End-of-life care research in Hong Kong: A systematic review of peer-reviewed publications

Practitioner accounts of end-of-life communication in Hong Kong, Mainland China and Taiwan: A systematic review

OBJECTIVE

Communication at the end-of-life (EOL) is complex and multidimensional. Although culture is acknowledged as a key influence, there remains a gap in knowledge about intracultural aspects of EOL communication in the Chinese context. This review presents a synthesis of practitioners' accounts of communication at the EOL in Hong Kong, Mainland China and Taiwan.

METHODS

This review was registered prospectively on PROSPERO (CRD42021297052). Five databases were systematically searched using the terms 'communication', 'End-of-Life', 'Hong Kong', 'China' and 'Taiwan'. Empirical research published between 2015 and 2021 was downloaded and appraised. Fifteen articles were included in the review.

RESULTS

Findings highlight the influence of Chinese culture and philosophy, inadequate communication skills training and psychological support for practitioners and legislative and organisational factors.

CONCLUSION

Education and training for practitioners and public education about the EOL needs strengthening. Enhanced understanding of how culture influences EOL communication will strengthen service delivery and enhance awareness in multicultural communities.

PRACTICE IMPLICATIONS

EOL workers need practical and workplace-based support to engage in meaningful communication practices. The influence of culture and the readiness of patients and families to engage in communication are also important considerations.

The Role Complexities in Advance Care Planning for End-of-Life Care-Nursing Students' Perception of the Nursing Profession

Nurses’ perceptions of being responsible for advance care planning (ACP) vary greatly across different studies. It could, however, affect their involvement in advance care planning and patients’ quality of death. Recent studies on this topic have mostly focused on advance directives but not ACP and nurses in the ward setting. This study aimed to assess the perception of Hong Kong nursing undergraduates of the nurse’s role in advance care planning and examine its associations with knowledge, attitude, and experience. A cross-sectional 57-item survey was delivered to nursing undergraduates between June and August 2020. The chi-squared test or Fisher’s exact test were used for univariate analysis. The multiple logistic regression model was used for multivariate analysis. A total of 469 participants were assessed for eligibility; 242 of them were included in the data analysis, with a response rate of 97.6%. The majority of respondents—77.3% (95% CI: 72.0–82.6%)—perceived having a role in ACP, but large discrepancies were found between their perception of their role regarding different aspects of ACP. Participants who had a better knowledge status (p = 0.029) or supported the use of ACP (p < 0.001) were more likely to have a positive perception of their role in ACP. A negative correlation was found between the experience of life threat and positive role perception (p < 0.001). Through strengthening training, the role clarity of nursing undergraduates could be achieved, maximizing their cooperation with and implementation of ACP in their future nursing career. The enhancement of end-of-life education could also be undertaken to fill nursing undergraduates’ knowledge gap in this area and change their attitudes.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Competing expectations: Advance care planning from the perspectives of doctors and nurses in the South-East Asian context

This study qualitatively examines the perspectives of doctors and nurses on the implementation of the Advance Care Planning program in Singapore. Findings suggest that a combination of structural and conceptual factors hindered the performance of ACP. Themes on structural factors indicated that low awareness of ACP among senior staff resulted overall lack of buy-in and incorrect implementation of the program due to misconceptions. Conceptual factors pointed to lack of clarity on intended outcomes or roles. Consequently, participants drew meaning through the prism of their profession, resulting in competing expectations and tensions on possible outcomes of the program.

Perceptions of optimal end-of-life care in hospitals: A cross-sectional study of nurses in three locations

AIM

To examine whether nurses' location of employment, demographics, or training influences their perceptions of what constitutes optimal care for dying patients in hospital.

DESIGN

Questionnaire-based, cross-sectional study.

METHODS

Between December 2016-June 2018, 582 registered or enrolled nurses from Australia (N = 153), South Korea (N = 241), and Hong Kong (N = 188) employed in a variety of hospital care units rated the extent to which they agreed with 29 indicators of optimal end-of-life care across four domains: patient, family, healthcare team, and healthcare system. Latent class analysis identified classes of respondents with similar responses.

RESULTS

Top five indicators rated by participants included: 'physical symptoms managed well'; 'private rooms and unlimited visiting hours'; 'spend as much time with the patient as families wish'; 'end-of-life care documents stored well and easily accessed' and 'families know and follow patient's wishes'. Four latent classes were generated: 'Whole system/holistic' (Class 1); 'Patient/provider-dominated' (Class 2); 'Family-dominated' (Class 3) and 'System-dominated' (Class 4). Class 1 had the highest proportion of nurses responding positively for all indicators. Location was an important correlate of perceptions, even after controlling for individual characteristics.

