Impact of Diagnosis Nondisclosure on Quality of Dying in Cancer Patients: A Bereavement Study

CONTEXT

Patients should be optimally informed about their illness for patients' autonomy and shared decision-making. However, diagnosis nondisclosure to patients is traditionally widespread in Japanese culture with family-oriented autonomy. There is insufficient research on quality of death (QOD) and quality of care (QOC) among patients who are not told their diagnosis.

OBJECTIVES

This study aimed to examine the impact of diagnosis nondisclosure on QOD and QOC in cancer patients.

METHODS

We performed a secondary analysis of a cross-sectional, nationwide mortality follow-back survey. The bereaved families responded to the questionnaire. Measurements included decedents' QOC, QOD, and bereaved families' outcomes. After using the propensity score matching method based on the covariates which can affect nondisclosure actions to compare the "disclosure" group and "nondisclosure" group, we compared differences in QOC, QOD, and bereaved families' outcomes between the two groups.

RESULTS

Of the 110,990 family members who were sent the questionnaires, we finally analyzed 46,672 responses. The disclosure group and nondisclosure group included 42,300 (90.6%) and 4,372 (9.4%) decedents, respectively. Most of the QOD domains (14/18) showed significantly higher scores in the disclosure group compared with the nondisclosure group. In terms of QOC domains, all domains showed higher scores in the disclosure group. Respondents in the disclosure group reported higher overall care satisfaction.

CONCLUSION

We demonstrated that overall QOD and QOC in decedents with cancer were significantly higher in decedents with explicit cancer diagnoses. Furthermore, bereaved family members' outcomes were better among the family members of decedents with an explicit cancer diagnosis.

Protocol of a nation-wide post-bereavement survey on quality of hospice and palliative care: J-HOPE 5 study

BACKGROUND

Maintaining quality of care and improving the quality of life (QOL) of patients and their families are important issues in palliative care. Therefore, there is a need to continuously evaluate the quality and outcomes of the care provided. In Japan, the Japan hospice and palliative evaluation (J-HOPE) study series has been conducted every three to four years since 2010, and we will conduct the fifth J-HOPE study (J-HOPE5). In the present paper, we describe the protocol of the J-HOPE5 study. The main objectives are: (1) to evaluate the processes, structures and outcomes of care at hospices or palliative care units; (2) to examine bereaved family members' self-reported psychosocial condition, such as grief and depression as bereavement outcomes; (3) to provide data to ensure and improve the quality of care provided by participating institutions via feedback based on the results from each institution; and (4) to provide clinical and academic information regarding the implications of various issues in palliative care by conducting specific research.

METHODS

We will conduct a cross-sectional, anonymous, self-reported questionnaire survey. In total, 153 institutions have agreed to participate in this study, meaning that approximately 12,240 bereaved family members (n = 80/institution) will be sent a questionnaire.

DISCUSSION

This is one of the largest cross-sectional bereavement surveys to evaluate the quality of specialized palliative care for patients with cancer, both in Japan and worldwide. The large sample size of this study will enable wide analyses of specific targets and topics.

Continuous Electrocardiographic Monitoring for 24 Hours Before Death in Patients with Terminal Cancer

BACKGROUND

Purposeless physiological monitoring at the end-of-life is not recommended. However, studies on how families feel regarding the death of patients with terminal cancer without continuous electrocardiographic monitoring (CEM) are lacking.

OBJECTIVES

To explore the impact on the quality of care and the feelings and psychological distress experienced by families when CEM is not used during the 24 hours preceding a patient's death.

METHODS

In this multicenter cross-sectional, self-report questionnaires were distributed to 1087 bereaved families at Japanese specialized palliative care units in 2018.

RESULTS

Out of 671 responses, 394 valid responses were analyzed. Families of nonmonitored patients (NM-group) accounted for 79.2%, while those with bedside electrocardiogram monitoring (MB-group) and remote nurse station monitoring (MC-group) comprised 11.9% and 8.9%, respectively. In the NM-group, 85.5% expressed satisfaction without CEM, which was more than 10% lower than other groups. While 14% in the NM-group desired patient monitoring, families who received adequate explanations about CEM had lower proportions compared to the MB-group (P = .021). Univariate analyses showed no significant differences in evaluations of the quality of care and families' psychological distress (mean scores of Overall Care Satisfaction, Care Evaluation Scale, Good Death Inventory, Brief Grief Questionnaires) across all groups.

CONCLUSION

While the majority of NM-group were satisfied with their patient's care without CEM, the proportion of dissatisfied families was higher than in other groups. Although not using CEM is not a major hindrance to end-of-life care for patients with terminal cancer, providing sufficient explanations may be important for satisfactory care.

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.

Bereaved family members' perspectives on quality of death in deceased acute cardiovascular disease patients compared with cancer patients - a comparison of the J-HOPE3 study and the quality of palliative care in heart disease (Q-PACH) study

BACKGROUND

Outcome measures during acute cardiovascular disease (CVD) phases, such as quality of death, have not been thoroughly evaluated. This is the first study that compared the family members' perceptions of quality of death in deceased CVD patients and in deceased cancer patients using a bereaved family survey.

METHODS

Retrospectively sent questionnaire to consecutive family members of deceased patients with CVD from ten tertiary hospitals from October 2017 to August 2018. We used the short version of the Good Death Inventory (GDI) and assessed overall care satisfaction. Referencing the GDI, the quality of death was compared between CVD patients admitted to a non-palliative care unit (non-PCU) and cancer patients in palliative care units (PCU) and non-PCUs in the Japan Hospice and Palliative Care Evaluation Study (J-HOPE Study). Additionally, in the adjusted analysis, multivariable linear regression was performed for total GDI score adjusted by the patient and participant characteristics to estimate the difference between CVD and other patients.

RESULTS

Of the 243 bereaved family responses in agreement (response rate: 58.7%) for CVD patients, deceased patients comprised 133 (54.7%) men who were 80.2 ± 12.2 years old on admission. The GDI score among CVD patients (75.0 ± 15.7) was lower (worse) than that of cancer patients in the PCUs (80.2 ± 14.3), but higher than in non-PCUs (74.4 ± 15.2). After adjustment, the total GDI score for CVD patients was 7.10 points lower [95% CI: 5.22-8.97] than for cancer patients in PCUs and showed no significant differences compared with those in non-PCUs (estimates, 1.62; 95% CI [-0.46 to 5.22]).

CONCLUSIONS

The quality of death perceived by bereaved family members among deceased acute CVD patients did not differ significantly from that of deceased cancer patients in general wards, however, was significantly lower than that of deceased cancer patients admitted in PCUs.

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.

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.

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.

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.

A Population-Based Mortality Follow-Back Survey Evaluating Good Death for Cancer and Noncancer Patients: A Randomized Feasibility Study

CONTEXT

Evaluation of end-of-life care is a key element in quality improvement, and population-based mortality follow-back designs have been used in several countries. This design was adapted to evaluate a good death in Japan.

OBJECTIVES

This study aimed to explain the scientific background and rationale for assessing the feasibility of a mortality follow-back survey using a randomized design.

DESIGN

We used a cross-sectional questionnaire survey to assess feasibility using response rate, sample representativeness, effect on response rate with two methods, and survey acceptability.

SETTING/PARTICIPANTS

The subjects were 4812 bereaved family members of patients who died from the major five causes of death: cancer, heart disease, cerebrovascular disease, pneumonia, or kidney failure, using mortality data.

