Cancer diagnosis and prognosis in Taiwan: patient preferences versus experiences

Cultivating Relationship-Centered Care: Patient, Caregiver, and Provider Communication Preferences for and Experiences with Prognostic Conversations

Prognostic conversations present many challenges for patients, caregivers, and providers alike. Most research examining the context of prognostic conversations have used a more siloed approach to gather the range of perspectives of those involved, typically through the lens of patient-centered care. However, the mutual influence evident in prognostic conversations suggests a relationship-centered care model may be useful in cancer communication research. Similarities and differences in preferences for and experiences with prognostic conversations among oncology patients, caregivers, and providers (N = 32) were explored. Identified themes were then mapped to the principles of the relationship-centered care framework to extend our understanding of prognostic conversations and contribute to a new direction in the application of relationship-centered care. Findings suggest fewer similarities than differences, point to important discrepancies among participant perspectives, and reinforce the utility of relationship-centered care in identifying communication practices that enhance the prognostic conversation experience.

Prognostic disclosure in cancer care: a systematic literature review

Background:

Collusion in cancer care is the diplomatic concealment of information between a triad of the health care professional (HCP), patient, and caregiver. Free and expressive communication is determined by multiple factors, which establishes a healthy balance between ‘patient-centric’ and ‘family-centric’ decision making. The lack of a universal approach to prognostic disclosure techniques emphasizes the need for a systematic review of contemporary practice.

Methods:

A systematic review of the literature was conducted till June 2020 using themes based on cancer, communication, prognostic disclosure, and collusion by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results:

Fifty-three studies involving 10,569 subjects were studied for their utility on prognostic disclosure using different communication methods and interfaces. Twenty-three studies used a face-to-face interview with subjects while in-person telephonic interviews were conducted in two studies, 16 studies implicated semi-structured questionnaires, and 6 studies mentioned the development of a new technique/tool for disclosure. The duration of a session for prognosis-disclosure ranged from 22 min to 1 h. The involvement of palliative care specialists and mental health professionals was limited during the disclosure of the prognosis.

Conclusion:

The findings of the review indicate that patients in cancer care are aware of their diagnosis and to a certain extent of prognosis despite nondisclosure by their family members and treating teams. This review emphasizes the assessment of ‘disclosure wishes’ among patients and caregivers in separate interviews rather than simply relying on one specific method of interviewing. The nonconfrontational approach and training among HCPs are of utmost importance to build therapeutic resilience among the treating team involved in cancer care. Since many factors such as family wishes, cultural dissonance, medical model, and patient perception could become barriers to prognostic disclosure, there is a need to develop a universal approach to prognostic disclosure and handling associated collusion.

Associations Between Prognostic Awareness, Acceptance of Illness, and Psychological and Spiritual Well-being Among Patients With Heart Failure

BACKGROUND

This study aimed to (1) investigate the association of prognostic awareness with psychological (distress level and emotional well-being) and spiritual well-being among patients with heart failure, and (2) assess the main and moderating effects of illness acceptance on the relationship between prognostic awareness and psychological and spiritual well-being.

METHODS AND RESULTS

This study used baseline data of a Singapore cohort of patients with heart failure (N = 245) who had New York Heart Association class 3 or 4 symptoms. Patients reported their awareness of prognosis and extent of illness acceptance. Multivariable linear regressions were used to investigate the associations. Prognostic awareness was not significantly associated with psychological and spiritual well-being. Illness acceptance was associated with lower levels of distress (β [SE] = -0.9 [0.2], P < .001), higher emotional well-being (β [SE] = 2.2 [0.4], P < .001), and higher spiritual well-being (β [SE] = 5.4 [0.7], P < .001). Illness acceptance did not moderate the associations of prognostic awareness with psychological and spiritual well-being.

CONCLUSIONS

This study suggests that illness acceptance could be a key factor in improving patient well-being. Illness acceptance should be regularly assessed and interventions to enhance illness acceptance should be considered for those with poor acceptance.

Patient Preferences for Discussing Life Expectancy: a Systematic Review

BACKGROUND

Discussing life expectancy helps inform decisions related to preventive medication, screening, and personal care planning. Our aim was to systematically review the literature on patient preferences for discussing life expectancy and to identify predictors for these preferences.

METHODS

We searched PubMed, Cochrane Library, Embase, MEDLINE, PsycInfo, and gray literature from inception until 17 February 2021. Two authors screened titles/abstracts and full texts, and extracted data and one author assessed quality. The outcome of interest was the proportion of patients willing to discuss life expectancy. We reported descriptive statistics, performed a narrative synthesis, and explored sub-groups of patients according to patient characteristics.

RESULTS

A total of 41 studies with an accumulated population of 27,570 participants were included, comprising quantitative survey/questionnaire studies (n=27) and qualitative interview studies (n=14). Willingness to discuss life expectancy ranged from 19 to 100% (median 61%, interquartile range (IQR) 50-73) across studies, with the majority (77%) reporting more than half of subjects willing to discuss. There was considerable heterogeneity in willingness to discuss life expectancy, even between studies from patients with similar ages, diseases, and cultural profiles. The highest variability in willingness to discuss was found among patients with cancer (range 19-100%, median 61%, IQR 51-81) and patients aged 50-64 years (range 19-97%, median 61%, IQR 45-87). This made it impossible to determine predictors for willingness to discuss life expectancy.

DISCUSSION

Most patients are willing to discuss life expectancy; however, a substantial proportion is not. Heterogeneity and variability in preferences make it challenging to identify clear predictors of willingness to discuss. Variability in preferences may to some extent be influenced by age, disease, and cultural differences. These findings highlight the individual and complex nature in which patients approach this topic and stress the importance of clinicians considering eliciting patient's individual preferences when initiating discussions about life expectancy.

Prevalence of collusion in cancer communications: A meta-analysis

INTRODUCTION

Collusion is the non-disclosure of information about diagnosis or prognosis, frequently encountered in cancer care and palliative services. Unraveling collusion is a skill and differences among communication techniques by Health Care Workers have maintained the process of non-disclosure to patients and caregivers. Identifying the prevalence of collusion in cancer care is required to improve the existing strategies across the world.

METHODS

A systematic review of the literature from 1991 to 2020 in the English language was conducted with the protocol registration on PROSPERO ID (CRD 42021249216.) to identify the pooled prevalence of collusion.

RESULTS

By using random effect model, the pooled prevalence estimate among patients for the diagnostic and prognostic collusion was 24.15, (95% CI [17.09; 32.96], Tou2 = 1.0801, I²  = 97.9%, Cochran's Q = 1058.22, df = 21, p-value < 0.001) and 37.92, (95% CI [22.46; 56.30], Tou2 = 1.9641, I²  = 98.6%, Cochran's Q = 944.26, df = 13, p-value < 0.001) respectively. There was no difference across subgroups with different types of setting for the interview, WHO regions and trend over the years.

