Inpatient Hospice Care in Korea during the COVID-19 Pandemic: A Preliminary Study.

Purpose: This study examined the quality of life (QoL) and quality of care (QoC) in inpatient hospice settings in Korea before and during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Data were obtained from three institutions that participated in two prospective cohort studies. The primary outcomes measured were the QoL of patients with terminal cancer and their family caregivers (FCs), as well as the QoC as perceived by the FCs. Results: Multivariable regression analysis revealed that during the COVID-19 pandemic, both patients and FCs experienced better QoL than before the pandemic, and FCs reported a higher QoC. Conclusion: Health policymakers should consider our findings when planning for future pandemics.

Attitudes toward Social Issues Related to Opioid Use among Palliative Care Physicians.

Purpose: This study investigated palliative care physicians' attitudes regarding social issues related to opioid use. Methods: An email survey was sent to 674 physicians who were members of the Korean Society for Hospice and Palliative Care (KSHPC). Results: Data from 66 physicians were analyzed (response rate, 9.8%). About 70% of participants stated that their prescribing patterns were not influenced by social issues related to opioid use, and 90% of participants thought that additional regulations should be limited to non-cancer pain. Under the current circumstances, pain education for physicians is urgently needed, as well as increased awareness among the public. Half of the respondents identified the KSHPC as the primary organization responsible for providing pain education. Conclusion: Palliative care physicians' prescribing patterns were not influenced by social issues related to opioid use, and these issues also should not affect cancer pain control.

Association of Body Mass Index and Waist Circumference with Osteoarthritis among Korean Adults: A Nationwide Study.

BACKGROUND: Evidence on the association between obesity parameters, including body mass index (BMI) and waist circumference (WC), and osteoarthritis is limited. This study aimed to investigate these associations in Korean adults. METHODS: This nationwide cross-sectional study used data from 24,101 adults aged ≥19 years who participated in the Korea National Health and Nutrition Examination Survey 2016-2020. Odds ratios (ORs) and 95% confidence intervals (CIs) for osteoarthritis according to BMI and WC were analyzed using multivariable logistic regression analyses. RESULTS: The prevalence of osteoarthritis was higher in individuals with general (10.0%) and abdominal obesity (12.8%) compared with those without. Greater BMI and WC were associated with a higher prevalence (P<0.001) and risk of osteoarthritis (Model 3, P for trend <0.001). Individuals with general and abdominal obesity were associated with a 1.50-fold (OR, 1.50; 95% CI, 1.35-1.67) and 1.64-fold (OR, 1.64; 95% CI, 1.47-1.84) increased risk of osteoarthritis, compared with those without. Similar associations were observed in subgroups according to age, sex, smoking status, and presence of diabetes mellitus. The odds of osteoarthritis 1.73-fold increased (OR, 1.73; 95% CI, 1.53-1.95) in individuals with both general and abdominal obesity compared with those without any of them. CONCLUSION: Greater BMI, WC, and general and abdominal obesity were associated with an increased risk of osteoarthritis in Korean adults. Appropriate management of abdominal and general obesity may be important to reduce the risk of osteoarthritis.

Association Between Oral Health Status and Survival Time in Terminally Ill Cancer Patients.

INTRODUCTION: Patients with terminal cancer often experience various oral problems. Whether oral health status is associated with the survival of terminally ill cancer patients receiving palliative care remains unclear. METHODS: We analyzed the data of 59 Korean patients with terminal cancer receiving palliative care, including their oral health status, using a modified Korean version of the Oral Health Assessment Tool (OHAT). Patients were categorized into "Good," "Moderate," or "Poor" groups based on OHAT scores. The Kaplan-Meier method was used to compare the median survival time, and the prognosis between groups was estimated using Cox proportional hazard models. RESULTS: The most common oral symptoms observed were xerostomia (69.5%) and mucositis (17.0%). Significantly shorter survival times were observed in patients with hyperbilirubinemia, elevated creatinine levels, and no use of dentures. The "Poor" group had a shorter survival than the "Good" oral group (P = .010). A multivariate Cox proportional hazards analysis revealed that the "Poor" group was significantly associated with poor survival compared to the "Good" group (hazard ratio, 2.05; P = .047). CONCLUSION: Terminally ill cancer patients with poor oral health may have a higher risk of shorter survival. Palliative care professionals should pay attention to oral health. Further research is needed to determine the effects of oral care on survival.

