Effects of hospice-shared care on terminal cancer patients in Taiwan: A hospital-based observational study.

PURPOSE: To assess how hospice-shared care (HSC) affected the likelihood of aggressive medical treatments and the life quality among terminal cancer patients. METHODS: In the first part, a cohort of 160 late-stage cancer patients who died in non-hospice wards were identified to review their charts in their last 22 days before death. In the second part, a total of 19 late-stage cancer patients with clear consciousness admitted to non-hospice wards were identified to investigate their quality of life for the final 2 weeks before death. RESULTS: The utilization rate of HSC was 55.6%. Among these, the rate for late referral to HSC (≤7 days before death) was 43.8% and early referral (>3 months before death) was 5.6%. Compared to the non-HSC group, in the last few weeks of life, the HSC group underwent lower incidence of chemotherapy use (10.1% vs. 39.4%, p < .001), signed do-not-resuscitate orders (0% vs. 21.1%, p < .001), emergency room visits (13.5% vs. 40.8%, p < .001), intensive care unit admission or ventilator use (2.2% vs. 11.3%, p = .019), and endotracheal intubation (2.2% vs. 9.9%, p = .038). However, the quality of life did not appear to have obvious differences between the two groups (p > .05). CONCLUSION: In Taiwan, late HSC referral in terminal cancer patients is common. HSC is associated with a reduced likelihood of aggressive medical utilization. However, the effect of HSC in improving patients' quality of life in the last few weeks needs to be further evaluated.

The integrated analysis and underlying mechanisms of FNDC5 on diabetic induced cognitive deficits.

OBJECTIVES: Chronic hyperglycemia is considered as an important factor to promote the neurodegenerative process of brain, and the synaptic plasticity as well as heterogeneity of hippocampal cells are thought to be associated with cognitive dysfunction in the early process of neurodegeneration. To date, fibronectin type III domain-containing protein 5 (FNDC5) has been highlighted its protective role in multiple neurodegenerative diseases. However, the potential molecular and cellular mechanisms of FNDC5 on synaptic plasticity regulation in cognitive impairment (CI) induced by diabetics are still need to known. METHODS/DESIGN: To investigate the heterogeneity and synaptic plasticity of hippocampus in animals with CI state induced by hyperglycemia, and explore the potential role of FNDC5 involved in this process. Firstly, the single cell sequencing was performed based on the hippocampal tissue from db diabetic mice induced CI and normal health control mice by ex vivo experiments; and then the integrated analysis and observations validation using Quantitative Real-time PCR, western blot as well as other in vitro studies. RESULTS: We observed and clarified the sub-cluster of type IC spiral ganglion neurons expressed marker genes as Trmp3 and sub-cluster of astrocytes with marker gene as Atp1a2 in hippocampal cells from diabetic animals induced CI and the effect of those on neuron-glial communication. We also found that FNDC5\BDNF-Trk axis was involved in the synaptic plasticity regulation of hippocampus. In high glucose induced brain injury model in vitro, we investigated that FNDC5 significantly regulates BDNF expression and that over-expression of FNDC5 up-regulated BDNF expression (p < 0.05) and can also significantly increase the expression of synapsin-1 (p < 0.05), which is related to synaptic plasticity, In addition, the unbalanced methylation level between H3K4 and H3K9 in Fndc5 gene promoter correlated with significantly down-regulated expression of FNDC5 (p < 0.05) in the hyperglycemia state. CONCLUSION: The current study revealed that the synaptic plasticity of hippocampal cells in hyperglycemia might be regulated by FNDC5\BDNF-Trk axis, playing the protective role in the process of CI induced by hyperglycemia and providing a target for the early treatment of hyperglycemia induced cognitive dysfunction in clinic.

A Review of Gap Junction Protein and its Potential Role in Nervous System-Related Disease.

Gap junction (GJ) is a special cell membrane structure composed of connexin. Connexin is widely distributed and expressed in all tissues except differentiated skeletal muscle, red blood cells, and mature sperm cells, which is related to the occurrence of many genetic diseases due to its mutation. Its function of regulating immune response, cell proliferation, migration, apoptosis, and carcinogenesis makes it a therapeutic target for a variety of diseases. In this paper, the possible mechanism of its action in nervous system-related diseases and treatment are reviewed.

[Effect of a Simple Home-Based Oral Care Regimen on Oral Mucositis in Patients With Oral Cavity and Nasopharyngeal Cancer: A Quasi-Experimental Study].

