Chien-Yi Wu

Background: Artificial hydration (AH) in terminally ill cancer patients remains ethically and clinically controversial. Although evidence suggests limited benefit near the end of life, AH is frequently administered, particularly in East Asian settings where it may carry symbolic meaning. This study conceptualized physician decision-making as a clinical spectrum and examined demographic, clinical, and ethical factors associated with AH decision orientations. Materials and Methods: A nationwide cross-sectional survey of palliative care–trained physicians in Taiwan assessed clinical practices and ethical domains (autonomy, beneficence, non-maleficence, justice, cultural, and emotional factors). Scenario-based scores were used to derive continuation, withdrawal, and variability indices. Two-step cluster analysis identified decision-orientation profiles. Group differences were analyzed using ANOVA, chi-square tests, and multinomial logistic regression. Results: Among 377 respondents, 4 decision-orientation clusters emerged: contextual/proportional, selective continuation, conservative/continuation-leaning balancing, and consistent withdrawal. Several demographic and professional characteristics differed across clusters. Ethical domains also differed significantly. Multinomial regression showed that cultural and emotional factors were associated with contextual/proportional orientation, whereas beneficence independently predicted selective continuation orientation. Hydration volume and consideration of life expectancy differed across clusters, supporting behavioral distinctions among decision orientations. Conclusion: AH decision-making reflects multiple context-sensitive physician orientations shaped by both ethical considerations and professional characteristics, rather than a binary continuation–withdrawal model.

Background: With a gradually aging global population, more and more older persons are receiving care in long-term care institutions during the final stages of their lives. A variety of factors, including the process of aging, dependence on assistance, and psychological problems, are known to undermine the self-perceived sense of dignity of older persons living in long-term care institutions. Purpose: The purpose of this study was to examine the factors that influence dignity and the incidence of low self-perceived dignity among older persons living in long-term care institutions. Methods: This cross-sectional descriptive study was conducted from April to December 2022 on a sample of 188 older persons living in seven long-term care institutions in southern Taiwan. A structured questionnaire, including a demographic characteristics datasheet, Barthel Index, Patient Dignity Inventory—Mandarin version, and Patient Health Questionnaire-9, was used to collect data. The independent samples t test, one-way analysis of variance (ANOVA), and Pearson’s correlation coefficient were used to examine the correlation between demographic variables and dignity, while binary logistic regression was used to analyze the probability of low dignity. Results: Dignity was found to relate significantly with marital status ( t = 2.49, p = .014), number of children ( r = −.19, p = .008), educational level ( t = −2.42, p = .016), chronic condition ( r = .25, p = .001), ability to perform activities of daily living ( r = −.36, p < .001), dependency level ( F = 9.85, p < .001), mobility level ( t = 2.84, p = .005), indwelling catheter status ( t = −3.29, p = .001), and depression level ( r = .47, p < .001). The results of binary logistic regression analysis showed factors including having fewer children ( OR = 0.652, p < .001) or no children ( OR = 0.101, p = .007), a higher education level ( OR = 3.441, p = .001), or lower activities of daily living ( OR = 0.976, p = .001) as well as suffering from depression ( OR = 6.025, p = .047) or being unable to walk ( OR = 0.448, p = .045) to be significantly associated with self-perceived low dignity. Conclusions/Implications for Practice: The findings indicate that older persons living in long-term care institutions with fewer or no children, a higher level of education, and/or lower activities of daily living, as well as those unable to walk and/or suffering from depression, face a relatively greater risk of suffering from low dignity. In light of this, professional caregivers working in long-term care institutions should place greater emphasis on providing dignified care to older persons.

Background/Objectives: The place where a person dies serves as an indicator of end-of-life care quality. This study aims to identify the congruence of place of death (POD) and the reasons behind decision-making among terminally ill cancer patients in East Asia. Methods: We conducted a prospective multicenter cohort study in palliative care units in Japan, Korea, and Taiwan. Data were collected by the responsible physicians during routine clinical practice. Sankey diagrams were applied to present changes in reasons for POD incongruence. Results: A total of 2638 participants from 37 palliative care units in the three countries were enrolled, and most of them died at PCUs (Japan: 95.7%, Korea: 94%, Taiwan: 82%, p < 0.05). The congruence rate of the preferred and actual POD among PCU inpatients ranged from 70% to 80%. Availability of end-of-life care is the most common reason for preferred and eventual PCU death (78.6%, 72.2%, and 52.1%, respectively, p < 0.05). However, 13–22% of patients admitted to PCUs still preferred to die at home, for which traditional culture (20.2%, 40.8%, and 82%, respectively, p < 0.05) or family influence (44.4%, 38.8%, and 51.7%, respectively, p > 0.05) are the main reasons. Cultural and environmental factors, such as influences from family members’ preferences in the three countries or the ownership of housing/housing settings in Japan, are the main challenges in achieving POD congruence. Conclusions: Culturally inclusive strategies in clinical practice and policy implementation for identifying the preferred POD, enhancing communication among stakeholders, and facilitating transitional support may improve the quality of goal-concordant care.

