Improved Symptom Change Enhances Quality of Dying in Patients With Advanced Cancer: An East Asian Cross-Cultural Study.

BACKGROUND: Symptom burdens tend to increase for patients with cancer and their families over the disease trajectory. There is still a lack of evidence on the associations between symptom changes and the quality of dying and death. In this context, this research investigated how symptom changes influence the quality of dying and death. METHODS: This international prospective cohort study (the East Asian Collaborative Cross-Cultural Study to Elucidate the Dying Process (EASED), 2017-2019) included 22, 11, and 4 palliative care units across Japan, South Korea, and Taiwan. Eligible participants were adults (Japan and Korea, ≥18 years; Taiwan, ≥20 years) with locally advanced or metastatic cancer. Physical and psychological symptoms were assessed by physicians upon admission and within 3 days before death. Death quality was assessed using the Good Death Scale (GDS), developed in Taiwan. Univariate and multivariate regression analyses were used to identify correlations between symptom severity changes and GDS scores. RESULTS: Among 998 patients (542 [54.3%] men and 456 [45.7%] women; mean [SD] age = 70.1 [± 12.5] years), persistent dyspnea was associated with lower GDS scores when compared to stable dyspnea (ß = -0.427, 95% CI = -0.783 to -0.071). Worsened (-1.381, -1.932 to -0.831) and persistent (-1.680, -2.701 to -0.659) delirium were also significantly associated with lower GDS scores. CONCLUSIONS: Better quality of dying and death was associated with improved symptom control, especially for dyspnea and delirium. Integrating an outcome measurement for the quality of dying and death is important in the management of symptoms across the disease trajectory in a goal-concordant manner.

Shared decision making with Oncologists and Palliative care specialists (SOP) model help advanced pancreatic cancer patients reaching goal concordant care: A prospective cohort study.

BACKGROUND: Pancreatic cancer is often diagnosed at a late stage with a poor prognosis due to insidious symptoms and lack of evidence-based screening in general population. Palliative care's acceptance in Asian cultures is hindered by misconceptions and ineffective communication about management that improve quality of life other than cancer directed treatment. Our study aimed to determine the effect of the Shared decision-making with Oncologists and Palliative care specialists (SOP) model developed from the traditional shared decision-making (SDM) model on the palliative care acceptance rate and medical resource utilization. METHODS: This is a prospective cohort study implementing the SOP model at the National Taiwan University Hospital from January 2018 to December 2019 for patients with advanced pancreatic cancer. Medical resource utilization was defined and recorded as the rate of hospitalization, emergency room (ER), and intensive care unit admissions. We compared the results between two groups: patients who received the SOP model in 2019 and patients who did not receive it in 2018. RESULTS: 137 patients with advanced pancreatic cancer were included in our study. The result showed that the acceptance rate of palliative care significantly increased from 50% to 78.69% after the SOP model (p = 0.01). The hospitalization rate did not show a significant difference between 2018 (93.42%, 95% CI: 0.88-0.99) and 2019 (93.44%, 95% CI: 0.87-1.00). 83.61% (95% CI: 0.74-0.93) of our patients in 2019 had at least one ER visit; the rate was 81.5% (95% CI: 0.73-0.91) in 2018 (p = 0.28). The percentage of patients admitted to the ICU increased from 3.95% in 2018 to 8.2% (95% CI: -0.05-0.08) in 2019 (95% CI: 0.11-0.15) (p = 0.00). The hospitalization and ER visit showed no statistically difference between 2 years. CONCLUSIONS: The modified SOP model markedly augmented palliative care's acceptance of patients with advanced pancreatic cancer. Adoption of the SOP model would provide these patients a more proactive and systematic approach to deliver needed healthcare.

Natural language processing and network analysis in patients withdrawing from life-sustaining treatments: a retrospective cohort study.