BACKGROUND: The majority of patients with oral cavity and nasopharyngeal cancer experience severe oral mucositis during concurrent radiochemotherapy. The effectiveness of routine nursing education remains limited. PURPOSE: To evaluate the effect of a simple home-based oral care regimen on oral mucositis. METHODS: A double-group quasi-experimental design was adopted in this study. The participants were all newly diagnosed patients with oral cavity and nasopharyngeal cancer who were scheduled to receive concurrent radiochemotherapy in a northern medical center. A total of 31 patients in the experimental group and 32 patients in the control group were enrolled as participants. The control group received routine care, while the experimental group received an additional six- to seven-week two-way interactive home-based oral care regimen. The measurement tools included a plaque record and oral assessment guide (OAG) implemented twice during the study period. Study data were collected at 8 time points, including before treatment, at 1-5 weeks of treatment, at the end of treatment, and at one-month post-treatment. Data analysis was performed using two-way repeated measures ANCOVA. RESULTS: After controlling for OAG score, nutrition, age, living habits, and oral hygiene, the development of mucositis was found to be significantly slower in the experimental group than in the control group during the traumatic phase (effect of group: F = 11.1, p < .01; effect of group x time: F = 3.5, p = .01). However, both groups reported a statistically similar rate of improvement during the repair phase (effect of group and group x time: F = 0.19, p = .67). CONCLUSIONS / IMPLICATIONS FOR PRACTICE: The simple home-based oral care regimen introduced in this study may be used to improve traumatic oral mucositis in patients with oral cavity and nasopharyngeal cancer. It is recommended that even after the completion of radiotherapy, medical staffs should continue to strengthen patients' execution of proper oral care to maintain the positive effect until the mucositis has abated.

Association between changes in body fat and disease progression after breast cancer surgery is moderated by menopausal status.

BACKGROUND: Obesity is linked to poor disease outcomes in breast cancer patients. However, this link was mostly based on body weight or BMI rather than body-fat. The purpose of this study was to evaluate the relationship between body-fat gain and disease progression in Taiwanese women after breast cancer surgery and how this relationship is influenced by menopausal status. METHODS: Body fat percentage was measured 1 day before and 6 months after surgery in 131 women with stages 0-III breast cancer. Disease outcomes (metastasis and death) were assessed by chart review and telephone contact 7 to 8 years after diagnosis. These data were analyzed by multivariate Cox proportional hazard model analysis. RESULTS: The percentage of women with over 5% gain in body-fat was 56% for premenopausal and 42% for postmenopausal. Rates of distant metastasis and all-cause mortality were 17.6 and 9.9%, respectively over the follow-up period. Distant metastases were predicted in postmenopausal but not premenopausal women with breast cancer by increased body fat percentage (HR = 1.3, p = 0.035), after controlling other potential covariates, including disease severity, estrogen receptor expression, progesterone receptors expression, age, and exercise habit before diagnosis. Survival was not significantly associated with body-fat percentage gains. CONCLUSIONS: Our results suggest that increased body fat percentage 6 months after breast surgery is an important predictor of distant metastasis in postmenopausal Taiwanese women with breast cancer. Clinicians may need to measure patients' body fat periodically. Our findings should be validated in studies with a longer follow-up time.

A Decade of Changes in Family Caregivers' Preferences for Life-Sustaining Treatments for Terminally Ill Cancer Patients at End of Life in the Context of a Family-Oriented Society.

CONTEXT: Temporal changes in different family caregiver cohorts' preferences for life-sustaining treatments (LSTs) at end of life (EOL) have not been examined nor have the concept of whether caregivers' LST preferences represent a homogeneous or heterogeneous construct. Furthermore, LST preferences are frequently assessed from multiple treatments, making clinical applications difficult/infeasible. OBJECTIVES: To identify parsimonious patterns and changes in the pattern of LST preferences for two independent cohorts of family caregivers for terminally ill Taiwanese cancer patients. METHODS: Preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis were assessed among 1617 and 2056 family caregivers in 2003-2004 and 2011-2012, respectively. Patterns and changes in LST preferences were examined by multigroup latent class analysis. RESULTS: Five distinct classes were identified: uniformly preferring, uniformly rejecting, uniformly uncertain, and favoring nutritional support but rejecting or uncertain about other treatments. Class probability significantly decreased from 29.3% to 23.7% for the uniformly rejecting class, remained largely unchanged for the uniformly preferring (16.9%-18.6%), and favoring nutritional support but rejecting (37.1%-37.5%) or uncertain about other treatments (8.0%-10.4%) classes, but significantly increased from 7.0% to 11.5% for the uniformly uncertain class over time. CONCLUSION: Family caregivers' LST preferences for terminally ill cancer patients are a heterogeneous construct and shifted from uniformly rejecting all LSTs toward greater uncertainty. Surrogate EOL-care decision making may be facilitated by earlier and thorough assessments of caregivers' LST preferences and tailoring interventions to the unique needs of caregivers in each class identified in this study.

