Sedation for refractory symptoms of terminal cancer patients in Taiwan.

This study assessed sedation in terminal cancer patients in terms of three characteristics: frequency; relationship to intractable symptoms; and the extent to which medical staff, family, and patients found sedation to be ethically acceptable and efficacious. Two hundred seventy-six consecutive patients, who were admitted to the palliative care unit of National Taiwan University Hospital in Taiwan between August 1998 and the end of May 1999, were enrolled. A recording form was completed every day. This included demographic data, pain and common symptom scores, and the use of sedation in the terminal phase. Seventy (27.9%) of 251 patients who died received sedation. Sedation was administered to relieve agitated delirium in 40 (57.1%), dyspnea in 16 (22.8%), severe pain in 7 (10%) and insomnia in 5 (7.2%). The drugs used for sedation were haloperidol in 35 (50%), midazolam in 17 (24.3%), and rapidly increasing dosage of morphine in 9 (12.9%). In fewer than half (42.9%) of the patients, sedation was with the consent of both patient and family, and half (50%) had the consent of family alone. The overwhelming majority of medical staff and family felt the decision to use terminal sedation was ethically acceptable. There was no significant difference in survival time between sedated and non-sedated patients (28.49 vs. 24.71 days, t = -0.791, P = 0.430). Positive ethical acceptability and higher satisfaction with symptom control with terminal sedation were found in both medical staff and family in this study. Further work is needed to find the most appropriate time of intervention and to improve management of refractory symptoms in dying patients.

Development of a Chinese chronic illness-related stress inventory for primary care.

This study evaluates the construct validity and internal consistency of a Chronic Illness-Related Stress Inventory (CRSI) for primary care Chinese patients and studies the relationship between chronic illness-related stress and sociodemographic characteristics and indices of disease severity. A total of 301 patients were interviewed using a structured questionnaire. The responses to the CRSI were divided into a frequency scale and a severity scale. Six factors including physical integrity and discomfort, psychosocial function and economic burdens, self-fulfillment and daily life, sexual function, self-esteem, and diet limitations were obtained for each CRSI scale. Except for the last factor, all other factors and the scale as a whole for both scales have a Cronbach alpha of > 0.90. The results of the convergent and discriminant validity analysis were promising. In addition, chronic illness-related stress was related to insurance status and the self-perceived severity of disease.

Mortality trends of elderly people in Taiwan from 1974 to 1994.

BACKGROUND: the hypothesis that disability and death will eventually be compressed to a period late in life needs empirical confirmation. OBJECTIVES: we have examined the secular trends of life expectancy and common causes of death in the aged population of Taiwan. METHOD: we compared the life expectancy, causes of death and probability of death for people at birth, at age 65 and at age 85 for both sexes from 1974 to 1994 using data from Taiwan government statistics. RESULTS: there has been a substantial gain in life expectancy, especially for men age 85 and over, in the past 20 years. . Mortality due to stroke, ischaemic heart disease, hypertension and chronic pulmonary disease has declined. There has been a steep increase in cancer deaths and deaths associated with diabetes mellitus. Tuberculosis and injury-related deaths have declined but pneumonia deaths have increased. For elderly people, the probability of dying from cancer and ischaemic heart disease increased with time. However, the probability of dying from stroke decreased. Although there was a decrease in probability of deaths associated with falls, there was an increase of deaths due to 'frailty' (as judged by falls, pneumonia and septicaemia). CONCLUSIONS: cancer is a major cause of death in the elderly population of Taiwan. This rapidly expanding elderly population seemed to suffer from poorer health in the later period of their life.

Screening of depression in patients with chronic medical diseases in a primary care setting.

