Beyond death and dying: how Chinese spouses navigate the final days with their loved ones suffering from terminal cancer

Effectiveness of family centred interventions for family caregivers: A systematic review and meta-analysis of randomized controlled trials

AIMS AND OBJECTIVES

To examine the effectiveness of family-centred interventions among family caregivers.

BACKGROUND

Family-centred interventions are an emerging form of intervention that can be effective at improving physical and mental health outcomes for patients and family caregivers. To date, no reviews have examined the effectiveness of family-centred interventions for family caregivers.

DESIGN

A systematic review, including a meta-analysis, was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA 2020) checklist.

METHODS

Seven English and two Chinese electronic databases were compressively searched from the outset to March 2023. Two researchers independently reviewed the abstracts and full texts, extracted the data and assessed the risk of bias independently by using the Cochrane 'Risk of bias assessment tool'.

RESULTS

This systematic review and meta-analysis included 20 articles. The results of the meta-analysis showed that family-centred interventions could significantly improve caregiver burden (p=0.003), quality of life (p = 0.007), depression (p = 0.0002), and stress (p < 0.0001) but not anxiety or family functioning. According to our subgroup analysis, the family-centred empowerment model (p = 0.009) was superior to the other family intervention (p=0.004) in reducing caregiver burden. Family-centred interventions are more effective at reducing the burden of caregiving on family caregivers of adolescent patients (SMD=-0.79, 95% CI[-1.22,-0.36], p = 0.0003) than on adult patients (SMD=-0.37, 95% CI [-0.61,-0.12], p = 0.004).

CONCLUSIONS

Family-centred interventions could enhance family caregivers' burden, quality of life, stress and depression but had no significant impact on anxiety or family functioning.

RELEVANCE TO CLINICAL PRACTICE

Family-centred interventions have the potential to improve the health status and caregiving burden of family caregivers. Rigorous and high-quality evidence is needed to confirm the long-term effects of these interventions on family caregivers.

TRIAL REGISTRATION DETAILS

The protocol has been registered in the PROSPERO international prospective register of systematic reviews (Protocol registration ID: CRD42023453607).

The effect of Chinese culture-adapted dignity therapy on advanced cancer patients receiving chemotherapy in the day oncology unit: A quasi-experimental study

PURPOSE

To examine the effects of Chinese culture-adapted dignity therapy on dignity-related and psychological, spiritual distress and family function for advanced cancer patients receiving chemotherapy in the day oncology unit.

METHOD

This is a quasi-experimental study. Patients were recruited from a day oncology unit at a tertiary cancer hospital in Northern China. A total of 39 patients agreeing to participate were assigned to receive Chinese culture-adapted dignity therapy (intervention group, n = 21) or supportive interview (control group, n = 18) according to their admission time. Patients' dignity-related, psychological, spiritual distress, and family function were assessed at baseline (T0) and after completing the intervention (T1) and the scores were compared between and within the groups. Besides, the interviews were conducted with patients at T1 to obtain their feedback, which were analyzed and integrated with the quantitative results.

RESULTS

There was no statistical significance in all outcomes at T1 between the two groups, as well as in most outcomes between T0 and T1 in the intervention groups except for the relieved dignity-related distress (P = 0.017), especially the physical distress (P = 0.026), and the improved family function (P = 0.005), especially the family adaptability (P = 0.006). The synthesized quantitative and qualitative results showed that the intervention could relieve physical and psychological distress, enhance the sense of dignity, and improve the spiritual well-being and family function of patients.

CONCLUSIONS

The Chinese culture-adapted dignity therapy showed positive effects on the life experiences of patients receiving chemotherapy in the day oncology unit and their family, and it might be a suitable, indirect communication prompt for Chinese families.

