ORIGINAL ARTICLE
A comprehensive approach in hospice shared
care in Taiwan: Nonelderly patients have more
physical, psychosocial and spiritual suffering
Chiu-Hsien Yang
a, Yu-Wen Chiu
b,c, Chia-Tsuan Huang
a,b,*
,
Yu-Wen Haung
d, Hung-Yi Chuang
e,f aDepartment of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
b
School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
c
Department of Family Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
d
Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
e
Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
f
Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
Received 9 April 2012; accepted 28 August 2012 Available online 6 April 2013
KEYWORDS
Advanced cancer; Comprehensive care; Palliative care; Spiritual care
Abstract While symptomatic differences exist between younger and older advanced cancer patients, few studies have examined the differences in their care with respect to age. Our goals were to examine the influences of age differences on physical, psychosocial and spiritual distress among advanced cancer patients. Advanced cancer patients who resided in Kaohsiung Medical University Hospital during 2007e2008 were recruited. Data were collected through professional consultants. The influences of age variations on physical, psychosocial and spir-itual distress in nonelderly (<60 years old) and elderly (S60 years old) patients were analyzed. A total of 1013 advanced cancer patients were included in the analyses with 467 nonelderly patients and 546 elderly patients. Nonelderly patients were identified to have a higher base-line pain level (4.0 vs. 2.8, p< 0.001), breakthrough pain (19.3% vs. 9.9%, p < 0.01), insomnia (6.4% vs. 2.7%, pZ 0.006), emotional distress (69.0% vs. 60.6%, p Z 0.013), and unwillingness to pass away because of concern for loved ones (18.8% vs. 11.9%, pZ 0.003) with significant * Corresponding author. Department of Family Medicine, Kaohsiung Medical University Hospital, 100 Tzyou First Road, Kaohsiung 807, Taiwan.
E-mail address:[email protected](C.-T. Huang).
1607-551X/$36 Copyrightª 2013, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.kjms.2012.12.005
Available online atwww.sciencedirect.com
difference. Elderly ones were concerned about unfulfilled wishes (29.7% vs. 18.4%, p< 0.001) in spiritual concerns. After adjustments in regression models, nonelderly age (<60 years old) still revealed significant positive or negative impact on all categories of distress. Patients aged under 60 years have more physical, psychosocial and spiritual suffering. This study suggested that professional practitioners should provide intensive care for vulnerable terminally ill can-cer patients.
Copyrightª 2013, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rights reserved.
Introduction
Great advances in palliative care have been made in the past 10 years in Taiwan. The “quality of death” report from the Economist Intelligence Unit in 2010 suggested that Taiwan was ranked the 14th in the world and the highest among the Asian countries for the quality of end of life care
[1]. However, our empirical works recognized some chal-lenges in caring for nonelderly advanced cancer patients. Therefore, we conducted this research to identify the special needs of nonelderly cancer patients in terms of a comprehensive biopsychospiritual view in Taiwan.
Advanced cancer patients are distressed by troublesome suffering in the incurable metastatic stage [2]. Palliative care providers exert great efforts to provide comprehensive care for advanced cancer patients to improve their quality of life. In the literature, there are some variations in physical symptoms as well as psychological suffering be-tween nonelderly and elderly cancer subjects[3e7]. Prior research also indicates that nonelderly patients have more spiritual distress as compared to elderly patients[8].
We aimed to provide the first comprehensive Asian analysis with regard to physical, psychosocial, and spiritual needs of advanced cancer patients specific to age varia-tions in Taiwan. The literature has demonstrated an overt difference in physical symptoms between those individuals below and over 60 years of age [3,9,10]. Therefore, we used the age of 60 years as the cut-off value between nonelderly and elderly groups in this study. Furthermore, our society employs the Chinese calendar, which in-corporates a system of heavenly stems and earth branches. In this cultural system, 60 years make a cycle termed “jiǎzǐ”, which is used to mean “a full lifespan”. People who have lived more than a jiǎzǐ are believed to be blessed.
Limited literature has been identified in researching psychosocial and spiritual characteristics in nonelderly advanced cancer patients in Taiwan. To our knowledge, no research has examined how age matters in advanced cancer patients in terms of a comprehensive view, including spir-itual concerns. Better understanding of the age variations of cancer sufferings in advanced cancer patients will enhance the quality of palliative care.
