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Ozdemir S, Chaudhry I, Malhotra C, Teo I, Finkelstein EA. Goals of Care Among Patients With Advanced Cancer and Their Family Caregivers in the Last Years of Life. JAMA Netw Open 2024; 7:e245866. [PMID: 38602677 PMCID: PMC11009823 DOI: 10.1001/jamanetworkopen.2024.5866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/13/2024] [Indexed: 04/12/2024] Open
Abstract
Importance Understanding goals of care for terminally ill patients at the end of life is crucial to ensure that patients receive care consistent with their preferences. Objectives To investigate the patterns of goals of care among patient-caregiver dyads over the last years of the patient's life and the associations of the goals of care with patient-caregiver characteristics. Design, Setting, and Participants This prospective cohort study of 210 patient-caregiver dyads involved surveys every 3 months from July 8, 2016, until the patient's death or February 28, 2022. Data from the last 2 years of the patients' lives were analyzed. Dyads, which comprised patients with stage IV solid cancer and their caregivers, were recruited from outpatient clinics at 2 major cancer centers in Singapore. Main Outcomes and Measures Goals of care were examined via the tradeoffs between life extension and symptom management and between life extension and cost containment. The actor-partner interdependence framework was implemented using mixed-effects linear regressions. Results This study included 210 dyads (patients: mean [SD] age, 62.6 [10.5] years; 108 men [51.4%]; caregivers: mean [SD] age, 49.4 [14.6] years; 132 women [62.9%]). On average, 34% of patients (264 of 780 observations; range, 23%-42%) and 29% of caregivers (225 of 780 observations; range, 20%-43%) prioritized symptom management over life extension, whereas 24% of patients (190 of 780 observations; range, 18%-32%) and 19% of caregivers (148 of 780 observations; range, 8%-26%) prioritized life extension. Between cost containment and life extension, on average, 28% of patients (220 of 777 observations; range, 22%-38%) and 17% of caregivers (137 of 780 observations; range, 10%-25%) prioritized cost containment, whereas 26% of patients (199 of 777 observations; range, 18%-34%) and 35% of caregivers (271 of 780 observations; range, 25%-45%) prioritized life extension. Goals of care did not change as patients approached death. Patients prioritized symptom management if they experienced higher symptom burden (average marginal effect [SE], 0.04 [0.01]), worse spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and accurate (vs inaccurate) prognostic awareness (average marginal effect [SE], 0.40 [0.18]) and if their caregivers reported accurate prognostic awareness (average marginal effect [SE], 0.53 [0.18]), lower impact of caregiving on finances (average marginal effect [SE], -0.28 [0.08]), and poorer caregiving self-esteem (average marginal effect [SE], -0.48 [0.16]). Compared with patients, caregivers expressed lower preferences for cost containment (average marginal effect [SE], -0.63 [0.09]). Patients prioritized cost containment if they were older (average marginal effect [SE], 0.03 [0.01]), had higher symptom burden (average marginal effect [SE], 0.04 [0.01]), had poorer spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and their caregivers reported poorer caregiving self-esteem (average marginal effect [SE], -0.51 [0.16]) and more family support (average marginal effect [SE], -0.30 [0.14]). Conclusions and Relevance In this cohort study of patient-caregiver dyads, findings suggested the importance of interventions aimed at reducing discordance in goals of care between patients and caregivers and helping them develop realistic expectations to avoid costly, futile treatments.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
- Department of Population Health Sciences, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Isha Chaudhry
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Irene Teo
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
- Department of Psychosocial Oncology, National Cancer Centre, Singapore
| | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
- Department of Population Health Sciences, Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Choi J, Jeon H, Lee I. Characteristics of Life-Sustaining Treatment Decisions: National Data Analysis in South Korea. Asian Bioeth Rev 2024; 16:33-46. [PMID: 38213986 PMCID: PMC10776518 DOI: 10.1007/s41649-023-00266-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 01/13/2024] Open
Abstract
This study analyzed the national data on life-sustaining treatment decisions from 2018 to 2020 to find out the characteristics of South Korea's end-of-life procedure according to the decision-making approach and process. We collected the data of 84,422 patients registered with the National Agency for Management of Life-sustaining Treatment. We divided the patients into four groups (G1, G2, G3, and G4) according to the decision-making approach. A descriptive analysis of each group was conducted using indicators such as the patient's age, status, diagnosis, and content of forgoing life-sustaining treatment. Additionally, logistic regression analysis was performed by dividing the patients into self-determining (G1, G2) and non-self-determining patients (G3, G4). Cancer was the most common diagnosis for each group. The period from life-sustaining treatment decision to implementation was 10.76, 1.01, 0.86, and 1.19 days for G1, G2, G3, and G4, respectively. In the logistic regression analysis, the self-determination ratio was higher for 40-49 years old and lower for cardiovascular disease and gastrointestinal disease. Age was has a major impact on life-sustaining treatment decisions (LSTD), and with increase in age, the family, and not the patient, made the LSTD. The LSTD method also differed depending on the disease. The self-determination rates of patients with circulatory or digestive diseases were somewhat lower than that of those with neoplastic diseases. The period from decision-making to implementation is short for end-of-life care.
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Affiliation(s)
- Jiyeon Choi
- Division of Medical Law and Ethics, Department of Medical Humanities and Social Sciences, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Heejung Jeon
- Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea
| | - Ilhak Lee
- Department of Medical Humanities and Social Sciences, College of Medicine, Yonsei University, Seoul, Republic of Korea
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Tsai SF, Chang CY, Yang JY, Ho YY, Hsiao CC, Hsu SC, Chen SY, Lin HY, Yeh TF, Chen CH. Exploring knowledge, attitude, and intention towards advance care planning, advance directive, and the patient self-determination act among hemodialysis patients. BMC Palliat Care 2023; 22:201. [PMID: 38097993 PMCID: PMC10720199 DOI: 10.1186/s12904-023-01321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Hemodialysis holds the highest incidence and prevalence rate in Taiwan globally. However, the implementation of advance care planning (ACP), advance directives (AD), and patient self-determination acts (PSDA) remains limited. Our objective was to examine the current status of ACP, AD and PSDA and potential opportunities for enhancement. METHODS We developed a novel questionnaire to assess individuals' knowledge, attitudes, and intentions regarding ACP, AD, and PSDA. We also collected baseline characteristics and additional inquiries for correlation analysis to identify potential factors. Student's t-test and Analysis of Variance were employed to assess significance. RESULTS Initially, a cohort of 241 patients was initially considered for inclusion in this study. Subsequently, 135 patients agreed to participate in the questionnaire study, resulting in 129 valid questionnaires. Among these respondents, 76 were male (59.9%), and 53 were female (41.1%). Only 13.2% had signed AD. A significant portion (85.3%) indicated that they had not discussed their dialysis prognosis with healthcare providers. Additionally, a mere 14% engaged in conversations about life-threatening decisions. Ninety percent believed that healthcare providers had not furnished information about ACP, and only 30% had discussed such choices with their families. The findings revealed that the average standardized score for ACP and AD goals was 84.97, while the attitude towards PSDA received a standardized score of 69.94. The intention score stood at 69.52 in standardized terms. Potential candidates for ACP initiation included individuals aged 50 to 64, possessing at least a college education, being unmarried, and having no history of diabetes. CONCLUSION Patients undergoing hemodialysis exhibited a significant knowledge gap concerning ACP, AD, and the PSDA. Notably, a substantial number of dialytic patients had not received adequate information on these subjects. Nevertheless, they displayed a positive attitude, and a considerable proportion expressed a willingness to sign AD. It is imperative for nephrologists to take an active role in initiating ACP discussions with patients from the very beginning.
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Affiliation(s)
- Shang-Feng Tsai
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, 160, Sec. 3, Taiwan Boulevard, Taichung, 407, Taiwan
- Department of Life Science, Tunghai University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ching-Yi Chang
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jia-Yi Yang
- Department of Ophthalmology, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Yu-Ying Ho
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ching-Ching Hsiao
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shu-Chuan Hsu
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Yun Chen
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Huan-Yi Lin
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Te-Feng Yeh
- Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, 160, Sec. 3, Taiwan Boulevard, Taichung, 407, Taiwan.
- Department of Life Science, Tunghai University, Taichung, Taiwan.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
- Ph.D. Program in Tissue Engineering and Regenerative Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
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Quinn KL, Krahn M, Stukel TA, Grossman Y, Goldman R, Cram P, Detsky AS, Bell CM. No Time to Waste: An Appraisal of Value at the End of Life. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:S1098-3015(22)01966-0. [PMID: 35690518 DOI: 10.1016/j.jval.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 04/13/2022] [Accepted: 05/02/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined. METHODS MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life. RESULTS A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed. CONCLUSIONS Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada.
| | - Murray Krahn
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada
| | - Thérèse A Stukel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada
| | - Yona Grossman
- Arts and Science Program, McMaster University, Hamilton, ON, Canada
| | - Russell Goldman
- Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON, Canada; Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Allan S Detsky
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
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Lim MK, Lai PSM, Lim PS, Wong PS, Othman S, Mydin FHM. Knowledge, attitude and practice of community-dwelling adults regarding advance care planning in Malaysia: a cross-sectional study. BMJ Open 2022; 12:e048314. [PMID: 35165104 PMCID: PMC8845205 DOI: 10.1136/bmjopen-2020-048314] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study aimed to assess the knowledge, attitude and practice (KAP) among community-dwelling adults in Malaysia regarding advance care planning (ACP), and its associated factors. DESIGN This cross-sectional study was conducted from July-September 2018. SETTING This study was conducted at the University Malaya Medical Centre, Kuala Lumpur, Malaysia. PARTICIPANTS We recruited community-dwelling adults (ambulatory care patients or their accompanying persons) who were ≥21 years old and able to understand English or Malay. A 1:10 systematic sampling procedure was used. Excluded were community-dwelling adults with intellectual disabilities or non-Malaysian accompanying persons. A trained researcher administered the validated English or Malay Advance Care Planning Questionnaire at baseline and 2 weeks later. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the KAP regarding ACP. The secondary outcomes were factors associated with KAP. RESULTS A total of 385/393 community-dwelling adults agreed to participate (response rate 98%). Only 3.1% of the community-dwelling adults have heard about ACP and 85.7% of them felt that discussion on ACP was necessary after explanation of the term. The desire to maintain their decision-making ability when seriously ill (94.9%) and reducing family burden (91.6%) were the main motivating factors for ACP. In contrast, resorting to fate (86.5%) and perceived healthy condition (77.0%) were the main reasons against ACP. Overall, 84.4% would consider discussing ACP in the future. Community-dwelling adults who were employed were less likely to know about ACP (OR=0.167, 95% CI 0.050 to 0.559, p=0.004) whereas those with comorbidities were more likely to favour ACP (OR=2.460, 95% CI 1.161 to 5.213, p=0.019). No factor was found to be associated with the practice of ACP. CONCLUSIONS Despite the lack of awareness regarding ACP, majority of community-dwelling adults in Malaysia had a positive attitude towards ACP and were willing to engage in a discussion regarding ACP after the term 'ACP' has been explained to them.
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Affiliation(s)
- Mun Kit Lim
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Pei Shan Lim
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Pei Se Wong
- School of Pharmacy, International Medical University, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Sajaratulnisah Othman
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Fadzilah Hanum Mohd Mydin
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
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Lin LS, Huang LH, Chang YC, Wang CL, Lee LC, Hu CC, Hsu PS, Chu WM. Trend analysis of palliative care consultation service for terminally ill non-cancer patients in Taiwan: a 9-year observational study. BMC Palliat Care 2021; 20:181. [PMID: 34823512 PMCID: PMC8614035 DOI: 10.1186/s12904-021-00879-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/08/2021] [Indexed: 01/03/2023] Open
Abstract
Backgrounds Early integration of palliative care for terminally ill non-cancer patients improves quality of life. However, there are scanty data on Palliative Care Consultation Service (PCCS) among non-cancer patients. Methods In this 9-year observational study Data were collected from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH). Terminally ill non-cancer patients with 9 categories of diagnoses who received PCCS during 2011 to 2019 were enrolled. Trend analysis was performed to evaluate differences in categories of diagnosis throughout study period, duration of PCCS, patient outcomes, DNR declaration, awareness of disease by patients and families before and after PCCS. Results In total, 536 non-cancer patients received PCCS from 2011 to 2019 with an average age of 70.7 years. The average duration of PCCS was 18.4 days. The distributions of age, gender, patient outcomes, family’s awareness of disease before PCCS, and patient’s awareness of disease after PCCS were significantly different among the diagnoses. Organic brain disease and Chronic kidney disease (CKD) were the most prevalent diagnoses in patients receiving PCCS in 2019. For DNR declaration, the percentage of patients signing DNR before PCCS remained high throughout the study period (92.8% in 2019). Patient outcomes varied according to the disease diagnoses. Conclusion This 9-year observational study showed that the trend of PCCS among non-cancer patients had changed over the duration of the study. An increasing number of terminally ill non-cancer patients received PCCS during late life, thereby increasing the awareness of disease for both patients and families, which would tend to better prepare terminally ill patients for end-of-life as they may consider DNR consent. Early integration of PCCS into ordinary care for terminally non-cancer patients is essential for better quality of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00879-z.