Public awareness of advance care planning and hospice palliative care: a nationwide cross-sectional study in Korea.

CONTEXT: Advance care planning (ACP) and hospice palliative care (HPC) have potential benefits for individuals and health systems. Public awareness of them might increase their acceptance. OBJECTIVES: To examine public awareness of ACP and HPC and related factors including individuals' experience of health care among Korean population. METHODS: A cross-sectional study based on a nationally representative sample was conducted. Data from participants aged 15 years or older were examined. Socio-demographic characteristics, health-related factors, health care experience in the past year, and awareness of ACP and HPC were analyzed. Subgroup analysis was conducted to determine associations between specific experiences during outpatient visit and awareness of ACP and HPC. RESULTS: Of a total of 13,546 subjects, 39.3% and 35.7% reported awareness of ACP and HPC, respectively. About half (48.6%) of participants reported that they were completely unaware of ACP or HPC. Recent outpatient visit was positively associated with HPC awareness. Participants were more likely to recognize ACP or HPC if they had experience in hospitalization and health checkup over the past year and had trust in the medical system. Conversely, participants who had inadequate health care access due to cost burden showed low awareness of ACP and HPC. CONCLUSION: There was a lack of public awareness of ACP and HPC. There were significant differences depending on various factors, especially individual health care experiences. Appropriate interventions are needed to facilitate discussion of ACP and HPC, thereby increasing public awareness.

Association of low muscle strength with metabolic dysfunction-associated fatty liver disease: A nationwide study.

BACKGROUND: There is limited evidence regarding the association between muscle strength and metabolic dysfunction-associated fatty liver disease (MAFLD). AIM: To investigate the association between muscle strength and MAFLD in the general population in Korea. METHODS: This nationwide representative cross-sectional study included 31649 individuals aged ≥ 19 years who participated in the Korea National Health and Nutrition Examination Survey between 2015 and 2018. Odds ratios (ORs) and 95% confidence intervals (95%CIs) for MAFLD according to sex-specific quartiles of muscle strength, defined by relative handgrip strength, were calculated using multivariable logistic regression analysis. Additionally, multivariable logistic regression analysis was used to assess the association between muscle strength and probable liver fibrosis in patients with MAFLD. RESULTS: Of all the participants, 29.3% had MAFLD. The prevalence of MAFLD was significantly higher in the lower muscle strength quartile groups for all participants, sexes, and age groups (P < 0.001). A 1.92-fold (OR = 1.92, 95%CI: 1.70-2.16) and 3.12-fold (OR = 3.12, 95%CI: 2.64-3.69) higher risk of MAFLD was observed in the lowest quartile (Q1) group than in the other groups (Q2-Q4) and the highest quartile (Q4) group, respectively. The ORs of MAFLD were significantly increased in the lower muscle strength quartile groups in a dose-dependent manner (P for trend < 0.001). These associations persisted in both sexes. An inverse association between muscle strength and the risk of MAFLD was observed in all subgroups according to age, obesity, and diabetes mellitus. In patients with MAFLD, the odds of severe liver fibrosis were higher in Q1 (OR = 1.83, 95%CI: 1.25-2.69) than in other groups (Q2-Q4). CONCLUSION: Among Korean adults, low muscle strength was associated with an increased risk of MAFLD and liver fibrosis in patients with MAFLD.

Association Between Premature Menopause and Cardiovascular Diseases and All-Cause Mortality in Korean Women.