RESULTS

Overall, 682 (14.2%) questionnaires could not be delivered, and 2294 (55.5%) family members agreed to participate in the survey. There was little difference in the distribution of characteristics between the study subjects and the full population, and sample representativeness was acceptable. Sending the questionnaire with a pen achieved a higher response rate than without (weighted: 48.2% vs. 40.8%; P < 0.001). In follow-up contact, there was no difference in response rate between resending the questionnaire and a reminder letter alone (weighted: 32.9% vs. 32.4%; P = 0.803). In total, 84.8% (weighted) of the participants agreed with improving quality of care through this kind of survey.

CONCLUSION

This study demonstrated the feasibility of conducting a population-based mortality follow-back survey using a randomized design. An attached pen with the questionnaire was effective in improving the response rate.

A Nationwide Survey of Bereaved Family Members' Perception of the Place Patients Spent Their Final Days: Is the Inpatient Hospice Like or Unlike a Home? Why?

Background: During end-of-life care, the place in which the patients spend time influences their quality of life.

Objective: To clarify what it means to spend last days at home and in inpatient hospice.

Design: This study was a part of a nationwide multicenter questionnaire survey of bereaved family members of cancer patients evaluating the quality of end-of-life care in Japan.

Setting/Subjects: A nationwide questionnaire survey was conducted with 779 family members of cancer patients who had died at inpatient hospices. We asked participants about the perceived benefits of spending last days at home and inpatient hospice during the patient's last days.

Measurements: A nationwide questionnaire.

Results: Of participants, 37.6% (n = 185 [95% confidence interval, 33%–42%]) felt that the inpatient hospice was like a home. The family members who reported that the inpatient hospice felt like home significantly tended to report high satisfaction with the level of care (p < 0.01). Factors that the participants perceived as benefits of the inpatient hospice were: “If anything changes, as health care professionals are easily available, he/she can handle it” (88.1%), “he/she is reassured” (78.4%), and “he/she is safe” (72.7%). On the contrary, factors that they perceived as benefits of home were: “He/she can do what he/she wants to do without worrying about the eye of other people” (44.1%), “he/she can relax” (43.5%), and “he/she is free” (42.0%).

Conclusions: Spending the last days of life in either an inpatient hospice or at home has specific benefits. The place a patient spends his/her end-of-life days should be based on patient and family values.

Survey of satisfaction regarding palliative care provided to patients who died at home or in a hospital

BACKGROUND

Improvement in quality of life (QoL) of patients is one of the most important goals of palliative care, but evaluation of QoL of patients is difficult.

AIM

To evaluate QoL of patients who died at home or in a hospital.

METHODS

We administered the Good Death Inventory (10 core and 8 optional domains) to the bereaved families of patients who died at home or in a hospital. A total of 107 bereaved families undertook a survey.

FINDINGS

If a bereaved family chose 'somewhat agree', 'agree' or 'absolutely agree', the answer was regarded as a 'satisfactory answer'. Regarding the 10 core domains, of patients who died in a hospital, <50% respondents gave a 'satisfactory answer' to three questions, whereas of patients who died at home, >60% of respondents gave a 'satisfactory answer' to seven questions. Regarding the eight optional domains, of patients who died in a hospital, <50% respondents gave a 'satisfactory answer' to five questions, whereas of patients who died at home, >60% of respondents gave a 'satisfactory answer' to four questions.

CONCLUSIONS

QoL of patients who died at home appeared higher than that of those who died in a hospital. Patients prefer to remain at home rather than in a hospital, probably because at home they are surrounded by familiar things and can live according to their usual habits.

The Bereaved Families' Preferences for Individualized Goals of Care for Terminal Dyspnea: What Is an Acceptable Balance between Dyspnea Intensity and Communication Capacity?

Background: Toward the individualized care of terminally ill patients with dyspnea (“terminal dyspnea”), it is essential to identify individualized goals of care (GOC) to achieve an acceptable balance between dyspnea intensity and communication capacity.

Objective: To explore preferences for individualized GOC for terminal dyspnea, and factors associated with the preferences.

Design: A nationwide cross-sectional survey.

Setting/Subjects: In total, 1055 bereaved families of cancer patients admitted to 167 inpatient hospices in Japan.

Measurements: Preferences for individualized GOC for terminal dyspnea to achieve an acceptable balance between dyspnea intensity and communication capacity, should individuals experience continuous moderate or severe/overwhelming dyspnea despite optimal palliative care, and perceptions about a good death.

Results: Among 548 participants (response rate = 52%), we analyzed responses of 477 families whose loved one suffered dyspnea in the last week of life. In total, 167 (45%; 95% confidence interval [CI] = 40%–50%) and 272 (80%; 95% CI = 75%–84%) participants would prioritize dyspnea relief over communication capacity, should they continuously suffer moderate or severe/overwhelming dyspnea, respectively. In multivariate analyses, the determinants of the prioritization of dyspnea relief were perceiving physical comfort as important for a good death (odds ratio [OR] = 1.389; 95% CI = 1.062–1.818; p = 0.017) in moderate dyspnea, and perceiving physical comfort (OR = 2.505; 95% CI = 1.718–3.651; p < 0.001) and not perceiving mental awareness (OR = 0.695; 95% CI = 0.529–0.913; p = 0.009) as important in severe/overwhelming dyspnea.

Conclusions: Preferences for individualized GOC for terminal dyspnea can vary among individuals and with different symptom intensity, and may be influenced by perceptions about a good death. Outcome measurements incorporating an acceptable balance between dyspnea intensity and communication capacity should be developed.

Associations between Japanese People's Concern about Family Caregiver Burden and Preference for End-Of-Life Care Location

Through a cross-sectional nationwide survey, this study identified the associations between Japanese people's choice of end-of-life care location and their sense of being a burden or a source of concern to their family members. A total of 1,042 people responded to the survey (a response rate of 55 percent). Of these, 44 percent said they would prefer to receive end-of-life care at home, 15 percent in hospital, 19 percent in a palliative care unit, 10 percent in a public nursing home, and 2 percent in a private nursing home. Multinomial logistic regression analysis revealed that those who thought it most important to relieve caregiver burden on family members tended to prefer a palliative care unit or a public nursing home to their own homes; those who were most concerned about the effect their death would have on their family members tended to prefer a hospital or a palliative care unit to their own homes. These findings may assist in the development of a more effective end-of-life care system in Japan and in other countries.

Achievement of a good death among young adult patients with cancer: analyses of combined data from three nationwide surveys among bereaved family members

PURPOSE

Although little improvement has been made in the survival rate among young cancer patients over recent decades, whether they have achieved a good death has never been systematically explored. We aimed to clarify whether young cancer patients (aged 20-39 years) have achieved a good death, and compare their achievement with that of middle-aged patients (aged 40-64 years).

METHODS

We analyzed combined data of three nationwide, cross-sectional surveys of families of cancer patients who died at inpatient hospices in Japan (2007-2014). We measured 10 core items of the Good Death Inventory (GDI) short-version on a 7-point scale, and calculated rates of "agree/absolutely agree" and the mean scores.

RESULTS

We analyzed 245 and 5140 responses of families of young and middle-aged patients, respectively. Less than 60% of families of young patients reported "agree/absolutely agree" regarding 9 items, which included "feeling that one's life was completed" in 44 (18%; 95% confidence interval (CI) = 14-23%), "being independent in daily life" in 48 (20%; 95% CI = 15-25%), and "being free from physical distress" in 103 (42%; 95% CI = 36-48%) young patients. Young patients were significantly less likely to feel "one's life was completed" (mean = 3.3 (standard deviation = 2.0) vs. 3.8 (1.9), respectively; effect size (ES) = 0.29; adjusted p value = 0.000) and "not being a burden to others" (3.1 (1.5) vs. 3.5 (1.6), respectively; ES = 0.24; adjusted p value = 0.010) than the middle-aged.

