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van der Werff HFL, Michelet TH, Fredheim OM, Steine S. "Do not resuscitate" order and end-of-life treatment in a cohort of deceased in a Norwegian University Hospital. Acta Anaesthesiol Scand 2022; 66:1009-1015. [PMID: 35699950 PMCID: PMC9544634 DOI: 10.1111/aas.14104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/31/2022] [Accepted: 05/11/2022] [Indexed: 11/27/2022]
Abstract
Background A “Do not resuscitate” (DNR) order implies that cardiopulmonary resuscitation will not be started. Absent or delayed DNR orders in advanced chronic disease may indicate suboptimal communication about disease stage, prognosis, and treatment goals. The study objective was to determine clinical practice and patient involvement regarding DNR and the prevalence of life‐prolonging treatment in the last week of life. Methods A cross‐sectional observational study was made of a cohort of 315 deceased from a large general hospital in Norway. Data on DNR and other treatment limitations, life‐prolonging treatment in the last week of life, and cause of death were obtained from medical records. Results A DNR order was documented for 287 (91%) patients. Almost half the DNR orders, 142 (49%), were made during the last 7 days of life. The main causes of death were cancer (31%), infectious diseases (31%), and cardiovascular diseases (19%). The most frequent life‐prolonging treatments during the last week of life were intravenous fluids in 221 patients (70%) and antibiotics in 198 (63%). During the last week of life, 103 (36%) patients received ICU treatment. Death by cancer (odds ratio 2.5, 95% confidence interval 1.24–5.65) and DNR decision made by a palliative care physician (odds ratio 3.4, 95% CI 1.21–3.88) were predictors of not receiving life‐prolonging treatment. Conclusion The findings of a high prevalence of life‐prolonging treatment in the last week of life and DNR orders being made close to the time of death indicate that decisions about limiting life‐prolonging treatment are often postponed until the patient's death is imminent.
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Affiliation(s)
| | - Torstein H Michelet
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Olav M Fredheim
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Norwegian Advisory Unit on Complex Symptom Disorders, St. Olavs Hospital, Trondheim, Norway
| | - Siri Steine
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway
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2
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Kizawa Y, Yamaguchi T, Sakashita A, Aoyama M, Morita T, Tsuneto S, Shima Y, Miyashita M. Physician's Communication in Code Status Discussions for Terminally Ill Cancer Patients in Inpatient Hospice/Palliative Care Units in Japan: A Nationwide Post-Bereavement Survey. J Pain Symptom Manage 2021; 62:e120-e129. [PMID: 33757891 DOI: 10.1016/j.jpainsymman.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 11/20/2022]
Abstract
CONTEXT Cardiopulmonary resuscitation is one of the most important end-of-life care decisions. However, the experience of bereaved families during code status discussions is not well documented. OBJECTIVE The aims of this study were to describe the degree of emotional distress of bereaved families when discussing code status, identify their perceived areas for improvement and determine associated factors. METHODS This study is part of a nationwide post-bereavement survey, the Japan Hospice and Palliative care Evaluation 3 (J-HOPE3) study. Questionnaires were sent to the relatives of cancer patients who had died in palliative care units in Japan in 2014. RESULTS From an analysis of 338 questionnaires, 37% of families reported high emotional distress during code status discussions and 32% reported a need for improvement. Multiple logistic regression analyses revealed the following were associated with high-level distress: the family had hoped for the miraculous and spontaneous recovery of the patient (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.31-4.43, P = 0.0049), the family felt they could not voice their opinion about Cardiopulmonary resuscitation (OR 2.07, CI 1.12-3.81, P = 0.02), or the physician failed to adapt the explanation to the family's preparation level (OR 0.36, CI 0.18-0.68, P = 0.0015). Factors identified for improvement were: holding discussions in a relaxing atmosphere conducive to questioning (OR 0.36, CI 0.16-0.80, P = 0.012), and ensuring the physician adapted the explanation to the family's preparation level (OR 0.47, CI 0.23-0.96, P = 0.037). CONCLUSION We recommend the development of educational programs for code status discussions to improve the experience of bereaved family members.
