Advance Care Planning for Older People with Cancer and Its Implications in Asia: Highlighting the Mental Capacity and Relational Autonomy

Experiences of cancer patients in palliative care with advanced care planning: A systematic review and meta-synthesis of qualitative studies

PURPOSE

This systematic review and meta-synthesis aims to synthesize the perspectives and experiences of patients with advanced cancer of advanced care planning and advanced directives in a PC setting.

METHODS

Qualitative studies published between 1991 and 2024 were included. A comprehensive search was performed across six electronic databases: CINAHL, Cochrane, OVID, PubMed, Scopus, and ScienceDirect. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was applied for quality assessment. Thematic synthesis was applied to analyze data from 20 selected studies, involving 534 participants.

RESULTS

Six key themes emerged: (1) Meaning of advanced care planning (ACP), (2) Initiating ACP, (3) Barriers and facilitators, (4) Communication in ACP, (5) Outcomes of ACP, and (6) Needs and wishes in ACP. Findings highlight ACP as a complex and dynamic process shaped by emotional, social, and institutional factors. While ACP promotes patient autonomy and reduces anxiety, reluctance, avoidance, and cultural barriers limit engagement. Effective clinician-patient communication, emotional readiness, and tailored interventions enhance ACP participation.

CONCLUSIONS

Understanding the perspectives of advanced cancer patients is essential for improving ACP implementation in PC settings. Healthcare professionals must foster trust, provide culturally sensitive communication, and adapt ACP approaches to patients' evolving needs. Future research should focus on addressing emotional and systemic barriers to increase ACP participation and improve end-of-life care quality.

Mapping provider and consumer voices using the AACTT framework: a focus group study of advance care planning

BACKGROUND

The provision of healthcare is complex. When evidence-practice gaps are identified, interventions to improve practice across multi-level systems are required. These interventions often consist of multiple interacting components and behaviours. To effectively address these complexities, it is crucial to first identify the specific roles and actions required at each stage of the intervention. This approach enables a thorough examination of what is working well and what needs to be optimised. The action, actor, context, target, time (AACTT) framework provides a consistent approach to identifying key elements such as 'who' (actor) does 'what' (action), 'where' (context), 'to or with whom' (target) and 'when' (time). To our knowledge the AACTT has not yet been applied: 1) to specify complex interventions across patient journeys; and 2) to investigate consumer views, despite the importance of patient-centred care.

AIM

Using advance care planning (ACP) as an exemplar complex healthcare process, we describe a method for using the AACTT framework to 1) map a complex model of care across a patient journey 2) capture the consumer perspective; and 3) operationalise these perspectives by comparing across groups and identifying alignments or misalignments.

METHODS

Two groups were recruited (healthcare professionals and consumers). Informed by the AACTT framework, four focus groups discussed the process of ACP across existing care pathways. Maps visually representing the perspectives and preferences of healthcare professionals and consumers were co-created iteratively. Qualitative data was deductively coded to the AACTT framework and inductively coded to identify themes within domains. Maps were circulated for critical feedback and refined.

RESULTS

Healthcare professional (n-13) and consumer perspectives (n = 11) highlighted what is 'currently occurring' in practice, what is 'not occurring', and what 'should be occurring' to align practice with consumer preferences of care. Comparing participant perspectives identified that most misalignment occurred within the actor, context, and time domains. Misalignment was found predominantly in actions 'occurring sometimes', with no converging perspectives reported for the context and time domains.

CONCLUSION

This novel application of the AACTT framework systematically brings in the consumer voice in ways that may influence the delivery of care. This approach to specifying healthcare professional and consumer perspectives across a complex care pathway identifies barriers that are not found with traditional mapping methods or in current applications of the AACTT framework.

Cross-sectional survey on public attitudes and factors related to physician-assisted dying in Taiwan

OBJECTIVE

To examine the public's stance on physician-assisted dying (PAD) in Taiwan across different PAD scenarios and identify demographic and psychosocial factors associated with the levels of support.

DESIGN

Cross-sectional survey design. Independent variables included individual sociodemographic characteristics, healthcare professionals, perceived quality of life, formal caregiver experience, Patient Right to Autonomy Act (PRAA) awareness and advance care planning (ACP) preparedness.

SETTING

An online survey of the general population in Taiwan was conducted in 2022.

PARTICIPANTS

A total of 3922 Taiwanese adults who completed all survey questions.

OUTCOME MEASURES

Agreement levels with PAD in three scenarios: terminal illnesses, unbearable non-terminal pain and severe cognitive impairments. Multivariate logistic regression was used to examine agreement with each PAD scenario as separate dependent variables in the first three models and overall agreement across all scenarios as the dependent variable in the fourth model.

RESULTS

High levels of public support for PAD were observed, with 86.2% supporting PAD for terminal illnesses, 79.2% for unbearable non-terminal pain and 72.6% for severe cognitive impairments. Support for PAD was associated with factors including younger age, male gender, lack of religious affiliation, a non-healthcare professional background, employment as a formal caregiver, lack of awareness of PRAA and higher preparedness in ACP.

CONCLUSIONS

The results indicate a potential cultural shift in Taiwan towards greater emphasis on individual autonomy in end-of-life decisions. There appears to be significant public support for developing legal frameworks in favour of PAD, carefully considering the psychosocial factors that highlight the importance of individual rights in end-of-life care.

Definition and recommendations of advance care planning: A Delphi study in five Asian sectors

BACKGROUND

In Confucian-influenced Asian societies, explicit end-of-life conversations are uncommon and family involvement in decision-making is crucial, which complicates the adoption of culturally sensitive advance care planning.

AIM

To develop a consensus definition of advance care planning and provide recommendations for patient-centered and family-based initiatives in Asia.

