can closely observe their well-being and offer timely guidance on lifestyle choices. 3) It can enhance the humanistic and palliative care skills of nurses, thus elevating the standard of care. 4) Master’s degree nursing students can cultivate a more profound understanding of dignity, resulting in greater reverence for patients in future clinical engagements. 5) It can assist in honing empathy and communication skills, thereby mitigating medical conflicts. 6) From a public policy standpoint, living wills can lead to cost savings and more effective resource allocation, preventing unnecessary expenses. 7) It fosters the concept of dignified dying and the importance of living wills. 8) Furthermore, it provides easy access for medical staff in making advance medical arrangements.
When inquired about their readiness to introduce living wills to patients in need during clinical practice, three respondents took the initiative to recommend living wills to patients who were in suitable circumstances.
“During my conversations with patients, I utilize a natural and friendly tone, while also proactively conveying my thoughts and suggestions in a gentle and tactful manner. ”(Participant 12).
Among the six participants, a consensus emerged to recommend living wills to patients who are open-minded and receptive, when the situation warrants it.
“Certain individuals demonstrate a more profound understanding and exhibit more enlightened perspectives on this issue. I would suggest introducing the concept to them, as it could be beneficial in their professional capacities. However, for individuals who are elderly or rigid in their views, and who show resistance to change and a predisposition towards pessimism, I would advise against offering such a recommendation. ” (Participant 14).
However, three participants conveyed their hesitancy to proactively recommend living wills to patients:
“I considered it inappropriate to offer a recommendation unsolicited, considering the nurses were occupied with their clinical duties. ”(Participant 3).
Anticipations of the living wills
High expectation of improvement knowledge
The majority of participants expressed an increased anticipation for enhancing their understanding of living wills. Three participants concurred that the subject matter should be incorporated into classroom instruction, advocating for its inclusion in educational curricula and for it to be expounded upon by specialists. There is a notable disparity between theoretical knowledge and practical experience. One participant suggested that a simulation of the living will process could offer signatories a practical experience, thereby improving their comprehension. Three participants concurred that clinical case teaching is the most effective method for grasping the concepts of living wills. Additionally, seven participants proposed that the dissemination of short videos, brochures, hospital department newsletters, public social media updates, and educational seminars could serve as potent strategies to expand advocacy efforts. Alternative strategies to enhance understanding of living wills include integrating them into medical dramas, establishing dedicated websites, organizing forums such as "death cafes" for group discussions, and promoting them via reputable online platforms and television networks。These approaches can enhance credibility and persuasiveness. The detailed analysis of the educational content is presented in Table 3.
Table 3
Analysis of educational content (order of demand)
Interview theme | Cognitive contents |
|---|---|
What you want to know about living wills | Existing legal support |
Specific content of the living wills | |
To what extent / stage has been carried out | |
The significance of the living wills | |
The maker, time and whether the living will can be repented | |
Person in charge of the living wills | |
Living will formulation process | |
Place of signature | |
real case | |
Practice Filling |
“This strategy is exceptionally potent for education, utilizing real-case scenarios to underscore the importance of establishing living wills. ”(Participant 11).
“My vision encompasses the creation of a specialized website designed to enable individuals with similar ideas and needs to directly access and monitor the progress of participants’ implementation. ”(Participant 12).
Factors influencing promotion
Several factors have significantly influenced the promotion of living wills. With legal frameworks increasingly supporting the legalization of living wills, their adoption is becoming more likely. Factors such as an aging population, health challenges among the middle-aged and elderly, higher rates of depression among younger people, and the prevalence of suboptimal physical health statuses are driving a growing public demand for living wills [34]. Additionally, as the populace experiences rising life quality and educational levels, there is a heightened focus on achieving a dignified quality of life and death. The receptivity to death education is on the rise. The accessibility of information has improved, thus aiding in the implementation and promotion of living wills. However, the development of living wills is still in its infancy and encounters numerous obstacles.
“It is more difficult for people with low educational level to accept.”(Participant 9).
“The messaging efforts have not been fully effective, and some people remain uninformed or unresponsive.”(Participant 13).
The obstacles and their impact on living wills are detailed in Table 4.