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Affiliation(s)
- Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University School of Medicine, Kobe, Japan.
| | - Takashi Yamaguchi
- Department of Palliative Medicine, Konan Medical Center, Kobe, Japan
| | - Akihiro Sakashita
- Department of Palliative Medicine, Kobe University School of Medicine, Kobe, Japan
| | - Maho Aoyama
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara Hospital, Shizuoka, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuo Shima
- Tsukuba Medical Center Hospital, Department of Palliative Medicine, Ibaraki, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
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Can primary palliative care education change life-sustaining treatment intensity of older adults at the end of life? A retrospective study. BMC Palliat Care 2021; 20:84. [PMID: 34154579 PMCID: PMC8218503 DOI: 10.1186/s12904-021-00783-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/27/2021] [Indexed: 11/16/2022] Open
Abstract
Background Palliative care education has been carried out in some hospitals and palliative care has gradually developed in mainland China. However, the clinical research is sparse and whether primary palliative care education influence treatment intensity of dying older adults is still unknown. This study aims to explore the changes to the intensity of end-of-life care in hospitalized older adults before and after the implementation of primary palliative care education. Methods A retrospective study was conducted. Two hundred three decedents were included from Beijing Tongren Hospital’s department of geriatrics between January 1, 2014 to December 31, 2019. Patients were split into two cohorts with regards to the start of palliative care education. Patient demographics and clinical characteristics as well as analgesia use, medical resources use and provision of life-sustaining treatments were compared. We used a chi-square test to compare categorical variables, a t test to compare continuous variables with normal distributions and a Mann–Whitney U test for continuous variables with skewed distributions. Results Of the total participants in the study, 157(77.3%) patients were male. The median age was 88 (interquartile range; Q1-Q3 83–93) and the majority of patients (N = 172, 84.7%) aged 80 years or older. The top 3 causes of death were malignant solid tumor (N = 74, 36.5%), infectious disease (N = 74, 36.5%), and cardiovascular disease (N = 23, 11.3%). Approximately two thirds died of non-cancer diseases. There was no significant difference in age, gender, cause of death and functional status between the two groups (p > 0.05). After primary palliative care education, pain controlling drugs were used more (p < 0.05), fewer patients received electric defibrillation, bag mask ventilation and vasopressors (p < 0.05). There was no change in the length of hospitalization, intensive care admissions, polypharmacy, use of broad-spectrum antibiotics, blood infusions, albumin infusions, nasogastric/nasoenteric tubes, parenteral nutrition, renal replacement and mechanical ventilation (p > 0.05). Conclusions Primary palliative care education may promotes pain controlling drug use and DNR implementation. More efforts should be put on education about symptom assessment, prognostication, advance care planning, code status discussion in order to reduce acute medical care resource use and apply life-sustaining treatment appropriately.
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Friend JM, Alden DL. Improving Patient Preparedness and Confidence in Discussing Advance Directives for End-of-Life Care with Health Care Providers in the United States and Japan. Med Decis Making 2020; 41:60-73. [PMID: 33161836 DOI: 10.1177/0272989x20969683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The low completion rate of advance directives (ADs) has received attention in Japan and the United States, as policy makers and health care professionals face aging populations with multiple comorbidities. Among the barriers to AD planning, cultural values and attitudes appear to be particularly influential. A comparison of culturally distinct societies provides a deeper understanding of these barriers. Through such an approach, this study identifies strategies for increasing AD planning among late-middle-age Japanese and US individuals. METHODS After giving informed consent for the Institutional Review Board-approved study, Japanese and US respondents (45-65 y; 50% female) without ADs completed a language-appropriate online survey. Participants were asked to review a decision aid as part of a scenario-based physician consultation regarding artificial nutrition and hydration (ANH). Hypotheses were analyzed using multigroup structural equation modeling. RESULTS Important similarities were identified across the 2 groups. After reviewing the decision aid, both samples strongly preferred "no ANH." Respondents who strongly valued either self-reliance or interpersonal relationships experienced greater preparedness for AD planning. In both countries, greater decision preparedness and positive death attitude predicted greater confidence to discuss care options with a provider. Finally, cultural values predicted preference for family participation: respondents with a strong interdependent self-concept desired more family involvement, whereas high independents preferred less. CONCLUSIONS Findings indicate the importance of documenting care preferences and accounting for individual differences. To increase AD adoption, providers should identify patient segments likely to benefit most from the interventions. Targeting individuals in both countries who value self-reliance and interpersonal relationships appears to be a good place to begin. Such individuals can be identified clinically through administration of validated measures used in this study.