Intra-Family End-Of-Life Conflict: Findings of a Research Investigation to Identify Its Incidence, Cause, and Impact

With few investigations of intra-family end-of-life conflict, this study sought to identify its incidence, cause, and impacts. A questionnaire was completed by 102 hospice/palliative nurses, physicians, and other care providers in Alberta, a Canadian province. Participants reported on how often they had observed intra-family conflict when someone in the family was dying, and the impacts of that conflict. 12 survey participants were then interviewed about the intra-family conflict that they had encountered, with interviews focused on why conflict occurred and what the impacts (if any) were. Nearly 80% of families were thought to experience end-of-life conflict, periodically or continuously, among various family members. The interviews confirmed three reasons for intra-family end-of-life conflict and three conflict outcomes that were revealed in a recent literature review. The findings indicate routine assessments for intra-family end-of-life conflict are advisable. Attention should be paid to preventing or mitigating this conflict for the good of all.

Dignity therapists' experience of conducting dignity therapy with terminal cancer patients in mainland China: A descriptive qualitative study

OBJECTIVE

This study investigated the experience of conducting dignity therapy with terminal cancer patients from the perspective of dignity therapists in mainland China.

METHODS

Semistructured interviews were conducted with 15 trained dignity therapists from across mainland China who have performed at least one time dignity therapy for terminal cancer patients. Data were analysed using content analysis.

RESULTS

Four main themes emerged. Firstly, therapists reported that they had many culture-specific experiences of conducting dignity therapy with Chinese patients. Secondly, they encountered various challenges while recruiting and delivering dignity therapy to patients. Thirdly, through conducting dignity therapy, therapists gained personal development although sometimes they empathised with patients' negative emotions. Lastly, they perceived great benefits of conducting dignity therapy to the culture of caring in clinical practice and healthcare provider-patient relationship.

CONCLUSION

Chinese culture influenced dignity therapists' experience of conducting dignity therapy in mainland China. A series of challenges and benefits of conducting dignity therapy to therapists' personal growth and clinical work were perceived. It is suggested that cultural impacts on dignity therapy implementation and the therapists' ability to deal with practical and emotional challenges need to be addressed in dignity therapy training. A more resource-saving dignity therapy protocol would be significant for dignity therapy implementation.

Understanding the experiences of older caregivers of patients with lung cancer during palliative chemotherapy in China: a qualitative study

PURPOSE

Although there has been an increase in research on caregivers of patients with cancer, there has been little focus on the specific experiences of older caregivers of patients with lung cancer and the effect of their cultural backgrounds on their experiences. This study explored the caregiver experience among the ageing population in China.

METHODS

Older caregivers of patients with lung cancer undergoing palliative chemotherapy were recruited. Data were collected using a qualitative descriptive design involving semi-structured interviews, which were recorded, transcribed verbatim and analysed qualitatively using inductive content analysis.

RESULTS

Eighteen caregivers aged 61-81 years completed the interviews. The following four themes were identified: physical difficulty, living with ambivalence, perception of role and role-related behaviour changes. These themes enabled a greater understanding of role-related behaviours in older caregivers and their challenges in addressing biological and psychosocial challenges related to older age.

CONCLUSION

The present study highlighted the vulnerability and perceived challenges of the role of older caregivers. These findings help lay the foundation for interventions to improve the care provided to caregivers and their health outcomes, especially caregivers with chronic conditions.

Development and feasibility of culturally sensitive family-oriented dignity therapy for Chinese patients with lung cancer undergoing chemotherapy

Objective

It is well-documented in the literature that dignity therapy is feasible and effectively improves the end-of-life experience of the terminally ill. In a similar vein, this study aimed to develop and investigate the feasibility of evidence-based and culturally sensitive family-oriented dignity therapy for Chinese patients with lung cancer undergoing chemotherapy.

Methods

Three phases of the Medical Research Council framework were adopted to guide the development of the novel dignity therapy intervention. It was preliminarily designed based on a qualitative study and a systematic review, Erikson's eighth stage of psychosocial development, and the dignity model. The feasibility and acceptability of the intervention were examined in a pilot randomized controlled trial with 12 recruited dyads of patients and family caregivers.

