Understandings of death and dying for people of Chinese origin

Do People Prefer Home Palliative Care? A Survey Study and Assessment of Associated Factors in China

Objectives: This study examined people's preference for the location to receive palliative care services and determined the associated factors. Methods: A questionnaire with reference to the Chinese version of the Hospice Attitude Scale and the Death Correspondence Scale was designed, piloted, revised, and distributed online and in person to collect data (N = 762). Binary logistic regression was used to analyze the effects of relevant factors. Results: The average age of the participants was 38.1, with a relatively even gender distribution. Over 90% of the participants were either single/never married (44.9%) or married with children (46.0%). 58.1% of the respondents (N = 428) indicated that they would like to receive palliative care at home, compared to 41.9% who preferred receiving such care in institutions or other places (N = 309). Each time people's attitudes toward death became one point more positive, they were 10.2% more likely to choose to receive palliative care services at home. People with a neutral attitude toward palliative care, single/never married or divorced with children, and having/had an occupation in health and social work had higher odds of preferring receiving palliative care at home. Those who had poor self-rated health or with an educational background of primary school or lower or some college had lower odds of preferring receiving palliative care at home. Conclusions: The research showed that attitudes toward death and other factors were associated with people's preferences for palliative care locations. More accessible and affordable community-based and home-based palliative care services should be further explored and provided.

In Every Detail: Spiritual Care in Pediatric Palliative Care Perceived by Healthcare Providers

CONTEXT

Spiritual care is an essential domain of pediatric palliative care. The current mainland China faces a lack of national guidance and a shortage of specialized personnel to provide spiritual care in a traditional developing country.

OBJECTIVES

To identify spiritual care in pediatric palliative care services in mainland China from the perspective of healthcare professionals.

METHODS

A qualitative descriptive interview study was conducted individually with 27 participants: 14 physicians, seven nurses, and six social workers. The data were analyzed using thematic analysis.

RESULTS

Participants described that the essence of spiritual support was provided "in every detail" throughout pediatric palliative care. Four major themes and eleven subthemes were identified. 1) Assessing spiritual needs: paying attention to different perspectives; considering religion, tradition, and culture; discovering spiritual needs behind other needs. 2) Facilitating spiritual exploration: being with the family; providing resources; guiding by providers' own faith; 3) Supporting connections: encouraging the building of personal bonds; facilitating the establishment of spiritual connections. 4) Relieving spiritual suffering: facilitating a family review of child's life; supporting building meaning in daily life; assisting in leaving a legacy for the child.

CONCLUSION

This study illustrated that current spiritual support, though not formally organized, is provided individually in pediatric palliative care services in mainland China. Strategies for a practice guide, education and training for professionals, and cultural building need to be rationally developed to strengthen and structure spiritual support integrated into pediatric palliative care.

Taiwanese family members' bereavement experience following an expected death: a systematic review and narrative synthesis

BACKGROUND

Bereavement experience is shaped by cultural and social contexts. No systematically constructed reviews were identified to explore the bereavement experience for people who are influenced by Chinese culture valuing filial piety and mutual dependence. This review aimed to systematically review the bereavement experience of Taiwanese family members living in Taiwan following an expected death.

METHODS

MEDLINE, PsycINFO, CINAHL, China Academic Journal Database, and Chinese Electronic Periodical Services were searched with no date restrictions from inception to 20 October 2022. The methodological rigour of studies was assessed using Hawker's appraisal tool. A narrative synthesis approach using Popay's work was employed to synthesise the findings of the studies. Studies investigating Taiwanese family members' bereavement experiences were included. We excluded papers studying bereavement through the death of a child.

RESULTS

Searches retrieved 12,735 articles (after de-duplication), 17 of which met the inclusion criteria and were included for synthesis: English [9] and Chinese [8], published between 2006 and 2021. The studies varied in quality with scores ranging from 22 to 33 out of 36. The studies differed in the relationship between participants and the deceased, the bereaved time frames, and the definitions of bereavement. Most studies focussed on family members of cancer patients receiving specialist palliative care. Three bereavement theories and four tools were used. Risk factors of bereavement outcomes included family members feeling less prepared for death and deaths where palliative sedative therapy was used. Protective factors were higher caregiving burden and longer caregiving periods. Four themes regarding Taiwanese bereavement experience were generated: multiple impacts of death; problem-based coping strategies; importance of maintaining connections; influential religious beliefs and rituals.

CONCLUSION

Continuing the relationship with the deceased is a key element of Taiwanese bereavement experience and it is influenced by religious and cultural beliefs. Suppressing or hiding emotions during bereavement to connect with the deceased and maintain harmonious relationships needs to be acknowledged as culturally acceptable and encouraged by some religions in Taiwan. The findings could be potentially relevant for other Chinese populations, predominantly Buddhist countries or other East Asian societies. The role of preparing for death in bereavement outcomes is little understood and requires further research.

Age does matter for hospice care: Health care providers' attitudes toward hospice care in Binzhou, China

Death is still a taboo subject in China. Consequently, hospice remains a relatively new concept in many parts of China. In addition, China is also a rapidly aging country which will likely impact health care delivery, making hospice a potentially effective addition to current healthcare systems. The goal of this study was to better understand health care providers' (physicians and nurses) views about potential hospice implementation, especially with regards to patients' age. Semi-structured, open-ended interviews were conducted with 15 health care providers in Binzhou. Most participants felt that hospice care was only appropriate for older patients and rarely, if ever, for younger ones regardless of disease or prognosis. They also mentioned the links between traditional Chinese medicine (TCM) and many hospice principles. Given deeply held cultural attitudes about dying, hospice implementation would be most successful if directed toward older patients with terminal prognosis and with an emphasis on TCM.

The effect of expressive writing on Chinese cancer patients: A systematic review and meta-analysis of randomized control trails

Cancer patients in China encounter distinctive challenges stemming from cultural disparities and variations in the healthcare systems. This meta-analysis aimed to provide a synthesis of the expressive writing (EW) interventions delivered to Chinese cancer patients and assess the pooled effect of EW on their well-being. The review adheres to the latest PRISMA 2020 guidelines to ensure transparency and rigour. Randomized control trials (RCTs) published before 1 April 2023, and meeting the inclusion criteria were included. Keywords searching was performed in both English and Chinese electronic databases. Ten RCTs were identified and included in the analysis. The results showed that EW usually encompassed four to six writing sessions; the most common writing themes were 'emotional expression', 'cognitive appraisal', 'benefit finding', 'coping strategies' and 'looking to the future'. The meta-analysis suggested that EW had a substantial impact on reducing anxiety levels (Hedges' g = -1.22, 95% CI [-1.54, -0.90], I2 = 0.00%). It is worth noting that although the results of these studies could not be statistically synthesized, their individual findings suggest that EW may be beneficial in reducing anxiety, self-perceived burden and depressive symptoms, as well as increasing self-efficacy in Chinese cancer patients. In conclusion, this review highlights the importance and effectiveness of Ewin alleviating anxiety among Chinese cancer patients and underscores the potential benefits of incorporating EW into comprehensive care programmes for cancer patients in China. More RCTs are needed to explore the broader impact of EW in China.

Decision-making trade-offs: A classic grounded theory study of Chinese acute leukaemia patients and their family caregivers across the trajectory of illness

AIM AND OBJECTIVES

To identify the main concern of patients with acute leukaemia and their family caregivers in the process of coping with the disease and to determine how patients and their family caregivers address these concerns on an ongoing basis.

BACKGROUND

Acute leukaemia is a progressive disease that may lead to physical problems and mental stress in patients. It also affects the psychological well-being and quality of life of family caregivers. Nevertheless, few studies explore the behavioural pattern across the trajectories of illness in Chinese patients with acute leukaemia and their family caregivers.

DESIGN

Grounded theory.

METHODS

Theoretical sampling was performed to collect 14 sets of secondary data from Bilibili platform, literature, articles from WeChat official account, press releases and documentary. A total of 29 participants were selected to participate in semistructured interviews from the haematology department of a tertiary care hospital in Fuzhou, Fujian Province from January 2021 to November 2021. Data collection and analysis were conducted in a synchronous iterative manner until theoretical saturation was reached. Data analysis included open coding, selective coding and constant comparison, et al. The CCOREQ checklist was utilised.

