Health Care Providers’ Perspectives on Providing End-Of-Life Psychiatric Care Between Cardiovascular and Oncological Hospitals: A Cross-Sectional Questionnaire Survey

Purpose Psychological distress is a serious problem for patients with heart disease or cancer at the end of life. The aim of this study was to compare the barriers to providing end-of-life psychiatric care in cardiovascular compared to oncological settings. Methods In this cross-sectional questionnaire survey conducted in Japan, we mailed questionnaires to physicians and nurses in 347 oncological and 427 cardiovascular hospitals in March 2018 to assess health care providers’ perspectives. First, we applied the Palliative Care Diculties Scale and assessed end-of-life psychiatric care diculties. Second, we asked about barriers to providing end-of-life psychiatric care in free description. A total of 224 oncological and 213 cardiovascular hospitals responded to the questionnaires. The mean scores of palliative and end-of-life psychiatric care diculties showed no signicant differences between oncological and cardiovascular hospitals. Eight barriers to providing end-of-life psychiatric care were identied and were based on patients’ personal, interfamilial, clinicians’ personal, clinician-patient communication, end-of-life care, psychiatric care, systematic or environmental, and disease-specic problems. In addition, health care providers in cardiovascular hospitals were found to have a signicantly higher rate of disease-specic issues compared with oncological hospitals.

hospitals and 427 ICD specialized hospitals, asking them to deliver the questionnaires directly to oncological and cardiovascular physicians and nurses in March 2018. Designated cancer hospitals, recommended by the prefectural governments, can provide high-quality cancer treatment guaranteed by the Ministry of Health, Labour and Welfare in Japan. They provide specialized cancer treatments, establish local cooperation systems for cancer treatments, and provide consultation, support, and information for cancer patients. Additionally, ICD specialized hospitals can operate implantation of implantable cardioverter-de brillators (ICDs).

Ethics
Our study was approved without undergoing assessment by the institutional review board at the Tokyo Medical and Dental University in Japan, as it was an anonymized non-invasive self-completed questionnaire study for health care providers. However, all procedures were in accordance with the ethical standards of the responsible committees on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. All participating physicians and nurses were volunteers and were not provided with any incentive to participate. The anonymized questionnaires were individually returned from each health care provider and not speci ed by an individual person or facility.

Demographic and clinical characteristics
We collected demographic and clinical information from the self-completed questionnaires. First, we included the following data: sex, age, and medical license of the staff of each health care provider. Second, we included the following data: area (Hokkaido/Tohoku, Kanto/Koshinetsu, Chubu/Hokuriku, Kinki, Chugoku/Shikoku, and Kyushu/Okinawa area), hospital type (national medical center, academic medical center, general hospital except academic medical center, specialized hospital), the number of hospital beds, and the presence of a palliative care unit, palliative care team, liaison psychiatry team, palliative care physicians, psychiatrists, and psychologists at hospitals.

Outcome measures
Di culty of providing palliative care The Palliative Care Di culties Scale, a 15-item self-reported scale, was developed in Japan [31]. It is a 4-point Likert-type scale ranging from 0 to 3 (overall score range: 0-42). The scale contains ve factors with three items each: (1) alleviating symptoms, (2) expert support, (3) multidisciplinary communication, (4) communication with patient/family, and (5) community coordination. The reliability and validity of this measure were su ciently supported in an earlier study [31].
Di culty of providing end-of-life psychiatric care We developed the following question for assessing the di culty of providing end-of-life psychiatric care: "Do you feel challenged to provide psychiatric care for patients at their end of life?"; possible answers were "yes" or "no." Barriers to providing end-of-life psychiatric care To identify barriers to providing end-of-life psychological care, we asked participants who answered "yes" in the above question: "Why do you feel challenged to provide psychological care for patients at their end of life?" and asked to submit written answers in free description.