CONCLUSIONS

Substantial prevalence of collusion goes unnoticed in cancer care. A meaningful understanding of such a large prevalence requires inquiry into the existing communication paradigm in cancer care across the world. The findings also question the need of formulating uniform interview techniques and structured assessment tools or questionnaires in cancer care to improve the disclosure rates.

Cultural implications for disclosure of diagnosis and prognosis toward terminally ill cancer patients in China: A literature review

OBJECTIVE

Health professionals in China tend to avoid open communication with terminally ill cancer patients concerning their diagnosis and prognosis. This review aims to explore Chinese cultural beliefs and attitudes concerning disclosure and death among health professionals and cancer patients in China and to investigate preferences of terminally ill cancer patients for a "good death."

METHOD

A narrative literature review was conducted in May 2020 on MEDLINE, EMBASE, and WEB OF SCIENCE to include all studies with clear study design which presented its own study data or referred to data within underlying studies, published between January 2000 and May 2020, having cancer patients and/or healthcare professionals as participants, conducted in Mainland China, Hong Kong, or Taiwan and containing relevant data concerning "medical disclosure" or "good death." Quality assessment of publications was conducted using the NIH and CASP checklists.

RESULTS

Primary database search revealed a total of 108 papers of which 9 were ultimately included. The additional hand search led to the inclusion of eight further papers. In total, there were 11 quantitative studies, 4 qualitative studies and 2 literature reviews included in this review. Our findings indicated that most terminally ill cancer patients in China want to know the truth about their diagnosis and prognosis and preferred to be informed by their doctors. Terminally ill cancer patients valued a good relationship with family and medical staff as well as being respected as an individual and wanted to be able to prepare for death.

SIGNIFICANCE OF RESULTS

Terminally ill cancer patients in China often have a substantial need for information about their condition while their preferences are widely consistent with those in Western societies. Training for health professionals needs to focus on communication skills in order to overcome barriers in patient interaction.

Oncologist-patient-caregiver decision-making discussions in the context of advanced cancer in an Asian setting

Objective

Patient involvement in treatment decisions is recommended in clinician‐patient encounters. Little is known about how oncologists engage patients in shared decision making in non‐Western countries. We assessed the prevalence of shared decision making among Singaporean oncologists and analysed how they discussed prognosis.

Methods

We audio‐recorded 100 consultations between advanced cancer patients and their oncologists. We developed a coding system to assess oncologist encouragement of patient participation in decision making and disclosure of an explicit prognosis. We assessed patient and oncologist characteristics that predicted these behaviours.

Results

Forty‐one consultations involved treatment discussions. Oncologists almost always listed more than one treatment option (90%). They also checked patient understanding (34%), discussed pros and cons (34%) and addressed uncertainty (29%). Oncologists discussed prognosis mostly qualitatively (34%) rather than explicitly (17%). They were more likely to give an explicit prognosis when patients/caregivers asked questions related to prognosis.

Conclusion

Oncologists in our sample engaged their patients in decision making. They have areas in which they can improve to involve patients at a deeper level to ensure shared decision making. Findings will be used to develop an intervention targeting oncologists and patients to promote patient involvement in decision making.

Older people's preferences for prognostic information in a situation of serious illness with less than a year to live

This study aimed to determine the preferences of community-dwelling older people about information disclosure regarding poor prognosis, the likely symptoms and problems, and the care options available in a situation of serious illness with less than a year to live; and to identify factors associated with a preference for information disclosure regarding poor prognosis. The Brazilian version of the Preferences and Priorities for End of Life Care (PRISMA) questionnaire was administered face-to-face to 400 older people, living in the city of Belo Horizonte, Minas Gerais, Brazil. The main results indicated that 74.0% preferred to be informed that they had limited time left, 89.3% wished to be informed about symptoms and problems, and 96.3% about available care options. The factors associated with preferences for information about poor prognosis were: gender (women: OR = 0.446, 95% CI: 0.269-0.738) and choosing the least preferred place to die (home of a relative or friend: OR = 2.423, 95% CI: 1.130-5.198. These results show that most older people want to be informed in an advanced illness situation with less than a year to live. Health care professionals need to be prepared to anticipate news about poor prognosis and the disease.

Sociocultural Barriers Related to Late-Stage Presentation of Breast Cancer in Morocco

Breast cancer is the most prevalent cancer affecting women globally and in Morocco, where more than one fourth of patients are diagnosed at advanced stages. This study aimed to investigate sociocultural barriers that contribute to delayed presentation and diagnosis of breast cancer among women in Marrakesh, Morocco. Qualitative interviews were conducted with 25 breast cancer patients who received care at the CHU Mohammed VI Hospital in Marrakesh to elicit barriers to diagnosis and treatment and ease of access to care. Interviews with breast cancer patients revealed several themes regarding structural and sociocultural barriers to initial diagnosis and treatment. Structural barriers included high treatment-associated costs for patients and their families, burden of transportation to central treatment centers, and limited access to appropriate health care resources. Sociocultural barriers included perceived attack on one's identity associated with breast cancer diagnosis and treatment, influence of the local community, and ideas of faith, spirituality, and conception of death. Findings from this study can help identify areas for improved access and education of patients in order to improve breast cancer diagnostic and treatment efforts and enhance opportunities for early detection.

Factors associated with a preference for disclosure of life expectancy information from physicians: a cross-sectional survey of cancer patients undergoing radiation therapy

PURPOSE

This study aimed to investigate experiences and preferences for disclosure of life expectancy, agreement between them, and the factors associated with preferences for disclosure of life expectancy with physicians among cancer patients undergoing radiation therapy.

METHODS

Cancer patients aged 20 years or older were consecutively sampled when they started radiation therapy at two university hospitals. Patients completed self-administered questionnaires concerning their experiences of and preferences for disclosure of life expectancy, treatment decision-making, psychological distress, physical symptoms, sociodemographic and medical factors, physician's communication style, and provision of psychological, physical, and practical support.

RESULTS

Among the 226 respondents (response rate: 58%) who responded, 54% experienced disclosure of life expectancy, and 45% preferred it. The agreement is 65%. Eighty-five percent recognized their aim of radiation therapy as curative. A univariate analysis indicated that having a full/part-time job and wishing to leave treatment decisions to doctors were significantly associated with preference for disclosure of life expectancy, but psychological distress was not. A multiple regression analysis revealed that having a full-time/part-time job was significantly associated with preference of communication about life expectancy.

CONCLUSIONS

Fifty-four percent of the patients experienced and 45% of the patients preferred disclosure of life expectancy. The agreement is moderate. Our results show that there was a significant association between employment status and patient's preference for disclosure of life expectancy with physicians. Communication of prognosis is difficult but whether a patient continues to work or not may be an indicator of preference.