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Affiliation(s)
- Lian-Shin Lin
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ling-Hui Huang
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Chen Chang
- Technology Transfer and Incubation Center, National Health Research Institutes, Miaoli, Taiwan
| | - Chun-Li Wang
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Lung-Chun Lee
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chung-Chieh Hu
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Pi-Shan Hsu
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Min Chu
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan. .,Department of Occupational Medicine, Taichung Veterans General Hospital, Taichung, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Institue of Health Policy and Management, National Taiwan University, Taipei, Taiwan.
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Lin JL, Lipstein EA, Wittenberg E, Tay D, Lundstrom R, Lundstrom GL, Sediqzadah S, Wright DR. Intergenerational Decision Making: The Role of Family Relationships in Medical Decision Making. MDM Policy Pract 2021; 6:23814683211039468. [PMID: 34734118 PMCID: PMC8559218 DOI: 10.1177/23814683211039468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/06/2021] [Indexed: 12/12/2022] Open
Abstract
A symposium held at the 42nd annual Society for Medical Decision Making conference on October 26, 2020, focused on intergenerational decision making. The symposium covered existing research and clinical experiences using formal presentations and moderated discussion and was attended by 43 people. Presentations focused on the roles of pediatric patients in decision making, caregiver decision making for a child with complex medical needs, caregiver involvement in advanced care planning, and the inclusion of spillover effects in economic evaluations. The moderated discussion, summarized in this article, highlighted existing resources and gaps in intergenerational decision making in four areas: decision aids, economic evaluation, participant perspectives, and measures. Intergenerational decision making is an understudied and poorly understood aspect of medical decision making that requires particular attention as our society ages and technological advances provide new innovations for life-sustaining measures across all stages of the lifespan.
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Affiliation(s)
- Jody L Lin
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ellen A Lipstein
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eve Wittenberg
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Djin Tay
- College of Nursing, University of Utah, Salt Lake City, Utah
| | | | | | - Saadia Sediqzadah
- Department of Psychiatry, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Davene R Wright
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Zhang Y, Ma C, Li C, Chen Q, Shen M, Wang Y. Clinician's attitude to enteral nutrition with percutaneous endoscopic gastrostomy: a survey in China. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2021; 40:42. [PMID: 34565469 PMCID: PMC8474729 DOI: 10.1186/s41043-021-00264-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/07/2021] [Indexed: 04/19/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition. However, long-term nasogastric (NGT) feeding is still commonplace in China. We surveyed Chinese clinicians' opinions toward PEG feeding in order to identify the potential barriers to acceptancy of PEG feeding. METHODS A self-reported questionnaire was developed and distributed to 600 doctors. Five-point Likert scales were used for most responses. RESULTS Of 525 respondents, the mainly nutritional support method was NGT while PEG was less used. Doctors working in the tertiary class A hospitals and radiotherapy department were more likely to choose PEG feeding (p = 0.000). Overall, 241 (46%) participants did not know PEG and 284 (54%) have different understanding degree of PEG. Age (p = 0.002), working life (p = 0.044) and professionalism (p = 0.005) were significantly related to the understanding of PEG. Levels of agreement was high (score of 3.47) for using PEG in patients with prolonged stroke-associated dysphagia. There was high agreement level in the statement that PEG was unnecessary when NGT could sustain the basic needs of patients, though better outcome can be predicted with PEG feeding. The highest scoring factor (score of 3.91) that influenced clinicians' choice of PEG was resistance from patients and families and the second one was the poor cooperation among departments (score of 3.80). CONCLUSIONS Doctors' insufficient knowledge of PEG feeding, resistance from patients and families, poor cooperation among departments, all these factors leading physicians to prefer more conservative treatment to avoid disputes rather than better ones.
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Affiliation(s)
- Yijie Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, China
- School of Nursing, Medical College of Soochow University, No.188 Shizi St, Suzhou, China
| | - Chen Ma
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, China
| | - Chenxi Li
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, China
| | - Qian Chen
- School of Nursing, Medical College of Soochow University, No.188 Shizi St, Suzhou, China
| | - Meifen Shen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, China
| | - Yuyu Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, China
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Yang CH, Wu CY, Low JTS, Chuang YS, Huang YW, Hwang SJ, Chen PJ. Exploring the Impact of Different Types of Do-Not-Resuscitate Consent on End-of-Life Treatments among Patients with Advanced Kidney Disease: An Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8194. [PMID: 34360487 PMCID: PMC8346049 DOI: 10.3390/ijerph18158194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/27/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022]
Abstract
Background: Patients with advanced kidney disease have a symptomatic and psychological burden which warrant renal supportive care or palliative care. However, the impact of do-not-resuscitate consent type (signed by patients or surrogates) on end-of-life treatments in these patients remains unclear. Objective: We aim to identify influential factors correlated with different do-not-resuscitate consent types in patients with advanced kidney disease and the impact of do-not-resuscitate consent types on various life-prolonging treatments. Methods: This was a retrospective observational study. We included patients aged 20 years and over, diagnosed with advanced kidney disease and receiving palliative and hospice care consultation services between January 2014 and December 2018 in a tertiary teaching hospital in Taiwan. We reviewed medical records and used logistic regression to identify factors associated with do-not-resuscitate consent types and end-of-life treatments. Results: A total of 275 patients were included, in which 21% signed their do-not-resuscitate consents. A total of 233 patients were followed until death, and 32% of the decedents continued hemodialysis, 75% underwent nasogastric (NG) tube placement, and 70% took antibiotics in their final seven days of life. Do-not-resuscitate consents signed by patients were associated with reduced life-prolonging treatments including feeding tube placement and antibiotic use in the last seven days (odd ratio and 95% confidence interval were 0.16, 0.07-0.34 and 0.33, 0.16-0.69, respectively) compared to do-not-resuscitate consents signed by surrogates. Conclusions: Do-not-resuscitate consent signed by patients and not by surrogates may reflect better patients' autonomy and reduced life-prolonging treatments in the final seven days of patients with advanced kidney disease.
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Affiliation(s)
- Chiu-Hsien Yang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
| | - Chien-Yi Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
| | - Joseph T. S. Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK;
| | - Yun-Shiuan Chuang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
| | - Yu-Wen Huang
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK;
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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Ozdemir S, Ng S, Malhotra C, Teo I, Finkelstein EA. Patient-Caregiver Treatment Preference Discordance and Its Association With Caregiving Burden and Esteem. Innov Aging 2021; 5:igab020. [PMID: 34316519 PMCID: PMC8306724 DOI: 10.1093/geroni/igab020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Indexed: 11/14/2022] Open
Abstract
Background and Objectives Many patient–caregiver dyads report conflicting treatment decisions regarding preferences for life extension treatments and symptom management. It is possible that this discordance will lead to negative psychological outcomes including lowered caregiving esteem and increased caregiver burden. However, the relationships between treatment discordance among dyads and caregiver psychological outcomes are not well studied among advanced cancer patients—a gap this study aims to fill. Research Design and Methods Outcome variables included caregiver burden and caregiving esteem, measured via a modified 4-domain Caregiver Reaction Assessment Scale. The main independent variable was patient–caregiver treatment preference discordance, examined using questions adapted from an existing protocol. Analyses were conducted using multivariable regressions. Results A convenience sample of 285 patient–caregiver dyads were recruited from outpatient clinics at 2 tertiary hospitals in Singapore. The majority (60%) of patient–caregiver dyads reported discordant treatment preferences. Discordance in this study arose because caregivers wanted a balance between life extension and symptom management while patients preferred life-extending treatment. In multivariable analyses, discordance predicted caregiver burden arising from impact on caregiver schedule and health (β = 0.16, p = .07) and lack of family support (β = 0.13, p = .04). Discussion and Implications Theoretically, this study provided a more nuanced understanding of how dyad discordance may worsen the burdens felt by caregivers, and which aspects of their lives (i.e., burden due to impact of caregiver schedule and health and lack of family support) are most affected. Our findings can aid in establishing therapeutic interventions targeted toward improving communication skills and encouraging end-of-life discussions among patients, caregivers, and their health care providers. The importance of establishing and improving therapy programs specifically targeted toward caregivers was also underlined.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Sean Ng
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Irene Teo
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,National Cancer Centre Singapore, Singapore
| | - Eric A Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
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Baek SK, Kim HJ, Kwon JH, Lee HY, Won YW, Kim YJ, Baik S, Ryu H. Preparation and Practice of the Necessary Documents in Hospital for the "Act on Decision of Life-Sustaining Treatment for Patients at the End-of-Life". Cancer Res Treat 2021; 53:926-934. [PMID: 34082493 PMCID: PMC8524011 DOI: 10.4143/crt.2021.326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/01/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Six forms relating to decisions on life-sustaining treatment (LST) for patients at the end-of-life (EOL) in hospital are required by the “Act on Decision of LST for Patients at the EOL.” We investigated the preparation and creation status of these documents from the database of the National Agency for Management of LST. Materials and Methods We analyzed the contents and details of each document necessary for decisions on LST, and the creation status of forms. We defined patients completing form 1 as “self-determined” of LST, and those whose family members had completed form 11/12 as “family decision” of LST. According to the determination subject, we compared the four items of LST on form 13 (the paper of implementation of LST) and the documentation time interval between forms. Results The six forms require information about the patient, doctor, specialized doctor, family members, institution, decision for LST, and intention to use hospice services. Of 44,381 who had completed at least one document, 36,693 patients had form 13. Among them, 11,531, 10,976, and 12,551 people completed forms 1, 11, and 12, respectively. The documentation time interval from forms 1, 11, or 12 to form 13 was 8.6±13.6 days, 1.0±9.5 days, and 1.5±9.7 days, respectively. Conclusion The self-determination rate of LST was 31% and the mean time interval from self-determination to implementation of LST was 8.6 days. The creation of these forms still takes place when the patients are close to death.
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Affiliation(s)
- Sun Kyung Baek
- Division of Hematology and Oncology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Hwa Jung Kim
- Department of Preventive Medicine, Ulsan University College of Medicine, Seoul, Korea
| | - Jung Hye Kwon
- Division of Hematology and Oncology, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Chungnam, Korea
| | - Ha Yeon Lee
- Division of Hematology and Oncology, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Young-Woong Won
- Division of Hematology and Oncology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yu Jung Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sujin Baik
- Korea National Institute for Bioethics Policy, Seoul, Korea
| | - Hyewon Ryu
- Division of Hematology and Oncology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
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12
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Kuosmanen L, Hupli M, Ahtiluoto S, Haavisto E. Patient participation in shared decision-making in palliative care - an integrative review. J Clin Nurs 2021; 30:3415-3428. [PMID: 34028923 DOI: 10.1111/jocn.15866] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/28/2021] [Accepted: 05/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shared decision-making is a process where the decisions regarding patients' care are done in collaboration with the patient, the patient's family and a healthcare professional or an interdisciplinary team. Shared decision-making is considered to be a part of patient centred care, and it enables patient autonomy which is a cornerstone of palliative care. In the past, research on the experiences of palliative care patients' participation in shared decision-making involving a nurse has been limited as the focus has mainly been on specific medical interventions, rather than holistic palliative care. OBJECTIVES To synthesise research findings on patient participation in shared decision-making in palliative care. RESEARCH DESIGN An integrative literature review. METHODS The literature search was conducted by searching computerised databases (CINAHL, PubMed, PsychINFO and COCHRANE). The search resulted in 12 articles. The quality of the included articles was evaluated with JBI checklist, and the data analysis was done using inductive content analysis. Reporting was done according to a PRISMA checklist. FINDINGS Patients do participate in shared decision-making and desire to participate in everyday nursing care decisions, treatment-related medical decisions and end-of-life decisions. The prerequisites for patient participation in shared decision-making are interdisciplinary teamwork, open communication, good patient-healthcare professional relationship, a favourable environment and mutual information. CONCLUSION Palliative care patients do participate and desire to participate in decisions that cover a much broader range of topics than just medical interventions and this should be addressed in future research and in practise. The main responsibility for successful patient participation in shared decision-making lies with the healthcare professionals and the organisations providing palliative care. There is a need to conduct more research from the patient's perspective and explore the meaning of participating in shared decision-making from the patient's point of view.