Table 4
Hindrance factors and modes of influence on living wills
Interview theme | Factor | Influence mechanism |
|---|---|---|
Hindrance factors of implementation and promotion of the living wills | imperfect law | The living wills lack legal support |
Traditional cultural restrictions | The imprisonment of thought on life and death | |
Poor awareness of rights | Patient are in a weak awareness of rights protection for medical autonomy rights | |
Fewer relevant institutions | Lack of funds leads to fewer hospice-related institutions | |
Death education not in place | Correct view and concept of life and death not deeply rooted in the hearts of the people | |
Unattended Living will service | Doctors and nurses are busy with their work and have no time for hospice care | |
Can ' t be immersive | Formulation rate is low when a person is not in terminal condition | |
Low knowledge level | Learning ways are not clear | |
Inadequate publicity | Low publicity | |
Low education level | Cultural level / education is low |
Suggestions for improvement
The study utilized the "My Five Wishes" document, which was developed by the Beijing Living Will Promotion Association.
Content
Two participants suggested that the content of living wills could be expanded to include more compassionate elements, such as unfulfilled desires. Meanwhile, two respondents felt that the text was excessively lengthy. Additionally, one participant noted the presence of technical jargon in the text, which might be challenging for individuals with limited medical knowledge, potentially leading to misunderstandings and biased decision-making. To enhance the comprehensibility of the text for the general public, it is essential to refine the language used:
Furthermore, I believe it is feasible to incorporate patients' personal wishes, detailing their goals and the actions that others should take to support them. (W7)
Medical postgraduates have a grasp of appropriate life support interventions; however, individuals without medical expertise may not be as well-versed in this area. (W4)
Forms
The majority of participants concurred that the current approach to creating living wills was overly simplistic and limiting, with the document's language not being comprehensive enough. It was suggested that living wills should be developed in various formats. For example, supplementing written directives with concise videos to explain them could enhance the clarity of living wills:
Drawing from personal experience, I have observed that relying exclusively on written instructions can be impractical for patients who are physically incapable of completing forms, such as those who have lost their hands. In these instances, offering alternative methods like voice or video recordings could prove more accessible and intuitive for users. (M2)
Discussion
Cultural challenges
Placing the wishes of patients at the forefront should be of paramount importance in all healthcare settings. The profound influence of traditional Chinese culture presents a significant challenge to the acceptance and understanding of living wills among the Chinese population. By examining the perceptions and beliefs surrounding living wills and discussing the expectations among Master’s degree nursing students, we have provided compelling evidence regarding the implementation and advancement of living wills in China.
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In Chinese culture, traditional beliefs such as the taboo of discussing death, the desire for longevity, and the emphasis on filial piety pose significant challenges to the promotion of living wills. The concept of "talking about death brings bad luck" leads many to avoid making decisions related to end-of-life care, as death is considered an inauspicious topic. Furthermore, the deep-rooted desire for longevity and the avoidance of death foster a misconception that signing an advance directive equates to "giving up on life," causing concerns about being abandoned by doctors or family members. Filial piety, which emphasizes the duty of children to care for their aging parents, can make families hesitant to support living wills, fearing ethical dilemmas or a failure to fulfill their responsibilities. Additionally, some individuals may lack trust in the healthcare system, worrying that their medical needs may not be adequately addressed, or that their directive could be misinterpreted as a request to withdraw treatment. These cultural attitudes contribute to resistance toward living wills.
Culturally sensitive education and outreach are key strategies for overcoming barriers to the adoption of living wills. First, redefining living wills is crucial; public education efforts should clarify that they are not about giving up on life but about respecting an individual’s end-of-life wishes, ensuring that they receive the care they desire even if they are unconscious or unable to make decisions. Terms like "health management" or "advance health planning" can be used to minimize the direct association with death, reducing resistance. Encouraging open discussions, such as public forums and family dialogues, can help people understand that living wills are not merely about death, but about personal rights, dignity, and quality of life, prompting more families to address these sensitive issues early on. Additionally, leveraging the influence of celebrities and community leaders to publicly discuss and endorse living wills can help create a ripple effect. Media campaigns featuring real-life examples can further educate the public on the benefits.
Incorporating living wills into routine medical processes is another effective measure. Hospitals and healthcare institutions should make consultations and signing of living wills a part of regular health checkups. Physicians and nurses need to be trained to discuss these matters with patients and their families in a sensitive and appropriate manner. Furthermore, legal and policy support from governments and healthcare authorities is essential. Laws that protect the rights of individuals with living wills and policies that incentivize their adoption, such as offering medical cost reductions, could promote wider acceptance.
