Caregivers' Death-Preparedness States Impact Caregiving Outcomes and Patients' End-of-Life Care

Exploring the Role of Practical and Emotional Death Preparation in Reducing Emotional Distress Among Family Caregivers of Terminally Ill Cancer Patients: A Multicenter Cross-Sectional Study

Family caregivers (FCs) play a vital role in supporting terminally ill patients with cancer by providing emotional, physical, and practical care throughout the illness trajectory [...].

Use of multimedia shared decision-making aids (EATING program) for improving advance care planning engagement among community-dwelling older adults with chronic diseases: A cluster randomized controlled trial

BACKGROUND

Discussing advance care planning (ACP) preferences for nasogastric tube (NG) insertion remains challenging among older adults. Multimedia decision-making aids have demonstrated potential to enhance understanding and support informed decision-making.

AIM

To evaluate the effectiveness of the EATING program (multimedia decision-making aids + traditional educational module) compared to usual care (traditional educational module alone) in improving ACP readiness on NG insertion for community older adults with chronic illness.

METHODS

A single blind, two-arm parallel cluster randomized controlled trial was conducted across four community villages in Northern Taiwan. Participants from two villages received the EATING program, while the other two villages received the usual care. Eligible criteria included community older adults aged ≥65 with at least one chronic disease who were able to provide informed consent. Exclusion criteria included hearing or visual impairments or a history of mental illness. Pre- and post-intervention outcomes, along with one-month follow-up data, were analyzed using descriptive statistics and generalized estimating equations.

RESULTS

Both groups showed significant immediate improvements in knowledge (p < 0.001), belief/behavior (p < 0.001), decision confidence (p < 0.001), and readiness for ACP (p < 0.001). The experimental group showed greater improvement, particularly in emotional response and preferences (Z = -5.51, p < 0.001), observed only in this group. Sustained effect on knowledge (B = 35.029, p < 0.001), emotional response and preferences (B = 9.342, p < 0.001), refusal NG tube insertion (Z = -2.770, p = 0.006), and likelihood of signing official documents (p = 0.035) were observed after one month.

CONCLUSION

The study highlights the potential of multimedia program to enhance NG insertion discussions among community older adults. Further qualitative investigations and cultural adaptation are recommended.

'Regrets become a lasting source of pain': A qualitative study on family caregivers' experiences leading up to a relative's death

BACKGROUND

Death preparations can benefit families both before and during bereavement. While these preparations are culturally influenced, evidence from non-Western cultures, like Eastern Asia, is limited.

AIM

To explore how family caregivers prepare for a relative's death in Taiwan.

DESIGN

A qualitative interview study analysed with reflexive thematic analysis.

SETTING/PARTICIPANTS

Twenty-two primary family caregivers following a death involving specialist palliative care were interviewed.

RESULTS

An overarching theme was 'getting everything right to have no regrets between the dead and the living'. Within this, two themes focussed upon improving the dying relative's outcomes and the families' subsequent bereavement: (1) 'making the right end-of-life decisions is crucial but complex', exploring preparations to involve (or not) the dying relative in making choices to minimise regrets. Participants often felt they understood the dying relative's wishes so respected their preferences while maintaining family harmony through consensus-building and professional guidance. (2) 'becoming a competent caregiver is the priority', addressing preparations for fulfilling responsibilities, making sacrifices and developing caregiving competence to ensure the dying relative's comfort. This would help reduce feelings of regret about not having done enough.

CONCLUSION

Preparing for end-of-life decisions and caregiving is important for participants to reduce regret, benefiting subsequent bereavement. Of particular importance is family involvement and consensus-building in end-of-life decisions, reflecting Taiwan's family-led culture. These findings can inform clinical practices in family-centric decision-making cultures where healthcare workers should be aware of the need to build consensus, sometimes without involving the dying person. Future research should include patients' and healthcare professionals' perspectives.

Death Preparation and Quality of Life amongst Family Caregivers of Terminal Cancer Patients: A Multicentre Cross-sectional Study

Objectives

Caring for ill cancer patients imposes a considerable burden on families, significantly reducing quality of life (QoL). This study examined the association between death preparation and QoL amongst family caregivers (FCs) of terminally ill patients with cancer in South Korea.

Materials and Methods

A multicentre cross-sectional survey using questionnaires was conducted in nine inpatient palliative care units in South Korea. Data from 170 FCs who answered questions about preparedness for death were analysed. A stepwise multivariate logistic model was used to identify the factors associated with FCs' QoL. The estimated QoL scores were also compared between the groups according to preparedness level.

