This study was conducted as one of the secondary analysis of the East-Asian collaborative cross-cultural Study to Elucidate the Dying process (The EASED study), an international multicenter prospective cohort study for the cultural differences of advanced cancer patients at palliative care units (PCUs) in Japan, Korea, and Taiwan. The participating institutions for The EASED study included 22, 11, and 4 PCUs in Japan, Korea, and Taiwan, respectively. Only the Korean data were included for the present analysis, as our main aim was to identify differences in symptom improvements within the group of palliative physicians in Korea. Informed consent was obtained from patients or families (in case of patients’ lack of decisional capacity). We enrolled cancer patients who admitted to 11 PCUs in Korea. Inclusion criteria were 1) age 18 or older, 2) locally advanced or metastatic cancer (histological, cytological, or clinical diagnosis), and 3) admitted to the participating PCUs. Exclusion criteria were: 1) patients with scheduled discharge within a week, 2) patients or their families who declined participation. From January 2017 to March 2019, 919 terminally ill cancer patients admitted to the PCUs in 11 hospitals of South Korea, 417 were eligible to the study and a total 334 were analyzed except those who could not follow up, lacked available data or refused to participate in the study. We categorized 334 terminally ill cancer patients into non-dedicated and dedicated hospice care group. In this paper, the definition of dedicated hospice physician was designated as a family doctor who does not have many inpatients other than hospice patients. Oncological and others, which have relatively large patient loadings other than hospice patients, were classified as non- dedicated hospice physician.
Measurement outcomes included variables related to dying process, end of life (EOL) care, and demographic data. These measurement outcomes were developed from a systematic literature review on this topic and extensive discussions among the research group (6). We collected data regarding the patients’ age, sex, primary cancer sites, comorbidity (items per Charlson Comorbidity Index: CCI), highest level of education, living situation, having children under age 20 years-old, marital status, nd psychological factors (emotional stability over the past 3 days). We also collected the data about whether the preference for place for death is hospice unit or not. Symptoms (dyspnea, fatigue, drowsiness, dry mouth) and signs (myoclonus, respiratory secretion, leg edema, ascites) are investigated (at/on) initial admission and one week after the initial investigation, we followed-up symptoms and signs improvements (7). Physicians requested participants to report the intensity of symptoms (fatigue, drowsiness, and dry mouth) based on a scale of on scale of 0-5 (0: not at all, 1; slightly, 2; moderately, 3; severe, 4; overwhelmingly, 5; cannot assess) (8). Dyspnea was checked on a scale with 0; no, 1; yes on exertion only, 2: yes at rest. Myoclonus was counted with frequency of jerks/10 sec at rest (0: No, 1: ≤1 jerk, 2: 2-3 jerks, 3: 4-9 jerks, 4: ≥10 jerks). The severity of respiratory secretion was evaluated using Back’s Scale (0: Not audible, 1: Only audible at the head of bed, 2: Clearly audible at the foot of bed, 3: Clearly audible at 6m away from the foot of bed) (9). Peripheral edema on a scale based on severity on the leg with less edema (0: No, 1: Mild (<5mm), 2: Moderate (5-10mm), 3: Severe (>10mm)). Physicians rated the severity of ascites on a scale of 0 to 2 (0: Physically undetectable, 1: Physically detectable but asymptomatic, 2: Symptomatic). We also checked mental status with Memorial Delirium Assessment Scale (MDAS), item 9（MDAS #9, decreased or increased psychomotor activity (10), and Delirium Rating Scale-revised-98 (DRS-R-98), item 2 (Perceptual disturbances and hallucinations). ECOG and Karnofsky performance scales are widely used functional scales that describe the functional ability of cancer patients (11). ECOG ranges from 0 to 5, where 0 means fully active, and 5 means patient death. The Karnofsky scale ranges from 0 to 100, where 0 indicates the dead and 100 indicates the normal. Primary tumors were categorized as lung, breast, gynecologic, gastrointestinal, prostate, pancreas, urologic, head and neck, hematologic, and others. Comorbidities were also collected to allow reporting of patients’ Charlson comorbidity index (CCI). The CCI is calculated based on 15 comorbidities (1: myocardial infarction, 2: congestive heart failure, 3: peripheral vascular diseases, 4: cerebral vascular disease, 5: dementia, 6: chronic pulmonary disease, 7: connective tissue disease, 8: gastric ulcer disease, 9: liver disease, 10: diabetes with no end-organ damage, 11: hemiplegia, 12: moderate/severe renal disease (Cr≥3mg/dL), 13: diabetes with end-organ damage, 14: moderate/severe liver disease (cirrhosis with portal hypertension), 15: AIDS)(12). The definition of improvement is that it improves when it falls below the initial score.
Basic characteristics of each group were compared using the chi-square test. P-values < 0.05 were considered statistically significant. All data were analyzed using SPSS for Windows (version 21.0; SPSS Inc., Chicago, IL, USA).