Current Research Trends in Hospice-Related Domestic Nursing Research Theses (1998~2017) / 한국호스피스완화의료학회지

PURPOSE: In this study, the hospice nursing research trend in 1998~2017 was investigated by analyzing research articles on hospice nursing. METHODS: Literature search was performed with keywords of ‘nursing’ and ‘hospice on an academic research information service. Also reviewed were all articles published in the Korean Journal of Nursing Science and its 8 subcategory journals, the Korean Journal of Hospice and Palliative Care and the Korean Hospice Association from 1998 through 2017, except thesis papers. RESULTS: In 2013~2017, 79 articles (31.0%) were relevant, up over 7% from 61 articles (23.9%) in 2008~2012. The most studied field was psychology (92 papers, 36.2%) in the Korean Journal of Hospice and Palliative Care. Enrolled in most papers were patients with end-stage cancer (75, 29.5%), which is overwhelmingly high. Most studies used quantitative methods (183, 72.0%). Recognition was the most studied theme (62, 24.4%), and 16 of them focused on recognition of death (6.3%). Intervention studies totaled 34 (13.4%), and most of them (7, 2.8%) were conducted for palliative education. CONCLUSION: Most hospice nursing studies were quantitative studies, conducted with patients, and hospice nursing intervention programs were similar to each other. Thus, more studies with hospice patients and their families are needed. And more experimental and qualitative studies are needed to build an evidence-based nursing study environment. Considering how most studies examined psychological factors, physiological factors such as pain, a major issue in hospice care, should be analyzed in experimental studies to construct a pain intervention program for hospice patients.

Changes in the Medical Cost and Practice Pattern according to the Implementation of per Diem Payment in Hospice Palliative Care / 보건행정학회지

BACKGROUND: As of July 2015, per diem payment was changed from fee for service Therefore, this study aims to analyse changes in medical charges and medical services before and after enforcement of the palliative care, targeting palliative care wards in a general hospital, and provide basic data needed for development of per diem payment. METHODS: The subjects of the study were a total of 610 cases consisting of 351 patients of service fee who left hospital (died) from July 2014 to June 2016 and 259 ones of per diem payment at Chosun University Hospital in Gwangju Metropolitan City. RESULTS: The results are summarized as follows. First, after the palliative care system was applied, benefit medical service charges and insurance increased significantly (p<0.001). As benefit medical service charges increased, benefit private insurance payment increased significantly (p<0.001). Second, after the per diem payment was applied, total private insurance payment to medical institutes decreased significantly (p=0.050) and non-benefit also decreased significantly (p=0.001). CONCLUSION: It is suggested that additional rewards in the obligatory palliative care items should be continuously remedied and monitored to provide good quality hospice palliative care.

Text Network Analysis of Newspaper Articles on Life-sustaining Treatments

PURPOSE: This study tried to understand discourses of life-sustaining treatments in general daily and healthcare newspapers. METHODS: A text-network analysis was conducted using the NetMiner program. Firstly, 572 articles from 11 daily newspapers and 258 articles from 8 healthcare newspapers were collected, which were published from August 2013 to October 2016. Secondly, keywords (semantic morphemes) were extracted from the articles and rearranged by removing stop-words, refining similar words, excluding non-relevant words, and defining meaningful phrases. Finally, co-occurrence matrices of the keywords with a frequency of 30 times or higher were developed and statistical measures—indices of degree and betweenness centrality, ego-networks, and clustering—were obtained. RESULTS: In the general daily and healthcare newspapers, the top eight core keywords were common: “patients,” “death,” “LST (life-sustaining treatments),” “hospice palliative care,” “hospitals,” “family,” “opinion,” and “withdrawal.” There were also common subtopics shared by the general daily and healthcare newspapers: withdrawal of LST, hospice palliative care, National Bioethics Review Committee, and self-determination and proxy decision of patients and family. Additionally, the general daily newspapers included diverse social interest or events like well-dying, euthanasia, and the death of farmer Baek Nam-ki, whereas the healthcare newspapers discussed problems of the relevant laws, and insufficient infrastructure and low reimbursement for hospice-palliative care. CONCLUSION: The discourse that withdrawal of futile LST should be allowed according to the patient's will was consistent in the newspapers. Given that newspaper articles influence knowledge and attitudes of the public, RNs are recommended to participate actively in public communication on LST.

