Aresearch on global disease burden, published in 2016 on The Lancet, suggested that the life expectancy has been elongated to 72.5 years old, and chronic non-infectious diseases accounted for 72.3% of the total death worldwide.1 Contemporary health condition puts forward an important issue—the care of dying. The 2015 Quality of Death Index, published by The Economist Intelligence Unit, took the hospice environment, staff numbers and skills, care affordability and quality into account to compare the death quality of citizens in 80 countries. China ranked the 71st and was reported to be “facing difficulties from slow adoption of palliative care and a rapidly aging population”, which indicating palliative care as an increasingly urgent issue in China.2
Palliative care emphasizes the comprehensive treatment of physical, psychological, social and spiritual care for the end-stage patients in aims of improving life quality of patients and their family members. This concept, initiated decades ago, has been advanced rapidly in developed countries, but is low accepted in developing countries, including China. Barriers for developing palliative care in China do exist.3 The shortage of professional palliative care staff is significant. It is of great importance to promote the recognition of the concept in Chinese clinicians and improve their clinical skills in practicing palliative care. The goals of the present study is to survey the doctors’ feeling when facing end-stage patients and their perception of theoretical concept of palliative medicine.
MATERIALS AND METHODS
Questionnaire design and survey conduction
We delivered a self-designed questionnaire survey to 1500 clinicians in 10 provinces of China through WeChat online. The questionnaire contains 16 questions covering the aspects of background information of the subjects (Q1-7), prior educational history on hospice and palliative care (Q8,9), personal experience (Q10-12), self-assessment of familiarity to palliative care and living will(Q13,14), emotional attitude to the end-stage patients (Q15), and reflection on clinical practice (Q16-18). Contents of the questionnaire is shown in Table 1.
Table 1 Design and the contents of questionnaire in the survey
| Basic information | Q1 | Your age |
|---|---|---|
| Q2 | Your specialty | |
| Q3 | Do you have membership of a palliative care association | |
| Q4 | What is the type of hospital you are working in | |
| Q5 | Where does the hospital you are working locate (Beijing, others) | |
| Q6 | How long is your clinical experience as a doctor (<15 years, ≥15 years) | |
| Q7 | Your religion | |
| Prior training history | Q8 | How many times have you ever attended palliative care training (<2 times, or ≥2 times) |
| Q9 | Have you ever attended education course on death? (true or false) | |
| Personal experiences | Q10 | Self-experience in family member’s death (true or false) |
| Q11 | Talking about death at physician’s own home (never, tried to avoid, discussed reluctantly, or discussed openly) | |
| Q12 | Number of patient’s death each month? | |
| Self-assessment of familiarity | Q13 | Are you familiar with palliative care? |
| Q14 | Are you familiar with the Living Will? | |
| Emotional attitude | Q15 | How do you feel when facing end-stage patients (multiple choices) |
| Reflection on their clinical practice | Q16 | Patients’ own opinion was considered when discussing treatment with patients’ family. |
| Q17 | Agree that doctor should concern about patients’ family members? | |
| Q18 | Which is better way to treat end-stage patients? (traditional care, or palliative care) |
Note:Q13, score from 0-5, larger score means more familiar; Q14, score from 1-3, representing not understand, heard but have no idea, and being familiar with the concept, respectively; Q15, multiple choices, including worried, want to escape, powerless, confused, scared, confident, anxious, hopeless; Q16: score from 1-4, representing never, occasionally, sometimes and always, respectively; Q17, score from 1 to 5, larger score means more likely to agree.
Statistical analysis
Percentage and proportion were used to describe enumeration data. Logistic regression analysis was used for determining which factor was associated with the perception in palliative medicine. Chi-squared analysis was used to explore the impacts of perception in palliative medicine on the clinical management for the end-stage patients. Statistic analyses were performed using SPSS (version 21.0). A P value less than 0.05 was considered statistically significant.
