End Stage Of Life Research Articles

Morbidity Patterns and Health Seeking Behaviour of 50+ Elderly People in the Rural Community at Fateyabad in Chattogram

Background: Bangladesh is a nation with 9.3% geriatric population who are above 60 years of age and it is expected to rise to 22% in 2050. Health related problems of the elderly need comprehensive geriatric care. This study aimed to explore the morbidity pattern and its associated factors among the elderly population in a rural area of the Chattogram district of Bangladesh. Materials and methods: A cross-sectional study was conducted at Fateyabad in Hathazari, Chattogram, during the period from April to October 2023 which included 260 respondents aged 50 years and above. Data were collected by face-to-face interview by using a pretested mixed type questionnaire. Data were compiled and analysis were done by using scientific calculator and computer. Results: HTN and Diabetes Mellitus were the most common morbidities among elderly population which was 151 (58%) and 92 (35%) respectively. Female respondents were 143 (55%) and male were 117 (45%). Majority of the elderly population belonged to age group 50-59 which was 160 (61%) years and lion share of the respondents were housewife 134 (51%). The rates of seeking healthcare services was higher among elderly population with primary and secondary education, those living with spouses and children, those residing in extended families with seven or more members and older men and women with diabetes and cardiac diseases. Conclusion: On the basis of the findings, it is suggested that the traditional extended family structure should be sustained, wherein older people are treated with care and respect, thereby promoting health of the aged in rural Bangladesh. Furthermore, family relationships should be strengthened, because older individuals, require emotional and familial support to their end stage of life. IAHS Medical Journal Volume 6(2) December 2023; 64-67

Factors Associated With the Initiation of Comfort-Focused Nutrition Care Orders for Long-Term Care Residents at End of Life.

Comfort-focused nutrition orders are recommended to manage eating changes among long-term care (LTC) residents nearing the end of life, though little is known about their current use. This investigation aims to describe current practices and identify resident-level and time-dependent factors associated with comfort-focused nutrition orders in this context. Data were retrospectively extracted from resident charts of decedents (≥65 years at death, admitted ≥6 months) in 18 LTC homes from two sampling frames across southern Ontario, Canada. Observations occurred at 6 months (baseline), 3 months, 1 month and 2 weeks prior to death. Extracted data included functional measures (e.g. cognitive performance, health instability) at baseline, formalised restorative and comfort-focused nutrition care interventions at each timepoint and eating changes reported in the progress notes in 2 weeks following each timepoint. Logistic regression and time-varying logistic regression models determined resident-level (e.g. functional characteristics) and time-dependent factors (e.g. eating changes) associated with receiving a comfort-focused nutrition order. Less than one-third (30.5%; n = 50) of 164 participants (61.0% female; mean age = 88.3 ± 7.5 years) received a comfort-focused nutrition order, whereas most (99%) received at least one restorative nutrition intervention to support oral food intake. Discontinuation of nutrition interventions was rare (8.5%). Comfort orders were more likely with health instability (OR [95% CI] = 4.35 [1.49, 13.76]), within 2 weeks of death (OR = 5.50 [1.70, 17.11]), when an end-of-life conversation had occurred since the previous timepoint (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]) and with a greater number of eating changes (OR = 1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding timepoint. Comfort-focused nutrition orders were initiated for less than one-third of decedents and most often in the end stages of life, possibly representing missed opportunities to support the quality of life for this vulnerable population. An increase in eating changes, including new dysphagia, may signal a need for proactive end-of-life conversations involving comfort nutrition care options. Early and open conversations with residents and family about potential eating changes and comfort-focused nutrition care options should be encouraged and planned for among geriatric nursing teams working in LTC. These conversations may be beneficial even as early as resident admission to the home.

Comparative analysis of symptom burdens and influential factors among diverse terminally-ill patients.