RESULTS

This study discovered the main concern (i.e. seeking survival) and main behavioural pattern of how patients with acute leukaemia and their family caregivers addressed this issue. Three decision-making strategies, 'responding' 'accommodating' and 'resisting' also emerged.

CONCLUSIONS

This study explored the behavioural pattern of patients with acute leukaemia and their family caregivers in the process of coping with disease. The study found that the main concern of patients with acute leukaemia and their family caregivers, and provided a theoretical basis for disease management and nursing interventions for them in the future.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study contribute to nursing knowledge, practice in the field of patients' participation in decision-making.

PATIENT OR PUBLIC CONTRIBUTION

Due to the characteristics of grounded theory (no presupposition of research questions), the interviews in this study mainly focus on theory generation. Participants were not asked to assess the burden of the intervention and the time required to participate in the study, as interviews were conducted for theory generation. This study may assist patients and family caregivers in obtaining better understand and adapt to changes across the trajectory of illness, as well as to promote public destigmatisation of acute leukaemia and reforms in family-hospital-community diversified care.

Efficacy of meaning-centered group psychotherapy in Chinese patients with cancer: A randomized controlled trial

OBJECTIVES

Meaninglessness is one of the most common psychological problems in cancer patients, which can lead to anxiety, depression and psychological distress, and diminished quality of life. Recent evidence indicates that meaning-centered group psychotherapy (MCGP) effectively enhances the meaning in life among cancer patients. This study aimed to evaluate the impact of MCGP on the meaning in life, post-traumatic growth, psychological distress, and fear of recurrence among Chinese cancer patients with a favorable prognosis.

METHODS

Sixty-six cancer patients were randomly assigned to either the MCGP group (n = 33) or the control group (n = 33). Participants in the MCGP group underwent a 4-week, 8-session MCGP, while those in the control group received usual care. Meaning in life, post-traumatic growth, psychological distress, and fear of recurrence were assessed at both baseline and postintervention to evaluate the impact of the intervention. The intervention outcomes were analyzed using paired t-tests or analysis of covariance, as appropriate.

RESULTS

Patients in the MCGP group demonstrated significant improvements in meaning in life, post-traumatic growth, and fear of recurrence from baseline to postintervention. In comparison to the control group, the MCGP group displayed positive effects on meaning in life and post-traumatic growth following the intervention. However, no significant effects were observed in terms of psychological distress and fear of recurrence.

SIGNIFICANCE OF RESULTS

Our research offers evidence supporting the effectiveness of MCGP in enhancing meaning in life and post-traumatic growth among Chinese cancer patients with a favorable prognosis.

Public sentiments and the influence of information-seeking preferences on knowledge, attitudes, death conversation, and receptiveness toward palliative care: results from a nationwide survey in Singapore

Background

Low awareness about palliative care among the global public and healthcare communities has been frequently cited as a persistent barrier to palliative care acceptance. Given that knowledge shapes attitudes and encourages receptiveness, it is critical to examine factors that influence the motivation to increase knowledge. Health information-seeking from individuals and media has been identified as a key factor, as the process of accessing and interpreting information to enhance knowledge has been shown to positively impact health behaviours.

Objective

Our study aimed to uncover public sentiments toward palliative care in Singapore. A conceptual framework was additionally developed to investigate the relationship between information-seeking preferences and knowledge, attitudes, receptiveness of palliative care, and comfort in death discussion.

Design and Methods

A nationwide survey was conducted in Singapore with 1226 respondents aged 21 years and above. The data were analysed through a series of hierarchical multiple regression to examine the hypothesised role of information-seeking sources as predictors.

Results

Our findings revealed that 53% of our participants were aware of palliative care and about 48% were receptive to receiving the care for themselves. It further showed that while information-seeking from individuals and media increases knowledge, attitudes and receptiveness to palliative care, the comfort level in death conversations was found to be positively associated only with individuals, especially healthcare professionals.

Conclusion

Our findings highlight the need for public health authorities to recognize people's deep-seated beliefs and superstitions surrounding the concept of mortality. As Asians view death as a taboo topic that is to be avoided at all costs, it is necessary to adopt multipronged communication programs to address those fears. It is only when the larger communicative environment is driven by the media to encourage public discourse, and concurrently supported by timely interventions to trigger crucial conversations on end-of-life issues between individuals, their loved ones, and the healthcare team, can we advance awareness and benefits of palliative care among the public in Singapore.

The concept of spirituality in the context of Chinese patients with cancer: A scoping review

AIM

To elucidate how the concept of spirituality has been addressed in studies with Chinese people with cancer.

DESIGN

A scoping review.

METHODS

Patterns in conceptual definitions of spirituality and indicators for measuring spirituality were analysed.

DATA SOURCES (INCLUDE SEARCH DATES)

Literature published from inception to August 2022 was searched in five electronic databases (CINAHL, PubMed, Web of Science, PsycINFO and a Chinese database).

RESULTS

Using data from 10 qualitative studies, a new taxonomy of concepts of spirituality among Chinese people with cancer was derived, consisting of four categories: Creation of meaning, Connection, Transcendence and Existence. A total of 12 instruments developed outside of Chinese contexts and used to measure dimensions of spirituality across 27 quantitative studies were compared to the taxonomy developed in this review, and patterns were identified according to the dimensions of spirituality. Several instruments required modifications or additional explanations in questions regarding God/Higher Power and religion.

CONCLUSION

The four categories of spirituality classified in the current review are considered universal across all cultural contexts. Spirituality is multidimensional and functional concept, and the components of the instruments differed depending on which dimension of spirituality was being measured.

IMPACT

The findings of this study suggest that for measuring spirituality in research and clinical settings with Chinese people with cancer, it is important to use culturally appropriate scales that are consistent with the dimensions of spirituality being measured.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Even instruments developed outside of the Chinese context could be used for Chinese people with cancer if appropriately selected for their intended use.

REPORTING METHOD

This paper adheres to the EQUATOR guidelines and has no direct patient or public contribution.

Culture, ethnicity, and socio-economic status as determinants of the management of patients with advanced heart failure who need palliative care: A clinical consensus statement from the Heart Failure Association (HFA) of the ESC, the ESC Patient Forum, and the European Association of Palliative Care

The delivery of effective healthcare entails the configuration and resourcing of health economies to address the burden of disease, including acute and chronic heart failure, that affects local populations. Increasing migration is leading to more multicultural and ethnically diverse societies worldwide, with migration research suggesting that minority populations are often subject to discrimination, socio-economic disadvantage, and inequity of access to optimal clinical support. Within these contexts, the provision of person-centred care requires medical and nursing staff to be aware of and become adept in navigating the nuances of cultural diversity, and how that can impact some individuals and families entrusted to their care. This paper will examine current evidence, provide practical guidance, and signpost professionals on developing cultural competence within the setting of patients with advanced heart failure who may benefit from palliative care.

The role of acculturation in the process of advance care planning among Chinese immigrants: A narrative systematic review

BACKGROUND

Acculturation is the process of two different cultures coming into contact. It is unclear how acculturation influences Chinese immigrants' engagement in advance care planning due to the complexity and multifaceted nature of both acculturation and advance care planning.

AIMS

To synthesize evidence regarding the role of Chinese immigrants' acculturation in their engagement in advance care planning.

DESIGN

Systematic mixed-method review, registered in PROSPERO (CRD42021231822).

DATA SOURCES

EMBASE, MEDLINE, Web of Science, and Google Scholar were searched for publications until January 21, 2021.

RESULTS

Twenty-one out of 1112 identified articles were included in the analysis. Of those 21 articles, 17 had a qualitative design and 13 originated from the United States. Three of four quantitative studies reported that higher acculturation levels were associated with better knowledge or higher rate of engagement in advance care planning. Analysis of qualitative studies showed that Chinese immigrants' engagement in advance care planning was associated with their: (1) self-perceived cultural identity (native or non-native); (2) interpretation of filial piety (traditional or modern); and (3) interpretation of autonomy (individual or familial). To facilitate their engagement, Chinese immigrants prefer an implicit approach, non-family-related initiators, contextualization advance care planning in Chinese culture and using Chinese language.