RESULTS
The characteristics of responding doctors
There were 379 responders who completed all the questions and submitted data successfully. Among them, 272 (71.8%) were doctors majored in the Medical oncology, 9 (2.4%) from the Surgical oncology, 26 (6.9%) from the Radiotherapy, 21 (5.5%) from the Traditional Chinese Medicine, and 51 (13.5%) from other specialties. Of 379 participants, 110 (29.0%) were member of palliative care association of their specialities, 321 (84.7%) were working in tertiary hospitals, 303(80.0%) were from cities or regions other than the capital city, Beijing, 201 (53.0% ) have a professional working experience over 15 years, and 325 (85.8%) were non-religious professionals.
There were 253 (66.8%) doctors who have attended at least 2 palliative medicine lectures, while only 83 (21.9% ) had ever received education on death. In terms of personal experience, 300 (79.2%) subjects experienced family member’s death, while only 128 (33.8%) described “open” atmosphere when talking about death at home. About 134 (35.3%) clinicians claimed that chemotherapy was performed in over 70% of their patients, and 137 (36.1%) reported more than 2 cases of death per month.
The emotional attitude toward end-stage patients
There were 253 (66.8%) clinicians in the survey who felt “powerless” when facing end-stage patients. 37.8% of them claimed “confused” in this process, and 23.5% perceived “hopeless” feeling when facing end-stage patient (Fig. 1).
Doctors were less likely to perceive powerless feeling when facing end-stage patients in sub-groups who hold membership of a palliative care association (P=0.003), who had attended courses on palliative care more than twice (P=0.001), course on the death (P<0.001), who had experience of family member’s death (P=0.031) and who had working experience over 15 years (P=0.022). The powerless feeling were not distributed differently in subgroups of doctors’ specialty, religion, hospital levels, and location of their hospital, atmosphere of talking about death, and number of patients′ death each month (Table 2).
Table 2 Analysis of clinicians characteristics and the powerless feeling when facing end-stage patient
| Characteristics | n | (%) | Feel powerless (n) | Χ2 | P | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| Specialty | ||||||
| Medical oncology | 272 | 71.8 | 176 | 96 | 1.822 | 0.185 |
| Others | 107 | 28.2 | 77 | 30 | ||
| Member of a palliative care association | ||||||
| Yes | 110 | 29.0 | 61 | 49 | 8.917 | 0.003 |
| No | 269 | 71.0 | 192 | 77 | ||
| Hospital level | ||||||
| Tertiary hospital | 321 | 84.7 | 211 | 110 | 0.988 | 0.365 |
| Non-teriary hospital | 58 | 15.3 | 42 | 16 | ||
| Location of hospital | ||||||
| Beijing | 76 | 20.1 | 49 | 27 | 0.223 | 0.683 |
| Non-capital cities | 303 | 80.0 | 204 | 99 | ||
| Working experience | ||||||
| ≤15 years | 201 | 53.0 | 145 | 56 | 5.591 | 0.022 |
| >15 years | 178 | 47.0 | 108 | 70 | ||
| Religion | ||||||
| Non-religious | 325 | 85.0 | 214 | 111 | 0.848 | 0.436 |
| Religious | 54 | 15.0 | 39 | 15 | ||
| Previous attended palliative care course | ||||||
| ≥2 times | 253 | 66.8 | 155 | 98 | 10.334 | 0.001 |
| <2 times | 126 | 33.2 | 98 | 28 | ||
| Whether attended courses on the death | ||||||
| Yes | 83 | 21.9 | 38 | 45 | 21.061 | <0.001 |
| No | 296 | 78.1 | 215 | 81 | ||
| Whether experienced family member’s death | ||||||
| Yes | 300 | 79.2 | 192 | 108 | 4.921 | 0.031 |
| No | 79 | 20.8 | 61 | 18 | ||
| Atmosphere talking about death at home | ||||||
| Openly | 128 | 33.8 | 78 | 50 | 2.947 | 0.106 |
| Seldom | 251 | 66.2 | 175 | 76 | ||
| Number of patient death | ||||||
| >2 cases/ month | 144 | 38.0 | 92 | 52 | 0.859 | 0.370 |
| ≤2 cases/ month | 235 | 62.0 | 161 | 74 | ||
| sum | 379 | 100 | 253 | 126 | ||
Doctors′ familiarity to the palliative care and the living will
Among 379 subjects, less than 30% thought they were familiar with the concept of palliative care (defined as score ≥4), and approximately 20% subjects claimed they knew the living will (defined as score ≥3). Doctors who hold membership of palliative care association showed better familiarity to palliative care (OR=3.228, P<0.001) and the living will (OR=3.062, P=0.007). Doctors who had ever attended educational course on palliative medicine or course on the death were more familiar with the living will and had better understanding of the palliative care (Table 3).