DESIGN

A five-round Delphi study was performed. The rating of a definition and 84 recommendations developed based on systematic reviews was performed by experts with clinical or research expertise using a 7-point Likert scale. A median = 1 and an inter-quartile range = 0-1 were considered very strong agreement and very strong consensus, respectively.

SETTING/PARTICIPANTS

The Delphi study was carried out by multidisciplinary experts on advance care planning in five Asian sectors (Hong Kong/Japan/Korea/Singapore/Taiwan).

RESULTS

Seventy-seven of 115 (67%) experts rated the statements. Advance care planning is defined as "a process that enables individuals to identify their values, to define goals and preferences for future medical treatment and care, to discuss these values, goals, and preferences with family and/or other closely related persons, and health-care providers, and to record and review these preferences if appropriate." Recommendations in the domains of considerations for a person-centered and family-based approach, as well as elements, roles and tasks, timing for initiative, policy and regulation, and evaluations received high levels of agreement and consensus.

CONCLUSIONS

Our definition and recommendations can guide practice, education, research, and policy-making in advance care planning for Asian populations. Our findings will aid future research in crafting culturally sensitive advance care planning interventions, ensuring Asians receive value-aligned care.

Association Between Current Medical Decision-Making Participation Self-Efficacy and Advance Care Planning Engagement Among Older Adults: Baseline Findings from a Nationwide Longitudinal Cohort Study

Background and Objectives: Misconceptions of and cultural differences in aging influence older adults' medical decision-making self-efficacy and engagement in advance care planning (ACP). This study aims to investigate the association between current medical decision-making participation self-efficacy and ACP engagement among older individuals receiving home-based medical care (HBMC) in Taiwan. Design: Baseline data analysis of a nationwide cohort study. Setting and Participants: Patients aged ≥50 years who had been consistently receiving HBMC for > two months between November 2019 and December 2022 were recruited. Study recruitment took place at six hospitals and 12 community home care institutions. Measurement and Analysis: A structured questionnaire was used to collect data on sociodemographic characteristics, decision-making participation self-efficacy, and ACP engagement. Descriptive, stratified, and multivariate logistic regression analyses were performed. Results: In total, 408 HBMC recipients were enrolled (average age: 80.4 years; 55% women). The respondents reported moderate decision-making participation self-efficacy but low ACP engagement. In light of the transtheoretical model of behavior change, participants with moderate or high self-efficacy had a significantly higher chance of reaching the "contemplation stage" for ACP decisions (odds ratio or OR 4.06-27.13). Participants were more likely to reach the "preparation and action stages" for ACP decisions only when they had high self-efficacy (OR 2.76-14.73). Conclusions: Although participants with better current medical decision-making self-efficacy were more likely to contemplate ACP, many did not take action beyond appointing a medical surrogate(s). Strategies to enhance decisional self-efficacy, thereby increasing timely ACP discussions among older adults in home settings in Chinese culture, are warranted. Trial registration number: ClinicalTrials.gov Identifier is NCT04250103 which has been registered on 31st January 2020.

Advance Care Planning in Palliative Care in Asia: Barriers and Implications

Advance care planning (ACP) in palliative care is essential for patient autonomy and quality of dying. This review explores ACP practices in South Korea, Japan, and Taiwan, highlighting how legislation and cultural values shape those practices. In these three sectors, which are influenced by Confucian values, family involvement plays a significant role in decision-making. In South Korea, the Life-Sustaining Treatment Decisions Act made ACP processes mandatory at all healthcare institutions and rapidly created advance directive registration agencies nationwide, with a national web-based system for legal documentation. The Act's narrow focus on terminal illness and dying phase may inadvertently delay end-of-life discussions. A broader social consensus is needed to allocate end-of-life care resources in a way that reflects patients' and families' wishes. Japan's family-based approach highlights relational autonomy, with ACP timing varying and no formal legal frameworks for advance directives. Expanded palliative care, ACP guidelines, systemic support, and public awareness drive progress in Japan. Taiwan's two relevant legislative frameworks-the Hospice Palliative Care Act and Patient Right to Autonomy Act-expand palliative care services for terminal illnesses and non-cancer diseases such as severe dementia, irreversible coma, and a persistent vegetative state. Misunderstandings of ACP and family-led decision-making may hinder ACP uptake. ACP referral based on patient care needs rather than terminal diagnoses is suggested. Overcoming common barriers in Asia necessitates open dialogues about death and public education. A standardized legal framework and comprehensive training for healthcare providers are equally important. Further international collaboration will suggest culturally sensitive ACP conversations across Asia.

Ecology of End-of-life Medical Care for Advanced Cancer Patients in China

AIMS

Cancer is a leading cause of death worldwide. Approximately 30% of global cancer-related deaths occur in mainland China. However, there is a paucity of information regarding the end-of-life care-seeking behavior of patients with advanced cancer in China. Our study was to investigate end-of-life care-seeking behavior and to quantify the association between sociodemographic characteristics and the location and pattern of end-of-life care.

METHODS

We conducted a mortality follow-back survey using caregivers' interviews to estimate the number of individuals pre 1000 who died between 2013 and 2021 in the last 3 months of life. We collected data on hospitalization, outpatient visits, cardiopulmonary resuscitation, palliative care and hospice utilization, and place of death, stratified by age, gender, marital status, household income, residential zone, insurance type, and the primary end-of-life decision-maker of the decedents.

RESULTS

We analyzed data from 857 deceased cancer patients, representing an average of 1000 individuals. Among these patients, 861 experienced at least moderate or more severe pain, 774 were hospitalized at least once, 468 received intensive treatment, 389 had at least one outpatient visit, 270 died in the hospital, 236 received cardiopulmonary resuscitation and 99 received specialist hospice care.

