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Background: In the palliative care setting, infection control measures implemented due to COVID-19 have become barriers to end-of-life care discussions (eg, discharge planning and withdrawal of life-sustaining treatments) between patients, their families, and multidisciplinary medical teams. Strict restrictions in terms of visiting hours and the number of visitors have made it difficult to arrange in-person family conferences. Phone-based telehealth consultations may be a solution, but the lack of nonverbal cues may diminish the clinician-patient relationship. In this context, video-based, smartphone-enabled family conferences have become important., Objective: We aimed to establish a smartphone-enabled telehealth model for palliative care family conferences. Our model integrates principles from the concept of shared decision making (SDM) and the value, acknowledge, listen, understand, and elicit (VALUE) approach., Methods: Family conferences comprised three phases designed according to telehealth implementation guidelines-the previsit, during-visit, and postvisit phases. We incorporated the following SDM elements into the model: "team talk," "option talk," and "decision talk." The model has been implemented at a national cancer treatment center in Taiwan since February 2020., Results: From February to April 2020, 14 telehealth family conferences in the palliative care unit were analyzed. The patients' mean age was 73 (SD 10.1) years; 6 out of 14 patients (43%) were female and 12 (86%) were married. The primary caregiver joining the conference virtually comprised mostly of spouses and children (n=10, 71%). The majority of participants were terminally ill patients with cancer (n=13, 93%), with the exception of 1 patient with stroke. Consensus on care goals related to discharge planning and withdrawal of life-sustaining treatments was reached in 93% (n=13) of cases during the family conferences. In total, 5 families rated the family conferences as good or very good (36%), whereas 9 were neutral (64%)., Conclusions: Smartphone-enabled telehealth for palliative care family conferences with SDM and VALUE integration demonstrated high satisfaction for families. In most cases, it was effective in reaching consensus on care decisions. The model may be applied to other countries to promote quality in end-of-life care in the midst of the COVID-19 pandemic., (©Yu-Rui Wu, Tzu-Jung Chou, Yi-Jen Wang, Jaw-Shiun Tsai, Shao-Yi Cheng, Chien-An Yao, Jen-Kuei Peng, Wen-Yu Hu, Tai-Yuan Chiu, Hsien-Liang Huang. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 28.10.2020.)

Background: Communication in do not resuscitate (DNR) and artificial nutrition and hydration (ANH) at the end of life is a key component of advance care planning (ACP) which is essential for patients with advanced cancer to have cares concordant with their wishes. The SOP model (Shared decision making with Oncologists and Palliative care specialists) aimed to increase the rate of documentation on the preferences for DNR and ANH in patients with advanced cancer., Methods: The SOP model was implemented in a national cancer treatment center in Taiwan from September 2016 to August 2018 for patients with advanced cancer visiting the oncology outpatient clinic. The framework was based on the model of shared decision making as "choice talk" initiated by oncologists with "option talk" and "decision talk" conducted by palliative care specialists., Results: Among 375 eligible patients, 255 patients (68%) participated in the model testing with the mean age of 68.5 ± 14.7 years (mean ± SD). Comparing to 52.3% of DNR documentation among patients with advanced cancer who died in our hospital, the rate increased to 80.9% (206/255) after the decision talk in our model. Only 6.67% (n = 17) of the participants documented their preferences on ANH after the model. A worse Eastern Cooperative Oncology Group Performance Status was the only statistically significant associating factor with a higher rate of DNR documentation in the multiple logistic regression model., Conclusions: The SOP model significantly increased the rate of DNR documentation in patients with advanced cancer in this pilot study. Dissemination of the model could help the patients to receive care that is concordant with their wishes and be useful for the countries having laws on ACP.

