Eunice Park-Clinton, DNP, MSN, MBE, is standing before a crowd of Korean American senior citizens, and she wants to talk about the end of life.
She knows that preparing for future decisions about one’s medical care if they become seriously ill or unable to communicate their wishes isn’t a comfortable conversation topic for most people. Who wants to discuss the possibility of having dementia, getting hooked up to a ventilator, or being fed through a tube, and losing the ability to speak for oneself?
But Park-Clinton, a nurse case manager in the Hospital of the University of Pennsylvania’s Emergency Department and an assistant nursing professor at West Chester University, is undeterred. Speaking in Korean, she takes a kind but frank approach as she walks the seniors through life-sustaining treatments they might be offered in their final days and the need to decide what they will—and won’t—want for a dignified end of life.
“I know that if I had lung cancer and had three weeks of life left, I would not want a ventilator. I would not want to die in a hospital. I would want to be surrounded by my family members. I would want to maximize the quality of my life,” she said later. “A lot of Korean American seniors who do not speak English do not even know there’s such a concept that you can prepare. They do not know what a ventilator is. They do not know what hemodialysis is—a very, very difficult treatment. So, when I explain this to the seniors, they say, ‘Wow, I need to think about this.’”
Tackling obstacles to advance care planning
Eunice Park-Clinton explains that seniors have their choice of end-of-life care, such as palliative and hospice care, which focus on pain management.
This presentation was one of two seminars Park-Clinton held at senior centers in Lansdale, PA, this summer with support from a Penn Medicine CAREs grant. They were part of a multi-stage research project Park-Clinton is leading around “advance care planning,” as it’s known in health care.
During the seminars, Park-Clinton explained the importance of discussing one’s wishes with their loved ones and providers and designating surrogate decision-makers who can carry out those wishes on their behalf if needed.
Resistance to talking about death and dying exists across cultures. A 2021 study in the American Journal of Hospice & Palliative Medicine found the majority of elderly patients and their families “possess a severe knowledge deficit” about end-of-life care, and many have never talked about advance care planning with their primary health care providers.
Barriers to advance care planning among ethnic minority groups in the U.S. are a rising concern—especially in Korean immigrant communities, where completion rates for advanced directives such as living wills are lowest compared to many ethnic groups. Higher rates of economic hardship, uninsurance, and limited English proficiency all play a role.
A personal connection
Eunice Park-Clinton explains life-sustaining treatments that may be offered to patients, including feeding tubes and mechanical ventilation.
As a Korean American herself, Park-Clinton’s passion for culturally sensitive planning comes from her personal familiarity with the community and its norms. In her work as a nurse, she has personally witnessed older Korean and other Asian immigrants experience health disparities due to their lack of knowledge of the concept.
That lack of awareness, coupled with language barriers, can lead to their surrogates—often their children—left making decisions late in the process. And this, in turn, can lead to hasty decisions that family members later regret.
Park-Clinton tells a story about how this played out early in her nursing career—and planted the seeds for her current work. She was working in an intensive care unit, when an older Korean woman was admitted with pneumonia. The patient was being prepared to be intubated—in which a tube is placed into the airway to keep it open—and connected to a ventilator. That meant she couldn’t eat or drink anything by mouth.
Neither the patient nor her adult children spoke English well. Their pastor interpreted a doctor’s explanation of the advance care planning sheet to one of the patient’s daughters, and she signed it, but it was clear to Park-Clinton that the daughter didn’t fully understand what she had agreed to on her mother’s behalf.
“She was asking me, ‘Can you tell me what is going to happen? What is the ventilator?’” Park-Clinton said. Then, while she and the daughter were speaking in Korean, the patient asked for water. Park-Clinton explained in Korean that the patient couldn’t have anything to drink before being intubated, because the liquid could get into her lungs.
The patient died not long after. Months later, the daughter recognized Park-Clinton on the street and told the nurse she had been thinking about her mom’s last wish every day. “‘We could have just gone with water and food—what she wanted—without intubation,’” Park-Clinton remembers her saying. “And we started to cry on the street. At that moment, I decided, I’m going to continue my education and I’m going to teach all the Korean Americans about end-of-life care.”
After completing her bachelor’s degree in nursing, Park-Clinton went on to get master’s degrees in both nursing and bioethics at the University of Pennsylvania, and later—emboldened by another upsetting experience, when a Do Not Resuscitate form was insensitively handed to her mother-in-law, as she was dying of cancer—she obtained her a doctorate of nursing practice with a specialty in geriatrics.
Making an impact
Eunice Park-Clinton, center, with team members HUP ED case manager Noah Brophy, in back; West Chester University nursing students Kylie Trankle, Emily Goodwin, and Juhi Cho; and Penn Asian Senior Services social worker Jiyoun Park.
Park-Clinton has found a more willing audience for her presentations since the COVID pandemic, as people are realizing that death may not be that remote in their life, she said. Taking an active role in their own care may alleviate their anxiety about what’s to come, knowing their values and wishes will be followed in a medical crisis.
Fellow HUP case manager Noah Brophy, BSN, said he knew, on an emotional level, that Park-Clinton’s work was important when she first described it to him; he had lived through his own traumatic family experience when his mother was dying. But watching the seniors’ reactions as she showed and explained the things that can happen leading up to death really brought it home.
“She had them absolutely transfixed. Seeing the gears clicking and the people thinking and realizing what this work means, was awesome,” said Brophy, a member of Park-Clinton's research project team, along with HUP hospitalist Jason D. Park, MD, MPH; three West Chester nursing students; and a social worker with Penn Asian Senior Services. “And it’s not only pertinent for Korean immigrants: She introduces the idea that in this world we inhabit, plans need to be in place for these end-of-life decisions—plans developed by the individual who’s in the process of passing.”
The research project has several stages, with increasing seniors’ knowledge around advance care planning as the first step. At the seminars, the seniors filled out forms about what matters most to them, which will be turned into letters that Park-Clinton’s team will send to participants’ children, to avoid any discomfort over talking face-to-face.
The team also plans to set up meetings for the elders with their primary care providers to discuss their wishes. Ultimately, she wants to teach surrogate decision makers—in most cases, adult children—about the various choices they may be called on to make, so they can make educated decisions for their parents. She also wants to spread the word to primary care physicians about the importance of having these discussions with patients.
Park-Clinton said it’s rewarding to see the wide eyes of seniors taking in what she’s saying about the need to plan for the end.
“Yes, you need to think about it. You may have a stroke. You may have a heart attack. You may have Alzheimer’s. You may not be able to express yourself, and you have to let your children know: What kind of care do you want?” she says she tells them. “Those are the dignified end-of-life choices I want to teach people.”