CONCLUSIONS

Our study provides insights into the end-of-life care-seeking behavior of advanced cancer patients in China and our findings serve as a useful benchmark for estimating the use of end-of-life medical care. It highlights the need for the establishment of an accessible and patient-centered palliative care and hospice system.

Factors impacting the demonstration of relational autonomy in medical decision-making: A meta-synthesis

BACKGROUND

Relational autonomy is an alternative concept of autonomy in which an individual is recognized as embedded into society and influenced by relational factors. Social context, including social location, political structure, and social forces, significantly influence an agent to develop and exercise autonomy skills. The relational approach has been applied in clinical practice to identify relational factors impacting patient autonomy and decision-making, yet there is a knowledge gap in how these factors influence the demonstration of relational autonomy in the context of medical decisions of adults.

OBJECTIVE

The present study targeted the existing knowledge of what and how relational factors impact individuals making medical decisions using the theoretical framework of relational autonomy.

METHODS

A meta-synthesis study was utilized. Four electronic databases, including Embase, OVID Medline, CINAHL, and PubMed, were searched, along with gray literature and reference lists, to identify relevant studies.

RESULTS

23 studies reporting 21 qualitative and two mixed-method studies were reviewed. Four themes emerged from the qualitative findings: (1) supportive relationships facilitate an individual's relational autonomy; (2) obtaining comprehensive information from broader sources helps individuals exercise relational autonomy; (3) undue family pressure impedes the exercising of patient relational autonomy; and (4) healthcare providers' dominant voice hampers the demonstration of relational autonomy.

CONCLUSIONS

Applying relational autonomy to assist adults in making well-considered decisions is essential. The meta-synthesis suggests establishing a supportive relationship between individuals, healthcare providers, and family. A supportive relationship will allow healthcare providers to make judgments in line with an individual's values and wishes with the aim of promoting relational autonomy. Advance care planning was proposed as the effective solution to obtain a consensus between individuals and their families while respecting an individual's values and preferences. Furthermore, it is considered crucial for healthcare providers to appreciate an individual's values and incorporate their preferences into recommendations.

Readiness for advance care planning and related factors in the general population: a cross sectional study in Iran

CONTEXT

Advance Care Planning (ACP), as a process for expressing and recording patients' preferences about end-of-life care, has received increasing attention in recent years. However, implementing ACP has been challenging in Iran.

OBJECTIVES

To assess the readiness for advance care planning and related factors in the general population of Iran.

METHODS

This cross-sectional study was conducted on the general population of Iran in 2022. The data was collected using demographic information questionnaire and The RACP Scale. The purpose and methodology of the research was explained to all participants, and upon their agreement an informed consent was obtained. Participants were invited to fill out the questionnaires wherever is more convenient for them, either alone or if needed, with the help of the researcher to protect their privacy. Chi-square, fisher exact test and multiple logistic Regression model were used to assess the effective factors on the RACP. The data were analyzed by SPSS software version 26.

RESULTS

A total of 641 people with an average age of 36.85 ± 12.05 years participated in this study. Of those, 377 (58.8%) had high RACP. The logistics model showed an association between the chance of readiness for receiving ACP with participants' education level, such that the chance of readiness in those with Master's or Ph.D. degrees was three times higher than those with a diploma (p = 0.00, OR:3.178(1.672, 6.043)). However, the chances of readiness in those with bachelor's degrees was not significantly different from those with a diploma (p = 0.936, OR: 0.984 (0.654, 1.479)). Moreover, the chance of readiness was 1.5 higher in participants over 40 years of age compared with participants under the age of 40 (P = 0.01, OR: 1.571(1.10, 2.23)).

CONCLUSION

According to the findings of this study, it can be concluded that there is a relatively RACP among people in Iranian society. The readiness of individuals for ACP increases by their age and education level. Therefore, by holding appropriate training intervention, we can increase the readiness of the public for ACP to improve their end-of-life outcome.

Fostering relational autonomy in end-of-life care: a procedural approach and three-dimensional decision-making model

Respect for patient autonomy is paramount in resolving ethical tensions in end-of-life care. The concept of relational autonomy has contributed to this debate; however, scholars often use this concept in a fragmented manner. This leads to partial answers on ascertaining patients' true wishes, meaningfully engaging patients' significant others, balancing interests among patients and significant others, and determining clinicians' obligations to change patients' unconventional convictions to enhance patient autonomy. A satisfactory solution based on relational autonomy must incorporate patients' competence (apart from decisional capacity), authenticity (their true desires or beliefs) and the involvement level of their significant others. To that end, we argue that John Christman's procedural approach to relational autonomy provides critical insights, such as the diachronic or socio-historical personhood, sustained critical reflection and his recent explication of the nature of asymmetrical relationships and helpful interlocutors. This study reviews Christman's account, proposes minor modifications and advocates for an integrated three-dimensional model for medical decision-making. Clarifying the relationship among the three elements promotes an ethical framework with a coherent understanding of relational autonomy. This model not only provides a descriptive and normative framework for end-of-life care practice but also reconsiders the nature of the clinician-patient relationship and its normative implications. We further present a case study to illustrate the merits of our proposed model. Altogether, our proposal will help navigate complex medical decision-making, foster trust and negotiate shared values between patients and their significant others, particularly in end-of-life care.