Characteristics and Correlates of Increasing Use of Surgery in Taiwanese Cancer Patients' Last Month of Life, 2001-2010.

BACKGROUND/OBJECTIVES: Surgery offers the potential to relieve symptoms for patients with cancer at the end of life (EOL) but at significant physiological and economic costs. However, the characteristics and correlates of surgery in last month of life (EOL surgery) of patients with cancer have not been comprehensively explored. This population-based study characterized EOL surgery use and identified its correlates. METHODS: This retrospective cohort study examined administrative data among 339,546 Taiwanese cancer decedents, 2001 to 2010. We classified procedures according to their likely intent. RESULTS: Approximately 1 in 10 (11.44%, range: 11.08%-11.86%) patients underwent EOL surgery with an increasing utilization over time. The intention for EOL surgery was primarily palliative, followed by cancer-directed, nonmalignancy-directed, and diagnostic. EOL surgery for palliative intent increased whereas other intents decreased significantly over time. EOL surgery was more likely among those who were male, younger, and married; not diagnosed with hepatic-pancreatic or lung cancers; had no comorbidity or documented metastatic codes; and survived less than 1 year from diagnosis. The likelihood of EOL surgery use was higher for patients who received care in a teaching hospital with more acute care hospital beds and higher EOL care intensity. CONCLUSIONS: Rates of EOL surgery are lower in Taiwan than those reported in the United States. The increasing use of EOL surgery in Taiwan is primarily for palliative intent. Appropriateness of EOL surgery should be carefully evaluated to avoid underutilizing potentially beneficial, palliative-intent surgery and overutilizing cancer-directed and other surgical procedures, especially for physicians working in hospitals with abundant health care resources and a tendency to treat at-risk patients with cancer aggressively.

Presurgical symptom profiles predict quality of life 2 years after surgery in women with breast cancer.

PURPOSE: Higher symptom burden in oncology patients is associated with poorer quality of life (QOL). However, the long-term predictive relationship between pre-treatment symptom profiles and QOL is unknown. The aim of this study was to identify subgroups of breast cancer patients based on their presurgical symptom profiles and to examine the predictive effect of group membership on QOL 2 years after surgery. METHODS: Data were analyzed from a longitudinal study of women's (N = 198) symptoms after breast cancer surgery. Patient subgroups were identified by latent class analysis based on presurgical severity of five symptoms (i.e., attentional and physical fatigue, sleep disturbance, depression, and anxiety). Among these 198 women, quality of life 2 years after surgery was available for 97. Group differences in QOL were examined by general linear models. RESULTS: We identified four distinct patient groups. Group A (All Low) had low levels of all symptoms. Group B (Low Fatigue and Moderate Mood) was characterized by low attentional and physical fatigue but moderate sleep disturbance, depression, and anxiety. Group C (All Moderate) was characterized by moderate levels of all five symptoms. Group D was characterized by moderate attentional and physical fatigue and severe sleep disturbance, depression, and anxiety (Moderate Fatigue and High Mood). Group D had significantly lower overall QOL scores 2 years after surgery than Group A (p = 0.002). CONCLUSIONS: Breast cancer patients' presurgical symptom profile had a long-term predictive effect on QOL. Routine assessment of patients' pre-treatment symptom is suggested to identify high risk group.

A Decade of Changes in Preferences for Life-Sustaining Treatments Among Terminally Ill Patients With Cancer.