The suffering experienced by terminally-ill patients encompasses physiological, psychosocial and spiritual dimensions. While previous studies have investigated symptom burden intensity for specific disease groups, such as cancer or heart failure patients, a research gap exists in understanding major distressing symptoms among diverse terminally-ill patients. This study assessed symptom burden intensity and explored its influential factors among diverse patient disease groups. This cross-sectional study utilized the baseline Integrated Palliative care Outcome Scale (IPOS) assessment data. The study participants were terminally-ill patients enrolled in an end-of-life care (EoLC) intervention in Hong Kong. Statistical methods including relative importance index (RII), one-way analysis of variance (ANOVA), and generalized linear regression (GLR) were employed. Final sample consisted of 1,549 terminally-ill patients (mean age =77.4 years, SD =11.6). The five top-rated distressing symptoms among these patients, revealed by the RII analysis, were poor mobility (RII =64.4%), family anxiety (RII =63.5%), sharing feelings with family/friends (RII =61.4%), weakness/lack of energy (RII =58.1%), and hardly feeling at peace (RII =50.7%). One-way ANOVA showed significant differences among the eight disease groups in perceived physical and emotional symptom burden intensity (P<0.05). Analysis of RII symptom scores for each disease group revealed that poor mobility was rated as the most distressing symptom (RII =85.1-62.9%) by patients with motor neurone disease, Parkinson's disease, heart failure, dementia, end-stage renal disease and other serious diseases (including stroke, hematological disease, multiple sclerosis and liver diseases). Perceived family anxiety (RII =66.1%) and shortness of breath (RII =63.8%) were the most distressing symptoms for cancer patients and those with chronic obstructive pulmonary disease, respectively. GLR analysis showed that illness type is the most significant factor influencing the perceived burden intensity in terms of the IPOS total and subscale scores of physical symptoms, emotional symptoms and communication/practical issues. Demographic characteristics such as age, gender, marital status and co-residing status were also identified as influential factors of various symptom categories. However, patients' educational level and relationship with primary caregiver did not significantly influence any perceived symptom burden. This study provides valuable insights into the symptom burdens experienced by diverse patient disease groups at end-stage of life. The findings highlight the major distressing symptoms of poor mobility, family anxiety, and shortness of breath. Addressing these symptoms is crucial in improving the quality of care for terminally-ill patients. Furthermore, the study identifies influential factors that can affect the perceived intensity of symptom burden, primarily the main type of terminal illness and patient's age. Tailored care support and improved clinical care should be implemented, particularly for high-risk groups such as patients with non-cancer terminal illnesses and older aged patients. These findings contribute to existing literature and emphasize the need for comprehensive and individualized care in EoLC.

"The Commitment of a Lifetime": The Role of Emotionally Focused Couple Therapy in Strengthening Attachment Bonds and Improving Relationship Health in Later-Life Couples—The Teletherapy Case of "Alice" and "Steve"

A healthy marriage is a crucial protective factor for adapting to the challenges of late life. Emotionally Focused Couple Therapy (EFCT) is an attachment-based model of psychotherapy that emphasizes here-and-now processing of emotion in a safe holding environment; enhanced understanding of the patterned interactions between self and other; and a non-pathologizing, growth-oriented approach toward couples’ difficulties. This case study examines the benefits of EFCT for addressing issues specific to late life, including existential concerns such as aging, illness, and mortality; caregiving burdens and stress; cumulative relational trauma over the lifespan; and forgiveness and healing from emotional injuries. The case study involved a 20-session, teletherapy treatment of a couple named "Alice" and "Steve," aged 74 and 75, respectively, with Steve suffering from advanced Parkinson’s Disease. The couple presented with hopelessness and resentment about their caregiving situation, unresolved traumas from early childhood fueling their relationship’s sore spots, and unprocessed grief and fears concerning losses at the end stage of life. The EFCT-guided treatment focused on promoting transformational and corrective experiences of secure attachment bonding. Throughout therapy, Alice and Steve cultivated coherent, positive perspectives of their marriage and related hardships by engaging in reminiscence; embraced their longings for each other by relinquishing their defenses against loss and mourning; and strengthened the legacy of their marriage by exploring their shared values and vision of family life. At the end of therapy, the clients retrospectively completed several standardized, quantitative measures assessing aspects of emotional and relational health. Their responses evidenced their heightened emotional awareness and acceptance, increased marital adjustment and satisfaction, and improved attachment security over the course of the therapy. This case study highlights EFCT as a potent therapeutic intervention for fostering relationship health in later-life individuals to reduce the public health risks associated with social disconnection and loneliness in the aging population.

Analysis of microbiological tests in patients withholding or withdrawing life-sustaining treatment at the end stage of life in 2 Korean hospitals.