Summary of evidence to facilitate the implementation of advance care planning among advanced cancer patients

Advance care planning (ACP) is designed to ensure that patients lacking autonomous decision-making capacity receive medical services in accordance with their expectations and preferences. Individuals with advanced cancer are a crucial target for ACP implementation. However, the current practice of ACP in this group in China is suboptimal, demanding high-quality implementation evidence to strengthen ACP in the clinical practice of patients with advanced cancer. The existing literature can be summarized into 27 pieces of evidence across 7 dimensions, including initiation time, intervention content, intervention providers, intervention modalities, communication skills, outcome indicators, and environmental support. The aforementioned evidence could provide crucial support for improving ACP implementation for patients with advanced cancer. Subsequent research efforts should integrate patient preferences and explore the most suitable implementation strategies for ACP in the Chinese population with advanced cancer, considering diverse aspects such as traditional culture, ACP education and training, legislative support, and healthcare system refinement.

Association Between Primary Decision-Maker and Care Intensity Among Patients With Advanced Cancer in Mainland China

Purpose: In China, decisions regarding the treatment of seriously ill patients are usually made by family caregivers. This study aimed to explore the association between the primary decision-makers and the intensity of care given to patients with advanced cancer in China. Methods: We conducted a survey of family members and other caregivers representing 828 cancer patients who died between July 2013 and July 2016. The survey asked: "After the physician conveyed that the disease is incurable, what treatment did the patient and caregiver prefer?" and "Who was the primary decision-maker?" We compared the treatment intensity with locus of decision-making using multivariable logistic regression, adjusting for socio-demographic and clinical covariates informed. Results: Of the 792 patients in our sample, the majority were male (67·2%), 60 years or older (64·0%), married (82·2%), lived with family (98·2%), had medical insurance (94·8%), earned below-average income (53·5%), lived rurally (61·5%), had a gastrointestinal cancer diagnosis (50·8%), experienced moderate or severe pain (86·3%), never received palliative care (80·4%) and had caregivers as primary decision-makers (70·6%). We found that patients were more likely to receive intensive disease-modifying treatments when the primary decision-maker were their children (adjusted odds ratio [AOR] = 1·86, 95% CI:1·26-2·74), spouse (AOR = 2·04, 95% CI:1·26-3·30), or other caregivers (AOR = 3·46, 95% CI:1·24-9·69). Conclusions: When patients with advanced cancer in China did not make their own medical decisions, they were more likely to receive intensive disease-modifying treatments at the end-of-life. Actions should be taken to better understand and ensure that caregivers' decisions reflect the values and presence of patients.

Delivering Palliative and Supportive Care for Older Adults with Cancer: Interactions between Palliative Medicine and Geriatrics

The world's population is aging rapidly, with projections indicating that by 2050 one in six people will be aged ≥65 years. As a result, the number of cancer cases in older people is expected to increase significantly. Palliative care is an essential component of cancer care with a direct impact on quality of life. However, older adults with cancer often suffer from multiple comorbidities, cognitive impairment, and frailty, posing unique challenges in the delivery of palliative care. The complex healthcare needs of older patients with cancer therefore require a comprehensive assessment, including a geriatric evaluation. Collaboration between geriatrics and palliative care can offer a solution to the challenges faced by older people with cancer, since this is a population with overlapping concerns for both disciplines. This review highlights the importance of palliative care for older adults with cancer and the benefits of a multidisciplinary approach. It also addresses the coordination of palliative care and geriatrics for specific symptom management and decision making.

Why is advance care planning underused in oncology settings? A systematic overview of reviews to identify the benefits, barriers, enablers, and interventions to improve uptake

Background

Advance care planning (ACP) centres on supporting people to define and discuss their individual goals and preferences for future medical care, and to record and review these as appropriate. Despite recommendations from guidelines, rates of documentation for people with cancer are considerably low.

Aim

To systematically clarify and consolidate the evidence base of ACP in cancer care by exploring how it is defined; identifying benefits, and known barriers and enablers across patient, clinical and healthcare services levels; as well as interventions that improve advance care planning and are their effectiveness.

Methods

A systematic overview of reviews was conducted and was prospectively registered on PROSPERO. PubMed, Medline, PsycInfo, CINAHL, and EMBASE were searched for review related to ACP in cancer. Content analysis and narrative synthesis were used for data analysis. The Theoretical Domains Framework (TDF) was used to code barriers and enablers of ACP as well as the implied barriers targeted by each of the interventions.

Results

Eighteen reviews met the inclusion criteria. Definitions were inconsistent across reviews that defined ACP (n=16). Proposed benefits identified in 15/18 reviews were rarely empirically supported. Interventions reported in seven reviews tended to target the patient, even though more barriers were associated with healthcare providers (n=40 versus n=60, respectively).

Conclusion

To improve ACP uptake in oncology settings; the definition should include key categories that clarify the utility and benefits. Interventions need to target healthcare providers and empirically identified barriers to be most effective in improving uptake.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?, identifier CRD42021288825.

A model for the uptake of advance care planning in older cancer adults: a scoping review

BACKGROUND AND AIMS

Advance care planning (ACP) might assist older cancer patients in expressing their goals, values, and care preferences; yet, the ACP uptake rates in this group are low. The goal of this study is to discover factors that influence ACP uptake in older cancer adults and to construct a model that integrates these factors.

METHODS

Using Arksey and O' Malley's methodology, we systematically searched seven electronic databases of ACP literature in older cancer adults from inception to March 2022. To identify factors linked to ACP uptake in elderly cancer patients, researchers used a pre-piloted extraction form. There were two phases to the thematic analysis of the labeled factors. First, factors were grouped into one of three categories using a directed content analysis approach: patient context, provider context, or mechanism. Second, we took both a deductive and inductive thematic approach to identifying and coding contributing factors in each category to identify themes and subthemes. Deductive coding was undertaken using the Andersen's Behavioral Model of Health Services Utilization. Finally, results were visualized into a conceptual model.