CONCLUSION

Chinese immigrants' willingness to engage in advance care planning varied with their acculturation level. To engage them in advance care planning, we recommend adapting the introduction of advance care planning to address people's perceptions of their cultural identity, filial piety, and autonomy, as well as their preference for certain approach, initiator, context, and language.

Spiritual and cultural influences on end-of-life care and decision-making in NICU

Understanding and respecting the spiritual beliefs, ethnic roots, cultural norms and customs of individual families is essential for neonatologists to provide clinically appropriate and humane end-of-life care. This review describes the religious/philosophical principles, cultural-related practices/rituals, and traditions in end-of-life care in major spiritual groups of today's multi-cultural, multi-faith societies. The spiritual groups include Christians, Muslims, Jewish Judaism believers and Asian religious/philosophy followers such as Buddhists, Hindus, Taoists, Confucianism devotees and ancestral worshippers. It is vital to understand that substantial variation in views and practices may exist even within the same religion and culture in different geographic locations. Ethical views and cultural practices are not static elements in life but behave in a fluidic and dynamic manner that could change with time. Interestingly, an evolving pattern has been observed in some Asian and Middle East countries that more parents and/or religious groups are beginning to accept a form of redirection of care most compatible with their spiritual belief and culture. Thus, every family must be assessed and counseled individually for end-of-life decision-making. Also, every effort should be made to comply with parents' requests and to treat infants/parents of different religions and cultures with utmost dignity so that they have no regret for their irreversible decisions.

The Death Literacy Index: translation, cultural adaptation, and validation of the Chinese version

Objective

Applying public health approaches to address palliative care allows for a broader perspective. The Death Literacy Index (DLI) is a novel instrument designed to assess the knowledge and skills required to access, comprehend, and make informed decisions regarding end-of-life care. Translation of the DLI could strengthen the capacity to build desirable services and policies regarding dying and death. It could also help to identify the barriers to services and future advocacy efforts.

Methods

The DLI was forward translated into Chinese and backward translated through two panels. Two rounds of cognitive interviews and a pilot test were conducted before the survey. A sample of 3,221 participants was recruited via an online survey in five cities in southern China (Guangzhou, Zhuhai, Jiangmen, Hong Kong and Macao) to evaluate the factor structure, validity and reliability of the translated DLI. Additionally, multi-group confirmatory factor analyses (MGCFA) were performed to examine measurement invariance across genders and the experiences of parental death.

Results

Exploratory factor analysis showed a six-factor structure for the translated DLI, and confirmatory factor analysis confirmed the structure. The overall scale and subscales had high internal consistency and satisfactory validity. The results from MGCFA showed that death literacy was adequately invariant for different genders and experiences of parental death.

Conclusion

The Chinese DLI is a reliable and valid instrument for measuring death literacy among people in southern China, and therefore can be used for both research and community practice.

Bereavement and Professional Competencies: Exploring the Personal Experience of Death Among Nursing Students - A Qualitative Study

Purpose: To explore the death experiences of nursing students in their personal lives. Methods: This study employed a qualitative descriptive design using the semi-structured interview approach. A purposive sampling method was used to recruit 24 nursing students from September 2020 to July 2022. Data were analyzed using Colaizzi's analysis method. Lincoln and Guba's criteria was used to evaluate the trustworthiness of the data. Results: Four main themes emerged from the interviews: (a) reactions to encounters with death; (b) adjustment strategies; (c) personal growth induced by the death experiences; and (d) professional reflections for preparing nurse role. Conclusions: Although the death of a loved one makes nursing students suffer from grief and emotional distress, we show that the experience promotes the personal growth and professional competencies of nursing students and thereby, developing their overall aptitude towards the profession. Death experiences of nursing students have shown to allow them to reflect on both life and death, to consider the demands of the nursing profession, and to provide foundation for nursing students to be more empathetic and compassionate when facing death in the future. Exploring death experiences of nursing students is vital in better providing better quality education and personal support for nursing students.

The Lived Experiences of Spousal Bereavement and Adjustment Among Older Chinese Immigrants in Calgary

Spousal bereavement poses considerable challenges to adults in late life. Some populations, such as older immigrants, may experience heightened negative outcomes as a consequence of spousal bereavement, due to migratory stress and social isolation. Spousal bereavement is culturally embedded as it is related to cultural beliefs and attitudes concerning death and family relationships. However, studies on spousal bereavement or widowhood among older immigrants are extremely limited. This study aims to fill the gap by exploring, via a phenomenological approach, the lived experiences of widowed older Chinese immigrants in Calgary and responding to the question: What are the lived experiences of widowed Chinese older immigrants in coping with their spousal bereavement? With the data drawn from 12 in-depth qualitative interviews, findings were categorized into individual, family, community and societal levels. Study participants experienced long-lasting grief that was private and impacted by their culture and immigration status. Although family and ethno-cultural communities provided various types of supports during participants' widowhood, they did not directly assist them in coping with spousal loss. Most participants did not access social services for bereavement support, more often relying on cultural rituals and faith practices. Findings suggest the need for culturally appropriate bereavement supports and family/community involvement for older immigrant adults who have experienced spousal loss.

Information disclosure to cancer patients in Mainland China: A meta-analysis

OBJECTIVE

This study aims to systematically examine Chinese cancer patients' and families' preferences for information disclosure to the patient, patient awareness, and predictors of patient awareness.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. Web of Science, Scopus, Proquest, Taylor & Francis Online, and China National Knowledge Infrastructure were searched in April 2022 and Chinese Biomedical Literature Database in July 2022 for quantitative studies. The Mixed Methods Appraisal Tool was used for quality assessment.

RESULTS

A total of 22 studies were included, and the average quality score was 0.65/1. Meta-analyses showed that 89.6% and 81.8% of cancer patients wanted to know their diagnosis and prognosis, respectively. Meanwhile, 50.0% and 32.4% of families prefer diagnosis disclosure and prognosis disclosure to the patient, respectively. Significantly more patients than families favored disclosure to the patient. In reality, only 59.3% of cancer patients know their diagnosis, and 19.9% know their prognosis. For predictors, while patients' gender, cancer type (breast cancer or not), treatment method (operation or other), or complications (yes or no) do not influence diagnosis awareness, being younger, being married, having higher educational attainment, having early-stage rather than late-stage cancer, and being in a higher-grade hospital all predict better chances of knowing a diagnosis. No study explored predictors of patients' prognosis awareness. The findings did not vary according to publication time or sample size.

CONCLUSIONS

Chinese cancer patients are eager to know their diagnosis and prognosis, but families are hesitant about disclosure to the patient, and patients' awareness is low. While cultural, legal, and medical backgrounds lay the foundation for information disclosure in Mainland China, case-by-case practical factors also make a difference.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Chinese American Patients

The Chinese American population is one of the fastest-growing communities in the United States, composed of ∼5.4 million people, and represents ∼5.5% of overseas Chinese populations. With an expected exponential population rise, Chinese American patients who experience serious illness or approach end-of-life (EOL) may find their cultural values influencing the medical care they receive. Palliative care clinicians must recognize diverse cultural beliefs and preferences of Chinese American patients and their families. In this study, we provide 10 cultural pearls to guide the provision of palliative and EOL care for Chinese American patients, including discussions of Chinese traditions, communication strategies for Chinese patients and families, advance care planning, and EOL care beliefs.

Communication between mothers with breast cancer and minor children: a qualitative systematic review and meta-synthesis

PURPOSE

Both women with breast cancer and their minor children were affected by a breast cancer diagnosis. The purpose of this review was to synthesize the evidence from qualitative studies on illness-related communication between mothers with breast cancer and their minor children from mothers' perspectives.

METHODS

A thorough systematic review and meta-synthesis of qualitative studies was conducted. English articles published prior to 6 November 2021 were searched from five databases, including PubMed/ MEDLINE, EMBASE, Web of Science, CINAHL, and PsycINFO. After screening the titles, abstracts, and full texts, seven articles were finally included in the quality appraisal and meta-aggregation.

RESULTS

Four synthesized findings were derived from seven articles, including disclosure dilemma, factors impacting disclosure, methods of communication, and information needs.