BACKGROUND: Providing palliative care to patients who withdraw from life-sustaining treatments is crucial; however, delays or the absence of such services are prevalent. This study used natural language processing and network analysis to identify the role of medications as early palliative care referral triggers. METHODS: We conducted a retrospective observational study of 119 adult patients receiving specialized palliative care after endotracheal tube withdrawal in intensive care units of a Taiwan-based medical center between July 2016 and June 2018. Patients were categorized into early integration and late referral groups based on the median survival time. Using natural language processing, we analyzed free texts from electronic health records. The Palliative trigger index was also calculated for comparison, and network analysis was performed to determine the co-occurrence of terms between the two groups. RESULTS: Broad-spectrum antibiotics, antifungal agents, diuretics, and opioids had high Palliative trigger index. The most common co-occurrences in the early integration group were micafungin and voriconazole (co-correlation = 0.75). However, in the late referral group, piperacillin and penicillin were the most common co-occurrences (co-correlation = 0.843). CONCLUSION: Treatments for severe infections, chronic illnesses, and analgesics are possible triggers for specialized palliative care consultations. The Palliative trigger index and network analysis indicated the need for palliative care in patients withdrawing from life-sustaining treatments. This study recommends establishing a therapeutic control system based on computerized order entry and integrating it into a shared-decision model.

Smartphone-Enabled, Telehealth-Based Family Conferences in Palliative Care During the COVID-19 Pandemic: Pilot Observational Study.

BACKGROUND: In the palliative care setting, infection control measures implemented due to COVID-19 have become barriers to end-of-life care discussions (eg, discharge planning and withdrawal of life-sustaining treatments) between patients, their families, and multidisciplinary medical teams. Strict restrictions in terms of visiting hours and the number of visitors have made it difficult to arrange in-person family conferences. Phone-based telehealth consultations may be a solution, but the lack of nonverbal cues may diminish the clinician-patient relationship. In this context, video-based, smartphone-enabled family conferences have become important. OBJECTIVE: We aimed to establish a smartphone-enabled telehealth model for palliative care family conferences. Our model integrates principles from the concept of shared decision making (SDM) and the value, acknowledge, listen, understand, and elicit (VALUE) approach. METHODS: Family conferences comprised three phases designed according to telehealth implementation guidelines-the previsit, during-visit, and postvisit phases. We incorporated the following SDM elements into the model: "team talk," "option talk," and "decision talk." The model has been implemented at a national cancer treatment center in Taiwan since February 2020. RESULTS: From February to April 2020, 14 telehealth family conferences in the palliative care unit were analyzed. The patients' mean age was 73 (SD 10.1) years; 6 out of 14 patients (43%) were female and 12 (86%) were married. The primary caregiver joining the conference virtually comprised mostly of spouses and children (n=10, 71%). The majority of participants were terminally ill patients with cancer (n=13, 93%), with the exception of 1 patient with stroke. Consensus on care goals related to discharge planning and withdrawal of life-sustaining treatments was reached in 93% (n=13) of cases during the family conferences. In total, 5 families rated the family conferences as good or very good (36%), whereas 9 were neutral (64%). CONCLUSIONS: Smartphone-enabled telehealth for palliative care family conferences with SDM and VALUE integration demonstrated high satisfaction for families. In most cases, it was effective in reaching consensus on care decisions. The model may be applied to other countries to promote quality in end-of-life care in the midst of the COVID-19 pandemic.

Awareness of, attitude toward, and willingness to participate in pay for performance programs among family physicians: a cross-sectional study.

