CONTEXT: To respect a patient's wish for end-of-life care, "the Act on Decisions on Life-Sustaining Treatment for Patients at the End-of-Life" was enacted in South Korea in 2016. Current understanding of people who would be involved in advance care planning (ACP) is crucial to disseminate it systematically.
OBJECTIVES: To investigate awareness and attitudes toward ACP in South Korea.
METHODS: A multicenter, nationwide cross-sectional study was conducted a survey regarding ACP among four groups that would have different positions and experiences: 1,001 cancer patients, 1,006 family caregivers, 928 physicians, and 1,241 members of the general public.
RESULTS: A total of 15% of the general population, 33% of the patients and caregivers, and 61% of the physicians had knowledge of advance directives. More than 64% of the general population, above 72% of the patients and caregivers, and 97% of the physicians were willing to do so when the disease status was aggravated or terminal. The possibility for changing the plan, uncertainty as to whether directives would actually be followed, and psychological discomfort were common reasons for not wanting to engage in ACP. Routine recommendations for a specific medical condition, heightened accessibility, and health insurance support were common factors that could help facilitate ACP.
CONCLUSION: Our findings suggest that strategies for promoting ACP should reflect different perspectives among the general public, patients, family caregivers, and physicians. Public advocacy, resources for approaching and integrating ACP into routine healthcare, as well as systematic support provisions, are needed.
OBJECTIVES: Delirium is highly prevalent in patients with advanced cancer. This study aimed to investigate delirium rates and potential associated factors such as mortality in patients admitted to an acute palliative care unit (APCU). Our second aim was to validate the Korean version of the Memorial Delirium Assessment Scale (K-MDAS).
METHODS: A total of 102 patients with advanced cancer, and who were admitted to the APCU, were assessed. Demographic data were collected alongside clinical diagnosis, Eastern Cooperative Oncology Group (ECOG) performance status, clinical symptoms according to the Edmonton Symptom Assessment System (ESAS), history of smoking, alcohol use, hypnotic use, and daily dose of morphine were collected. The Confusion Assessment Method (CAM), the Delirium Rating Scale-Revised 98 (DRS-R98), and the K-MDAS were measured at admission and 1 week later.
RESULTS: Twenty-four patients (23.52%) were diagnosed with delirium, and associated factors were old age (p = 0.007), higher ECOG (p = 0.011), and drowsiness (p < 0.001). The presence of delirium was an independent predictor of 1-month mortality; male gender, higher body mass index, and hypnotic use were also related to 1-month mortality. The K-MDAS had reliable internal consistency (α = 0.942) and showed sensitivity of 0.958 and specificity of 0.921 at the optimal cutoff score for diagnosing delirium of 9.
CONCLUSIONS: Delirium was prevalent in patients admitted to the APCU, and was associated with 1-month mortality. The K-MDAS showed acceptable reliability and validity and can be used to screen for delirium in a palliative care setting.
OBJECTIVE: The aim of this study was to determine the factors associated with a feeling of well-being using the Edmonton Symptom Assessment Scale (ESAS)-Feeling of Well-Being item (ESAS-FWB; where 0 = best and 10 = worst) among advanced lung or non-colonic gastrointestinal cancer patients who were referred to an outpatient palliative care clinic (OPCC). We also examined the association of performance on the ESAS-FWB with overall survival (OS).
METHOD: We reviewed the records of consecutive patients with incurable advanced lung cancer and non-colonic gastrointestinal cancer presenting to an OPCC from 1 January 2008 through to 31 December 2013. Descriptive statistics were employed to summarize patient characteristics. Multivariate regression analysis was used to determine the factors associated with ESAS-FWB severity. We also examined the association of ESAS-FWB scores and survival using Kaplan-Meier survival analysis.
RESULTS: A total of 826 evaluable patients were analyzed (median age = 62 years, 57% male). Median ESAS-FWB scores were five times the interquartile range (5 × IQR; 3-7). ESAS-FWB score was found to be significantly associated with ESAS fatigue (OR = 2.31, p < 0.001); anxiety (OR = 1.98, p < 0.001); anorexia (OR = 2.31, p < 0.001); cut down, annoyed, guilty, eye opener (CAGE) score (hazard ratio [HR] = 1.80, p = 0.008); and family caregiver distress (HR = 1.93, p = 0.002). A worse ESAS-FWB score was significantly associated with decreased OS (r = -0.18, p < 0.001). However, ESAS-FWB score was not independently associated with OS in the final multivariate model (p = 0.35), which included known major clinical prognostic factors.