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Affiliation(s)
- Lotta Kuosmanen
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Maija Hupli
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Satu Ahtiluoto
- Helsinki University Hospital, Palliative Care Center, Helsinki, Finland
| | - Elina Haavisto
- Department of Nursing Science, University of Turku, Turku, Finland.,Hospital District of Satakunta, Pori, Finland
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13
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Chung H, Harding R, Guo P. Palliative Care in the Greater China Region: A Systematic Review of Needs, Models, and Outcomes. J Pain Symptom Manage 2021; 61:585-612. [PMID: 32916261 DOI: 10.1016/j.jpainsymman.2020.08.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT There is rapidly increasing need for palliative care in Greater China because of rapidly aging populations. OBJECTIVES This study aimed to systematically review and appraise evidence for palliative care needs, models of care, interventions, and outcomes in Greater China. METHODS Four databases (MEDLINE, EMBASE, CINAHL, and PsycINFO) were searched, with hand searching of local journals and databases. Narrative synthesis was applied to the qualitative and quantitative evidence. RESULTS Nineteen qualitative studies and 47 quantitative studies were retained. With respect to care needs, nine themes were synthesized: pain control, reduced aggressive end-of-life care, truth telling, physical, emotional, and spiritual supports, and achieving preferred place of care/death. Informal caregivers expressed their needs for education and burden reduction. Health care professionals called for training and national policy support. Twenty-four studies evaluated interventions, mostly among patients with advanced cancer. Positive effects were suggested for improvements in quality of life, pain, anxiety and depression, readmission rate, and costs. Models of care evaluated were mostly specialist palliative care delivered in various settings (hospitals, residential care, and home). Outcome measures used were grouped into six categories of construct: quality of life, pain, physical assessment, psychospiritual assessment, quality of care, and implementation assessment. Limited rigorous randomized controlled trials are available to document intervention outcomes, and some problems (such as high attrition rates) reduced the strength of the evidence. CONCLUSION Palliative care services within Greater China should pay more attention to management of nonmalignant disease and to integration into primary services. Policy support is key to establishing culturally appropriate person-centered services.
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Affiliation(s)
- Huei Chung
- Department of Pharmacy, Zhongxiao Branch, Taipei City Hospital, Taipei, Taiwan
| | - Richard Harding
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Ping Guo
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK; School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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14
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Ketcher D, Thompson C, Otto AK, Reblin M, Cloyes KG, Clayton MF, Baucom BR, Ellington L. The Me in We dyadic communication intervention is feasible and acceptable among advanced cancer patients and their family caregivers. Palliat Med 2021; 35:389-396. [PMID: 33225821 PMCID: PMC8258799 DOI: 10.1177/0269216320972043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Advanced cancer affects the emotional and physical well-being of both patients and family caregivers in profound ways and is experienced both dyadically and individually. Dyadic interventions address the concerns of both members of the dyad. A critical gap exists in advanced cancer research, which is a failure of goals research and dyadic research to fully account for the reciprocal and synergistic effects of patients' and caregivers' individual perspectives, and those they share. AIM We describe the feasibility and acceptability of the Me in We dyadic intervention, which is aimed at facilitating communication and goals-sharing among caregiver and patient dyads while integrating family context and individual/shared perspectives. DESIGN Pilot study of a participant-generated goals communication intervention, guided by multiple goals theory, with 13 patient-caregiver dyads over two sessions. SETTING/PARTICIPANTS Patients with advanced cancer and their self-identified family caregivers were recruited from an academic cancer center. Dyads did not have to live together, but both had to consent to participate and all participants had to speak and read English and be at least 18 years or age. RESULTS Of those approached, 54.8% dyads agreed to participate and completed both sessions. Participants generated and openly discussed their personal and shared goals and experienced positive emotions during the sessions. CONCLUSIONS This intervention showed feasibility and acceptability using participant-generated goals as personalized points of communication for advanced cancer dyads. This model shows promise as a communication intervention for dyads in discussing and working towards individual and shared goals when facing life-limiting or end-of-life cancer.
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15
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Jin S, Kim J, Lee JY, Ko TY, Oh GM. End-of-Life Care Practice in Dying Patients after Enforcement of Act on Decisions on Life-Sustaining Treatment For Patients in Hospice and Palliative Care or at the End of Life : A Single Center Experience. HAN'GUK HOSUP'ISU WANHWA UIRYO HAKHOE CHI = THE KOREAN JOURNAL OF HOSPICE AND PALLIATIVE CARE 2020; 23:93-102. [PMID: 37497083 PMCID: PMC10332712 DOI: 10.14475/kjhpc.2020.23.2.93] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 07/28/2023]
Abstract
Purpose The Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End of Life came into force in February 2018 in Korea. This study reviews the practices of end-of-life care for patients who withdrew or withheld lifesustaining treatment at a tertiary care hospital, addresses the limitations of the law, and discusses necessary steps to promote patient-centered self-determination. Methods We retrospectively analyzed the medical records of patients who died after agreeing to withhold lifesustaining treatment in 2018 at our university hospital. The cause of death, the intensity of end-of-life care, and other characteristics were reviewed and statistically analyzed. Results Of a total of 334 patients, 231 (69%) died from cancer. The decision to stop life-sustaining treatment was made by family members for 178 patients overall (53.3%) and for 101 (43.7%) cancer patients, regardless of the patient's wishes. When the patient decided to stop lifesustaining treatment, the time from the authorization to withhold life-sustaining treatment to death was longer than when the decision was made by family members (28.7±41.3 vs 10.5±23.2 days, P<0.001). Conclusion In many cases, the decision to discontinue lifesustaining treatment was made by the family, not by the patient. In order to protect human dignity based on the patients' self-determination, it is necessary for patients to understand their disease based on careful explanations from physicians. Ongoing survey-based research will be necessary in the future.
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Affiliation(s)
- Sol Jin
- Departments of Internal medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Jehun Kim
- Departments of Pulmonology, Kosin University Gospel Hospital, Busan, Korea
| | - Jin Young Lee
- Departments of Infectious disease, Kosin University Gospel Hospital, Busan, Korea
| | - Taek Yong Ko
- Departments of Internal medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Gyu Man Oh
- Departments of Internal medicine, Kosin University Gospel Hospital, Busan, Korea
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16
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Ketcher D, Ellington L, Baucom BRW, Clayton MF, Reblin M. "In Eight Minutes We Talked More About Our Goals, Relationship, Than We Have in Years": A Pilot of Patient-Caregiver Discussions in a Neuro-Oncology Clinic. JOURNAL OF FAMILY NURSING 2020; 26:126-137. [PMID: 32475300 PMCID: PMC9119347 DOI: 10.1177/1074840720913963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Primary brain cancer is a diagnosis that can have drastic health impacts on patient and caregiver alike. In high-stress situations, dyadic coping can improve psychosocial and health outcomes and communication about personal life goals maybe one way to facilitate this coping. In this study, we describe the feasibility and accessibility of a one-time, self-directed goal discussion pilot intervention for neuro-oncology patients and their primary caregivers. Ten dyads were taken to a private room to complete a pre-discussion questionnaire, a worksheet to elicit personal goals, complete an 8-min discussion of goals, a post-discussion questionnaire, and provided open-ended feedback about the process. Post-discussion, dyads reported that the intervention was not stressful. In open-ended feedback, dyads overwhelmingly reported that the intervention was a positive experience, providing a safe, calm environment to have difficult conversations. This intervention provides a positive framework for improving communication and discussion of goals between patient-caregiver dyads.
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Huang YT, Wang YW, Chi CW, Hu WY, Lin R, Shiao CC, Tang WR. Differences in medical costs for end-of-life patients receiving traditional care and those receiving hospice care: A retrospective study. PLoS One 2020; 15:e0229176. [PMID: 32078660 PMCID: PMC7032706 DOI: 10.1371/journal.pone.0229176] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 02/02/2020] [Indexed: 12/20/2022] Open
Abstract
Background Hospice care has a positive effect on medical costs. The correlation between survival time after receiving hospice care and medical costs has not been previously investigated in the literature on Taiwan. This study aimed to compare the differences in medical costs between traditional care and hospice care among end-of-life patients with cancer. Methods Data from Taiwan’s National Health Insurance program on all patients who had passed away between 2010 and 2013 were used. Those whose year of death was between 2010 and 2013 were defined as end-of-life patients. The patients were divided into two groups: traditional care and hospice care. We then analyzed the differences in end-of-life medical cost between the two groups. Results From 2010 to 2013, the proportion of patients receiving hospice care significantly increased from 22.2% to 41.30%. In the hospice group, compared with the traditional group, the proportions of hospital stays over 14 days and deaths in a hospital were significantly higher, but the proportions of outpatient clinic visits; emergency room admissions; intensive care unit admissions; use of ventilator; use of cardiopulmonary resuscitation; and use of hemodialysis, surgery, and chemotherapy were significantly lower. Total medical costs were significantly lower. A greater number of days of survival for end-of-life patients when receiving hospice care results in higher saved medical costs. Conclusion Hospice care can effectively save a large amount of end-of-life medical costs, and more medical costs are saved when patients are referred to hospice care earlier.
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Affiliation(s)
- Ya-Ting Huang
- Department of Nursing, Camillian Saint Mary`s Hospital Luodong, Luodong, Yilan, Taiwan, R.O.C.,Saint Mary's Junior College of Medicine, Nursing and Management, Sanxing Township, Taiwan, R.O.C
| | - Ying-Wei Wang
- Health Promotion Administration, Ministry of Health and Welfare. Datong Dist., Taipei City, Taiwan, R.O.C
| | - Chou-Wen Chi
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan Dist., Taoyuan City, Taiwan, R.O.C.,College of Medicine, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan, ROC
| | - Wen-Yu Hu
- Department of Nursing College of Medicine, National Taiwan University, Taipei, Taiwan R.O.C
| | - Rung Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Guishan Dist., Taoyuan City, Taiwan, R.O.C.,Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan, ROC.,Graduate Institute of Clinical Medicine, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan, ROC
| | - Chih-Chung Shiao
- Saint Mary's Junior College of Medicine, Nursing and Management, Sanxing Township, Taiwan, R.O.C.,Division of Nephrology, Department of Internal Medicine, Camillian Saint Mary`s Hospital Luodong, Luodong, Yilan, Taiwan, R.O.C
| | - Woung-Ru Tang
- School of Nursing, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan, ROC
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Hsu TH, Li IC, Fang CK, Tang WR, Lin CT. A preliminary study of the effectiveness of cancer communication skills training for interdisciplinary staff. Jpn J Clin Oncol 2020; 49:734-742. [PMID: 31063193 DOI: 10.1093/jjco/hyz065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 02/27/2019] [Accepted: 04/16/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Studies have emphasized that the disclosure of a diagnosis and prognosis is the doctor's responsibility, but little attention has been given to the importance of interdisciplinary cooperation. OBJECTIVE Therefore, this study examined and compared the effectiveness of cancer communication skills training (CST) for doctors and interdisciplinary staff in Taiwan. METHODS This study utilized a quasi-experimental design. The participants were 124 oncology professionals who participated in cancer CST. These 124 professionals included a group of 65 doctors and a group of 59 interdisciplinary professionals, both of which received the same CST. After the participants have received CST, the changes in their disease disclosure skills were evaluated. RESULTS Significant pretest-posttest differences were observed in the overall truth-telling scores for both groups (doctors: t = 6.94, P < 0.001; interdisciplinary professionals: t = 7.71, P < 0.001) and in different constructs. However, in many items, the doctors demonstrated no progress after receiving the training (P > 0.05), whereas the interdisciplinary professionals demonstrated significant progress (P < 0.05). In particular, the doctors' scores for 'disclosing information in a monotonous tone' showed significant retrogression (P < 0.05). There were no significant differences in the overall truth-telling scores of the two groups with regard to pre- and post-CST (P > 0.05 and P > 0.05, respectively), and there were also no significant differences in the four sub-scales' scores. CONCLUSION The CST for interdisciplinary professionals improved their cooperation and communication skills.
