Objectives: The National Health Insurance programme started providing coverage for inpatient care in palliative care (PC) units of acute care hospitals in 2000; however, initially, only PC provided to patients with terminal cancer was covered. A PC policy that enabled PC reimbursement for patients with dementia was implemented in 2009. However, the association of this PC policy with end-of-life care remains unclear. The study aims to compare the association of the PC policy with end-of-life care between patients with dementia and patients with cancer during the last 6 months of their lives.
Methods: We analysed the claims data of 7396 patients dying with dementia (PDD) and 24 319 patients dying with cancer (PDC) during 1997–2013.
Results: Among PDC, while the percentage of receiving PC increased from 3.6% in 1999 to 14.2% by the end of 2000 (adjusted OR (aOR)=4.07, 95% CI 2.70 to 6.13) and from 20.9% in 2010 to 41.0% in 2013 (aOR=1.40, 95% CI 1.33 to 1.47), vasopressor use decreased from 71.6% in 1999 to 35.5% in 2001 (aOR=0.90, 95% CI 0.82 to 0.98). Among PDD, PC use increased from 0.2% in 2009 to 4.9% in 2013 (aOR=2.05, 95% CI 1.60 to 2.63) and cardiopulmonary resuscitation use decreased from 17.6% in 2009 to 10.0% in 2013 (aOR=0.83, 95% CI 0.76 to 0.90).
Conclusions: Implementation of the PC policy in Taiwan was associated with improved PC utilisation among patients with cancer and dementia, which may reduce unnecessary medical care procedures.
BACKGROUND/PURPOSE: Do-not-resuscitate (DNR) is a legal order that demonstrates a patient's will to avoid further suffering from advanced treatment at the end of life. The concept of palliative care is increasingly accepted, but the impacts of different major illnesses, geographic regions, and health expenses on DNR rates remain unclear.
METHODS: This study utilized the two-million National Health Insurance (NHI) Research Database to examine the percentage of DNR rates among all deaths in hospitals from 2001 to 2011. DNR in the study was defined as no resuscitation before death in hospitals. Death records were extracted from the database and correlated with healthcare information. Descriptive statistics were compiled to examine the relationships between DNR rates and variables including major illnesses, geographic regions, and NHI spending.
RESULTS: A total of 126,390 death records were extracted from the database for analysis. Among cancer-related deaths, pancreatic cancer patients had the highest DNR rate (86.99%) and esophageal cancer patients had the lowest DNR rate (71.62%). The higher DNR rate among cancer-only patients (79.53%) decreased with concomitant dialysis (66.07%) or ventilator use (57.85%). The lower DNR rates in patients with either chronic dialysis (51.27%) or ventilator use (59.10%) increased when patients experienced these two conditions concomitantly (61.31%). Although DNR rates have consistently increased over time across all regions of Taiwan, a persistent disparity was noted between the East and the South (76.89% vs. 70.78% in 2011, p < 0.01). After adjusting for potential confounders, DNR patients had significantly lower NHI spending one year prior to death ($67,553), compared with non-DNR patients.
CONCLUSION: Our study found that DNR rates varied across cancer types and decreased in cancer patients with concomitant chronic dialysis or ventilator use. Disparities in DNR rates were evident across geographic regions in Taiwan. A wider adoption of the DNR policy may achieve substantial savings in health expenses and improve patients' quality of life.
BACKGROUND: The concept of advance care planning is largely derived from Western countries. However, the decision-making process and drivers for choosing palliative care in non-Western cultures have received little attention.
AIM: To explore the decision-making processes and drivers of receiving palliative care in advance care planning discussions from perspectives of advanced cancer patients, families and healthcare professionals in northern Taiwan.
METHOD: Semi-structured qualitative interviews with advanced cancer patients, their families and healthcare professionals independently from inpatient oncology and hospice units. Thematic analysis with analytical rigour enhanced by dual coding and exploration of divergent views.
RESULTS: Forty-five participants were interviewed (n = 15 from each group). Three main decision-making trajectories were identified: (1) 'choose palliative care' was associated with patients' desire to reduce physical suffering from treatments, avoid being a burden to families and society, reduce futile treatments and donate organs to help others; (2) 'decline palliative care' was associated with patients weighing up perceived benefits to others as more important than benefits for themselves; and (3) 'no opportunity to choose palliative care' was associated with lack of opportunities to discuss potential benefits of palliative care, lack of staff skill in end-of-life communication, and cultural factors, notably filial piety.
