Estimating Life Expectancy From Chinese Medicine Could Improve End-of-Life Care in Terminally Ill Cancer Patients.

Preparing for a good death is an important and meaningful concept in Chinese culture because people hope to know residual life to make effort for their unfinished business. However, the family of terminally ill patients with cancer may be annoyed and frustrated about unexpected bereavement if they have unresolved conflicts with the loved one, missing a chance for declaring love, untimely apologizing and saying goodbye. The study aimed to explore this difficult issue. The medical records of 121 deceased terminally ill patients with cancer at National Cheng Kung University Hospital between December 2010 and February 2012 were reviewed. The signs and awareness of dying among these patients were collected using palliative routine instruments in the hospice ward. The top 3 most prevalent dying signs were coolness and cyanosis (prevalence 98.3%, median period from the first documented dying sign to death 2 days, P = .028), mirror-like tongue (prevalence 94.2%, median period 5 days, P = .007), and earlobe crease (prevalence 93.4%, median period 4 days, P = .052). In addition, the prevalence of dying awareness was 71.1% (median period 4 days, P = .001). Furthermore, terminal agitation was identified more frequently in terminally ill patients with hepatoma and colon cancer (adjusted odds ratio = 3.240, P = .043), but turbid sclera with edema was noted more often in terminally ill patients with head and neck cancer (adjusted odds ratio = 5.698, P = .042). The results provide evidence to support clinical practice, offering knowledge and techniques to health care providers, and increasing quality of life for terminally ill patients with cancer.

[Hospice palliative care is a universal value and the essence of nursing].

This article uses four examples to illustrate the recent rise of hospice palliative care as a universal value. These examples include the story of Dame Cecily Saunders, the pioneer of the palliative care movement in the U.K.; the national healthcare plan currently promoted by United States' President Obama; a survey on the topic of quality of death in 40 countries conducted by the Lien Foundation (Singapore); and the story of the Hospice Movement in Taiwan. This article further describes how hospice palliative care has changed the healthcare culture and presents the World Health Organization's definition of palliative care and the implications of this definition. Additionally, this article identifies the common palliative-care mistakes that have been made by the general public and by healthcare workers. Healthcare professionals must acquire essential relevant knowledge and skills in order to ensure that hospice palliative care addresses the needs of terminally ill patients adequately. Finally, the author describes a novel approach to instilling proper palliative-care concepts and practices that is entitled Life, Peace, Care, and Honor (LPCH or the "3344" concept).

Bioethics education for practicing nurses in Taiwan: Confucian-Western clash.

To understand the gaps between current bioethics education and the requirements of practicing nurses, a semistructured questionnaire was used to invite the directors of nursing departments at all 82 teaching hospitals in Taiwan to participate in this survey. The response rate was 64.6%. Through content analysis we obtained information about previous bioethical training, required themes and content, recommended teaching strategies, and difficulties with education and its application. The results suggest that Taiwanese nursing personnel need to be instilled with both self-cultivation of morality and mental cultivation to acquire nursing virtues and the right attitudes toward bioethical issues. Good communication skills to prevent damage to the harmonious relationships between patients, their families and medical team members, policies that support the provision of systematic formal knowledge of ethics, small group training, and clarification of values were also shown to be important in bioethics education.

[Development and prospects of hospice palliative care in Taiwan].

Hospice palliative care is an approach to healthcare that integrates high technology and highly humanized care. Service, education, and policymaking are the three critical areas of focus in the development of this specialty of care. Under hospice palliative care, holistic, high quality services covering in-patient care, homecare, and shared care are provided for terminally ill patients and their families. Healthcare team members must be taught not only knowledge but also skills and attitudes that reflect their responsibilities and level of competence. General public education is important also. Regulations and relevant policies have been implemented by Department of Health (DOH) since 1995. The Natural Death Act was legislated in 2000. Members of Healthcare team concerned regarding the proper development of hospice palliative care in Taiwan have organized to, "do the right things and do things right." The future vision of hospice palliative care embraces: 1. Expanding services to other life threatening illness such as terminal liver, renal, respiratory and heart diseases; 2. Securing appropriate DOH supervision and funds; 3. Developing a care model appropriate to the needs of Taiwan's culture; 4. Expanding the limits of service models; 5. Integrating services and enhancing expertise among those charged with delivering services, conducting research, and education; 6. Integration into the long term care system and enhancing quality.