We evaluated the adequacy of microbiological tests in patients withholding or withdrawing life-sustaining treatment (WLST) at the end stage of life. The study was conducted at 2 tertiary-care referral hospitals in Daegu, Republic of Korea. Retrospective cross-sectional study. Demographic findings, clinical and epidemiological characteristics, statistics of microbiological tests, and microbial species isolated from patients within 2 weeks before death were collected in 2 tertiary-care referral hospitals from January to December 2018. We also reviewed the antimicrobial treatment that was given within 3 days of microbiological testing in patients on WLST. Of the 1,187 hospitalized patients included, 905 patients (76.2%) had WLST. The number of tests per 1,000 patient days was higher after WLST than before WLST (242.0 vs 202.4). Among the category of microbiological tests, blood cultures were performed most frequently, and their numbers per 1,000 patient days before and after WLST were 95.9 and 99.0, respectively. The positive rates of blood culture before and after WLST were 17.2% and 18.0%, respectively. Candida spp. were the most common microbiological species in sputum (17.4%) and urine (48.2%), and Acinetobacter spp. were the most common in blood culture (17.3%). After WLST determination, 70.5% of microbiological tests did not lead to a change in antibiotic use. Many unnecessary microbiological tests are being performed in patients with WLST within 2 weeks of death. Microbiological testing should be performed carefully and in accordance with the patient's treatment goals.

2. Home Health Care Nurses Practicing Medical Care in the End Stage of Life -Message for Medical Doctors

2. Home Health Care Nurses Practicing Medical Care in the End Stage of Life -Message for Medical Doctors

The impacts of the scope of benefits expansion on hospice care among adult decedents: a nationwide longitudinal observational study

ObjectivesCompared to aggressive treatment for patients at the end stage of life, hospice care might be more likely to satisfy such patients’ need and benefits and improve their dignity and quality of life. Whether the reimbursement policy expansion affect the use of hospice care among various demographics characteristics and health status was unknown. Therefore, the purpose of this study was to explore the impacts of reimbursement policy expansion on hospice care use, and to investigate the effects on people with various demographics characteristics and health status.MethodsWe used the 2001–2017 Taiwan NHI claims data, Death Registry, and Cancer Registry in this study, and we included people who died between 2002 and 2017. The study period was divided into 4 sub-periods. hospice care use and the initiation time of 1st hospice care use were used as dependent variables; demographic characteristics and health status were also collected.ResultsThere were 2,445,781 people who died in Taiwan during the study period. The results show that the trend of hospice care use increased over time, going steeply upward after the scope of benefits expansion, but the initiation time of 1st hospice care use did not increase after the scope of benefits expansion. The results also show that the effects of expansion varied among patients by demographic characteristics.ConclusionThe scope of benefits expansion might induce people’s needs in hospice care, but the effects varied by demographic characteristics. Understanding the reasons for the variations in all populations would be the next step for Taiwan’s health authorities.

MO473: Conservative Management in Hospitalized Patients With Advanced Chronic Kidney Disease—A Single Centre 4-Years’ Experience