CONCLUSIONS

Overall, young cancer patients did not achieve a good death. Future efforts are needed to improve the quality of palliative care for young patients, focusing on psychosocial/spiritual suffering.

Voices that matter: end-of-life care in two acute hospitals from the perspective of bereaved relatives

Background

End-of-life care (EoLC) is an experience that touches the lives of everyone. Dying in an acute hospital is a common occurrence in developed countries across the world. Previous studies have shown that there is wide variation in EoLC and at times is experienced as being of poor quality. Assessing and measuring the quality of care provided is a key component of all healthcare systems. This paper reports on the qualitative analysis of open-ended free text questions that were asked as part of a post-bereavement survey conducted in two adult acute hospitals in Ireland.

Methods

This was a quantitative descriptive post-bereavement postal survey, gathering data retrospectively from relatives or friends of patients who died, utilising an adapted version of the VOICES (Views of Informal Carers - Evaluation of Services) questionnaire. VOICES MaJam has 29 core questions, seven questions requesting personal demographic information and four open-ended questions gathering descriptive data about the care experience during the patient’s last admission to hospital. A total of 356 valid questionnaires were returned. Qualitative data were managed, coded and analysed with NVivo 10, using a template analysis framework approach.

Results

Three quarters (75%: n = 268) responded to at least one of the open-ended questions. Several key themes emerged, indicating areas that require particular attention in EoLC. Two themes relate to how care needs are met and how the hospital environment has a critical influence on EoLC experiences. The remaining three themes relate more to the interpersonal context including whether patients are treated with dignity and respect, the psychological, emotional and spiritual needs of patients and their family members and communication.

Conclusions

Acute hospitals need to ensure that patients and their relatives receive high quality EoLC. Seeking the views of bereaved relatives should be considered by all hospitals and healthcare settings to ascertain the quality of care at end of life. This study contributes to our understanding and knowledge of what good EoLC looks like and where care can be improved, thus enabling hospitals to direct and inform quality improvement.

Communication about the impending death of patients with cancer to the family: a nationwide survey

Objectives

Explanation about the impending death of imminently dying patients with cancer is important for their families. However, little is known about how clinicians explain impending death and how families perceive the explanation. We aimed to clarify bereaved families’ perception of the need for improvements in the explanation about impending death and to explore the factors contributing to the need.

Methods

In a nationwide survey of 818 bereaved families of patients with cancer admitted to inpatient hospices in Japan, we evaluated family-perceived need for improvements in the explanation about impending death and families’ experiences of the explanation.

Results

Among all the participants (n=516, 63%), 35 (6.8%), 123 (24%) and 297 (58%) families felt that much/considerable, some and no improvements were needed, respectively. Independent determinants of the need were a younger patient age (OR=0.97; 95% CI 0.95 to 0.99; P=0.009); not receiving an ‘explicit explanation about physical signs of impending death’ (OR=0.67; 95% CI 0.51 to 0.88; P=0.004); not receiving an ‘explanation of how long the patient and family could talk’ (OR=0.67; 95% CI 0.51 to 0.88; P<0.001); receiving an ‘excessive warning of impending death’ (OR=1.45; 95% CI 1.03 to 2.03; P=0.033) and having a feeling of ‘uncertainty caused by vague explanations about future changes’ (OR=1.77; 95% CI 1.38 to 2.27; P<0.001).

Conclusions

Nearly a third of the bereaved families perceived some need to improve the explanation about impending death. To better help patients/families prepare for their end-of-life, clinicians should recognise and explain various impending death signs; find a balance between detailed explanation and excessive warning and address how long they could talk in the remaining time.

Developing the methods and questionnaire (VOICES-SF) for a national retrospective mortality follow-back survey of palliative and end-of-life care in England

The National Survey of Bereaved People was conducted by the Office for National Statistics on behalf of NHS England for the first time in 2011, and repeated annually thereafter. It is thought to be the first time that nationally representative data have been collected annually on the experiences of all people who have died, regardless of cause and setting, and made publicly available informing palliative and end-of-life policy, service provision and development, and practice. This paper describes the development of the questionnaire used in the survey, VOICES-SF, a short-form of the VOICES (Views Of Informal Carers-Evaluation of Services) questionnaire, adapted specifically to address the aims of the national survey. The pilot study to refine methods for the national survey is also described. The paper also reports on the development of the retrospective, after-death or mortality follow-back method in palliative and end-of-life care, and reviews its strengths and weaknesses.

Meaningful Communication Before Death, but Not Present at the Time of Death Itself, Is Associated With Better Outcomes on Measures of Depression and Complicated Grief Among Bereaved Family Members of Cancer Patients

CONTEXT

Few studies have explored the clinical significance of the family's presence or absence at the moment of a patient's death and meaningful communication (saying "goodbye") in terms of post-bereavement outcomes.

OBJECTIVES

To explore the potential association between the family's depression/complicated grief and their presence at the moment of a patient's death and the patient's communication with the family.

METHODS

A nationwide questionnaire survey was conducted on 965 family members of cancer patients who had died at palliative care units.

RESULTS

More than 90% of family members wished to have been present at the moment of death (agree: 40%, n = 217; strongly agree: 51%, n = 280); 79% (n = 393) thereof were present. Families' presence at death was not significantly associated with the occurrence of depression and complicated grief, but the dying patient's ability to say "goodbye" to the family beforehand was (depression: adjusted odds rate, 0.42; 95% CI, 0.26-0.69 adjusted P = 0.001; complicated grief: adjusted odds rate, 0.53; 95% CI, 0.29-0.94 adjusted P = 0.009).

CONCLUSION

Many families wished to be present at the moment of the patient's death; however, meaningful communication (saying "goodbye") between the patient and family members, and not their presence or absence itself, was associated with better outcomes on measures of depression or complicated grief. Health care professionals could consider promoting both mutual communication (relating to preparation for death) between family members and patients before imminent death, as well as the family's presence at the moment of death.

Areas for quality improvements in heart failure care: quality of care from the family members' perspective

BACKGROUND

The complex needs of people with chronic heart failure (HF) place great demands on their family members, and it is important to ask family members about their perspectives on the quality of HF care.

OBJECTIVE

To describe family members' perceptions of quality of HF care in an outpatient setting.

METHODS

A cross-sectional study using a short form of the Quality from Patients' Perspective (QPP) questionnaire for data collection. The items in the questionnaire measure four dimensions of quality, and each item consists of both the perceived reality of the care and its subjective importance. The study included 57 family members of patients with severe HF in NYHA class III-IV.

RESULTS

Family members reported areas for quality improvements in three out of four dimensions and in dimensionless items. The lowest level of perceived reality was reported for treatment for confusion and loss of appetite. Treatment for shortness of breath, access to the apparatus and access to equipment necessary for medical care were the items with the highest subjective importance for the family members.

CONCLUSION

Family members identified important areas for quality improvement in the care for patients with HF in an outpatient setting. In particular, symptom alleviation, information to patients, patient participation and access to care were identified as areas for improvements. Thus, measuring quality from the family members' perspective with the QPP might be a useful additional perspective when it comes to the planning and implementation of changes in the organisation of HF care.