CONCLUSION

Nurses' perceptions of optimal end-of-life care are associated with location, but perhaps not in the direction that stereotypes would suggest. Findings highlight the importance of developing and implementing location-specific approaches to optimize end-of-life care in hospitals.

IMPACT

The findings may be useful to guide education and policy initiatives in Asian and Western countries that stress that end-of-life care is more than symptom management. Indicators can be used to collect data that help quantify differences between optimal care and the care actually being delivered, thereby determining where improvements might be made.

Preferences for end-of-life care: a study protocol for a cross-sectional survey of Chinese frail elderly home residents in Hong Kong

INTRODUCTION

Existing literature on attitudes toward end-of-life care (EoLC) covers the general public but has little information on the frail elderly population. The aim of the current study is to investigate the preferences of Chinese frail elderly home residents with respect to EoLC by conducting cross-sectional surveys.

METHODS AND ANALYSIS

Surveys, including resident and family versions, were developed based on the existing literature and our pilot interviews. The targeted participants were 400 frail elderly home residents (aged ≥65 years old) and 200 family caregivers. Purposive sampling will be used as each elderly home will help to recruit five to 15 elderly participants for the study. Descriptive analysis and modelling will be used to examine preferences on EoLC and related factors, as well as to compare the responses of elderly home residents with those of their family caregivers.

ETHICS AND DISSEMINATION

The cross-sectional survey has obtained approval from the Institutional Review Board. Confidentiality and safety issues will be carefully observed. The results of the study will be disseminated through international conferences, peer-reviewed academic journal publications, and a report in plain language to be shared with elderly residential homes.

Nurses' perceptions of and barriers to the optimal end-of-life care in hospitals: A cross-sectional study

AIMS AND OBJECTIVES

To assess nurses' perceptions of what constitutes optimal end-of-life (EOL) care in hospital and evaluate nurses' perceived barriers to EOL care delivery.

BACKGROUND

Care of dying patients is common in hospitals. However, little is known about the important elements of and barriers to optimal EOL care from key service providers' perspective, which is crucial for quality EOL care in hospital settings.

METHOD

This is a cross-sectional survey. Nurses practising in hospitals recruited by convenience sampling completed self-report survey questionnaires. STROBE checklist was used in study reporting.

RESULTS

One hundred and-seventy-five nurses participated in the survey. The majority (70%) had experience in caring for dying patients. The five most highly perceived factors constituting optimal EOL care included the following: "families know and follow patient's EOL wishes"; "patients emotional concerns identified and managed well"; "patients participating in decision-making"; "EOL care documents stored well and easily accessed"; and "provide private rooms and unlimited visiting hours for families of dying patients". Top five barriers were "doctors are too busy"; "nurses are too busy"; "insufficient private room/space"; "nurses have limited training in EOL care"; and "families have unrealistic expectations of patient's prognosis." Multivariate regression analysis identified that nurses without experience in caring for dying patients reported a significantly higher number of perceived barriers towards EOL care (p = .012). Those with postgraduate degree training reported significantly fewer perceived barriers (p = .007).

CONCLUSION

Findings identified essential elements for optimal hospital EOL care not only involving patients and families in EOL decision and care, but also documentation and environmental issues in the healthcare system level and the needs for strengthening manpower and expertise at palliative care policy level.

RELEVANCE TO CLINICAL PRACTICE

This study revealed quantitative data to inform health service managers and policy makers in terms of training and service development/ re-design for EOL care in hospital settings.

Associations of Advance Directive Knowledge, Attitudes, and Barriers/Benefits With Preferences for Advance Treatment Directives Among Patients With Heart Failure and Their Caregivers

BACKGROUND

Patients with heart failure (HF) have not been considered as major beneficiaries of advance directives (ADs). We analyzed factors affecting the preferences for the adoption of ADs by patients with HF and their caregivers.

METHODS AND RESULTS

Seventy-one patient (mean age: 68 years)-caregiver (mean age: 55 years) dyads were enrolled during clinic visits for routine care at a single institution and completed questionnaires during in-person visits. Cohen's kappa coefficients and generalized estimating equation models were used to analyze the data. The agreement on dyadic perspectives for aggressive treatments was poor or fair, whereas agreement relative to hospice care was moderate (k = 0.42, 95% confidence interval = 0.087-0.754). Both patients and caregivers demonstrated poor knowledge of ADs and similar levels of perceived benefits and barriers to advance care planning. However, the caregivers had more positive attitudes toward ADs than patients. Patients and caregivers who were older and/or males had greater odds of preferring aggressive treatments and/or hospice care. Further, those with depressive symptoms had lower odds of preferring hospice care.