Materials and methods
This study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital, Taiwan. Advanced cancer patients who resided in Kaohsiung Medical University Hospital during the years 2007 and 2008 were recruited as our study participants. We defined advanced cancer patients as
having cancer which continued to progress, with metastases, and had a poor response to or was not suitable for curative treatment as judged by their cancer treatment physicians.
Data including demographic information, cancer types, metastatic sites, physical symptoms, awareness of diseases/ prognosis, psychosocial problems, and spiritual distresses were collected by professional consultants (including a boarded palliative medicine physician and licensed hospice nurse). Cancer types and metastatic sites were obtained by chart review. Metastatic sites were recorded as “positive” according to image examinations and the consulting physi-cian’s diagnosis. The professional consultants in this study were well-trained to evaluate physicalepsychosocial and spiritual problems in advanced cancer patients. They administered detailed interviews as well as providing pal-liative consultation to these cancer patients. The contents of consultations included the most frequent psychosocial and spiritual concerns for these patients.
The collected information of physical symptoms inclu-ded baseline pain level, breakthrough pain, delirium, weakness, anorexia, abdominal fullness, ascites, severe cough, edema, fungating tumor wound, dizziness/vertigo, pressure sore, infection, fever and insomnia. Pain level was measured by numerical rating scale (0e10 points, with a larger number representing a higher pain level).
Psychosocial problems including six major domains (awareness of disease/prognosis, emotional distress, diffi-culty in disease adaption, insufficient family support, inad-equate financial support, and other psychological distress) were explored by professional consultants. “Awareness of disease/prognosis” meant that the patient clearly realized their cancer situation as well as its prognosis. “Emotional distress” was coded as categorized data, and emotional disturbance including anxiety, depression, sadness, and any other mood fluctuation were recorded as “yes”. Although validated scales would have been more accurate in mood distress screening, most advanced cancer patients were too weak to fill out a complicated questionnaire sheet. There-fore, we evaluated patients’ mood distress according to hospice professionals. “Difficulty in disease adaption” referred to patients who showed problems in disease acceptance, and it was recorded as categorized data.
The Hospice and Palliative Association designed and validated a special form for spiritual distress screening in Taiwan. This included six items of spiritual concerns (fear of death, doubt about existence, doubt about life meaning and death, after-death uncertainty, unfulfilled wishes, and unwillingness to pass away because of concern for loved ones). This questionnaire has been employed in most hos-pice wards in Taiwan for a number of years. All the infor-mation was collected at the beginning when the patients
were referred to hospice shared care consultants. In the spiritual domain, three items were demonstrated in our results including fear of death, unfulfilled wishes, and un-willingness to pass away because of concern for loved ones. Another three items (doubt about existence, doubt about life meaning and death, and after-death uncertainty) were questioned in the interview; however, they were elimi-nated from our results because of too few answers.
SPSS for Windows, version 14.0 (SPSS Inc., Chicago, IL, USA) was employed for statistical analysis. The level of statistical significance was set at 0.05 and all tests were two-tailed. Statistics used include frequencies, compared means (independent sample t tests were used to compare numer-ical variables) and X2tests. Comparisons of primary cancer types, metastasis sites, physical, psychosocial, and spiritual variables among nonelderly (<60 years old) patients and elderly patients (S60 years old) were analyzed to identify variations between different age groups. Furthermore, multiple logistic regression was employed to analyze the influences of age accompanying demographic and medical factors on physical, psychosocial and spiritual factors.
Results
A total of 1013 advanced cancer patients were recruited for this analysis. The demographic variations among the two age groups (younger than 60 years vs. 60 years and above) are demonstrated in Table 1. There were 467 patients (46.1%) in the nonelderly group with a mean age of 49.2 7.9 years, and 546 patients (53.9%) in the elderly group with a mean age of 72.2 8.4 years. Comparisons of cancer sites and metastasis showed that head and neck cancer, respiratory tract cancer, hepatobiliary cancer,
breast cancer, and urinary tract cancer presented group differences with statistical significance. Head and neck cancer and breast cancer were more likely to occur in the nonelderly group, which is different from most other cancer types. Head and neck cancer ranked the highest in the nonelderly group (30.2%). Concerning metastatic sites, bone metastases tended to occur more frequently in the nonelderly group (31.0%).
