<p>(A)In the left panel, impairment was defined by PSMS ≥ 7. (B)In the right panel, impairm... more <p>(A)In the left panel, impairment was defined by PSMS ≥ 7. (B)In the right panel, impairment was defined by PSMS ≥ 2 points of increase relative to baseline. The predicted conditional probability of death over the first 6 years was calculated for each sex (men in blue and women in red) assuming either intact (the solid lines) or impaired (the dashed lines) basic ADL at time of observation.</p
BackgroundArtificial hydration (AH) is a challenging issue in terminally ill patients with cancer... more BackgroundArtificial hydration (AH) is a challenging issue in terminally ill patients with cancer, because it influences patients' symptoms control, quality of life, and quality of dying (QOD). To date, it is not clear how much AH supply is proper for imminently dying patients. This study aimed to investigate the association between the amount of AH and QOD.MethodsThis study is part of the East Asian Collaborative Cross‐Cultural Study to Elucidate the Dying Process (EASED) conducted in Japan, Korea, and Taiwan from January 2017 to September 2018. Patients' demographics, symptoms, and managements on admission to palliative care units (PCUs) and before death were recorded. The AH amount was classified into different groups by 250‐mL intervals to compare their difference. The Good Death Scale (GDS) was used to measure QOD, with patients classified into higher or lower QOD groups using GDS = 12 as the cutoff point. We used logistic regression analysis to assess the association between AH amount and QOD.ResultsIn total, 1530 patients were included in the analysis. Country, religion, spiritual well‐being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with QOD. After conducting regression analysis, patients administered with 250 to 499 mL AH had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072‐4.730; P = .032) than those without AH.ConclusionsAH use impacts the QOD of terminally ill patients with cancer admitted to PCUs. Communication with patients and their families on appropriate AH use has a positive effect on QOD.Lay Summary Our prospective cross‐cultural multicenter study aims to investigate the relationship between artificial hydration (AH) amount and quality of dying among terminally ill patients with cancer. The findings reveal that country, religion, spiritual well‐being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with quality of death (QOD). After multivariable logistic regression, patients administered with AH amount 250 to 499 mL had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072‐4.730; P = .032) than those without AH. Communication with patients and their families regarding AH is recommended as it may help them be better prepared for the end‐of‐life stage and achieve a good death.
ObjectivesThe National Health Insurance programme started providing coverage for inpatient care i... more ObjectivesThe National Health Insurance programme started providing coverage for inpatient care in palliative care (PC) units of acute care hospitals in 2000; however, initially, only PC provided to patients with terminal cancer was covered. A PC policy that enabled PC reimbursement for patients with dementia was implemented in 2009. However, the association of this PC policy with end-of-life care remains unclear. The study aims to compare the association of the PC policy with end-of-life care between patients with dementia and patients with cancer during the last 6 months of their lives.MethodsWe analysed the claims data of 7396 patients dying with dementia (PDD) and 24 319 patients dying with cancer (PDC) during 1997–2013.ResultsAmong PDC, while the percentage of receiving PC increased from 3.6% in 1999 to 14.2% by the end of 2000 (adjusted OR (aOR)=4.07, 95% CI 2.70 to 6.13) and from 20.9% in 2010 to 41.0% in 2013 (aOR=1.40, 95% CI 1.33 to 1.47), vasopressor use decreased from 71.6% in 1999 to 35.5% in 2001 (aOR=0.90, 95% CI 0.82 to 0.98). Among PDD, PC use increased from 0.2% in 2009 to 4.9% in 2013 (aOR=2.05, 95% CI 1.60 to 2.63) and cardiopulmonary resuscitation use decreased from 17.6% in 2009 to 10.0% in 2013 (aOR=0.83, 95% CI 0.76 to 0.90).ConclusionsImplementation of the PC policy in Taiwan was associated with improved PC utilisation among patients with cancer and dementia, which may reduce unnecessary medical care procedures.
