The Healing through Arts (HeARTS) program for children bereaved by cancer: Pilot study findings from Singapore

OBJECTIVES

The article aims to investigate the feasibility, acceptability, and initial efficacy of a short-term 3-day art therapy group for children who have experienced parental death to cancer.

METHODS

The study utilized a pretest-posttest design and included children (n = 20) aged 7-12 years. The feasibility of the intervention was measured by recruitment ability, study compliance, and intervention adherence, while acceptability was assessed using a child-reported satisfaction survey. Efficacy was examined using the child-reported Pediatric Quality of Life Inventory (PedsQL), while the emotional, social, and behavioral functioning of children was measured using the parent-reported Strengths and Difficulties Questionnaire. Paired sample t-tests were used for analyses.

RESULTS

The intervention was found to be feasible (80% recruitment rate and 100% session adherence). Acceptability was high, and all participants were satisfied and found the intervention to be helpful. While results did not reach statistical significance, improvements in psychosocial and physical quality of life were reported by all the children post-intervention and at the 3-month follow-up. Parent-reported a decrease in behavioral difficulties scores and an increase in prosocial behavior scores at post-intervention and at the 3-month follow-up.

SIGNIFICANCE OF RESULTS

The 3-day art therapy group intervention was shown to be feasible to conduct and acceptable to the recipients. The intervention shows promise in improving post-death adjustment and quality of life outcomes of children bereaved by parental death due to cancer that were maintained after 3 months. The use of art therapy groups to ameliorate difficulties associated with parental loss and to assist children in coping day-to-day difficulties should be further investigated.

Goals of Care Among Patients With Advanced Cancer and Their Family Caregivers in the Last Years of Life

Importance

Understanding goals of care for terminally ill patients at the end of life is crucial to ensure that patients receive care consistent with their preferences.

Objectives

To investigate the patterns of goals of care among patient-caregiver dyads over the last years of the patient's life and the associations of the goals of care with patient-caregiver characteristics.

Design, Setting, and Participants

This prospective cohort study of 210 patient-caregiver dyads involved surveys every 3 months from July 8, 2016, until the patient's death or February 28, 2022. Data from the last 2 years of the patients' lives were analyzed. Dyads, which comprised patients with stage IV solid cancer and their caregivers, were recruited from outpatient clinics at 2 major cancer centers in Singapore.

Main Outcomes and Measures

Goals of care were examined via the tradeoffs between life extension and symptom management and between life extension and cost containment. The actor-partner interdependence framework was implemented using mixed-effects linear regressions.

Results

This study included 210 dyads (patients: mean [SD] age, 62.6 [10.5] years; 108 men [51.4%]; caregivers: mean [SD] age, 49.4 [14.6] years; 132 women [62.9%]). On average, 34% of patients (264 of 780 observations; range, 23%-42%) and 29% of caregivers (225 of 780 observations; range, 20%-43%) prioritized symptom management over life extension, whereas 24% of patients (190 of 780 observations; range, 18%-32%) and 19% of caregivers (148 of 780 observations; range, 8%-26%) prioritized life extension. Between cost containment and life extension, on average, 28% of patients (220 of 777 observations; range, 22%-38%) and 17% of caregivers (137 of 780 observations; range, 10%-25%) prioritized cost containment, whereas 26% of patients (199 of 777 observations; range, 18%-34%) and 35% of caregivers (271 of 780 observations; range, 25%-45%) prioritized life extension. Goals of care did not change as patients approached death. Patients prioritized symptom management if they experienced higher symptom burden (average marginal effect [SE], 0.04 [0.01]), worse spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and accurate (vs inaccurate) prognostic awareness (average marginal effect [SE], 0.40 [0.18]) and if their caregivers reported accurate prognostic awareness (average marginal effect [SE], 0.53 [0.18]), lower impact of caregiving on finances (average marginal effect [SE], -0.28 [0.08]), and poorer caregiving self-esteem (average marginal effect [SE], -0.48 [0.16]). Compared with patients, caregivers expressed lower preferences for cost containment (average marginal effect [SE], -0.63 [0.09]). Patients prioritized cost containment if they were older (average marginal effect [SE], 0.03 [0.01]), had higher symptom burden (average marginal effect [SE], 0.04 [0.01]), had poorer spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and their caregivers reported poorer caregiving self-esteem (average marginal effect [SE], -0.51 [0.16]) and more family support (average marginal effect [SE], -0.30 [0.14]).

Conclusions and Relevance

In this cohort study of patient-caregiver dyads, findings suggested the importance of interventions aimed at reducing discordance in goals of care between patients and caregivers and helping them develop realistic expectations to avoid costly, futile treatments.

The association of prognostic awareness with quality of life, spiritual well-being, psychological distress, and pain severity in patients with advanced cancer: Results from the APPROACH Study in Indonesia

BACKGROUND AND OBJECTIVES

Advanced cancer patients' understanding of their illness is key for making informed treatment decisions. Despite the known importance of patients' awareness of their disease prognosis, it is debatable whether this awareness is positively, negatively, or not associated with clinical and psychological outcomes among patients with advanced cancer. This paper aims to determine the prevalence of and factors associated with prognostic awareness and its association with quality of life (QoL), spiritual well-being, pain control, and psychological distress in patients with advanced cancer in Indonesia.

METHODS

This cross-sectional questionnaire-based survey was part of a multicountry study titled "Asian Patient Perspectives Regarding Oncology Awareness, Care and Health (APPROACH)." Patients were asked what they knew about their cancer and treatment. QoL and spiritual well-being were measured using the Functional Assessment of Cancer Therapy - General (FACT-G) and Functional Assessment of Chronic Illness Therapy - Spiritual Well-being (FACIT-Sp) questionnaire. Psychological distress experienced by patients was recorded via the Hospital Anxiety and Depression Scale. Pain severity was also assessed. Data from 160 patients were analyzed using descriptive statistics and multivariable regression models.

RESULTS

Of the 160 patients who participated, 55 (34.4%) were unaware of their cancer stage. Those who were aware of their stage of cancer were younger than those who were not aware (45.7 years vs 50.4 years, p = .015). There was no significant difference in spiritual well-being and other domains of QoL between those who were aware and those who were not aware of their advanced cancer stage. There was also no significant difference in anxiety depression or pain severity, even after adjustment for demographic and clinical characteristics.

SIGNIFICANT OF RESULTS

Given the high prevalence of patients who wrongly thought their cancer was curable, more could be done to improve disease and prognostic understanding among patients with advanced cancer in Indonesia. Those who were aware of their advanced cancer stage did not have a poorer QoL, nor did they have more anxiety or depression than those who were unaware. This finding suggests that concerns about the negative impact of prognostic disclosure may be unfounded.

Deathbed experiences and meaning-making: Perspectives of family caregivers of patients who received cancer palliative care

OBJECTIVES

The deathbed symbolizes a time when the patient is dangerously ill and where death is imminent. The memories of family caregivers during this time can potentially shape their meaning-making of the patient's death and bereavement adjustment. We aimed to understand the experiences of family caregivers at the deathbed of patients receiving palliative care. We also examined caregiver's meaning-making that occurred after the patient's death.

METHODS

In this retrospective qualitative study, family caregivers of cancer patients who received palliative care in Singapore were recruited through purposive sampling. In-person, semi-structured interviews were individually conducted with study participants to understand their experiences from a caregiver's perspective before and after the death of the patient. Thematic content analysis method was conducted.

RESULTS

A total of 25 bereaved family caregivers were interviewed, with spouses, adult children, and others comprising one-third each of the sample. Six themes emerged from caregivers' recollected experiences around the patient deathbed: Lasting image of the patient, A time of intense emotions, Healthcare providers prepare caregivers, A time for saying goodbye, Rituals provide comfort, and Impact on family ties. Four themes emerged surrounding post-loss meaning-making: An end to the pain and suffering, "Have I done enough?," Significance in the timing of events, and Gaining strength and personal growth.

SIGNIFICANCE OF RESULTS

The deathbed is a salient time for family caregivers as they prepare for patient's death. There are opportunities to provide support to the family based on the study findings.

Understanding the experiences of mothers receiving perinatal palliative care: A qualitative study

BACKGROUND

Despite the diagnosis of life-limiting foetal conditions, some mothers choose to continue their pregnancies. The experiences of these individuals are relatively unknown, making it difficult for perinatal palliative services to be targeted towards their needs.

AIM

To examine maternal experiences in perinatal palliative care among those who choose to continue their pregnancies despite life-limiting foetal condition.

DESIGN

Qualitative, retrospective study involving semi-structured interviews. Braun & Clarke's reflexive thematic analyses using a constructionist-interpretive approach were conducted.

SETTING/PARTICIPANTS

A total of 15 adult women participants who decided to continue their pregnancies after learning of life-limiting foetal diagnoses were recruited from a Singaporean tertiary hospital. Interviews were conducted in-person or via video conferencing.

RESULTS

Seven themes were synthesized from the data: (1) Internal upheaval - 'World turns upside down'; (2) Role of religion and spirituality in hope of miracles; (3) Support from family and close friends; (4) Navigating a fragmented healthcare system; (5) Value added by the perinatal palliative service; (6) Goodbye and grieving and (7) No regrets and other personal reflections.

CONCLUSIONS

Continuing a pregnancy despite the diagnosis of a life-limiting foetal condition can be challenging for mothers. To better meet their needs during this difficult period, perinatal palliative care must be patient-centred, multidisciplinary and non-judgmental. Efforts must be made to streamline the healthcare delivery process.

