“Collision of Eastern and Western Cultures”: A Qualitative Study on Changing Perceptions of End‐of‐Life Care Among Older Chinese Immigrants

ABSTRACT

Introduction

Older Chinese immigrants have lower rates of end‐of‐life (EOL) care planning and use than non‐Hispanic White counterparts, resulting in unmet palliative and hospice care needs. While acculturation is identified as a facilitator of end‐of‐life care planning, little is known about how perceptions shift throughout the acculturation process. Guided by the process model of acculturation, this qualitative study explored how perceptions of EOL care among older foreign‐born Chinese immigrants changed during acculturation.

Methods

A qualitative descriptive design with language‐matched focus groups was used. Thirty‐one Chinese‐speaking older immigrants satisfied eligibility criteria. Five focus groups were conducted in Mandarin (n = 3) and Cantonese (n = 2). Participants' mean age was 76.4 (SD = 6.3; range 63–86) with an average of 22.9 years in the U.S. (SD = 11.1).

Results

Using a thematic constant comparison approach combined with inductive coding, guided by the process model of acculturation, we revealed how participants' perceptions of EOL care evolved through the acculturation process at familial, institutional, and societal levels. Familial and social networks served as key sources of new information; encounters with healthcare and other institutions reshaped care preferences and decision‐making; and broader cultural contexts facilitated deeper attitudinal shifts.

Conclusions

Participants reflected a dynamic interplay between exposure to U.S. healthcare, social network influences, and cultural or religious frameworks. Through this process, they developed new understandings of hospice and palliative care, reconciled these concepts with traditional values (e.g., filial piety), and gradually embraced more person‐centered decision‐making.

Older Chinese immigrants described evolving perceptions of end‐of‐life care following their immigration, shaped by interactions with family and social networks, healthcare institutions, and broader societal contexts. These experiences fostered greater understanding of hospice and palliative care, comfort‐focused care, person‐centered decision‐making, and openness to discussing death.

1. Introduction

Effective communication among patients with serious illness, family caregivers, and health care providers regarding end‐of‐life (EOL) care is often lacking, resulting in unwanted intensive interventions, increased medical costs, feelings of regret among caregivers, and poor quality of life at EOL [1, 2, 3]. In response, improving the quality of EOL care has become a clinical priority in the United States, with increased emphasis on EOL care planning, timely palliative care referral, and hospice utilization [4, 5, 6]. These approaches have been associated with care that is more aligned with patients' preferences, improved quality of life, reduced burdensome interventions, and greater support for family caregivers [7, 8].

However, racial and ethnic disparities in EOL care planning and use persist in the United States [9, 10]. Among Asian American populations, engagement in EOL care planning and use remains substantially lower than among non‐Hispanic White individuals, particularly among older adults with serious illness. Recent cross‐sectional studies reported that only 18.6%–26% of Asian older adults had engaged in EOL care planning [11, 12, 13]. Partially due to the low prevalence of EOL care planning, EOL care remains poorly utilized in Asian older adults. Only 38.1% of Asian Americans utilized hospice services, compared to 51.6% of Non‐Hispanic white individuals [14]. Chinese Americans are among the fastest‐growing ethnic groups in the United States, representing the largest subgroup of Asian Americans, with approximately 5.5 million currently residing in the country [15]. Understanding factors influencing older Chinese immigrants' EOL planning and utilization is particularly important for addressing these disparities.

Factors of EOL planning and care among older Chinese immigrants in the United States include language barriers and cultural beliefs [16, 17]. Culture shapes how individuals make meaning out of illness, suffering, and dying [18]. In Chinese culture, filial piety profoundly shapes family relationships and defines the primary duty of adult children: to respect and provide the best possible care for their parents until the end of life [19]. Influenced by filial piety, family caregivers often favor aggressive treatments and life‐prolonging care more than patients themselves [20]. Beliefs that death‐related discussions can bring bad luck further hinder EOL planning [21, 22], making older Chinese Americans much less likely to engage in EOL care planning [23].