Results

The intervention consists of three face-to-face sessions that facilitate participants’ reminiscences and promote their communication. Recruitment and response rates for the feasibility study of the intervention were 92.3% and 75%, respectively. Both patients and family caregivers reported that the intervention alleviated their psychological distress and improved communication.

Conclusions

The Medical Research Council framework serves as a useful scientific basis for modifying dignity therapy with a culturally sensitive approach. The results of the feasibility study suggest that the family-oriented dignity therapy intervention is feasible, acceptable and has the potential to enhance the effects of dignity therapy.

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This study devised a stepwise procedure for developing a culturally sensitive family-oriented dignity therapy intervention.

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The family-oriented dignity therapy intervention is feasible and acceptable for Chinese patients with lung cancer .

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The family-oriented dignity therapy has the potential toalleviate patients' dignity-related and psychological distress.

A Scoping Research Literature Review to Identify Contemporary Evidence on the Incidence, Causes, and Impacts of End-of-Life Intra-Family Conflict

When someone is terminally ill, it is often a very stressful time for the dying person and their family. It would not be unusual for intra-family conflict, involving one or more family members and even the dying person, to occur. However, this type of conflict has not been identified as an end-of-life issue needing to be noticed and addressed or prevented when possible. This lack of attention could be because it is not known how common or how impactful this type of conflict is. A scoping research literature review was conducted for available 2004-2019 evidence on the incidence or prevalence of intra-family conflict, factors contributing to it or causing it, and the outcomes or impact of it. A search for published peer-review articles identified 18 research reports for a scoping review. The 18 studies, all conducted in developed countries, revealed intra-family conflict is often present; and with a range of harmful effects for the dying person, the family as a whole or individual family members, and other persons and organizations. The identified factors contributing to or predisposing intra-family conflict were grouped into three categories: (a) family disagreements over curative treatment and/or end-of-life care and decisions, (b) previous family conflict and other family dynamic matters, and (c) the dying process itself. The evidence identified through this scoping review, although relatively minimal, should be useful for planning future research and for raising awareness of end-of-life intra-family conflict to improve social services and palliative programs or services.

Family Caregiver-Receiver Mutuality: A Concept Analysis

There are more than 43 million family caregivers in the United States. In studies of family caregivers and receivers, evidence suggests that family caregiver-receiver mutuality is linked to health. Lack of a clear definition of family caregiver-receiver mutuality is an obstacle that prevents scientific progress and effective operationalization of the concept. To address this issue, the authors applied Walker and Avant's method for concept analysis and clarified the concept of family caregiver-receiver mutuality. A standardized definition of caregiver-receiver mutuality is presented along with antecedents, consequences, defining attributes, empirical referents, and case illustrations.

Discovery of novel N-sulfonamide-tetrahydroisoquinolines as potent retinoic acid receptor-related orphan receptor γt agonists

Cancer immunotherapy has become a research hotspot in recent years. A variety of targets were developed for small molecule immuno-oncology agents, including retinoic acid-related orphan receptor gamma t (RORγt), chemokine receptor, stimulator of interferon genes (Sting), indoleamine 2,3-dioxygenase (IDO), toll-like receptors (TLR), etc. Among them, the retinoic acid receptor-related orphan receptor γt (RORγt) has gradually attracted more attention in these years. In particular, LYC-55716 (cintirorgon), a small molecule RORγt agonist developed by Lycera, has entered the phase II clinical study. In this work, starting from compound 7, compound 28 was obtained after 4 rounds of compound design, synthesis and SAR studies, which had an EC₅₀ of 0.021 ± 0.002 μM in dual Fluorescence Resonance Energy Transfer (dual-FRET) assay and an EC₅₀ of 0.021 ± 0.002 μM in mouse Th17 cell differentiation assay. It indicated that compound 28 had excellent RORγt agonistic activity and was expected to be developed as a new type of small molecule drug for cancer immunotherapy. The molecular dynamic simulation revealed that the agonist 28 formed a strong HYF triplet intramolecular interaction to stabilize H12, which helped RORγt to form the protein-binding site and therefore made the receptor ready to recruit coactivator. When the inverse agonist s27 bound with RORγt, the steric hindrance between s27 and H479 caused the destruction of the HYF triplet, leading to the collapse of H12, thus the transcription function of RORγt was interrupted due to the failure of recruiting a coactivator molecule. The triplet HYF in RORγt and the rigidity of 28 and s27 were identified to be the structural determinants for the functional switch of RORγt.

