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

Background

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

Objectives

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

Design

A cross-sectional survey.

Methods

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

Results

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

Conclusion

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

Room to Improve: An Audit of In-Hospital End-of-Life Care for Oncology Patients in a Tertiary Cancer Centre in Ireland During the COVID-19 Pandemic

The COVID-19 pandemic compounded isolation for patients through social distancing measures and staff shortages. We were concerned about the impact of COVID-19 on the quality of care provided at end-of-life in 2021 in a national cancer centre, and instigated the first ever review of the care of the dying. Quality of care was assessed retrospectively using a validated instrument developed by the United Kingdom's National Quality Board. Sixty-six patient deaths occurred in our cancer centre in 2021. The 'risk of dying' was documented in 65.2% of records. Palliative care services were involved in 77%, and pastoral care in 10.6%. What was important to the patient was documented in 24.2%. The 'quality-of-death' score was satisfactory for most but poor in 21.2%. Our study prompted change, including appointment of an end-of-life coordinator, development of a checklist to ensure comprehensive communication, expansion of the end-of-life committee to include junior doctors, and regular audit.

Clinician perception of care at the end of life in a quaternary neonatal intensive care unit

Introduction

Care for neonates at the end of life (EOL) is often challenging for families and medical teams alike, performed suboptimally, and requires an experienced and compassionate clinician. Much literature exists on adult and pediatric EOL care, but limited studies examine the neonatal process.

Methods

We aimed to describe clinicians' experiences around EOL care in a single quaternary neonatal intensive care unit as we implemented a standard guideline using the Pediatric Intensive Care Unit-Quality of Dying and Death 20 tool.

Results

Surveys were completed by 205 multidisciplinary clinicians over three time periods and included 18 infants at EOL. While most responses were high, a meaningful minority were below goal (<8 on 0-10 scale) for troubling symptom management, conflict between parents and staff, family access to resources, and parent preparation of symptoms. Comparison between Epochs revealed improvement in one symptom management and four communication categories. Satisfaction scores related to education around EOL were better in later Epochs. Neonatal Pain, Agitation, and Sedation Scale scores were low, with few outliers.

Discussion

These findings can guide those aiming to improve processes around neonatal EOL by identifying areas with the greatest challenges (e.g., conflict management) and areas that need further study (e.g., pain management around death).

Understanding the Relationships Between Health Care Providers' Moral Distress and Patients' Quality of Death

Introduction: Moral distress is a commonly recognized phenomenon among health care providers; however, the experience of moral distress by staff caring for patients who die during an acute care hospital stay has not been previously examined. It also remains unclear how the quality of a death may impact moral distress among these providers. Objectives: We sought to understand levels of moral distress experienced by intern physicians and nurses who provided care during a patient's final 48 hours of life, and how the perceived quality of death impacted moral distress. Materials and Methods: We utilized a mixed-method prospective cohort design, surveying nurses and interns following inpatient hospital deaths at an academic safety-net hospital in the United States. Participants completed surveys and answered open-ended questions to evaluate moral distress and the quality of the patient's death. Results: A total of 126 surveys were sent to nurses and interns caring for 35 patients who died, with 46 surveys completed. Overall moderate-to-high levels of moral distress were identified among participants, and we found that higher levels of moral distress correlated with lower perceived quality of death. We identified five themes in our qualitative analysis highlighting the challenges nurses and interns face in end-of-life care, including the following: poor communication, unexpected deaths, patient suffering, resource limitations, and failure to prioritize a patient's wishes or best interests. Conclusions: Nurses and interns experience moderate-to-high levels of moral distress when caring for dying patients. Lower quality of end-of-life care is associated with higher levels of moral distress.

Measuring quality of dying, death and end-of-life care for children and young people: A scoping review of available tools

BACKGROUND

The circumstances and care provided at the end of a child's life have a profound impact on family members. Although assessing experiences and outcomes during this time is challenging, healthcare professionals have a responsibility to ensure high quality of care is provided.

AIM

To identify available tools which measure the quality of dying, death and end-of-life care for children and young people; describe the content, and data on validity and reliability of existing tools.

