Background: To effectively care for dying patients, nurses need to possess death self-efficacy—the state of having both a range of skills and capabilities to provide care to dying patients and confidence in one’s ability to do so. A paucity of death self-efficacy may lead to burnout.
Objectives: The aims of this study are to clarify oncology nurses’ death self-efficacy and to explore its relationships with attitudes toward death and burnout.
Methods: A cross-sectional study was performed in 7 cancer hospitals across mainland China between June and July 2019. Oncology nurses completed an online survey consisting of the Death Self-efficacy Scale, Death Attitude Profile–Revised Scale, and Maslach Burnout Inventory.
Results: The 755 oncology nurses completing the survey reported low death self-efficacy and high levels of burnout. Those who had more years of clinical experience, had the highest professional rank, talked death quite often, and have received palliative care trainings, doing no shift work, scored higher on death self-efficacy. Death self-efficacy was positively correlated with positive attitudes toward death and negatively correlated with levels of burnout. The multiple regression analysis showed that death self-efficacy and attitudes toward death were independent, significant predictors of oncology nurses’ burnout.
Conclusions: Chinese oncology nurses are not well prepared to care for dying cancer patients and cope with death-related issues.
Much of the scholarly literature sees death as a taboo topic for Chinese. To test this assumption, this study held seven focus groups in the Greater Toronto Area in 2017. It found that the majority of the older Chinese immigrant participants talked about death freely using either the word death or a euphemism. They talked about various issues including medical treatment and end-of-life care, medical assistance in dying, death preparation, and so on. A small number did not talk about death, but it seemed their reluctance was related to anxiety or discomfort or simply reflected a choice of words. The study concludes death as taboo could be a myth, at least for older Chinese immigrants.
Background: Frailty is a natural consequence of the aging process. With the increasing aging population in Mainland China, the quality of life and end-of-life care for frail older people need to be taken into consideration. Advance Care Planning has also been used worldwide in long-term facilities, hospitals and communities to improve the quality of end-of-life care, increase patient and family satisfaction, and reduce healthcare costs and hospital admissions in Western countries. However, it has not been practiced in China.
Research objective: This study aimed to evaluate the effectiveness of a modified Advance Care Planning intervention in certainty of end-of-life care, preferences for end-of-life care, quality of life concerns, and healthcare utilization among frail older people.
Research design: This study used a quasi-experimental design, with a single-blind, control group, pretest and repeated posttest approach.
Participants and research context: A convenience sample of 74 participates met the eligibility criteria in each nursing home. A total of 148 frail older people were recruited in two nursing homes in Zhejiang Province, China.
Ethical considerations: The study received ethical approval from the Clinical Research Ethics Committee, the Faculty of Medicine, and The Chinese University of Hong Kong, CREC Ref. No: 2016.059.
Findings: The results indicated the Advance Care Planning programme was effective at increasing autonomy in decision making on end-of-life care issues, decreasing decision-making conflicts over end-of-life care issues, and increasing their expression about end-of-life care.
Discussion: This study promoted the participants’ autonomy and broke through the inherent custom of avoiding talking about death in China.
Conclusion: The modified Advance Care Planning intervention is effective and recommended to support the frail older people in their end-of-life care decision in Chinese society.
Aim: This study aims to analyze the prognostic value of seven tumor makers and also investigate the response of palliative chemotherapy in advanced NSCLC patients with advanced disease.
Methods: Medical records of 278 advanced NSCLC Chinese patients who received six cycles of palliative chemotherapy were retrospectively reviewed under ethical approval (JSCH2019K-011). Univariate and multivariate Cox regression analyses were performed using SPSS 24 to find the clinical value of these tumor markers and to identify the factors that were associated with progression-free survival (PFS), as well as the response to palliative chemotherapy.