Cancer-related physical symptoms in these two groups are shown inTable 2. Nonelderly subjects were more likely to suffer from higher baseline pain level as well as more breakthrough pain with statistical significance. Prevalence of breakthrough pain was 19.3% in the nonelderly group, and 9.9% in the elderly group. A higher prevalence in the nonelderly group than in the elderly group was also noted in fungating tumor wound, dizziness, and insomnia with sta-tistical significance. However older patients suffered more from anorexia, leg edema and pressure sores, which occurred more frequently in the elderly group.
Psychosocial and spiritual issues are demonstrated in
Table 3. We compared six psychosocial problems and three spiritual problems that the majority of advanced cancer patients experienced in Taiwan. Nonelderly patients had higher prevalence (69.0%) in emotional distress experience than elderly patients (60.6%) with statistical difference (pZ 0.013). In contrast, elderly patients (44.1%) were un-aware of their diagnosis/prognosis compared with the nonelderly group, with statistical significance.
Regarding spiritual issues, the fear of death, unfulfilled wishes, and unwillingness to pass away because of concern for loved ones were three domains out of six items of the questionnaire that were identified to have statistical sig-nificance in our study. These three concerns ranked as the most important that advanced cancer patients in Taiwan Table 1 Demographic comparison of participants between nonelderly and elderly groups.
Demographic characteristics Age stratification
<60 y S60 y p nZ 467 nZ 546 Age (y) (mean SD ) 49.2 7.9 72.2 8.4 <0.001a Gender (male) 325 (69.6%) 330 (60.4%) 0.002
Cancer type and site
Head and neck 141 (30.2%) 61 (11.2%) <0.001
Gastrointestinal tract 100 (21.4%) 105 (19.2%) 0.390 Respiratory tract 47 (10.1%) 115 (21.1%) <0.001 Hepatobiliary 68 (14.6%) 117 (21.4%) 0.005 Pancreatic 13 (2.8%) 21 (3.8%) 0.385 Breast 32 (6.9%) 19 (3.5%) 0.02 Gynecological 23 (4.9%) 22 (4.0%) 0.542 Urinary tract 7 (1.5%) 37 (6.8%) <0.001 Hematology 13 (2.8%) 20 (3.7%) 0.481 Metastatic site Lung 108 (23.1%) 96 (17.6%) 0.034 Liver 104 (22.3%) 136 (24.9%) 0.336 Bone 145 (31.0%) 136 (24.9%) 0.035 Brain 52 (11.1%) 55 (10.1%) 0.609
% out of age stratifications.
suffered from. Among these three domains, the most common distress that patients in both groups experienced was fear of death. Nonelderly patients were more likely to suffer from “unwillingness to pass away because of concern for loved ones” (18.8%) compared with 11.9% in the elderly group which was a statistically significant difference (pZ 0.003). Elderly patients, however, were more con-cerned about unfulfilled wishes (29.7%) than nonelderly patients (18.4%) with statistical significance (p< 0.001).
The impact of age on symptomatic differences may be confounded by other factors. Therefore, we analyzed the influences of physical factors on psychosocial or spiritual factors by multiple logistic regressions. The results are demonstrated in Tables 4 and 5. After adjustment,
nonelderly age (<60 years old) still revealed a significant positive or negative impact on psychosocial and spiritual suffering. Moreover, the positive or negative correlation was consistent with comparison analysis: nonelderly age (<60 years old) was related to higher frequency of break-through pain [odds ratio (OR) 1.61], emotional distress (OR 1.32), and unwillingness to pass away because of concern for loved ones (OR 1.99). In contrast, elderly age was related to unawareness of disease/prognosis (OR 0.46) and unfulfilled wishes (OR 0.64). In addition to young age, fe-male gender also has a significantly greater risk in emo-tional distress (OR 1.50). Morphine use for cancer pain revealed less risk of breakthrough pain (OR 0.51), anorexia (OR 0.39) and emotional distress (OR 0.53).
Table 2 Comparison of physical symptoms between nonelderly and elderly groups.
