An empirical analysis of the decision-making of limiting life-sustaining treatment for patients with advanced chronic obstructive pulmonary disease in Hong Kong, China

European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.

The experience of hospitalization in people with advanced chronic obstructive pulmonary disease: A qualitative, phenomenological study

OBJECTIVES

People with advanced chronic obstructive pulmonary disease (COPD) are frequently hospitalized, reporting high physical, psychological and spiritual suffering. Existing research focused on discrete aspects of hospitalization, such as care or treatment, yet lacks a complete picture of the phenomenon. The aim of this study is to understand the lived experience of hospitalization in people with advanced COPD.

METHODS

A qualitative, descriptive phenomenological approach was employed to study the phenomenon of hospitalization for people with advanced COPD. Unstructured interviews were conducted during hospitalization at a tertiary care hospital in India, in 2017, audio-recorded, and then transcribed. Giorgi's descriptive phenomenological analysis method guided the analysis.

RESULTS

Fifteen people with advanced COPD participated. Emergency admissions were common because of acute breathlessness, leading to repeated hospitalizations. Hospitalization gave a sense of safety but, despite this, people preferred to avoid hospitalization. Care influenced trust in hospitalization and both shaped the experience of hospitalization. Multi-dimensional suffering was central to the experience and was described across physical, psychological and spiritual domains.

DISCUSSION

Hospitalization was identified largely as a negative experience due to the perception of continued suffering. Integrating palliative care into the routine care of people with advanced COPD may enable improvements in care.

Obstacles and Facilitating Factors in Decision-Making of Elderly Patients' Living Will in the Chinese Context-A Literature Review

Background

The living will provide patients at the end of life with the autonomy to choose medical care, so that the patients at the end of life can get dignified and die. In many countries such as Europe and the United States, this choice of people is guaranteed by the law. However, China is in its infancy in the field of living wills, lacking legal support, and the Chinese people have relatively low awareness of living wills and their acceptance is not optimism. China's aging population is developing rapidly, and death education is getting more and more attention, and the popularity of living wills will increase further in the future.

Objective

The aim of this review is to find out the obstacles and facilitating factors in the decision-making of elderly patients in the Chinese context, and to propose countermeasures.

Methods

By searching for relevant literature in databases such as Cnki, Wanfang date, Weipu, Pubmed, Springer, Elsevier, etc., we can understand the connotation of the living wills of elderly patients at home and abroad and the obstacles and promotion factors that affect the signing of the living wills of elderly patients in China.

Results

In the Chinese context, obstacles and facilitating factors in the decision-making of elderly patients' living will can be summarized at the individual, social, and national levels. The obstacles are: low quality of hospice care, social ethics, and lack of legal support. Facilitating factors include: meeting people's psychological expectations, respecting personal autonomy, conducive to the mental health of dying patients and their caregivers, and patients' willingness to accept living will.

Conclusion

Need to determine relevant specific influencing factors, formulate intervention measures, and promote the development of death education in China to ensure gradual progress.

Application of VIP Care in Patients with Advanced Tumors in the Western Region of China

Objective

The objective of this study is to explore the application of a very important person (VIP) intervention mode in patients with advanced tumors in the western region of China.

Methods

One hundred and sixty-three patients were randomly divided into a control and experimental groups. The control group received routine care, and the experimental group received VIP future care. The willingness to end-of-life treatment, decision-making certainty, and quality of life were compared between the two groups before intervention (T0), after intervention (T1), and 1 month after intervention (T2).

Results

There were no significant differences in the basic data of the two groups. Unlike the control group, the experimental group preferred palliative care at the end of T1 (P < 0.05), and the acceptance rate of cardiopulmonary resuscitation and mechanical treatment decreased significantly. After the VIP intervention, the patient was transferred to the intensive care unit (ICU) (P < 0.05). After 1 month of intervention (T2), the results showed that the overall quality of life, physical discomfort, negative emotions, care and support, survival predicament, and lifetime value of the patients were significantly higher than those before the intervention (all P < 0.05). Decision certainty results showed that the differences between the T0, T1, and T2 time points and the interaction between groups and time were statistically significant, and the interaction was more significant at T2 (P < 0.05).