Abstract BACKGROUND AND AIMS There is an increasing number of patients with advanced chronic kidney disease (CKD) who are older, frail, with multi-morbidity, and with poor functional status. Renal palliative medicine or kidney supportive care is an evolving branch of nephrology. In medicine, strict respect for the patient's wishes related to their health is essential, but the medical decision to suspend or not initiate treatments considered inappropriate or futile is also crucial, whenever the limits of diagnostic and/or therapeutic intervention dictated by the current state of knowledge are exceeded. There is a need for better evidence about medical management versus dialysis at different ages, to better support our patients in all stages of their renal disease. The aim of this study was to analyze the applicability and outcomes of a conservative management of advanced CKD in patients admitted to a nephrology ward between January 2018 and December 2021. METHOD Retrospective observational study was carried out through the analysis of digital data of all patients admitted to a nephrology ward between January 2018 and December 2021. All the patients included in this study had a decision of therapeutic limitation signed. This was applicable in situations of advanced illness and at the end stage of life, in which the use of extraordinary means for sustaining life may be considered inappropriate, or even a cause of damage. Therapeutic limitation parameters include the artificial route for nutrition, parenteral nutrition, use of vasoactive drugs, transfusions, invasive mechanical ventilation, defibrillators, cardiopulmonary resuscitation and renal function replacement techniques. Data regarding patients’ baseline characteristics, the Katz Index of independence in activities of daily living, comorbidities, symptoms, laboratory findings, length of hospital stay, treatment regimens and clinical outcomes were collected by consulting electronic medical records. Statistical analyses were performed using SPSS statistics version 23.0. RESULTS A total of 102 patients (female 55.9%) with a mean age of 86 ± 9 (range 55–99) years were selected. Prior to hospitalization, patients were mostly residing in nursing homes (n = 41, 40.2%), followed by their private residences (n = 40, 39.2%) and then continuous care units (n = 16, 15.7%). Diseases of the respiratory tract were the most common causes of hospitalization (n = 21, 20.7%), followed by acute kidney injury/worsening of CKD (n = 20, 19.6%) and heart failure (n = 15, 14.8%). We defined two groups: patients who died (group 1) and patients who were discharged (group 2). G1 (n = 88; 86.3%) and G2 (n = 14; 13.7%) had similar distributions of gender (female: 50.7% versus 54.9%, P = .081) opposite to age (82.9 ± 9 versus 73.8 ± 10 years, P = .016). At admission, groups were compared for dementia (62.1% versus 47.4%, P &amp;lt; .001), arterial hypertension (48.3% versus 37.9%, P = .061), diabetes (52.2% versus 37.8%, P &amp;lt; .001), oncologic disease (50.4% versus 26.6%, P &amp;lt; 0.001), hypoalbuminaemia (serum albumin &amp;lt;3.0 g/dL) (57.7% versus 59.9%, P = .056) and Katz Index of independence in activities of daily living &amp;lt;3 points (66.9% versus 62.3%, P = .081). Dialysis was suspended (n = 89; 87%) or not started (n = 13; 13%) in the number total of patients. A total of 86.3% of patients died (n = 88). The average number of days between the decision to limit therapy and death was 7 days (ranging from 1 to 23 days). The rest of the patients were discharged from the hospital, maintaining the conservative strategy. CONCLUSION Currently, we have a group of patients with CKD who are older and have more comorbidities. As demonstrated in our study, conservative management or the suspension of supportive treatment is a legitimate option for frail, elderly CKD patients in whom dialysis may not lead to an improvement in quality or duration of life. In fact, it is possible to medically ∼10%–15% of patients with advanced CKD and refer them to a renal palliative care consultation.

Caregivers' Experience of End-of-Life Stage Elderly Patients: Longitudinal Qualitative Interview.

Objectives: This study seeks to provide an understanding of the changing experiences in caregivers of end-of-life patients in Hong Kong through exploring their caregiving journey. Methods: Using longitudinal individual qualitative interviews, a total of 14 caregivers of community-dwelling elderly patients receiving end-of-life care were recruited between 2015 and 2016. A series of in-depth interviews and observations were conducted in 14 cases during the end-of-life journey. Results: A thematic analysis revealed four sequential experiential stages, abbreviated as “CAPE” that caregivers confronted: Stage 1 Certainty, (1a) lack of certainty regarding the progression of decline at the end-stage of life (1b) feelings of despair as patients’ function decreased; Stage 2 Ambivalence, (2a) feelings of ambivalence after decisions were made regarding EOL care, (2b) struggle over care responsibility within families; Stage 3 Perturbed, (3a) varied in quality of EOL care, (3b) depressed mood arisen from frequent exposure to the suffering of elderly patients; and Stage 4 Expectation, (4a) losing the caregiving role as patients showing signs of imminent death. Conclusions: These findings increase our understanding of caregivers’ in-depth experience over time that arise within the structural context of end-of-life care. Our data highlights the need for end of life related knowledge and information, provision of a caring atmosphere and communication, and professional-led detachment in creating caregiving-friendly service in healthcare system, thus as to provide support and alleviate stress for caregivers with their critical responsibility and role during the course of end-of-life care.

Patient-Centered Discussion on End-of-Life Care for Patients with Advanced COPD.

Exacerbations of chronic obstructive pulmonary disease (COPD) may lead to a rapid decline in health and subsequent death, an unfortunate tyranny of having COPD—an irreversible health condition of 16 million individuals in the USA totaling 60 million in the world. While COPD is the third largest leading cause of death, causing 3.23 million deaths worldwide in 2019 (according to the WHO), most patients with COPD do not receive adequate treatment at the end stages of life. Although death is inevitable, the trajectory towards end-of-life is less predictable in severe COPD. Thus, clinician-patient discussion for end-of-life and palliative care could bring a meaningful life-prospective to patients with advanced COPD. Here, we summarized the current understanding and treatment of COPD. This review also highlights the importance of patient-centered discussion and summarizes current status of managing patients with advanced COPD.