CONCLUSION: Choice for palliative care among advanced cancer patients in Taiwan is influenced by three decision-making trajectories. Opinions from families are highly influential, and patients often lack information on palliative care options. Strategies to facilitate decision-making require staff confidence in end-of-life discussions, working with the patients and their family while respecting the influence of filial piety.
BACKGROUND: We previously developed a robust prognostic model (GS model) to predict the survival outcome of patients with advanced pancreatic cancer (APC) receiving palliative chemotherapy with gemcitabine plus S-1 (GS). This study aimed to validate the application of the GS model in APC patients receiving chemotherapy other than the GS regimen.
PATIENTS AND METHODS: We retrospectively analyzed 727 APC patients who received first-line palliative chemotherapy other than the GS regimen between 2010 and 2016 at four institutions in Taiwan. The patients were categorized into three prognostic groups based on the GS model for comparisons of survival outcome, best tumor response, and in-group survival differences with monotherapy or combination therapy.
RESULTS: The median survival times for the good, intermediate, and poor prognostic groups were 13.4, 8.4, and 4.6 months, respectively. The hazard ratios for the comparisons of intermediate and poor to good prognostic groups were 1.51 (95% confidence interval [CI]), 1.22-1.88, P < .001) and 2.84 (95% CI, 2.34-3.45, P < .001). The best tumor responses with either partial response or stable disease were 57.5%, 40.4%, and 17.2% of patients in the good, intermediate, and poor prognostic groups (P < .001), respectively. For patients in the good prognostic group, first-line chemotherapy with monotherapy and combination therapy had similar median survival times (13.8 vs 12.9 months, P = .26), while combination therapy showed a better median survival time than monotherapy in patients in the intermediate and poor prognostic groups (8.5 vs 8.0 months, P = .038 and 5.7 vs 3.7 months, P = .001, respectively).
CONCLUSION: The results of our study supported the application of the GS model as a general prognostic tool for patients with pancreatic cancer receiving first-line palliative chemotherapy with gemcitabine-based regimens.
CONTEXT: Nearly 70% of do-not-resuscitate (DNR) directives for chronic obstructive pulmonary disease (COPD) patients are established during their terminal hospitalization. Whether patient use of end-of-life resources differs between early and late establishment of a DNR is unknown.
OBJECTIVES: To compare end-of-life resource use between patients according to DNR directive status: no DNR, early DNR (EDNR) (established before terminal hospitalization), and late DNR (LDNR) (established during terminal hospitalization).
METHODS: Electronic health records from all COPD decedents in a teaching hospital in Taiwan were analyzed retrospectively with respect to medical resource use during the last year of life and medical expenditures during the last hospitalization. Multivariate linear regression analysis was used to determine independent predictors of cost.
RESULTS: Of the 361 COPD patients enrolled, 318 (88.1%) died with a DNR directive, 31.4% of which were EDNR. COPD decedents with EDNR were less likely to be admitted to intensive care units (12.0 %, 55.5%, and 60.5% for EDNR, LDNR, and no DNR, respectively), had lower total medical expenditures, and were less likely to undergo invasive mechanical ventilator support during their terminal hospitalization. The average total medical cost during the last hospitalization was nearly 2-fold greater for LDNR than for EDNR decedents. Multivariate linear regression analysis revealed that nearly 60% of medical expenses incurred were significantly attributable to no EDNR, younger age, longer length of hospital stay, and more comorbidities.
CONCLUSION: Although 88% of COPD decedents died with a DNR directive, 70% of these directives were established late. LDNR results in lower quality of care and greater intensive care resource use in end-of-life COPD patients.
BACKGROUND: Charitable donations play a major role in the provision of hospice and palliative care (HPC) services, most of which are not reimbursed by health insurance programs. A good understanding of the constitution and use of donations is thus conducive to maintaining a high-quality HPC unit.
METHODS: The data sources were the publicly available balance sheet, work report, and donor lists of a foundation exclusively supporting one of the best HPC units in Taiwan in the fiscal year of 2017. The analysis included the donation amounts and frequencies by donor type (individual, corporate, and group) and the categories of expenses.