Measurement Properties of the 15-Item Singapore Caregiver Quality of Life Scale (SCQOLS-15) in Family Caregivers of Patients with Heart Diseases

PURPOSE

To evaluate the measurement properties of the 15-item Singapore Caregiver Quality of Life Scale (SCQOLS-15) in family caregivers of patients with heart diseases.

METHODS

The SCQOLS-15 survey was self-administered by family caregivers of patients with chronic heart diseases, at baseline and 1 week later. The criterion validity of SCQOLS-15 and its domain scores was assessed by calculating the Spearman correlation coefficient (ρ) with the Brief Assessment Scale for Caregivers (BASC), Caregiver Reaction Assessment (CRA), and their sub-scores. Known-group validity was assessed using the New York Heart Association (NYHA) functional class. Test-retest reliability was evaluated using the intraclass correlation coefficient (ICC).

RESULTS

Of the 327 caregivers included, 65% were adult children and 28% were spouses. The distribution of NYHA classes of the patients was I: 27%, II: 40%, III: 24%, and IV: 9%. There was a positive correlation between the SCQOLS-15 and BASC total scores (ρ = 0.7). SCQOLS-15 domain scores were also correlated with BASC and CRA sub-scores as per a priori hypotheses, with absolute values of ρ ranging from 0.4 to 0.6. The mean values of SCQOLS-15 total and all domain scores were lower among caregivers of patients with NYHA class III/IV compared to those of class I/II patients (each P < 0.05). Among 146 caregivers who completed the follow-up and self-rated a stable quality-of-life, ICCs for test-retest reliability of SCQOLS-15 total and all domain scores were ≥ 0.8.

CONCLUSION

The SCQOLS-15 is a valid and reliable instrument for measuring the quality of life in caregivers of heart disease patients.

Healthcare utilization and costs of singaporean youth with symptoms of depression and anxiety: results from a 2022 web panel

BACKGROUND

There is evidence that the prevalence of depression and anxiety among youth is increasing and that these factors contribute to high healthcare costs and poor school performance. The goal of this study is to provide up-to-date estimates of the prevalence and economic burden of depression and anxiety among youth in Singapore.

METHODS

Using an existing web panel, 991 parents filled out the PHQ-4 screener on behalf of 1,515 youth. 104 of these parents whose children (ages 4 to 21) had symptoms consistent with depression or anxiety filled out a full survey with questions on mental health symptoms, school absences, school performance, and healthcare utilization. The survey was fielded between April and June 2022. Publicly available prices were used to estimate the cost associated with the observed rates of health service use.

FINDINGS

Based on parental responses, 11.7% (95% CI:10.2 - 13.5%) of youth had symptoms consistent with depression and 12.8% (95% CI:11.2 - 14.6%) had symptoms consistent with anxiety. In total, 16.2% (95% CI:14.5 - 18.3%) were reported to have symptoms consistent with at least one of these conditions. These youths missed an average of 190 (95% CI: 126-254) hours of school per year due to their mental health conditions and parents reported that school and daily activities performance was significantly degraded. Per capita annual healthcare costs averaged S$10,250 (95% CI: 7,150-13,350), with 64% of youth receiving emergency or inpatient services. In aggregate, annual costs associated with these conditions were estimated to be S$1.2 billion (95% CI:S$1.1bn - S$1.4bn).

INTERPRETATION

Even with significant potential for underreporting, these results reveal concerning rates of Singaporean youth with symptoms consistent with depression or anxiety, many of whom remain untreated. Results also reveal the short-term economic burden caused by these symptoms and hint at longer-term consequences resulting from poor school performance. This study should represent a call to action for Singapore to address poor mental health among youth.

A cognitive behavioral therapy-based intervention to address body image in patients with facial cancers: Results from a randomized controlled trial

OBJECTIVES

Body image adjustment is a crucial issue for patients with facial cancer, but body image-specific interventions are scarce. We report results of a novel psychotherapeutic intervention to address body image concerns during acute postoperative recovery following facial reconstructive surgery. Our primary aims were to evaluate the intervention's feasibility, acceptability, and efficacy on body image concerns, psychological distress, and quality of life (QOL).

METHODS

Adults with facial cancers who endorsed body image concerns were recruited to participate in a randomized controlled trial. The intervention group participated in 4 in-person counseling sessions. The control group received an educational booklet and a brief phone call. Participants completed measures of body image, distress, and QOL at baseline and at the 4-week follow-up to assess the impact of the intervention. Intervention outcomes were assessed with 2 sample t-tests or Mann-Whitney U tests as appropriate.

RESULTS

Twenty-nine participants completed both the baseline and follow-up assessments. The intervention demonstrated good feasibility with a high retention rate (79%), visit completion rate (81%), and high satisfaction scores (75% reported mean satisfaction score of >3). Intervention did not result in an observed statistically significant difference in reduction in body image dissatisfaction and disturbance, psychological distress, or improvement in QOL compared with the control group. However, intervention resulted in statistically significant difference in perceived social impact (-1 vs. -8.3, p = 0.033) compared to control group.

SIGNIFICANCE OF RESULTS

Our study highlights the potential clinical benefits of a novel psychotherapeutic intervention that targets body image concerns and suggests the need for further evaluation.

Quality of life and psychological distress of patients with advanced cancer in the Philippines

PURPOSE

This study aimed to describe the quality of life (QOL) and psychological distress (anxiety and depression) of Filipino patients with advanced solid cancers and identify sociodemographic and clinical-related factors associated with them.

METHODS

195 patients with advanced cancer were recruited from a major hospital treating cancer patients in the Philippines. Participants completed self-reported surveys on Quality-of-life (QOL-FACT-G) and psychological distress (HADS-D, HADS-A). Multi-variable OLS regression models were performed where sociodemographic, health history and clinical characteristics were included as predictors.

RESULTS

The average total FACT-G score was 65.39/108 (Standard deviation (SD) = 13.76), with the physical well-being scale having the lowest scores (M = 14.14/28, SD = 5.92). The two most common symptoms reported were fatigue (88%) and pain (86.5%). Physical symptom burden was significantly negatively associated with QOL and psychological distress. The average HADS-total score was 14.46/21 (SD = 5.77), with 8% with probable anxiety and 27% with probable depression. Participants who reported greater reliance on their spiritual faith for strength in coping with illness reported lower depression scores.

CONCLUSIONS

Our findings underline the importance of understanding the multi-dimensional outcomes of Filipino advanced cancer patients. Results may be used to improve QOL and reduce the psychological distress of advanced cancer patients.

A prospective study of psychological distress among patients with advanced cancer and their caregivers

BACKGROUND

Cancer can impact the psychological well-being of both patients and their informal caregivers. We investigated the joint trajectories of psychological distress among Singaporean advanced cancer patients-caregiver dyads. We also examined predictors of trajectory group membership.

METHODS

This study utilised data from 299 patients with advanced solid cancer and their caregivers over 33 months (12 times points). Group-based trajectory modelling was used to examine the joint trajectories of patient anxiety, patient depression, caregiver anxiety and caregiver depression scores using the Hospital Anxiety and Depression Scale.

RESULTS

Four joint trajectory groups were found: (1) Patient-caregiver low distress (27%), (2) patient-caregiver increasing distress (28.5%), (3) patient low- caregiver borderline distress (25%), (4) patient-caregiver high distress (19.5%). Dyads where the patient is below 50 years of age were more likely to be in Group 4. Dyads where caregiver-patient emotional closeness was low were more likely to be in Groups 2 or 4 where dyads reported increasing/high distress. Dyads that reported financial inadequacy were more likely to be in Groups 2, 3 and 4, while dyads with caregivers who were employed were more likely to be in group 3.

CONCLUSIONS

A substantial proportion of patients and caregivers reported anxiety and/or depression that lasted or increased throughout the study duration. We found significant heterogeneity in how dyads experienced psychological distress, suggesting that efforts should consider dyadic differences when providing psychological support. Particular focus should be placed on identifying dyads that are at risk and who require additional support.

Prevalence and economic burden of depression and anxiety symptoms among Singaporean adults: results from a 2022 web panel

BACKGROUND

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are leading causes of disability and premature mortality. At a global level, over 300 million people are estimated to suffer from major depressive disorders, equivalent to 4·4% of the world's population. Pandemic era stressors have increased rates for depression and anxiety by upwards of 25%. The goal of this study is to estimate the prevalence and economic burden of depression and anxiety symptoms in Singapore after the peak of the COVID-19 pandemic.

METHODS

An existing web panel was queried between April 2022 and June 2022. Adult participants aged > 21 years old who screened positive for depression and anxiety symptoms based on the Patient Health Questionnaire-4 (PHQ-4) Screener were eligible for participation. Prevalence estimates were quantified by dividing the number of respondents who screened positive for these symptoms by the total number of respondents. Participants who screened positive were asked about healthcare utilization, days missed from work, and reduced productivity due to these symptoms. These values were then monetized and scaled based on prevalence and population counts to generate per capita and total annual costs.

RESULTS

Two thousand three hundred forty-eight respondents filled out the PHQ-4 depression/anxiety screener on behalf of the 5,725 adults living in their households (including respondents themselves). Prevalence estimates were calculated based on the responses recorded for these 5,725 adults. 14.1% adults had symptoms consistent with depression and 15.2% had symptoms consistent with anxiety. In total, 20.0% may experience symptoms consistent with at least one of these two conditions, yet approximately half reported never being formally diagnosed. 350 respondents screened positive for depression or anxiety symptoms and thus were eligible to fill out the healthcare utilization, presenteeism, and absenteeism survey. Direct annual healthcare costs due to depression and anxiety symptoms averaged Singapore dollar (SGD) $1,050 for these respondents. The employed subset (n = 304) missed an extra 17.7 days of work on average per year, which translates to SGD $4,980 per worker. These workers also reported being ~ 40% less productive at work, which equates to SGD $28,720 in economic losses annually. In total, these symptoms caused SGD $15.7 billion in increased costs. Presenteeism accounts for 81.6% of this total (SGD $12.8 billion), absenteeism for 14.2% (SGD $2.3 billion) and healthcare accounts for 4.2% (SGD $0.7 billion).

