Strategies of information disclosure to Chinese cancer patients in an Asian community

A study of Chinese medical students' communication pattern in delivering bad news: an ethnographic discourse analysis approach

BACKGROUND

Breaking bad news is inevitable for prospective doctors, it is important for medical students to learn how to humanely communicate devastating news to patients. This study explores the discourse strategies used by Chinese medical students when conducting critical conversations via role-play scenarios.

METHODS

Fifty Year-6 medical students attending the 'Serious Illness Communication Module' were recruited from a local medical school in Hong Kong. They were asked to participate voluntarily in two role-play scenarios requiring them to break bad news to a simulated patient in Cantonese. The verbal interactions were video-recorded and analysed using an ethnographic discourse approach to unpack the quality of the observed interaction sequences and identify the discourse strategies strategically used by the medical students to overcome any communication breakdowns (e.g. linguistic expressions conveying diagnoses) and show empathy to patients.

RESULTS

Six discourse strategies for delivering bad news were identified in the Chinese context: (1) placing great emphasis on patients' emotional needs; (2) informing patients with a balanced focus on medical and emotional needs; (3) directing patients' attention to treatment options; (4) acknowledging concerns about dying patients' physical discomfort and wishes; (5) directing bad news disclosure to patients; and (6) addressing the family expectations of patients. The majority of the Chinese medical students in this study used a patient-oriented approach to cater to the patients' emotional and physical needs. They also often informed and acknowledged the patients' family members.

CONCLUSIONS

When delivering bad news, medical students should be equipped with discourse strategies that effectively balance interpersonal communication with the communication of medical expertise, which is integral to ensuring patients' participation, their understanding and satisfaction with their clinicians. This is in accordance with the existing communication frameworks for critical conversation and demonstrates awareness of the needs in the Chinese context. However, some students demonstrated poor sensitivity to non-verbal cues, such as tone, manners and attitude. Thus, more training using a culturally appropriate model of   communication for critical conversation should be promoted.

Breaking bad news about cancer in China: Concerns and conflicts faced by doctors deciding whether to inform patients

OBJECTIVES

We aimed to explore how doctors in China decide whether to inform cancer patients about diagnosis and prognosis.

METHODS

We conducted in-depth, semi-structured interviews with 24 doctors and residents from a leading hospital in Hunan, China. Data were analyzed by content analysis.

RESULTS

Doctors routinely told the family about cancer first, then withheld information from patients if the family did not want to tell the patient. Three main themes emerged in relation to hiding bad news from patients: 1) fear that most patients lack resilience to cope with bad news; 2) fear of direct or legal conflict with the family, and 3) a value conflict between respecting the patient's "right to know" and respecting the family's interest in protecting the patient.

CONCLUSIONS

Doctors consider decisions to withhold information from cancer patients to be a non-ideal but necessary compromise of the patient's "right to know." Culturally adjusted training and guidelines could help with including the patient in information disclosure while still respecting China's cultural value of family decision-making.

PRACTICE IMPLICATIONS

Future training and guidelines should help doctors mediate between patient and family interests and understand changing laws and regulations. Other important elements include reflection, senior mentorship, self-awareness, and building trust.

Patient Experiences Using an Inpatient Personal Health Record

OBJECTIVE

To investigate patients' experience using an inpatient personal health record (PHR) on a tablet computer to increase engagement in their hospital care.

METHODS

We performed observations and conducted semi-structured interviews with 14 post-operative cardiac surgical patients and their family members who received an inpatient PHR. Themes were identified using an inductive coding scheme.

RESULTS

All participants responded favorably to having access to view their clinical information. A majority (85.7%) of participants used the application following an initial training session. Patients reported high satisfaction with being able to view their hospital medications and access educational materials related to their medical conditions. Patients reported a desire to view daily progress reports about their hospital stay and have access to educational information about their post-acute recovery. In addition, patients expressed a common desire to view their diagnoses, laboratory test results, radiology reports, and procedure notes in language that is patient-friendly.

CONCLUSION

Patients have unmet information needs in the hospital setting. Our findings suggest that for some inpatients and their family members, providing personalized health information through a tablet computer may improve satisfaction, decrease anxiety, increase understanding of their health conditions, and improve safety and quality of care.

Diagnosis, disease stage, and distress of Chinese cancer patients

BACKGROUND

The objective is to assess how cancer patients know about their diagnosis what they know about their real stage, and the relationship between cancer stage and psychological distress.

METHODS

A questionnaire including the Distress Thermometer was delivered to 422 cancer inpatients. Multivariate logistic regression analysis was used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Most of patients (68.7%) knew the bad news immediately after diagnosis. Half of patients knew their diagnosis directly from medical reports. Nearly one third of patients were informed by doctors. Cancer stages, which patients believed, differed significantly from their real disease stages (P<0.001). Over half of patients did not know their real disease stages. Patients with stage I-III cancer were more likely to know their real disease stage than patients with stage IV cancer (P<0.001). Distress scores of cancer patients were determined by the real cancer stage (P=0.012), not the stage which patients believed.

CONCLUSIONS

Although most of participants knew the bad news immediately after diagnosis, less than half of them knew their real disease stage. Patient with stage I-III cancer was more likely to know the real disease stage and had a DT score <4 than patient with stage IV disease.

How doctors communicate the initial diagnosis of cancer matters: cancer disclosure and its relationship with Patients' hope and trust

OBJECTIVE

The study is to examine the relationships between perceived initial cancer disclosure communication with doctors, levels of hope, and levels of trust in doctors among cancer patients in China.