Trends and associated factors in place of death among individuals with cardiovascular disease in China, 2008-2020: A population-based study

SummaryBackgroundCardiovascular disease (CVD) is the leading cause of death (COD) in China. Understanding the characteristics of place of death (POD) among CVD deaths would be of great importance to evaluate the healthcare service utilization at the end stage of life. Limited studies have reported the POD distribution among CVD deaths, and little was known about the associated factors of hospital CVD deaths.MethodsBy using data from National Mortality Surveillance System (NMSS) in China, this study presented the characteristics of POD distribution during 2008 and 2020. Afterwards, multilevel logistic regression was used to explore associated factors of hospital CVD deaths and quantify the magnitude to which the spatial variations of hospital CVD deaths could be explained by those associated factors.FindingsDuring 2008-2020, there was 7101871 CVD deaths collected by NMSS in China, with 77·13% home deaths and 18·49% hospital deaths. Shanghai (59·40%) had the highest percentage of hospital CVD deaths. Age, sex, ethnicity, marital status, education, occupation, underlying COD were significant influential factors of hospital CVD deaths. Spatial variations were shown at provincial level, with 33·88% of them being explained by factors at individual level.InterpretationHome was the leading POD among CVD deaths in China, those CVD decedents characterized as the female, the youngest, Han population, the married, the retiree, lived in urban areas, with higher socioeconomic status and died of chronic CVDs had a higher probability of hospital deaths. Providing accessible and available healthcare services were priorities to improve quality of end-of-life care, significant variations among provinces and sub-population also reminded us of the requirements for equal healthcare resources allocation and multiple options for minorities of POD preference at the end stage of life.FundingNational Key Research & Development Program of China (grant number 2018YFC1315301)

It's all about the individual's right to choose: A qualitative study of Australian culturally and linguistically diverse nurses’ knowledge of and attitudes to voluntary assisted dying

BackgroundNurses have a fundamental role in providing care for people at the end of life. Some nurses from culturally and linguistically diverse (CALD) backgrounds may have diverse opinions about death which may affect their views about voluntary assisted dying (VAD) and may impact on the care they provide. To date, there has not been a focus on the views of nurses from different CALD backgrounds on VAD. The implementation of VAD may place them at risk of ethical, moral, social and professional distress. AimsThe study was conducted to determine the knowledge and attitudes of Victorian nurses from CALD backgrounds about VAD. The other aims were to understand their perceptions about how VAD might affect their professional practice and recommend strategies that might assist in their readiness and preparation for exposure to VAD. MethodsThis study used a qualitative descriptive approach. The knowledge and attitudes toward VAD of nurses from CALD backgrounds were explored using face-to-face focus group discussion and in-depth interviews. Interviews were transcribed verbatim and thematic analysis was undertaken. FindingsSeventeen female and four male nurses from CALD backgrounds were recruited through partner healthcare organisations. They came from nine different countries, with ages ranging from late 20s to 60 years. All had experienced caring for individuals at the end stage of life, and about half had experienced being asked directly about VAD. Three themes emerged from the focus group meeting and interviews. These were: ‘Mixed level of knowledge about VAD’, ‘Conflicting cultural and religious beliefs’ and ‘Supremacy of professional and ethical values and attitudes’. DiscussionAll of the participants were aware of VAD, but the depth of knowledge varied. Some attitudes revealed that their cultural and religious beliefs and practices conflicted with their views and practices related to VAD, but they considered the interest, autonomy, and decisions of the people they served as the primary focus. Most nurses were able to set aside and distinguish their current and past beliefs, backgrounds, culture and ethnicity, and prioritised their patients’ wellbeing and choices. For these nurses, professional and ethical values and attitudes were significant determinants of their personal belief systems when it came to VAD. This study provided a greater understanding of CALD nurses’ awareness, knowledge and attitudes about VAD, the impact of culture, religion and other variables on their perceptions of assisted dying and on professional practice, as well as the identification of strategies to increase the capacities of nurses in managing assisted dying. ConclusionThe findings of this study indicate a need for a broad-based educational program in VAD focused on building the capability of nurses who may lack knowledge about VAD and strategies to deal with VAD, and/or are experiencing difficulty reconciling their own cultural and/or religious beliefs with patients’ decisions to opt for voluntary assisted dying.