Although these cultural beliefs shape EOL decision‐making, they are not static. As immigrants navigate life in a new sociocultural environment, exposure to different healthcare systems, social norms, and family dynamics may reshape their perspectives on EOL care. While traditional cultural beliefs may discourage EOL planning and utilization, acculturation offers a pathway for older Chinese immigrants to adopt different views. Acculturation, the process of adapting behaviors, values, and identity through contact with another culture [24]. has been associated with more EOL care conversations among older Chinese immigrants in the U.S. [12, 23, 25]. Despite evidence linking acculturation with greater engagement in EOL care planning and greater EOL care use among older Chinese immigrants [26, 27], the processes through which immigration‐related experiences shape perceptions of EOL care remain poorly understood. Little is known about how older Chinese immigrants' understanding of EOL care changes after immigration, if at all, and how exposure to different healthcare systems and sociocultural contexts may influence these perceptions through the acculturation process.

The process model of acculturation conceptualizes cultural adaptation as a dynamic, iterative process shaped by interactions across multiple ecological contexts, including (1) family and social networks, (2) institutions (e.g., healthcare systems), and (3) broader societal influences [28]. Traditional acculturation models, such as Berry's framework, have been critiqued for treating acculturation as static and unidirectional, overlooking structural power dynamics, and failing to capture the fluid, context‐dependent, and multidimensional nature of immigrants' cultural adaptation [29, 30]. Rather than viewing acculturation as a linear movement toward assimilation, we use the process model of acculturation as a sensitizing framework to understand how older Chinese immigrants' perceptions of EOL care evolve through interactions across familial, institutional, and societal contexts, while recognizing that these changes are heterogeneous and shaped by broader social structures. Guided by the process model of acculturation, this qualitative study explored how older foreign‐born Chinese immigrants retrospectively described and interpreted perceived changes in EOL care beliefs and experiences following immigration to the United States. Specifically, we examined how participants described the influence of family and social networks, healthcare systems, and broader societal contexts on their understanding of EOL care.

2. Methods

We adopted a qualitative descriptive design with language‐matched focus groups. The study was guided by a constructivist epistemological orientation, which assumes that participants' understandings of end‐of‐life care are shaped by social and cultural experiences, including immigration and acculturation processes [31]. To maximize sample diversity, we used purposive, community‐based recruitment and venue‐based sampling (e.g., targeted community gathering places). Focus groups were conducted using a semi‐structured interview guide and in the participants' preferred language (Mandarin/Cantonese). All study procedures were approved by the Institutional Review Board (IRB) from [blinded for review] (IRB Number: [blinded for review]).

2.1. Participant Eligibility and Recruitment

To be eligible for the study, participants had to be 60 or older, self‐identify as Chinese American, reside in the United States, and be able to communicate in either Mandarin or Cantonese. Length of residence in the United States was not used as an eligibility criterion because acculturation is conceptualized as a heterogeneous, non‐linear process. Including participants with varying years since immigration allowed us to capture diverse acculturation trajectories.

To maximize participant diversity, they were purposively recruited from various locations and venues, such as senior apartments, a university research registry with contact information for eligible participants interested in research, religious organizations, Chinese restaurants, and Chinese grocery stores. Participants first completed a screening survey that included eligibility questions, demographic information, and a question asking whether they would like to be contacted for study focus group participation. As a result, 31 participants were enrolled in the focus groups, including 22 Mandarin and nine Cantonese speakers. A total of five focus groups were hosted, including three in Mandarin and two in Cantonese. The number of participants ranged from four to eight across groups. Informed consent was obtained.

2.2. Data Collection

The Mandarin‐speaking focus group interviews were conducted in person due to participants' geographic proximity and limited digital literacy. The Cantonese‐speaking focus group interviews were both conducted virtually via Zoom due to participants' geographic spread. All focus group interviews were audio‐recorded. The focus group interviews lasted between 50 min and 90 min. Each focus group interview was co‐facilitated by two researchers in the team following a semi‐structured interview protocol covering the following topics: (1) knowledge and understanding of EOL care, (2) personal and family experiences with serious illness and dying, (3) cultural beliefs and attitudes toward death and dying, and (4) changes in perceptions and decision‐making following immigration. Each participant was compensated with a $40 gift card after completing the focus group interview. Data analysis occurred concurrently with data collection. No new themes emerged after the fourth focus group, indicating near saturation; recruitment and data collection concluded after the fifth group.