Results: In baseline characteristic, the high levels of CEA, CA-125, CA-199, AFP, NSE, CYFRA21-1, and CA15-3 were detected in 209 (75.18%), 139 (50.0%), 62 (22.30%), 18 (6.47%), 155 (55.75%), 176 (63.30%), and 180 (64.74%) patients, respectively. Univariate analysis revealed that patients with high vs. normal levels of all tumor markers had an increased risk of poor prognosis. In the multivariable Cox regression model, the patient with (high vs. normal) CYFRA21-1 levels (HR = 1.454, P = 0.009) demonstrated an increased poor PFS. However, patients with (high vs. normal) CA19-9 levels (HR = 0.524, P < 0.0001) and NSE levels (HR = 0.584, P < 0.0001) presented a decreased risk of PFS. Also, patients receiving 3-drugs regimen had better PFS compared to those on 2-drugs regimen (P = 0.043).
Conclusions: The high levels of CYFRA21-1 was correlated with a poor prognostic factor of PFS for Advanced NSCLC patients. However, the high levels of CA19-9 and NSE were associated with a better prognostic factor of PFS. Additionally, smoking habits and tumor status had a poor prognostic factor of PFS. Moreover, we found that antiangiogenic therapy has high efficacy with first-line chemotherapy and longer PFS of NSCLC patients.
Context: Patients with end-stage renal disease undergoing dialysis experience multiple concurrent symptoms. These symptoms cluster together and have negative impacts on patient outcomes. However, information on changes in symptom clusters over time is limited.
Objectives: This longitudinal study examined the stability of symptom clusters and their impacts on health-related quality of life and functional status over a period of one year.
Methods: Eligibility criteria were patients diagnosed with end-stage renal disease; had received dialysis consecutively for at least three months; and had given written informed consent. Dialysis Symptom Index, Kidney Disease Quality of Life 36, and Karnofsky Performance Status Scale were used to evaluate the impacts of symptom clusters and outcomes. Exploratory factor analyses and multiple regression analyses were used to determine symptom clusters and their associations with patient outcomes.
Results: Among the 354 recruited patients, 271 completed the 12-month assessment. Four symptom clusters were identified across the three assessments, namely, uremic, gastrointestinal, skin, and emotional. Within each cluster, the specific symptoms were varied. The uremic symptom cluster accounted for the largest amount of variability. Across the three assessments, a higher uremic cluster factor score was associated with poorer physical well-being, whereas a higher emotional cluster factor score was consistently associated with poorer mental well-being.
Conclusion: Symptoms in patients on dialysis clustered in relatively stable patterns. The four symptom clusters identified had consistent negative effects on various aspects of patients' well-being. Our findings suggest the need for ongoing symptom assessment and early recognition of symptoms that may contribute to adverse patient outcomes.
Traditional Chinese art practices such as brush painting and calligraphy are thought to promote self-development through holistically engaging both physical and mental health. This pilot study investigated the beneficial effects of a community-based self-help group incorporating Chinese art practices as a culturally adapted bereavement intervention. Twenty-six Chinese parents aged over 49 years and who had lost their only child participated in a 20-session Chinese brush painting group over a 6-month period. Ten bereaved parents from the same community who did not participate in the art course but received living support were recruited as a control group. Compared with the control group, the art practice group exhibited a pre-post intervention effect in terms of promoting positive affect and preventing deterioration of prolonged grief symptoms, particularly through the improvement of accessory grief symptoms (e.g., "emotional numbness due to the loss", and "feeling that life is unfulfilling, empty or meaningless after the loss"). No effect was found on negative affect. These findings indicate that a culturally adapted community-based art group may be an effective means of improving grief-related health.
Background: Nurses feature prominently in promoting advance care planning (ACP), but only a limited amount of relevant research has been conducted from the nurses' viewpoint, and little is known about the nurses' knowledge of and their willingness to promote ACP in China.
Aims: The aims of this study were to investigate oncology nurses' knowledge of and their willingness to promote ACP, and to explore associated factors.
Methods: A multi-centre study was conducted to investigate 350 nurses in the oncology departments of four university hospitals in southwestern China. Cluster sampling was used in data collection, which involved three categories of questionnaires concerning demographic characteristics, knowledge about ACP and willingness to promote ACP. Chi-squared tests and multiple linear regression were employed in data analysis.
