Decreased aggressive care at the end of life among advanced cancer patients in the Republic of Korea: a nationwide study from 2012 to 2018.

BACKGROUND: This study aimed to investigate the trends of aggressive care at the end-of-life (EoL) for patients with advanced cancer in Korea and to identify factors affecting such care analyzing nationwide data between 2012 to 2018. METHODS: This was a population-based, retrospective nationwide study. We used administrative data from the National Health Insurance Service and the Korea Central Cancer Registry to analyze 125,350 patients aged 20 years and above who died within one year of a stage IV cancer diagnosis between 2012 and 2018. RESULTS: The overall aggressiveness of EoL care decreased between 2012 and 2018. In patients' last month of life, chemotherapy use (37.1% to 32.3%; p < 0.05), cardiopulmonary resuscitation (13.2% to 10.4%; p < 0.05), and intensive care unit admission (15.2% to 11.1%; p < 0.05) decreased during the study period, although no significant trend was noted in the number of emergency room visits. A steep increase was seen in inpatient hospice use in the last month of life (8.6% to 26.6%; p < 0.05), while downward trends were observed for hospice admission within three days prior to death (13.9% to 11%; p < 0.05). Patients were more likely to receive aggressive EoL care if they were younger, women, had treatment in tertiary hospitals, or had hematologic malignancies. In the subgroup analysis, the overall trend of aggressive EoL care decreased for all five major cancer types. CONCLUSION: The aggressiveness of EoL care in stage IV cancer patients showed an overall decrease during 2012-2018 in Korea.

Changes in the treatment rate of patients newly diagnosed with stage IV cancer near the end of life from 2012 to 2017 in Korea.

OBJECTIVES: This study aimed to evaluate changes in the cancer treatment rate among patients newly diagnosed with stage IV cancer using socio-demographic and clinical subgroups in a nationwide cohort of Korean patients. METHODS: This retrospective, national-level study used the Korea Central Cancer Registry (KCCR), which is linked to the National Health Insurance Service (NHIS) database, from January 1, 2012 to December 31, 2017. The records of patients newly diagnosed with stage IV of the 5 cancers with the highest cancer-related mortality rate were identified to analyze changes in the treatment rate. The main outcome examined in this study was the change in the cancer treatment rate between 2012 and 2017, as measured using the annual percent change (APC). RESULTS: A total of 106,082 patients with newly diagnosed gastric, colorectal, liver, pancreatic, and lung cancers at the end of life (EoL) were identified from the KCCR-NHIS database. Of these patients, 76,533 (72.1%) received cancer treatment. Over the study period (2012-2017), the proportion of patients who received cancer treatment at EoL decreased by 8.3%, with an APC of -2.1% (95% confidence interval, -2.6 to -1.6). This declining trend of cancer treatment among patients with advanced cancer stage at EoL was consistent among socio-demographic and clinical subgroups. CONCLUSIONS: The proportion of untreated patients with stage IV cancer is increasing in the Korea. For patients who are not undergoing standard cancer treatment near EoL, an alternative care plan, such as early palliative care, should be considered.

Analgesic Efficacy of Melatonin: A Meta-Analysis of Randomized, Double-Blind, Placebo-Controlled Trials.

Previous systematic reviews and meta-analyses of randomized controlled trials have reported controversial findings regarding the effects of melatonin on pain reduction. The aim of this study was to evaluate the efficacy of melatonin on pain among adults using a meta-analysis of randomized, double-blind, placebo-controlled trials (RDBPCTs). PubMed, EMBASE, the Cochrane Library, and the bibliographies of relevant articles were searched up to February 2020. Two of the authors independently evaluated eligibility of the studies based on the pre-determined criteria and extracted data. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) for the pain score change were calculated using a random-effects meta-analysis. Out of 463 that met the initial criteria, a total of 30 trials, which involved 1967 participants with 983 in an intervention group and 984 in a control group, were included in the final analysis. In a random-effects meta-analysis, the use of melatonin reduced chronic pain in all the trials (5 studies, SMD -0.65, 95% CI -0.96 to -0.34, I2 = 57.2%) and high-quality trials (4 studies, SMD -0.62, 95% CI -1.01 to -0.23, I2 = 49.3%). Moreover, the use of melatonin significantly reduced acute postoperative pain (11 studies, SMD -0.82, 95% CI -1.40 to -0.25, I2 = 93.0%). However, the subgroup meta-analysis of high-quality RDBPCTs showed no significant association between them (6 studies, SMD -0.21, 95 % CI -0.66 to 0.24, I2 = 82.4%). The current study suggests that melatonin might be used in treatment of chronic pain, while there is no sufficient evidence for acute postoperative or procedural pain. Further trials are warranted to confirm its analgesic effect.