METHODS

A total number of 192 cancer inpatients in a cancer hospital in China were surveyed. Perceived disclosure strategies, levels of hope, levels of trust in their doctors, as well as the demographic information were obtained from the participants.

RESULTS

In addition to age, patients who had higher levels of perceived emotional support from doctors, or higher levels of perceived personalized disclosure from doctors, or higher levels of perceived discussion of multiple treatment plans with doctors were more likely to have higher levels of trust in doctors. In addition to perceived health status, perceived emotional support from doctors significantly predicted participants' levels of hope. That is, patients who had higher higher levels of perceived doctors' emotional support were more likely to have higher levels of hope. Key disclosure person was a marginally significant variable, that is, patients who were mainly disclosed by family members might have higher levels of hope compared with patients who were mainly disclosed by doctors.

CONCLUSIONS

When communicating with a cancer patient, doctors might not ignore the importance of emotional support during cancer diagnosis communication. Doctors might want to involve family and collaborate with family to find out ways of personalized disclosure. During the communication process, doctors could provide their patients with multiple treatment options and discuss the benefits and side effects of each treatment. Copyright © 2016 John Wiley & Sons, Ltd.

Poor-prognosis disclosure preference in cancer patient-caregiver dyads and its association with their quality of life and perceived stress: a cross-sectional survey in mainland China

BACKGROUND

This study attempted to examine the discordance between family caregivers and cancer patients in their poor-prognosis disclosure preferences in mainland China and then ascertained the associations between quality of life (QoL), perceived stress, and poor-prognosis disclosure preferences.

METHODS

Six hundred fifty-one pairs of inpatients and their matched caregivers (participation rate = 92.2%) were recruited in this cross-sectional survey. A set of paired self-administered questionnaires were completed independently by patient-caregiver dyads.

RESULTS

Fewer family caregivers than cancer patients felt that poor prognosis should be disclosed to patients (61.2% vs. 90.0%, p < 0.001). Patients' positive poor-prognosis disclosure preference was associated with patients' better QoL (p < 0.05) and caregivers' reduced perceived stress levels (p = 0.013). However, caregivers' poor-prognosis disclosure preference correlated only with their own physical state (p = 0.028). Moreover, the caregivers who concurred with patients in positive poor-prognosis disclosure preference were more likely to experience a better QoL (p < 0.05) and lower perceived stress levels (p = 0.048) in the III-IV stage subgroup.

CONCLUSIONS

There was a significant discrepancy in poor-prognosis disclosure preference between cancer patients and caregivers in China. The caregivers' preference of concealing poor prognosis from patients was not related to cancer patients' QoL or perceived stress. In addition, caregivers had better QoL and lower stress levels when they held the same positive poor-prognosis disclosure preference as the patients. Copyright © 2015 John Wiley & Sons, Ltd.

Communicative characteristics of interactions between surgeons and Chinese women with breast cancer in oncology consultation: a conversation analysis

BACKGROUND

While previous studies have analysed features of interaction in cancer consultations using observational coding frames, relatively little attention is being given to how actual interactions are sequentially organized and achieved by participants in the course of talk-in-interaction. Research into the interactional practices in consultations, which involves Chinese patients, is largely absent.

OBJECTIVE

To provide insight into the talk-in-interaction in surgical-oncology consultations in the context of a Chinese medical setting.

METHODS

Thirty-one consultations involving 31 patients with breast cancer and eight surgeons were videotaped. The recordings were transcribed verbatim and analysed using conversation analysis.

RESULTS

The manner in which surgeons delivered the diagnostic results was fairly similar across all the consultations. Most surgeons gave the diagnosis in a very straightforward and abrupt manner at the outset of the consultation with no mitigation. While patients in our study conformed to the traditional information giving and receiving roles, how information was presented by surgeons shaped the subsequent sequential organization of surgeon-patient interaction and turn-taking patterns. More importantly, there was a tendency by the surgeons to move from issues of psychosocial nature to clinical matters regardless of the topics taken up in the specific encounter.

CONCLUSIONS

This study demonstrated the potential of conversation analysis as a context-sensitive method that enabled researchers to gain a more thorough understanding of dynamics of interaction in cancer consultations, thereby informing training interventions for surgeons. Our findings underscore the importance of discursive practices in shaping and encouraging (or discouraging) patient participation in oncology consultation.

A longitudinal analysis on pain treatment satisfaction among Chinese patients with chronic pain: predictors and association with medical adherence, disability, and quality of life

BACKGROUND

Patient satisfaction research in chronic pain treatment is scarce internationally and is nonexistent in Chinese communities like Hong Kong. This longitudinal study examined the relationships between medical adherence, pain treatment satisfaction, disability, and quality of life (QoL) in a sample of Chinese patients with chronic pain.

METHODS

A total of 178 patients with chronic pain were assessed at baseline, 3 and 6 months following baseline. Medical adherence and pain treatment satisfaction were assessed by the Participant Compliance Reporting Scale and the Pain Treatment Satisfaction Scale (PTSS), respectively. QoL, depression, pain catastrophizing, and pain-related fear were assessed using SF-12, the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D), the Pain Catastrophizing Scale, and the Tampa Scale for Kinesiophobia, respectively. Linear mixed effects models (LME) were fitted to identify predictors of pain treatment satisfaction, medical adherence, and QoL.

