Factors influencing terminal cancer patients' autonomous DNR decision: a longitudinal statutory document and clinical database study

Objective

Much of our knowledge of patient autonomy of DNR (do-not-resuscitate) is derived from the cross-sectional questionnaire surveys. Using signatures on statutory documents and medical records, we analyzed longitudinal data to understand the fact of terminal cancer patients’ autonomous DNR decision-making in Taiwan.

Methods

Using the medical information system database of one public medical center in Taiwan, we identified hospitalized cancer patients who died between Jan. 2017 and Dec. 2018, collected their demographic and clinical course data and records of their statutory DNR document types, letter of intent (DNR-LOI) signed by the patient personally and the consent form signed by their close relatives.

Results

We identified 1,338 signed DNR documents, 754 (56.35%) being DNR-LOI. Many patients had the first DNR order within their last week of life (40.81%). Signing the DNR-LOI was positively associated with being under the care of a family medicine physician prior to death at last hospitalization and having hospice palliative care and negatively associated with patient age ≥ 65 years, no formal education, having ≥ 3 children, having the first DNR order to death ≤ 29 days, and the last admission in an intensive care unit.

Conclusions

A substantial proportion of terminal cancer patients did not sign DNR documents by themselves. It indicates they may not know their actual terminal conditions and lose the last chance to grasp time to express their life values and wishes. Medical staff involving cancer patient care may need further education on the legal and ethical issues revolving around patient autonomy and training on communicating end-of-life options with the patients. We suggest proactively discussing DNR decision issues with terminal cancer patients no later than when their estimated survival is close to 1 month.

Do elderly cancer patients have different care needs compared with younger ones?

Aims and background

The increasingly older population confronts oncologists with an imposing challenge: older cancer patients have specific healthcare needs both independent of and associated with the diagnosis of cancer. The aim of the present study is to examine whether elderly versus younger cancer patients have different needs with respect to attendance, treatment and information.

Methods and study design

This is an observational and cross-sectional study. Cancer patients aged 35 to 82 years were consecutively interviewed. The group was divided into two subgroups aged ≤65 and ≥66 years old. The Needs Evaluation Questionnaire (NEQ) was used to assess patients' needs and demographic variables were collected. Data analysis was carried out by means of cross-tabulation analyses and the chi-square test.

Results

The requests most frequently expressed by the older group concerned financial-insurance information (73.9%), the need to talk to people with the same illness (71.7%), the need to receive more comprehensible information from doctors and nurses (71.7%), and the need for a better dialogue with clinicians (69.6%). Few significant differences between the two age subgroups were found, with the exception of issues such as the need for intimacy and support.

Conclusions

Elderly patients have informational and relational needs similar to those of younger patients. In fact, most of the whole sample flagged up the need for higher levels of satisfaction especially concerning a better dialogue with health staff, along with a new factor: the need to talk to people with the same illness.

The myth of not disclosing the diagnosis of cancer: does it really protect elderly patients from depression?

BACKGROUND

The disclosure of a diagnosis of cancer is complex, particularly in older patients. The aim of this study was to investigate the association between age and not knowing the diagnosis, and its impact on mood.

MATERIALS AND METHODS

The study included 70 patients with various types of solid and hematologic cancer in early stages, which were followed up in an outpatient oncology/hematology clinic in Turkey between January, 2014 and June, 2014. Initially the caregivers of patients were asked whether the patients knew their diagnosis or not. A questionnaire for the Geriatric Depression Scale was then administered to the patients. Patient age, gender, marital status and education level were noted and analyzed with respect to knowing the diagnosis and depression.

RESULTS

Of the 70 patients, 40% of them were female. The mean age was 68.2±8.9. The rate of the patients who does not know their diagnosis was 37.1% (n=26). The overall depression rate with GDS was found 37.1% (n=26) among the participants. There was no association with knowing the diagnosis (p=0.208) although the association between not knowing the diagnosis and age was significant (p=0.01).

CONCLUSIONS

In this study we revealed no association between not knowing the diagnosis and depression in elderly patients. Contrary to what some has thought, the patient is not protected from psychological distress by not being informed about the diagnosis. We believe this study and similar ones will help to discuss and further explore patient autonomy, the principle of respect to self-determination and end of life issues in different cultures.