Development the Care Evaluation Scale Version 2.0: a modified version of a measure for bereaved family members to evaluate the structure and process of palliative care for cancer patient

BACKGROUND

The Care Evaluation Scale (CES1.0) was designed to allow bereaved family members to evaluate the structure and process of care, but has been associated with a high frequency of misresponses. The objective of this study was to develop a modified version of CES1.0 (CES2.0) that would eliminate misresponses while maintaining good reliability and validity.

METHODS

We conducted a cross-sectional questionnaire survey by mail in October 2013. The participants were bereaved family members of patients who died from cancer in seven institutions in Japan. All family members were asked to complete CES2.0, the short form CES1.0, items on overall care satisfaction, the Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale, the Patient Health Questionnaire-9 (PHQ-9) and the Brief Grief Questionnaire (BGQ). To examine test-retest reliability, all participants were asked to complete a second CES2.0.

RESULTS

Of 596 questionnaires sent, 461 (77%) were returned and 393 (66%) were analyzed. In the short form CES1.0, 17.1% of the responses were identified as misresponses. No misresponses were found in CES2.0. We identified 10 CES2.0 subscales similar to those in CES1.0 using exploratory factor analysis. Cronbach's alpha was 0.96, and the intraclass correlation coefficient was 0.83. Correlations were found between CES2.0 and overall satisfaction (r = 0.83) and FAMCARE (r = 0.58). In addition, total CES2.0 scores were negatively correlated with the PHQ-9 (r = -0.22) and BGQ (r = -0.10).

CONCLUSION

These results suggest that CES2.0 eliminated misresponses associated with CES1.0 while maintaining good reliability and validity and greatly improving test-retest reliability.

Development the Care Evaluation Scale Version 2.0: a modified version of a measure for bereaved family members to evaluate the structure and process of palliative care for cancer patient

BACKGROUND

The Care Evaluation Scale (CES1.0) was designed to allow bereaved family members to evaluate the structure and process of care, but has been associated with a high frequency of misresponses. The objective of this study was to develop a modified version of CES1.0 (CES2.0) that would eliminate misresponses while maintaining good reliability and validity.

METHODS

We conducted a cross-sectional questionnaire survey by mail in October 2013. The participants were bereaved family members of patients who died from cancer in seven institutions in Japan. All family members were asked to complete CES2.0, the short form CES1.0, items on overall care satisfaction, the Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale, the Patient Health Questionnaire-9 (PHQ-9) and the Brief Grief Questionnaire (BGQ). To examine test-retest reliability, all participants were asked to complete a second CES2.0.

RESULTS

Of 596 questionnaires sent, 461 (77%) were returned and 393 (66%) were analyzed. In the short form CES1.0, 17.1% of the responses were identified as misresponses. No misresponses were found in CES2.0. We identified 10 CES2.0 subscales similar to those in CES1.0 using exploratory factor analysis. Cronbach's alpha was 0.96, and the intraclass correlation coefficient was 0.83. Correlations were found between CES2.0 and overall satisfaction (r = 0.83) and FAMCARE (r = 0.58). In addition, total CES2.0 scores were negatively correlated with the PHQ-9 (r = -0.22) and BGQ (r = -0.10).

CONCLUSION

These results suggest that CES2.0 eliminated misresponses associated with CES1.0 while maintaining good reliability and validity and greatly improving test-retest reliability.

Nationwide Japanese Survey About Deathbed Visions: "My Deceased Mother Took Me to Heaven"

OBJECTIVES

Primary aim was to clarify the prevalence and factors associated with the occurrence of deathbed visions, explore associations among deathbed visions, a good death, and family depression. Additional aim was to explore the emotional reaction, perception, and preferred clinical practice regarding deathbed visions from the view of bereaved family members.

METHODS

A nationwide questionnaire survey was conducted involving 3964 family members of cancer patients who died at hospitals, palliative care units, and home.

RESULTS

A total of 2827 responses (71%) were obtained, and finally 2221 responses were analyzed. Deathbed visions were reported in 21% (95% CIs, 19-23; n = 463). Deathbed visions were significantly more likely to be observed in older patients, female patients, female family members, family members other than spouses, more religious families, and families who believed that the soul survives the body after death. Good death scores for the patients were not significantly different between the families who reported that the patients had experienced deathbed visions and those who did not, whereas depression was more frequently observed in the former than latter, with marginal significance (20 vs. 16%, respectively, adjusted P = 0.068). Although 35% of the respondents agreed that deathbed visions were hallucinations, 38% agreed that such visions were a natural and transpersonal phenomenon in the dying process; 81% regarded it as necessary or very necessary for clinicians to share the phenomenon neutrally, not automatically labeling them as medically abnormal.

CONCLUSIONS

Deathbed vision is not an uncommon phenomenon. Clinicians should not automatically regard such visions as an abnormal phenomenon to be medically treated and rather provide an individualized approach.

The Japan HOspice and Palliative Care Evaluation Study 3: Study Design, Characteristics of Participants and Participating Institutions, and Response Rates

This article describes the whole picture of Japan HOspice and Palliative Care Evaluation Study 3 (J-HOPE3 Study) including study design and demographic data. The aims of the J-HOPE3 study were to (1) evaluate the process, structure, and outcome of palliative care in the following care settings: acute hospitals, inpatient hospice/palliative care units (PCUs), and home hospice services; (2) examine bereaved family members’ self-reported psychosocial conditions, such as grief and depression, as bereavement outcomes; (3) provide data to ensure and improve the quality of care provided by participating institutions through feedback concerning results for each institution; and (4) perform additional studies to explore specific clinical research questions. We conducted a cross-sectional, anonymous, self-report questionnaire survey involving patients’ bereaved family members in 20 acute hospitals, 133 PCUs, and 22 home hospice services between May and July 2014. Two types of questionnaires were used: main and specific studies questionnaires. The questionnaire was sent to totally 13 584, and 10 157 returned the questionnaire. The analysis included 9126 family members’ questionnaires from acute hospitals, PCUs, and home hospice services. Respondents’ average age was 61.6 years, 55% were women, and 40% had been married to the deceased. With respect to the characteristics of participating institutions, most institutions did not have religious affiliations, and most PCUs and home hospice services provided bereavement care. These results of the analysis of common and additional questionnaires could play an important role in clinical settings, quality improvement, research, and public accountability.

Association Between Bereaved Families' Sense of Security and Their Experience of Death in Cancer Patients: Cross-Sectional Population-Based Study

CONTEXT

The sense of security scale was developed to indicate care quality within the community. Bereaved families have perspective to evaluate the quality of the care system.

OBJECTIVES

The aim was to examine associations between end-of-life care and sense of security regarding regional cancer care among bereaved families.

METHODS

A cross-sectional population-based survey was conducted with families of cancer patients who died in regional areas of Japan.

RESULTS

A total of 1046 family caregivers of patients responded to surveys (effective response rate of 65%). In multiple regression analyses, the families' higher age (P < 0.001), home death (P = 0.039), better health status of the family at patients' end of life (P = 0.016), lower caregiving burden (P < 0.001), and elements of perceived good patient death, including being free from physical distress (P < 0.001), trusting the physician (P < 0.001), living in calm circumstances (P = 0.042), and feeling that one's life was fulfilling (P = 0.035), were associated with a higher sense of security.

CONCLUSION

Quality of death and lower burden on family caregivers were associated with families' sense of security. This suggests strategies for improving care quality for each patient to improve the sense of security.

Spanish Validation of the Care Evaluation Scale for Measuring the Quality of Structure and Process of Palliative Care From the Family Perspective

CONTEXT

A reliable and valid measure of the structure and process of end-of-life care is important for improving the outcomes of care.

