Barriers to referral to inpatient palliative care units in Japan: a qualitative survey with content analysis

Objectives We investigated the barriers to referral to inpatient palliative care units (PCUs) through a qualitative study across various sources of information, including terminal cancer patients, their families, physicians, and nurses. Materials and methods There were 63 participants, including 13 advanced cancer patients, 10 family members, 20 physicians, and 20 nurses in palliative care and acute care cancer settings from five regional cancer institutes in Japan. Semi-structured interviews were conducted regarding barriers to referral to PCU, and data were analyzed by content analysis method. Results A total of 21 barriers were identified by content analysis. The leading barriers were (1) a negative image of PCUs by patients and families (n = 39), (2) delay of termination of anti-cancer treatment by physicians in the general wards (n = 24), (3) unwillingness to end anti-cancer treatment and denial of the fatal nature of the disease by patients and families (n = 22), (4) patient’s wish to receive care from familiar physicians and nurses (n = 20), and (5) insufficient knowledge of PCUs by medical staff in general wards (n = 17). Conclusions To correct these unfavorable images and misconceptions of PCUs, it is important to eliminate the negative image of PCUs from the general population, patients, families, and medical staffs. In addition, early introduction of palliative care options to patients and communication skills training regarding breaking bad news are relevant issues for a smooth transition from anti-cancer treatment to palliative care.     

Factors associated with place of death of cancer patients in the Mexico City Metropolitan area

Objective To improve the care of cancer patients by understanding the factors associated with the place of death. Patients and methods We conducted a retrospective study of death certificates registered in Mexico during 2003. Adult cases were included if the underlying cause of death was cancer, death location was in the Mexico City Metropolitan Area (MCMA), and information was available on sociodemographic characteristics and place of death (home or medical unit). Main results Of the 10,561 cases meeting the inclusion criteria, 54% died at home. More women (55%) than men died of cancer and at a younger age (63 vs 64 years, respectively; p < 0.001). Multivariate analysis indicated that patients diagnosed with leukemia and lymphoma were 3.6 times more likely to die in hospitals than patients diagnosed with other cancers (p < 0.001). Compared with patients who died at home, patients who died in hospitals were significantly more educated, younger, and residents of counties with more hospital beds density (p < 0.001, p < 0.001, and p = 0.003, respectively). Certificates for in-hospital deaths were more likely to be signed by other physician or health professional than were those for at-home deaths (p < 0.001). Cases with usual residency located outside the study area were 27 times more likely to die in hospitals than were metropolitan-area residents (p < 0.001). Conclusions Patients dying at home tended to be of older age, less educated, diagnosed with prostate, urinary tract or gastrointestinal cancers, and residents of the MCMA. Health planners should consider determinants of place of death when allocating hospital or home-based palliative care units.     

Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center

Background  There is wide variation in the frequency of reported use of palliative sedation (PS) to control intractable and refractory symptoms in terminally ill patients. The aim of this study was to determine the frequency and outcomes of PS use and examine patterns of practice after establishment of a policy for the administration of midazolam for PS in our palliative care unit (PCU). Materials and methods  This retrospective study reviewed PCU admissions for 2004 and 2005 and pharmacy records to identify patients who received chlorpromazine, lorazepam, or midazolam for PS in the PCU. Data on indication for PS, drug used, and discharge outcome were assessed for each patient. Results  During the period studied, there were 1,207 PCU admissions. Of these patients, 186 (15%) received PS; and 143 (41%) of the 352 patients who died in the PCU received PS. The median age of PS patients was 58 (range, 20–84) years, and 106 (57%) were male. The most common indications for PS were delirium, 153 cases (82%); dyspnea, 11 (6%); and multiple indications, 12 (6%). Midazolam was used in 18 PS cases (10%). Six (55%) of 11 patients with dyspnea received midazolam for PS, compared with 12 (7%) of 175 patients with other indications for PS (p < 0.001). Forty-three (23%) of 186 PS patients were discharged alive, compared with 812 (80%) of 1,021 patients who did not receive PS (p < 0.001). Conclusions  PS was required in 15% of PCU admissions, and 23% of PS patients were discharged alive. Our findings suggest a potential for significant underreporting of overall PS. If our institution’s policy on midazolam use for PS were less restrictive, midazolam use might increase. More research is needed to define the optimal agent for inducing rapid, effective, and easily reversible PS. These data were presented in part at the Annual meeting of the American Society of Clinical Oncology; Atlanta, GA, 2006.     