CONCLUSIONS

This systematic review offered insight into the communication between mothers with breast cancer and their minor children. Various factors influenced the decision-making process on illness-related disclosure, as well as the methods and contents of the communication. Future studies should be undertaken to explore the common model shared by mothers and children who have had comparable experiences, as well as to completely analyze the differences between different cultures in this topic.

Intern nursing students’ perceived barriers to providing end-of-life care for dying cancer patients in a death taboo cultural context: A qualitative study

Objective

Internationally, intern nursing students' experiences with dying patients and death are an area of great concern. However, barriers to providing end-of-life care for dying cancer patients have not been extensively investigated in mainland China, where death remains a taboo issue. Therefore, this study aimed to elucidate intern nursing students' perceived barriers to their performance in providing end-of-life cancer care in the Chinese cultural context.

Methods

This was a descriptive, qualitative study. Twenty-one intern nursing students from three cancer centers in mainland China were interviewed between January 2021 and June 2022. A thematic analysis method was used to analyze the data. The theory of planned behavior was adopted to design the study and identify themes.

Results

A range of barriers related to attitudes, subjective norms, and perceived behavioral control that hindered intern nursing students from acquiring abilities to deal with patient dying and death were identified in the Chinese cultural context.

Conclusions

Chinese intern nursing students encountered many barriers that affected their provision of end-of-life care to dying cancer patients. Strategies to improve their ability to provide appropriate end-of-life care should focus on helping them develop appropriate attitudes toward dying and death and how to overcome subjective norms and behavioral control barriers.

The decision-making process of transferring patients home to die from an intensive care unit in mainland China: A qualitative study of family members' experiences

OBJECTIVES

To map the decision-making process of family members involved in transferring a critically ill patient home to die from an intensive care unit in mainland China and to explore the experiences of those family members.

DESIGN

A constructivist qualitative study.

SETTING

One hospitals intensive care unit in Southeast China.

METHODS

Thirteen adult family members (of ten patients) who participated in decision-making related to transferring a relative home to die from the intensive care unit were purposively selected. Data were collected via interviews and analysed applying thematic analysis.

FINDINGS

A two-stage decision-making process was identified. Family decision-making was mediated by factors including: accepting the impending death and hope that the patient would not die; time pressures in which decisions had to be made, and the challenges of meeting cultural expectations of a home death. Transfer home was a family-centred decision constrained by a gender-based hierarchy restricting the involvement of different family members.

CONCLUSION

The stages and key factors in the decision-making process of family members when involved in transferring a patient home to die from an intensive care unit in China are rooted and informed by cultural expectations and limits in the current healthcare system regarding end-of-life care options. Understanding the climate in which family members must make decisions will facilitate supportive interventions to be implemented by healthcare professionals. Further empirical research is needed to explore family members' needs when the patient has been transferred and dies at home in mainland China.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals need to understand the challenges family members face when deciding to transfer a relative home to die from an intensive care unit. For example time pressures can limit the choices of family members so that to provide them with timely, ongoing, realistic updates for a greater involvement of family members in generating end of life care plans could be beneficial.¹.

Bereavement After Patient Deaths Among Chinese Physicians and Nurses: A Qualitative Description Study

In order to achieve an in-depth understanding of professional caregivers' experiences of bereavement after patient deaths in Mainland China, qualitative description was employed. 24 physicians and nurses from hospitals in Nanjing, China, participated in one-to-one, semi-structured interviews. Thematic analysis was adopted for data analysis. Five themes were generated: the nature of professional bereavement experiences, the meaning of patient deaths, immediate bereavement reactions, long-term changes, and coping strategies. Each theme included personal and professional dimensions. Professional bereavement experiences in Mainland China were found to be influenced by workplace violence against professional caregivers, traditional Chinese medical ethics, the strong death taboo, and inadequacies of the healthcare system. Professional bereavement experiences are meaning-driven, comprehensive, and usually disenfranchised. They involve multidimensional reactions and have both short-term and long-lasting, both event-specific and accumulated impacts. Cultural and systemic factors could shape professional bereavement experiences.

Buddhism

After Christianity, Judaism, and Hinduism, Buddhism is the 4th major religion of the world. The Pew Research Center estimates that as of 2020, about 500 million people (or 6.6% of the world's population) practice Buddhism. China has the largest Buddhist population at 254 million, followed by Thailand at 66 million, and then Myanmar and Japan at about 41 million.

Practitioner accounts of end-of-life communication in Hong Kong, Mainland China and Taiwan: A systematic review

OBJECTIVE

Communication at the end-of-life (EOL) is complex and multidimensional. Although culture is acknowledged as a key influence, there remains a gap in knowledge about intracultural aspects of EOL communication in the Chinese context. This review presents a synthesis of practitioners' accounts of communication at the EOL in Hong Kong, Mainland China and Taiwan.

METHODS

This review was registered prospectively on PROSPERO (CRD42021297052). Five databases were systematically searched using the terms 'communication', 'End-of-Life', 'Hong Kong', 'China' and 'Taiwan'. Empirical research published between 2015 and 2021 was downloaded and appraised. Fifteen articles were included in the review.

RESULTS

Findings highlight the influence of Chinese culture and philosophy, inadequate communication skills training and psychological support for practitioners and legislative and organisational factors.

CONCLUSION

Education and training for practitioners and public education about the EOL needs strengthening. Enhanced understanding of how culture influences EOL communication will strengthen service delivery and enhance awareness in multicultural communities.

PRACTICE IMPLICATIONS

EOL workers need practical and workplace-based support to engage in meaningful communication practices. The influence of culture and the readiness of patients and families to engage in communication are also important considerations.

Trajectories of Instrumental and Emotional Social Support and the Associated Risk of Mortality in Bereaved Older Adults in Taiwan

This study identified the trajectories of instrumental and emotional perceived social support (PSS) from 1996 to 2003 and investigated the associated risk of mortality in bereaved older adults in Taiwan. The study analyzed 1,188 bereaved older adults who had experienced loss of a spouse, a child, or both before 1996 from the Taiwan Longitudinal Study on Aging. More favorable trajectories of PSS are associated with lower mortality risk in bereaved older adults. Compared with the spousal or dual bereavement, the parental bereavement benefited more from consistently high instrumental PSS. The present study revealed that consistently high emotional PSS had a stronger protective effect on mortality risk for a widow or widower than did consistently high instrumental support. The findings of this study can serve as an empirical reference to inform social policies and clinical practices for bereaved older adults in culturally similar societies.

The 'good death' in Mainland China - A Scoping Review

Background

Since the mid 80'ies, the western palliative care philosophy has influenced the development of palliative care in mainland China. However, it has caused several challenges.

Objective

To explore the understanding of the 'good death' among authorities, professionals, patients, and their relatives in end-of-life care settings in mainland China.

Design

Scoping review. The PRISMA-ScR checklist was used. The study is not registered.

Settings

End-of-life care settings, Mainland China.

Participants

Authorities, healthcare professionals, adult patients, and general population in mainland China.

Method

Literature searches were performed through Medline, CINAHL, PsycInfo, and Web of Sciences from 2001-2021, last search 21.4.2021. Inclusion criteria were: Empirical research studies investigating 'good death' or political documents about 'good death', perspectives from authorities, professionals, patients, and/or relatives, and studies following the Declaration of Helsinki. Exclusion criteria were: Literature reviews, languages other than English and Chinese, editorials, letters, comments, and children's death/dying.The analysis consisted of analysing the data including a descriptive numerical summary analysis and a qualitative thematic analysis.

Results

Nineteen articles and two political documents were included. The 19 studies were carried out from 2003-2020, with data collected from 1999 to 2019. The political documents were written in 2012 and 2017, respectively. The thematic analysis resulted in three themes: 'Medicalisation of death', 'Communication about death - a clash between two philosophies', and 'Dying and death were socially dependent'. The medicalisation of death meant the understanding of the 'good death' primarily focused on physical symptoms and treatments. The good death was understood as painless and symptom-free, where all symptoms could be measured and assessed. Dignity and shared decision-making were connected to the understanding of the 'good death'. However, the contents of the 'good death' varied across the different actors. The understanding of the 'good death' in mainland China was a negotiation between Chinese traditional philosophy and contemporary western medicine practice. There was a tension between openness and silence about death, which reflected the importance of death education. The understanding of the 'good death' consisted partly of a timely and practical preparation for the death and afterlife, partly of a matter of social and financial issues.

