Shinmi Kim

Communication for end-of-life care planning among Korean patients with terminal cancer: A context-oriented model.

OBJECTIVE In Korea, patients with terminal cancer are often caught out of the loop in end-of-life (EoL) care discussions. Healthcare professionals also have difficulty engaging in such communication in a variety of healthcare contexts. Therefore, the objective of our study was to develop a communication model for EoL care decision making compatible with the clinical environment in Korea. METHODS Using focus-group interview methodology, participants included eight doctors and five nurses who provide EoL care for terminal cancer patients in acute hospital settings or hospice care facilities in various provinces of Korea. RESULTS Five themes emerged regarding EoL care discussion, which included: (1) timing, (2) responsible professionals, (3) disclosure of bad news, (4) content areas of EoL care discussion, and (5) implementing strategies for EoL care discussions. These themes were based on development of a communication algorithm for EoL discussion among patients with terminal cancer. A structural communication step for delivery of a terminal prognosis was specified at the phase of disclosure of bad news: beginning with determination of a patients decision-making capability, followed by a patients perception of his/her condition, a patients wish to know, family dynamics, and a patients and/or familys readiness for EoL discussions. SIGNIFICANCE OF RESULTS The proposed context-oriented communication algorithm could provide a helpful guideline for EoL communication and, accordingly, facilitate meaningful improvements in EoL care in Korean clinical practice. The feasibility of this algorithm has not yet been determined, and its validation in a larger sample of patients with terminal cancers, using a quantitative research methodology, is a priority of research.

Professional Opinions on Advance Directives in Korea

A Korean advance directive (K-AD) draft was developed for establishment of a unified and evidence-based form of AD in Korea. Yet, it remains unknown whether this K-AD is culturally and practically compatible for employment in a clinical environment. Therefore, the aim of this study was to solicit professional opinions regarding this K-AD draft. Using a panel of experts in hospice and end-of-life (EOL) care, a 3-round Delphi study was conducted for evaluation of K-AD, composed of 16 specifics in 5 components, including introduction, a value statement, treatment options, proxy appointment, and stakeholders’ signatures. A consensus was determined: An item scored as important (≥4 on a 5-point Likert scale) among 75% of experts or content validity ratio of 0.59 or greater. Forty experts, 35% (n = 14) and 79% (n = 11) of previous-round participants, completed each round. Item evaluation did not differ across 3 rounds (Friedman &khgr;2 = 0.00-6.00, P = .05-1.00). Experts reached a consensus on 5 K-AD components, all-encompassing. Among EOL treatment options, cardiopulmonary resuscitation, artificial ventilation, artificial feeding, and hospice care were determined for inclusion of the K-AD. Important-item content validity ratios ranged from 0.64 to 1.00. In conclusion, K-AD could be used as a vehicle to facilitate the decision-making process for EOL care.

Facilitators and Barriers to Use of Advance Directives in Korea

Few studies assessing professional opinions regarding facilitators and barriers to use of advance directives (ADs) in Korea have been reported. The aims of this study were to (1) identify facilitators and barriers to use of ADs and (2) evaluate their importance in clinical practice. To address the aims of the study, a panel of experts in end-of-life care was invited and their opinions regarding facilitators and barriers to use of ADs were solicited using a semistructured survey (round 1). The relative importance of facilitators and barriers that emerged from the survey was evaluated on a 10-point Likert scale (round 2). Forty experts participated in round 1; 38% of them completed round 2. Five facilitators were identified with regard to knowledge, legal system, patient-provider paradigm shift, public and professional education, and cultural understanding. Seven barriers emerged, including negative attitudes, lack of a legal system, Korean Confucian belief, limited support, professional incompetence, and advances in medical therapy. Knowledge and negative attitudes were the most important facilitator and barrier for successful implementation of ADs, respectively. In conclusion, public and professional education is believed to be critical to increasing knowledge and enhancing positive attitudes toward ADs and professional competence in end-of-life care. A legal model of ADs that is compatible with Korean culture is also needed.

Awareness of advance directives among Korean nurses.

Awareness of advance directives (AD) among 293 nurses working in acute hospitals was evaluated through a structured questionnaire. Nurses were poorly acquainted with AD. Education about AD and related concepts are required in college and field experience to improve practice and communication with patients at the end of life.

