Patient autonomy problems in palliative care: systematic development and evaluation of a questionnaire

Recognition of social health: A conceptual framework in the context of dementia research

Objective

The recognition of dementia as a multifactorial disorder encourages the exploration of new pathways to understand its origins. Social health might play a role in cognitive decline and dementia, but conceptual clarity is lacking and this hinders investigation of associations and mechanisms. The objective is to develop a conceptual framework for social health to advance conceptual clarity in future studies.

Process

We use the following steps: underpinning for concept advancement, concept advancement by the development of a conceptual model, and exploration of its potential feasibility. An iterative consensus-based process was used within the international multidisciplinary SHARED project.

Conceptual framework

Underpinning of the concept drew from a synthesis of theoretical, conceptual and epidemiological work, and resulted in a definition of social health as wellbeing that relies on capacities both of the individual and the social environment. Consequently, domains in the conceptual framework are on both the individual (e.g., social participation) and the social environmental levels (e.g., social network). We hypothesize that social health acts as a driver for use of cognitive reserve which can then slow cognitive impairment or maintain cognitive functioning. The feasibility of the conceptual framework is demonstrated in its practical use in identifying and structuring of social health markers within the SHARED project.

Discussion

The conceptual framework provides guidance for future research and facilitates identification of modifiable risk and protective factors, which may in turn shape new avenues for preventive interventions. We highlight the paradigm of social health in dementia as a priority for dementia research.

Comprehensive Assessment of Incidence, Risk Factors, and Mechanisms of Impaired Medical and Psychosocial Health Outcomes among Adolescents and Young Adults with Cancer: Protocol of the Prospective Observational COMPRAYA Cohort Study

Adolescent and young adult (AYA) cancer patients suffer from delay in diagnosis, and lack of centralized cancer care, age-adjusted expertise, and follow-up care. This group presents with a unique spectrum of cancers, distinct tumor biology, cancer risk factors, developmental challenges, and treatment regimens that differ from children and older adults. It is imperative for advances in the field of AYA oncology to pool data sources across institutions and create large cohorts to address the many pressing questions that remain unanswered in this vulnerable population. We will create a nationwide infrastructure (COMPRAYA) for research into the incidence, predictive/prognostic markers, and underlying mechanisms of medical and psychosocial outcomes for AYA between 18-39 years diagnosed with cancer. A prospective, observational cohort of (n = 4000), will be established. Patients will be asked to (1) complete patient-reported outcome measures; (2) donate a blood, hair, and stool samples (to obtain biochemical, hormonal, and inflammation parameters, and germline DNA); (3) give consent for use of routinely archived tumor tissue and clinical data extraction from medical records and registries; (4) have a clinic visit to assess vital parameters. Systematic and comprehensive collection of patient and tumor characteristics of AYA will support the development of evidence-based AYA care programs and guidelines.

Effective Interventions on Improving Elderly's Independence in Activity of Daily Living: A Systematic Review and Logic Model

This systematic review aimed to investigate the types and characteristics of effective interventions when improving the independence of the elderly during activities of daily living. After developing a search strategy, the various databases, including PubMed, Scopus, Cochrane Library, Science Direct, Proquest, and Embase, were searched up to October 16, 2019. The Review Manager 5.1 software was used to determine the risk of bias. The randomized clinical trials were reviewed to find if their interventions' main goal was to improve the elderly's independence in activities of daily living. Data were extracted independently by two authors. Eight randomized controlled trials were included in the final analysis. Three types of interventions were identified and categorized as cognitive training, physical exercises, and multicomponent interventions. All reviewed studies provided evidence of the effectiveness of interventions in improving older people's ability to perform the activities of daily living. However, the lack of uniform measurement indicators to identify and compare the most effective interventions forced us to develop a conceptual framework for designing future interventional research. This conceptual framework included designing tailored interventions, creating an age-friendly environment as well as financial, psychological, and social support. The proposed conceptual framework can also help develop future systematic reviews focusing on a particular intervention type.

Effectiveness of a nurse-supported self-management programme for dual sensory impaired older adults in long-term care: a cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a nurse-supported self-management programme to improve social participation of dual sensory impaired older adults in long-term care homes.

DESIGN

Cluster randomised controlled trial.

SETTING

Thirty long-term care homes across the Netherlands.

PARTICIPANTS

Long-term care homes were randomised into intervention clusters (n=17) and control clusters (n=13), involving 89 dual sensory impaired older adults and 56 licensed practical nurses.

