BACKGROUND: Palliative care involves providing comprehensive physical, psychological, and social care to improve clinical symptoms and quality of life, as well as to ensure patients\' dignity at the end of life. Nurses are important members of hospice care teams, and undergraduate nursing students are the hospice care providers of the future. The ability of undergraduate nursing students to provide hospice care will, thus, directly affect service quality.
OBJECTIVE: To understand the relationship between hospice competence and the death-coping abilities of nursing students and provide a theoretical basis for promoting the development of hospice education for nursing students.
METHODS: A convenience sample of 204 nursing students from a university in China completed the general conditions questionnaire, Hospice Competency Assessment Questionnaire, and a simplified version of the Coping with Death Scale.
RESULTS: The participants\' overall average hospice competency score was 46 (35-52), with an average score of 3.0 (2.3-3.3) for effective caregiving skills, 2.6 (2.0-3.0) for cultural and ethical values, and 3.0 (2.2-3.4) for interprofessional teamwork. The average death-coping competency score was 92 (72-107). Multivariate logistic regression and Spearman\'s correlation analysis showed a positive correlation between death-coping and hospice competencies (P < 0.05).
CONCLUSIONS: Nursing students\' overall hospice competency is low to moderate. Consequently, nurse educators should effectively modify the hospice education curriculum using the Dedicated Education Unit model.

OBJECTIVE: To understand family caregivers\' decision-making process to place their family members with terminal cancer in inpatient hospice care, especially in the social-cultural contexts whereby the caregivers have a dominant say about the care of their seriously ill family members.
METHODS: A qualitative study with a phenomenological approach was undertaken to understand the lived experience of caregivers of persons with terminal cancer in the decision-making process. Semi-structured qualitative interviews were conducted with a purposive sample of 17 caregivers in Shanghai, China. Thematic analysis was used to analyze the data.
RESULTS: The caregivers underwent a winding and socioculturally mediated four-stage process. The stages are (i) trigger for alternatives: lost hope for a cure, (ii) meandering the see-saw process, (iii) the last straws: physical limitations and witnessing unbearable suffering, and (iv) the aftermath: acceptance versus lingering hope. Caregivers\' attitudes towards death and their family members with advanced cancer expressed care wishes influence the state of the aftermath.
CONCLUSIONS: Chinese sociocultural values and beliefs about caregiving and death provide insightful explanations for the observed process.
CONCLUSIONS: Training healthcare professionals in cultural competence, developing an effective hospice referral system, and delivering socioculturally acceptable death education are critical interventions to facilitate better decision-making experiences.

BACKGROUND: Symptom burdens tend to increase for patients with cancer and their families over the disease trajectory. There is still a lack of evidence on the associations between symptom changes and the quality of dying and death. In this context, this research investigated how symptom changes influence the quality of dying and death.
METHODS: This international prospective cohort study (the East Asian Collaborative Cross-Cultural Study to Elucidate the Dying Process (EASED), 2017-2019) included 22, 11, and 4 palliative care units across Japan, South Korea, and Taiwan. Eligible participants were adults (Japan and Korea, ≥18 years; Taiwan, ≥20 years) with locally advanced or metastatic cancer. Physical and psychological symptoms were assessed by physicians upon admission and within 3 days before death. Death quality was assessed using the Good Death Scale (GDS), developed in Taiwan. Univariate and multivariate regression analyses were used to identify correlations between symptom severity changes and GDS scores.
RESULTS: Among 998 patients (542 [54.3%] men and 456 [45.7%] women; mean [SD] age = 70.1 [± 12.5] years), persistent dyspnea was associated with lower GDS scores when compared to stable dyspnea (β = -0.427, 95% CI = -0.783 to -0.071). Worsened (-1.381, -1.932 to -0.831) and persistent (-1.680, -2.701 to -0.659) delirium were also significantly associated with lower GDS scores.
CONCLUSIONS: Better quality of dying and death was associated with improved symptom control, especially for dyspnea and delirium. Integrating an outcome measurement for the quality of dying and death is important in the management of symptoms across the disease trajectory in a goal-concordant manner.

