Evaluating health literacy from an organizational perspective: A cross-sectional study of community health centers.

OBJECTIVES: To investigate community health centers' (CHCs) health literacy. DESIGN: A cross-sectional study. SAMPLE: A total of 374 CHCs were surveyed and 258 CHCs responded, with an effective questionnaire response rate of 69.0%. MEASUREMENTS: Data were collected by using a self-developed health literacy assessment tool to survey CHCs' health literacy throughout Taiwan from January to December 2019. RESULTS: The item of organizational health literacy (OHL) with the highest proportion of CHCs not implementing them was "Design of easy-to-use computer applications and new media" (47.3% not yet achieved), followed by "Involving target audiences in document and service development" (34.9% not yet achieved). CHCs located in northern Taiwan had higher health literacy achievement scores than those in other regions, and those in urban areas had higher health literacy achievement scores than those in general and remote areas. CONCLUSIONS: This study identified items with poor implementation of OHL and found regional differences in health literacy among CHCs. The findings can inform the development of targeted interventions to improve health literacy in underperforming CHCs and guide policymakers in allocating resources to regions and areas in need of.

Status of resource recycling stations in Taiwan and recycling work-related health effects.

Resource recycling has become an integral part of environmental protection efforts. At present, the development of Taiwan's resource recovery and related works are quite mature. However, laborers or volunteers working in resource recycling stations may be exposed to different types of hazards during the recycling process. These hazards can be divided into biological, chemical, and musculoskeletal problems. These hazards are usually related to the work environment and work habits; therefore, a related control strategy is needed. Tzu Chi's recycling business has been running for over 30 years. In addition to leading the trend of resource recycling in Taiwan, many elderly people have also participated in Tzu Chi recycling stations as volunteers. These older volunteers may be more sensitive to exposure to hazards, and thus the focus of this review is to illustrate the possible hazards and health impacts of resource recovery work and to recommend relevant interventions to improve occupational health during resource recovery work.

Terminally ill patients' and their relatives' experiences and behaviors regarding complementary and alternative medicine utilization in hospice palliative inpatient care units: a cross-sectional, multicenter survey.

BACKGROUND: Terminally ill patients often experience exacerbations of diseases that render mainstream medicine ineffective in relieving symptoms, prompting attempts at complementary and alternative medicine (CAM). This study collected data from terminally ill patients and their relatives to determine differences between CAM use, behavioral patterns, and perceptions of health information about CAM. METHODS: A cross-sectional design using a self-administered questionnaire was adopted. Eight medical institutions in Taiwan with inpatient hospice palliative care units were chosen. Ninety-two terminally ill patients and 267 relatives met the inclusion criteria. The questions concerned the experience of CAM use, the kinds of products/services CAM provided, the purpose of CAM use, the source of CAM information, and the perceptions and attitudes toward CAM. RESULTS: Both terminally ill patients and their relatives have a high proportion of lifetime and one-year prevalence of CAM use (88.0% vs. 88.4%; p = 0.929). CAM use for musculoskeletal and neurological discomfort is higher among terminally ill patients than among their relatives. Relatives/friends are the most frequent sources of information on CAM (53.3% vs. 62.2%; p = 0.133). The percentage of terminally ill patients who discontinued mainstream medical treatment because of CAM use was higher than that of their relatives (18.5% vs. 9.3%; p = 0.026). More than half the terminally ill patients and their relatives had never been asked about CAM by medical staff (64.1% vs. 66.7%), nor had they informed medical professionals about the use of CAM products and services (63% vs. 66.9%). Random inquiries by medical professionals may be associated with increased disclosure of CAM use (terminally ill patients: odds ratio, 9.75; 95% confidence interval, 1.97-48.35 vs. relatives: odds ratio, 5.61; 95% confidence interval, 2.66-11.83). CONCLUSIONS: The high prevalence and concealment of CAM use in terminally ill patients should be considered. Medical professionals should establish a friendly and barrier-free communication model, encourage patients to share CAM experiences, and provide evidence-based information on the use of CAM products and services, to reduce the potential damage caused by harmful use.

Effectiveness of the refined health literacy course on improving the health literacy competencies of undergraduate nursing students: quantitative and qualitative perspectives.