Agreement between patients' and radiation oncologists' cancer diagnosis and prognosis perceptions: A cross sectional study in Japan

This study assessed agreement between radiation oncologist- and cancer patient-reported perceptions about cancer diagnosis, time since diagnosis, treatment purpose, and whether life expectancy had been discussed; and described preferences for prognosis discussions. Adult cancer patients receiving radiotherapy at a Japanese hospital were invited to complete a touchscreen tablet survey. Patient survey responses were linked and comparisons made with a survey completed by their radiation oncologist. Among 146 cancer patient-oncologist dyads, there was almost perfect agreement on cancer diagnosis (ĸ = 0.88, 95% CI: 0.82–0.94), substantial agreement on time since diagnosis (ĸ = 0.70, 95% CI: 0.57–0.83) and moderate agreement on whether treatment goal was curative or palliative (ĸ = 0.44, 95% CI: 0.28–0.57; all p’s < 0.0001). Agreement about whether a life expectancy discussion had occurred was less than expected by chance (κ = -0.06, p = 0.9). Radiation oncologists reported that they had spoken to over two thirds of patients about this, whilst less than one third of patients stated that this discussion had occurred with their radiation oncologist. Over half of the patients who had not discussed life expectancy wanted to. Patients had variable preferences for whether they (80%), their radiation oncologist (78%) or their partner/family (52%) should decide whether they discuss their life expectancy. Although patient self-reported information about diagnosis and time since diagnosis appears to be reasonably accurate (compared with clinician-reported information), limitations of self-reported data about prognostic discussions were highlighted by poor agreement between patient- and clinician-reported information about whether prognostic discussions have occurred. Additional support is needed to improve prognosis communication and understanding in radiation oncology settings.

Providing Palliative Care in Rural Nepal: Perceptions of Mid-Level Health Workers

Introduction:

Nepal is beginning to develop palliative care services across the country. Most people live in rural areas, where the Mid-Level Health Workers (MHWs) are the major service providers. Their views on providing palliative care are most important in determining how the service is organized and developed.

Aim:

This study aims to ascertain the perceptions of MHWs about palliative care in their local community, to inform service development.

Methods:

A qualitative descriptive design, using focus group discussions, was used to collect data from a rural district of Makwanpur, 1 of the 75 districts of Nepal. Twenty-eight MHWs participated in four focus group discussions. The data were analyzed using content analysis.

Result:

Four themes emerged from the discussion: (i) suffering of patients and families inflicted by life-threatening illness, (ii) helplessness and frustration felt when caring for such patients, (iii) sociocultural issues at the end of life, and (iv) improving care for patients with palliative care needs.

Conclusion:

MHWs practicing in rural areas reported the suffering of patients inflicted with life-limiting illness and their family due to poverty, poor access, lack of resources, social discrimination, and lack of knowledge and skills of the health workers. While there are clear frustrations with the limited resources, there is a willingness to learn among the health workers and provide care in the community.

Truth Telling in the Setting of Cultural Differences and Incurable Pediatric Illness: A Review

IMPORTANCE

Navigating requests from parents or family caregivers not to disclose poor prognosis to seriously ill children can be challenging, especially when the requests seem culturally mediated. Pediatric clinicians must balance obligations to respect individual patient autonomy, professional truth telling, and tolerance of multicultural values.

OBSERVATIONS

To provide suggestions for respectful and ethically appropriate responses to nondisclosure requests, we used a hypothetical case example of a Middle Eastern adolescent patient with incurable cancer and conducted an ethical analysis incorporating (1) evidence from both Western and Middle Eastern medical literature and (2) theories of cultural relativism and justice. While Western medical literature tends to prioritize patient autonomy and corresponding truth telling, the weight of evidence from the Middle East suggests high variability between and within individual countries, patient-physician relationships, and families regarding truth-telling practices and preferences. A common reason for nondisclosure in both populations is protecting the child from distressing information. Cultural relativism fosters tolerance of diverse beliefs and behaviors by forbidding judgment on foreign societal codes of conduct. It does not justify assumptions that all individuals within a single culture share the same values, nor does it demand that clinicians sacrifice their own codes of conduct out of cultural respect. We suggest some phrases that may help clinicians explore motivations behind nondisclosure requests and gently confront conflict in order to serve the patient's best interest.

CONCLUSIONS AND RELEVANCE

It is sometimes ethically permissible to defer to family values regarding nondisclosure, but such deferral is not unique to cultural differences. Early setting of expectations and boundaries, as well as ongoing exploration of family and health care professional concerns, may mitigate conflict.

Clinical characteristics and survival outcomes of terminally ill patients undergoing withdrawal of mechanical ventilation

BACKGROUND

Withdrawal of mechanical ventilation is an important, but rarely explored issue in Asia during end-of-life care. This study aimed to describe the clinical characteristics and survival outcomes of terminally ill patients undergoing withdrawal of mechanical ventilation in Taiwan.

METHODS

One-hundred-thirty-five terminally ill patients who had mechanical ventilation withdrawn between 2013 and 2016, from a medical center in Taiwan, were enrolled. Patients' clinical characteristics and survival outcomes after withdrawal of mechanical ventilation were analyzed.

RESULTS

The three most common diagnoses were organic brain lesion, advanced cancer, and newborn sequelae. The initiator of the withdrawal process was family, medical personnel, and patient him/herself. The median survival time was 45 min (95% confidence interval, 33-57 min) after the withdrawal of mechanical ventilation, and 102 patients (75.6%) died within one day after extubation. The median time from diagnosis of disease to receiving life-sustaining treatment and artificial ventilation support, receiving life-sustaining treatment and artificial ventilation support to "Withdrawal meeting," "Withdrawal meeting" to ventilator withdrawn, and ventilator withdrawn to death was 12.1 months, 19 days, 1 day, and 0 days, respectively. Patients with a diagnosis of advanced cancer and withdrawal initiation by the patients themselves had a significantly shorter time interval between receiving life-sustaining treatment and artificial ventilation support to "Withdrawal meeting" compared to those with non-cancer diseases and withdrawal initiation by family or medical personnel.

CONCLUSION

This study is the first observational study to describe the patients' characteristics and elaborate on the survival outcome of withdrawal of mechanical ventilation in patients who are terminally ill in an Asian population. Understanding the clinical characteristics and survival outcomes of mechanical ventilation withdrawal might help medical personnel provide appropriate end-of-life care and help patients/families decide about the withdrawal process earlier.