RESULTS: The foundation received 3033 donations worth a total of 7.8 million New Taiwan dollars (NTD) (approximately 258 thousand US dollars) in 2017. Two-thirds of the donations were allocated to the provision of direct care services. Of the 3033 donations, only 11 (0.4%) were worth 100 000 NTD or more, while 108 (3.6%) were valued between 10 000 and 99 999 NTD, 1268 (41.8%) were valued between 1000 and 9999 NTD, and 1646 (54.2%) were worth less than 1000 NTD. Of 1051 donors, 974 (92.7%) were individuals, 378 (36.0%) donated more than once, and 106 (10.1%) donated 12 or more times in one year.
CONCLUSION: HPC services in Taiwan are sponsored by lots of individuals and small donations. For sustainability of standards-based and quality HPC services, the benevolence of the public should be thus cherished and adequately responded to.
Background: The work continuity of physicians in hospice and palliative medicine (HPM) has a great impact on the quality of care and practice experiences. However, nationwide studies providing a general overview of the work continuity of HPM physicians are scarce.
Methods: Data relating to inpatient HPM care provided from July 2000 to December 2013 were obtained from the National Health Insurance Research Database of Taiwan. Specifically, the numbers of hospitals, patients, patient hospitalization days, and physicians involving HPM in each year were calculated. The years of HPM work experience and total HPM workdays of each physician were also computed.
Results: Of the 40,965,153 inpatient records during the study, 121,258 (0.3%) records were related to inpatient HPM care, with 60 participating hospitals and 604 attending physicians. The annual number of HPM physicians increased with time from 77 in 2000 to 217 in 2013. The largest percentage (38.4%) of physicians practiced HPM for only one year, while only 23 (3.8%) physicians practiced HPM in each year without interruption. Of the 217 HPM physicians in 2013, 45 (20.7%) were newcomers, 78 (36.0%) had 1-4 years of prior HPM work experience, 54 (24.9%) had 5-9 years, and 40 (18.4%) had at least 10 years. Conclusions: Among HPM physicians in Taiwan, only a small percentage exhibited long-term dedication to the field, whereas most HPM physicians had short practice periods. More strategies are needed to improve work continuity among HPM physicians.
Background: Palliative care has improved the quality of end-of-life (EOL) care and lowered the health care cost of cancer, and these benefits should be extended to patients with other serious illnesses including end-stage kidney disease. We evaluated the quality of EOL care, survival probabilities, and health care costs for dialysis patients in their last month of life.
Methods: We conducted a population-based study and analyzed data from Taiwan’s Longitudinal Health Insurance Database, which contains claims information of patient medical records, health care costs, and insurance system exit dates (our proxy for death between 2006 and 2011).
Results: Data of 1177 adult patients who died of chronic hemodialysis or peritoneal dialysis were investigated. The mean age of these patients was 69.7 ± 11.9 years, and 585 (49.7%) were women. Some patients with dialysis received cardiopulmonary resuscitation (66.9%), died in a hospital (65.0%), or were admitted to an intensive care unit (51.0%) in the last month of life. We further classified these patients into two groups, namely dialysis with cancer (DC) (n = 149) and dialysis without cancer (D) (n = 1028). Only 19 dialysis patients received palliative care, and the proportion of patients receiving palliative care was higher in the DC group than in the D group (11.4% vs. 0.2%). The mean health care costs per person during the final month of life was similar between the DC and D groups (USD 2755 ± 259 vs. USD 2827 ± 88). Multivariate logistic regression showed that the DC group had lower odds of receiving cardiopulmonary resuscitation (CPR) (OR: 0.39, CI = 0.26–0.56, p < 0.001) procedures, higher odds of longer hospital stays than the third quartile (> 25 days) (OR: 1.52, CI = 1.01–2.29, p = 0.0046), and higher odds of being hospitalized more than once (OR: 2.26, CI = 1.42–3.59, p = 0.001) than the D group in the last month of life after adjustments.
Conclusions: DC patients received hospice care more frequently, received CPR less frequently, and had similar health care costs. DC patients also had a higher risk of a hospital stay that lasted more than 25 days and more than one hospitalization compared with D patients in the final month of life.
CONTEXT: Evidence is mixed regarding the impact of advance directives (ADs) on the utilization of end-of-life treatments.
OBJECTIVES: This study evaluated the effect of AD on the utilization of end-of-life treatments during the last month of life in older patients.