CONCLUSIONS

The health and economic burden associated with depression and anxiety symptoms is large in Singapore, representing 2.9% of Singapore's gross domestic product (GDP). Employers and governments should look to identify effective remediation strategies, including strategies to address the high rates of undiagnosed cases. Increasing psychiatric resources, general practitioner mental health competency, access to peer support, and increased efforts to reduce mental health stigma should be considered to address this growing public health crisis.

Caregiver-Reported Roles in Treatment Decision Making in Advanced Cancer and Associated Caregiving Burden and Psychological Distress: A Longitudinal Study

OBJECTIVE

To longitudinally examine caregiver-reported treatment decision-making roles and to investigate the associations of these roles with caregiver burden, caregiving esteem, caregiver anxiety, and depression.

METHODS

281 caregivers of patients with stage IV solid cancers were recruited from outpatient clinics in Singapore. Caregivers were eligible if they were aged ≥21 y, primary informal caregiver, and involved in treatment decision making. We used 3 y of longitudinal data. The decision-making roles were grouped into 4 categories: no family involvement, patient/physician-led, joint, and family-led/alone decision making. Mixed-effects linear regressions were used to assess associations between decision-making roles and caregiver outcomes.

RESULTS

On average, 72% of caregivers reported family involvement in decision making. Compared with baseline, a higher proportion of caregivers at the 36-mo follow-up reported no family involvement (from 23% to 34%, P = 0.05) and patient/physician-led decision making (from 22% to 34%, P = 0.02), while a lower proportion reported family-led/alone (from 19% to 7%, P = 0.01) decision making. Compared with family-led/alone decision making, caregivers reporting no family involvement reported lower impact on finances (-0.15 [-0.28, -0.01], P = 0.03) while caregivers who reported patient/physician-led decision making reported lower impact on schedule and health (-0.12 [-0.20, -0.03], P = 0.01), and finances (-0.15 [-0.28, -0.03], P = 0.02), and lower anxiety (-0.69 [-1.17, -0.22], P < 0.01), and depressive symptoms (-0.69 [-1.12, -0.26], P < 0.01). Caregivers who reported joint decision making reported higher caregiving esteem (0.07 [0.01, 0.14], P = 0.02).

CONCLUSIONS

Higher family involvement in decision making was associated with higher caregiver burden and psychological distress. Help should be given so that family caregivers can support patient decision-making in a meaningful way.

HIGHLIGHTS

Compared with baseline, a lower proportion of caregivers at the 36-mo follow-up reported family-led or family-alone decision making, and a higher proportion of caregivers reported patient-led or physician-led decision making.Higher levels of family involvement in decision making were associated with burdens on caregivers' daily life, health, and finances and increased caregiver anxiety and depression.Support must be given so that family members can contribute to making medical decisions in a rewarding manner.

Variation in Patient-Reported Decision-Making Roles in the Last Year of Life among Patients with Metastatic Cancer: A Longitudinal Study

OBJECTIVE

We investigated the variation in patient-reported decision-making roles in the past year of life among patients with metastatic solid cancer and the associations of these roles with patient quality of life and perceived quality of care.

METHODS

We used the last year of life data of 393 deceased patients from a prospective cohort study. Patients reported their decision-making roles, quality of life (emotional well-being, spiritual well-being, and psychological distress) and perceived quality of care (care coordination and physician communication) every 3 months until death. We used mixed effects linear regressions to investigate the associations of decision-making roles with patients' quality of life and perceived quality of care.

RESULTS

The most reported roles, on average, were patient-led (37.9%) and joint (23.4%; with physicians and/or family caregivers) decision making, followed by no patient involvement (14.8%), physician/family-led (12.9%), and patient alone (11.0%) decision making. Patient level of involvement in decision making decreased slightly as death approached (P < 0.05). Compared with no patient involvement, joint decision making was associated with better emotional well-being (β [95% confidence interval] = 1.02 [0.24, 1.81]), better spiritual well-being (1.48 [0.01, 2.95]), lower psychological distress (-1.99 (-3.21, -0.77]), higher perceived quality of care coordination (5.04 [1.24, 8.85]), and physician communication (5.43 [1.27, 9.59]). Patient-led decision making was associated with better spiritual well-being (1.69 [0.24, 3.14]) and higher perceived quality of care coordination (6.87 [3.17, 10.58]) and physician communication (6.21 [2.15, 10.27]).

CONCLUSION

Joint and patient-led decision-making styles were reported by 61% of the patients and were associated with better quality of life and quality of care. A decrease in the level of patient involvement over time indicates reliance on family and physicians as death approached.

HIGHLIGHTS

Among patients with metastatic cancer, the level of patient involvement in decision making decreased slightly as death approached.Joint decision making of patients with their physicians and/or family caregivers and patient-led decision making were associated with better quality of life and perceived quality of care.Patients with metastatic cancer should be encouraged to be involved in decision making together with their physicians and/or family caregivers to potentially improve their end-of-life experience.

Prognostic awareness and its association with health outcomes in the last year of life

BACKGROUND

Little research has examined changes in prognostic awareness (PA) in the last year of life and the extent PA change was associated with anxiety, depression, and spiritual well-being among metastatic cancer patients.

METHODS

Two surveys were administered in the last year of life to 176 conveniently sampled Singaporean patients with stage 4 solid cancers. PA was assessed by asking patients whether they were aware that their treatments were unlikely to cure their cancer. Multivariable linear regression models were used to investigate the association of PA change with anxiety, depression, and spiritual well-being.

RESULTS

The proportion of patients with accurate PA increased (39.2%-45.5%; p < 0.05) from the second-last assessment to the last assessment before death. Those with inaccurate PA decreased (26.1%-20.4%; p < 0.05) while a third of patients remained uncertain at both assessments (34.7% and 34.1%). Compared to patients with inaccurate PA at both assessments, patients who reported accurate PA at both assessments reported worsened anxiety (β = 2.08), depression (β = 3.87), and spiritual well-being (β = -4.45) while patients who reported being uncertain about their prognosis at both assessments reported worsened spiritual well-being (β = - 6.30) at the last assessment before death (p < 0.05 for all).

CONCLUSIONS

Interventions should dually focus on decreasing prognostic uncertainty at the end-of-life while minimising the psychological and spiritual sequelae associated with being prognostically aware. More research is needed to clarify the causes of prognostic uncertainty.

Disparities in end-of-life outcomes among advanced cancer patients in Sri Lanka: Results from the APPROACH study

OBJECTIVE

A Universal Health Coverage goal is to provide access to affordable palliative care to reduce disparities in end-of-life (EOL) outcomes. To assess progress toward this goal in Sri Lanka, our primary aim was to systematically assess differences in patients' physical, psychological, social and spiritual outcomes, and their perceived quality of care by their socioeconomic status (SES).

METHODS

As part of the multi-country APPROACH (Asian Patient Perspectives Regarding Oncology Awareness, Care and Health) study, we surveyed 199 patients with a stage IV solid malignant tumor and aged >21 years from the largest government cancer hospital in Sri Lanka. We assessed their physical (physical and functional well-being, symptom burden), psychological (anxiety, depression, emotional well-being), social (social well-being), and spiritual outcomes and perceived quality of care (physician communication, nursing care, and coordination/responsiveness).

RESULTS

Low SES patients reported significantly lower physical and functional well-being, emotional well-being, spiritual well-being including meaning/peace and faith; and significantly higher symptom burden, anxiety and depressive symptoms compared with patients from high SES (p < 0.05 for all outcomes).

SIGNIFICANCE OF RESULTS

Results have implications regarding reducing barriers in access to appropriate palliative care and EOL care services to stage IV cancer patients from low SES in Sri Lanka.

Trajectories of Health-related quality of life in patients with Advanced Cancer during the Last Year of Life: findings from the COMPASS study

Background

Patients with advanced cancer prioritise health-related quality of life (HrQoL) in end-of-life care, however an understanding of pre-death HrQoL trajectories is lacking. We aimed to delineate and describe the trajectories of physical, social, emotional and functional HrQoL during last year of life among advanced cancer patients. We assessed associations between these trajectories and patient socio-demographic characteristics, healthcare use and place of death.

Methods

We used data from 345 decedents from a prospective cohort study of 600 patients with a solid advanced cancer receiving secondary care at public hospitals in Singapore. Patients were surveyed every three months until death and HrQoL was assessed using the Functional Assessment of Cancer Therapy – General (FACT-G) questionnaire. Interviews were conducted between July 2016 and December 2019. Group-based multi-trajectory modelling was used to assess potential heterogeneity in the four HrQoL dimensions during patients’ last year of life.

Results

We identified four distinct trajectories of HrQoL − (1) overall high HrQoL (47% of sample), (2) progressively decreasing HrQoL (32%), (3) asymmetric decline in HrQoL (13%), (4) overall low HrQoL (8%). Compared to patients with secondary or above education, those with primary education or less (β = 1.39, SE = 0.55, p-value = 0.012) were more likely to have “progressively decreasing HrQoL” or “overall low HrQoL” in contrast to “overall high HrQoL”. Compared to patients with ‘overall high HrQoL’, those with ‘overall low HrQoL’ had longer length of hospital stay during the last year of life (β = 0.47, SE = 0.21, p-value = 0.026) and were more likely to die in a hospice/care home (β = 1.86, SE = 0.66, p-value = 0.005).