UNASSIGNED: The present study aimed to explore the biophilic design attributes within a hospice care center from the healthcare professionals\' perspective by utilizing a qualitative research and investigated the effect of hospice professionals\' attitudes toward the uncovered green features on the prediction of their workplace attachment through a quantitative research.
UNASSIGNED: In hospice establishments, studies showed that applying biophilic design principles significantly reduces stress and improves emotional well-being. Yet, despite its importance, attitude toward biophilic design, and its significant influence on well-being, satisfaction and attachment to the workplace of hospice healthcare professionals have not yet been researched.
UNASSIGNED: The qualitative research used semi-structured in-depth interviews among hospice professionals to reveal biophilic design features that exert an influence on their activity, while the quantitative research employed a confirmatory factor analysis and the structural equation modeling to analyze the data.
UNASSIGNED: The qualitative research generated five biophilic design features, such as open spaces with natural light, natural decorative elements, landscape provided by nature through windows, wooden furniture, and colors that create a warm atmosphere within the hospice care center. The quantitative approach indicated that attitude toward the uncovered biophilic design features in the context of the COVID-19 pandemic significantly improved the healthcare providers\' emotional well-being. This dimension, in turn, contributed to their satisfaction with green features/natural decor and attachment to the workplace. Results of this study provide practitioners and researchers valuable strategies to incorporate biophilic design features in the working environments of hospice settings.

OBJECTIVE: To map and synthesise the literature on loneliness at end-of-life and identify key knowledge gaps in loneliness research.
BACKGROUND: Declined health conditions, reduced social engagement, loss of social roles, and fear of death may lead to loneliness at end-of-life. However, systematic information about loneliness at end-of-life is scant.
METHODS: This scoping review followed the methodology proposed by Arksey and O\'Malley. Nine electronic databases were searched from January 2001 to July 2022. Studies about loneliness at end-of-life were included. Two review authors independently screened and selected relevant studies and performed the data charting. The PAGER framework was employed to collate, summarise and report the results. The PRISMA-ScR checklist was included.
RESULTS: A total of 23 studies were included in this review (12 qualitative, 10 quantitative, and one mixed-methods design). There was not reliable data about the prevalence of loneliness among adults at end-of-life internationally. Three or 20-item UCLA loneliness scale was frequently used to measure loneliness. Factors predisposed adults at end-of-life to loneliness included passive and active withdrawal from social networks, inability to share emotions and to be understood, and inadequate support on spirituality. Four strategies were identified to alleviate loneliness, yet none have been substantiated in clinical trials. Interventions facilitating spirituality, social interactions and connectedness seem effective in alleviating loneliness.
CONCLUSIONS: This is the first scoping review on loneliness at end-of-life, synthesising evidence from qualitative, quantitative, and mixed-methods studies. Loneliness among adults at end-of-life is under-investigated and there is a prominent need to address existential loneliness at end-of-life.
CONCLUSIONS: All nurses should proactively assess loneliness or perceived social isolation for clients with life-limiting conditions, regardless of social networks. Collaborative efforts (e.g., medical-social collaborations) to promote self-worthiness, social engagement and connectedness with significant others and social networks are needed.
UNASSIGNED: No patient or public involvement.

This study investigates whether reliance on monetary donations alters nonprofit firms\' behaviors. Specifically, in the hospice industry, a shorter patients\' length of stay (LOS) speeds up overall patient turnover, allowing a hospice to serve more patients and expand its donation network. We measure hospices\' donation reliance using the donation-revenue ratio, which indicates the importance of donations for revenue structure. By exploiting the supply shifter of donation, we adopt the number of donors as an instrument to control for the potential endogeneity issue. Our result suggests that a one-percentage-point increase in the donation-revenue ratio decreases patient LOS by 8%. Hospices that are more reliant on donations serve patients diagnosed with diseases that have shorter life expectancies to achieve a lower average LOS of all patients\' stay. Overall, we find that monetary donations alter the behavior of nonprofit organizations.

OBJECTIVE: Explore the existing literature on the experience and needs of palliative nurses facing job burnout.
BACKGROUND: On a global scale, with the increase of aging, the number of people in need of palliative care has increased significantly, which has a huge impact on the professional pressure of palliative nurses. Existing literature focuses on examining palliative care from the perspective of patients, but palliative nurses also face the threats to physical and mental health caused by job burnout.
RESULTS: A systematic literature search has been carried out in the following databases as of October 2021:PubMed, EMBASE, CINAHL, Web of Science, and Scopus. The Cochrane Library and Joanna Briggs Institute Library were also searched to confirm if there are any available systematic reviews on the subject. Manually searched the reference list of included papers.
RESULTS: Seventeen studies were included in this review. Five key issues in the palliative care nurse\'s experience: (1) psychological harm, (2) physical symptoms, (3) negative emotions, (4) Burnout caused by communication barriers, and (5) Lack of experience. Two key issues in the needs of palliative care nurses: (1) social support, and (2) training and education.
CONCLUSIONS: The pressure of facing death for a long time and controlling the symptoms of patients has a very important impact on the mental and physical health of palliative nurses. Nursing staff have needed to be satisfied, and it is essential to provide support and help relieve the pressure on palliative nurses.