2.3. Data Analysis

All audio recordings were transcribed verbatim in Mandarin or Cantonese and de‐identified. Two bilingual researchers translated the transcripts into English, and two additional team members, also bilingual, independently reviewed the translations to ensure accuracy and preserve cultural meanings.

We conducted data analysis using an iterative, thematic constant comparison approach, combining inductive coding with theoretical guidance from the process model of acculturation. Three team members (blinded for review) independently reviewed transcripts using open coding to identify meaningful units of text. Codes were then compared, discussed, and organized into preliminary categories based on shared meanings and differences. This iterative process allowed us to capture both anticipated and emergent concepts. The codebook was developed inductively and refined through multiple iterations as additional transcripts were coded, followed by team reflection and discussion (blinded for review). Two coders (blinded for review) then systematically applied the finalized codebook to all transcripts in Microsoft Word (Version 16.1). Any coding discrepancies were resolved through discussion with a third researcher (blinded for review) to reach consensus and ensure trustworthiness. Drawing on the identified codes and illustrative quotations, two researchers (blinded for review) developed analytic statements in a spreadsheet to capture changes in participants' perceptions, knowledge, and experiences related to EOL during acculturation. Guided by the process model of acculturation, we categorized codes and quotes by contextual level (i.e., familial, institutional, and social) and by timing of immigration (i.e., before vs. after immigration). This structured approach enabled us to trace how participants' perceptions evolved through the acculturation process while remaining grounded in participants' own narratives. During analysis, we observed recurring patterns across the first three focus groups, suggesting preliminary saturation. Review of the remaining focus groups did not yield new themes, supporting data saturation.

2.4. Reflexivity

Reflexivity was addressed throughout data collection and analysis. The focus group facilitator is a bilingual Chinese‐English professor with extensive training in end‐of‐life research among Asian American older adults, and the analytic team comprised two additional bilingual junior faculty‐level researchers with expertise in qualitative research and end‐of‐life issues, and one doctoral‐level social work student with experience in end‐of‐life care among Chinese Americans. The team engaged in ongoing reflexive discussions during the data analysis and results reporting phases to consider how their cultural identities, disciplinary backgrounds, and clinical/research experiences might influence their coding decisions and interpretations of the themes. Throughout the analysis, the research team held regular reflexive meetings to examine assumptions, consider alternative interpretations, and enhance analytic rigor.

3. Results

3.1. Participant Characteristics

The sample (n = 31) included 24 females and seven males, with a mean age of 76.4 (SD = 6.3; range 63–86). All participants were born outside the United States and had lived in the country for an average of 22.9 years (range = 7–47 years). Most had some college and higher education (n = 28, 90.3%). See Table 1 for detailed demographics.

TABLE 1.

Demographic characteristics of the participants (N = 31).

Characteristics	N (%) or M (SD)
Gender
Female	24 (77.2)
Male	7 (22.8)
Age	76.4 (6.3)
Length of time in the U.S.	22.9 (11.1)
Education
Below high school	3 (9.7)
High school	4 (12.9)
Some college education	12 (38.7)
Bachelor's degree	9 (29.0)
Master's or doctoral degree	3 (9.7)

This study revealed how participants' perceptions of EOL care evolved through the acculturation process at familial, institutional, and societal levels. Familial and social networks served as entry points for new information; institutional encounters reshaped care preferences and decision‐making; and broader cultural contexts, such as religious beliefs and norms of open discussion, facilitated deeper attitudinal shifts. Figure 1 summarizes these three themes across familial, institutional, and societal levels of acculturation.

FIGURE 1.

The process of acculturation model for older Chinese immigrants regarding end‐of‐life care.