Artificial nutrition and hydration in terminal cancer patients: the real and the ideal

Introduction To better understand current practice relating to artificial nutrition/hydration in terminal cancer patients, we enrolled terminal cancer patients who were admitted at Seoul National University Boramae Hospital for supportive care only and who died with a duration of hospital stay to death of more than 1 week between 2003 and 2004. We detailed oral intake and intravenous nutrition/hydration status on admission, 1 week after admission, and 2 days before death. Administered calories and changes in these according to time and “DNR” (do-not-resuscitate) status were noted. Results Of the total 165 patients, oral intake was possible in 84 patients (50.9%) on admission, in 79 patients (47.8%) on 1 week after admission, and in 29 patients (17.5%) 2 days before death (p < 0.01). Intravenous nutrition/hydration was administered to 133 patients (80.6%) on admission, to 125 patients (75.7%) at 1 week, and to 137 patients (83.0%) 2 days before death (p = 0.7). The calories administered to the patient by oral intake were 393 kcal on admission, 353 kcal 1 week after admission, and 89 kcal 2 days before death. In addition, the calories delivered by intravenous fluid were 369, 386 and 465 kcal, respectively. Near to death, calories by oral intake continuously reduced (p < 0.01) and intravenous calories continuously increased (p = 0.04), but total administered calories reduced (p = 0.03). Intravenous nutrition/hydration stopped after the attainment of the advance directive of DNR in 9% of patients. Conclusion This study showed the high prevalence of artificial nutrition/hydration, especially intravenous infusion, in Korean terminal cancer patients compared with situation in other countries. More studies are needed to verify the efficacy of artificial nutrition/hydration in terminal cancer patients.     

The current status of palliative care teams in Japanese University Hospitals: a nationwide questionnaire survey

Goal Although the importance of the palliative care team (PCT) to university hospitals is widely accepted, the issues of palliative care at the national level have not been clarified. We conducted a nationwide survey of the current status of PCTs in all (123) Japanese university hospitals. Materials and methods In 2003, 2004 and 2005, the authors conducted a self-reporting cross-sectional survey. Questionnaires were mailed to nursing directors and selected PCT members of all Japanese university hospitals. Results Of 123 hospitals in 2005, 99 (80%) returned the questionnaire; 33% used PCTs, and 11% used certified PCTs. Our findings include: annual number of patients treated by PCTs (83/70 ± 64, mean/median ± SD), daily number of patients treated by PCTs (12/11 ± 14), and days of PCT care per patient (30/30 ± 22). Certified PCTs treated more patients per year (p = 0.004) and more patients per day (p < 0.001) compared to noncertified PCTs. Over the 3-year period, the number of hospitals utilizing PCTs only slightly increased (2003: 27%, 2004: 29%, 2005: 33%), as did those using certified PCTs (2003: 3%, 2004: 9%, 2005:11%). In 2005, the reasons for noncertification of PCTs included “lack of physicians who specialize in palliative care (82%)” and “lack of nurses who specialize in palliative care (56%).” Conclusions The entire system of palliative care in Japanese university hospitals is currently insufficient. The lack of physicians and nurses who specialize in palliative care is a significant barrier, and therefore, the initiation of a formal training system for these health care professionals is a high priority issue. The Society of Paliative Care for University Hospital.     

Clinicians’ practice and attitudes toward cancer pain management in Korea

Objectives The purposes of this study were to assess clinicians’ (n = 250) current practices and attitudes about cancer pain management and to identify perceived concerns about and barriers to pain control in urban cancer-treatment settings in Korea. Materials and methods Survey data (20 items) were collected either by mail or interview. Approximately 40% of the sample were nurses. More medical clinicians than surgical clinicians had more than 5 years of experience with cancer care (43 vs 31%) and committed more than 30% of their working hours to palliation (61 vs 19%). Significantly more medical clinicians claimed to be somewhat more or much more liberal than their professional peers in using analgesics compared with surgical clinicians (54 vs 35%). The liberal sample was more likely to be male (OR = 3.3, p < 0.001) and to be more experienced with cancer care (OR = 1.2, p < 0.001). Medical clinicians also reported more adequate pain-management training and a more proactive approach to assessing and treating pain. Results Overall, the greatest concerns regarding opioid use were safety, side effects, and fear of addiction. Inadequate pain assessment and lack of staff knowledge and time were identified as barriers to pain management. Unrealistic expectations and denial from both patient and family were the most troublesome issues for delivery of care to dying patients. This study suggests a more conservative attitude toward cancer pain management in Korea than in other countries surveyed in a similar manner. Conclusion A combination of routine professional education and dissemination of guidelines is needed to bring about significant improvement in cancer pain control in Korea.     