Conclusion

Our results showed heterogeneity in deterioration of HrQoL among patients with advanced cancer in the last year of life. Systematic monitoring of HrQoL, early identification and referral of high-risk patients to palliative care may provide timely relief and mitigate the steep decline in their HrQoL.

Trial Registration

: NCT02850640.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01075-3.

Awareness and Utilization of Palliative Care Among Advanced Cancer Patients in Asia

CONTEXT

To date, little is known about palliative care (PC) awareness and utilization in low- and middle-income countries (LMICs) in Asia.

OBJECTIVES

This study aimed to investigate PC awareness and its predictors, utilization of PC services, and perceived utilization barriers among advanced cancer patients from select hospitals in Asian LMICs.

METHODS

This cross-sectional study analyzed data of 759 advanced cancer patients at major hospitals of four LMICs in Asia (i.e., Bangladesh, Philippines, Sri Lanka, and Vietnam). The predictors of PC awareness were investigated using multivariable logistic regression.

RESULTS

Overall PC awareness was 30.8% (n = 234). Patients with higher education (OR = 1.0; CI = 1.0,1.1), from upper-middle or high-income households (compared to low-income) (OR = 2.0; CI = 1.2,3.3), awareness of disease severity (OR = 1.5; CI = 1.0,2.2), and higher pain severity (OR = 1.1; CI = 1.0,1.2) had higher odds of PC awareness. Compared to patients who perceived themselves as being very informed about disease trajectory, those who were unsure (OR = 0.5; CI = 0.3,0.8) or uninformed (OR = 0.5; CI = 0.3,0.9) had lower odds of PC awareness. The PC utilization rate was 35.0% (n = 82) among those with PC awareness, and 47.8% (n = 66) among patients recommended PC by a healthcare professional (n = 138). The most cited PC utilization barriers were currently receiving anti-cancer treatment (n = 43; 33.9%), and having insufficient information about PC (n = 41; 32.3%).

CONCLUSION

The low awareness of PC services in these major hospitals in Asian LMICs highlights that more effort may be required to promote the awareness of PC in this region. The efforts should especially focus on those from disadvantaged groups to reduce the gap in PC awareness.

Understanding the needs of health care workers in Singapore during the COVID-19 outbreak: A qualitative analysis

BACKGROUND

A successful public health response during the COVID-19 pandemic pivots on the ability of health care workers (HCWs) to work through immense workplace-related physical and psychological pressures.

OBJECTIVE

The aim of current study was to explore support needs of HCWs during the COVID-19 outbreak in Singapore and to identify implications for practice and workplace policies.

METHODS

A descriptive qualitative approach was adopted in this study. HCWs from a major public health care cluster in Singapore (n = 612) responded to an open-ended question in an online survey. Results were analyzed using content analysis via an inductive approach.

RESULTS

Five main themes that borrows from Maslow's Hierarchy of Needs emerged from content analysis, with 17 categories under the themes. The 5 main themes are: physical needs, safety needs, love and belonging needs, esteem needs and self-actualization needs.

CONCLUSIONS

Findings from this study indicate that there were many unmet needs among HCWs during the COVID-19 pandemic. An overview of various need areas identified in this study may guide future research and development of interventions to mitigate the negative impact of disease outbreaks on HCWs.

Epidemiology of Pain Among Patients with Solid Metastatic Cancer During the Last Year of Life

Background

Despite medical advancements, pain is a major source of suffering at the end of life for patients with a solid metastatic cancer. We aimed to assess the trajectory of pain prevalence, severity, interference, and inadequacy of analgesia during the last year of life.

Methods

We analysed data from the last year of life of 345 decedents from a prospective cohort study of 600 patients with a solid metastatic cancer in Singapore. Patients were surveyed every 3 months and their pain outcomes (prevalence, severity, and interference) and inadequacy of analgesia were analysed. We used mixed-effects regressions to assess the association of pain outcomes with patients’ time from death, demographics, and planned or unplanned hospitalisations.

Results

Prevalence of pain was higher in the last 2 months (65%) compared to 11 to 12 months (41%) before death. Pain severity and interference scores (mean ± SD) were also higher in the last month (severity: 2.5±2.6; interference: 2.6±3.0) compared to 12 months before death (severity: 1.4±2.0; interference: 1.4±2.0). At any time during the last year of life, 38% of the patients were prescribed non-steroidal anti-inflammatory drugs, 11% were prescribed weak-opioids and 29% were prescribed strong opioids. These analgesics were prescribed through either oral, topical or injectable route. Pain outcomes were significantly worse (p-value<0.05) for younger patients, those with higher education, and more financial difficulties, while interference was higher after an unplanned hospitalisation in the last month. Females reported higher pain severity score during their last year of life compared to males. For patients reporting moderate to severe pain, inadequacy of analgesia was lower in the last 2 months (43%) compared to 11 to 12 months before death (83%).

Conclusion

Findings highlight the need for greater attention in monitoring and treatment of pain even earlier in the disease trajectory, and increased attention to patients discharged from an unplanned hospitalisation.

A year after COVID-19: its impact on nurses' psychological well-being

Background

Nurses' burnout and psychological well‐being are a significant concern during the pandemic.

Aims

The aim of this study is to (i) examine the level of burnout, anxiety, depression, perceived stress and self‐rated health for nurses at two time‐points, 2020 and 2021, and (ii) examine the socio‐demographic characteristics, work‐related factors and perceived workplace support factors in relation to the level of burnout.

Methods

This is a cross‐sectional study with a longitudinal approach. A convenience sample of registered nurses who worked in an acute care tertiary hospital in Singapore were surveyed during two time‐points. Participants' health, socio‐demographic characteristics, work‐related factors and perceived workplace support factors were collected.

Results

Among the 179 nurses, there was a significant increase in burnout level, poorer self‐rated health and reduced job dedication. A decrease in the percentage of nurses who felt appreciated at work was reported in 2021 (p = 0.04). Nurses who felt their team was not working well together were 3.30 times more likely to experience burnout (95% CI 1.12 to 9.69; p = 0.03). Nurses who reported that they never felt appreciated by their department/hospital were 8.84 times more likely to experience burnout (95% CI 2.67 to 29.21; p < 0.001). Nurses with poorer self‐rated health were more likely to report burnout (95% CI: 1.32–6.03; p = 0.008).

Conclusion

Nurses had an increased experience of burnout, reduced job dedication and poorer self‐rated health after the outbreak.

Implications for Nursing Management

Interventions at the departmental and organizational levels are needed to improve the workplace support. Strategies to support nurses' psychological well‐being during the aftermath of COVID‐19 are vital to managing nurses' burnout and improving job dedication and self‐rated health.

Effects of Mobile App-Based Mindfulness Practice on Healthcare Workers: a Randomized Active Controlled Trial

Objectives

Amidst the COVID-19 pandemic, healthcare workers (HCWs) may be at greater risk of suffering from psychological distress compared to the general population. This study aimed to investigate the effects of mindfulness practice as delivered using Headspace on psychological and cognitive outcomes among HCWs in Singapore.

Methods

A total of 80 HCWs were recruited and randomly assigned to engage in either 3 weeks (10 min/day) of mindfulness practice using Headspace or an active control condition (Lumosity; involving playing cognitive games). Participants were administered several self-report measures and two working memory (digit span) tasks at pre- and post-intervention, and one-month follow-up.

Results

There were no significant between-condition changes on any outcome variables from pre- to post-intervention. From pre-intervention to 1-month follow-up, there were significantly greater improvements among Headspace participants on fear of COVID-19 (p = .005), compassion satisfaction (p = .007), trait mindfulness (p = .002), self-compassion (p = .005), sleep quality (p = .002), and the forward digit span task (p < .001). Several outcomes were mediated by increases in trait mindfulness or self-compassion.

Conclusions

Use of Headspace may lead to downstream benefits in reducing distress and improving psychological health outcomes among HCWs. The findings have implications for improving psychological support resources for HCWs amidst a pandemic.

Trial Registration

ClinicalTrials.gov (Identifier: NCT04936893).

A prospective cohort study assessing aggressive interventions at the end-of-life among patients with solid metastatic cancer

Background

Many patients with a solid metastatic cancer are treated aggressively during their last month of life. Using data from a large prospective cohort study of patients with an advanced cancer, we aimed to assess the number and predictors of aggressive interventions during last month of life among patients with solid metastatic cancer and its association with bereaved caregivers’ outcomes.

Methods

We used data of 345 deceased patients from a prospective cohort study of 600 patients. We surveyed patients every 3 months until death for their physical, psychological and functional health, end-of-life care preference and palliative care use. We surveyed their bereaved caregivers 8 weeks after patients’ death regarding their preparedness about patient’s death, regret about patient’s end-of-life care and mood over the last week. Patient data was merged with medical records to assess aggressive interventions received including hospital death and use of anti-cancer treatment, more than 14 days in hospital, more than one hospital admission, more than one emergency room visit and at least one intensive care unit admission, all within the last month of life.

Results

69% of patients received at least one aggressive intervention during last month of life. Patients hospitalized during the last 2–12 months of life, male patients, Buddhist or Taoist, and with breast or respiratory cancer received more aggressive interventions in last month of life. Patients with worse functional health prior to their last month of life received fewer aggressive interventions in last month of life. Bereaved caregivers of patients receiving more aggressive interventions reported feeling less prepared for patients’ death.

Conclusion

Findings suggest that intervening early in the sub-group of patients with history of hospitalization prior to their last month may reduce number of aggressive interventions during last month of life and ultimately positively influence caregivers’ preparedness for death during the bereavement phase.