RESULTS

Results of univariate LME analyses showed significant quadratic time effects on four PTSS scores and significant associations between disability grade and PTSS scores (all p < 0.05). Medical adherence was not significantly associated with satisfaction regarding pain medication (model 1). Satisfaction with medication characteristics emerged as an independent predictor of medical adherence (model 2: std β = -0.11, p < 0.05) after controlling for sociodemographic and pain variables. Neither medical adherence nor pain treatment satisfaction predicted QoL outcomes (models 3 and 4).

CONCLUSIONS

Distinct trajectories in pain treatment satisfaction were displayed in the current sample of Chinese patients with different disability grading chronic pain. Within pain treatment, only medication characteristics significantly impacted patients' medical adherence.

Should Patients and Family be Involved in "Do Not Resuscitate" Decisions? Views of Oncology and Palliative Care Doctors and Nurses

Background:

“Do not resuscitate” (DNR) orders are put in place where cardiopulmonary resuscitation is inappropriate. However, it is unclear who should be involved in discussions and decisions around DNR orders.

Aim:

The aim was to determine the views of oncology and palliative care doctors and nurses on DNR orders.

Materials and Methods:

A questionnaire survey was conducted on 146 doctors and nurses in oncology and palliative care working within a tertiary specialist cancer center in Singapore.

Results:

Perceived care differences as a result of DNR determinations led to 50.7% of respondents reporting concerns that a DNR order would mean that the patient received a substandard level of care. On the matter of DNR discussions, majority thought that patients (78.8%) and the next of kin (78.1%) should be involved though with whom the ultimate decision lay differed. There was also a wide range of views on the most appropriate time to have a DNR discussion.

Conclusions:

From the viewpoint of oncology and palliative care healthcare professionals, patients should be involved at least in discussing if not in the determination of DNR orders, challenging the norm of familial determination in the Asian context. The varied responses highlight the complexity of decision making on issues relating to the end of life. Thus, it is important to take into account the innumerable bio-psychosocial, practical, and ethical factors that are involved within such deliberations.

Racial/ethnic minority access to end-of-life care: a conceptual framework

Minority underutilization of hospice care has been well-documented; however, explanations addressing disparities have failed to examine the scope of factors in operation. Drawing from previous health care access models, a framework is proposed in which access to end-of-life care results from an interaction between patient-level, system-level, and societal-level barriers with provider-level mediators. The proposed framework introduces an innovative mediating factor missing in previous models, provider personal characteristics, to better explain care access disparities. This article offers a synthesis of previous research and proposes a framework that is useful to researchers and clinicians working with minorities at end of life.

End-of-life care in the general wards of a Singaporean hospital: an Asian perspective

BACKGROUND

Despite international differences in cultural perspectives on end-of-life issues, little is known of the care for the dying in the general wards of acute hospitals in Asia.

METHODS

We performed a retrospective medical chart review of all 683 adult patients who died without intensive care unit (ICU) admission in our Singaporean hospital in 2007. We first evaluated the prevalence of do-not-resuscitate (DNR) orders and orders for or against life-sustaining therapies; second, if such orders were discussed with the patients and/or family members; and third, the actual treatments provided before death.

RESULTS

There were DNR orders for 66.2% of patients and neither commitment for DNR nor cardiopulmonary resuscitation (CPR) for 28.1%. Orders to limit life-sustaining therapies, including ICU admission, intubation, and vasopressors/inotropes were infrequent. Only 6.2% of the alert and conversant patients with DNR orders were involved in discussions on these orders. In contrast, such discussions with their family members occurred 82.9% of the time. Interventions in the last 24 hours of life included CPR (9.4%), intubation (6.4%), vasopressors/inotropes (14.8%), tube feeding (24.7%), and antibiotics (44.9%). Analgesia was provided in 29.1% of patients.

CONCLUSIONS

There was a lack of commitment by doctors on orders for DNR/CPR and to limit life-sustaining therapies, infrequent discussions with patients on end-of-life decisions, and excessive burdensome interventions with inadequate palliative care for the dying. These findings may reflect certain Asian cultural biases. More work is required to improve our quality of end-of-life care.

Experiences and Attitudes of Patients With Terminal Cancer and Their Family Caregivers Toward the Disclosure of Terminal Illness

Purpose

We investigated the experiences of cancer patients and their family caregivers who became aware that the cancer was terminal, how they became aware, and how they felt about disclosure of the information.

Patients and Methods

In this cohort study, we administered questionnaires to 619 consecutive patients determined by physicians to be terminally ill and to their family caregivers.

Results

A total of 481 patients and 381 family caregivers completed the questionnaire. A majority of patients (58.0%) and caregivers (83.4%) were aware of the patient's terminal status. Approximately 28% of patients and 23% of caregivers reported that they guessed it from the patient's worsening condition. The patient group was more likely than the caregiver group (78.6% v 69.6%) to prefer that patients be informed of their terminal status. Patients informed of their terminal diagnosis had a significantly better quality of life and fewer symptoms and had a lower rate of emotional distress than patients who guessed it from their worsening condition. Younger patients and patients who paid the treatment costs themselves were significantly more likely to want to be told when their illness was terminal. If the patient paid the treatment cost and was employed at the time of the cancer diagnosis, the family caregivers were more likely to prefer disclosure of terminal illness.

Conclusion

Most patients with terminal cancer and their family caregivers preferred disclosure, and patients who knew of their terminal diagnosis had a lower rate of emotional distress and a higher health-related quality of life.