Results: Some 293 valid questionnaires were collected, among which, 60.1% of respondents never received palliative care education, 89.1% never received training about ACP and 72.7% had not even heard of ACP. Nurses with higher position titles ( 2=18.41, p<0.001) and longer working experience ( 2=12.25, p=0.001) were more likely to have received palliative care education; nurses with higher educational background levels ( 2=12.91, p<0.001), higher position titles ( 2=9.77, p=0.003) and longer working experience ( 2=7.92, p=0.006) were more likely to have learned about ACP; nurses with higher position titles had more access to relevant training ( 2=5.10, p=0.03). Furthermore, whether the nurse had ‘heard about ACP’ (B=3.113, p=0.018) and ‘received training about ACP’ (B=3.894, p=0.04) were both associated with their willingness to promote ACP.
Conclusions: The findings of this study indicated that oncology nurses were highly inclined to promote ACP, but limited by their lack of knowledge and understanding of it. Therefore, a systematic and adequate training programme about ACP for nurses is an urgent requirement to effectively enhance the implementation of ACP in China.
CONTEXT: Many in the rapidly-growing Chinese-American population are non-English-speaking and medically-underserved, and few engage in advance care planning (ACP). Evaluating culturally-determined factors that may inhibit ACP can inform programs designed to increase ACP engagement.
OBJECTIVES: To describe attitudes and beliefs concerning ACP in older, non-English speaking Chinese-Americans in a medically-underserved urban region.
METHODS: Patients were consecutively recruited from a primary care practice in New York City to participate in a cross-sectional survey. Attitudes and beliefs were measured using an ACP Survey tool and the validated Traditional Chinese Death Beliefs measure. Exploratory analyses evaluated associations between these two measures, and between each measure and sociodemographics, primary dialect, acculturation (using The Suinn-Lew Asian Self Identity Acculturation Scale), and health status (using the Short Form-8 Health Survey).
RESULTS: Patients (n=179) were 68.2 years on average; 55.9% were women, and 81.0% were non-English speaking (42.8% Cantonese, 15.2% Mandarin, 19.3% Toisanese, 19.3% Fuzhounese). Most had low acculturation (mean=1.7/5.0), and highly-rated physical and mental health (means=70.1/100 and 81.5/100). Few patients (15.1%) had an advance directive and 56.8% were unfamiliar with any type; 74.4% were willing to complete one in the future. Thirty-two percent "agreed" that "talking about death in the presence of a dying person would accelerate death". The analyses revealed no significant associations.
CONCLUSION: These Chinese-American older adults had low acculturation and very limited knowledge of, or engagement in, ACP. Factors that may predict culturally-determined attitudes and beliefs about ACP were not identified. Further research can inform efforts to improve ACP engagement in this population.
Introduction: Existing literature on attitudes toward end-of-life care (EoLC) covers the general public but has little information on the frail elderly population. The aim of the current study is to investigate the preferences of Chinese frail elderly home residents with respect to EoLC by conducting cross-sectional surveys.
Methods and analysis: Surveys, including resident and family versions, were developed based on the existing literature and our pilot interviews. The targeted participants were 400 frail elderly home residents (aged = 65 years old) and 200 family caregivers. Purposive sampling will be used as each elderly home will help to recruit five to 15 elderly participants for the study. Descriptive analysis and modelling will be used to examine preferences on EoLC and related factors, as well as to compare the responses of elderly home residents with those of their family caregivers.
Ethics and dissemination: The cross-sectional survey has obtained approval from the Institutional Review Board. Confidentiality and safety issues will be carefully observed. The results of the study will be disseminated through international conferences, peer-reviewed academic journal publications, and a report in plain language to be shared with elderly residential homes.
Objective: To investigate the clinical implications of sleep quality, anxiety and depression in patients with advanced lung cancer (LC) and their family caregivers (FCs).
Methods: A total of 98 patients with advanced LC and their FCs (n=98) were recruited from the Oncology Department in Nanfang Hospital. The Pittsburgh Sleep Quality Index (PSQI), consisting of seven components that evaluate subjective sleep quality, sleep latency, duration of sleep, sleep efficiency, sleep disturbances, sleep medication usage and daytime dysfunction, was used to assess sleep quality. Using the tool of Zung Self-rating Anxiety Scale (SAS) and Zung Self-rating Depression Scale (SDS), we tested the patients’ status of anxiety and depression, respectively.