BACKGROUND: Patients with chronic medical diseases may have depression that is not recognized by their primary care physicians. OBJECTIVES: We aimed to examine the application of Zung's Self-Rating Depression Scale (SDS) in the screening of depression in primary care patients with chronic medical diseases in a Chinese population. METHODS: We studied 268 patients with chronic medical diseases in the Family Medicine Outpatient Clinic using a structured questionnaire including basic demographic data, a Chinese version of the SDS and a rating for the self-perceived severity of physical condition. The severity of chronic medical diseases was assessed by the authors using the Duke University Severity of Illness Scale from a chart audit. Fifty patients were randomly selected for a diagnostic interview according to the DSM-IV criteria. The construct validity and internal consistency reliability, sensitivity and specificity of the SDS were examined. RESULTS: The results revealed that the SDS has good construct validity and internal consistent reliability in the evaluation of depression in Chinese patients with chronic medical diseases. A cut-off point of 55 had a sensitivity of 66.7% and a specificity of 90.0%. Depressed patients reported more cognitive symptoms than depressed affect and physical symptoms. Female patients had more severe depressed affect than male patients, but males had more prominent diurnal variation of mood than females. CONCLUSIONS: We concluded that SDS can be a good screening tool for depression in Chinese patients with chronic medical diseases. Owing to constraints in the expression of sexual desire in the Chinese, elderly subjects tended to report loss of libido in the response to the SDS.

Self-rated health and mortality in Chinese institutional elderly persons.

The relationship between self-rated health (SRH) and subsequent mortality was examined in a cohort of 411 Chinese elderly individuals living in institutions. SRH was assessed by a global health rating, by comparing health with others of the same age, and by perception of recent physical condition. Covariates including age, sex, daily activity function, instrumental daily activity function, cognitive function, self-reported visual acuity, urinary function, number of chronic conditions, number of medications, and history of falls were controlled by the Cox proportional hazard model. Elderly people who rated their global health as "fair or poor" had increased mortality compared to those in the "good" category (RR = 6.00; 95% CI 1.39-25.1) and a borderline significant increase in mortality risk for those who rated themselves in the "average" category (RR = 4.05; 95% CI 0.93-17.70). Elderly people who compared their health with others of the same age as "worse or worst" and "similar" had an RR of 2.75; 95% CI of 0.64-11.83 and RR of 2.40; 95% CI of 0.64-8.96, respectively. Elderly people who rated their physical symptoms as "moderate or severe" and "slight" had an RR of 2.54; 95% CI 0.65-9.80 and RR of 1.05; 95% CI 0.32-3.41, respectively. Age, institutional factors, and history of multiple falls were associated with an increased risk of mortality. We concluded that only the global health rating has direct predictive power for mortality in institutionalized elderly people.

'Being a foreigner, I may be punished if I make a small mistake': assessing transcultural experiences in caring for patients.

BACKGROUND: Emotionally charged issues that arise during graduate medical education often are unrecognized and consequently not addressed by training programmes. Little attention has been given to the emotional challenges encountered by international medical graduates (IMG) in caring for patients transculturally. OBJECTIVES: We aimed to examine the value of qualitative approaches to assessing the transcultural experiences of IMG residents during primary care training. METHODS: Two qualitative research techniques (the critical incident and the focus group) were used to assess the transcultural challenges in caring for patients of IMG and American medical graduates (AMG) resident in a primary care residency programme. Each resident wrote a narrative describing a challenging experience and facilitators then conducted a focus group to discuss these experiences. Key themes were identified from the written narratives and from the transcript of the videotaped focus group. RESULTS: Previously unacknowledged feelings emerged during the assessment. Themes of struggles for acceptance, fear of rejection, and fear of disappointing patients were identified from analysis of the written narrative, while themes of struggle to express caring transculturally were identified from the focus group transcript. Based on these findings, significant changes were made to the residency training curriculum. CONCLUSIONS: Qualitative methods are useful for assessing the transcultural experiences of IMG residents and for informing curricular changes in residency training. These methods may help other training programmes to identify the particular needs of their trainees in addressing emotionally laden experiences.

Family involvement in routine health care: a survey of patients' behaviors and preferences.