People with limited health literacy comprise a high-risk group for adverse health outcomes. Nurses must be made aware of the importance of health literacy and communicate with patients in plain language, which will solve the obstacles for patients using health care services. Providing health literacy education for nurses is an important strategy for health literacy practices. This study aimed to develop a refined health literacy course for nursing students and evaluate its effectiveness. The study used a single-group pre- and post-test quasi-experimental design and conducted focus group interviews. The intervention was an eight-hour course and applied team-based learning combined with various teaching methods. The study enrolled second-year nursing students of a university in eastern Taiwan via convenient sampling. A self-reported structured questionnaire was used to compare the participants' familiarity with health literacy, attitude, confidence in oral communication, and ability in written communication before and after the course. To discuss the learning experience of the course, the study held two focus groups with 12 participants. A total of 81 participants completed the pre- and post-test questionnaires. The results showed that familiarity with health literacy (t=9.12, t<.001), attitude (t=4.89, t<.001), confidence in oral communication (t=4.12, t<.001), and ability in written communication (t=8.83, t<.001) showed improvement after the course. Data analysis of focus group interviews yielded two categories and seven themes for the learning experience, most of which showed participants' positive learning experiences in the health literacy course. The course effectively enhanced the nursing students' knowledge and attitude toward health literacy and the ability to communicate with patients using health literacy principles. The results can provide a reference for integrating health literacy education into the undergraduate nursing curriculum.

Health literacy training program for community healthcare providers using hybrid online team-based learning in Taiwan.

BACKGROUND: Health literacy (HL) has proven to be a determining factor influencing the health of individuals. Community health providers (CHPs) work on the front line of improving public HL. Increasing their understanding of HL and their ability to incorporate HL into healthcare can reduce obstacles in healthcare services. This study evaluated the effectiveness of an HL training program for CHP by using the hybrid online team-based learning (TBL) model. METHODS: A quasi-experimental study and focused group interviews were conducted. We developed a six weeks HL online course for CHPs. The program included teaching videos for pre-class preparation, a 90-min online TBL model, and a case discussion in the last two weeks. Team application activities were designed for each class to enhance knowledge application. A total of 81 CHPs from 20 public health centers took the course and provided complete data for analysis. Learning effectiveness was evaluated based on the familiarity, attitude, and confidence in implementing HL practices, course satisfaction, and participants' learning experiences. RESULTS: The comparison showed that the participants' familiarity with HL (4.29 ± 1.76 vs 6.92 ± 1.52, p < .001), attitude (7.39 ± 1.88 vs 8.10 ± 1.44, p = .004), and confidence in implementing HL practices (6.22 ± 1.48 vs 7.61 ± 1.34, p < .001) increased after the course. The average satisfaction with the teaching strategies was 4.06 ± .53 points, the average helpfulness to practice was 4.13 ± .55 points, and the overall feedback on satisfaction with learning was 4.06 ± .58 points (the full score was 5 points). According to the learning experience of the 20 participants in the focus group discussion, the experiences of teaching strategies and the learning experiences of the HL course were summed up into two categories, seven themes, and 13 subthemes. The results showed a positive experience with the hybrid online TBL program. CONCLUSION: The use of hybrid online TBL model is a feasible and valid approach for the HL training of CHPs. The result can serve as a reference for the on-the-job training of various healthcare workers.

Profiles of Physical Activity and Physical Performance in Matched Religious Vegetarian and Nonvegetarian Women: A Preliminary Observational Study in Taiwan.

Religious vegetarianism has become more popular with women and increases with age. However, concerns have been raised that vegetarians are less productive than nonvegetarians. Thus, we aimed to compare the characteristics of physical activity and physical performance in properly matched religious vegetarian and nonvegetarian women aged ≥ 45 years. Participants (n = 160) were recruited via convenience sampling in the community of Hualien, Taiwan, and matched by demographic and cognitive characteristics. Physical activity was assessed using the International Physical Activity Questionnaire-Short Form (IPAQ-SF). Physical performance was assessed with handgrip strength, five-times-sit-to-stand, gait speed, timed up-and-go, and functional reach tests (FRT). Overall, 90% of religious vegetarians practiced lacto-ovo-vegetarianism. The proportions of those with low physical activity levels and poor physical performance did not significantly differ between religious vegetarians and nonvegetarians. Additionally, there were no significant between-group differences in IPAQ-SF scores and physical performance, except for FRT performance (mean 24.5 cm vs. 19.7 cm, p < 0.001). Exhaustion after work, busyness, and a lack of interest were three main reasons for low physical activity levels, and none of these had significant between-group differences (p = 0.936). Our results show a similar profile of physical activity and physical performance in religious vegetarian and nonvegetarian women.

