Good death inventory: a measure for evaluating good death from the bereaved family member's perspective

Enhancing end-of-life care quality and achieving a good death for the elderly in Japan

BACKGROUND

In the context of an aging populations, there is an escalating need for palliative care tailored to the needs of the elderly. This study aimed to assess differences in symptoms and good death among the elderly, along with the structures and processes involved in end-of life care, and to explore the impact of age on achieving a good death.

METHODS

We conducted a questionnaire survey for bereaved family members of patients with cancer, heart disease, stroke, pneumonia, and kidney failure in 2019 and 2020. The study population was categorized into the following age groups: ≤64, 65-74, 75-84, and ≥85. The outcomes included symptom intensity, achievement of a good death, and receipt of quality care.

RESULTS

In total, 62,576 bereaved family members agreed to participate in the survey (response rate; 54.0 %). The weighted percentages of 'severe' and 'very severe' symptoms decreased with age. These trends were observed across age groups, even among the elderly. The strongest effect of age on achieving a good death was found for 'feeling that life is complete' with reference to those aged ≤64 years: 65-74 years (odds ratio [OR]; 2.09, 95 % CI; 1.94 to 2.25), 75-84 years (OR; 4.86, 95 % CI; 4.52 to 5.22) and ≥85 years (OR; 12.8, 95 % CI; 11.9 to 13.8).

CONCLUSION

Age-specific differences were observed in quality of death, quality of care, and symptom intensity. It is important to provide individualized consideration for each age group rather than categorizing them broadly as the elderly when caring for them.

Narrating Final Memories From Spousal Loss: The Role of Place and Quality of Death

Objective: Personal memories of the death of a spouse can guide bereavement adjustment. Place of death and quality of death are end-of-life factors that are likely to influence death experiences and formation of subsequent personal memories. The current study employs narrative content-analysis to examine how place and quality of death relate to affective sequences present in older adults' final memories from the death of their spouse. Method: Based on power analyses, 53 older adults were recruited and completed a Final Memory Interview. They also reported place of spouse's death (ie, in hospital, out of hospital) and quality of death across four subscales. Final memory narratives were reliably content-analyzed (interrater agreements >.70), revealing positive and negative affective sequences, including: redemption, contamination, positive stability, and negative stability. Findings: Experiencing the death of a spouse in hospital was related to narrating final memories with contamination. In terms of quality of death, reporting a less comforting social environment at time of death was related to the presence of redemption in final memories. Reporting that one's spouse received appropriate medical care related to narrating memories that showed positive stability. Conclusions: Final memories are carried with the bereaved long after their loss. Positive final memories appear to stem from witnessing a comfortable, medically appropriate death outside of a hospital setting. End-of-life 'that is' between care and aligned with patients' values for place and treatment may be critical for spouses' formation of constructive final memories and bereavement adjustment.

Dying Patients' Quality of Care for Five Common Causes of Death: A Nationwide Mortality Follow-Back Survey

Background: The importance of high-quality care for terminal patients is being increasingly recognized; however, quality of care (QOC) and quality of death and dying (QOD) for noncancer patients remain unclear. Objectives: To clarify QOC and QOD according to places and causes of death. Design, Subjects: A nationwide mortality follow-back survey was conducted using death certificate data for cancer, heart disease, stroke syndrome, pneumonia, and kidney failure in Japan. The questionnaire was distributed to 115,816 bereaved family members between February 2019 and February 2020. Measurements included QOC, QOD, and symptoms during the last week of life. Analyses used generalized estimating equations adjusting for age, sex, and region. Results: Valid responses were returned by 62,576 (54.0%). Family-reported QOC and QOD by the place of death were significantly higher at home than in other places across all causes of death (for all combinations with hospital p < 0.01). In stroke syndrome and pneumonia, QOD significantly differed between hospital and home (stroke syndrome: 57.1 vs. 72.4, p < 0.001, effect size 0.77; pneumonia: 57.3 vs. 71.1, p < 0.001, effect size 0.78). No significant differences were observed in QOC and QOD between cancer and noncancer. The prevalence of symptoms was higher for cancer than for other causes of death. Conclusions: QOC and QOD were higher at home than in other places of death across all causes of death. The further expansion of end-of-life care options is crucial for improving QOC and QOD for all terminal patients.

Trajectories of Activities of Daily Living in the Last Eight Weeks of Life Among Patients With Terminal Cancer in a Palliative Care Unit: A Retrospective Study

Background

Although cancer patients' activities of daily living (ADL) are reported to decline before death, ADL trajectories have not been sufficiently clarified due to limitations in the assessment and analysis methods.

Objectives

To clarify the multiple trajectories of ADL in patients with terminal cancer using a comprehensive assessment measure.

Design

This was a retrospective observational study.

Setting/Study Subjects

Cancer patients aged ≥18 years discharged at death from a single-center palliative care unit.

Measurements

Functional Independence Measure (FIM) total scores for eight weeks retrospectively.

Results

In total, 306 patients were analyzed. Group-based trajectory modeling analysis estimated four groups as the best model for the FIM trajectory over eight weeks using the following trajectories: (1) a No Decline group, in which ADL did not decline until just before death; (2) a Rapid Decline group, in which ADL declined rapidly two weeks before death from a trajectory similar to the No Decline group; (3) a Moderate Disability and Slow Decline group, in which the patient slowly declined from requiring mild-to-severe assistance; and (4) a Severe Disability group, in which the patient continuously required severe assistance.

Conclusions

Multiple ADL trajectories were identified in the last eight weeks of life of patients with terminal cancer. These findings suggest that palliative care needs to be tailored to the characteristics of each patient.

Depression and complicated grief in bereaved caregivers in cardiovascular diseases: prevalence and determinants

OBJECTIVES

Despite the recommendation that patients with cardiovascular disease (CVD) receive bereavement care, few studies have examined the psychological disturbances in bereaved caregivers. We examined the prevalence and determinants of depression and complicated grief among bereaved caregivers of patients with CVD.

METHODS

We conducted a cross-sectional survey using a self-administered questionnaire for bereaved caregivers of patients with CVD who had died in the cardiology departments of nine Japanese tertiary care centres. We assessed caregiver depression and grief using the Patient Health Questionnaire-9 (PHQ-9) and Brief Grief Questionnaire (BGQ), respectively. The questionnaire also covered caregivers' perspectives toward end-of-life care and the quality of the deceased patient's death.

RESULTS

A total of 269 bereaved caregivers (mean age: 66 (57-73) years; 37.5% male) of patients with CVD were enrolled. Overall, 13.4% of the bereaved caregivers had depression (PHQ-9 ≥10) and 14.1% had complicated grief (BGQ ≥8). Depression and complicated grief's determinants were similar (ie, spousal relationship, unpreparedness for the death, financial and decision-making burden and poor communication among medical staff). Patients and caregivers' positive attitudes toward life-prolonging treatment were associated with complicated grief. Notably, in caregivers with complicated grief, there was less discussion with physicians about end-of-life care. Caregivers who felt that the patients did not receive sufficient treatment suffered more frequently from depression and complicated grief.

CONCLUSIONS

Approximately 15% of bereaved caregivers of patients with CVD suffered from depression and complicated grief. Cardiologists should pay particular attention to caregivers with high-risk factors to identify those likely to develop depression or complicated grief.

Relationship between implementation of systematic advance care planning and the quality of death among nursing home residents: a survey

Background

Advance care planning (ACP) is beneficial for the quality of death (QOD). However, the effects of ACP on the QOD may vary across cultures.

Objectives

This study aimed to explore the relationship between the 15-step ACP program and the QOD among Japanese nursing home residents.

Design

A cross-sectional survey.

Methods

A cross-sectional survey was conducted among the family members of 39 nursing home residents who died between April 2017 and March 2019 by distributing the survey questionnaire by post. The survey included questions about the QOD of residents, and responses were evaluated using the Good Death Inventory (GDI) scale.

