| Background:There are two categories of clinical plans defined in a macroscopical view: curative therapy and palliative therapy. In the practice of end-stage cancer or other chronic deseases treatments, we tend to use hospice and palliative care synonymously. It is extremely important to decide the big picture and road map first, for all the subsequent treatments and care activities depend on this direction. It is a hard choice, however, influenced by various factors. Different decision-makers pay more attention on their own point and it is quite easy to evolve severe conflicts, which is common in cancer cases. Cancer is an irreversible disease develops chronically. So far all the therapies are beyond our satisfaction. For complicated causes and reasons, over-treatment or excessive treatment is not rare in practice, esp. in terminal-stage patient management. Patients themselves are not the only victims of the adverse event. Typically, it involves the whole family or even more. The conflicts are the leading reason for later regret after the patient passed away. Macroscopically, cancer is still the second leading cause of death globally, only behind the cardiovascular diseases. For most nations, cancer could be the biggest disease burden currently and in the coming decades. Over-treatment induces more DALYs lost, labor lost, Medicare burden increases directly or indirectly, and finally, threatens the well-balance of the national finance and tax. Evitable, and it is, that most governments put it as a priority job to prevent excessive treatment. Compared with the European and North American countries with much more abundant resources, hospice is not as welcome as in those developed regions. The masses of the people in China, including healthcare personnel, put the survival prolongation in the first place, even do not care the price must be pay. Easy to find out, most people feel very confused and worried when made this decision. What is worse, they even cannot tell what made them confused or worried. If so, how can we face this big choice with wisdom and peace, and even expect no regret in the feature? So, overall considered, it is necessary to find the influence factors of this decision and make in-depth analysis in strength and directions. That is the only way that we could promote our limited understanding about this clinical problem further and then try to expect to improve the application of hospice in the terminal-stage cancer case management. Method:After the literature review, we designed three subject-specific questionnaires for cancer patients, main caregivers and clinical practitioners. The information we collected included demographic information, decision-related information, intuitive medical plan choice and refined decision after given24specific premises, respectively. In the mid-term analysis and reports, we applied stratification, correlation analysis and non-parametric analysis, using the statistical software SPSS17.0(IBM). In the final analysis after the whole data were collected, we appliedx test or Fisher’s Exact test on nominal var or ordinal var, and used Student’s t test in scale var, given the var distributions followed the required rules. More, we chose unpaired multiple logit model to make estimates in our data. If the var distribution could not satisfy the requirement, necessary transformations were taken until reaching the assumptions. The models adjusted participants’age, gender, education, income, having medical insurance or not, cancer stage, treatment history, patients’quality of life, current main problem, current mood and the priority of consideration in medical plan choice. The statistical software we used was Stata/MP (v11.2; Statacorp, College Station, TX, USA), α-level was defined as0.05. All the p-values given in our study were two-tailed p-value.Results:The total number of participants was688, with the distribution as268cancer patients,312main caregivers and108clinical practitioners from Guang’anmen Hospital and Puxiang Hospital. Among the580participants, there were147males and121females in patient group, with the age ranged from17to92years, and the average age±standard deviation(SD) was58.26±13.01years; in the caregiver group, there were134males and178females, with the age ranged from22to79years, and the average age±SD was45.56±13.99years. When considering about the medical plans in the terminal-stage,63.05%of the participated patients’priority was the survival prolongation,18.47%cared the tumor shrinkage,10.44%put the economic pressure at the first place, and the other8.03%considered the side-effect first. Similarly, the caregivers’ data showed that,68.77%of the participated primary caregivers thought the survival prolongation the most important issue,13.29%cared the tumor shrinkage,12.62%considered the adverse-effect first, and the last5.32%admitted they treated the economic pressure due to the treatment plan the first consideration. In the intuitive choice, the choosing probabilities of hospice plan were0.4563and0.4680in the two groups, respectively, far lower than the expected 1. The adjusted models showed, for patients, they did care about whether or not having Medicare insurances, nutrition problems, sleeping problems and the priorities about treatment plan; but for primary caregivers, it seemed that they did not worry as much as the patients, and the only thing mattered was the patient’s stage. After fitting96multiple logit models, we gave out the estimated crude and adjusted OR. Given specific premises, however, the probability raised a lot in most cases. Through the premise-specific models, we could make considerably accurate point estimates and their ranges of the preferences under different situations, analyzing healthcare-related factors, social-related factors and spirit and psychology related factors in strength and directions. Also, we found some counter-intuitive facts. For instance, it was generally believed that knowing the cancer-diagnosis would break down the patients and make them prefer palliative care and hospice, rather than "fight against the demon". In fact, interestingly, it was not the case. Though the marginal choice probability of palliative care was higher when knowing the diagnosis, it was just the integrated appearance of confounding. After adjusting potential confounders, it turned out just the opposite.Conclusion:For the hospice decision-making in terminal-stage cancer cases, the extent of perceived diagnosis information and the extent of intimacy and trust among families had potent influence in final decision. The compliance of doctor in charge was related with doctor’s preference and the trusts extent about the doctor simultaneously. Physician’s advice showed strong weight on the final choice, but the families’opinion had no such power. Related experiences may affect the patients’decision and having beliefs or not did not show potential distinctions as expected. |
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