Finally, engaging religious and cultural leaders in the conversation can clarify that living wills do not conflict with moral, religious, or cultural beliefs, and in some cases, they protect individual rights and dignity. Such partnerships can help break down religious and cultural taboos. By implementing these culturally sensitive strategies, more people can overcome the psychological barriers stemming from the fear of death and the desire for longevity, thereby becoming more open to living wills. This not only safeguards individual end-of-life rights but also reduces the pressure on families and healthcare systems during critical moments.
Importance of education
A positive perception of living wills is predicated on an accurate and comprehensive understanding [35]. Enhancing the understanding of Master’s degree nursing students about living wills is crucial for fostering an accurate perception of mortality and for increasing the rate at which living wills are executed. The study participants, who were knowledgeable individuals with medical expertise, demonstrated that despite actively seeking information about living wills, some were still unaware of the existence of specialized websites dedicated to this subject, indicating potential barriers to accessibility for the general public. It is evident that the perception of living wills is ambiguous and not adequately disseminated. This finding is consistent with previous studies [36, 37] and underscores the necessity for education and training to ensure effective execution [38, 39]. Considering that living wills are essential instruments for ensuring a dignified passing, the promotion of their implementation necessitates the strengthening of death education [40]. In the modern era, it is crucial to surpass the constraints imposed by traditional culture. We must extract its core tenets, strip away its superficial aspects, and provide a comprehensive and systematic education on the subject of mortality. It is essential to clarify the subtleties of dignified dying to Master's degree nursing students, empowering them to identify and correct any misconceptions stemming from preconceived notions. Furthermore, it is vital to differentiate between living wills and euthanasia. Individuals with practical experience in creating living wills are well-positioned to clarify these concepts, thereby enhancing the understanding of Master's degree nursing students and optimizing learning outcomes. Introducing specialized education, such as simulation exercises and experimental courses on drafting living wills in medical colleges, could provide signatories with practical exposure and enhance their understanding and acceptance of the concept. It is recommended to expand the reach of advocacy efforts collectively, including organizing scientific lectures, creating concise videos, publishing informative leaflets, displaying posters or brochures in hospital departments, and disseminating public tweets, to optimize the impact of living wills' services.
Moreover, it is advisable to introduce specialized education, such as simulation exercises and experimental courses on creating living wills in medical colleges, to provide signatories with practical exposure and enhance their comprehension and acceptance of the concept. Role-playing and case simulations can help families practice discussing sensitive end-of-life decisions and demonstrate the challenges of making medical decisions without living wills. Healthcare providers can benefit from communication skills training, learning how to sensitively discuss living wills with patients, especially those from diverse cultural backgrounds, while interdisciplinary team simulations can foster coordination in implementing living wills within healthcare settings. Public education through virtual reality (VR) or augmented reality (AR) experiences can immerse individuals in critical medical scenarios, helping them visualize the importance of living wills. Interactive workshops and decision-making games can further engage the public in understanding the impact of living wills on healthcare outcomes. Additionally, electronic tools such as living wills’simulator or e-learning modules can guide users through the process of creating living wills, offering personalized advice based on individual health conditions and preferences. Legal and cultural seminars for leaders can help reconcile cultural and religious concerns with legal frameworks, promoting consensus and wider acceptance. Finally, community engagement activities, such as public forums, health exhibitions, and one-on-one consultations, can raise awareness and encourage more individuals to consider living wills. It is suggested to broaden the reach of advocacy efforts collectively, including organizing science lectures, creating concise videos, publishing informative leaflets, displaying posters or brochures in hospital departments, and disseminating public tweets, to optimize the impact of living wills' services [41]. By incorporating these diverse and culturally sensitive training approaches, the widespread understanding and acceptance of living wills can be significantly enhanced.
