Family experience with difficult decisions in end-of-life care

Role of patients' family members in end-of-life communication: an integrative review

OBJECTIVES

To synthesise empirical findings on the role of family in end-of-life (EOL) communication and to identify the communicative practices that are essential for EOL decision-making in family-oriented cultures.

SETTING

The EOL communication settings.

PARTICIPANTS

This integrative review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline. Relevant studies published between 1 January 1991 and 31 December 2021 were retrieved from four databases, including the PsycINFO, Embase, MEDLINE and Ovid nursing databases, using keywords with meanings of 'end-of-life', 'communication' and 'family'. Data were then extracted and coded into themes for analysis. The search strategy yielded 53 eligible studies; all 53 included studies underwent quality assessment. Quantitative studies were evaluated using the Quality Assessment Tool, and Joanna Briggs Institute Critical Appraisal Checklist was used for qualitative research.

PRIMARY AND SECONDARY OUTCOME MEASURES

Research evidence on EOL communication with a focus on family.

RESULTS

Four themes emerged from these studies: (1) conflicts in family decision-making in EOL communication, (2) the significance of timing of EOL communication, (3) difficulty in identification of a 'key person' who is responsible for decisions regarding EOL care and (4) different cultural perspectives on EOL communication.

CONCLUSIONS

The current review pointed towards the importance of family in EOL communication and illustrated that family participation likely leads to improved quality of life and death in patients. Future research should develop a family-oriented communication framework which is designed for the Chinese and Eastern contexts that targets on managing family expectations during prognosis disclosure and facilitating patients' fulfilment of familial roles while making EOL decision-making. Clinicians should also be aware of the significance of the role of family in EOL care and manage family members' expectations according to cultural contexts.

Aggressiveness of care in the last days of life in the emergency department of a tertiary hospital in Korea

Background

High-quality end-of-life (EOL) care requires both comfort care and the maintenance of dignity. However, delivering EOL in the emergency department (ED) is often challenging. Therefore, we aimed to investigate characteristics of EOL care for dying patients in the ED.

Methods

We conducted a retrospective cohort study of patients who died of disease in the ED at a tertiary hospital in Korea between January 2018 and December 2020. We examined medical care within the last 24 h of life and advance care planning (ACP) status.

Results

Of all 222 disease-related mortalities, 140 (63.1%) were men, while 141 (63.5%) had cancer. The median age was 74 years. As for critical care, 61 (27.5%) patients received cardiopulmonary resuscitation, while 80 (36.0%) received mechanical ventilation. The absence of serious illness (p = 0.011) and the lack of an advance statement (p < 0.001) were both independently associated with the receipt of more critical care. Only 70 (31.5%) patients received comfort care through opioids. Younger patients (< 75 years) (p = 0.002) and those who completed life-sustaining treatment legal forms (p = 0.001) received more comfort care. While EOL discussions were initiated in 150 (67.6%) cases, the palliative care team was involved only in 29 (13.1%).

Conclusions

Patients in the ED underwent more aggressive care and less comfort care in a state of imminent death. To ensure better EOL care, physicians should minimize redundant evaluations and promptly introduce ACP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00988-3.

Concerns and potential improvements in end-of-life care from the perspectives of older patients and informal caregivers: a scoping review

Background

Overtreatment in advanced age i.e. aggressive interventions that do not improve survival and are potentially harmful, can impair quality of care near the end of life (EOL). As healthcare provider perspectives on care quality may differ from that of service users, the aim of this study was to explore the views of older patients near EOL or their caregivers about the quality of health care at the EOL based on their lived experience, and to identify healthcare service improvements.

Methods

Medline and backward citation searches were conducted for qualitative or quantitative studies reported on the views of patients and/or informal caregivers about EOL care quality. Thematic analysis was used to summarise qualitative data (primary analysis); narrative and tabulations were used to summarise quantitative data (secondary analysis).

Results

Thirty articles met the inclusion criteria. Five main qualitative themes regarding quality care emerged: (1) Effective communication between clinicians and patients/caregivers; (2) Healthcare that values patient preferences and shared decision making; (3) Models of care that support quality of life and death with dignity; (4) Healthcare services that meet patient expectations; and (5) Support for informal caregivers in dealing with EOL challenges. The quantitative articles supported various aspects of the thematic framework.

