Impact of perception of socioeconomic burden on advocacy for patient autonomy in end-of-life decision making: a study of societal attitudes

Nurse's, physician's and family member's experiences of withholding or withdrawing life-sustaining treatment process in an intensive care unit

AIMS

To explore nurse's, physician's and family member's experiences of withholding or withdrawing life-sustaining treatment in an intensive care unit.

BACKGROUND

In South Korea, withholding or withdrawing life-sustaining treatment is legalised by the enforcement of the Hospice, Palliative Care and Life-sustaining Treatment Decision-making Act (2018). The Act (2018) is the first legal ground for making decisions regarding life-sustaining treatment in South Korea.

DESIGN

Focused ethnography. The standards for reporting qualitative research checklist is used.

METHODS

Interview data are collected between August 2018 and January 2019 using semi-structured interviews with 23 nurses, 10 physicians and four family members in a South Korean intensive care unit. The interview data are analysed following the thematic analysis of Braun and Clarke.

RESULTS

An overarching theme of 'constructing death' is identified from the experiences of nurses, physicians and family members regarding withholding or withdrawing life-sustaining treatment in a South Korean intensive care unit. Family members had the strongest power in the withholding or withdrawing life-sustaining treatment process whilst the process had to be based on medical consideration. All the research participants shared the purpose and motivation of withholding or withdrawing life-sustaining treatment as the dying patient's dignity. Due to the South Korean national health insurance system, the relationships between medical staff and family members were driven by customer ideology.

CONCLUSION

The impact and linkage of the context of familism culture and health insurance with the process of withholding or withdrawing life-sustaining treatment in South Korea are shown in this research. The findings of this research inspire future studies to uncover the impact of the cultural context in the decision-making process of a patient's death, to explore the dynamics of family members under cultural values and to explore the influence of the healthcare system and medical costs on the relationships between medical staff and family members.

RELEVANCE TO CLINICAL PRACTICE

By integrating the experiences of nurses, physicians and family members, the findings of this study inform the shared values in the context of familism culture and the health insurance system. In particular, understanding family dynamics when a patient's dying and death as a result of withholding or withdrawing life-sustaining treatment informs nurses to provide quality of care in the intensive care setting. Therefore, the findings of this research contribute to distinguishing the priority in care when withholding or withdrawing life-sustaining treatment, rapidly changing the aims of care from the patient's recovery to a dignified death.

Factors associated with place of death for terminal cancer patients who wished to die at home

A patient's desired place of death is an important indicator of the quality of dying. The purpose of this study was to investigate the actual places of death of terminal cancer patients who wished to die at home and the factors affecting their actual place of death. A retrospective survey was used to analyze the medical records of 143 terminal cancer patients who wanted to die at home among a population of 168 patients who used a home hospice care service more than once between March 2016 and December 2019. Patients who wanted to die at home represented 85.1% of the total study population (143 patients). Of these, 31.5% and 68.5% were home and hospital deaths, respectively. Factors associated with the actual place of death of patients who desired to die at home were marital status (odds ratio [OR] = 2.57, confidence interval [CI]: 1.08-6.13), the patient's status at the time of their enrollment in a home hospice care service (OR = 3.30, CI: 1.56-7.02), and the primary caregiver's relationship with the patient (OR = 2.52, CI: 1.12-5.66). Most terminal cancer patients studied did not die in their preferred place. Support from policies and hospice professionals is needed to decrease caregiver burden and help patients die wherever they want. Consequently, quality of end-of-life care can be improved.

Advance care planning in Asian culture

Ageing has been recognized as one of the most critically important health-care issues worldwide. It is relevant to Asia, where the increasing number of older populations has drawn attention to the paramount need for health-care investment, particularly in end-of-life care. The advocacy of advance care planning is a mean to honor patient autonomy. Since most East Asian countries are influenced by Confucianism and the concept of 'filial piety,' patient autonomy is consequently subordinate to family values and physician authority. The dominance from family members and physicians during a patient's end-of-life decision-making is recognized as a cultural feature in Asia. Physicians often disclose the patient's poor prognosis and corresponding treatment options to the male, family member rather to the patient him/herself. In order to address this ethical and practical dilemma, the concept of 'relational autonomy' and the collectivism paradigm might be ideally used to assist Asian people, especially older adults, to share their preferences on future care and decision-making on certain clinical situations with their families and important others. In this review article, we invited experts in end-of-life care from Hong Kong, Indonesia, Japan, South Korea, Singapore and Taiwan to briefly report the current status of advance care planning in each country from policy, legal and clinical perspectives. According to the Asian experiences, we have seen different models of advance care planning implementation. The Asian Delphi Taskforce for advance care planning is currently undertaken by six Asian countries and a more detailed, culturally sensitive whitepaper will be published in the near future.