Results

Factors associated with high QoL included old age, fewer daily caregiving hours, fewer caregiving durations and practical preparedness for death. The well-prepared group had significantly higher QoL scores in the burdensome domain. This significant association remained robust in FCs with low educational or social support levels, poor resilience and dysfunctional families.

Conclusion

Practically, well-prepared FCs experienced a high QoL in hospice care settings. FCs are likely to benefit from assessment and encouragement of their preparedness for death.

Patient-caregiver concordance on death preparedness over Taiwanese cancer patients' last 6 months

BACKGROUND

Worldwide patient-caregiver concordance on cognitive prognostic awareness (PA) has been extensively examined, but concordance on sufficient (ie, cognitive and emotional) death preparedness is unexplored. We comprehensively examine the evolution of patient-caregiver concordance on death preparedness over the patient's last 6 months.

MATERIALS/METHODS

This study re-examined data from 2 cohort studies on 694 dyads of cancer patients and their caregivers recruited from a single medical center in Taiwan. Patient and caregiver death-preparedness states were individually identified by latent transition analysis. Patient-caregiver concordance was examined by percentages and kappa coefficients.

RESULTS

No-, cognitive-, emotional-, and sufficient-death-preparedness states were identified for both groups. The no-death-preparedness state reflects neither accurate PA nor adequate emotional preparedness for death. The sufficient-death-preparedness state reflects accurate PA and adequate emotional preparedness for death. In the cognitive- and emotional-death-preparedness states, participants had only accurate PA or adequate emotional-death preparedness, respectively. Prevalence of the sufficient-death-preparedness state increased substantially for patients but decreased slightly for caregivers. Membership in the no- and emotional-preparedness states declined throughout the last 6 months with substantially lower prevalence for caregivers than for patients, whereas the prevalence of the cognitive-death-preparedness state increased. Concordance was poor throughout the patient's last 6 months (percent concordance: 31.6% [95% CI, 24.7%, 38.5%]-43.5% [39.2%, 47.9%], kappa: 0.077 [-0.009, 0.162]-0.115 [0.054, 0.176]) with significant improvement in the last month only.

CONCLUSION

Poor patient-caregiver concordance on death-preparedness states likely reflects the cultural practice of family-consent prognostic disclosure, patients' adjustment for death, and difficulties in patient-caregiver communication on end-of-life (EOL) issues, indicating targets for improving EOL care.

A Model of Death Preparedness in Patients With Advanced Cancer: A Grounded Theory Study

BACKGROUND

Death preparedness in patients with advanced cancer is an important prerequisite for improving the quality of death. However, there are insufficient studies on death preparedness in patients with advanced cancer, and the level of death preparedness needs to be further improved.

AIM

To develop a model of death preparedness in patients with advanced cancer.

METHODS

A qualitative approach with grounded theory was used. Data were collected between February 2024 and July 2024 in the oncology wards of the two general hospitals in Wuhan. We recruited 12 patients, 11 family members, 16 nurses and 4 doctors for semistructured interviews. Data analysis included open coding, axial coding and selective coding. The study is reported using the COREQ checklist.

RESULTS

Death preparedness in patients with advanced cancer is a spiralling process whose core components include death awareness, emotional response, hospice programme and reflexive care, and multiple personal, interpersonal and social factors influence it.

CONCLUSION

A model of death preparedness in advanced cancer patients was constructed through rooted theory, revealing its formation and change process. This model deepens the understanding of death preparedness and helps healthcare providers identify patients' preparedness status in advance to provide more targeted support and care. This personalised care enhances patients' quality of life and reduces the psychological burden on them and their families, achieving more comprehensive and humanised end-of-life care.

IMPACT

To better understand patients' death preparedness, healthcare providers should focus on patients' cognitive, emotional, behavioural and social needs in the process of death preparation from a multifactorial perspective, and provide targeted support and assistance. No Patient or Public Contributions were included in this paper.

'A good ending but not the end': Exploring family preparations surrounding a relative's death and the Afterlife - A qualitative study

BACKGROUND

Adequate death preparation positively influences families' experience before death and during bereavement. However, how to prepare families in non-Western cultures has received scant attention.

AIM

To explore family caregivers' experiences in preparing for a relative's death in specialist palliative care in Taiwan.

DESIGN

A qualitative study employing reflexive thematic analysis of data collected from semi-structured interviews was conducted.

SETTING/PARTICIPANTS

Twenty-two family caregivers from seven hospitals participated.

RESULTS

The overarching theme was 'getting everything right to have no regrets between the dead and the living'. We developed two themes to explain preparations for the time surrounding and after the death, including the deceased' afterlife: (1) 'having a good ending but not the end of the relationship', which addresses preparations for the death itself, the funeral, the afterlife and maintaining connections and (2) 'using religious beliefs and cultural norms to guide preparation', which explores perceptions of a good death, including refrain from strong emotions before and after the death.

