Background: Understanding attitudes towards life and death issues in different cultures is critical in end-of-life care and the uptake of advance care planning (ACP) in different countries. However, existing research suffers from a lack of cross-cultural comparisons among countries. By conducting this comparative study, we hope to achieve a clear understanding of the linkages and differences among healthcare cultures in different Chinese societies, which may serve as a reference for promoting ACP by considering cultural differences. Methods: Our researchers recruited Chinese adults who could communicate in Mandarin and lived in metropolitan areas in Taiwan, Hong Kong, Singapore, and Australia. Focus group interviews were conducted, and the interview contents were recorded and subjected to thematic analysis. Results: Between June and July 2017, 14 focus groups with 111 participants were conducted in four regions. With traditional Chinese attitudes towards death as a taboo, many participants felt it would be challenging to discuss ACP with elderly family members. Most participants also desire to avoid suffering for the self and family members. Although the four regions’ participants shared a similar Chinese cultural context, significant regional differences were found in the occasions at which participants would engage in end-of-life discussions and select settings for end-of-life care. By contrast, participants from Singapore and Australia exhibited more open attitudes. Most participants from Taiwan and Hong Kong showed a preference for end-of-life care at a hospital. Conclusions: The developmental experiences of ACP in Western countries, which place a strong emphasis on individual autonomy, cannot be directly applied to family-centric Asian ones. Healthcare professionals in Asian societies should make continuous efforts to communicate patient status to patients and their family members to ensure family involvement in decision-making processes.

// <![CDATA[ $('.header-date').hide();$('#titleAuthors').hide();$('#abstractHeader').hide(); // ]]> Huei-Kai Huang1, Jyh-Gang Hsieh1, 2, Chia-Jung Hsieh3 and Ying-Wei Wang1, 2 1Department of Family Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan 2School of Medicine, Tzu Chi University, Hualien, Taiwan 3Department of Public Health, Tzu Chi University, Hualien, Taiwan Correspondence to: Ying-Wei Wang, email: drywwang@gmail.com Keywords: cancer, dementia, palliative care, terminal care, end-of-life care Received: January 28, 2017 Accepted: June 02, 2017 Published: June 29, 2017 ABSTRACT Dementia is a progressive, incurable disease that can deprive patients of the ability to make decisions. This study determines whether dementia influences the medical care that a cancer patient receives at the end of life. We conducted a nationwide population-based cohort study on patients aged ≥20 with newly diagnosed cancer during 2000–2012. After matching to reduce confounders, there were 7,111 patients with and 28,444 without dementia. The adjusted odd ratios (OR) for medical interventions, including intensive care, palliative care, invasive procedures, and advanced diagnostic testing, were calculated for the final month and three months of life by a multiple logistic regression model. In the final month before death, the dementia cohort had longer hospital stays (17.7 vs. 17.1 days), more intensive care unit stays (OR = 1.32), and less palliative care (OR = 0.80) than the non-dementia cohort and were more likely to receive invasive procedures, including cardiopulmonary resuscitation (OR = 1.32), endotracheal intubation (OR = 1.27), mechanical ventilation (OR = 1.45), urinary catheterization (OR = 1.24), and feeding tube (OR = 1.88), but less likely to undergo chemotherapy (OR = 0.60) and diagnostic procedures such as computed tomography, magnetic resonance imaging, and sonography (OR = 0.87) or bone scan (OR = 0.69). The analysis examining the three months before death had similar results. In summary, patients with cancer and dementia are more likely to receive intensive care and invasive procedures but less likely to undergo advanced diagnostic testing, chemotherapy, or hospice care than those with cancer but without dementia.

Background: Medical professionalism is often considered difficult to be clearly observed and learned. However, although most medical students or residents affirm the necessity of medical professionalism courses, few agree that those currently offered are adequate for a medical career. Objective: To develop a curriculum for teaching professionalism by enabling students to share positive examples of professionalism in social media that reflects the authentic experience in clinical environment. Design: Between October 2015 and June 2017, the authors developed a clerkship program to teach professionalism with the support of social media and appreciative inquiry. Medical students were required to write posts on the positive behaviors they observed during clinical practice in the Facebook group. Other students and course instructors commented or responded to the posted content. The content on Facebook analyzed by course instructors and was based on the definition of medical professionalism according to the 18 attributes proposed by Cruess et al. Results: In total, 103 medical students in their first clinical year participated and posted 435 records of role model learning in the Facebook group. The majority of students learned the most when the clinical instructors were passionate about their teaching and guidance in medical expertise; this accounted for 23.0% of all role model behaviors. Other attributes of professionalism that students appreciated most were being caring and compassionate (17.2%), competence (9.6%), openness (8.8%), and presence (7.7%). More than 90% of the students reported enjoying this type of course and would like to integrate their learning experiences into future behavior. Conclusions: This innovative training program was well accepted in the formal curriculum and the predesigned social media environment. Appreciative inquiry for medical professionalism should be integrated into the organizational culture and the culture of social media interaction.

Physicians have a responsibility to discuss do-not-resuscitate (DNR) decisions and end-of-life (EOL) care with patients and family members. The aim of this study was to explore the DNR and EOL care discussion experience among physicians in Taiwan. A qualitative study was conducted with 16 physicians recruited from the departments of hospice care, surgery, internal medicine, emergency, and the intensive care unit. The interview guidelines included their DNR experience and process and EOL care discussions, as well as their concerns, difficulties, or worries in discussions. Thematic analysis was used to analyze data. Four themes were identified. First, family members had multiple roles in the decision process. Second, the characteristics of the units, including time urgency and relationships with patients and family members, influenced physicians’ work. Third, the process included preparation, exploration, information delivery, barrier solution, and execution. Fourth, physicians shared reflections on their ability and the conflicts between law, medical professionals, and the best interests of patients. Physicians must consider not only patients’ but also family members’ opinions and surmount several barriers in decision-making. They also experienced negative and positive impacts from these discussions.