Physical symptoms Age stratification p
<60 y S60 y
nZ 467 nZ 546
Baseline pain level 4.0 3.0 2.8 2.8 <0.001a
Weakness 454 (97.2%) 520 (95.2%) 0.140 Anorexia 342 (73.2%) 440 (80.6%) 0.007 Abdominal fullness 186 (39.8%) 250 (45.8%) 0.057 Leg edema 127 (27.2%) 186 (34.1%) 0.02 Infection 93 (19.9%) 105 (19.2%) 0.812 Breakthrough pain 90 (19.3%) 54 (9.9%) <0.001 Ascites 88 (18.8%) 102 (18.7%) 0.999
Fungating tumor wound 64 (13.7%) 28 (5.1%) <0.001
Fever 49 (10.5%) 49 (9.0%) 0.456 Delirium 48 (10.3%) 73 (13.4%) 0.837 Severe cough 31 (6.6%) 33 (6.0%) 0.7 Insomnia 30 (6.4%) 15 (2.7%) 0.006 Dizziness 16 (3.4%) 4 (0.7%) 0.003 Pressure sore 12 (2.6%) 33 (6.0%) 0.009
% out of age stratifications.
at-test was used for analysis; Chi-square analysis was used for other variables.
Table 3 Comparison of psychosocial and spiritual distress between nonelderly and elderly groups.
Psychosocial and spiritual distress Age stratification p
<60 y S60 y
nZ 467 nZ 546
Psychosocial issues
Unawareness of disease and prognosis 115 (24.6%) 241 (44.1%) <0.001
Emotional distress 322 (69.0%) 331 (60.6%) 0.013
Difficult in disease adaption 349 (74.7%) 424 (77.5%) 0.239
Insufficient family support 20 (4.3%) 17 (3.1%) 0.505
Inadequate financial support 14 (3.0%) 6 (1.1%) 0.070
Other psychosocial problems 29 (6.2%) 33 (6.0%) 0.606
Spiritual issues
Fear of death 162 (34.7%) 205 (37.5%) 0.230
Having unfulfilled wishes 86 (18.4%) 162 (29.7%) <0.001
Concern for loved onesa 88 (18.8%) 65 (11.9%) 0.003
% out of age stratifications.
Chi-square analysis was used in this table.
Discussion
This is the first study to describe the physical, psychosocial and spiritual needs of nonelderly advanced cancer patients in Taiwan. Our findings indicated that nonelderly cancer patients suffered more from pain, fungating tumor wound, insomnia, dizziness, emotional distress, and unwillingness to pass away because of concern for loved ones. The impact of age on symptomatic differences remains great and is significant after adjustment. Palliative care emphasizes comprehensive care, which provides relief for physical symptoms as well as psychological and spiritual suffering
[11]. Therefore, palliative professional consultants should notice these characteristics in nonelderly advanced cancer patients and provide more individualized and tailored pal-liative care plans.
Higher baseline pain level and more frequent break-through pain were identified in nonelderly cancer patients in the present study. The literature generally supports this observation. Cheung et al. are in agreement with our finding that younger patients reported worse pain [3]. Although Green et al. indicated no significant differences in pain severity between different age groups[12], they identified more pain flares in younger patients. Svendsen et al. dem-onstrated that higher frequencies of breakthrough pain were
reported in developed countries than in developing ones
[13]. Significant physical and psychological burdens caused by breakthrough cancer pain may result in a severely diminished quality of life in the limited life expectancy of advanced cancer patients. Uncontrolled pain is a major factor in vulnerability to suicide in patients with advanced cancer[14]. Our findings suggested that morphine use was associated with less breakthrough pain and less emotional distress. This trend is compatible with the literature. We advocate that palliative care providers should pay great attention to nonelderly patients with advanced cancer regarding the pain level and breakthrough pain, especially in Asian populations where pain levels may be under-reported. Head and neck cancer was more prevalent in nonelderly patients according to our results. An official government report demonstrated that the most common malignancy in the 25e44-year-old male population in Taiwan is oral can-cer, and its incidence is increasing rapidly[4]. Oral cancer (95%) accounts for most head and neck cancer in the pre-sent study. Oral cancer prevalence differs between eastern (about 40% of all cancers) and western countries (less than 5%)[15,16]. The habit of betel nut chewing in some of our country’s population may explain this feature [15]. Gold-stein et al. advocated the importance of the interdiscipli-nary team in the care of head and neck cancer patients Table 4 Influence of age (<60 y) plus demographic and medical factors on metastases and physical symptoms in advanced cancer patients.
