Association of filial attitude, filial behavior and death literacy: implications for development of death system in Guangdong-Hong Kong-Macao Greater Bay Area of China

The FPR-EoL was developed and validated by Che et al. [23]. The FPR-EoL is a 19-item scale measures the filial piety representations of Chinese adult children when their parents are at the end of their lives. The scale consists of four subscales: (1) respect and comfort, (2) acceptance of death, (3) spending final days, and (4) disclosing bad news. It exhibited a reliability of Cronbach’s alpha of 0.73. This study examined the discrepancies between the participants’ attitudes and behaviors in terms of filial piety when they encountered parents’ EoL. In this context, the responses of the questionnaire were scored in two ways. Respondents could select an option on a scale ranging from ‘extremely agree’ (a score of 5) to ‘extremely disagree’ (a score of 1) with respect to their filial piety representations with the goal of assessing their attitudes with regard to filial piety in an EoL context; in contrast, filial piety-related behavior in an EoL context was measured by asking respondents to select an option on a scale ranging from ‘extremely tend to do’ (a score of 5) to ‘extremely not tend to do’ (a score of 1) in response to the given filial piety representations. Higher scores indicate greater levels of agreement with filial piety behaviors and a greater tendency to put them in practice.

The DLI was developed and validated by Leonard and colleagues in 2020 as part of the Groundswell Project of Australia [29, 32]. This measure is used to assess the knowledge and skills that enable people to gain access to, to understand, and to make informed choices about death and end-of-life care options. This notion serves as an index that can be used to predict the death quality of individuals as well as to reflect the overall quality of public health palliative care [33]. DLI is a 29-item scale comprising 4 subscales: ‘Practical Knowledge’ (8 items), ‘Experiential Knowledge’ (5 items), ‘Factual Knowledge’ (7 items) and ‘Community Knowledge’ (9 items). Higher DLI scores indicate better death literacy [32]. The DLI has been translated into Swedish [34], Turkish [35] and Chinese [36]. This study utilized the Chinese version, which was validated by Che et al. [36] as the participants in this study were all Chinese. Its internal consistency was good, with an overall Cronbach’s alpha of 0.94.

Descriptive analysis was used to demonstrate demographic data, representations of filial piety, and death literacy. Paired t tests were used to compare the FPR-EoL (attitude) and FPR-EoL (behavior) scores of the participants, and the difference between attitudes and behaviors pertaining to filial piety. As behavior is more closely associated with the actual actions taken by the individual, FPR-EoL (behavior) was subjected to further inferential statistical analysis, including a one-way ANOVA used to examine the differences in FPR-EoL (behavior) exhibited by participants with different demographic characteristics. Post hoc analysis was used to examine the differences among different age groups and occupations.

The current study demonstrated a significant gap between the filial attitudes and filial behaviors of Chinese adult children toward their parents at the end stages of their lives. Children’s filial behaviors were stronger than their filial attitudes in three aspects, including ‘respect and comfort’, ‘acceptance of death’ and ‘spending final days’, indicating that they might be more willing to accept and to perform their filial duties when they are required to respect their parents [37]. An example item pertaining to this theme is ‘even if I do not agree to parents’ instructions about funeral arrangements, I would carry them out according to their wishes’. Another observation is that Chinese adult children tended to act less conservatively than indicated by their beliefs regarding filial piety in an EoL context; an example item in this context is ‘if doctors say that the treatments are no longer able to improve my parents’ condition, I would consider talking with my parents about stopping the treatments’. These findings indicated that if children prefer providing their dying parents comfort, they are more determined to execute it. From another perspective, children may suffer due to the struggle between their own filial attitudes and filial behaviors during the critical or the end stage of their parents’ lives. In addition, among all subscales of FPR-EoL, the behavior associated with disclosing bad news is significantly stronger than the attitudes of Chinese adult children. It could be explained that these adult children consciously agreed to disclose bad news to their parents, such as a terminal prognosis. However, when they truly put into action, they were reluctant to do so. Chinese adult children may tend to believe that a terminal prognosis could be devastating to their parents and that their parents could not withstand such a big shock [38]. Not only do they hesitate to inform their parents, they often object to others’ opinions including opinions from healthcare professionals, conveying them such bad news [38]. However, relevant studies in China have indicated that desiring others to tell the truth were higher in patients than in family members and medical staff [39, 40]. Patients’ willingness to be informed may be underestimated, and withholding the truth may prevent patients from knowing what they want to know during their final days of life. Chen’s study [41] even raised the concern that patients’ awareness of their terminal prognosis were more beneficial to bereaved family caregivers with regard to adapting to their grief. Difficulty in disclosing bad news poses the problem that dying patient may not be able to fulfill their last wishes while the bereaved family may experience more intense grief if their parents are unaware of their terminal prognosis, leading to reciprocal harmful consequences. Therefore, specific support for truth disclosure, for instance, professional training in disclosing bad news is suggested to be provided to Chinese families facing terminally ill situations. Trained family caregivers reported higher tendency to perform truth disclosure [38].