Purpose: This study aims to examine accuracy of CPS for 7-, 21-, and 42-day survival of inpatient... more Purpose: This study aims to examine accuracy of CPS for 7-, 21-, and 42-day survival of inpatients with faradvanced cancer in 37 palliative care units in Japan, Korea, and Taiwan and its association with prognostic con dence. Methods: In this study, discrimination of CPS was investigated through sensitivity, speci city, overall accuracy, and area under the receiver operating curves (AUROCs) according to 7-, 21-, and 42-day survival. The accuracies of CPS were compared with those of Performance Status-based Palliative Prognostic Index (PS-PPI) in three timeframe prediction. Clinicians were instructed to rate con dence level for each prediction on a 0-10-point scale. Results: A total of 2,571 patients were analyzed. Among the three time-frames, the speci city was highest at 93.2-100.0% for the 7-day CPS and sensitivity was highest at 71.5-86.8% for the 42-day CPS. The AUROCs of the 7-day CPS were 0.88, 0.94, and 0.89 while those of PS-PPI were 0.77, 0.69, and 0.69 for JP, KR, and TW, respectively. In all timeframe, CPS was more accurate than the PS-PPI. As for 42-day prediction, sensitivities of PS-PPI were higher than those of CPS. Clinicians' con dence was strongly associated with the accuracy of prediction in all three countries (all p values <0.01). Conclusions: CPS accuracies were highest (0.88-0.94) for the 7-day survival prediction. CPS was more accurate than PS-PPI in all timeframe prediction. Meanwhile, PS-PPI can be a screening tool in 42-day survival prediction which may be supplementary to CPS. Prognostic con dence was signi cantly associated with the accuracy of CPS.
Purpose Few large-scale studies have focused on the prevalence of symptoms and signs during the l... more Purpose Few large-scale studies have focused on the prevalence of symptoms and signs during the last days of patients diagnosed with advanced cancer. Identifying the patterns of speci c symptoms according to cancer type is helpful to provide end-of-life care for patients with advanced cancer. We investigated the prevalence and severity of symptoms and signs associated with impending death in patients with advanced cancer. Methods In this secondary analysis of an international multicenter cohort study conducted in three East Asian countries, we compared the severity of symptoms and signs among dying patients 3 days before death according to the type of primary cancer using one-way analysis of variance (ANOVA). Post hoc analysis was conducted for multiple comparisons of each symptom according to the type of primary cancer. Results We analyzed 2131 patients from Japan, Korea and Taiwan. Fatigue, dry mouth, drowsiness and dyspnea were present in nearly half of the patients, and edema of lower extremities was the most common sign in all dying patients. According to cancer type, edema of lower extremities was the most common symptom and fatigue/ ascites were the most severe symptoms in digestive tract cancer. For lung cancer, respiratory secretion was the most prevalent and dyspnea/ respiratory secretion were the most severe symptoms. Conclusion We demonstrated the prevalence and severity of symptoms and signs associated with impending death of patients with advanced cancer in East Asia. Our study can enable clinicians to recognize the speci c symptoms and signs at the very end of life.
BackgroundArtificial hydration (AH) is a challenging issue in terminally ill patients with cancer... more BackgroundArtificial hydration (AH) is a challenging issue in terminally ill patients with cancer, because it influences patients' symptoms control, quality of life, and quality of dying (QOD). To date, it is not clear how much AH supply is proper for imminently dying patients. This study aimed to investigate the association between the amount of AH and QOD.MethodsThis study is part of the East Asian Collaborative Cross‐Cultural Study to Elucidate the Dying Process (EASED) conducted in Japan, Korea, and Taiwan from January 2017 to September 2018. Patients' demographics, symptoms, and managements on admission to palliative care units (PCUs) and before death were recorded. The AH amount was classified into different groups by 250‐mL intervals to compare their difference. The Good Death Scale (GDS) was used to measure QOD, with patients classified into higher or lower QOD groups using GDS = 12 as the cutoff point. We used logistic regression analysis to assess the association b...
<p><i>h</i><sub><i>I</i></sub><i>(t)</i> is... more <p><i>h</i><sub><i>I</i></sub><i>(t)</i> is the hazard rate for the time to basic ADL impairment. <i>h</i><sub><i>D</i>1</sub><i>(t)</i> is the hazard rate for the time to death among basic ADL-intact patients. <i>h</i><sub><i>D</i>2</sub><i>(t)</i> is the hazard rate for the time to death among basic ADL-impaired patients. The transitions between disease onset, development of basic ADL impairment, and death were modeled by quantifying the effect of baseline characteristics on basic ADL impairment and survival as well as the effect of developing basic ADL impairment on survival.</p
Purpose: It has been suggested that psychosocial factors are related to survival time in patients... more Purpose: It has been suggested that psychosocial factors are related to survival time in patients with cancer. However, there is no cross-cultural study examining the relationship between spiritual well-being (SWB) and survival time among countries. This study investigated the relationship between SWB and survival time among three East Asian countries. Methods: This international multicenter cohort study is a secondary analysis involving newly admitted inpatients with advanced cancer in palliative care units in Japan, South Korea and Taiwan. SWB was measured at admission. We performed multivariate analysis using the Cox proportional hazards model to identify independent prognostic factors. Results: A total of 2638 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. The median survival time was 18.0 days (95% confidence interval [CI] 16.5 to 19.5) in Japan, 23.0 days (95% CI 19.9 to 26.1) in Korea and 15.0 days (95% CI 13.0 to 17.0) in Taiw...