Perceptions of and Attitudes Toward Death, Dying, Grief, and the Finitude of Life-A Representative Survey Among the General Public in Germany

Some end-of-life aspects have become a significant political and social issue such as elderly care and euthanasia. But hardly anything is known about how the general public in Germany thinks about death and dying more generally. Therefore, we conducted a representative online survey (N = 997) regarding 21 end-of-life aspects. Differences between subgroups were analyzed by conducting analyses of variance and Tukey honestly significance difference post hoc tests and by performing t tests. The findings revealed that the general public is open to engaging with topics of death, dying, and grief and that death education might even be promoted for children. Most participants appraised dealing with the finitude of life as part of a good life, but few have contemplated death and dying themselves so far. Attitudes and perceptions were related to age, subjective health, religious denomination, and gender. The survey provides useful implications for community palliative care, death education, and communication with dying people.

Translation and cultural adaptation of the quality of communication questionnaire for ICU family members in Korea

BACKGROUND

There are no Korean instruments to assess the concepts associated with end-of-life communication quality.

OBJECTIVES

To translate and culturally adapt the Quality of Communication (QOC) questionnaire into Korean and evaluate its acceptability and internal consistency.

METHODS

We first translated the QOC from English into Korean, then back-translated from Korean to English, and evaluated the cultural appropriateness of the items. We pretested and refined the Korean version of the QOC with 11 ICU family members. Subsequently, the Korean version of the QOC was administered to 62 family members of chronically critically ill patients recruited from 10 ICUs to evaluate its internal consistency.

RESULTS

Participants completed the Korean QOC without difficulty during the pretest, and it showed acceptable internal consistency (Cronbach's alpha ≥0.85).

CONCLUSION

This study provided preliminary evidence of the acceptability and reliability of the Korean QOC in ICU family members. Nonetheless, further evaluation, including item relevance and other psychometric properties, is warranted.

Physicians' attitude toward the withdrawal of life-sustaining treatment: A comparison between Korea, Japan, and China

End-of-life care decision making has become a matter of serious ethical and legal concern in the three Far East Asian Countries of China, Japan, and Korea. Researchers in the three countries collaboratively conducted a comparative descriptive study with respect to physicians' perspectives concerning end-of-life care decisions. In spite of cultural similarities, each country has its own unique set of social, cultural, and political circumstances. So the content and scope of policies and laws on end-of-life decision reflect the differing views of people based on their social status, moral values, religious beliefs, and economic status.

Association between the emotional status of family caregivers and length of stay in a palliative care unit: A retrospective study

OBJECTIVE

Several factors associated with referral time to hospice and/or palliative care services have been identified, but there is no literature on the association between these services and the emotional status of the family caregivers (FCs). This article is intended to address that issue.

METHOD

A semistructured interview was employed to collect data for a retrospective cohort study. The primary FCs of terminally ill cancer patients were interviewed at the time of the patient's referral to the palliative care unit. Interview data were combined with patients' medical record data for our analysis. The emotional status of the FCs was categorized into one of three groups according to their responses to the anticipated death of their family member: acceptance, anxious/depressed, and denial/angry. A Cox proportional hazard model was used to examine and identify the factors related to the length of stay (LOS) in the palliative care unit.

RESULTS

A total of 198 patient-FC pairs were identified. The median LOS was 18 days. A multivariate analysis with adjustment for potential variables revealed significant differences in LOS according to cancer type and time since cancer diagnosis. The denial/angry FC category was independently associated with a shorter LOS (vs. acceptance, adjusted hazard ratio (aHR) 2.11; 95% confidence interval (CI), 1.11-4.03).