The Problems and the Improvement Plan of the Hospice/Palliative Care and Dying Patient's Decisions on Life-Sustaining Treatment Act / 한국호스피스완화의료학회지

Nearly 20 years after the Boramea Hospital case, the act on decisions on life-sustaining treatment for patients in hospice and palliative care or at the end of life has taken effect on February 4, 2018 as recommended by the National Bioethics Committee. However, during the legislation process, some parts of the bill that stakeholders and concerned parties did not see eye to eye were either revised or removed. Moreover, the hospice and palliative care part was added in the last minute before the enactment. As a result, the law includes parts that are not in line with the recommendations from the National Bioethics Committee, thereby causing various problems. Therefore, it is crucial to monitor how the decisions on life-sustaining treatments are made in the field and gather various opinions of concerned parties to identify and address problems in the early stage of the implementation of the law. Based on the data, the legislation must be amended to fulfill its purpose that is “to protect the dignity and value of human beings by assuring the best interests of the patients and by respecting their self-determination”.

Design of a Hospice Referral System for Terminally Ill Cancer Patients Using a Standards-Based Health Information Exchange System / 대한의료정보학회지

OBJECTIVES: The demand for hospice has been increasing among patients with cancer. This study examined the current hospice referral scenario for terminally ill cancer patients and created a data form to collect hospice information and a modified health information exchange (HIE) form for a more efficient referral system for terminally ill cancer patients. METHODS: Surveys were conducted asking detailed information such as medical instruments and patient admission policies of hospices, and interviews were held to examine the current referral flow and any additional requirements. A task force team was organized to analyze the results of the interviews and surveys. RESULTS: Six hospices completed the survey, and 3 physicians, 2 nurses, and 2 hospital staff from a tertiary hospital were interviewed. Seven categories were defined as essential for establishing hospice data. Ten categories and 40 data items were newly suggested for the existing HIE document form. An implementation guide for the Consolidated Clinical Document Architecture developed by Health Level 7 (HL7 CCDA) was also proposed. It is an international standard for interoperability that provides a framework for the exchange, integration, sharing, and retrieval of electronic health information. Based on these changes, a hospice referral scenario for terminally ill cancer patients was designed. CONCLUSIONS: Our findings show potential improvements that can be made to the current hospice referral system for terminally ill cancer patients. To make the referral system useful in practice, governmental efforts and investments are needed.

Prediction of Patient Discharge Status Based on Indicators on Admission / 한국호스피스완화의료학회지

PURPOSE: To provide effective palliative care, it is important to predict not only patients' life expectancy but their discharge status at a time of inpatient admission to a hospice care facility. This study was aimed to identify meaningful life expectancy indicators that can be used to predict patients' discharge status on admission to the facility. METHODS: Among 568 patients who were admitted to the hospice ward of P hospital from April 1, 2016 through December 31, 2017, 377 terminal cancer patients were selected. This retrospective cohort study was performed by using performance status, symptoms and signs, socioeconomic status, laboratory findings on admission. RESULTS: Alive discharge was associated with a good performance status that was measured with the Karnofsky and Eastern Cooperative Oncology Group (ECOG) scales and the Global health and Mental status. Less anorexia, dyspnea, dysphagia and fatigue were also associated with symptoms and signs. Associated laboratory findings were close to normal Complete Blood Cell (CBC) count, Liver Function Test (LFT) and Blood Urea Nitrogen (BUN). CONCLUSION: Our findings suggest that Karnofsky Performance Status (KPS), ECOG, Global health, Mental status, anorexia, dyspnea, dysphagia, fatigue, CBC, LFT, BUN are meaningful indicators when predicting discharge status for inpatients. Further investigation is warranted.

Impact of a Palliative Care Education Program on Korean Hospice Volunteers: Motivation, Death Anxiety, and Communication with the Dying / 한국호스피스완화의료학회지

PURPOSE: This study was conducted to evaluate the impact of a two-week palliative care education program on Korean Hospice volunteers. METHODS: A total of 71 volunteers were assigned to two groups: Group A (intervention, n=34) and Group B (usual care, n=37). Group A received six sessions of palliative care education for two weeks. The level of volunteers' motivation, death anxiety, and communication with the dying were measured at baseline and after the program ended. RESULTS: The palliative care education program had positive influence on the volunteers' motivation (t=2.341, P=0.022), death anxiety (t=−2.166, P=0.034), and communication with the dying (t=−2.808, P=0.006). CONCLUSION: The findings of this study suggest that a palliative care education program may be an effective way to boost hospice volunteers' motivation, ease their death anxiety and improve their communication with the dying.