Purpose: To explore knowledge, attitudes, and behavioral intentions of physicians, and to analyze... more Purpose: To explore knowledge, attitudes, and behavioral intentions of physicians, and to analyze the factors influencing physicians' behavioral intentions toward provision of artificial nutrition and hydration in terminal cancer patients. The implications for nursing care were also examined. Material and Method: A quantitative study was conducted in a medical center in Taiwan during April 2005 to April 2006. Forty-six physicians working rotations in general surgery wards were recruited. A structured questionnaire was administered to the enrolled physicians. Results: Physicians' knowledge of providing artificial nutrition and hydration to terminal cancer patients was insufficient. Although physicians considered artificial nutrition and hydration for terminal cancer patients as more of a burden than a benefit, their behavioral intentions were still to provide it. Overall patient condition should be taken into account in the provision of artificial nutrition and hydration, and ethical acceptability had a significant impact on the physicians' behavioral intentions (Adjusted R^2=0.342). Conclusion: Physicians are concerned with the overall condition of their terminal cancer patients but may not be performing a comprehensive assessment. Nurses should be aware of the factors influencing physicians' decisions about administering artificial nutrition and hydration for terminal cancer patients and should assist physicians in gathering comprehensive information to be discussed with patients and their family about making decisions appropriate to the needs of the patient.
Studies show a strong association between dementia and lower urinary tract symptoms (LUTS). The a... more Studies show a strong association between dementia and lower urinary tract symptoms (LUTS). The aim of this study was to investigate whether LUTS are a risk factor for cognitive impairment. We enrolled 50-year-old and older subjects with LUTS (LUTS [+]) (= 6801) and controls without LUTS (LUTS [−]) (= 20,403) from Taiwan's National Health Insurance Research Database. LUTS, dementia, and other confounding factors are defined by International Classification of Diseases, Ninth Revision, Clinical Modification Codes. Participants were recruited from 2000 to 2004 and then followed up until death or the end of 2011. The outcome was the onset of dementia, which was assessed using Poisson regression analysis, Cox hazards models, and Kaplan-Meier survival curves. The incidence of dementia was significantly higher in the LUTS [+] group than in the LUTS [−] group (124.76 versus 77.59/1000 person-years). The increased risk of dementia related to LUTS remained significant after adjustment for potential confounders (adjusted hazard ratio (AHR): 1.61, 95% confidence interval (CI) 1.47-1.76, < 0.0001) and higher than that related to cerebrovascular disease (AHR: 1.43, 95% CI 1.26-1.61, < 0.0001). The outcome suggests the need for early screening and appropriate intervention to help prevent cognitive impairment of patients with LUTS.
Geriatrics & Gerontology International, Jun 16, 2017
Aim: Little is known about the pattern of healthcare services for end-of-life patients with demen... more Aim: Little is known about the pattern of healthcare services for end-of-life patients with dementia (PwDs) in East Asia. We compared this pattern between PwDs and cancer patients in their last year of life in Taiwan. Methods: Taiwan's National Health Insurance Research Database was applied for this case-control analysis. The records of patients who had dementia and died between 2002 and 2011 were reviewed. The control group was decedents with cancer. The utilization of hospitalization, emergency department visits, and life-sustaining interventions during the last year of life between two groups were compared. Results: Of the 2724 patients enrolled, 908 had dementia and 1816 had cancer. PwDs were more likely to have higher frequency of admission to hospital and ICU and longer stays by comparing to cancer patients. PwDs had a higher risk of enteral tube insertion and feeding, endotracheal intubation and tracheostomy, mechanical ventilation, hemodialysis, and cardiopulmonary resuscitation (OR = 4.36, 95% CI = 3.51-5.41) the highest among selected procedures. Conclusions: PwDs in their last year of life in Taiwan underwent aggressive interventions significantly more frequently than did their counterparts in Western countries. Providing comfort-centered care for better quality-of-life for end-of-life PwDs is a priority of Taiwan's national health policy.
