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

Purpose

The purpose of this study was to investigate Korean attitudes toward advance directives (ADs) among cancer patients, family caregivers, oncologists, and the general public.

Methods

A multicenter survey study explored the attitudes of participants to ADs, and hospice–palliative care (HPC) was conducted. A total of 1,242 cancer patients, 1,289 family caregivers, 303 oncologists, and 1,006 members of the general public participated in the survey.

Results

The majority of patients, family caregivers, oncologists, and general public agreed with the necessity of ADs. However, oncologists regard “when became terminal status” as an optimal timing for completion of ADs (52.2 %), while other groups regard earlier periods as it. More than 95 % oncologist answered that cardiopulmonary resuscitation and mechanical ventilator are necessity items for ADs form, while around 70 % of other groups answered so. Multivariate analysis revealed that several factors including agreement with terminal disclosures and a positive attitude toward HPC were independently associated with necessity of ADs.

Conclusions

We found that attitudes toward ADs among cancer patients, family caregivers, oncologists, and the general public were significantly different. Our study also suggests that favorable attitudes toward comfort end-of-life care and HPC are keys that influence the perceived need for ADs.     

Are written advance directives helpful to guide end-of-life therapy in the intensive care unit? A retrospective matched-cohort study

Purpose

The purpose of the study was to determine whether treatment preferences in patients' advance directives (ADs) are associated with life-supporting treatments received during end-of-life care in the intensive care unit (ICU).

Material and methods

This is a retrospective cohort study, including patients who died in 4 ICUs of a university hospital in Germany. Patients with ADs were matched with 2 patients each without ADs using propensity scores.

Results

Sixty-four (13%) of 477 patients had ADs, written a median of 109 weeks before admission. Five categories of applicability conditions were identified, most of them difficult to interpret in the ICU (eg, “advanced brain impairment” or “imminent death”). Advance directives contained a number of treatment refusals. Specifically, 63 of 64 refused “life-sustaining measures.” Compared to patients without ADs, patients with ADs were less likely to receive cardiopulmonary resuscitation (9% vs 23%, P = .029) and more likely to have do-not-resuscitate orders (77% vs 56%, P = .007). Therapy-limiting decisions and ICU length of stay did not differ between those with or without ADs.

Conclusions

Patients with ADs are less likely to receive cardiopulmonary resuscitation but otherwise receive similar life-sustaining treatments compared to matched patients without ADs. More research is needed to explore reasons for potential noncompliance with patient preferences.     

Association of Advance Directives Completion With the Utilization of Life-Sustaining Treatments During the End-of-Life Care in Older Patients

Context

Evidence is mixed regarding the impact of advance directives (ADs) on the utilization of end-of-life treatments.

Ectopic pregnancy: MRI findings and clinical utility

Purpose

To assess the utility of magnetic resonance imaging (MRI) in patients with clinically suspected ectopic pregnancy (EP).

Methods

We retrospectively reviewed MRIs of 26 consecutive patients who were clinically suspected of having an EP. The diagnostic utility of MRI features of EP was analyzed retrospectively as follows: (1) Direct sign detection of ectopic gestational sac (GS); (2) Indirect signs tubal dilatation with hemosalpinx, adnexal hematoma, and hemorrhagic ascites. The diagnostic accuracy of each sign and their combination was compared to surgical records. The MRI findings of an ectopic GS were reviewed as follows: size, shape, signal intensity, and enhancement pattern.

Results

Of 26 patients, 24 had a tubal pregnancy; 22 of these 24 patients (92%) had a direct sign (sensitivity: 91.3%; specificity: 100%; positive predictive value: 100%). The diagnostic accuracy of the direct sign was 92%; this was more accurate than that of any single indirect sign (39%, 54%, and 50%, respectively). However, the diagnostic accuracy of EP increased to 100% when diagnostic criteria required the presence of a direct sign or at least two indirect signs.