Background Mortality from cardiovascular diseases in Asian populations is considerable. Menopause is a risk-enhancing factor for cardiovascular disease, but it is unclear whether menopause is an independent risk factor for cardiovascular disease and mortality in Asian women. Methods and Results A total of 1 159 405 postmenopausal women, who had participated in the health examinations of the Korean National Health Insurance Service in 2009, were analyzed, and their reproductive histories were taken. A multivariable Cox proportional hazard model assessed the hazard ratios (HRs) of myocardial infarction (MI), ischemic stroke, and all-cause mortality, according to the history of premature menopause and age at menopause. After an average 10-year follow-up, there were 31 606, 45 052, and 77 680 new cases of MI, ischemic stroke, and all-cause mortality, respectively. The women with premature menopause exhibited increased risks of MI (HR, 1.40 [95% CI, 1.31-1.50]), ischemic stroke (HR, 1.24 [95% CI, 1.17-1.31]), and all-cause mortality (HR, 1.19 [95% CI, 1.14-1.24]) when compared with women with menopause aged ≥50 years. The highest risk was evident with menopause between the ages of 30 and 34 years (HR for MI, 1.52 [95% CI, 1.30-1.78]; HR for ischemic stroke, 1.29 [95% CI, 1.12-1.48]; HR for all-cause mortality, 1.33 [95% CI, 1.20-1.47]) when compared with women with menopause aged ≥50 years. Conclusions Earlier age at menopause was associated with increased risks for MI, ischemic stroke, and all-cause mortality. Future guidelines and risk assessment tools should consider menopause as an independent risk factor of cardiovascular disease in Korean women.

Low Serum Creatinine as Well as High Serum Creatinine Is Associated with Prognosis of Patients with Cancer in End-of-Life.

Background: The prognosis of end-of-life patients is challenging, and clinicians have attempted to predict survival more accurately. High serum creatinine (sCr) levels are associated with lower survival rates in patients with various cancers; however, low sCr levels are commonly expected in patients with terminal cancer because of muscle wasting and malnutrition. Therefore, we investigated the prevalence of low and high sCr levels and their association with survival duration in patients with terminal cancer in a palliative care unit. Methods: We analyzed the medical records of 280 patients admitted to a palliative care unit. Patients were divided into low (<0.5 mg/dL), normal (0.5-1.2 mg/dL), and high (>1.2 mg/dL) sCr groups. Kaplan-Meier survival curves using sCr levels were plotted and compared using the log-rank test. Using stepwise selection, a multivariable Cox proportional hazards model was used to identify the significant prognostic factors. Results: The median survival durations in the high-, low-, and normal-sCr groups were 9.57 days, 22.26 days, and 27.51 days, respectively. Multivariable Cox proportional hazard model identified that males (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.16-2.85), poor performance status (HR, 3.43; 95% CI, 1.12-10.54), total parenteral nutrition use (HR, 1.84; 95% CI, 1.09-3.1), high sCr (HR, 2.74; 95% CI, 1.52-4.94), and low sCr (HR, 1.22; 95% CI, 1.07-1.43) were significantly associated with a shorter survival time. Conclusion: Low and high serum creatinine levels were significantly associated with poor survival in patients with cancer at the end-of-life stage. Therefore, readily available and simple biomarkers may help plan advanced care in palliative care settings.

Association between metabolic syndrome and mortality in patients with COVID-19: A nationwide cohort study.

OBJECTIVES: We investigated the association between metabolic syndrome (MetS) and mortality among coronavirus disease 2019 (COVID-19) patients in Korea. METHODS: We analyzed 3876 individuals aged ≥ 20 years who were confirmed with COVID-19 from January 1 to June 4, 2020 based on the Korea National Health Insurance Service (NHIS)-COVID-19 database and had undergone health examination by NHIS between 2015 and 2017. Multivariable Cox proportional hazard regression analyses were performed. RESULTS: Of total participants, the prevalence of MetS was 21.0% (n = 815). During 58.6 days of mean follow-up, 3.1 % (n = 120) of the participants died. Compared to individuals without MetS, COVID-19 patients with MetS had a significantly increased mortality risk after adjusting for confounders in total participants (hazard ratio [HR]: 1.68, 95 % confidence interval [CI]: 1.14-2.47) and women (HR: 2.41, 95 % CI: 1.17-4.96). A low high-density lipoprotein cholesterol level in total participants (HR: 1.63, 95 % CI: 1.12-2.37) and hyperglycemia in women (HR: 1.97, 95 % CI: 1.01-3.84) was associated with higher mortality risk. The mortality risk increased as the number of MetS components increased among total participants and women (P for trend = 0.009 and 0.016, respectively). In addition, MetS groups had higher mortality risk in aged ≥ 60 years (HR: 1.60, 95 % CI: 1.07-2.39), and never-smokers (2.08, 1.21-3.59). CONCLUSIONS: The presence of MetS and greater number of its components were associated with increased mortality risks particularly in female patients with COVID-19. Managing MetS may contribute to better outcomes of COVID-19.