Intrapersonal and interpersonal dimensions of cancer perception: a confirmatory factor analysis of the cancer experience and efficacy scale (CEES)

PURPOSE

Sociocultural factors influence psychological adjustment to cancer in Asian patients in two major ways: prioritization of relationships over individual orientations and belief in the efficacy of interpersonal cooperation. We derived and validated among Chinese colorectal cancer (CRC) patients an instrument assessing cancer perceptions to enable the study of the sociocultural processes.

PATIENTS AND METHODS

Qualitative interviews (n = 16) derived 15 items addressing interpersonal experience in Chinese CRC patients' adjustment. These 15 items and 18 corresponding self-referent items were administered to 166 Chinese CRC survivors and subjected to exploratory factor analysis (EFA) to establish the initial scale structure and reliability. The final 29 items, together with other psychometric measures, were administered to a second cohort of 215 CRC patients and subjected to confirmatory factor analysis (CFA).

RESULTS

EFA (63.35% of the total variance) extracted six factors: personal strain, socioeconomic strain, emotional strain, personal efficacy, collective efficacy, and proxy efficacy. CFA confirmed the psychometric structure [chi (2)(df) = 702.91(368); Comparative Fit Index = 0.95; Nonnormed Fit Index = 0.94; Incremental Fit Index = 0.95; standardized root mean square residual = 0.08] of the six factors by using a model with two latent factors: experience and efficacy. All subscales were reliable (alpha = 0.76-0.92). Appropriate correlations with adjustment outcomes (symptom distress, psychological morbidity, and subjective well-being), optimistic personalities, and social relational quality indicated its convergent and divergent validity. Known group comparisons (i.e., age, active treatment, and colostomy) showed its clinical utility.

CONCLUSION

The cancer experience and efficacy scale is a valid multidimensional instrument for assessing intrapersonal and interpersonal dimensions of cancer experience in Asian patients, potentiating existing patient-reported outcome measures.

Congruence of Knowledge, Experiences, and Preferences for Disclosure of Diagnosis and Prognosis between Terminally-Ill Cancer Patients and Their Family Caregivers in Taiwan

BACKGROUND

Over the last 40 years, studies have shown cultural differences in attitudes toward truth telling at the end-of-life. Nevertheless, the argument that cancer patients from an Asian culture have different preferences about information disclosure that necessitate significantly modifying information disclosure practices has not been validated by direct investigation from patients' points of view.

METHODS

Six hundred seventeen dyads of patient-designated family caregivers across 21 hospitals throughout Taiwan were surveyed and interviewed by a semistructured interview guide. Percentage of agreement, kappa coefficients, McNemar tests, and paired t-tests were conducted to examine the extent of congruence of knowledge, experiences, and preferences for disclosure of diagnosis and prognosis between the dyads.

RESULTS

There were substantial discrepancies in the knowledge and experiences of being informed about the diagnosis and prognosis between Taiwanese terminally-ill cancer patients and their family caregivers (kappa values ranged from 0.08 to 0.44). Cancer patients strongly proclaimed their superior rights to be informed about their disease over their family and preferred their physicians to inform themselves before releasing any information to their family caregivers.

CONCLUSION

The arguments that cancer patients from an Asian culture (i.e., Chinese/Taiwanese culture) have different preferences regarding being informed of their diagnosis and prognosis and that family members have legitimate superior power in decision making could not be supported by data from this group of terminally-ill cancer patients. Physicians need to respect patients' preferences rather than routinely taking the family's opinions into consideration first in the event of disagreement. Equipped with adequate information, terminally-ill cancer patients from Asia may have better opportunities to make end-of-life care decisions that are in accord with their wishes.

Understandings of death and dying for people of Chinese origin

This article introduces the primary beliefs about ancestor worship, Taoism, Confucianism, Buddhism and traditional Chinese medicine that have influenced Chinese people for thousands of years, particularly in relation to death and dying. These cultures and traditions remain important for Chinese people wherever they live. Over a long period, Chinese people have integrated these philosophies and religions to form the basis of their culture and traditions. Although they agree that death is a natural part of the life span, a unique belief about death and dying has emerged among the Chinese from this integration. From this, the people find a significant definition of death and dying.

Different attitudes of Chinese patients and their families toward truth telling of different stages of cancer

OBJECTIVE

Cancer patients and their families differed in their attitude toward truth telling. The objective is to investigate different attitudes of Chinese patients or families toward whether and how to disclose diagnosis to patients with different stages of cancer and to examine the difference between the two groups.

METHODS

A questionnaire was delivered to 1023 participants.

RESULTS

Three hundred and eighty-two patients and 482 families completed the questionnaire. Cancer patients were more likely than families to believe that patient should be informed of the diagnosis (early-stage, 90.8 vs 69.9%, P<0.001; terminal stage, 60.5 vs 34.4%, P<0.001), and that doctor-in-charge was the appropriate person to disclose the diagnosis. Most participants thought that patient should be disclosed immediately after the diagnosis. Nearly half of participants reported that patient should be disclosed in a quiet and undisturbed room. When the hypothetic diagnosis changed from early-stage cancer to terminal illness, the number of participants, who wanted patient to know the diagnosis, decreased significantly.

CONCLUSION

Our findings indicated that Chinese cancer patients and their families differed in their attitude toward truth telling and the attitudes toward such a disclosure were influenced by disease stage. Physicians should realize this phenomenon and pay more attention to the skills of how to disclose the cancer diagnosis.

Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review

Many health professionals (HPs) express discomfort at having to broach the topic of prognosis, including limited life expectancy, and may withhold information or not disclose prognosis. A systematic review was conducted of 46 studies relating to truth-telling in discussing prognosis with patients with progressive, advanced life-limiting illnesses and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO and Cochrane Register of Controlled Trials) up to November 2004, with handsearching of studies, as well as inclusion of studies satisfying selection criteria reported in 2005 by the authors. The reference lists of identified studies were hand-searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Results showed that although the majority of HPs believed that patients and caregivers should be told the truth about the prognosis, in practice, many either avoid discussing the topic or withhold information. Reasons include perceived lack of training, stress, no time to attend to the patient's emotional needs, fear of a negative impact on the patient, uncertainty about prognostication, requests from family members to withhold information and a feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment. Studies suggest that patients can discuss the topic without it having a negative impact on them. Differences and similarities in findings from different cultures are explored.

Surgical treatment preferences in Chinese-American women with early-stage breast cancer

Breast-conserving treatment (BCT) is considered preferable to radical or modified radical mastectomy (MRM) for most women diagnosed with early-stage breast cancer. Studies have found that Chinese-American women are more likely to be treated with MRM, regardless of age or stage of disease. The central question posed in this study is: what are the cultural factors that influence the selection of treatments by Chinese-American patients and the presentation of treatment options by providers? Focused group discussions, semi-structured interviews, and ethnographic observations were conducted with 69 Chinese-American women and 14 health professionals. Results indicated that (1) many Chinese-American women, regardless of age, migration status, education, and income level, expressed a preference for MRM because it was seen as safer; (2) this was primarily a communal belief that even women who had BCT felt pressure to conform to; (3) some women felt pressured into the BCT decision by their physician and/or were unhappy with their choice; (4) patient and physician bias and difficulties with translation issues and supplemental materials all led to cross-cultural miscommunication; and (5) this miscommunication was cited as a reason for (a) not completing treatment regimes or (b) drastic changes in the treatment selected.

Quality of life and pain in Chinese lung cancer patients: Is optimism a moderator or mediator?

OBJECTIVE

To clarify if optimism exerts a primarily moderating or mediating influence on the pain-QoL association in Chinese lung cancer patients.

METHODS

About 334 Chinese lung cancer patients were interviewed at baseline during the first outpatient visit (Baseline), at 4 months after Baseline (FU1), and at 8 months after Baseline (FU2). Respondents completed the Chinese version of the FACT-G version-3 scale (FACT-G (Ch)). Optimism and pain were assessed using two 11-point self-rated items. Linear mixed effects (LME) models tested the moderating and mediating effects of optimism on QoL.

RESULTS

Optimism, pain, and QoL were most strongly correlated at FU1. LME models failed to show any moderating effect by optimism on the pain-QoL association (standardized beta = -0.049, 95% CI -0.097 to 0.001). After adjustment for age, cancer stage, and disease recurrence, a modest mediating effect was observed for optimism on the pain-QoL association over the duration of the study (standardized beta = 0.047; Sobel test z = -4.317, p < 0.001).

CONCLUSIONS

Optimism qualifies as a mediator between pain and QoL suggesting that pessimistic lung cancer patients are likely to experience greater QoL decrements in response to pain in the early post-diagnostic period. Effective pain control may be enhanced by inclusion of interventions that facilitate optimistic perspectives in patients. This study lends further support to the view that lung cancer patients' psychological needs are important in both pain control and QoL.

Qualitative study of Chinese widows in Hong Kong: insights for psycho-social care in hospice settings

In an exploratory, phenomenological study of seven Chinese widows in Hong Kong, five major themes are identified: relationship with the deceased, relationship with others, grief reactions, coping and emotional expression. This paper focuses on the first theme: the widows' relationship with the deceased husband along a timeline from the time of diagnosis to after death. The experiences in the final days with the deceased were frequently referred to when the informants talked about this theme. This paper aims to give added voice, based on the experience of Chinese widows, to the possible role of hospice and palliative care on influencing the bereavement experience. Issues of awareness and acceptance of death, the supportive environment and support for family carers, the moment of death, creation of legacies, and sensitivity towards cultural embedded practices, are discussed. It is hoped that the experiences of these bereaved widows will stimulate new research to elucidate and verify the findings reported in this paper.

The influence of awareness of terminal condition on spiritual well-being in terminal cancer patients

We developed a Spirituality Transcendence Measure (STM) and studied whether awareness of terminal illness affects spiritual well-being in terminal cancer patients. Three sources of spiritual transcendence--the situational, the moral and biographical, and the religious aspect--were assessed in the STM. Cronbach's alpha of the STM was 0.95, and the principle axis factor analysis extracted only one factor. Thirty-seven terminal cancer patients with male predominance (59.5%) were studied. Awareness of terminal illness was associated with a higher total STM score (Z = -2.21, P = 0.027), along with the individual scores for each of the three transcendences (Z = -2.39, P = 0.017; Z = -2.71, P = 0.007; and Z = -1.96, P = 0.050). Acceptance of death was associated with a higher situational score (Z = 2.01, P = 0.046) and a higher religious score (Z = -2.27, P = 0.023). Announcement of testament was associated with a higher situational score (Z = -2.30, P = 0.021). We conclude that awareness of terminal illness is associated with spiritual well-being. Telling the complete truth is necessary even when dealing with terminal conditions.

Different attitudes of oncology clinicians toward truth telling of different stages of cancer

OBJECTIVES

To investigate different attitudes of oncology clinicians toward whether and how to disclose diagnosis to patients with different stages of cancer.