Results: The prevalences of poor sleep quality, anxiety and depression in patients were 56.1%, 48.9% and 56.1%, respectively, while those in FCs were 16.3%, 32.6% and 25.5%, respectively. Patients had higher PSQI, SAS and SDS scores than did FCs (p<0.05). Significant correlations were found between the patients’ and FCs’ scores of PSQI/SAS/SDS (p<0.05). Multivariate Cox regression analyses indicated that sleep disturbances in patients (HR 0.413, 95% CI 0.21 to 0.80, p=0.01) and the global PSQI score of FCs (HR 0.31, 95% CI 0.14 to 0.71, p=0.00) were independent risk factors for patients’ first-line progression-free survival (PFS). Moreover, patients’ sleep latency (HR 2.329, 95% CI 1.36 to 3.96, p=0.00) and epidermal growth factor receptor mutations (HR 1.953, 95% CI 1.12 to 3.38, p=0.01) were significant prognostic factors for their overall survival (OS).
Conclusions: We demonstrated that presence of sleep disturbances in patients with advanced LC and the global PSQI Score of their FCs may be risk predictors for patients’ poor first-line PFS. Patients’ sleep latency was a potential risk factor for their OS.
Background: Understanding the preferences for end-of-life (EOL) care is imperative in providing quality care to patients with life-threatening illness. However, it is difficult for patients, families, and health-care providers to initiate EOL conversations in China. An easy-to-use tool that could help health-care providers initiate EOL discussions is the Heart to Heart Card Game (HHCG), originally designed for Chinese Americans.
Objective: To evaluate the EOL preferences among Chinese patients with cancer using the HHCG.
Methods: We conducted a descriptive study to assess EOL preferences using HHCG among patients at the oncology chemoradiotherapy department of a Chinese tertiary hospital.
Results: We recruited 58 patients in total of which 40 (69%) patients completed HHCG. The most frequently selected card was “I want my family to get along,” followed by “I don’t want to be a burden to my family,” and “I want to maintain my dignity.” Among the 3 cards selected, social needs were rated as the most important (36.7%), followed by spiritual needs (35.8%), physical needs (20.0%), and financial needs (7.5%). The evaluation of the HHCG revealed that more than 70% of the participants highly valued HHCG.
Conclusion: The HHCG can be used as a communication tool to encourage EOL discussions between cancer patients and health-care providers in China. Moreover, Chinese patients with cancer attach significant importance to their family and maintaining dignity at the EOL.
BACKGROUND: Ethnicity may be associated with important aspects of end-of-life care, such as what treatments are received, access to palliative care and where people die. However, most studies have focused on end-of-life care of white, Hispanic and black patients. We sought to compare end-of-life care delivered to people of Chinese and South Asian ethnicity with that delivered to others from the general population, in Ontario, Canada.
METHODS: In this population-based cohort study, we included all people who died in Ontario, Canada, between Apr. 1, 2004, and Mar. 31, 2015. People were identified as having Chinese or South Asian ethnicity on the basis of a validated surname algorithm. We used modified Poisson regression analyses to assess location of death and care received in the last 6 months of life.
RESULTS: We analyzed 967 339 decedents, including 18 959 (2.0%) of Chinese and 11 406 (1.2%) of South Asian ethnicity. Chinese (13.6%) and South Asian (18.5%) decedents were more likely than decedents from the general population (10.1%) to die in the intensive care unit (ICU). The adjusted relative risk of dying in intensive care was 1.21 (95% confidence interval [CI] 1.15 to 1.27) for Chinese and 1.25 (95% CI 1.20 to 1.30) for South Asian decedents. In their last 6 months of life, decedents of Chinese and South Asian ethnicity experienced significantly more ICU admission, hospital admission, mechanical ventilation, dialysis, percutaneous feeding tube placement, tracheostomy and cardiopulmonary resuscitation than the general population.
INTERPRETATION: Decedents of Chinese and South Asian ethnicity in Ontario were more likely than decedents from the general population to receive aggressive care and to die in an ICU. These findings may be due to communication difficulties between patients and clinicians, differences in preferences about end-of-life care or differences in access to palliative care services.
Introduction: Nurses play an important role in caring for dying patients. However, little is known about the attitude towards death of the registered nurses in China.