Conclusions

There seemed to be a clash between two different cultures in the understanding of a good death in Mainland China, where western philosophy seemed to rule the political medical actors while traditional Chinese philosophy seemed to rule parts of the population.

Willingness of patients with cancer pain to participate in end-of-life decisions: a multi-center cross-sectional study from three coastal provinces in southern China

BACKGROUND

Little is known about patients' intention for participation in end-of-life decisions (EOLD) in three coastal provinces in southern China. This study aimed to explore the willingness of patients with cancer pain to participate in EOLD and potential influencing factors.

METHODS

A multi-center cross-sectional study was performed in three coastal provinces in southern China. Two hundred and thirty patients with cancer pain were recruited and consented to fill out the questionnaires. The patients' willingness to participate in EOLD, demographic and disease-related data was surveyed.

RESULTS

In total, 223 patients completed and returned the survey (response rate = 96.95%). One hundred four cases (46.64%) were willing to participate in EOLD. 119 (54.36%) cases not willing to participate in EOLD, respectively. Multivariate logistic regression analysis shows that educational level (OR: 0.683, 95% CI: 0.482-0.966), history of alcoholism (OR: 8.353, 95%CI: 2.535-27.525), Eastern Cooperative Oncology Group (ECOG) score (OR: 0.645, 95% CI: 0.450-0.925) and experience of explosive pain (OR: 6.367, 95% CI: 3.103-13.062) and clinical rescue (OR: 3.844, 95% CI: 1.722-8.577) had significant effects on EOLD intention (P <  0.05). Finally, a predictive model combined above five factors was established, which showed a good discrimination (area under receiver operating characteristic curve: 0.849, 95% CI: 0.796-0.899, P <  0.001) and calibration (Hosmer-Lemeshow Test: Chi-square = 10.103, P = 0.258) for which patients more willing to participate in EOLD.

CONCLUSIONS

The willingness of patients with cancer pain to participate in EOLD is at a modest level in three coastal provinces in southern China. Patients with lower educational level, history of alcoholism, better health status and experience of explosive pain and clinical rescue may be more prone to participate in EOLD.

Trajectories to a cancer diagnosis: Why and when women seek help for breast symptoms in Vietnam

Women in low- and middle-income countries where the prevalence and mortality of breast cancer are growing rapidly are more likely to be diagnosed at advanced stages, which negatively affects their treatment outcomes and chance of survival. The current literature in those settings tends to focus largely on explaining patient delay in seeking medical attention for breast symptoms. Meanwhile, little is known as to what prompts women to attend screening and diagnostic services after discovering symptomatic breasts. Drawn upon the data from in-depth interviews with 33 breast cancer patients in Central Vietnam conducted in 2019, this paper examines the context of women's decisions about breast screening and how the practice of seeking cancer diagnosis occurred. Our findings reveal an absence of a national screening program and that seeking medical advice was conducted on an ad hoc basis after self-detection of breast symptoms. Women's interpretations of symptomatic breasts as suspicious signs of cancer, the co-occurrence of important life events, or encouragement by people in their social network motivated women to seek medical attention at different public and private health facilities. Their encounters with the health sector often involved multiple visits across time and space in which they experienced various forms of diagnosis delay produced by the health system. Our study carries implications for interventions to encourage women's awareness of early cancer symptoms and prompt medical presentation after self-discovery of symptomatic breasts.

A Descriptive and Phenomenological Exploration of the Spiritual Needs of Chinese Children Hospitalized with Cancer

Spiritual well-being is the fourth dimension of health, as equally important as physical, mental, and social well-being. The shadow of death associated with cancer triggers children to explore their personal values, meanings, and life goals throughout the illness trajectory, enabling them to identify their unique spiritual needs. Chinese children are generally non-religious, unlike Western children, which affects their spiritual needs. To address the literature gaps, we applied a qualitative, descriptive, phenomenological approach for exploring the spiritual needs of Chinese children hospitalized with cancer. Purposive sampling was conducted in two public hospitals with special wards for pediatric oncology patients in Hunan Province, China. Consequently, 22 children, hospitalized with cancer, were recruited and individually interviewed using a semi-structured interview format. We conducted a thematic analysis of the interview transcripts. Four important themes were identified: the need for self-exploration, inner needs, need for a connection with others, and need for a connection with gods, supernatural powers, and fictional characters. We found that culture significantly influenced the spiritual needs of Chinese children with cancer. Hope was a key factor motivating the children to continue cancer treatment. To address their unique spiritual needs, culturally specific interventions should be developed and incorporated into their care to enhance their spiritual well-being.

The experiences of clinical nurses coping with patient death in the context of rising hospital deaths in China: a qualitative study

Background

Chinese clinical nurses are increasingly confronting patient death, as the proportion of hospital deaths is growing. Witnessing patient suffering and death is stressful, and failure to cope with this challenge may result in decreased well-being of nurses and impediment of the provision of “good death” care for patients and their families. To our knowledge, few studies have specifically explored clinical nurses’ experiences coping with patient death in mainland China. 

Objective

We aimed to explore nurses’ experiences coping with patient death in China in order to support frontline clinical nurses effectively and guide the government in improving hospice care policy.

Methods

Clinical nurses were recruited using purposive and snowball sampling between June 2020 and August 2020. We gathered experiences of clinical nurses who have coped with patient death using face-to-face, semi-structured, in-depth interviews. Audio recordings were transcribed verbatim and analyzed using thematic analysis.

Results

Three thematic categories were generated from data analysis. The first was “negative emotions from contextual challenges.” This category involved grief over deaths of younger persons, pity for deaths without family, and dread related to coping with patient death on night duty. The second category was “awareness of mortality on its own.” Subthemes included the ideas that death means that everything stops being and good living is important because we all die and disappear. The third category was “coping style.” This category included focusing on treating dying patients, recording the signs and symptoms, and responding to changes in the patient’s condition. It also involved subthemes such as avoiding talk about death due to the grief associated with dying and death, and seeking help from colleagues.

Conclusions

Clinical nurses’ emotional experiences are shaped by intense Chinese filial love, charity, and cultural attitudes towards death. Reasonable nurse scheduling to ensure patient and staff safety is a major priority. “Good death” decisions based on Chinese ethical and moral beliefs must be embedded throughout hospital care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01054-8.

Experiences of redeployed healthcare workers in the fight against COVID-19 in China: A qualitative study

Introduction

Public health responses were triggered while COVID-19 was spreading. China redeployed healthcare workers to serve the most vulnerable populations and communities in the initial epicentre—Wuhan. However, it is not known how redeployment processes impacted on healthcare workers in a pandemic crisis.

Aims

To explore the experiences and needs of frontline healthcare workers who were redeployed to care for COVID-19 patients in Wuhan, China, and understand the long-term impacts of the redeployment experience on their work and life.

Methods

A qualitative study was conducted with redeployed healthcare workers using semi-structured interviews and thematic analysis. This study is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) guidelines.

Findings

A total of 20 redeployed healthcare workers (13 nurses and seven physicians) participated, and four themes were generated: (1) Initial feelings and emotions of redeployment—Participants experienced worries and concerns, a sense of isolation and loneliness on their arrival to the epicentre. (2) ‘It is like a war zone’—Healthcare workers faced a range of risks and challenges of caring for COVID-19 patients in Wuhan in the context of resource strain. (3) Uncertainty and coping strategies in patient care—Despite the hardships experienced, participants continued to deliver high-quality patient care including psychological care and palliative care, good communication and building mutual trusting relationships. (4) Reflection and far-reaching impacts of caring for COVID-19 patients—Participants felt motivated and encouraged as efforts were recognised by the government and wider society.

Conclusions

Redeployed healthcare workers shared their unique needs and experiences of coping with redeployment and challenges they faced in the context of resource strain, which has significant implications for policy and future practice. The reality of a pandemic may reduce healthcare workers’ willingness to work due to various reasons including inadequate preparedness of facilities and workplace safety. It is important to support frontline healthcare workers in order to maintain an adequate healthcare workforce in pandemic crises. Continuously evolving pandemic circumstances and uncertainty highlight the importance of an organized national pandemic response plan for subsequent waves of COVID-19 and future pandemics.