Conclusion

VIP future care can change patients' wishes for end-of-life care, improve patients' and quality of life, and increase patient decision-making certainty.

A Systematic Review with Thematic Synthesis of the Experience of Hospitalization in People with Advanced Chronic Obstructive Pulmonary Disease

Hospital admissions are common for people with advanced chronic obstructive pulmonary disease (COPD). To provide effective, responsive care, it is important to understand how people experience hospitalization. The aim of this review was to explore the experience of hospitalization in people with advanced COPD, drawing from qualitative research data. Guided by a thematic synthesis approach, a systematic search of databases (n = 13) including PubMed, CINAHL, PsycINFO and ProQuest was undertaken from database inception to May 2020. Inclusion criteria included papers reporting qualitative research focused on any aspect of hospitalization for people with advanced COPD and reported in English language from peer reviewed journals. Following quality appraisal, relevant data were extracted, and a three-stage thematic synthesis method used to develop inductive themes. From 1935 papers, the 11 included studies focused on specific aspects of hospitalization (e.g., care and treatment), rather than the totality of the experience. Four analytical themes were identified: unpredictable hospitalization, benefits and burdens of treatment, overwhelming distress and the communicative attitude of staff. Hospitalization was unpredictable because of the frequent, sudden admissions required for acute breathlessness. Hospital could be perceived both as a safe place, due to immediate symptom relief, but also as a place for experiencing overwhelming distress. Breathlessness was the most difficult symptom experienced, causing physical and psychological distress. Both communication and attitudes of the staff could influence the experience. A holistic approach to the care of hospitalized individuals with advanced COPD is required to improve care.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1971186 .

How common are Chinese patients with multimorbidity involved in decision-making and having a treatment plan? A cross-sectional study

BACKGROUND

Creating a treatment plan (TP) through shared decision-making (SDM) with healthcare professionals is of paramount importance for patients with multimorbidity (MM). This study aims to estimate the prevalence of SDM and TP in patients with MM and study the association between SDM/TP with patients' confidence to manage their diseases and hospitalization within the previous 1 year.

METHOD

This cross-sectional study used an internationally recognized survey. A total of 1032 patients aged 60 or above with MM were recruited from a specialist outpatient clinic, general outpatient clinic (GOPC) and a geriatric day hospital. The proportion of patients reported to have SDM and TP was estimated. Associations between the presence of SDM/TP and patients' demographic data, the confidence level to manage their illnesses and hospitalization in previous 1 year were then studied using logistic regression.

RESULTS

The prevalence of SDM and TP was 35.8% and 82.1%, respectively. The presence of TP was associated with receiving healthcare from the same doctor or in the same facilities and being recruited from GOPC. The presence of SDM (OR = 1.352, P = .089) and TP (OR = 2.384, P < .001) was associated with enhanced confidence in dealing with diseases.

CONCLUSION

Most people with MM had TP in Hong Kong, but fewer patients had SDM.

PRACTICE IMPLICATIONS

Ways to promote SDM in HK are needed.

A Scoping Review Mapping Research on Green Space and Associated Mental Health Benefits

BACKGROUND

There is a growing interest in research investigating the association between green space (GS) and mental health and wellbeing (HWB), in order to understand the underlying mechanisms. Accordingly, there is a need to map the literature and create an overview of the research.

METHODS

A scoping review approach was used to map literature on GS, including context and co-exposures (the GS exposome), and their associations with mental HWB. The review considers mental HWB definitions and measurements and how GS is characterized. Furthermore, the review aims to identify knowledge gaps and make recommendations for future research.

RESULTS

We identified a great diversity in study designs, definitions, outcome measures, consideration of the totality of the GS exposome, and reporting of results. Around 70% of the 263 reviewed studies reported a positive association between some aspect of GS and HWB. However, there is a limited amount of research using randomized controlled crossover trails (RCTs) and mixed methods and an abundance of qualitative subjective research.

CONCLUSIONS

The discords between study designs, definitions, and the reporting of results makes it difficult to aggregate the evidence and identify any potential causal mechanisms. We propose key points to consider when defining and quantifying GS and make recommendations for reporting on research investigating GS and mental HWB. This review highlights a need for large well-designed RCTs that reliably measure the GS exposome in relation to mental HWB.