RESULTS

In the including 37 articles, 131 factors were extracted. Thematic analysis of patient context factors (n = 72) showed that ACP uptake in older cancer adults is associated with predisposing characteristics, enabling resources and need. Factors attributed to provider context (n = 28) concerned predisposing characteristics and enabling resources. Mechanism factors (n = 31) are related to perceived value and patient trust, and the C-ACP uptake model was created.

CONCLUSION

ACP uptake in older cancer patients is commonly influenced by patient-provider-related contextual factors, and highlights the fact that ACP uptake is more likely to be mediated through both perceived value and patient trust. This review serves as a resource for providers exploring ACP implementation options in older cancer adults.

Experiences of Older Adults with Frailty Not Completing an Advance Directive: A Qualitative Study of ACP Conversations

Advance care planning (ACP) facilitates individuals to proactively make decisions on their end-of-life care when they are mentally competent. It is highly relevant to older adults with frailty because they are more vulnerable to cognitive impairment, disabilities, and death. Despite devoting effort to promoting ACP among them, ACP and advance directive completion rates remain low. This study aims to explore the experiences among frail older adults who did not complete an advance directive after an ACP conversation. We conducted a thematic analysis of audiotaped nurse-facilitated ACP conversations with frail older adults and their family members. We purposively selected ACP conversations from 22 frail older adults in the intervention group from a randomized controlled trial in Hong Kong who had ACP conversation with a nurse, but did not complete an advance directive upon completing the intervention. Three themes were identified: “Refraining from discussing end-of-life care”, “Remaining in the here and now”, and “Relinquishing responsibility over end-of-life care decision-making”. Participation in ACP conversations among frail older adults and their family members might improve if current care plans are integrated so as to increase patients’ motivation and support are provided to family members in their role as surrogate decision-makers.

Knowledge of and Barriers to Palliative Care Perceived by Healthcare Providers before and after Promotion of the Patient Autonomy Act: A Cross-Sectional Study

This study was designed to investigate healthcare providers’ knowledge of palliative care and perceptions of palliative care barriers before and after promoting the Patient Autonomy Act (PAA). A convenience sample was recruited, including 277 healthcare providers in 2013 and 222 healthcare providers in 2018. Multivariate linear regression analyses were used to identify predictors of knowledge of and perceived barriers to palliative care. A principal component analysis was carried out to identify the most appropriate factorial structure for the contents of knowledge and perceived barriers to palliative care. Three factors related to knowledge of palliative care were identified in both 2013 and 2018 data: ‘policy, regulation, and promotion’, ‘philosophy and treatments’, and ‘myths and misunderstandings’. Study findings for the two periods were similar. As for barriers to providing palliative care, three factors were identified for 2013: ‘quality care’, ‘difficulties’ and ‘communication’, and for 2018, ‘information’, ‘attitudes’ and ‘quality care’ were identified. Study findings differed between the two periods. Policies can better reinforce mitigating strategies—including opportunities for education, shared decision making, and changes in institutions and care systems. Additionally, assessing barriers creates important opportunities for further research to address the most critical aspects in improving end-of-life care for patients and their families.

Developing an Instrument to Assess the Readiness for Advance Care Planning

CONTEXT

In recent times, advance care planning for patients' end-of-life care preferences has attracted much attention worldwide.

OBJECTIVES

To develop the Readiness for Advance Care Planning (RACP) Scale.

METHODS

Participants included 624 Japanese citizens who were registered with a web-based survey company as of February 2019. Items regarding the process of advance care planning (ACP) were developed based on a literature review and expert panel discussions. The expert panel included nine experts and practitioners in the field of end-of-life care. Construct validity, concurrent validity, internal consistency, and test-retest reliability were evaluated.

RESULTS

Initially, 37 items were collected. Examination of the floor effect, item-total, good-poor analysis, and exploratory factor analysis yielded a five-factor model with 28 items. The goodness of fit of the model was GFI = 0.80, CFI = 0.91, and RMSEA = 0.08. The concurrent validity was statistically significant (rs = 0.26-0.45, ps < 0.001). Cronbach's alpha for the overall scale was 0.95. The corresponding values for the subscales ranged from 0.90 to 0.97. The intraclass correlation coefficients indicating test-retest reliability was 0.66 (P < 0.001) for the total scale and ranged from 0.52-0.65 for the five subscales.

CONCLUSIONS

The validity and reliability of the scale were generally acceptable. The RACP is an appropriate instrument to evaluate the level of readiness for ACP behaviors among people of various generations at every health stage. More studies are needed to examine the clinical utility of the RACP, both nationally and internationally.

Suffering and Attitudes Toward Death of Patients With Heart Failure in Japan: A Grounded Theory Approach

Early palliative care is needed for patients with heart failure (HF). However, little is known about the suffering and attitudes toward death of these patients before they reach end-stage HF. This study aimed to identify the suffering and attitudes toward death of patients with early- and intermediate-stage HF. Our qualitative research process was guided with a grounded theory approach and consolidated criteria for reporting qualitative research. Participants were selected through theoretical sampling. Data were collected through semistructured interviews, participant observations, and medical records examination. The study included 10 patients. Analysis of the data revealed the core category of "evaluating whether HF hinders the current and future self." From this core category, 6 categories of causal conditions and 3 categories of consequences emerged. Participants with HF evaluated the causal conditions and suffering in the context of how they hindered the ideal state. After recognizing their own suffering, they expressed specific attitudes toward death. The 10 categories revealed in this study elucidate the process by which patients with HF form their attitudes toward death based on suffering. Health care professionals should consider these findings to help facilitate early palliative care interventions.

Nurses' knowledge and attitudes towards palliative care and death: a learning intervention

Background

In many countries, nurses are ill-prepared to provide care to patients with terminal illnesses. Limited education and training affect their ability to deliver proper palliative care. Only a few studies have explored appropriate and effective training methods of palliative care in China. Therefore, we aimed to provide evidence for a palliative care training system by appraising the effects of a mixed-method intervention on participants’ knowledge of palliative care and attitudes towards dying patients and death.