Trial registration

NCT02850640.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00970-z.

Re-Conceptualizing Bereavement Care Practices: Insights Gained from Service Providers

The management and delivery of bereavement care and support services present practical challenges. A national-level, qualitative study was conducted to examine the current practices in Singapore. The study's purpose was to inform bereavement care practices by drawing from perspectives of service providers offering death, dying and bereavement-related services. This qualitative study was undertaken using focused group discussion (FGD) with service providers from the health, social and death-related sectors. Ten FGDs were conducted with a total of 69 participants. Thematic analysis yield two themes - identifying challenging circumstances to provide bereavement care and strategies for dealing with the gaps in service delivery. The service providers' experiential knowledge could be borrowed to strengthen the current bereavement care practices for the good of the community. The findings have informed the reconceptualization of a local bereavement care and support service model, with the public health model as the recommended underpinning conceptual framework.

Longitudinal trajectories of caregiving experiences among primary informal caregivers of patients with metastatic solid cancer (Stage IV)

OBJECTIVE

Cancer is a significant cause of mortality worldwide. The diagnosis of advanced cancer affects both patients and their family caregivers. Understanding the course of both negative and positive experiences of caregiving provides a more comprehensive understanding of the caregiving experience. The study aims to identify joint trajectories of burden and esteem among family caregivers of patients with solid metastatic cancer, and to identify caregiver characteristics that predict membership for each delineated trajectory.

METHODS

A prospective longitudinal study of 346 informal family caregivers of patients with solid metastatic cancer were recruited between July 2016 and December 2019. Surveys were conducted every 3 months for 2 years. We assessed caregiver burden and positive aspects of caregiving using the modified Caregiver Reaction Assessment. We estimated the joint trajectories for these outcomes using group-based multi-trajectory modelling.

RESULTS

We identified 4 trajectories describing caregivers with 1) low burden, moderate esteem (38.3%), 2) low burden, high esteem (20.3%), 3) high burden, low esteem (16.4%), 4) high burden, high esteem (24.9%). Compared to the "low burden, high esteem" trajectory, male and non-spousal caregivers were more likely to experience high burden and esteem while caregivers from low socioeconomic status were more likely to belong to trajectories with a high burden.

CONCLUSION

Recognising caregivers at high risk of belonging to trajectories with high burden or low esteem may enable healthcare professionals to anticipate and provide appropriate support to mitigate the impact of negative outcomes.

Perceived Stigma and Its Correlates Among Asian Patients with Advanced Cancer: A Multi-Country APPROACH Study

OBJECTIVES

Perceived cancer-related stigma can affect mental health and potentially treatment choices for patients with cancer. Nevertheless, perceived stigma is not very well understood in Asia. This study investigated across six developing Asian countries: 1) the prevalence of perceived stigma among advanced cancer patients, 2) its risk factors, and 3) its association with patient treatment preferences.

METHODS

This cross-sectional study recruited patients receiving oncology care across major hospitals in Bangladesh, China, India, Philippines, Sri Lanka and Vietnam. Participants (N = 1358) were adults diagnosed with stage IV metastatic solid cancer who completed self-reported surveys. Multi-variable logistic regression and ordered logit models examined the associations with perceived stigma and variables of interest.

RESULTS

Across the countries, 35%, 95% CI [32%, 38%] of patients reported experiencing at least one facet of cancer-related stigma often or always, while 60% [57%, 63%] reported it occurring occasionally. Top-endorsed facets of perceived stigma across the Asian countries suggest a distinct pattern. Having knowingly engaged in health-risk behaviours (OR = 2.03-2.24, 95% CI [1.14-1.19, 3.43-4.41]), unemployment (2.64 [1.67, 4.19]) and body image change (1.57 [1.00, 2.45]) were associated with higher odds of perceived stigma, while time mitigated perceived stigma (0.49-0.65 [0.30-0.45, 0.76-0.92]). Perceived stigma was associated with lower odds of preference for life-extending treatments, although the associations did not hold up in the adjusted model.

CONCLUSIONS

Perceived stigma is unique among Asian advanced cancer patients. Stigma is important to assess and address, taking into consideration the various sociodemographic, clinical and psychological factors of cancer patients. This article is protected by copyright. All rights reserved.

Patient-Reported Roles in Decision-Making Among Asian Patients With Advanced Cancer: A Multicountry Study

Purpose. We investigated 1) perceived roles in decision-making among advanced cancer patients in 5 Asian countries 2) associations of patient characteristics with these roles, and 3) the association of perceived roles with quality of life and perceived quality of care. Methods. We surveyed 1585 patients with stage IV solid cancer. Multinomial logistic regressions were used to analyze associations of patient characteristics with decision-making roles. Multivariate regressions were used to analyze associations of decision-making roles with quality of life and care. Results. The most common perceived-role was no patient involvement. Most patients (73%) reported roles consistent with their preferences. Being male, nonminority, higher educated, aware of advanced cancer diagnosis, and knowledge of cancer diagnosis for ≥1 year were associated with higher levels of patient involvement in decision-making. Compared to no patient involvement, joint decision-making (together with physicians/family) was associated with higher social (β = 2.49, P < 0.01) and spiritual (β = 2.64, P < 0.01) well-being, and better quality of physician communication (β = 9.73, P < 0.01) and care coordination (β = 13.96, P < 0.01) while making decisions alone was associated with lower emotional (β = -1.43, P < 0.01), social (β = -2.39, P < 0.01), and spiritual (β = -2.98, P < 0.01) well-being. Conclusions. Findings suggest that a substantial number of advanced cancer patients were not (and preferred not to be) involved in decision-making. Despite this finding, joint decision-making together with physicians/family was associated with better quality of life and care. Implications. Physicians should explain the benefits of shared decision making to patients and encourage participation in decision-making, while ensuring that patients feel supported and do not find decision-making overwhelming.

High anxiety and depression scores and mental health service use among South Asian advanced cancer patients: A multi-country study

CONTEXT

Addressing symptoms of anxiety and depression is important in cancer palliative care. However, little information exists on the prevalence of anxiety and depression and mental health service use among advanced cancer patients in South Asia.

OBJECTIVES

To examine among South Asian advanced cancer patients, the 1) prevalence of high anxiety and depression scores, 2) factors associated with high anxiety and depression scores, and 3) mental health service use.

METHODS

This cross-sectional, multi-site study recruited patients receiving oncology care across six major public hospitals in India, Bangladesh and Sri Lanka. Participants were adults, diagnosed with stage IV metastatic solid cancer and aware they had cancer. Participants' high anxiety and depression scores (using clinically-relevant Hospital Anxiety and Depression Scale threshold of >10), sociodemographic characteristics, patient-perceived cancer stigma and mental health service use were assessed.

RESULTS

In the overall sample (N = 1140), 54% met threshold for high anxiety and/or depression scores: 32% reported high anxiety scores and 47% reported high depression scores. Symptom burden (OR's [95% CI's] = 1.09-1.13 [1.05-1.09, 1.12-1.17]) and perceived stigma (1.11-1.16 [1.06-1.11, 1.16-1.22]) were statistically significantly associated with high anxiety and depression scores. Of the patients with high anxiety and/or depression scores (n = 617), 97% had not received mental health services, and 38% of them indicated they were open to a referral.

CONCLUSION

High, clinically-relevant anxiety and depression scores are common among South Asian advanced cancer patients. Efforts should be made to alleviate psychological morbidity, including providing greater access to supportive/palliative medicine teams or mental health services.

Healthcare worker stress, anxiety and burnout during the COVID-19 pandemic in Singapore: A 6-month multi-centre prospective study

Aim

The long-term stress, anxiety and job burnout experienced by healthcare workers (HCWs) are important to consider as the novel coronavirus disease (COVID-19) pandemic stresses healthcare systems globally. The primary objective was to examine the changes in the proportion of HCWs reporting stress, anxiety, and job burnout over six months during the peak of the pandemic in Singapore. The secondary objective was to examine the extent that objective job characteristics, HCW-perceived job factors, and HCW personal resources were associated with stress, anxiety, and job burnout.

Method

A sample of HCWs (doctors, nurses, allied health professionals, administrative and operations staff; N = 2744) was recruited via invitation to participate in an online survey from four tertiary hospitals. Data were gathered between March-August 2020, which included a 2-month lockdown period. HCWs completed monthly web-based self-reported assessments of stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7), and job burnout (Physician Work Life Scale).

Results

The majority of the sample consisted of female HCWs (81%) and nurses (60%). Using random-intercept logistic regression models, elevated perceived stress, anxiety and job burnout were reported by 33%, 13%, and 24% of the overall sample at baseline respectively. The proportion of HCWs reporting stress and job burnout increased by approximately 1·0% and 1·2% respectively per month. Anxiety did not significantly increase. Working long hours was associated with higher odds, while teamwork and feeling appreciated at work were associated with lower odds, of stress, anxiety, and job burnout.

Conclusions

Perceived stress and job burnout showed a mild increase over six months, even after exiting the lockdown. Teamwork and feeling appreciated at work were protective and are targets for developing organizational interventions to mitigate expected poor outcomes among frontline HCWs.

Trajectories of Suffering in the Last Year of Life Among Patients With a Solid Metastatic Cancer

BACKGROUND

Reducing suffering at the end of life is important. Doing so requires a comprehensive understanding of the course of suffering for patients with cancer during their last year of life. This study describes trajectories of psychological, spiritual, physical, and functional suffering in the last year of life among patients with a solid metastatic cancer.

PATIENTS AND METHODS

We conducted a prospective cohort study of 600 patients with a solid metastatic cancer between July 2016 and December 2019 in Singapore. We assessed patients' psychological, spiritual, physical, and functional suffering every 3 months until death. Data from the last year of life of 345 decedents were analyzed. We used group-based multitrajectory modeling to delineate trajectories of suffering during the last year of a patient's life.