Effects of educational intervention on nurses’ knowledge, attitudes, and behavioral intentions toward supplying artificial nutrition and hydration to terminal cancer patients

Introduction  This study aimed to investigate the effects of educational intervention on nurses’ knowledge, attitudes, and behavioral intentions regarding supplying artificial nutrition and hydration (ANH) to terminal cancer patients. Materials and methods  A quasi-experimental design was adopted. A structured questionnaire evaluated the effects of educational intervention. From April to June 2005, 88 nurses were enrolled in the gastroenterology, general surgery, and intensive care unit of Taipei Veterans General Hospital in Taiwan. The nurses were randomly assigned into experimental and control groups in equal numbers (44 nurses in each group). After the experimental and control groups completed the pretest, the experimental group participated in a 50-min lecture. Both groups received a post-test 2 weeks after the lecture. Results  This study showed that prior to educational intervention, nurses have possessed experiences of ANH use in routine caring for terminal cancer patients. However, due to the lack of knowledge about supplying ANH to terminal cancer patients, the nurses trended toward the negative behavioral intention, although they realized the burdens of ANH in these patients. After educational intervention, mean scores of knowledge, attitudes and behavioral intentions of the experimental group increased significantly (z = −5.255, p < 0.001; t = −5.191, p < 0.001; z = −3.274, p ≦ 0.001). Mean score changes of knowledge and attitude between these two groups reached significant differences (t = −7.306, p < 0.001; t = −4.165, p < 0.001), but no significant difference was observed in the mean score change of behavioral intention (z = −1.943, p > 0.05). Conclusion  The educational intervention remarkably improved nurses’ knowledge and attitudes regarding supplying terminal cancer patients with ANH. As for the changes in the behavioral intentions, it requires long-term moral and ethical training and communication. The results of this research emphasized the importance of educational interventions, which should be considered seriously in future reference nursing education program.     

Development and evaluation of a problem-focused psychosocial intervention for patients with head and neck cancer

Goals of the work  Patients with head and neck cancer have complex needs that affect many basic functions of life and contribute to substantial psychosocial problems. The aim of this study was to evaluate the effectiveness of a problem-focused intervention for patients with psychosocial dysfunction who had completed treatment for head and neck cancer. Patients and methods  Using a quasi-experimental design, 54 participants who were above pre-determined cutoff points for psychosocial dysfunction (hospital and depression scale, work and social adjustment scale) were given the opportunity to self-select into either the experimental group for the psychosocial intervention programme which was delivered in an individualised format, with bibliotherapy as an adjunct, or the control group for usual care. Main results  Analysis of covariance results demonstrated a reduction in psychological distress (anxiety, p = 0.001; depression, p = 0.005), improving social functioning (p = 0.048) and quality of life scores (p = <0.05) for the experimental group, all of which were sustained into the 3-month follow-up period. No such improvements were evident for the control group. Conclusions  This study suggests that head and neck cancer patients with post-treatment psychosocial dysfunction can benefit from a problem-focused psychosocial intervention. Such evidence can inform practice, policy and future research, aimed at improving post-treatment quality of life for patients with head and neck cancer.     

General perceived self-efficacy: validation analysis in Greek cancer patients

Goals of work  The present study aims to validate the General Perceived Self-efficacy Scale (GSE) in Greek cancer patients. Materials and methods  The scale was administered twice, with a 3-day interval, to 99 advanced cancer patients. The patients also completed the Anxiety Subscale from the Greek Hospital Depression and Anxiety Scale. Main results  Factor analyses identified a one-factor solution, explaining 74.6% of the variance. The Greek version of the GSE had a Cronbach’s alpha of 0.927. Validity as performed using known-group analysis showed good results. Satisfactory construct validity was supported by the correlation analysis between the GSE and anxiety (r = −0.507, p < 0.0005). Interitem correlations was also satisfactory at p < 0.0005. Conclusions  These psychometric properties of the Greek version of the GSE showed that it is a valid and reliable measured when administered to cancer patients.     