CONCLUSION

The dyadic agreement was moderately high only for hospice care preferences. Both patients and caregivers demonstrated knowledge of shortfalls regarding ADs. Timely AD discussions could increase dyadic agreement and enhance informed and shared decision-making regarding medical care.

Development and Validation of a Prognostic Tool for Identifying Residents at Increased Risk of Death in Long-Term Care Facilities

BACKGROUND

To promote better care at the end stage of life in long-term care facilities, a culturally appropriate tool for identifying residents at the end of life is crucial.

OBJECTIVE

This study aimed to develop and validate a prognostic tool, the increased risk of death (IRD) scale, based on the minimum data set (MDS).

DESIGN

A retrospective study using data between 2005 and 2013 from six nursing homes in Hong Kong.

SETTING/SUBJECTS

A total of 2380 individuals were randomly divided into two equal-sized subsamples: Sample 1 was used for the development of the IRD scale and Sample 2 for validation.

MEASUREMENTS

The measures were MDS 2.0 items and mortality data from the discharge tracking forms. The nine items in the IRD scale (decline in cognitive status, decline in activities of daily living, cancer, renal failure, congestive heart failure, emphysema/chronic obstructive pulmonary disease, edema, shortness of breath, and loss of weight), were selected based on bivariate Cox proportional hazards regression.

RESULTS

The IRD scale was a strong predictor of mortality in both Sample 1 (HR_sample1 = 1.50, 95% confidence interval [CI]: 1.37-1.65) and Sample 2 (HR_sample2 = 1.31, 1.19-1.43), after adjusting for covariates. Hazard ratios (HRs) for residents who had an IRD score of 3 or above for Sample 1 and Sample 2 were 3.32 (2.12-5.21) and 2.00 (1.30-3.09), respectively.

CONCLUSIONS

The IRD scale is a promising tool for identifying nursing home residents at increased risk of death. We recommend the tool to be incorporated into the care protocol of long-term care facilities in Hong Kong.

Lessons from filial piety: A social-life-span approach to building the connection that survives death

The purpose of this article is to unpack concepts surrounding "the connection that survives death" between living people and the deceased. The study was designed as the qualitative arm of an integrated project on filial piety in contemporary times, and data were collected from 17 interviews with Korean human service professionals from Australia, New Zealand and Korea. The findings from the study indicate that the connectedness with the dead is an important part of the participants' mental and social lives, and this postmortem relationship can be embodied through practising "memorial piety" and "memorial work".

Examining palliative and end of life care research in Ireland within a global context: a systematic mapping review of the evidence

Background

Globally the state of palliative care research remains uncertain. Questions remain regarding impact, funding, and research priorities. Building upon previous research, this review examines palliative care research in Ireland and contributes to a wider international debate on the state of palliative care research.

Methods

A systematic mapping review was undertaken. Eight bibliographic databases and thesis repositories were searched from May 2012 to April 2017. Palliative care related search terms were combined with “Ireland” or “Irish” to increase search sensitivity. Inclusion criteria were applied by two independent reviewers. Descriptive analysis was completed using IBM SPSS v23. Thematic analysis was undertaken using a data-driven approach to develop new themes.

Results

In total, 808 studies were screened and 151 papers from 117 studies were included for review. The top two areas of research focus included: (1) specific groups, services, and settings (n = 70); and (2) identification, communication and education (n = 37). A diverse variety of research methods were used including mixed methods (25%), surveys (22%), interviews (20%), and reviews (17%). One randomised control trial was conducted. The predominance of research papers focused solely on health care professionals (n = 35%), and the community setting was the most frequent location for data collection (41%). The majority of data was collected across the two jurisdictions of the Republic of Ireland (ROI) and Northern Ireland (NI) (37%), and 23% of studies included data outside of Ireland and the UK. The most frequent sources of funding were: consortiums (n = 40); government (n = 24); and philanthropic bodies (n = 20). Forty percent (n = 60) of papers were either unfunded or did not acknowledge a funder.

Conclusions

There is a continued increase in palliative care research in Ireland with increased collaborative working nationally and internationally. The quantity and impact of research has increased from the previous review, which can be attributed to significant investment in research funding and collaborative networks. However, research gaps continue to exist including out of hours’ care, physical and psychological symptom control, intervention studies, and the patient and family perspective. Areas for attention include the need to ensure knowledge exchange and demonstrate impact of the research on patient and family carer outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0364-7) contains supplementary material, which is available to authorized users.

Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons

BACKGROUND

Advance care planning (ACP) involves important decision making about future medical needs. The high-volume and disparate nature of ACP research makes it difficult to grasp the evidence and derive clear policy lessons for policymakers and clinicians.