Qualitative analyses
Content analysis was used to analyze free description data. Content analysis is an objective and systematic procedure used to draw conclusions by creating categories of data from verbatim or unstructured data [32]. We conducted a quantitative content analysis according to previous studies in palliative care settings [33,34]. Our content analysis procedure was conducted as follows: (1) all text data were divided into thematic units, which are the units of words with one logical meaning; (2) two researchers, a clinical psychologist and a cardiovascular nurse (IK and MS, respectively) extracted all statements from the free descriptions related to the study topic, such as the barriers to providing end-of-life psychiatric care; (3) a clinical psychologist (IK), a cardiovascular nurse (MS), and two psychiatrists in the palliative care team (ME and TT) carefully conceptualized similarities and differences in the content, and de ned all categories; and (4) two coders, a student of psychology and a psychiatric clinical nurse, independently determined how each thematic unit that was identi ed corresponded with any category. The concordance rate and kappa coe cient of the determinations of the categories were used as reliability indicators. The kappa coe cient was calculated using 20% of the data and random sampling was conducted based on the data from a standard set derived from a previous study, with more than 10% or 50 units of data [35,36].

Statistical analyses
First, we summarized the characteristics of the participants and hospitals using standard descriptive statistics. Second, the mean difference in di culties in providing palliative care was compared between oncological and cardiovascular hospitals using a t test, and the frequency of di culties in providing end-oflife psychiatric care was compared between oncological and cardiovascular hospitals using a χ 2 test. Third, the frequency of the thematic units that were categorized in the above content analysis was compared between health care providers in oncological and cardiovascular hospitals using a χ 2 test. The signi cance level was set at 5%. All data were analyzed using IBM SPSS Statistics for Windows, version 24 (IBM Corp., NY, USA).
Of the 347 oncological and 427 cardiovascular hospitals, 130 oncological physicians (37.5%), 94 oncological nurses (27.1%), 120 cardiovascular physicians (28.1%), and 93 cardiovascular nurses (21.8%) were included in the analysis (Fig. 1). The characteristics of the study participants and hospitals are listed in Table 1. More than 90% of physicians were specialized, such as lung cancer or cardiovascular specialists, and almost half of the nurses were certi ed in a special eld, including cancer nursing or palliative care. The sex ratio (men:women) was 1.4:1. In both cancer and cardiovascular hospitals, more than 90% were general hospitals, almost 60% were large-scale facilities (≥500 hospital beds), more than 80% had palliative care teams, and almost 70% had psychiatric or psychological care specialists. The barrier of providing end-of-life psychiatric care using qualitative methods We extracted 52 attributes from the content analysis, 40 of which were classi ed by the semantic content into "patients' personal problems," "family members' problems," "professionals' personal problems," "communication problems between professionals and patients," "problems speci c to end-of-life care," "problems speci c to psychiatric care," "problems of institution or system," and "problems speci c to non-cancer patients" ( Table 2). The Kappa coe cient derived by the two independent coders was 0.54 in the random 20% data of this study.
The frequency of barriers to providing psychiatric end-of-life care is shown in Table 3. We found that problems speci c to non-cancer patients occurred more frequently in health care providers among cardiovascular than oncological hospitals (χ 2 [1] = 22.475, p = 0.00). There was no signi cant difference between the frequency of any other barrier between health care providers among oncological and cardiovascular hospitals.