Physical Inactivity and Possible Sarcopenia in Rural Community Daycare Stations of Taiwan: A Cross-Sectional Study.

Physical inactivity and possible sarcopenia pose a challenge for long-term care, especially in rural areas. We aimed to examine the prevalence of and associated factors for physical inactivity and possible sarcopenia in rural community daycare stations. A total of 275 adults aged 55-98 years (75% women) were recruited from all 11 rural community daycare stations in Northern Hualien, Taiwan. Physical inactivity was defined as less than 150 min/week of moderate-intensity aerobic physical activity. Possible sarcopenia was defined according to the Asian-specific criteria from 2019. Multiple linear and logistic regression analyses were used to determine associated factors for physical inactivity and possible sarcopenia. The prevalence of physical inactivity and possible sarcopenia was 29.1% and 68.7%, respectively. About 86.8% of possible sarcopenia were ascribed to poor five-times-sit-to-stand performance. After adjusting for covariates, poor lower-limb muscle function, e.g., slow gait speed, was associated with possible sarcopenia and physical inactivity. However, physical inactivity was not independently associated with possible sarcopenia (adjusted odds ratio 1.95, 95% confidence interval 0.88-4.30, p = 0.100). Our results indicated that individuals with poor lower-limb muscle function were more likely to have possible sarcopenia and physical inactivity. Improving lower-limb muscle function would be a priority task in rural community daycare stations.

IFIT2-depleted metastatic oral squamous cell carcinoma cells induce muscle atrophy and cancer cachexia in mice.

BACKGROUND: Interferon-induced protein with tetratricopeptide repeat 2 (IFIT2) is a reported metastasis suppressor in oral squamous cell carcinoma (OSCC). Metastases and cachexia may coexist. The effect of cancer metastasis on cancer cachexia is largely unknown. We aimed to address this gap in knowledge by characterizing the cachectic phenotype of an IFIT2-depleted metastatic OSCC mouse model. METHODS: Genetically engineered and xenograft tumour models were used to explore the effect of IFIT2-depleted metastatic OSCC on cancer cachexia. Muscle and organ weight changes, tumour burden, inflammatory cytokine profiles, body composition, food intake, serum albumin and C-reactive protein (CRP) levels, and survival were assessed. The activation of the IL6/p38 pathway in atrophied muscle was measured. RESULTS: IFIT2-depleted metastatic tumours caused marked body weight loss (-18.2% vs. initial body weight, P < 0.001) and a poor survival rate (P < 0.01). Skeletal muscles were markedly smaller in IFIT2-depleted metastatic tumour-bearing mice (quadriceps: -28.7%, gastrocnemius: -29.4%, and tibialis: -24.3%, all P < 0.001). Tumour-derived circulating granulocyte-macrophage colony-stimulating factor (+772.2-fold, P < 0.05), GROα (+1283.7-fold, P < 0.05), IL6 (+245.8-fold, P < 0.001), IL8 (+616.9-fold, P < 0.001), IL18 (+24-fold, P < 0.05), IP10 (+18.8-fold, P < 0.001), CCL2 (+439.2-fold, P < 0.001), CCL22 (+9.1-fold, P < 0.01) and tumour necrosis factor α (+196.8-fold, P < 0.05) were elevated in IFIT2-depleted metastatic tumour-bearing mice. Murine granulocyte colony-stimulating factor (+61.4-fold, P < 0.001) and IL6 (+110.9-fold, P < 0.01) levels were significantly increased in IFIT2-depleted metastatic tumour-bearing mice. Serum CRP level (+82.1%, P < 0.05) was significantly increased in cachectic shIFIT2 mice. Serum albumin level (-26.7%, P < 0.01) was significantly decreased in cachectic shIFIT2 mice. An assessment of body composition revealed decreased fat (-81%, P < 0.001) and lean tissue (-21.7%, P < 0.01), which was consistent with the reduced food intake (-19.3%, P < 0.05). Muscle loss was accompanied by a smaller muscle cross-sectional area (-23.3%, P < 0.05). Muscle atrophy of cachectic IFIT2-depleted metastatic tumour-bearing mice (i.v.-shIFIT2 group) was associated with elevated IL6 (+2.7-fold, P < 0.05), phospho-p38 (+2.8-fold, P < 0.05), and atrogin-1 levels (+2.3-fold, P < 0.05) in the skeletal muscle. Neutralization of IL6 rescued shIFIT2 conditioned medium-induced myotube atrophy (+24.6%, P < 0.01). CONCLUSIONS: Our results suggest that the development of shIFIT2 metastatic OSCC lesions promotes IL6 production and is accompanied by the loss of fat and lean tissue, anorexia, and muscle atrophy. This model is appropriate for the study of OSCC cachexia, especially in linking metastasis with cachexia.