Assessing Quality of Life of Patients with Advanced Chronic Obstructive Pulmonary Disease in the End of Life

Given the limitations of existing health-related quality-of-life (QOL) measures in capturing the end-of-life experience of patients with advanced chronic diseases, an empirically grounded instrument, the quality-of-life concerns in the end of life questionnaire (QOLC-E), was developed. Though it was built on the McGill quality of life questionnaire (MQOL), its sphere is more holistic and culturally specific for the Chinese patients in Hong Kong. One hundred and forty-nine patients with advanced chronic obstructive pulmonary disease (COPD) or metastatic cancer completed the questionnaire. Seven factors (28 items) which emerged from the factor analysis were grouped into four positive (support, value of life, food-related concerns, and healthcare concerns) and four negative (physical discomfort, negative emotions, sense of alienation, and existential distress) subscales. Good internal consistency and concurrent validity were shown. The results also revealed that these two groups of patients had similar QOL concerns. The validity of applying QOLC-E as an outcome measure to evaluate the effectiveness of palliative and psychoexistential interventions has yet to be tested.

Prevalence, Perception, and Predictors of Advance Directives among Hong Kong Chinese: A Population-based Survey

Advance directives (AD) can be used for the communication of healthcare decisions that may be required in the future when individuals have lost their capacity to make such decisions. The aim of this study is to examine the prevalence, perception, and predictors of AD completion in the Hong Kong general population with a diverse culture. Through random-digit dialing, a population-based telephone survey was conducted with participants aged 18 or above. Socio-demographic characteristics, self-perception and health status, prevalence of AD, and perceptions related to AD were assessed. The acceptance on completing AD was measured by the summed score on the level of agreement in making AD. In total, 2002 participants completed the survey, with only 0.5% having made AD. However, the majority of those who had heard about AD had made or intended to make AD (80.2%). Multivariable regression analysis showed that being religious, being optimistic, and agreeing to respect patients' wishes are independently associated with higher AD acceptance. Being a student is associated with lower AD acceptance. The extremely low completion rate of AD, but high acceptance of AD urges for more active promotion of AD to the public and education on end-of-life care among university students.

What Patients, Families, Health Professionals and Hospital Volunteers Told Us about Advance Directives

Objective:

An advance directive (AD) is a document that allows mentally competent individuals to make healthcare decisions about their condition that they might no longer be able to make in the future. This study aimed to explore the perceptions of AD decision-making of various stakeholders in the Chinese palliative care setting.

Methods:

Patients with life-limiting diseases, family members, health professionals, and hospital volunteers were recruited in the palliative care unit of two hospitals in Hong Kong by purposive sampling on age and sex. Qualitative semi-structured individual interviews were conducted.

Results:

A total of 96 participants, including 24 participants from each group, completed the study. Most participants were willing to discuss AD but had not heard about it before the interview. Patients regarded the decisions made in the AD as a way to reduce their future sufferings, while they also considered the welfare of their family. Family members were concerned about the psychological burden when discussing about the AD. Health professionals emphasized the logistic and process of the AD. Hospital volunteers pointed out the impact of Chinese culture on AD acceptance and the lack of AD promotion in the community.

Conclusions:

The findings of the study indicated the need for more promotion of AD in the society. It is important to consider the opinion of a patient's family during AD discussions in a Chinese culture. Health professionals may need to identify the best timing for the discussion of AD with patients and their families.

Factors associated with life-sustaining treatment restriction in a general intensive care unit

Purpose

Few previous studies have investigated associations between clinical variables available after 24 hours in the intensive care unit (ICU), including the Charlson Comorbidity Index (CCI), and decisions to restrict life-sustaining treatment. The aim of this study was to identify factors associated with the life-sustaining treatment restriction and to explore if CCI contributes to explaining decisions to restrict life-sustaining treatment in the ICU at a university hospital in Norway from 2007 to 2009.