BACKGROUND: The National Health Insurance Administration of Taiwan has introduced several pay-for-performance programs to improve the quality of healthcare. This study aimed to provide government with evidence-based research findings to help primary care physicians to actively engage in pay-for-performance programs. METHODS: We conducted a questionnaire survey among family physicians with age-stratified sampling from September 2016 to December 2017. The structured questionnaire consisted of items including the basic demographics of the surveyee and their awareness of and attitudes toward the strengths and/or weaknesses of the pay-for-performance programs, as well as their subjective norms, and the willingness to participate in the pay-for-performance programs. Univariate analysis and multivariate logistic regression analysis were performed to compare the differences between family physicians who participate in the pay-for-performance programs versus those who did not. RESULTS: A total of 543 family physicians completed the questionnaire. Among family physicians who participated in the pay-for-performance programs, more had joined the Family Practice Integrated Care Project [Odds ratio (OR): 2.70; 95% Confidence interval (CI): 1.78 ~ 4.09], had a greater awareness of pay-for-performance programs (OR: 2.37; 95% CI: 1.50 ~ 3.83), and a less negative attitude to pay-for-performance programs (OR: 0.50; 95% CI: 0.31 ~ 0.80) after adjusting for age and gender. The major reasons for family physicians who decided to join the pay-for-performance programs included believing the programs help enhance the quality of healthcare (80.8%) and recognizing the benefit of saving health expenditure (63.4%). The causes of unwillingness to join in a pay-for-performance program among non-participants were increased load of administrative works (79.6%) and inadequate understanding of the contents of the pay-for-performance programs (62.9%). CONCLUSIONS: To better motivate family physicians into P4P participation, hosting effective training programs, developing a more transparent formula for assessing financial risk, providing sufficient budget for healthcare quality improvement, and designing a reasonable profit-sharing plan to promote collaboration between different levels of medical institutions are all imperative.

Shared decision making with oncologists and palliative care specialists effectively increases the documentation of the preferences for do not resuscitate and artificial nutrition and hydration in patients with advanced cancer: a model testing study.

BACKGROUND: Communication in do not resuscitate (DNR) and artificial nutrition and hydration (ANH) at the end of life is a key component of advance care planning (ACP) which is essential for patients with advanced cancer to have cares concordant with their wishes. The SOP model (Shared decision making with Oncologists and Palliative care specialists) aimed to increase the rate of documentation on the preferences for DNR and ANH in patients with advanced cancer. METHODS: The SOP model was implemented in a national cancer treatment center in Taiwan from September 2016 to August 2018 for patients with advanced cancer visiting the oncology outpatient clinic. The framework was based on the model of shared decision making as "choice talk" initiated by oncologists with "option talk" and "decision talk" conducted by palliative care specialists. RESULTS: Among 375 eligible patients, 255 patients (68%) participated in the model testing with the mean age of 68.5 ± 14.7 years (mean ± SD). Comparing to 52.3% of DNR documentation among patients with advanced cancer who died in our hospital, the rate increased to 80.9% (206/255) after the decision talk in our model. Only 6.67% (n = 17) of the participants documented their preferences on ANH after the model. A worse Eastern Cooperative Oncology Group Performance Status was the only statistically significant associating factor with a higher rate of DNR documentation in the multiple logistic regression model. CONCLUSIONS: The SOP model significantly increased the rate of DNR documentation in patients with advanced cancer in this pilot study. Dissemination of the model could help the patients to receive care that is concordant with their wishes and be useful for the countries having laws on ACP.

Family physician system in Taiwan.

Following economic development and increasing healthcare demand, Taiwan has not only built a universal healthcare coverage payment system in 1995, but has also developed an accountable family physician system, called the Family Practice Integrated Care Project (FPICP), to deal with the pressures of an ageing society, since 2003. The community healthcare group-based family physician system is not only an important milestone for the development of family medicine in Taiwan but may also even serve as a global example for future family doctor systems. In this review, we aim to review the development of family medicine in Taiwan, the implementation and achievement of the FPICP, as well as the future prospects of system-based healthcare system. We firmly believe that only when the family physician system is well developed and put into practice with person-centered, family as a care unit, and community-oriented holistic care, can the objective of "everyone has their own family doctor" and sustainable operation of National Health Insurance be achieved.

What influences the willingness of cancer patients to receive hospice palliative care at end of life?