Background: The benefits of hospice palliative care (HPC) for end-of-life (EoL) patients have been widely acknowledged in recent years. There is still limited knowledge about cancer patients' willingness toward HPC. This study aimed to investigate the willingness of cancer patients to receive HPC and the influencing factors., Methods: A cross-sectional study was conducted with cancer patients enrolled from teaching hospitals in Taiwan. The questionnaire included demographic characteristics, EoL care preferences, and scales for measuring the willingness to receive HPC, HPC knowledge, and attitude towards HPC. Data were collected by senior nurses and they were analyzed using descriptive and a regression analysis., Results: A total of 148 valid questionnaires were collected. The participants indicated that they 'willing to receive' HPC (mean3.8 on a 5-point scale). The predictors for their willingness to receive HPC were knowledge about HPC (P = 0.001), positive attitude towards HPC (P = 0.008), preference for hospital death (P = 0.022), and preference for quality of life (P = 0.047) as the goal of EoL care. These factors explained 32.7% of the total variance in the willingness to receive HPC., Conclusions: Cancer patients were generally willing to receive HPC. Clinician should discuss EoL care with them earlier. Develop appropriate educational strategies that can provide cancer patients with sufficient and tailored HPC information to develop their knowledge and to create a positive attitude about HPC is necessary, thereby to allow for early HPC intervention and to fulfill the patients' need for HPC., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The current ethical dilemmas met by healthcare professionals were never compared with those 15 years ago when the palliative care system was newly developing in Taiwan. The aim of the study was to investigate the ethical dilemmas met by palliative care physicians and nurses in 2013 and compare the results with the survey in 1998. This cross-sectional study surveyed 213 physicians and nurses recruited from 9 representative palliative care units across Taiwan in 2013. The compared survey in 1998 studied 102 physicians and nurses from the same palliative care units. All participants took a questionnaire to survey the "frequency" and "difficulty" of 20 frequently encountered ethical dilemmas, which were grouped into 4 domains by factor analysis. The "ethical dilemma" scores were calculated and then compared across 15 years by Student's t tests. A general linear model analysis was used to identify significant factors relating to a high average "ethical dilemma" score in each domain. All of the highest-ranking ethical dilemmas in 2013 were related to insufficient resources. Physicians with less clinical experience had a higher average "ethical dilemma" score in clinical management. Physicians with dissatisfaction in providing palliative care were associated a higher average "ethical dilemma" score in communication. Nurses reported higher "ethical dilemma" scores in all items of resource allocation in 2013. Further analysis confirmed that, in 2013, nurses had a higher average "ethical dilemma" score in resource allocation after adjustment for other relating factors. Palliative care nursing staff in Taiwan are more troubled by ethical dilemmas related to insufficient resources than they were 15 years ago. Training of decision making in nurses under the framework of ethical principles and community palliative care programs may improve the problems. To promote the dignity of terminal cancer patients, long-term fundraising plans are recommended for countries in which the palliative care system is in its early stages of development.

Context: The use of antibiotics is a common ethical dilemma in palliative care, thus identifying the concerns of patients with terminal cancer and respecting their wishes are important in making an ethically justified decision., Objectives: The aim of this study was to understand wishes of patients with terminal cancer and determine influencing factors toward the use of antibiotics., Methods: Two hundred and one patients with terminal cancer, admitted to a palliative care unit in Taiwan, completed a structured questionnaire interview, including demographic characteristics, knowledge and attitudes on antibiotics, the health locus of control, subjective norms, and the wishes to use antibiotics., Results: The most common misconception was "Antibiotics use is helpful to all terminal patients with infection," which only 13.4% respondents disagreed. Of the 201patients, 92 (45.8%) expressed their wishes to use antibiotics even in the very terminal stage, and around one-fourth (26.4%) of patients wished not to use antibiotics, the remaining 27.8% were unclear. The most influential persons were medical professionals. The results of logistic regression analysis that showed familiarity with antibiotics, subjective norms, and the attitude toward burdens of antibiotics were the most significant predicting variables for those wishing to use antibiotics (odds ratio [OR] = 4.133, 95% confidence interval [CI] = 1.012-16.880; OR = 1.890, 95% CI = 1.077-3.317; and OR = 1.255, 95% CI = 1.047-1.503)., Conclusion: This study indicated the responsibility of medical professionals to convey burdens of using antibiotics to patients and family. Otherwise, by enhancing professional training and performing effective communication with patients, we can reach a more appropriate decision in the use of antibiotics., (© The Author(s) 2014.)

