This is the first study from Southern Thailand that surveyed the EoL care preferences of cancer patients. The five most important components of EoL care discovered were: receiving the full truth about their illnesses, being relieved from uncomfortable symptoms such as pain and shortness of breath, having loved ones around when needed, being mentally aware until the time of death, and feeling meaningful in life. Furthermore, the participants placed a high level of preference on receiving the full truth about their illnesses, disclosing the full truth about their illnesses to the family, passing away at home with loved ones around when needed, and being mentally aware until the time of death. These findings support those of prior reports from the United States of America [8, 9] and the EU [4] as well as a study conducted among Thai elderly patients from the Central and Northeastern Regions of Thailand in 2017 [13]. A reason for this might be the fact that most participants in this study were older adults with a mean age of 55.8 years. Also, knowing the full truth about one’s illnesses, being mentally aware until the time of death, preparing for death, and dying peacefully while feeling comfortable and without pain or suffering might be universal core EoL care preferences among terminally ill patients [4, 8, 9]. Although this study found a statistically different distribution among age groups regarding the end-of-life care preference of receiving both physical and psychological treatment, it was observed that the majority of respondents were in accord regarding this preference. Therefore, it could be said that there was insufficient evidence to conclude a difference between ages related to what type of treatment they preferred to receive.
Almost all participants identified ‘receiving the full truth about their illnesses’ as their number one need in regard to EoL care. Moreover, being mentally aware at the last hour of life was one of the five top EoL care preferences. This indicates that autonomy was of a critical importance to our cancer patients. However, since ‘disclosing the full truth regarding their illnesses to family members’ was a significant preference, it could be said that they were also likely to involve their family in the decision-making process related to EoL care. This finding is consistent with those of a prior study on Northern Thai patients with a terminal illness; they desired that both physicians and relatives be involved in deciding the EoL care they received [13]. Furthermore, this finding supports the report of a former study that Asian patients were more likely to have their family involved in medical decision-making rather than exercising full autonomy or decide only by themselves like most American and European patients do [1, 15, 16]. Concerning this matter and in light of this finding, Thai physicians should ask their patients whether they wish to receive information regarding their health conditions and treatment and to what extent, as well as whether they would like to be involved in making decisions related to their care or prefer that their families handle such matters [17].
In relation to being relieved from uncomfortable symptoms, the participants identified that ‘being free from symptoms such as pain and shortness of breath’, which cause suffering, was the second important component of EoL care. Once more, this finding is consistent with those of a prior study. They found that even before the EoL stage, nearly half of patients with cancer reported moderate to severe pain; up to 30.0% identified the pain as severe, and an estimated 25.0% died in pain [18]. Therefore, all physicians should make the exploration and relief of their patients’ distress and suffering a priority of medical care. Moreover, knowledge of pain concepts, basic end-of-life pain management, and symptom control should be offered to patients and their families [19–21].
Regarding passing away, a good death is one that is free from avoidable suffering, for the patient, their relatives, and caregivers alike; in general accord with the patient's and family's wishes; and reasonably consistent with clinical, cultural, and ethical standards [10, 22]. Prior studies have identified some factors that influence the passing away process; they are: the location of patient domicile, previous occupation, educational level, family income, family size, and dissatisfaction with life [13, 23]. Moreover, it is known that most elderly Thai patients prefer dying at home [13]. However, this study revealed that only two-thirds of the participants agreed with passing away at home with loved ones around when needed and being mentally aware at the time of death, whereas one-third of them had no opinion on this matter. It seems that death with meaning and being remembered may be more significant than the place of death [24]. For cancer patients and their families, palliative home care might be difficult to manage due to factors such as the low level of home care support received by the public health system, and weakened family networks [25, 26]. Hence, the choice to die in a hospital might be less difficult for their families [23]. However, the preference for dying at home is greater when the patient lives with a caregiver, and the family physician makes home visits [27]. Therefore, both physicians and caregivers should pay attention to the patients’ desires regarding the care they wish to receive as well as respect their characterization of a meaningful death. Moreover, patient care during the last hour in hospitals should be modified in order to make it as similar to passing away at home as possible.
Towards the good death, the concept, attitude, interconnectedness among family, caregiver, and health-care provider should be tuned in. These refer to the physical (symptom control), social (loved ones' presence), emotional (sharing emotions), and spiritual (inner peace) dimensions. Moreover, the patient's awareness, acceptance of death, ability to say goodbye to family and friends meaningfully, and the respect for the patient's wishes should be ensured [23]. For dying individuals to experience love and be understood as valuable even were both of healing. If health-care professionals can provide a compassionate and peaceful environment that facilitates acceptance and hope, the spiritual life of patients is enhanced [22, 28].
Finally, given the importance of family caregivers and health-care providers in providing care and their impact on the patients' dying process, it is necessary to reflect upon how their attitudes and prior experiences influence the care for the dying [23, 28]. Hence, a good relationship with family members and healthcare providers improves the patient’s level of self-satisfaction, makes the avoidance of death less likely and the acceptance of death more possible, and enhances their feeling of interconnectedness [13, 28]. These would go a long way in optimizing the terminally ill patients’ quality of life during their EoL period.
To our knowledge, this is the only study on this topic conducted in Southern Thailand during the past decade, which employed an adequate sample size. However, the study was quantitative, and the sample size was restricted to only cancer outpatients in the lower Southern Thailand. Hence, its findings may not represent the situation of cancer patients in the whole country fairly. Henceforward, future studies should include a larger number of cancer outpatients from other hospitals within Thailand; in other words, multi-center research that aims to elucidate issues should be conducted. Moreover, such studies should employ a more qualitative approach or in-depth methodology that is adept to explore specific disorders.