Results

Responses were obtained from 30 of the 39 bereaved families (76.9%). Data were analyzed using hierarchical clustering to determine five groups and conduct multiple comparisons. The following three domains of interest were identified: 'Dying in a favorite place', 'Good relationship with the medical staff', and 'Independence'. GDI scores were significantly higher for residents with higher ACP completion rates than for those with lower rates (p < 0.01). Residents who had taken ACP interviews had significantly higher GDI scores (p < 0.01) than those who had not taken interviews.

Conclusion

Overall, these findings suggest that systematic ACP might be related to the QOD among Japanese nursing home residents in the above mentioned three domains. Limitations of the present study were small sample size, cross-sectional survey design as opposed to a cohort survey design, and multiple biases, including the emotional instability of bereaved family members, the length of stay of the residents, the degree of dementia of the residents, and their tendency to talk about the place of death and to develop good relationships with the medical staff.

End-of-Life Discussions and Their Timing for Patients With Cardiovascular Diseases - From the Perspective of Bereaved Family Members

BACKGROUND

Enhanced discussions regarding end-of-life (EOL) are crucial to provide appropriate care for seriously ill patients. However, the current status of EOL discussions, especially their timing and influencing factors, among patients with cardiovascular diseases (CVD) remains unknown.Methods and Results: We conducted a cross-sectional questionnaire survey of bereaved family members of CVD patients who died at 10 tertiary care institutes in Japan. In all, 286 bereaved family members (38.2% male; median age 66.0 [interquartile range 58.0-73.0] years) of CVD patients were enrolled; of these, 200 (69.9%) reported that their families had had EOL discussions with physicians. The major topic discussed was resuscitation (79.0%), and 21.5% discussed the place of EOL care. Most discussions were held during hospitalization of the patient (88.2%). More than half (57.1%) the discussions were initiated less than 1 month before the patient died, and 22.6% of family members felt that this timing of EOL discussions was late. Bereaved family members' perception of late EOL discussions was associated with the family members aggressive attitude towards life-prolonging treatment, less preparedness for bereavement, and less satisfaction with EOL care.

CONCLUSIONS

Approximately 70% of bereaved family members of CVD patients had EOL discussions, which were often held shortly before the patient died. Further research is required to establish an ideal approach to EOL discussions at an appropriate time, which may improve the quality of EOL care.

What we learnt from parents' death experience: A cross-sectional study of death literacy and parent's death quality among adult children in China

OBJECTIVES

This study aims at investigating the current status of death literacy and parent's death quality among adult children in China. A cross-sectional survey was conducted to explore the associations between death literacy and parent's death quality and to provide evidence for developing public policies for improving the quality of death and end-of-life care for the population in the Greater Bay Area (GBA) of China.

METHODS

A cross-sectional design was adopted. Participants who experienced their father's and/or mother's death were recruited from 5 cities in the GBA of China in 2022. The Good Death Inventory (GDI) and the Death Literacy Index (DLI) were used to investigate the perceived quality of death of the parents of the participants and the death literacy of the participants.

RESULTS

A total of 511 participants were recruited. Participants with higher GDI scores were positively associated with DLI scores (p < 0.001). Adult children who had close relationships before their parents' death also had higher levels of DLI.

SIGNIFICANCE OF RESULTS

This study investigated death literacy among bereaved adult children in China, filling a gap in the investigation of death literacy among Chinese residents. It found that parents' death experience can have a significant impact on the death literacy of adult children, which may affect their understanding and preparation for their own eventual death. Promotion of family discussion on death, development of community palliative care, and improving public death literacy are urgently needed in China.

Web-Based Post-Bereavement Survey System in Specialized Palliative Care: A Feasibility Pilot Study

Web-based post-bereavement survey systems for specialized palliative care will enable obtaining timely results on the care quality from more participants at a lower cost. The primary aim of the study was to develop a web-based post-bereavement survey system and to compare response rates for different number of items. The secondary aim was to examine response bias between web-based and mail survey in post-bereavement surveys. Between January and April 2019, two cross-sectional web-based questionnaire surveys were conducted among the bereaved families from six inpatient palliative care units in Japan. Measurements included structure and process of end-of-life (EOL) care, overall care satisfaction, achievement of a good death, depression, grief status, web survey usability, and participant and bereaved family member characteristics. The long survey included 34 items, and the short survey included 16 items. There were no significant differences in the response rates between the long and short surveys (24% and 27%, respectively, p = 0.376). Compared with a previous nationwide post-bereavement mail survey, more children responded; however, the quality rating scores was unchanged. Despite low response rate, no apparent response bias was observed, indicating its feasibility. This survey method is low-cost, less burdensome to the institution, and allows for ongoing quality assurance.

Good death for people living with dementia: a qualitative study

BACKGROUND

Ensuring a good death is one of the primary objectives of palliative care and end-of-life care. There is insufficient evidence regarding what defines a good death for people living with dementia. Obtaining an understanding of what constitutes a good death could help improve dementia care. This study aimed to explore how multiple stakeholders perceive a good death for people living with dementia.

METHODS

This qualitative study was carried out across six prefectures in Japan. Enrollment of participants took place within dementia outpatient clinics, hospitals, daycare centers, and community centers. A total of thirty-three in-depth interviews with people living with dementia, physicians, and nurses were conducted. Six focus group discussions were performed with family caregivers and care workers. Verbatim transcripts of the interviews were prepared, and inductive content analysis was used to examine the data.

FINDINGS

Regarding the perception of a good death, the following themes were derived: (1) painless death; (2) dying in a preferred environment; (3) family's coping with loss; (4) maintaining regular life; (5) living with respect; and (6) preparation for death. All these themes are interrelated. Participants viewed a good death as a process rather than a single event.

CONCLUSION

This study identifies crucial components of a good death for people living with dementia. The findings could be used to improve dementia care.

Perceptions of Palliative and End-Of-Life Care Capacity Among Frontline Staff and Administrators in Long-Term Care Homes During the COVID-19 Pandemic in Ontario, Canada: A Mixed-Methods Evaluation

OBJECTIVES

The COVID-19 pandemic has greatly affected the morbidity and mortality of residents in long-term care (LTC) homes. However, not much is known about its impact on staff's perception of their capacity to provide palliative and end-of-life (EOL) care for LTC residents over the course of the pandemic. We investigated changes in self-reported confidence among LTC workers and their experience in providing palliative and EOL care to residents before and during the COVID-19 pandemic.

DESIGN

Mixed-methods evaluation using a survey (n = 19) and semistructured interviews (n = 28).

SETTING AND PARTICIPANTS

Frontline workers from 9 LTC homes who participated in Communication at End-of-Life Program in Ontario, Canada, between August 2019 and March 2020.

METHODS

The survey captured LTC staff's confidence level, including attitudes toward death and dying; relationships with residents and families; and participation in palliative and EOL care. The interviews identified facilitators and barriers to providing palliative and EOL care during the pandemic.

RESULTS

The COVID-19 pandemic negatively impacted frontline LTC staff's confidence in their role as palliative care providers. Participants also reported notable challenges to providing resident-centered palliative and EOL care. Specifically, visitation restriction has led to increased loneliness and isolation of residents and impeded staff's ability to build supportive relationships with families. Furthermore, staffing shortages due to the single-site work restriction and illness increased workload. Psychological stress caused by a fear of COVID-19 infection and transmission also hindered staff's capacity to provide good palliative and EOL care.

CONCLUSIONS AND IMPLICATIONS

Frontline LTC staff-even those who felt competent in their knowledge and skills in providing palliative and EOL care after receiving training-reported notable difficulties in providing resident-centered palliative and EOL care during the COVID-19 pandemic.