Conclusion

The findings of this study show that many of the issues highlighted by patients or bereaved relatives have persisted over the past two decades. There is an urgent need for comprehensive evaluation of care across the healthcare system and targeted redesign of existing EOL care pathways to ensure that care aligns with what patients and informal caregivers consider high-quality patient-centred care at the EOL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02680-2.

Caregiver experience with decision-making difficulties in end-of-life care for patients with cardiovascular diseases

BACKGROUND

The decisional burden on caregivers in the end-of-life (EOL) care for patients with cardiovascular diseases (CVD) is unknown. We aimed to evaluate the frequency and circumstances of caregiver difficulties in decision-making during EOL care for CVD patients, its determinants, and associations with psychological distress in the bereaved caregivers.

METHODS

We conducted a cross-sectional survey using a questionnaire for bereaved caregivers of CVD patients who had died in 10 tertiary care centers. We assessed their overall and situation-specific decision-making difficulties during EOL care. The questionnaire also covered the attitudes of patients, caregivers, and attending physicians during EOL care and the respondents' depression (Patient Health Questionnaire-9) and grief status (Brief Grief Questionnaire).

RESULTS

We enrolled 266 bereaved caregivers [median age, 65 (57-72) years; 38.4% male] of CVD patients. Overall, 28.9% of them experienced difficulties in decision-making. The most difficult decision-making situations involved informing the patient of the prognosis (18.2%), life-prolonging treatment (17.9%), and discontinuation of hydration and artificial nutrition (15.6%). Difficulties were associated with patient and/or caregiver factors (poor understanding of disease status and the patient's wishes, caregiver's emotional inability), physician factors (poor understanding of the patient's and/or caregiver's values, inadequate support for decision-making), and both (insufficient communication, conflict of opinions and wishes). Decision-making difficulties were associated with subsequent depression (20.5% vs. 10.3%, p=0.029) and complicated grief (27.0% vs. 9.0%, p<0.001) among bereaved caregivers.

CONCLUSIONS

Approximately 30% of bereaved caregivers experienced decisional burdens during EOL care of CVD patients. The caregiver's decisional burdens were associated with subsequent psychological distress.

To hydrate or not to hydrate? The effect of hydration on survival, symptoms and quality of dying among terminally ill cancer patients

Background

Artificial nutrition and hydration do not prolong survival or improve clinical symptoms of terminally ill cancer patients. Nonetheless, little is known about the effect of artificial hydration (AH) alone on patients’ survival, symptoms or quality of dying. This study explored the relationship between AH and survival, symptoms and quality of dying among terminally ill cancer patients.

Methods

A pilot prospective, observational study was conducted in the palliative care units of three tertiary hospitals in Taiwan between October 2016 and December 2017. A total of 100 patients were included and classified into the hydration and non-hydration group using 400 mL of fluid per day as the cut-off point. The quality of dying was measured by the Good Death Scale (GDS). Multivariate analyses using Cox’s proportional hazards model were used to assess the survival status of patients, the Wilcoxon rank-sum test for within-group analyses and the Mann-Whitney U test for between-groups analyses to evaluate changes in symptoms between day 0 and 7 in both groups. Logistic regression analysis was used to assess the predictors of a good death.

Results

There were no differences in survival (p = 0.337) or symptom improvement between the hydration and non-hydration group, however, patients with AH had higher GDS scores.

Conclusions

AH did not prolong survival nor significantly improve dehydration symptoms of terminally ill cancer patients but it may influence the quality of dying. Communication with patients and their families on the effect of AH may help them better prepared for the end-of-life experience.

Forgoing life-sustaining treatment - a comparative analysis of regulations in Japan, Korea, Taiwan, and England

BACKGROUND

Regulations on forgoing life-sustaining treatment (LST) have developed in Asian countries including Japan, Korea and Taiwan. However, other countries are relatively unaware of these due to the language barrier. This article aims to describe and compare the relevant regulatory frameworks, using the (more familiar) situation in England as a point of reference. We undertook literature reviews to ascertain the legal and regulatory positions on forgoing LST in Japan, Korea, Taiwan, and England.