The Potential Win-win Strategy for Healthy Aging and Environmental Protection: Environmental Volunteering.

PURPOSE: To explore the physical activity level of community environmental volunteering (CEV) participants and the differences in physical functions and daily activity patterns between the older adults who engaged in intensive CEV (≥15 hours/week) and non-intensive CEV (<15 hours/week) groups. DESIGN: Cross-sectional study. SETTING: Three recycling stations in Taiwan. SAMPLE: In total, 113 community-dwelling older adults who regularly participated in CEV. The response rate was 53%. MEASURES: The ActiGraph wGT3x-BT accelerometer for the percentage of sedentary, light, and moderate to vigorous physical activity (MVPA) of CEV time and awaken time; the Jamar hand dynamometer for grip strength; and the MicroFET3 muscle testing dynamometer for knee extension strength. ANALYSIS: Analysis of covariance with the baseline characteristics as covariates. RESULTS: Overall, MVPA, light, and sedentary activities accounted for 53.73%, 41.10%, and 5.23% of CEV time, respectively. The intensive group (n = 61) displayed greater dominant handgrip strength (P = .004) and higher MVPA percentage in daily life (P = .044) than the non-intensive group (n = 52). CONCLUSION: CEV provides sufficient opportunities for older adults to perform physical activity. Intensive CEV is related to greater handgrip strength but not lower limb strength. Further study is needed to establish the causal relationship between CEV and health variates.

Insufficient pain control for patients with cancer and dementia during terminal cancer stages.

PURPOSE: To estimate differences in pain control between patients with cancer and with or without dementia during terminal cancer stages 3 months or 1 month before cancer death. PATIENTS AND METHODS: We conducted frequency matching cohort for age, sex, and year of death for both groups at a 1:4 ratio. The prescription prevalence, total cumulative dose, and average daily dose of opioids during the terminal cancer stages 3 months and 1 month before cancer death were estimated. RESULTS: Patients with cancer and dementia were prescribed lower amounts of opioids 3 months before death (57.5% vs. 73.9%, respectively; adjusted odds ratio [OR] 0.46; 95% confidence interval [CI] 0.44-0.49) and 1 month before death (54.4% vs. 70.3%, respectively; adjusted OR 0.50; 95% CI 0.47-0.53). The total cumulative dose of opioids (mg) was lower in patients with cancer and dementia 3 and 1 month(s) before death (3 months: 1,578 mg vs. 2,666 mg, respectively; ß=-1,125.9, P<0.001; 1 month: 921 mg vs. 1,533 mg, respectively; ß=-622.1, P<0.001). The average daily opioid dose (mg/day), patients with cancer and dementia received a lower dose 3 months before death (31 mg vs. 48 mg; ß=-22.6, P<0.001) and 1 month before death (38 mg vs. 60 mg; ß=-17.1, P<0.001). CONCLUSION: The prevalence of opioid prescription was significantly lower in patients with both cancer and dementia during their terminal cancer stages 3 months and 1 month before death.

Familiarity, Attitude, and Confidence of Health Literacy Practice among Community Healthcare Providers in Taiwan.