Needs of developing the skills of palliative care at the oncology ward

Background To clarify the prevalence and severity of the symptoms, 203 consecutive patients with breast, prostate and other cancers treated mainly for palliation were surveyed. Materials and methods The series includes 116 men and 87 women with the mean age of 65 years (range 27–86 years). The patients filled-up the Edmonton Symptom Assessment System (ESAS) questionnaire with 11 items describing cancer-related symptoms in the visual analogue scale (VAS). Results Altogether, 98% of the patients reported at least 1 of the 10 symptoms. There was a significant difference in the score frequencies between the 10 symptoms (p = 0.0001), fatigue receiving the highest frequency (50.8%) of the high scores. Fatigue was also the single most frequent symptom reported by 86.3% of the patients, followed by pain at effort (71.5%), sleeplessness (71.1%) and depression (59.0%). The most disturbing syndrome was pain (n = 48, 23.9%), followed by fatigue (n = 28, 13.9%), depression (9.5%) and dyspnoea (6.0%). Altogether, 75% had more than 5 symptoms and 10% reported all 10 symptoms. The total number of symptoms was not significantly associated with sex (p = 0.781) or age (p = 0.062), but it was associated with the diagnostic group; patients with breast cancer (n = 41) and those with prostate cancer (n = 44) reported fewer symptoms than the patients with other cancers (n = 116)(p = 0.023, Kruskal–Wallis). Conclusions Symptoms related to cancer are common among patients treated with palliative indication, but if not specifically surveyed, may remain un-detected and un-treated. ESAS as a clinical tool brings more symptoms to the attention of the physicians and helps in getting a comprehensive insight into the patient’s problems.     

The palliative prognostic score and survival in patients with advanced solid tumors receiving chemotherapy

Purpose To evaluate the accuracy of the Palliative Prognostic Score (PaP score) in selecting metastatic gastrointestinal or nonsmall-cell lung cancer patients candidate to palliative chemotherapy. Materials and methods The PaP score was calculated in 173 patients with advanced, pretreated gastrointestinal or nonsmall-cell lung cancer before starting a further line of chemotherapy with palliative aim. Symptom distress score was calculated using the Edmonton Symptom Assessment System (ESAS) before every course of chemotherapy. Univariate analysis of survival was performed using the logrank test; multivariate analysis was performed using the Cox regression model. Symptom distress scores were compared using multivariate analysis of variance test for repeated measures, and overall symptom distress score was compared using analysis of variance test for repeated measures. Results Overall median survival was 26 weeks; in PaP score class A it was 32 weeks, and in class B 8 weeks (p < 0.0001). No patient was classified in class C. The two-class PaP score resulted in an independent prognostic factor (p = 0.022), as well as Karnofsky performance status (p = 0.002) and colorectal cancer (p = 0.017). A trend towards worsening of symptom distress was observed in the entire population and in class A. The high number of missed data did not permit an adequate analysis in class B. Conclusions The PaP score seems to discriminate patients who could benefit by palliative chemotherapy from those who could better benefit by supportive and palliative approach. However, the data are insufficient to validate the use of the PaP score in patients to be treated with palliative chemotherapy, and further trials should be planned to assess its ability to improve the quality of care in oncology and the appropriateness in the choice of palliative chemotherapy.     

Chemotherapy-induced dermatological toxicity: frequencies and impact on quality of life in women’s cancers. Results of a prospective study