Conclusions

MRI is an effective modality for diagnosing EP with a high detection rate of extrauterine GSs. The combination of direct and indirect signs is useful for establishing the correct diagnosis.     

The relatives’ perspective on advanced cancer care in Denmark. A cross-sectional survey

Purpose

In order to improve advanced cancer care, evaluations are necessary. An important element of such evaluations is the perspective of the patient’s relatives who have the role of being caregivers as well as co-users of the health care system. The aims were to investigate the scale structure of the FAMCARE scale, to investigate satisfaction with advanced cancer care from the perspective of the relatives of a representative sample of advanced cancer patients, and to investigate whether some sub-groups of relatives were more dissatisfied than others.

Method

From 977 patients treated at 54 different Danish hospital departments, 569 patients provided us with the name and address of their relative. Of these, 544 received the FAMCARE scale that measures the families’ satisfaction with advanced cancer care. For the four FAMCARE sub-scales, internal consistency was analyzed using Cronbach’s alpha; convergent and discriminant validity was analyzed using multitrait-scaling analysis. Associations between the relatives’ dissatisfaction and clinical and sociodemographic variables were investigated in explorative analyses using multiple logistic regressions.

Results

Of the relatives receiving the questionnaire, 467 (86%) responded. The original scale structure of FAMCARE could not be supported in the present sample, and therefore, results are reported at singe-item level. The proportion of dissatisfied relatives ranged from 5% to 28% (median 13%). Highest levels of dissatisfaction were found for time taken to make a diagnosis (28%) and the speed with which symptoms were treated (25%). Younger relatives were more dissatisfied than older relatives. Other sociodemographic and clinical variables had little impact on the relatives’ levels of satisfaction.

Conclusion

The relatives’ level of dissatisfaction with some of the areas included in this survey needs to be taken seriously. Younger relatives were most dissatisfied.     

Insights into Chinese perspectives on do-not-resuscitate (DNR) orders from an examination of DNR order form completeness for cancer patients

Purpose

Discussing end-of-life care with patients is often considered taboo, and signing a do-not-resuscitate (DNR) order is difficult for most patients, especially in Chinese culture. This study investigated distributions and details related to the signing of DNR orders, as well as the completeness of various DNR order forms.

Methods

Retrospective chart reviews were performed. We screened all charts from a teaching hospital in Taiwan for patients who died of cancer during the period from January 2010 to December 2011. A total of 829 patient records were included in the analysis. The details of the DNR order forms were recorded.

Results

The DNR order signing rate was 99.8 %. The percentage of DNR orders signed by patients themselves (DNR-P) was 22.6 %, while the percentage of orders signed by surrogates (DNR-S) was 77.2 %. The percentage of signed DNR forms that were completely filled out was 78.4 %. The percentage of DNR-S forms that were completed was 81.7 %, while the percentage of DNR-P forms that were completely filled out was only 67.6 %.

Conclusion

Almost all the cancer patients had a signed DNR order, but for the majority of them, the order was signed by a surrogate. Negative attitudes of discussing death from medical professionals and/or the family members of patients may account for the higher number of signed DNR-S orders than DNR-P orders. Moreover, early obtainment of signed DNR orders should be sought, as getting the orders earlier could promote the quality of end-of-life care, especially in non-oncology wards.     

Using mixed methods to assess how cancer patients’ needs in relation to their relatives are met in the Danish health care system: a report from the population-based study “The Cancer Patient’s World”

Aim

The aims of this paper were to validate four items assessing how patients’ needs regarding support to and from their relatives are met and to investigate patients’ evaluation of this support.

Method

Items were validated by patient–observer agreement and cognitive interviews. Adequacy of support was assessed in a cross-sectional study of 1,490 Danish cancer patients; 147 of these also answered an open-ended question.