Translation and psychometric evaluation of the Persian version of "good death inventory- short Form" from the perspective of family-members of cancer patients

INTRODUCTION

Achieving good death is among the objectives of palliative care in patients with cancer. There should be an instrument for evaluating the quality of palliative care provided by family members at the end of life. This study was done to assess the psychometric properties of good death inventory- short form according to the perspective of family of patients with cancer.

METHOD

This methodological study was done in 2022 at two hospitals in Tehran. The translation was done via forward-backward method. Face validity was examined through cognitive interviewing with 10 family members. The content validation, were used by assessment the opinions of 10 palliative care specialists. The construct validity was explored through exploratory factor analysis and examination of convergent validation with care evaluation scale 2.0, as well as inspection of correlation by answering two general questions of satisfaction with treatment and end of life quality of life. The scale's reliability, internal consistency was calculated using Cronbach's alpha coefficient and stability via test-retest.

RESULTS

Overall, 204 family members of patients with cancer were included. In the exploratory factor analysis, three factors of peace, hope, and value as well as quality of care were extracted with cumulative variance of 41.8%.A significant and suitable correlation between the total scores of the participants Good death inventory-short form and care evaluation scale2.0 (r = 0.459, P < 0.001) and general satisfaction with end-of-life care (r = 0.423, p < 0.001) as well as the patient's general quality of life (r = 0.539, p < 0.001). The Cronbach's alpha coefficient for the questionnaire was found 0.842, and the stability was confirmed with Intra cluster correlation coefficient = 0.851.

CONCLUSION

the Persian version of good death inventory-short form is a valid and reliable questionnaire which can investigate the factors associated with good death according to patients' family members' perspective.

Development of a Japanese Version of the Quality of Life at the End of Life-Cancer Scale

CONTEXT

The Quality of Life at the End of Life-Cancer Scale (QUAL-EC) is a self-reported instrument to assesses the quality of life of patients with cancer near the end of life.

OBJECTIVE

To test the reliability and validity of the QUAL-EC-J, a Japanese translated version of the QUAL-EC.

METHODS

A total of 179 Japanese patients with advanced cancer completed the QUAL-EC-J, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Rosenberg Self-Esteem Scale, Multidimensional Scale of Perceived Social Support, Functional Assessment of Cancer Therapy-General Scale, and Functional Assessment of Chronic Illness Therapy-Spiritual questionnaires. We performed confirmatory factor analysis of the four structures of the QUAL-EC and exploratory factor analysis of the QUAL-EC-J. Internal consistency was assessed using Cronbach's α coefficient and validity was examined by calculating correlations with relevant scales.

RESULTS

Confirmatory factor analysis showed an inadequate fit to the original QUAL-EC structure. Exploratory factor analysis revealed a three-factor structure of the QUAL-EC-J, with Cronbach's α values of 0.68-0.88. All subscales were negatively correlated with depression and anxiety. Each subscale was correlated with related measures: "symptom control" with "physical well-being"; "acceptance of disease and life" with "social and family well-being" and "meaning/peace"; and "preparation for end of life" with "emotional well-being" and "meaning/peace."

CONCLUSIONS

The QUAL-EC-J has a three-factor structure with acceptable reliability and sufficient validity. Differences in the factor structure between the QUAL-EC-J and the QUAL-EC may be due to cultural factors. Study findings suggest that utilization of the QUAL-EC-J could help to improve research and clinical care in advanced cancer in Japan.

Conceptualizations of "good death" and their relationship to technology: A scoping review and discourse analysis

Background and Aims

By the 1960s, medicine experienced technological revolutions that enabled it to control and medicalize death in many circumstances. The modern conceptualization of "good death" emerged in the late 1960s with the beginning of the hospice movement, and palliative care became an official medical specialty in 1987. This project aims to elucidate how the idea of "good death" has been discussed and perceived since then, as well as the impact of medical technologies on death.

Methods

The terms "good death," "technology," and "palliative care" were searched. One hundred ninety English sources that discussed "good death" explicitly or implicitly, published between 1987 and 2020, were included in the final analysis. Texts were analyzed for discursive themes related to "good death" and technology and demographic data related to authors, geographies, types of text, and date of publication.

Results

The discourse of a "good death" with the patient being in control dominated the archive. Other discourses include a good death being peaceful and comfortable, one where the patient is not alone, and one that is not prolonged. Medical technology discourses are largely negative in the setting of death.

Conclusion

Findings indicate a strong critique of the medicalization of death in the literature. This also complements the dominance of discourses on patient autonomy. Medical discourses of "good death" and technology permeate discussion outside of the healthcare context, and there is an absence of spirituality and neutrality in "good death" discourses. The results of this study are relevant for ethics and communication in geriatric and palliative care.

Perspectives on a good death: A comparative study of veterans and civilians

This study aimed to identify any differences between veterans and non-veterans in the importance of domains of the Good Death Inventory. Participants were recruited from Amazon Mechanical Turk to complete a Qualtrics survey on the importance of the 18 domains of the Good Death Inventory scale. Logistic regression models were then used to analyze any differences between veterans (n = 241) and nonveterans (n = 1151). Results showed that veterans (mostly aged 31-50, men, and White) were more likely to indicate that pursuing all treatment possible and maintaining their pride were important aspects of a good death. The results support other studies that have found military culture to be a significant factor in the way veterans view preferences at the end of life. Interventions may include increasing access to palliative care and hospice services for military members and veterans and providing education/training on end-of-life care for healthcare providers who work with this population.

Association between types of home healthcare and emergency house calls, hospitalization, and end-of-life care in Japan

BACKGROUND

To meet the increasing demand for home healthcare in Japan, as part of the national healthcare system, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012 respectively. This study aimed to evaluate whether HCSCs has succeeded in providing 24-h home care services through the end of life.

METHODS

A retrospective cohort study was conducted using the national database in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and September 2015, and used general clinics, conventional HCSCs, or enhanced HCSCs. Each patient was followed up for 6 months after the first visit. The outcome measures were (i) emergency house call(s), (ii) hospitalization(s), and (iii) end-of-life care defined as in-home death. Multivariable logistic regression analyses were performed for statistical analysis.

RESULTS

The analysis included 160,674 patients, including 13,477, 64,616, and 82,581 patients receiving regular home visits by general clinics, conventional HCSCs, and enhanced HCSCs respectively. Compared to general clinics, the use of conventional and enhanced HCSCs was associated with an increased likelihood of emergency house calls (adjusted odds ratio [aOR] and 95% confidence intervals [CIs] of 1.62 [1.56-1.69] and 1.86 [1.79-1.93], respectively) and a decreased likelihood of hospitalizations (aOR [95% CIs] of 0.86 [0.82-0.90] and 0.88 [0.84-0.92] respectively). Among 39,082 patients who died during the follow-up period, conventional and enhanced HCSCs had more in-home deaths (aOR [95% CIs] of 1.46 [1.33-1.59] and 1.60 [1.46-1.74], respectively) compared to general clinics.

CONCLUSIONS

HCSCs (especially enhanced HCSCs) provided more emergency house calls, reduced hospitalization, and enabled expected deaths at home, suggesting that further promotion of HCSCs (especially enhanced HSCSs) would be advantageous.

Real-world data on home end-of-life care for older adults with cancer: A retrospective claims data analysis

Background

Cancer incidence is expected to increase with population aging, making the availability of places for treating patients with terminal cancer a pressing issue. However, little is known about the actual state of home end-of-life care (HEC) in Japan.

Objective

The objective of this study was to examine the real-world state of HEC for older adults with cancer.

Methods

The Yokohama Original Medical Database was used to identify the cohort. Data of target patients was extracted based on three criteria: age ≥65 years, malignant neoplasm diagnosis, and having a specific billing code of HEC. Multivariable linear and logistic regression models were used to evaluate the association between age groups and HEC services or outcome indexes.