Background: The Supportive and Palliative Care Indicators Tool (SPICT) was developed for identifying, in a timely manner, patients who may benefit from supportive and palliative care for better treatment review, care-plan discussion, and end-of-life care. Although the SPICT has been validated in different languages and for patients living in different settings, it has not been validated for patients receiving home-based medical care (HBMC), or in the context of using traditional Chinese characters. Objectives: The present study aimed to validate the Taiwanese version of the SPICT (SPICT-TW) and to measure its ability to predict six-month mortality in patients who received HBMC in Taiwan. Methods: Seven HBMC agents (five clinics and two hospitals) participated in this validation study. We recruited 129 patients aged ≥ 50 years who had been consistently receiving HBMC for >two months. Results: The results revealed that the SPICT-TW demonstrated similar reliability and validity compared to other language versions of the SPICT. It may be an appropriate tool for healthcare professionals to detect, in a timely manner, the needs for palliative care in older people who receive home healthcare. Furthermore, we found that a combination of four general indicators and one clinical indicator in the SPCIT-TW has the best prediction ability at predicting six-month mortality in these HBMC recipients. This multi-center study validated the SPICT-TW among HBMC recipients in Taiwan. Conclusions: The SPICT-TW demonstrated high reliability and validity through the Kuder–Richardson 20, an intraclass correlation coefficient, Cohen’s kappa, and receiver operating characteristic analysis, supporting its potential as a practical tool for identifying older adults at risk of dying within six months who have not yet received palliative care but may benefit from it.

The Supportive and Palliative Indicators Tool (SPICT) was developed for timely identifying patients who may benefit from supportive and palliative care for a better treatment review, care plan discussion, and end-of-life care. Although the SPICT has been validated in different languages and patients living in different settings, it has not been validated in patients receiving home-based medical care (HBMC), or in the context of using traditional Chinese characters. The present study aimed to validate the Taiwan version of SPICT (SPICT-TW) and to measure its ability to predict six-month mortality in patients who received HBMC in Taiwan. Seven HBMC agents (five clinics and two hospitals) participated in this validation study. We recruited 129 patients aged ≥50 years who had been consistently receiving HBMC for > two months. The results revealed that the SPICT-TW demonstrated similar reliability and validity compared to other language versions of SPICT. It may be an appropriate tool for healthcare professionals to timely detect the needs of palliative care in older people who received home healthcare. Furthermore, we found that a combination of four general indicators and one clinical indicator in SPCIT-TW has the best prediction ability at predicting six-month mortality in these HMBC recipients. This multicenter study validated the SPICT-TW among HBMC recipients in Taiwan. SPICT-TW demonstrated high reliability and validity and may be a practical tool for identifying older people at risk of dying within six months who would benefit from palliative care.

Background: Artificial hydration (AH) is a challenging issue in terminally ill patients with cancer, because it influences patients' symptoms control, quality of life, and quality of dying (QOD). To date, it is not clear how much AH supply is proper for imminently dying patients. This study aimed to investigate the association between the amount of AH and QOD.Methods: This study is part of the East Asian Collaborative Cross‐Cultural Study to Elucidate the Dying Process (EASED) conducted in Japan, Korea, and Taiwan from January 2017 to September 2018. Patients' demographics, symptoms, and managements on admission to palliative care units (PCUs) and before death were recorded. The AH amount was classified into different groups by 250‐mL intervals to compare their difference. The Good Death Scale (GDS) was used to measure QOD, with patients classified into higher or lower QOD groups using GDS = 12 as the cutoff point. We used logistic regression analysis to assess the association between AH amount and QOD.Results: In total, 1530 patients were included in the analysis. Country, religion, spiritual well‐being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with QOD. After conducting regression analysis, patients administered with 250 to 499 mL AH had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072‐4.730; P = .032) than those without AH.Conclusions: AH use impacts the QOD of terminally ill patients with cancer admitted to PCUs. Communication with patients and their families on appropriate AH use has a positive effect on QOD.Lay Summary: Our prospective cross‐cultural multicenter study aims to investigate the relationship between artificial hydration (AH) amount and quality of dying among terminally ill patients with cancer. The findings reveal that country, religion, spiritual well‐being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with quality of death (QOD). After multivariable logistic regression, patients administered with AH amount 250 to 499 mL had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072‐4.730; P = .032) than those without AH. Communication with patients and their families regarding AH is recommended as it may help them be better prepared for the end‐of‐life stage and achieve a good death.