Results

All items performed well in the validation. Only 4?% reported lack of support from their relatives, whereas 9 and 11?% had lacked support from the health care professionals regarding how to tell the relatives about the disease and regarding the relatives in general, respectively. Although the patients’ expectations are not unequivocal, a large proportion (35?%) reported that the health care professionals had shown little interest in how the relatives were doing. This was most pronounced for female patients and patients sampled in urban areas. Compared to older patients, younger patients lacked more support with respect to the relatives in general and regarding how to tell them about the disease. Divorced patients were less satisfied than married patients on all measures.

Conclusion

While most patients felt well-supported by their relatives, the oldest, the divorced, and those without children may be a vulnerable group. Many patients reported that the health care staff showed insufficient interest in the well-being of the relatives. Thus, it may be beneficial for both the patient and the relatives if health care professionals acknowledge and support the relatives in fulfilling their important role as caregiver and companion.     

Wissen,Haltung und Meinung von Patienten zum neuen Patientenverfügungsgesetz

Background

In September 2009 a new legislation for advance care planning was introduced in Germany with the important characteristics of bindingness and unlimited validity for individual directives. Knowledge regarding this act and the attitude towards its characteristics among patients is unclear.

Aim of this study

Analysis of knowledge, attitude and opinion of patients in a general internal medical department regarding advance care planning in general and the recent German legislation.

Methods

A total of 200 consecutive patients in an internal medicine ward were interviewed with the help of a questionnaire regarding their attitude to and knowledge on advance care planning in general and the current legislation.

Results

Approximately 40?% of the patients had issued some form of directive (either advance care directive or health care proxy) and only 7.5?% were advised by their physicians to make an advance directive. Patients with no directive were not willing to deal with dying and death, were not well-informed about directives or assumed that relatives or physicians would make an appropriate decision. Characteristics of the new legislation were controversially assessed; only 21?% of the patients wished to have a literal implementation of their directive. Regarding the content of an advance directive, more than 80?% of the patients voted for pain control in the palliative setting.

Conclusion

The proportion of patients with a directive regarding advance care planning is only slowly increasing. Many patients are not well-informed, do not want to deal with dying or would like to delegate decisions to relatives and physicians. The present characteristics of the German legislation are controversially assessed and often do not represent the wishes of the patients.

     

Neurobehavioural changes in patients following brain tumour: patients and relatives perspective

Purpose

Patients and relatives experiences of behavioural and personality changes following brain tumour were assessed to determine whether these changes are more prominent in the experience of patients with frontal tumours and their relatives as a first step to evaluate the need to develop appropriate support and management of such changes, which have a substantial impact on social functioning, and ultimately to improve quality of life.

Methods

Patients and relatives rated the patients’ current levels of apathy, disinhibition and executive dysfunction on the Frontal Systems Behaviour Scale. Patients also completed the Hospital Anxiety and Depression Scale. The data from 28 patients with frontal tumours and 24 of their relatives, and 27 patients with nonfrontal tumours and 25 of their relatives, were analysed.

Results

Patients with frontal tumours rated themselves significantly higher than patients with nonfrontal tumours on all frontal systems-related behaviours. The number of patients reporting clinical levels of difficulty was significantly greater in patients with frontal tumours for disinhibition. The ratings of relatives of patients with frontal tumours were significantly higher than those of relatives of patients with nonfrontal tumours for apathy. Clinically significant levels of apathy and executive dysfunction were however reported by at least 40 % of patients and relatives regardless of tumour location. Clinical levels of anxiety were reported by significantly more patients with frontal tumours than those with nonfrontal tumours.

Conclusion

Support and management of behavioural and personality change for patients with brain tumours and their relatives, regardless of tumour location, would be most appropriate.     

ICU research: the impact of invasiveness on informed consent

Purpose

Studies into the preferences of patients and relatives regarding informed consent for intensive care unit (ICU) research are ongoing. We investigated the impact of a study’s invasiveness on the choice of who should give consent and on the modalities of informed consent.