MAIN TEXT

Findings from a literature review are first presented to describe the development of the regulatory frameworks surrounding the option of forgoing LST in each country. Based on the findings from the four countries, we suggest five ethically important points, reflection on which should help to inform the further development of regulatory frameworks concerning end-of-life care in these countries and beyond. There should be reflection on: (1) the definition of - and reasons for defining - the 'terminal stage' and associated criteria for making such judgements; Korea and Taiwan limit forgoing LST to patients in this stage, but there are risks associated with defining this too narrowly or broadly; (2) foregoing LST for patients who are not in this stage, as is allowed in Japan and England, because here too there are areas of controversy, including (in England) whether the law in this area does enough to respect the autonomy of (now) incapacitated patients; (3) whether 'foregoing' LST should encompass withholding and withdrawing treatment; this is also an ethically disputed area, particularly in the Asian countries we examine; (4) the family's role in end-of-life decision-making, particularly as, compared with England, the three Asian countries traditionally place a greater emphasis on families and communities than on individuals; and (5) decision-making with and for those incapacitated patients who lack families, surrogate decision-makers or ADs.

CONCLUSION

Comparison of, and reflection on, the different legal positions that obtain in Japan, Korea, Taiwan, and England should prove informative and we particularly invite reflection on five areas, in the hope the ensuing discussions will help to establish better end-of-life regulatory frameworks in these countries and elsewhere.

Patients' preferences and factors influencing initial advance care planning discussions' timing: A cross-cultural mixed-methods study

BACKGROUND

Although advance care planning discussions are increasingly accepted worldwide, their ideal timing is uncertain and cultural factors may pertain.

AIM

To evaluate timing and factors affecting initiation of advance care planning discussions for adult patients in Japan and Taiwan.

DESIGN

Mixed-methods questionnaire survey to quantitatively determine percentages of patients willing to initiate advance care planning discussions at four stages of illness trajectory ranging from healthy to undeniably ill, and to identify qualitative perceptions underlying preferred timing.

SETTING/PARTICIPANTS

Patients aged 40-75 years visiting outpatient departments at four Japanese and two Taiwanese hospitals were randomly recruited.

RESULTS

Overall (of 700 respondents), 72% (of 365) in Japan and 84% (of 335) in Taiwan (p < 0.001) accepted discussion before illness. In Japan, factors associated with willingness before illness were younger age and rejection of life-sustaining treatments; in Taiwan, older age, stronger social support, and rejection of life-sustaining treatments. Four main categories of attitudes were extracted: the most common welcomed discussion as a wise precaution, responses in this first category outnumbered preference for postponement of discussion until imminent end of life, acceptance of the universal inevitability of death, and preference for discussion at healthcare providers' initiative.

CONCLUSION

The majority of patients are willing to begin discussion before their health is severely compromised; about one out of five patients are unwilling to begin until clearly facing death. To promote advance care planning, healthcare providers must be mindful of patients' preferences and factors associated with acceptance and reluctance to initiate advance care planning.

Humanity behind the intention of primary caregiver to choose withdrawing life-sustaining treatment for terminating patients

OBJECTIVE

Mechanical ventilation, a measure of life-sustaining treatment (LST), may not be helpful and can be devastating for patients with terminal illness. We explored the effects of demographic characteristics, attitude, subjective norms, and perceived behavioral control on the behavioral intentions of primary caregivers to withdraw LST of long-term ventilator-dependent patients.

METHODS

Primary caregivers of ventilator-dependent patients in the respiratory care units of six hospitals participated in the study. A cross-sectional design including the domains of attitude, subjective norms, perceived behavioral control, and behavioral intention was adopted.

RESULTS

Valid data for 99 participants were analyzed using logistic regression. Religious belief, a spousal relationship with the patient, item 5 in subjective norms, and item 5 in perceived behavioral control positively influenced the intention to withdraw patient LST.

CONCLUSIONS

Religious beliefs, a spousal relationship, perceived behavioral control (confidence in relieving patient suffering), and the opportunity of current favorable subjective norms are major determinants of the intention to withdraw patients' LST.

PRACTICE IMPLICATIONS

Shared decision-making with the kin and primary caregivers of long-term ventilator-dependent patients at the end of life is crucial.

Differences between COPD patients and their families regarding willingness toward life-sustaining treatments

BACKGROUND/PURPOSE

Patients with chronic obstructive pulmonary disease (COPD) receive more life-sustaining treatments (LSTs) than those with other diseases. The aims of this study were to explore the willingness of COPD patients and their families to consent to LSTs and compare the differences between their levels of willingness.

METHODS

A cross-sectional survey was conducted, and structured questionnaires were used for data collection.