Associations Between the Intention to Use Early Palliative Care, Sources of Information, and Attitudes Toward a Good Death in Korean Adults.

CONTEXT: Providing hospice and palliative care (HPC) early in the course of care for patients with life-threatening illness is important for improving patient quality of life. However, little literature exists for factors affecting to the intention to use early palliative care (EPC) of general population. OBJECTIVES: This study aimed to identify the sources of information about HPC, investigate whether they affect intention to use HPC and EPC, and examine the relationship between the components of a good death and the intention to use HPC and EPC. METHODS: A stratified nationwide cross-sectional survey including 1500 participants, 20-74 years old, was conducted to investigate their intentions to use HPC and EPC, available information sources, and perceived components of a good death. RESULTS: The main sources of information about HPC were television and radio. Information acquired from health professionals was positively associated with the intention to use EPC. Although regarding a good relationship with family as a component of a good death was related to low intention to use EPC, being able to trust medical staff, being involved in decisions about care, and being respected as an individual were associated with high intention to use EPC. CONCLUSION: Information from health care providers and public awareness through education and publicity efforts are necessary to inform the public about the benefits of EPC. Furthermore, it is essential that medical staff cultivate the skills necessary to secure public trust and provide care that respects patients until the end of their lives.

Changes of End of Life Practices for Cancer Patients and Their Association with Hospice Palliative Care Referral over 2009-2014: A Single Institution Study.

PURPOSE: In Korea, hospice palliative care (HPC) provision for cancer patients has increased recently. However, whether end of life (EoL) care practices have improved along with the development of HPC is unclear. We intended to investigate the changes in EoL care practices and their association with HPC referral. MATERIALS AND METHODS: Retrospective medical record review of adult cancer patients who died at National Cancer Center Korea from 1 January 2009 to 31 December 2014 was performed. Changes of EoL practices including chemotherapy within 2 weeks from death, death in intensive care unit (ICU), documentation of "do not resuscitate (DNR)" within 7 days from death and referral to HPC from 2009 to 2014 were analyzed as well as the association between referral to HPC and other practices. RESULTS: A total of 2,377 cases were included in the analysis. Between 2009 and 2014, referral to HPC increased and DNR documentation within 7 days from death decreased significantly. Cases for chemotherapy within 2 weeks from death and death in ICU didn't change over the study period. Patients referred to HPC were less likely to receive chemotherapy within 2 weeks from death, die in ICU and document DNR within 7 days from death. CONCLUSION: During the study period, EoL practices among cancer patients partly changed toward less aggressive in our institution. HPC referral was associated with less aggressive cancer care at the EoL. Policies to promote EoL discussion are necessary to improve the EoL practices of cancer patients.

Effectiveness of home hospice care: a nationwide prospective observational study.

PURPOSE: Many assert the need for home hospice care. However, limited research has shown its effectiveness. The authors of this study thus evaluated the effectiveness of a home hospice care pilot project regarding (1) early enrollment in hospice care, (2) efficient use of inpatient hospice resources, and (3) enabling terminally ill patients to stay at their preferred place of care. METHODS: The authors conducted a nationwide prospective observational study. Patients were divided into home hospice care users (ever-users, n = 902) and inpatient-only hospice care users (never-users, n = 8210). Information about hospice service utilization was collected from a web-based registry system. Patients were registered if they started to receive the hospice service after providing written informed consent during the pilot project from March 2016-July 2017. RESULTS: Most ever-users preferred to stay at home (84.0%), while never-users preferred hospital admission (66.9%). Most ever-users were enrolled in hospice by home care (78.9%) and used both home and inpatient care (72.4%). The overall duration of hospice care was significantly longer among ever-users than never-users (median 39 vs. 15 days, respectively; mean ± SD 59.6 ± 62.8 vs. 24.8 ± 32.1, respectively; p < .001). Participation in the pilot program improved bed utilization (p = .025) and turnover rate (p < .001) of inpatient hospice service. CONCLUSIONS: Home hospice care enabled early enrollment in hospice services and provided a valid option to patients who wished to stay at home. Policy efforts to facilitate home hospice care are needed.