Materials and Methods: A knowledge, attitude, and the practice (KAP) survey using standardized questionnaires was conducted at eight teaching hospitals in Jiangsu Province, China. In total, 366 nursing interns were recruited and 357 turned in valid response. Data about the interns' demographic characteristics and their attitudes to death in five domains, including fear of death, death avoidance, natural acceptance, approach acceptance, and escape acceptance, were collected.
Results: Compared to the norms, the nursing interns had statistically significantly higher scores in the domains death avoidance, approach acceptance, and fear of death (14.9 vs. 11.1, 26.2 vs. 24.2, and 20.3 vs. 19.0, respectively); however, statistically significantly lower scores were in the domains natural acceptance and escape acceptance (18.4 vs. 22.0, and 13.6 vs. 15.1, respectively). Religious belief, experience of a deceased relative in family, death education, and family atmosphere of discussing death are positively associated with one or more domains of attitude towards death.
Conclusion: The positive attitude towards death and death education before clinical practice are helpful for nursing interns when they care for dying patients. In general, the scores of attitude towards death are at a moderate level in the surveyed Chinese nursing interns. The death education for nursing students needs to be reinforced in China.
With the emergence of organ donation and donation technology, the previous indivisibility of the human body becomes divisible, and different human organs form a new life subject. With reference to specific case studies in China, a new life, consisting of donated organs from different bodies by donation, can be called "donated life." Donated life is a win-win action between altruism and egoism, that is, to save the lives of others and to regenerate the organs of donors or their relatives. Due to the emergence of this kind of life, traditional social ethics theories based on the marriage-related family find it difficult to difficult to explain the new realities. Thus, new thinking about social ethics is necessary.
CONTEXT: Quality of palliative care and death in mainland China is at a low level of the rest of the world, the public is lacked of proper understanding of the relevant information is one of the important reasons. There has been a shift in policy of palliative care in municipalities recently in mainland China.
OBJECTIVES: To measure the advance care planning-related knowledge and attitudes of Chinese community-dwelling older adults, in the hope of presenting a specific implementation of the strategy.
METHODS: We conducted a mixed-method sequential explanatory study, composed of a quantitative survey followed by qualitative interviews. The first quantitative phase included 523 community elderly individuals, who completed a validated questionnaire. After statistical analysis, a semistructured qualitative interview has been developed and conducted with 16 of them in order to help explain findings obtained in the first phase.
RESULTS: The study was conducted with 523 community-dwelling older adults. The cognition level of advance care planning (ACP) was low, and attitude toward ACP was active. Living alone or living with a spouse (and children), have a religion, poor health condition, and life-sustaining treatment-related experience can affect how they behave with ACP. However, lack of trust in ACP, lack of life education and relevant legislation or policies, and Chinese traditional culture and emotion may impede their take-up.
CONCLUSIONS: This study indicated that the awareness and participation of ACP of community-dwelling older adults in mainland China are not enough. The influence of national conditions and culture should be fully considered during the process of ACP development.
This study explored the death narrative in the late Qing dynasty as expressed in Chinese newspapers in the 19th century. Using textual analysis, this study identified three themes regarding death and dying during this period: euphemism of death, definition of “good death,” and Western influence on the death narrative. The study results of death narrative in the 19th century indicate the historical root of perception of death among the current Chinese people, which could help the development of a culturally sensitive hospice services for Chinese people in China and other countries by suggesting language use, patients approaching, and mental health intervention for the service providers and policy makers.
OBJECTIVE: The purpose of this study is to understand the attitude of undergraduate nursing students toward advanced care planning (ACP) and their willingness to implement ACP and to analyze its influencing factors, so as to provide evidence-based basis for life and death education and ACP-related training in colleges and universities.
METHODS: A total of 312 nursing undergraduates from a university in Chengdu (China) were surveyed by using general information questionnaire, attitude scale of ACP, and willingness questionnaire to implement ACP.
RESULTS: The scores of undergraduate nursing students' attitude toward ACP were 24.97 ± 2.75, and the scores of total willingness to ACP were 79.26 ± 9.70. Univariate analysis and multivariate linear regression analysis showed that religious belief, grade, family relationship, and family discussion of death were the factors influencing the willingness of nursing students to carry out ACP.