CONCLUSIONS: Worse ESAS-FWB scores were significantly associated with high scores on ESAS fatigue, anorexia, anxiety, CAGE, and family caregiver distress. More research is necessary to understand how palliative care interventions are capable of improving the contributory factors related to ESAS-FWB score.
CONTEXT: Spiritual well-being (SWB) is very important in palliative care patients.
OBJECTIVES: The aim of this study is to investigate the SWB among palliative care patients in Korea with different religious affiliations, and to identify the correlates of SWB.
METHODS: This study is a cross-sectional, multicenter study involving hospitalized patients seen by palliative care teams. We collected data on basic clinicodemographic characteristics, factors related to religion (meaningful religious events, religious activities such as attending worship, individual spiritual activities such as prayer), overall quality of life (QOL) and SWB. SWB was measured using Functional Assessment of Chronic Illness Therapy-Spirituality 12 (FACIT-Sp 12). We examined the differences in SWB among patients who reported themselves as Protestants, Catholics, Buddhists, and no religious affiliations.
RESULTS: Among the 202 patients enrolled, 69 (33.8%), 48 (23.5%), 43 (20.6%), and 42 (20.6%) persons were Protestants, Catholics, Buddhists, and have no religious affiliation, respectively. The FACIT-Sp12 was highest among Protestants, followed by Catholics, Buddhists, and those without religious affiliation (29.8 vs. 27.0 vs. 23.2 vs 16.3, P<0.001). The faith subscale (12.4 vs. 10.4 vs. 7.7 vs. 2.5, P<0.001) showed similar distributions. Christians reported higher SWB in the meaning and the peace subscale than patients without a religious affiliation. In the multivariate analysis, religious affiliation (P<0.001), individual spiritual activities (P<0.001), and QOL (P<0.001) were significantly related to a greater SWB. Age was inversely associated with the meaning subscale (P=0.002).
CONCLUSIONS: Although faith practices may be particularly helpful to improve spiritual well-being among Christians, further research is needed to determine what individual spiritual activities can support non-Christians.
BACKGROUND: There is limited evidence about the response of breakthrough pain (BTP) to the most commonly used oral immediate-release (IR) opioids. Our aim was to determine response rate to oral IR opioids for BTP control in patients with advanced cancer.
MATERIALS AND METHODS: In this prospective study, palliative care outpatients, with advanced cancer and adequately managed background pain, were asked to complete a self-administered survey. We assessed patients' baseline demographics, pain characteristics, alcoholism (CAGE questionnaire), tobacco and substance abuse, and Edmonton Symptom Assessment Scores (ESAS). We determined the effectiveness of oral IR BTP opioids by using a 7-point Likert scale ranging from "very ineffective" to "very effective." "Effective" and "very effective" were defined a priori as a good response to IR opioids for BTP.
RESULTS: Of 592 evaluable patients, 192 (32%) had background pain of =3 (ESAS pain scale 0–10). Among these 192 patients, 152 (79%) reported BTP, 143/152 (94%) took oral IR opioids for BTP, and 127/143 (89%) responded to a median dose of 10% of the total morphine equivalent daily dose. In univariate logistic regression analysis, younger age (odds ratio [OR], 0.94 per year; p = .008), higher ESAS scores for pain (OR, 1.32; p = .012), anxiety (OR, 1.24; p = .017), and dyspnea (OR, 1.31; p = .007) had statistically significant association with poor response to IR opioids for BTP. In multicovariate logistic regression, adjusted for age, a higher ESAS dyspnea score was significantly associated with poor response to oral IR opioids (OR, 1.44; p = .002).
CONCLUSION: The vast majority of patients with advanced cancer with adequately controlled background pain reported a good response to oral IR opioids for BTP, supporting their use in clinical practice.
IMPLICATIONS FOR PRACTICE: Oral immediate-release opioids are standard treatment for cancer breakthrough pain. However, information regarding treatment response to these commonly used opioids is limited. This study provides information that the vast majority of patients with advanced cancer, with adequately controlled background pain, reported good response to oral immediate release opioids for managing their breakthrough pain episodes. Results of this study support the use of conventional oral immediate release opioids that are relatively inexpensive and readily available for management of breakthrough pain in patients with advanced cancer.
Introduction: To determine whether an upfront combination compared to single-agent therapy is beneficial for elderly patients with advanced non-small cell lung cancer (NSCLC) in the real world, a population-based epidemiologic study was conducted.
Methods: Patients =70 years with advanced NSCLC from 2007 to 2012 were identified in the National Health Insurance Service Database of Korea. A Cox proportional-hazards regression model and propensity score analysis were used to examine the effect of treatment modality on survival.