Gender stereotyping has traditionally influenced the dynamics and relationships between parents and children in the Chinese family system [42]. Notably, females (mother and daughter) are viewed as occupying an inferior position to that of males (father and son). Patriarchal parenting is a typical phenomenon in the child-parent relationships observed in some Chinese families [43]. The son of a family is even expected to bear higher filial obligations to care for his parents than a daughter does [44]. However, our study revealed that females exhibited a higher probability to perform filial behaviors than males in the context of parental EoL. This finding verified an observation previously reported [4], which indicated a reversal of the predominant role of daughters over sons in contemporary Chinese families. Females have undertaken the primary responsibility for providing care to their parents during the terminal stage [45, 46], and it is the concrete embodiment of filial behavior. This phenomenon can be comprehended and elucidated through various perspectives. Firstly, females typically shoulder a greater burden of household chores and caregiving duties within the family unit, and due to traditional gender roles that assign them nurturing responsibilities, they are more inclined to undertake the diverse caregiving tasks required in their parents’ final phase [47]. Secondly, females may also possess heightened emotional sensitivity and play a pivotal role in offering companionship to their parents during challenging times [48]. O’Neill [44] found that daughters exhibited stronger filial obligations due to the moderating effects of feelings of affection and gratitude, the binding of norms, and their own self-images in the context of emotional work. Moreover, particularly in Eastern cultures, filial piety is esteemed as a virtue and moral principle influenced by societal expectations and traditional beliefs, consequently, many females consciously or unconsciously embrace this significant responsibility and formed their filial perception [49, 50]. This situation represents either a great improvement in gender equality or a shift in filial obligations from the previous generation. This situation represents either a great improvement in gender equality or a shift in filial obligations from the previous generation.

Nevertheless, the findings of this study also indicated a higher probability among participants to exhibit filial representations if their father was dead rather than alive, while no such difference was noted in the case of mother’s death. This finding implies that Chinese adult children may usually not be able to exhibit their filial representations toward their living fathers. Owing to the authoritative role of fathers in Chinese families, children view their fathers as serious, respectful and, to a certain extent, relatively distant, leading to possible filial anxiety among children when communicating with their fathers [3, 19]. In Singapore, which is greatly influenced by filial norm, families’ adoption of an authoritarian filial piety approach has been found to be associated with poorer palliative care knowledge than family adoption of a reciprocal filial piety approach [17]. When faced with authoritative fathers, children tend to comply with their fathers’ directives, exhibit reluctance to voice their opinions, and more inclined owards performing certain “filial behaviors” in accordance with social norms, such as seeking ways to prolong their fathers’ life rather than addressing quality of life. Therefore, authoritarian father-child relationships could be an obstacle to the promotion of advanced care planning for the entire family. Lack of communication, palliative knowledge, and advanced care planning are likely to fail to guarantee quality EoL care. Moreover, a significant number of individuals in this study reported a higher probability to perform filial behaviors after their father has passed away. This is most likely due to the fact that such individuals have deeply reflected on father’s death and felt regretful of the ‘inadequate’ filial support that they provided to the dead father, which in turn may result in suffering from intense grief.

The findings of this study indicated that age was relevant to filial piety representations in an EoL context. The older the Chinese adult children were, the more they perform filial piety behaviors to their parents. In traditional filial piety practices, adult children, especially sons, are expected to care for their older parents with regard to both daily living and periods of illness [42, 51]. In addition, senior parents occupy an authoritative position in the family hierarchy and should be fully respected [52]. On the other hand, as parents age, the remaining time that children can spend with their parents are viewed as less, which may also remind the children of their filial obligations toward the parents [4]. Meanwhile, as children age, they may become more mature or may have encountered the deaths of their peers’ parents, and thus become aware of their own greater filial obligation toward their parents. Older adult children tended to uphold the core values and traditional familial expectation than those who are younger in terms of providing direct care to parents [53]. They may also have retired and become more available to serve filial duties or they would like to be role-models to younger generation to continue the tradition of filial piety. Moreover, strong filial piety was identified as a protective factor that could reduce the negative impact of caregiving stress [47, 54], in spite of caregivers’ age and the care recipients’ dependency level [55]. The adult children may even experience a sense of gain, role reward or conformity to social morality after fulfillment of filial duties, which in turn buffers their caregiving burden [56, 57]. The beneficial effect of filial piety indicated the necessity of incorporating cultural values in supporting family, particularly in Eastern cultures. Provided that younger adult children were found to hesitate to engage in filial behaviors toward their dying parents in an EoL context, more guidance pertaining to filial representation should be provided to adult children, particularly to young adult children, when their parents are at the end stages of their lives. This approach may promote not only the quality of death of parents but also takes into account the adaptation of adult children to bereavement.