A Content Analysis of Death Conferences for Patients Who Died in a Palliative Care Unit of Cancer Specialist Hospital

Objectives: To clarify the content of death conferences. Methods: 60 death conferences held in the palliative care unit of the National Cancer Center Hospital East between May 2012 and November 2014 were analyzed in a retrospective study. Medical records and notes from the time of the meeting were used. Results: 170 units of data were abstracted from the death conferences held during the studied period. These data were categorized into five groups: 1. supporting family members as subjects of care, 2. understanding and cherishing patient’s thoughts, 3. reducing symptoms and relieving pain, 4. realizing the importance of communication between medical personnel, and 5. becoming anxious due to interaction with patients. Conclusion: The results suggest that the death conference is a useful opportunity to look back on support from various perspectives and directions.

The Impact of Nursing Hospital Workers' Hospice·Palliative Care Knowledge and Awareness, End-of-Life Care Attitude and Death Awareness on Their End-of-Life Care Performance / 한국호스피스완화의료학회지

PURPOSE: This descriptive study is aimed at identifying how nursing hospital workers' performance of end-of-life care is influenced by their knowledge and awareness of hospice palliative care, attitude towards end-of-life care, performance, importance, awareness of death and the factors. METHODS: A self-reported questionnaire was used to collect data from 113 workers at an accredited nursing hospital in K province. Variables were their knowledge and awareness of hospice palliative care, attitude towards end-of-life care, end-of-life care performance and importance and awareness of death. An analysis was performed with the frequency, percentage, mean, standard deviation, t-test, ANOVA, Scheffe's test, Pearson's correlation coefficient and multiple regression using IBM SPSS 21.0. RESULTS: The factors affecting the nursing hospital workers' end-of-life care performance were the importance of end-of-life care and their marital status, which showed an explanatory power of 38.2%. CONCLUSION: In order to improve the nursing hospital workers' end-of-life care performance, a training on the importance of end-of-life care should be provided. Therefore, we would like to propose establishing administrative measures such as 1) efficient staffing to help the caregivers better perform what they think is important, 2) development of a training program that can improve their performance of end-of-life nursing care and 3) a study to verify the effectiveness of the program.

The Characteristics of Terminally Ill Cancer Patients in Hospice and Palliative Care according to Family Composition / 한국호스피스완화의료학회지

PURPOSE: The purpose of this study was to investigate the family composition of terminally ill cancer patients admitted to the hospice unit and how it affects their hospice care. METHODS: We retrospectively analyzed the medical records of terminal cancer patients who died in one hospice unit between January 2009 and March 2014. The demographic and clinical characteristics of the patients were examined, and any different made by their marital status was evaluated. We calculated the time interval between cancer diagnosis and hospice admission and the survival period from hospice admission to death and analyzed their association with family composition. RESULTS: When divided by the median time of 13 months between diagnosis and admission, Group B (>13 months) had a significantly higher proportion of patients living with their spouses; (P < 0.01). The main decision maker was a spouse (52.9%) in Group B; (P=0.04). CONCLUSION: Among the characteristics of the family composition, the presence of spouse was an important factor associated with admission to a hospice unit. Clinicians need to be aware of the impact of marital status on end-of-life care. This study indicates that it is helpful to understand family composition of terminally-ill cancer patients for an effective palliative and hospice care.

