scholarly journals Changes in End-of-Life Discussion for Patients with Advanced Cancer after the Life- Sustaining Treatment Decisions-Making Act in Korea

2021 ◽  
Author(s):  
Hyeyoung Kim ◽  
Hyeon-Su Im ◽  
Kyong Og Lee ◽  
Young Joo Min ◽  
Jae-Cheol Jo ◽  
...  
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Cancer Patients ◽  
Multivariable Analysis ◽  
Terminally Ill ◽  
Self Determination ◽  
Do Not Resuscitate ◽  
Life Sustaining Treatment ◽  
Group 2 ◽  
Group 1

Abstract Background: Cancer is a leading cause of death in Korea. To protect the autonomy and dignity of terminally ill patients, the Life-Sustaining Treatment Decision-Making Act (LST-Act) came into full effect in Korea in February 2018. However, it is unclear whether the LST-Act influences end-of-life (EOL) discussion and decision-making processes for terminally ill cancer patients. Methods: This was a retrospective study conducted with a medical record review of cancer patients who died at Ulsan University Hospital between July 2015 and May 2020. Patients were divided into two groups: those who died in the period before the implementation of the LST-Act (from July 2015 to October 2017, Group 1) and after the implementation of the LST-Act (from February 2018 to May 2020, Group 2). We measured the self-determination rate and the timing of documentation of Do-Not-Resuscitate (DNR) or Physician Orders for Life-Sustaining Treatment (POLST) in both groups. Results: A total of 1,834 patients were included in the analysis (Group 1, n=943; Group 2, n=891). Documentation of DNR or POLST was completed by patients themselves in 1.5% and 63.5% of patients in Groups 1 and 2, respectively (p<0.001). The mean number of days between documentation of POLST or DNR and death was higher in Group 2 than in Group 1 (21.2 days vs. 14.4 days, p=0.001). The rate of late discussion, defined as documentation of DNR or POLST within seven days prior to death, decreased significantly in Group 2 (46.6% vs. 41.4%, p=0.027). In the multivariable analysis, hospice palliative care referral (OR [odds ratio] 0.25, p<0.001) and patients’ years of education (OR 0.68, p=0.027) were positively related to self-determination. However, physicians with clinical experience of less than three years had a higher rate of surrogate decision-making (OR 5.1, p=0.029) and late discussion (OR 2.53, p=0.019). Conclusions: After the implementation of the LST-Act, the rate of self-determination increased and EOL discussion occurred earlier than in the era before the implementation of the LST-Act.

scholarly journals Changes in decision-making process for life-sustaining treatment in patients with advanced cancer after the life-sustaining treatment decisions-making act

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Hyeyeong Kim ◽  
Hyeon-Su Im ◽  
Kyong Og Lee ◽  
Young Joo Min ◽  
Jae-Cheol Jo ◽  
...  
Keyword(s):  
Decision Making ◽  
Terminally Ill ◽  
Self Determination ◽  
Decision Making Process ◽  
Surrogate Decision Making ◽  
Life Sustaining Treatment ◽  
Group 2 ◽  
Surrogate Decision ◽  
Reduced Rate ◽  
Group 1

Abstract Background Cancer is a leading cause of death in Korea. To protect the autonomy and dignity of terminally ill patients, the Life-Sustaining Treatment Decision-Making Act (LST-Act) came into full effect in Korea in February 2018. However, it is unclear whether the LST-Act influences decision- making process for life-sustaining treatment (LST) for terminally ill cancer patients. Methods This was a retrospective study conducted with a medical record review of cancer patients who died at Ulsan University Hospital between July 2015 and May 2020. Patients were divided into two groups: those who died in the period before the implementation of the LST-Act (from July 2015 to October 2017, Group 1) and after the implementation of the LST-Act (from February 2018 to May 2020, Group 2). We measured the self-determination rate and the timing of documentation of do-not-resuscitate (DNR) or Physician Orders for Life-Sustaining Treatment (POLST) in both groups. Results A total of 1,834 patients were included in the analysis (Group 1, n = 943; Group 2, n = 891). Documentation of DNR or POLST was completed by patients themselves in 1.5 and 63.5 % of patients in Groups 1 and 2, respectively (p < 0.001). The mean number of days between documentation of POLST or DNR and death was higher in Group 2 than in Group 1 (21.2 days vs. 14.4 days, p = 0.001). The rate of late decision, defined as documentation of DNR or POLST within 7 days prior to death, decreased significantly in Group 2 (56.1 % vs. 47.6 %, p < 0.001). In the multivariable analysis, female patients (odds ratio [OR] 0.71, p = 0.002) and patients with more than 12 years of education (OR 0.70, p = 0.019) were significantly related to a reduced rate of late decision. More than 12 years of education (OR 0.53, p = 0.018) and referral to hospice palliative care (OR 0.40, p < 0.001) were significantly related to self-determination. Enforcement of LST-Act was related to a reduced rate of surrogate decision-making (OR 0.01, p < 0.001) and late decision (OR 0.51, p < 0.001). However, physicians with clinical experience of less than 3 years had a higher rate of surrogate decision-making (OR 5.08, p = 0.030) and late decision (OR 2.47, p = 0.021). Conclusions After the implementation of the LST-Act, the rate of self-determination increased and decisions for LST occurred earlier than in the era before the implementation of the LST-Act.