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Affiliation(s)
- John M Friend
- Visiting Research Scholar, Department of Marketing, Shidler College of Business, University of Hawai'i at Mānoa, Honolulu, HI, USA
| | - Dana L Alden
- Visiting Research Scholar, Department of Marketing, Shidler College of Business, University of Hawai'i at Mānoa, Honolulu, HI, USA
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Cheng SY, Lin CP, Chan HYL, Martina D, Mori M, Kim SH, Ng R. Advance care planning in Asian culture. Jpn J Clin Oncol 2020; 50:976-989. [PMID: 32761078 DOI: 10.1093/jjco/hyaa131] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 07/20/2020] [Indexed: 11/14/2022] Open
Abstract
Ageing has been recognized as one of the most critically important health-care issues worldwide. It is relevant to Asia, where the increasing number of older populations has drawn attention to the paramount need for health-care investment, particularly in end-of-life care. The advocacy of advance care planning is a mean to honor patient autonomy. Since most East Asian countries are influenced by Confucianism and the concept of 'filial piety,' patient autonomy is consequently subordinate to family values and physician authority. The dominance from family members and physicians during a patient's end-of-life decision-making is recognized as a cultural feature in Asia. Physicians often disclose the patient's poor prognosis and corresponding treatment options to the male, family member rather to the patient him/herself. In order to address this ethical and practical dilemma, the concept of 'relational autonomy' and the collectivism paradigm might be ideally used to assist Asian people, especially older adults, to share their preferences on future care and decision-making on certain clinical situations with their families and important others. In this review article, we invited experts in end-of-life care from Hong Kong, Indonesia, Japan, South Korea, Singapore and Taiwan to briefly report the current status of advance care planning in each country from policy, legal and clinical perspectives. According to the Asian experiences, we have seen different models of advance care planning implementation. The Asian Delphi Taskforce for advance care planning is currently undertaken by six Asian countries and a more detailed, culturally sensitive whitepaper will be published in the near future.
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Affiliation(s)
- Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Cheng-Pei Lin
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Helen Yue-Lai Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Central Ave, Hong Kong
| | - Diah Martina
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine Universitas Indonesia, Jakarta Pusat, Indonesia
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Sun-Hyun Kim
- Department of Family Medicine, International St. Mary's Hospital, College of Medicine, Catholic Kwandong University, Incheon, Republic of Korea
| | - Raymond Ng
- Department of Palliative Medicine, Tan Tock Seng Hospital, Jln Tan Tock Seng, Singapore
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Ding CQ, Zhang YP, Wang YW, Yang MF, Wang S, Cui NQ, Jin JF. Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland. World J Emerg Med 2020; 11:231-237. [PMID: 33014219 DOI: 10.5847/wjem.j.1920-8642.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland. METHODS This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded. RESULTS There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001). CONCLUSIONS In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.