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Affiliation(s)
- Tsui-Hsia Hsu
- School of Nursing, National Yang-Ming University, Taiwan.,Health Promotion Administration, Ministry of Health and Welfare
| | - I-Chuan Li
- School of Nursing, National Yang-Ming University, Taiwan
| | - Chun-Kai Fang
- Department of Psychiatry and Suicide Prevention Center.,Department of Medicine, Mackay Medical College, New Taipei.,Mackay Memorial Hospital, Taipei.,Taiwan Psycho-Oncology Society
| | - Woung-Ru Tang
- Taiwan Psycho-Oncology Society.,School of Nursing, College of Medicine, Chang Gung University, Taoyuan
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19
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Zivkovic T. About face: Relationalities of ageing and dying in Chinese migrant families. Soc Sci Med 2020; 291:112827. [DOI: 10.1016/j.socscimed.2020.112827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 01/20/2020] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
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20
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Chuang IF, Shyu YIL, Weng LC, Huang HL. Consistency in End-of-Life Care Preferences Between Hospitalized Elderly Patients and Their Primary Family Caregivers. Patient Prefer Adherence 2020; 14:2377-2387. [PMID: 33299304 PMCID: PMC7721293 DOI: 10.2147/ppa.s283923] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE This study explored the consistency between preferences for end-of-life care for elderly hospitalized patients and their primary caregivers and predictors of consistency. PATIENTS AND METHODS This cross-sectional correlational study recruited 100 dyads of elderly hospitalized patients and their primary caregivers from a medical center in Central Taiwan. A structural questionnaire about preferences for seven end-of-life medical treatment options involved cardiopulmonary resuscitation, intravenous therapy, nasogastric tube feeding, intensive care unit, blood transfusion, tracheotomy, and hemodialysis. RESULTS The consistency was 42.28% for preferences of end-of-life medical care between patients and caregivers. The Kappa values for seven life-sustaining medical treatments ranged from 0.001 to 0.155. Logistic regression showed that the predictors of consistency for preferences of treatment were: a patient with a signed living will (odds ratio [OR] = 6.20, p<0.01) and a male family caregiver (OR= 0.23, p<0.01) for cardiopulmonary resuscitation; a patient who visited relatives in the intensive care unit (OR= 2.94, p< 0.05) and a spouse caregiver (OR= 3.07, p< 0.05) for nasogastric tube feeding; a spouse caregiver (OR=3.12, p<0.05) and a caregiver who visited the intensive care unit (OR= 5.50, p<0.01) for tracheotomy; and a spouse caregiver (OR= 2.76, p<0.05) and a caregiver who visited the intensive care unit (OR= 4.42, p<0.05) for hemodialysis. CONCLUSION End-of-life medical treatment preferences were inconsistent between patients and family caregivers, which might be influenced by Asian culture, the nature of the relationship and individual experiences. Implementation of advance care planning that respects the patient's autonomy and preferences about end-of-life care is recommended.
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Affiliation(s)
- I-Fei Chuang
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yea-Ing Lotus Shyu
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Healthy Aging Research Center, Chang Gung University, TaoyuanCity, Taiwan
- Traumatological Division, Department of Orthopedics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Li-Chueh Weng
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Hsiu-Li Huang
- Department of Long-TermCare, College of Health Technology, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- Correspondence: Hsiu-Li Huang No. 83-1, Nei-Chiang St, Wan-Hwa Dist, Taipei10845, TaiwanTel +886-2-28227101 Ext. 6134Fax +886-2-23891464 Email
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Huang YL, Yates P, Thorberg FA, Wu CJ(J. Adults’ perspectives on cultural, social and professional support on end-of-life preferences. Collegian 2019. [DOI: 10.1016/j.colegn.2019.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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22
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Kim J, Heo S, Kim MY, Park EY, Seo EJ, Lee MO, Jeong BY, Lee JA. Correlates of life-support treatment preferences among low-income home-based cancer management recipients. Eur J Oncol Nurs 2019; 43:101665. [PMID: 31590070 DOI: 10.1016/j.ejon.2019.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To examine the correlates of life-support treatment (LST) preferences from attitudes toward advance directives (ADs), perceived susceptibility, symptom frequency, symptom burden, and global health among low-income community-dwelling cancer management recipients, controlling for age, sex, education, and duration after cancer diagnosis. METHODS A cross-sectional, correlational study design was used to assess LST preferences and correlates. Data were collected from low-income cancer survivors during nurses' home visits. RESULTS Survivors who had mostly solid cancer participated (N = 107, mean age = 67.39 ± 11.57 years, 32.7% males). Hospice care was the most desired (66.4%), while aggressive treatments were less preferred: cardiopulmonary resuscitation (15.9%), ventilation support (15.0%), hemodialysis (18.7%), or chemotherapy (12.1%). Higher symptom frequency was associated with a greater likelihood of preferring all aggressive treatments (odds ratios = 1.44-1.75). In addition, longer cancer duration was associated with a greater likelihood of preferring ventilation support; females had a lesser likelihood of preferring hemodialysis and chemotherapy. Higher education was associated with a lesser likelihood of preferring chemotherapy. More positive attitudes (B = 0.15, p = .001) were associated with a greater likelihood of preferring hospice care, and greater symptom burden of pain (B = -0.03, p = .047) was associated with a lesser likelihood. CONCLUSION Results support the feasibility of incorporating ADs into cancer management among community-dwelling cancer survivors, with consideration of AD attitudes and symptom monitoring. An integration of AD discussion into the home visiting service could be a liaison for the quality and continuity of cancer survivorship care that guides and manages patients' survivorship issues.
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Affiliation(s)
- JinShil Kim
- Gachon University, College of Nursing, 191 Hambakmeoro, Yeonsu-gu, Incheon, 21936, South Korea.
| | - Seongkum Heo
- Mercer University, Georgia Baptist College of Nursing, 3001 Mercer University Drive, Atlanta, 30341, USA.
| | - Mi Yeong Kim
- Gachon University Gil Medical Center, 21, Namdong-daero, 774beon-gil, Namdong-gu, Incheon, 21565, South Korea.
| | - Eun Young Park
- Gachon University, College of Nursing, 191 Hambakmeoro, Yeonsu-gu, Incheon, 21936, South Korea.
| | - Eun Ju Seo
- National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, South Korea.
| | - Mee Ok Lee
- Gachon University Gil Medical Center, 21, Namdong-daero, 774beon-gil, Namdong-gu, Incheon, 21565, South Korea.
| | - Bo Yoon Jeong
- National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, South Korea.
| | - Jung-Ah Lee
- University of California, Irvine, Sue and Bill Gross School of Nursing, Irvine, CA, 92697, USA.
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23
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George LS, Breitbart W, Prigerson HG. "My Family Wants Something Different": Discordance in Perceived Personal and Family Treatment Preference and Its Association With Do-Not-Resuscitate Order Placement. J Oncol Pract 2019; 15:e942-e947. [PMID: 31509484 DOI: 10.1200/jop.19.00250] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients make treatment decisions based not only on what they want, but what they think their families want. Discordance in such perceived preferences may therefore pose challenges for advance care planning. This study examines discordance in preference for life-extending care versus comfort-focused care and its association with do-not-resuscitate (DNR) order placement. METHODS One hundred eighty-nine patients with advanced cancers refractory to at least one chemotherapy regimen were enrolled in a multisite observational study. In structured interviews, patients reported their preference for treatment maximizing either life extension or comfort; patients also indicated their perception of their families' preference. DNR placement was reported by patients and verified using medical records. RESULTS Approximately 23% of patients (n = 43) perceived discordance between their preference and their families' preference. Patients who perceived discordance were less likely to have completed a DNR compared with those who perceived concordance, even after controlling for relevant confounds (odds ratio = .35; P = .02). Subgroups of discordance and concordance showed varying DNR placement rates (χ2, 19.95; P < .001). DNR placement rate was lowest among discordant subgroups, where there was either a personal (26.7%; four of 15) or family preference for comfort care (28.6%; eight of 28), followed by patients who perceived concordance for wanting life-extending care (34.5%; 29 of 84) and by patients who perceived concordance in wanting comfort-focused care (66.1%; 41 of 62). CONCLUSION Many patients may perceive discordance between personal and family treatment preferences, posing impediments to advance care planning. Such patients may benefit from additional decision support.
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24
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Morgan DJR, Eng D, Higgs D, Beilin M, Bulsara C, Wong M, Angus L, Waldron N. Advance care planning documentation strategies; goals-of-care as an alternative to not-for-resuscitation in medical and oncology patients. A pre-post controlled study on quantifiable outcomes. Intern Med J 2019; 48:1472-1480. [PMID: 30043464 DOI: 10.1111/imj.14048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/09/2018] [Accepted: 07/11/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Health services in Tasmania, Victoria and now Western Australia are changing to goals-of-care (GOC) advance care planning (ACP) documentation strategies. AIM To compare the clinical impact of two different health department-sanctioned ACP documentation strategies. METHODS A non-blinded, pre-post, controlled study over two corresponding 6-month periods in 2016 and 2017 comparing the current discretional not-for-resuscitation (NFR) with a new, inclusive GOC strategy in two medical/oncology wards at a large private hospital. Main outcomes were the uptake of ACP forms per hospitalisation and the timing between hospital admission, ACP form completion and in-patient death. Secondary outcomes included utilisation of the rapid response team (RRT), palliative and critical care services. RESULTS In total, 650 NFR and 653 GOC patients underwent 1885 admissions (mean Charlson Comorbidity Index = 3.7). GOC patients had a higher uptake of ACP documentation (346 vs 150 ACP forms per 1000 admissions, P < 0.0001) and a higher proportion of ACP forms completed within the first 48 h of admission (58 vs 39%, P = 0.0002) but a higher incidence of altering the initial ACP level of care (P = 0.003). All other measures, including ACP documentation within 48 h of death (P = 0.50), activation of RRT (P = 0.73) and admission to critical (P = 0.62) or palliative (P = 0.81) care services, remained similar. GOC documentation was often incomplete, with most sub-sections left blank between 74 and 87% of occasions. CONCLUSION Despite an increased uptake of the GOC form, overall use remained low, written completion was poor, and most quantitative outcomes remained statistically unchanged. Further research is required before a wider GOC implementation can be supported in Australia's healthcare systems.
