Wen-Cheng Chang

Use of chemotherapy at the end of life among Taiwanese cancer decedents, 2001–2006

Abstract Introduction. The availability of new chemotherapeutic agents has lengthened the treatment timeline for advanced cancers and increases the likelihood of receiving chemotherapy near death. Use of chemotherapy near the end of life may not benefit cancer patients. However, no population-based study has examined the determinants for continuing chemotherapy at the end of life for all ages and cancer groups as well as for a whole country. This population-based study assessed the association between continuation of chemotherapy in the last month of life and patient demographics, disease characteristics, primary physicians specialty, hospital characteristics, and healthcare resource availability at the hospital and regional levels. Materials and methods. Retrospective population-based cohort study using administrative data among 204 850 Taiwanese cancer decedents in 2001–2006. Results. Rates of continued chemotherapy in the last month of life for each study year were 17.5%, 17.4%, 17.3%, 19.0%, 20.0%, and 21.0%, respectively and have remained steady since 2001. Taiwanese cancer patients had greater odds for continuation of chemotherapy in the last month of life if they were male [adjusted odds ratio (AOR) 1.19, 95% confidence interval (CI) 1.13–1.25], younger, single [1.21 (1.09–1.35)], had lower comorbidity levels, were diagnosed with hematologic malignancies [1.90 (1.09–1.35)] and breast cancer [1.24 (1.08–1.43)], had metastatic disease [1.36 (1.27–1.46)], and survived <  1 year but longer than two months post-diagnosis. The odds for continued chemotherapy in patients’ last month was significantly increased by being cared for by a medical oncologist [3.49 (3.04–3.99)] or in a teaching hospital [1.39 (1.11–1.74)] and with the highest intensity of total inpatient hospital beds [1.63 (0.99–2.68)], but was not influenced by regional healthcare resources (total hospital and hospice beds). Conclusion. The relative risk for continuation of chemotherapy in the last month of life was determined by patient demographics and disease characteristics, physician specialty, and healthcare resources at the primary hospital level.

Trajectory and predictors of quality of life during the dying process: roles of perceived sense of burden to others and posttraumatic growth

PurposeQuality of life (QOL) at end of life (EOL) is related to important themes, e.g., “sense of burden to others” and “perceived posttraumatic growth,” which have never been investigated concurrently. The purposes of this study were: (1) to describe the trajectory of QOL during the dying process and (2) to identify determinants of QOL, including the roles of perceived sense of burden to others and posttraumatic growth.MethodsA convenience sample of 313 terminally ill cancer patients was surveyed and longitudinally followed until death. QOL was measured by a modified McGill quality of life scale, and determinants were evaluated by a multiple linear regression model with the generalized estimating equation.ResultsTerminally ill Taiwanese cancer patients’ QOL decreased substantially as their death approached. However, after controlling for confounders, patients’ QOL did not change significantly in the last months of their life. QOL was significantly better for female and non-middle-aged patients with a religious affiliation of Buddhism/Taoism. Poorer QOL tended to be experienced by patients with greater physical symptom distress, anxiety, and depression. Patient QOL increased with greater tangible support, but decreased with greater emotional and affectionate social support. QOL was diminished by a greater degree of perceived burden to others but improved with greater perceived posttraumatic growth.ConclusionsDeteriorating QOL as death approaches may not be inevitable. Optimal QOL at EOL may be achieved by interventions designed to adequately manage physical and psychological symptoms, enhance social support, lighten perceived sense of burden to others, and facilitate experiences of posttraumatic growth.

Impact of high self‐perceived burden to others with preferences for end‐of‐life care and its determinants for terminally ill cancer patients: a prospective cohort study

Self‐perceived burden to others (SPB) is a major concern of terminally ill cancer patients and is frequently factored into end‐of‐life (EOL) care decision‐making. However, changes in and determinants of SPB and its longitudinal impact on preferences for EOL care over the dying process have not been investigated. Our study was aimed at filling this gap in knowledge.

Prevalence of severe depressive symptoms increases as death approaches and is associated with disease burden, tangible social support, and high self-perceived burden to others

PurposeTerminally ill cancer patients experience progressive functional decline, accelerating symptom severity, deteriorating social support, and self-perceived burden to others (SPB), predisposing them to depressive symptoms. However, changes in the prevalence of severe depressive symptoms as death approaches and the unique roles of these four variables have not been adequately studied. This study explored longitudinal changes in and associations of symptom distress, functional dependence, social support, and SPB with prevalence of severe depressive symptoms in the last year of life.MethodsA convenience sample of 325 cancer patients was longitudinally followed until death. Prevalence of severe depressive symptoms (score ≥11 on the depression subscale of the Hospital Anxiety and Depression Scale) was examined by multivariate logistic regression modeling with the generalized estimating equation.ResultsThe prevalence of severe depressive symptoms increased as death approached. The likelihood of severe depressive symptoms was significantly higher in patients who had higher levels of symptom distress and functional dependence, received greater tangible support, and reported high SPB, but lower for patients reporting a higher level of affectionate support and positive social interactions with their supportive network.ConclusionPrevalence of severe depressive symptoms increased as death approached and was associated with several modifiable factors. Healthcare professionals should become familiar with these factors to identify vulnerable patients. To decrease the likelihood of terminally ill cancer patients’ severe depressive symptoms, they should receive effective interventions to manage their symptoms, appropriately foster social support to restore their fragile self-esteem due to depending on others, and lighten their SPB.

Quality of life and psychological distress are differentially associated with distinct symptom‐functional states in terminally ill cancer patients' last year of life

Quality of life (QOL) and psychological distress at end of life (EOL) heavily depend on symptom distress and functional impairment, which may not deteriorate synchronously at EOL.