Factors Influencing Chinese Professional Caregivers’ Bereavement Experiences After Patient Deaths: A Secondary Qualitative Study

This study aims to identify the factors that influence Chinese professional caregivers’ bereavement experiences after patient deaths. Through a content analysis, the study reanalyzed the qualitative data initially collected to understand the lived experiences of professional bereavement in Mainland China. Specifically, the study assessed semi-structured interview transcripts conducted with 24 Chinese physicians and nurses and generated 15 open codes, reflecting the influencing factors. These were further categorized into four themes: dying and death conditions, professional caregivers' characteristics, professional caregivers’ involvement, and the bereaved family. The results revealed that professional bereavement experiences and the unveiled factors relate to both the personal and professional lives of the interviewees. Overall, the health care system and cultural backgrounds should be listed as influencing factors for professional bereavement experiences in addition to the aforementioned four.

Lessons learned from a social worker's approach to advance care planning discussions with Chinese-immigrant oncology outpatients

PURPOSE

To examine Chinese-immigrant cancer patients' openness to advance care planning (ACP) in an outpatient oncology setting.

DESIGN

Retrospective review of social work assessment data.

SAMPLE

150 Chinese-immigrant patient charts were reviewed (55% Cantonese, 45% Mandarin).

METHODS

Data were summarized descriptively and with logistic regression analyses.

FINDINGS

Sixteen percent of patients had completed ACP prior to meeting with the oncology social worker (OSW). Twenty percent of patients agreed to complete a health care proxy (HCP) after receiving culturally-tailored education in their language of origin from the OSW, while 75% remained open to ongoing consideration of ACP and HCP completion.

CONCLUSIONS

This study illuminates how Chinese immigrants engage in ACP discussions in an oncology setting.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDER

OSWs can play an integral role in advocating, educating, and intervening with this population and can assist the interdisciplinary team in understanding the importance of the cultural differences, even if the OSW's primary language differs from that of a patient's.

The Impact of Cultural Diversity on End-of-Life Care

Despite the universality of death for humanity, end-of-life care needs and expectations are highly unique and influenced by the individual’s cultural conditioning, values, and beliefs. In the pursuit of quality end-of-life care provision within the increasingly complex and diverse contemporary medical context, it is vital for cultural idiosyncrasies to be taken into consideration in order to attend to the individual patient’s needs and end-of-life goals. Palliative chaplains, as the spiritual care specialists within the multidisciplinary healthcare team, play a crucial role in the support and facilitation of the holistic vision of end-of-life care delivery. However, the capacity of the chaplains to become culturally competent practitioners are often insufficiently addressed in their professional educational pathways, creating additional challenges for them in their practice. Using Hong Kong as a case study, this article examines the impact of cultural diversity on the effectiveness of the chaplains’ delivery of end-of-life spiritual care. Specifically, special attention will be focused on two identified challenges resulting from the lack of integration of local cultural understandings within the religion-cultural practice framework of chaplaincy formation: the cultural taboo of death, and the cultural idiosyncrasies in end-of-life communication. This article hopes to raise awareness of cultural incongruencies within the current chaplaincy professional formation and development, and to initiate further attention and efforts to support chaplains in becoming culturally competent practitioners in the pluralistic healthcare landscape.

The meaning of patient deaths for professional caregivers: A quantitative construct validation

The meaning of patient deaths is key to understanding professional bereavement. To validate its construct, we applied partial least square structural equation modeling (PLS-SEM) to online survey data from 563 Chinese physicians and nurses. Both the personal meaning and professional meaning contribute significantly while not interchangeably to the meaning of patient deaths. In addition to the loss of an acquaintance, the loss of a valuable life, and the loss of a professional goal, patient deaths can also mean trauma, bad luck, identity crisis, a warning, a learning opportunity, and a time to empathize with others' sufferings.

Neighborhood collective efficacy in stressful events: The stress-buffering effect

Although research on neighborhood effects has shown positive outcomes of collective efficacy in mental health, few studies have examined whether its protective role is universally applicable to all residents or the vulnerable population. Building on a stress-buffering model, this study examines whether or not neighborhood collective efficacy serves as a stress buffer to ameliorate the deleterious effects of exposure to stressful events across different population groups. Analyses are conducted based on a city-wide representative sample in Hong Kong linked to suicide events through spatial and temporal information. Neighborhood-level collective efficacy is constructed by the aggregated mean score of individual perceived collective efficacy within the same residential neighborhoods. Results from the logistic regression models show that individuals exposed to suicide in the residential surroundings have a higher risk of mental distress symptoms. Moreover, neighborhood-level collective efficacy tends to alleviate the mental distress upon exposure, but such a stress-buffering effect is only observed in older adults. Our findings provide a new perspective informed by the variation of stress-buffering effect across population groups. Thus, this study contributes to the understandings of neighborhood collective by demonstrating the stress-buffering effects among the vulnerable population.

Knowledge, Attitudes, and Cultural Beliefs about Healthy Aging and Alzheimer's Disease among Older Chinese Americans in New York City

Alzheimer's Disease (AD) and Related Dementias (ADRD) are a growing concern across the globe. Unfortunately, racial/ethnic minorities in the United States (U.S.), such as Chinese Americans, have lower ADRD knowledge, and these individuals are less likely to be targeted and engaged in recommended dementia prevention and care. The objective of this study is to examine knowledge, attitudes, and beliefs about healthy aging and ADRD among older Chinese Americans living in New York City. Chinese Americans with very low English proficiency were recruited from a senior center in New York City. Accordingly, surveys were translated and focus groups were conducted in Mandarin or Cantonese. Questionnaires assessed demographic and health characteristics. Focus groups followed an open-ended protocol which was guided by the published literature. Focus group discussions were audio recorded, transcribed, and translated to English for qualitative analysis. Analysis of qualitative data proceeded according to the constant comparative method. A total of 18 participants were recruited. Average age of participants was 76.4 years and participants were 72.2% female. The majority were married (72.2%). Participants reported chronic conditions, including diabetes (38.9%) and dyslipidemia (22.2%). Participants commonly reported that their health limited their ability to accomplish things (66.7%) and achieve things (66.7%). While 16.7% of participants reported no bodily pain, slight pain was reported by 44.4%, moderate pain by 33.3%, and extreme pain by 5.6%. Qualitative analysis revealed several prominent themes, including: (1) perceptions about normal aging; (2) fears about loneliness and cognitive decline; (3) understanding of healthy aging; (4) cultural influences on aging; and (5) perceptions of ADRD. Results from this study highlight a set of cultural beliefs about healthy aging as well as knowledge, attitudes, and beliefs pertaining to ADRD. These results may inform opportunities for increasing healthy aging practices and knowledge about dementia among underserved older Chinese Americans.

Similarities and differences between China and Sweden regarding the core features of palliative care for people aged 60 or older: a systematic scoping review

Background

Despite the increasing longevity of the world’s population, with an unprecedented rise in the number of people who need palliative care (PC), there has been sparse research regarding palliative care for older people, especially when it comes to comparison of PC between healthcare systems and cultures. The aim of this systematic scoping review was to identify the characteristics of the body of literature and to examine the knowledge gaps concerning PC research for older people (> 60 years) in two healthcare systems and cultures, mainland China and Sweden.

Methods

The guidelines PRISMA (Preferred Reporting Items for Systematic Reviews), and PICOS (Patient/population, Intervention, Comparison/control, and Outcome) were used. Empirical studies on patients 60 years or older, next of kin or staff participating in a palliative care intervention or setting were included. They were conducted in mainland China or in Sweden during 2007–2019, were published in English and were extracted from seven databases: Embase, PubMed, Scopus, Cinahl, PsycInfo, Academic Search Complete and Cochrane Library. Two independent researchers conducted the selection of studies, data extraction and methodological evaluation. Any disagreements were resolved in consultation with a third researcher. The analysis was manifest directed content analysis based on PICOS domains.

Results

Of the 15 studies, four were from mainland China and 11 from Sweden. Both countries included older patients with cancer but also other end-stage diseases such as heart failure and dementia. The studies differed in design, method and the content of the interventions. The study in China based on traditional Chinese medicine concerns traditional Chinese folk music. The six qualitative studies from Sweden were evaluations of five interventions.