Accurate prognostic awareness and preference states influence the concordance between terminally ill cancer patients’ states of preferred and received life-sustaining treatments in the last 6 months of life

2019 ◽  
Vol 33 (8) ◽  
pp. 1069-1079 ◽  
Author(s):  
Fur-Hsing Wen ◽  
Jen-Shi Chen ◽  
Wen-Cheng Chang ◽  
Wen-Chi Chou ◽  
Chia-Hsun Hsieh ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
End Of Life Care ◽  
Nutritional Support ◽  
Terminally Ill ◽  
Cardiac Massage ◽  
Life Care ◽  
Terminally Ill Cancer Patients ◽  
Life Sustaining Treatment ◽  
To Receive

Background: Factors facilitating/hindering concordance between preferred and received life-sustaining treatments may be distorted if preferences and predictors are measured long before death. Aim: To examine factors facilitating/hindering concordance between cancer patients’ preferred and received life-sustaining-treatment states in their last 6 months. Design: Longitudinal, observational design. Setting/participants: States of preferred and received life-sustaining treatments (cardio-pulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, and nasogastric tube feeding) were examined in 218 Taiwanese cancer patients by a latent transition model with hidden Markov modeling. Multivariate logistic regression modeling was used to examine factors facilitating/hindering concordance between preferred and received life-sustaining-treatment states. Results: Concordance between preferred and received life-sustaining-treatment states was poor (40.8%, kappa value (95% confidence interval): 0.05 [–0.03, 0.14]). Patients who accurately understood their prognosis and preferred comfort care were significantly more likely to receive preferred life-sustaining treatments before death than those who did not know their prognosis but wanted to know, those who were uniformly uncertain about what life-sustaining treatments they preferred to receive, and those who preferred nutritional support but declined other life-sustaining treatments. Patient age, physician–patient end-of-life-care discussions, symptom distress, and functional dependence were not associated with concordance between preferred and received life-sustaining-treatment states. Conclusion: Prognostic awareness and preferred states of life-sustaining treatments were significantly associated with concordance between preferred and received life-sustaining-treatment states. Personalized interventions should be developed to cultivate terminally ill cancer patients’ accurate prognostic awareness, allowing them to formulate realistic life-sustaining-treatment preferences and facilitating their receiving value-concordant end-of-life care.

Bronchial Stump Recurrence after Complete Resection of Lung Cancer: Effect of the Distance between the Tumor and Bronchial Resection Margin

2016 ◽  
Vol 66 (02) ◽  
pp. 156-163
Author(s):  
Celalettin Kocaturk ◽  
Adalet Demir ◽  
Halide Urer ◽  
Seyyit Dincer ◽  
Mehmet Bedirhan ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Cancer Patients ◽  
Resection Margin ◽  
Multivariable Analysis ◽  
Complete Resection ◽  
Bronchial Stump ◽  
Lung Cancer Patients ◽  
Group 2 ◽  
Bronchial Resection ◽  
Group 1

Purpose The purpose of this study was to evaluate the following parameters after complete resection in established lung cancer patients: the frequency of bronchial stump recurrence (BSR), the effect of the distance between the tumor and bronchial resection margin (DBTM) on BSR, the survival of patients with BSR, and the effect of the DBTM on survival. Patients and Methods We retrospectively evaluated 553 consecutive lung cancer patients who underwent complete lung resection. The patients were classified as DBTM: ≤ 10 mm (group 1), 11 to 20 mm (group 2), and > 20 mm (group 3). Results We found BSR in eight (1.5%) patients. Six patients were in group 1, and two were in group 2. The difference was found to be statistically significant (p = 0004; groups 1 vs. 3). In multivariable analysis, we observed a trend toward significance for the effect of a DBTM on BSR development (p = 0.1). The DBTM did not significantly affect survival (p = 0.61). The survival of patients who developed BSR was significantly poor compared with those who did not develop BSR (p = 0.001). Conclusion BSR can develop even after complete resection of lung cancer. The DBTM is associated with BSR risk, and the survival of patients who develop BSR is poor.

scholarly journals 139. association of Physician Orders for Life-sustaining Treatment (POLST) with Antimicrobial Use at End of Life in Cancer Patients: An Antimicrobial Stewardship Opportunity

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S199-S200
Author(s):  
Olivia Kates ◽  
Elizabeth M Krantz ◽  
Juhye Lee ◽  
John Klaassen ◽  
Jessica Morris ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
Symptom Management ◽  
Research Study ◽  
Antibiotic Use ◽  
Antimicrobial Use ◽  
Study Investigator ◽  
Days Of Therapy ◽  
Life Sustaining Treatment ◽  
Rate Ratios