Results

Overall, 1323 people (554 and 769 aged < 80 and ≥ 80 years, respectively; men, 59.2%) had planned to receive HEC. The < 80 years group had more frequent emergent home visits than the ≥ 80-year group (P < 0.001), but the number of monthly home visits was similar between the two groups (P = 0.267). The rate of emergent admission was 5.9% in the ≥ 80-year group, which was higher than that in the < 80-year group (3.1%; P = 0.018). Conversely, the rates of central venous nutrition and opioid use were higher in the < 80-year group than those in the ≥ 80-year group.

Conclusions

This study reported patterns of use of HEC among older adults with cancer in the terminal stage. Our findings may provide the basis for providing HEC for older adults with cancer.

The feasibility and effects of a pharmacological treatment algorithm for cancer patients with terminal dyspnea: A multicenter cohort study

BACKGROUND

How clinicians treat patients with terminal dyspnea widely varies, which could hamper quality care. We visualized comprehensive pharmacological treatment delivered by palliative care physicians.

AIM

To examine adherence to a comprehensive pharmacological treatment algorithm for patients with terminal dyspnea, and to explore its outcomes during 48 h.

DESIGN

A multicenter cohort study at five sites (February 2020 to June 2021).

SETTING/PARTICIPANTS

We prospectively enrolled consecutive patients with advanced cancer, Eastern Cooperative Oncology Group performance status 3-4, and moderate/severe dyspnea. Participating palliative care physicians initiated algorithm-based treatment. The primary outcome was the proportion of adherence to the treatment algorithm over 24 h (predefined goal, 70%). We evaluated the adherence, goal achievement, and dyspnea level with a numerical rating scale (NRS), as well as adverse events over 48 h.

RESULTS

All 108 patients received algorithm-based pharmacological treatment. Among 96 and 87 patients who were alive at 24 and 48 h, respectively, 96 (100%; 95% confidence interval [CI] = 96%-100%) and 82 (94%; 95%CI = 87%-98%) continued to receive the algorithm treatment, respectively, and 66 (69%; 95%CI = 59%-77%) and 64 (74%; 95%CI = 63%-82%) achieved the treatment goals, respectively. Using a complete case analysis with paired t-tests, mean dyspnea NRS scores significantly reduced from 7.3 (standard error, 0.2) at the baseline to 4.9 (0.3) at 24 h (n = 72; p < 0.001), and 7.2 (0.3) at the baseline to 4.6 (0.4) at 48 h (n = 55; p < 0.001). Most adverse events were mild to moderate.

CONCLUSIONS

The comprehensive pharmacological treatment algorithm was feasible, and the study data supports its preliminary efficacy and safety. The use of this algorithm may help clinicians improve care for patients with terminal dyspnea.

Quality of death after elective surgery: a questionnaire survey for the bereaved family

PURPOSE

Postoperative death is the third leading cause of death in the world, but the quality of death after surgery has been poorly documented. This study aimed to evaluate the feasibility of a questionnaire survey for the bereaved family regarding the postoperative quality of death and the impact of preoperative functional disability on the quality of death.

METHODS

Patients aged ≥55 years who underwent scheduled surgery under general anesthesia in a tertiary-care hospital in Japan between April 2016 and December 2018 were enrolled. Patients' functional disability was assessed using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) before surgery and scored based on the sum of the 12 items (0-48). Postoperative deaths were detected in medical records 3 months and 1 year after surgery. When death had occurred, a questionnaire on the quality of death using the short version of the Good Death Inventory (GDI) was sent to the bereaved family, which was scored as the sum of the 10 domains (10-70).

RESULTS

Of 4020 eligible patients, 148 patients (3.6 %) died within 1 year after surgery. A hundred and twenty-nine bereaved families were sent the questionnaire, and 83 of them (64.3%) submitted valid responses suggesting the high feasibility of this questionnaire survey. There were no differences between the GDI and WHODAS 2.0 scores (median 49 [interquartile range 41-55] vs. 49 [43-54], respectively, p = 0.90). In addition, multiple regression analysis of related factors using the short version of the GDI as a continuous variable showed that age and death in a facility other than that in which the surgery was performed were associated with lower GDI scores (p = 0.004 and p = 0.04, respectively).

CONCLUSION

The completion rate was 64.3%. There was no association between the quality of death and preoperative functional disability; however, older age was associated with a higher quality of death, while death in a facility other than that in which the surgery was performed was associated with lower quality of death.

Perspectives of Indonesian Muslim patients with advanced lung cancer on good death: A qualitative study

PURPOSE

Lung cancer is the leading cause of cancer-related death. Patients with advanced lung cancer may experience burdensome distress at the end of life. The concept of good death has been shown to be complex, and continues to be expanded by gaining a better understanding of the cultural views of different populations. This study aimed to explore the perspective of Indonesian Muslims patients with advanced cancer on the concept of good death.

METHOD

A qualitative design comprising in-depth interviews was employed. Seven male and 3 female Muslim patients between ages 36 and 68 and diagnosed with advanced lung cancer were recruited from a teaching hospital in Central Java, Indonesia.

RESULTS

Content analysis of the interviews revealed five themes: dying without physical discomfort, dying in religious ways and in a desirable place, dying without emotional discomfort, receiving help and support, and having a good relationship with medical staff.

CONCLUSIONS

Indonesian Muslim patient with advanced lung cancer have unique perspectives on good death, especially based on the themes of religious ways of dying and support from family. Health care providers should be aware that good death is not an individual concern and should thus adopt highly sensitive observation skills to assess the physical and emotional state of patients. These providers must also understand their patients' preferences and respect their needs, regardless of their own beliefs.

Prognostic awareness in Japanese patients with advanced cancer: a follow-up cohort study

BACKGROUND

Patients with advanced cancer have been reported to be more likely to receive goal-concordant care if they have accurate prognostic awareness. However, many patients do not have this awareness. This study aimed to examine the prognostic awareness among Japanese patients with advanced cancer.

METHODS

This single-center, follow-up cohort study included Japanese patients with advanced cancer who received chemotherapy at Tohoku University Hospital between January 2015 and January 2016. Patients were surveyed at enrollment and followed up for clinical events for 5 years thereafter. We compared (i) the patients' prognostic awareness with both actual survival time and physician's prediction of survival and (ii) physician's prediction of survival time with actual survival. Factors associated with accurate prognostic awareness were identified by univariate analysis.

RESULTS

Of the 133 patients eligible for the study, 57 patients were analyzed. Only 10 (17.5%) patients had accurate prognostic awareness. Forty-three patients (75.4%) were optimistic about their prognosis; >80% of patients were more optimistic than their physicians about their prognosis. The physicians' predictions were accurate in for patients (37.5%). Accurate prognostic awareness was associated with physician's explanation of the prognosis and patients' perception of a good death.

CONCLUSIONS

A majority of the patients with advanced cancer in this study had prognostic awareness that was more optimistic in comparison with their actual survival, and most were more optimistic than their physicians about their prognosis. Further research is needed to develop programs to facilitate the discussion of life expectancy with patients in a manner that is consistent with their preferences.

Relationships between bereaved families' decision-making regret about end-of-life care place for patients with cancer and relevant factors

Objective

Decision-making regarding end-of-life care (EOLC) place causes psychological burden on families and 70% of bereaved families have regrets. Healthcare professionals need to support families to prevent regrets. This study aims to clarify the relationship between the factors related to the decision-making methods used to choose a place of care for terminal cancer patients and the regret experienced by bereaved families.

Methods

Participants were 1110 bereaved family members of patients with cancer. The questionnaire items were as follows: the agreement between patients and their families regarding their preferred place of EOLC, decision-making methods, satisfaction with the factors involved in the decision-making processes, experience regarding communication with medical personnel, and regret experienced by the bereaved families.