UNASSIGNED: The prevalence of end-stage renal disease (ESRD) and the number of patients undergoing dialysis in Taiwan are high. Since September 2009, the National Health Insurance has started to provide hospice care to patients with renal failure in Taiwan. Therefore, it is necessary to understand the use of hospice and nonhospice care in patients with ESRD on dialysis. We aim to understand trends in patients with ESRD receiving hospice and nonhospice care as well as medical care efforts during the last month of their lives (2009-2013).
UNASSIGNED: The cohort study was conducted using 1 million randomly selected samples from the Taiwan Health Insurance Research Database for millions of people in Taiwan in 2009-2013. Descriptive statistics were presented to summarize the characteristics of data. To compare differences between cohorts, Chi-square tests and Student\'s t-tests were used. Mann-Whitney U-tests were performed for nonnormally distributed data. Mantel-Haenszel test was test for trend.
UNASSIGNED: We recruited 770 ESRD patients who underwent hemodialysis; among them, 154 patients received hospice care. Patients who received hospice care had a significantly longer survival time after removal of mechanical ventilator (20 vs. 0 days) and after discontinuation of dialysis (2 vs. 0 days) compared with those who did not receive hospice care. Patients who received hospice care had more pain control (61.04% vs. 17.37%, P < 0.0001) and other symptomatic control (55.84% vs. 43.18% with diuretics, P < 0.05; 64.29% and 48.21% with laxatives, P = 0.0004) medications than those who did not. Nevertheless, the overall medical cost in the hospice group was significantly lower (90 USD and 280 USD, P < 0.0001).
UNASSIGNED: Our results suggest that the addition of hospice care may permit patients a longer life-support-free survival time. In addition, despite a more frequent symptomatic controlling agent use, hospice care significantly reduced the overall medical expenditure.

BACKGROUND: Artificial hydration (AH) is a challenging issue in terminally ill patients with cancer, because it influences patients\' symptoms control, quality of life, and quality of dying (QOD). To date, it is not clear how much AH supply is proper for imminently dying patients. This study aimed to investigate the association between the amount of AH and QOD.
METHODS: This study is part of the East Asian Collaborative Cross-Cultural Study to Elucidate the Dying Process (EASED) conducted in Japan, Korea, and Taiwan from January 2017 to September 2018. Patients\' demographics, symptoms, and managements on admission to palliative care units (PCUs) and before death were recorded. The AH amount was classified into different groups by 250-mL intervals to compare their difference. The Good Death Scale (GDS) was used to measure QOD, with patients classified into higher or lower QOD groups using GDS = 12 as the cutoff point. We used logistic regression analysis to assess the association between AH amount and QOD.
RESULTS: In total, 1530 patients were included in the analysis. Country, religion, spiritual well-being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with QOD. After conducting regression analysis, patients administered with 250 to 499 mL AH had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072-4.730; P = .032) than those without AH.
CONCLUSIONS: AH use impacts the QOD of terminally ill patients with cancer admitted to PCUs. Communication with patients and their families on appropriate AH use has a positive effect on QOD.
BACKGROUND: Our prospective cross-cultural multicenter study aims to investigate the relationship between artificial hydration (AH) amount and quality of dying among terminally ill patients with cancer. The findings reveal that country, religion, spiritual well-being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with quality of death (QOD). After multivariable logistic regression, patients administered with AH amount 250 to 499 mL had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072-4.730; P = .032) than those without AH. Communication with patients and their families regarding AH is recommended as it may help them be better prepared for the end-of-life stage and achieve a good death.

Background: Mainland China is facing increasing demand for palliative care and has launched related policies after 2010. Research and publications are important for sustainable development of palliative care, and should be encouraged by policy. Objectives: This study aimed to describe the development of palliative care-related publications in Mainland China in various aspects. Design: We searched Web of Science, Scopus, PubMed, Cumulative Index of Nursing and Allied Health Literature, Ovid MEDLINE, and China National Knowledge Infrastructure for publications from Mainland China for 2010-2020, with the topic words \"hospice,\" \"palliative care,\" \"end-of-life care,\" or \"terminal care.\" The publishing year, region, impacts, journals, publication types, and topics were analyzed. Results: A total of 3682 publications were identified, 754 of them (20.5%) published in Chinese core journals or international journals. The annual publication number and impact factor rose rapidly after 2016 and dropped again in 2020. There is no specialized palliative care journal in Mainland China. The publication numbers differed significantly between East and Western China and were closely linked to the economy (R2 = 0.8120, P < .0001). The megacities Beijing and Shanghai comprised 2.6% of the total population of Mainland China but produced 22.6% of the publications. Palliative care in cancer patients was the most common topic (37.7% of the publications). Practical keywords such as \"pain management\" and \"living will\" gained popularity recently. Conclusions: Palliative care-related research and publication in Mainland China are growing in recent years. However, the early stage growth is unstable, with a conspicuous regional disparity. Policies should be designed, in an equitable manner, to encourage original research and publication of palliative care.