Age at menopause and risk of heart failure and atrial fibrillation: a nationwide cohort study.

AIMS: This study aimed to examine the association of premature menopause and age at menopause with the risk of heart failure (HF) and atrial fibrillation (AF). METHODS AND RESULTS: A total of 1 401 175 postmenopausal women, who had undergone health examination provided by the Korean National Health Insurance Service, were included, and their reproductive histories were collected. Multivariable Cox proportional hazard models were performed to determine the hazard ratios (HRs) and 95% confidence intervals (CIs) of incident HF and AF, according to the history of premature menopause and age at menopause. At a mean follow-up of 9.1 years, there were 42 699 (3.0%) and 44 834 (3.2%) new cases of HF and AF, respectively. Women with history of premature menopause had an increased risk of HF (HR: 1.33, 95% CI: 1.26-1.40) and AF (HR: 1.09, 95% CI: 1.02-1.16), compared to women without the history. Compared with women aged ≥50 years at menopause, those aged 45-49, 40-44, and <40 years at menopause showed a significantly increased trend in HRs for the incident risk of both HF and AF (P for trend <0.001). The robustness of the results of a series of sensitivity analyses further strengthens the main findings. CONCLUSION: Our findings suggest that postmenopausal women with a history of premature menopause or early menopausal age may have an increased risk of HF and AF. These reproductive factors need to be considered for preventing the future risk of HF and AF.

Body Weight Variability and the Risk of Cardiovascular Outcomes and Mortality in Patients With Type 2 Diabetes: A Nationwide Cohort Study.

OBJECTIVE: Obesity and type 2 diabetes are risk factors for cardiovascular diseases and mortality, and they commonly result in weight variabilities. We aimed to investigate the association between body weight variability and risk of major cardiovascular outcomes and mortality in individuals with type 2 diabetes using large-scale, nationwide cohort data on the Korean population. RESEARCH DESIGN AND METHODS: We enrolled 624,237 individuals with type 2 diabetes who underwent health examinations provided by the Korean National Health Insurance System between 2009 and 2010, with three or more body weight measurements within 5 years since enrollment and followed up until the end of 2017. We assessed body weight variability using four indices, including variability independent of the mean (VIM). A multivariate-adjusted Cox proportional hazards regression analysis was performed. RESULTS: During the follow-up, 15,832, 25,038, and 44,716 cases of myocardial infarction (MI), stroke, and all-cause mortality, respectively, were recorded. Body weight variability was associated with increased risks of major cardiovascular outcomes after adjusting for confounding variables. Compared with the hazard ratios (HRs) of the lowest quartile group, the HRs (95% CIs) of the highest quartile group of VIM for body weight were 1.15 (1.10-1.20), 1.22 (1.18-1.26), and 1.58 (1.53-1.62) for MI, stroke, and all-cause mortality, respectively. CONCLUSIONS: Body weight variability was associated with increased risks of MI, stroke, and all-cause mortality in patients with type 2 diabetes and may be a predictor of cardiovascular outcomes in such patients. Appropriate interventions to maintain stable weight could positively influence health outcomes in patients with type 2 diabetes.

Analysis of the Time Interval between the Physician Order for Life-Sustaining Treatment Completion and Death.

BACKGROUND: This study aimed to explore the time interval distribution pattern between the Physicians Order for Life-Sustaining Treatment (POLST) form completion and death at a tertiary hospital in South Korea. It also examined the association between various independent parameters and POLST form completion timing. METHODS: A total of 150 critically ill patients admitted to Korea University Guro Hospital between June 1, 2018 and December 31, 2018 who completed the POLST form were retrospectively analyzed and included in this study. Data were analyzed with descriptive statistics, and group comparisons were performed using the chi-square test for categorical variables. Fisher's exact test was also used to compare cancer versus non-cancer groups. RESULTS: More than half the decedents (54.7%) completed their POLST within 15 days of death and 73.4% within 30 days. The non-cancer group had the highest percentage of patients (77.8%) who died within 15 days of POLST form completion while the colorectal (39.1%) and other cancer (37.5%) groups had the lowest (P=0.336). CONCLUSION: Our findings demonstrated a current need for more explicit guidance to assist physicians with initiating more timely, proactive end-of-life discussions.

Development and Evaluation of a Hospice and Palliative Care Music Therapy Education Program.