BACKGROUND: The benefits of hospice palliative care (HPC) for end-of-life (EoL) patients have been widely acknowledged in recent years. There is still limited knowledge about cancer patients' willingness toward HPC. This study aimed to investigate the willingness of cancer patients to receive HPC and the influencing factors. METHODS: A cross-sectional study was conducted with cancer patients enrolled from teaching hospitals in Taiwan. The questionnaire included demographic characteristics, EoL care preferences, and scales for measuring the willingness to receive HPC, HPC knowledge, and attitude towards HPC. Data were collected by senior nurses and they were analyzed using descriptive and a regression analysis. RESULTS: A total of 148 valid questionnaires were collected. The participants indicated that they 'willing to receive' HPC (mean3.8 on a 5-point scale). The predictors for their willingness to receive HPC were knowledge about HPC (P = 0.001), positive attitude towards HPC (P = 0.008), preference for hospital death (P = 0.022), and preference for quality of life (P = 0.047) as the goal of EoL care. These factors explained 32.7% of the total variance in the willingness to receive HPC. CONCLUSIONS: Cancer patients were generally willing to receive HPC. Clinician should discuss EoL care with them earlier. Develop appropriate educational strategies that can provide cancer patients with sufficient and tailored HPC information to develop their knowledge and to create a positive attitude about HPC is necessary, thereby to allow for early HPC intervention and to fulfill the patients' need for HPC.

Prevailing Ethical Dilemmas Encountered by Physicians in Terminal Cancer Care Changed After the Enactment of the Natural Death Act: 15 Years' Follow-up Survey.

CONTEXT: Advance directive laws have influences on ethical dilemmas encountered by physicians caring for terminal cancer patients. OBJECTIVES: To identify the prevailing ethical dilemmas among terminal care physicians 15 years after the Natural Death Act was enacted in Taiwan. METHODS: This study is a cross-sectional survey from April 2014 to February 2015 using the clustering sampling method and a well-structured questionnaire. Targeted participants included physicians at oncology and related wards or palliative care units where terminal cancer care may be provided in Taiwan. RESULTS: Among the 500 physicians surveyed, 383 responded (response rate 76.6%) and 346 valid questionnaires were included in the final analysis (effective response rate 69.2%). The most frequently identified ethical dilemma was "place of care," followed by "use of antimicrobial agents" and "artificial nutrition and hydration." The dilemma of "truth telling," which ranked first in the 2005-2006 survey, now ranked at the fourth place. Stepwise logistic regression analysis revealed that female gender and knowledge of palliative care were negatively correlated with the extent of dilemmas regarding issues of "life and death." CONCLUSION: The prevailing ethical dilemmas have changed in Taiwan 15 years after the enactment of the Natural Death Act, supporting that some previous strategies had worked. Our results suggest that education on the core values of palliative care, improvement of community-based hospice care program, and creating treatment guidelines with prognostication may resolve the current dilemmas. This type of survey should be adapted by individual countries to guide policy decisions on end-of-life care.

Factors affecting compliance with confirmatory colonoscopy after a positive fecal immunochemical test in a national colorectal screening program.

BACKGROUND: Screening with the fecal immunochemical test (FIT) is effective in reducing deaths from colorectal cancer (CRC). Since 2004, biennial FIT screening has been available to a target population in Taiwan as a national screening program. The objective of the current study was to identify the factors that influence willingness to undergo a confirmatory colonoscopy after a positive FIT, because related references in the published literature were scarce. METHODS: A semistructured questionnaire was based on the Health Belief Model (HBM) and a literature review. A stratified, random sampling method was used to recruit participants who had a positive FIT from all cities/counties in Taiwan. Cross-sectional, computer-assisted telephone interviews were conducted in 2012, and the results were analyzed using a logistic regression model that took into account population demographics, core content of the HBM, and HBM-modifying variables. RESULTS: In total, 2807 respondents were included in the analysis. The completion rate was 50%. Multivariate analyses revealed that higher perceived threat (adjusted odds ratio [aOR], 1.62; 95% confidence interval [CI], 1.31-2.01), higher cues for action (aOR, 2.18; 95% CI, 1.68-1.82), lower perceived barriers (aOR, 0.42; 95% CI, 0.34-0.42) and higher health behavior scores (aOR, 1.30; 95% CI, 1.05-1.60) were associated with a greater willingness to participate in confirmatory colonoscopy. Participants who were older (aOR, 0.74; 95% CI, 0.55-0.98) or unmarried (aOR, 0.72; 95% CI, 0.56-0.92) were less likely to participate in verification. CONCLUSIONS: The government could improve the screening rate by training case managers to assist in following patients until they complete colonoscopy, subsidizing sedated colonoscopies, and providing health education not only to the general public but also to physicians. Cancer 2018;124:907-15. © 2017 American Cancer Society.

