Physicians have a responsibility to discuss do-not-resuscitate (DNR) decisions and end-of-life (EOL) care with patients and family members. The aim of this study was to explore the DNR and EOL care discussion experience among physicians in Taiwan. A qualitative study was conducted with 16 physicians recruited from the departments of hospice care, surgery, internal medicine, emergency, and the intensive care unit. The interview guidelines included their DNR experience and process and EOL care discussions, as well as their concerns, difficulties, or worries in discussions. Thematic analysis was used to analyze data. Four themes were identified. First, family members had multiple roles in the decision process. Second, the characteristics of the units, including time urgency and relationships with patients and family members, influenced physicians' work. Third, the process included preparation, exploration, information delivery, barrier solution, and execution. Fourth, physicians shared reflections on their ability and the conflicts between law, medical professionals, and the best interests of patients. Physicians must consider not only patients' but also family members' opinions and surmount several barriers in decision-making. They also experienced negative and positive impacts from these discussions.
Background: Medical staff may have difficulties in using conventional medicine to manage symptoms among terminally ill patients, including adverse effects of the treatment. Traditional Chinese medicine (TCM) is regarded as a complementary or alternative medicine, and has been increasingly used in the field of palliative medicine in recent years. This study aimed to investigate the experiences of and attitudes toward using TCM among palliative care professionals, and to provide preliminary information about its use in palliative care.
Methods: This was a cross-sectional survey study conducted in eight inpatient hospice wards in Taiwan between December 2014 and February 2016. The questionnaire was self-administered, and was analyzed with descriptive statistics including Pearson’s Chi-square test and Fisher’s exact test.
Results: A total of 251 palliative care professionals responded to the questionnaire, of whom 89.7% and 88.9% believed that the use of TCM could improve the physical symptoms and quality of life in terminally ill patients, respectively. Overall, 59.8%, of respondents suggested that TCM had rare side effects, and 58.2% were worried that TCM could affect the liver and kidney function of patients. In total, 89.7% and 88.0% of professionals agreed there were no suitable clinical practice guidelines and educational programs, respectively, for TCM use in palliative care.
Conclusions: Most of the respondents agreed there was insufficient knowledge, skills-training, and continuing education on the use of TCM in terminally ill patients in Taiwan. These results show that to address patient safety considerations, guidelines about use of TCM in palliative care should be established.
The aging of the Taiwanese population has become a major issue. Previous research has focused on the burden and stress faced by caregivers, but has not explored how the experience of these caregivers influences decisions of advance care planning (ACP). Semi-structured and in-depth interviews were conducted. Qualitative content analysis was used to identify important themes. Five themes and fourteen sub-themes were identified: (1) Past experiences: patient wishes, professional recommendations, and expectation about disease progress; (2) Impact of care on family members: positive affirmation, open-minded life, social isolation and health effects, and financial and life planning effects; (3) Attitude toward life: not forcing to stay, and not becoming a burden, (4) Expected proxy dilemmas: torment between doing or not, seeing the extension of suffering and toil, and remorse and self-blame; (5) Expectation of end of life (EOL) care: caregiver's experience and EOL care decisions, and practicality of EOL decision making. After making multiple medical decisions for their disabled relatives, caregivers are able to calmly face their own medical decisions, and "not becoming a burden" is their primary consideration. It's suggested that implementation of shared decision-making on medical care for patients with chronic disability will not only improve the quality of their medical care but also reduce the development of remorse and guilty feelings of caregivers after making medical decisions.
CONTEXT: It is uncertain whether terminally ill schizophrenic cancer patients are hypoalgesic or have disparities in pain management.
OBJECTIVES: To analyze the dosage of opioids used in terminally ill cancer patients with and without schizophrenia.
METHODS: This is a population-based retrospective cohort study based on data derived from the Taiwan National Health Insurance Research Database. Patients aged > 20 and newly diagnosed between 2000 and 2012 with at least one of the six most common cancers were included. After 1:4 matching, 1001 schizophrenic cancer patients comprised the schizophrenia cohort, while 4004 cancer patients without schizophrenia comprised the non-schizophrenia cohort. The percentage of opioid use, accumulated dose, and average daily dose near the end of life were analyzed for each cohort using multiple logistic and linear regression models.