Experiences and Opinions Related to End-of-Life Discussion: From Oncologists' and Resident Physicians' Perspectives

Purpose The aims of this study were to explore how oncologists and resident physicians practice end-of-life (EOL) discussions and to solicit their opinions on EOL discussions as a means to improve the quality of EOL care. Materials and Methods A survey questionnaire was developed to explore the experiences and opinions about EOL discussions among oncologists and residents. Descriptive statistics, the t test, and the chisquare test were performed for the analyses. Results A total of 147 oncologists and 229 residents participated in this study. The study respondents reported diverse definitions of “terminal state,” and mostrespondents tried to disclose the patient’s condition to the patient and/or family members. Both groups were involved in EOL care discussions, with a rather low satisfaction level (57.82/100). The best timing to initiate discussionwas consideredwhen metastasis or disease recurrence occurred orwhen withdrawal of chemotherapy was anticipated. Furthermore, the study respondents suggested that patients and their family members should be included in the EOL discussion. Medical, legal, and ethical knowledge and communication difficulties along with practical issues were revealed as barriers and facilitators for EOL discussion. Conclusion This study explored various perspectives of oncologists and resident physicians for EOL discussion. Since the Life-Sustaining-Treatment Decision-Making Act will be implemented shortly in Korea, now is the time for oncologists and residents to prepare themselves by acquiring legal knowledge and communication skills. To achieve this, education, training, and clinical tools for healthcare professionals are required.

End-of-life care decisions using a Korean advance directive among cancer patient–caregiver dyads

OBJECTIVE The Korean advance directive (K-AD) comprises a value statement, treatment directives, preferences for cardiopulmonary resuscitation (CPR), artificial ventilation, tube feeding, and hospice care, as well as a proxy appointment. The K-AD can facilitate a patients decision making with respect to end-of-life (EoL) care. The present study aimed to examine the extent to which patient-caregiver dyads would use the K-AD and agree on EoL care decisions. METHODS Using a descriptive study design, 81 cancer patients were invited to participate. The final sample consisted of 44 patient-caregiver dyads who completed survey questionnaires, including the K-AD. One patient did not complete all parts of the questionnaire, and 36 (44.4%) declined to participate. Content analysis was conducted to examine the K-AD value statements. Cohens kappa coefficient was calculated to determine the degree of patient-caregiver dyadic agreement on K-AD treatment directives (Sudore & Fried, 2010). RESULTS Our patient participants had the following cancer diagnoses: colorectal 29.5%, breast 29.5%, and liver/biliary tract cancers, 15.9%. Half of the sample had advanced-stage disease. Spouses (70.5%) or adult children (20.4%) were the primary caregivers, with perceived bonding rated as fair (31.8%) or good (65.9%). Rejection of the K-AD was mainly due to the difficulty involved in deciding on EoL care (50%). Comfort while dying was the most common theme expressed by patients (73.8%) and caregivers (66.7%). In terms of treatment directives, dyads advocated for hospice care (66.7%) and reduced support for aggressive treatments of CPR or artificial ventilation. The use of CPR (κ = 0.43, p = 0.004) and artificial ventilation (κ = 0.28, p = 0.046) showed significantly mild to moderate concordance among the dyads. Some 16 of the 21 dyads identified their spouses as a proxy, with others designating their adult children. SIGNIFICANCE OF RESULTS The degree of patient-caregiver concordance on the K-AD seemed applicable, and achieved mild to moderate concordance. Our findings are exploratory but suggest the need for EoL discussions where patient-caregiver dyads are encouraged to participate in EoL care decision making.

A Context-oriented Communication Algorithm for Advance Care Planning: A Model to Assist Palliative Care in Heart Failure

Background: Access to consultation or referral for decisions about advance care planning (ACP) is limited, particularly for nonmalignant models pertinent to palliative care in heart failure (HF). Objectives: The aim of this study was to solicit professional opinions about the feasibility of using an exemplary context-oriented communication algorithm for ACP discussions. Methods: Using a panel of expert physicians and nurses in cardiovascular care, a 3-round Delphi study was conducted to evaluate the proposed model. Results: A consensus was determined based on a content validity ratio (CVR) of 0.318 or greater, a critical value for selection of an item scored as important (≥4 on a 5-point Likert scale). A total of 50, 44, and 38 experts in Korea completed each round, respectively. Item evaluation did not differ across rounds (Friedman &khgr;2 > P = .05), except for timing of the ACP discussion. A lack of consensus was observed on the issue of after HF diagnosis for right timing of the ACP discussion across rounds (CVRs from −0.80 to −0.83); consensus was reached on the expectation of a terminal state (CVRs from 0.60 to 0.78). Content validity ratios were moderately high for Korean advance directive, ranging from 0.59 to 0.91. Experts also reached consensus about each of 5 steps of a communication model—patients’ determination of decisional capacity (CVR, 0.72–1.0), awareness (CVR, 0.95–1.0), willingness for advance care planning (CVR, 0.76–0.84), family dynamics (CVR, 0.92–1.0) and patient readiness for advance care planning (CVR, 0.76–0.95). Conclusions: A context-oriented communication model could be used to facilitate the decision-making process for palliative care and continuity of care in HF.