DESIGN

Scoping review was conducted following the Arksey and O'Malley methodological framework.

DATA SOURCES

Four electronic databases (MEDLINE, EMBASE, CINAHL and PsycINFO) and grey literature were searched for studies published in English (January 2000-June 2021). A review of reference lists and citation searching was also undertaken. Tools needed to include a focus on the 'dying' phase of illness (defined as the last month of life).

RESULTS

From 2078 articles, a total of 18 studies, reporting on 11 tools were identified. All tools were completed by primary caregivers or healthcare professionals as 'proxy' assessments; all except one was undertaken after death. Question items about quality of life and preparation for death were found in all tools; items relating to cultural aspects of care, grief and financial costs were less common. Only 6/11 had undergone psychometric testing within a paediatric palliative care setting.

CONCLUSIONS

Future research should include ways to adapt, refine and improve existing tools. Assessing their wider application in different clinical and cultural settings and conducting further psychometric assessment represent areas of focus.

Validation of 'Care Of the Dying Evaluation' (CODETM) within an international study exploring bereaved relatives' perceptions about quality of care in the last days of life

CONTEXT

Assessing quality of care provided during the dying phase using validated tools aids quality assurance and recognizes unmet need.

OBJECTIVE

To assess construct validity and internal consistency of 'Care Of the Dying Evaluation' (CODE^TM) within an international context.

METHODS

Post-bereavement survey (August 2017 to September 2018) using CODE^TM. Respondents were next-of-kin to adult patients (≥ 18 years old) with cancer who had an 'expected' death within 22 study site hospitals in 7 countries: Argentina, Brazil, Germany, Norway, Poland, United Kingdom, Uruguay. Exploratory and Confirmatory Factor Analysis (EFA and CFA) were conducted, and internal reliability was assessed using Cronbach alpha (α). Known group validity was assessed by ability to discriminate quality of care based in place (Palliative Care Units (PCUs)) and country (Poland, where most deaths were in PCUs) of care. Differences were quantified using effect sizes (ES).

RESULTS

A 914 CODE^TM questionnaires completed (54% response rate). 527 (58%) male deceased patients; 610 (67%) next-of-kin female who were most commonly the 'spouse/partner' (411, 45%). EFA identified 4 factors: 'Overall care,' 'Communication and support,' 'Trust, respect and dignity,' and 'Symptom management' with good reliability scores (α = 0.628 - 0.862). CFA confirmed the 4-factor model; these were highly correlated and a bifactor model showed acceptable fit. The ES for quality of care in PCU's was 0.727; ES for Poland was 0.657, supporting the sensitivity of CODE^TM to detect differences.

CONCLUSION

Within an international context, good evidence supports the validity and reliability of CODE^TM for assessing the quality of care provided in the last days of life.

Good Death in Neurological Practice

Background

Clinicians in neurological practice, particularly surgeons, encounter more deaths than most other specialists.

Objective

This communication reviews the literature on "good death" and extrapolates the observations and inferences to neurological practice. Changes in approaches to "good death" in the COVID-19 era (coronavirus disease 2019) are also discussed.

Materials and Methods

The author, over a 40-year period, has come across 2,500 deaths in a government, trust, and corporate hospital in Chennai, India. Retrospectively, the author questions if, in spite of his conservatism and obsession with quality of life, he should have taken proactive measures to also ensure a good quality of death.

Results and Conclusion

In the background of the lessons learned in a metro, across various socioeconomic groups and with varied access to technology, the author concludes that ensuring "good death" should also fall within the domain of neurologic practice.

Factors Associated with Quality of Dying and Death in Korean Intensive Care Units: Perceptions of Nurses

The objective of this study was to investigate the factors affecting the quality of dying and death among terminally ill patients in an intensive care unit in Korea using a cross-sectional, online survey. A total of 300 nurses in the intensive care unit who had cared for a terminally ill patient for at least 48 h prior to death in the past six months were chosen to participate. The person-centered critical care nursing (PCCN) score and quality of dying and death (QODD) had a positive correlation. The QODD score increased when the consultation was conducted between the terminally ill patients and their doctors when CPR was not performed within 48 h of death, and when the PCCN score increased. The quality of death of patients is affected by whether they have sufficiently consulted with healthcare providers regarding their death and how much respect they receive. It is important for nurses to practice and improve patient-centered nursing care in order to ensure a good quality of death for terminally ill patients.