BACKGROUND: Changes over time in preferences for life-sustaining treatments (LSTs) at end of life (EOL) in different patient cohorts are not well established, nor is the concept that LST preferences represent more than 2 groups (uniformly prefer/not prefer). PURPOSE: The purpose of this study was to explore heterogeneity and changes in patterns of LST preferences among 2 independent cohorts of terminally ill patients with cancer recruited a decade apart. METHODS: Preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, nasogastric tube feeding, and dialysis were surveyed among 2,187 and 2,166 patients in 2003-2004 and 2011-2012, respectively. Patterns and changes in LST preferences were examined by multigroup latent class analysis. RESULTS: We identified 7 preference classes: uniformly preferring, uniformly rejecting, uniformly uncertain, favoring nutritional support but rejecting other treatments, favoring nutritional support but uncertain about other treatments, favoring intravenous nutritional support with mixed rejection of or uncertainty about other treatments, and preferring LSTs except intubation with mechanical ventilation. Probability of class membership decreased significantly over time for the uniformly preferring class (15.26%-8.71%); remained largely unchanged for the classes of uniformly rejecting (41.71%-40.54%) and uniformly uncertain (9.10%-10.47%), and favoring nutritional support but rejecting (20.68%-21.91%) or uncertain about (7.02%-5.47%) other treatments, and increased significantly for the other 2 classes. The LST preferences of Taiwanese terminally ill patients with cancer are not a homogeneous construct and shifted toward less-aggressive treatments over the past decade. CONCLUSIONS: Identifying LST preference patterns and tailoring interventions to the unique needs of patients in each LST preference class may lead to the provision of less-aggressive EOL care.

Physician-patient end-of-life care discussions: correlates and associations with end-of-life care preferences of cancer patients-a cross-sectional survey study.

BACKGROUND: Honoring patients' treatment preferences is a key component of high-quality end-of-life care. Connecting clinical practices to patients' preferences requires effective communication. However, few cancer patients reported discussing end-of-life-care preferences with their physicians. AIM: To identify correlates of physician-patient end-of-life-care discussions and to investigate associations of physician-patient end-of-life-care discussions with patient end-of-life-care preferences. DESIGN: A cross-sectional survey from April 2011 through November 2012. SETTING/PARTICIPANTS: A convenience sample of 2467 cancer patients (89.3% participation rate) whose disease was diagnosed as terminal and unresponsive to current curative cancer treatment was recruited from 23 teaching hospitals throughout Taiwan. RESULTS: Only 7.8% of respondents reported discussing end-of-life-care preferences with their physicians. Physicians were more likely to discuss end-of-life-care preferences with cancer patients who accurately understood their prognosis but less likely to do so if patients were married or received care in a hospital with an inpatient hospice unit. Furthermore, physician-patient end-of-life-care discussions were significantly, positively associated with the likelihood of preferring comfort-oriented care and hospice care, but negatively associated with preferences for receiving cardiopulmonary resuscitation when life is in danger and aggressive life-sustaining treatments at end of life, including intensive care unit admission, cardiac massage, intubation, and mechanical ventilation support. CONCLUSION: Physician-patient end-of-life-care discussions are correlated with accurate prognostic awareness, marital status, and institutional characteristics and negatively associated with terminally ill cancer patients' preferences for aggressive end-of-life care. Interventions should be developed to facilitate timely end-of-life-care discussions between at-risk patients and their physicians, thus honoring patients' end-of-life-care preferences and possibly avoiding futile life-sustaining treatments.

Determinants of preference for home death among terminally ill patients with cancer in Taiwan: a cross-sectional survey study.

BACKGROUND: Studies worldwide have shown that most patients with cancer prefer to die at home. Few studies have directly explored the determinants of preference for home death in patients with cancer living in Asia, and none has been conducted in Taiwan. OBJECTIVES: This study was designed to identify determinants of home-death preference among terminally ill patients with cancer in Taiwan. METHODS: A convenience sample of 2,188 terminally ill patients with cancer from 24 hospitals nationwide was surveyed. This study used multivariate logistic regression analysis to identify the determinants of preference for home death in the realms of patient demographics and disease characteristics, awareness of prognosis, and family support. RESULTS: Slightly more than half of the participants expressed the preference to die at home (n = 1,114, 54.7%). The adjusted odds of preferring to die at home were greater for participants described by one or more of the following: (1) family members knew the participant's preference for place of death (p < .001), (2) participant knew his or her prognosis (p = .032), (3) participant had greater functional dependency (p < .001), (4) participant was diagnosed with either liver/pancreatic (p = .028) or head/neck (p = .012) cancer, and (5) participant had less than a junior high school education (p < .001). CONCLUSIONS/IMPLICATIONS FOR PRACTICE: This study supports the argument that most terminally ill patients with cancer in Taiwan prefer to die at home. To achieve patient preferences for home death, healthcare professionals should provide prognostic information and initiate end-of-life care discussions among patients and their family to facilitate family understanding of their ill relative's place-of-death preference. Developing clinical interventions to alleviate physical symptoms and providing hospice homecare services for terminally ill patients with cancer, especially those with lung cancer and greater functional dependency, may facilitate a preference for and actualization of home death.