Table 3 Impact factors on the understanding of the palliative care and the living will in Chinese doctors (n=379)
| Characteristics of doctors | Palliative care | Living will | |||
|---|---|---|---|---|---|
| OR | P value | OR | P value | ||
| Age | 0.999 | 0.949 | 0.975 | 0.340 | |
| Specialty | 1.042 | 0.920 | 0.823 | 0.687 | |
| Religion | 1.270 | 0.599 | 1.225 | 0.700 | |
| Member of palliative care associations | 3.228 | <0.001 | 3.062 | 0.007 | |
| Hospital level | 2.710 | 0.066 | 2.171 | 0.264 | |
| location of working hospital | 1.529 | 0.254 | 1.825 | 0.159 | |
| Years of working experience | 1.292 | 0.476 | 1.022 | 0.969 | |
| Attending courses on palliative care | 6.923 | 0.002 | 1.781 | 0.409 | |
| Attending courses on the death | 5.582 | <0.001 | 7.340 | <0.001 | |
| Experienced family member’s death | 0.829 | 0.649 | 1.202 | 0.746 | |
| Atmosphere when talking about death at home | 1.468 | 0.237 | 1.657 | 0.194 | |
| Number of patient death each month | 1.332 | 0.372 | 1.039 | 0.923 | |
Reference categary of each variates: specialty:others; religion: non-religious; member of palliative care associations: no; hospital level: non-tertiary hospital; working place: non-capital cities; working experience: ≤15 years; attending courses on palliative care: ≤2 times; attending courses on death: no; experienced family member’s death: no; atmosphere when talking about death at home: seldom; number of patient death: ≤2 cases/ month.
Impacts of doctor’s perception on clinical practice
Doctors who are familiar or unfamiliar with concept of palliative care perceived different reflections on their clinical practice. Doctors who claimed familiar with palliative medicine concerned about patients’ family more than those not (χ2=24.406, P<0.001), and were more willing to consider patients’ own preference for the treatment (χ2=28.754, P<0.001), and were more apt to adopt the palliative care (χ2=10.764, P<0.01). The data also suggested that doctors knowing more about palliative care were less likely to have powerless feeling when facing end-stage patients (χ2=13.015, P<0.001) (Table 4).
Table 4 Familiarity to the Palliative care and doctors’ reflection on patients management (n=379)
| Questions and responses | Familiar with palliative care | χ2 | P value | |
|---|---|---|---|---|
| Yes (n=90) n(%) | No (n=289) n(%) | |||
| Q15: How do you feel when facing end-stage patients? | ||||
| Powerless | 46(51.1) | 207(71.6) | 13.015 | <0.001 |
| Others | 44(48.9) | 82(28.4) | ||
| Q16: Do you considert patients’ own willing for treatment? | ||||
| 1 | 2(2.2) | 18(6.2) | 28.754 | <0.001 |
| 2 | 8(8.9) | 78(27.0) | ||
| 3 | 33(36.7) | 121(41.9) | ||
| 4 | 47(52.2) | 72(24.9) | ||
| Q17: Do you agree that doctors should concern about patients’ family members? | ||||
| 1 | 0(0) | 4(1.4) | 24.406 | <0.001 |
| 2 | 1(1.1) | 7(2.4) | ||
| 3 | 6(6.7) | 60(20.8) | ||
| 4 | 12(13.3) | 74(25.6) | ||
| 5 | 71(78.9) | 144(49.8) | ||
| Q18: Which do you think is better way to treat end-stage patients? | ||||
| Palliative care | 86(95.6) | 236(81.6) | 10.764 | 0.005 |
| Traditional care | 4(4.4) | 53(18.4) | ||
DISCUSSION
Palliative medicine was introduced into China in 1980s. Compared to the development of institutions and services of palliative care in China, whereas, the acceptance of this concept by clinical doctors has still been unsatisfied. According to a study summarizing the total acceptance rate of palliative care, the overall acceptance proportion in Chinese ranged from 25.3% to 86.6%.4 A survey conducted in China in terminal cancer patients indicated that only 56.2% patients and 67.1% family members accepted palliative care.5 Moreover, Chinese medical professionals are short of knowledge and clinical skills in palliative care. Compared to Austrian interns, remarkedly less Chinese interns were familiar to the theoretical concepts of pain management and palliative medicine.6,7Another survey, conducted at a tertiary hospital in Shanghai revealed lack of knowledge in appropriate using morphine in Chinese profesionals.8 These studies indicated that despite the development of palliative care in China, there exists an urgent issue for medical educators: how the acceptance of palliative care in Chinese doctors can be improved.