OBJECTIVES

This study evaluated the validity and reliability of the Spanish adaptation of a satisfaction tool of the Care Evaluation Scale (CES), which was developed in Japan to evaluate palliative care structure and process from the perspective of family members.

METHODS

Standard forward-backward translation and a pilot test were conducted. A multicenter survey was conducted with the relatives of patients admitted to palliative care units for symptom control. The dimensional structure was assessed using confirmatory factor analyses. Concurrent and discriminant validity were tested by correlation with the SERQVHOS, a Spanish hospital care satisfaction scale and with an 11-point rating scale on satisfaction with care. The reliability of the CES was tested by Cronbach α and by test-retest correlation.

RESULTS

A total of 284 primary caregivers completed the CES, with low missing response rates. The results of the factor analysis suggested a six-factor solution explaining 69% of the total variance. The CES moderately correlated with the SERQVHOS and with the overall satisfaction scale (intraclass correlation coefficients of 0.66 and 0.44, respectively; P = 0.001). Cronbach α was 0.90 overall and ranged from 0.85 to 0.89 for subdomains. Intraclass correlation coefficient was 0.88 (P = 0.001) for test-retest analysis.

CONCLUSION

The Spanish CES was found to be a reliable and valid measure of the satisfaction with end-of-life care structure and process from family members' perspectives.

Desirable Information of Opioids for Families of Patients With Terminal Cancer

OBJECTIVE

The aims of this study are to clarify the state of information regarding opioids for families and what kinds of experiences they had with opioids while the patient was followed as an outpatient and inpatient.

PARTICIPANTS

This study was part of a cross-sectional nationwide survey of bereaved families of patients with cancer, namely, the Japan Hospice and Palliative Care Evaluation 2 study. The participants in this study comprised 572 bereaved families who had experienced the death of a family member during the period from January 2008 to December 2009 at 1 of 103 certificated palliative care units.

MAIN OUTCOME MEASURES

In response to the question of "how much improvement was needed for information regarding opioids," 41% answered "improvement is not necessary at all," 43% answered "improvement is slightly necessary," 14% answered "improvement is necessary," and 2% answered "improvement is extremely necessary." Regarding anxiety about the use of opioid, it was found that 14% of respondents indicated "opioids are very safe," 65% of respondents indicated "opioids are relatively safe," 19% of respondents indicated "opioids are not so safe," and 2% of respondents indicated "opioids are not so safe at all." from the information obtained for opioids. It was found that 90% of families agreed with the item, "I would like to be clearly explained that drugs for medical purposes are safe and that the patient will not develop a drug addiction and their life expectancy will not be reduced."

CONCLUSION

From this study, it is important for families of patients with cancer to be explained profound and careful information of opioid.

Factors Associated with Participation, Active Refusals and Reasons for Not Taking Part in a Mortality Followback Survey Evaluating End-of-Life Care

BACKGROUND

Examination of factors independently associated with participation in mortality followback surveys is rare, even though these surveys are frequently used to evaluate end-of-life care. We aimed to identify factors associated with 1) participation versus non-participation and 2) provision of an active refusal versus a silent refusal; and systematically examine reasons for refusal in a population-based mortality followback survey.

METHODS

Postal survey about the end-of-life care received by 1516 people who died from cancer (aged ≥18), identified through death registrations in London, England (response rate 39.3%). The informant of death (a relative in 95.3% of cases) was contacted 4-10 months after the patient died. We used multivariate logistic regression to identify factors associated with participation/active refusals and content analysis to examine refusal reasons provided by 205 nonparticipants.

FINDINGS

The odds of partaking were higher for patients aged 90+ (AOR 3.48, 95%CI: 1.52-8.00, ref: 20-49yrs) and female informants (AOR 1.70, 95%CI: 1.33-2.16). Odds were lower for hospital deaths (AOR 0.62, 95%CI: 0.46-0.84, ref: home) and proxies other than spouses/partners (AORs 0.28 to 0.57). Proxies of patients born overseas were less likely to provide an active refusal (AOR 0.49; 95% CI: 0.32-0.77). Refusal reasons were often multidimensional, most commonly study-related (36.0%), proxy-related and grief-related (25.1% each). One limitation of this analysis is the large number of nonparticipants who did not provide reasons for refusal (715/920).

CONCLUSIONS

Our survey better reached proxies of older patients while those dying in hospitals were underrepresented. Proxy characteristics played a role, with higher participation from women and spouses/partners. More information is needed about the care received by underrepresented groups. Study design improvements may guide future questionnaire development and help develop strategies to increase response rates.

A Nationwide Survey of Quality of End-of-Life Cancer Care in Designated Cancer Centers, Inpatient Palliative Care Units, and Home Hospices in Japan: The J-HOPE Study

CONTEXT

End-of-life (EOL) cancer care in general hospitals and home care has not previously been evaluated in Japan.

OBJECTIVES

This study aimed to evaluate EOL cancer care from the perspective of bereaved family members in nationwide designated cancer centers, inpatient palliative care units (PCUs), and home hospices in Japan.

METHODS

We conducted a cross-sectional, anonymous, self-report questionnaire survey for bereaved family members of cancer patients in March 2008 for 56 designated cancer centers and in June 2007 for 100 PCUs and 14 home hospices. Outcomes were overall care satisfaction, structure and process of care (Care Evaluation Scale), and achievement of a good death (Good Death Inventory).

RESULTS

In designated cancer centers, PCUs, and home hospices, 2794 (response rate 59%), 5312 (response rate 69%), and 292 (response rate 67%) bereaved family members participated, respectively. Mean scores for overall care satisfaction were high for all places of death, at 4.3 ± 1.2 for designated cancer centers, 5.0 ± 1.2 for PCUs, and 5.0 ± 1.0 for home hospices. Designated cancer centers showed significantly lower ratings than PCUs and home hospices for structure and process of care and achievement of a good death (P = 0.0001 each). Home hospices were rated significantly higher than PCUs for achievement of a good death (P = 0.0001).

CONCLUSION

The main findings of this study were: (1) overall, bereaved family members were satisfied with end-of-life care in all three places of death; (2) designated cancer centers were inferior to PCUs and home hospices and had more room for improvement; and 3) home hospices were rated higher than PCUs for achieving a good death, although home hospices remain uncommon in Japan.

The effects of community-wide dissemination of information on perceptions of palliative care, knowledge about opioids, and sense of security among cancer patients, their families, and the general public

PURPOSE

Prejudices against palliative care are a potential barrier to quality end-of-life care. There have been few large-scale community-wide interventions to distribute appropriate information about palliative care, and no studies have investigated their impact on cancer patients, their families, and the general public. Thus, we conducted a 3-year community intervention and evaluated the effects of distributing such information at the community level, and explored associations among levels of exposure, perceptions, knowledge, and the sense of security achieved.

METHODS

Over a period of 3 years, we provided flyers, booklets, posters, and public lectures about palliative care in four regions of Japan, and carried out pre- and post-intervention surveys with repeated cross-sectional samplings of cancer patients (pre 859, post 857), bereaved family members (1110, 1137), and the general public (3984, 1435). The levels of exposure to the provided information were measured by a multiple-choice questionnaire after intervention. Multiple logistic regression analyses were used to estimate multivariable-adjusted odds ratios (ORs) for perceptions of palliative care, knowledge about opioids, and sense of security among the exposure groups.