RESULTS

A total of 219 valid samples were collected, including 109 patients and 110 families. Sixty percent of family members indicated that they did not know the intentions of the patient. Families were significantly more willing for patients to receive LSTs than the patients themselves. The level of willingness of patients and families varied according to the situation and LST interventions. When patients were in a vegetative state or medical treatments were futile, the willingness of COPD patients and their families to receive LSTs significantly decreased. Endotracheal intubation and external defibrillation were the least likely to be requested, whereas the willingness to receive medication injections and noninvasive ventilation was greatest.

CONCLUSION

Communication between families and patients on the issue of LST should be facilitated. Adequate information on the patient's condition and possible LSTs should be provided to avoid COPD patients receiving inappropriate LSTs.

Prevailing Ethical Dilemmas Encountered by Physicians in Terminal Cancer Care Changed After the Enactment of the Natural Death Act: 15 Years' Follow-up Survey

CONTEXT

Advance directive laws have influences on ethical dilemmas encountered by physicians caring for terminal cancer patients.

OBJECTIVES

To identify the prevailing ethical dilemmas among terminal care physicians 15 years after the Natural Death Act was enacted in Taiwan.

METHODS

This study is a cross-sectional survey from April 2014 to February 2015 using the clustering sampling method and a well-structured questionnaire. Targeted participants included physicians at oncology and related wards or palliative care units where terminal cancer care may be provided in Taiwan.

RESULTS

Among the 500 physicians surveyed, 383 responded (response rate 76.6%) and 346 valid questionnaires were included in the final analysis (effective response rate 69.2%). The most frequently identified ethical dilemma was "place of care," followed by "use of antimicrobial agents" and "artificial nutrition and hydration." The dilemma of "truth telling," which ranked first in the 2005-2006 survey, now ranked at the fourth place. Stepwise logistic regression analysis revealed that female gender and knowledge of palliative care were negatively correlated with the extent of dilemmas regarding issues of "life and death."

CONCLUSION

The prevailing ethical dilemmas have changed in Taiwan 15 years after the enactment of the Natural Death Act, supporting that some previous strategies had worked. Our results suggest that education on the core values of palliative care, improvement of community-based hospice care program, and creating treatment guidelines with prognostication may resolve the current dilemmas. This type of survey should be adapted by individual countries to guide policy decisions on end-of-life care.

Decision Making Regarding the Place of End-of-Life Cancer Care: The Burden on Bereaved Families and Related Factors

CONTEXT

Decision making regarding the place of end-of-life (EOL) care is an important issue for patients with terminal cancer and their families. It often requires surrogate decision making, which can be a burden on families.

OBJECTIVES

To explore the burden on the family of patients dying from cancer related to the decisions they made about the place of EOL care and investigate the factors affecting this burden.

METHODS

This was a cross-sectional mail survey using a self-administered questionnaire. Participants were 700 bereaved family members of patients with cancer from 133 palliative care units in Japan. The questionnaire covered decisional burdens, depression, grief, and the decision-making process.

RESULTS

Participants experienced emotional pressure as the highest burden. Participants with a high decisional burden reported significantly higher scores for depression and grief (both P < 0.001). Multiple regression analyses revealed that higher burden was associated with selecting a place of EOL care that differed from that desired by participants (P < 0.001) and patients (P = 0.034), decision making without knowing the patient's wishes and values (P < 0.001) and without participants sharing their wishes and values with the patient's doctors and/or nurses (P = 0.022), and making the decision because of a due date for discharge from a former facility or hospital (P = 0.005).

CONCLUSION

Decision making regarding the place of EOL care was recalled as burdensome for family decision makers. An early decision-making process that incorporates sharing patients' and family members' values that are relevant to the desired place of EOL care is important.

Establishment of a renal supportive care program: Experience from a rural community hospital in Taiwan

Renal supportive care (RSC) denotes a care program dedicated for patients with acute, chronic renal failure, and end-stage renal disease (ESRD), aiming to offer maximal symptom relief and optimize patients' quality of life. The uncertainty of prognosis for patients with chronic kidney disease and ESRD, the sociocultural issues inherent to the Taiwanese society, and the void of structured and practical RSC pathway, contributes to the underrecognition and poor utilization of RSC. Taiwanese patients rarely receive information regarding RSC as part of a standardized care and are not commonly offered this option. In National Taiwan University Hospital Jinshan branch, we started a RSC subprogram, supported by the community-based palliative/hospice care main program. We focused on understanding the need and providing the choice of RSC to suitable candidates. A three-step and four-phase protocol was designed and implemented to identify appropriate patients and to enhance the applicability of the RSC. We harnessed family visit and home-based family meeting as a vehicle to understand the patients' preferences, to discover what ESRD patients and their family value most, and to introduce the option of RSC. In the current review, we described our pilot experience of establishing a RSC program in Taiwan, and discuss its potential advantage.