A 10-year review of health care reform on Family Practice Integrated Care Project-Taiwan experience.

Objective: Taiwan has launched a Family Practice Integrated Care Project (FPICP) to develop an accountable family doctor system since March 2003. We aim to report the effectiveness of this nationwide demonstration programme over a 10-year period. Methods: Papers and reports related to the FPICP published both in English and in Chinese from 2003 to 2015 were collected systematically based on keywords including 'family doctor', 'primary care', 'integrated care' and 'Taiwan'. Also collected and reviewed were national health insurance administration annual reports and related publications from Taiwan Association of Family Medicine. Quality care indicators including structure, process and outcome for programme monitoring were reported. Results: Up to June 2015, the project had enrolled a total of 10.5% of Taiwan's population. Approximately 24.9% of primary care physicians and 29.7% of community clinics joined the project to serve the members of 426 community health care groups (CHCGs). Compared to non-members, CHCG members received more preventive care services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (43% versus 31%) (P < 0.01). Members showed a markedly high level of satisfaction (>95%), especially in overall satisfaction, provision of health consultation and information, and improvement in understanding personal health condition. Conclusions: In the future, through the support of family physicians and CHCGs, a person-centred integrated health care delivery system can be an effective solution to the current barriers in the medical care system.

Quick screening tool for patients with severe negative emotional reactions to chronic illness: psychometric study of the negative emotions due to chronic illness screening test (NECIS).

Background: Severe negative emotional reactions to chronic illness are maladaptive to patients and they need to be addressed in a primary care setting. Objective: The psychometric properties of a quick screening tool-the Negative Emotions due to Chronic Illness Screening Test (NECIS)-for general emotional problems among patients with chronic illness being treated in a primary care setting was investigated. Method: Three studies including 375 of patients with chronic illness were used to assess and analyze internal consistency, test-retest reliability, criterion-related validity, a cut-off point for distinguishing maladaptive emotions and clinical application validity of NECIS. Self-report questionnaires were used. Results: Internal consistency (Cronbach's α) ranged from 0.78 to 0.82, and the test-retest reliability was 0.71 (P < 0.001). Criterion-related validity was 0.51 (P < 0.001). Based on the 'severe maladaptation' and 'moderate maladaptation' groups defined by using the 'Worsening due to Chronic Illness' index as the analysis reference, the receiver-operating characteristic curve analysis revealed an area under the curve of 0.81 and 0.82 (ps < 0.001), and a cut-off point of 19/20 was the most satisfactory for distinguishing those with overly negative emotions, with a sensitivity and specificity of 83.3 and 69.0%, and 68.5 and 83.0%, respectively. The clinical application validity analysis revealed that low NECIS group showed significantly better adaptation to chronic illness on the scales of subjective health, general satisfaction with life, self-efficacy of self-care for disease, illness perception and stressors in everyday life. Conclusion: The NECIS has satisfactory psychometric properties for use in the primary care setting.

Medical care utilization and costs on end-of-life cancer patients: The role of hospice care.