Effects of family participatory dignity therapy on the psychological well-being and family function of patients with haematologic malignancies and their family caregivers: A randomised controlled trial

BACKGROUND

Strong family ties appear to buffer patient's and family members' difficult experiences during life and health crises. The family participatory dignity therapy programme, a patient-family-centred psychological intervention, was developed based on dignity therapy and performed by one therapist in the form of interview according to a specific question prompt.

OBJECTIVES

This study aimed to confirm the efficacy of the family participatory dignity therapy programme in improving the psychological well-being and family cohesion and adaptability of patients with haematologic malignancies and their family caregivers.

DESIGN

A single-blinded, two-arm parallel group, randomised controlled trial was conducted.

SETTING(S)

and Participants: Participants were patient-family caregiver dyads recruited from Fujian Medical University Union Hospital from March to September 2019.

METHODS

A total of 68 eligible dyads agreed to participate and were randomly assigned to the intervention group (n = 33) or control group receiving usual care (n = 35). Each pair of patient-family dyads in the intervention group received two or three interviews (each interview approximately lasting 45 to 60 min) performed by one therapist according to a specific question prompt containing 10 questions for patients and 10 corresponding questions for their family caregivers. To evaluate the effects of the intervention, we assessed patients' hope, spiritual well-being, and family cohesion and adaptability, as well as their family caregivers' depression, anxiety, and family cohesion and adaptability at baseline (T0), 1 week (T1), 4 weeks (T2), and 8 weeks post-intervention (T3) and compared the scores between the groups. A two-way repeated-measures analysis of variance was conducted to examine the effects of time, group, and their interaction.

RESULTS

For patients, there was a significant difference in hope (p = 0.001), spiritual well-being (p = 0.002), and family cohesion (p<0.001) and adaptability (p<0.001) between the intervention and control groups. The difference over time was also significant in family cohesion (p = 0.018) and adaptability (p = 0.003). The interaction effects were significant for hope (p = 0.034), spiritual well-being (p<0.001), and family cohesion (p<0.001) and adaptability (p<0.001). For family caregivers, there was a significant difference in anxiety (p = 0.037), depression (p = 0.001), and family adaptability (p = 0.036) between the intervention and control groups. Within groups, a significant difference in family adaptability (p = 0.012) was found. Moreover, the interaction effects were significant on anxiety (p = 0.001) and family cohesion (p = 0.038).

CONCLUSIONS

The family participatory dignity therapy programme showed a positive effect on promoting patients' hope, spiritual well-being, and family cohesion and adaptability; amongst family caregivers, it decreased anxiety and depression, and enhanced family cohesion and adaptability. Registration number: ChiCTR1900021433 Tweetable abstract: The family participatory dignity therapy programme promoted patients' hope, spiritual well-being, and family cohesion and adaptability, decreased their family caregivers' anxiety and depression, and enhanced the caregivers' family cohesion and adaptability.

Palliative Care in the Greater China Region: A Systematic Review of Needs, Models, and Outcomes

CONTEXT

There is rapidly increasing need for palliative care in Greater China because of rapidly aging populations.

OBJECTIVES

This study aimed to systematically review and appraise evidence for palliative care needs, models of care, interventions, and outcomes in Greater China.

METHODS

Four databases (MEDLINE, EMBASE, CINAHL, and PsycINFO) were searched, with hand searching of local journals and databases. Narrative synthesis was applied to the qualitative and quantitative evidence.