Methods

At ICU discharge, randomized pairs of patients and relatives were asked to answer a questionnaire about informed consent for research. One group received a vignette of a noninvasive study; the other, of an invasive study. Each study comprised two scenarios, featuring either a conscious or unconscious patient. Multivariate models assessed independent factors related to their preferences.

Results

A total of 185 patients (40 %) and 125 relatives (68 %) responded. The invasiveness of a study had no impact on which people were chosen to give consent. This increased the desire to get more than one person to give consent and decreased the acceptance of deferred or two-step consent. Up to 31 % of both patients and relatives chose people other than the patient himself to give consent, even when the patient was conscious. A range of 3 to 17 % of the respondents reported that they would accept a waiving of consent. Younger respondents and individuals feeling coerced into study participation wanted to be the decision makers.

Conclusions

Study invasiveness had no impact on patients’ and relatives’ preferences about who should give consent. Many patients and relatives were reluctant to give consent alone. Deferred and two-step consent were less acceptable for the invasive study. Further work should investigate whether sharing the burden of informed consent with a second person facilitates participation in ICU research.     

Public opinion of a stroke clinical trial using exception from informed consent

Background

Acute stroke is a leading cause of morbidity and mortality. Clinical trials in stroke are challenging because victims often do not have the capacity to provide informed consent, excluding those patients most likely to benefit from the research.

Aim

We evaluated patient willingness to participate in a hypothetical acute stroke trial using an exception from informed consent.

Methods

Consecutive patients presenting to four emergency departments (EDs) underwent structured interviews regarding a hypothetical stroke trial using an exception from informed consent.

Results

Of 461 (72% of eligible) participants, 55% (95% CI, 50%–59%) were willing to be enrolled in the hypothetical study without giving informed consent. After multivariable analysis, independent predictors of willingness to enroll included Catholic religion (OR 1.57, 95% CI 1.17–2.10) and belief that current therapy offers a >50% chance of full recovery (OR 1.29, 95% CI 1.05–1.57). There was no difference between the proportion willing to enroll in a cardiac arrest study vs. a stroke study (55% vs. 55%, p?=?0.83)

Conclusions

Fifty-five percent of ED patients would be willing to be enrolled in a stroke trial using exception from informed consent.     

Evaluation of whether the ultrasonographic onion skin sign is specific for the diagnosis of an appendiceal mucocele

Purpose

To evaluate whether the onion skin sign on ultrasonography (US) of the lower abdomen is specific for the diagnosis of an appendiceal mucocele.

Methods

Our study included 231 lesions from 229 patients in whom transabdominal US detected lesions in the lower abdomen and who had definitive pathological diagnoses in the small bowel, ileocecal valve, cecum, appendix, mesentery, adnexa uteri or pelvic cavity outside the major organs. Patients with metastatic tumors were excluded. We reviewed the reports and images from transabdominal US and checked for the presence of the onion skin sign. The sensitivity, specificity, and accuracy of the sign for the diagnosis of an appendiceal mucocele were calculated.

Results

Five (2.2 %) of the 231 lesions showed the onion skin sign on US and all were diagnosed with an appendiceal mucocele. The sensitivity, specificity, and accuracy of the sign for the diagnosis of an appendiceal mucocele were 63, 100, and 99 %, respectively.

Conclusions

The onion skin sign in the lower abdomen appears to be specific for the diagnosis of an appendiceal mucocele. In cases where the onion skin sign is obviously present in the lower abdomen on US, an appendiceal mucocele should be considered as the leading diagnosis.     

Noninvasive mechanical ventilation in patients having declined tracheal intubation

Purpose

Noninvasive ventilation (NIV) is a treatment option in patients with acute respiratory failure who are good candidates for intensive care but have declined tracheal intubation. The aim of our study was to report outcomes after NIV in patients with a do-not-intubate (DNI) order.

Methods

Prospective observational cohort study in all patients who received NIV for acute respiratory failure in 54 ICUs in France and Belgium, in 2010/2011.