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Affiliation(s)
- David J R Morgan
- Department of Intensive Care Medicine, St John of God Subiaco Hospital, Western Australia, Australia
| | - Derek Eng
- Department of Palliative Care Medicine, St John of God Subiaco Hospital, Western Australia, Australia
| | - Dominic Higgs
- Department of Palliative Care Medicine, St John of God Subiaco Hospital, Western Australia, Australia.,Department of Oncology, St John of God Subiaco Hospital, Western Australia, Australia
| | - Maria Beilin
- Department of Research, St John of God Subiaco Hospital, Western Australia, Australia
| | - Caroline Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Milly Wong
- Internal Medicine, St John of God Subiaco Hospital, Western Australia, Australia
| | - Louise Angus
- Department of Palliative Care Medicine, St John of God Subiaco Hospital, Western Australia, Australia
| | - Nicholas Waldron
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Australia.,Health Strategy and Networks, System Policy and Planning, Department of Health, Government of Western Australia, Perth, Australia.,School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
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25
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Hammami MM, Abuhdeeb K, Hammami MB, De Padua SJS, Al-Balkhi A. Prediction of life-story narrative for end-of-life surrogate's decision-making is inadequate: a Q-methodology study. BMC Med Ethics 2019; 20:28. [PMID: 31053127 PMCID: PMC6500001 DOI: 10.1186/s12910-019-0368-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/18/2019] [Indexed: 11/29/2022] Open
Abstract
Background Substituted judgment assumes adequate knowledge of patient’s mind-set. However, surrogates’ prediction of individual healthcare decisions is often inadequate and may be based on shared background rather than patient-specific knowledge. It is not known whether surrogate’s prediction of patient’s integrative life-story narrative is better. Methods Respondents in 90 family pairs (30 husband-wife, 30 parent-child, 30 sibling-sibling) rank-ordered 47 end-of-life statements as life-story narrative measure (Q-sort) and completed instruments on decision-control preference and healthcare-outcomes acceptability as control measures, from respondent’s view (respondent-personal) and predicted pair’s view (respondent-surrogate). They also scored their confidence in surrogate’s decision-making (0 to 4 = maximum) and familiarity with pair’s healthcare-preferences (1 to 4 = maximum). Life-story narratives’ prediction was examined by calculating correlation of statements’ ranking scores between respondent-personal and respondent-surrogate Q-sorts (projection) and between respondent-surrogate and pair-personal Q-sorts before (simulation) and after controlling for correlation with respondent-personal scores (adjusted-simulation), and by comparing percentages of respondent-surrogate Q-sorts co-loading with pair-personal vs. respondent-personal Q-sorts. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was determined by percent concordance. Results were compared among subgroups defined by intra-pair relationship, surrogate’s decision-making confidence, and healthcare-preferences familiarity. Results Mean (SD) age was 35.4 (10.3) years, 69% were females, and 73 and 80% reported ≥ very good health and life-quality, respectively. Mean surrogate’s decision-making confidence score was 3.35 (0.58) and 75% were ≥ familiar with pair’s healthcare-preferences. Mean (95% confidence interval) projection, simulation, and adjusted-simulation correlations were 0.68 (0.67–0.69), 0.42 (0.40–0.44), and 0.26 (0.24–0.28), respectively. Out of 180 respondent-surrogate Q-sorts, 24, 9, and 32% co-loaded with respondent-personal, pair-personal, or both Q-sorts, respectively. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was 47 and 52%, respectively. Surrogate’s decision-making confidence score correlated with adjusted-simulation’s correlation score (rho = 0.18, p = 0.01). There were significant differences among the husband-wife, parent-child, and sibling-sibling subgroups in percentage of respondent-surrogate Q-sorts co-loading with pair-personal Q-sorts (38, 32, 55%, respectively, p = 0.03) and percent agreement on healthcare-outcomes acceptability (55, 35, and 67%, respectively, p = 0.002). Conclusions Despite high self-reported surrogate’s decision-making confidence and healthcare-preferences familiarity, family surrogates are variably inadequate in simulating life-story narratives. Simulation accuracy may not follow the next-of-kin concept and is 38% based on shared background. Electronic supplementary material The online version of this article (10.1186/s12910-019-0368-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia. .,Alfaisal University College of Medicine, Riyadh, Saudi Arabia.
| | - Kafa Abuhdeeb
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
| | | | - Sophia J S De Padua
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
| | - Areej Al-Balkhi
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
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26
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Ozdemir S, Jafar TH, Choong LHL, Finkelstein EA. Family dynamics in a multi-ethnic Asian society: comparison of elderly CKD patients and their family caregivers experience with medical decision making for managing end stage kidney disease. BMC Nephrol 2019; 20:73. [PMID: 30823872 PMCID: PMC6397496 DOI: 10.1186/s12882-019-1259-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/18/2019] [Indexed: 12/02/2022] Open
Abstract
Background Elderly end stage kidney patients face a decision concerning whether or not to initiate dialysis. In Asia, this decision is highly influenced by family caregivers. The objective of this paper was to understand patients’ experience with and preferences for family involvement in treatment decisions, and via a series of hypothetical vignettes, to identify whether there was discordance in treatment preferences between patients and their caregivers, and how any potential conflicts were reconciled. Methods We conducted a survey with 151 elderly (aged ≥65) chronic kidney disease patients and their caregivers at outpatient renal clinics. The survey asked, when making treatment decisions, whom they wish makes the final decisions (i.e., preference) and who usually makes the final decisions (i.e., experience). The survey also presented a series of choice vignettes for managing patient’s condition and asked respondents to choose between two hypothetical treatment profiles in each vignette. Patients and caregivers were first interviewed separately in tandem, and then were brought together to choose a treatment jointly for vignettes where the initial treatment choice differed within the dyad. We used multivariate regressions to investigate the predictors of discordance and reconciliation. Results We found that most (51%) patients preferred and experienced (64%) significant involvement from caregivers. However, 38% of patients preferred to make final decisions alone but only 27% of patients did. In the hypothetical vignettes, caregivers chose the more intensive option (i.e., dialysis) more than patients did (26% vs 19%; p < 0.01). Overall, 44% of the dyads had discordance in at least 3 vignettes, and the odds of discordance within patient-caregiver dyads was higher when caregivers chose dialysis or treatment with the higher cost (p < 0.01). In half the cases, discordance resolved in the patients’ favor, and this was more likely to be the case if the patient was employed and wanted to be in charge of final decisions (p < 0.01). Conclusions Our results highlight the important role of caregivers in decision-making but also the potential for them to overstep. Clinicians should be aware of this challenge and identify strategies that minimize the chances that patients may receive treatments not consistent with their preferences. Electronic supplementary material The online version of this article (10.1186/s12882-019-1259-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,Programme in Health Services and Systems Research Programme, Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857, Singapore
| | - Tazeen H Jafar
- Programme in Health Services and Systems Research Programme, Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857, Singapore
| | - Lina Hui Lin Choong
- Department of Renal Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore. .,Programme in Health Services and Systems Research Programme, Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857, Singapore.
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27
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Kim K, Heinze K, Xu J, Kurtz M, Park H, Foradori M, Nolan MT. Theories of Health Care Decision Making at the End of Life: A Meta-Ethnography. West J Nurs Res 2018; 40:1861-1884. [PMID: 28816094 PMCID: PMC6474239 DOI: 10.1177/0193945917723010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The aim of this meta-ethnography is to appraise the types and uses of theories relative to end-of-life decision making and to develop a conceptual framework to describe end-of-life decision making among patients with advanced cancers, heart failure, and amyotrophic lateral sclerosis (ALS) and their caregivers or providers. We used PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases to extract English-language articles published between January 2002 and April 2015. Forty-three articles were included. The most common theories included decision-making models ( n = 14) followed by family-centered ( n = 11) and behavioral change models ( n = 7). A conceptual framework was developed using themes including context of decision making, communication and negotiation of decision making, characteristics of decision makers, goals of decision making, options and alternatives, and outcomes. Future research should enhance and apply these theories to guide research to develop patient-centered decision-making programs that facilitate informed and shared decision making at the end of life among patients with advanced illness and their caregivers.
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Affiliation(s)
| | | | - Jiayun Xu
- University of Utah, Salt Lake City, USA
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28
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Hu X, Peng X, Su Y, Huang W. Caregiver burden among Chinese family caregivers of patients with lung cancer: A cross-sectional survey. Eur J Oncol Nurs 2018; 37:74-80. [DOI: 10.1016/j.ejon.2018.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 09/14/2018] [Accepted: 11/02/2018] [Indexed: 01/28/2023]
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29
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Chan HYL, Ng JSC, Chan KS, Ko PS, Leung DYP, Chan CWH, Chan LN, Lee IFK, Lee DTF. Effects of a nurse-led post-discharge advance care planning programme for community-dwelling patients nearing the end of life and their family members: A randomised controlled trial. Int J Nurs Stud 2018; 87:26-33. [PMID: 30048916 DOI: 10.1016/j.ijnurstu.2018.07.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/13/2018] [Accepted: 07/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although evidence increasingly demonstrates the effects of advance care planning, the relevant studies are of questionable quality, and lack consensus regarding when and with whom to initiate the conversation. OBJECTIVE To examine the effects of a structured, nurse-led post-discharge advance care planning programme on congruence between the end-of-life care preferences of the patient and family members, decisional conflicts and the documentation of care preferences. DESIGN A two-arm parallel-group randomised controlled trial. PARTICIPANTS A total of 230 dyads comprising community-dwelling patients screened by the Gold Standards Framework Prognostic Indicator Guidance and their designated family members. METHODS Patients in the experimental group participated in a structured advance care planning programme administered by a trained nurse during three weekly home visits following hospital discharge. In contrast, the post-discharge home visits provided to the control group focused on self-care management as attention control. The study outcomes were the dyadic congruence regarding end-of-life care preferences, the patients' level of decisional conflict regarding end-of-life decision-making and the documentation of these preferences at baseline and 1 and 6 months after enrolment. Generalised estimating equation models were used to compare changes in the outcomes between the groups across time. RESULTS At baseline, few participants had ever heard of advance directives (12/460, 2.6%) and few patients had ever discussed end-of-life issues with family members (34/230, 14.8%). After six months, the experimental group exhibited a greater increase in dyadic congruence regarding various end-of-life care preferences than the control group (Ps < 0.04). The experimental group also exhibited a greater improvement in decisional conflict at 6 months relative to the control group (P = 0.003). However, the groups did not differ significantly in terms of changes in any outcomes after one month. The experimental group had significantly higher rates of completion of advance directives and electronic medical record documentation of do-not-attempt cardiopulmonary resuscitation orders than the control group. CONCLUSIONS This study showed that a nurse-led structured advance care planning programme could effectively improve dyadic congruence regarding end-of-life care preferences, reduce patients' decisional conflict and increase the documentation of care preferences. The findings underscored the importance of supporting nurses to introduce advance care planning at an earlier time that enable patients with sufficient time to contemplate end-of-life issues, empower patients to deliberate their choices and engage patients and their family members in open discussion.
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Affiliation(s)
- Helen Yue-Lai Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong.
| | | | | | | | | | - Carmen Wing-Han Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong
| | | | - Iris Fung-Kam Lee
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong
| | - Diana Tze-Fan Lee
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong
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30
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Chen TR, Hu WY, Chiu TY, Kuo HP. Differences between COPD patients and their families regarding willingness toward life-sustaining treatments. J Formos Med Assoc 2018; 118:414-419. [PMID: 30031601 DOI: 10.1016/j.jfma.2018.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/14/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND/PURPOSE Patients with chronic obstructive pulmonary disease (COPD) receive more life-sustaining treatments (LSTs) than those with other diseases. The aims of this study were to explore the willingness of COPD patients and their families to consent to LSTs and compare the differences between their levels of willingness. METHODS A cross-sectional survey was conducted, and structured questionnaires were used for data collection. RESULTS A total of 219 valid samples were collected, including 109 patients and 110 families. Sixty percent of family members indicated that they did not know the intentions of the patient. Families were significantly more willing for patients to receive LSTs than the patients themselves. The level of willingness of patients and families varied according to the situation and LST interventions. When patients were in a vegetative state or medical treatments were futile, the willingness of COPD patients and their families to receive LSTs significantly decreased. Endotracheal intubation and external defibrillation were the least likely to be requested, whereas the willingness to receive medication injections and noninvasive ventilation was greatest. CONCLUSION Communication between families and patients on the issue of LST should be facilitated. Adequate information on the patient's condition and possible LSTs should be provided to avoid COPD patients receiving inappropriate LSTs.
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Affiliation(s)
- Ting-Ru Chen
- Department of Nursing, Chang Gung University of Science and Technology, Taiwan; Department of Nursing, College of Medicine, National Taiwan University, Taiwan
| | - Wen-Yu Hu
- Department of Nursing, College of Medicine, National Taiwan University, Taiwan.
| | - Tai-Yuan Chiu
- Department of Family, National Taiwan University Hospital, Taiwan
| | - Han-Pin Kuo
- College of Medicine, Taipei Medical University, Taiwan
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31
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Miaris N, Samantas E, Siafaka I, Logothetis E, Iacovidou N, Chalkias A, Xanthos T. Views of cancer patients regarding cardiopulmonary resuscitation in Greece. Eur J Cancer Care (Engl) 2018; 27:e12850. [PMID: 29672984 DOI: 10.1111/ecc.12850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 11/28/2022]
Abstract
Cardiopulmonary resuscitation (CPR) in patients with cancer is an ethical issue of worldwide interest. A questionnaire-based study was carried out in a Greek oncology hospital aiming to explore the attitude of Greek cancer patients towards CPR. Overall, 200 patients (94 male, 106 female) of a mean age of 62.8 years took part in the study. Only 42 (21%) patients indicated that they knew what CPR really involves and only 20 (10%) patients thought that CPR has serious side effects, while the mean estimated in-hospital CPR survival rate to hospital discharge was 56.6% (minimum = 2%, maximum = 99%, standard deviation [SD] = 25.16) and 42.1% (minimum = 0%, maximum = 90%, SD = 24.56%) in case of unselected and cancer patients respectively. Despite their poor knowledge, 177 (88.5%) patients were willing to undergo CPR in case of an in-hospital arrest, 127 (63.5%) thought that they had the right to choose their CPR status and 141 (70.5%) believed that they should be asked about it when they enter the hospital. Most patients (36%) wanted their CPR status to be decided by themselves, their family and their doctor jointly. These findings indicate that specific measures should be applied to clinical practice in order to best manage this ethical issue, and consequently, improve cancer care.