INTERVENTION

Nurse-supported self-management programme.

MEASUREMENTS

Effectiveness was evaluated by the primary outcome social participation using a participation scale adapted for visually impaired older adults distinguishing four domains: instrumental activities of daily living, social-cultural activities, high-physical-demand and low-physical-demand leisure activities. A questionnaire assessing hearing-related participation problems was added as supportive outcome. Secondary outcomes were autonomy, control, mood and quality of life and nurses' job satisfaction. For effectiveness analyses, linear mixed models were used. Sampling and intervention quality were analysed using descriptive statistics.

RESULTS

Self-management did not affect all four domains of social participation; however. the domain 'instrumental activities of daily living' had a significant effect in favour of the intervention group (P=0.04; 95% CI 0.12 to 8.5). Sampling and intervention quality was adequate.

CONCLUSIONS

A nurse-supported self-management programme was effective in empowering the dual sensory impaired older adults to address the domain 'instrumental activities of daily living', but no differences were found in addressing the other three participation domains. Self-management showed to be beneficial for managing practical problems, but not for those problems requiring behavioural adaptations of other persons.

TRIAL REGISTRATION NUMBER

NCT01217502; Results.

Patient- and Caregiver-Reported Assessment Tools for Palliative Care: Summary of the 2017 Agency for Healthcare Research and Quality Technical Brief

CONTEXT

Assessment tools are data collection instruments that are completed by or with patients or caregivers and which collect data at the individual patient or caregiver level.

OBJECTIVES

The objectives of this study are to 1) summarize palliative care assessment tools completed by or with patients or caregivers and 2) identify needs for future tool development and evaluation.

METHODS

We completed 1) a systematic review of systematic reviews; 2) a supplemental search of previous reviews and Web sites, and/or 3) a targeted search for primary articles when no tools existed in a domain. Paired investigators screened search results, assessed risk of bias, and abstracted data. We organized tools by domains from the National Consensus Project Clinical Practice Guidelines for Palliative Care and selected the most relevant, recent, and highest quality systematic review for each domain.

RESULTS

We included 10 systematic reviews and identified 152 tools (97 from systematic reviews and 55 from supplemental sources). Key gaps included no systematic review for pain and few tools assessing structural, cultural, spiritual, or ethical/legal domains, or patient-reported experience with end-of-life care. Psychometric information was available for many tools, but few studies evaluated responsiveness (sensitivity to change) and no studies compared tools.

CONCLUSION

Few to no tools address the spiritual, ethical, or cultural domains or patient-reported experience with end-of-life care. While some data exist on psychometric properties of tools, the responsiveness of different tools to change and/or comparisons between tools have not been evaluated. Future research should focus on developing or testing tools that address domains for which few tools exist, evaluating responsiveness, and comparing tools.

Problems and needs in patients with incurable esophageal and pancreaticobiliary cancer: a descriptive study

Patients with incurable esophageal cancer (EC) or pancreaticobiliary cancer (PBC) often have multiple symptoms and their quality of life is poor. We investigated which problems these patients experience and how often care is expected for these problems to provide optimal professional care. Fifty-seven patients with incurable EC (N = 24) or PBC (N = 33) from our outpatient clinic completed the validated "Problems and Needs for Palliative Care" (PNPC) questionnaire and two disease-specific quality of life questionnaires, European Organization for Research and Treatment in Cancer (EORTC). Although patients in general had several problems, physical, emotional, and loss of autonomy (LOA) problems were most common. For these physical and emotional problems, patients also expected professional care, although to a lesser extent for LOA problems. Inadequate care was received for fatigue, fear, frustration, and uncertainty. We conclude that an individualized approach based on problems related to physical, emotional, and LOA issues and anticipated problems with healthcare providers has priority in the follow-up policy of patients with incurable upper gastrointestinal cancer. Caregivers should be alert to discuss needs for fatigue, feelings of fear, frustration, and uncertainty.

Receiving a diagnosis of dementia

There are strong opinions about the advantages and disadvantages of a disclosure of dementia to the individual affected, but little is known about how they and their families understand and respond to this information. This article reports and examines the impact of receiving a diagnosis of dementia, by comparing descriptions of its impact at two weeks, with descriptions explored at 12 weeks. Interviews were undertaken on two occasions with 18 couples, one of whom had received a diagnosis of dementia, the other being a family member. The interviews revealed a gradual process of realization of what the diagnosis meant, resulting in important subtle changes in understandings of dementia and personal relationships. Disclosure of dementia occurs at one point in time, but its impact should be seen as a process. Suggestions are made on how the process of diagnosis and its sharing may enhance family partnerships and social relationships through support of both individuals with dementia and families.