A Retrospective Study of the Factors Influencing the Necessity of Holding Death Conferences for Patients Who Died in a Palliative Care Unit of Cancer Specialist Hospital

<p>Objective: To determine the factors influencing the necessity of holding death conferences. Methods: Data of 416 cancer patients who died in the palliative care unit of the National Cancer Center Hospital East between August 2013 and February 2015 were reviewed. Patients’ medical charts and data sheets of conferences held after their deaths were analyzed. Results: A total of 25.7% of participants saw the necessity of holding death conferences. Multiple logistical regression analyses revealed four independent factors that influenced the holding of death conferences: age <50 years; length of stay in the palliative care unit ≥20 days; epidural analgesia; aphonia; and abdominal distention. Conclusion: These factors might explain nurses’ difficulty in providing end-of-life care for cancer patients.</p>

Impact of Community Health Care Resources on the Place of Death of Older Persons with Dementia in South Korea Using Public Administrative Big Data / 보건행정학회지

BACKGROUND: This study aimed to analyze the impact of community health care resources on the place of death of older adults with dementia compared to those with cancer in South Korea, using public administrative big data. METHODS: Based on a literature review, we selected person- and community-level variables that can affect older people's decisions about where to die. Data on place-of-death and person-level attributes were obtained from the 2013 death certification micro data from Statistics Korea. Data on the population and economic and health care resources in the community where the older deceased resided were obtained from various open public administrative big data including databases on the local tax and resident population statistics, health care resources and infrastructure statistics, and long-term care (LTC) insurance statistics. Community-level data were linked to the death certificate micro data through the town (si-gun-gu) code of the residence of the deceased. Multi-level logistic regression models were used to simultaneously estimate the impacts of community as well as individual-level factors on the place of death. RESULTS: In both the dementia (76.1%) and cancer (87.1%) decedent groups, most older people died in the hospital. Among the older deceased with dementia, hospital death was less likely to occur when the older person resided in a community with a higher supply of LTC facility beds, but hospital death was more likely to occur in communities with a higher supply of LTC hospital beds. Similarly, among the cancer group, the likelihood of a hospital death was significantly lower in communities with a higher supply of LTC facility beds, but was higher in communities with a higher supply of acute care hospital beds. As for individual-level factors, being female and having no spouse were associated with the likelihood of hospital death among older people with dementia. CONCLUSION: More than three in four older people with dementia die in the hospital, while home is reported to be the place of death preferred by Koreans. To decrease this gap, an increase in the supply of end-of-life (EOL) care at home and in community-based service settings is necessary. EOL care should also be incorporated as an essential part of LTC. Changes in the perception of EOL care by older people and their families are also critical in their decisions about the place of death, and should be supported by public education and other related non-medical, social approaches.

Experience of Spiritual Conflict in Hospice Nurses: A Phenomenological Study

PURPOSE: This aim of this phenomenological study was to describe and understand the experience of spiritual conflict in hospice nurses by identifying the meanings and structures of the experience. METHODS: Participants were 12 nurses working for one year or more at hospice units of general hospitals in a metropolitan city and experiencing of spiritual conflict as hospice nurses. Over six months data were collected using individual in-depth interviews and analyzed with the method suggested by Colaizzi. RESULTS: The experience of spiritual conflict in participants was organized into three categories, six theme-clusters, and 13 themes. The participants felt existential anxiety on death and a fear of death which is out of human control and skepticism for real facts of human beings facing death. They also experienced agitation of fundamental beliefs about life with agitation of the philosophy of life guiding themselves and mental distress due to fundamental questions that are difficult to answer. Also they had distress about poor spiritual care with guilty feelings from neglecting patients' spiritual needs and difficulties in spiritual care due to lack of practical competencies. CONCLUSION: Findings indicate the experience of spiritual conflict in hospice nurses is mainly associated with frequent experience of death in hospice patients. The experience of spiritual conflict consisted of existential anxiety, agitation of fundamental beliefs and distress over poor spiritual care. So, programs to help relieve anxiety, agitation and distress are necessary to prevent spiritual conflict and then spiritual burnout in hospice nurses.

