Strength Perspective: An Analysis of Ageing in Place Care Model in Taiwan Based on Traditional Filial Piety

In the 1990s, the government in Taiwan proposed a series of community care related policies, in which the main care model was designed to be ‘the local taking care of the local’. In response to the social problems arising from the ageing of the population and the growing demands for welfare, Executive Yuan of Taiwan formulated the Development Program for the Care Service Industry in 2001. The government designed the elderly care policies based on the notions of community care in promoting the care industry. The community care policies would better serve the elderly and encourage families to purchase affordable services. The government aimed to encourage the non-profit sector and the commercial sector to provide care services. In Taiwan, with the notion of ‘in place’ care, the community care model has become a new trend. This study first analyzes the policies and the practices of community care in Taiwan. Secondly, it discusses how to make use of the ‘strength culture’ among Chinese people to construct a community care model based on the strength perspective of traditional filial piety. Finally, it analyzes the ‘community care centers’ that Taiwan is currently running with the aim of constructing a system of ‘ageing-in-place’ community care based upon the tenets of filial piety.

The Utilization of Palliative Care Services in Patients with Cirrhosis who have been Denied Liver Transplantation: A Single Center Retrospective Review

Introduction and AimUtilization of palliative care services in patients dying of end-stage liver disease (ESLD) is understudied. We performed a retrospective review of palliative care services among patients with ESLD unsuitable for liver transplantation (LT) at a tertiary care center.Material and MethodsDeceased ESLD patients considered unsuitable for LT from 2007-2012 were identified. Patients were excluded if they received a transplant, had an incomplete workup, were lost to follow up or whose condition improved so LT was not needed. Of the 1,175 patients reviewed, 116 met inclusion criteria.ResultsForty patients (34.4%) received an inpatient palliative care (PC) consultation and forty-one patients (35.3%) were referred directly to hospice. Thirty-three patients (28.4%) transitioned to comfort measures without PC consultation (median survival < 1 day). The median interval between LT denial and PC consultation or hospice was 28 days. Median survival after PC consult or hospice referral was 15 days. In conclusion, in a single center retrospective review of ESLD patients, palliative care services, when utilized, were for care at the very end of life. Without consultation, aggressive interventions continued until hours before death. We propose that ESLD patients could benefit from PC consultation at time of LT evaluation or based on MELD scores.     

Prevalence and structure of palliative care services in California hospitals

BACKGROUND: Most Americans die in hospitals where shortcomings in end-of-life care are endemic. Hospital-based palliative care services can improve the care of these patients, yet there are limited data regarding the availability of such services. We sought to determine the prevalence of palliative care services in California hospitals. METHODS: We conducted a cross-sectional survey of a random sample of 25% of all California hospitals. We recorded the percentage of hospitals reporting current or planned palliative care consultation services or inpatient palliative care units. RESULTS: We collected data from 107 (96%) of 112 hospitals. Only 17% of hospitals have a palliative care consult service, and 6% have an inpatient palliative care unit. Nearly all services are multidisciplinary. Twenty percent of hospitals have a contract to provide inpatient hospice beds, 19% have an outpatient-based hospice service affiliated with the hospital, and 74% offer bereavement services. Half of all palliative care services are funded exclusively by the hospital. Thirty-eight hospitals (36%) reported an interest in developing palliative care services. CONCLUSIONS: Few California hospitals currently have palliative care services, though more express interest in developing them. Bereavement and hospice services are more common and offer opportunities for increasing the number of palliative care services in hospitals. Further studies are needed to characterize palliative care services more fully and to assess the quality of care provided by these services.     

