During the 2022 Asia Conference on Lung Cancer, which took place in October in Nara, Japan, National Taiwan University Hospital Physician Chih-Yuan Shih, MD, provided an overview of the policy resulting from Patient Right to Autonomy Death Act, a law implemented in 2019 in Taiwan. This law, the first of its kind in Asia, is intended to respect patients’ autonomy and allow people to die naturally in their desired setting.
He discussed in this context how the clinical experience of home-based palliative care in Taiwan has changed since the law went into effect and how this type of care can be optimized in the years ahead.
According to his presentation, nearly 70% of elder adults receiving home-based palliative care are cancer patients. Dr. Shih cited a 2015 study1 that showed only 24% of respondents in Taiwan would prefer to receive end-of-life (EOL) care at home versus at a healthcare facility. However, when the same question was posed with the provision that home-based palliative care services would be included with EOL care, more than 60% of respondents said they would prefer to receive EOL care in their homes. This data suggests a need for the expansion of home-based palliative care services to allow more people to die in their preferred place.
To access home-based palliative care services, “patients must [initially] go through formal events care planning by a multi-disciplinary team, including a physician, nurse, and clinical psychologist or social worker,” Dr. Shih explained.
Services from these providers are eligible for some reimbursement. The frequency of visits is usually between once every two weeks to twice per week, Dr. Shih said.
Before intaking a patient for this type of care, physicians conduct a screening and hold a family meeting to discuss the prognosis, goals of care, a defined care plan, and the patient’s preferred place of death. The patient then enters a “stabilizing” phase. The aim throughout this period is to keep the patient as comfortable as possible.
“Sometimes, in the stabilizing phase, we can fulfill the patient’s last wishes,” Dr. Shih said.
Patients eventually enter a phase of instability as their health declines. At this time, caregivers increase the frequency of their home visits and provide the family with “just-in-case” medications, such as morphine, that can be used to comfort patients if they are experiencing severe pain or discomfort. An online portal is also created for the family to contact the patient’s care team in real-time.
“The family can use text, send pictures, or record videos to show the patient’s condition,” Dr. Shih explained.
Bereavement services for the patient’s family are also included after death.
According to Dr. Shih, the most significant challenges related to home-based palliative care are the increased burden placed on patients’ families and a higher percentage of patients reporting moderate to severe pain upon admission. The data suggest that it takes approximately 3 days for a patient to stabilize in the home environment. Dr. Shih is optimistic that this adjustment period will improve as the capacity for care increases.
“High-value care needs trust, but trust needs good communication, and good communication needs time,” he concluded.
References
- 1. Shih CY, Hu WY, Cheng SY, et al. Patient Preferences versus Family Physicians’ Perceptions Regarding the Place of End-of-Life Care and Death: A Nationwide Study in Taiwan. J Palliat Med. 2015;18(7):625-630. doi:10.1089/jpm.2014.0386
