Formal assessment of What Matters in end-of-life care is often done in medical settings through legal forms. Past research indicates that Native Hawaiians are less likely to complete these forms than Whites. The purpose of this study was to explore health care preferences among Native Hawaiian elders and to identify cultural themes that may impact quality care at end of life. To explore What Matters to Native Hawaiian elders, as culture likely impacts health care and end-of-life preferences. A secondary analysis of qualitative data collected through a multiyear interview project in Hawai'i. Twenty participants age 60+ living in rural Hawai'i. Deductive coding was informed by guidelines on What Matters according to the Institute of Healthcare Improvement's 4Ms Framework. Inductive coding identified themes specific to Native Hawaiian elders as part of their culture. Themes suggest the criticality of: (1) incorporating cultural traditions into health care routines; (2) involving family in health and end-of-life decisions; (3) supporting home-based care at the end of life; and (4) building strong patient-provider relationships. Although findings parallel preferences expressed in other populations, the data provide additional insights into the preferences of Native Hawaiian elders anticipating end-of-life care. Recommendations for culturally competent care include: (1) develop relationships with Native Hawaiian patients well before end-of-life care is needed to facilitate discussions of care preferences; (2) work collaboratively with the patient and the patient's defined family; (3) ask about cultural practices and engage traditional healers as directed by the patient; and (4) provide services in patients' homes and communities.