Purpose The study aimed to determine the prevalence of dermatological side effects and its impact on quality of life in patients receiving systemic chemotherapy for women’s cancers. Materials and methods A prospective study was conducted on patients with histologically confirmed advanced women’s cancers who were deemed candidates for adjuvant or palliative chemotherapy. Patients were systemically examined for skin, hair, and nail side effects. The impact of those side effects on their quality of life was assessed using the health-related quality of life score (HRQL). Results Between April 2001 and October 2001, 91 patients received 1 to 17 (median 4) courses of chemotherapy. Malignancies included breast cancer (n = 39, 43%), ovarian cancer (n = 32, 35%), cervical cancer (n = 12, 13%), endometrial cancer (n = 5, 6%), fallopian tube cancer (n = 2, 2%), and vaginal cancer (n = 1, 1%). Chemotherapy agents included taxanes (n = 42, 46%), PEG doxorubicin (n = 17, 7%), other anthracyclines (epirubicin and doxorubicin; n = 6, 19%), topotecan (n = 13, 14%), and other agents (n = 13, 14%). Overall incidence of skin, nail, and hair side effects was 86.8% (n = 79). Seventeen patients (18.7%) developed a palmo-plantar erythrodysesthesia (PPE), and nine of those (53%) were of grade 3 in common toxicity criteria scale (NCI). Twenty-one patients (23.1%) developed nail changes such as subungual hematomas, onycholysis, and leukonychias or nail loss, while 69 (75.8%) developed hair loss. There was a higher incidence of PPE in patients receiving chemotherapy for palliation rather than cure (percent over percent, p < 0.001, Fisher’s exact test). Using the HRQL score, skin changes were the most frequently reported unpleasant side effect (34.1%), and of those patients who developed PPE, this was reported by n = 8 (47%) as the most unpleasant. Conclusions Dermatological chemotherapy side effects are frequent after treatment of women’s cancers and have a major impact on quality of life as assessed by HRQL. Counseling of patients with women’s cancers and the profile of side effects of chemotherapeutic agents should be considered before considering an adjuvant or palliative chemotherapy regimen.     

The impact of an educational DVD on cancer patients considering participation in a phase I clinical trial

Goals of work The quality of informed consent in phase I trials is controversial, partially due to gaps in patient understanding. We assessed an educational DVD’s impact on knowledge and satisfaction in cancer patients newly referred to a phase I clinic. Materials and methods Forty-nine patients were randomly assigned to view an educational DVD (n = 22) which explained phase I trials or a placebo DVD (n = 27). Patients completed a questionnaire assessing knowledge of phase I studies and satisfaction with the DVD. The blinded interviewing physician (n = 8) rated the patient’s understanding of phase I trials. Main results The mean patient age was 56; 61% were male. Patients who viewed the educational DVD were less likely to believe that phase I trials determine drug efficacy (p = 0.019), more likely to know that phase I drugs have not been thoroughly studied in humans (p = 0.003), and less likely to believe that these agents have proven activity against human cancers (p = 0.008). More patients who viewed the educational DVD agreed/strongly agreed that the DVD provided useful information (p < 0.001), were confident in their knowledge of phase I trials (p = 0.031), felt aided in their decision to enter a phase I study (p = 0.011), and would have more questions for their physicians because of the DVD (p = 0.017). No statistically significant difference in physician perception of patient understanding or phase I trial accrual was observed between the educational and placebo DVD groups. Conclusions An educational DVD increased patient knowledge and satisfaction regarding participation in phase I clinical trials.     

Fear of recurrence,treatment satisfaction,and quality of life after radical prostatectomy for prostate cancer

Goals of work Fear of cancer recurrence (FOR) is common in prostate cancer patients, but little research has examined the impact of FOR on quality of life (QOL) or the mechanism by which these fears become intensified. The objective of this study was to examine treatment satisfaction (TS) as a moderator of the relationship between FOR and QOL. Patients and methods Data were drawn from the CaPSURE™ database, a 12,000-man national observational prostate cancer registry. Three hundred and thirty-three patients who underwent radical prostatectomy (RP) to treat their prostate cancer completed self-report measures. TS was measured 0–6 months post-RP with a nine-item scale developed for this study, FOR was measured 6–12 months post-RP with a previously validated five-item scale, and QOL was measured 12–18 months post-RP with the Short Form 36. Main results After controlling for age, education, number of comorbid medical conditions, and cancer severity, lower FOR (B = −0.12, p < 0.0001), higher TS (B = 0.09, p < 0.001), and the interaction of TS × FOR (B = 0.87, p < 0.05) significantly predicted higher mental health QOL scores. Furthermore, lower FOR (B = −0.08, p < 0.01), and the interaction of TS × FOR (B = −1.11, p < 0.01) significantly predicted higher physical health QOL scores. Conclusions TS levels mitigated the impact of high FOR on lower levels of QOL. Specifically, patients who reported lower TS and greater FOR endorsed significantly lower levels of QOL compared to other patients in the sample.     

Quality of end-of-life care for patients with metastatic non-small-cell lung cancer in general wards and palliative care units in Japan

Purpose  

Patients with lung cancer in Japan often receive aggressive care near the end of life and die in an acute care hospital. We describe the differences in end-of-life care for metastatic non-small-cell lung cancer (NSCLC) patients between general wards and a palliative care unit (PCU).     