Abstract Background IDSA/SHEA guidelines recommend that antimicrobial stewardship programs support providers in antibiotic decisions for end of life care. Washington State Physician Orders for Life-Sustaining Treatment (POLST) forms allow patients to indicate antimicrobial use preferences. We sought to characterize antimicrobial use in the last 30 days of life for cancer patients by presence of a POLST and antimicrobial use preferences. Methods We performed a single-center, retrospective cohort study of cancer patient deaths from January 1, 2016 - June 30, 3018. Patient demographics, clinical characteristics, POLST, and antimicrobial use within 30 days before death were extracted from electronic records. To test for an association between POLST completed at least 30 days before death and inpatient antimicrobial days of therapy (DOT) in the 30 days before death, we used negative binomial models adjusted for age, sex, race, and service line (hematologic versus solid malignancy); model estimates are presented as incidence rate ratios (IRR) with 95% confidence intervals (CI) Results Of 1796 patients, 406 (23%) had a POLST. 177/406 (44%) were completed less than 30 days before death, and 58/177 (32.8%) specified limited antibiotic use; 40/177 (23%) did not specify any antimicrobial use preference (Fig 1). Of 1295 patients with at least 1 inpatient day in the 30 days before death, 1070 (83%) received at least 1 inpatient antimicrobial with median DOT of 1077 per 1000 inpatient days (Tab 1). There was no difference in DOT among patients with and without a POLST &gt; /= 30 days before death (IRR 0.92, CI 0.77, 1.10). Patients with a POLST specifying limited antibiotic use had significantly lower inpatient IV antimicrobial DOT compared to those without a POLST (IRR 0.64, CI 0.42–0.97) (Fig 2). Figure 1. Classification of Patients by Presence of POLST, Timing, and Antimicrobial Preference Content of POLST. Numbers shown represent the number of patients (percentage). Full antibiotic use refers to the selection “Use antibiotics for prolongation of life.” Limited antibiotic use refers to the selection “Do not use antibiotics except when needed for symptom management.” Table 1: Antimicrobial use for all patients and by advance directive group Figure 2. Forest plot of model estimates, represented as incidence rate ratios (IRR) with 95% confidence intervals (CI), for associations between POLST antimicrobial specifications completed at least 30 days before death and inpatient antibiotic days of therapy (DOT) in the 30 days before death. Estimates represent comparisons between each POLST category and no POLST completed at least 30 days before death. Dots represent the IRR and brackets extend to the lower and upper limit of the 95% CI. Blue estimates are for the inpatient antibiotic DOT outcome and red estimates are for the inpatient IV antibiotic DOT outcome. Conclusion POLST completion is rare &gt; /= 30 days before death, with few POLSTs specifying antimicrobial use. Compared to those with no POLST in this time frame, patients who indicated that antibiotics should be used only for symptom management received significantly fewer inpatient IV antimicrobials. Early discussion of advance directives including POLST with specification of antimicrobial use preferences may promote more thoughtful use of antimicrobials near the end of life in a compassionate, patient-centered way. Disclosures Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis)

scholarly journals Relationship between two year PSA nadir and biochemical recurrence in prostate cancer patients treated with iodine-125 brachytherapy

2014 ◽  
Vol 47 (2) ◽  
pp. 89-93 ◽  
Author(s):  
Carlos Antônio da Silva Franca ◽  
Sérgio Lannes Vieira ◽  
Antonio Carlos Pires Carvalho ◽  
Antonio Jose Serrano Bernabe ◽  
Antonio Belmiro Rodrigues Campbell Penna
Keyword(s):  
Prostate Cancer ◽  
Cancer Patients ◽  
Biochemical Recurrence ◽  
Disease Free Survival ◽  
Disease Recurrence ◽  
Recurrence Rates ◽  
Psa Nadir ◽  
Group 2 ◽  
Iodine 125 ◽  
Group 1

Objective To evaluate the relationship between two year PSA nadir (PSAn) after brachytherapy and biochemical recurrence rates in prostate cancer patients. Materials and Methods In the period from January 1998 to August 2007, 120 patients were treated with iodine-125 brachytherapy alone. The results analysis was based on the definition of biochemical recurrence according to the Phoenix Consensus. Results Biochemical control was observed in 86 patients (71.7%), and biochemical recurrence, in 34 (28.3%). Mean PSAn was 0.53 ng/ml. The mean follow-up was 98 months. The patients were divided into two groups: group 1, with two year PSAn < 0.5 ng/ml after brachytherapy (74 patients; 61.7%), and group 2, with two year PSAn ≥ 0.5 ng/ml after brachytherapy (46 patients; 38.3%). Group 1 presented biochemical recurrence in 15 patients (20.3%), and group 2, in 19 patients (43.2%) (p < 0.02). The analysis of biochemical disease-free survival at seven years, stratified by the two groups, showed values of 80% and 64% (p < 0.02), respectively. Conclusion Levels of two year PSAn ≥ 0.5 ng/ml after brachytherapy are strongly correlated with a poor prognosis. This fact may help to identify patients at risk for disease recurrence.

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