Maternity care and Human Rights: what do women think?

BACKGROUND

A human rights approach to maternal health is considered as a useful framework in international efforts to reduce maternal mortality. Although fundamental human rights principles are incorporated into legal and medical frameworks, human rights have to be translated into measurable actions and outcomes. So far, their substantive applications remain unclear. The aim of this study is to explore women's perspectives and experiences of maternal health services through a human rights perspective in Magu District, Tanzania.

METHODS

This study is a qualitative exploration of perspectives and experiences of women regarding maternity services in government health facilities. The point of departure is a Human Rights perspective. A total of 36 semi-structured interviews were held with 17 women, between the age of 31 and 63, supplemented with one focus group discussion of a selection of the interviewed women, in three rural villages and the town centre in Magu District. Data analysis was performed using a coding scheme based on four human rights principles: dignity, autonomy, equality and safety.

RESULTS

Women's experiences of maternal health services reflect several sub-standard care factors relating to violations of multiple human rights principles. Women were aware that substandard care was present and described a range of ways how the services could be delivered that would venerate human rights principles. Prominent themes included: 'being treated well and equal', 'being respected' and 'being given the appropriate information and medical treatment'.

CONCLUSION

Women in this rural Tanzanian setting are aware that their experiences of maternity care reflect violations of their basic rights and are able to voice what basic human rights principles mean to them as well as their desired applications in maternal health service provision.

Dealing with symptoms and issues of hospitalized patients with cancer in indonesia: the role of families, nurses, and physicians

OBJECTIVE

Patients with cancer often face physical, psychological, social, spiritual, and emotional symptoms. Our aim was to study symptoms and issues of hospitalized patients with cancer in Indonesia, a country with strong family ties, and how family members, nurses, and physicians deal with them.

METHODS

In 2011, 150 hospitalized cancer patients in 3 general hospitals in Indonesia were invited to fill in a questionnaire, which was based on the validated Problems and Needs of Palliative Care (short version) questionnaire. Descriptive statistics were performed.

RESULTS

Of 119 patients (79%) who completed the questionnaire, 85% stated that their symptoms and issues were addressed. According to these patients, financial (56%), autonomy (36%), and psychosocial (34%) issues were most often addressed by the family alone. Physical symptoms (52%) and spiritual issues (33%) were addressed mainly by a combination of family, nurses, and physicians.

CONCLUSIONS

Hospitalized patients with cancer in Indonesia felt that most of their symptoms and issues had been addressed, and the family was highly involved. The strong family ties in Indonesian culture may have contributed to this family role. More research is needed to clarify how this influences patient outcome, quality of care, and quality of life of both the patients and their families, along with the degree of partnership between families and professionals. This information might help answer the question what advantages and disadvantages the family role in caring for a hospitalized patient with cancer generates for the patient, the family, and professional caregivers.

Respecting autonomy in the end-of-life care of people with intellectual disabilities: a qualitative multiple-case study

BACKGROUND

The aim of this article was to describe how caregivers and relatives shape respect for autonomy in the end-of-life care for people with intellectual disabilities (ID) and to discuss to what extent this corresponds with a relational concept of autonomy, such as described in care ethics.

METHOD

This study consisted of a qualitative design in which the cases of 12 recently deceased people with ID were reconstructed by interviewing the caregivers and relatives who were closest to the person at the end of their life. A cyclic process of data collection and analysis was used. Interviews were transcribed verbatim and data were analysed inductively.

RESULTS

Respect for autonomy in the end-of-life care of people with ID was mainly reflected in helping the person with ID familiarise with three transitions: new information on the diagnosis and prognosis, changing care needs and wishes, and important decisions that were at stake. In respecting autonomy, relatives and caregivers encountered several challenges. These concerned ascertaining information needs, communicating about illness and death, inexperience in end-of-life care, eliciting current and hidden last wishes, the dependence of people with ID and conflicting wishes. Several qualities were important for respecting autonomy: attention to information needs, connecting, recognising end-of-life care needs, giving space to show wishes and preferences, and discussing dilemmas.