RESULTS

We identified 5 trajectories representing suffering: (1) persistently low (47% of the sample); (2) slowly increasing (14%); (3) predominantly spiritual (21%); (4) rapidly increasing (12%); and (5) persistently high (6%). Compared with patients with primary or less education, those with secondary (high school) (odds ratio [OR], 3.49; 95% CI, 1.05-11.59) education were more likely to have rapidly increasing versus persistently low suffering. In multivariable models adjusting for potential confounders, compared with patients with persistently low suffering, those with rapidly increasing suffering had more hospital admissions (β=0.24; 95% CI, 0.00-0.47) and hospital days (β=0.40; 95% CI, 0.04-0.75) during the last year of life. Those with persistently high suffering had more hospital days (β=0.70; 95% CI, 0.23-1.17).

CONCLUSIONS

The course of suffering during the last year of life among patients with cancer is variable and related to patients' hospitalizations. Understanding this variation can facilitate clinical decisions to minimize suffering and reduce healthcare costs at the end of life.

Patients' Awareness of Advanced Disease Status, Psychological Distress and Quality of Life Among Patients With Advanced Cancer: Results From the APPROACH Study, India

BACKGROUND

Prognostic disclosure to patients with advanced cancer facilitates treatment decisions and goals of care discussions. However, the perspectives of patients, families and physicians differ in this regard across different cultures. Non-disclosure of cancer diagnosis or prognosis is commonly observed in family-centric cultures such as India.

AIM

To assess the prevalence of and factors associated with cancer patients' awareness of advanced disease status; and its with quality of life and psychological distress.

METHODS

Patients for this cross-sectional questionnaire-based survey were recruited from oncology and palliative medicine clinics at a tertiary cancer hospital in India from January 2017 to June 2018. Patients aged ≥ 21 years, aware of cancer diagnosis and receiving oncology treatment for Stage IV solid cancer were included in the study after obtaining written informed consent.

RESULTS

Two hundred patients were enrolled, of which 146 (73%) were not aware of the stage of their malignancy and 9 (4.5%) believed that their disease was at stage I, II or III. Those who were aware of their advanced cancer stage had more years of education (9.9 years vs 8.1 years, p = .05) and had poorer spiritual wellbeing in the faith domain (adjusted difference -1.6, 95% confidence interval -3.1 to -0.1, p = .03) compared to those who were unaware.

CONCLUSION

It is recommended that future studies may explore prognostic understanding in Indian patients according to their socio-cultural, spiritual and educational background.

Trajectories of physical symptom burden and psychological distress during the last year of life in patients with a solid metastatic cancer

OBJECTIVE

To delineate the trajectories of physical symptoms and psychological distress among patients with a solid metastatic cancer during the last year of life.

METHODS

We used data of 345 decedents from a prospective cohort of 600 patients with a Stage IV solid cancer. Using group-based trajectory modelling, we assessed (a) demographic (age, gender, education, cancer site) predictors of trajectory membership, (b) shift in trajectories associated with planned and unplanned hospitalizations, emergency room visits and chemotherapy, and (c) the association between trajectory membership and place of death.

RESULTS

We identified three trajectories of physical symptoms-"persistent mild" (56%), "progressive moderate" (36%), and "progressive severe" (8%), and two for psychological distress-"persistent mild" (72%) and "progressive distress" (28%). Females (β = 1.40 [SE = 0.55], p-value = 0.01) and highly educated patients (β = 1.46 [SE = 0.62], p-value = 0.02) were more likely to experience progressive severe symptoms compared to persistent mild symptoms. Older patients were less likely (β = -1.01 [SE = 0.33], p-value = 0.003), while those with gynecological cancers (β = 1.51 [SE = 0.65], p-value = 0.02) were more likely to experience progressive distress compared to persistent mild distress. Planned and unplanned hospitalizations, emergency room visits, and chemotherapy were associated with a worsening in trajectories. Patients with higher distress were more likely to die in a hospice compared to a hospital.

CONCLUSIONS

Interventions to improve physical symptoms and distress can focus on patients at risk of being in worse trajectories and at critical time points in the last year of life-hospitalizations, emergency room visits, and chemotherapy.

A Prospective Cohort Study of Stability in Preferred Place of Death Among Patients With Stage IV Cancer in Singapore

BACKGROUND

Advance care planning (ACP) involves documentation of patients' preferred place of death (PoD). This assumes that patients' preferred PoD will not change over time; yet, evidence for this is inconclusive. We aimed to assess the extent and correlates of change in patients' preferred PoD over time.

MATERIALS AND METHODS

Using data from a cohort study of patients with advanced cancer in Singapore, we analyzed preferred PoD (home vs institution including hospital, hospice, and nursing home vs unclear) among 466 patients every 6 months for a period of 2 years. At each time point, we assessed the proportion of patients who changed their preferred PoD from the previous time point. Using a multinomial logistic regression model, we assessed patient factors (demographics, understanding of disease stage, ACP, recent hospitalization, quality of life, symptom burden, psychologic distress, financial difficulty, prognosis) associated with change in their preferred PoD.

RESULTS

More than 25% of patients changed their preferred PoD every 6 months, with no clear trend in change toward home or institution. Patients psychologically distressed at the time of the survey had increased likelihood of changing their preferred PoD to home (relative risk ratio [RRR], 1.02; 95% CI, 1.00-1.05) and to an institution (RRR, 1.06; 95% CI, 1.02-1.10) relative to no change in preference. Patients hospitalized in the past 6 months were more likely to change their preferred PoD to home (RRR, 1.56; 95% CI, 1.07-2.29) and less likely to change to an institution (RRR, 0.50; 95% CI, 0.28-0.88) relative to no change in preference.

CONCLUSIONS

The present study provides evidence of instability in the preferred PoD of patients with advanced cancer. ACP documents need to be updated regularly to ensure they accurately reflect patients' current preference.

Adapting ENABLE for patients with advanced cancer and their family caregivers in Singapore: a qualitative formative evaluation

BACKGROUND

ENABLE (Educate, Nurture, Advise, Before Life Ends) is a nurse coach-led, early palliative care model for patients with advanced cancer and their family caregivers. Content covered includes problem-solving, advance care planning, symptom management and self-care. The aim was to evaluate the cultural acceptability of ENABLE among patients with advanced cancer and their caregivers in Singapore and identify modifications for an adapted ENABLE-SG model.

METHODS

Qualitative formative evaluation with a thematic analysis approach in two hospitals in Singapore, involving patients (n = 10), family caregivers (n = 11) and healthcare professionals (n = 10) who care for patients with advanced cancer. Semi-structured interviews were conducted to explore (i) the main needs and challenges facing individuals with advanced cancer and their family caregivers; (ii) patient involvement in healthcare decision making; and (iii) content and delivery of ENABLE.

RESULTS

While physical needs were largely well met, participants expressed that psychosocial care was delivered too late in the illness trajectory. Healthcare decision making approaches varied from a patient-centred shared decision-making model to a family-centred model where patients may not know their cancer diagnosis and prognosis. The content was considered to be relevant, comprehensive and practical; financial assistance, adjustment to body image, and evaluation of complementary therapy were also recommended. Face-to-face rather than telephone sessions were preferred to facilitate rapport building.

CONCLUSIONS

ENABLE was broadly acceptable with some modifications, including adjusting the content to ensure it can be delivered even if the patient is not fully aware of cancer diagnosis and delivering the first session face-to-face with flexibility for subsequent sessions.

Patient-Caregiver Treatment Preference Discordance and Its Association With Caregiving Burden and Esteem

Background and Objectives

Many patient–caregiver dyads report conflicting treatment decisions regarding preferences for life extension treatments and symptom management. It is possible that this discordance will lead to negative psychological outcomes including lowered caregiving esteem and increased caregiver burden. However, the relationships between treatment discordance among dyads and caregiver psychological outcomes are not well studied among advanced cancer patients—a gap this study aims to fill.

Research Design and Methods

Outcome variables included caregiver burden and caregiving esteem, measured via a modified 4-domain Caregiver Reaction Assessment Scale. The main independent variable was patient–caregiver treatment preference discordance, examined using questions adapted from an existing protocol. Analyses were conducted using multivariable regressions.

Results

A convenience sample of 285 patient–caregiver dyads were recruited from outpatient clinics at 2 tertiary hospitals in Singapore. The majority (60%) of patient–caregiver dyads reported discordant treatment preferences. Discordance in this study arose because caregivers wanted a balance between life extension and symptom management while patients preferred life-extending treatment. In multivariable analyses, discordance predicted caregiver burden arising from impact on caregiver schedule and health (β = 0.16, p = .07) and lack of family support (β = 0.13, p = .04).

Discussion and Implications

Theoretically, this study provided a more nuanced understanding of how dyad discordance may worsen the burdens felt by caregivers, and which aspects of their lives (i.e., burden due to impact of caregiver schedule and health and lack of family support) are most affected. Our findings can aid in establishing therapeutic interventions targeted toward improving communication skills and encouraging end-of-life discussions among patients, caregivers, and their health care providers. The importance of establishing and improving therapy programs specifically targeted toward caregivers was also underlined.

Perceptions of Mobile Health Apps and Features to Support Psychosocial Well-being Among Frontline Health Care Workers Involved in the COVID-19 Pandemic Response: Qualitative Study

BACKGROUND

Frontline health care workers are experiencing a myriad of physical and psychosocial challenges amid the COVID-19 pandemic. There is growing recognition that digital technologies have the potential to improve the well-being of frontline workers. However, there has been limited development of wellness interventions using mobile health (mHealth) technology. More importantly, little research has been conducted on how frontline workers perceive mHealth-based support to promote their well-being.