3.2. Theme 1: Experience of Family and Social Networks in the U.S. Increased the Understanding of EOL Care

Many participants described only learning about hospice after immigrating to the U.S., often through the experiences of relatives or friends who received hospice care. One participant reflected:

Before coming to the US, I didn't know about end‐of‐life care. I only recently learned this term because a friend of my daughter passed away. Before passing away, they entered a hospice service, which is when I first heard the term “end‐of‐life care”. (Mandarin‐Speaking Focus Group 2, Participant 1, Male, 85 years old)

After immigration, participants came to understand that end‐of‐life care focuses on symptom management, comfort, and dignity, in contrast to earlier beliefs shaped by filial piety. One participant explained:

China values filial piety. Even knowing that that person can't be saved, none of the three sons would dare to say stop trying to save them. If an older person enters the ICU, no one dares to mention removing the older person's tubes. If you give up on rescue attempts, you would be considered unfilial.

Through the experience of their family members and social networks who received hospice care, they realized that “a person can actually pass away in a state of mental peace, not in a state of tension, fear, and suffering.” One participant shared:

The first time I encountered it was with a good friend's daughter…That was the first time I heard about a hospice. It's for when you're beyond treatment, and any more medication or treatment would just be a waste of social resources. They maintain your dignity, let you go peacefully, without suffering. When she passed, her father and mother were holding her hands, sitting by her side, and she went quietly and peacefully. That was the first time I understood what end‐of‐life care is like.

Participants also noted that hospice care shifted responsibility from being solely on family caregivers to a shared model that included formal care providers. One participant explained:

In China, end‐of‐life care is left to family members. Hospitals focus on life‐saving measures and often over‐treat. When someone is near death, it exhausts the entire family—there's even a saying, ‘it's like peeling off a layer of skin.’ When my relative was in pain [in the U.S.], the hospital gave painkillers, sometimes even morphine, to reduce suffering and improve quality of life. I only learned about this after coming to the U.S. I hadn't heard of hospices in China, but here, major hospitals all have hospice units. (Mandarin‐Speaking Focus Group 2, Participant 4, Male, 79 years old)

3.3. Theme 2: Availability of Palliative and Hospice Care Changed EOL Care Preferences

The availability of and access to palliative and hospice care in the U.S. encouraged openness to EOL discussions among older Chinese immigrants, shifted treatment goals from prolongation to comfort, and challenged family‐centered decision‐making norms.

3.3.1. Encouraging Greater Openness to Discussing EOL Care

Before coming to the U.S., most participants believed that discussing EOL care would bring bad luck, fearing that such discussions could lead them to the end stage of life. But after receiving palliative care, they realized the value of discussing care preferences in advance to make informed decisions. One participant shared:

With my limited knowledge and experience, I really didn't understand what end‐of‐life care meant before. My parents and in‐laws all passed away in China. I didn't understand it then. I experienced it myself because I have an illness. My specialist arranged for a team of three to come for end‐of‐life care. I said, “What are you doing? I'm fine, why are you talking about end‐of‐life?” At first, I didn't accept it; I felt a bit resistant. This is where the cultural difference comes in. For them, it's a normal arrangement, but for us, we think, “Why are you bringing up an end‐of‐life team? Are you cursing me?” The cultural difference is huge. But I gradually accepted it, based on their explanations. My daughter and I both accepted it. One person on the team was responsible for the religious aspects. He introduced himself. Another was responsible for social relationships, and the third was a nurse responsible for the medical aspect. (Mandarin‐Speaking Focus Group 1, Participant 6, Female, 79 years old)

3.3.2. Shifting Treatment Preferences From Life Prolongation to Comfort

After witnessing how hospice care in the U.S. supported loved ones through the dying phase, many participants shifted their preferences from pursuing all possible treatments to prioritizing quality of life, dignity, and comfort. One participant described this transformation as a “collision of Eastern and Western cultures,” explaining: “After we understood, we felt the Western concept is more scientific and more humane. We originally thought if technology could still be useful, not rescuing you was inhumane.” (Mandarin Focus Group 3, Participant 3, Male, 77 years old).

Education from palliative care physicians also played an important role in reshaping participants' perspectives. Another participant noted: “In the U.S., doctors told me that more treatment does not necessarily mean better. That's when I slowly began to change my thinking.” (Cantonese‐Speaking Focus Group 2, Participant 2, Female, 77 years old).