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Affiliation(s)
- Chuan-Qi Ding
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Ping Zhang
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Wei Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min-Fei Yang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Sa Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Nian-Qi Cui
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jing-Fen Jin
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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7
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Influence of advance directives on reducing aggressive measures during end-of-life cancer care: A systematic review. Palliat Support Care 2020; 19:348-354. [PMID: 32854813 DOI: 10.1017/s1478951520000838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Although the literature recognizes the participation of patients in medical decisions as an important indicator of quality, there is a lack of consensus regarding the influence of advance directives (ADs) on reducing aggressive measures during end-of-life care involving cancer patients. OBJECTIVE A systematic review was conducted to analyze the influence of ADs on reducing aggressive end-of-life care measures for cancer patients. METHOD We searched the Medline, Embase, Web of Science, and Lilacs databases for studies published until March 2018 using the following keywords, without language restrictions: "advance directives," "living wills," "terminal care," "palliative care," "hospice care," and "neoplasms." Article quality was assessed using study quality assessment tools from the Department of Health and Human Services (NHLBI). RESULTS A total of 1,489 studies were identified; 7 met the inclusion criteria. The studies were recently published (after 2014, 71.4%). Patients with ADs were more likely to die at the site of choice (n = 3) and received less chemotherapy in the last 30 days (n = 1). ADs had no impact on intensive care unit admission (n = 1) or hospitalization (n = 1). One study found an association between ADs and referral to palliative care, but other did not find the same result. SIGNIFICANCE OF RESULTS Of the seven articles found, four demonstrated effects of ADs on the reduction in aggressive measures at the end of life of cancer patients. Heterogeneity regarding study design and results and poor methodological quality are challenges when drawing conclusions.
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Cui P, Ping Z, Wang P, Bie W, Yeh CH, Gao X, Chen Y, Dong S, Chen C. Timing of do-not-resuscitate orders and health care utilization near the end of life in cancer patients: a retrospective cohort study. Support Care Cancer 2020; 29:1893-1902. [PMID: 32803724 DOI: 10.1007/s00520-020-05672-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The objectives are to explore the prevalence of DNR orders, the factors influencing them, and the association between DNR signing and health care utilization among advanced cancer patients. METHODS This was a retrospective cohort study. Data from cancer decedents in three hospitals in China from January 2016 to December 2017 during their last hospitalization before death were obtained from the electronic medical records system. RESULTS In total, 427 cancer patients were included; 59.0% had a DNR order. Patients who had solid tumors, lived in urban areas, had more than one comorbidity, and had more than five symptoms were more likely to have DNR orders. The cut-off of the timing of obtaining a DNR order was 3 days, as determined by the median number of days from the signing of a DNR order to patient death. Patients with early DNR orders (more than 3 days before death) were less likely to be transferred to the intensive care unit and undergo cardiopulmonary resuscitation, tracheal intubation, and ventilation, while they were more likely to be given morphine and psychological support compared with those with late (within 3 days before death) and no orders. CONCLUSIONS Advanced cancer patients with solid tumors living in urban areas with more symptoms and comorbidities are relatively more likely to have DNR orders. Early DNR orders are associated with less aggressive procedures and more comfort measures. However, these orders are always signed late. Future studies are needed to better understand the timing of DNR orders.
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Affiliation(s)
- Panpan Cui
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China.,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhiguang Ping
- College of Public Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Panpan Wang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wenqian Bie
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Chao Hsing Yeh
- Johns Hopkins School of Nursing, 525 N. Wolfe Street, Baltimore, USA
| | - Xinyi Gao
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yiyang Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shiqi Dong
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changying Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China. .,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.