Results

This analysis included 332 valid responses from 343 respondents. The regret score was significantly lower for the group wherein patients and their caregivers/families had similar preferences regarding the EOLC place (P ​< ​0.001). Regret scores were significantly higher in the physician-led decision-making group (vs. positive role group P ​= ​0.004, vs. shared role group P ​= ​0.014). The regret scores for the bereaved family members were negatively correlated with the satisfaction scores for "friend support," "relationship with doctor," "information," "explanation by doctor," "thought as oneself," and "participation in the decision" (ρ ​= ​-0.207-0.400, P ​≤ ​0.001).

Conclusions

To reduce bereaved families' regret, family members should know the patients' preferred place of EOLC, and patients and their families should be supported by physicians and nurses to understand their options and participate in the decision-making process.

The Good Death Among Black, Indigenous, and/or People of Color: Which Aspects of a Good Death Are Most Important?

A good death is one where a patient's preferences and wishes are fully respected. The purpose of this study was to determine which aspects of a good death are most important to Black/Indigenous, and/or people of color (BIPOC). Participants were recruited from Amazon Mechanical Turk, and then directed to complete a quantitative survey indicating the importance of each item on the Good Death Inventory. A logistic regression model was used to identify any differences in the importance of each item based on the racial background of the respondent. After accounting for other independent variables, the results showed that BIPOC were more likely to indicate that factors such as life completion, receiving all treatment possible, and religious/spiritual support were important aspects of a good death. Results indicate the need for culturally tailored tools that account for cultural differences in what constitutes a good death.

Factors associated with good death of patients with advanced cancer: a prospective study in Japan

PURPOSE

It is important for palliative care providers to identify what factors are associated with a "good death" for patients with advanced cancer. We aimed to identify factors associated with a "good death" evaluated by the Good Death Scale (GDS) score among inpatients with advanced cancer in palliative care units (PCUs) in Japan.

METHODS

The study is a sub-analysis of a multicenter prospective cohort study conducted in Japan. All variables were recorded on a structured data collecting sheet designed for the study. We classified each patient into better GDS group or worse GDS group, and examined factors associated with better GDS using multivariate analysis.

RESULTS

Between January and December 2017, 1896 patients were enrolled across 22 PCUs in Japan. Among them, a total of 1157 patients were evaluated. Five variables were significantly associated with a better GDS score in multivariate analysis: preferred place of death at PCU (odds ratio [OR] 2.85; 95% confidence interval [CI] 1.72-4.71; p < 0.01), longer survival time (OR 1.02; 95% CI 1.00-1.03; p < 0.01), not sudden death (OR 1.96; 95% CI 1.27-3.04; p < 0.01), better spiritual well-being in the last 3 days in life (OR 0.53; 95% CI 0.42-0.68; p < 0.01), and better communication between patient and family (OR 0.81; 95% CI 0.66-0.98; p = 0.03).

CONCLUSIONS

We identified factors associated with a "good death" using GDS among advanced cancer patients in Japanese PCUs. Recognition of factors associated with GDS could help to improve the quality of end-of-life care.

Meaning of death among care workers of geriatric institutions in a death-avoidant culture: Qualitative descriptive analyses of in-depth interviews by Buddhist priests

OBJECTIVE

Care workers' views of clients' death have not been explored in Japan because of a cultural tendency to avoid talking openly about death. However, given the arising problems in end-of-life care settings, such as abuse and burnout, understanding care workers' views regarding death is essential for designing effective interventions. We had two main research questions: Do care workers in Japan have their own ideas about death after working in the landscape of dying and death? Do these ideas influence care workers' professional lives?

METHODS

We recruited interviewees based on a quantitative survey of care workers at 10 geriatric institutions in Tokyo. Among the 323 respondents, 23 survey respondents were willing to participate in an interview. After the scheduling process, nine individuals were able to participate in an in-depth interview. To overwhelm cultural avoidance regarding death that prevents care workers from talking openly about death, Buddhist priests conducted interviews in the current study. Physicians and researchers assisted the interviews. Because this was exploratory studies in which little is known about the topic in question, we adapted a qualitative descriptive approach.

FINDINGS

Thematic analysis revealed that: 1) care workers had clear views about conditions of clients' good death after working in the field of dying and death; 2) care workers were motivated by past experiences of being close to dying themselves; and 3) care workers regarded their care for the dying as an experience that enriched their lives. In addition, the results revealed that the concept of spiritual care in Japan is still its infancy among care workers because of its vague definition.

CONCLUSIONS

Care workers were willing to work for dying people with their view of death, and regarded their jobs as important opportunities for personal growth through caring for the dying.

Protocol for the development and multisite validation of the Quality of Dying and Death-Revised Global Version scale

INTRODUCTION

Evaluating the quality of dying and death is essential to ensure high-quality end-of-life care. The Quality of Dying and Death (QODD) scale is the best-validated measure of the construct, but many items are not relevant to participants, particularly in low-resource settings. The aim of this multisite cross-sectional study is to develop and validate the QODD-Revised Global Version (QODD-RGV), to enhance ease of completion and relevance in higher-resource and lower-resource settings.

METHODS AND ANALYSIS

This study will be a two-arm, multisite evaluation of the cultural relevance, reliability and validity of the QODD-RGV across four participating North American hospices and a palliative care site in Malawi, Africa. Bereaved caregivers and healthcare providers of patients who died at a participating North American hospice and bereaved caregivers of patients who died of cancer at the Malawian palliative care site will complete the QODD-RGV and validation measures. Cognitive interviews with subsets of North American and Malawian caregivers will assess the perceived relevance of the scale items. Psychometric evaluations will include internal consistency and convergent and concurrent validity.

ETHICS AND DISSEMINATION

The North American arm received approval from the University Health Network Research Ethics Board (21-5143) and the University of North Carolina Institutional Review Board (21-1172). Ethics approval for the Malawi arm is being obtained from the University of North Carolina Institutional Review Board and the Malawian National Health Science Research Committee. Study findings will be disseminated through publication in peer-reviewed journals and conference presentations.

Older individuals' perceptions of a good death: A systematic literature review

The purpose of this literature review was to describe older individuals' perceptions of a good death. A systematic data search of CINAHL, Medline, PsycINFO, ASSIA, and Medic databases from 2010 to 2020, supplemented with a manual search, resulted in 16 studies that met the inclusion criteria. Study quality was assessed using the JBI critical appraisal criteria. Data were analyzed by inductive content analysis. The core elements of older individuals' perceptions of a good death were a dignified moment of death, factors that enhance the desire to live, an active agency in adapting to death, and equal interpersonal relationships.

Depression and Complicated Grief, and Associated Factors, of Bereaved Family Members of Patients Who Died of Malignant Pleural Mesothelioma in Japan

OBJECTIVES

we investigated the prevalence and associated factors of depression and complicated grief (CG) among bereaved family members of malignant pleural mesothelioma (MPM) patients in Japan.

METHODS

Bereaved family members of MPM patients (n = 72) were surveyed. The Japanese version of the Patient Health Questionnaire-9 (PHQ-9) and the Japanese version of the Brief Grief Questionnaire (BGQ) were used to assess depression and complicated grief (CG), respectively. Socio-economic factors, anger toward asbestos, care satisfaction, achievement of good death, and quality of end-of-life care were assessed in relation to depression and CG.

RESULTS

In the family members of MPM patients, the frequencies of depression and CG were 19.4% and 15.3%, respectively. The bereaved family members who were not compensated by the asbestos-related health-damage relief system (p = 0.018) and who felt the financial impacts of the patient's MPM on the family (p = 0.006) had a higher likelihood of depression. The bereaved family members who were not satisfied with the care given when the patient became critical (p = 0.034), who were not compensated by the asbestos-related health-damage relief system (p = 0.020), who felt the financial impact of the patient's MPM on the family (p = 0.016), and whose deceased relative underwent surgery (p = 0.030) had a higher likelihood of CG.