Methods

An e-learning intervention approach was adopted for 97 nurses from oncology departments across five hospitals, using a mobile terminal combined with a virtual forum and face-to-face interactions. We conducted a pre- and post-training evaluation through the Palliative Care Quiz of Nursing (PCQN), Frommelt Attitude Toward Care of the Dying Scale Form B (FATCOD-B), and Death Attitude Profile-Revised (DAP-R).

Results

After a three-week intervention, there was a significant increase in the PCQN and FATCOD-B scores as compared to the baseline. For PCQN, the total score increased from 10.3 ± 1.9 to 11.1 ± 2.2 (p = .011) and the score for management of pain and other symptoms increased from 7.7 ± 1.7 to 8.4 ± 1.7 (p = .003). FATCOD-B scores increased noticeably from 100.6 ± 7.9 to 102.9 ± 8.9 (p = .019). The DAP-R scores showed no obvious difference between pre- and post-intervention results.

Conclusions

The mixed-method intervention was effective in improving participants’ knowledge and attitudes about palliative care. The implementation of training for nurses at appropriate intervals during both education and professional life is required, especially regarding the improvement in participants’ attitudes towards death. Therefore, palliative care training in China should receive more attention.

Days Spent at Home near the End of Life in Japanese Elderly Patients with Lung Cancer: Post hoc Analysis of A Prospective Study

Objective:

Days spent at home (DASH) near the end of life is considered an important patient-centered goal and outcome because many patients want to stay at home toward the end of life. This study aimed to estimate the individual DASH near the end of life and identify its early predictors, including muscle mass and physical function, among elderly patients with advanced non-small-cell lung cancer (NSCLC).

Methods:

We conducted a post hoc analysis of the prospective observational study (UMIN000009768) that recruited patients aged ≥ 70 years who were scheduled to undergo first-line chemotherapy because of advanced NSCLC. We measured the muscle mass by bioelectrical impedance analysis at baseline. DASH was calculated as 30 days minus the number of days spent in hospitals, palliative care facilities, or nursing homes during the last 30 days of life. We performed linear regression analyses to evaluate the predictors of DASH.

Results:

Altogether, 16 women and 28 men with a median overall survival of 15.5 months (range: 2.9–58.9) were included. The median DASH in the last 30 days of life was 8 days (range: 0–30, interquartile range: 0–23). Men had longer DASH than women by 7.3 days. Patients who had good trunk muscle mass index and hand-grip strength had significantly longer DASH than those who did not (4.7 days per kg/m² increase [P = 0.017] and 0.4 days per kg increase [P = 0.032], respectively).

Conclusions:

Most elderly patients with advanced NSCLC had a limited DASH near the end of life. The risk factors for reduced DASH were women, reduced muscle mass, and poor physical function at the time of diagnosis of advanced NSCLC. Our findings would encourage early discussions about end-of-life care for patients with advanced cancers with risk factors for short DASH at the time of diagnosis, and thus, improve the quality of end-of-life care.

Communication and Behavior of Palliative Care Physicians of Patients With Cancer Near End of Life in Three East Asian Countries

BACKGROUND

The characteristics of physician communication with patients at the end of life (EOL) in East Asia have not been well studied. We investigated physicians' communications with imminently dying patients with cancer and their families in palliative care units (PCUs) in Japan, South Korea, and Taiwan.

METHODS

This observational study included patients with cancer newly admitted and deceased during their first admission to 39 PCUs in three countries. We evaluated 1) the prevalence and timing of informing patients and families of patients' impending death and 2) the prevalence of communication to assure the families of the patient's comfort.

RESULTS

We analyzed 2138 patients (Japan: 1633, South Korea: 256, Taiwan: 249). Fewer Japanese (4.8%: 95% confidence interval [95% CI], 3.8%-5.9%) and South Korean (19.6%: 95% CI, 15.2%-25.0%) patients were informed of their impending death, whereas 66.4% (95% CI, 60.2%-72.1%) of Taiwanese were informed; among all three countries, ≥90% of families were informed. Although most patients in all three countries and the families in South Korea and Taiwan were informed of the impending death greater than or equal to four days before death, 62.1% (95% CI, 59.6%-64.6%) of Japanese families were informed less than or equal to three days prior. Most families in all three countries received assurance that the patient would remain comfortable (could hear until death, no distress with death rattle or respiration with mandibular movement).

CONCLUSIONS

Physicians in Taiwan communicated about patient's impending death most frequently, and physicians in all three countries generally provided assurance to families that the patients would remain comfortable. Further studies should explore the reasons for these differences and the effects of such communications in East Asia.

Preferences on the Timing of Initiating Advance Care Planning and Withdrawing Life-Sustaining Treatment between Terminally-Ill Cancer Patients and Their Main Family Caregivers: A Prospective Study

Background: The Western individualistic understanding of autonomy for advance care planning is considered not to reflect the Asian family-centered approach in medical decision-making. The study aim is to compare preferences on timing for advance care planning initiatives and life-sustaining treatment withdrawal between terminally-ill cancer patients and their family caregivers in Taiwan. Methods: A prospective study using questionnaire survey was conducted with both terminally-ill cancer patient and their family caregiver dyads independently in inpatient and outpatient palliative care settings in a tertiary hospital in Northern Taiwan. Self-reported questionnaire using clinical scenario of incurable lung cancer was employed. Descriptive analysis was used for data analysis. Results: Fifty-four patients and family dyads were recruited from 1 August 2019 to 15 January 2020. Nearly 80% of patients and caregivers agreed that advance care planning should be conducted when the patient was at a non-frail stage of disease. Patients’ frail stage of disease was considered the indicator for life-sustaining treatments withdrawal except for nutrition and fluid supplements, antibiotics or blood transfusions. Patient dyads considered that advance care planning discussions were meaningful without arousing emotional distress. Conclusion: Patient dyads’ preferences on the timing of initiating advance care planning and life-sustaining treatments withdrawal were found to be consistent. Taiwanese people’s medical decision-making is heavily influenced by cultural characteristics including relational autonomy and filial piety. The findings could inform the clinical practice and policy in the wider Asia–Pacific region.