Factors Related with Utilizing Hospice Palliative Care Unit among Terminal Cancer Patients in Korea between 2010 and 2014: a Single Institution Study.

BACKGROUND: Establishing and designating specialized hospice palliative care units (HPCUs) has been an important part of national policy to promote hospice palliative care in Korea in the recent decade. However, few studies have sought to identify patterns and barriers for utilizing HPCU over the period of national policy implementation. We aimed to investigate factors related with utilizing HPCU for terminal cancer patients after consultation with a palliative care team (PCT). METHODS: We reviewed medical records for 1,028 terminal cancer patients who were referred to the PCT of the National Cancer Center in 2010 and 2014. We compared the characteristics of the patients who decided to utilize HPCU and those who did not. We also analyzed factors influencing choices for a medical institution and reasons for not selecting an HPCU. RESULTS: The patients' mean age was 61.0 ± 12.2, with lung cancer patients (24.3%) comprising the largest percentage of these patients. The percentage of referred patients who utilized an HPCU was 53.9% in 2014, increasing from 44.6% in 2010. Older age and awareness of terminal illness were found to be positively associated with utilization of an HPCU. The most common reason for not selecting an HPCU was "refusing hospice facility" (34.9%), followed by "near death," "poor accessibility to an HPCU," and "caregiving problems." CONCLUSION: Compared to 2010, HPCU utilization by terminal cancer patients increased in 2014. Improving awareness of terminal condition among patients and family members and earlier discussion of end-of-life care would be important to promote utilization of HPCU.

Outpatient Palliative Care and Aggressiveness of End-of-Life Care in Patients with Metastatic Colorectal Cancer.

BACKGROUND: Palliative care in outpatient setting has been shown to promote better symptom management and transition to hospice care among patients with advanced cancer. Nevertheless, specialized palliative care is rarely provided at cancer centers in Korea. Herein, we aimed to assess aggressiveness of end-of-life care for patients with metastatic colorectal cancer according to the use of outpatient palliative care (OPC) at a single cancer center in Korea. METHODS: We performed a retrospective medical record review for 132 patients with metastatic colorectal cancer who died between 2011 and 2014. Fifty patients used OPC (OPC group), while 82 patients did not (non-OPC group). Indicators of aggressiveness of end-of-life care including chemotherapy use, emergency department visits, hospitalization, and utilization of hospice care were analyzed according to the use of OPC. RESULTS: More patients in the OPC group were admitted to hospice than those in the non-OPC group (32% vs 17%, P = .047). The mean of inpatient days within 30 days of death was shorter for the OPC group than the non-OPC group (4.02 days vs 7.77 days, respectively, P = .032). There were no differences in the proportions of patients who received chemotherapy and visited the emergency department within 30 days from death. CONCLUSION: Among patients with metastatic colorectal cancer, OPC was associated with shorter inpatient days near death and greater hospice utilization. Further prospective studies are needed to evaluate the impact of OPC on end-of-life care in Korea.

Do Korean Doctors Think a Palliative Consultation Team Would Be Helpful to Their Terminal Cancer Patients?

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.

Prospective Validation of the Objective Prognostic Score for Advanced Cancer Patients in Diverse Palliative Settings.

CONTEXT: Prognostication is an essential part of palliative care to aid decision making and negotiate goals of care. The Objective Prognostic Score (OPS) is an easy-to-use prognosticating tool to predict survival among far-advanced cancer patients in palliative care units (PCUs) in Korea. OBJECTIVES: This study aimed to prospectively validate the OPS for advanced cancer patients in the palliative care teams (PCTs), PCUs, and home-based palliative care (HPC) in Japan. METHODS: This was a substudy of a multicenter prospective cohort study that was conducted to validate and compare prognostic tools among advanced cancer patients in Japan. Participants' survival was calculated according to OPS 3 as a cutoff for predicting survival of less than three weeks. Overall accuracy and area under the receiver operator characteristic curves of OPS 3 were calculated for PCT, PCU, and HPC, respectively. RESULTS: A total of 1146 cases (PCTs 441, PCUs 519, and HPCs 186 cases) were included in final analyses. The overall accuracy of OPS 3 for predicting three-week survival ranged from 0.70 to 0.78 across diverse palliative care settings. The c-statistics ranged from 0.742 to 0.808 across three settings. Participants in the PCT showed the highest overall accuracy and c-statistics for OPS. CONCLUSION: The OPS can be used for prognostication among advanced cancer patients in PCT, PCU, and HPC settings.