CONCLUSIONS

For bereaved family members of MPM patients, routine screening for depression and CG and the provision of grief care are suggested. In addition, for family members of MPM patients, financial support, including the promotion of the asbestos-related health-damage relief system, and improved care for patients who undergo surgery and when patients become critical, are recommended.

Development and Validation of Filial Piety Representations at Parents’ End of Life Scale

Filial piety has a long historical standing in Chinese communities. However, the filial piety practices of adult children at the end of a parent’s life are under-explored. This study aims to develop a measurement for filial piety representations of the adult children of Macao Chinese, whose parents are at the stage of end of life. By adopting a scale development and validation framework, a 19-item Filial Piety Representations at Parents’ End of Life Scale (FPR-EoL) was formulated based on a Dual Filial Piety Model and literature, through procedures of item identification, panel review, cognitive interviews, and pre-test. The FPR-EoL was examined on 274 individuals. Factor analysis showed four factors in the scale; respect and comfort, acceptance of death, spending final days, and disclosing bad news. The Cronbach’s alpha of FPR-EoL was 0.73, and the four factors were 0.73, 0.66, 0.58 and 0.77, respectively. Discriminant validity was examined between FPR-EoL, the Good Death Inventory (GDI) and the Filial Piety Scale (FPS). The results suggested that there were differences between the three scales. FPR-EoL is found to be a reliable, valid and novel measure of filial piety representations among Macao Chinese. It may be a potential tool to probe and achieve good death among older persons of Chinese ethnicity in clinical settings.

An exploration of person-centred approach in end-of-life care policies in England and Japan

Background

Increasing evidence has suggested that a person-centred approach (PCA) is beneficial not only for improving care outcomes but also for mitigating the pressure on public health systems. However, policy implementation gaps have prevented the translation of this complex framework into useful practical, ethical and moral stances for end-of-life care (EOLC). This article aims to explore the meaning and implications of person-centredness in EOLC policy discourses.

Methods

By perceiving policy documents as a medium embodied with socio-political and cultural norms, we analysed how PCA in EOLC is constructed within specific socio-cultural contexts and the implications of these contexts on resultant care. Focusing on England and Japan, we conducted a critical policy analysis to examine and compare key policy and legal documents released between 2000 and 2019 in these two post-industrial and socio-culturally distinctive countries.

Results

Our analysis found that the PCA is mobilised in policy discourses primarily through three interconnected dimensions: individual, relational and existential. While acknowledging that both countries have developed varied policy and legal mechanisms to emphasise holistic and integrated care with respect to these three dimensions, we also identified significant gaps in the pol icies both within and between England and Japan. They include ambiguity in defining patients’ best interests, fragmented support for social and family care and the neglect of existential needs.

Conclusions

This cross-cultural analysis has revealed the complex nature of discourses around PCA in English and Japanese EOLC policies, which often concentrate on the multifaceted aspects of experiences as one approaches the end of life. Despite this, we argue that a more holistic construction of PCA is needed in EOLC policies not only in England and Japan but also more broadly, to encapsulate the richness of end-of-life experiences.

Bereaved Family Members’ Perspectives of Good Death and Quality of End-of-Life Care for Malignant Pleural Mesothelioma Patients: A Cross-Sectional Study

Objective: This study investigated whether malignant pleural mesothelioma (MPM) patients achieved good deaths and good quality of end-of-life care compared with other cancer patients from the perspective of bereaved family members in Japan. Methods: This cross-sectional study was part of a larger study on the achievement of good deaths of MPM patients and the bereavement of their family members. Bereaved family members of MPM patients in Japan (n = 72) were surveyed. The Good Death Inventory (GDI) was used to assess the achievement of good death. The short version of the Care Evaluation Scale (CES) version 2 was used to assess the quality of end-of-life care. The GDI and CES scores of MPM patients were compared with those of a Japanese cancer population from a previous study. Results: MPM patients failed to achieve good deaths. Only 12.5% of the MPM patients were free from physical pain. The GDI scores of most of the MPM patients were significantly lower than those of the Japanese cancer population. The CES scores indicated a significantly poorer quality of end-of-life care for the MPM patients than the Japanese cancer population. The total GDI and CES scores were correlated (r = 0.55). Conclusions: The quality of end-of-life care for MPM patients remains poor. Moreover, MPM patients do not achieve good deaths from the perspective of their bereaved family members.

Nationwide survey on family caregiver-perceived experiences of patients with cancer of unknown primary site

PURPOSE

Cancer of unknown primary site (CUP) is an aggressive disease with poor prognosis. As research on the experiences of CUP patients and their families is scarce, this study aimed to compare the family caregiver-perceived burden of CUP with that of common cancers (lung, colon, and stomach cancers). The association between family caregiver-perceived burden and CUP patients' quality of life (QOL) at end-of-life and family depression, respectively, was also explored.

METHODS

This was a pre-planned secondary analysis of nationwide cross-sectional survey data from the bereaved family caregivers of patients with cancer who died at 286 institutions. The major measurements were the eight-item family caregiver-perceived Burden scale (comprising specialist access, uncertainty, and prolonged diagnosis), Good Death Inventory, and Patient Health Questionnaire 9.

RESULTS

Of 27,591 survey responses, we analyzed 97 and 717 responses from family caregivers of patients with CUP and common cancer, respectively. The families of CUP patients scored significantly higher on all three burden subscales than those of common cancer patients (effect sizes: specialist access subscale, 0.3; uncertainty subscale, 0.66; and prolonged diagnosis subscale, 0.69; adjusted P < 0.01). Greater family burden was significantly associated with lower patient QOL and higher family depression. Burden was significantly associated with being a spouse, second opinion consultation, and diagnosis period of > 1 month.

CONCLUSION

The family caregivers of CUP patients experience poor specialist access, greater uncertainty, and a prolonged diagnosis. They should be cared for from the initial stages to establish access to specialists, obtain an early diagnosis, and reduce uncertainty.

Impact of end-of-life respiratory modalities on quality of dying and death and symptom relief in patients with interstitial lung disease: a multicenter descriptive cross-sectional study

BACKGROUND

Respiratory modalities applied at the end of life may affect the burden of distressing symptoms and quality of dying and death (QODD) among patients with end-stage interstitial lung disease (ILD); however, there have been few studies into respiratory modalities applied to these patients near death. We hypothesized that high-flow nasal cannula (HFNC) might contribute to improved QODD and symptom relief in patients with end-stage ILD.

OBJECTIVES

This multicenter study examined the proportion of end-of-life respiratory modalities in a hospital setting and explored its impact on QODD and symptom relief among patients dying with ILD.

METHODS

Consecutive patients with ILD who died in four participating hospitals in Japan from 2015 to 2019 were identified and divided into four groups according to end-of-life respiratory modality: conventional oxygen therapy (COT), HFNC, non-invasive ventilation (NIV), and invasive mechanical ventilation (IMV). In addition, a mail survey was performed to quantify the QODD and symptom relief at their end of life from a bereaved family's perspective. QODD and symptom relief were quantified using the Good Death Inventory (GDI) for patients with a completed bereavement survey. The impact of end-of-life respiratory modalities on QODD and symptom relief was measured by multivariable linear regression using COT as a reference.

RESULTS

Among 177 patients analyzed for end-of-life respiratory modalities, 80 had a completed bereavement survey. The most common end-of-life respiratory modality was HFNC (n = 76, 42.9%), followed by COT (n = 62, 35.0%), NIV (n = 27, 15.3%), and IMV (n = 12, 6.8%). Regarding the place of death, 98.7% of patients treated with HFNC died outside the intensive care unit. Multivariable regression analyses revealed patients treated with HFNC had a higher GDI score for QODD [partial regression coefficient (B) = 0.46, 95% CI 0.07-0.86] and domain score related to symptom relief (B = 1.37, 95% CI 0.54-2.20) than those treated with COT.