Transitions in Prognostic Awareness Among Terminally Ill Cancer Patients in Their Last 6 Months of Life Examined by Multi-State Markov Modeling

BACKGROUND

Developing accurate prognostic awareness, a cornerstone of preference-based end-of-life (EOL) care decision-making, is a dynamic process involving more prognostic-awareness states than knowing or not knowing. Understanding the transition probabilities and time spent in each prognostic-awareness state can help clinicians identify trigger points for facilitating transitions toward accurate prognostic awareness. We examined transition probabilities in distinct prognostic-awareness states between consecutive time points in 247 cancer patients' last 6 months and estimated the time spent in each state.

METHODS

Prognostic awareness was categorized into four states: (a) unknown and not wanting to know, state 1; (b) unknown but wanting to know, state 2; (c) inaccurate awareness, state 3; and (d) accurate awareness, state 4. Transitional probabilities were examined by multistate Markov modeling.

RESULTS

Initially, 59.5% of patients had accurate prognostic awareness, whereas the probabilities of being in states 1-3 were 8.1%, 17.4%, and 15.0%, respectively. Patients' prognostic awareness generally remained unchanged (probabilities of remaining in the same state: 45.5%-92.9%). If prognostic awareness changed, it tended to shift toward higher prognostic-awareness states (probabilities of shifting to state 4 were 23.2%-36.6% for patients initially in states 1-3, followed by probabilities of shifting to state 3 for those in states 1 and 2 [9.8%-10.1%]). Patients were estimated to spend 1.29, 0.42, 0.68, and 3.61 months in states 1-4, respectively, in their last 6 months.

CONCLUSION

Terminally ill cancer patients' prognostic awareness generally remained unchanged, with a tendency to become more aware of their prognosis. Health care professionals should facilitate patients' transitions toward accurate prognostic awareness in a timely manner to promote preference-based EOL decisions.

IMPLICATIONS FOR PRACTICE

Terminally ill Taiwanese cancer patients' prognostic awareness generally remained stable, with a tendency toward developing higher states of awareness. Health care professionals should appropriately assess patients' readiness for prognostic information and respect patients' reluctance to confront their poor prognosis if they are not ready to know, but sensitively coach them to cultivate their accurate prognostic awareness, provide desired and understandable prognostic information for those who are ready to know, and give direct and honest prognostic information to clarify any misunderstandings for those with inaccurate awareness, thus ensuring that they develop accurate and realistic prognostic knowledge in time to make end-of-life care decisions.

Prevalence, risk factors, and the desire for help of distressed newly diagnosed cancer patients: A large-sample study

Objective:

Beginning in 2007, all newly diagnosed cancer patients at the Koo Foundation Sun Yat-Sen Cancer Center (KF–SYSCC) were screened for psychosocial distress. Our social workers, as part of the psychosocial care team (PCT), have engaged in proactive outreach with patients identified as distressed. The goal of the present study was to assess the prevalence of psychosocial distress and the extent of contact between the PCT and distressed patients.

Method:

Newly diagnosed patients who were treated at KF–SYSCC between 2007 and 2010 for cancer were eligible if there were at least 100 patients with the same type of cancer. Before treatment began, they were screened with the Pain Scale and the Distress Thermometer (DT) and had the option to specify a desire for help. The rates of distress were analyzed by cancer type and by probable related factors. Information regarding contact with the PCT was retrieved from computerized databases.

Results:

Overall, some 5,335 cancer patients representing 12 major cancer types were included in our study. Of these, 1,771 (33.20%) were significantly distressed. By multivariate logistic regression, younger age, female gender, higher pain score, and disease stage, but not cancer type, were found to be associated with higher rates of distress. Among these distressed patients, 628 (36%) had some contact with the PCT.

Significance of results:

This Taiwanese study with a large sample size revealed a prevalence rate of psychosocial distress similar to rates found in Western countries. Contact with the PCT was established in only 36% of significantly distressed patients, despite a proactive outreach program. It is very important to have screening results made available in a timely fashion to the psycho-oncology team so that appropriate care can be offered promptly.

Poor-prognosis disclosure preference in cancer patient-caregiver dyads and its association with their quality of life and perceived stress: a cross-sectional survey in mainland China

BACKGROUND

This study attempted to examine the discordance between family caregivers and cancer patients in their poor-prognosis disclosure preferences in mainland China and then ascertained the associations between quality of life (QoL), perceived stress, and poor-prognosis disclosure preferences.

METHODS

Six hundred fifty-one pairs of inpatients and their matched caregivers (participation rate = 92.2%) were recruited in this cross-sectional survey. A set of paired self-administered questionnaires were completed independently by patient-caregiver dyads.

RESULTS

Fewer family caregivers than cancer patients felt that poor prognosis should be disclosed to patients (61.2% vs. 90.0%, p < 0.001). Patients' positive poor-prognosis disclosure preference was associated with patients' better QoL (p < 0.05) and caregivers' reduced perceived stress levels (p = 0.013). However, caregivers' poor-prognosis disclosure preference correlated only with their own physical state (p = 0.028). Moreover, the caregivers who concurred with patients in positive poor-prognosis disclosure preference were more likely to experience a better QoL (p < 0.05) and lower perceived stress levels (p = 0.048) in the III-IV stage subgroup.

CONCLUSIONS

There was a significant discrepancy in poor-prognosis disclosure preference between cancer patients and caregivers in China. The caregivers' preference of concealing poor prognosis from patients was not related to cancer patients' QoL or perceived stress. In addition, caregivers had better QoL and lower stress levels when they held the same positive poor-prognosis disclosure preference as the patients. Copyright © 2015 John Wiley & Sons, Ltd.

Comprehension of Randomization and Uncertainty in Cancer Clinical Trials Decision Making Among Rural, Appalachian Patients

Comprehension of randomization is a vital, but understudied, component of informed consent to participate in cancer randomized clinical trials (RCTs). This study examines patient comprehension of the randomization process as well as sources of ongoing uncertainty that may inhibit a patient's ability to provide informed consent to participate in RCTs. Cancer patients living in rural Appalachia who were offered an opportunity to participate in a cancer treatment RCT completed in-depth interviews and a brief survey. No systematic differences in randomization comprehension between patients who consented and those who declined participation in a cancer RCT were detected. Comprehension is conceptually distinct from uncertainty, with patients who had both high and low comprehension experiencing randomization-related uncertainty. Uncertainty about randomization was found to have cognitive and affective dimensions. Not all patients enrolling in RCTs have a sufficient understanding of the randomization process to provide informed consent. Healthcare providers need to be aware of the different types of randomization-related uncertainty. Efforts to improve informed consent to participate in RCTs should focus on having patients teach back their understanding of randomization. This practice could yield valuable information about the patient's cognitive and affective understanding of randomization as well as opportunities to correct misperceptions. Education about RCTs should reflect patient expectations of individualized care by explaining how all treatments being compared are appropriate to the specifics of a patient's disease.