RESULTS

Overall perceptions of palliative care, opioids, and receiving care at home improved significantly among the general public and families, but not among the patients at the community level. However, multiple regression revealed that patients of extensive exposure category had significantly more positive perceptions of palliative care to those of non-exposure category (p = 0.02). The sense of security regarding cancer care of all patients, family members, and the general public improved. Among others, the respondents who reported extensive exposure in the general public and family members scored significantly higher sense of security.

CONCLUSION

Our findings indicate that providing palliative care information via small media and lectures in the community is effective in improving perceptions of palliative care and knowledge about opioids among the community dwellers, especially for caregivers of the patients. The acquisition of adequate knowledge about palliative care from various information sources may improve people's sense of security regarding cancer.

Why people accept opioids: role of general attitudes toward drugs, experience as a bereaved family, information from medical professionals, and personal beliefs regarding a good death

CONTEXT

Many surveys have evaluated patient-related barriers to pain management.

OBJECTIVES

To explore associations between a preference for opioids and general attitudes toward drugs, the experience and information received as a bereaved family, and beliefs regarding a good death.

METHODS

A cross-sectional survey, performed in 2010, of bereaved families of patients with cancer in palliative care units across Japan. Questionnaires were sent to 997 families.

RESULTS

A total of 66% of families responded. Of these, 224 responses were excluded because the family declined to participate in the study (n = 38), the patient was not receiving any opioid analgesics, and there were missing data (n = 164), or data were missing for the primary end points (n = 22). Thus, 432 responses were finally analyzed (43%). In total, 26%, 41%, and 31% of family members stated that they strongly want to receive, want to receive, or slightly want to receive opioids if needed in the future, respectively. Determinants associated with a preference for receiving opioid treatment were the following: a general appreciation of the drugs (P = 0.005), witnessing an improvement in the patient's quality of life as a result of pain relief (P = 0.003), information provided by medical professionals that the opioid could be discontinued if side effects developed (P = 0.042), and the belief that a good death was one that was free from pain and physical distress (P < 0.001).

CONCLUSION

More than 90% of bereaved families whose relatives were treated with opioid analgesics reported a preference to receive opioid analgesics for the treatment of cancer pain, if necessary, in the future.

Does the Approach of Disclosing More Detailed Information of Cancer for the Terminally Ill Patients Improve the Quality of Communication Involving Patients, Families, and Medical Professionals?

Purpose:

Effective and faithful communication between patients and medical professionals could improve patients' quality of life and is an essential and fundamental factor in cancer treatment. The purpose of this study was to examine whether disclosing more detailed information about disease progression toterminally ill patients could improve the quality of communication.

Methods:

This was a before/after study of 91 consecutive terminal cancer patients. Based on the previous studies, we categorized cancer disclosure into 4 groups: A;“non-disclosure”, B;“disclosure of cancer diagnosis”, C;“disclosureof life-threatening disease”, and D;“disclosure of poor prognosis”. We disclosed more detailed information based on the SPIKES protocol and compared the scores of 3 communication items of Support Team Assessment Schedule (Japanese version) measured between at admission and one-week after this approach.

Results:

A, B, C and D groups included 8, 25, 40, and 18 cases, respectively. This approach to cancer disclosure was implemented in 37.5% of group A, 60% of group B, and 40% of group C. In group B, all 3 communications were significantly improved (2.40 ± 0.51 vs 1.53 ± 0.83, 1.93 ± 0.96 vs 1.00 ± 0.38, 2.13 ± 0.64 vs 1.13 ± 0.64; p = 0.0035, 0.0062, 0.0013). In group C, all 3 communications were significantly improved (1.25 ± 0.58 vs 0.81 ± 0.66, 1.13 ± 0.34 vs 0.69 ± 0.48, 1.31±0.60 vs 0.56 ± 0.63; p = 0.020, 0.0082, 0.0057).

Conclusions:

This study revealed that disclosing more detailed information of cancer for terminally ill cancer patients contributed to improving the quality of communication, irrespective of the stage of disclosure.

Length of home hospice care, family-perceived timing of referrals, perceived quality of care, and quality of death and dying in terminally ill cancer patients who died at home

PURPOSE

This study aims to clarify the length of home hospice care, family-perceived timing of referrals, and their effects on the family-perceived quality of care and quality of death and dying of terminally ill cancer patients who died at home and identify the determinants of perceived late referrals.

METHODS

A multicenter questionnaire survey was conducted involving 1,052 family members of cancer patients who died at home supported by 15 home-based hospice services throughout Japan.

RESULTS

A total of 693 responses were analyzed (effective response rate, 66 %). Patients received home-based hospice care for a median of 35.0 days, and 8.0 % received home hospice care for less than 1 week. While 1.5 % of the families reported the timing of referrals as early, 42 % reported the timing as late or too late. The families of patients with a length of care of less than 4 weeks were more likely to regard the timing of referrals as late or too late. The patients of family members who regarded the timing of referrals as late or too late had a significantly lower perceived quality of care (effect size, 0.18; P = 0.039) and lower quality of death and dying (effect size, 0.15, P = 0.063). Independent determinants of higher likelihoods of perceived late referrals included: frequent visits to emergency departments, patient being unprepared for worsening condition, and patient having concerns about relationship with new doctor. Discharge nurse availability was independently associated with lower likelihoods of perceived late referrals.

CONCLUSIONS

A significant number of bereaved families regarded the timing of referrals to home hospices as late, and the perceived timing was associated with the family-perceived quality of care and quality of death and dying. Systematic strategies to overcome the barriers related to perceived late referrals are necessary.

Care evaluation scale-patient version: measuring the quality of the structure and process of palliative care from the patient's perspective

CONTEXT

Recently, greater emphasis has been placed on patient-reported outcomes. However, there are only a few measures to evaluate the quality of care from the patient's perspective.

OBJECTIVES

To report the development of a scale to measure the quality of the structure and process in palliative care from the patient's perspective and examine the reliability and validity of the scale.

METHODS

A cross-sectional anonymous questionnaire was administered to cancer patients who were being treated on an oncology inpatient ward, who visited an oncology outpatient clinic at Saitama Medical University International Medical Center, or who were in an inpatient palliative unit in Japan between August 2007 and March 2008.

RESULTS

A total of 405 cancer patients participated in the study. Factor analysis revealed that the Care Evaluation Scale-Patient version (CES-P) consisted of 23 items with eight subscales: physical care by physicians, physical care by nurses, psychoexistential care, help with decision making for patients, environment, cost, availability, and coordination/consistency. The total CES-P score was correlated with satisfaction (r = 0.63) but not with quality of life (r = 0.18). The Cronbach α coefficient of the total score was 0.97, and the intraclass correlation coefficient of the total score was 0.67. The CES-P total score was not significantly correlated with the self-reported Eastern Cooperative Oncology Group performance status (ρ = -0.05).

CONCLUSION

The CES-P has sufficient validity and reliability. In addition, this scale is independent of the general physical condition of the patient.

Burden for family carers at the end of life; a mixed-method study of the perspectives of family carers and GPs

Background

Since many patients spend most of the time at home at the end of life, this may affect the burden for family carers and constitute a risk factor for the patients’ hospitalisation. This study aimed to explore family carers’ burden in the final three months of the patient’s life, from the perspective of both carers and general practitioners (GPs), and to assess whether family burden, as defined by the GP, is associated with hospitalisation.

Methods

A cross-sectional nationwide survey among GPs and family carers was performed. Participants were 194 GPs and 74 family carers of patients who died non-suddenly. Additionally, in-depth interviews were conducted with 18 family carers. For the quantitative analyses descriptive statistics, weighted Kappa and multivariate logistic regression analysis was performed. For the qualitative part thematic analysis was conducted.