The present survey showed that 66.8% Chinese doctors felt powerless when facing end-stage patients. The powerless feeling in Chinese doctors originated from the subsistent clinical situation in China. Many Chinese oncologists want to “cure” patients with radiotherapy or chemotherapy at all expense till the end of patient life.9 End-stage patients suffer from so-called life-saving treatment, such as blood transfusions, albumin infusion, or high dosages of antibiotics, as well as the side effects of chemotherapy. As we know, for end-stage cancer patients with chemotherapy, morphine is the most commonly used opioid in clinic. However, 66% medical professionals did not fully understand the dosage principle of morphine according to a survey conducted in Chinese doctors.10 In terms of pain management, although the World Health Organization advocates using opioids to relieve severe cancer pain, Chinese oncologists were reluctant to use opioids in fear of drug addiction and respiratory depression.Overaggressive treatment may weaken patients and even shorten their lives; additionally, it also causes financial burden for patients’ family. The irreversible life ceasing with limited benefits of multiple choices of therapeutic methods in traditional care contributes to the negative feelings in Chinese clinicians.
Palliative medicine emphasizes comprehensive care for patients health of mental, physical, as well as soul. It not only helps control patients’ pain, but also release doctors’ burden. 6 To improve the life quality of end stage patients and their family in China, Chinese doctors need to practice palliative medicine in end stage patients care. There are two issues that need to be addressed.
Firstly, how the comprehension of palliative care helps releasing doctor’s negative feelings? The present study showed doctors who had better understandings of palliative care were less likely to feel powerless when facing end stage patients. Our results also suggested that through training courses on palliative care, doctors concern more about their patients and patients’ family. They were more willing to consider patients’ own opinion on the treatment, and take care of patients’ family members. Additionally, doctors who know palliative medicine were found to be more sensitive to identify this concept in their practice, and are more willing to spontaneously apply it in patients care. These results suggested the importance of palliative medcine education in alleviating negative feelings of clinicians when caring end-stage patients.
Secondly, how to improve doctors’ comprehension of this concept? The present study suggested cognition degree for palliative care is determined by several factors. Attending training courses on palliative medicine and on the death were related to better understanding of palliative care and the living will. This result indicated the current education programs on palliative care in China do have disseminated the concept in the country and facilitated Chinese doctors to learn the concept. Moreover, more efforts should be made to promote education on palliative care to more doctors in wider range of specialties and to improve the efficiency of training program, so that more trainee clinicians can practice palliative care in their clinical work, and more terminal patients can get benefits of it with good life quality as a result.
Nowadays, education on palliative medicine has been increasingly carried out all over the world. In England, the palliative care education curriculum comprise basics of palliative care, pain and symptom management, psychosocial and spiritual aspects, ethical and legal issues, communication, teamwork and self-reflection. There are multipile teaching formats, such as lectures, small group discussion, case studying, watching movies, role playing. 11 In US, up to 99% medical schools offer palliative care courses in 2010, with topics covering 18 aspects including communication, pain management, living will, and so on.12 In Chinese Taiwan, clinical practice of palliative care for inpatient is added to palliative medicine training curriculum to enhance clinical experience in a real situation. 13Through adopting experiences outside the country, and with a deep understand of Chinese doctors’ perception and reflection on palliative medicine, we are able to safely plan the upcoming training course on palliative medicine in China.