Background: Home healthcare (HHC) comprises clinical services provided by medical professionals f... more Background: Home healthcare (HHC) comprises clinical services provided by medical professionals for people living at home with various levels of care needs and health conditions. HHC may reduce care transitions from home to acute hospitals, but its long-term impact on homebound people living with dementia (PLWD) towards end-of-life remains unclear. We aim to describe the impact of HHC on acute healthcare utilization and end-of-life outcomes in PLWD. Methods: Design: Systematic review of quantitative and qualitative original studies which examine the association between HHC and targeted outcomes. Interventions: HHC. Participants: At least 80% of study participants had dementia and lived at home. Measurements: Primary outcome was acute healthcare utilization in the last year of life. Secondary outcomes included hospice palliative care, advance care planning, continuity of care, and place of death. We briefly reviewed selected national policy to provide contextual information regarding these outcomes. Results: From 6831 articles initially identified, we included five studies comprising data on 4493 participants from USA, Japan, and Italy. No included studies received a "high" quality rating. We synthesised core properties related to HHC at three implementational levels. Micro-level: HHC may be associated with a lower risk of acute healthcare utilization in the early period (e.g., last 90 days before death) and a higher risk in the late period (e.g. last 15 days) of the disease trajectory toward end-of-life in PLWD. HHC may increase palliative care referrals. Advance care planning was an important factor influencing end-of-life outcomes. Meso-level: challenges for HHC providers in medical decisionmaking and initiating palliative care for PLWD at the end-of-life may require further training and external support. Coordination between HHC and social care is highlighted but not well examined. Macro-level: reforms of national policy or financial schemes are found in some countries but the effects are not clearly understood. Conclusions: This review highlights the dearth of dementia-specific research regarding the impact of HHC on endof-life outcomes. Effects of advance care planning during HHC, the integration between health and social care, and coordination between primary HHC and specialist geriatric/ palliative care services require further investigation.
<p>(A)In the left panel, impairment was defined by PSMS ≥ 7. (B)In the right panel, impairm... more <p>(A)In the left panel, impairment was defined by PSMS ≥ 7. (B)In the right panel, impairment was defined by PSMS ≥ 2 points of increase relative to baseline. The predicted conditional probability of death over the first 6 years was calculated for each sex (men in blue and women in red) assuming either intact (the solid lines) or impaired (the dashed lines) basic ADL at time of observation.</p
BackgroundArtificial hydration (AH) is a challenging issue in terminally ill patients with cancer... more BackgroundArtificial hydration (AH) is a challenging issue in terminally ill patients with cancer, because it influences patients' symptoms control, quality of life, and quality of dying (QOD). To date, it is not clear how much AH supply is proper for imminently dying patients. This study aimed to investigate the association between the amount of AH and QOD.MethodsThis study is part of the East Asian Collaborative Cross‐Cultural Study to Elucidate the Dying Process (EASED) conducted in Japan, Korea, and Taiwan from January 2017 to September 2018. Patients' demographics, symptoms, and managements on admission to palliative care units (PCUs) and before death were recorded. The AH amount was classified into different groups by 250‐mL intervals to compare their difference. The Good Death Scale (GDS) was used to measure QOD, with patients classified into higher or lower QOD groups using GDS = 12 as the cutoff point. We used logistic regression analysis to assess the association between AH amount and QOD.ResultsIn total, 1530 patients were included in the analysis. Country, religion, spiritual well‐being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with QOD. After conducting regression analysis, patients administered with 250 to 499 mL AH had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072‐4.730; P = .032) than those without AH.ConclusionsAH use impacts the QOD of terminally ill patients with cancer admitted to PCUs. Communication with patients and their families on appropriate AH use has a positive effect on QOD.Lay Summary Our prospective cross‐cultural multicenter study aims to investigate the relationship between artificial hydration (AH) amount and quality of dying among terminally ill patients with cancer. The findings reveal that country, religion, spiritual well‐being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with quality of death (QOD). After multivariable logistic regression, patients administered with AH amount 250 to 499 mL had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072‐4.730; P = .032) than those without AH. Communication with patients and their families regarding AH is recommended as it may help them be better prepared for the end‐of‐life stage and achieve a good death.