Discussion
This is the rst study that investigated the barriers to providing end-of-life psychiatric care. Our results yielded two major ndings. First, the health care providers included in this study were found to have eight barriers to providing psychiatric care: problems concerning the (1) patients, (2) family members, and (3) professionals, (4) di culties in the communication amongst professionals, di culties speci c to (5) end-of-life care, (6) psychiatric care, or (7) non-cancer patients, and (8) issues related to the institution or system. Second, cardiovascular health care providers have psychiatric care problems speci c to non-cancer patients, such as obtaining professional support, useful guidelines, or training opportunities. This study was useful in exploring solutions for providing su cient psychiatric care for end-stage HF patients due to the extraction of barriers using a bottom-up qualitative approach.
Our results indicate that there are three challenges in providing psychiatric care to end-of-life patients. First, cardiovascular health care providers nd it particularly di cult to improve their knowledge and skills in psychiatric assessment and treatment of psychological as well as cardiac symptoms. In particular, depression, in addition to fatigue or pain, is one of the most common symptoms and imposes a heavy burden on patients with advanced HF [12,13,37]. Some clinical practice guidelines on HF emphasize the need for psychiatric care for depressive HF patients as part of symptom management in Western countries [5,38]. However, even these guidelines have insu cient information about a speci c psychiatric assessment and treatment for patients with HF. Participants in this study also described that they had little access to improve their knowledge and skills in psychiatric care. In cancer patients, lack of knowledge and training is a barrier to providing psychiatric care [39], and therefore some Japanese academic societies have held seminars or workshops to promote psychiatric care knowledge for oncologists or any other health care providers in the last few decades. Taken together, we recommend an expansion of the training system and provision of detailed guidelines as a way to provide access to methods of psychiatric assessment and treatment for patients with advanced HF.
In addition, physical symptom management was also identi ed as a di cult problem for cardiovascular professionals compared with oncological colleagues in this study. Interventions directed at alleviating physical symptoms related to HF can lead to a reduction in psychological symptoms in palliative care [40]. In the future, we should develop a training system for end-of-life care professionals in parallel with both physical and psychiatric care.
Second, many health care providers felt that it was di cult to coordinate professional-patient relationships in both cardiovascular and oncological settings.
Interventions to enhance communication between professionals and patients can improve the psychological well-being [41]. The professional-patient relationship and communication are also important for the quality and outcome of medical treatment [42,43]. Particularly in palliative settings, a lack of communication between professionals and patients can lead to the inhibition of critical decisions such as ICD deactivations [44,45]. Practically, general education and specialized education can improve communication skills among health care providers and facilitate professional-patient communication [46,47]. Advanced care planning can also encourage effective communication between professionals and patients with HF [48,49]. Therefore, we conclude that a useful tool or training system for improving communication skills as well as psychiatric care skills among health care providers could enhance end-of-life care in cardiovascular settings.
Third, professionals' personal psychological or physical distress can be a barrier to providing psychiatric care. Professional participants in this study described that many cardiovascular and oncological hospitals do not have su cient staff and are consequently overwhelmed by the workload, leading to unsatisfactory psychiatric care for palliative patients. Health care providers also feel unable to provide su cient spiritual psychiatric care for end-of-life patients [29].
Reducing the workload and ensuring adequate time management for health care providers remain critical goals in modern Japanese medical settings.

Limitations
Our study has two major limitations. First, recall bias may have occurred because of the self-reported nature of the questionnaires. However, we conducted a content analysis by two researchers independently and ensured objectivity. Second, selection bias might have occurred because of the implementation of a national study exclusively in Japan. Therefore, future studies investigating the same issues in other countries will be of importance to con rm our ndings.

Conclusion
Our study suggests that health care providers in cardiovascular hospitals, in contrast to oncological counterparts, experience problems in obtaining useful guidelines or training opportunities. We should provide continuous educational opportunities for health care providers involved with psychiatric and palliative care for patients with HF. However, our study also indicates that both oncological and cardiovascular health care providers experience di culties in providing end-of-life psychiatric care, which stem from patients' or health care providers' personal problems, among others. Therefore, we should also develop strategies to overcome not only the understa ng situation in medical services but also a lack of professionals' psychiatric care skills.
Declarations IK, MS, and ME conceptualized this study. IK curated the data. IK, MS, and IH conducted the formal analyses. IK and ME acquired the funding. IK conducted the study, designed the study methodology, oversaw the project administration, obtained the study's resources, and operated the software. CH supervised the qualitative analyses. TH and TT supervised the study. IK validated the study results, created the visualizations, and wrote the original draft. MS, CH, IH, FY, MH, TH, TT, and ME reviewed and edited the draft. All authors read and approved the nal manuscript.

Ethics approval
Our study was approved without undergoing assessment by the institutional review board at the Tokyo Medical and Dental University in Japan, as it was an anonymized non-invasive self-completed questionnaire study for health care providers. However, all procedures were in accordance with the ethical standards of the responsible committees on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000.

Consent to participate
Not applicable Consent for publication Not applicable Figure 2 Di culty of providing palliative care (scores) Figure 3 Di culty of providing end-of-life psychiatric care (%)