Purpose: This study was conducted to develop a hospice music therapist training program and to evaluate its effects. Methods: The educational program consisted of training on the theory of hospice and the theory and practice of hospice music therapy. The course lasted for 4 weeks, with 8 hours of training per week, and 33 music therapists completed the course. In order to assess the effectiveness of the course, participants' knowledge and confidence regarding hospice music therapy and readiness for hospice music therapy before and after education were measured. The statistical analysis was done using SPSS version 18.0 and the paired t-test was used to assess the effectiveness of the program. Results: The trainees showed significant improvements in knowledge (P<0.001) and confidence (P<0.001) in all areas of this course, as well as in readiness for hospice music therapy (P<0.001). Participants' satisfaction with the lectures was assessed using a 5-point Likert scale. The average score for all lecture areas exceeded 4 (yes), and the satisfaction level was mostly high. Students were most satisfied with the lectures on music therapy theory, followed in order by those on music therapy practice and hospice theory. Conclusion: This hospice music therapist training program is considered to be suitable because of its positive educational effects and the high satisfaction of participants with the lectures. In order to provide high-quality music therapy services to patients and their families, this training course should be regularly offered to cultivate competent music therapists, and the content of the education should be standardized and applied in various clinical settings.

Clinical Practice Guideline for Care in the Last Days of Life.

A clinical practice guideline for patients in the dying process in general wards and their families, developed through an evidence-based process, is presented herein. The purpose of this guideline is to enable a peaceful death based on an understanding of suitable management of patients' physical and mental symptoms, psychological support, appropriate decision-making, family care, and clearly-defined team roles. Although there are limits to the available evidence regarding medical issues in patients facing death, the final recommendations were determined from expert advice and feedback, considering values and preferences related to medical treatment, benefits and harms, and applicability in the real world. This guideline should be applied in a way that takes into account specific health care environments, including the resources of medical staff and differences in the available resources of each institution. This guideline can be used by all medical institutions in South Korea.

Completion rate of physician orders for life-sustaining treatment for patients with metastatic or recurrent cancer: a preliminary, cross-sectional study.

BACKGROUND: "End of life" is a difficult topic of conversation in East Asian cultures, even among patients and doctors who share a good rapport. In 2016, the Hospice, Palliative Care, and Life-Sustaining Treatment Decision-Making Act, which took the form of "Physician Orders for Life-Sustaining Treatment," was introduced in South Korea. This study was conducted to investigate the completion rate of Physician Orders for Life-Sustaining Treatment in patients with advanced cancer on the active recommendation of physicians, as well as patients' general attitudes toward end-of-life care. METHODS: We conducted a preliminary, cross-sectional descriptive survey on patients with advanced cancer. A total of 101 patients with advanced solid cancer agreed to participate in the study. The primary endpoint was the rate of completion of Physician Orders for Life-Sustaining Treatment based on a doctor's suggestion. Written interviews were conducted to understand the perceptions and factors influencing patients' decisions. RESULTS: Of the 101 patients, 72 (71.3%) agreed to prepare Physician Orders for Life-Sustaining Treatment. Patients who had an educational level of high school or higher were more likely to agree to complete Physician Orders for Life-Sustaining Treatment documentation as compared to the lower educational status group. More than half of the respondents who completed Physician Orders for Life-Sustaining Treatment documentation reported that they had more than a fair understanding of "life-sustaining care" or "Physician Orders for Life-Sustaining Treatment." Participants' reasons for Physician Orders for Life-Sustaining Treatment completion were diverse. CONCLUSIONS: We found that highly educated patients, who understood the concept behind the policy well, tended to accept Physician Orders for Life-Sustaining Treatment without hesitation. Better education, information shared through the media, and conversations with health care providers might improve understanding of Physician Orders for Life-Sustaining Treatment in patients with cancer.

Yeast (1 → 3)-(1 → 6)-ß-d-glucan alleviates immunosuppression in gemcitabine-treated mice.