ObjectivesThe National Health Insurance programme started providing coverage for inpatient care i... more ObjectivesThe National Health Insurance programme started providing coverage for inpatient care in palliative care (PC) units of acute care hospitals in 2000; however, initially, only PC provided to patients with terminal cancer was covered. A PC policy that enabled PC reimbursement for patients with dementia was implemented in 2009. However, the association of this PC policy with end-of-life care remains unclear. The study aims to compare the association of the PC policy with end-of-life care between patients with dementia and patients with cancer during the last 6 months of their lives.MethodsWe analysed the claims data of 7396 patients dying with dementia (PDD) and 24 319 patients dying with cancer (PDC) during 1997–2013.ResultsAmong PDC, while the percentage of receiving PC increased from 3.6% in 1999 to 14.2% by the end of 2000 (adjusted OR (aOR)=4.07, 95% CI 2.70 to 6.13) and from 20.9% in 2010 to 41.0% in 2013 (aOR=1.40, 95% CI 1.33 to 1.47), vasopressor use decreased from 71.6% in 1999 to 35.5% in 2001 (aOR=0.90, 95% CI 0.82 to 0.98). Among PDD, PC use increased from 0.2% in 2009 to 4.9% in 2013 (aOR=2.05, 95% CI 1.60 to 2.63) and cardiopulmonary resuscitation use decreased from 17.6% in 2009 to 10.0% in 2013 (aOR=0.83, 95% CI 0.76 to 0.90).ConclusionsImplementation of the PC policy in Taiwan was associated with improved PC utilisation among patients with cancer and dementia, which may reduce unnecessary medical care procedures.
Purpose: This study aims to examine accuracy of CPS for 7-, 21-, and 42-day survival of inpatient... more Purpose: This study aims to examine accuracy of CPS for 7-, 21-, and 42-day survival of inpatients with faradvanced cancer in 37 palliative care units in Japan, Korea, and Taiwan and its association with prognostic con dence. Methods: In this study, discrimination of CPS was investigated through sensitivity, speci city, overall accuracy, and area under the receiver operating curves (AUROCs) according to 7-, 21-, and 42-day survival. The accuracies of CPS were compared with those of Performance Status-based Palliative Prognostic Index (PS-PPI) in three timeframe prediction. Clinicians were instructed to rate con dence level for each prediction on a 0-10-point scale. Results: A total of 2,571 patients were analyzed. Among the three time-frames, the speci city was highest at 93.2-100.0% for the 7-day CPS and sensitivity was highest at 71.5-86.8% for the 42-day CPS. The AUROCs of the 7-day CPS were 0.88, 0.94, and 0.89 while those of PS-PPI were 0.77, 0.69, and 0.69 for JP, KR, and TW, respectively. In all timeframe, CPS was more accurate than the PS-PPI. As for 42-day prediction, sensitivities of PS-PPI were higher than those of CPS. Clinicians' con dence was strongly associated with the accuracy of prediction in all three countries (all p values <0.01). Conclusions: CPS accuracies were highest (0.88-0.94) for the 7-day survival prediction. CPS was more accurate than PS-PPI in all timeframe prediction. Meanwhile, PS-PPI can be a screening tool in 42-day survival prediction which may be supplementary to CPS. Prognostic con dence was signi cantly associated with the accuracy of CPS.
Purpose Few large-scale studies have focused on the prevalence of symptoms and signs during the l... more Purpose Few large-scale studies have focused on the prevalence of symptoms and signs during the last days of patients diagnosed with advanced cancer. Identifying the patterns of speci c symptoms according to cancer type is helpful to provide end-of-life care for patients with advanced cancer. We investigated the prevalence and severity of symptoms and signs associated with impending death in patients with advanced cancer. Methods In this secondary analysis of an international multicenter cohort study conducted in three East Asian countries, we compared the severity of symptoms and signs among dying patients 3 days before death according to the type of primary cancer using one-way analysis of variance (ANOVA). Post hoc analysis was conducted for multiple comparisons of each symptom according to the type of primary cancer. Results We analyzed 2131 patients from Japan, Korea and Taiwan. Fatigue, dry mouth, drowsiness and dyspnea were present in nearly half of the patients, and edema of lower extremities was the most common sign in all dying patients. According to cancer type, edema of lower extremities was the most common symptom and fatigue/ ascites were the most severe symptoms in digestive tract cancer. For lung cancer, respiratory secretion was the most prevalent and dyspnea/ respiratory secretion were the most severe symptoms. Conclusion We demonstrated the prevalence and severity of symptoms and signs associated with impending death of patients with advanced cancer in East Asia. Our study can enable clinicians to recognize the speci c symptoms and signs at the very end of life.