Although there are 3 hospice care programs for terminal cancer patients in Taiwan, the medical utilization and expenses for these patients by programs have not been well-explored. The aim of this study was to examine the medical utilization and expenses of terminal cancer patients under different programs of hospice care in the last 90, 30, and 14 days of life.This was a retrospective observational study by secondary data analysis. By using the National Health Insurance claim database and Hospice Shared Care Databases. We identified cancer descents from these databases and classified them into nonhospice care and hospice care groups based on different combination of hospice care received. We then analyzed medical utilization including inpatient care, outpatient care, emergency room visits, and medical expenses by patient groups in the last 90, 30, and 14 days of life.Among 118,376 cancer descents, 46.9% ever received hospice care. Patients had ever received hospice care had significantly lower average medical utilization and expenses in their last 90, 30, and 14 days of life (all P < 0.001) compared to nonhospice care group. Each hospice care group had significantly less medical utilization and expenses in the last 90, 30, and 14 days of life (all P < 0.01).Different kinds of hospice care program have different effects on medical care utilization reduction and cost-saving at different stage of the end of life of terminal cancer patients.

Change of government's subsidization policy improves smoking cessation services: a cross-sectional study from the perspectives of physicians.

BACKGROUND: The Taiwanese government increased financial subsidies for smoking cessation services in 2012. We aimed to evaluate the effects of this new policy on smoking cessation services from the physician's perspective. METHODS: This was a cross-sectional nationwide survey. Physicians who provided smoking cessation services for more than ten patient encounters in the preceding year of the new policy (February 2011 to March 2012) were recruited. The questionnaire was developed by two experts and was validated by a committee consisting of 11 delegates. RESULTS: We sent a total of 1,319 questionnaires. The response rate was 45.9 %. The majority of respondents were male (88.4 %), middle-aged (65.3 %), and worked as family physicians (56.1 %). Most physicians agreed that the new policy had increased the number of patients seeking smoking cessation, increased patients' willingness to adopt pharmacotherapy, helped physicians to prescribe medications, improved patients' adherence to medications, and improved quality of care. These changes were most prominent in medical centers. Changes in the practice of the 5As (ask, advise, assess, assist, arrange) were moderate. Among different medical settings, the most significant change was an increase in the expenditure on smoking cessation medications. CONCLUSIONS: The new subsidization policy in Taiwan has improved smoking cessation services. Overall, physicians reported positive effects of the new policy. Further study is warranted to evaluate the long-term influence of the policy.

The Changes of Ethical Dilemmas in Palliative Care. A Lesson Learned from Comparison Between 1998 and 2013 in Taiwan.

The current ethical dilemmas met by healthcare professionals were never compared with those 15 years ago when the palliative care system was newly developing in Taiwan. The aim of the study was to investigate the ethical dilemmas met by palliative care physicians and nurses in 2013 and compare the results with the survey in 1998. This cross-sectional study surveyed 213 physicians and nurses recruited from 9 representative palliative care units across Taiwan in 2013. The compared survey in 1998 studied 102 physicians and nurses from the same palliative care units. All participants took a questionnaire to survey the "frequency" and "difficulty" of 20 frequently encountered ethical dilemmas, which were grouped into 4 domains by factor analysis. The "ethical dilemma" scores were calculated and then compared across 15 years by Student's t tests. A general linear model analysis was used to identify significant factors relating to a high average "ethical dilemma" score in each domain. All of the highest-ranking ethical dilemmas in 2013 were related to insufficient resources. Physicians with less clinical experience had a higher average "ethical dilemma" score in clinical management. Physicians with dissatisfaction in providing palliative care were associated a higher average "ethical dilemma" score in communication. Nurses reported higher "ethical dilemma" scores in all items of resource allocation in 2013. Further analysis confirmed that, in 2013, nurses had a higher average "ethical dilemma" score in resource allocation after adjustment for other relating factors. Palliative care nursing staff in Taiwan are more troubled by ethical dilemmas related to insufficient resources than they were 15 years ago. Training of decision making in nurses under the framework of ethical principles and community palliative care programs may improve the problems. To promote the dignity of terminal cancer patients, long-term fundraising plans are recommended for countries in which the palliative care system is in its early stages of development.