Prevalence and Associated Factors of Anxiety and Depressive Symptoms Among Bereaved Family Members of Cancer Patients in Korea: A Nation-Wide Cross-Sectional Study.

Bereaved family members of cancer patient are at risk of having psychological problems such as anxiety and depression. However, prevalence and associated factors of anxiety and depressive symptoms among this population have not been explored in Korea.We conducted a nation-wide cross-sectional questionnaire survey of 3522 bereaved family members of cancer patients who died at 44 hospice palliative care unit (HPCU) in Korea in 2012. The questionnaire comprised the Hospital Anxiety and Depression Scale (HADS) and Good Death Inventory (GDI). Deceased patient's age, sex, primary site of cancer, duration of stay at HPCU, awareness of terminal status, bereaved family member's age, sex, and relation to the deceased were collected from Korean Terminal Cancer Patients Information System.1121 returned questionnaires were analyzed (response rate, 31.8%). Using a cut-off value of 8 for HADS subscale, the prevalence of anxiety and depressive symptoms was 48.0% and 57.6%, respectively. Mean scores for HADS-A and HADS-D were 7.88 ±â€Š4.87 and 8.91 ±â€Š4.82, respectively. Among the bereaved, older age, being a spouse to the deceased, family members of younger patient, and negative score for a few GDI items were significantly associated with an increased risk of having anxiety or depressive symptoms in the multivariate logistic analysis.In conclusion, we noted the high prevalence of anxiety and depressive symptoms among the bereaved of cancer patients and identified associated factors for these psychological morbidities. Systematic efforts are needed to improve the mental health of the bereaved family members of cancer patients.

Terminal Versus Advanced Cancer: Do the General Population and Health Care Professionals Share a Common Language?

PURPOSE: Many end-of-life care studies are based on the assumption that there is a shared definition of language concerning the stage of cancer. However, studies suggest that patients and their families often misperceive patients' cancer stages and prognoses. Discrimination between advanced cancer and terminal cancer is important because the treatment goals are different. In this study, we evaluated the understanding of the definition of advanced versus terminal cancer of the general population and determined associated socio-demographic factors. MATERIALS AND METHODS: A total of 2,000 persons from the general population were systematically recruited. We used a clinical vignette of a hypothetical advanced breast cancer patient, but whose cancer was not considered terminal. After presenting the brief history of the case, we asked respondents to choose the correct cancer stage from a choice of early, advanced, terminal stage, and don't know. Multinomial logistic regression analysis was performed to determine sociodemographic factors associated with the correct response, as defined in terms of medical context. RESULTS: Only 411 respondents (20.6%) chose "advanced," while most respondents (74.5%) chose "terminal stage" as the stage of the hypothetical patient, and a small proportion of respondents chose "early stage" (0.7%) or "don't know" (4.4%). Multinomial logistic regression analysis found no consistent or strong predictor. CONCLUSION: A large proportion of the general population could not differentiate advanced cancer from terminal cancer. Continuous effort is required in order to establish common and shared definitions of the different cancer stages and to increase understanding of cancer staging for the general population.

Caregiver burden, patients' self-perceived burden, and preference for palliative care among cancer patients and caregivers.

OBJECTIVE: Recently, caregiver burden (CB) has emerged as an important issue in the area of palliative medicine. However, patients' feelings related to being a burden to their families (i.e., self-perceived burden [SPB]) is also a significant issue. We evaluated the relation of CB and SPB as preference for palliative care. METHODS: A national, multicenter, cross-sectional survey of 326 patient-caregiver dyads was performed. A set of paired questionnaires evaluating CB and SPB (five domain items assessed on a four-point Likert scale) were independently administered to patients and their caregivers. Among the respondents, only the patients with distant stage cancer and their caregivers were included. Multivariate analyses were conducted to identify the associations between CB and SPB and preference for palliative care. RESULTS: Caregivers and patients who preferred palliative care to life sustaining treatment reported higher CB and SPB scores, respectively. Caregivers who felt more of a burden were more likely to prefer palliative care over life sustaining treatment for their patients (adjusted odds ratio [aOR] = 1.67, 95% CI: 1.21-2.31). In addition, patients who perceived their caregivers' burden as large tended to prefer palliative care (aOR = 1.61, 95% CI: 1.16-2.22). CONCLUSIONS: Both CB and SPB increased preference for palliative care. This could be interpreted that high CB can lead to preference for palliative care in both patients and their caregivers, potentially threatening patient autonomy. Efforts to relieve CB and SPB are needed.

