The impact of caregiver's role preference on decisional conflicts and psychiatric distresses in decision making to help caregiver's disclosure of terminal disease status.

PURPOSE: The objective of this study was to investigate the impact of caregivers' role preference in decision making on conflicts and psychiatric distresses. METHODS: The responses of 406 caregivers of terminal cancer patients enrolled in a trial determining the efficacy of a decision aid focused on the disclosure of terminal disease status were included in this secondary analysis. The outcomes include the change scores of the Decision Conflict Scale (DCS) and depression and anxiety subscales of the Hospital Anxiety and Depression Scale (HADS) at the 1 and 3 months from baseline. The linear mixed model was employed to discover the impact of caregivers' decisional role preference on the outcomes. FINDINGS: Of the 406, 137 (33.7%) showed an active role preference and 269 (66.3%) showed a passive role preference. In the post hoc analysis of the adjusted differences of change scores between passive caregivers who received decision aid (passive-decision aid) and active caregivers with decision aid (active-decision aid), non-significant differences were observed in the DCS. However, at the 3-month, the change scores of the HADS depression subscale increased by 4.43 (effect size, 0.71) and those of the HADS anxiety subscale increased by 4.14 (effect size, 0.61) in the passive-decision aid group than in active-decision aid group, showing moderate to large difference. CONCLUSIONS: These findings suggest that information might be ethically recommended in a format that is interactive and tailored to how much an individual wishes to be involved in the decision-making process.

The Understanding of Terminal Cancer and Its Relationship with Attitudes toward End-of-Life Care Issues.

BACKGROUND: Although terminal cancer is a widely used term, its meaning varies, which may lead to different attitudes toward end-of-life issues. The study was conducted to investigate differences in the understanding of terminal cancer and determine the relationship between this understanding and attitudes toward end-of-life issues. METHODS: A questionnaire survey was performed between 2008 and 2009. A total of 1242 cancer patients, 1289 family caregivers, 303 oncologists from 17 hospitals, and 1006 participants from the general population responded. RESULTS: A "6-month life expectancy" was the most common understanding of terminal cancer (45.6%), followed by "treatment refractoriness" (21.1%), "metastatic/recurrent disease" (19.4%), "survival of a few days/weeks" (11.4%), and "locally advanced disease" (2.5%). The combined proportion of "treatment refractoriness" and "6-month life expectancy" differed significantly between oncologists and the other groups combined (76.0% v. 65.9%, P = 0.0003). Multivariate analyses showed that patients and caregivers who understood terminal cancer as "survival of a few days/weeks" showed more negative attitudes toward disclosure of terminal status compared with participants who chose "treatment refractoriness" (adjusted odds ratio [aOR] 0.42, 95% confidence interval [CI] 0.22-0.79 for patients; aOR 0.34, 95% CI 0.18-0.63 for caregivers). Caregivers who understood terminal cancer as "locally advanced" or "metastatic/recurrent disease" showed a significantly lower percentage of agreement with withdrawal of futile life-sustaining treatment compared with those who chose "treatment refractoriness" (aOR 0.19, 95% CI 0.07-0.54 for locally advanced; aOR 0.39, 95% CI 0.21-0.72 for metastatic/recurrent). CONCLUSIONS: The understanding of terminal cancer varied among the 4 participant groups. It was associated with different preferences regarding end-of-life issues. Standardization of these terms is needed to better understand end-of-life care.

The attitudes of Korean cancer patients, family caregivers, oncologists, and members of the general public toward advance directives.

PURPOSE: The purpose of this study was to investigate Korean attitudes toward advance directives (ADs) among cancer patients, family caregivers, oncologists, and the general public. METHODS: A multicenter survey study explored the attitudes of participants to ADs, and hospice-palliative care (HPC) was conducted. A total of 1,242 cancer patients, 1,289 family caregivers, 303 oncologists, and 1,006 members of the general public participated in the survey. RESULTS: The majority of patients, family caregivers, oncologists, and general public agreed with the necessity of ADs. However, oncologists regard "when became terminal status" as an optimal timing for completion of ADs (52.2 %), while other groups regard earlier periods as it. More than 95 % oncologist answered that cardiopulmonary resuscitation and mechanical ventilator are necessity items for ADs form, while around 70 % of other groups answered so. Multivariate analysis revealed that several factors including agreement with terminal disclosures and a positive attitude toward HPC were independently associated with necessity of ADs. CONCLUSIONS: We found that attitudes toward ADs among cancer patients, family caregivers, oncologists, and the general public were significantly different. Our study also suggests that favorable attitudes toward comfort end-of-life care and HPC are keys that influence the perceived need for ADs.

Quality of life and mental health in the bereaved family members of patients with terminal cancer.

OBJECTIVE: This study specifically aimed to compare quality of life (QOL) and mental health in bereaved family members of patients with cancer with that of the general population and to examine factors associated with QOL and mental health in this population. DESIGN: A nationwide multicenter, cross-sectional survey was administered to the bereaved family members of patients with terminal cancer. SETTING: Thirty-three palliative care centers designated by the Ministry of Health and Welfare participated in this study. PARTICIPANTS: The participants in this study were 501 bereaved family members of patients with terminal cancer and matched control individuals from the Korean National Health and Nutrition Examination Survey. MEASUREMENT: EQ-5D and several questions used in Korean National Health And Nutrition Examination Survey were used in to measure health-related QOL and mental health. RESULTS: Health-related QOL, as determined by EQ-5D, was significantly lower in bereaved family members than in controls (0.88 ± 0.20 vs 0.93 ± 0.13, p = 0.002). Bereaved family members experienced more frequent episodes of depression (33.1% vs 12.5%, p < 0.001) and suicidal thoughts (31.4% vs 16.4%, p < 0.001) during the previous year than did controls. Female sex, lower income, spousal relationship, and longer duration of survival after palliative care referral were negatively correlated with health-related QOL. Younger age and higher mental burden of caregiving were associated with a higher risk of impaired mental health. DISCUSSION: Our results confirm that bereaved family members of patients with cancer have lower health-related QOL and mental health than the general population. Healthcare providers should focus more attention on this vulnerable group, and various support programs should be developed to improve their health-related QOL.