BackgroundArtificial hydration (AH) is a challenging issue in terminally ill patients with cancer... more BackgroundArtificial hydration (AH) is a challenging issue in terminally ill patients with cancer, because it influences patients' symptoms control, quality of life, and quality of dying (QOD). To date, it is not clear how much AH supply is proper for imminently dying patients. This study aimed to investigate the association between the amount of AH and QOD.MethodsThis study is part of the East Asian Collaborative Cross‐Cultural Study to Elucidate the Dying Process (EASED) conducted in Japan, Korea, and Taiwan from January 2017 to September 2018. Patients' demographics, symptoms, and managements on admission to palliative care units (PCUs) and before death were recorded. The AH amount was classified into different groups by 250‐mL intervals to compare their difference. The Good Death Scale (GDS) was used to measure QOD, with patients classified into higher or lower QOD groups using GDS = 12 as the cutoff point. We used logistic regression analysis to assess the association b...
<p><i>h</i><sub><i>I</i></sub><i>(t)</i> is... more <p><i>h</i><sub><i>I</i></sub><i>(t)</i> is the hazard rate for the time to basic ADL impairment. <i>h</i><sub><i>D</i>1</sub><i>(t)</i> is the hazard rate for the time to death among basic ADL-intact patients. <i>h</i><sub><i>D</i>2</sub><i>(t)</i> is the hazard rate for the time to death among basic ADL-impaired patients. The transitions between disease onset, development of basic ADL impairment, and death were modeled by quantifying the effect of baseline characteristics on basic ADL impairment and survival as well as the effect of developing basic ADL impairment on survival.</p
Purpose: It has been suggested that psychosocial factors are related to survival time in patients... more Purpose: It has been suggested that psychosocial factors are related to survival time in patients with cancer. However, there is no cross-cultural study examining the relationship between spiritual well-being (SWB) and survival time among countries. This study investigated the relationship between SWB and survival time among three East Asian countries. Methods: This international multicenter cohort study is a secondary analysis involving newly admitted inpatients with advanced cancer in palliative care units in Japan, South Korea and Taiwan. SWB was measured at admission. We performed multivariate analysis using the Cox proportional hazards model to identify independent prognostic factors. Results: A total of 2638 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. The median survival time was 18.0 days (95% confidence interval [CI] 16.5 to 19.5) in Japan, 23.0 days (95% CI 19.9 to 26.1) in Korea and 15.0 days (95% CI 13.0 to 17.0) in Taiw...
Purpose: To explore knowledge, attitudes, and behavioral intentions of physicians, and to analyze... more Purpose: To explore knowledge, attitudes, and behavioral intentions of physicians, and to analyze the factors influencing physicians' behavioral intentions toward provision of artificial nutrition and hydration in terminal cancer patients. The implications for nursing care were also examined. Material and Method: A quantitative study was conducted in a medical center in Taiwan during April 2005 to April 2006. Forty-six physicians working rotations in general surgery wards were recruited. A structured questionnaire was administered to the enrolled physicians. Results: Physicians' knowledge of providing artificial nutrition and hydration to terminal cancer patients was insufficient. Although physicians considered artificial nutrition and hydration for terminal cancer patients as more of a burden than a benefit, their behavioral intentions were still to provide it. Overall patient condition should be taken into account in the provision of artificial nutrition and hydration, and ethical acceptability had a significant impact on the physicians' behavioral intentions (Adjusted R^2=0.342). Conclusion: Physicians are concerned with the overall condition of their terminal cancer patients but may not be performing a comprehensive assessment. Nurses should be aware of the factors influencing physicians' decisions about administering artificial nutrition and hydration for terminal cancer patients and should assist physicians in gathering comprehensive information to be discussed with patients and their family about making decisions appropriate to the needs of the patient.