CONCLUSION

Funeral arrangements, enhancing the deceased's afterlife and maintaining connections to the deceased are crucial for families' experiences which can be impacted by actions they take as they prepare for the death. A culturally appropriate death is beneficial for the dying relative which includes preparing to not show strong emotions during and after the death. These insights inform the importance of the cultural context in death preparation in Taiwan and provide perspectives for palliative care beyond Western culture, potentially benefiting Chinese populations, predominantly East Asian and Buddhist societies.

Awareness of Imminent Death: Results From a Mixed Methods Study of Israeli Family Caregivers' Perceptions of Their Awareness and That of the Patients for Whom They Cared

We studied levels of awareness of impending death in older patients and their family caregivers. Using a mixed methods approach, we interviewed 70 family caregivers in Israel. Of the caregivers, 64% reported having been aware of the impending death, 33% were unaware, and 3% uncertain. Caregivers reported their perception that 36% of patients were aware, 27% unaware, and for 37% they were uncertain about the patient's awareness. Mechanisms that increased caregivers' awareness were specific diagnosis, significant deterioration in health, preparation by a health professional, or patient preparations for death. This study clarifies processes which aid awareness, and the relationship between awareness and actual preparation for dying.

Caregiver Burden and Readiness in Patients with Moderate and Severe Traumatic Brain Injury: The Chain Mediation Effect of Disease Uncertainty and Mental Resilience

OBJECTIVE

To analyze the mediating effects of caregiver illness uncertainty and psychological resilience in caregiver burden and readiness in patients with moderate-to-severe traumatic brain injuries (TBIs). This can help improve caregiver readiness in patients with moderate-to-severe TBIs.

METHODS

A purposive sampling method was used to recruit patients with moderate-to-severe TBIs, and their caregivers, who were hospitalized in the Department of Neurosurgery of the Affiliated Hospital of Yangzhou University between October 2022 and August 2023. The Zarit Caregiver Burden Interview, Mishel Uncertainty In Scale for Family Member, Connor-Davidson Resilience Scale, and Caregivers Preparedness Scale, as well as general information questionnaire, were used to conduct the survey.

RESULTS

Caregiver readiness correlated with caregiver burden, illness uncertainty, and psychological resilience in patients with moderate-to-severe TBI (P < 0.01). Caregiver readiness was not only directly affected by caregiver burden (95% confidence interval: -0.510, -0.196) but was also affected through the chain mediation of illness uncertainty and psychological resilience (95% confidence interval: -0.146, -0.011).

CONCLUSIONS

Caregiver burden in patients with moderate-to-severe TBI influences caregiver readiness levels and is mediated by illness uncertainty and psychological resilience. By improving caregivers' illness uncertainty and increasing their psychological resilience, the impact of low caregiver readiness caused by high caregiver burden could be reduced.

Factors Associated With Family Surrogate Decisional-Regret Trajectories

CONTEXT/OBJECTIVES

The scarce research on factors associated with surrogate decisional regret overlooks longitudinal, heterogenous decisional-regret experiences and fractionally examines factors from the three decision-process framework stages: decision antecedents, decision-making process, and decision outcomes. This study aimed to fill these knowledge gaps by focusing on factors modifiable by high-quality end-of-life (EOL) care.

METHODS

This observational study used a prior cohort of 377 family surrogates of terminal-cancer patients to examine factors associated with their membership in the four preidentified distinct decisional-regret trajectories: resilient, delayed-recovery, late-emerging, and increasing-prolonged trajectories from EOL-care decision making through the first two bereavement years by multinomial logistic regression modeling using the resilient trajectory as reference.

RESULTS

Decision antecedent factors: Financial sufficiency and heavier caregiving burden increased odds for the delayed-recovery trajectory. Spousal loss, higher perceived social support during an EOL-care decision, and more postloss depressive symptoms increased odds for the late-emerging trajectory. More pre- and postloss depressive symptoms increased odds for the increasing-prolonged trajectory. Decision-making process factors: Making an anticancer treatment decision and higher decision conflict increased odds for the delayed-recovery and increasing-prolonged trajectories. Making a life-sustaining-treatment decision increased membership in the three more profound trajectories. Decision outcome factors: Greater surrogate appraisal of quality of dying and death lowered odds for the three more profound trajectories. Patient receipt of anticancer or life-sustaining treatments increased odds for the late-emerging trajectory.

CONCLUSION

Surrogate membership in decisional-regret trajectories was associated with decision antecedent, decision-making process, and decision outcome factors. Effective interventions should target identified modifiable factors to address surrogate decisional regret.