Preferences on End-Of-Life Decisions Among Older Chinese in Macau

Purpose: The purpose of the present study was to learn about the perspectives on end-of-life decision making among older Chinese people in Macau. Method: A qualitative approach was used, and interviews were conducted with 18 Chinese aged 65 years or older. Results: Four major themes were identified: (a) institutionalized care at the end of life was preferred as not to be a burden on family, (b) life-prolonging measures were not preferred, (c) funeral arrangement preferences were based on personal and religious beliefs, and (d) end-of-life decision making would be deferred to others. Discussion and Conclusions: These themes provide an understanding of personal preferences of older Chinese on end-of-life issues, and personal preferences are always secondary to their respect toward family and medical doctors. This compliance with family and medical authority can be understood through Chinese cultural beliefs. Implications for Practice: Knowledge of cultural influences is needed for nursing professionals to deal effectively with older adults and families regarding end-of-life issues.

Family members' perceptions of inpatient palliative care consult services: a qualitative study

BACKGROUND

Family members are commonly involved in end-of-life decision making and typically involved in inpatient palliative care consultations. Although much research has documented patient outcomes following inpatient palliative care consultation, little is known about family member perceptions of the consultation.

AIM

The purpose of this study was to determine how inpatient palliative care consultations impacted family members' understanding of the patient's condition, knowledge of available care options, and decision-making ability.

DESIGN

An exploratory, qualitative study was conducted employing individual interviews among family members of seriously ill patients, recruited purposively. Interviews were conducted in person, at the hospital, or via telephone, using a semistructured protocol.

SETTING/PARTICIPANTS

Family members of seriously ill patients were recruited from a nonprofit, community hospital.

RESULTS

Interviews were conducted among 23 family members. Four themes were identified and included: perceived qualities of the inpatient palliative care consultation, family readiness, impact on decision-making process, and focus on comfort and quality of life. While most comments reflected positive aspects of the inpatient palliative care consult, such as improved pain control and communication, and increased access to medical professionals and time to discuss patient conditions, some themes reflected a lack of adequate preparation for the inpatient palliative care consultation and readiness for discussing prognosis.

CONCLUSION

Family members report discussion with the inpatient palliative care team results in improved communication and knowledge, which contributes to decision-making ability. However, palliative care consultation may be improved by developing stronger protocols for introducing palliative care and by including the attending physician in the process to preclude conflicting, inconsistent information and recommendations.

The ongoing westernization of East Asian biomedical ethics in Taiwan

Family autonomy/family-determination (FA/FD) is deeply rooted in Confucianism, and is an important core value in East Asian biomedical ethics. Individual autonomy/self-determination (IA/SD) did not originate in East Asia, and is the most important core value of Western biomedical ethics. IA/SD and FA/FD are different from each other not only because of where they originated but also in their general sense and moral foundations. We investigated the influence of Western biomedical ethics on the Eastern hemisphere. We examined the secular trends of IA/SD use in ethics and biomedical ethics articles published in Taiwan from 1991 to 2010. The published articles were collected from a popular online library called the Chinese Electronic Periodical Services. A total of 1737 articles were associated with ethics, and 300 of them were associated with biomedical ethics. The total number of times IA/SD was used in each ethics and biomedical ethics article was calculated. The secular trends were plotted graphically and analyzed by time series linear regression analysis. The results showed that the secular trend of the proportion of the yearly total of biomedical ethics articles to the yearly total of ethics articles was significantly increasing (p = 0.007). The secular trends of the average of times IA/SD showed that one unit of yearly increase was associated with an increment of 0.056 IA/SD use per ethics article (p < 0.001), and 0.331 IA/SD use per biomedical ethics article (p = 0.027), respectively. These findings suggest that Western biomedical ethics have become increasingly influential in Taiwan over the past two decades. Thus, assuming that FA/FD takes priority over IA/SD in an East Asian medical encounter is too simplistic. Whether FA/FD or IA/SD takes priority in a medical encounter should be carefully evaluated.