This shift resonated with a participant who cared for a dying spouse:

I witnessed my spouse's journal from illness to death closely. My perspective has completely changed. As family members, our initial thought was to let him live just one more day if possible… When he was nearing the end of his life, the American hospital took measures to prevent suffering. They used a different treatment method from that in China. Maybe it's due to differences in medical technology or available medications; I'm not sure. But I came to accept the American method. It reduces suffering and allows for a peaceful passing. This was very educational for me. (Mandarin‐Speaking Focus Group 1, Participant 7, Female, 82 years old)

3.3.3. Decision‐Making Preferences

Among participants who described exposure to palliative care in the U.S., these experiences sometimes challenged their assumptions about who should make end‐of‐life decisions. In China, family‐centered decision‐making was taken for granted, with relatives often making choices on behalf of the patient. As one participant explained: “We are accustomed to letting the family make decisions, rather than the patient themselves.” (Cantonese‐Speaking Focus Group1, Participant 4, Male, 74 years old). In contrast, participants observed that in the U.S., physicians typically addressed questions directly to patients. As another participant noted: “The doctor directly asked the patient what they wanted, but we felt the family should decide together.” Another participant echoed, “In the United States, I realized that I could make decisions for myself, instead of having my family decide for me.” (Cantonese‐Speaking Focus Group 2, Participant 3, Female, 71 years old).

3.4. Theme 3: “Open Culture” Changed Their Attitudes Toward Talking About Death and Dying

Participants noted that U.S. culture is more open to discussing death than in China. One participant expressed, “After coming to the United States, I found that people are more willing to talk about how to face death.” (Cantonese‐Speaking Focus Group 2, Participant 4, Female, 71 years old).

Religion emerged as a key cultural difference, given its varied prevalence between the two countries. Several participants shared the changes in their attitudes toward death after becoming religious. As one participant said, “Later, after I became a Christian, my view of death also changed—it became more about acceptance and peace.” Similarly, another participant said, “After coming to faith, I felt that death is arranged by God, not something we can control. I'm not afraid of talking about it anymore.” (Cantonese‐Speaking Focus Group 2, Participant 5, Male, 71 years old).

This openness was reflected not only in the availability of palliative and hospice care but also in the practice of truth‐telling in diagnosis, which is rooted in individual autonomy:

I feel that in the U.S., people are more open about this… Doctors [here] will ask you directly what your decision is and openly discuss it. This is quite different from the way we Chinese used to handle things. In the past, Chinese doctors usually wouldn't tell the patient their condition directly, but instead would inform the family, for example, telling the children and letting them decide about disclosure of the diagnosis. (Cantonese‐Speaking Focus Group 1, Participant 1, Male, 71 years old)

3.5. Study Synthesis

Overall, across familial/social network, institutional, and societal contexts, participants described interconnected changes in their perceptions of EOL care following immigration (Table 2). At the familial and social‐network level, exposure to relatives' and friends' experiences introduced participants to hospice and palliative care and provided alternative models of dying and caregiving. At the institutional level, encounters with U.S. healthcare systems exposed participants to comfort‐focused care, direct patient communication, and greater emphasis on individual decision‐making. At the societal level, perceived openness toward discussing death and, for some participants, religious involvement provided broader cultural frameworks through which EOL care could be reconsidered. Together, these accounts illustrate that perceived changes were not attributed to a single influence but emerged through interactions across familial, institutional, and societal contexts.

TABLE 2.

Summary of themes.

Levels	Perceptions about EOL care (before immigration)	Perceptions about EOL care (after immigration)	Key acculturation factors triggering changes
Family and social networks	Filial piety prioritizes life‐prolonging treatment; family shoulders most end‐of‐life care responsibilities; decision‐making led by relatives; talking about death seen as taboo/jinx; little to no awareness of hospice/palliative care.	Family and social networks introduce hospice/palliative care; recognition that a peaceful, dignified death is possible; responsibility shifts from solely family to shared model with formal providers; greater patient autonomy in decisions; growing openness to discuss EOL.	Exposure to end‐of‐life care through experiences of family members, friends, and social networks.
Institutional organizational	Hospitals focus on “saving life,” frequent overtreatment; little exposure to palliative services; clinicians disclose to family rather than patient; limited pain/symptom management options known.	Availability of hospice/palliative services in U.S.; clinicians educate that “more treatment ≠ better”; emphasis on symptom relief, comfort, and dignity; direct questions to patients; increased advance care planning conversations.	Personal exposure to palliative care
Societal	Cultural beliefs (e.g., death talk brings bad luck); norms discourage open discussion of dying; filial duty equated with continuing aggressive care; less influence of religion on EOL views.	Perceived “more open” culture around death and dying; faith/religion (e.g., Christianity) fosters acceptance and peace; quality‐of‐life orientation becomes legitimate; hospice viewed as a normal option within the care continuum	Open culture, and church activities