Effects of a Death Education Intervention for Older People with Chronic Disease and Family Caregivers: A Quasi-Experimental Study

PURPOSE

To investigate the effectiveness of a structured death education program for older adults with chronic illness and their family caregivers.

METHODS

This study adopted two-group, nonrandomized quasi-experimental design. Patient-caregiver dyads in the intervention group (N = 40 dyads) engaged in the death education program at the bedside once a week for 5 weeks, and were compared with participants (N = 40 dyads) in the control group who received usual health education. The program consisted of five sessions based on the Interaction Model of Client Health Behavior. Death attitude, death competence, well-being, family function, and satisfaction were measured at baseline (T0), immediately after the intervention (T1), and 1 month later (T2). Data collection was conducted from July 30, 2019, to December 30, 2019.

RESULTS

The intention-to-treat analysis The intention-to-treat analysis of between groups at 1-month follow-up revealed that the intervention group had greater decreases in the fear of death (p=.002, 95% CI -2.53, -0.47; p<.001, 95% CI -3.61, -1.65) and death avoidance (p<.001, 95% CI -3.46, -1.84; p<.001, 95% CI -3.89, -2.43), had greater increases in the neutral acceptance (p=.032, 95% CI 0.05, 1.38; p<.001, 95% CI 0.99, 2.56) and death competence (p<.001, 95% CI 4.10, 8.01; p<.001, 95% CI 7.80, 12.11) in patients and caregivers, respectively. There were significant intergroup differences over time for patient well-being of (p<.001, 95% CI 3.06, 9.74) and satisfaction of (p<.001, 95% CI 2.01, 4.59). Results were consistent with the results from the sensitivity analysis.

CONCLUSION

This study demonstrated the feasibility and benefits of death education in hospitals and provided an implementation plan for nursing professionals. Nurses should consider providing death education for older adults with chronic diseases and their families to promote the development of palliative care and the quality of end-of-life.

Feasibility and acceptability of a culturally adapted advance care planning intervention for people living with advanced cancer and their families: A mixed methods study

BACKGROUND

Increasing evidence shows that advance care planning is effective in improving outcomes. However, its applicability and acceptability outside Western cultures remain unknown. Examination of relevant cultural adaptations is required prior to wider adoption.

AIM

To examine the feasibility and acceptability of a culturally adapted advance care planning intervention in a Taiwanese inpatient hospital for advanced cancer patients, family members and healthcare professionals.

METHODS

A single-group, non-controlled, mixed methods feasibility study guided by a previously developed logic model. The culturally adapted advance care planning intervention represented a one-time intervention, comprising pre-advance care planning preparation and follow-up consultation. Qualitative interviews explored participants' view on their involvement in the study. Patients' medical records were examined to assess intervention fidelity. Findings from both data sets were integrated following analysis.

RESULTS

N = 29 participants (n = 10 patients; n = 10 family members and n = 9 healthcare professionals) participated in the intervention, of who 28 completed follow-up interviews. Of the 10 advance care planning interventions delivered, most components (n = 10/13) were met. Key contextual moderators influencing the intervention feasibility included: (1) resource constraints resulting in increased workload; (2) care decisions informed by relatives' experiences of care; (3) the requirement for financial and policy support; and (4) a presumption for end-of-life care provision and surrogate decision-making. Six areas of intervention refinement were identified for future research.

CONCLUSION

Implementing a culturally adapted advance care planning intervention in an inpatient hospital setting in Taiwan is possible. The participants reported the intervention to be acceptable. However, careful attention to the conceptual underpinning using local primary data is imperative for its success.

The Principles of Revised Clinical Guidelines about Palliative Sedation Therapy of the Japanese Society for Palliative Medicine

Background: When the suffering of a terminally ill patient is intolerable and refractory, sedatives are sometimes used for symptom relief. Objective: To describe the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Design: Consensus methods using the Delphi technique were used. Results: The main principles of the guidelines that were newly defined or developed are as follows: (1) palliative sedation was defined as "administration of sedatives for the purpose of alleviating refractory suffering" (excluding the aim of reducing patient consciousness); (2) palliative sedation was classified according to the method of administration of sedatives: respite sedation versus continuous sedation (including (continuous) proportional sedation and continuous deep sedation); (3) a description of state-of-the-art recommended treatments for difficult symptoms such as delirium, dyspnea, and pain before the symptom was determined as refractory was included; (4) the principle of proportionality was newly defined from an ethical point of view; and (5) families' consent was regarded as being desirable (mandatory in the previous version). Conclusions: We described the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Further consensus building is necessary.

Rebuilding and guiding a care community: A grounded theory of end-of-life nursing care practice in long-term care settings

AIMS

To investigate the end-of-life (EOL) nursing care practice process in long-term care (LTC) settings for older adults in Japan.

DESIGN

A qualitative study based on grounded theory developed by Corbin and Strauss.

METHODS

Sampling, interviewing, and analysis were performed cyclically, with results for each stage used as the basis for data collection and next-stage analysis decisions. Semi-structured interviews were conducted from March 2015-March 2019 with 22 nurses from eight LTC settings. Analysis was performed using coding, constant comparison, and emerging categories.