The present study explores the basic cognition about palliative care in Chinese clinicians. The study was performed with some limitations. The questionnaire was delivered to participants of lectures (training course) who were actually interested in this concept, which cause bias of specimen in this study and should be taken into account when interpretating the results. Secondly, cognition of palliative care was measured subjectively in this survey. Questions on detailed knowledge of palliative care are needed to precisely evaluation doctors’ understanding. Further studies should focus on how to improve doctors’ acceptance to palliative care and how to encourage doctors to voluntarily practice palliative care in their dialy work.
In conclusion, the powerless feeling is prevalent in Chinese doctors when facing end stage patients. The overall comprehension and knowledge on palliative care are still unsatisfied. More education strategies with careful designation that adapt to actual situations of the country are needed to improve doctors’ cognition of palliative care.
Conflict of interest statement
All authors have no conflict of interests disclosed.
参考文献
Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: a systematic analysis for the Global Burden of Disease Study 2016.BD 2016 Mortality Collaborators. Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: a systematic analysis for the Global Burden of Disease Study 2016
The 2015 Quality of Death Index. Ranking palliative care across the world
Barriers in palliative care in China
The development of palliative care in China is vital to the care of its aging population and associated increase in cancer incidence. There are physician-related and population-related barriers which impede palliative care development. The first institute for hospice care was established in Tianjin. Community hospices (Ning Yang Yuan) have been established by the Li Ka Shing Foundation. Academic centers such as the one in Chengdu associated with Sichuan University have partnered with the World Health Organization to establish centers of excellence to both develop and teach palliative care to physicians in training and practice. The National Hospice Service Program has developed five principles to the practice of palliative care in China.
The current situation for acceptance of palliative care in mainland China
The preference for palliative care among advanced cancer patients and their families
Objective To investigate the preference for palliative care and its influencing factors among advanced cancer patients and their families,and offer evidence for the development of palliative care.Methods A total of 146 patients with advanced cancer and 143 relatives of cancer patients were investigated with a self-designed questionnaire.Results 56.2% of the advanced cancer patients and 67.1% of the relatives preferred palliative care.The influencing factors were attitude to death,age and gender.Conclusion It is necessary and feasible to provide palliative care for the advanced cancer patients.The death education should be strengthened to promote the development of palliative care.
Psychotherapy targeting depression and anxiety for use in palliative care: a Meta-analysis
Abstract BACKGROUND: Research on the effectiveness of evidence-based practices in the treatment of depression and anxiety with palliative care populations is primarily limited to individuals having specific conditions such as cancer. OBJECTIVE: This meta-analysis examined the effect of psychotherapy on depression and anxiety among individuals with any condition appropriate for palliative care. METHODS: We searched PubMed, PsycINFO, Cochrane Library, and EMBASE databases until August 2017. Eligible studies were randomized controlled trials of psychotherapy that reported outcomes of depression and anxiety and included adults with serious illnesses. RESULTS: The current meta-analysis included 32 randomized controlled trials with 36 samples including 1536 participants undergoing psychotherapy. Overall, findings suggest that psychotherapy in palliative care populations reduced depression (large effect) and anxiety (small effect) symptoms. Psychotherapy also improved quality of life (small effect). Significant moderators of intervention effects included type of intervention and provider, number and length of treatment sessions, and sample age. Cognitive-behaviorally based and other therapies (e.g., acceptance, mindfulness) showed significant effects, as did interventions delivered by mental health providers. More treatment sessions were associated with greater effect sizes; longer sessions were associated with decreased effect sizes. As the sample age increased, the study effect size decreased. CONCLUSION: Findings suggest that psychotherapy for individuals with serious illnesses appropriate for palliative care can mitigate symptoms of depression and anxiety and improve quality of life. Methodological reporting and quality of research designs in studies of psychotherapy for palliative patient populations could be improved. Future research is needed with a broader range of patient populations.