BACKGROUND: The purpose of this study was to assess the behavior and preferences of patients regarding family involvement in their routine health care visits. METHODS: A self-administered questionnaire was given to a convenience sample of patients visiting a family medicine center for an appointment. RESULTS: Thirty-nine percent of patients came to the physician's office with a family member or friend. Married patients and those with higher emotional involvement scores were significantly more likely to come to the office with someone. Two thirds of accompanied patients reported that this person came into the examination room with them. One third of the accompanied patients, however, thought that their physician was unaware that someone had accompanied them to the office. The majority (55%) of patients indicated that they would prefer to have a friend or family member in the examination room with them for some of their visits. No patient indicated that they never wanted a family member or friend to come into the examination room. CONCLUSIONS: Patients prefer direct family involvement in their health care more often than what occurs in practice. Physicians can easily address this discrepancy by asking patients whether and in what way they would like others to be involved in their health care.

Cardiac end-organ changes: comparison between white coat hypertension and persistent mild hypertension.

Conflicting viewpoints exist concerning the risk of cardiovascular morbidity for patients with white coat hypertension. The aim of this study was to compare cardiac end-organ change in white coat hypertension with persistent mildly hypertensive patients. Twenty-two white coat hypertensive patients and 15 persistently hypertensive patients were considered eligible for the study after 24 hour ambulatory blood pressure monitoring. Echocardiography was performed on all patients. The results demonstrated that both groups had similar clinical backgrounds except that white coat hypertensives were predominantly female and had less family history of hypertension. Persistent hypertensives had significantly higher average ambulatory blood pressures and pressure loads than white coat hypertensives but there was no difference in blood pressure variability. There were no differences in cardiac structural and functional changes between the two groups. As a result, we were unable to ascertain whether white coat hypertension is a benign condition. The prognostic significance of white coat hypertension requires long term follow-up and further investigation.

Reliability and validity of using a Brief Psychiatric Symptom Rating Scale in clinical practice.

To develop a reliable and valid psychiatric self-rating scale for use in medical practice, the authors modified Derogatis' Symptom Check List-90-R (SCL-90-R) and designed a shorter form, named Brief Symptom Rating Scale (BSRS). The BSRS comprises 50 items, which best reflect the original ten symptom dimensions and three indices of psychopathology from the SCL-90-R. The BSRS has been proven in different populations to have an excellent split-half reliability as well as good internal structure according to factor analysis. In addition, BSRS scores are highly correlated with the parental form SCL-90-R among medical populations for each symptom dimension and the three indices. The rate of accurate classification for BSRS between psychiatric and nonpsychiatric cases was 75.8%, with a sensitivity of 66.7% and a specificity of 86.7% by discriminant analysis based on 10 dimensional scores obtained from 1,638 subjects, randomly selected from the Psychiatric Outpatient Clinic, the Family Medicine Clinic and nonpsychiatric medical inpatients. Therefore, the BSRS is a satisfactory global measure and case-finding screening instrument for psychopathology in both psychiatric and nonpsychiatric medical settings.

[Clinical evaluation of psychiatric disorders among first-visit patients to a primary care unit].

It is important for a primary care physician to know the most common psychiatric diagnoses, criteria for these diagnoses, and proper treatment. During a 4-month period from December 1987 to March 1988, the authors conducted this prospective study in a rural group practice center and investigated 189 first-visit patients aged from 16 to 60 years. Among them, 55 cases (29.1%) were diagnosed as having psychiatric disorders which included: psychological factors affecting physical condition, 29 cases; generalized anxiety disorder, 12 cases; adjustment disorder, 10 cases; and others, 4 cases. There were no significant differences in marital status, social class, or family structure between patients with and without psychiatric disorders. However, the patients with psychiatric disorders tended to have a longer duration of illness, to exhibit more salient features of introversion and neuroticism in their personalities, to show poorer family function and to experience more stressful life events. Although all the psychiatric patients presented somatic symptoms as their primary complaints, we also found that they reported significantly higher scores for psychiatric symptoms on a self-rating scale. This study demonstrates that in order to promote comprehensive primary health care, psychiatry and behavioral science are essential training curricula for family physicians.