Access and awareness
The majority of participants demonstrated an inclusive and receptive attitude towards living wills. It is important to recognize that beliefs surrounding life and death differ between Chinese and Western societies [42]. Indeed, discussions about life and death are rarely initiated in Chinese daily conversations. On one hand, traditional culture discourages conversations about death, considering it inauspicious [43]. Furthermore, traditional concepts of filial piety emphasize the pursuit of longevity, thus the promotion of the idea of dignified dying may conflict with traditional filial piety and challenge the moral principle of prioritizing filial duties. On the other hand, the Chinese population is often uninformed about living wills and end-of-life care, as their focus is primarily on their current existence. There is a prevalent belief that advancements in modern medicine will prevent them from having to confront mortality in the near future. Ebra Dobbs et al. [44] have indicated that unfavorable beliefs about life and death serve as significant barriers to the dissemination of living wills. However, as societal norms evolve, an increasing number of individuals are embracing the concept of dignified dying and pursuing an enhanced quality of life. The study's findings suggest that Master's degree nursing students who have encountered patient mortality or undergone death education are more optimistic about living wills. Such experiences have the potential to alleviate the fear of death and influence one's perception of it [45]. Indeed, the application of living wills is not confined to a one-size-fits-all model; it should be tailored to align with the beliefs, preferences, and characteristics of the target group [46], reflecting their diverse preferences [47]. In the digital era, it has become increasingly convenient for well-educated young individuals to understand living wills through diverse information channels, including the internet, media platforms, and WeChat. With exposure to a vast array of information, they have an enhanced ability for information processing, analytical reasoning, and rational problem-solving, making them more open to the concept of living wills. Consequently, scholars may initially introduce living wills to a receptive and persuadable audience, and then gradually expand its influence to encompass the entire population. Target groups for such initiatives include those working in high-risk industries, individuals with terminal illnesses/chronic diseases/long-term treatments, those with a family history of cancer, patients with dementia, highly educated individuals, young adults, patients with a strong sense of self-regulation, families of patients, healthcare professionals, and medical postgraduates. Their attitudes towards living wills are progressively improving [48].
Limitation
This study has several limitations. The small, localized sample may limit diversity of perspectives and restrict transferability to broader nursing student populations. Additionally, the qualitative nature introduces potential subjectivity, as analysis relies on researcher interpretation. Response bias is a concern, as participants may align responses with perceived expectations. Beyond sample size, single-institution scope, and subjectivity, factors such as limited demographic diversity, lack of longitudinal data to capture evolving views, interviewer influence, and reliance on self-reported data, which may carry recall or social desirability bias, also warrant consideration.
Future research
In future studies, it is recommended that studies be conducted comparing the perceptions of living wills among individuals of different age groups and cultural backgrounds. Additionally, studies on how the impact of educational programs can be sustained in the long term and how this education is reflected in students' clinical practice may also be useful.
Conclusion
To ensure the widespread adoption of living wills, prioritizing death education is essential. A key strategy is to equip Master's degree nursing students with training on living wills. Additionally, establishing and refining legislation is a fundamental safeguard. This study underscores the importance of educating Master's degree nursing students about living wills. Enhancing the infrastructure to effectively promote living wills is crucial. This can be accomplished by increasing the involvement of knowledgeable caregivers in shaping legislation and regulations, developing comprehensive guidelines and standards, and disseminating knowledge and practices of living wills through lectures, seminars, and scholarly research.
Acknowledgements
We would like to express our sincere gratitude to all participants that have contributed to this research.
Clinical trial number
Not applicable.
Statement of interest
The authors hereby declare that there are no personal or professional interests that could be construed as influencing the outcomes of the research presented in this submission. No commercial organizations or entities have provided financial support or influenced the design, data collection, analysis, interpretation of data, or writing of this manuscript. Any role played by individuals or organizations in the preparation of this work has been purely academic and in the interest of scientific advancement. The authors confirm that all financial and material support has been clearly acknowledged, and there are no conflicts of interest to report in relation to this study.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the ethical standards of Tianjin University of Traditional Chinese Medicine and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval was obtained from the Tianjin University of Traditional Chinese Medicine, and all participants provided informed consent prior to their inclusion in the study.
For all research involving human subjects, freely-given, informed consent to participate in the study must be obtained from participants (or their parent or legal guardian in the case of children under 16) and a statement to this effect should appear in the manuscript.
Consent for publication
Informed consent was obtained from all individual participants included in the study. Additionally, informed consent was obtained from all individuals for whom identifying information is included in this article.
Competing interests
The authors declare no competing interests.
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