SIGNIFICANCE OF RESULTS

We found that terminally ill cancer patients who were referred late had FCs who were in denial or were angry about the anticipated death of their loved one. The emotional status of FCs should be considered when patients with terminal cancer are referred to palliative care.

Preferences for autonomy in end-of-life decision making in modern Korean society

Background:

The demand for autonomy in medical decision making is increasing among Korean people, but it is not well known why some people prefer autonomy in decision making but others do not.

Research objectives:

The aim of this study was to determine the extent to which Korean adults wished to exercise autonomy in the process of decision making regarding end-of-life treatment and to determine whether economic issues and family functioning, in particular, were associated with preferences for participation in decision making in Korean people.

Research design:

This study was a cross-sectional correlational study using a survey.

Participants and research context:

Data were collected using structured questionnaires from 354 patients or their families who visited ambulatory departments at two general hospitals in South Korea, recruited by the proportionate quota sampling method. Data analysis was performed using multinomial logistic regression analyses.

Ethical considerations:

The study was approved by the hospitals’ directors and the ethics committee of Kyungpook National University Hospital. Written informed consent was given by all participants.

Findings:

A majority of Korean people wanted to make autonomous decisions regarding treatment at the end of life. Preferences for autonomous decision making regarding end-of-life treatment, rather than relying on family, showed a significant increase in association with poor family functioning and low income.

Discussion:

Results of this study suggested the necessity for development of alternatives to a dominant traditional “family-centered” approach in Korean people, in order to enhance end-of-life decision making for people who wish to take an active role in the decision-making process.

Conclusion:

Healthcare providers need to examine not only patients’ preferred decision-making style but also any reasons for their choice, in particular, family conflict and financial burden.

Perceived risks around choice and decision making at end-of-life: a literature review

BACKGROUND

the World Health Organization identifies meeting patient choice for care as central to effective palliative care delivery. Little is known about how choice, which implies an objective balancing of options and risks, is understood and enacted through decision making at end-of-life.

AIM

to explore how perceptions of 'risk' may inform decision-making processes at end-of-life.

DESIGN

an integrative literature review was conducted between January and February 2010. Papers were reviewed using Hawker et al.'s criteria and evaluated according to clarity of methods, analysis and evidence of ethical consideration. All literature was retained as background data, but given the significant international heterogeneity the final analysis specifically focused on the UK context.

DATA SOURCE

the databases Medline, PsycINFO, Assia, British Nursing Index, High Wire Press and CINAHL were explored using the search terms decision*, risk, anxiety, hospice and palliative care, end-of-life care and publication date of 1998-2010.

RESULTS

thematic analysis of 25 papers suggests that decision making at end-of-life is multifactorial, involving a balancing of risks related to caregiver support; service provider resources; health inequalities and access; challenges to information giving; and perceptions of self-identity. Overall there is a dissonance in understandings of choice and decision making between service providers and service users.

CONCLUSION

the concept of risk acknowledges the factors that shape and constrain end-of-life choices. Recognition of perceived risks as a central factor in decision making would be of value in acknowledging and supporting meaningful decision making processes for patients with palliative care needs and their families.

Measuring the structure and process of end-of-life care in Korea: validation of the Korean version of the Care Evaluation Scale (CES)

CONTEXT

A reliable and valid measure of structure and process of end-of-life care is important for improving the outcomes of care.

OBJECTIVES

This study examined the validity and reliability of the Korean version of Care Evaluation Scale (CES), which was developed in Japan to evaluate structure and process of palliative care from the perspective of bereaved family members.

METHODS

Standard forward-backward translation and a pilot test were conducted. A multicenter cross-sectional survey was conducted with bereaved family members (n=501) of patients who had died from cancer two to six months before the study. Descriptive analyses were performed. The reliability of the CES was tested by Cronbach's alpha. The dimensional structure was assessed using confirmatory factor analyses. Concurrent and discriminant validity were tested by correlation with the overall satisfaction with care, patient's overall quality of life (QoL), and family member's own QoL as measured by the EQ-5D.