Promoting emancipated decision-making for surgical treatment of early stage breast cancer among Jordanian women

To use the critical social theory as a framework to analyze the oppression of Jordanian women with early stage breast cancer in the decision-making process for surgical treatment and suggest strategies to emancipate these women to make free choices. This is a discussion paper utilizing the critical social theory as a framework for analysis. The sexist and paternalistic ideology that characterizes Jordanian society in general and the medical establishment in particular as well as the biomedical ideology are some of the responsible ideologies for the fact that many Jordanian women with early stage breast cancer are denied the right to choose a surgical treatment according to their own preferences and values. The financial and political power of Jordanian medical organizations (e.g., Jordan Medical Council), the weakness of nursing administration in the healthcare system, and the hierarchical organization of Jordanian society, where men are first and women are second, support these oppressing ideologies. Knowledge is a strong tool of power. Jordanian nurses could empower women with early stage breast cancer by enhancing their knowledge regarding their health and the options available for surgical treatment. To successfully emancipate patients, education alone may not be enough; there is also a need for health care providers' support and unconditional acceptance of choice. To achieve the aim of emancipating women with breast cancer from the oppression inherent in the persistence of mastectomy, Jordanian nurses need to recognize that they should first gain greater power and authority in the healthcare system.

Preferences on End-Of-Life Decisions Among Older Chinese in Macau

Purpose: The purpose of the present study was to learn about the perspectives on end-of-life decision making among older Chinese people in Macau. Method: A qualitative approach was used, and interviews were conducted with 18 Chinese aged 65 years or older. Results: Four major themes were identified: (a) institutionalized care at the end of life was preferred as not to be a burden on family, (b) life-prolonging measures were not preferred, (c) funeral arrangement preferences were based on personal and religious beliefs, and (d) end-of-life decision making would be deferred to others. Discussion and Conclusions: These themes provide an understanding of personal preferences of older Chinese on end-of-life issues, and personal preferences are always secondary to their respect toward family and medical doctors. This compliance with family and medical authority can be understood through Chinese cultural beliefs. Implications for Practice: Knowledge of cultural influences is needed for nursing professionals to deal effectively with older adults and families regarding end-of-life issues.

Ethical, Socioeconomic, and Cultural Considerations in Gynecologic Cancer Care in Developing Countries

Gynaecologic cancers contribute significantly to the cancer burden in developing countries, resulting in higher mortality and morbidity rates among women in these nations. This situation is further compounded by the occurrence of wars, famine, poverty and natural disasters, and infectious diseases like hepatitis B and HIV/AIDS. In addition, merge resources and manpower lack in these countries further compound this very delicate situation. Often times, socioeconomic, cultural, and ethical factors such as truth-telling, choice of place of care, place of death, treatment choices, medication use, and terminal sedation can interfere in patient management. Availability and use of oral morphine for pain relief, spiritual care and availability of palliative care services, the individuals’ autonomy, and family and community participation in care, end of life issues, and preservation of fertility are also big issues that determine the course of care. This review discusses these pertinent factors, discusses how they affect cancer care in women, and proffers ideas for healthcare workers and policy makers on implementation of sustainable models for cancer care in developing countries. Addressing socioeconomic, cultural, and ethical issues affecting gynaecologic cancer care will aid in ensuring development of viable models of cancer care in resource-limited countries.

Practices and evaluations of prognostic disclosure for Japanese cancer patients and their families from the family's point of view

OBJECTIVE

The primary end points of this analysis were to explore 1) the practices of prognostic disclosure for patients with cancer and their family members in Japan, 2) the person who decided on the degree of prognosis communication, and 3) family evaluations of the type of prognostic disclosure.

METHOD

Semistructured face-to-face interviews were conducted with 60 bereaved family members of patients with cancer who were admitted to palliative care units in Japan.

RESULTS

Twenty-five percent of patients and 75% of family members were informed of the predicted survival time of the patient. Thirty-eight percent of family members answered that they themselves decided on to what degree to communicate the prognosis to patients and 83% of them chose not to disclose to patients their prognosis or incurability. In the overall evaluation of prognosis communication, 30% of the participants said that they regretted or felt doubtful about the degree of prognostic disclosure to patients, whereas 37% said that they were satisfied with the degree of prognostic disclosure and 5% said that they had made a compromise. Both in the “prognostic disclosure” group and the “no disclosure” group, there were family members who said that they regretted or felt doubtful (27% and 31%, respectively) and family members who said that they were satisfied with the degree of disclosure (27% and 44%, respectively).

SIGNIFICANCE OF RESULTS

In conclusion, family members assume the predominant role as the decision-making source regarding prognosis disclosure to patients, and they often even prevent prognostic disclosure to patients. From the perspective of family members, any one type of disclosure is not necessarily the most acceptable choice. Future surveys should explore the reasons why family members agree or disagree with prognostic disclosures to patients and factors correlated with family evaluations.

Public attitudes toward cancer and cancer patients: a national survey in Korea

BACKGROUND

Regardless of improved survival rate, negative images and myths about cancer still abound. Cancer stigma may reduce patients' life opportunities resulting in social isolation, decreased level of emotional well-being, and poor health outcomes. This study was aimed to evaluate public attitudes toward cancer and cancer patients and people's willingness to disclose cancer diagnosis in South Korea.

METHODS

A cross-sectional survey was conducted in August and September 2009. A nationally representative sample of 1011 men and women with no history of cancer was recruited. A set of 12 questions grouped into three domains (impossibility of recovery, cancer stereotypes, and discrimination) was used to assess public attitudes toward cancer.

RESULTS

It was found 58.5% of study participants agreed that it is impossible to treat cancer regardless of highly developed medical science, 71.8% agreed that cancer patients would not be able to make contributions to society, and 23.5% agreed that they would avoid working with persons who have cancer. The proportions of people who said that that they would not disclose a cancer diagnosis to family, friends or neighbors, or coworkers were 30.2%, 47.0%, and 50.7%, respectively. Negative attitudes toward cancer were strongly associated with lower willingness to disclose a cancer diagnosis.

CONCLUSIONS

Negative attitudes, stereotypes, and discriminating attitudes toward cancer and people affected by the disease were very common in spite of clinical progress and improved survivorship.

IMPACT

Our findings emphasize the need for health policy and social changes to provide a more supportive environment for cancer survivors.

Attitudes of Saudi medical students toward the disclosure of information on cancer in eastern Saudi Arabia

Objective:

To assess the attitude of future physicians regarding the disclosure of diagnosis, prognosis, benefits, and adverse effects of therapeutic intervention if they happen to have cancer. It also examined the differences if any between regions or gender.