Cancer patient autonomy and quality of dying-a prospective nationwide survey in Taiwan.

BACKGROUND: Patient autonomy is an essential factor in the measurement of quality of dying. We aimed to conduct a study to investigate the factors affecting the autonomy of advanced cancer patients in Taiwan. METHODS: We conducted a prospective, multicenter study and recruited 574 advanced cancer patients from four inpatient hospice wards in Taiwan; their quality of dying was measured using the validated good death scale and the audit scale. Physician-assessed autonomy and the other scales were measured in a team conference by the primary care physician and the team 1 week after the patient had passed away. The good death scale was measured twice, once at admission and then after the patient had passed away for comparison. We measured factors affecting the improvement in quality of dying of these patients initially by applying multiple linear regression analysis. Then, taking physician-assessed autonomy as a dependent variable, we identified the factors that affected this variable. RESULTS: The good death score at admission, clear consciousness, number of admission days beyond 7, better physical care, higher physician-assessed autonomy, better emotional support, better communication, better continuity of life, and physician-reported rate of closure were factors affecting the quality of dying. Further analysis identified age (p = 0.031), consciousness (p = 0.01), and total good death scale score at death (p < 0.001) as determinants of physician-assessed autonomy. CONCLUSIONS: We concluded that physician-assessed autonomy would affect a good death and was highly correlated with age, consciousness level, and quality of dying at the end for advanced cancer patients in Taiwan.

The relationship between pain management and psychospiritual distress in patients with advanced cancer following admission to a palliative care unit.

BACKGROUND: Although many cross-sectional studies have demonstrated the association between cancer pain and psychospiritual distress, the time-dependent relationship has not been fully explored. For that reason, this study aims to investigate the time-dependent relationship between psychospiritual distress and cancer pain management in advanced cancer patients. METHODS: This is a prospective observational study. Two hundred thirty-seven advanced cancer patients were recruited from a palliative care unit in Taiwan. Demographic and clinical data were retrieved at admission. Pain and psychospiritual distress (i.e.: anxiety, depression, anger, level of family and social support, fear of death) were assessed upon admission and one week later, by using a "Symptom Reporting Form". Patients were divided into two groups according to the pain status one week post-admission (improved versus not improved groups). RESULTS: One hundred sixty-three (68.8 %) patients were assigned to the improved group, and 74 (31.2 %) patients were assigned to the not improved group. There were no differences in the psychospiritual variables between groups upon admission. In overall patients, all psychospiritual variables improved one week post-admission, but the improvement of depression and family/social support in the not improved group was not significant. Consistent with this, for depression scores, there was a statistically significant pain group x time interaction effect detected, meaning that the pain group effect on depression scores was dependent on time. CONCLUSIONS: We demonstrated a time-dependent relationship between depression and pain management in advanced cancer patients. Our results suggest that poor pain management may be associated with intractable depression. The inclusion of interventions that effectively improve psychospiritual distress may contribute to pain management strategies for advanced cancer patients.

Truth Telling and Treatment Strategies in End-of-Life Care in Physician-Led Accountable Care Organizations: Discrepancies Between Patients' Preferences and Physicians' Perceptions.