RESULTS

Participants could complete the CES readily, with low missing response rates. Cronbach's alpha for internal consistency was 0.93 overall, and ranged from 0.88 to 0.94 for subdomains. The hypothesized 10 subscale model of the CES appeared to fit the data (goodness-of-fit index=0.854). The overall score of the CES moderately correlated with overall satisfaction with care (r=0.54, P<0.001), more weakly correlated with the patient's QoL (r=0.32, P<0.001), but did not correlate with the family member's QoL (r=0.03, P=0.548).

CONCLUSION

The CES was found to be a reliable and a valid measure of the necessity for improvement in the structure and process of end-of-life care from bereaved family members' perspectives.

Is patient autonomy a critical determinant of quality of life in Korea? End-of-life decision making from the perspective of the patient

PURPOSE

We aimed to investigate the current practice of the involvement in decision making from the perspectives of terminal cancer patients, and to explore its possible associations with quality of life and quality of death in Korea.

METHODS

A multi-center, cross-sectional survey was performed on 93 terminal cancer patients. The questionnaire solicited their opinions regarding participation in treatment decision making, as well as quality of life (European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire for Palliative Care) and quality of death (Good Death Inventory-Patient Version).

RESULTS

A total of 78.5% of the patients had awareness of their terminal status, while 21.5% did not; 42.4% stated that they knew their condition and shared the decision-making responsibility with the medical staff and their family, while 21.7% made decisions on their own, and 35.9% left the decision-making responsibility to others. Patients who were aware of their illness and who actively participated in the decision making did not score higher than others on outcome measures of quality of life and quality of death. Moreover, the former even showed lower scores in some domains, including the 'physical and psychological comfort' (4.99 versus 5.61, p = 0.03), 'environmental comfort' (5.51 versus 6.04, p = 0.08), and 'emotional functioning' (55.70 versus 71.01, p = 0.06).

CONCLUSION

in Korea, patient autonomy is not a universally accepted value from the perspectives of terminal cancer patients, nor is patient involvement in decision making always conducive to high quality of life or quality of death. The level of information and the pace at which it is provided should be tailored to each individual's ability, preference, need, and culture.

Measuring comprehensive outcomes in palliative care: validation of the Korean version of the Good Death Inventory

CONTEXT

No systematic or comprehensive attempts have yet been made to assess quality of death as an indicator of palliative care outcomes in Korea, and no validated instruments exist for the assessment of a good death in Koreans.

OBJECTIVES

This study examined the validity and reliability of the Korean version of the Good Death Inventory (GDI), which was developed in Japan to evaluate the quality of death from the perspective of bereaved family members.

METHODS

Forward and backward translations and a pilot test were conducted. In a multicenter cross-sectional survey, a questionnaire packet, including the GDI, overall quality of life during the last week, and overall satisfaction with care, was mailed to bereaved family members (n=501) of patients who had died from cancer two to six months before the study. Descriptive analyses were performed, including response rate, mean, median, skewness, and kurtosis for each item. The reliability of the GDI was tested by Cronbach's alpha. The dimensional structure was assessed using confirmatory factor analyses. Concurrent validity was tested by correlation with the overall quality of life and overall satisfaction with care.

RESULTS

Participants were able to complete the GDI, and the compliance rates were satisfactory. Cronbach's alpha coefficient for internal consistency was 0.93 overall and ranged from 0.69 to 0.94 for subdomains. The hypothesized 18-factor model of a good death appeared to fit the data (goodness of fit index [GFI]=0.964; adjusted GFI index=0.960; normal fit index=0.952). The overall scores on the GDI correlated with patients' quality of life (0.56; P<0.001) and overall satisfaction with care (0.44; P<0.001).

CONCLUSION

The Korean version of the GDI is a reliable and valid measure of the comprehensive outcomes of palliative care from the perspective of bereaved Korean family members.

Trends in Cancer Screening Rates among Korean Men and Women: Results from the Korean National Cancer Screening Survey (KNCSS), 2004-2010

Purpose

The Korean National Cancer Screening Survey (KNCSS) is a continuous nationwide survey implemented by the National Cancer Center in Korea since 2004. The purpose of the present study was to report trends in cancer screening rates for the five major cancers (stomach, liver, colorectal, breast, and cervix uteri) in Korean men and women.