Demographic and medical factors
Metastases and physical symptoms
Bone metastasis Lung metastasis Breakthrough pain Anorexia <60 y 1.65 (1.21e2.24)** 1.43 (1.03e1.99)* 1.61 (1.09e2.38)* 0.59 (0.43e0.82)** Gender (female) 0.71 (0.50e0.99)* 0.89 (0.62e1.29) 1.04 (0.68e1.61) 1.05 (0.74e1.50) Head and neck cancer 0.53 (0.34e0.83)** 0.33 (0.20e0.54)** 1.44 (0.92e2.26) 0.43 (0.29e0.64)** Respiratory tract cancer 3.52 (2.43e5.10)** 0.27 (0.14e0.50)** 0.48 (0.25e0.95)* 0.57 (0.37e0.87)* Breast cancer 9.61 (4.89e18.91)** 4.26 (2.26e8.06)** 1.06 (0.44e2.56) 1.15 (0.52e2.54)
Bone metastasis e e 0.94 (0.61e1.45) 1.26 (0.88e1.81)
Morphine use e e 0.51 (0.34e0.75)** 0.39 (0.26e0.58)**
All results are presented as odds ratios and the intervals of 95% confidence are presented in parenthesis. *Significant at 5% level.
**Significant at 1% level.
Table 5 Influences of age (<60 y) plus demographic and medical factors on psychosocial and spiritual symptoms in advanced cancer patients.
Demographic and medical factors
Psychosocial and spiritual symptoms Unawareness of
disease/prognosis
Emotional distress Having unfulfilled wishes
Concern for loved ones <60 y 0.46 (0.35e0.62)** 1.32 (1.00e1.74)* 0.64 (0.47e0.88* 1.99 (1.37e2.88)* Gender (female) 0.90 (0.66e1.21) 1.50 (1.11e2.03)* 0.86 (0.62e1.20) 0.75 (0.50e1.13) Head and neck cancer 1.12 (0.77e1.63) 1.25 (0.87e1.81) 0.76 (0.49e1.17) 0.85 (0.52e1.37) Respiratory tract cancer 1.38 (0.95e2.01) 0.87 (0.60e1.27) 1.10 (0.73e1.65) 1.36 (0.82e2.25) Breast cancer 0.47 (0.21e1.07) 0.60 (0.31e1.16) 1.03 (0.48e2.19) 1.48 (0.61e3.56) Bone metastasis 1.38 (0.99e1.91) 0.77 (0.56e1.06) 1.24 (0.87e1.78) 1.79 (1.13e2.84)* Morphine use 1.44 (1.03e2.01)* 0.53 (0.39e0.72)** 1.83 (1.23e2.70* 1.44 (0.93e2.24) All results are presented as odds ratios and the intervals of 95% confidence are presented in parenthesis.
*Significant at 5% level. **Significant at 1% level.
[17]. Occurrence of younger age, malignant fungating wound, intractable neuropathic pain caused by tumor compression or invasion, facial disfigurement and loss of swallowing and speech function make head and neck can-cer patients suffer from unique and heavy physical and psychosocial burdens[18]; therefore, intensive holistic support is most important in this patient population.
A higher prevalence of breast cancer was identified in the nonelderly group compared with the elderly group in the present study. Leong et al. demonstrated that the peak age of breast cancer was lower (40e50 years old) in Asians, and this was quite different from the peak age in Western countries [19]. Grabsch et al. pointed out that women with advanced breast cancer had higher prevalence of psychological stress, which would affect quality of life
[20]. Therefore, intensive physical and psychological care is necessary for women with advanced breast cancer
[19e21].