Differences between dedicated and not dedicated hospice physicians in symptoms and signs improvement among advanced cancer patients

The hospice and palliative care can improve the symptoms and signs of terminal cancer patients. The purposes of this study are how to improve terminally ill cancer patients’ symptoms and signs and how the dedicated palliative care service effects on these improvements.From January 2017 to March 2019, among 919 terminally ill cancer patients admitted to the palliative care units in 11 hospitals of South Korea, we analyzed 334 patients with prospective cohort method and categorized them into non-dedicated hospice care group of 234 and dedicated hospice care group of 100.Symptoms improvement of dyspnea, fatigue, drowsiness, and dry mouth during the first week of admission were respectively 298 (89.2%), 25 (7.5%), 204 (61.1%), 76 (22.8%). Signs improvement of myoclonus, respiratory secretion, leg edema, and ascites between admission and a week after were 5 (1.5%), 41 (12.3%), 47 (14.1%), 12 (3.6%). Significant differences between dedicated hospice care physician group and non-dedicated hospice care physician group were shown in drowsiness (67.5% vs 46%, P < .001) and respiratory secretion (15% vs 6%, P < .028). Compared to non-dedicated care group, the odds ratio for more than 2 symptoms or signs was 1.78 (95% confidence interval, 1.05–3.02) in the dedicated care group after adjusting confounding variables.In conclusion, terminally ill cancer patients who received palliative or hospice service showed significant improvement in symptoms and signs. And, family doctors (dedicated hospice physician group) performed better than oncologists (non-dedicated physician group).     

Older Persons: the Case of South Africa

The South African Constitution (Act 108 of 1996) laid the foundation for the transformation agenda of the new democracy to protect the human rights of older persons and to terminate all the forms of racial discrimination and inequality that had been instituted against them by the apartheid state. New legislation was passed in 2006, making provision for the protection of the rights of older persons and shifting services from primarily institutional care to community-based care, with a view to keeping the elderly in the community as long as possible. The old age pension, which is received by the majority of older persons in South Africa, targets household poverty rather than facilitating older persons’ independent living. Recurring themes in qualitative studies conducted in South Africa include the erosion of the traditional extended family, which impacts on families’ ability to care for older people, and the high incidence of HIV/AIDS in South Africa. Consequently, the elderly have become primary care-givers for sick children and orphaned grandchildren. They now face financial hardship, because they have to share their meagre income with their intergenerational households. In their caregiver role, the elderly experience renewed meaning for their lives in contributing to society, which instils resilience and a sense of empowerment. Despite this, they remain a vulnerable group who can be exploited. The South African government and society are challenged to implement the Act on Older Persons, No 13 of 2006, which forms the cornerstone for services that will facilitate older people’s protection and their full integration into South African society.     

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

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

A Cross-Cultural Study on Behaviors When Death Is Approaching in East Asian Countries: What Are the Physician-Perceived Common Beliefs and Practices?

The primary aim of this study was to explore common beliefs and practices when death is approaching in East-Asian countries.A cross-sectional survey was performed involving palliative care physicians in Japan, Korea, and Taiwan. Measurement outcomes were physician-perceived frequencies of the following when patient death was approaching: (1) reluctance to take part in end-of-life discussions, (2) role of family members, (3) home death, and (4) circumstances surrounding death.A total of 505, 211, and 207 responses were obtained from Japanese, Korea, and Taiwan physicians, respectively. While 50% of the Japanese physicians reported that they often or very often experienced families as being reluctant to discuss end-of-life issues, the corresponding figures were 59% in Korea and 70% in Taiwan. Two specific reasons to avoid end-of-life discussion, “bad things happen after you say them out loud” and “a bad life is better than a good death” were significantly more frequently observed in Taiwan. Prioritizing the oldest of the family in breaking bad news and having all family members present at the time of death were significantly more frequently observed in Korea and Taiwan. Half of Taiwanese physicians reported they often or very often experienced the patients/family wanted to go back home to die because the soul would not be able to return from the hospital. In all countries, more than 70% of the physicians reported certain family members were expected to care for the patient at home. At the time of death, while no Japanese physicians stated that they often experienced patients wanted a religious person to visit, the corresponding figure in Korean and Taiwan was about 40%. Uncovered expression of emotion was significantly frequently observed in Korean and Taiwan, and 42% of the Japanese physicians reported family members cleaned the dead body of the patient themselves.There seem to be significant intercountry differences in beliefs and practices when death is approaching in East Asian countries. Future studies on direct observations of patients and families are needed.     