MATERIALS AND METHODS

A questionnaire investigating physician's demographic information and attitude toward truth telling was delivered to 256 Chinese oncology clinicians.

RESULTS

Two hundred thirty-two (90.6%) physicians completed the questionnaire. Of these oncology clinicians, 87.5% reported that a patient with early-stage cancer should be informed of the diagnosis, while only 40.5% believed that a patient with terminal illness should know the truth (P<0.001). Physicians who preferred to tell the truth reported that patients with early or terminal stage of cancer should be informed by the doctor-in-charge (81.3 vs 77.7%, respectively; P>0.05), immediately after the diagnosis (83.7 vs 87.2%, respectively), and in a quiet and undisturbed room (63.5 vs 68.1%, respectively; P>0.05). In stepwise multiple logistic regression analyses, no demographic information showed association with truth telling of early-stage cancer. Women doctors [odds ratio (OR), 2.25; 95% CI, 1.31 to 3.89; P=0.004] were more likely than men to want the patient to be informed of the terminal illness. Physicians with cancer relatives (OR, 0.55; 95% CI, 0.31 to 0.97; P=0.04) were less likely than physicians without cancer relatives to want the patient to be informed of the terminal illness.

CONCLUSION

Oncology clinicians differed in their attitudes toward truth telling of different stages of cancer. Physicians reported that the doctor-in-charge should be the ones to disclose the condition of the patient, immediately after the diagnosis, and in a quiet and undisturbed room.

Family centred decision making and non-disclosure of diagnosis in a South East Asian oncology practice

AIM

To audit the extent of non-disclosure of cancer diagnosis (NDD) in South-East Asian patients referred to a Western trained oncologist, and determine the factors associated with this pattern of decision-making.

METHODS

Over a 12-month period, all new patients referred to a single radiation oncologist's practice were prospectively audited at time of the initial consultation. Data obtained included patient demographic features, tumour details, proposed treatment and decision-making process. A shared decision-making consultation was attempted but if there was a persistent request by family to avoid disclosure, then a family-centred model was adopted. Patient autonomy was maintained by formally asking desire to participate in decision-making process, and subsequent permission then sought to involve family members as surrogates. Treatment aim, predicted median survival and NDD was recorded at end of consultation. Endpoints of patient NDD and non-discussion of prognosis were audited over a 12-month period, and factors potentially associated with these endpoints were assessed.

RESULTS

Over a 12-month period 369 new patients were referred to the oncologist's practice. Forty per cent were >65 years, 84% Chinese race, and 66% non-English speaking. Lung (33%) and breast (32%) primaries were prominent. Forty-seven per cent were managed with palliative intent and 24% had expected median survivals of <6 months. NDD was recorded in 66 patients or 17% of the patient group. Quantitative discussion of prognosis was avoided in 36.8% of patients. On univariate analysis advanced patient age (p<0.001, OR=9.6, 95% CI 4.9-18.9), female sex (p=0.035, OR=1.8, 95% CI 1.04-3.1), non-English speaking (p<0.001, OR=21.4, 95% CI 5.1-89.1), palliative treatment aim (p<0.001, OR=5.9, 95% CI 3.1-11.2) and short expected median survival (p<0.001, OR=4.0, 95% CI 2.3-7.1) were associated with NDD. Advanced patient age (p<0.001, OR=7.9, 95% CI 3.6-17.5), female sex (p<0.001, OR=6.4, 95% CI 2.8-14.7), non-English speaking (p=0.010, OR=7.4, 95% CI 1.6-33.3) and palliative treatment aim (p=0.010, OR=3.3, 95% CI 1.3-8.0) remained significantly associated with NDD on multivariate logistic regression analysis.

CONCLUSIONS

A high rate of desired NDD is evident in this Asian oncology population when a family-centred model to medical decision making is used. This data confirms that NDD and the model of decision making remains a significant ethical issue.

Concordance of Quality-of-Life Assessments Between Terminally Ill Cancer Patients and Their Primary Family Caregivers in Taiwan

Physical or cognitive deterioration may hamper the ability or willingness of cancer patients to participate and remain in quality-of-life (QOL) research at the end of life. Use of family caregivers as proxy informants to report patients' QOL has been suggested as a way of resolving the problem of nonresponse bias and nonrandom missing data in end-of-life research. However, there is a dearth of information in the literature about the extent of concordance of QOL assessments between terminally ill patients and their family caregivers outside Western countries. A prospective and descriptive study was conducted to fill the gap in the literature. Results from 114 dyads of Taiwanese terminally ill cancer patients and their family caregivers indicated that QOL assessments from family informants agreed at least moderately well with patients' QOL reports. None of the standardized absolute mean differences for individual items and composite (sub)scales between the 2 respondents exceed the threshold of moderate (>0.50) set by Cohen. Generally, when discrepancies existed, family caregivers held a more negative view of patients' QOL than did patients. At the individual patient level, family caregivers were best able to assess functional dependency, followed by symptom distress, but were least reliable when evaluating the psychological-social-spiritual concerns of patients. The conclusion made by Western researchers that family caregivers can act as a not perfect but reliable alternative source of QOL data for terminally ill cancer patients who are no longer able to speak for themselves is cross-culturally confirmed in this study. It is suggested from the findings that, for family caregivers to function well in their role as proxy informants on the psychological reactions and social/spiritual domains of QOL as well as surrogate decision makers for terminally ill cancer patients in Asian countries, an open and frequent dialogue between terminally ill cancer patients and their family caregivers should become standard.