Health literacy (HL), which is a determinant of individuals' health as well as a personal and public asset, can be improved by community healthcare providers (CHPs) with the capability of providing HL services. The purpose of this study was to explore CHPs' familiarity with and attitudes toward HL and their confidence in implementing HL practices. A cross-sectional online survey was conducted involving a total of 104 CHPs from 20 public health centers in Taiwan. It was based on a structured questionnaire involving self-evaluation by participants. The scores for familiarity, attitudes, and confidence in implementing HL practices were mean = 4.36, SD = 1.99; mean = 7.45, SD = 1.93; and mean = 6.10, SD = 1.77 (out of 10 points), respectively. The results of the multiple regression analysis showed that the two independent variables of familiarity and attitude could predict confidence in implementing HL practices (R2 = 0.57, F(2101) = 58.96, p < 0.001). The CHPs surveyed were not especially familiar with HL; thus, they recognized its importance, but they lacked confidence in implementing HL practices. Increasing practitioners' familiarity with HL may therefore boost their confidence in implementation. The research results can serve as a reference when planning HL education and training.

Palliative inter-professional learning via cased based tele-videoconference: Experience from the hospice development stage in Taiwan and China.

ABSTRACT: Palliative care in rural areas can be difficult to assess and, often is of lower quality compared to more densely populated regions. A program of multicenter palliative care discussion forum via tele-videoconference may be a promising tool for exchanging valuable experience and constructing a comprehensive hospice care system in Taiwan and China.The multicenter palliative care discussion forum began 1997 and 2010 in Taiwan and China, respectively. In every forum, 1 to 2 cases were presented by multiple field specialists, and multi-dimensional problems were discussed. All of these case reports and reference materials from the forums were analyzed.The conference discussed 199 and 143 cases in Taiwan and China, including 172 and 143 cancer patients. The most common mentioned symptom was pain (66.3% in Taiwan, 96.95% in China). As time went on, the rate of discussion in pain management issues decreased, but the social and psycho-spiritual issues increased in Taiwan. After some major legal and social changes, the discussion of ethical issues increased rapidly. In China, the trends and ranking in discussion of nonpain management issues stabilized and showed most frequently in psycho-spiritual issues, followed by social, ethical and legal issues.Sharing palliative experience via tele-videoconferences is an effective tool to improve the quality of care, and also saves a significant amount of time and expense. Experts in different professions from different hospitals should discuss any palliative problems, share their valuable experience, and ponder a comprehensive hospice care.

How Acculturation Influences Attitudes about Advance Care Planning and End-of-Life Care among Chinese Living in Taiwan, Hong Kong, Singapore, and Australia.

BACKGROUND: Understanding attitudes towards life and death issues in different cultures is critical in end-of-life care and the uptake of advance care planning (ACP) in different countries. However, existing research suffers from a lack of cross-cultural comparisons among countries. By conducting this comparative study, we hope to achieve a clear understanding of the linkages and differences among healthcare cultures in different Chinese societies, which may serve as a reference for promoting ACP by considering cultural differences. METHODS: Our researchers recruited Chinese adults who could communicate in Mandarin and lived in metropolitan areas in Taiwan, Hong Kong, Singapore, and Australia. Focus group interviews were conducted, and the interview contents were recorded and subjected to thematic analysis. RESULTS: Between June and July 2017, 14 focus groups with 111 participants were conducted in four regions. With traditional Chinese attitudes towards death as a taboo, many participants felt it would be challenging to discuss ACP with elderly family members. Most participants also desire to avoid suffering for the self and family members. Although the four regions' participants shared a similar Chinese cultural context, significant regional differences were found in the occasions at which participants would engage in end-of-life discussions and select settings for end-of-life care. By contrast, participants from Singapore and Australia exhibited more open attitudes. Most participants from Taiwan and Hong Kong showed a preference for end-of-life care at a hospital. CONCLUSIONS: The developmental experiences of ACP in Western countries, which place a strong emphasis on individual autonomy, cannot be directly applied to family-centric Asian ones. Healthcare professionals in Asian societies should make continuous efforts to communicate patient status to patients and their family members to ensure family involvement in decision-making processes.

Depressive mood and its risk factors, and persistent complex bereavement disorder among caregivers who received hospice care: A longitudinal study.

This aims of this longitudinal study were to identify the risk factors of and depressive mood in caregivers who received hospice care 6 months after their patients' death, and the cutoff pint of the bereavement risk index, as well as, the prevalence of persistent complex bereavement disorder (PCBD). There were 30.28 and 4.59% of caregivers with depressive mood and PCBD, respectively. The risk factors included resistance to the reality of patients' death, anger, self-blame and guilt, support networks, and coping. The cutoff points of total bereavement risk index and five-item short form were 10/11 and 9/10, respectively.