Providing patient-centered care from preventive medicine to end-of-life care in order to improve care quality and reduce medical cost is important for accountable care. Physicians in the accountable care organizations (ACOs) are suitable for participating in supportive end-of-life care especially when facing issues in truth telling and treatment strategy. This study aimed to investigate patients' attitudes toward truth telling and treatment preferences in end-of-life care and compare patients' attitudes with their ACOs physicians' perceptions.This nationwide study applied snowball sampling to survey physicians in physician-led ACOs and their contracted patients by questionnaire from August 2010 to July 2011 in Taiwan. The main outcome measures were beliefs about palliative care, attitudes toward truth telling, and treatment preferences.The data of 314 patients (effective response rate = 88.7%) and 177 physicians (88.5%) were analyzed. Regarding truth telling about disease prognosis, 94.3% of patients preferred to be fully informed, whereas only 80% of their physicians had that perception (P < 0.001). Significant differences were also found in attitudes toward truth telling even when encountering terminal disease status (98.1% vs 85.3%). Regarding treatment preferences in terminal illness, nearly 90% of patients preferred supportive care, but only 15.8% of physicians reported that their patients had this preference (P < 0.001).Significant discrepancies exist between patients' preferences and physicians' perceptions toward truth telling and treatment strategies in end-of-life care. It is important to enhance physician-patient communication about end-of-life care preferences in order to achieve the goal of ACOs. Continuing education on communication about end-of-life care during physicians' professional development would be helpful in the reform strategies of establishing accountable care around the world.

The numbers of people who suffer from age-related and chronic diseases have been increased worldwide. This has lead to an increased emphasis in the medical community on end of life care. This paper references the processes followed overseas in developing palliative care education programs as well as the domestic experiences promoting the hospitalization, home care, and "share care" models of palliative care. Particular emphasis is given to considerations of cultural diversity in palliative care. The aim of this paper is to elaborate on the prevalent clinical end-of-life care issues that are faced in Taiwan, to cultivate core capabilities in end-of-life care, to elicit the current status and development of formal nursing education, and to promote continuing education in palliative care. Kern formulated a six-step approach to curriculum development in education and the details has been discussed . Finally, this paper reflects on the current bottlenecks, challenges, and expectations related to palliative care curriculum development in order to help medical professionals further put humanistic and social care into practice, increase ethical reflection in end of life care and nursing competency, and encourage the creation of localized textbooks / multimedia e-teaching materials. The fostering of "patient-centered, family unit and the social-cultural contexture" for palliative care professionals and the ability to respond to the needs of terminal patients and patients with chronic diseases are critical to increasing the quality of Taiwan healthcare.