Materials and Methods:

A total of 332 medical students from University of Dammam, in the Eastern Province of the Kingdom of Saudi Arabia were surveyed using a self-administered questionnaire. The questionnaire consisted of nine questions on the attitudes to disclosure of information on cancer. This self-administered questionnaire was completed by the students in the presence of an investigator.

Results:

The vast majority of Saudi medical students stated that they would like to know about diagnosis of cancer (92.8%) and only 7.2% wanted information withheld from them. Further, 67% of the males and 74.1% of the females wanted family members to know (P = 0.01), but one-third (33%) did not want their family to know. Only 24.1% of the male and 21.1% of female students wanted their friends to know. In addition, –97% of the males and 98.8% of the females wanted to know the diagnosis, and 97% and 95.8% of females and males, respectively, would like to know the side effects of the therapy. Almost 95% of male and 93.4% of female students wanted to know the prognosis. Also, 98% of medical students from the Eastern Region would want the diagnosis of cancer to be disclosed compared to 73.6% of those from other regions (P = 0.01). There is no difference between the genders in attitudes toward the disclosure of the diagnosis, 94.6% and 92.2% (P = 0.38).

Conclusions:

There was a consensus among Saudi medical students on the knowledge of the benefits of treatment, adverse effects of therapy, and prognosis. Female students significantly more than males would like their families to be informed. Significantly more medical students from the Eastern Region than those from other regions would like the diagnosis of cancer to be disclosed.

Experience with prognostic disclosure of families of Japanese patients with cancer

CONTEXT

Prognosis is difficult to discuss with patients who have advanced cancer and their families.

OBJECTIVES

This study aimed to explore the experiences of families of patients with cancer in Japan in receiving prognostic disclosure, explore family perception of the way the prognosis was communicated, and investigate relevant factors of family-perceived need for improvement.

METHODS

A multicenter questionnaire survey was conducted with 666 bereaved family members of patients with cancer who were admitted to palliative care units in Japan.

RESULTS

In total, 86.3% of the families received prognostic disclosure. The overall evaluation revealed that 60.1% of the participants felt that the method of prognostic disclosure needed some, considerable, or much improvement. The parameter with the highest value explaining the necessity for improvement was the family perception that the amount of information provided by the physician was insufficient (beta=0.39, P<0.001). Furthermore, the family perception that they had lost hope and that health care providers failed to facilitate preparation for the patient's death had significant direct effects on the necessity for improvement (beta=0.21, P<0.001; and beta=0.18, P<0.001, respectively). The feelings for the necessity for improvement also were affected significantly by seven communication strategies (i.e., not saying "I can do nothing for the patient any longer," pacing explanation with the state of the patient's and family's preparation, saying "We will respect the patient's wishes," making an effort to understand the family's distress, being knowledgeable about the most advanced treatments, assuring continuing responsibility as the physician for medical care, and respecting the family's values).

CONCLUSION

This model suggests that strategies for care providers to improve family perception about prognostic disclosure should include 1) providing as much prognostic information as families want; 2) supporting families' hopes by keeping up with up-to-date treatments and by assuring the continuing responsibility for medical care; 3) facilitating the preparation for the patient's death by providing information in consideration of the family's preparations and values; 4) stressing what they can do instead of saying that nothing can be done for the patient; and 5) assuring the family that they will respect the patient's wishes.

Do-not-resuscitate orders for critically ill patients in intensive care

End-of-life decision making frequently occurs in the intensive care unit (ICU). There is a lack of information on how a do-not-resuscitate (DNR) order affects treatments received by critically ill patients in ICUs. The objectives of this study were: (1) to compare the use of life support therapies between patients with a DNR order and those without; (2) to examine life support therapies prior to and after the issuance of a DNR order; and (3) to determine the clinical factors that influence the initiation of a DNR order in ICUs in Taiwan. A prospective, descriptive, and correlational study was conducted. A total of 202 patients comprising 133 (65.8%) who had a DNR order, and 69 (34.1%) who did not, participated in this study. In the last 48 hours of their lives, patients who had a DNR order were less likely to receive life support therapies than those who did not have a DNR order. Older age, being unmarried, the presence of an adult child as a surrogate decision maker, a perceived inability to survive ultimate discharge from the ICU, and longer hospitalization in the ICU were significant predictors of issuing a DNR order for critically ill patients. This study will draw attention to how, when, and by whom, critically ill patients’ preferences about DNR are elicited and honored.

Experiences and Attitudes of Patients With Terminal Cancer and Their Family Caregivers Toward the Disclosure of Terminal Illness

Purpose

We investigated the experiences of cancer patients and their family caregivers who became aware that the cancer was terminal, how they became aware, and how they felt about disclosure of the information.

Patients and Methods

In this cohort study, we administered questionnaires to 619 consecutive patients determined by physicians to be terminally ill and to their family caregivers.

Results

A total of 481 patients and 381 family caregivers completed the questionnaire. A majority of patients (58.0%) and caregivers (83.4%) were aware of the patient's terminal status. Approximately 28% of patients and 23% of caregivers reported that they guessed it from the patient's worsening condition. The patient group was more likely than the caregiver group (78.6% v 69.6%) to prefer that patients be informed of their terminal status. Patients informed of their terminal diagnosis had a significantly better quality of life and fewer symptoms and had a lower rate of emotional distress than patients who guessed it from their worsening condition. Younger patients and patients who paid the treatment costs themselves were significantly more likely to want to be told when their illness was terminal. If the patient paid the treatment cost and was employed at the time of the cancer diagnosis, the family caregivers were more likely to prefer disclosure of terminal illness.

Conclusion

Most patients with terminal cancer and their family caregivers preferred disclosure, and patients who knew of their terminal diagnosis had a lower rate of emotional distress and a higher health-related quality of life.

Preferences for disclosure of information about serious illness among older Korean American immigrants in New York City

BACKGROUND

The majority of persons of Western European background want to know their diagnosis and prognosis of serious illness, but minimal information is preferred by some ethnic groups, including Asians. Little is known about disclosure preferences of Korean Americans, the fourth largest East Asian immigrant group in the United States.

OBJECTIVE

The objective was to describe disclosure preferences about serious illness of Korean Americans in New York City and characteristics associated with disclosure preferences.

METHODS

A cross-sectional study of a volunteer sample of 26 Korean Americans, 65 years and older, was conducted. Interviews were conducted in Korean. Measures included comfort in talking about death and dying, disclosure preferences, disclosure to relatives, self-rated physical and mental health, and sociodemographic characteristics.

RESULTS

Most agreed doctors should tell patients (n = 23) and relatives (n = 25) if they have cancer, and should tell patients (n = 22) and relatives if they are likely to die from this disease. Less than half (n = 9) agreed doctors should not discuss death and dying with patients, yet 15 agreed it is best to avoid talking about serious illness and dying before they occur. Participants who agreed a doctor should tell patients their cancer diagnosis were younger and had lived in the United States longer than those who disagreed. Self-rated physical health and mental health were associated with disclosure preferences.