Results

Goals of care, comfort, and vital status were assessed daily. On day 90, a telephone interview with patients and relatives recorded health-related quality of life (HRQOL), posttraumatic stress disorder-related symptoms, and symptoms of anxiety and depression. Post-ICU burden was compared between DNI patients and patients receiving NIV with no treatment-limitation decisions (TLD). Of 780 NIV patients, 574 received NIV with no TLD, and 134 had DNI orders. Hospital mortality was 44 % in DNI patients and 12 % in the no-TLD group. Mortality in the DNI group was lowest in COPD patients compared to other patients in the DNI group (34 vs. 51 %, P = 0.01). In the DNI group, HRQOL showed no significant decline on day 90 compared to baseline; day-90 data of patients and relatives did not differ from those in the no-TLD group.

Conclusions

Do-not-intubate status was present among one-fifth of ICU patients who received NIV. DNI patients who were alive on day 90 experienced no decrease in HRQOL compared to baseline. The prevalences of anxiety, depression, and PTSD-related symptoms in these patients and their relatives were similar to those seen after NIV was used as part of full-code management (clinicaltrial.govNCT01449331).     

End-of-life decisions in Greek intensive care units: a multicenter cohort study

Introduction

Intensive care may prolong the dying process in patients who have been unresponsive to the treatment already provided. Limitation of life-sustaining therapy, by either withholding or withdrawing support, is an ethically acceptable and common worldwide practice. The purpose of the present study was to examine the frequency, types, and rationale of limiting life support in Greek intensive care units (ICUs), the clinical and demographic parameters associated with it, and the participation of relatives in decision making.

Methods

This was a prospective observational study conducted in eight Greek multidisciplinary ICUs. We studied all consecutive ICU patients who died, excluding those who stayed in the ICU less than 48 hours or were brain dead.

Results

Three hundred six patients composed the study population, with a mean age of 64 years and a mean APACHE II score on admission of 21. Of study patients, 41% received full support, including unsuccessful cardiopulmonary resuscitation (CPR); 48% died after withholding of CPR; 8%, after withholding of other treatment modalities besides CPR; and 3%, after withdrawal of treatment. Patients in whom therapy was limited had a longer ICU (P < 0.01) and hospital (P = 0.01) length of stay, a lower Glasgow Coma Scale score (GCS) on admission (P < 0.01), a higher APACHE II score 24 hours before death (P < 0.01), and were more likely to be admitted with a neurologic diagnosis (P < 0.01). Patients who received full support were more likely to be admitted with either a cardiovascular (P = 0.02) or trauma diagnosis (P = 0.05) and to be surgical rather than medical (P = 0.05). The main factors that influenced the physician's decision were, when providing full support, reversibility of illness and prognostic uncertainty, whereas, when limiting therapy, unresponsiveness to treatment already offered, prognosis of underlying chronic disease, and prognosis of acute disorder. Relatives' participation in decision making occurred in 20% of cases and was more frequent when a decision to provide full support was made (P < 0.01). Advance directives were rare (1%).

Conclusions

Limitation of life-sustaining treatment is a common phenomenon in the Greek ICUs studied. However, in a large majority of cases, it is equivalent to the withholding of CPR alone. Withholding of other therapies besides CPR and withdrawal of support are infrequent. Medical paternalism predominates in decision making.     

Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support

Purpose

To describe the characteristics of patients who die in emergency departments and the decisions to withhold or withdraw life support.

Methods

We undertook a 4-month prospective survey in 174 emergency departments in France and Belgium to describe patients who died and the decisions to limit life-support therapies.