Concordance of preferences for end-of-life care between terminally ill cancer patients and their family caregivers in Taiwan

There is a dearth of information in the literature about the concordance of preferences for end-of-life care between terminally ill patients and their family surrogates outside the Western countries. The purpose of this study was to examine the extent of concordance in preferences for end-of-life care goals and life-sustaining treatments between Taiwanese terminally ill cancer patients and their primary family caregivers. A total of 617 dyads of patients-family caregivers across 21 hospitals throughout Taiwan were surveyed. Overall agreements on the goals for end-of-life care and preferences for initiating life-sustaining treatments ranged from 62.4% to 96.9% (average: 71.0%). Kappa values for the extent of concordance ranged from 0.13 to 0.46 (average: 0.29), indicating poor to moderate consistency in personal preferences. Family caregivers had a significantly more aggressive attitude toward each examined life-sustaining treatment for their ill family members than the patients' own stated preferences. In societies, such as in Asian countries, where physicians' respect for patient autonomy is frequently subordinate to the power of family, disagreements between a patient and family about end-of-life care may result in the patient's preferences being overridden at the end of life. To effect real change and to gain increased agreement on preferences for end-of-life care, an open dialogue between patients and their primary family caregivers should become standard.

Patient-professional communication research in cancer: an integrative review of research methods in the context of a conceptual framework

This paper uses the conceptual framework of Feldman-Stewart et al. to organize and review the types of research methodologies used to investigate various aspects of patient-health care professional communication in the context of cancer. Research methods employed are classified as either non-experimental or experimental. Non-experimental designs include naturalistic observational studies (e.g. participant observation, audio- or videotaping of interactions) and retrospective introspective descriptions (e.g. self-report questionnaires, qualitative interview methods). Experimental designs often involve interventions aimed at improving communication, such as physician or patient training, and the use of technology to enhance communication (e.g. audiotapes, computers). Using the conceptualization of the communication framework description, we argue that the outcome measures used in these studies address either primary goals, enabling goals, or secondary communication outcomes. Outcomes that are related to primary goals of the communication exchange include assessing the level of understanding of information conveyed, aspects of decision making, planning around treatments, or general provision of care. Outcomes related to enabling goals focus on elements that affect the ability to achieve primary goals. Outcomes secondary to the communication do not relate directly to what the communication is attempting to achieve. We conclude by identifying priority areas for further research, such as identifying the goals of both participants, understanding how particular aspects of the communication process affect their ability to achieve their goals, and examining the external environment in which communication takes place.

Relationships among perceived diagnostic disclosure, health locus of control, and levels of hope in Taiwanese cancer patients

OBJECTIVES

To explore relationships among perceived diagnostic disclosure, health locus of control, and levels of hope in Taiwanese cancer patients.

RESEARCH DESIGN

A cross-sectional, descriptive correlational design was used in this study. One hundred and twenty-four (N=124) patients were recruited. The Background Information Form, the Multidimensional Health Locus of Control (MHLC) Scales, the Herth Hope Index (HHI), and patients' medical records were used. Data were analyzed using descriptive statistics, t-test, ANOVA, Chi-square, Pearson's correlation, and multiple regression.

RESULTS

The major findings of this study are as follows: (1) overall, cancer patients had medium levels of hope; (2) patients who were aware of their own diagnosis reported significantly higher levels of hope than those who were not informed of their own diagnosis; (3) patients who were aware of their diagnosis tended to have higher levels of the internal locus of control than those who were not informed; (4) the internal health locus of control was significantly positively related to levels of hope; (5) the chance health locus of control was significantly negatively related to levels of hope.

CONCLUSIONS

The results of this study provide important implications for Taiwanese clinicians concerning the practice of diagnostic disclosure of cancer to patients.

Understanding community beliefs of Chinese-Australians about cancer: Initial insights using an ethnographic approach

Ethnography was employed to investigate the hypothesis that the cultural meaning of cancer is one of the possible barriers to access of cancer services. The objectives were to identify indigenous terminologies, taxonomies and illness explanatory models of cancer in a community-based sample of 15 Chinese-Australians and a sample of 16 informants who had been recruited through two Sydney familial cancer clinics. Many of the informants included in their narrative terms that seemed to match Western biomedical explanations for cancer. The majority of informants also maintained traditional Chinese beliefs, despite high acculturation and beliefs in biomedical explanations about cancer. Explanations of illness including cancer, referred to the following concepts: (i) karma (yeh), (ii) retribution (bao ying), (iii) fate (ming yun) or Heaven's or God's will, (iv) geomancy (feng-shui), (v) touched evil (zhong chia), (vi) misfortune or bad luck (shui wan, dong hark); (vii) offending the gods or deities requiring prayers or offerings for appeasement; and (viii) kong-tau (spells invoked through human intervention). Taking into consideration the heterogeneity of the Chinese population, the findings provide an insight into Chinese illness conceptualization that may assist health professionals to develop an understanding of how the cultural explanatory models affect access to screening services, communication of diagnosis of cancer and management of treatment regimen.

The communication goals and needs of cancer patients: a review

The aim of this review paper is to critique the empirical literature pertaining to the communication needs and goals of cancer patients, and to provide direction for research in this area. According to the conceptual framework of Feldman-Stewart et al., patient-physician communication occurs for the fundamental purpose of addressing each participant's goal(s). This review is divided into two categories of goals: (a) optimal medical management of the cancer, and (b) optimal attention to the patient's psychosocial response to cancer. Optimal medical management includes discussions about disease status and the treatment plan, and the effectiveness of these discussions is frequently determined by assessing patient understanding, satisfaction, and well-being. The literature suggests that cancer patients continue to have unmet communication needs, and communication outcomes are enhanced when physicians attend to the emotional needs of patients. Research gaps in communication research are highlighted, including the need for additional study of several external factors affecting the patient and provider.