Background: The hospital-based palliative care team model has been implemented in most Western countries, but this model is new in Taiwan and there is little research to evaluate its outcomes., Objectives: The purpose of this study was to evaluate the effects of the hospital-based palliative care team on the care for cancer patients., Design: The design was a quasi-experimental study with a pretest-posttest design., Setting: A medical center, National Taiwan University Hospital in Taipei, Taiwan., Participants: Cancer patients were excluded after the hospital-based palliative care team visited if they were unable to give informed consent, were not well enough to finish the baseline assessment, were likely to die within 24h or would be discharged within 24h, or could not communicate in Mandarin or Taiwanese. A sample of 60 patients who consulted the hospital-based palliative care team was recruited., Methods: Patients recruited to the study were divided to receive the usual care only (control group, n=30) or the usual care plus visits from the hospital-based palliative care team (intervention group, n=30). Data were collected using questionnaires including the Symptom Distress Scale, Hospital Anxiety and Depression Scale, Spiritual Well-Being Scale, and Social Support Scale at the initial assessment and one week later., Results: Comparison between groups revealed that the degree change for edema, fatigue, dry mouth, abdominal distention, and spiritual well-being in the intervention group showed significant improvement compared to the control group (p<0.05). However, there was no difference between groups on measures of anxiety, depression and feeling of social support. Within group analysis showed patients' pain score, dyspnea, and dysphagia improved in both groups (p<0.05). In addition, the average degree of constipation and insomnia in the control group declined from baseline (p<0.05), while the degree of edema, fatigue, dry mouth, appetite loss, abdominal distention, and dizziness decreased significantly in the intervention group (p<0.05)., Conclusion: The findings indicated the hospital-based palliative care team can improve the care for patients in relation to symptom management and spiritual well-being. The hospital-based palliative care team is a good care model for patients and worth implementing in clinical practice in Taiwan. The results also provide a general understanding about how the hospital-based palliative care team works in Taiwanese culture., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Community physicians have a vital role in delivering palliative care, yet their willingness and factors that influence its provision have rarely been explored. Our aims were to identify the willingness of community physicians to provide palliative care for patients with terminal cancer and to investigate the factors that influence their willingness to provide such care., Methods: Through a structured questionnaire, this nationwide study surveyed 708 community physicians who were potential pilots to provide palliative care. Four hundred and ten valid questionnaires (58.0%) were retrieved and analysed., Results: The majority of respondents expressed a willingness (92.4%) to provide palliative care if they encountered patients with terminal cancer. However, they would limit their services to consultation (83.4%) and referral (86.8%), and were less likely to see patients and prescribe medicine (62.0%), to provide phone follow-ups (45.6%), to provide home visits (42.2%) or to offer bereavement care for the family (35.1%). The results of stepwise logistic regression analysis for the willingness to provide home visits showed that 'less perception of barriers', 'family medicine specialist' and 'older than 50 years' significantly predicted higher willingness, while 'female' predicted lower willingness. There was no significant association between the willingness and the knowledge score., Conclusions: Community physicians' beliefs and experience in palliative care rather than their knowledge influence their willingness to provide palliative care for patients with terminal cancer. Only through active participation in the real-world clinical setting and active health policy administration can community physicians overcome obstacles to providing palliative care.

Background: Compassion is the key value of humanities perspective. Little is known, however, concerning the impact of enhancing compassion on ethical decision making in end-of-life care., Methods: A total of 251 preclinical medical students were enrolled in a palliative care training course. A structured self-report questionnaire was administered before and after training., Results: Experience with caring for patients with terminal cancer was positively related to improvement in the decision of "truth telling is helpful to a good death." In addition, improvement in the perception of "compassionate care" was correlated with higher improvement in the decision of "discharge planning and home care.", Conclusion: Compassion-focused training program can be helpful to improve medical students' competence in making more appropriate ethical decisions in end-of-life care.

Background: Achieving a good death is the ultimate goal of palliative medicine. Yet, very few studies have investigated factors affecting improvement in quality of dying. We therefore conducted a study to evaluate these factors in terminally ill Taiwanese cancer patients treated in a multidisciplinary palliative care unit., Methods: We included data from terminally ill patients with cancer admitted to the Hospice and Palliative Care Unit in the National Taiwan University Hospital from 2000 to 2009. Quality of dying was assessed by patients' multidisciplinary team at admission and after death using the Good Death Scale and the Audit Scale. We used multivariable regression to assess the association between patient factors, including gender, age, diagnosis, days of hospitalization, calendar year of admission, Good Death score at admission, and process of care scores for physical care, physician-assessed autonomy, emotional support, communication, continuity of life, and physician-reported rate of closure, with the quality of dying., Results: Multivariate regression analysis identified lower Good Death score at admission, lower age 40-65 years, longer unit length of stay (>7 days), higher physician-assessed autonomy, better physician-assessed emotional support, and better physician-reported rate of closure as positively related (all p<0.0001) with improvement in good death scores., Conclusion: In this study in a Taiwanese palliative care unit; we found that late referral to the unit and low physician-assessed autonomy were key factors negatively affecting quality of dying. Earlier truth-tellling and end-of-life care discussions between physicians and patients might improve the quality of dying in this population.