Methods

Patients’ Simplified Acute Physiology Score II (SAPS II), age, sex, type of admission, and length of hospital stay prior to being admitted to the unit were recorded. We retrospectively registered the CCI for all patients based on the medical records prior to the index stay. A multivariable logistic regression analysis was used to assess factors associated with treatment restriction during the ICU stay.

Results

We included 936 patients, comprising 685 (73%) medical, 204 (22%) unscheduled and 47 (5%) scheduled surgical patients. Treatment restriction was experienced by 241 (26%) patients during their ICU stay. The variables that were significantly associated with treatment restriction in multivariable analysis were older age (odds ratio [OR] = 1.48 per 10 years, 95% confidence interval [CI] = 1.28–1.72 per 10 years), higher SAPS II (OR = 1.05, 95% CI = 1.04–1.07) and CCI values relative to the reference of CCI = 0: CCI = 2 (OR = 2.08, 95% CI = 1.20–3.61) and CCI≥3 (OR = 2.72, 95% CI = 1.65–4.47).

Conclusions

In multivariable analysis, older age, greater illness severity after 24 h in the ICU and greater comorbidity at hospital admission were independently associated with subsequent life-sustaining treatment restriction. The CCI score contributed additional information independent of the SAPS II illness severity rating.

The effect of a virtual ward program on emergency services utilization and quality of life in frail elderly patients after discharge: a pilot study

Introduction

Attendance at emergency departments and unplanned hospital readmissions are common for frail older patients after discharge from hospitals. A virtual ward service was piloted to deliver “hospital-at-home” services by community nurses and geriatricians to frail older patients immediately after their discharge from hospital to reduce emergency services utilization.

Objectives

This study examined the impacts of the virtual ward service on changes in the patients’ emergency attendance and medical readmissions, and their quality of life (QOL).

Methods

A matched-control quasi-experimental study was conducted at four hospitals, with three providing the virtual ward service (intervention) and one providing the usual community nursing care (control). Subjects in the intervention group were those who are at high risk of readmission and who are supported by home carers recruited from the three hospitals providing the virtual ward service. Matched control patients were those recruited from the hospital providing usual care. Outcome measures include emergency attendance and medical readmission in the past 90 days as identified from medical records, and patient-reported QOL as measured by the modified Quality-of-Life Concerns in the End of Life Questionnaire (Chinese version). Wilcoxon signed-rank tests compared the changes in the outcome variables between groups.

Results

A total of 39 patients in each of the two groups were recruited. The virtual ward group showed a greater significant reduction in the number of unplanned emergency hospital readmissions (−1.41±1.23 versus −0.77±1.31; P=0.049) and a significant improvement in their overall QOL (n=18; 0.60±0.56 versus 0.07±0.56; P=0.02), but there was no significant difference in the number of emergency attendances (−1.51±1.25 versus −1.08±1.48; P=0.29).

Conclusion

The study results support the effectiveness of the virtual ward service in reducing unplanned emergency medical readmissions and in improving the QOL in frail older patients after discharge.

Experience of advanced chronic obstructive pulmonary disease: metasynthesis of qualitative research

CONTEXT

Chronic obstructive pulmonary disease (COPD) is a life-limiting illness. Despite best available treatments, individuals continue to experience symptom burden and have high health care utilization.

OBJECTIVES

To increase understanding of the experience and ongoing needs of individuals living with COPD.

METHODS

Medline, PsycINFO, CINAHL, and Sociological Abstracts were searched for articles published between January 1990 and June 2013. Metasynthesis of qualitative data followed the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Metasyntheses are increasingly used to gain understandings of complex research questions through synthesizing data from individual qualitative studies. Descriptive and analytical themes were developed through thematic synthesis and expert panel discussion of extracted primary quotes, not the primary data themselves.

RESULTS

Twenty-two studies were included. Four hundred twenty-two free codes were condensed into seven descriptive themes: better understanding of condition, breathlessness, fatigue, frailty, anxiety, social isolation, and loss of hope and maintaining meaning. These seven themes were condensed further into three analytical themes that described the experience and ongoing needs of individuals with COPD: the need for better understanding of condition, sustained symptom burden, and the unrelenting psychological impact of living with COPD.