METHODS: Taipei City Hospital initiated an advance care planning program to promote AD for admitted patients in 2015. This prospective study recruited deceased older patients who completed advance care planning communication between 2015 and 2016. Multiple logistic regression was used to determine the association of AD completion with utilization of life-sustaining treatments.
RESULTS: Of 1307 deceased older patients, overall mean age was 84.1 years and 78.7% of the subjects had AD completion. During the study follow-up period, 31 older patients received life-sustaining treatments during the last month of life, including 17 patients (1.7%) with AD completion and 14 patients (5.0%) without AD completion. After adjusting for the sociodemographic factors and co-morbidities, older patients with AD completion were less likely to receive life-sustaining treatments during the last month of life (adjusted odds ratio [AOR] = 0.32, 95% confidence interval [CI]: 0.16-0.67). Considering type of life-sustaining treatments, AD completion was associated with a lower likelihood of receiving cardiopulmonary resuscitation (AOR = 0.21, 95% CI: 0.06-0.70) as well as intubation and mechanical ventilation support (AOR = 0.32, 95% CI: 0.14-0.70) during the last month of life in older patients.
CONCLUSION: AD completion was associated with a lower likelihood of receiving life-sustaining treatments during the last month of life in older patients. These findings support the continued use of AD in older population.
Objective: The aim of this study was to determine whether do-not-resuscitate (DNR) orders affect outcomes in patients with sepsis admitted to intensive care unit (ICU).
Design: This is a retrospective observational study.
Participants: We enrolled 796 consecutive adult intensive care patients at Kaohsiung Chang Gung Memorial Hospital, a 2700-bed tertiary teaching hospital in southern Taiwan. A total of 717 patients were included.
Main measures: Clinical factors such as age, gender and other clinical factors possibly related to DNR orders and hospital mortality were recorded.
Key results: There were 455 patients in the group without DNR orders and 262 patients in the group with DNR orders. Within the DNR group, patients were further grouped into early (orders signed on intensive care day 1, n=126) and late (signed after day 1, n=136). Patients in the DNR group were older and more likely to have malignancy than the group without DNR orders. Mortality at days 7, 14 and 28, as well as intensive care and hospital mortality, were all worse in these patients even after propensity-score matching. There were higher Charlson Comorbidity Index in the emergency room, but better outcomes in those with early-DNR orders compared with late-DNR orders.
Conclusion: DNR orders may predict worse outcomes for patients with sepsis admitted to medical ICUs. The survival rate in the early-DNR order group was not inferior to the late-DNR order group.
BACKGROUND: Factors facilitating/hindering concordance between preferred and received life-sustaining treatments may be distorted if preferences and predictors are measured long before death.
AIM: To examine factors facilitating/hindering concordance between cancer patients' preferred and received life-sustaining-treatment states in their last 6 months.
DESIGN: Longitudinal, observational design.
SETTING/PARTICIPANTS: States of preferred and received life-sustaining treatments (cardio-pulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, and nasogastric tube feeding) were examined in 218 Taiwanese cancer patients by a latent transition model with hidden Markov modeling. Multivariate logistic regression modeling was used to examine factors facilitating/hindering concordance between preferred and received life-sustaining-treatment states.
RESULTS: Concordance between preferred and received life-sustaining-treatment states was poor (40.8%, kappa value (95% confidence interval): 0.05 [-0.03, 0.14]). Patients who accurately understood their prognosis and preferred comfort care were significantly more likely to receive preferred life-sustaining treatments before death than those who did not know their prognosis but wanted to know, those who were uniformly uncertain about what life-sustaining treatments they preferred to receive, and those who preferred nutritional support but declined other life-sustaining treatments. Patient age, physician-patient end-of-life-care discussions, symptom distress, and functional dependence were not associated with concordance between preferred and received life-sustaining-treatment states.
CONCLUSION: Prognostic awareness and preferred states of life-sustaining treatments were significantly associated with concordance between preferred and received life-sustaining-treatment states. Personalized interventions should be developed to cultivate terminally ill cancer patients' accurate prognostic awareness, allowing them to formulate realistic life-sustaining-treatment preferences and facilitating their receiving value-concordant end-of-life care.
BACKGROUND: Communication skills may be an important skill for the front-line emergency physicians.
AIM: This study aimed to investigate the effect of training in a SHARE communication course by emergency physicians on patient notification and signing of do-not-resuscitate (DNR) orders for critical patients in the emergency room.