Studies show a strong association between dementia and lower urinary tract symptoms (LUTS). The a... more Studies show a strong association between dementia and lower urinary tract symptoms (LUTS). The aim of this study was to investigate whether LUTS are a risk factor for cognitive impairment. We enrolled 50-year-old and older subjects with LUTS (LUTS [+]) (= 6801) and controls without LUTS (LUTS [−]) (= 20,403) from Taiwan's National Health Insurance Research Database. LUTS, dementia, and other confounding factors are defined by International Classification of Diseases, Ninth Revision, Clinical Modification Codes. Participants were recruited from 2000 to 2004 and then followed up until death or the end of 2011. The outcome was the onset of dementia, which was assessed using Poisson regression analysis, Cox hazards models, and Kaplan-Meier survival curves. The incidence of dementia was significantly higher in the LUTS [+] group than in the LUTS [−] group (124.76 versus 77.59/1000 person-years). The increased risk of dementia related to LUTS remained significant after adjustment for potential confounders (adjusted hazard ratio (AHR): 1.61, 95% confidence interval (CI) 1.47-1.76, < 0.0001) and higher than that related to cerebrovascular disease (AHR: 1.43, 95% CI 1.26-1.61, < 0.0001). The outcome suggests the need for early screening and appropriate intervention to help prevent cognitive impairment of patients with LUTS.
Geriatrics & Gerontology International, Jun 16, 2017
Aim: Little is known about the pattern of healthcare services for end-of-life patients with demen... more Aim: Little is known about the pattern of healthcare services for end-of-life patients with dementia (PwDs) in East Asia. We compared this pattern between PwDs and cancer patients in their last year of life in Taiwan. Methods: Taiwan's National Health Insurance Research Database was applied for this case-control analysis. The records of patients who had dementia and died between 2002 and 2011 were reviewed. The control group was decedents with cancer. The utilization of hospitalization, emergency department visits, and life-sustaining interventions during the last year of life between two groups were compared. Results: Of the 2724 patients enrolled, 908 had dementia and 1816 had cancer. PwDs were more likely to have higher frequency of admission to hospital and ICU and longer stays by comparing to cancer patients. PwDs had a higher risk of enteral tube insertion and feeding, endotracheal intubation and tracheostomy, mechanical ventilation, hemodialysis, and cardiopulmonary resuscitation (OR = 4.36, 95% CI = 3.51-5.41) the highest among selected procedures. Conclusions: PwDs in their last year of life in Taiwan underwent aggressive interventions significantly more frequently than did their counterparts in Western countries. Providing comfort-centered care for better quality-of-life for end-of-life PwDs is a priority of Taiwan's national health policy.
Background: Home healthcare (HHC) comprises clinical services provided by medical professionals f... more Background: Home healthcare (HHC) comprises clinical services provided by medical professionals for people living at home with various levels of care needs and health conditions. HHC may reduce care transitions from home to acute hospitals, but its long-term impact on homebound people living with dementia (PLWD) towards end-of-life remains unclear. We aim to describe the impact of HHC on acute healthcare utilization and end-of-life outcomes in PLWD. Methods: Design: Systematic review of quantitative and qualitative original studies which examine the association between HHC and targeted outcomes. Interventions: HHC. Participants: At least 80% of study participants had dementia and lived at home. Measurements: Primary outcome was acute healthcare utilization in the last year of life. Secondary outcomes included hospice palliative care, advance care planning, continuity of care, and place of death. We briefly reviewed selected national policy to provide contextual information regarding these outcomes. Results: From 6831 articles initially identified, we included five studies comprising data on 4493 participants from USA, Japan, and Italy. No included studies received a "high" quality rating. We synthesised core properties related to HHC at three implementational levels. Micro-level: HHC may be associated with a lower risk of acute healthcare utilization in the early period (e.g., last 90 days before death) and a higher risk in the late period (e.g. last 15 days) of the disease trajectory toward end-of-life in PLWD. HHC may increase palliative care referrals. Advance care planning was an important factor influencing end-of-life outcomes. Meso-level: challenges for HHC providers in medical decisionmaking and initiating palliative care for PLWD at the end-of-life may require further training and external support. Coordination between HHC and social care is highlighted but not well examined. Macro-level: reforms of national policy or financial schemes are found in some countries but the effects are not clearly understood. Conclusions: This review highlights the dearth of dementia-specific research regarding the impact of HHC on endof-life outcomes. Effects of advance care planning during HHC, the integration between health and social care, and coordination between primary HHC and specialist geriatric/ palliative care services require further investigation.
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Papers by Ping-Jen Chen