Objectives: Hospice and early palliative care are generally considered as an alternative and supportive care to offer symptoms relief and optimize the quality of life among end-stage renal disease (ESRD) patients, but hospice care remains underutilized. This study aimed to examine patient and health system characteristics and develop a patient assessment scale to evaluate ESRD patients for hospice care after the implementation of non-cancer hospice care reimbursement policy in 2009 in Taiwan. Method: We conducted a retrospective cohort study using nationwide population-based datasets. Adult long-term dialysis patients between 2009 and 2012 were included. Multivariable logistic regression and the Firth penalized likelihood estimation were used to estimate the likelihood of receiving hospice care. A receiver operating characteristic curve (ROC) analysis and C-statistic were calculated to determine the optimal models for a patient assessment of hospice use. Results: Patients who were older, comorbid with anemia (odds ratio [OR] 3.53, 95% CI 1.43–8.70) or sepsis (OR 1.62, 95% CI 1.08–2.44), with longer dialysis durations, more hospitalizations (OR 4.68, 95% CI 2.56–8.55), or primary provider care with hospice (OR 5.15, 95% CI 2.80–9.45) were more likely to receive hospice care. The total score of the patient assessment scale of hospice care was 0–28 with a cut-off value of 19 based on the results of the receiver operating characteristic curve. Conclusion: Given the “Patient Right to Autonomy Act” implemented in Taiwan in 2019 to promote the concept of a “good quality of death”, this patient assessment scale may help health professionals target ESRD patients for hospice care and engage in shared decision making and the advance care planning process.

Hospitals have played a leading role in providing palliative care in Taiwan as its care model has developed over the past few decades. However, earlier local studies in Taiwan showed that terminal patients prefer to die at home, highlighting the need to promote community-based palliative care instead of hospital-based care. Along with this shift, how community nurses provide palliative home care merits further exploration. This qualitative descriptive study aims to understand (1) how community nurses implement community-based palliative care, (2) what preparations are needed, and (3) what challenges they may face. Purposive sampling was used for recruiting nurses. We conducted one-on-one, in-depth, semi-structured interviews. Interview recordings were transcribed verbatim and analyzed using thematic analysis. Eight community nurses with a range of experience in palliative home care were interviewed. Four major themes emerged: (1) Opportunities, (2) Qualifications, (3) Support, and (4) Commitments. Psychological preparedness, well-developed professional capabilities, external assistance, and peer support motivate community nurses to offer community-based palliative care. As the requests for palliative home care services increase, community nurses play a critical role in palliative home care. Although the sample size is small and the findings retrieved from a small number of experiences might not be generalized to every region, the study results could inform future experience-sharing and workshop sessions to train more nurses for community-based care, expanding service coverage, and providing optimal palliative care.

Background: With a rapidly aging population, there is an increasing need for do-not-resuscitate (DNR) and advance care planning (ACP) discussions. This study investigated the factors associated with signing DNR documents of older patients in the geriatric ward. Methods: We conducted a retrospective cohort study at a geriatric ward in a tertiary hospital in Southern Taiwan. Three hundred and thirty-seven hospitalized older patients aged ≥65 years in the geriatric ward from 2018 to 2019. The Hospital Information System and electronic medical records were accessed to obtain details regarding patients’ demographics, daily living activities, serum albumin level, nutrition screening score, intensive care unit transferal, resuscitation procedure, days of hospital stay, and survival status on discharge, and DNR status was recorded retrospectively. Patients were classified into DNR and non-DNR groups, with t-tests and Chi-square tests applied to compare the differences between groups. Logistic regression was performed to predict factors related to the DNR documents. Results: A total of 337 patients were included, 66 of whom had signed a DNR during hospitalization. After multivariate logistic regression, age 85 or more compared to age 65–74 (adjusted odds ratio, aOR 5.94), poor nutrition with screening score two or more (aOR 2.71), albumin level less than 3 (aOR 3.24), Charlson Comorbidity Index higher than 2 (aOR 2.46) and once transferred to ICU (aOR 5.11) were independently associated with DNR documentation during hospitalization. Conclusions: Several factors related to DNR documents for geriatric patients were identified which could provide clinical information for physicians, patients, and their families to discuss DNR and ACP.

Background: Patients with advanced kidney disease have a symptomatic and psychological burden which warrant renal supportive care or palliative care. However, the impact of do-not-resuscitate consent type (signed by patients or surrogates) on end-of-life treatments in these patients remains unclear. Objective: We aim to identify influential factors correlated with different do-not-resuscitate consent types in patients with advanced kidney disease and the impact of do-not-resuscitate consent types on various life-prolonging treatments. Methods: This was a retrospective observational study. We included patients aged 20 years and over, diagnosed with advanced kidney disease and receiving palliative and hospice care consultation services between January 2014 and December 2018 in a tertiary teaching hospital in Taiwan. We reviewed medical records and used logistic regression to identify factors associated with do-not-resuscitate consent types and end-of-life treatments. Results: A total of 275 patients were included, in which 21% signed their do-not-resuscitate consents. A total of 233 patients were followed until death, and 32% of the decedents continued hemodialysis, 75% underwent nasogastric (NG) tube placement, and 70% took antibiotics in their final seven days of life. Do-not-resuscitate consents signed by patients were associated with reduced life-prolonging treatments including feeding tube placement and antibiotic use in the last seven days (odd ratio and 95% confidence interval were 0.16, 0.07–0.34 and 0.33, 0.16–0.69, respectively) compared to do-not-resuscitate consents signed by surrogates. Conclusions: Do-not-resuscitate consent signed by patients and not by surrogates may reflect better patients’ autonomy and reduced life-prolonging treatments in the final seven days of patients with advanced kidney disease.