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Feng C, Wu J, Li J, Deng HY, Liu J, Zhao S. Advance directives of lung cancer patients and caregivers in China: A cross sectional survey. Thorac Cancer 2019; 11:253-263. [PMID: 31851775 PMCID: PMC6996976 DOI: 10.1111/1759-7714.13237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/18/2019] [Indexed: 02/05/2023] Open
Abstract
Background This study aimed to investigate lung cancer patients and attitudes of their caregivers toward advance directives (ADs) in China. Methods A cross sectional study was conducted in the Department of Oncology outpatient clinic in West China Hospital, Sichuan University. A questionnaire was used to survey the attitudes of lung cancer patients and caregivers toward ADs. Results A total of 148 lung cancer patients and 149 caregivers were enrolled into the study. Of these, 94.6% and 89.9% of patients and caregivers had not heard of AD and none of those in the study had ever signed an AD. A total of 79.7% patients and 75.2% caregivers were willing to sign ADs after they were provided with information. Patients who preferred the end of life period to sign ADs were 5.4 times more likely to have ADs than patients who chose to sign ADs when their disease was diagnosed (P < 0.05, 95%CI [1.27–22.93]). Caregivers who were reluctant to undergo chemotherapy when diagnosed with cancer were 2.16 times more likely to sign ADs than those willing to receive chemotherapy (P < 0.05, 95%CI [1.20–3.90]). Conclusions In China, lung cancer patients and their caregivers showed lack of knowledge about ADs, and the completion rate of ADs was extremely low. However, participants were positive about ADs and public education on ADs may help to increase the completion rate of ADs in China.
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Affiliation(s)
- Chenchen Feng
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
| | - Juan Wu
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
| | - Junying Li
- Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Han Yu Deng
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jiewei Liu
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shuzhen Zhao
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
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10
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Advance Directive Preferences Among Terminally Ill Older Patients and Its Facilitators and Barriers in China: A Scoping Review. J Am Med Dir Assoc 2019; 20:1356-1361.e2. [DOI: 10.1016/j.jamda.2019.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 05/05/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022]
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11
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Cheng MT, Shih FY, Tsai CL, Tsai HB, Tsai DFC, Fang CC. Impact of major illnesses and geographic regions on do-not-resuscitate rate and its potential cost savings in Taiwan. PLoS One 2019; 14:e0222320. [PMID: 31513648 PMCID: PMC6742372 DOI: 10.1371/journal.pone.0222320] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 08/27/2019] [Indexed: 11/21/2022] Open
Abstract
Background/Purpose Do-not-resuscitate (DNR) is a legal order that demonstrates a patient’s will to avoid further suffering from advanced treatment at the end of life. The concept of palliative care is increasingly accepted, but the impacts of different major illnesses, geographic regions, and health expenses on DNR rates remain unclear. Methods This study utilized the two-million National Health Insurance (NHI) Research Database to examine the percentage of DNR rates among all deaths in hospitals from 2001 to 2011. DNR in the study was defined as no resuscitation before death in hospitals. Death records were extracted from the database and correlated with healthcare information. Descriptive statistics were compiled to examine the relationships between DNR rates and variables including major illnesses, geographic regions, and NHI spending. Results A total of 126,390 death records were extracted from the database for analysis. Among cancer-related deaths, pancreatic cancer patients had the highest DNR rate (86.99%) and esophageal cancer patients had the lowest DNR rate (71.62%). The higher DNR rate among cancer-only patients (79.53%) decreased with concomitant dialysis (66.07%) or ventilator use (57.85%). The lower DNR rates in patients with either chronic dialysis (51.27%) or ventilator use (59.10%) increased when patients experienced these two conditions concomitantly (61.31%). Although DNR rates have consistently increased over time across all regions of Taiwan, a persistent disparity was noted between the East and the South (76.89% vs. 70.78% in 2011, p < 0.01). After adjusting for potential confounders, DNR patients had significantly lower NHI spending one year prior to death ($67,553), compared with non-DNR patients. Conclusion Our study found that DNR rates varied across cancer types and decreased in cancer patients with concomitant chronic dialysis or ventilator use. Disparities in DNR rates were evident across geographic regions in Taiwan. A wider adoption of the DNR policy may achieve substantial savings in health expenses and improve patients’ quality of life.