What are the information needs of Chinese breast cancer patients receiving chemotherapy?

Cancer patients demand information, not only to assist them to understand the disease and its treatment, but also to allow them to interpret the aversive events and action taken, so that the threat inherent from the diagnosis becomes lessened. With the goal of studying the information needs of women with breast cancer who were receiving chemotherapy, 51 patients were invited to complete a self-administered questionnaire at the beginning and again at half way through their chemotherapy treatment. The results showed that for these patients the cancer and its spread, the side effects of chemotherapy and the management of the side effects were the priority information needs in the early stages and following chemotherapy. Among 52 questions, only six items were revealed to have significant difference when compared with the Time 1 and Time 2 measures. The results reflect that over time information needs for this group of patients was relatively stable. Marital status and subscale of disease was found significant difference at the first and second time points. The findings indicate that there is a need for the provision of a family-centered education program that addresses patient's information needs, cultural sensitivity, the use of building up and ongoing.

Cancer diagnosis and prognosis in Taiwan: patient preferences versus experiences

Considering the emphasis of nonmaleficence and beneficence and the relative power of family, there is a well-recognized suggestion that, in Asian culture, informing cancer patients about their diagnosis and prognosis should be modified according to the family's opinion. However, up until now, except in Japan, the argument that cancer patients from an Asian culture have different preferences about being informed of their diagnosis and prognosis has not been demonstrated by evidence-based studies especially by directly exploring cancer patients' preferences. The purpose of this study was to describe Taiwanese cancer patients' knowledge and experiences of being informed of their diagnosis and prognosis. Preferences of information from health-care professionals and attitudes toward disclosing information to family and even respecting family's opinions not to disclose the life-threatening diagnosis and prognosis to patients have also been explored from the patient's point of views. Evidence from this study demonstrated that Taiwanese cancer patients' information needs are substantial. However, the common practice of nondisclosure of prognosis and detailed disease-related information by health-care professionals continues. Cancer patients in Taiwan expressed a strong preference for health-care professionals to inform them of disease-related information before disclosing information to their family members. Health-care professionals need to consider and respect cancer patients' views rather than routinely taking the family's opinions into consideration first in the event of disagreement.

Participation and satisfaction with surgical treatment decision-making in breast cancer among Chinese women

PURPOSE

To report Chinese women's preferred and perceived participation in breast cancer treatment decision making (TDM), describe influences on women's participation preference and participation congruence (PC) (correspondence between preferred and actual amount of participation in TDM), and explore subsequent satisfaction with TDM.

PATIENTS AND METHODS

Of 172/211 eligible and available Chinese women recently undergoing breast cancer surgery at one of six Hong Kong government hospitals 154 (89.5%) were recruited. Within 12 days after surgery, women provided interview information on preferred and perceived TDM participation, satisfaction with TDM consultation, difficulties in TDM, and medical and demographic information.

RESULTS

Half (55%) reported a treatment choice: 33% wanted the choice to be their own, 59% wanted to share and 8% wanted to delegate the decision. Only age predicted participation preference with older women preferring a more passive role. Eighty percent of women participated as much as, 13% more than and 6% less than desired. Adjusted for age, women reporting PC had fewer difficulties in TDM (beta = 0.21, p = 0.009) than women not reporting PC, while over-involved women had more doubts about their choice (beta = -0.23, p = 0.005). PC was associated with being offered a treatment option (chi2 = 15.59, p < 0.001) and surgeons expressing a surgical preference (chi2 = 6.63, p = 0.036). Satisfaction was unrelated to PC.

CONCLUSION

Most Chinese women want shared TDM and to know their surgeon's treatment preference. Over-involved women are at greater risk of difficulties and doubts in TDM and under-involved women perceive a lack of time and information to make their decision.

Giving bad news: the family perspective

BACKGROUND

Death from trauma frequently comes without forewarning. Relating the news of death to the family is often the responsibility of trauma surgeons. The purpose of this study was to investigate the key characteristics and methods of delivering bad news from the perspective of surviving family members.

METHODS

We designed and administered a survey tool to surviving family members of trauma patients dying in the emergency department or intensive care unit. The tool consisted of 14 elements that surviving family members graded in importance when receiving bad news (1, least; 6, most). Respondents also judged the attention given to these elements (good, fair, or poor) by the person giving the bad news of death.

RESULTS

Fifty-four family members of 48 patients who died completed the survey (44 intensive care unit deaths, 4 emergency room deaths). Deceased patients ranged in age from 12 to 91 years (mean, 53 years). Death occurred within 2 days of injury in 69% of the patients and within 1 week in 83%. The most important features of delivering bad news were judged to be attitude of the news-giver (ranked most important by 72%), clarity of the message (70%), privacy (65%), and knowledge/ ability to answer questions (57%). The attire of the news-giver ranked as least important (3%). Sympathy, time for questions, and location of the conversation were ranked of intermediate importance. Touching was unwanted by 30% of the respondents, but encouraged or acceptable in 24%.

CONCLUSION

The attitude of the news-giver, combined with clarity of the message and the time, privacy, and knowledge to answer questions are the most important aspects of giving bad news. This information should be incorporated into resident training.