Our results identified that nonelderly patients were more likely to suffer from insomnia, which was similar to the results in the literature [22], which suggested that physical discomfort, especially intractable pain, may dis-rupt sleep[23,24]. Psychosocial distress including anxiety and depression may also cause sleep problems [25]. Therefore, the higher prevalence of sleep disturbance in nonelderly advanced cancer patients may reflect more physical as well as psychosocial distress in nonelderly pa-tients and this warrants further attention.
Our study revealed that nonelderly advanced cancer patients had a significantly higher percentage of emotional distresses than elderly patients. Ellis et al. reported similar results [26]. Walsh et al. also demonstrated that younger patients were associated with anxiety and depression[22]. Thompson et al. showed that younger advanced cancer patients tended to experience nonacceptance of the prognosis and reported more frequently feelings of hope-lessness, suffering, depression and anxiety [27]. This may explain the higher emotional distress seen in nonelderly cancer patients.
Empirical evidence suggested that a large proportion of cancer patients in Taiwan were unaware of their disease/ prognosis as they were approaching death [28]. In the present study, the overall proportion of unawareness of disease/prognosis is 35.1%, with 24.6% and 44.1% in the nonelderly group and elderly groups, respectively. This finding is compatible with previous research in Taiwan, which indicated that nonelderly patients had a higher level of disease awareness than elderly patients prior to death
[29]. Another study from Taiwan revealed that truth-telling problems occurred in nearly one-half (42.6%) of the elderly population (>65 years old) with advanced cancer in Taiwan
[30]. In Taiwanese culture, older ill patients rely heavily on family caregivers. “Unawareness of disease” is taken to be the result of a “white lie” by which family members maintain patients’ will to live on. However, the higher prevalence of disease unawareness may indicate higher rates of unfulfilled wishes and unprepared funerals in the elderly patients, which are necessarily based on prognosis disclosure. Cross-cultural difference regarding disclosure of cancer prognosis was evident in the literature[31]. Truth-telling or disease disclosure to the elderly cancer subjects constitutes an important issue in Taiwan’s hospice care.
Spirituality is one of the most important parts of pal-liative care for advanced cancer patients[6,7]. The liter-ature identified relationship, meaning identification, peace and faith as four major elements of spirituality in terminal patients [8,32e35]. Though some instruments have been developed to assess spirituality [6,36], few scales are suitable for the Asian population because of religious and cultural differences. Christianity and Catholicism account for only 13% of the religious belief in Taiwan’s population
[37]. Religious differences cause differences of “death view” and pre-dying adjustments between western and eastern populations. Our study indicated that the six-item questionnaire of spiritual concerns would be pertinent to evaluate spiritual well-being in Taiwan’s population and suitable for employment in further research.
Our study found that unfulfilled wishes were significantly more prevalent in the elderly group. As we have discussed, unawareness of disease/prognosis was more prevalent in the elderly group. We conducted further correlation anal-ysis between these two factors, and the results revealed that unfulfilled wishes and unawareness of disease/prog-nosis were significantly correlated (correlation coefficient 0.206, p< 0.01). Fulfilling wishes would indicate accom-plishing a good death for advanced cancer patients. For instance, seeing children finishing an educational degree or getting married are two examples given in the literature
[18]. Not to inform a senior patient with advanced cancer of disease/prognosis may result in higher rates of unfulfilled wishes because approaching death was not included in communication, let alone talking about the wishes before death.
Our study revealed that younger patients were con-cerned more by an “unwillingness to pass away because of concern for loved ones”. There is limited reference to this in the literature. However, nonelderly patients with advanced cancer have more concerns for loved ones because they may care more about their surviving parents, spouses or small children[18]. This specific spiritual suf-fering might also be explained by Erikson’s psychosocial stages in the life cycle. In his theory, people who are more than 20 years old should primarily establish “intimacy” and those who are 40e60 years old should take “generativity” as their major task[38].
There are strengths and limitations in the present study. A retrospective study design which restricted the clar-ification of the causal relationship is one limitation. Though this is a single-center study, a large sample size with a good power is its strength. Another strength is that our data were collected by palliative care professionals and licensed hospice nurses, which increases the reliability of the investigation.