Professionals' experiences and attitudes toward use of Traditional Chinese Medicine in hospice palliative inpatient care units: A multicenter survey in Taiwan.

BACKGROUND: Medical staff may have difficulties in using conventional medicine to manage symptoms among terminally ill patients, including adverse effects of the treatment. Traditional Chinese medicine (TCM) is regarded as a complementary or alternative medicine, and has been increasingly used in the field of palliative medicine in recent years. This study aimed to investigate the experiences of and attitudes toward using TCM among palliative care professionals, and to provide preliminary information about its use in palliative care. METHODS: This was a cross-sectional survey study conducted in eight inpatient hospice wards in Taiwan between December 2014 and February 2016. The questionnaire was self-administered, and was analyzed with descriptive statistics including Pearson's Chi-square test and Fisher's exact test. RESULTS: A total of 251 palliative care professionals responded to the questionnaire, of whom 89.7% and 88.9% believed that the use of TCM could improve the physical symptoms and quality of life in terminally ill patients, respectively. Overall, 59.8%, of respondents suggested that TCM had rare side effects, and 58.2% were worried that TCM could affect the liver and kidney function of patients. In total, 89.7% and 88.0% of professionals agreed there were no suitable clinical practice guidelines and educational programs, respectively, for TCM use in palliative care. CONCLUSIONS: Most of the respondents agreed there was insufficient knowledge, skills-training, and continuing education on the use of TCM in terminally ill patients in Taiwan. These results show that to address patient safety considerations, guidelines about use of TCM in palliative care should be established.

The Experience of Do-Not-Resuscitate Orders and End-of-Life Care Discussions among Physicians.

Physicians have a responsibility to discuss do-not-resuscitate (DNR) decisions and end-of-life (EOL) care with patients and family members. The aim of this study was to explore the DNR and EOL care discussion experience among physicians in Taiwan. A qualitative study was conducted with 16 physicians recruited from the departments of hospice care, surgery, internal medicine, emergency, and the intensive care unit. The interview guidelines included their DNR experience and process and EOL care discussions, as well as their concerns, difficulties, or worries in discussions. Thematic analysis was used to analyze data. Four themes were identified. First, family members had multiple roles in the decision process. Second, the characteristics of the units, including time urgency and relationships with patients and family members, influenced physicians' work. Third, the process included preparation, exploration, information delivery, barrier solution, and execution. Fourth, physicians shared reflections on their ability and the conflicts between law, medical professionals, and the best interests of patients. Physicians must consider not only patients' but also family members' opinions and surmount several barriers in decision-making. They also experienced negative and positive impacts from these discussions.

Potential benefits of environmental volunteering programs of the health of older adults: a pilot study.

PURPOSE: To study the effects of participating in a 12-week environmental volunteering program on the physical performance of older adults across different age groups MATERIALS AND METHODS: We conducted a pretest-posttest pilot study with a single group. The intervention consisted of twice-weekly recycling activities and once-weekly rehabilitation exercise at community-based care centers. The recycling activities of the environmental volunteering program included sorting and handling paper products, plastics, and metals; disposing electronic products; and sorting clothes. The rehabilitation exercise program comprised a 90-min course for special needs and 30 min of health education. The evaluation tools were the handgrip strength, five-times-sit-to-stand test, sit-and-reach test, Timed Up and Go (TUG) test and usual and fast gait speeds. RESULTS: In total, 45 participants completed the program. After the program, the participants showed significantly great improvements compared to baseline in all outcome measures. We further divided these participants into two age subgroups [65-75 years (n = 31) and >75 years (n = 14)]. The 65-75-year subgroup only showed significant improvements in handgrip strength, TUG and usual gait speed. However, the >75-year subgroup showed significant improvements in all outcome measures. CONCLUSIONS: This innovative environmental volunteering program conducted in a local Taiwanese community can be a sustainable and feasible model to improve physical performance in the participants, the subgroup aged >75 years in particular. It also provides a potential avenue for researchers and policymakers to address environmental and aging-related issues.

Does the Experience of Caring for a Severely Disabled Relative Impact Advance Care Planning? A Qualitative Study of Caregivers of Disabled Patients.