Rehabilitation for Cancer Patients in Inpatient Hospices/Palliative Care Units and Achievement of a Good Death: Analyses of Combined Data From Nationwide Surveys Among Bereaved Family Members

CONTEXT

In end-of-life care, rehabilitation for patients with cancer is considered to be an important means for improving patients' quality of death and dying.

OBJECTIVES

To determine whether the provision of rehabilitation for patients with cancer in palliative care units is associated with the achievement of a good death.

METHODS

This study involved a cross-sectional, anonymous, and self-report questionnaire survey of families of patients with cancer who died in palliative care units in Japan. We evaluated the short version of Good Death Inventory (GDI) on a seven-point scale. A logistic regression model was used to calculate the propensity score. Covariates included in this model were survey year, patients' characteristics, and families' characteristics. The associations between rehabilitation and GDI were tested using trend tests after propensity score matching adjustment.

RESULTS

Of the 1965 family caregivers who received the questionnaires, available data were obtained from 1008 respondents (51.2%). Among them, 285 (28.2%) cases received rehabilitation in palliative care units. There was no difference in total GDI score between the groups with and without rehabilitation. In exploratory analyses, patients receiving rehabilitation were significantly more likely to feel maintaining hope and pleasure (mean 4.50 [SE 0.10] vs. 4.05 [0.11], respectively; effect size [ES] 0.31; P = 0.003), good relationships with medical staff (mean 5.67 [SE 0.07] vs. 5.43 [0.09], respectively; ES 0.22; P = 0.035), and being respected as an individual (mean 6.08 [SE 0.06] vs. 5.90 [0.07], respectively; ES 0.19; P = 0.049) compared with patients not receiving rehabilitation.

CONCLUSION

Rehabilitation in palliative care units may contribute to several domains of quality of death and dying, particularly maintaining hope and pleasure. Further research is needed to investigate whether palliative rehabilitation contributes to the achievement of a good death.

Quality of death: The unspoken experiences of patients with advanced cancers in India - An exploratory qualitative study

OBJECTIVE

End-of-life (EOL) care is a developing concept in India, with well-established practices in certain states like Kerala, but not in all the states. As there is a substantial stigma associated with death discussion across the Indian population, the experiences of caregivers of people with advanced cancer have not been explored. Our aim in this study was to explore the experience and perceptions of caregivers of people diagnosed with advanced cancer regarding the quality of the individuals' death.

METHODS

An exploratory study where the caregivers (n = 108) of advanced cancer patients, who died either during hospitalization or at home, were interviewed to assess quality of death (QOD), using an open-ended question to explore the sufferings of the patients in the final days and caregivers' coping mechanism.

RESULTS

Majority of the patients died at home (n = 79, 73.1%). The thematic analysis of the transcripts resulted in seven sub-themes, which were categorized under four major themes, namely 'bodily discomfort', 'psychological experiences' with the sub-themes resilience and existential distress, 'awareness of prognoses' with the sub-themes aware, unaware and conjecture, and 'carers coping' with the sub-themes perceived strain and contentment.

CONCLUSION

Patients under EOL care experience physical and psychological suffering, as reported by the caregivers. Efforts must be undertaken to reduce suffering by means of improving focus on and strengthening symptom management and enhancing psychosocial support, for optimally utilizing the available interventions to manage the physical symptoms and to address the psychosocial issues.

The Quality of Dying and Death in a Residential Hospice

CONTEXT

Residential hospices may be an optimal compromise between home and hospital settings for end-of-life care, but there has been little systematic research regarding the quality of dying and death in such locations.

OBJECTIVES

The objective of this study was to assess the quality of dying and death of patients who received end-of-life care in a residential hospice and its relationship to hospice length of stay (LOS) and prior receipt of palliative care.