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Affiliation(s)
- N Miaris
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Third Department of Medical Oncology, "Agioi Anargyroi" General Oncology Hospital of Kifisia, Athens, Greece.,Department of Cardiology, "Tzaneio" General Hospital of Piraeus, Piraeus, Greece
| | - E Samantas
- Third Department of Medical Oncology, "Agioi Anargyroi" General Oncology Hospital of Kifisia, Athens, Greece
| | - I Siafaka
- Pain Relief and Palliative Care Unit, Department of Anesthesiology and Pain Therapy, First Anesthesiology Clinic, Medical School, Aretaieio University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - E Logothetis
- Department of Biopathology, Aretaieio University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - N Iacovidou
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neonatology, Aretaieio University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - A Chalkias
- Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - T Xanthos
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.,Medical School, European University Cyprus, Nicosia, Cyprus
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32
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Applebaum AJ, Buda K, Kryza-Lacombe M, Buthorn JJ, Walker R, Shaffer KM, D'Agostino TA, Diamond EL. Prognostic awareness and communication preferences among caregivers of patients with malignant glioma. Psychooncology 2017; 27:817-823. [PMID: 29125714 DOI: 10.1002/pon.4581] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/28/2017] [Accepted: 10/27/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Malignant glioma (MG) is a devastating neuro-oncologic disease with almost invariably poor prognosis, yet many families facing malignant glioma have poor prognostic awareness (PA), or the awareness of the patient's incurable disease and shortened life expectancy. Accurate PA is associated with favorable medical outcomes at end-of-life for patients and psychosocial outcomes for informal caregivers (ICs) through bereavement. To date, however, no study has specifically examined PA among MG ICs and the information they receive that shapes their awareness. METHODS Thirty-two ICs of patients with malignant glioma completed a semi-structured assessment of their awareness of the incurability and life expectancy of their loved one's illness, and to understand their sources of prognostic information and preferences for communication of prognostic information. RESULTS Twenty-two (69%) ICs had full PA-awareness of the incurability of malignant glioma and accurate estimates of their loved ones' life expectancy. Twenty-three (72%) felt that prognostic information was extremely or very important to possess, and 16 (50%) desired more prognostic information. The majority of ICs received prognostic information from physicians and the Internet. Qualitative analyses revealed that many ICs had difficulty navigating medical encounters in which they concurrently wanted to elicit prognostic information from physicians and protect patients from such information. CONCLUSIONS Accurate and timely PA is necessary for ICs to serve as critical members of health care teams. Interventions are needed to foster ICs' skills in navigating prognostic communication with patients and health care providers and thereby improve their ability to advocate for their loved one's wishes.
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Affiliation(s)
- A J Applebaum
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - K Buda
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - M Kryza-Lacombe
- San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, CA, USA
| | - J J Buthorn
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - R Walker
- Skidmore College, Saratoga Springs, NY, USA
| | - K M Shaffer
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - T A D'Agostino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - E L Diamond
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Center for Research on End of Life Care, Weill Cornell Medical College, New York, NY, USA
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Patient-family EoL communication and its predictors: Reports from caregivers of Latino patients in the rural U.S.-Mexico border region. Palliat Support Care 2017; 16:520-527. [PMID: 29072148 DOI: 10.1017/s147895151700092x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Family caregivers play an important role in end-of-life (EoL) decision making when the patient is unable to make his/her own decisions. While communication about EoL care between patients and family is perhaps a first step toward advance care planning (ACP)/EoL decisions, not every culture puts great value on open communication about this topic. The aims of the present study were to explore EoL communication and the aspects of communication among caregivers of Latino patients in the rural United States (U.S.)-Mexico border region. METHOD This study analyzed data from a hospice needs assessment collected from 189 family caregivers of Latino patients at a home health agency in a rural U.S.-Mexico border region. Bivariate tests and logistic regression were used to address our aims. RESULTS About half of the family caregivers (n = 96, 50.8%) reported to have ever engaged in EoL discussion with patients. Significant predictors of EoL discussion included life-sustaining treatment preference (odds ratio [OR] = 0.44, p < 0.05); knowledge of an advance directive (AD) (OR = 5.50, p < 0.01); and distrust of physicians (OR = 0.29, p < 0.01). Caregivers who preferred extending the life of their loved one even if he/she had to rely on life supports were less likely to engage in EoL communication. Also, caregivers who worried that physicians might want to stop treatments (i.e., "pull the plug") too soon were less likely to do so. Conversely, caregivers who had knowledge about ADs were more likely to engage in EoL communication. SIGNIFICANCE OF RESULTS EoL communication is a complex process influenced by individual, social, and cultural values and the beliefs of both the patient and his/her family. Inclusion of family caregivers in the ACP process and facilitating culturally tailored EoL communication between patients and family caregivers is important.
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Determinants of Receiving Palliative Care and Ventilator Withdrawal Among Patients With Prolonged Mechanical Ventilation. Crit Care Med 2017; 45:1625-1634. [PMID: 28658025 DOI: 10.1097/ccm.0000000000002569] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Increasing numbers of patients with prolonged mechanical ventilation generates a tremendous strain on healthcare systems. Patients with prolonged mechanical ventilation suffer from long-term poor quality of life. However, no study has ever explored the willingness to receive palliative care or terminal withdrawal and the factors influencing willingness. DESIGN Cross-sectional study. SETTING Five different hospitals of Taipei City Hospital system. PATIENTS Adult patients with ventilatory support for more than 60 days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified the family members of 145 consecutive patients with prolonged mechanical ventilation in five hospitals of Taipei City Hospital system and enrolled family members for 106 patients (73.1%). We collected information from patient families' regarding concepts (knowledge, attitude, and experiences) of palliative care, caregiver burden, family function, patient quality of life, and physician-family communications. From the medical record, we obtained duration of hospitalization, consciousness level, disease severity, medical cost, and the presence of do-not-resuscitate orders. The vast majority of family members agreed with the concept of palliative care (90.4%) with 17.3% of the family members agreeing to ventilator withdrawal currently and 67.5% terminally in anticipation of death. Approximately half of the family members regretted having chosen prolonged mechanical ventilation (56.7%). Reduced patient quality of life and increased family understanding of palliative care significantly associated with increased caregiver willingness to endorse palliative care and withdraw life-sustaining agents in anticipation of death. Longer duration of ventilator usage and hospitalization was associated with increased feelings of regret about choosing prolonged mechanical ventilation. CONCLUSIONS During prolonged mechanical ventilation, physicians should thoroughly discuss its benefits and burdens. Families should be given the opportunity to discuss the circumstances under which they might request the implementation of palliative care or withdrawal of mechanical ventilation in order to avoid prolonging the dying process.
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Liu TW, Wen FH, Wang CH, Hong RL, Chow JM, Chen JS, Chiu CF, Tang ST. Terminally Ill Taiwanese Cancer Patients' and Family Caregivers' Agreement on Patterns of Life-Sustaining Treatment Preferences Is Poor to Fair and Declines Over a Decade: Results From Two Independent Cross-Sectional Studies. J Pain Symptom Manage 2017; 54:35-45.e4. [PMID: 28450219 DOI: 10.1016/j.jpainsymman.2017.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/16/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT/OBJECTIVE Temporal changes have not been examined in patient-caregiver agreement on life-sustaining treatment (LST) preferences at end of life (EOL). We explored the extent of and changes in patient-caregiver agreement on LST-preference patterns for two independent cohorts of Taiwanese cancer patient-family caregiver dyads recruited a decade apart. METHODS We surveyed preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis among 1049 and 1901 dyads in 2003-2004 and 2011-2012, respectively. LST-preference patterns were examined by multi-group latent class analysis. Extent of patient-caregiver agreement on LST-preference patterns was determined by percentage agreement and kappa coefficients. RESULTS For both patients and family caregivers, we identified seven distinct LST-preference classes. Patient-caregiver agreement on LST-preference patterns was poor to fair across both study cohorts, indicated by 24.4%-43.5% agreement and kappa values of 0.06 (95% CI: 0.04, 0.09) to 0.27 (0.23, 0.30), and declined significantly over time. Agreement on LST-preference patterns was most likely when both patients and caregivers uniformly rejected LSTs. When patients disagreed with caregivers on LST-preference patterns, discrepancies were most likely when patients totally rejected LSTs but caregivers uniformly preferred LSTs or preferred nutritional support but rejected other treatments. CONCLUSION Patients and family caregivers had poor-to-fair agreement on LST-preference patterns, and agreement declined significantly over a decade. Encouraging an open dialogue between patients and their family caregivers about desired EOL care would facilitate patient-caregiver agreement on LST-preference patterns, thus honoring terminally ill cancer patients' wishes when they cannot make EOL-care decisions.
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Affiliation(s)
- Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Cheng-Hsu Wang
- Division of Hematology-Oncology and Director of Cancer Center, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Ruey-Long Hong
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jyh-Ming Chow
- Section of Hematology and Medical Oncology, Wan-Fang Hospital, Taipei, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center, China Medical University Hospital, Taichung, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan.
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Do cancer patients with dementia receive less aggressive treatment in end-of-life care? A nationwide population-based cohort study. Oncotarget 2017; 8:63596-63604. [PMID: 28969014 PMCID: PMC5609946 DOI: 10.18632/oncotarget.18867] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 06/02/2017] [Indexed: 12/31/2022] Open
Abstract
Dementia is a progressive, incurable disease that can deprive patients of the ability to make decisions. This study determines whether dementia influences the medical care that a cancer patient receives at the end of life. We conducted a nationwide population-based cohort study on patients aged ≥20 with newly diagnosed cancer during 2000–2012. After matching to reduce confounders, there were 7,111 patients with and 28,444 without dementia. The adjusted odd ratios (OR) for medical interventions, including intensive care, palliative care, invasive procedures, and advanced diagnostic testing, were calculated for the final month and three months of life by a multiple logistic regression model. In the final month before death, the dementia cohort had longer hospital stays (17.7 vs. 17.1 days), more intensive care unit stays (OR = 1.32), and less palliative care (OR = 0.80) than the non-dementia cohort and were more likely to receive invasive procedures, including cardiopulmonary resuscitation (OR = 1.32), endotracheal intubation (OR = 1.27), mechanical ventilation (OR = 1.45), urinary catheterization (OR = 1.24), and feeding tube (OR = 1.88), but less likely to undergo chemotherapy (OR = 0.60) and diagnostic procedures such as computed tomography, magnetic resonance imaging, and sonography (OR = 0.87) or bone scan (OR = 0.69). The analysis examining the three months before death had similar results. In summary, patients with cancer and dementia are more likely to receive intensive care and invasive procedures but less likely to undergo advanced diagnostic testing, chemotherapy, or hospice care than those with cancer but without dementia.