Associations between accurate prognostic understanding and end-of-life care preferences and its correlates among Taiwanese terminally ill cancer patients surveyed in 2011-2012.

OBJECTIVE: Adequate knowledge of prognosis is a prerequisite for planning appropriate end-of-life (EOL) care. However, questions remain about whether the association between prognostic understanding and EOL-care intensity reflects terminally ill cancer patients' preferences for EOL care. This study investigated the associations between accurate prognostic understanding and EOL-care preferences, and identified correlates of accurate prognostic understanding. METHODS: A cross-sectional survey of 2452 terminally ill cancer patients from 23 hospitals throughout Taiwan. RESULTS: Nearly half the participants (49.80%) accurately understood their prognosis. These patients were significantly more likely to prefer comfort-oriented care as their goal for EOL care, but less likely to prefer life-prolonging treatments. Accurately understanding prognosis decreased the likelihood of preferring intensive care unit care, cardiac pulmonary resuscitation, cardiac massage, intubation, and mechanical ventilation support, but increased preference for hospice care. Participants were significantly more likely to accurately understand their prognosis if they were male, younger, better educated, with a stronger preference for physicians to disclose their prognosis to them, and receiving care at a hospital accredited as a medical center and in northwest Taiwan. The likelihood of accurate prognostic understanding was lower for patients recently (≤ 12 months) diagnosed with cancers with better prognosis and hematologic malignancies than for lung cancer patients. CONCLUSIONS: Accurately understanding prognosis is associated with fewer preferences for life-sustaining treatments and is correlated with both patient and institutional characteristics. Interventions should be developed to improve accurate prognostic understanding, thus facilitating informed EOL-care decisions that may limit the use of aggressive interventions.

Weight change trajectory in women with breast cancer receiving chemotherapy and the effect of different regimens.

AIMS AND OBJECTIVES: To investigate the trajectory of weight change in Taiwanese women with breast cancer after starting chemotherapy and the impact of chemotherapy regimens on weight change while controlling for age, menopausal status, body mass index, lymph node involvement and changes in habits of dietary fat intake and exercise. BACKGROUND: Weight gain after adjuvant chemotherapy in women with breast cancer has negative impact on health outcomes. DESIGN: Longitudinal, clinical observational study. METHODS: Weights were repeatedly measured in 147 women with breast cancer stages I-III. Hierarchical linear modelling was used to analyse these longitudinal data. RESULTS: The overall pattern of weight change was a cubic form beginning with a mean of 56·9 kg before chemotherapy. It gradually increased to 59·4 kg at 8·5 months after the first chemotherapy followed by a decrease to 58·5 kg at 21·5 months. During the last 2·5 months, weight increased slightly and never returned to the initial level. After controlling for confounders, steeper weight change was observed among women receiving cyclophosphamide, methotrexate and fluorouracil. The highest weight gain in the cyclophosphamide, methotrexate and fluorouracil group was 2·9 kg (5%) vs. 0·9 kg (1%) in the anthracycline-based group. CONCLUSION: The trajectory of body weight change within two years after chemotherapy shows a trend of gradual ascent, followed by a small decline and a slight increase in the last 2·5 months. The chemotherapy regimen can predict the trend after controlling for other confounders; women on cyclophosphamide, methotrexate and fluorouracil have a steeper weight change. RELEVANCE TO CLINICAL PRACTICE: Nurses can inform women with breast cancer about the expected changes in body weight after chemotherapy to reduce their uncertainty. Future studies on effective interventions to minimise chemotherapy-induced weight gain are needed.

Changes in perceived attentional function in women following breast cancer surgery.