In conclusion, nonelderly patients with advanced cancer suffered from more physical, psychosocial and spiritual distress, including baseline pain level, breakthrough pain, insomnia, emotional distress, and unwillingness to pass away because of concern for loved ones. On the contrary, elderly cancer patients have a higher prevalence of prog-nosis unawareness and having unfulfilled whishes. There is much room for improvement on this condition. Intensive support for these vulnerable patients is therefore impor-tant in palliative care, especially in Taiwan’s advanced cancer patients.
References
[1] Murray S. The quality of death e ranking end of life care across the world. A report from the Economist Intelligence Unit, London: Economist Intelligence Unit; 2010.
[2] Cherney NI. The challenge of palliative medicine. In: Hanks G, Cherney NI, editors. Oxford textbook of palliative medicine. 4th ed. Oxford: Oxford University Press; 2010. p. 43e57. [3] Cheung WY, Le LW, Gagliese L, Zimmermann C. Age and
gender differences in symptom intensity and symptom clus-ters among patients with metastatic cancer. Support Care Cancer 2011;19:417e23.
[4] Bureau of Health Promotion, Department of Health, R.O.C Tai-wan. The effects of a national cancer prevention five-year proj-ect. Available at:http://www.bhp.doh.gov.tw/BHPnet/Portal/ Them_Show.aspx?SubjectZ200712250030&ClassZ0&NoZ 201009170001[accessed on 05.01.11].
[5] Tsai JS, Wu CH, Chiu TY, Hu WY, Chen CY. Fear of death and good death among the young and elderly with terminal can-cers in Taiwan. J Pain Symptom Manage 2005;29:344e51. [6] Yanez B, Edmondson D, Stanton AL, Park CL, Kwan L, Ganz PA,
et al. Facets of spirituality as predictors of adjustment to cancer: relative contributions of having faith and finding meaning. J Consult Clin Psychol 2009;77:730e41.
[7] Edwards A, Pang N, Shiu V, Chan C. The understanding of spirituality and the potential role of spiritual care in end-of-life and palliative care: a meta-study of qualitative research. Palliat Med 2010;24:753e70.
[8] Williams AL. Perspectives on spirituality at the end of life: a meta-summary. Palliat Support Care 2006;4:407e17. [9] Caraceni A, Portenoy RK. An international survey of cancer
pain characteristics and syndromes. IASP Task Force on Cancer Pain. International Association for the Study of Pain. Pain 1999;82:263e74.
[10] Gagliese L, Jovellanos M, Zimmermann C, Shobbrook C, Warr D, Rodin G. Age-related patterns in adaptation to cancer pain: a mixed-method study. Pain Med 2009;10:1050e61. [11] Word Health Organization. WHO Definition of Palliative Care.
Available at:http://www.who.int/cancer/palliative/definition/ en/[accessed on 11.01.11].
[12] Green CR, Hart-Johnson T. Cancer pain: an age-based analy-sis. Pain Med 2010;11:1525e36.
[13] Svendsen KB, Andersen S, Arnason S, Arner S, Breivik H, Heiskanen T, et al. Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms. Eur J Pain 2005;9:195e206.
[14] Breitbart W. Psychological and psychiatric interventions in pain control. In: Hanks G, Cherney NI, editors. Oxford text-book of palliative medicine. 4th ed. Oxford: Oxford University Press; 2010. p. 786e7.
[15] Auluck A, Hislop G, Poh C, Zhang L, Rosin MP. Areca nut and betel quid chewing among South Asian immigrants to Western countries and its implications for oral cancer screening. Rural Remote Health 2009;9:1118.
[16] Musani MA, Jawed I, Marfani S, Khambaty Y, Jalisi M, Khan SA. Carcinoma cheek: regional pattern and management. J Ayub Med Coll Abbottabad 2009;21:87e91.
[17] Goldstein NE, Genden E, Morrison RS. Palliative care for pa-tients with head and neck cancer: “I would like a quick re-turn to a normal lifestyle”. J Am Med Assoc 2008;299: 1818e25.
[18] Bhikkhuni TT, Baikkhuni MS, Chen CY, Hu WY, Chiu TY, Bhikkhu HM. Spiritual care for terminal patients with head and neck cancer. Taiwan J Hospice Palliative Care 2002;7:269e82. [19] Leong SP, Shen ZZ, Liu TJ, Agarwal G, Tajima T, Paik NS, et al. Is breast cancer the same disease in Asian and Western countries? World J Surg 2010;34:2308e24.