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Ohr S, Jeong S, Saul P. Cultural and religious beliefs and values, and their impact on preferences for end-of-life care among four ethnic groups of community-dwelling older persons. J Clin Nurs 2017; 26:1681-1689. [DOI: 10.1111/jocn.13572] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Seok Ohr
- Multicultural Health Service; Hunter New England Local Health District (HNELHD); Newcastle NSW Australia
| | - Sarah Jeong
- The School of Nursing & Midwifery; The University of Newcastle; Ourimbah NSW Australia
| | - Peter Saul
- John Hunter Hospital; New Lambton Heights NSW Australia
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Malhotra C, Xiang L, Ozdemir S, Kanesvaran R, Chan N, Finkelstein EA. A comparison of attitudes toward length and quality of life between community-dwelling older adults and patients with advanced cancer. Psychooncology 2017; 26:1611-1617. [PMID: 27943487 DOI: 10.1002/pon.4344] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 11/01/2016] [Accepted: 12/05/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Applying prospect theory to end-of-life decision making, we hypothesize that community-dwelling older adults (CDOAs) will be relatively less inclined towards extending length over improving quality of life compared with patients. We also hypothesize that differences in relative inclination for length over quality of life between the 2 groups will decrease with advancing age. METHODS We tested these hypotheses by administering the quality-quantity questionnaire to 1067 CDOAs and 320 stage IV cancer patients and applying a linear regression model to assess whether relative inclination for length over quality of life, as estimated by the questionnaire, differed between CDOAs and patients after controlling for differences in sociodemographic characteristics. We also assessed the effect of interaction between age and participant status (CDOA compared to patient) on relative inclination for length over quality of life. RESULTS Consistent with prospect theory, a lower proportion of CDOAs (26%) than patients (42%) were relatively more inclined towards length over quality of life. Results were significant even after adjusting for differences in sociodemographics (P < .01). With increasing age, the difference in relative inclination between CDOAs and patients increased (P = .01). CONCLUSIONS Findings indicate that attitudes towards length and quality of life differ by life stage. This has implications for end-of-life care decisions made by CDOAs, such as purchasing health or disability insurance and signing advance directives or care plans.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Ling Xiang
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | | | - Noreen Chan
- National University Cancer Institute, Singapore
| | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
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End-of-life care decisions using a Korean advance directive among cancer patient–caregiver dyads. Palliat Support Care 2016; 15:77-87. [DOI: 10.1017/s1478951516000808] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
ABSTRACTObjective:The Korean advance directive (K–AD) comprises a value statement, treatment directives, preferences for cardiopulmonary resuscitation (CPR), artificial ventilation, tube feeding, and hospice care, as well as a proxy appointment. The K–AD can facilitate a patient's decision making with respect to end-of-life (EoL) care. The present study aimed to examine the extent to which patient–caregiver dyads would use the K–AD and agree on EoL care decisions.Methods:Using a descriptive study design, 81 cancer patients were invited to participate. The final sample consisted of 44 patient–caregiver dyads who completed survey questionnaires, including the K–AD. One patient did not complete all parts of the questionnaire, and 36 (44.4%) declined to participate. Content analysis was conducted to examine the K–AD value statements. Cohen's kappa coefficient was calculated to determine the degree of patient–caregiver dyadic agreement on K–AD treatment directives (Sudore & Fried, 2010).Results:Our patient participants had the following cancer diagnoses: colorectal 29.5%, breast 29.5%, and liver/biliary tract cancers, 15.9%. Half of the sample had advanced-stage disease. Spouses (70.5%) or adult children (20.4%) were the primary caregivers, with perceived bonding rated as fair (31.8%) or good (65.9%). Rejection of the K–AD was mainly due to the difficulty involved in deciding on EoL care (50%). Comfort while dying was the most common theme expressed by patients (73.8%) and caregivers (66.7%). In terms of treatment directives, dyads advocated for hospice care (66.7%) and reduced support for aggressive treatments of CPR or artificial ventilation. The use of CPR (κ = 0.43, p = 0.004) and artificial ventilation (κ = 0.28, p = 0.046) showed significantly mild to moderate concordance among the dyads. Some 16 of the 21 dyads identified their spouses as a proxy, with others designating their adult children.Significance of results:The degree of patient–caregiver concordance on the K–AD seemed applicable, and achieved mild to moderate concordance. Our findings are exploratory but suggest the need for EoL discussions where patient–caregiver dyads are encouraged to participate in EoL care decision making.
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Baek SK, Chang HJ, Byun JM, Han JJ, Heo DS. The Association between End-of-Life Care and the Time Interval between Provision of a Do-Not-Resuscitate Consent and Death in Cancer Patients in Korea. Cancer Res Treat 2016; 49:502-508. [PMID: 27586675 PMCID: PMC5398395 DOI: 10.4143/crt.2016.073] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 08/11/2016] [Indexed: 11/21/2022] Open
Abstract
Purpose We explored the relationship between the use of each medical intervention and the length of time between do-not-resuscitate (DNR) consent and death in Korea. Materials and Methods A total of 295 terminal cancer patients participated in this retrospective study. Invasive interventions (e.g., cardiopulmonary resuscitation, intubation, and hemodialysis), less invasive interventions (e.g., transfusion, antibiotic use, inotropic use, and laboratory tests), and the time interval between the DNR order and death were evaluated. The subjects were divided into three groups based on the amount of time between DNR consent and death (G1, time interval ≤ 1 day; G2, time interval > 1 day to ≤ 3 days; and G3, time interval > 3 days). Results In general, there were fewer transfusions and laboratory tests near death. Invasive interventions tended to be implemented only in the G1 group. There was also less inotrope use and fewer laboratory tests in the G3 group than G1 and G2. Moreover, the G3 group received fewer less invasive interventions than those in G1 (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.03 to 0.84; 3 days before death, and OR, 0.16; 95% CI, 0.04 to 0.59; the day before death). The frequency of less invasive interventions both 1 and 3 days before death was significantly lower for the G3 group than the G1 (p ≤ 0.001) and G2 group compared to G1 (p=0.001). Conclusion Earlier attainment of DNR permission was associated with reduced use of medical intervention. Thus, physicians should discuss death with terminal cancer patients at the earliest practical time to prevent unnecessary and uncomfortable procedures and reduce health care costs.
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Affiliation(s)
- Sun Kyung Baek
- Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Hye Jung Chang
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae Joon Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dae Seog Heo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Kim J, Choi SM, Park YS, Lee CH, Lee SM, Yim JJ, Yoo CG, Kim YW, Han SK, Lee J. Factors influencing the initiation of intensive care in elderly patients and their families: A retrospective cohort study. Palliat Med 2016; 30:789-99. [PMID: 26934945 DOI: 10.1177/0269216316634241] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The number of elderly patients admitted to the intensive care unit is constantly growing. However, a decision regarding intensive care in these populations remains a challenge. AIM To identify factors that influences the decision of elderly patients and their families about whether to initiate intensive care in case of an acute event. DESIGN/PARTICIPANTS Medical records of patients (>80 years), who were admitted to general wards and referred for intensive care, were retrospectively reviewed. Patients who received intensive care were compared with those not agreeing to the initiation of intensive care. RESULTS Among the 125 patients, 45 agreed to receiving intensive care. Baseline characteristics at the time of intensive care unit referral were similar between the intensive care and non-intensive care groups. Only one patient had advance directives before the intensive care unit referral. Lower economic status (odds ratio = 0.27, 95% confidence interval = 0.08-0.94) and cognitive impairment (odds ratio = 0.20, 95% confidence interval = 0.07-0.56) were found associated with a lower likelihood of agreeing to intensive care, while a large number of participants involved in the decision-making process were associated with a higher likelihood of intensive care unit use (odds ratio = 1.82, 95% confidence interval = 1.08-3.09). Mean duration of hospital stay was longer for the intensive care group as compared with the non-intensive care group (28.8 days and 19.8 days, respectively, p = 0.03). However, there was no significant difference in the survival rate. CONCLUSION The initiation of intensive care in elderly patients was influenced not only by medical conditions but also by the patient's economic status and the number of family members involved in the decision-making process.
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Affiliation(s)
- Junghyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Sik Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chul-Gyu Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Whan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Kim H, Deatrick JA, Ulrich CM. Ethical frameworks for surrogates' end-of-life planning experiences. Nurs Ethics 2016; 24:46-69. [PMID: 27005954 DOI: 10.1177/0969733016638145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the growing body of knowledge about surrogate decision making, we know very little about the use of ethical frameworks (including ethical theories, principles, and concepts) to understand surrogates' day-to-day experiences in end-of-life care planning for incapacitated adults. OBJECTIVES AND METHODS This qualitative systematic review was conducted to identify the types of ethical frameworks used to address surrogates' experiences in end-of-life care planning for incapacitated adults as well as the most common themes or patterns found in surrogate decision-making research. FINDINGS Seven research papers explicitly identified ethical theories, principles, or concepts, such as autonomy, substituted judgment, and best interest standards as guidelines for the research. Surrogate decision making themes included the responsibilities and goals of being a surrogate, factors influencing surrogates' decision making, outcomes for surrogates, and an overarching theme of "wanting to do the right thing" for their loved one and/or themselves. DISCUSSION Understanding the complexity of surrogates' experiences of end-of-life care planning is beyond the scope of conventional ethical frameworks. CONCLUSION Ethical frameworks that address individuality and contextual variations related to decision making may more appropriately guide surrogate decision-making research that explores surrogates' end-of-life care planning experiences.
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Tang ST, Wen FH, Liu LN, Chiang MC, Lee SCK, Chou MC, Feng WL, Lin YC, Liu IP, Kuo YH, Chi SC, Lee KC. A Decade of Changes in Family Caregivers' Preferences for Life-Sustaining Treatments for Terminally Ill Cancer Patients at End of Life in the Context of a Family-Oriented Society. J Pain Symptom Manage 2016; 51:907-915.e2. [PMID: 26921491 DOI: 10.1016/j.jpainsymman.2015.12.326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/20/2015] [Accepted: 12/24/2015] [Indexed: 11/22/2022]
Abstract
CONTEXT Temporal changes in different family caregiver cohorts' preferences for life-sustaining treatments (LSTs) at end of life (EOL) have not been examined nor have the concept of whether caregivers' LST preferences represent a homogeneous or heterogeneous construct. Furthermore, LST preferences are frequently assessed from multiple treatments, making clinical applications difficult/infeasible. OBJECTIVES To identify parsimonious patterns and changes in the pattern of LST preferences for two independent cohorts of family caregivers for terminally ill Taiwanese cancer patients. METHODS Preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis were assessed among 1617 and 2056 family caregivers in 2003-2004 and 2011-2012, respectively. Patterns and changes in LST preferences were examined by multigroup latent class analysis. RESULTS Five distinct classes were identified: uniformly preferring, uniformly rejecting, uniformly uncertain, and favoring nutritional support but rejecting or uncertain about other treatments. Class probability significantly decreased from 29.3% to 23.7% for the uniformly rejecting class, remained largely unchanged for the uniformly preferring (16.9%-18.6%), and favoring nutritional support but rejecting (37.1%-37.5%) or uncertain about other treatments (8.0%-10.4%) classes, but significantly increased from 7.0% to 11.5% for the uniformly uncertain class over time. CONCLUSION Family caregivers' LST preferences for terminally ill cancer patients are a heterogeneous construct and shifted from uniformly rejecting all LSTs toward greater uncertainty. Surrogate EOL-care decision making may be facilitated by earlier and thorough assessments of caregivers' LST preferences and tailoring interventions to the unique needs of caregivers in each class identified in this study.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University School of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Li Ni Liu
- Department of Nursing, Fu Jen Catholic University, New Taipei City, Taiwan, Republic of China
| | - Ming-Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China
| | - Shiuyu C K Lee
- School of Nursing, National Taipei University of Nursing and Health Science, Taipei City, Taiwan, Republic of China
| | - Man Chun Chou
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China
| | - Wei-Lien Feng
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan, Republic of China
| | - Yu-Chuan Lin
- Department of Nursing, Tzu Chi University, Hualien City, Taiwan, Republic of China
| | - I-Ping Liu
- Chi-Mei Hospital, Chi Ali, Taiwan, Republic of China
| | - Ya-Hui Kuo
- Chia-Yi Christian Hospital, Chiayi City, Taiwan, Republic of China
| | - Shu Ching Chi
- Department of Nursing, E-Da Hospital and I-Shou University, Kaohsiung City, Taiwan, Republic of China
| | - Kwo C Lee
- School of Nursing, China Medical University, Taichung, Taiwan, Republic of China; Department of Nursing, China Medical University Hospital, Taichung, Taiwan, Republic of China
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Lu CY, Shen WC, Kao CY, Wang HM, Tang SC, Chin TL, Chi CC, Yang JM, Chang CW, Lai YF, Yeh YC, Hung YS, Chou WC. Impact of Palliative Care Consultation Service on Terminally Ill Cancer Patients: A 9-Year Observational Cohort Study in Taiwan. Medicine (Baltimore) 2016; 95:e2981. [PMID: 26962805 PMCID: PMC4998886 DOI: 10.1097/md.0000000000002981] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The palliative care consultation service (PCCS) that has been enthusiastically promoted in Taiwan since 2005 was designed to provide comprehensive end-of-life care for terminally ill patients with qualified interdisciplinary specialists in acute care ward setting. This study aims to evaluate the impact of PCCS on terminally ill cancer patients.A total of 10,594 terminal cancer patients who were referred to PCCS from a single medical center in Taiwan between 2006 and 2014 were enrolled. The percentages of patients' and their families' disease awareness, do-not-resuscitate (DNR) designation, refusal and acceptance of palliative care among terminally ill cancer patients were analyzed retrospectively.At the beginning of PCCS, the percentages of disease awareness among patients and their family were increased from 25.4% to 37.9% (P = 0.007) and from 61.2% to 84.7% between 2006 and 2014 (P = 0.001), respectively. Patients' disease awareness after PCCS referral between 2006 and 2014 was increased from 47.1% to 64.5% (P = 0.016). Family's awareness of diagnosis and prognosis after PCCS referral researched to a steady plateau, 94.1% to 97.8% in different year cohort (P = 0.34). The percentage of DNR designation rate at the beginning of PCCS (in 2006) was 15.5%, and the designation rate was increased annually and finally reached to 42.0% in 2014 (P = 0.004). The percentage of DNR consents after PCCS was also improved from 44.0% in 2006 up to 80.0% in 2014 (P = 0.005). PCCS refusal rate decreased gradually and dropped to 1.6% in 2014 (P = 0.005). The percentage of PCCS utilization was increased 5-fold during the 9-year period after the promotion of PCCSIn the program of PCCS promotion, an increasing trend of PCCS utilization, better patients' and their families' awareness of diagnosis and prognosis, more consent to DNR, more patients were discharged with stable condition at the end of PCCS and a decrease refusal rate of end-of-life palliative care among terminal cancer patients were observed in Taiwan between 2006 and 2014.