Palliative care education in China: insight into one medical university
There has been an increase in the amount of palliative care available in developing countries, including in China. However, palliative care is still very limited, and it is not mandatory to teach courses on palliative care in Chinese medical universities. To assess Chinese interns awareness of palliative care concepts. Using a questionnaire selected from an earlier Austrian study, interns in a Chinese medical university were surveyed. All those surveyed had already been interns for at least six months. Four hundred interns from a Chinese medical university (response rate 99.5%) were surveyed. Twenty-one percent were female (84 of 400), and the average age was 23 years. Approximately one-third (34.5%) of interns were familiar with the pain scale, and 31% of interns were familiar with the concept of pain management. Only 7.5% of interns felt adequately trained in basic pain management, and 13% felt adequately trained to manage symptoms of dying patients. Seventy-seven percent of interns reported inadequate education regarding discussion of death with patients and family members. More than 80% of interns felt that more education about palliative care should be included in the basic medical curriculum and clinical intern training. Palliative care education is inadequate from the perspective of the Chinese medical interns. An improvement in the medical school curriculum is needed.
End-of-life care in urban areas of China: a survey of 60 oncology clinicians
Although cancer is a leading cause of death, little is known about cancer-related end-of-life care in China. We surveyed 60 Chinese oncology clinicians' practices and attitudes toward end-of-life care. Fewer than half reported available hospital-based hospice service, although most urban cancer patients die in the hospital. Most clinicians reported they felt competent to care for dying patientsore competent in controlling pain, constipation, nausea, and vomiting, but less competent in managing depression, anorexia, and dyspnea. Regarding disclosure, most believed that patients should know and want to know their diagnosis and stage, whereas families strongly resist informing patients. Unrealistic family expectations, fears of depressing patients, and physician reluctance to stop treatment were barriers to disclosing prognosis to patients, to ending anti-cancer therapy, and to starting palliative care. Results of the survey suggest specific training and research in symptom management that might improve end-of-life care for Chinese cancer patients.
Palliative care in urban areas of China
A survey on physician knowledge and attitudes towards clinical use of morphine for cancer pain treatment in China
BACKGROUND: The WHO's three-step guideline for cancer pain management has been introduced in China; however, there remain large differences in the standards of cancer pain management between China and other developed countries. This survey was carried out to determine the degree of physician knowledge on morphine use and the factors that impede morphine use in clinical practice in China. METHODS: A self-reported questionnaire was designed and administered to randomly selected physicians in four tertiary hospitals in the cities of Changchun and Changsha in China. Statistical analyses were conducted using SPSS statistical software. RESULTS: Two hundred and one clinical physicians participated in the survey. Physicians who reported having received training in cancer pain management and drug use demonstrated a significantly higher mean score of basic knowledge compared to physicians who reported not having received training (9.31 +/- 2.88:8.23 +/- 2.70, u = 2.74, p < 0.001). The top three cited impediments to widespread clinical use of morphine for cancer pain were: (1) lack of professional knowledge and training; (2) fear of opioid addiction; and (3) physicians' personal preferences to select other drugs. CONCLUSIONS: Medical staffs lack the basic knowledge and harbor misconceptions about the clinical use of morphine for cancer pain treatment. Creating training opportunities for medical staffs is necessary to increase their awareness and knowledge of effective cancer pain management.
Palliative care in undergraduate medical education. Status report and future directions
Thirty-five years of end-of-life issues in US medical schools
The objective of this study was to examine US medical school offerings on end-of-life issues between 1975 and 2010. Data were obtained from a mailed survey to the US medical schools in 1975, 1980, 1985, 1990, 1995, 2000, 2005, and 2010. Survey response rates for the 8 points in time (in percentages) were 95, 96, 90, 90, 93, 92, 81, and 79, respectively. Between 1975 and 2010, the overall offerings in death and dying increased so that 100% of US medical schools, beginning in 2000, offered something on death and dying. A multidisciplinary-team approach continued over the 35-year period. Palliative care is offered to some extent in 99% of US medical schools today. Numerous end-of-life topics are currently covered in the curriculum. Increased attention to end-of-life issues in medical schools should enhance medical students' relationship with terminally ill patients and their families.
The present developing status and prospect of palliative medicine in mainland China