CONCLUSIONS

If caregivers and relatives embrace autonomy as a relational construct, attained through an open, active and reflective attitude, and have more access to knowledge about communication and how to identify end-of-life care needs, this could lead to improved respect for the ID persons' autonomy at the end of life. We discuss the view that a relational concept of autonomy is useful for describing respect for autonomy in end-of-life care for people with ID, but that more reflection and openness is needed to sufficiently employ relationships and regard autonomy as a product of joint work.

Comparison of problems and unmet needs of patients with advanced cancer in a European country and an Asian country

BACKGROUND

Patients with advanced cancer experience problems and unmet needs. However, we assume that patients with advanced cancer will have more problems and unmet needs in a country with a lower economic status than in an economically stronger country. We studied whether patients with advanced cancer in Indonesia have more problems and unmet needs than a similar group of patients in the Netherlands.

METHODS

We performed a cross-sectional survey. We compared the data for 180 Indonesian and 94 Dutch patients relating to 24 items of the Problems and Needs in Palliative Care-short version questionnaire. We performed descriptive and χ(2) analysis with Bonferroni correction.

RESULTS

The prevalence of most physical problems, including pain, was similar in the 2 groups. In Indonesia, financial problems were the most common: 70 to 80% vs. 30 to 42% in the Netherlands. In Indonesia, 25 to 50% of the patients reported psychological and autonomy problems versus 55 to 86% in the Netherlands. The Indonesian group had many more unmet needs for each problem (> 54%) than the Dutch group (< 35%).

CONCLUSION

Apparently, economic and cultural differences hardly influence physical problems. Nonetheless, fewer Indonesian patients reported psychological and autonomy problems than Dutch patients. This difference contradicts our hypothesis. However, we found more unmet needs for professional attention in Indonesia than in the Netherlands, which is compatible with our hypothesis. These simple comparative data provide interesting insights into problems and unmet needs and give rise to our new hypothesis about cultural influences. This hypothesis should be studied in more depth.

The interplay between autonomy and dignity: summarizing patients voices

Patients have to be respected with dignity as the masters of their own lives. The problem, however, is that autonomy may become so dominant and the fundamental value of caring in professional nursing that the patient's dignity is affected. The aim of this article is to point out some of the issues with the interplay between autonomy, also called self-management and dignity. Given voice to the patient perspective the background is provided by cases from research conducted through qualitative interviews with patients and expanded by summarizing empirical research concerning the interplay between autonomy and dignity. The search strategy and the research question gave five empirical research papers and three theoretical studies and concept analyses. A concise overview of the relevant research contains information about all the major elements of the studies. The background research and an interpretative summary address new issues to be taken into account in dignity conserving care.

Multimorbidity's research challenges and priorities from a clinical perspective: the case of 'Mr Curran'

Older patients, suffering from numerous diseases and taking multiple medications are the rule rather than the exception in primary care. A manifold of medical conditions are often associated with poor outcomes, and their multiple medications raise additional risks of polypharmacy. Such patients account for most healthcare expenditures. Effective approaches are needed to manage such complex patients in primary care. This paper describes the results of a scoping exercise, including a two-day workshop with 17 professionals from six countries, experienced in general practice and primary care research as well as epidemiology, clinical pharmacology, gerontology and methodology. This was followed by a consensus process investigating the challenges and core questions for multimorbidity research in primary care from a clinical perspective and presents examples of the best research practice. Current approaches in measuring and clustering multimorbidity inform policy-makers and researchers, but research is needed to provide support in clinical decision making. Multimorbidity presents a complexity of conditions leading to individual patient's needs and demanding complex processes in clinical decision making. The identification of patterns presupposes the development of strategies on how to manage multimorbidity and polypharmacy. Interventions have to be complex and multifaceted, and their evaluation poses numerous methodological challenges in study design, outcome measurement and analysis. Overall, it can be seen that complexity is a main underlying theme. Moreover, flexible study designs, outcome parameters and evaluation strategies are needed to account for this complexity.

Effectiveness of a self-management program for dual sensory impaired seniors in aged care settings: study protocol for a cluster randomized controlled trial

BACKGROUND

Five to 25 percent of residents in aged care settings have a combined hearing and visual sensory impairment. Usual care is generally restricted to single sensory impairment, neglecting the consequences of dual sensory impairment on social participation and autonomy. The aim of this study is to evaluate the effectiveness of a self-management program for seniors who acquired dual sensory impairment at old age.