4. Discussion

Guided by the acculturation model, we found that familial context and social networks were important factors in initiating the acculturation process. Participants often learned about palliative and hospice care through personal networks rather than formal education. This suggests that families, friends, and Chinese American community members may be better positioned than healthcare professionals to introduce EOL care concepts and initiate EOL care planning. Prior studies similarly indicated that indirect, informal approaches to EOL communication are preferred by older Chinese adults [16, 32, 33]. The reliance on social networks in our study highlights that community‐based settings, such as community centers and Chinese American senior centers, are natural settings for informal education among older Chinese immigrants. Peer navigator models, in particular, may be effective, as peers are often bilingual in English and Chinese and bring both language skills and cultural competence [34]. The role of social support in facilitating engagement in EOL planning conversations highlights that using trusted social circles can not only increase knowledge but also normalize these discussions, which may reduce anxiety or stigma associated with them.

While knowledge about EOL care is a starting point, changes in perceptions and attitudes often require reconciling new understandings of Western professional models with traditional Chinese values of filial piety, which involve interactions with healthcare institutions. In China, EOL care is strongly tied to notions of filial responsibility, as families often continue curative treatment and choose to prolong the lives of their dying parents [35, 36]. When doctors determine that a patient is incurable and discharge them to return home, professional hospice care is rarely available in most places, with a shortage of specialized hospice care professionals [37]. Adult children were often the primary family caregivers, providing EOL care and witnessing their suffering at the end of life. The distress was described by a participant as “it's like peeling off a layer of skin.” Participants' exposure to hospice in the U.S., however, revealed an alternative model in which maintaining dignity and reducing suffering are prioritized, and caregiving responsibilities are shared between family members and professionals. Rather than undermining filial piety, participants' narratives suggest that hospice can be reframed as an expression of filial devotion, allowing loved ones to be present and supportive without being overwhelmed by caregiving burdens. This balance between honoring cultural traditions and accepting new models of care is crucial to engage older Chinese immigrants in EOL care conversations and utilization.

Exposure to palliative care in the U.S. challenged participants' assumptions about who should make end‐of‐life decisions. In China, family‐centered decision‐making is the norm, with families often making choices on behalf of patients. Participants observed a striking difference in the U.S., where physicians typically addressed questions directly to patients. In contrast, there is currently no law in mainland China requiring doctors to inform patients of their diagnoses [38]. Compounded by the influence of collectivist culture, which directly affects how healthcare decisions are made and who makes them, family often controls the disclosure of the patient's diagnosis and prognosis, with patient autonomy not valued [39, 40]. Out of protection for patients' optimism and psychological well‐being, influenced by filial piety, families often choose not to disclose diagnosis, especially when it was a serious illness, such as cancer. One participant explained, “We are accustomed to letting the family make decisions, rather than the patient themselves.” One notable finding is that participants described a shift from this family‐centered model to a more person‐centered or shared approach after exposure to U.S. palliative care practices. Contrary to earlier studies suggesting that Asian Americans tend to prefer family‐centered decision‐making [41], our participants demonstrated greater openness to autonomy and self‐determination than expected. These findings underscore the importance of clinicians understanding the acculturation level of older foreign‐born Chinese and exploring decision‐making preferences, rather than assuming uniform family‐centeredness.