DESIGN: From a total of 29 attending physicians in the emergency department, 19 physicians had been trained in the SHARE communication course. An observation form designed based on the SHARE training was completed by two observers who noted the communication process between physicians and patients and family members during patient notification and signing a DNR order. To assess the influence of physicians trained in a SHARE communication course on the signing of DNR orders, a propensity score-matched population was created to reduce the potential selection bias of patients and family members.
SETTING: Level 1 trauma medical center in southern Taiwan.
RESULTS: There were 145 individuals enrolled in the study, of which 93 signed the DNR order, and 52 did not sign it. Analysis from 23 matched pairs from this population revealed that significantly more family members would sign a DNR order if the physician had been trained in the SHARE communication course than when they did not receive this training (78.3% vs. 39.1%, respectively, p=0.017). The overall score of the observation form for physicians was higher in those individuals who had signed a DNR order than in those who did not sign it (29.48±3.72 vs. 26.13±3.52, respectively, p=0.003), especially when the physician had chosen a quiet environment (1.35±0.65 vs. 0.87±0.69, respectively, p=0.020), understood the patient's wishes and confirmed them (1.78±0.42 vs. 1.30±0.70, respectively, p=0.008), and expressed concern (1.48±0.79 vs. 0.96±0.77, respectively, p=0.028). In addition, a feedback survey about the feelings experienced by these physicians during the process of patient notification did not reveal a significant difference during the communication with those who had or had not signed DNR orders.
CONCLUSION: The training in a SHARE communication course can improve the communication skills of emergency physicians in patient notification and signing of DNR orders for critical patients.
This study investigated (a) whether significant health changes occur before imminent widowhood and (b) the effects of widowhood on the physical and psychological health of men and women = 50 years old. Generalized estimating equations were used to examine a matched-pair sample of the Taiwanese Elderly. We found that for men, the major effect of widowhood was on psychological health, but that for women, the major effect was on physical health. Psychological health was significantly worse for widowed than for non-widowed women, but not for men. The difference in psychological health between widowed and non-widowed women, however, changed before widowhood.
The study was to describe the essence of the lived experience of parents with a child with incurable cancer at the end of life (EOL). A descriptive phenomenological study was conducted with ten parents of children with incurable cancer in a medical centre in Taiwan. Data were collected from in-depth interviews and were analysed according to the method of Giorgi. Two major themes emerged: (a) immersion in the struggling and suffering, which included conflicts and arguments, witnessing their child suffering, denying their child being at EOL and waiting for a miracle; and (b) acceptance of death, which included an end to suffering, living in the moment, discussion of death and letting go. Parents had difficulty adapting to a palliative care perspective due to their misconception that this meant giving up on their child. In addition, religion and belief played varied and important roles in the lived experience of these parents with a child with incurable cancer. Healthcare providers must address the core value of palliative care and help parents accept the reality of their child's situation at an earlier stage in order to provide a better quality of life for the child.
Objective To investigate symptom-relief and comorbid drug uses at the end of life for older people with different dying trajectories (cancer, organ failure, frailty and sudden death) in Taiwan.
Methods In a retrospective observational study of older people aged 65 years and older who died in hospitals between 2008 and 2012, we used NHIRD to measure numbers, incremental changes and determinants of symptom-relief and comorbid drug use in the last month of outpatient care and last hospitalisation before death.
Results We included 59 407 older adults (cancer 37%, organ failure 26%, frailty 35% and sudden death 2%) who died in hospitals for this study. In the last hospitalisation before death, individuals who died of cancer received greatest number of symptom-relief drugs (mean: 4.65, [SD 2.77]) and increased most the average change in the number of symptom-relief drug use (+1.60; SD 3.36). However, individuals who died of organ failure received the highest number of comorbid drugs (mean 2.88, [SD 1.95]) and also increased most the average change in the number of comorbid drug use (+0.17; SD 2.28) at last hospitalisation. Different dying trajectories were key determinants of receiving symptom-relief and comorbid drugs in our study.
Conclusions Our study suggests that the drug use of older adults at the end of life in the cancer group is different from that in the organ failure and frailty groups. Policymakers and health professionals should consider the different strategies to optimise drug use for older people with different dying trajectories near their end of life.