CONCLUSIONS

Health professionals are advised to determine the disclosure preferences about serious illness of older Korean Americans and avoid stereotypical assumptions that do not apply to many in this population.

Congruence of Knowledge, Experiences, and Preferences for Disclosure of Diagnosis and Prognosis between Terminally-Ill Cancer Patients and Their Family Caregivers in Taiwan

BACKGROUND

Over the last 40 years, studies have shown cultural differences in attitudes toward truth telling at the end-of-life. Nevertheless, the argument that cancer patients from an Asian culture have different preferences about information disclosure that necessitate significantly modifying information disclosure practices has not been validated by direct investigation from patients' points of view.

METHODS

Six hundred seventeen dyads of patient-designated family caregivers across 21 hospitals throughout Taiwan were surveyed and interviewed by a semistructured interview guide. Percentage of agreement, kappa coefficients, McNemar tests, and paired t-tests were conducted to examine the extent of congruence of knowledge, experiences, and preferences for disclosure of diagnosis and prognosis between the dyads.

RESULTS

There were substantial discrepancies in the knowledge and experiences of being informed about the diagnosis and prognosis between Taiwanese terminally-ill cancer patients and their family caregivers (kappa values ranged from 0.08 to 0.44). Cancer patients strongly proclaimed their superior rights to be informed about their disease over their family and preferred their physicians to inform themselves before releasing any information to their family caregivers.

CONCLUSION

The arguments that cancer patients from an Asian culture (i.e., Chinese/Taiwanese culture) have different preferences regarding being informed of their diagnosis and prognosis and that family members have legitimate superior power in decision making could not be supported by data from this group of terminally-ill cancer patients. Physicians need to respect patients' preferences rather than routinely taking the family's opinions into consideration first in the event of disagreement. Equipped with adequate information, terminally-ill cancer patients from Asia may have better opportunities to make end-of-life care decisions that are in accord with their wishes.

Preferences of cancer patients regarding communication of bad news: a systematic literature review

Most physicians regard the communication of bad news to be a difficult issue in clinical oncology practice. The optimal manner of communicating bad news to patients so that physicians can create maximal understanding in patients and facilitate their psychological adjustment is unknown. A systematic review of the literature was conducted to clarify available knowledge on patient preferences regarding the communication of bad news and associated factors. A comprehensive computer search of databases (MEDLINE and PsychINFO) and a manual search identified 24 studies. The above issue has been discussed mainly in Western countries. Most studies used different measures to obtain information on patient preferences and have provided mostly descriptive evidence. The findings in this review suggest that patient preferences with regard to the communication of bad news by physicians consist of four components: setting, manner of communicating bad news, what and how much information is provided and emotional support, and that patients' preferences are associated with demographic factors. Younger patients, female patients and more highly educated patients consistently expressed a desire to receive as much detailed information as possible and to receive emotional support. Asian patients were shown to prefer that relatives be present when receiving bad news more than Westerners do and to prefer to discuss their life expectancy less than Westerners. Physicians need to recognize these preferences to help patients understand.

Different attitudes of Chinese patients and their families toward truth telling of different stages of cancer

OBJECTIVE

Cancer patients and their families differed in their attitude toward truth telling. The objective is to investigate different attitudes of Chinese patients or families toward whether and how to disclose diagnosis to patients with different stages of cancer and to examine the difference between the two groups.

METHODS

A questionnaire was delivered to 1023 participants.

RESULTS

Three hundred and eighty-two patients and 482 families completed the questionnaire. Cancer patients were more likely than families to believe that patient should be informed of the diagnosis (early-stage, 90.8 vs 69.9%, P<0.001; terminal stage, 60.5 vs 34.4%, P<0.001), and that doctor-in-charge was the appropriate person to disclose the diagnosis. Most participants thought that patient should be disclosed immediately after the diagnosis. Nearly half of participants reported that patient should be disclosed in a quiet and undisturbed room. When the hypothetic diagnosis changed from early-stage cancer to terminal illness, the number of participants, who wanted patient to know the diagnosis, decreased significantly.

CONCLUSION

Our findings indicated that Chinese cancer patients and their families differed in their attitude toward truth telling and the attitudes toward such a disclosure were influenced by disease stage. Physicians should realize this phenomenon and pay more attention to the skills of how to disclose the cancer diagnosis.

Ways to obtain a breast cancer diagnosis, consistency of information, patient satisfaction, and the presence of relatives

GOALS OF WORK

What physicians told breast cancer patients about their diagnosis, who informed them, and how this information was conveyed were examined in this study. Finally, the relatives' role in this communication process was considered.

MATERIALS AND METHODS

Women with primary breast cancer (N = 222) below the age of 70 were interviewed after surgery and after they were informed about their diagnosis.

MAIN RESULTS

One hundred twenty-one women consulted their primary gynecologist first, then they were referred to a radiologist, and finally to the secondary care gynecologist. Forty-seven women omitted the radiologist and only five went directly to the hospital for treatment. In most cases (N = 199), the general practitioner was not involved. Receiving inconsistent information was associated with patient dissatisfaction. This also applies to women who received their diagnosis on the phone. Women awaiting a worse diagnosis were more likely to be accompanied by another person.

CONCLUSIONS

Future studies should focus on the possible involvement of family doctors and relatives during the diagnostic process. Giving inconsistent information should be avoided.

Reluctance to disclose difficult diagnoses: a narrative review comparing communication by psychiatrists and oncologists

INTRODUCTION

National guidance in most medical specialties supports the full and open disclosure of diagnoses to patients.

RESULTS

Surveys show that most patients want to know their diagnosis, whether it is medical or psychiatric, and a substantial proportion want to know detailed prognostic information. In the past, oncologists have been criticised for failing to reveal a diagnosis of cancer to patients in a sensitive and timely manner. Over the last 30 years, there is evidence that this practice has improved. Yet, clinicians still have difficulty when the diagnosis is not certain, when the prognosis is unfavourable, and when relatives request "not to tell." All of these influences are present in mental health settings.

DISCUSSION

Psychiatrists and general practitioners may be equally reluctant to reveal difficult diagnoses and prognoses of conditions such as schizophrenia and dementia. The reluctance to reveal a difficult diagnosis may be a routine, but little acknowledged the aspect of medical care that should be incorporated into undergraduate and postgraduate education and openly discussed during peer group supervision.

Anxiety and depression in patients with gastrointestinal cancer: does knowledge of cancer diagnosis matter?

Background

Gastrointestinal cancer is the first leading cause of cancer related deaths in men and the second among women in Iran. An investigation was carried out to examine anxiety and depression in this group of patients and to investigate whether the knowledge of cancer diagnosis affect their psychological distress.