After treatment for breast cancer, many women experience cognitive problems, as determined by objective neuropsychological tests. However, the ecological validity of these tests has been questioned. This study explored the trajectory of perceived attentional function from before to 24 months after surgery in women with breast cancer and examined the effect of adjuvant treatment on this perceived attentional function. Women with breast cancer (N = 200) were assessed for perceived cognitive function by measuring attentional function using the attentional function index (AFI). Covariates included anxiety, depression, fatigue, and sleep disturbance. Perceived attentional function declined in 54% of women at 1 month after surgery. At 1 and 2 years after surgery, 41 and 30% of women, respectively, still perceived this decline. The mean AFI decreased to the lowest point 1 month after surgery, but improved gradually afterward, taking about 1 year to return to the pre-surgery level. Decreases in perceived attentional function were associated with increases in anxiety, depression, fatigue, and sleep disturbance. After controlling for baseline differences and covariates, mean AFI scores were not associated with adjuvant treatment. Perceived cognitive function deteriorated after surgery but improved over time. It was not associated with adjuvant cancer treatment.

Accuracy of body mass index to determine obesity in women with breast cancer: an observational study of Taiwanese sample.

BACKGROUND: Obesity is common in women with breast cancer. The risk of obesity-induced metabolic syndrome is higher in Asians than in Caucasians. Excessive body fat accumulation has been associated with a worse prognosis. However, the most popular clinical indicator of obesity is not fat itself, but body mass index (BMI). OBJECTIVES: The purposes of this study were to determine the consistency of BMI and body fat percentage (BF%) in determining obesity and to identify the best BMI cutoffs for identifying obesity in Taiwanese women with breast cancer. METHODS: Body fat and fat-free mass were measured by bioelectrical impedance 1 day before breast surgery for 200 women with breast cancer. BMI was calculated as weight (in kilograms) divided by height (in meters) squared. RESULTS: BMI and BF% were highly correlated (r=0.91; p<0.001). However, BMI exhibited poor sensitivity for identifying obesity (47%). The sensitivity of BMI to detect obesity was better in women over age 60. The best BMI cutoff for obesity was 22.3 kg/m2 with a sensitivity and specificity of 89% (95% CI=83-94%) and 87% (95% CI=77-93%) respectively, and the total accuracy rate improved from 65% to 89%. CONCLUSIONS: Using BMI to identify obesity in Taiwanese women with breast cancer requires careful attention to the diagnostic criterion chosen. The World Health Organization criterion tends to underestimate the prevalence of obesity, especially for younger women with breast cancer (under age 40).

Cancer pain as the presenting problem in emergency departments: incidence and related factors.

GOALS OF WORK: Since emergency departments (ED) are designed to manage people with urgent and life-threatening conditions, cancer patients presenting with pain may not receive the appropriate care in the ED. The purpose of this study was to identify the incidence and factors related to ED visits by cancer patients with pain complaints. MATERIALS AND METHODS: Medical charts selected by stratified random sampling were retrospectively reviewed to obtain information about ED visits by cancer patients during a 1-year period. The sample included 1,179 ED visits by 1,026 cancer patients. MAIN RESULTS: Pain was the most common reason for ED visits by cancer patients. The incidence of ED visits for pain as a presenting problem was 27.8%. The 72-h ED return-visit rate was 8.2% for cancer patients who visited the ED with pain complaints. Patients with gastrointestinal and genitourinary cancers were more likely to visit the ED for pain. Patients who had received radiation therapy were less likely to visit the ED for pain. CONCLUSION: Effective cancer pain management programs need to be developed and tested to reduce ED visits by cancer patients with pain. More research is needed to explore why cancer patients with pain visit the ED.

Patient awareness of prognosis, patient-family caregiver congruence on the preferred place of death, and caregiving burden of families contribute to the quality of life for terminally ill cancer patients in Taiwan.

OBJECTIVES: The main goal of end-of-life care is to achieve the best quality of life (QOL) for patients. The purpose of this study was to investigate the impact of (1) the patients' awareness of their prognosis, (2) the extent of patient-family caregiver congruence on the preferences for end-of-life care options, and (3) the perceived caregiving burden of family caregivers when they provide end-of-life care to their dying relative, on the QOL for terminally ill cancer patients in Taiwan. METHODS: A total of 1108 dyads of patient-family caregiver from 24 hospitals throughout Taiwan were one-time surveyed. Predictors of the QOL were identified by multiple regression analysis. RESULTS: Controlling for the effects of age, financial status, and symptom distress, a novel finding of this study was that the patient awareness of prognosis, patient-family caregiver congruence on the preferred place of death, and the subjective family caregiving burden had a significant impact on the QOL of Taiwanese terminally ill cancer patients. CONCLUSIONS: QOL is not only related to the unavoidable decline in physical condition and daily functioning of the dying patient but is also related to domains that, as death approaches, have the potential to show improvement through the efforts of health-care professionals, such as presenting prognostic information to optimize the patients' understanding and assists them with psychological adjustments, facilitating patient-family caregiver congruence on the end-of-life care decision regarding the place of death and lightening the caregiving burden of family caregivers.