Increasing access and quality in Department of Veterans Affairs care at the end of life: a lesson in change

The pursuit of a "good death" remains out of reach for many despite numerous piecemeal solutions to address the growing need for access to quality care at the end of life. In 2002, U.S. veteran deaths were at an all-time high, few Department of Veterans Affairs (VA) hospitals had inpatient palliative care services, and there was no reliable approach to meet home hospice needs. The VA embarked on a course of major change to improve veterans' care at the end of life.
A coordinated plan to increase access to hospice and palliative care services was established, addressing policy development, program and staff development, collaboration with community hospices, outcomes measurement, and proving value to the organization. To determine progress and monitor resource allocation, workload and outcome measures were established in all settings.
Within 3 years, the number of veterans receiving VA-paid home hospice had tripled, all VA hospitals had a palliative care team, 42% of all veterans who died as VA inpatients received a palliative care consultation, and a nationwide network of VA partnerships with community hospice agencies was established. Through a multifaceted strategic plan and a mission of honoring veterans' preferences for care at the end of life, the VA has made rapid progress in improved access to palliative care services for inpatients and outpatients. The VA's experience serves as a powerful example of the magnitude of change possible in a complex health system and a model for improving access and quality of palliative care services in other health systems.     

Palliative care teaching in medical residency: a review of two POGO-e teaching products

This is a comparison review of GeriaSims and Care of the Aging Medical Patient (CHAMP) modules addressing issues in palliative and hospice medicine found in the Portal of Geriatric Online Education, a free on-line repository of geriatric educational materials for medical educators. GeriaSims is a self-directed teaching module designed to systematically address many of the important questions involved in caring for individuals with chronic progressive and life-limiting illnesses. It is well suited for physicians, particularly medical residents and fellows in-training, who provide care for medically complicated elderly and terminally ill individuals. The CHAMP module is designed to familiarize physician educators with palliative and hospice medicine basics to teach residents and fellows through didactic slides, although it can probably be adapted for use by residents and fellows if audio commentary accompanies the slides. Both modules address practical approaches to addressing palliative care in patients and their families. They are useful teaching tools that address an important learning need and can be readily used to supplement current residency curriculum in hospice and palliative medicine.     

Interdisciplinary End-of-Life Care in Nursing Homes

ABSTRACT

About 25% of deaths in the United States now occur in nursing homes, and this proportion is increasing. Current end-of-life (EOL) care in these facilities faces substantial challenges, including under-management of pain, dyspnea, and other symptoms, a clash of cultures between palliative care/hospice teams and the nursing facility, and reimbursement policy that discourages the use of hospice. For ethnic minorities, these challenges are more striking. Improvement in EOL care in nursing homes requires integration between the traditional rehabilitative/restorative mission of long-term care and the palliative model of hospice. Education, better utilization of hospice, cooperation in quality improvement, and changes in reimbursement policy will lead to better care for these increasingly frail and elderly patients.     

The influence of patient and carer age in access to palliative care services

BACKGROUND: Older patients are less likely to receive palliative care than younger patients. As patient and primary carer age correlate positively, patterns may be due to carer rather than patient age, and reflect better ability to obtain support among younger carers. OBJECTIVE: To investigate how both patient and carer age relate to palliative care use, controlling for relevant variables. DESIGN: Comparison of patients who received community Macmillan nurse specialist advice, Marie Curie nursing or inpatient hospice care with patients who did not, using univariate analysis and multivariate logistic regression. Patient and carer data were collected through electronic service record linkage and carer post-bereavement interviews. Sample: patients referred to a hospice at home service whose primary carer could be interviewed (n = 123). RESULTS: Whilst a cancer diagnosis was an important determinant of access for all services considered, logistic regression shows that carer age, but not patient age, and hospice at home access predicted Marie Curie nursing use. Both patient and carer age predicted use of Macmillan nurse advice. Age of the patient, but not carer age, predicted admission to inpatient hospice, alongside requiring care for over a month (all P < 0.05). CONCLUSIONS: Carer age may be as important a predictor of palliative home care use as patient age. We need to investigate whether younger carers have greater support needs or show greater effectiveness in obtaining help and to assess whether older carers need more assistance in recruitment of support.     