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Affiliation(s)
- Ching-Yi Lu
- From the Department of Nursing (C-YL, S-CT, T-LC, C-CC, J-MY, C-WC, Y-FL, Y-CY), Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou (W-CS, C-YK, H-MW, Y-SH, W-CC), and Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan (W-CC)
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Chang HT, Chen CK, Lin MH, Chou P, Chen TJ, Hwang SJ. Readmissions in Cancer Patients After Receiving Inpatient Palliative Care in Taiwan: A 9-Year Nationwide Population-Based Cohort Study. Medicine (Baltimore) 2016; 95:e2782. [PMID: 26937907 PMCID: PMC4779004 DOI: 10.1097/md.0000000000002782] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Few studies have reported on readmissions among cancer patients receiving inpatient palliative care (IPC). This study investigated readmissions in cancer patients after their first discharge from IPC in Taiwan from 2002 to 2010.This study was a secondary data analysis using information from the National Health Insurance Database in Taiwan from 2002 to 2010. We included subjects ≥20 years old diagnosed with malignant neoplasms who were listed in the registry of catastrophic illness. Patients diagnosed with cancer before January 1, 2002 or who had ever been admitted to an inpatient hospice palliative care unit before the study period were excluded. Readmission was defined as hospital readmission at least once after discharge from first admission to IPC until mortality or the end of the study period.A total of 42,022 patients who met the inclusion criteria were identified. The majority of these patients were male (60.4%). The mean age of cancer diagnosis was 64.0 ± 14.4 years for men and 64.5 ± 14.7 years for women. The mean age at first hospice ward admission was 65.2 ± 14.2 years for men and 65.9 ± 14.9 years for women. During their first admission to IPC, 59.2% patients died, and the median stay of first IPC admission was 8.0 days. Among those discharged alive from their first admission to IPC, 64.9% were readmitted, and 19.4% of these patients were readmitted on the same day of discharge. From first IPC discharge until mortality, 54.8% of patients were readmitted once, 23.9% were readmitted twice, 9.9% were readmitted 3 times, and 11.5% were readmitted 4 or more times. Being male, having a higher insurance premium level, having a longer length of stay during first IPC admission, being admitted to a teaching hospital, or being admitted to a tertiary hospital increased the adjusted hazard ratio for readmission.We found that terminal cancer patients in Taiwan received relatively late referrals for first admission to IPC and experienced a high rate of readmission after first discharge from IPC. Policies to improve hospice palliative care referrals and decrease readmissions should be considered.
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Affiliation(s)
- Hsiao-Ting Chang
- From the Department of Family Medicine, Taipei Veterans General Hospital, and School of Medicine and Institute of Public Health and Community Medicine Research Center, National Yang-Ming University (H-TC); Department of Radiology, Taipei Veterans General Hospital, and School of Medicine and Institute of Clinical Medicine, National Yang-Ming University (C-KC); Department of Family Medicine, Taipei Veterans General Hospital, and School of Medicine, National Yang-Ming University (M-HL and S-JH); Institute of Public Health and Community Medicine Research Center, National Yang-Ming University (PC); and Department of Family Medicine, Taipei Veterans General Hospital, and School of Medicine and Institute of Hospital and Health Care Administration, National Yang-Ming University (T-JC), Taipei, Taiwan
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Lin KH, Chen YS, Chou NK, Huang SJ, Wu CC, Chen YY. The Associations Between the Religious Background, Social Supports, and Do-Not-Resuscitate Orders in Taiwan: An Observational Study. Medicine (Baltimore) 2016; 95:e2571. [PMID: 26817913 PMCID: PMC4998287 DOI: 10.1097/md.0000000000002571] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Prior studies have demonstrated important implications related to religiosity and a do-not-resuscitate (DNR) decision. However, the association between patients' religious background and DNR decisions is vague. In particular, the association between the religious background of Buddhism/Daoism and DNR decisions has never been examined. The objective of this study was to examine the association between patients' religious background and their DNR decisions, with a particular focus on Buddhism/Daoism.The medical records of the patients who were admitted to the 3 surgical intensive care units (SICU) in a university-affiliated medical center located at Northern Taiwan from June 1, 2011 to December 31, 2013 were retrospectively collected. We compared the clinical/demographic variables of DNR patients with those of non-DNR patients using the Student t test or χ test depending on the scale of the variables. We used multivariate logistic regression analysis to examine the association between the religious backgrounds and DNR decisions.A sample of 1909 patients was collected: 122 patients had a DNR order; and 1787 patients did not have a DNR order. Old age (P = 0.02), unemployment (P = 0.02), admission diagnosis of "nonoperative, cardiac failure/insufficiency" (P = 0.03), and severe acute illness at SICU admission (P < 0.01) were significantly associated with signing of DNR orders. Patients' religious background of Buddhism/Daoism (P = 0.04), married marital status (P = 0.02), and admission diagnosis of "postoperative, major surgery" (P = 0.02) were less likely to have a DNR order written during their SICU stay. Furthermore, patients with poor social support, as indicated by marital and working status, were more likely to consent to a DNR order during SICU stay.This study showed that the religious background of Buddhism/Daoism was significantly associated with a lower likelihood of consenting to a DNR, and poor social support was significantly associated with a higher likelihood of having a DNR order written during SICU stay.
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Affiliation(s)
- Kuan-Han Lin
- From the Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine (K-HL, C-CW, Y-YC); and Department of Surgery, National Taiwan University College of Medicine, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan (Y-SC, N-KC, S-JH)
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Hammami MM, Hammami S, Amer HA, Khodr NA. Typology of end-of-life priorities in Saudi females: averaging analysis and Q-methodology. Patient Prefer Adherence 2016; 10:781-94. [PMID: 27274205 PMCID: PMC4876108 DOI: 10.2147/ppa.s105578] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Understanding culture-and sex-related end-of-life preferences is essential to provide quality end-of-life care. We have previously explored end-of-life choices in Saudi males and found important culture-related differences and that Q-methodology is useful in identifying intraculture, opinion-based groups. Here, we explore Saudi females' end-of-life choices. METHODS A volunteer sample of 68 females rank-ordered 47 opinion statements on end-of-life issues into a nine-category symmetrical distribution. The ranking scores of the statements were analyzed by averaging analysis and Q-methodology. RESULTS The mean age of the females in the sample was 30.3 years (range, 19-55 years). Among them, 51% reported average religiosity, 78% reported very good health, 79% reported very good life quality, and 100% reported high-school education or more. The extreme five overall priorities were to be able to say the statement of faith, be at peace with God, die without having the body exposed, maintain dignity, and resolve all conflicts. The extreme five overall dis-priorities were to die in the hospital, die well dressed, be informed about impending death by family/friends rather than doctor, die at peak of life, and not know if one has a fatal illness. Q-methodology identified five opinion-based groups with qualitatively different characteristics: "physical and emotional privacy concerned, family caring" (younger, lower religiosity), "whole person" (higher religiosity), "pain and informational privacy concerned" (lower life quality), "decisional privacy concerned" (older, higher life quality), and "life quantity concerned, family dependent" (high life quality, low life satisfaction). Out of the extreme 14 priorities/dis-priorities for each group, 21%-50% were not represented among the extreme 20 priorities/dis-priorities for the entire sample. CONCLUSION Consistent with the previously reported findings in Saudi males, transcendence and dying in the hospital were the extreme end-of-life priority and dis-priority, respectively, in Saudi females. Body modesty was a major overall concern; however, concerns about pain, various types of privacy, and life quantity were variably emphasized by the five opinion-based groups but masked by averaging analysis.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Correspondence: Muhammad M Hammami, Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, PO Box # 3354 (MBC 03), Riyadh 11211, Saudi Arabia, Tel +966 11 442 4527, Fax +966 11 442 7894, Email
| | - Safa Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Hala A Amer
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Nesrine A Khodr
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
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Hammami MM, Al Gaai E, Hammami S, Attala S. Exploring end of life priorities in Saudi males: usefulness of Q-methodology. BMC Palliat Care 2015; 14:66. [PMID: 26611147 PMCID: PMC4661936 DOI: 10.1186/s12904-015-0064-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 11/24/2015] [Indexed: 11/29/2022] Open
Abstract
Background Quality end-of-life care depends on understanding patients’ end-of-life choices. Individuals and cultures may hold end-of-life priorities at different hierarchy. Forced ranking rather than independent rating, and by-person factor analysis rather than averaging may reveal otherwise masked typologies. Methods We explored Saudi males’ forced-ranked, end-of-life priorities and dis-priorities. Respondents (n = 120) rank-ordered 47 opinion statements on end-of-life care following a 9-category symmetrical distribution. Statements’ scores were analyzed by averaging analysis and factor analysis (Q-methodology). Results Respondents’ mean age was 32.1 years (range, 18–65); 52 % reported average religiosity, 88 and 83 % ≥ very good health and life-quality, respectively, and 100 % ≥ high school education. Averaging analysis revealed that the extreme five end-of-life priorities were to, be at peace with God, be able to say the statement of faith, maintain dignity, resolve conflicts, and have religious death rituals respected, respectively. The extreme five dis-priorities were to, die in the hospital, not receive intensive care if in coma, die at peak of life, be informed about impending death by family/friends rather than doctor, and keep medical status confidential from family/friends, respectively. Q-methodology classified 67 % of respondents into five highly transcendent opinion types. Type-I (rituals-averse, family-caring, monitoring-coping, life-quality-concerned) and Type-V (rituals-apt, family-centered, neutral-coping, life-quantity-concerned) reported the lowest and highest religiosity, respectively. Type-II (rituals-apt, family-dependent, monitoring-coping, life-quantity-concerned) and Type-III (rituals-silent, self/family-neutral, avoidance-coping, life-quality & quantity-concerned) reported the best and worst life-quality, respectively. Type-I respondents were the oldest with the lowest general health, in contrast to Type-IV (rituals-apt, self-centered, monitoring-coping, life-quality/quantity-neutral). Of the extreme 14 priorities/dis-priorities for the five types, 29, 14, 14, 50, and 36 %, respectively, were not among the extreme 20 priorities/dis-priorities identified by averaging analysis for the entire cohort. Conclusions 1) Transcendence was the extreme end-of-life priority, and dying in the hospital was the extreme dis-priority. 2) Quality of life was conceptualized differently with less emphasize on its physiological aspects. 3) Disclosure of terminal illness to family/close friends was preferred as long it is through the patient. 4) Q-methodology identified five types of constellations of end-of-life priorities and dis-priorities that may be related to respondents’ demographics and are partially masked by averaging analysis. Electronic supplementary material The online version of this article (doi:10.1186/s12904-015-0064-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia. .,Alfaisal University College of Medicine, Riyadh, Saudi Arabia.
| | - Eman Al Gaai
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia.
| | - Safa Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia.
| | - Sahar Attala
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia.
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Finkelstein EA, Bilger M, Flynn TN, Malhotra C. Preferences for end-of-life care among community-dwelling older adults and patients with advanced cancer: A discrete choice experiment. Health Policy 2015; 119:1482-9. [DOI: 10.1016/j.healthpol.2015.09.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 05/19/2015] [Accepted: 09/04/2015] [Indexed: 11/30/2022]
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Do-not-resuscitate orders and related factors among family surrogates of patients in the emergency department. Support Care Cancer 2015; 24:1999-2006. [DOI: 10.1007/s00520-015-2971-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 09/28/2015] [Indexed: 12/21/2022]
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