RESULTS

Nineteen qualitative studies and 47 quantitative studies were retained. With respect to care needs, nine themes were synthesized: pain control, reduced aggressive end-of-life care, truth telling, physical, emotional, and spiritual supports, and achieving preferred place of care/death. Informal caregivers expressed their needs for education and burden reduction. Health care professionals called for training and national policy support. Twenty-four studies evaluated interventions, mostly among patients with advanced cancer. Positive effects were suggested for improvements in quality of life, pain, anxiety and depression, readmission rate, and costs. Models of care evaluated were mostly specialist palliative care delivered in various settings (hospitals, residential care, and home). Outcome measures used were grouped into six categories of construct: quality of life, pain, physical assessment, psychospiritual assessment, quality of care, and implementation assessment. Limited rigorous randomized controlled trials are available to document intervention outcomes, and some problems (such as high attrition rates) reduced the strength of the evidence.

CONCLUSION

Palliative care services within Greater China should pay more attention to management of nonmalignant disease and to integration into primary services. Policy support is key to establishing culturally appropriate person-centered services.

Palliative care utilization in oncology and hemato-oncology: a systematic review of cognitive barriers and facilitators from the perspective of healthcare professionals, adult patients, and their families

BACKGROUND

Despite the high potential to improve the quality of life of patients and families, palliative care services face significant obstacles to their use. In countries with high-resource health systems, the nonfinancial and nonstructural obstacles to palliative care services are particularly prominent. These are the cognitive barriers -knowledge and communication barriers- to the use of palliative care. To date no systematic review has given the deserved attention to the cognitive barriers and facilitators to palliative care services utilization. This study aims to synthesize knowledge on cognitive barriers and facilitators to palliative care use in oncology and hemato-oncology from the experiences of health professionals, patients, and their families.

METHODS

A systematic review was conducted. PubMed, PsycINFO, International Association for Hospice and Palliative Care/Cumulative Index of Nursing and Allied Health Literature (IAHPC/CINAHL), and Communication & Mass Media Complete (CMMC) were systematically searched for the main core concepts: palliative care, barriers, facilitators, perspectives, points of view, and related terms and synonyms. After screening of titles, abstracts, and full-texts, 52 studies were included in the qualitative thematic analysis.

RESULTS

Four themes were identified: awareness of palliative care, collaboration and communication in palliative care-related settings, attitudes and beliefs towards palliative care, and emotions involved in disease pathways. The results showed that cognitive barriers and facilitators are involved in the educational, social, emotional, and cultural dimensions of palliative care provision and utilization. In particular, these barriers and facilitators exist both at the healthcare professional level (e.g. a barrier is lack of understanding of palliative care applicability, and a facilitator is strategic visibility of the palliative care team in patient floors and hospital-wide events) and at the patient and families level (e.g. a barrier is having misconceptions about palliative care, and a facilitator is patients' openness to their own needs).

CONCLUSIONS

To optimize palliative care services utilization, awareness of palliative care, and healthcare professionals' communication and emotion management skills should be enhanced. Additionally, a cultural shift, concerning attitudes and beliefs towards palliative care, should be encouraged.

Factors associated with quality of life of adult patients with acute leukemia and their family caregivers in China: a cross-sectional study

Background

Acute leukemia (AL) not only impairs the quality of life (QOL) of patients, but also affects that of their family caregivers (FCs). Studies on QOL of AL patients and their FCs are limited. This study aimed to evaluate the QOL of AL patients and their FCs, and to explore the factors associated with QOL of patients and of FCs.

Methods

A multicenter cross-sectional study was conducted. The QOL of 196 patient–FC dyads was assessed. The Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu) was used for patients, and the 36-item Short-Form Health Survey (SF-36) was used for FCs. Independent-samples t-tests or one-way analysis of variance were used to compare QOL subscale scores between groups with different sociodemographic/clinical characteristics. Multiple regression analysis was conducted to identify the factors associated with QOL of AL patients and their FCs.