Advance care planning and end-of-life care for hospitalized nursing home residents

OBJECTIVES: To describe advance care planning (ACP) and end-of-life care for nursing home residents who are hospitalized in the last 6 weeks of life. DESIGN: Constant comparative analysis of deceased nursing home resident cases.SETTING: A not-for-profit Jewish nursing home. PARTICIPANTS: Forty-three deceased residents hospitalized within the last 6 weeks of life at a tertiary medical center. MEASUREMENTS: Trained nurse reviewers abstracted data from nursing home records and gerontological advanced practice nurse field notes. Clinical and outcome data from the original study were used to describe the sample. Data were analyzed using the constant comparative method and validated in interviews with a gerontological advanced practice nurse and social worker. RESULTS: The analysis revealed distinct characteristics and identifiable transition points in ACP and end-of-life care with frail nursing home residents. ACP was addressed by social workers as part of the nursing home admission process, focused primarily on cardiopulmonary resuscitation preference, and reviewed only after the crisis of acute illness and hospitalization. Advance directive forms specifying preferences or limitations for life-sustaining treatment contained inconsistent language and vague conditions for implementation. ACP review generally resulted in gradual limitation of life-sustaining treatment. Transition points included nursing home admission, acute illness or hospitalization, and decline toward death. Relatively few nursing home residents received hospice services, with most hospice referrals and palliative care treatment delayed until the week before death. Most residents in this sample died without family present and with little documented evidence of pain or symptom management. CONCLUSION: Limiting discussion of advance care plans to cardiopulmonary resuscitation falsely dichotomized and oversimplified the choices about medical treatment and care at end-of-life, especially palliative care alternatives, for these older nursing home residents. Formal hospice services were underutilized, and palliative care efforts by nursing home staff were often inconsistent with accepted standards. These results reinforce the need for research and program initiatives in long-term care to improve and facilitate individualized ACP and palliative care at end of life.     

Integrating palliative care in severe chronic obstructive lung disease

Palliative care services for patients with chronic obstructive pulmonary disease (COPD) have been limited in most health care schemes despite the significant impact its symptoms can have on quality of life (QOL). Palliative care must be integrated to address physical and emotional distress and QOL deterioration more effectively. Multi-factorial barriers in current health care systems impede the provision of palliative care, including the lack of familiarity among health care professionals. There are sparse evidence-based studies and guidelines for clinicians to better recognize the need for palliative care in COPD patients compared to the large experience and resources available to cancer patients and hospice care. The multidisciplinary approach of palliative care should help COPD patients navigate through the continuum of chronic disease management. Highest QOL, not necessarily the highest physiologic goals, with relief of physical and emotional suffering, are most important to patients. Hospice care, the last phase of palliative care, can be offered to COPD patients when their goal of care has changed from life-prolonging therapies to comfort treatment. We suggest a scheme for identifying COPD patients for palliative care and for delivering simultaneous disease-directed care to help patients live life to the fullest. Pulmonary rehabilitation offers the best venue for incorporating palliative care. We review the need for, barriers to, and key activities for integrating palliative care into the current health care management of patients living with COPD.     

Advance directives and intensity of care delivered to hospitalized older adults at the end-of-life

BackgroundOlder adults prefer comfort over life-sustaining care. Decreased intensity of care is associated with improved quality of life at the end-of-life (EOL).ObjectivesThis study explored the association between advance directives (ADs) and intensity of care in the acute care setting at the EOL for older adults.MethodsA retrospective, correlational study of older adult decedents (N = 496) was conducted at an academic medical center. Regression analyses explored the association between ADs and intensity of care.ResultsAdvance directives were not independently predictive of aggressive care but were independently associated with referrals to palliative care and hospice; however, effect sizes were small, and the timing of referrals was late.ConclusionThe ineffectiveness of ADs to reduce aggressive care or promote timely referrals to palliative and hospice services, emphasizes persistent inadequacies related to EOL care. Research is needed to understand if this failure is provider-driven or a flaw in the documents themselves.     