Perceived timeliness of referral to hospice palliative care among bereaved family members in Korea.

PURPOSE: We aimed to explore the perceived timeliness of referral to hospice palliative care unit (HPCU) among bereaved family members in Korea and factors associated therewith. METHODS: Cross-sectional questionnaire survey was performed for bereaved family members of patients who utilized 40 designated HPCUs across Korea. The questionnaire assessed whether admission to the HPCU was "too late" or "appropriate" and the Good Death Inventory (GDI). RESULTS: A total of 383 questionnaires were analyzed. Of participants, 25.8 % replied that admission to HPCU was too late. Patients with hepatobiliary cancer, poor performance status, abnormal consciousness level, and unawareness of terminal status were significantly related with the too late perception. Family members with younger age and being a child of the patient were more frequently noted in the too late group. Ten out of 18 GDI scores were significantly lower in the too late group. Multiple logistic regression analysis revealed patients' unawareness of terminal status, shorter stay in the HPCU, younger age of bereaved family, and lower scores for two GDI items (staying in a favored place, living without concerning death or disease) were significantly associated with the too late group. CONCLUSIONS: To promote timely HPCU utilization and better quality of end of life care, patients need to be informed of the terminal status and their preference should be respected.

Evaluation of the National Train-the-Trainer Program for Hospice and Palliative Care in Korea.

BACKGROUND: To evaluate the effectiveness of the National Train-the-Trainers Program for Hospice and Palliative Care Experts (TTHPC) sponsored by the National Cancer Center of Korea between 2009 and 2012. This program was developed to improve the teaching skills of those in the field of hospice and palliative care (HPC). MATERIALS AND METHODS: Training was offered in eight 1-day sessions between 2009 and 2012. The effect of the program was measured using Kirkpatrick's model of educational outcomes. First, levels 1 and 2 were evaluated immediately after the 1-day program (n=120). In 2012, the level-3 evaluation test was administered to trainers who offered at least one HPC training (n=78) as well as to their trainees (n=537). RESULTS: The level-1 evaluation addressed participant reactions to and satisfaction with the program. Participants (n=120) were generally satisfied with the content, the method, and the overall course (mean range: 3.94-4.46 on a five-point Likert scale). The level-2 evaluation (learning) showed that participants gained knowledge and confidence related to teaching HPC (4.24 vs. 4.00). The level-3 evaluation (behavioral), which assessed trainers' application of teaching skills to HPC, showed that trainees rated the teaching methods of trainers (mean range: 4.03-4.08) more positively than did trainers (p<0.05). Female trainers were more likely than were male trainers to plan sessions in consideration of their trainees' characteristics (4.11 vs. 3.58; p<0.05), and nurse trainers were more likely than physician trainers to use a variety of instructional methods (4.05 vs. 3.36; p<0.05) CONCLUSIONS: We conducted systematic evaluations based on Kirkpatrick's model to assess the effectiveness of our train-the- trainers program. Our educational program was practical, effective, and followed by our HPC experts, who needed guidance to learn and improve their clinical teaching skills.

Knowledge, practices, and perceived barriers regarding cancer pain management among physicians and nurses in Korea: a nationwide multicenter survey.

PURPOSE: Medical professionals' practices and knowledge regarding cancer pain management have often been cited as inadequate. This study aimed to evaluate knowledge, practices and perceived barriers regarding cancer pain management among physicians and nurses in Korea. METHODS: A nationwide questionnaire survey was administered to physicians and nurses involved in the care of cancer patients. Questionnaire items covered pain assessment and documentation practices, knowledge regarding cancer pain management, the perceived barriers to cancer pain control, and processes perceived as the major causes of delay in opioid administration. RESULTS: A total of 333 questionnaires (149 physicians and 284 nurses) were analyzed. Nurses performed pain assessment and documentation more regularly than physicians did. Although physicians had better knowledge of pain management than did nurses, both groups lacked knowledge regarding the side effects and pharmacology of opioids. Physicians working in the palliative care ward and nurses who had received pain management education obtained higher scores on knowledge. Physicians perceived patients' reluctance to take opioids as a barrier to pain control, more so than did nurses, while nurses perceived patients' tendency to under-report of pain as a barrier, more so than did physicians. Physicians and nurses held different perceptions regarding major cause of delay during opioid administration. CONCLUSIONS: There were differences between physicians and nurses in knowledge and practices for cancer pain management. An effective educational strategy for cancer pain management is needed in order to improve medical professionals' knowledge and clinical practices.