OBJECTIVE

This study aimed to explore frontline workers' experience of conventional psychological wellness programs and their perceptions of the usefulness of mHealth apps and features for promoting well-being. It also sought to identify factors that could potentially influence uptake and retention of an mHealth-based wellness program.

METHODS

We conducted semistructured interviews using purposive sampling with frontline workers involved in the COVID-19 response. Various visual materials, collated from existing mHealth app features, were presented to facilitate discussion. Interviews were audio-recorded and transcribed verbatim. Thematic analysis based on grounded theory was undertaken. Themes were subsequently mapped to key nudge strategies-those commonly used for mHealth development-to assess participants' preferences for particular features and their reasoning.

RESULTS

A total of 42 frontline workers participated in 12 one-on-one interviews or focus group discussions. Frontline workers generally had a limited ability to identify their own psychological problems and liked the reminders functionality of the app to track their mood over time. A personalized goal-setting feature (ie, tailoring) and in-app resources were generally valued, while frequent coaching and messages (ie, framing) were seen as a distraction. The majority of participants desired a built-in chat function with a counselor (ie, guidance) for reasons of accessibility and protection of privacy. Very few participants appreciated a gamification function. Frontline workers commonly reported the need for ongoing social support and desired access to an in-app peer support community (ie, social influence). There were, however, concerns regarding potential risks from virtual peer interactions. Intrinsic motivational factors, mHealth app technicality, and tangible rewards were identified as critical for uptake and retention.

CONCLUSIONS

Our study highlights the potential of mHealth apps with relevant features to be used as wellness tools by frontline health care workers. Future work should focus on developing a nonintrusive and personalized mHealth app with in-app counseling, peer support to improve well-being, and tangible and extrinsic rewards to foster continued use.

Experiences with health care practitioners among advanced cancer patients and their family caregivers: A longitudinal dyadic study

BACKGROUND

Assessing patient and caregiver experiences with care is central to improving care quality. The authors assessed variations in the experiences of advanced cancer patients and their caregivers with physician communication and care coordination by patient and caregiver factors.

METHODS

The authors surveyed 600 patients with a stage IV solid malignancy and 346 caregivers every 3 months for more than 2 years. Patients entered the cohort any time during their stage IV trajectory. The analytic sample was restricted to patient-caregiver dyads (n = 299). Each survey assessed patients' experiences with physician communication and care coordination; patients' symptom burden; caregivers' quality of life; and patients' and caregivers' anxiety, financial difficulties, and perceptions of treatment goals. An actor-partner interdependence framework was used for analysis.

RESULTS

Patients reported better physician communication (average marginal effect [AME], 6.04; 95% confidence interval [CI], 3.82 to 8.26) and care coordination (AME, 8.96; 95% CI, 6.94 to 10.97) than their caregivers. Patients reported worse care coordination when they (AME, -0.56; 95% CI, -1.07 to -0.05) or their caregivers (AME, -0.58; 95% CI, -0.97 to -0.19) were more anxious. Caregivers reported worse care coordination when they were anxious (AME, -1.62; 95% CI, -2.02 to -1.23) and experienced financial difficulties (AME, -2.31; 95% CI, -3.77 to -0.86). Correct understanding of the treatment goal (vs being uncertain) was associated with caregivers reporting physician communication as better (AME, 3.67; 95% CI, 0.49 to 6.86) but with patients reporting it as worse (AME, -3.29; 95% CI, -6.45 to -0.14).

CONCLUSIONS

Patients' and caregivers' reports of physician communication and care coordination vary with aspects of their own and each other's well-being and with their perceptions of treatment goals. These findings may have implications for improving patients' and caregivers' reported experiences with health care practitioners.

Financial difficulties and patient-reported outcomes among patients with advanced heart failure

PURPOSE

Management of congestive heart failure (CHF) is associated with high health care costs and financial difficulties for patients. We aimed to comprehensively assess the association between financial difficulties and patients' quality of life (QOL) (physical, emotional, social and spiritual), perceived health care quality, and perception of being a burden to the family among patients with CHF; and to assess whether perceived control over stress moderated these associations.

METHODS

This was a cross-sectional study of 250 patients using the baseline data of the Singapore Cohort of Patients with Advanced Heart Failure (SCOPAH). Patients had class 3 or 4 CHF symptoms based on the New York Heart Association and were recruited between July 2017 and August 2019. We used a 3-item questionnaire to measure financial difficulties among patients. We used multivariable linear/ordered logistic regressions to test associations between financial difficulties and each dependent variable.

RESULTS

41% of participants reported financial difficulties. A higher financial difficulties score (range: 0-6, higher score indicating greater difficulty) was associated with lower QOL (emotional, social, and spiritual) and perceived health care coordination, and a higher likelihood of patients perceiving themselves to being a burden to family (all p < 0.05) CONCLUSION: Patients with financial difficulties are vulnerable to poor outcomes. Heart failure clinics should directly assess patients' financial difficulties to help guide treatment-related discussions and to identify patients vulnerable to poor QOL.

Stressors and coping strategies of migrant workers diagnosed with COVID-19 in Singapore: a qualitative study

INTRODUCTION

The health, psychological and socioeconomic vulnerabilities of low-wage migrant workers have been magnified in the COVID-19 pandemic, especially in high-income receiving countries such as Singapore. We aimed to understand migrant worker concerns and coping strategies during the COVID-19 pandemic to address these during the crisis and inform on comprehensive support needed after the crisis.

METHODS

In-depth semi-structured interviews were carried out with migrant workers diagnosed with COVID-19. The participants were recruited from a COVID-19 mass quarantine facility in Singapore through a purposive sampling approach. Interviews were transcribed verbatim and thematic analysis performed to derive themes in their collective experience during the crisis.

RESULTS

Three theme categories were derived from 27 interviews: migrant worker concerns during COVID-19, coping during COVID-19 and priorities after COVID-19. Major stressors in the crisis included the inability to continue providing for their families when work is disrupted, their susceptibility to infection in crowded dormitories, the shock of receiving the COVID-19 diagnosis while asymptomatic, as well as the isolating conditions of the quarantine environment. The workers coped by keeping in contact with their families, accessing healthcare, keeping updated with the news and continuing to practise their faith and religion. They looked forward to a return to normalcy after the crisis with keeping healthy and having access to healthcare as new priorities.

CONCLUSION

We identified coping strategies employed by the workers in quarantine, many of which were made possible through the considered design of care and service delivery in mass quarantine facilities in Singapore. These can be adopted in the set-up of other mass quarantine facilities around the world to support the health and mental well-being of those quarantined. Our findings highlight the importance of targeted policy intervention for migrant workers, in areas such as housing and working environments, equitable access to healthcare, and social protection during and after this crisis.

Role in decision making among congestive heart failure patients and its association with patient outcomes: a baseline analysis of the SCOPAH study

OBJECTIVE

We investigated the predictors of patient-experienced and preferred roles for decision making, and the association between patient-experienced role in decision making and patient outcomes among congestive heart failure (HF) patients in a multi-ethnic Asian population.

METHODS

We surveyed 246 HF patients classified as New York Heart Association class 3/4. Multivariable regressions were used to analyse the associations between patient-experienced roles and patient outcomes.

RESULTS

Patients who were male, attained higher education, and had a higher cognitive score were more likely to experience and prefer active roles in decision making. Younger patients and patients with lower symptom burden were more likely, while married patients were less likely to prefer leading decision making. Patients with collaborative (family and/or physician) decision making reported higher emotional well-being and sense of meaning/peace. Collaborative and patient-led decision making were associated with higher perceived control over illness. Those who were led by others or made decisions alone reported lower quality of physician communication.

CONCLUSION

Collaborative decision making was associated with higher emotional well-being, sense of meaning/peace, and higher perceived control over illness among HF patients.

PRACTICE IMPLICATIONS

Physicians should explain the benefits of shared decision making and encourage patients to participate in treatment decisions.

A survey of anxiety and burnout in the radiology workforce of a tertiary hospital during the COVID-19 pandemic

Introduction

We aimed to study anxiety and burnout among Division of Radiological Sciences (RADSC) staff during the COVID‐19 pandemic and identify potential risk and protective factors. These outcomes were compared with non‐RADSC staff.

Methods

A cross‐sectional online study was conducted between 12 March and 20 July 2020 in the largest public tertiary hospital receiving COVID‐19 cases. Burnout and anxiety were assessed with the Physician Work‐Life Scale and the Generalized Anxiety Disorder‐7 Scale, respectively. Workplace factors were examined as potential risk and protective factors using multivariable ordinary least squares regression analyses, adjusting for pertinent demographic characteristics.

Results

RADSC staff (n = 180) and non‐RADSC staff (n = 1458) demonstrated moderate‐to‐severe anxiety rates of 6.7 and 13.2 % and burnout rates of 17.8 and 23.9 %, respectively. RADSC staff reported significantly lower anxiety (mean ± SD: 4.0 ± 3.7 vs 4.9 ± 4.5; P‐value < 0.05), burnout (mean ± SD: 1.9 ± 0.7 vs 2.1 ± 0.8; P‐value < 0.01), increased teamwork (82.2% vs 74.1%; P‐value < 0.05) and fewer night shifts (36.7% vs 41.1%; P‐value < 0.01). Among RADSC staff, higher job dedication was associated with lower anxiety (b (95% CI) = −0.28 (−0.45, −0.11)) and burnout (b (95% CI) = −0.07 (−0.11,‐0.04)), while longer than usual working hours was associated with increased anxiety (b (95% CI) = 1.42 (0.36, 2.45)) and burnout (b (95% CI) = 0.28 (0.09, 0.48)).