BACKGROUND: This study was conducted to examine whether a longitudinal advance care planning (ACP) intervention facilitates concordance between the preferred and received life-sustaining treatments (LSTs) of terminally ill patients with cancer and improves quality of life (QoL), anxiety symptoms, and depressive symptoms during the dying process.
PATIENTS AND METHODS: Of 795 terminally ill patients with cancer from a medical center in Taiwan, 460 were recruited and randomly assigned 1:1 to the experimental and control arms. The experimental arm received an interactive ACP intervention tailored to participants' readiness to engage in this process. The control arm received symptom management education. Group allocation was concealed, data collectors were blinded, and treatment fidelity was monitored. Outcome measures included 6 preferred and received LSTs, QoL, anxiety symptoms, and depressive symptoms. Intervention effectiveness was evaluated by intention-to-treat analysis.
RESULTS: Participants providing data had died through December 2017. The 2 study arms did not differ significantly in concordance between the 6 preferred and received LSTs examined (odds ratios, 0.966 [95% CI, 0.653-1.428] and 1.107 [95% CI, 0.690-1.775]). Participants who received the ACP intervention had significantly fewer anxiety symptoms (β, -0.583; 95% CI, -0.977 to -0.189; P= .004) and depressive symptoms (ß, -0.533; 95% CI, -1.036 to -0.030; P= .038) compared with those in the control arm, but QoL did not differ.
CONCLUSIONS: Our ACP intervention facilitated participants' psychological adjustment to the end-of-life (EoL) care decision-making process, but neither improved QoL nor facilitated EoL care honoring their wishes. The inability of our intervention to improve concordance may have been due to the family power to override patients' wishes in deeply Confucian doctrine-influenced societies such as Taiwan. Nevertheless, our findings reassure healthcare professionals that such an ACP intervention does not harm but improves the psychological well-being of terminally ill patients with cancer, thereby encouraging physicians to discuss EoL care preferences with patients and involve family caregivers in EoL care decision-making to eventually lead to patient value-concordant EoL cancer care.
CONTEXT: Postloss depressive-symptom trajectories are heterogeneous and predicted by preloss psychosocial resources, but this evidence was from one old study on terminal cancer patients' caregivers for whom these issues are highly relevant.
OBJECTIVES: To identify depressive-symptom trajectories among cancer patients' bereaved caregivers and examine if they are predicted by preloss psychosocial resources while considering caregiving burden.
METHODS: Preloss psychosocial resources (sense of coherence [SOC] and social support) were measured among 282 caregivers. Depressive symptoms were measured by the Center for Epidemiological Studies-Depression [CES-D] scale 1, 3, 6, 13, 18, and 24 months postloss (CES-D scores >16 indicate severe depressive symptoms). Distinct depressive-symptom trajectories and their predictors were identified by latent-class growth analysis.
RESULTS: We identified five depressive-symptom trajectories (prevalence): endurance (47.2%), resilience (16.7%), transient-reaction (20.2%), prolonged symptomatic (11.7%), and chronically distressed (4.2%). Over 2 years postloss, the endurance group never experienced severe depressive symptoms. Severe depressive symptoms lasted 6, 7-12, and 18 months for the resilience, transient-reaction, and prolonged-symptomatic groups, respectively. The chronically distressed group's severe depressive symptoms persisted. The endurance and chronically distressed groups had the best and weakest psychological resources, respectively. Endurance-group caregivers perceived the greatest social support, whereas the resilience and transient-reaction groups had higher social support than the prolonged-symptomatic group.
CONCLUSIONS: Most (84.1%) caregivers' depressive symptoms subsided within 1-year postloss. Preloss psychosocial resources predicted depressive-symptom trajectories for bereaved caregivers. Healthcare professionals can help caregivers adjust their bereavement by providing support to enhance their SOC and encouraging social contacts while they are providing end-of-life care.
PURPOSE: To examine the effectiveness of an advance care planning (ACP) intervention in facilitating concordance between cancer patients' preferred and received life-sustaining treatment (LST) states and to explore modifiable factors facilitating or impeding such concordance.
METHODS: Terminal cancer patients (N=460) were randomly assigned 1:1 to the experimental and control arms of a randomized clinical trial, with 430 deceased participants comprising the final sample. States of preferred LSTs (cardiopulmonary resuscitation, intensive care unit care, chest compression, intubation with mechanical ventilation, intravenous nutrition, and nasogastric tube feeding) and LSTs received in the last month were examined by hidden Markov modeling. Concordance and its modifiable predictors were evaluated by kappa and multivariate logistic regression, respectively.