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Affiliation(s)
- Ming-Tai Cheng
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Fuh-Yuan Shih
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Bin Tsai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Daniel Fu-Chang Tsai
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Cheng-Chung Fang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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12
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Huang BY, Chen HP, Wang Y, Deng YT, Yi TW, Jiang Y. The do-not-resuscitate order for terminal cancer patients in mainland China: A retrospective study. Medicine (Baltimore) 2018; 97:e0588. [PMID: 29718859 PMCID: PMC6392573 DOI: 10.1097/md.0000000000010588] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
With the development of palliative care, a signed do-not-resuscitate (DNR) order has become increasingly popular worldwide. However, there is no legal guarantee of a signed DNR order for patients with cancer in mainland China. This study aimed to estimate the status of DNR order signing before patient death in the cancer center of a large tertiary affiliated teaching hospital in western China. Patient demographics and disease-related characteristics were also analyzed.This was a retrospective chart analysis. We screened all charts from a large-scale tertiary teaching hospital in China for patients who died of cancer from January 2010 to February 2015. Analysis included a total of 365 records. The details of DNR order forms, patient demographics, and disease-related characteristics were recorded.The DNR order signing rate was 80%. Only 2 patients signed the DNR order themselves, while the majority of DNR orders were signed by patients' surrogates. The median time for signing the DNR order was 1 day before the patients' death. Most DNR decisions were made within the last 3 days before death. The time at which DNR orders were signed was related to disease severity and the rate of disease progression.Our findings indicate that signing a DNR order for patients with terminal cancer has become common in mainland China in recent years. Decisions about a DNR order are usually made by patients' surrogates when patients are severely ill. Palliative care in mainland China still needs to be improved.
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Affiliation(s)
- Bo-Yan Huang
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Hui-Ping Chen
- Department of Palliative Medicine, West China Fourth Hospital, Sichuan University
| | - Ying Wang
- Department of Medical Oncology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, People's Republic of China
| | - Yao-Tiao Deng
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Ting-Wu Yi
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Yu Jiang
- Department of Medical Oncology, Cancer Center, West China Hospital
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13
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Increased rate of DNR status in hospitalized end-of-life patients in Taiwan. Intensive Care Med 2016; 42:1816-1817. [DOI: 10.1007/s00134-016-4509-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 10/21/2022]
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14
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Zhang Q, Xie C, Xie S, Liu Q. The Attitudes of Chinese Cancer Patients and Family Caregivers toward Advance Directives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13080816. [PMID: 27529264 PMCID: PMC4997502 DOI: 10.3390/ijerph13080816] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/05/2016] [Accepted: 08/08/2016] [Indexed: 11/25/2022]
Abstract
Advance directives (ADs) have been legislated in many countries to protect patient autonomy regarding medical decisions at the end of life. China is facing a serious cancer burden and cancer patients’ quality at the end of life should be a concern. However, limited studies have been conducted locally to gather information about attitudes toward ADs. The purpose of this study was to investigate the attitudes of Chinese cancer patients and family caregivers toward ADs and to explore the predictors that are associated with attitudes. The study indicated that although there was low awareness of ADs, most cancer patients and family caregivers had positive attitudes toward ADs after related information was explained to them. Participants preferred to discuss ADs with medical staff when they were diagnosed with a life-threatening disease. Preferences for refusing life-sustaining treatment and choosing Hospice-Palliative Care (HPC) at the end of life would increase the likelihood of agreeing with ADs. This suggests that some effective interventions to help participants better understand end-of-life treatments are helpful in promoting ADs. Moreover, the development of HPC would contribute to Chinese cancer patients and family caregivers agreeing with ADs.
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Affiliation(s)
- Qiu Zhang
- Department of Health Service Management, Public Health School of Sun Yat-sen University, Guangzhou 510060, China.
| | - Chuanbo Xie
- State Key Laboratory of Oncology in South China, Department of Preventive Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.
| | - Shanghang Xie
- State Key Laboratory of Oncology in South China, Department of Preventive Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.
| | - Qing Liu
- State Key Laboratory of Oncology in South China, Department of Preventive Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.