In a broader societal and cultural context, another noteworthy finding was the role of religion as a potential mediator that facilitated greater openness during acculturation. In China, where only about 10% of the population formally affiliates with a religion [42], death is rarely viewed through a spiritual lens. For those who adopted Christianity, death was reframed as part of a spiritual journey, associated with acceptance, peace, and divine order. Other traditions, such as Buddhism and ancestral worship, provide alternative frameworks for death, emphasizing continuity, transcendence, or honoring family lineage [43]. Taken together, spirituality and religion may offer alternative entry points for EOL conversations.

This study has several limitations. First, the data were retrospective and based on people's recall rather than longitudinal observation. Participants reflected on their past experiences with EOL care, which may not represent current practices in China and may introduce recall bias. Second, Cantonese‐speaking groups were conducted virtually, restricting non‐verbal cues and spontaneous interaction, which may have constrained the depth of responses. Additionally, because participants had lived in the United States for an average of approximately 23 years, changes attributed retrospectively to experiences following immigration cannot be disentangled from changes associated with aging and accumulated life experiences. Finally, the sample was drawn from specific community and research registry settings on a voluntary basis, possibly underrepresenting individuals reluctant to discuss EOL care and limiting transferability.

Future research should conduct longitudinal examinations of changes in EOL care perceptions across different stages of immigration and aging to better distinguish the influences of acculturation, aging, and accumulated experiences with serious illness and EOL care. Future studies may also examine how these changes vary by individual and contextual characteristics, including age at immigration, language, religious involvement, and prior EOL care experiences. Finally, intervention research is needed to develop and test culturally responsive approaches that leverage trusted social networks and community resources to support EOL care communication and planning among older Chinese immigrants.

In conclusion, our findings demonstrate how the acculturation process shapes older Chinese immigrants' knowledge and perceptions regarding EOL care. Guided by the process model of acculturation, our analysis of participants' experiences reveals a dynamic interplay among exposure to U.S. healthcare practices, personal and social networks, and cultural and religious frameworks. Through interactions with family, friends, and professional palliative care providers, participants gained new understandings of hospice and palliative care, reconciled these practices with traditional values, such as filial piety, and gradually embraced a more person‐centered approach to decision‐making and openness in discussing death. These insights hold important implications for both clinical practice and community interventions. Clinicians should approach Chinese immigrant patients and families with cultural humility, assessing individual preferences for decision‐making and information disclosure rather than assuming uniform family‐centered norms. Community programs, including peer navigator and culturally sensitive education models, may effectively raise awareness of palliative and hospice care. Finally, integrating culturally resonant approaches, whether through language, social networks, or spiritual and cultural frameworks, can facilitate meaningful conversations about advance care planning and EOL care, supporting patient autonomy and family engagement while respecting cultural values.

Author Contributions

Peiyuan Zhang: conceptualization, data analysis, and manuscript writing. Jing Wang: data analysis and manuscript writing. Fei Sun: manuscript review and editing. Xiaoyouxiang Li: data analysis and manuscript review. Yaofeng Chen: data analysis and manuscript review. Kaipeng Wang: study design, funding acquisition, participant recruitment, manuscript review, and data analysis. All authors contributed to the revision of the manuscript and approved the manuscript submission.

Funding

Kaipeng Wang received funding support from the National Institute on Aging (NIA) under the National Institutes of Health (NIH; Grant Number: R03AG080374). Recruitment was partially supported by the Collaborative Approach for Asian Americans, Native Hawaiians, & Pacific Islanders Research and Education (CARE) Registry, funded by NIH/NIA R24AG063718. The contents are solely the responsibility of the authors and do not necessarily represent the official views of any funding institution above.

Ethics Statement

The study was approved by the University of Denver Institutional Review Board.

Consent

Verbal consent was obtained from all participants.

Conflicts of Interest

The authors declare no conflicts of interest.

Zhang P., Wang J., Sun F., Li X., Chen Y., and Wang K., ““Collision of Eastern and Western Cultures”: A Qualitative Study on Changing Perceptions of End‐of‐Life Care Among Older Chinese Immigrants,” Geriatrics & Gerontology International 26, no. 10 (2026): e70861, 10.1111/ggi.70861.

Data Availability Statement

Deidentified interview transcripts are available upon reasonable request.