Conclusions

Despite the high age of the participating patients, there was no focus on an ageing perspective concerning palliative care. To adapt to the changes taking place in most societies, future research should have increased focus on older persons’ need for palliative care and should take account of issues concerning research ethics, ethnicity and culture.

Registered in Prospero

CRD42020078685, available from.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00906-7.

Barriers and Facilitators to Advance Care Planning among Chinese Patients with Advanced Cancer and Their Caregivers

Background: Chinese American adults experience health disparities at the end of life. Culturally tailored advance care planning (ACP) may promote goal-concordant care across the continuum of serious illness. However, seriously ill Chinese Americans' preferences for ACP remain unknown. Objective: To explore barriers and facilitators to ACP among Chinese patients with advanced cancer and their caregivers. Design: Informed by socioecological theory, we conducted an exploratory qualitative study using semistructured interviews that were thematically analyzed. Setting/Participants: We recruited participants at one U.S. comprehensive cancer center. Of 27 eligible patients approached, we recruited 20 patients (74.1%) and 8 accompanying caregivers. Overall, participants were middle aged (55.6 ± 13.5 years), 60.7% female, 85.7% partnered/married, 89.3% college educated, and had low acculturation (mean Suinn-Lew Asian Self-Identify Acculturation = 2.0 ± 1.6/5.0). More patients were privately insured (35%) than self-pay (30%), Medicare (25%), and Medicaid (10%). Caregivers were split between "spouse" and "child." Results: Findings highlight participants' trust in their clinicians and the study institution as primary supports for clinicians to lead ACP. However, participants' preconceptions of clinicians' professional responsibilities and participants' belief in an uncertain future may hinder an open discussion of goals and values for future medical care. A key moderating factor in how participants view ACP may be their level of acculturation to local care, behavioral, and communication norms. Conclusions: Chinese patients may prefer a routinized clinician-led ACP approach that supports their actionable priorities in the present by leveraging patient-clinician trust, gauging acculturation level, and using indirect communication strategies. Future studies should investigate preferred communication strategies to support in-the-moment care planning.

Challenges and Opportunities for Academic Journals to Serve the Older Population in Western Pacific Region

Annals of Geriatric Medicine and Research held its inaugural international editorial board virtual meeting on September 16, 2021, to brainstorm ideas for sustainable growth. This special article summarizes the key concepts obtained from the webinar proceedings, with further development of ideas from ensuing discussions occurring after the meeting. From the initial discussion points provided by eight editorial board members, including six presenters, email discussions further enriched these ideas to construct the current special article. The key points discussed were: impactful research and impact factors, international and Asian perspectives, and challenges to sustainable growth. The editors noted the existing gap between the impact factor and research impact as a challenge for the growth paths of regional journals. However, they agreed that persevering with impactful research would ultimately translate into parallel and gradual gains in impact, which is, therefore, consistent with the organic growth of the journal. Acknowledging challenges in navigating between unique Asian perspectives and international outlooks, the editors encouraged academic journals to serve as bridges linking international evidence with the richness of local perspectives. For sustainable growth, the editors suggested that journals may be forged into the academic ecosystems of the region, diversify value streams, and establish themselves as reputable brands in disciplines. By combining these discussions, we proposed the “IMPACT” strategy for journals on the growth path in the region, which stands for IMmersive user experience encompassing authors, reviewers, and readers; Pasteur’s quadrant use-inspired research; Asia-Pacific context; Collaborative; and Translation to practice and policy.

Factors Associated with Behaviors Toward End-of-life Care Among Chinese Oncology Nurses: A Cross-Sectional Study

PURPOSE

The goal of this study was to describe the current status of oncology nurses' behaviors toward end of life (EOL) care in China and to explore the factors associated with oncology nurses' behaviors toward EOL care.

METHODS

A cross-sectional design was applied and a convenience sample of 1038 oncology nurses from 22 grade A hospitals were recruited into this study. A general social demographic data questionnaire was administered, and the Chinese version of Nurses' Behaviors of Caring for Dying Patients Scale was used to assess nurse behavior toward EOL care. The total score ranges from 40 to 200 points. Data were analyzed with SPSS 26.0 software.

RESULTS

Chinese oncology nurses' average score of holistic EOL care behaviors was 2.97 ± 0.59. Oncology nurses provide physical care most (3.81 ± 0.76), followed by family care (3.02 ± 0.86), and spiritual care (2.37 ± 0.67). Multiple regression analysis showed that a higher frequency of sharing EOL care experience with colleagues, in-service palliative care education, higher level of head nurse support for EOL patient care, more cases of EOL care, higher working position, and nurse's perceived high level of support were positively associated with behavior toward EOL care. These six factors explained 16.2% of the total variance.

CONCLUSIONS

The results may help provide a basis for converting behavior for EOL care among oncology nurses and design interventions to better improve quality of life for EOL patients with cancer in China.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Advance care planning preferences in Chinese nursing home residents: results from two cross-sectional studies in Hong Kong and Taiwan

Background

The proportion of hospital deaths has declined in the past few decades, while the proportions of nursing home deaths have increased. This trend of increasing deaths in long-term care facilities underlines the importance of improving end-of-life care provisions in these settings to meet individual preferences and needs. Under these circumstances, a comprehensive understanding of end-of-life care preferences in local nursing home residents can help healthcare professionals and policymakers develop strategies to increase the advance directive completion rate and quality of care. This study aimed to explore and compare advance directive and end-of-life care preferences of nursing home residents in Hong Kong and Taiwan.

Methods

A structured questionnaire was developed by the research team to investigate advance directive and end-of-life care preferences in older Chinese nursing home residents. Nursing home residents with frail or pre-frail status and over the age of 64 were invited to participate in the study, and information on demographics, functional status, advance directive experiences, and end-of-life care expectations was collected through questionnaire interviews.

Results

A total of 325 eligible participants from 32 facilities completed the survey, including 238 older residents in Hong Kong and 87 in Taiwan. A significantly lower proportion of the Hong Kong residents had completed an advance directive compared with the Taiwanese (3 vs. 13%, p = 0.001). Among participants who did not have an advance directive, 46% of the Taiwanese participants said they would consider completing one in the future, compared with 20% of the Hong Kong participants (p < 0.001). A total of 79% of the Hong Kong participants and 80% of the Taiwanese participants responded that prolonging life in the given hypothetical dying scenario was “not important” (p = 0.76). Only 14% of participants in Hong Kong and 18% of participants in Taiwan reported prior occurrence of end-of-life care discussions with family members or health professionals (p = 0.37).

Conclusions

This paper adds evidence in support of improving end-of-life communication and the advance directive completion rate in nursing homes in Hong Kong and Taiwan. Further research is necessary to explore cross-cultural differences in end-of-life preferences and its applications in predicting decision-making and the quality of end-of-life care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00820-4.

Effects of message framing on recruiting Rh-D-negative blood donors in an emergency situation: Two randomized trials

OBJECTIVES

Prospect theory categorizes message framing according to whether it emphasizes a possible loss or a possible gain. Promotions of blood donation worldwide mainly focus on gain-framed appeal. The objective of the current study is to examine the effects of message framing on recruiting Rh-D-negative blood donors (RDNBDs) in an emergency situation.

DESIGN

Two randomized trials.

METHODS

In Study 1, 813 group O and 500 group B RDNBDs were randomly assigned to three groups receiving three different recruitment text messages: (1) gain-framed, (2) loss-framed, and (3) information messages. In addition, 613 group A and 148 group AB RDNBDs were marked as (4) no message group. In Study 2, 758 RDNBDs were randomly provided one of two versions of materials focusing on either the possible survival (gain-framed) or the death (loss-framed) of a Rh-D-negative patient needed a blood transfusion. These participants then completed a questionnaire to examine the possible mechanisms underlying the observed effects.

RESULTS

Compared to not receiving any message, significantly more RDNBDs re-donated within 14 days after they received a loss-framed message. Study 2 found that RDNBDs who read the loss-framed material expressed more willingness to donate immediately than those who read the gain-framed material. RDNBDs with high-risk perception expressed a greater blood donation intention in the loss-framed group. The loss-framed message made participants perceive others' needs more strongly, which generated more empathy, and thus increased blood donation intention.