Background: Fatigue is a multidimensional phenomenon that has different meanings according to different societal and cultural settings. This study aims to decipher fatigue in Taiwanese patients with cancer., Methods: We recruited 440 patients with advanced cancer admitted consecutively to the palliative care unit of a major medical center in Taiwan. The data were collected at admission, 1 and 2 weeks after admission, and 2 days before death., Results: The subject group consisted of 51.8% males and 48.2% females with a median age of 67 years (ranging from 27 to 93 years). The leading primary tumor sites among these patients were lung (20.2%), liver (18.0%), and colon-rectum (10.7%), and the median survival was 15 days, with a range of 1 to 418 days. All symptoms improved 1 week after admission, but most of them significantly worsened 2 days before death. In general, the physical signs manifested variation patterns similar to those of symptoms. The severity of psychosocial distress and death fear was lower after admission and retained the same level at 2 days before death, defying the consistent patterns found in other symptoms and signs. In the correlation analysis, most symptoms were correlated with fatigue during admission, with weakness being the most significant one. Although self-efficacy and emotion were correlated with fatigue both on admission and 1 week after admission, social support and death fear were not correlated with fatigue at all times., Conclusion: The meaning of fatigue is mainly associated with physical factors among these patients. Education of complexities in fatigue in tandem with psychosocial and spiritual care may help alleviate this symptom, and promote quality of life.

Aim: This study describes the relationship between symptoms and quality of life in patients with malignant fungating wounds., Background: Malignant fungating wounds are complex wounds that can bleed, become malodorous due to infection and are painful causing physical and psychological distress. However, there is a lack of literature on the impact that such wounds can have on quality of life., Methods: This was a descriptive, cross-sectional multi-centre study of patients with malignant fungating wounds. Participants were recruited from the palliative care, hospice, outpatient clinic and oncology units of three medical centres in Taiwan. Data were collected from February 2008 to August 2009. A structured questionnaire obtained socio-demographic information, medical details, wound assessment information and the Taiwanese version of the McGill quality of life questionnaire was administered by interview., Results:   McGill quality of life scores indicated that the participants had the lowest quality of life. The participant's age, dressing change frequency, pain, wound dressing comfort, wound symptom, bleeding and malodour had statistically significant negative correlations with quality of life. Multiple regression analysis showed that age, malodour, pain issues and psychological issues explained 87% of the total variance in quality of life., Conclusion:   This study contributes to our understanding of the impact of malignant fungating wounds and how correct assessment and management is necessary to improve quality of life. Educational intervention research is needed for patients and caregivers in countries where this has not yet been performed. Further research should also identify whether nursing competence has a direct impact on quality of life., (© 2011 Blackwell Publishing Ltd.)

Background: Preferences for end-of-life care and attitudes toward executing advance directives (ADs) vary depending on ethical and cultural influences. In traditional Asian family-centered decision making, the family makes important medical decisions. Few studies have examined willingness of Taiwanese to execute ADs., Objective: This study aimed to investigate factors associated with willingness of bereaved families of cancer patients in Taiwan to execute ADs., Methods: Participants were 280 individual family members of deceased cancer patients randomly selected from a cancer registry of an urban medical center in Taiwan. They completed self-reported questionnaires with information about their knowledge of and attitudes toward ADs., Results: Participants showed high willingness (86.4%) to complete ADs. Logistic regression analysis revealed 4 important factors associated with their willingness: (1) participants were primary caregivers (odds ratio [OR], 2.64), (2) willingness to reelect to disclose terminal illness (OR, 4.39), (3) knowledge of the Hospice-Palliative Care Act (HPCA) (OR, 1.27), and (4) negative perceptions of the HPCA (ie, "cons") (OR, 1.07). Advanced analysis revealed that participants with more knowledge of the HPCA had fewer negative perceptions (β = .60; P < .0001)., Conclusion: Having more knowledge of hospice/palliative care and fewer negative perceptions of HPCA increases willingness to execute ADs for family members or self., Implications for Practice: Active promotion of hospice/palliative care and public education about the HPCA provided by medical professionals would contribute to awareness of end-of-life care and knowledge of HPCA, thereby encouraging willingness to complete ADs.