METHODS

A total of 100 caregivers of patients who died in a residential hospice in downtown Toronto, Canada, were recruited four to six months after patient's death. The quality of dying and death was measured, based on interviews with bereaved caregivers, using the Quality of Dying and Death (QODD) questionnaire.

RESULTS

The overall mean QODD score was 68.85 ± 11.62, which is in the intermediate ("neither good nor bad") range (30-70) of the scale. The lowest QODD subscale score was on the Transcendence subscale, which evaluates death-related concerns; this was 59.48 ± 25.37, with ratings in 14.6% of the sample in the "terrible to poor" (0-29) range. QODD scores were higher for patients with hospice LOS of more than one week (72.21 ± 9.64) than for those with a shorter LOS (60.38 ± 11.92) (P < 0.001).

CONCLUSION

Overall quality of dying and death was perceived as average to above average, in an urban residential hospice, although death-related distress was present in a substantial minority of patients. The association of better QODD with hospice LOS of more than one week may be due to better clinical status on admission and/or longer duration of time that is needed to achieve optimal outcomes.

Retrospective chart review to assess domains of quality of death (recognition of dying, appropriate limitations, symptom monitoring, anticipatory prescribing) of patients dying in the acute hospital under the care of a nephrology service with renal supportive care support over time

AIM

To explore the quality of deaths in an acute hospital under a nephrology service at two teaching hospitals in Sydney with renal supportive care services over time.

METHODS

Retrospective chart review of all deaths in the years 2004, 2009 and 2014 at St George Hospital (SGH) and in 2014 at the Concord Repatriation General Hospital. Domains assessed were recognition of dying, invasive interventions, symptom assessment, anticipatory prescribing, documentation of spiritual needs and bereavement information for families. End-of-life care plan (EOLCP) use was also evaluated at SGH.

RESULTS

Over 90% of patients were recognized to be dying in all 3 years at SGH. Rates of interventions in the last week of life were low and did not differ across the 3 years. There was a significant increase in the prescription of anti-psychotic, anti-emetic and anti-cholinergic medication over the years at SGH. Use of EOLCP was significantly higher at SGH, and their use improved several quality domains. Of all deaths, 68% were referred to palliative care at SGH and 33% at Concord Repatriation General Hospital (not significant). Cessation of observations and non-essential medications and documentation of bereavement information given to families was low across both sites in all years, although this significantly improved when EOLCP were used.

CONCLUSION

While acute teams are good at recognizing dying, they need support to care for dying patients. The use of EOLCP in acute services can facilitate improvements in caring for the dying. Renal supportive care services need time to become embedded in the culture of the acute hospital.

Beyond Pain: Nurses' Assessment of Patient Suffering, Dignity, and Dying in the Intensive Care Unit

CONTEXT

Deaths in the intensive care unit (ICU) are increasingly common in the U.S., yet little is known about patients' experiences at the end of life in the ICU.

OBJECTIVES

The objective of this study was to determine nurse assessment of symptoms experienced, and care received by ICU patients in their final week, and their associations with nurse-perceived suffering and dignity.

METHODS

From September 2015 to March 2017, nurses who cared for 200 ICU patients who died were interviewed about physical and psychosocial dimensions of patients' experiences. Medical chart abstraction was used to document baseline patient characteristics and care.

RESULTS

The patient sample was 61% males, 70.2% whites, and on average 66.9 (SD 15.1) years old. Nurses reported that 40.9% of patients suffered severely and 33.1% experienced severe loss of dignity. The most common symptoms perceived to contribute to suffering and loss of dignity included trouble breathing (44.0%), edema (41.9%), and loss of control of limbs (36.1%). Most (n = 9) remained significantly (P < 0.05) associated with suffering, after adjusting for physical pain, including fever/chills, fatigue, and edema. Most patients received vasopressors and mechanical ventilation. Renal replacement therapy was significantly (<0.05) associated with severe suffering (adjusted odds ratio [AOR] 2.53) and loss of dignity (AOR 3.15). Use of feeding tube was associated with severe loss of dignity (AOR 3.12).