Materials and Methods

The study used KNCSS data collected between 2004 and 2010. The survey was conducted on Korean men aged 40-74 years and Korean women aged 30-74 years with no history of cancer diagnosis. The annual percentage change and corresponding 95% confidence intervals were used to examine changes in annual screening rates.

Results

Screening rates with recommendation increased by 4.4% annually for stomach cancer, 1.5% for liver cancer, 2.8% per year for colorectal cancer, 4.5% for breast cancer, and 1.2% for cervix uteri cancer. The increasing trend in cancer screening rates, with the exception of liver cancer, was significant.

Conclusion

Cancer screening rates have increased consistently from 2004 to 2010 among Korean men and women. Stomach and breast cancer screening rates in particular have increased markedly.

Factors influencing preferences of Korean people toward advance directives

Although Korean society has begun to seek a way of utilizing advance directives, there is not much known about the factors influencing the average Korean person's preference toward advance directives. The purpose of this study was to examine factors, in addition to demographic variables, influencing preferences regarding advance directives. These include: to what extent people's awareness of advance directives, preferences of extending their life at the end of life, experience of illness and medical care, and family functioning independently influence the preferences toward advance directives. The participants were 382 community-dwelling Korean people. The data analysis was performed using hierarchical multiple logistic regression analysis. The findings showed that a majority of Korean people had a positive preference on advance directives and the factors influencing their preferences for advance directives were the preferences against the use of life-sustaining treatment at the end of life, a good self-rated heath status, and an unsatisfactory family functioning.

Estimation of nationwide vaccination coverage and comparison of interview and telephone survey methodology for estimating vaccination status

This study compared interview and telephone surveys to select the better method for regularly estimating nationwide vaccination coverage rates in Korea. Interview surveys using multi-stage cluster sampling and telephone surveys using stratified random sampling were conducted. Nationwide coverage rates were estimated in subjects with vaccination cards in the interview survey. The interview survey relative to the telephone survey showed a higher response rate, lower missing rate, higher validity and a less difference in vaccination coverage rates between card owners and non-owners. Primary vaccination coverage rate was greater than 90% except for the fourth dose of DTaP (diphtheria/tetanus/pertussis), the third dose of polio, and the third dose of Japanese B encephalitis (JBE). The DTaP4: Polio3: MMR1 fully vaccination rate was 62.0% and BCG1:HepB3:DTaP4:Polio3:MMR1 was 59.5%. For age-appropriate vaccination, the coverage rate was 50%-80%. We concluded that the interview survey was better than the telephone survey. These results can be applied to countries with incomplete registry and decreasing rates of landline telephone coverage due to increased cell phone usage and countries. Among mandatory vaccines, efforts to increase vaccination rate for the fourth dose of DTaP, the third dose of polio, JBE and regular vaccinations at recommended periods should be conducted in Korea.

Late referral to palliative care services in Korea

CONTEXT

Although timely referral to palliative care services can help improve quality of life by minimizing patient and family suffering during a life-threatening illness, it remains unclear whether patients in Korea who suffer from advanced cancer are referred to palliative care services in a timely manner.

OBJECTIVES

We aimed to investigate the timeliness of patient referral to palliative care services in Korea by examining the duration of survival after enrollment and identify the factors contributing to earlier or later referral.

METHODS

Patient- and episode-level data were collected from 3867 terminal cancer patients, who were registered in 34 inpatient palliative care services designated by the Ministry of Health, Welfare, and Family Affairs. Cox proportional hazard models were used to determine factors associated with the duration of survival after enrollment in palliative care services.

RESULTS

The median duration of survival after enrollment in palliative care services was 18 days. Male sex, liver cancer diagnosis, poor performance status, being covered by National Health Insurance, and being married were significantly associated with shorter duration of survival after enrollment, whereas a prostate cancer diagnosis was associated with longer survival.

CONCLUSION

Korean terminal cancer patients are referred to palliative care very late, and the timing appears to be influenced by some socioeconomic and medical factors. Interventions, such as physician education and establishing palliative care teams, are required to promote earlier referrals in Korea.