CONCLUSION

Combining discrete qualitative studies provided a useful perspective of the experience of living with COPD over the past two decades. Further studies into the ongoing needs of individuals with COPD are unlikely to add to this well-established picture. Future research should focus on solutions through the development of interventions that address patients' ongoing needs.

Palliative care or end-of-life care in advanced chronic obstructive pulmonary disease: a prospective community survey

BACKGROUND

Calls for better end-of-life care for advanced chronic obstructive pulmonary disease (COPD) reflect the large number who die from the disease and their considerable unmet needs.

AIM

To determine palliative care needs in advanced COPD.

DESIGN

Cross-sectional interview study in patients' homes using structured questionnaires generated from 44 south London general practices.

METHOD

One hundred and sixty-three (61% response) patients were interviewed, mean age 72 years, 50% female, with diagnosis of COPD and at least two of: forced expiratory volume in the first second (FEV(1)) <40% predicted, hospital admissions or acute severe exacerbations with COPD, long-term oxygen therapy, cor pulmonale, use of oral steroids, and being housebound. Patients with advanced cancer, severe alcohol-related or mental health problems, or learning difficulties, were excluded; 145 patients were included in the analysis.

RESULTS

One hundred and twenty-eight (88%) participants reported shortness of breath most days/every day, 45% were housebound, 75% had a carer. Medical records indicated that participants were at least as severe as non-participants. Eighty-two (57%) had severe breathlessness; 134 (92%) said breathlessness was their most important problem; 31 (21%) were on suboptimal treatment; 42 (30%) who were severely affected had not been admitted to hospital in the previous 2 years; 86 of 102 who had been admitted would want admission again if unwell to the same extent. None expressed existential concerns and few discussed need in terms of end-of-life care, despite severe breathlessness and impairment.

CONCLUSION

Needs in advanced COPD were considerable, with many reporting severe intractable breathlessness. Palliation of breathlessness was a priority, but discussion of need was seldom in terms of 'end-of-life care'.

End of life care in chronic obstructive pulmonary disease: in search of a good death

Chronic obstructive pulmonary disease (COPD) is an incurable, progressive illness that is the fourth commonest cause of death worldwide. Death tends to occur after a prolonged functional decline associated with uncontrolled symptoms, emotional distress and social isolation. There is increasing evidence that the end of life needs of those with advanced COPD are not being met by existing services. Many barriers hinder the provision of good end of life care in COPD, including the inherent difficulties in determining prognosis. This review provides an evidence-based approach to overcoming these barriers, summarising current evidence and highlighting areas for future research. Topics include end of life needs, symptom control, advance care planning, and service development to improve the quality of end of life care.

Quality of life concerns and end-of-life care preferences of aged persons in long-term care facilities

AIMS AND OBJECTIVES

This study aimed at understanding quality of life (QOL) concerns and end-of-life care preferences of older people living in long-term care facilities in Hong Kong.

BACKGROUND

Previous studies about the QOL of residents in long-term care facilities were often from a qualitative perspective, because it could yield an in-depth description of the experience. Quantitative studies in this area were not only scarce, but also less specific in capturing the concerns of this vulnerable group. Their forethought about their care planning was also overlooked.

DESIGN AND METHOD

We successfully interviewed 287 older residents from 10 long-term care homes using the modified Quality-of-Life Concerns in the End of Life Questionnaire (QOLC-E) in a cross-sectional survey.

RESULTS

The mean (SD) ages of the frail and non-frail groups were 83.8 (6.74) and 82.35 (5.82) respectively. The majority of them were female and widowed. Existential distress, value of life and food-related concerns were the least desirable QOL concerns in both groups. Considerable numbers were uncertain about their end-of-life care preferences and they preferred their physician to be their surrogate.

CONCLUSION

The older residents had similar QOL concerns as patients with terminal or advanced diseases. Most of the older residents welcomed discussion about death and dying but had not planned for their end-of-life care and had a high regard for their physicians' authority.

RELEVANCE TO CLINICAL PRACTICE

The results reveal the major QOL concerns among the older residents living in long-term care facilities. This study, which is an initial step in profiling the older people's end-of-life care preferences, also shed light on how to formulate advance care planning in long-term care facilities.