CONCLUSIONS: The attitude of undergraduate nursing students toward ACP tended to be positive, but their cognition of ACP was misunderstood, and their willingness to implement ACP needed to be improved. To improve the awareness and implementating willingness of undergraduate nursing students to ACP, it was recommended that colleges and universities carried out systematic standardized life and death education courses and ACP-related training.
BACKGROUND: Spiritual support should be offered to all patients and their families regardless of their affiliated status with an organized religion.
AIM: To understand nonreligious theistic parents' spirituality and to explore how parents discuss death with their terminally ill children in mainland China.
DESIGN: Qualitative study.
SETTING/PARTICIPANTS: This study was conducted in the hematology oncology center at Beijing Children's Hospital. Participants in this study included 16 bereaved parents.
RESULTS: Participants described themselves as nonreligious but showed a tendency toward a particular religion. Parents sought religious support in the face of the life-threatening conditions that affected their child and regarded the religious belief as an important way to get psychological and spiritual comfort after experiencing the death of their child. Religious support could partially address parents' spiritual needs. Parents' spiritual needs still require other supports such as bereavement services, death education, and family support groups. Some parents stated that it was difficult to find a way to discuss death with their children. For patients who come from nonreligious theistic families, their understanding of death was more complex and may be related to atheism.
CONCLUSION: Religious support could be an element of spiritual support for nonreligious theistic parents of terminally ill children. Multiple strategies including religious supports and nonreligious supports should be rationally integrated into spiritual support of nonreligious theistic family. Patient's personal belief in death should be assessed before discussing death with them.
Purpose: Burnout in nursing is a global phenomenon. Caring for dying patients could increase nurses' death anxiety. However, minimal information about oncology nurses' burnout and attitudes towards death in Chinese culture has been reported. This study aims to assess Chinese oncology nurses’ burnout, and its relationship with attitudes towards death.
Method: A cross-sectional design was used. A total of 279 oncology nurses from a cancer hospital in northern China were recruited using convenience sampling, and completed a survey containing a demographic form, the Death Attitudes Profile Scale and the Maslach Burnout Inventory. Descriptive statistics, independent t-test and one-way ANOVA, Pearson correlation analysis and multiple regression analysis were conducted to analyze data.
Results: An average of 73.1%–86.9% of oncology nurses reported moderate to high levels of burnout. Specifically, 48.7%, 45.4% and 65.1% of oncology nurses reported high levels of emotional exhaustion, depersonalization and personal accomplishment, respectively. Multiple regression analysis showed that fear of death, escape acceptance, younger age and participation of death education/training were significantly associated with emotional exhaustion ( p < 0.01), accounting for 22.0% of the variance; fear of death, escape acceptance, and neutral acceptance in total explained 17.8% of depersonalization; fear of death, escape acceptance and neutral acceptance accounted for 8.5% of personal accomplishment.
Conclusions: Oncology nurses with more positive attitudes towards death experience less burnout. Death education and death related training including discussion of personal attitudes towards death should be part of nursing education programs, which would in turn prevent oncology nurses from burnout.
In order to explore frailty subtypes and find their associated risk factors, we conducted cross-sectional surveys of 5,341 seniors aged 60 and over in China using the Frailty Index (FI) scale. We identified four frailty subtypes, namely multi-frail, cognitive and functionally frail, psychologically frail and physiologically frail. Old age and low education level were the common risk factors among the four subtypes. Being widowed, divorced or unmarried was a risk factor for multi-frail, cognitive and functionally frail and psychologically frail, and male sex was a protective factor against cognitive and functionally frail and psychologically frail subtypes. Having a harmonious relationship with family was a protective factor against multi-frail, and fewer visits to the elderly by their children was a risk factor for psychologically frail. Dissatisfaction with their housing was a risk factor for cognitive and functionally frail, psychologically frail and physiologically frail, and a pension being the main source of income was a risk factor for cognitive and functionally frail and psychologically frail. Exercising every day was a protective factor against multi-frail and cognitive and functionally frail, and a lower level of physical activity was a risk factor for all four frailty subtypes. Our findings confirm the heterogeneity of frailty and suggest that different frail elderly individuals need more targeted care interventions.