CONCLUSION

Dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. Attention to symptoms such as dyspnea and edema may improve the quality of death in the ICU.

Trust in Physicians, Continuity and Coordination of Care, and Quality of Death in Patients with Advanced Cancer

BACKGROUND

Provider-centered factors contribute to unexplained variation in the quality of death (QOD). The relationship between healthcare providers (HCPs) and patients, bidirectional communication, and consistency of longitudinal care planning are important provider-centered factors.

OBJECTIVE

To explore whether the level of trust in HCPs, the quality of continuity of care, and the level of coordination of care among home HCPs are associated with the QOD for cancer patients dying at home.

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

We investigated 702 family members of cancer patients who died at home.

MEASUREMENTS

The QOD was evaluated from nine core domains of the short version of the Good Death Inventory (GDI). We measured five factors on a Likert scale, including patient and family trust in HCPs, continuity of care by home hospice and hospital physicians, and coordination of care among home hospice staff.

RESULTS

A total of 538 responses (77%) were obtained and 486 responses were analyzed. Trust in HCPs was correlated with the GDI score (r = 0.300-0.387, p < 0.001). The quality of care coordination was associated with the GDI score (r = 0.242, p < 0.001).

CONCLUSIONS

Trust of the patient and family in home hospice staff, as well as coordination of care among hospice staff, are associated with the QOD for cancer patients dying at home.

Association of code status discussion with invasive procedures among advanced-stage cancer and noncancer patients

Background

Code status discussion is associated with a decrease in invasive procedures among terminally ill cancer patients. We investigated the association between code status discussion on admission and incidence of invasive procedures, cardiopulmonary resuscitation (CPR), and opioid use among inpatients with advanced stages of cancer and noncancer diseases.

Methods

We performed a retrospective cohort study in a single center, Ito Municipal Hospital, Japan. Participants were patients who were admitted to the Department of Internal Medicine between October 1, 2013 and August 30, 2015, with advanced-stage cancer and noncancer. We collected demographic data and inquired the presence or absence of code status discussion within 24 hours of admission and whether invasive procedures, including central venous catheter placement, intubation with mechanical ventilation, and CPR for cardiac arrest, and opioid treatment were performed. We investigated the factors associated with CPR events by using multivariate logistic regression analysis.

Results

Among the total 232 patients, code status was discussed with 115 patients on admission, of which 114 (99.1%) patients had do-not-resuscitate (DNR) orders. The code status was not discussed with the remaining 117 patients on admission, of which 69 (59%) patients had subsequent code status discussion with resultant DNR orders. Code status discussion on admission decreased the incidence of central venous catheter placement, intubation with mechanical ventilation, and CPR in both cancer and noncancer patients. It tended to increase the rate of opioid use. Code status discussion on admission was the only factor associated with the decreased use of CPR (P<0.001, odds ratio =0.03, 95% CI =0.004–0.21), which was found by using multivariate logistic regression analysis.

Conclusion

Code status discussion on admission is associated with a decrease in invasive procedures and CPR in cancer and noncancer patients. Physicians should be educated about code status discussion to improve end-of-life care.

Effects of End-of-Life Discussions on the Mental Health of Bereaved Family Members and Quality of Patient Death and Care

CONTEXT

End-of-life discussions are crucial for providing appropriate care to patients with advanced cancer at the end of their lives.

OBJECTIVES

The objective of this study was to explore associations between end-of-life discussions and bereaved families' depression and complicated grief and the quality of patient death and end-of-life care.

METHODS

A nationwide questionnaire survey of bereaved family members was conducted between May and July 2014. A total of 13,711 bereaved family members of cancer patients who were cared for by specialist palliative care services at 75 institutions throughout Japan and died before January 2014 participated. We evaluated the prevalence of depression (defined as the Patient Health Questionnaire-9 ≥ 10) and complicated grief (defined as the Brief Grief Questionnaire ≥ 8) in bereaved family members. Moreover, we evaluated the quality of death and end-of-life care with the Good Death Inventory and the Care Evaluation Scale, respectively.