[20] Grabsch B, Clarke DM, Love A, McKenzie DP, Snyder RD, Bloch S, et al. Psychological morbidity and quality of life in women with advanced breast cancer: a cross-sectional survey. Palliat Support Care 2006;4:47e56.
[21] Butler LD, Koopman C, Cordova MJ, Garlan RW, DiMiceli S, Spiegel D. Psychological distress and pain significantly increase before death in metastatic breast cancer patients. Psychosom Med 2003;65:416e26.
[22] Walsh D, Donnelly S, Rybicki L. The symptoms of advanced cancer: relationship to age, gender, and performance status in 1,000 patients. Support Care Cancer 2000;8:175e9. [23] Kvale EA, Shuster JL. Sleep disturbance in supportive care of
cancer: a review. J Palliat Med 2006;9:437e50.
[24] Jimenez-Gordo AM, Feliu J, Martinez B, de-Castro J, Rodri-guez-Salas N, Sastre N, et al. Descriptive analysis of clinical factors affecting terminally ill cancer patients. Support Care Cancer 2009;17:261e9.
[25] Teunissen SC, de Graeff A, Voest EE, de Haes JC. Are anxiety and depressed mood related to physical symptom burden? A study in hospitalized advanced cancer patients. Palliat Med 2007;21:341e6.
[26] Ellis J, Lin J, Walsh A, Lo C, Shepherd FA, Moore M, et al. Predictors of referral for specialized psychosocial oncology care in patients with metastatic cancer: the contributions of age, distress, and marital status. J Clin Oncol 2009;27: 699e705.
[27] Thompson GN, Chochinov HM, Wilson KG, McPherson CJ, Chary S, O’Shea FM, et al. Prognostic acceptance and the well-being of patients receiving palliative care for cancer. J Clin Oncol 2009;27:5757e62.
[28] Tang ST, Liu TW, Tsai CM, Wang CH, Chang GC, Liu LN. Patient awareness of prognosis, patientefamily caregiver congruence on the preferred place of death, and caregiving burden of families contribute to the quality of life for terminally ill cancer patients in Taiwan. Psychooncol 2008;17:1202e9. [29] Cheng SY, Hu WY, Liu WJ, Yao CA, Chen CY, Chiu TY. Good
death study of elderly patients with terminal cancer in Tai-wan. Palliat Med 2008;22:626e32.
[30] Chiu TY, Hu WY, Cheng SY, Chen CY. Ethical dilemmas in palliative care: a study in Taiwan. J Med Ethics 2000;26: 353e7.
[31] Mitchell JL. Cross-cultural issues in the disclosure of cancer. Cancer Pract 1998;6:153e60.
[32] Whitford HS, Olver IN, Peterson MJ. Spirituality as a core domain in the assessment of quality of life in oncology. Psy-chooncol 2008;17:1121e8.
[33] Weaver AJ, Flannelly KJ. The role of religion/spirituality for cancer patients and their caregivers. South Med J 2004;97: 1210e4.
[34] Visser A, Garssen B, Vingerhoets A. Spirituality and well-being in cancer patients: a review. Psychooncol 2010;19:565e72. [35] Travado L, Grassi L, Gil F, Martins C, Ventura C, Bairradas J. Do
spirituality and faith make a difference? Report from the Southern European Psycho-Oncology Study Group. Palliat Support Care 2010;8:405e13.
[36] Selman L, Harding R, Gysels M, Speck P, Higginson IJ. The measurement of spirituality in palliative care and the content of tools validated cross-culturally: a systematic review. J Pain Symptom Manage 2011;41:728e53.
[37] Statistical Yearbook of Interior in Taiwan - General Conditions of Religions. Available from: http://sowf.moi.gov.tw/stat/ year/elist.htm[accessed 12.03.06].
[38] Sadock BJ, Sadock VA. Eight stages of the life cycle. Theories of personality and psychopathology. In: Grebb JA, Norman Cussman CSP, editors. Kaplan & Sadock’s synopsis of psychi-atry: behavioral sciences/clinical psychiatry. 10th ed. Phila-delphia: Lippincott Williams & Wilkins; 2007. p. 208e11.