Purpose: To explore the factors that influence the willingness of junior doctors to provide palliative care in future clinical practice and to evaluate the effect of palliative care education in ameliorating these factors., Methods: A 2-week clinical training course consisting of clinical patient care, multidisciplinary team meetings, home visits, and lecture series was conducted for interns in a palliative care unit of a university hospital. A structured self-report questionnaire was administered before and after the training., Results: One hundred forty-seven interns were enrolled and completed the questionnaire, which demonstrated significant improvements in knowledge and beliefs toward palliative care after the training (p < 0.001). Although the interns' willingness to provide palliative medical care was influenced by relatives' support before the training (odds ratio [OR] = 3.861, 95% confidence interval [CI] = 1.217-12.243), this relationship vanished after training. A higher willingness to provide home visits was noted in participants who received palliative care education at medical school. In contrast, information received from mass media was shown to be negatively correlated with willingness. After the training, the only independent variable that was positively correlated with interns' willingness to provide home visits was their own beliefs on palliative care (OR = 1.074, 95% CI = 1.058-8.089)., Conclusions: Educating junior doctors to build positive beliefs toward palliative care is strongly encouraged. Palliative care education contributes to increased junior doctors' willingness toward providing palliative care, which suggests that this kind of training course should be emphasized in medical education.

Background: Family physicians in Taiwan have expressed low willingness to provide palliative home care., Objective: To explore the medical needs of terminal cancer patients in home care and thus clarify the role and tasks of family physicians in providing palliative home care., Methods: Seventy-seven terminal cancer patients discharged from a palliative care unit from July 2003 to July 2004 who had received family physician home visits were enrolled. A structured assessment form was applied to each visit., Results: Under the collaboration by the palliative home care team and family physicians, the average interval from discharge to the first physician visit was 20.3 days and the average interval between physician visits was 37.9 days. The patients had an average of 5.9 active medical problems: the most frequent problem was pain (58.4%), followed by anorexia (42.9%) and constipation (42.9%). Forty-four patients (58.7%) died at home, while 31 patients (41.3%) eventually died in the hospital. Through multiple logistic regression analysis, patients who had never been rehospitalized [odds ratio (OR) = 12.95, 95% confidence interval (CI) = 3.41-49.19], who preferred to die at home (OR = 4.68, 95% CI = 1.21-18.09) and who were most functionally dependent with an Eastern Cooperative Oncology Group scale = 4 (OR = 4.36, 95% CI = 1.02-18.64) were found to be most likely to die at home under this care model., Conclusion: Through palliative home care with the participation of family physicians, patients' preference could be a significant determinant of home death. Our finding can be helpful to the establishment of an ethical care model for terminal cancer patients.

Background/purpose: The objective of this study was to investigate the effects of educational intervention using a multimodule curriculum of palliative care on medical students, and to explore significant factors that influence improvement in beliefs of ethical decision-making., Methods: A total of 259 medical students enrolled in the "Family, Society and Medicine" course, and accepted a multimodule palliative care curriculum that included a 1-hour lecture, 1 hour of patient contact, 1 hour of literature reading, and 1 hour of discussion. A questionnaire was administered before and after the course to evaluate improvements in medical students' knowledge (principles and clinical management) of palliative care and their beliefs concerning ethical decision-making in palliative care., Results: The students showed significant improvements after the course in their knowledge of the principles of palliative care (pretest 58.4% vs. posttest 73.1%; p less than 0.01) and clinical management of palliative care (pretest 58.8% vs. posttest 67.9%; p less than 0.01). Although their beliefs about ethical decision-making were also improved after the course, the medical students did not have a positive belief of "artificial nutrition and hydration is not always beneficial for terminal cancer patients", with a mean score of only 3.15 and 3.51 (pretest and posttest, respectively; range, 1-5). The logistic regression model showed that improvement in knowledge of either principles or clinical management did not significantly improve beliefs about ethical decision-making., Conclusion: A multimodule curriculum of palliative care for medical students can significantly improve their knowledge on principles of clinical management and beliefs about ethical decision-making in palliative care. As for changes in beliefs about ethical decision-making in palliative care, continued ethical and clinical training is required.