Gemcitabine (2'-deoxy-2',2'-difluorocytidine, dFdC) is one of the most effective chemotherapy drugs commonly used for treatment of various tumors. Despite its significant anticancer effects, some adverse effects create obstacles to treatment. The main toxicity of gemcitabine is myelosuppression, which not only reduces patient quality of life, but also hinders further anticancer treatment. In this respect, immunotherapy can address these drawbacks because of its ability to enhance the patient's immune system. To improve immune system function, yeast-derived ß-glucans, which are well-known biologic response modifiers, were administered to gemcitabine-treated mice. The in vivo experiment revealed that orally administered yeast (1 → 3)-(1 → 6)-ß-d-glucan effectively alleviated myelosuppression associated with gemcitabine-induced pancytopenia. Moreover, analysis of myelopoiesis-related cytokine expression through real-time PCR demonstrated that ß-glucan treatment significantly upregulated hematopoietic responses in gemcitabine-treated mice. Furthermore, orally administered ß-glucan significantly induced the expression of IFN-γ and IL-2 in splenocytes of gemcitabine-treated mice. It also restored the cytotoxicity of splenocytes against YAC-1 in gemcitabine-treated mice and displayed a positive effect on gemcitabine-damaged bone marrow tissue. In conclusion, yeast ß-glucans have the potential to be used as adjuvants for alleviating chemotherapy-induced immunosuppression in patients.

Obesity, abdominal obesity and subsequent risk of kidney cancer: a cohort study of 23.3 million East Asians.

BACKGROUND: Limited evidence exists regarding associations between obesity and kidney cancer among Asians. We examined the associations between obesity measures and risk of kidney cancer. METHODS: We included 23,313,046 adults who underwent health examinations provided by the Korean National Health Insurance Service 2009-2012 and performed multivariable Cox proportional hazards regression analyses. RESULTS: During 5.4 years of follow-up, 18,036 cases of kidney cancer were recorded, and cumulative incidence was 0.12%. General and abdominal obesity were associated with 1.32-fold increased risk of kidney cancer compared with groups without either obesity status. Underweight individuals showed decreased adjusted hazard ratio (HR) for kidney cancer (0.76, 95% confidence interval: 0.68-0.85) compared to those with normal body mass index (BMI), while the HRs increased among individuals with BMI 23-24.9 kg/m2 (1.23, 1.18-1.28), 25-29.9 kg/m2 (1.41, 1.36-1.46) and ≥30 kg/m2 (1.77, 1.65-1.90) (P for trend < 0.001). HRs of kidney cancer increased with increasing waist circumference (WC) (P for trend < 0.001). Compared to non-obese condition, the coexistence of general and abdominal obesity increased the HR (1.45, 1.40-1.50). CONCLUSIONS: This study demonstrated positive associations of BMI and WC with kidney cancer risk. General and abdominal obesity may be risk factors of kidney cancer.

Antioxidative and anti-inflammatory effect of Phellinus igniarius on RAW 264.7 macrophage cells.

This study investigated the antioxidative and anti-inflammatory effect of Phellinus igniarius (PI) on RAW264.7 mouse macrophages. Cell viability was determined using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Measurement of nitric oxide (NO) synthesis was performed using the NO detection. To identify mRNA expressions of cyclooxygenase-2 (COX-2), inducible NO synthase (iNOS), interleukin (IL)-1α, IL-1ß, IL-6, and tumor necrosis factor (TNF)-α, real time polymerase chain reaction (PCR) was performed. Assessment of prostaglandin E2 (PGE2) synthesis was performed using the PGE2 immunoassay. Measurement of free radical scavenging activity was performed using the 2,2-diphenyl-1-picrylhydrazyl (DPPH) assay. The MTT assay revealed that PI exerted no significant cytotoxicity in the RAW 264.7 macrophage cells. From the PGE2 immunoassay and NO detection, PGE2 and NO synthesis were significantly suppressed in the PI treated groups compared to the lipopolysaccharide (LPS) treated groups. Real-time PCR analysis revealed that the mRNA expression of COX-2, iNOS, IL-1α, IL-1ß, IL-5, and TNF-α were significantly decreased in the PI treated groups compared to the LPS treated groups. And, PI showed dose-dependent increase in the DPPH radical scavenging activity. In conclusion, PI maybe offer a valuable mode of therapy for the treatment of inflammatory diseases.

Correction to: The impact of caregiver's role preference on decisional conflicts and psychiatric distresses in decision making to help caregiver's disclosure of terminal disease status.

In the original publication of the article, the incorrect grant number HC13C1391 was published in the acknowledgement section. The correct grant number is HC15C1391.