Predictors of patient self-report of chronic kidney disease: baseline analysis of a randomised controlled trial

Background

Improving the quality of care for patients with vascular disease is a priority. Clinical guidance has emphasised the importance of early identification and active management of chronic kidney disease (CKD) in primary care in order to maintain vascular health. However, awareness of stage 3 CKD amongst patients remains limited. We aimed to identify predictors of patient self-report of CKD to inform tailoring of conversations around CKD in primary care for diverse patient populations.

Methods

We conducted a cross-sectional analysis of baseline data from 436 patients with stage 3 CKD from 24 GP practices taking part in a randomised controlled trial (RCT) evaluating a complex self-management intervention, which aimed to support the maintenance of vascular health in patients with stage 3 CKD. Potential predictors of patient self-report of CKD included demographics, stage of CKD, cardiovascular risk, self-reported co-morbidities, health status, self-management ability, and health service utilisation.

Results

Around half (52%, n = 227) of patients did not self-report CKD. Self-report rates did not appreciably differ by practice. Multivariate analysis revealed that female patients (p = 0.004), and patients with stage 3b CKD (p < 0.001), and with higher anxiety levels (p < 0.001), were more likely to self-report CKD.

Conclusions

Self-report of kidney problems by patients on CKD registers was variable and patterned by sociodemographic factors. Although it cannot be assumed that failure to self-report indicates a lack of awareness of CKD, our data do suggest the need for greater consistency in discussions around kidney health, with meaningful and relevant clinical dialogue that is aligned with existing clinical encounters to enable shared decision making and minimise anxiety.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-014-0196-3) contains supplementary material, which is available to authorized users.

'Active ageing': from empty rhetoric to effective policy tool

‘Active ageing’ is a topic of increasing attention in scientific and policy discussions on ageing, yet there is no consensus on its actual meaning. The current paper proposes a detailed classification of various definitions that have been used since its introduction. These definitions are subjected to critical investigation, and subtle differences with regard to such terms as ‘healthy ageing’ and ‘productive ageing’ are clarified. Bearing the hazards of previous definitions in mind, a comprehensive strategy is initiated. Given that earlier definitions have tended to exclude frail older adults, this strategy pays particular attention to the translation of the active-ageing concept to situations of dependency by centring on three key principles: fostering adaptability, supporting the maintenance of emotionally close relationships and removing structural barriers related to age or dependency.

[Fourteen-year attitude survey on cancer disclosure to new outpatients of urology department]

PURPOSE

To investigate if timing of first visit, ages, sex, family history of cancer, and smoking history would cause any differences in patients' attitude toward cancer disclosure.

SUBJECTS AND METHODS

Subjects were 10,552 patients who first visited Urology Department of Nihonkai Hospital between 1993 and 2007, and were asked to fill in the questionnaire. The questionnaire contents are as follows: "If you were diagnosed as having cancer, would you like to be informed about the diagnosis of your disease?", and "If your families were diagnosed as having cancer, would you like to inform them about the diagnosis of their disease?". The subjects were asked to select their answers from the following options: (1) "fully informed", (2) "informed only when it is curable", (3) "not informed", and (4) "can not decide now". The relation of patients' attitude toward cancer disclosure with the timing of first visit, ages, sex, family history of cancer, and smoking history was investigated.

RESULTS

The response rate was approximately 80%. If the subjects would have cancer, 71.5% preferred to be informed ("fully informed" or "informed if it is curable"), and 9.2% did not. If the subjects' family would have cancer, 55.5% preferred their family to be informed ("fully informed" or "informed if it is curable"), and 14.9% did not. As it became more recent, both the rate of subjects who did not prefer to be informed (11.5% in 1993-1995, and 8.0% in 2005-2007) and the rate of those who did not prefer their family to be informed (18.6% in 1993-1995, and 11.0% in 2005-2007) decreased. Young subjects, men, and smokers more preferred to be informed. The subjects who had family history of cancer more preferred to inform them, but less to inform their family.

CONCLUSIONS

As it became more recent, both the subjects who did not prefer to be informed and those who did not prefer their family to be informed decreased. The idea that cancer disclosure was necessary to select the treatment methods based on each patient's preference and decision had been pervasive.