METHODS/DESIGN

In a cluster randomized, single-blind controlled trial, with aged care settings as the unit of randomization, the effectiveness of a self-management program will be compared to usual care. A minimum of 14 and maximum of 20 settings will be randomized to either the intervention cluster or the control cluster, aiming to include a total of 132 seniors with dual sensory impairment. Each senior will be linked to a licensed practical nurse working at the setting. During a five to six month intervention period, nurses at the intervention clusters will be trained in a self-management program to support and empower seniors to use self-management strategies. In two separate diaries, nurses keep track of the interviews with the seniors and their reflections on their own learning process. Nurses of the control clusters offer care as usual. At senior level, the primary outcome is the social participation of the seniors measured using the Hearing Handicap Questionnaire and the Activity Card Sort, and secondary outcomes are mood, autonomy and quality of life. At nurse level, the outcome is job satisfaction. Effectiveness will be evaluated using linear mixed model analysis.

DISCUSSION

The results of this study will provide evidence for the effectiveness of the Self-Management Program for seniors with dual sensory impairment living in aged care settings. The findings are expected to contribute to the knowledge on the program's potential to enhance social participation and autonomy of the seniors, as well as increasing the job satisfaction of the licensed practical nurses. Furthermore, an extensive process evaluation will take place which will offer insight in the quality and feasibility of the sampling and intervention process. If it is shown to be effective and feasible, this Self-Management Program could be widely disseminated.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov, NCT01217502.

Dual sensory loss: development of a dual sensory loss protocol and design of a randomized controlled trial

Background

Dual sensory loss (DSL) has a negative impact on health and wellbeing and its prevalence is expected to increase due to demographic aging. However, specialized care or rehabilitation programs for DSL are scarce. Until now, low vision rehabilitation does not sufficiently target concurrent impairments in vision and hearing. This study aims to 1) develop a DSL protocol (for occupational therapists working in low vision rehabilitation) which focuses on optimal use of the senses and teaches DSL patients and their communication partners to use effective communication strategies, and 2) describe the multicenter parallel randomized controlled trial (RCT) designed to test the effectiveness and cost-effectiveness of the DSL protocol.

Methods/design

To develop a DSL protocol, literature was reviewed and content was discussed with professionals in eye/ear care (interviews/focus groups) and DSL patients (interviews). A pilot study was conducted to test and confirm the DSL protocol. In addition, a two-armed international multi-center RCT will evaluate the effectiveness and cost-effectiveness of the DSL protocol compared to waiting list controls, in 124 patients in low vision rehabilitation centers in the Netherlands and Belgium.

Discussion

This study provides a treatment protocol for rehabilitation of DSL within low vision rehabilitation, which aims to be a valuable addition to the general low vision rehabilitation care.

Trial registration

Netherlands Trial Register (NTR) identifier: NTR2843

Screening for Distress and Unmet Needs in Patients With Cancer: Review and Recommendations

Purpose

This review summarizes the need for and process of screening for distress and assessing unmet needs of patients with cancer as well as the possible benefits of implementing screening.

Methods

Three areas of the relevant literature were reviewed and summarized using structured literature searches: psychometric properties of commonly used distress screening tools, psychometric properties of relevant unmet needs assessment tools, and implementation of distress screening programs that assessed patient-reported outcomes (PROs).

Results

Distress and unmet needs are common problems in cancer settings, and programs that routinely screen for and treat distress are feasible, particularly when staff are supported and links with specialist psychosocial services exist. Many distress screening and unmet need tools have been subject to preliminary validation, but few have been compared head to head in independent centers and in different stages of cancer. Research investigating the overall effectiveness of screening for distress in terms of improved recognition and treatment of distress and associated problems is not yet conclusive, but screening seems to improve communication between patients and clinicians and may enhance psychosocial referrals. Direct effects on quality of life are uncertain, but screening may help improve discussion of quality-of-life issues.

Conclusion

Involving all stakeholders and frontline clinicians when planning screening for distress programs is recommended. Training frontline staff to deliver screening programs is crucial, and continuing to rigorously evaluate outcomes, including PROs, process of care, referrals, and economic costs and benefits is essential.