RESULTS

The core category, "guiding the rebuilt care community to assist the dying resident" comprised five categories: "assessing the resident's stage," "harmonizing care with the dying process," "rebuilding a care community," "helping community members care for the resident," and "encouraging community members to give meaning." The participants were described as "traditional village elders" who were the integral members of the care community, as well as guides who helped and encouraged the community.

CONCLUSION

Results revealed the holistic process of EOL nursing-care practice in Japan. Nurses aimed to allow LTC residents to die as social human beings, surrounded by people, and not just responding physical and psychological distress. Such practice requires nursing expertise, healthcare skills, and leadership qualities to build and serve care communities. Nurses must also consider residents' uncertainties and vulnerabilities as well as their cultural backgrounds.

IMPACT

This study showed that the nurses hold unique roles in providing dying people with care from a community. These findings can potentially be applied for developing a universal model for LTC nurses in many aging populations, to modify their EOL care practice, educate new LTC nurses, and collaborate with other healthcare professionals.

Paramedic information needs in end-of-life care: a qualitative interview study exploring access to a shared electronic record as a potential solution

Background

Limited access to, understanding of, and trust in paper-based patient information is a key factor influencing paramedic decisions to transfer patients nearing end-of-life to hospital. Practical solutions to this problem are rarely examined in research. This paper explores the extent to which access to, and quality of, patient information affects the care paramedics provide to patients nearing end-of-life, and their views on a shared electronic record as a means of accessing up-to-date patient information.

Method

Semi-structured interviews with paramedics (n = 10) based in the north of England, drawn from a group of health and social care professionals (n = 61) participating in a study exploring data recording and sharing practices in end-of-life care. Data were analysed using thematic analysis.

Results

Two key themes were identified regarding paramedic views of patient information: 1) access to information on patients nearing end-of-life, and 2) views on the proposed EPaCCS. Paramedics reported they are typically unable to access up-to-date patient information, particularly advance care planning documents, and consequently often feel they have little option but to actively treat and transport patients to hospital – a decision not always appropriate for, or desired by, the patient. While paramedics acknowledged a shared electronic record (such as EPaCCs) could support them to provide community-based care where desired and appropriate, numerous practical and technical issues must be overcome to ensure the successful implementation of such a record.

Conclusions

Access to up-to-date patient information is a barrier to paramedics delivering appropriate end-of-life care. Current approaches to information recording are often inconsistent, inaccurate, and inaccessible to paramedics. Whilst a shared electronic record may provide paramedics with greater and timelier access to patient information, meaning they are better able to facilitate community-based care, this is only one of a series of improvements required to enable this to become routine practice.

What influences patients' decisions regarding palliative care in advance care planning discussions? Perspectives from a qualitative study conducted with advanced cancer patients, families and healthcare professionals

BACKGROUND

The concept of advance care planning is largely derived from Western countries. However, the decision-making process and drivers for choosing palliative care in non-Western cultures have received little attention.

AIM

To explore the decision-making processes and drivers of receiving palliative care in advance care planning discussions from perspectives of advanced cancer patients, families and healthcare professionals in northern Taiwan.

METHOD

Semi-structured qualitative interviews with advanced cancer patients, their families and healthcare professionals independently from inpatient oncology and hospice units. Thematic analysis with analytical rigour enhanced by dual coding and exploration of divergent views.

RESULTS

Forty-five participants were interviewed (n = 15 from each group). Three main decision-making trajectories were identified: (1) 'choose palliative care' was associated with patients' desire to reduce physical suffering from treatments, avoid being a burden to families and society, reduce futile treatments and donate organs to help others; (2) 'decline palliative care' was associated with patients weighing up perceived benefits to others as more important than benefits for themselves; and (3) 'no opportunity to choose palliative care' was associated with lack of opportunities to discuss potential benefits of palliative care, lack of staff skill in end-of-life communication, and cultural factors, notably filial piety.

CONCLUSION

Choice for palliative care among advanced cancer patients in Taiwan is influenced by three decision-making trajectories. Opinions from families are highly influential, and patients often lack information on palliative care options. Strategies to facilitate decision-making require staff confidence in end-of-life discussions, working with the patients and their family while respecting the influence of filial piety.

Effects of an advance care planning educational programme intervention on the end-of-life care attitudes of multidisciplinary practitioners at an acute hospital: A pre- and post-study

BACKGROUND

Advance care planning is a crucial end-of-life care practice. However, an advance care planning educational programme for practitioners in an acute care setting has not yet been established. Consequently, we examined the effects of an advance care planning educational programme in an acute hospital in the hope of achieving increased awareness of end-of-life care.

DESIGN

A mixed-methods, pre- and post-design was employed to evaluate the change in attitudes of practitioners post-programme. The intervention programme was conducted thrice over 3 months in 90-min sessions.

SETTING/PARTICIPANTS

This study included 85 participants in the baseline assessment working at B acute hospital in Osaka.

RESULTS

Participants' scores on the 'Positive attitude for end-of-life care' subscale on the short version of the Frommelt Attitude Toward Care of Dying scale significantly increased after the 6-month intervention. A 'Positive attitude for end-of-life-care' implies that participants would not be afraid to practice end-of-life care. Further, participants' scores on the 'Death relief' subscale of the Death Attitude Inventory also significantly increased. The term 'Death relief' means that death helps in ending suffering. It means participants are not afraid of death. Qualitative results implied that participants believed advance care planning implementation and communicating with patients and patients' families were critical.

CONCLUSIONS

Six months post-intervention, participants displayed sustained positive attitudes towards end-of-life care. These results suggest that the present programme was effective at improving practitioners' attitudes towards patients' end-of-life care.