This study involved longitudinal evaluations of symptom severity and describes the symptom patterns of 77 terminal cancer patients (median age: 62 years; 61% female), selected from 537 consecutive patients admitted to the Palliative Care Unit of the National Taiwan University Hospital. The most common primary cancer sites in these patients were lung (23.4%), liver (15.6%), and stomach (13%). Nineteen physical and psychological symptoms were assessed using different scales. The median number of symptoms was 11 (range: 1-18) on admission, among which weakness, fatigue, anorexia, pain, and depression were the most common. A comparison of the initial symptom severity scores with those at one week after admission and two days before death suggested six symptom change patterns: A: continuous static (restless/heat, abdominal fullness, constipation, dizziness, and insomnia); B: static-increase (fatigue, weakness, nausea/vomiting, taste alteration, dysphagia, diarrhea, dry mouth, and night sweats); C: decrease-static (pain and depression); D: decrease-increase (anorexia and dyspnea); E: static-decrease (aggression); and F: gradually decrease (anxiety). These six symptom patterns can be divided into two categories on the basis of the relative severity of symptoms between one week after admission and two days before death. The first category included patterns A, C, E and F, and the symptoms improved with palliative care. However, the symptoms in the second category (patterns B and D), which were associated with the anorexia-cachexia syndrome and dyspnea, did not show improvement. As symptom management is an essential component of palliative care, holistic care, which encompasses physical, psychosocial and spiritual aspects, represents a rational approach for the relief of these incurable symptoms at the end stage of life for these patients.

Goals of Work: To identify the willingness, influencing factors, and educational needs of community physicians in providing palliative care in the rural areas of Taiwan., Methods: A questionnaire was sent to all medical directors of the 140 government health stations assigned to the rural areas of Taiwan., Results: The overall response rate was 62.8% with 85 valid questionnaires retrieved. The majority of respondents (84.7%) expressed a willingness to provide palliative care if they encountered an advanced cancer patient. However, they would limit their services to consultation and referral (93.0% and 87.5%, respectively), and were less likely to provide home visits (40.3%) or bereavement support of the family (29.2%). With respect to knowledge, the accurate answers to the philosophy/principles and clinical practice of palliative care were 93.4% and 57.3%, respectively. Regarding attitudes, the highest score item in perceiving the threat about providing palliative care was "uncomfortable to meet and take care of the advanced cancer patient." The highest score item in perceiving barriers was "providing palliative care may shorten patient's life, just like euthanasia." The results of stepwise logistic regression analysis for the willingness to provide home visits showed that only the subjective norms remained in the model (OR = 1.87, 95% CI = 1.17-3.01). Educational needs expressed by the respondents were ranked as follows: emotional support to, communication skills with, and bereavement support for the advanced cancer patients and their relatives., Conclusions: Effective training courses that emphasize the practical knowledge of palliative care for community physicians, incorporating palliative care into medical education particularly in terms of communication skills and ethical roles, and active health policy administration including insurance payments, are important for the enhancement of community palliative care in Taiwan.

Fear of death is a common characteristic among palliative care patients. We might think that the elderly display a higher degree of acceptance of the inevitability and less fear in the face of death. This study was aimed at investigating the relationship between the death fear level and the good-death scale in two age groups. The study was conducted in 224 patients with terminal cancers admitted to the Palliative Care Unit in National Taiwan University Hospital during the period of January 1 through October 31, 2001. The mean age was 62.13 +/- 15.47 years. The duration of admission in the elderly group was shorter than that of the younger group (P < 0.05). The severity of death fear decreased gradually in both groups after being admitted to the hospice (P < 0.05). However, the elderly (> or = 65 years of age) displayed higher levels of death fear than the younger group at two days before death (P < 0.05). A significant negative correlation was observed between the degree of death fear and the total good death score in both groups at two days before death (P < 0.05). The comprehensive care in the palliative care unit might relate to the relief of the death fear of terminal cancer patients. There is a need for psychological and spiritual care in elderly patients.