Providing patient-centered care from preventive medicine to end-of-life care in order to improve care quality and reduce medical cost is important for accountable care. Physicians in the accountable care organizations (ACOs) are suitable for participating in supportive end-of-life care especially when facing issues in truth telling and treatment strategy. This study aimed to investigate patients' attitudes toward truth telling and treatment preferences in end-of-life care and compare patients' attitudes with their ACOs physicians' perceptions.This nationwide study applied snowball sampling to survey physicians in physician-led ACOs and their contracted patients by questionnaire from August 2010 to July 2011 in Taiwan. The main outcome measures were beliefs about palliative care, attitudes toward truth telling, and treatment preferences.The data of 314 patients (effective response rate = 88.7%) and 177 physicians (88.5%) were analyzed. Regarding truth telling about disease prognosis, 94.3% of patients preferred to be fully informed, whereas only 80% of their physicians had that perception (P < 0.001). Significant differences were also found in attitudes toward truth telling even when encountering terminal disease status (98.1% vs 85.3%). Regarding treatment preferences in terminal illness, nearly 90% of patients preferred supportive care, but only 15.8% of physicians reported that their patients had this preference (P < 0.001).Significant discrepancies exist between patients' preferences and physicians' perceptions toward truth telling and treatment strategies in end-of-life care. It is important to enhance physician-patient communication about end-of-life care preferences in order to achieve the goal of ACOs. Continuing education on communication about end-of-life care during physicians' professional development would be helpful in the reform strategies of establishing accountable care around the world.

Palliative Care Physicians' Attitudes Toward Patient Autonomy and a Good Death in East Asian Countries.

CONTEXT: Clarification of the potential differences in end-of-life care among East Asian countries is necessary to provide palliative care that is individualized for each patient. OBJECTIVES: The aim was to explore the differences in attitude toward patient autonomy and a good death among East Asian palliative care physicians. METHODS: A cross-sectional survey was performed involving palliative care physicians in Japan, Taiwan, and Korea. Physicians' attitudes toward patient autonomy and physician-perceived good death were assessed. RESULTS: A total of 505, 207, and 211 responses were obtained from Japanese, Taiwanese, and Korean physicians, respectively. Japanese (82%) and Taiwanese (93%) physicians were significantly more likely to agree that the patient should be informed first of a serious medical condition than Korean physicians (74%). Moreover, 41% and 49% of Korean and Taiwanese physicians agreed that the family should be told first, respectively; whereas 7.4% of Japanese physicians agreed. Physicians' attitudes with respect to patient autonomy were significantly correlated with the country (Japan), male sex, physician specialties of surgery and oncology, longer clinical experience, and physicians having no religion but a specific philosophy. In all 12 components of a good death, there were significant differences by country. Japanese physicians regarded physical comfort and autonomy as significantly more important and regarded preparation, religion, not being a burden to others, receiving maximum treatment, and dying at home as less important. Taiwanese physicians regarded life completion and being free from tubes and machines as significantly more important. Korean physicians regarded being cognitively intact as significantly more important. CONCLUSION: There are considerable intercountry differences in physicians' attitudes toward autonomy and physician-perceived good death. East Asia is not culturally the same; thus, palliative care should be provided in a culturally acceptable manner for each country.

Plasma zinc α2-glycoprotein levels are elevated in smokers and correlated with metabolic syndrome.

BACKGROUND: Smoking is a strong risk factor of metabolic syndrome. Zinc α2-glycoprotein (ZAG) is a protein involved in metabolic syndrome. This study aims to investigate the effect of smoking on plasma ZAG levels and its relations to metabolic syndrome. MATERIALS AND METHODS: A group of 41 cigarette smokers and 47 non-smokers were enrolled. ZAG levels were measured to correlate to participants' demographic and metabolic parameters. RESULTS: Plasma ZAG levels of smokers were higher than those of controls (P < 0.0001). Plasma ZAG levels were positively correlated with male gender (P = 0.0002), number of cigarettes smoked per day (P < 0.0001), smoking duration in years (P < 0.0001), smoking index (P < 0.0001) and nicotine dependence score (P < 0.0001). In the multiple regression analysis, smoking was a strong independent factor affecting plasma ZAG levels (P = 0.0034). Plasma ZAG levels elevated progressively with the number of metabolic syndrome components (P = 0.0143). In the multiple regression analysis, plasma ZAG was an independent factor for metabolic syndrome. CONCLUSIONS: Plasma ZAG levels are high in smokers and correlate with metabolic syndrome. Our results indicate ZAG is an independent risk factor, but also interacted with smoking, for the metabolic syndrome.