Use of a decision aid to help caregivers discuss terminal disease status with a family member with cancer: a randomized controlled trial.

PURPOSE: We tested whether a decision aid explaining how to discuss the approach of death with a family member with cancer would help family caregivers decide to discuss a terminal prognosis. PATIENTS AND METHODS: We randomly assigned caregivers of terminally ill patients with cancer to a group that received a video and a companion workbook that showed either how they can discuss the prognosis with their patient (experimental arm) or how cancer pain can be controlled (control arm). At baseline and 1 month, we evaluated the decision to discuss terminal prognosis as the primary outcome. At 0, 1, 3, and 6 months, we assessed the caregivers' decisional conflict and satisfaction as secondary outcomes using a Decision Conflict Scale (DCS). RESULTS: We found no difference in changes in the decision to discuss terminal prognosis between the two groups. Conflict (P = .003), uncertainty (P = .019), and value clarity (P = .007) subscale scores and total DCS score (P = .008) improved from baseline to 1 month significantly more in the experimental arm than in the control arm. Over 6 months, the significant between-group differences continued for the conflict (P = .031), uncertainty (P = .014), and value clarity (P = .039) subscale scores and total DCS score (P = .040). CONCLUSION: Decision aids can help caregivers, with the aid of trained professionals, to communicate with patients about their terminal illness.

Attitudes of cancer patients, family caregivers, oncologists and members of the general public toward critical interventions at the end of life of terminally ill patients.

BACKGROUND: Whereas most studies have focused on euthanasia and physician-assisted suicide, few have dealt comprehensively with other critical interventions administered at the end of life. We surveyed cancer patients, family caregivers, oncologists and members of the general public to determine their attitudes toward such interventions. METHODS: We administered a questionnaire to four groups about their attitudes toward five end-of-life interventions--withdrawal of futile life-sustaining treatment, active pain control, withholding of life-sustaining measures, active euthanasia and physician-assisted suicide. We performed multivariable analyses to compare attitudes and to identify sociodemographic characteristics associated with the attitudes. RESULTS: A total of 3840 individuals--1242 cancer patients, 1289 family caregivers and 303 oncologists from 17 hospitals, as well as 1006 members of the general Korean population--participated in the survey. A large majority in each of the groups supported withdrawal of futile life-sustaining treatment (87.1%-94.0%) and use of active pain control (89.0%-98.4%). A smaller majority (60.8%-76.0%) supported withholding of life-sustaining treatment. About 50% of those in the patient and general population groups supported active euthanasia or physician-assisted suicide, as compared with less than 40% of the family caregivers and less than 10% of the oncologists. Higher income was significantly associated with approval of the withdrawal of futile life-sustaining treatment and the practice of active pain control. Older age, male sex and having no religion were significantly associated with approval of withholding of life-sustaining measures. Older age, male sex, having no religion and lower education level were significantly associated with approval of active euthanasia and physician-assisted suicide. INTERPRETATION: Although the various participant groups shared the same attitude toward futile and ameliorative end-of-life care (the withdrawal of futile life-sustaining treatment and the use of active pain control), oncologists had a more negative attitude than those in the other groups toward the active ending of life (euthanasia and physician-assisted suicide).

Combination antitumor effects of micelle-loaded anticancer drugs in a CT-26 murine colorectal carcinoma model.

Experiments were designed to evaluate the in vitro cytotoxic interactions of anticancer drugs in combination, evaluate synergistic activity in vivo and utilize micelle-forming polymeric drugs as drug carriers in a murine cancer model. Antitumor effects of 5-fluorouracil, cisplatin, CPT-11, oxaliplatin, etoposide, mitomycin-C, doxorubicin and paclitaxel were evaluated by determination of in vitro cytotoxicity to CT-26 colorectal tumor cells or in vivo following a subcutaneous transplant in BALB/c mice. Single agent and combination in vivo studies were also performed using drug-loaded polymeric micelles composed of poly(gamma-benzyl L-glutamate) and poly(ethylene oxide) (GEG) or poly(L-lactide)/poly(ethylene glycol) (LE) diblock copolymer. After 3 days exposure, the mean IC(50) (microg/mL) for 5-fluorouracil, cisplatin, CPT-11, oxaliplatin, etoposide, mitomycin-C, doxorubicin and paclitaxel were 0.95, 2.01, 4.47, 3.34, 3.5, 1.96, 1.8 and 2.1, respectively. When tumor cells were exposed to doxorubicin concurrently with etoposide or paclitaxel, evidence of synergy was observed in CT-26 cells in vitro. Doxorubicin and paclitaxel loaded into GEG or LE copolymers at a high concentration (19.5 and 16.7 wt%, respectively) were almost completely released (83.2% and 93.7%, respectively) by day 3. When tumor-bearing mice were treated in combination with doxorubicin-paclitaxel or doxorubicin-etoposide, substantial antitumor activity was evident compared with single therapy. These data suggest that in vitro cytotoxicity of anticancer drugs is related to in vivo results, and chemotherapy using micelle-loaded anticancer drugs represents a promising potential as a carrier system in modulating drug delivery.