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Tsai SF, Chang CY, Yang JY, Ho YY, Hsiao CC, Hsu SC, Chen SY, Lin HY, Yeh TF, Chen CH. Exploring knowledge, attitude, and intention towards advance care planning, advance directive, and the patient self-determination act among hemodialysis patients. BMC Palliat Care 2023; 22:201. [PMID: 38097993 PMCID: PMC10720199 DOI: 10.1186/s12904-023-01321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Hemodialysis holds the highest incidence and prevalence rate in Taiwan globally. However, the implementation of advance care planning (ACP), advance directives (AD), and patient self-determination acts (PSDA) remains limited. Our objective was to examine the current status of ACP, AD and PSDA and potential opportunities for enhancement. METHODS We developed a novel questionnaire to assess individuals' knowledge, attitudes, and intentions regarding ACP, AD, and PSDA. We also collected baseline characteristics and additional inquiries for correlation analysis to identify potential factors. Student's t-test and Analysis of Variance were employed to assess significance. RESULTS Initially, a cohort of 241 patients was initially considered for inclusion in this study. Subsequently, 135 patients agreed to participate in the questionnaire study, resulting in 129 valid questionnaires. Among these respondents, 76 were male (59.9%), and 53 were female (41.1%). Only 13.2% had signed AD. A significant portion (85.3%) indicated that they had not discussed their dialysis prognosis with healthcare providers. Additionally, a mere 14% engaged in conversations about life-threatening decisions. Ninety percent believed that healthcare providers had not furnished information about ACP, and only 30% had discussed such choices with their families. The findings revealed that the average standardized score for ACP and AD goals was 84.97, while the attitude towards PSDA received a standardized score of 69.94. The intention score stood at 69.52 in standardized terms. Potential candidates for ACP initiation included individuals aged 50 to 64, possessing at least a college education, being unmarried, and having no history of diabetes. CONCLUSION Patients undergoing hemodialysis exhibited a significant knowledge gap concerning ACP, AD, and the PSDA. Notably, a substantial number of dialytic patients had not received adequate information on these subjects. Nevertheless, they displayed a positive attitude, and a considerable proportion expressed a willingness to sign AD. It is imperative for nephrologists to take an active role in initiating ACP discussions with patients from the very beginning.
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Affiliation(s)
- Shang-Feng Tsai
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, 160, Sec. 3, Taiwan Boulevard, Taichung, 407, Taiwan
- Department of Life Science, Tunghai University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ching-Yi Chang
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jia-Yi Yang
- Department of Ophthalmology, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Yu-Ying Ho
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ching-Ching Hsiao
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shu-Chuan Hsu
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Yun Chen
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Huan-Yi Lin
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Te-Feng Yeh
- Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, 160, Sec. 3, Taiwan Boulevard, Taichung, 407, Taiwan.
- Department of Life Science, Tunghai University, Taichung, Taiwan.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
- Ph.D. Program in Tissue Engineering and Regenerative Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
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Wang SC, Hu KC, Chang WC, Hsu CY. Utilization of hospice and nonhospice care in patients with end-stage renal disease on dialysis. Tzu Chi Med J 2021; 34:232-238. [PMID: 35465279 PMCID: PMC9020240 DOI: 10.4103/tcmj.tcmj_207_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/30/2021] [Accepted: 09/15/2021] [Indexed: 11/09/2022] Open
Abstract
Objectives: The prevalence of end-stage renal disease (ESRD) and the number of patients undergoing dialysis in Taiwan are high. Since September 2009, the National Health Insurance has started to provide hospice care to patients with renal failure in Taiwan. Therefore, it is necessary to understand the use of hospice and nonhospice care in patients with ESRD on dialysis. We aim to understand trends in patients with ESRD receiving hospice and nonhospice care as well as medical care efforts during the last month of their lives (2009–2013). Materials and Methods: The cohort study was conducted using 1 million randomly selected samples from the Taiwan Health Insurance Research Database for millions of people in Taiwan in 2009–2013. Descriptive statistics were presented to summarize the characteristics of data. To compare differences between cohorts, Chi-square tests and Student's t-tests were used. Mann–Whitney U-tests were performed for nonnormally distributed data. Mantel–Haenszel test was test for trend. Results: We recruited 770 ESRD patients who underwent hemodialysis; among them, 154 patients received hospice care. Patients who received hospice care had a significantly longer survival time after removal of mechanical ventilator (20 vs. 0 days) and after discontinuation of dialysis (2 vs. 0 days) compared with those who did not receive hospice care. Patients who received hospice care had more pain control (61.04% vs. 17.37%, P < 0.0001) and other symptomatic control (55.84% vs. 43.18% with diuretics, P < 0.05; 64.29% and 48.21% with laxatives, P = 0.0004) medications than those who did not. Nevertheless, the overall medical cost in the hospice group was significantly lower (90 USD and 280 USD, P < 0.0001). Conclusion: Our results suggest that the addition of hospice care may permit patients a longer life-support-free survival time. In addition, despite a more frequent symptomatic controlling agent use, hospice care significantly reduced the overall medical expenditure.