Methods

This was a cross sectional study of anxiety and depression in patients with gastrointestinal cancer attending to the Tehran Cancer Institute. Anxiety and depression was measured using the Hospital Anxiety and Depression Scale (HADS). This is a widely used valid questionnaire to measure psychological distress in cancer patients. Demographic and clinical data also were collected to examine anxiety and depression in sub-group of patients especially in those who knew their cancer diagnosis and those who did not.

Results

In all 142 patients were studied. The mean age of patients was 54.1 (SD = 14.8), 56% were male, 52% did not know their cancer diagnosis, and their diagnosis was related to esophagus (29%), stomach (30%), small intestine (3%), colon (22%) and rectum (16%). The mean anxiety score was 7.6 (SD = 4.5) and for the depression this was 8.4 (SD = 3.8). Overall 47.2% and 57% of patients scored high on both anxiety and depression. There were no significant differences between gender, educational level, marital status, cancer site and anxiety and depression scores whereas those who knew their diagnosis showed a significant higher degree of psychological distress [mean (SD) anxiety score: knew diagnosis 9.1 (4.2) vs. 6.3 (4.4) did not know diagnosis, P < 0.001; mean (SD) depression score: knew diagnosis 9.1 (4.1) vs. 7.9 (3.6) did not know diagnosis, P = 0.05]. Performing logistic regression analysis while controlling for demographic and clinical variables studied the results indicated that those who knew their cancer diagnosis showed a significant higher risk of anxiety [OR: 2.7, 95% CI: 1.1–6.8] and depression [OR: 2.8, 95% CI: 1.1–7.2].

Conclusion

Psychological distress was higher in those who knew their cancer diagnosis. It seems that the cultural issues and the way we provide information for cancer patients play important role in their improved or decreased psychological well-being.

Grief Reactions in Family Caregivers of Advanced Cancer Patients in Taiwan

Home death has a special cultural meaning for Taiwanese patients who are dying and their family members. However, very limited evidence has been presented on the impact of home death on caregiver bereavement outcomes. The purpose of this study was to explore the preference for place of death by Taiwanese patients dying of cancer and the actual place of death and to investigate the relationship between place of death of a patient and grief reactions of the family caregivers. This study consisted of 46 dying patients and 46 matched family caregivers (N = 92). The grief reaction was measured using the Texas Revised Inventory of Grief. Statistical analyses included descriptive statistics, t tests, logistic regression, and multiple regression. Most of the patients (74%) preferred to die at home; however, only 33% of family caregivers preferred the patient to die at home, and only 17% of patients actually died at home. Of these patients, 43% of their preferences were congruent with the actual place of death, whereas 79% of the family caregivers' preferences were congruent with the patients' actual place of death. Finally, the place of death was not a significant predictor of caregivers' grief reactions immediately after the loss of a loved one or at 1 month after the death occurred. This study provides important implications for future studies and clinical practice.

Illness Awareness of Patients in Hospice: Psychological Evaluation and Perception of Family Members and Medical Staff

BACKGROUND

Despite the widespread belief that patients should be given full information about their disease and prognosis, they actually they know very little. The purpose of this study was to evaluate the awareness of 100 patients (from the Hospices of Rimini and Savignano-Rubicone) about their diagnoses and prognoses. It is also investigated staff and relatives perceptions of patients' awareness.

METHODS

A semistructured interview of patients was performed by psychologists to evaluate their awareness about diagnosis and prognosis. Then psychologists completed a questionnaire about their own evaluation of patients' disease awareness. Moreover, the same questionnaire was completed by family members and by staff members (doctors and nurses) about their perceptions of patients' awareness. Doctors and nurses gave their answers based on their routine interactions with patients.

RESULTS

Despite the fact that patients in hospice were in the terminal phase of disease, 30% of patients had no diagnosis awareness, and an even higher percentage of patients (62%) who had no prognosis awareness.

Development and Testing of a Scale to Measure Caregiving Load in Caregivers of Cancer Patients in Taiwan, the Care Task Scale-Cancer

The purpose of this study was to develop and test an instrument to measure care tasks for Taiwanese spouse caregivers of cancer patients. A 37-item Care Task Scale-Cancer (CTS-C) was developed using both quantitative and qualitative approaches. The reliability and validity of the CTS-C was tested on a convenience sample of 150 spouse caregivers caring for patients with breast cancer, head neck cancer, or esophageal cancer. Factor analysis showed that the CTS-C had 4 underlying factors (subscales): (1) accompany patient and monitor care (12 items), (2) substitutive care for social and general affairs (12 items), (3) communication and emotional care (9 items), and (4) mobility maintenance care (4 items). These 4 factors explained 52.3% of the total variance. Cronbach alpha coefficients for these 4 subscales ranged from .83 to .88. Test-retest coefficients (r) ranged from 0.92 to 0.94. The construct validity of this scale was supported by demonstrating a negative correlation between CTS-C scores (demand, difficulty, and caregiving load) and functional performance status, and positive correlations with caregiver burden and symptom distress. These results showed satisfactory validity and reliability for the CTS-C.

Complementary and Alternative Medicine Among Advanced Cancer Patients Enrolled on Phase I Trials: A Study of Prognosis, Quality of Life, and Preferences for Decision Making

Purpose

We sought to describe complementary and alternative medicine (CAM) usage among phase I trial participants and to describe these patients' treatment decision-making preferences, awareness of prognosis, survival, and quality of life.

Patients and Methods

Advanced cancer patients enrolling onto phase I trials were surveyed regarding biologically based CAM use. Decision-making preferences and awareness of prognosis were assessed using validated and/or standardized instruments. The Functional Assessment of Cancer Therapy–General instrument was used to assess quality of life. Univariate and multivariate analyses were performed to detect differences between CAM users and nonusers.

Results

Of 212 interviewed patients, 34% (n = 72) described taking biologically based CAM. Median age of those taking biologically based CAM was 55 years, compared with 62 years for nonusers (P < .005). There were no statistically significant differences found between CAM usage and preferences for degree of patient involvement in medical decision making. Those patients who acknowledged that their deaths were likely to occur within 1 year were more likely to admit to prior CAM use (70% v 34%; P = .02). CAM users had poorer overall quality of life compared with nonusers (87.0 ± 12.4 v 91.2 ± 14.7; P = .007). No differences in survival were identified.

Conclusion

Prior CAM use among phase I cancer trial patients studied was common and associated with age, stated acknowledgment of prognosis, and quality of life. Patients enrolling onto early-phase trials should be questioned about CAM use. Additional study is needed to determine the frequency of use of those biologically based CAM agents that threaten the accuracy of early-phase cancer trial data.