Intriguingly, our findings indicated that Chinese adult children who neither live with their parents, nor serve as carers and financial supporters of their parents exhibited significantly more filial behaviors in an EoL context. As the traditional filial duties of Chinese families require children to live with and care for their parents [58], children who do not live with their parents might consider EoL filial behaviors in an EoL context as way of compensating their parents during their last course of life [18]. Conversely, children who have played day-to-day caring and supporting roles for their parents might be less eager to fulfill more filial duties at the end stages of their parents’ lives. They may believe that they have been fulfilling their filial duties all along and that no specified reinforcement is needed during parents’ end-of-life. On the other hand, this finding verified the proverb ‘Even a filial child will eventually be fed up with taking care of a bedridden and chronically ill parent’. In these circumstances, the dying parents might be perceived as a stressor by the children who may become reluctant to take on more filial duties [59]. Such strong and pertain filial responsibilities may also adversely affect the mental health of caregivers when they are financially challenged [60]. Providing both practical and emotional support to carers in the EoL context appears to be important for achieving quality EoL care. Practical support such as assistive services, welfare incentives, respite care and emotional support such as relaxation programs and peer support group were recommended to provide to caregivers based on their socio-psychological background to alleviate their caregiving burden [47].

Our multiple linear regression analysis indicated that gender, experience in caregiving with the mother, and death literacy can contribute to the prediction of filial behavior at the parent’s EoL, which is consistent with findings suggesting that daughters exhibited more filial obligation than sons in the context of providing care to parents and that filial piety is a predictor of caregiving burden [15, 44, 54]. Thus, our findings revealed that death literacy can at least partially explain filial behavior in an EoL context, the entirety of such behavior still requires a great deal of further explanation. Among all the domains in the DLI, ‘practical knowledge’ was a relatively strong predictor of filial behavior in an EoL context. This factor reflected the individual’s perceived knowledge with regard to providing hands-on and talking support during death incidents [32], implying that people who exhibited confidence in their ability to personal support could demonstrate their filial behaviors toward their parents under EoL care. However, ‘community knowledge’ of DLI was a significant but mild predictor of EoL filial behavior in an EoL context. Their knowledge of community support groups were even negatively associated with filial behavior in an EoL context. This phenomenon implies that adequate EoL community support might be perceived by adult children as a way to relieve their filial burden [61, 62]. The availability of EoL community support might enable adult children to seek physical, psychological, mental, spiritual or other types of help for their dying parents, which is an elusive task and difficult to be achieved by the general public. In other words, adult children might even only be able to meet the needs of their dying parents by strengthening the commitment to EoL filial behaviors when lack of support from the community in EoL context. After decades of de-familialization experience of palliative care in the Nordic context, recent report emerged an argument for a need to strengthen the support for informal caring of family members who are important agency in EoL care [63]. Since, death literacy is a significant attribute to filial behaviors as represented in our findings, it highlights the need to enhance the clinical and social care networks of the death system in order to improve the death literacy of individuals and the provision of quality EoL healthcare, which in turn may help them to better perform filial duties, for instance arranging funeral and burial for dying parents [23, 29]. Therefore, improvement in death literacy may potentially have a positive influence on the filial behaviors of adult children with regard to their parents’ dying and death.

The study investigated a large sample, and as convenience sampling was adopted, nonrandomization and uneven distribution of the number of participants among five cities limited the generalizability of the results. Participants were relatively young, and their relative lack of experience of loss and grief may have resulted in lower EoL filial piety (behavior) in this study. The proportion of medical (assistant) professionals among the participants was slightly higher than of the proportion observed in the general population in the area. The day-to-day work of these professionals involves dealing with life and death as well as families and their grief. Accordingly, these professionals may have more pronounced feelings and perceptions regarding EoL filial piety as well as a higher level of death literacy. This fact may have led to potential bias in the results regarding to both filial piety in an EoL context and death literacy. Future studies should explore the filial piety of the general population of China in terms of EoL. Additional variables can be examined to identify their associations with and contributes to filiality in an EoL context.