Structure and process of palliative care provision: a nationwide study of public hospitals in Thailand

BackgroundThe demand for palliative care in hospitals in Thailand has rapidly increased in recent years. Subsequently, the way in which palliative care systems should be arranged to facilitate the care process and patient preparation for their end stage of life is still an ongoing debate among policy makers and researchers. Although palliative care is provided in most facilities, there is no clear protocol for palliative care due to a lack of empirical evidence. Thus, this study attempts to analyse the situation and quality of palliative care provision in Thai public hospitals.MethodsA cross-sectional study was conducted in 2018. A questionnaire with measures concerning hospital characteristics, the structure of palliative care provision, and processes related to achieving a good death was developed. The questionnaire was sent to all 862 public hospitals across 76 provinces, and the response rate was 62.88%. A structural equation model was specified to operationalize Donabedian’s framework. To our knowledge, this is the first nationwide study to investigate facility-level palliative care provision in Thailand.ResultsThe study results confirmed the relationships between the structure and process of palliative care provision in hospitals. The sufficiency and competency of doctors and nurses and the variety of relaxation equipment were either directly or indirectly associated with the process components relevant to the response to the patient’s needs, effective communication, and respect for the patient’s dignity. In addition, the performance of palliative care research in hospitals was associated with the response to the patient’s needs and effective communication, while the allocation of physical areas was associated with effective communication.ConclusionThis model can be used to evaluate the overall situation of palliative care provision at the national level. It could also contribute to the development of standard measurements for evidence-based palliative care quality improvement in hospitals.

Seeking an Easeful Death: Permutations Within a Penumbra

This Monograph derives from a paper given at The Rothermere American Institute, University of Oxford in the United Kingdom, March 6, 2012. Contemporary society needs recognition of a fundamental right to compassionate care at the end-stage of life. In a very real way, a right to this quality of care should embrace and incorporate a collateral duty to prevent suffering. Indeed, the duty to relieve pain has long been acknowledged as the least disputed and most universal of the moral obligations of the physician. The human right to care should be acknowledged as a right grounded in a liberty interest which cannot be challenged unduly or restricted unreasonably by a state interest in judging the “morality” of autonomous actions designed only to give purpose and to promote the basic interest to die with dignity and relative ease. Accordingly, physician assistance for the terminally ill, is a futile medical condition, should be allowed for competent patients giving their informed consent. For the incompetent patient, allowance should be given by the state to physicians who determine — based upon a patient’s life value system and a medical prognosis of futility — that a standard of common sense, humaneness, and compassion dictates legal and immunity from criminal prosecution be allowed for physician assisted death.

Pleural Drainage Strategy After IPC Placement: A Focused Clinical Review.

The first indwelling pleural catheter (IPC) received Federal Drug Administration approval in 1997, nearly 40 years after John Chambers first described instillation of talc into the pleural space for palliation of malignant pleural effusions. Since then IPCs have revolutionized the management of malignant pleural effusions, providing an effective means of controlling dyspnea in the end stages of life without the pain and prolonged hospital stays long associated with chemical sclerosing agents. While palliation of symptoms is the primary purpose of IPCs, development of pleurodesis in the outpatient setting is often an important secondary goal. Historically, decisions regarding IPC drainage frequency have been largely arbitrary and only recently has the evidence started to emerge regarding the effects of specific drainage strategies on both symptom control and pleurodesis development. This focused clinical review explores the current literature regarding IPC drainage strategies as well as novel methods designed to improve the efficacy of IPCs in a thorough and systematic manner. In addition, this review provides an in-depth analysis and synthesis of the data focusing on key considerations needed to develop patient-centered and cost-effective strategies for the use of IPCs in malignancy.

Quality of Palliative and End-Of-Life Care in Hong Kong: Perspectives of Healthcare Providers.