Results

Of 2,512 patients enrolled, 92 (3.7%) were excluded prior to analysis because of missing data; 1,196 were men and 1,224 were women (mean age 77.3 ± 15 years). Of patients, 1,970 (81.4%) had chronic underlying diseases, and 1,114 (46%) had a previous functional limitation. Principal acute presenting disorders were cardiovascular, neurological, and respiratory. Life-support therapy was initiated in 1,781 patients (73.6%). Palliative care was undertaken for 1,373 patients (56.7%). A decision to withhold or withdraw life-sustaining treatments was taken for 1,907 patients (78.8%) and mostly concerned patients over 80 years old, with underlying metastatic cancer or previous functional limitation. Decisions were discussed with family or relatives in 58.4% of cases. The decision was made by a single ED physician in 379 cases (19.9%), and by at least two ED physicians in 1,528 cases (80.1%).

Conclusions

Death occurring in emergency departments mainly concerned elderly patients with multiple chronic diseases and was frequently preceded by a decision to withdraw and/or withhold life-support therapies. Training of future ED physicians must be aimed at improving the level of care of dying patients, with particular emphasis on collegial decision-taking and institution of palliative care.     

Liver adenomatosis: serial investigation on MRI

Purpose

To describe the natural history of liver adenomatosis (LA), including complications and changes in lesion size over time.

Materials and methods

Eighteen patients with clinical diagnosis of LA were included. Clinical and biochemical information were collected. The initial and follow-up MR studies were reviewed retrospectively to determine change in lesion size and imaging features.

Results

Seventeen patients were women (94.4%). The mean age of the initial MR study was 37.0 years (18–52 years). The median size of the largest lesion was 6.7 cm (range 3.0–13.5 cm). Intratumoral bleeding was detected on MRI in 9 lesions, in 7 patients (38.8%). The median size for hemorrhagic lesions was 7.6 cm (range 4.1–13.5 cm). During the mean follow-up period of 29.4 (range 4–98) months, 10 patients had stable disease (55.6%), and 8 patients had tumor regression (44.4%). Of 8 patients who were followed without intervention, 3 patients (37.5%) had spontaneous regression. No malignant transformation or lesion progression was occurred.

Conclusion

During an over 2-year follow-up period, the majority of lesions of LA appeared to remain stable or showed tumor regression. Spontaneous tumor regression can be observed in approximately 37% of individuals in the age range of 28–53 years.     

Reasons for hospitalisation at the end of life: differences between cancer and non-cancer patients

Purpose

Many patients are hospitalised during the final phase of life, even though most prefer to receive care at home until the end. This study aimed to explore the reasons and characteristics of hospitalisation in the final 3 months of life for patients who died non-suddenly, with a comparison between cancer patients and non-cancer patients.

Methods

This study used a nationwide retrospective cross-sectional survey among Dutch general practitioners.

Results

Of the 317 hospitalised patients, 65 % had cancer. Most common reasons for hospitalisation in the final 3 months of life were respiratory symptoms (31 %), digestive symptoms (17 %), and cardiovascular symptoms (17 %). Seventy-three percent of patients experienced an acute episode before hospitalisation, and for 46 % of patients, their own GP initiated the hospitalisation. Compared to non-cancer patients, cancer patients were significantly more likely to be aged less than 80 (81 versus 46 %), were more likely to be hospitalised because of digestive symptoms (22 versus 7 %), were less likely to have a curative treatment goal before the last hospitalisation (6 versus 22 %) and were less likely to die in hospital (22 versus 49 %).

Conclusions

Respiratory problems were the most common reasons for hospitalisation in the group of patients as a whole. Digestive problems were a frequent reason for hospitalisation in cancer patients and cardiovascular symptoms in non-cancer patients. Hospitalisation can therefore be anticipated by monitoring these relatively common symptoms. Also, timely communication with the patient is recommended about their preferences for hospital or home treatment in the case of an acute episode.     

Leben retten �C sterben zulassen

Background

Emergency missions can also be necessary for patients in the terminal phase of a progressive incurable disease. The emergency physician, accustomed to acting under strict procedures and whose training focuses on the restoration and stabilization of acutely threatened vital functions, can face severe difficulties when treating incurably ill patients in the terminal phase. This study investigates the number of such cases, patient symptoms and the events occurring during life-threatening emergencies of terminally ill patients.