Personality and fatigue in patients with benign or malignant breast disease

Goals of work The aim of the study was to examine the role of five general personality traits in fatigue in a group of patients with breast cancer (BC) and a group with benign breast problems (BBP). Materials and methods Of the 304 participating women, 127 patients had BC and 177 BBP. A fatigue scale was completed before diagnosis and 1, 3, and 6 months after diagnosis (benign patients) or surgical treatment (BC patients). A personality questionnaire (NEO-FFI) and a depression scale (CES-D) were completed before diagnosis. Main results The BC group was less tired before diagnosis, more tired 1 month after diagnosis, and equally tired 3 and 6 months after diagnosis. In the total group, women were more tired over time when they were more neurotic, less agreeable, or more introverted. After controlling for depressive symptoms, demographics, and medical factors, baseline depressive symptoms (β = 0.29, p < 0.05), neuroticism (β = 0.29, p < 0.05), and extraversion (β = −0.25, p < 0.05) predicted fatigue 6 months later. After also including baseline fatigue, only neuroticism (β = 0.22, p < 0.05) and baseline fatigue (β = 0.79, p < 0.001) predicted fatigue. Conclusions Personality is more strongly related to fatigue than demographics, the diagnosis cancer, receiving cancer treatment, and baseline depressive symptoms and fatigue. When replicated, screening and treating women who are at risk to experience high levels of fatigue is recommended.     

Maintenance of effects of a home-based physical activity program among breast cancer survivors

Purpose  Although physical activity (PA) adoption improves fitness and psychological well-being among cancer survivors, PA maintenance has not been examined. This paper presents follow-up of a home-based PA program for women treated for early-stage breast cancer. Materials and methods  Eighty-six sedentary women (mean age = 53.14 years, SD = 9.70) were randomly assigned to a PA or contact control group. The PA group received a 12-week telephone counseling program to adopt PA. Assessments were conducted at baseline, end-of-intervention (12 weeks), 6, and 9 months post-baseline. Results  When comparing change from end-of-intervention (12 weeks) between groups, a significant reduction was observed in minutes of PA at 6 months (t = −2.10, p < 0.05), but there was no decrease in intervention effect at 9 months (t = −0.19, p = 0.84). Similarly, post-intervention reductions in fatigue were lost at 6 months (t = 3.27, p < 0.01), but remained present at 9 months (t = 1.65, p = 0.10). PA group’s fitness improvements were maintained at both follow-ups (t = 1.04, p = 0.30 and t = 0.05, p = 0.96). The previously significant intervention effect on vigor was maintained at 6 months (t = 1.32, p = 0.19) but was significantly reduced at 9 months (t = −2.15, p < 0.05). PA participants were more likely to progress in motivational readiness at 6 (OR = 5.95, 95% CI = 2.30, 15.36) and 9 months (OR = 4.09, 95% CI = 1.69, 9.87); however, group differences in meeting PA guidelines were not maintained. Conclusion  Some positive effects of a home-based PA intervention for breast cancer patients were maintained at 6 and 9 months.     

Going home to die from surgical intensive care units

Purpose  To better understand events related to going home to die (GHTD) from the intensive care unit (ICU), with the hope that this information might improve the palliative care of ICU patients. Methods  This retrospective observational study was performed at a tertiary medical center—the National Taiwan University Hospital. All surgical ICU mortality cases between 1 January 2003 and 31 December 2007 were included in this study. Results  The rate of GHTD from the ICU declined annually, but has reached a plateau of around 25% in recent years. Multivariate logistic regression analysis found independently significant factors associated with GHTD, including older age (OR: 1.013; P = 0.001), married status (OR: 2.128; P < 0.001), lower educational level (OR: 1.799; P = 0.001), and lack of DNR consent (OR: 1.499; P = 0.006). When treatment intensity was compared on the date of death, GHTD patients in general received more treatments and diagnostic procedures than those who died in the ICU. Univariate analysis showed that GHTD patients received significantly more advanced antibiotics, more chest radiography, greater use of sedatives, greater use of analgesics, and more transfusions, but less FiO₂ and mechanical circulatory support than patients who died in the ICU. Conclusion  GHTD from the ICU is a special phenomenon in the Chinese cultural area, representing a cultural tradition rather than a form of palliative care. This article is discussed in the editorial available at: doi:.