AIM

The aim of this study was to synthesize ACP research evidence and identify relevant contextual elements, program features, implementation principles, and impacted outcomes to inform policy and practice.

DESIGN

An overview of systematic reviews using the Cochrane Handbook of Systematic Reviews of Interventions was performed. Study quality was assessed using a modified version of the AMSTAR (A MeaSurement Tool to Assess Reviews) tool.

DATA SOURCES

MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE were searched for ACP-related research from inception of each database to April 2017. Searches were supplemented with gray literature and manual searches. Eighty systematic reviews, covering over 1660 original articles, were included in the analysis.

RESULTS

Legislations, institutional policies, and cultural factors influence ACP development. Positive perceptions toward ACP do not necessarily translate into more end-of-life conversations. Many factors related to patients' and providers' attitudes, and perceptions toward life and mortality influence ACP implementation, decision making, and completion. Limited, low-quality evidence points to several ACP benefits, such as improved end-of-life communication, documentation of care preferences, dying in preferred place, and health care savings. Recurring features that make ACP programs effective include repeated and interactive discussion sessions, decision aids, and interventions targeting multiple stakeholders.

CONCLUSIONS

Preliminary evidence highlights several elements that influence the ACP process and provides a variety of features that could support successful, effective, and sustainable ACP implementation. However, this evidence is compartmentalized and limited. Further studies evaluating ACP as a unified program and assessing the impact of ACP for different populations, settings, and contexts are needed to develop programs that are able to unleash ACP's full potential.

State of advance care planning research: A descriptive overview of systematic reviews

OBJECTIVE

To provide an overview of the current state of research of advance care planning (ACP), highlighting most studied topics, publication time, quality of studies and reported outcomes, and to identify gaps to improve ACP receptivity, utilization, implementation, and outcomes.

METHOD

Cochrane methodology for conducting overviews of systematic reviews. Study quality was assessed using a modified version of the Assessing the Methodological Quality of Systematic Reviews tool. The following databases were searched from inception to April 2017: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE. Searches were supplemented with gray literature and manual searches.

RESULT

Eighty systematic reviews, covering 1,662 single articles, show that ACP-related research focuses on nine main topics: (1) ACP as part of end-of-life or palliative care interventions, (2) care decision-making; (3) communication strategies; (4) factors influencing ACP implementation; (5) ACP for specific patient groups, (6) ACP effectiveness; (7) ACP experiences; (8) ACP cost; and (9) ACP outcome measures. The majority of this research was published since 2014, its quality ranges from moderate to low, and reports on documentation, concordance, preferences, and resource utilization outcomes.

SIGNIFICANCE OF RESULTS

Despite the surge of ACP research, there are major knowledge gaps about ACP initiation, timeliness, optimal content, and impact because of the low quality and fragmentation of the available evidence. Research has mostly focused on discrete aspects within ACP instead of using a holistic evaluative approach that takes into account its intricate working mechanisms, the effects of systems and contexts, and the impacts on multilevel stakeholders. Higher quality studies and innovative interventions are needed to develop effective ACP programs and address research gaps.

The impact of palliative care training for oncologists and integrative palliative service in a public-funded hospital cluster-a retrospective cohort study

PURPOSE

Oncological care of advanced cancer patients was provided by multiple departments in Hong Kong. One of these departments, the clinical oncology department (COD), introduced systematic palliative care training for its oncologists since 2002. The COD was recognized as a European Society for Medical Oncology (ESMO) Designated Centre of Integrated Oncology and Palliative Care since 2009. This retrospective cohort study aims to review the impact of integrative training and service on palliative care coverage and outcome.

METHODS

Clinical information, palliative service provision, and end-of-life outcomes of patients who passed away from lung, colorectal, liver, stomach, or breast cancer in the Hong Kong West public hospital network during July 2015 to December 2015 were collected.

RESULTS

A total of 307 patients were analyzed. Around half (49.2%) were attended primarily by COD, and 68.9% received palliative service. There are significantly fewer patients referred to palliative care from other departments (p < 0.001), with only 19.9% of this patient group receiving palliative referral. COD patients had longer palliative coverage before death (median 65 days versus 24 days, p < 0.001), higher chance of receiving end-of-life care at hospice units (36.4 versus 21.2%, p = 0.003), lower ICU admission (0.66 versus 5.1%, p = 0.02), and higher percentage of receiving strong opioid in the last 30 days of life (51.0 versus 28.9%, p < 0.001) compared to other departments. In multivariable analysis, COD being the primary care team (odds ratio 12.2, p < 0.001) was associated with higher palliative care coverage.

CONCLUSION

The study results suggested that systematic palliative care training of oncologists and integrative palliative service model was associated with higher palliative service coverage and improved palliative care outcomes.