Developing competencies for multidisciplinary hospice and palliative care professionals in Korea.

PURPOSE: Competency-based assessment helps to improve performance and to standardize education programs for hospice and palliative care professionals. This paper aims to report the process and results of developing the hospice and palliative care competencies by multidisciplinary experts in Korea. METHODS: The competency development task force team of Korean hospice and palliative care professionals was comprised of seven physicians, four nurses, two social workers, and two clergy. To build consensus regarding competencies, the team performed a two-round Delphi survey. The importance of competency domains was assessed by using a 5-point Likert scale. After the completion of the Delphi survey, final competency domains were decided in a consensus meeting. RESULTS: The competencies were composed of knowledge, skills, and attitudes. The competency domains were identified as the following: 11 domains and 16 subdomains for physicians, 11 domains for nurses, 5 domains and 15 subdomains for social workers, as well as 3 domains and 5 subdomains for spiritual care providers. The high importance domains were different by specialties. Physical care and treatment for physicians, symptom management for nurses, bereavement care for social workers, and communication for spiritual care providers were ranked as highly important. For nurses and spiritual care providers, attitude-related domains were ranked the highest in importance. CONCLUSION: The competencies developed by multidisciplinary professionals are useful to identify the appropriate roles of each hospice and palliative care specialist involved in a team approach to patient care.

Efficacy of pain education in cancer patients: a meta-analysis of randomized controlled trials.

PURPOSE: Patient education has been considered as one of the important strategies to improve cancer pain control. However, randomized controlled trials (RCTs) have reported inconsistent findings on this issue. This study aims to evaluate the overall efficacy of pain education on improving pain management in cancer patients by using a meta-analysis of RCTs. METHODS: We searched PubMed, EMBASE, and the Cochrane Library in February 2012. Two evaluators independently reviewed and selected trials based on the predetermined selection criteria. Out of 213 articles meeting initial criteria, 12 RCTs involving 2,169 participants (1,069 intervention group and 1,100 control group), were included in the final analysis. RESULTS: In the meta-analysis of all 12 RCTs, compared with the control group, the intervention group showed a small significant lower pain intensity (standardized mean difference [SMD], -0.11; 95 % confidence interval [CI], -0.20 to -0.02). In the subgroup meta-analysis by various factors, a beneficial effect of pain education was observed for patients with an estimated prognosis of at least 3 months, a follow-up within 2 weeks after pain education, multiple sessions, measured worst pain, tailored education, general pain management, education by medical staff, and usual care for a control group. However, in the subgroup meta-analyses of trials using attention control as a control group and high-quality trials, there was no significant effect of pain education. CONCLUSIONS: Further large, high-quality RCTs using a placebo control such as attention control are required to investigate whether pain education has a true efficacy on pain control or is a placebo effect.

Factors that affect quality of dying and death in terminal cancer patients on inpatient palliative care units: perspectives of bereaved family caregivers.

CONTEXT: There is an increasing use of palliative care units (PCUs) for the treatment of terminally ill cancer patients. Thus, it is important to evaluate the care and quality of life of terminally ill cancer patients treated in PCUs so that improvements can be made. Limited research has investigated the quality of dying and death in PCUs. OBJECTIVES: The aim of this study was to identify factors associated with the quality of dying and death for terminally ill cancer patients in PCUs. METHODS: Data were collected from 570 bereaved family caregivers of terminally ill cancer patients. All patients were registered and died in one of the 40 inpatient PCUs designated by the Korean Ministry of Health and Welfare. We assessed the perceived timing of referral to a PCU; the quality of end-of-life cancer care with the Care Evaluation Scale; and the quality of dying and death with the Good Death Inventory. RESULTS: The perception of appropriate timing of referral, use of a community-based PCU, and higher quality of cancer care as assessed by the Care Evaluation Scale were associated with good dying and death in all domains of the Good Death Inventory. CONCLUSION: The good quality of end-of-life care in a PCU improves the quality of dying in terminally ill cancer patients. The data have the potential to guide the development of interventions aimed at achieving a good quality of dying for patients with terminal cancer.