The aging of the Taiwanese population has become a major issue. Previous research has focused on the burden and stress faced by caregivers, but has not explored how the experience of these caregivers influences decisions of advance care planning (ACP). Semi-structured and in-depth interviews were conducted. Qualitative content analysis was used to identify important themes. Five themes and fourteen sub-themes were identified: (1) Past experiences: patient wishes, professional recommendations, and expectation about disease progress; (2) Impact of care on family members: positive affirmation, open-minded life, social isolation and health effects, and financial and life planning effects; (3) Attitude toward life: not forcing to stay, and not becoming a burden, (4) Expected proxy dilemmas: torment between doing or not, seeing the extension of suffering and toil, and remorse and self-blame; (5) Expectation of end of life (EOL) care: caregiver's experience and EOL care decisions, and practicality of EOL decision making. After making multiple medical decisions for their disabled relatives, caregivers are able to calmly face their own medical decisions, and "not becoming a burden" is their primary consideration. It's suggested that implementation of shared decision-making on medical care for patients with chronic disability will not only improve the quality of their medical care but also reduce the development of remorse and guilty feelings of caregivers after making medical decisions.

Differences in the Opioid Consumption of Terminally Ill Schizophrenic and Nonschizophrenic Cancer Patients: Analysis of Secondary National Population Data.

CONTEXT: It is uncertain whether terminally ill schizophrenic cancer patients are hypoalgesic or have disparities in pain management. OBJECTIVES: The objective of this study was to analyze the dosage of opioids used in terminally ill cancer patients with and without schizophrenia. METHODS: This is a population-based retrospective cohort study based on data derived from the Taiwan National Health Insurance Research Database. Patients aged >20 years and newly diagnosed between 2000 and 2012 with at least one of the six most common cancers were included. After 1:4 matching, 1001 schizophrenic cancer patients comprised the schizophrenia cohort, while 4004 cancer patients without schizophrenia comprised the nonschizophrenia cohort. The percentage of opioid use, accumulated dose, and average daily dose near the end of life were analyzed for each cohort using multiple logistic and linear regression models. RESULTS: The percentage of opioid use was lower in the schizophrenic cohort than the nonschizophrenic cohort during the last month before death (69.6% vs. 84.8%, odds ratio = 0.40, 95% CI = 0.34-0.48). The accumulated dose of opioid consumption was also lower in the schizophrenic cohort (2407 mg vs. 3694 mg, P value < 0.05). CONCLUSION: Near the end of life, cancer patients with schizophrenia use less opioid than their nonschizophrenic counterparts. Cognitive impairment may be a cause in the disparity in end-of-life care for terminally ill schizophrenic cancer patients. Thus, we should formulate a more accurate pain scale system and pay attention to their need for pain treatment.

Learning medical professionalism - the application of appreciative inquiry and social media.

BACKGROUND: Medical professionalism is often considered difficult to be clearly observed and learned. However, although most medical students or residents affirm the necessity of medical professionalism courses, few agree that those currently offered are adequate for a medical career. OBJECTIVE: To develop a curriculum for teaching professionalism by enabling students to share positive examples of professionalism in social media that reflects the authentic experience in clinical environment. DESIGN: Between October 2015 and June 2017, the authors developed a clerkship program to teach professionalism with the support of social media and appreciative inquiry. Medical students were required to write posts on the positive behaviors they observed during clinical practice in the Facebook group. Other students and course instructors commented or responded to the posted content. The content on Facebook analyzed by course instructors and was based on the definition of medical professionalism according to the 18 attributes proposed by Cruess et al. Results: In total, 103 medical students in their first clinical year participated and posted 435 records of role model learning in the Facebook group. The majority of students learned the most when the clinical instructors were passionate about their teaching and guidance in medical expertise; this accounted for 23.0% of all role model behaviors. Other attributes of professionalism that students appreciated most were being caring and compassionate (17.2%), competence (9.6%), openness (8.8%), and presence (7.7%). More than 90% of the students reported enjoying this type of course and would like to integrate their learning experiences into future behavior. CONCLUSIONS: This innovative training program was well accepted in the formal curriculum and the predesigned social media environment. Appreciative inquiry for medical professionalism should be integrated into the organizational culture and the culture of social media interaction.