Results

The proportion of family carers experiencing a fairly heavy or severe burden increased significantly from 32% (second and third months before death) to 66% (one week before death). Most carers (95%) felt an emotional burden and 29% felt a physical burden in the final week. Three-quarters of carers did not perceive their burden as a problem because caring often felt rewarding. No significant association was found between the characteristics of family caregivers or professional care and the degree of family caregiver burden. Also, there was no significant evidence that patients of family carers for whom the GP assessed a fairly heavy to severe burden, were more likely to be hospitalised.

Conclusions

The different overall assessment of family carers’ burden between GPs and family carers and the increasing emotional and physical burden of family carers towards the end constitute relevant information for GPs that will help them understand and anticipate carers’ personal needs.

Palliative care in Japan: a review focusing on care delivery system

PURPOSE OF REVIEW

Providing palliative care in Japan is one of the most important health issues. Understanding palliative care delivery systems of other countries is useful when developing and modifying palliative care systems worldwide. This review summarizes the current status of palliative care in Japan, focusing on the structure and process development.

RECENT FINDINGS

Palliative care units and hospital palliative care consultation teams are the two main specialized palliative care services in Japan. The number of palliative care units is 215 (involved in 8.4% of all cancer deaths), and there are approximately 500 hospital palliative care teams. Conversely, specialized home care services are one of the most undeveloped areas in Japan. However, the government has been trying to develop more efficient home care services through modifying laws, healthcare systems, and multiple educational and cooperative projects. The numbers of palliative care specialists are increasing across all disciplines: cancer pain nurses (1365), palliative care nurses (1100), palliative care physicians (646), and palliative care pharmacists (238). Postgraduate education for physicians is performed via the special nationwide efforts of the Palliative care Emphasis program on symptom management and Assessment for Continuous medical Education (PEACE) project - a 2-day program adopting a trainer-trainee strategy. Over 30,000 physicians have participated in the PEACE program. A total of 1298 and 544 physicians have completed a trainer course for palliative medicine and psycho-oncology, respectively. Multiple structure and process evaluation, bereaved family surveys in palliative care units, and patient and family evaluation in the regional palliative care program indicate many improvements.

SUMMARY

Palliative care in Japan has progressed rapidly, and the Cancer Control Act has played a very important role in developing palliative medicine. Challenges include developing a structure for palliative care in the community or regional palliative care programs, establishing a method to measure and improve the quality of palliative care at a national level, developing evidence-based medicine and policy making, and palliative care for the noncancerous population.

The perspectives of bereaved family members on their experiences of support in palliative care

AIM

To explore family members' supportive interactions in palliative care and the emotional experiences that they associate with these interactions.

METHODS

Qualitative individual interviews were performed with bereaved family members recruited from an urban palliative care service in Sweden. The interviews were analysed using inductive qualitative content analysis.

RESULTS

Five categories of supportive interactions with staff members were linked with emotional consequences: informational support, supportive encounters, professional focus of staff, a supportive environment, and bereavement support. Having a dialogue with family members nurtured certainty and security, supportive encounters gave a warm and comforting feeling, and bereavement support contributed to feelings of strength. Environmental factors contributed to dignity.

CONCLUSION

Supportive interactions with staff and within a home-like environment help to build resilience if tailored to the family member's own needs.

The impact of awareness of terminal illness on quality of death and care decision making: a prospective nationwide survey of bereaved family members of advanced cancer patients

OBJECTS

We aimed to assess whether awareness of a terminal illness can affect care decision making processes and the achievement of a good death in advanced cancer patients receiving palliative care services.

METHODS

Awareness of terminal illness at the time of palliative care service admission was assessed by the health care professionals during the routine initial comprehensive assessment process and was recorded in the national terminal cancer patient registry. A follow-up nationwide bereavement survey was conducted, which contained questions regarding decision making processes and the Korean version of the Good Death Inventory.

RESULTS

Among the 345 patients included in the final analysis, the majority (68.4%) of the patients were aware of the terminal illness. Awareness of the terminal illness tended to reduce discordances in care decision making (adjusted odds ratio = 0.55; 95% CI: 0.29-1.07), and increased the patients' own decision making when there were discordances between patients and their families (adjusted odds ratio = 3.79; 95% CI: 1.31-10.94). The Good Death Inventory score was significantly higher among patients who were aware of their terminal illnesses compared with those who were not (5.04 vs. 4.80; p = 0.013) and especially in the domains of 'control over the future' (5.18 vs. 4.04; p < 0.001), 'maintaining hope and pleasure' (4.55 vs. 3.92; p = 0.002), and 'unawareness of death' (4.41 vs. 4.26; p = 0.024).

CONCLUSION

Awareness of the terminal illness had beneficial effect on the harmonious decision making, patient autonomy, and patient's quality of death. Disclosure of terminal illness should be encouraged.

A pilot study of adaptation of the transtheoretical model to narratives of bereaved family members in the bereavement life review

This study aimed to examine the possibility of adaptation of the transtheoretical model (TTM) to narratives from the Bereavement Life Review. Narratives from 19 bereaved family members were recorded, transcribed into sentences, and allocated into stages based on the TTM criteria. Those who lived in fantasy were allocated to the precontemplation stage and who recognized the patient's death but could not adjust to the death were allocated to the contemplation stage. Those who understood the need for changes and had new plans were allocated to the preparation stage, and those who were coping were allocated to the action stage, and those who had confidence to remember the loved one who died were allocated to the maintenance stage. These results provide deeper understanding of a bereaved family member and suggest that a different intervention method may be useful in each stage.

Factors that affect quality of dying and death in terminal cancer patients on inpatient palliative care units: perspectives of bereaved family caregivers

CONTEXT

There is an increasing use of palliative care units (PCUs) for the treatment of terminally ill cancer patients. Thus, it is important to evaluate the care and quality of life of terminally ill cancer patients treated in PCUs so that improvements can be made. Limited research has investigated the quality of dying and death in PCUs.

OBJECTIVES

The aim of this study was to identify factors associated with the quality of dying and death for terminally ill cancer patients in PCUs.

METHODS

Data were collected from 570 bereaved family caregivers of terminally ill cancer patients. All patients were registered and died in one of the 40 inpatient PCUs designated by the Korean Ministry of Health and Welfare. We assessed the perceived timing of referral to a PCU; the quality of end-of-life cancer care with the Care Evaluation Scale; and the quality of dying and death with the Good Death Inventory.

RESULTS

The perception of appropriate timing of referral, use of a community-based PCU, and higher quality of cancer care as assessed by the Care Evaluation Scale were associated with good dying and death in all domains of the Good Death Inventory.

CONCLUSION

The good quality of end-of-life care in a PCU improves the quality of dying in terminally ill cancer patients. The data have the potential to guide the development of interventions aimed at achieving a good quality of dying for patients with terminal cancer.

Measuring the structure and process of end-of-life care in Korea: validation of the Korean version of the Care Evaluation Scale (CES)

CONTEXT

A reliable and valid measure of structure and process of end-of-life care is important for improving the outcomes of care.

OBJECTIVES

This study examined the validity and reliability of the Korean version of Care Evaluation Scale (CES), which was developed in Japan to evaluate structure and process of palliative care from the perspective of bereaved family members.