日、韩新型冠状病毒肺炎疫情分析与趋势预测

目的对日韩两国新型冠状病毒肺炎疫情状况进行分析并预测其发展趋势,为中日韩三国有效开展联防联控工作提供理论依据。方法统计和计算日韩此次疫情单日新增病例、累计确诊病例数和病死率并绘制其折线图。通过构建传染病动力学SEIR模型以预测疫情发展趋势。结果日本新冠肺炎每日新增确诊病例近期可能还会呈上升趋势,韩国每日新增确诊病例总体呈现下降趋势,SEIR模型预测的结果与日韩当前疫情发展的真实数据吻合较好,日韩两国疫情出现拐点的时间分别大致为2020年5月3日和3月12日,疫情有望得到基本控制的时间分别大致为2020年9月16日和6月11日。结论韩国已经到达了疫情的拐点,但未来一段时间内还难以实现新增病例归零状态,而日本疫情尚处于传播阶段的早中期,确诊人数还可能会继续上升,两国政府要继续加大疫情防控力度,中日韩要有效开展联防联控工作,特别是要加强对于当前无症状感染者的管理和输入病例的控制。     

Does hospice have a role in nursing home care at the end of life?

OBJECTIVES: To assess the possible benefits and challenges of hospice involvement in nursing home care by comparing the survival and needs for palliative care of hospice patients in long-term care facilities with those living in the community. DESIGN: Retrospective review of computerized clinical care records. SETTING: A metropolitan nonprofit hospice. PARTICIPANTS: The records of 1,692 patients were searched, and 1,142 patients age 65 and older were identified. Of these, 167 lived in nursing homes and 975 lived in the community. MEASUREMENTS: Patient characteristics, needs for palliative care, and survival. RESULTS: At the time of enrollment, nursing home residents were more likely to have a Do Not Resuscitate order (90% vs 73%; P < .001) and a durable power of attorney for health care (22% vs 10%; P < .001) than were those living in the community. Nursing home residents also had different admitting diagnoses, most notably a lower prevalence of cancer (44% vs 74%; P < .032). Several needs for palliative care were less common among nursing home residents, including constipation (1% vs 5%; P = .02), pain (25% vs 41%; P < .001), and anticipatory grief (1% vs 9%; P < .001). Overall, nursing home residents had fewer needs for care (median 0, range 0-3 vs median 1, range 0-5; rank sum test P < .001). Nursing home residents had a significantly shorter survival (median 11 vs 19 days; log rank test of survivor functions P < .001) and were less likely to withdraw from hospice voluntarily (8% vs 14%; P = .03). However, there was no difference in the likelihood of becoming ineligible during hospice enrollment (6% for both groups). CONCLUSIONS: These results suggest that hospices identify needs for palliative care in a substantial proportion of nursing home residents who are referred to hospice, although nursing home residents may have fewer identifiable needs for care than do community-dwelling older people. However, the finding that nursing home residents' survival is shorter may be of concern to hospices that are considering partnerships with nursing homes. An increased emphasis on hospice care in nursing homes should be accompanied by targeted educational efforts to encourage early referral.     

Need for hospice and palliative care services in patients with end-stage heart failure treated with intermittent infusion of inotropes