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15
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Zafar W, Ghafoor I, Jamshed A, Gul S, Hafeez H. Outcomes of In-Hospital Cardiopulmonary Resuscitation Among Patients With Cancer. Am J Hosp Palliat Care 2016; 34:212-216. [PMID: 26589879 DOI: 10.1177/1049909115617934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review all episodes where an emergency code was called in a cancer-specialized hospital in Pakistan and to assess survival to discharge among patients who received a cardiopulmonary resuscitation (CPR). METHODS We reviewed demographic and clinical data related to all "code blue" calls over 3 years. Multivariate logistic regression analyses were used to test the association of clinical characteristics with the primary outcome of survival to discharge. RESULTS A total of 646 code blue calls were included in the analysis. The CPR was performed in 388 (60%) of these calls. For every 20 episodes of CPR among patients with cancer of all ages, only 1 resulted in a patient's survival to discharge, even though in 52.2% episodes there was a return of spontaneous circulation. No association was found between the type of rhythm at initiation of CPR and likelihood of survival to discharge. CONCLUSIONS The proportion of patients with advanced cancer surviving to discharge after in-hospital CPR in a low-income country was in line with the reported international experience. Most patients with cancer who received in-hospital CPR did not survive to discharge and did not appear to benefit from resuscitation. Advance directives by patients with cancer limiting aggressive interventions at end of life and proper documentation of these directives will help in provision of care that is humane and consonant with patients' wishes for a dignified death. Patients' early appreciation of the limited benefits of CPR in advanced cancer is likely to help them formulate such advance directives.
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Affiliation(s)
- Waleed Zafar
- 1 Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Irum Ghafoor
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Arif Jamshed
- 3 Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Sabika Gul
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Haroon Hafeez
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
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16
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Do-not-resuscitate orders and related factors among family surrogates of patients in the emergency department. Support Care Cancer 2015; 24:1999-2006. [DOI: 10.1007/s00520-015-2971-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 09/28/2015] [Indexed: 12/21/2022]
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17
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Tokito T, Murakami H, Mori K, Osaka I, Takahashi T. Implementation status and explanatory analysis of early advance care planning for Stage IV non-small cell lung cancer patients. Jpn J Clin Oncol 2014; 45:261-6. [DOI: 10.1093/jjco/hyu207] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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18
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Miyashita M, Kawakami S, Kato D, Yamashita H, Igaki H, Nakano K, Kuroda Y, Nakagawa K. The importance of good death components among cancer patients, the general population, oncologists, and oncology nurses in Japan: patients prefer "fighting against cancer". Support Care Cancer 2014; 23:103-10. [PMID: 24996829 DOI: 10.1007/s00520-014-2323-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/16/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND The objectives of this study were to compare the importance of components of a good death among cancer patients, the general population, oncologists, and oncology nurses, and explore which patients preferred "fighting against cancer." METHODS We conducted a cross-sectional anonymous self-reported survey of cancer patients who visited a radiation oncology outpatient clinic, oncologists, and oncology nurses at the Tokyo University Hospital and a random sample of the general population in the Tokyo metropolitan area. The outcomes were 18 previously developed components of a good death in Japanese cancer care consisting of 57 attributes. RESULTS Three hundred ten patients, 353 subjects from the general population, 109 oncologists, and 366 oncology nurses participated. The desire to "fight against cancer" was highly significantly different between patients and oncologists (effect size [ES] = -1.40; P = 0.001) and patients and oncology nurses (ES = -1.12; P = 0.001). "Physical and cognitive control" was, similarly, highly significantly different between patients and oncologists (ES = -1.30; P = 0.001) and patients and oncology nurses (ES = -1.06; P = 0.001). Patients who emphasized "maintaining hope and pleasure" (P = 0.0001), "unawareness of death" (P = 0.0001), and "good relationship with family" (P = 0.004) favored "fighting against cancer." The patients, however, who emphasized "physical and psychological comfort" did not significantly favor "fighting against cancer" (P = 0.004). CONCLUSION The importance of good death components differed between groups. Medical professionals should be aware of the diversity of values surrounding death and assess the patient's values and discuss them to support his or her quality of life. In addition, the development of care and a medical/social system to maintain hope and pleasure after failure of anticancer treatment is necessary.