[Hospice palliative care education for nursing students, nurses, and advanced nursing practitioners].

The aim of hospice palliative education care is to train nurses in hospice philosophy, terminal care skills, nursing care competencies, and professional reliability. Student nurses, staff nurses, and advanced practice nurses must be taught through a proper sequence, from novice to expert. Working together with patients and their families, nurses can educate and care for the physical, social and spiritual needs of terminally ill patients. Currently, problems faced in hospice palliative care education include: 1. The lack of a systematic plan focusing on hospice palliative care and terminal care in nursing schools; 2. The absence of comfort care, communications, ethics, and other relevant issues in extant education and training; 3. The limited number of institutes that currently provide in-service training; 4. The shortage of teachers proficient in both hospice care knowledge and practice; and 5. The current overdependence on traditional nursing education models, which hinders student nurse originality and delays staff nurse growth. Faced with the present issues, self-reflection, localization, and multiple teaching strategies should be the critical developmental directions of hospice palliative education. In order to improve terminal care quality, it is also important to integrate practice, education, and research in order to train more hospice palliative nurses.

[The application of hospice palliative care on discharge planning for the terminal cancer patient].

Whole person, family-centered, continued care, and multidisciplinary approach were four core values of hospice palliative care applied in this paper to assist in the difficult processes of discharging terminal cancer patients from the hospital and providing continued care until their peaceful death. Reasons underlying difficulties with discharges identified during hospitalizations between July 5th to 25th 2007 include: 1. 'whole person' aspects, including lack of confidence with the discharge on the part of the patient and his / her families due to inadequate symptoms control and loneliness due to lack of caregiver understanding and support; 2. 'family-centered' aspects, including failure to designate a key decision maker, differences of opinions, and overwhelming caregiver burdens; 3. 'continuity of care' aspects, including lack of appropriate and continuing palliative care and 4. 'multidisciplinary approach' aspects, including factitious relationships among patient, family members, and healthcare providers due to lack of trust. Furthermore, the healthcare team mapped out individual and continued care plans as follows: 1. 'whole person' aspects should focus on symptom control, enhancing comfort, and encouraging emotional expression; 2. 'family-centered' care aspects should identify the key person and significant others, decrease caregiver burdens, provide essential assistance and conduct family conferences; 3. 'continuity care' aspects should include consulting hospice home care and bereavement care professionals; 4. 'multidisciplinary approach' aspects should address comprehensive care so that team members learn from and reflect on their experiences. Ultimately, patients were successfully discharged from the hospital and peacefully passed away one week afterward. The writer hopes this nursing experience will provide a valuable reference for clinical practice to develop a family-centered approach to palliative care based on the four core values of hospice palliative care and the multidisciplinary discharge plan for terminal cancer patients.

[A nursing experience of holistic care on total suffering of a patient with terminal illness].

The purpose of this article was to describe a nursing experience using holistic care to relieve total suffering resulting from complex interactions amongst physical, psychological, social and spiritual aspects in a patient with terminal illness. Each aspect of problems was identified by means of direct participant care, observation, empathetic communication and holistic assessment. Such included: (1) physical aspect: distress caused by pain, nausea, vomiting and poor intake, infection and hypercalcaemia; (2) psychosocial aspect: caregiver's overwhelming burdens and financial concerns; (3) spiritual aspect: yearn for being with a higher-being and receiving unconditional love, pursuit of the meaning of suffering, proceed to the next stage to develop a unique care plan and nursing intervention program. Nursing goals were set up based on the patient's "life expectancy" represented by the hope for a painless and peaceful death. The author helped to provide unique, holistic and continued care for the purpose of humanity. The main nursing interventions included active control of symptoms, encouraging the expression of emotional distress, caring and emotional resonance with caregiver's overwhelming burdens, reconciling with a higher being through art therapy, pursuit of the meaning of suffering and sharing the darkness. This nursing experience of holistic care may be shared with other healthcare professionals and has been recorded as a positive response to the following quote from Dame Cicely Saunders: "The way care is given can reach the most hidden places and give space for unexpected development."

Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan.

The purpose of this study was to survey physicians attitudes toward DNR of terminally ill cancer patients in Taiwan. A total of 7626 structured questionnaires were sent by mail to physicians who were members of the Taiwan Society of Internal Medicine and the Surgical Association of Taiwan, and 1328 valid responses were received. The response rate was 17.6%. The instrument, a structured questionnaire, was composed of one scenario and six questions. A majority (77.6%) of the physicians under investigation would tell a terminally ill cancer patient or his family about the possibility of DNR and ask them to consider signing a consent form. Over one half of the physicians (58.4%) did not know whether the Medical Law in Taiwan permits natural death, and 96.1% of the subjects felt they would need legal protection for agreeing patient s autonomy to decide DNR. Unfortunately, 41.2% of the respondent admitted that they did not have a formal Informed Consent Form that could be used for DNR. Even of those who had such a form, only 27.4% had clear guidelines given by their institutions. Among 623 physicians whose institutions had an formal Informed Consent Form for DNR, 63.7% agreed that it was reasonably used. Surprisingly, 67.9% of the physicians had used Slow Codes. The findings of this study served as a solid base. The investigator and other colleagues used it to convince legislators to pass a Natural Death Act in Taiwan. Since some legislators disliked the term death and the main promotes were people engaged in hospice palliative care, the new law entitled Hospice Palliative Act was passed on May 23, 2000. The DNR order finally gained its legal base for medical practice. The limitation of this study was the low response rate. However, since the subjects, physicians, had a busy work load, this was still an acceptable response rate.

The essence of spirituality of terminally ill patients.

The purpose of this hermeneutic study was to investigate the essence of spirituality of terminally ill patients. In-depth unstructured interviews were used as the method for data collection. In the six-month period of data collection, the researcher was in the role of a hospice palliative care consultant who directly took care of the subject patients in a hospice ward of a teaching hospital. The six subjects were selected purposively according to various demographic backgrounds. Interview transcripts provided the data for analysis. The results were composed of four constitutive patterns and ten themes. The first constitutive pattern was "Communion with Self" which included three themes: (1) Self-identity--spirituality is the discovery of the authentic self. (2) Wholeness--a human being is full of contradictions but still in wholeness. (3) Inner peace--spirituality is negotiating conflicts for self-reconciliation. The second constitutive pattern was "Communion with others" which included two themes: (1) Love--spirituality is a caring relationship but not an over-attachment to others. (2) Reconciliation--spirituality is to forgive and to be forgiven. The third constitutive pattern was "Communion with Nature" which included two themes: (1) Inspiration from the nature--spirituality is the resonance of the marvelous beauty of nature. (2) Creativity--spirituality is conceiving imaginatively. The fourth constitutive pattern was "Communion with Higher Being" which included three themes: (1) Faithfulness--spirituality is keeping the trust dependably. (2) Hope--spirituality is claiming possibilities. (3) Gratitude--spirituality is giving thanks and embracing grace. The scientific rigor of this qualitative research as well as the strength and limitations of the study are reported. Implications for hospice palliative care and future research are recommended.

[Taiwan nursing accreditation for nursing education].

On 1st January 2003, with the support and assistance of Professor Kun-Yan Huang, the Ministry of Education assembled its University Nursing Departments Evaluation Planning Group. Professor Yu-Mei Yu Chao led the group in over a year of hard work and planned an accreditation of systematic evaluation of university nursing departments. The hope is to accumulate experience through this accreditation to promote nursing undergraduate programs evaluation to the Ministry of Education's technical and vocational training system. This article illustrates the 12 core disciplines that the evaluation system stresses as embodying the spirit and aims of nursing. Once the spirit and aims of education have been dealt with, the evaluation turns to the six important matters of conduct of departmental affairs, faculty, students, curriculum and teaching, teaching resources and educational outcomes. The system is expected to raise the quality of nursing education, help in the monitoring of the citizens' health care, and raise the success and satisfaction levels of students.