METHODS

Standard forward-backward translation and a pilot test were conducted. A multicenter cross-sectional survey was conducted with bereaved family members (n=501) of patients who had died from cancer two to six months before the study. Descriptive analyses were performed. The reliability of the CES was tested by Cronbach's alpha. The dimensional structure was assessed using confirmatory factor analyses. Concurrent and discriminant validity were tested by correlation with the overall satisfaction with care, patient's overall quality of life (QoL), and family member's own QoL as measured by the EQ-5D.

RESULTS

Participants could complete the CES readily, with low missing response rates. Cronbach's alpha for internal consistency was 0.93 overall, and ranged from 0.88 to 0.94 for subdomains. The hypothesized 10 subscale model of the CES appeared to fit the data (goodness-of-fit index=0.854). The overall score of the CES moderately correlated with overall satisfaction with care (r=0.54, P<0.001), more weakly correlated with the patient's QoL (r=0.32, P<0.001), but did not correlate with the family member's QoL (r=0.03, P=0.548).

CONCLUSION

The CES was found to be a reliable and a valid measure of the necessity for improvement in the structure and process of end-of-life care from bereaved family members' perspectives.

Specialized Palliative Care Services in Japan

Objective:

The aim of this study was to investigate the availability and utilization of specialized palliative care services among patients with cancer in Japan.

Methods:

We conducted a nationwide cross-sectional survey of 828 institutions predicted to provide specialized palliative care services.

Results:

Responses were received from 751 institutions (response rate, 91%); of these, 541 had specialized palliative care services. Adding the census data of palliative care units, the total estimated number of institutions with specialized palliative care services was 659. Of all the patients with cancer who died in the period from April 2009 to May 2010 in Japan, the estimated proportion who utilized specialized palliative care services was 24%.

Conclusions:

Usage of specialized palliative care services in Japan have increased explosively in the past decade.

In-advance end-of-life discussions and the quality of inpatient end-of-life care: a pilot study in bereaved primary caregivers of advanced cancer patients

PURPOSE

Advanced cancer care planning is encouraged to achieve individualized care. We hypothesized that in-advance end-of-life (EOL) discussions and establishment of do-not-resuscitate (DNR) status prior to the terminal admission would be associated with better quality of inpatient EOL care.

METHODS

We conducted a post-mortality survey, utilizing the validated Toolkit of Instruments to Measure End-of-Life Care. Primary caregivers (PCGs) of the advanced cancer patients who died at our institution between January 2009 and December 2010 were contacted more than 3 months after the patients' death. The endpoints included overall score for EOL care (0-10; 10 = best care), problem scores of six domains (0-1; 1 = worst problem), and score for supporting family's self-efficacy (knowing what to expect/do during the dying process) (1-3; 3 = greatest support).

RESULTS

Of 115 PCGs contacted, 50 agreed to participate (43.5 %). Patients with EOL discussions (n = 20), as compared to those without (n = 29), had higher rating of overall EOL care (9.7 vs. 8.7; p = 0.001): lower problem scores in "informing and promoting shared decision-making" (0.121 vs. 0.239; p = 0.007), "encouraging advanced care planning" (0.033 vs. 0.167; p = 0.010), "focusing on individual" (0.051 vs. 0.186; p = 0.014), "attending to emotional/spiritual needs of family" (0.117 vs. 0.333; p = 0.010), and "providing care coordination" (0.100 vs. 0.198; p = 0.032), and greater support for family's self-efficacy (2.734 vs. 2.310; p < 0.001). No significant differences were found in these outcomes between patients with DNR (n = 19) and those with full code (n = 31) on admission.

CONCLUSION

Advanced cancer patients may receive higher quality of inpatient EOL care if they had in-advance EOL discussions.

Associations with the Japanese population's preferences for the place of end-of-life care and their need for receiving health care services

PURPOSE

The aims of this study were to identify the associations with the Japanese population's preferences for the place of end-of-life care and their need for receiving health care services.

METHODS

A secondary analysis of a cross-sectional nationwide survey was conducted for 2000 randomly selected Japanese people aged 40-79 years.

RESULTS

A total of 1042 people (55%) responded. Regarding preferred place of care, we set the place within the choices of "Home" (preferred by 44% of respondents), "Acute Hospital" (15%), "Palliative Care Unit" (19%), "Public Nursing Home" (10%), and "Private Nursing Home" (2%). Multinomial logistic regression analysis revealed that the people who preferred "Acute Hospital" tended to have the following need compared to those who preferred "Home," "Palliative Care Unit," or "Nursing Home": higher need for receiving end-of-life care not from its experienced professionals but from the same staff; higher need for using health care services in highly supported environment such as the need for being near health care staff whenever and for receiving treatment possibly until the end; and higher need for consulting nurses whenever. They had lower need for using home care services and daycare services and also lower need for instructing families about how to use insurance/public health services.

CONCLUSIONS

The present findings may help to develop an effective end-of-life care system in Japan considering Japanese people's need for health care services. Also, the results of this study may underscore the importance of education on receiving home care services especially for the people who presently prefer the hospital for end-of-life care.

Evaluation of end-of-life cancer care in the ICU: perceptions of the bereaved family in Japan

The purpose of this study was to investigate the evaluation of end-of-life care from bereaved family of cancer patients who had died in intensive care units in Japan. Cross-sectional anonymous questionnaire surveys were conducted on community dwelling individuals aged 40-79 who were randomly sampled from census tracts. End-of-life care was assessed using the Good Death Inventory and Care Evaluation Scale. The respondents were 4011 bereaved family and response rate was 40%. Of 390 respondents had experienced bereavement in intensive care unit. Of 152 respondents had lost a loved one due to cancer. The result showed that bereaved family of cancer patients evaluated lower than the non-cancer patients for "The doctors dealt promptly with discomforting symptoms of the patients' (p=0.009), 'The nurses had adequate knowledge and skills' (p=0.016), 'Admission (use) was possible when necessary without waiting' (p=0.008) , Consideration was given to the health of the family (P=0.039) and Physical and psychological comfort (p=0.03). Overall, it can be presumed that the cancer patients' bereaved family evaluated about symptoms management and doctors and nurses skills was low. There is a need to improve for end-of-life care of cancer patients and to conduct further research to explore quality-improvement interventions to bereaved family of cancer in intensive care unit.

Is patient autonomy a critical determinant of quality of life in Korea? End-of-life decision making from the perspective of the patient

PURPOSE

We aimed to investigate the current practice of the involvement in decision making from the perspectives of terminal cancer patients, and to explore its possible associations with quality of life and quality of death in Korea.

METHODS

A multi-center, cross-sectional survey was performed on 93 terminal cancer patients. The questionnaire solicited their opinions regarding participation in treatment decision making, as well as quality of life (European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire for Palliative Care) and quality of death (Good Death Inventory-Patient Version).

RESULTS

A total of 78.5% of the patients had awareness of their terminal status, while 21.5% did not; 42.4% stated that they knew their condition and shared the decision-making responsibility with the medical staff and their family, while 21.7% made decisions on their own, and 35.9% left the decision-making responsibility to others. Patients who were aware of their illness and who actively participated in the decision making did not score higher than others on outcome measures of quality of life and quality of death. Moreover, the former even showed lower scores in some domains, including the 'physical and psychological comfort' (4.99 versus 5.61, p = 0.03), 'environmental comfort' (5.51 versus 6.04, p = 0.08), and 'emotional functioning' (55.70 versus 71.01, p = 0.06).

CONCLUSION

in Korea, patient autonomy is not a universally accepted value from the perspectives of terminal cancer patients, nor is patient involvement in decision making always conducive to high quality of life or quality of death. The level of information and the pace at which it is provided should be tailored to each individual's ability, preference, need, and culture.