Morphine for dyspnea control usually arouses ethical controversy in terminal cancer care. This study prospectively assessed the use of morphine for dyspnea control in terminal cancer patients in terms of two characteristics: the extent to which medical staff, family, and patients found morphine to be ethically acceptable and efficacious, and the influence of morphine on survival. One hundred and thirty-six palliative care patients meeting specific eligibility criteria were enrolled. A structured data collection form was used daily to evaluate clinical conditions, which were analyzed at the time of admission and 48 h before death. Sixty-six (48.6%) of the 136 patients had dyspnea on admission. The intensity was mild in 14.0% and moderate or severe in 34.6%. The intensity of dyspnea became worse 48 h before death (4.29+/-2.55 vs. 4.94+/-2.60, P < 0.001, range 0-10). Twenty-seven (40.9%) of 66 patients with dyspnea received morphine on admission for the control of dyspnea; the routes of administration were oral (59.3%) and subcutaneous (40.7%). Fewer than two-thirds (59.3%) of the patients were given morphine with the consent of both patient and family. More than one-third (40.7%) on admission and about one-half (52.8%) in the 48 h before death had the consent of family alone. Positive ethical acceptability and satisfaction with using morphine for dyspnea control were found in both medical staff and family in this study. Multiple Cox regression analysis showed that using morphine for dyspnea, both on admission and in the 48 h before death, did not significantly influence the patients' survival (HR: 0.015, 95% CI: 0.00-4.23; HR: 1.76, 95% CI: 0.73-4.24). In this population, the use of morphine for dyspnea control in the terminal phase of cancer was effective and ethically validated in the study. Research efforts to find the most appropriate route and dosage of morphine for dyspnea, based on the patient's situation, remain worthwhile.

The aims of this study are to identify the willingness of district nurses to provide palliative care in the rural communities in Taiwan and determine the predictors of this willingness. A questionnaire was sent to all 1,121 community nurses of the 174 government health stations assigned to all the rural areas of Taiwan. The overall response rate was 86.4%, with 940 valid questionnaires retrieved. The majority of respondents (93.0%) expressed a willingness to provide palliative care if they encountered a terminal cancer patient. However, they would limit their services to consultation and referral (91.6% and 87.3%), and were less likely to provide home visiting (51.0%) or bereavement support of family (38.4%). With regard to knowledge, the accurate answers to the philosophy/principles and clinical practice of palliative care were 88.5% and 43%, respectively. The results of stepwise logistic regression analysis showed that "palliative care knowledge," "the belief in external control by authority," and "the belief in external control by chance" were the most significant variables related to the willingness of district nurses to provide palliative care (OR=12.83, 95% CI=2.46-66.76, P<0.01; OR=2.11, 95% CI=1.32-3.35, P<0.01; OR=0.54, 95% CI=0.31-0.95, P<0.05, respectively). However, regarding the content of services, the willingness to provide home visiting was affected positively by the level of information resources, subjective norms, and the belief in external control by authority. This willingness was negatively affected by age of the patient. These data suggest that effective training courses focused on practical knowledge of palliative care for these district nurses, the incorporation of the palliative care into nursing education, and active health policy administration are critical for the community palliative care movement in Taiwan.

Objectives: To investigate the incidence and solution of ethical dilemmas in a palliative care unit., Design: Health care workers recorded daily all dilemmas in caring for each patient., Setting: Palliative care unit of National Taiwan University Hospital in Taiwan., Patients: Two hundred and forty-six consecutive patients with terminal cancer during 1997-8., Main Measurement: Ethical dilemmas in the questionnaire were categorised as follows: telling the truth; place of care; therapeutic strategy; hydration and nutrition; blood transfusion; alternative treatment; terminal sedation; use of medication, and others., Results: The type and frequency of ethical dilemmas encountered were: place of care (33.3%); truth-telling (32.1%); hydration and nutrition (25.2%); therapeutic strategy (24.8%), and use of medication (19.1%). Ethical problems relating to the place of care and to therapeutic strategy were unlikely to be solved with increased hospital stay and some ethical dilemmas remained unsolved even in the final week in hospital, including place of care (23.2%), truth-telling (17.1%) and therapeutic strategy (11.4%). Problems of truth-telling occurred in nearly half (42.6%) of patients over sixty-five-years-old. Conflicts about blood transfusion were experienced in all patients below 18-years-old, and the dilemmas concerning the place of care occurred most frequently with head and neck cancer patients (43.8%)., Conclusions: The solution of ethical dilemmas required refocusing by medical professionals on the importance of continuing communication. Improved ethical training for professionals would contribute to solving the moral dilemmas of palliative care.