Conclusions

A proportion of RADSC staff reported significant burnout and anxiety, although less compared to the larger hospital cohort. Measures to prevent longer than usual work hours and increase feelings of enthusiasm and pride in one’s job may further reduce the prevalence of anxiety problems and burnout in radiology departments.

Reference values for the short forms of the Singapore Caregiver Quality of Life Scale

PURPOSE

The 15- and 10-item short forms of the Singapore Caregiver Quality of Life Scale (SCQOLS-15 and SCQOLS-10) were recently developed as a quick assessment of caregiver quality of life. Reference values describing the distribution of the total and domain scores are available for the full-length version, but they are not yet available for the short forms. This study aimed to estimate the reference values for the short forms.

METHODS

Data from a cross-sectional survey of 612 family caregivers of patients with advanced cancer in Singapore were fitted in quantile regression models. Percentiles were estimated by regressing the short forms' scores on caregiver characteristics. Classification by the reference values for the short forms and the full-length version were compared and agreement was evaluated.

RESULTS

The caregiver's role in caring for the patient and the patient's performance status were associated with the percentiles of the total scores and most domain scores (each Bonferroni-adjusted p-value, P_B, < 0.05). Higher-educated caregivers were categorized into higher percentiles according to the SCQOLS-15 and SCQOLS-10 total scores and the SCQOLS-15 Mental Well-being and Financial Well-being domain scores (each P_B < 0.05). Ethnicity was associated with the SCQOLS-15 Physical Well-being and Experience & Meaning domains (each P_B < 0.05). The percentiles for the short forms showed moderate to substantial agreement with those for the full-length version in terms of classifying caregivers into percentile intervals (quadratic-weighted Kappa = 0.72 to 0.92).

CONCLUSION

Reference values for the SCQOLS-15 and SCQOLS-10 were estimated in relation to caregiver characteristics to facilitate interpretation of the short form scores.

The Feasibility and Acceptability of a Cognitive Behavioral Therapy-Based Intervention for Patients With Advanced Colorectal Cancer

CONTEXT

Advanced colorectal cancer and its treatment can bring about challenges associated with psychological distress.

OBJECTIVES

The primary aims of this study were to examine the feasibility and acceptability of a cognitive behavioral therapy (CBT)-based intervention to improve coping with the disease. The secondary aim is to evaluate preliminary intervention efficacy.

METHODS

Patients with advanced colorectal cancer in Singapore (N = 60) were randomized to either receive a four-session CBT intervention immediately or be waitlisted. Intervention feasibility (i.e., recruitment and intervention adherence) and acceptability (i.e., participant satisfaction and cultural sensitivity) were assessed. Changes in psychological distress and self-efficacy were examined.

RESULTS

The study successfully recruited the intended sample (mean age 61; 62% men). A proportion (12%) reported Hospital Anxiety and Depression Scale scores indicative of distress at baseline. Most (88%) completed all sessions. Participants reported high rates of satisfaction (97%), helpfulness (96%), and cultural sensitivity (95%) of the intervention. The intervention group did not show decrease in psychological distress; however, self-efficacy in cancer-related coping (information seeking: effect size [ES] = 0.64; 95% CI = 0.17, 0.85; coping with side effects: ES = 0.69; 95% CI = 0.33, 0.82; and maintaining positive attitude: ES = 0.45; 95% CI = 0.19, 0.79) increased in the intervention group compared with the waitlisted group.

CONCLUSION

The CBT-based intervention was feasible and acceptable to patients in Singapore. There is no sufficient evidence to warrant a larger trial in this sample with low baseline distress. Future work should identify and target those who are most in need of support.

Correction to: Health-related quality of life and its socio-economic and cultural predictors among advanced cancer patients: evidence from the APPROACH cross-sectional survey in Hyderabad-India

Following publication of the original article [1], the corresponding author reported an error on the name of the fourth author.

The association of self-blame with treatment preferences in a multi-country cohort of advanced cancer patients from the APPROACH study

OBJECTIVE

To understand the prevalence of behavioral and characterological self-blame and their associations with stated preferences for life-extension and the use of pain-relief medication in a multi-country cohort of advanced cancer patients.

METHODS

The prevalence of self-blame and reasons participants attributed to their diagnosis was assessed in a sample of 968 advanced cancer patients enrolled in one of five sites from four Asian countries of the multi-country cross-sectional survey titled APRROACH. Ordered probit and Firth logistic regressions were used to determine associations between each type of self-blame and two treatment-related outcomes: participants' stated preference for life-extension and the use of pain-relief medication in the last 24 h.

RESULTS

Behavioral and characterological self-blame were reported by 41% and 49% of the participants respectively, with only 19% and 2% of participants providing a logically consistent reason for the two types of self-blame. We observed no statistically significant differences in stated preferences for life-extension for either type of self-blame and in the use of pain-relief medication for participants reporting behavioral self-blame. However, participants reporting characterological self-blame were 9.7% (95% CI, 2.0% to 17.3%; p = 0.014) more likely to report using pain-relief medication compared to participants not reporting characterological self-blame.

CONCLUSIONS

A substantial proportion of patients report self-blame and those reporting characterological self-blame appear more likely to use pain medication. Therefore, developing interventions aimed at reducing characterological self-blame might help patients receive only appropriate treatments as opposed to treatments pursued in response to feelings of self-blame.

Development and evaluation of the Singapore Caregiver Quality of Life Scale - Dementia

PURPOSE

To develop and evaluate a measurement scale for multi-domain assessment of the quality of life of family caregivers of persons with dementia (PWD) in Singapore, a multi-ethic society in South-East Asia where English is the lingua franca.

METHODS

Items from the Singapore Caregiver Quality of Life Scale (SCQOLS), which was originally developed in the context of advanced cancers, were adopted as candidate items. Furthermore, a multi-disciplinary panel reviewed dementia-specific caregiver quality of life scales to identified items not covered in SCQOLS for inclusion as candidate items. A pilot study of 31 family caregivers of PWD was conducted to solicit inputs on candidate items; 102 family caregivers of PWD were surveyed for evaluation of the scale's measurement properties.

RESULTS

Factor analysis confirmed a 5-domain structure of the 63 candidate items. The Root Mean Square Error of Approximation was 0.056 and Comparative Fit Index was 0.928. Convergent validity of the total and domain scores was demonstrated in terms of correlation with the Brief Assessment Scale for Caregivers and its sub-scales. The scores also showed an expected pattern of correlation with hours spent on caregiving per week. Known-group validity was demonstrated by differences in mean scores between functional staging groups. Cronbach's alpha of the total and domain scores ranged from 0.89 to 0.95. Test-retest reliability (intraclass correlation coefficient) ranged from 0.77 to 0.92.

CONCLUSIONS

The Singapore Caregiver Quality of Life Scale - Dementia (SCQOLS-D) is a quality of life measurement scale for family caregivers of persons with dementia that is valid and reliable.

Awareness of and preference for disease prognosis and participation in treatment decisions among advanced cancer patients in Myanmar: Results from the APPROACH study

AIM

To investigate prognostic awareness, preference for prognostic information, and perceived and preferred roles in decision making among patients with advanced cancer in Myanmar.

METHODS

A cross-sectional survey was administered at the Yangon General Hospital to stage 4 cancer patients who were at least 21 years old and aware of their cancer diagnosis. Patients were asked questions about their prognosis, participation in treatment decisions, sociodemographic and clinical information. Data from 131 patients were analyzed using descriptive statistics and logistic regressions.

RESULTS

Only 15% of patients surveyed were aware that their cancer was advanced and only a quarter (26%) of patients knew that treatment intent was noncurative. The likelihood of treatment-intent awareness was higher among patients who were male, high income, and aware that they had advanced cancer. Roughly 60% of patients reported playing an active or collaborative role in treatment decisions, with a strong preference (59%) for the latter. For the majority of patients (69%), perceived and preferred roles in decision making were the same. Sociodemographic characteristics did not predict perceived and preferred roles in decision making.

CONCLUSIONS

This is the first effort to analyze prognostic awareness and decision-making practices among advanced cancer patients in Myanmar. Patients had inadequate knowledge on their disease progression and intent of treatment. Yet, the majority of them were keen to be involved in treatment decisions.

Socio-economic inequalities in suffering at the end of life among advanced cancer patients: results from the APPROACH study in five Asian countries

Background

A systematic understanding of socio-economic inequalities in end-of-life (EOL) suffering among advanced cancer patients is required to inform efforts to reduce these inequalities as part of Universal Health Coverage goals.

Aims

To assess inequalities in multiple domains of EOL suffering among advanced cancer patients – physical, functional, psychological, social, and spiritual –, using two socio-economic status (SES) indicators, education and perceived economic status of the household.

Methods

We used cross-sectional data from surveys of stage IV cancer patients (n = 1378) from seven hospitals across five countries (China, Sri Lanka, India, Vietnam and Myanmar). We conducted separate multivariable linear regression models for each EOL suffering domain. We also tested interactions between the two SES indicators and between each SES indicator and patient age.

Results

Patients living in low economic status households /with fewer years of education reported greater suffering in several domains. We also found significant interaction effects between economic status of the household and years of education for all EOL suffering outcomes. Age significantly moderated the association between economic status of the household and social suffering and between years of education and psychological, social, and spiritual suffering (p < 0.05 for all).

Conclusion

Results highlight that SES inequalities in EOL suffering vary depending on the suffering domain, the SES indicator assessed, and by patient age. Greater palliative care resources for patients with low SES may help reduce these inequalities.