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Affiliation(s)
- Mitsunori Miyashita
- Department of Adult Nursing/Palliative Care Nursing, School of Health Sciences and Nursing Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,
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Alsirafy SA, Mohammed AA, Al-Zahrani AS, Raheem AA, El-Kashif AT. The Relation Between the Timing of Palliative Care and the Frequency and Timing of Do-Not-Resuscitate Orders Among Cancer Deaths in a Tertiary Care Hospital. Am J Hosp Palliat Care 2014; 32:544-8. [PMID: 24671030 DOI: 10.1177/1049909114529014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The medical records of 246 in-hospital cancer deaths were reviewed to explore the relation between palliative care (PC) timing and the frequency and timing of do-not-resuscitate (DNR) designation. The rate of DNR designation was 100% in patients referred to PC and 82% in those never referred (P < .001). Patients were grouped into 4 groups: early PC (>90 days from PC referral to death), intermediate PC (>30-90 days), late PC (≤30 days), and no PC. The median DNR to death time was 96, 41, 11, and 3 days, respectively (P < .001). The proportion of intensive care unit (ICU) deaths was 0%, 1%, 3%, and 27%, respectively (P < .001). In conclusion, in a tertiary care hospital, earlier PC was associated with earlier DNR designation and less frequent ICU deaths among in-hospital cancer deaths.
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Affiliation(s)
- Samy A Alsirafy
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia Palliative Medicine Unit, Kasr Al-Ainy Center of Clinical Oncology & Nuclear Medicine (NEMROCK), Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Amrallah A Mohammed
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia Medical Oncology Department, Faculty of medicine, Zagazig University, Sharkia, Egypt
| | | | - Ahmad A Raheem
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia Medical Oncology Department, Faculty of medicine, Zagazig University, Sharkia, Egypt
| | - Amr T El-Kashif
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia Clinical Oncology Department, Kasr Al-Ainy Center of Clinical Oncology & Nuclear Medicine (NEMROCK), Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
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20
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Comparison of timing and decision-makers of do-not-resuscitate orders between thoracic cancer and non-cancer respiratory disease patients dying in a Japanese acute care hospital. Support Care Cancer 2014; 22:1485-92. [PMID: 24414996 DOI: 10.1007/s00520-013-2105-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of the study was to compare timing and decision-makers of do-not-resuscitate (DNR) orders between patients with end-stage thoracic cancer and non-cancer respiratory diseases in a Japanese acute care hospital. METHODS This study retrospectively reviewed the medical records of patients who died between January 2008 and March 2013 in the Department of Respiratory Medicine of Osaka Police Hospital, a teaching and acute care hospital. We compared the decision-making process, especially timing and decision-maker, of DNR orders between patients with thoracic cancer and patients with non-cancer respiratory diseases. RESULTS There were 300 cancer patients and 147 non-cancer patients. Cancer patients were significantly younger, were hospitalized more frequently and for longer, were more likely to have a DNR order placed earlier and decided in advance of last admission, and were more likely to have normal cognitive function at the time of the DNR order than non-cancer patients. Spouses of cancer patients were more likely to participate in DNR discussion. Only approximately 6 % of patients participated in DNR discussion in both groups. Cancer patients less frequently received aggressive treatment at the end of life (EOL) and were more likely to die in general wards than in intensive care units. CONCLUSIONS Our study found that most Japanese patients, with or without cancer, who died in an acute care respiratory department, were not included in DNR discussions and that familial surrogates usually made the DNR decision at the EOL.
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