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Lin CY, Lee YC. Choosing and Doing wisely: triage level I resuscitation a possible new field for starting palliative care and avoiding low-value care - a nationwide matched-pair retrospective cohort study in Taiwan. BMC Palliat Care 2020; 19:87. [PMID: 32563245 PMCID: PMC7305586 DOI: 10.1186/s12904-020-00590-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/09/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The association between palliative care and life-sustaining treatment following emergency department (ED) resuscitation is unclear. This study aims to analyze the usage of palliative care and life-sustaining treatments among ED triage level I resuscitation patients based on a nationally representative sample of patients in Taiwan. METHODS A matched-pair retrospective cohort study was conducted to examine the association between palliative care and outcome variables using multivariate logistic regression and Kaplan-Meier survival analyses. Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services (palliative care group) under a universal health insurance scheme. Retrospective cohort matching was performed with those who received standard care at a ratio of 1:4 (usual care group). Outcome variables included the number of visits to emergency and outpatient departments, hospitalization duration, total medical expenses, utilization of life-sustaining treatments, and duration of survival following ED triage level I resuscitation. RESULTS The mean survival duration following level I resuscitation was less than 1 year. Palliative care was administered to 15% of the resuscitation cohort. The palliative care group received significantly less life-sustaining treatment than did the usual care group. CONCLUSION Among patients who underwent level I resuscitation, palliative care was inversely correlated with the scope of life-sustaining treatments. Furthermore, triage level I resuscitation status may present a possible new field for starting palliative care intervention and reducing low-value care.
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Affiliation(s)
- Chih-Yuan Lin
- Department of Neurology, Taipei City Hospital, Taipei, Taiwan
- Institute of Health and Welfare Policy, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Health Care Management, National Taipei University of Nursing and Health, Taipei, Taiwan
| | - Yue-Chune Lee
- Institute of Health and Welfare Policy, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Master Program on Trans-disciplinary Long-Term Care and Management, National Yang-Ming University, Taipei, Taiwan
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Chiang JK, Chen JS, Kao YH. Comparison of medical outcomes and health care costs at the end of life between dialysis patients with and without cancer: a national population-based study. BMC Nephrol 2019; 20:265. [PMID: 31311518 PMCID: PMC6636130 DOI: 10.1186/s12882-019-1440-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/25/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Palliative care has improved the quality of end-of-life (EOL) care and lowered the health care cost of cancer, and these benefits should be extended to patients with other serious illnesses including end-stage kidney disease. We evaluated the quality of EOL care, survival probabilities, and health care costs for dialysis patients in their last month of life. METHODS We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information of patient medical records, health care costs, and insurance system exit dates (our proxy for death between 2006 and 2011). RESULTS Data of 1177 adult patients who died of chronic hemodialysis or peritoneal dialysis were investigated. The mean age of these patients was 69.7 ± 11.9 years, and 585 (49.7%) were women. Some patients with dialysis received cardiopulmonary resuscitation (66.9%), died in a hospital (65.0%), or were admitted to an intensive care unit (51.0%) in the last month of life. We further classified these patients into two groups, namely dialysis with cancer (DC) (n = 149) and dialysis without cancer (D) (n = 1028). Only 19 dialysis patients received palliative care, and the proportion of patients receiving palliative care was higher in the DC group than in the D group (11.4% vs. 0.2%). The mean health care costs per person during the final month of life was similar between the DC and D groups (USD 2755 ± 259 vs. USD 2827 ± 88). Multivariate logistic regression showed that the DC group had lower odds of receiving cardiopulmonary resuscitation (CPR) (OR: 0.39, CI = 0.26-0.56, p < 0.001) procedures, higher odds of longer hospital stays than the third quartile (> 25 days) (OR: 1.52, CI = 1.01-2.29, p = 0.0046), and higher odds of being hospitalized more than once (OR: 2.26, CI = 1.42-3.59, p = 0.001) than the D group in the last month of life after adjustments. CONCLUSIONS DC patients received hospice care more frequently, received CPR less frequently, and had similar health care costs. DC patients also had a higher risk of a hospital stay that lasted more than 25 days and more than one hospitalization compared with D patients in the final month of life.
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Affiliation(s)
- Jui-Kun Chiang
- Department of Family Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2, Minsheng Road, Dalin, 622, Chiayi, Taiwan
| | - Jean-Shi Chen
- Department of Nephrology, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), 670 Chung-Te Road, Tainan, 701, Taiwan
| | - Yee-Hsin Kao
- Department of Family Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), 670 Chung-Te Road, Tainan, 701, Taiwan.
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