The Palliative Care and Hospice for the People Living with HIV / 한국호스피스완화의료학회지

According to the advance of antiretroviral regimen and the early treatment strategy, people living with human immunodeficiency virus (PLWH) are achieving the goal of virologic suppression and immune restoration. Most of them no more die of acquired immunodeficiency syndrome (AIDS) defining illnesses, and become older with chronic comorbidities such as cardiovascular, metabolic, hepatic, renal and neurological diseases. However some PLWH still visit hospitals as late presenters with very low CD4+ T cell counts, so that they suffer AIDS defining illnesses to die or experience severe neurological complications resulting in disabilities. Early palliative interventions are needed on the various symptoms of PLWH. Thus far chronic pains such as distal symmetric sensory polyneuropathies have been underevaluated. Active pain-relieving interventions are important to them. Recently we define end of life condition of human immunodeficiency virus (HIV) or eligibility to hospice care after adjusting current status of HIV treatment. Hospice teams should pay attention to the specific medical conditions, psychological needs, and social circumstances of PLWH. With just standard precautions as common infection control measures, general hospice cares can be provided to them like to other hospices subjects. For giving PLWH opportunities to have the end of life with value and dignity, hospice multidisciplinary team should intervene them early and aggressively. Now we need more clinical experiences and institutional improvements.

A Qualitative Study of Physicians' Perspectives on Non-Cancer Hospice-Palliative Care in Korea: Focus on AIDS, COPD and Liver Cirrhosis / 한국호스피스완화의료학회지

PURPOSE: From August 2017, hospice-palliative care (HPC) will be provided to patients with acquired immunodeficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), and liver cirrhosis in Korea. To contribute to building a non-cancer (NC) hospice-palliative care model, NC specialists were interviewed regarding the goals, details, and provision methods of the model. METHODS: Four physicians specializing in HPC of cancer patients formulated a semi-structured interview with questions extracted from literature review of 85 articles on NC HPC. Eleven NC disease specialists were interviewed, and their answers were analyzed according to the qualitative content analysis process. RESULTS: The interviewees said as follows: It is difficult to define endstage NC patients. HPC for cancer patients and that for NC patients share similar goals and content. However, emphasis should be placed on alleviating other physical symptoms and emotional care rather than pain control. Timing of the care provision should be when patients are diagnosed as “end stage”. Special issues should be considered for each NC disease (e.g., use of anti-retroviral drugs for AIDS patients, oxygen supply for COPD patients suffering from dyspnea, liver transplantation for patients with liver cirrhosis) and education should be provided to healthcare professionals. NC patients tend to negatively perceive HPC, and the government's financial assistance is insufficient. CONCLUSION: It is necessary to define end-stage NC patients through in-depth discussion to minimize issues that will likely accompany the expansion of care recipients. This requires cooperation between medical staff caring for NC patients and HPC givers for cancer patients.

How to build successful hospice-palliative care systems in Korea

Although Korea was the first country to provide hospice services in Asia, in 1965, a hospice-palliative care system has not yet been firmly established. Because of controversies surrounding end-of-life decision-making, the passage of the Hospice-Palliative Care and End-of-Life Decision Act was delayed in the National Assembly. It will finally be implemented in August 2017. For this new legislation to be successful, regulatory support from the government is essential, because there are many pitfalls in the law. In addition, a cultural movement towards ‘death with dignity’ is necessary, and the National Health Insurance system should support the cost of providing adequate care to terminal patients.

A Comparison of Hospice Care Research Topics between Korea and Other Countries Using Text Network Analysis

PURPOSE: This study aimed to identify and compare hospice care research topics between Korean and international nursing studies using text network analysis. METHODS: The study was conducted in four steps: 1) collecting abstracts of relevant journal articles, 2) extracting and cleaning keywords (semantic morphemes) from the abstracts, 3) developing co-occurrence matrices and text-networks of keywords, and 4) analyzing network-related measures including degree centrality, closeness centrality, betweenness centrality, and clustering using the NetMiner program. Abstracts from 347 Korean and 1,926 international studies for the period of 1998–2016 were analyzed. RESULTS: Between Korean and international studies, six of the most important core keywords-“hospice,”“patient,”“death,”“RNs,”“care,” and “family”-were common, whereas “cancer” from Korean studies and “palliative care” from international studies ranked more highly. Keywords such as “attitude,”“spirituality,”“life,”“effect,” and “meaning” for Korean studies and “communication,”“treatment,”“USA,” and “doctor” for international studies uniquely emerged as core keywords in recent studies (2011~2016). Five subtopic groups each were identified from Korean and international studies. Two common subtopics were “hospice palliative care and volunteers” and “cancer patients.” CONCLUSION: For a better quality of hospice care in Korea, it is recommended that nursing researchers focus on study topics of patients with non-cancer disease, children and family, communication, and pain and symptom management.