RESULTS: We identified three LST-preference states (uniformly preferring LSTs, rejecting LSTs except intravenous nutrition support, and mixed LST preferences) and three received LST states (uniformly receiving LSTs, received intravenous nutrition only, and selectively receiving LSTs). Concordance was not significantly higher in the experimental than the control arm (kappa [95% CI]:0.126 [0.032, 0.221] vs. 0.050 [-0.028, 0.128]; arm difference: odds ratio [95% CI]: 1.008 [0.675, 1.5001]). Preferred-received LST-state concordance was facilitated by accurate prognostic awareness, better quality of life, and more depressive symptoms, whereas concordance was impeded by more anxiety symptoms.
CONCLUSIONS: Our ACP intervention did not facilitate concordance between terminally ill cancer patients' preferred and received LST states, but patient value-concordant end-of-life care may be facilitated by interventions to cultivate accurate prognostic awareness, improve quality of life, support depressive patients, and clarify anxious patients' over-expectations of LST efficacy.
OBJECTIVE: To compare perceptions of various aspects of palliative care for doctors and nurses; and examine factors contributing to perceived quality palliative care in intensive care units (ICUs).
DESIGN: A cross-sectional survey study conducted from November to December 2013. Questionnaires used were Knowledge, Attitudinal and Experiential Survey on Advance Directives (ADs), Clarke's Quality of Palliative Care and Nurses' Participation in the end-of-life (EOL) decision-making process.
SETTING: Seven adult medical and surgical ICUs at a medical center in Northern Taiwan.
PARTICIPANTS: In total, 172 doctors and nurses who worked in adult ICU for more than 3 months.
MAIN OUTCOME MEASURES: Nurses' and doctors' perception of quality palliative care.
RESULTS: Nurses provided better care than doctors in symptom management, comfort care and spiritual care; their participation in EOL decision-making was the sole modifiable contributor to perceived quality palliative care in ICUs (ß = 0.24, P < 0.01). Both doctors and nurses had positive attitudes towards ADs (mean = 4.05/10; standard deviation [SD] = 1.38) while their knowledge of ADs was poor (mean = 29.72/40; SD = 3.00). More than half of nurses currently participated in EOL decision-making and over 80% of doctors and nurses agreed both parties should engage in EOL decision-making process. Majority of doctors (83.9%) reckoned nurses agreed with their EOL decisions while a significant percentage (40%) of nurses were uncertain about doctors’ decisions ( 2 = 12.07, P < 0.01).
CONCLUSIONS: Nurses' participation in EOL decision-making and strengthening spiritual care are imperative to rendering quality palliative care in ICUs. Potential disagreements arose during EOL decision-making between doctors and nurses; and insufficient knowledge of ADs should be addressed.
BACKGROUND: We attempted to identify factors associated with physicians' decisions to terminate CPR and to explore the role of family in the decision-making process.
METHODS: We conducted a retrospective observational study in a single center in Taiwan. Patients who experienced in-hospital cardiac arrest (IHCA) between 2006 and 2014 were screened for study inclusion. Multivariate survival analysis was conducted to identify independent variables associated with IHCA outcomes using the Cox proportional hazards model.
RESULTS: A total of 1525 patients were included in the study. Family was present at the beginning of CPR during 722 (47.3%) resuscitation events. The median CPR duration was significantly shorter for patients with family present at the beginning of CPR than for those without family present (23.5 mins vs 30 min, p = 0.01). Some factors were associated with shorter time to termination of CPR, including arrest in an intensive care unit, Charlson comorbidity index score greater than 2, age older than 79 years, baseline evidence of motor, cognitive, or functional deficits, and vasopressors in place at time of arrest. After adjusting for confounding effects, family presence was associated with shorter time to termination of CPR (hazard ratio, 1.25; 95% confidence interval, 1.06-1.46; p = 0.008).
CONCLUSION: Clinicians' decisions concerning when to terminate CPR seemed to be based on outcome prognosticators. Family presence at the beginning of CPR was associated with shorter duration of CPR. Effective communication, along with outcome prediction tools, may avoid prolonged CPR efforts in an East Asian society.