The implications of autonomy: Viewed in the light of efforts to uphold patients dignity and integrity

This article focuses on Danish patients’ experience of autonomy and its interplay with dignity and integrity in their meeting with health professionals. The aim is to chart the meanings and implications of autonomy for persons whose illness places them in a vulnerable life situation. The interplay between autonomy and personal dignity in the meeting with health care staff are central concepts in the framework. Data collection and findings are based on eight qualitative semi-structured interviews with patients. Patients with acute, chronic, and life threatening diseases were represented including surgical as well as medical patients. The values associated with autonomy are in many ways vitalising, but may become so dominant, autonomy seeking, and pervasive that the patient's dignity is affected. Three types of patient behaviour were identified. (1) The proactive patient: Patients feel that they assume responsibility for their own situation, but it may be a responsibility that they find hard to bear. (2) The rejected patient: proactive patients take responsibility on many occasions but very active patients are at risk of being rejected with consequences for their dignity. (3) The knowledgeable patient: when patients are health care professionals, the patient's right of self-determination was managed in a variety of ways, sometimes the patient's right of autonomy was treated in a dignified way but the opposite was also evident. In one way, patients are active and willing to take responsibility for themselves, and at the same time they are “forced” to do so by health care staff. Patients would like health professionals to be more attentive and proactive.

Evaluation of quality-of-life measures for use in palliative care: a systematic review

PURPOSE

In this literature review we evaluated the feasibility and clinimetric quality of quality-of-life (QoL) measurement instruments suitable for use in palliative care.

METHODS

We conducted a systematic literature review to identify instruments measuring (at least one domain of) QoL. We selected articles that present data on patients receiving palliative care and at least one measurement property. A checklist was used to describe the characteristics of the instruments, and a widely accepted rating list was used to evaluate the clinimetric aspects.

RESULTS

29 instruments were identified and evaluated, most of which were targeted at palliative patients in general. None of the instruments demonstrated satisfactory results for all measurement properties. Fourteen instruments received positive ratings for construct validity. Thirteen instruments were tested for reliability, but only two were tested adequately and had positive results (ICC>0.70). Responsiveness was not tested adequately for any of the instruments. Very few of the studies provided information on the interpretation of the scores. Overall, the MQOL, followed by the QUAL-E and the QODD, received the best ratings for their measurement properties.

CONCLUSIONS

Many measurement instruments were identified, but most had not yet been adequately evaluated. The evaluation of existing instruments with good content validity should have priority over the development of new instruments.

Informing patients about cancer in Nepal: what do people prefer?

INTRODUCTION

Traditionally, doctors in Nepal do not discuss a diagnosis of malignancy with their patient. Instead, discussion is more likely to take place with family members, who then filter the information that the patient receives. This study aims to quantify the amount of actual disclosure of a cancer diagnosis that takes place, through a survey of patients admitted for hospice care, and to compare this with preferences regarding cancer disclosure from a survey of the general population.

OBJECTIVES

(a) To determine what proportion of patients, referred for hospice care with advanced cancer, who were aware of their disease and prognosis. (b) To determine the attitude among the public toward disclosure of information of a diagnosis of malignancy, if they or a close relative were to develop the disease. (c) To observe if educational attainment impacts on issues related to disclosure of a cancer diagnosis.

METHOD

(a) Prospective survey of patients with cancer admitted to 'Hospice Nepal' over a one-year period, recording details of how much patients knew of their diagnosis. (b) Survey of the general population in and around the Kathmandu valley, with a questionnaire asking the following two questions: If you were diagnosed with cancer would you like to be informed of your cancer? If a close relative was diagnosed with cancer would you like them to be informed of their cancer?

RESULTS

A survey of the 96 patients admitted to 'Hospice Nepal' over the one-year study period showed that 19 (20%) of the patients had knowledge of both their disease and the stage of the disease; 16 (17%) knew that they had cancer but did not know about their disease progression or prognosis; 61 (63%) were unaware of the nature, seriousness or prognosis of their disease. A survey of the general population in Kathmandu showed 204 (80%) of the 256 respondents wanted to be informed if they were diagnosed with cancer, even if it was incurable; 44 (17%) wanted to be informed of such a diagnosis only if it was curable; and 8 (3%) did not want to be informed of such a diagnosis at all.

CONCLUSION

In Nepal, there is a clear disparity between what patients would like to be told should they develop cancer, and what patients with cancer know about their disease. In the Asian context, it is not unusual to be advised that western practices of disclosure are inappropriate, yet this study, conducted in a very non-western culture, shows that the patient's wish to know about their illness is a desire which can transcend cultural and ethnic differences.