BACKGROUND: Hospice and palliative care programs to relieve suffering and optimize management of terminally ill patients have grown rapidly in the United States. However, there are no data on the need for these services among patients with end-stage heart failure receiving intermittent infusion of intravenous inotropes. HYPOTHESIS: The need for hospice and palliative care programs among patients in end-stage heart failure who receive intermittent infusion of inotropes is investigated. METHODS: The study included all stable patients with refractory heart failure symptoms treated with inotropes in our outpatient unit. A total of 73 patients (65 +/- 12 years; left ventricular ejection fraction 22 +/- 9%; New York Heart Association class 3.6 +/- 0.4) were seen during a 49-month period. Of these, 35 patients (48%) met hospice or palliative care evaluation criteria upon referral but were offered, and accepted, the alternative of parenteral inotropes. In all, 1,737 individual outpatient treatment sessions were given, with a mean of 24 +/- 19 sessions per patient (range 5 to 118 sessions), representing a minimum of 9,948 h of inotrope therapy. RESULTS: A total of 18 (25%) patients died, 6 (8%) patients were withdrawn from the program (3 by their primary physicians and 3 because of significant travel limitations); 4 (5%) patients required continuous intravenous home therapy; and 44 (61%) patients were discharged with significant improvement in their heart failure symptoms. Only 7 of the 18 patients who died had received hospice or palliative care intervention, mainly for the sake of comfort and to ease the transition among family members. The rest of the patients were comfortable and had accepted the natural evolution of their disease; they were not interested in or did not require hospice or palliative care intervention. Of the patients discharged from the outpatient cardiac infusion unit, the interval free of heart failure symptoms after the final infusion treatment ranged from 201 to 489 days, with no need for hospitalization or emergency room visits. CONCLUSION: Our results demonstrate that intermittent infusion of intravenous inotropes can be safely administered and can improve symptoms in a significant number of patients, probably by slowing the natural progression of heart failure. Although the full clinical impact of inotrope therapy in an outpatient setting has not been fully defined, other nonhemodynamic-related benefits should be sought and investigated. Our results suggest that intermittent infusion of intravenous inotropes is one of the prominent variables that requires particular attention. In our experience, the institution of intermittent infusions of intravenous inotropes can, in fact, modify end-stage heart failure symptoms that, in most patients, are currently perceived to lead to a terminal event. Thus, appropriate use of intermittent infusion of intravenous inotropes may not only improve functional class and symptoms in a significant number of patients identified as terminal by their poor response to conventional therapy, but it may also facilitate better utilization of hospice and palliative care resources among patients with end-stage heart failure. Furthermore, the need for hospice and palliative care in patients with heart failure should be revisited in view of adjuvant treatment options such as intermittent infusion of intravenous inotropes.     

Definitions and goals in palliative medicine

Especially in the last 15 years Palliative Care and Palliative Medicine in Germany have increasingly attracted professional and public attention and made remarkable progress. One of the characteristics of Palliative Care in Germany is the differentiation of palliative care from hospice care. Under different viewpoints structure, target groups and aims of Palliative Care have been under discussion in the last 30 years, which made an impact on different forms in the provision of care. Palliative therapy should be distinguished from supportive care and palliative medicine. The revised WHO-definition of Palliative Care broadened the aspects of care in a comprehensive and more holistic understanding of the social, emotional and spiritual needs of patients and their families, including bereavement; and, finally, interdisciplinary and team working issues. It is important to differentiate the palliative care approach from general and specialized palliative care provision for patients with incurable progressive illness and in old age. In Germany 10-12% of all dying patients per year are in need of a specialized palliative care service. The growth in the group of the "very old" will be an important challenge for palliative care in the near future.     

Definitionen und Ziele in der Palliativmedizin

Especially in the last 15?years Palliative Care and Palliative Medicine in Germany have increasingly attracted professional and public attention and made remarkable progress. One of the characteristics of Palliative Care in Germany is the differentiation of palliative care from hospice care. Under different viewpoints structure, target groups and aims of Palliative Care have been under discussion in the last 30?years, which made an impact on different forms in the provision of care. Palliative therapy should be distinguished from supportive care and palliative medicine. The revised WHO-definition of Palliative Care broadened the aspects of care in a comprehensive and more holistic understanding of the social, emotional and spiritual needs of patients and their families, including bereavement; and, finally, interdisciplinary and team working issues. It is important to differentiate the palliative care approach from general and specialized palliative care provision for patients with incurable progressive illness and in old age. In Germany 10?C12% of all dying patients per year are in need of a specialized palliative care service. The growth in the group of the ??very old?? will be an important challenge for palliative care in the near future.