CONCLUSION

HFNC was commonly used in patients with end-stage ILD who died in the hospital and was associated with higher bereaved family ratings of QODD and symptom relief. HFNC might contribute to improved QODD and symptom relief in these patients who die in a hospital setting.

[Assessment Items Emphasized by Visiting Nurses in How Older Patients Treated at Home and Their Families Decide the Place of Death]

Although 70% of people in Japan wish to die at home, only 13.6% do, and 72.9% die in hospitals. This study aimed to clarify, from the perspective of visiting nurses, the factors influencing patients and their families in deciding the place of death and their satisfaction with end-of-life care at the chosen place. We conducted a survey of 70 visiting nurses with over a year of home nursing experience. They responded to the key factors influencing the decisions of patients and their families regarding place of death, either hospital or home, and the satisfaction at each place of death on a 10-point scale. 67 nurses valued the following two items when the place of death was a hospital: "Less burden of care on the family" and "Specialized treatment to alleviate suffering." The following four items were emphasized in the home: "I can live my own life as I want," "I can have my family be there when I want them to be," "I can receive extensive nursing care," and "I can be seen by my family doctor." The nurses also rated the satisfaction of patients and their families much higher when they die at home than in a hospital. Therefore, improving the treatment environment based on the features of the place of death, and enhancing community-based end-of-life care support, would allow patients and their families to spend their own time in the hospital and get specialized treatment at home, resulting in greater satisfaction with end-of-life care.

Private or shared room? A nationwide questionnaire survey on bereaved family members' perceptions of where patients spend their last days

BACKGROUND

Where patients receive end-of-life care influences their quality of life.

OBJECTIVES

To clarify the effects of staying in a private or shared room in inpatient hospices.

DESIGN

A part of a Japanese multicentre survey to evaluate the quality of end-of-life care.

SETTING/PARTICIPANTS

779 bereaved families whose relatives who died from cancer in inpatient hospices.

MEASUREMENTS

The primary outcome was family-perceived need for improvement in environment-related professional care. Secondary end-points included: family satisfaction, environment-related family perception, and quality of death and dying (Good Death Inventory: GDI).

RESULTS

574 responded (73.7%). 300 patients were in a private room from admission to discharge, 47 were in a shared room less than 50% of the time, and the remaining 85 were in a shared room 50% or more. There were significant differences in the need for improvement in shared (vs private) rooms, and in favour of private rooms for: 'privacy was protected', 'easy for visitors to visit', 'could discuss sensitive issues with medical staff without concern', and 'could visit at night.', as well as 'living in calm circumstances' and 'spending enough time with family' of the GDI. Contrarily, significant differences were found in favour of shared rooms for: 'the patient could interact with other patients'. There was no significant difference in family satisfaction and total score of GDI.

CONCLUSION

There are the advantages and disadvantages of spending one's final days in a private or shared room, and adjusting rooms according to patients and their families' values is necessary.

Association between temporary discharge from the inpatient palliative care unit and achievement of good death in end-of-life cancer patients: A nationwide survey of bereaved family members

AIM

To explore the unclear association between temporary discharge home from the palliative care unit and achievement of good death, in the background of increases in discharge from the palliative care unit. Association between experiences and circumstances of patient and family and duration of temporary discharge was also examined.

METHODS

This study was a secondary analysis of data from a nationwide post-bereavement survey.

RESULTS

Among 571 patients, 16% experienced temporary discharge home from the palliative care unit. The total good death inventory score (p < .05) and sum of 10 core attributes (p < .05) were significantly higher in the temporarily discharged and stayed home ≥2 weeks group. Among all attributes, "Independent in daily activities" (p < .001) was significantly better in the temporarily discharged and stayed home ≥2 weeks group. Regarding the experience and circumstance of patient and family, improvement of patient's appetite (p < .05), and sleep (p < .05) and peacefulness (p < .05) of family caregivers, compared to the patient being hospitalized, were associated with longer stay at home after discharge.

CONCLUSIONS

Patient's achievement of good death was better in the temporarily discharged and stayed home longer group, but this seemed to be affected by high levels of independence of the patient. Temporary discharge from the palliative care unit and staying home longer was associated with improvement of appetite of patients and better sleep and mental health status of family caregivers. Discharging home from palliative care unit is worth being considered even if it is temporary.

Family experience of palliative sedation therapy: proportional vs. continuous deep sedation

PURPOSE

Some patients experience intense symptoms refractory to intensive palliative care, and palliative sedation is sometimes used. Palliative sedation may be classified into proportional and continuous deep sedation (CDS). The primary aim of this study was to compare family experience between families of patients who received proportional or CDS.

METHODS

A multicenter questionnaire survey was conducted involving bereaved families of cancer patients who received proportional or CDS based on a sedation protocol. Overall evaluation of sedation (satisfaction, family-perceived distress, appropriateness of timing, and patient distress) and 13-item family concerns, good death, satisfaction with care, depression, quality of care, unfinished business, and balance between symptom relief and maintaining communication were measured.

RESULTS

Among the 2120 patients who died, 222 patients received a continuous infusion of midazolam. A sedation protocol was used in 147 patients, and questionnaires were sent to 124 families. A total of 78 responses were finally returned (proportional, 58 vs. CDS, 20). There were no significant differences in the overall evaluation, family concerns, total score of good death, satisfaction, depression, or balance between symptom relief and maintaining communication. On the other hand, some quality of care items, i.e., relationship with medical staff (P < 0.01), physical care by nurses (P = 0.04), and coordination and consistency (P = 0.04), were significantly better in the CDS group than in the proportional sedation group. Family-reported unfinished business was also better in the CDS group, with marginal significance.

CONCLUSIONS

Family experience of CDS was not less favorable than proportional sedation, and actually rated more favorably for some elements of quality of care and unfinished business.

Association Among End-Of-Life Discussions, Cancer Patients' Quality of Life at End of Life, and Bereaved Families' Mental Health

End-of-life discussions are essential for patients with advanced cancer, but there is little evidence about whether these discussions affect general ward patients and family outcomes. We investigated the status of end-of-life discussions and associated factors and their effects on patients' quality of death and their families' mental health. Participants in this retrospective cross-sectional observational study were 119 bereaved family members. Data were collected through a survey that included questions on the timing of end-of-life discussions, quality of palliative care, quality of patient death, and depression and grief felt by the families. Approximately 64% of the bereaved family members participated in end-of-life discussions between the patient and the attending physician, and 55% of these discussions took place within a month before death. End-of-life discussions were associated with the patients' prognostic perception as "incurable, though there is hope for a cure" and "patients' experience with end-of-life discussions with family before cancer." There was a small decrease in depression and grief for families of patients who had end-of-life discussions. Those who did not have end-of-life discussions reported lower quality of end-of-life care.

Bereaved Family Members' Perceived Care at the End of Life for Patients with Noncancerous Respiratory Diseases

Background: Data regarding the quality of end-of-life care for patients with noncancerous illnesses are lacking.

Objective: This study aimed to evaluate end-of-life care for patients with noncancerous respiratory disease from the perspective of bereaved family members and explore the factors associated with the quality of patient death and care.

Design: This cross-sectional study included patients who had died of noncancerous respiratory disease in general wards of pulmonary department in Japan between 2014 and 2016 and conducted an anonymous self-report questionnaire survey for the patients' bereaved family members.

Measurements: We evaluated overall satisfaction with care and the quality of death and end-of-life care using the Good Death Inventory (GDI) and Care Evaluation Scale (CES), respectively. A multiple linear regression analysis was performed to explore the factors associated with these outcomes.

Results: In total, 130 questionnaires were distributed, and the effective response rate was 38% and 50 patients were included (median age: 82 [range 58–101] years; 37 men [74%]). Primary diagnoses at death included 29 cases of pneumonia (58%), 15 interstitial lung disease (30%), and 3 chronic obstructive pulmonary disease (6%). Of the bereaved family members, 26 (52%) were spouses, and 19 (38%) were children (median age [range]: 68 [33–102] years, 15 men [30%]). The overall CES and GDI scores (mean ± standard deviation) were 77 ± 15 and 79 ± 15, respectively. The presence of dementia was an independent factor associated with high CES and GDI scores in the multiple linear regression analysis.