Background: In response to population aging, there is a need for health systems to focus on care for chronic disease, specifically palliative care, while focusing on people-centered care. The objective of this study is to explore the healthcare system enablers and barriers to the provision of quality palliative and end-of-life care from the perspective of healthcare professionals. Materials and Methods: Using purposive sampling, fifteen focus group interviews and nine individual interviews involving 72 healthcare providers were conducted. Primary qualitative data were collected between May 2016 and July 2017. All recorded discussions were transcribed verbatim and analyzed. A thematic framework was developed. Results: The provision of quality palliative and end-of-life care is influenced by the interaction and integration of nine sub-themes under four identified themes: (1) political context; (2) organization setting; (3) support to patients, caregivers, and family members, and (4) healthcare workers and the public. Conclusions: Integration of palliative and end-of-life care is an important pillar of healthcare service to improve quality of life by addressing patients’ values, wishes and preference, and assist their family to handle challenges at the end stage of life. Further improvements to the service framework would be required, specifically in the political framework, multidisciplinary approach, and readiness and competence in healthcare workers and community. These were highlighted in our study as key components in service provision to ensure that patients can receive continuous and integrated care between hospitals and the community as well as dignified care at the end stage of life.

Bioethics in the 21st Century: Principlism, Situation Ethics, and Love

This Monograph derives from a paper written for delivery at the 14th UNESCO World Conference on Bioethics, Medical Ethics, and Health Law. Bioethics raises the central question of how to live, how to die, and how society should both direct and relate to the new, startling biotechnological and reproductive advances of the 21st century. This Monograph analyzes, critically, Principlism and Situation Ethics in an effort to determine which is more efficacious as a framework for advancing sound moral argumentation, developing policy and for supporting ethical decision making in these three principal areas of interest and concern. In order to assure an active, positive role and – indeed – relevance for bioethics in this century, the conclusion drawn is that the “traditional” template for ethical argumentation through Principlism should be re-calibrated in order to allow love to be the single or situational virtue of a common sense morality or – in other words – as the controlling vector of force in complex ethical cases which call for a resolution. Accordingly, decisions should be guided by a spirit of rational thinking and basic common sense which seeks, always, to direct a caring response – especially at the end-stage of life – or, in other words, one which is compassionate, loving, humane, and merciful and one which acknowledges a human right to dignity.

Deprescribing in end-of-life care

The aim of deprescribing in end-of-life care is to improve the patient's quality of life by reducing their drug burden. It is essential to engage the patients and enable them to make choices about medications by discussing their preferences and implement a pharmacy management plan. Withdrawing medications during the end stages of life is extremely complex because the period of care varies substantially. The aim of this article is to address polypharmacy within end-of-life care. It will review which medications should be stopped by examining the non-essential and essential drugs. The intention is to encourage an approach to care which provides an equal balance between treatment and patient expectation.

Deprescribing in end-of-life care.

The aim of deprescribing in end-of-life care is to improve the patient's quality of life by reducing their drug burden. It is essential to engage the patients and enable them to make choices about medications by discussing their preferences and implement a pharmacy management plan. Withdrawing medications during the end stages of life is extremely complex because the period of care varies substantially. The aim of this article is to address polypharmacy within end-of-life care. It will review which medications should be stopped by examining the non-essential and essential drugs. The intention is to encourage an approach to care which provides an equal balance between treatment and patient expectation.

ALOE VERA: AS A NATURAL MEDICAMENT IN PALLIATIVE CARE PATIENTS

Abstract Background Persons of the end of life require special attention to their rapidly failing oral health. Eighty nine percent of those terminally ill with cancer will complain of at least one oral symptom. Oral care is a very important part as a treatment aspect of palliative care department. As we all know during the end stage of life while the patient goes through all kind of radiotherapy, chemotherapy treatment, gradually patients immunity will be compromised. Most common oral problem is candidiasis (thrush) Different treatments have been used in application to symptomatic oral candidiasis, with variable result, perhaps caused by the refractory nature of the disease. The objective of this study was to evaluate the efficacy of the topical application of aloe vera in oral candidiasis compared with placebo. Methods A total of 40 patients of Palliative department with Oral candidiasis were randomized in a double blind study to either aloe vera twenty patients or placebo twenty patients, at a dose of four hundred microlitter ml 70 percent concentration three times a day at Palliative care department of S P Medical college Bikaner Rajasthan. A Visual Analog Scale was used for rating mucosal lesions, pain, with the application of a clinical scale for scoring the lesions, the Oral Health Impact Profile fourty nine The patients were evaluated after two and four weeks. Results Data analysis study groups that had been given aloe vera, by statically analysis, there was a statistically significant difference, mucosal lesion and oral discomfort as graded by visual analogue scale. Conclusion Within the limitation of this study aloe vera is effective as a topical antifungal agent. The topical application of aloe vera improves the total quality of life score in oral candidiasis patient.