Feasibility of the Korean-Advance Directives Among Community-Dwelling Elderly Persons

A newly developed Korean-Advance Directive (K-AD) consists of a value statement, treatment directives, and proxy appointment. It remains undetermined whether K-AD is applicable to community-dwelling persons (≥ aged 60 years). Using a descriptive study design, 275 elderly persons completed the K-AD (mean age = 77.28 ± 8.24 years). The most frequent value at the end of life was comfort dying, followed by no burden to family (23.6%). Among 4 K-AD treatment options, more than half had a preference for hospice care and had reluctance with aggressive treatment choices of cardiopulmonary resuscitation (76.4%), artificial ventilation (75.6%), and tube feeding (76.4%), with one-fifth having a desire for such options. All persons provided proxies, who were predominantly descendants (77.1%), followed by spouses (17.5%). For treatment preferences, men and those with no religion were more likely to receive life-sustaining treatments. These data support the K-AD as being applicable and acceptable among community-dwelling elderly persons; awareness of the K-AD in the community setting may facilitate future application when the need occurs.

End-of-life care decisions using Korean advance directives among cancer patient-caregiver dyads.

11 Background: The Korean advance directives (K-ADs) consist of a value statement, treatment directives (cardiopulmonary resuscitation [CPR], preferences for artificial ventilation, tube feeding, and hospice care). K-ADs can facilitate a patients decision-making for end-of-life (EOL) care. This study aims to examine the extent to which patient-caregiver dyads agreed on decisions for EOL care using the K-ADs. METHODS Using a descriptive study design, 81 cancer patients were invited to participate. The final sample consisted of 44 patient-caregiver dyads who completed K-ADs; 36 (44.4%) of the initial 81 patients declined to participate. RESULTS Patient participants had different cancerdiagnoses: 29.5% colorectal cancer, 29.5% breast, and 15.9% liver/biliary tract cancers; 59% of the sample had advanced stage cancer. Spouse (70.5%) and adult children of the patient (20.4%) were primary caregivers with perceived bonding rated as fair (31.8%) or good (65.9%). Rejection of K-ADs was mainly because of difficulty in deciding EOL care (50%). Comfort in dying was the most common theme of the value statement for patients (73.8%) and caregivers (66.7%). For treatment directives, dyads advocated for hospice care (66.7%) and reduced support for aggressive treatments of CPR or artificial ventilation, k = .43, p = .004 and k = .28, p = .046, respectively. These approaches showed significantly mild to moderate concordance among the dyads. Sixteen out of the 21 dyads identified their spouses as a proxy, with others designating their adult children. CONCLUSIONS The findings of the study are exploratory but suggest the need for ongoing EOL discussion where patient-caregiver dyads are encouraged to participate in the decision-making for EOL care.

Identifying and prioritizing topics for evidence‐based geriatric nursing practice guidelines in Korea

BACKGROUND Despite the increasing population of elderly individuals in Korea, there are no evidence-based geriatric nursing practice guidelines. AIM This study aimed to identify and prioritize topics related to the development of evidence-based geriatric nursing practice guidelines in long-term care facilities in Korea. METHODS To identify potential topics, 89 nurses responded to a questionnaire on activities that require further evidence and/or standardization in the long-term care facility setting. To prioritize these topics, 14 geriatric nursing experts completed surveys to prioritize five categories. RESULTS The collected data included 240 clinical topics, which were classified into 41 subcategories and 18 main categories. According to topic prioritization by the geriatric nursing experts, the following were the most heavily weighted categories: fall prevention, position change and prevention of pressure ulcers. CONCLUSIONS The development of standardized guidelines based on these results may help improve the quality of geriatric care and quality of life of older individuals. The small number of respondents may be a limitation of this study, and further study is needed to expand the population. IMPLICATIONS FOR NURSING AND HEALTH POLICY The development of evidence-based nursing guidelines based on the present findings will help improve the quality of nursing in long-term care facilities. Additionally, health policies and systems, such as introduction of a fee for nursing services for older individuals based on the evidence, are worth considering.