RESULTS

A total of 9123 questionnaires were returned (response rate 67%), and 80.6% of the respondents reported that they had end-of-life discussions. After propensity score-weighted adjustment, the results showed that bereaved family members who had end-of-life discussions had a lower frequently of depression (17.3% vs. 21.6%; P < 0.001) and complicated grief (13.7% vs. 15.9%; P = 0.03). End-of-life discussions were associated with better quality of death (the Good Death Inventory score, 47.2 ± 8.5 vs. 46.1 ± 9.4; P < 0.001) and end-of-life care (the Care Evaluation Scale score, 84.1 ± 11.4 vs. 78.9 ± 14.3; P < 0.001).

CONCLUSION

End-of-life discussions may contribute to reducing depression and complicated grief in bereaved family members and enable patients to experience quality end-of-life care and a good death.

Compassionate extubation for a peaceful death in the setting of a community hospital: a case-series study

BACKGROUND

The use of compassionate extubation (CE) to alleviate suffering by terminating mechanical ventilation and withdrawing the endotracheal tube requires professional adherence and efficiency. The Hospice Palliative Care Act, amended on January 9, 2013, legalizes the CE procedure in Taiwan.

METHODS

From September 20, 2013 to September 2, 2014, the hospice palliative care team at a community hospital received 20 consultations for CE. Eight cases were excluded because of non-qualification. Following approval from the Ethics Committee, the medical records of the remaining 12 patients were reviewed and grouped by the underlying disease: A, "terminal-stage cancer"; B, "non-cancer out-of-hospital cardiac arrest"; and C, "non-cancer organ failure". Time to extubation using a cut-off at 48 hours was assessed.

RESULTS

The mean ages of patients (standard deviation) in groups A, B, and C were 66.3 (14.9) years, 72 (19.1) years, and 80.3 (4.0) years, respectively. The mean number of days of intubation at consultation were 6.8 (4.9), 7.3 (4.9), and 179.3 (271.6), respectively. The mean total doses of opioids (as morphine-equivalent dose) in the 24 hours preceding CE were 76 (87.5) mg, 3.3 (5.8) mg, and 43.3 (15.3) mg. The median times from extubation (range) to death were 97 (0.2-245) hours, 0.3 (0.2-0.4) hours, and 6.1 (3.6-71.8) hours. Compared to those requiring <48-hour preparatory time, patients requiring >48 hours to the moment of CE were younger (62.8 years vs 75.5 years), required a mean time of 122 hours (vs 30 hours) to CE (P=0.004), had shorter length of stay (33.3 days vs 77.8 days), required specialist social worker intervention in 75% of cases (vs 37.5%), and had a median duration of intubation of 11.5 days (vs 5.5 days).

CONCLUSION

CE was carried out according to protocol, and the median time from extubation to death varies determined by the underlying disease which was 0.3 hour in patients admitted after out-of-hospital cardiac arrest and 97 hours in patients with advanced cancer.

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.

The Quality of Dying and Death Questionnaire (QODD): empirical domains and theoretical perspectives

We used exploratory factor analysis within the confirmatory analysis framework, and data provided by family members and friends of 205 decedents in Missoula, Montana, to construct a model of latent-variable domains underlying the Quality of Dying and Death questionnaire (QODD). We then used data from 182 surrogate respondents, who were survivors of Seattle decedents, to verify the latent-variable structure. Results from the two samples suggested that survivors' retrospective ratings of 13 specific aspects of decedents' end-of-life experience served as indicators of four correlated, but distinct, latent-variable domains: Symptom Control, Preparation, Connectedness, and Transcendence. A model testing a unidimensional domain structure exhibited unsatisfactory fit to the data, implying that a single global quality measure of dying and death may provide insufficient evidence for guiding clinical practice, evaluating interventions to improve quality of care or assessing the status or trajectory of individual patients. In anticipation of possible future research tying the quality of dying and death to theoretical constructs, we linked the inferred domains to concepts from identity theory and existential psychology. We conclude that research based on the current version of the QODD might benefit from the use of composite measures representing the four identified domains, but that future expansion and modification of the questionnaire are in order.