CONCLUSIONS

The results suggested that recruiting RDNBDs using a loss-framed message is suitable under an emergency.

Transferring home to die from critical care units: A scoping review of international practices

PURPOSE

To identify and characterise the international practices of transferring a dying patient home to die from critical care units.

MATERIALS AND METHODS

A systematic scoping review following the Joanne Briggs Institute methodology was applied searching fifteen data sources to identify papers published in English and Chinese from 1970 to 2019.

RESULTS

Of the 28 papers meeting eligibility criteria 19 were published in the West and seven in China. The number of patients being transferred home to die was larger in China (74/184-96/159) than in the West (1-7). Clinical characteristics of patients transferred included: consciousness, with or without intubation and ventilation, and clinical stability. Reported key barriers to transfer included: Lack of evidence guiding transfer practice, the CCU environment and culture, Practical and logistical factors and Family members expectations and reactions. Key facilitators of transfer were reported as: Engagement with the multidisciplinary team and Personal patient and family wishes.

CONCLUSIONS

Transferring patients home to die from critical care is a complex practice varying significantly across countries. Further research to address current knowledge gaps is important to inform policy and practice.

Exploring Differential Perceptions and Barriers to Advance Care Planning in Dementia among Asian Patient-Caregiver Dyads-A Mixed-Methods Study

A parallel mixed-methods study on 20 patient–caregiver dyads in an Asian population was conducted to explore the differential perceptions and barriers to ACP in dementia. We recruited English-speaking patients with mild dementia and their caregivers. A trained ACP facilitator conducted ACP counseling. Patient–caregiver dyads completed pre–post surveys and participated in post-counseling qualitative interviews. We used mixed-methods analysis to corroborate the quantitative and qualitative data. Differential perceptions of ACP were reported among dyads, with caregivers less inclined for further ACP discussions. Post-ACP counseling, caregivers were significantly more likely to acknowledge barriers to ACP discussions than patients (57.9% versus 10.5%, p = 0.005). Thematic analysis of the interview transcripts revealed four themes around barriers to ACP: patient-related factors (transference of decision making, poor cognition and lack of understanding, and dis-inclination to plan for the future), caregiver-related factors (perceived negative impact on the patient, caregiver discomfort, and confidence in congruent decision making), socio-cultural factors (taboos, superstitions, and religious beliefs), and the inappropriate timing of discussions. In a collectivist Asian culture, socio-cultural factors pose important barriers, and a family-centric approach to initiation of ACP may be the first step towards engagement in the ACP process. For ACP in dementia to be effective for patients and caregivers, these discussions should be culturally tailored and address patient, caregiver, socio-cultural, and timing barriers.

Increasing the completion rate of the advance directives in primary care setting - a randomized controlled trial

BACKGROUND

The completion rate of Advance Directives (ADs) has been low. This study aims to examine the effectiveness of two interventions 1) active counseling sessions coupled with passive patient education pamphlets, and 2) patient education pamphlets alone, compared with 3) control group (usual care), in increasing the completion rates of ADs in the primary care setting.

METHODS

Multicenter randomised controlled trial in four public primary care clinics in Singapore under Singapore Health Services. Randomization was performed via block randomization with Sequential Numbered Opaque Sealed Envelopes. Participants were randomized into 1) active intervention group (both counseling by primary care physicians and patient education pamphlets) or 2) passive intervention group (only patient education pamphlets), and 3) control group (usual care) with follow-up at 6 weeks. The main outcome measure is the proportion of participants who completed / planned to complete) ADs six weeks post-intervention.

RESULTS

Four hundred five participants were eligible to participate in the study. One hundred eighty-eight participants were recruited into the study (response rate = 46.4%), of which 158 completed the study. There was no significant difference between the control group, passive intervention group, and active intervention group, in terms of completion rates of ADs (29.4, 36.4, and 30.8% respectively).

CONCLUSIONS

This randomized controlled trial did not support the use of patient education pamphlets with or without active counseling sessions in increasing the completion of ADs in a primary care setting in Singapore. The optimal intervention strategy depends on each health system's context and resources, taking into consideration patients' profiles, which deserves further studies.

TRIAL REGISTRATION

Registered on April 17, 2018 clinicaltrials.gov ( NCT03499847 ).

"I decide myself"- A qualitative exploration of end of life decision making processes of patients and caregivers through Advance Care Planning

BACKGROUND

The Singapore national Advance Care Planning (ACP) programme was launched in 2011 with the purpose of ensuring that healthcare professionals are fully aware of patients' treatment preferences. There is little research assessing the performance of such programmes in ethnically diverse Asian countries; hence, the purpose of this study was to qualitatively examine patients and caregivers' experiences with the ACP programme.

METHOD

We conducted interviews with 28 participants, thirteen of whom identified as proxy decision makers (PDMs) and the remainder as patients. Interviews focused on respondents' experiences of chronic illness and of participating in the ACP programme. Textual data was analysed through a framework analysis approach.

RESULTS

Participants' narratives focused on four major themes with 12 subthemes: a) Engagement with Death, factors influencing respondents' acceptance of ACP; b) Formation of Preferences, the set of concerns influencing respondents' choice of care; c) Choice of PDM, considerations shaping respondents' choice of nominated health spokesperson; and d) Legacy Solidification, how ACP is used to ensure the welfare of the family after the patient passes. These findings led to our development of the directive decision-making process framework, which delineates personal and sociocultural factors influencing participants' decision-making processes. Respondents' continual participation in the intervention were driven by their personal belief system that acted as a lens through which they interpreted religious doctrine and socio-cultural norms according to their particular needs.

CONCLUSION

The directive decision-making process framework indicated that ACP could be appropriate for the Asian context because participants displayed an awareness of the need for ACP and were able to develop a concrete treatment plan. Patients in this study made decisions based on their perceived long-term legacy for their family, who they hoped to provide with a solid financial and psychological foundation after their death.

Life-and-Death Attitude and Its Formation Process and End-of-Life Care Expectations Among the Elderly Under Traditional Chinese Culture: A Qualitative Study

Introduction

With the global aging process intensified, the demand for end-of-life care has surged, especially in China. However, its development is restricted. Understanding the life and death attitude among the elderly and its formation process, and clarifying their needs, are so important to promote social popularization of end-of-life care.

Methodology

This qualitative study included 20 elderly residents in Nan and Shuangbei Communities, Chongqing City, People’s Republic of China. Data were collected through semistructured in-depth individual interviews and processed by thematic analysis method.

Results

Three themes and eight subthemes were identified: Characteristics of formation process (passive thinking, closed and single), life-and-death attitude (cherish and enjoy life, quality of life priority, let death take its course) and expectations of end-of-life care (preferences, basic needs, good death).

Discussion

Life-and-death attitude and end-of-life care expectations of the elderly support the development and delivery of end-of-life care. Furthermore, the individual-family-hospital linkage discussion channel needs to be further explored.

Effects and satisfaction of dignity therapy among patients with hematologic neoplasms in the Chinese cultural context: a randomized controlled trial

PURPOSE

To evaluate potential effects and satisfaction of dignity therapy among patients with hematologic neoplasms in the Chinese cultural context.

METHODS

Sixty-six patients with hematologic neoplasms were randomly assigned into either a dignity therapy group (N = 32) or control group (N = 34). The primary outcomes were level of hope and spiritual well-being, as measured according to the Herth Hope Index and the 12-item Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being, at baseline (T0), 1-week follow-up (T1), and 4-week follow-up (T2). Satisfaction with dignity therapy was assessed using a 5-grade marking system at T1.

RESULTS

Among the 66 participants, 61 remained at 1-week follow-up and 57 remained at 4-week follow-up. Group differences were found in the total score and the scores of each dimension of spiritual well-being and level of hope at T1 and T2 (p < 0.05). Interaction effects were statistically significant in terms of spiritual well-being (p < 0.001) and level of hope (p < 0.001). Majority of the patients (93.34%) and family members (96.67%) gave positive evaluations ("very satisfactory" or "relatively satisfactory") for the dignity therapy intervention.

CONCLUSION

Implementing dignity therapy among patients with hematologic neoplasms in China was associated with good efficacy in improving spiritual well-being and the level of hope in the short term. Difficulties and solutions involved in the implementation of dignity therapy in multiple cultures deserve attention.