Results

The total FACT-Leu score for AL patients was 76.80 ± 16.44, and the physical component summary (PCS) and mental component summary (MCS) scores for FCs were 64.67 ± 15.44 and 52.50 ± 13.49, respectively. All QOL subscales for patients (t = 12.96–34.73, p < 0.001) and FCs (t = 2.55–14.36, p < 0.05), except role emotional (t = − 0.01, p = 0.993), were lower than those reported in previous studies. Sex, employment, and chemotherapy were significantly associated with total FACT-Leu score in AL patients (p < 0.05). Age, sex, marital status, education, employment, and relationship to patients were significantly associated with SF-36 PCS or MCS (p < 0.05).

Conclusions

AL patients and their FCs both have lower QOL than the population in previous studies. These findings suggest that not only AL patients’ physical and mental health but also overall family QOL should be assessed. Interventions supporting patient–FC dyads should be developed to improve their QOL.

Reciprocal Dynamics of Dignity in End-of-Life Care: A Multiperspective Systematic Review of Qualitative and Mixed Methods Research

Background:

Preserving terminally ill patients’ dignity and well-being through dignified and holistic care has become the overarching goal in palliative care services. However, dignity is a multifaceted concept with a wide range of interpretations under different cultural contexts.

Aim:

The aim of this review is to understand the variations in subjective interpretations and constitutions of dignity in palliative or end-of-life care via an integrative worldview.

Design:

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and used SPIDER tool to screen for appropriate and relevant articles for analysis.

Data Sources:

Four major databases were searched including CINAHL, ERIC, Medline, and PsycARTICLES between 2009 and 2018. Forty-eight qualitative studies that examined dignity from the perspectives of patients, family caregivers, and health-care professionals were selected for full text data analysis using thematic synthesis.

Results:

Analysis of the various concepts of dignity revealed 18 themes that were further categorized into 7 conceptual categories: (1) self-determination, (2) existential liberty, (3) relational connectedness, (4) caregiving revitalization, (5) mindful humanity, (6) patient–family care, and (7) sustainable culture. These 7 categories span across individual, familial, and institutional dimensions, forming a new Dynamic Reciprocity of Dignity model.

Conclusions:

The Dynamic Reciprocity of Dignity model highlights the importance of adopting a systemic lens to address dignity-related needs and concerns at the end of life, while providing insights on how compassionate care and self-compassion can serve as the foundation of dignified care, which in turn serve as a buffer against patients’ existential suffering as well as caregivers’ burnout and fatigue. Recommendations for clinical practice and future research directions are discussed.

Recent advances in small molecule based cancer immunotherapy

Immunotherapy has been increasingly utilized for the treatment of cancer. Currently available cancer immunotherapies mainly involve the use of antibodies, which have advantages in terms of pharmacodynamics such as efficacy and specificity, however, they exhibit disadvantages in regard to the pharmacokinetics including but not limited to poor tissue and tumor penetration, very long half-life, and the lack of oral bioavailability. Also they are immunogenic and may cause undesired side effects. In addition, they are difficult and expensive to produce. In contrast to therapeutic antibodies, small molecule immuno-oncology agents generally have favorable pharmacokinetics, for example, better oral bioavailability, higher tissue and tumor penetration, reasonable half-lives etc. Furthermore, some small molecules are highly selective and efficacious with benign toxicity profiles. Therefore, small molecule immuno-oncology agents have the potential to overcome the drawbacks of therapeutic antibodies, and they can complement existing therapeutic antibodies and may also be used in combination with antibodies to achieve synergistic effects. In this article, we summarize the current advances in the field of small molecule approaches in tumor immunology which include the small molecules in clinical trials and preclinical studies, and the reported crystal structures of small molecules and their target proteins as well as the binding interactions between small molecules and the targets. The tumorigenesis mechanism of different targets (the programmed cell death 1/programmed cell death ligand 1(PD1/PD-L1), retinoic acid-related orphan receptor-gamma t (RORγt), Chemokine receptor, Stimulator of Interferon Genes (Sting), Indoleamine 2,3-dioxygenase (IDO), toll-like receptors (TLR) etc.) are also elucidated.