Building a bridge for nursing education and clinical care in Taiwan--using action research and Confucian tradition to close the gap.

BACKGROUND: Nursing workplaces in Taiwan are unable to retain talent. An examination of this problem has revealed that the causes of this phenomenon are that nursing education fails to cultivate the skills that meet workplace requirements and that there are gap between nursing education and clinical practice. OBJECTIVES: This paper is an action research that aims is to design educational programs that can close the gap between nursing education and clinical practice in Taiwan. DESIGN: In this action research project, 4 action cycles were used to design educational programs including concept mapping and focused discussion strategies. SETTINGS: Participants were invited to join the research in three teaching hospitals and one university. PARTICIPANTS: Two groups of participants, student nurses (SN) and nursing staff personnel (NS), were sampled and invited to participate in the research. METHODS: Participant observation, focus groups, and qualitative interviews were used to collect data. Qualitative data were not only profiled by content analysis, but they were also compared continuously between the two groups as well as between the 4 cycles. RESULTS: The qualitative data collected for the 135 participants were analysed. The themes of an effective nursing program were summarized. CONCLUSIONS: Many fundamental values of traditional Chinese education have gradually faded due to the Westernization of education. In this study, we discovered that Western educational models may play a critical role in improving traditionally taught nursing education programs.

"Does one size fit all?" Exploring the cultural applicability of NANDA nursing diagnoses to Chinese nursing practice.

East Asia has historically unique concepts of health and well-being and thus is an appropriate setting for exploring the multicultural applicability of the North American Nursing Diagnosis Association's Nursing Diagnoses (NANDA ND) system. This study aimed to explore how NANDA ND affect the growth and quality of professional nursing from the perspective of Taiwanese nurses. Grounded theory was employed in this interview-based investigation of 53 Taiwan-licensed nursing professionals at various hospitals in Taiwan. Data were analyzed using constant comparative analysis until theoretical saturation was reached. The core concept, Struggling with (the NANDA ND notion that) One Size Fits All, emerged after ongoing analysis of the effects of NANDA ND on good nursing, patient welfare, and professional development. The preliminary theoretical framework developed from this study provides evidence that NANDA ND may be incompatible with the cultural beliefs of the traditional Chinese health care setting in Taiwan, which emphasize holistic harmony and balance.

Efficacy of guided imagery with theta music for advanced cancer patients with dyspnea: a pilot study.

BACKGROUND: Dyspnea is a frequent and devastating symptom among advanced cancer patients for which improved and low-cost palliative techniques are needed. METHODS: A one-group repeated measures research design investigated the efficacy of guided imagery (GI) with theta music (M) on dyspnea in advanced cancer patients. The intervention consisted of four periods: (a) pretest; (b) intervention with peaceful non-M; (c) intervention with 10 min of GI with M (GI/M), with the first and last 3 min being M only (i.e., the middle 4 min was GI/M); and (d) posttest. Dyspnea outcome was measured with the Modified Borg Scale (MBS) for self-reported evaluation of dyspneic symptoms. Physiological parameters measured were pulse oxygen saturation (SpO(2)), end-tidal CO( 2) (EtCO(2)), heart rate (HR), and respiratory rate (RR). Posttest qualitative data were obtained via interview for subjective patient experience. RESULTS: Participants included 53 patients, 33% with lung cancer. GI/M produced a significant decrease in MBS scores; 90% of the subjects gave positive qualitative reviews of GI/M. SpO(2) did not change significantly over time. GI/M significantly increased EtCO(2), decreased RR, and decreased HR. DISCUSSION: This study demonstrates that GI/M is a useful intervention for palliative care of patients with dyspnea. M alone was demonstrated to be effective, while soothing non-M was not effective. GI/M was more effective than M alone. GI/M should be considered low-cost end-of-life palliative care for dyspnea.