RESULTS: The percentage of opioid use was lower in the schizophrenic cohort than the non-schizophrenic cohort during the last month prior to death [69.6 % versus 84.8%, odd ratio (OR) = 0.40, 95% confidence interval (CI) = 0.34-0.48]. The accumulated dose of opioid consumption was also lower in the schizophrenic cohort (2407 mg versus 3694 mg, p value <0.05).
CONCLUSION: Near the end of life, cancer patients with schizophrenia use less opioid than their non-schizophrenic counterparts. Cognitive impairment may be a cause in the disparity in end-of-life care for terminally ill schizophrenic cancer patients. Thus, we should formulate a more accurate pain scale system and pay attention to their need for pain treatment.
This aims of this longitudinal study were to identify the risk factors of and depressive mood in caregivers who received hospice care 6 months after their patients’ death, and the cutoff pint of the bereavement risk index, as well as, the prevalence of persistent complex bereavement disorder (PCBD). There were 30.28 and 4.59% of caregivers with depressive mood and PCBD, respectively. The risk factors included resistance to the reality of patients’ death, anger, self-blame and guilt, support networks, and coping. The cutoff points of total bereavement risk index and five-item short form were 10/11 and 9/10, respectively.
BACKGROUND: Cancer patients with schizophrenia may face disparities in end-of life care, and it is unclear whether schizophrenia affects their medical care and treatment.
METHODS: We conducted a nationwide population-based cohort study based on the National Health Insurance Research Database of Taiwan. The study population included patients >20years old who were newly diagnosed as having one of six common cancers between 2000 and 2012 (schizophrenia cohort: 1911 patients with both cancer and schizophrenia; non-schizophrenia cohort: 7644 cancer patients without schizophrenia). We used a multiple logistic regression model to analyze the differences in medical treatment between the two cohorts in the final 1 and 3months of life.
RESULTS: In the 1month before death, there was higher intensive care unit utilization in the schizophrenia group [odd ratio (OR)=1.21, 95% confidence interval (CI)=1.07-1.36] and no significant differences between the groups in-hospital stay length or hospice care. The schizophrenia patients received less chemotherapy (OR=0.60, 95% CI=0.55-0.66) but more invasive interventions, such as cardiopulmonary resuscitation (OR=1.34, 95% CI=1.15-1.57). Advanced diagnostic examinations, such as computed tomography/magnetic resonance imaging/sonography (OR=0.80, 95% CI=0.71-0.89), were used less often for the schizophrenia patients. The 1- and 3-month prior to death results were similar.
CONCLUSION: End-of-life cancer patients with schizophrenia underwent more frequent invasive treatments but less chemotherapy and examinations. Treatment plans/advance directives should be discussed with patients/families early to enhance end-of-life care quality and reduce health care disparities caused by schizophrenia.
Dementia is a progressive, incurable disease that can deprive patients of the ability to make decisions. This study determines whether dementia influences the medical care that a cancer patient receives at the end of life. The authors conducted a nationwide population-based cohort study on patients aged =20 with newly diagnosed cancer during 2000–2012. After matching to reduce confounders, there were 7,111 patients with and 28,444 without dementia. The adjusted odd ratios (OR) for medical interventions, including intensive care, palliative care, invasive procedures, and advanced diagnostic testing, were calculated for the final month and three months of life by a multiple logistic regression model. In the final month before death, the dementia cohort had longer hospital stays (17.7 vs. 17.1 days), more intensive care unit stays (OR = 1.32), and less palliative care (OR = 0.80) than the non-dementia cohort and were more likely to receive invasive procedures, including cardiopulmonary resuscitation (OR = 1.32), endotracheal intubation (OR = 1.27), mechanical ventilation (OR = 1.45), urinary catheterization (OR = 1.24), and feeding tube (OR = 1.88), but less likely to undergo chemotherapy (OR = 0.60) and diagnostic procedures such as computed tomography, magnetic resonance imaging, and sonography (OR = 0.87) or bone scan (OR = 0.69). The analysis examining the three months before death had similar results. In summary, patients with cancer and dementia are more likely to receive intensive care and invasive procedures but less likely to undergo advanced diagnostic testing, chemotherapy, or hospice care than those with cancer but without dementia.