Factors Associated with Willingness to Volunteer for End-Stage AIDS Patients among Hospice Volunteers / 한국호스피스완화의료학회지

PURPOSE: With the implementation of the Act on Life Sustaining Treatment, hospice-palliative care will be extended to non-cancer diseases including the acquired immunodeficiency syndrome (AIDS). However, there are concerns about negative perceptions and prejudice toward AIDS patients. The purpose of this study was to investigate factors related with willingness to volunteer (WV) for patients with end-stage AIDS among hospice volunteers. METHODS: Participants were 326 hospice volunteers from 19 institutions. A self-administered questionnaire was employed to investigate the participants' WV for end-stage AIDS patients, and the questions were answered using an 11-point rating scale. Demographics, volunteer activity, satisfaction with hospice volunteering, knowledge of AIDS, and attitudes towards AIDS patients (i.e., fear AIDS patients, negative attitude towards AIDS patients, personal stigmatization and stigmatizing attitude) were also investigated. A multiple regression analysis was performed to examine factors associated with WV for patients with end-stage AIDS. RESULTS: WV for patients with end-stage AIDS was 2.82 points lower than that for cancer patients (P < 0.001). The multiple regression analysis showed that the higher the level of satisfaction with hospice volunteering (P=0.002) and the lower the level of “personal stigmatization” (P < 0.001), participants showed greater WV for end-stage AIDS patients. CONCLUSION: The level of satisfaction with hospice volunteering and “personal stigmatization” were factors associated with participants' WV for patients with end-stage AIDS.

Do Korean Doctors Think a Palliative Consultation Team Would Be Helpful to Their Terminal Cancer Patients? / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Hospice and palliative care services (HPC) are not commonly utilized in Korea; however, palliative care teams (PCTs) have been found to be effective at addressing the shortcomings in HPC. In this study, we attempted to outline unmet palliative care needs of terminal cancer patients and the potential benefits of PCTs as perceived by doctors in Korea. MATERIALS AND METHODS: We surveyed 474 doctors at 10 cancer-related academic conferences from June to November 2014 with a self-report questionnaire to assess their perceptions of end-of-life care needs and the expected effects of PCTs on caring for terminal cancer patients. Among those surveyed, 440 respondents who completed the entire questionnaire were analyzed. RESULTS: In all domains, fewer participants reported satisfaction with palliative care services than those reporting needs (p < 0.001). The surveyed participants also reported difficulties with a shortage of time for treatment, psychological burden, lack of knowledge regarding hospice care, lengths of stay, and palliative ward availability. Multivariate logistic regression analysis revealed that female doctors (odds ratio [OR], 2.672; 95% confidence interval [CI], 1.035 to 6.892), doctors who agreed that referring my patients to a HPC means I must give up on my patient (OR, 3.075; 95% CI, 1.324 to 7.127), and doctors who had no experience with HPC education (OR, 3.337; 95% CI, 1.600 to 7.125) were associated with higher expected effectiveness of PCT activities. CONCLUSION: The PCT activities were expected to fill the doctor’s perceived unmet HPC needs of terminal cancer patients and difficulties in communications.

The Meaning of Dignified with Death / 한국호스피스완화의료학회지

PURPOSE: We explored Koreans' perception of the meaning of death with dignity that Korean people. METHODS: A phenomenological research methodology was applied. A total of 13 participants were sampled based on their age and gender. Participants were interviewed in depth from September 2015 through February 2016. Colaizzi's phenomenological analysis method was used for data analysis. To establish the validity of the study, we evaluated its realistic value, applicability, consistency and neutrality of the qualitative evaluation criteria of Lincoln and Guba. RESULTS: Koreans' perception of death with dignity was structured as 19 themes, nine theme clusters and four categories. The four categories were “comfortable death”, “good death”, “resolving problems before death”, and “death with good reputation”. The theme clusters were “death without pain”, “death submitting to one's fate”, “death that is not ugly”, “leaving good memories to others”, “dying in a way we want”, “death after proper settling of things”, “dealing with chronic resentment before death”, “death after living a good life”, and “death with recognition”. CONCLUSION: For Koreans, death with dignity meant not burdening others, settling things right and leaving good memories to their families and friends. Such perceptions can be applied to hospice care for terminally ill patients.