Results: Among 41,276 patients newly diagnosed with lung cancer, 8274 (20.0%) identified to be treated with upfront palliative chemotherapy were eligible for this study. After excluding 976 patients who received a first-line anti-epidermal growth factor receptor (EGFR) treatment, 7298 (88.2%) who received cytotoxic chemotherapy were included in further analyses: 5636 (77.2%) received doublet chemotherapy and 1662 (22.8%) received monotherapy. The most frequent regimen in combination group was gemcitabine and platinum doublet (44.7%), whereas that in monotherapy group was gemcitabine (46.7%). Multivariate analyses indicated lower use of combination chemotherapy with increasing age (odds ratio [OR] 0.73; 95% CI 0.67–0.79; P < 0.001) and female sex (OR 0.71; 95% CI 0.62–0.80; P < 0.001). Receipt of combination over single-agent chemotherapy was associated with a reduced risk of death (hazard ratio [HR] 0.91; 95% CI 0.86–0.96; P = 0.001) in overall population and (HR 0.89; 95% CI 0.80–0.98; P = 0.019) in the propensity-matched cohort.
Conclusion: In elderly patients with advanced NSCLC excluding those receiving frontline anti-EGFR targeted agents, receiving initial combination chemotherapy compared to single-agent was associated with improved survival.
BACKGROUND: There is significant variation in access to palliative care. We examined the pattern of outpatient palliative care referral among thoracic medical oncologists and identified oncologist characteristics associated with greater referral.
MATERIALS AND METHODS: We retrieved data on all patients who died of advanced thoracic malignancies at our institution between January 1, 2007, and December 31, 2012. Using median as a cutoff, we defined two groups (high-referring and low-referring oncologists) based on their frequency of referral. We examined various oncologist- and patient-related characteristics associated with outpatient referral.
Of 1,642 decedents, 444 (27%) had an outpatient palliative care referral. The median proportion of referral among 26 thoracic oncologists was 30% (range 9%–45%; median proportion of high-referring 37% vs. low-referring 24% when divided into two groups at median). High-referring oncologists were significantly younger (age 45 vs. 56) than low-referring oncologists; they were also significantly more likely to refer patients earlier (median interval between oncology consultation and palliative care consultation 90 days vs. 170 days) and to refer those without metastatic disease (7% vs. 2%). In multivariable mixed-effect logistic regression, younger oncologists (odds ratio [OR] 5 0.97 per year increase, 95% confidence interval [CI]
0.95–0.995), younger patients (OR 5 0.98per yeaI increase, 95% CI 0.97–0.99), and nonmetastatic disease status (OR 5 0.48, 95% CI 0.29–0.78) were significantly associated with outpatient palliative care referral.
CONCLUSION: The pattern of referral to outpatient palliative care varied widely among thoracic oncologists. Younger oncologists were not only referring a higher proportion of patients, but also referring patients earlier in the disease trajectory.
IMPLICATIONS FOR PRACTICE: This retrospective cohort study found that younger thoracic medical oncologists were significantly more likely to refer patients to outpatient palliative care and to do so earlier in the disease trajectory compared with older oncologists, even after adjusting for other known predictors such as patient demographics. The findings highlight the role of education to standardize palliative care access and imply that outpatient palliative care referral is likely to continue to increase with a shifting oncology workforce.
Integrated early palliative care (EPC) improves quality of life and reduces psychological distress in adult patients with cancer and caregivers, but attitudes toward EPC have been poorly studied. We aimed to investigate attitudes toward EPC in a nationwide survey of patients with cancer and caregivers. From July to October 2016, we administered nationwide questionnaires examining attitudes toward EPC in patients with cancer (n = 1001) and their families (n = 1006) from 12 Korean hospitals. When an individual considered EPC unnecessary, the reasons were collected and analyzed. Factors associated with perception of EPC were examined. A majority of patients (84.5%) and caregivers (89.5%) had positive attitudes toward EPC. The most common reasons for deeming EPC unnecessary were that EPC may be an obstacle to cancer treatment (patients: 37%; caregivers: 23%; respectively) or that they were not sure if EPC is beneficial (patients: 21%; caregivers: 24%; respectively). Financial burden as a reason was more evident in caregivers (23%) than in patients (17%). Male gender, age <50, early stage, intensive care unit admission, and not believing that dying people should prepare to practice charity were associated with patients' negative attitudes. In caregivers, opposition to EPC was associated with not thinking death should be feared, not thinking people should be remembered, and lower educational level. Our findings showed that significant numbers of patients with advanced cancer and family caregivers showed positive attitudes toward EPC. However, more than 10% of participants did not consider EPC necessary. Physicians' communication with patients and caregivers and financial support could help overcome the barriers of EPC.