Role of continuing supportive cares in increasing social support and reducing perceived uncertainty among women with newly diagnosed breast cancer in Taiwan.

The purpose of this study was to explore the roles of continuing supportive care in increasing the social support and reducing the perceived uncertainty among women newly diagnosed with breast cancer in Taiwan. A longitudinal, quasi-experimental design was used in this study. Sixty-one women younger than 60 years, newly diagnosed with breast cancer and undergoing surgery, were recruited from 2 urban teaching hospitals in northern Taiwan. The experimental group was provided with additional continuing supportive care for 3 months. Two instruments, including the Social Support Questionnaire and an uncertainty questionnaire, were administered to participants at 3 time points: presurgery within 2 weeks after diagnosis, 1 month after surgery, and 3 months after diagnosis. The experimental group reported significantly higher social support and lower disease uncertainty compared with the control group at 1 month after surgery and 3 months after diagnosis. With knowledge of the role that continuing-care intervention plays in social support and disease uncertainty, nurses and other healthcare professionals can continue to explore and strengthen strategies to enhance the coping ability of women with breast cancer in Taiwan.

Congruence of knowledge, experiences, and preferences for disclosure of diagnosis and prognosis between terminally-ill cancer patients and their family caregivers in Taiwan.

BACKGROUND: Over the last 40 years, studies have shown cultural differences in attitudes toward truth telling at the end-of-life. Nevertheless, the argument that cancer patients from an Asian culture have different preferences about information disclosure that necessitate significantly modifying information disclosure practices has not been validated by direct investigation from patients' points of view. METHODS: Six hundred seventeen dyads of patient-designated family caregivers across 21 hospitals throughout Taiwan were surveyed and interviewed by a semistructured interview guide. Percentage of agreement, kappa coefficients, McNemar tests, and paired t-tests were conducted to examine the extent of congruence of knowledge, experiences, and preferences for disclosure of diagnosis and prognosis between the dyads. RESULTS: There were substantial discrepancies in the knowledge and experiences of being informed about the diagnosis and prognosis between Taiwanese terminally-ill cancer patients and their family caregivers (kappa values ranged from 0.08 to 0.44). Cancer patients strongly proclaimed their superior rights to be informed about their disease over their family and preferred their physicians to inform themselves before releasing any information to their family caregivers. CONCLUSION: The arguments that cancer patients from an Asian culture (i.e., Chinese/Taiwanese culture) have different preferences regarding being informed of their diagnosis and prognosis and that family members have legitimate superior power in decision making could not be supported by data from this group of terminally-ill cancer patients. Physicians need to respect patients' preferences rather than routinely taking the family's opinions into consideration first in the event of disagreement. Equipped with adequate information, terminally-ill cancer patients from Asia may have better opportunities to make end-of-life care decisions that are in accord with their wishes.

Concordance of preferences for end-of-life care between terminally ill cancer patients and their family caregivers in Taiwan.

There is a dearth of information in the literature about the concordance of preferences for end-of-life care between terminally ill patients and their family surrogates outside the Western countries. The purpose of this study was to examine the extent of concordance in preferences for end-of-life care goals and life-sustaining treatments between Taiwanese terminally ill cancer patients and their primary family caregivers. A total of 617 dyads of patients-family caregivers across 21 hospitals throughout Taiwan were surveyed. Overall agreements on the goals for end-of-life care and preferences for initiating life-sustaining treatments ranged from 62.4% to 96.9% (average: 71.0%). Kappa values for the extent of concordance ranged from 0.13 to 0.46 (average: 0.29), indicating poor to moderate consistency in personal preferences. Family caregivers had a significantly more aggressive attitude toward each examined life-sustaining treatment for their ill family members than the patients' own stated preferences. In societies, such as in Asian countries, where physicians' respect for patient autonomy is frequently subordinate to the power of family, disagreements between a patient and family about end-of-life care may result in the patient's preferences being overridden at the end of life. To effect real change and to gain increased agreement on preferences for end-of-life care, an open dialogue between patients and their primary family caregivers should become standard.