Method

All cases of emergency events involving terminally ill patients were analyzed prospectively. In addition to the standardized protocol (following DIVI/Mind?2) an enquiry sheet was used, which contained an 8-item checklist specifically for terminally ill patients, to be filled out by the responding physician.

Results

The total number of patients in the terminal phase identified by the emergency physician was 55 (0.72% of total cases) and of these patients 30 (55%) were tumor patients. The most frequent complaint observed was dyspnea (30?patients, 55%), followed by relatives of the patients experiencing the stress of caring for a terminally ill person (19?patients, 35%). The leading symptom of 6?patients (11%) was pain. Only 17?cases (30.9%) required transport of the patient to hospital for further treatment.

Conclusion

Every emergency physician can be confronted with an emergency involving a patient with a progressive incurable disease. The condition of each patient must be assessed for each medical decision. Not only medical, but also psychosocial, ethical and legal aspects have to be considered.     

Decision making at the end of life—cancer patients’ and their caregivers’ views on artificial nutrition and hydration

Purpose

Deciding on artificial nutrition and hydration (ANH) at the end of life (EoL) may cause concerns in patients and their family caregivers but there is scarce evidence regarding their preferences. Therefore, the aim of this study was to assess the impact of factors associated with ANH decision making.

Methods:

Prospective, Cross-sectional survey. Adult patients admitted to hospital for symptoms of advanced cancer as well as their family caregivers completed a self-administered questionnaire. Items included personal views and concerns about ANH. Family caregivers additionally recorded their preference for their loved one and, if applicable, previous experience with ANH decisions.

Results

Thirty-nine out of sixty-five patients and 30/72 relatives responded. Higher age of the patient was significantly correlated with both the patient’s and the relative’s decision to forgo ANH (Kruskal-Wallis test, p?χ ² test, p <0.001), while 23, 23 and 24 %, respectively, wished to receive ANH. Patients felt more confident about decisions on artificial nutrition (AN) than caregivers (T test, p?χ ² test, p?p?Conclusion Cancer patients and their relatives have similar preferences regarding ANH at the EoL, but relatives are reluctant to withhold AH if deciding for their loved one. While patients seem to be confident with ANH decision making, their caregivers may particularly benefit from discussing ANH options to dissipate fears.     

Surrogate decision-making in Korean patients with advanced cancer: a longitudinal study

Purpose

Although surrogate decision-making in cancer patients is well-known, few studies investigating the prevalence of surrogate decision-making over time have been reported. The objectives of this study were to investigate the level of surrogate decision-making in advanced cancer patients over time and the impact of demographic and clinical variables on surrogate decision-making.

Methods

The level of surrogate decision-making was measured in 572 consecutive cancer patients who died between January 1 and December 31, 2009. We reviewed 8,639 informed consent forms of these patients, calculated the proportion of decisions made by a surrogate (PDS) for each patient, and analyzed the association of PDS with demographic and clinical variables.

Results

Surrogates completed 40.3?% of all consent forms. The prevalence of surrogate decision-making was higher in the end-of-life period (death <7?days, OR?=?29.05; reference, >365?days). Surrogates signed consent forms more frequently for do-not-resuscitate directives, intensive care unit admission, emergency hemodialysis, surgery and invasive interventions compared with chemotherapy, radiotherapy, and diagnostic tests (OR?=?3.88, P?<?0.001). Patients of older age (P?=?0.036) and those with a shorter duration of management (P?<?0.001) were independently associated with greater PDS.

Conclusions

Surrogate decision-making was frequently observed among Korean cancer patients in this study, especially when the patient??s death was imminent, and for decisions related to end-of-life care. Surrogates were also frequently involved in decisions for elderly or rapidly deteriorating patients. Healthcare professionals should consider the significant role of familial surrogates in the end-of-life period; comprehensive approaches are needed to preserve the best interest of the patients.