Conclusions: In patients who died of noncancerous respiratory disease, the presence of dementia could be associated with the higher quality of patient death and care. In dementia, an understanding of the terminal nature of this condition may lead to an appropriate end-of-life care.

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.

What Makes Chinese Adult Children Behave Differently during Parents' End of Life: A Discriminant Analysis of Macao Chinese

The daily practice of filial piety (FP) is well prescribed under the traditional filial norms in the Chinese community. However, exploration of FP practices at the end of parents' lives is limited. The current study explored the FP representation and good death preferences of Macao Chinese. A cross-sectional web-based survey was conducted and discriminant analysis was used to identify possible predictors of FP representation in the context of parents' end of life. Results showed that Macao Chinese were inclined to perform most of the filial duties in the last journey of their parents. Among 705 participants, 150 (21.3%) tended to practice authoritarian FP, and 555 (78.7%) tended to practice reciprocal FP. Age, education, religion, and good death preferences were identified as predictors of different FP representation groups. The findings could help clinicians to obtain a preliminary perception of FP representation of Chinese patients and to determine the appropriate approach for end-of-life care from a family perspective.

Healthcare Providers' Perceptions on the Timing of Initial Advance Care Planning Discussions in Japan: a Mixed-Methods Study

BACKGROUND

Most adult patients are willing to discuss advance care planning before the onset of any illness. There might be differences in preferences for timing when it comes to initiating advance care planning discussions by healthcare providers with patients.

OBJECTIVE

To identify healthcare providers' willingness to initiate advance care planning discussions in Japan.

DESIGN

A mixed-methods questionnaire comprising three case scenarios based on three different illness trajectories.

PARTICIPANTS

The study participants were physicians and nurses employed in four community hospitals in Japan.

MAIN MEASURES

Percentages of physicians' and nurses' willingness to initiate advance care planning discussions at four stages of patients' illness trajectory were quantitatively determined, and perceptions on preferred timing were qualitatively identified.

KEY RESULTS

From 108 physician and 123 nurse respondents (response rate: 99%), 291 physician and 362 nurse responses about three case scenarios were obtained. Overall, 51.2% of physicians and 65.5% of nurses (p < 0.001) accepted discussion before illness. Less than one-third of physicians considered advance care planning a "wise precaution," while about two-thirds of nurses did. Additionally, more than half of both physicians and nurses preferred to postpone advance care planning until the patient's imminent death.

CONCLUSIONS

Physicians are less willing than nurses to begin advance care planning discussions before patients' health has deteriorated though most prefer to wait until the patients are close to death. Healthcare providers' attitudes toward advance care planning will need to be addressed to improve rates of completion in Japan.

Preferences on advance care planning and end-of-life care in patients hospitalized for heart failure

AIMS

Early engagement in advance care planning (ACP) is recommended in heart failure (HF) management. We investigated the preferences of patients with HF regarding ACP and end-of-life (EOL) care, including their desired timing of ACP initiation.

METHODS AND RESULTS

Data were collected using a 92-item questionnaire survey, which was directly distributed to hospitalized patients by dedicated physicians and nurses in a university hospital setting. One-hundred eighty-seven patients agreed to participate (response rate: 92.6%), and 171 completed the survey [valid response rate: 84.7%; men: 67.3%; median age: 73.0 (63.0-81.0) years]. Logistic regression analyses were conducted to identify the predictors of positive attitudes towards ACP. Most recognized ACP as important for their care (n = 127, 74.3%), 48.1% stated that ACP should be initiated after repeated HF hospitalizations in the past year, and 29.0% preferred ACP to begin during the first or second HF hospitalization. Only 21.7% of patients had previously engaged in ACP conversations during HF management. Positive attitudes towards ACP were associated with lower depressive symptoms [two-item Patient Health Questionnaire; odds ratio (OR): 0.75, 95% confidence interval (CI): 0.61-0.92, P-value: 0.006], marriage (OR: 2.53, 95% CI: 1.25-5.12, P-value: 0.010), and a high educational level (OR: 2.66, 95% CI: 1.28-5.56, P-value: 0.009), but not with severity of HF (represented by Seattle Heart Failure Model risk score). Regarding EOL care, while 'Saying what one wants to tell loved ones' (83.4%), 'Dying a natural death' (81.8%), and 'Being able to stay at one's favorite place' (75.6%) were the three most important factors for patients, preferences for 'Receiving sufficient treatment' (56.5%) and 'Knowing what to expect about future condition' (50.3%) were divergent.

CONCLUSIONS

Despite patients' preferences for ACP conversations, there was a discrepancy between preference and engagement in ACP among patients hospitalized for HF. Patients' preferences regarding EOL care may differ; physicians need to consider the appropriate ACP approach to align with patients' care goals.

Factors related to spiritual well-being in the last days of life in three East Asian countries: An international multicenter prospective cohort study

BACKGROUND

Some factors associated with spiritual well-being in dying patients have previously been reported. However, there has been no cross-cultural study comparing factors related to spiritual well-being. The current investigation may shed light on this under-investigated area through a comparison of diverse factors.

AIM

We aimed to (1) examine factors associated with spiritual well-being in the last days and (2) compare those factors across three East Asian countries.

DESIGN

This is an international multicenter prospective cohort study.

SETTING/PARTICIPANTS

Newly admitted inpatients with far advanced cancer in palliative care units in Japan, Korea and Taiwan were enrolled. Each patient was classified into one of two groups based on spiritual well-being score in the last days of life. Univariate and multivariate analyses were performed to identify the factors related to better spiritual well-being score in each country.

RESULTS

A total of 1761 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. Seven variables were significant in Japan, three in Korea, and five in Taiwan. "Good death scale [acceptance]," "fatigue" and "expressed wish for hastened death" were unique in Japan. "Visit from a pastoral care worker within 48 h of death" was unique in Korea. "Patient's preferences for place of death," "dyspnea" and "continuous deep sedation" were unique in Taiwan.

CONCLUSIONS

This study found novel factors related to spiritual well-being in the last days of life, several of which differed according to country. Recognition of factors associated with spiritual well-being can improve the quality of palliative care.

Appropriate referral timing to specialized palliative care service: survey of bereaved families of cancer patients who died in palliative care units

Few studies have investigated appropriate referral timing of specialized palliative care (SPC) from the perspective of cancer patients' and families' experiences. We aimed to clarify appropriate SPC referral timing for patients with advanced cancer and their families. We used data from a nationwide bereaved family survey in Japan. We sent a questionnaire to 999 bereaved families of cancer patients who died in 164 palliative care units (PCUs) and analyzed the first SPC referral timing and how patients evaluated it. We defined SPC as outpatient or inpatient palliative care service comprising certified palliative care physicians, advanced-practice nurses, and multidisciplinary practitioners. Finally, 51.6% (n = 515) of all responses were analyzed. The SPC referral timing was evaluated as appropriate (26.1%), late or too late (20.2%), early or too early (1.2%), or none of these (52.5%). Of these, 32.3% reported that they were referred to an SPC when diagnosed with advanced or incurable cancer or during anti-cancer treatment, and 62.6% reported they were referred after anti-cancer treatment. Patient-perceived appropriateness of SPC referral timing was associated with their good death process. After excluding "none of these" responses, a significantly higher proportion of respondents who reported being referred to SPC at diagnosis and during anti-cancer treatment evaluated the response timing as appropriate, compared to those who reported being referred after anti-cancer treatment. Appropriate timing for SPC referrals relates to quality of death; findings suggest that appropriate timing is at the time of diagnosis or during anti-cancer treatment.