Factors of preparedness for loss from cancer among Taiwanese family caregivers

This cohort study investigated factors associated with 336 Taiwanese family caregivers' emotional and cognitive preparedness for death of a loved one with terminal cancer. Caregivers' death-preparedness states (no-death-preparedness [as reference], cognitive-death-preparedness-only, emotional-death-preparedness-only, and sufficient-death-preparedness states) were previously identified. Associations of factors with these states were determined by a hierarchical generalized linear model. Financial hardship decreased caregivers' likelihood for the emotional-death-preparedness-only and sufficient-death-preparedness states. Physician prognostic disclosure increased membership in the cognitive-death-preparedness-only and sufficient-death-preparedness states. The better the quality of the patient-caregiver relationship, the higher the odds for the emotional-death-preparedness-only and sufficient-death-preparedness states, whereas the greater the tendency for caregivers to communicate end-of-life issues with their loved one, the lower the odds for emotional-death-preparedness-only state membership. Stronger coping capacity increased membership in the emotional-death-preparedness-only state, but perceived social support was not associated with state membership. Providing effective interventions tailored to at-risk family caregivers' specific needs may facilitate their death preparedness.

Assessing the feasibility, acceptability, and preliminary efficacy of a novel symptom management care delivery intervention for caregivers receiving home hospice care: The I-HoME protocol

BACKGROUND

Terminally ill patients experience high symptom burden at the end of life (EoL), even when receiving hospice care. In the U.S., family caregivers play a critical role in managing symptoms experienced by patients receiving home hospice services. Yet, most caregivers don't receive sufficient support or formal training in symptom management. Therefore, providing additional visits and education to caregivers could potentially improve outcomes for both patient and caregiver. In response, we developed the Improving Home hospice Management of End-of-life issues through technology (I-HoME) intervention, a program designed for family caregivers of home hospice patients. This paper describes the intervention, study design, and protocol used to evaluate the intervention.

METHODS

The I-HoME study is a pilot randomized controlled trial aimed at reducing patient symptom burden through weekly tele-visits and education videos to benefit the patient's family caregiver. One hundred caregivers will be randomized to hospice care with (n = 50) or without (n = 50) the I-HoME intervention. Primary outcomes include intervention feasibility (e.g., accrual, attrition, use of the intervention) and acceptability (e.g., caregivers' comfort accessing the tele-visits and satisfaction). We will also examine preliminary efficacy using validated patient symptom burden and caregiver outcome measures (i.e., burden, depression, anxiety, satisfaction).

CONCLUSION

The trial is evaluating a novel symptom management intervention that supports caregivers of patients receiving home hospice services. The intervention employs a multi-pronged approach that provides needed services at a time when close contact and support is crucial. This research could lead to advances in how care gets delivered in the home hospice setting.

Associations of surrogates' death-preparedness states with decisional conflict and heightened decisional regret over cancer patients' last 6 months of life

OBJECTIVE

Preparing family surrogates for patient death and end-of-life (EOL) decision making may reduce surrogate decisional conflict and regret. Preparedness for patient death involves cognitive and emotional preparedness. We assessed the associations of surrogates' death-preparedness states (that integrate both cognitive and emotional preparedness for patient death) with surrogates' decisional conflict and regret.

METHODS

Associations of 173 surrogates' death-preparedness states (no, cognitive-only, emotional-only, and sufficient preparedness states) with decisional conflict (measured by the Decision Conflict Scale) and heightened decisional regret (Decision Regret Scale scores >25) were evaluated using hierarchical linear modeling and hierarchical generalized linear modeling, respectively, during a longitudinal observational study at a medical center over cancer patients' last 6 months.

RESULTS

Surrogates reported high decisional conflict (mean [standard deviation] = 41.48 [6.05]), and 52.7% of assessments exceeded the threshold for heightened decisional regret. Surrogates in the cognitive-only preparedness state reported a significantly higher level of decisional conflict (β = 3.010 [95% CI = 1.124, 4.896]) than those in the sufficient preparedness state. Surrogates in the no (adjusted odds ratio [AOR] [95% CI] = 0.293 [0.113, 0.733]) and emotional-only (AOR [95% CI] = 0.359 [0.149, 0.866]) preparedness states were less likely to suffer heightened decisional regret than those in the sufficient preparedness state.

CONCLUSIONS

Surrogates' decisional conflict and heightened decisional regret are associated with their death-preparedness states. Improving emotional preparedness for the patient's death among surrogates in the cognitive-only preparedness state and meeting the specific needs of those in the no, emotional-only, and sufficient preparedness states are actionable high-quality EOL-care interventions that may lessen decisional conflict and decisional regret.