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A caregiver’s prognostic awareness can affect clinical decisions for the patient. The purpose of this study was to examine the impact of family caregivers’ prognostic awareness on the quality of life (QOL) and emotional state of both patients with advanced cancer and their caregivers. This prospective cohort study was conducted from December of 2016 to January of 2018. A total of 159 patients with advanced cancer and an equal number of caregivers participated. The investigation tools used include the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C15-Palliative, the McGill Quality of Life Questionnaire, and the Patient Health Questionnaire-9, and evaluation was performed at baseline, 3 months, and 6 months. Covariance analysis with a general linear modeling was used to compare changes in quality of life scores according to the caregivers’ awareness of the prognosis. Mean patient overall QOL score increased in the group of caregivers who were aware of prognosis and decreased in the caregivers who were not aware of the prognosis (p = 0.018). The changes over time in the patients’ QOL scores associated with symptoms improved with caregiver awareness (pain, p = 0.017; dyspnea, p = 0.048; appetite loss, p = 0.045). The percentage of depressed patients was smaller after 3 months in the group with caregivers aware of the prognosis (baseline to 3 months p = 0.028). Caregivers who did not understand their patients’ prognosis exhibited better existential well-being (p = 0.036), and the incidence of depression was lower in this group at 3 months (p = 0.024). Caregivers’ prognostic awareness may improve the quality of life and mood in patients with advanced cancer; however, this awareness may harm the quality of life and mood of the caregivers. These results may aid in developing in-depth interventions regarding prognosis for both patients and their caregivers.

Little has been determined regarding the association between patients’ and families’ illness understanding and preferences for medical care. We aimed to evaluate the association of illness understanding with advance care planning (ACP) and preferences for end-of-life care, such as aggressive care, early palliative care (EPC), and hospice care, among advanced cancer patients and their family caregivers. Patients were recruited for a prospective cohort study at outpatient and inpatient facilities in nine university hospitals in Korea (n = 150), and their primary family caregivers were also asked to participate (n = 101). Data on ACP and end-of-life care preferences were collected only at baseline in the cohort study with optional questions and were used to analyze these study results. Patients with illness understanding were more likely to have documented physician orders for life-sustaining treatment (POLSTs) (adjusted odds ratio [aOR] of 4.94) and to have discussed ACP with their families (aOR 2.15) than those who did not. Being expected to live for several months, they were unlikely to prefer active treatment. Caregivers understanding patients’ illness were more likely to write advance directives (ADs) and to discuss ACP; furthermore, they had already discussed ACP with family members. They did not prefer active treatment or life-sustaining treatments when their family members were expected to die within a few weeks. There was no significant association between illness understanding and preferences for EPC. Accurately recognizing an incurable disease is associated with preferences for more ACP and less aggressive care but not with preferences for EPC or hospice care among both advanced cancer patients and their family caregivers.

Understanding the concept of a "good death" is crucial to end-of-life care, but our current understanding of what constitutes a good death is insufficient. Here, we investigated the components of a good death that are important to the general population, cancer patients, their families, and physicians.We conducted a stratified nationwide cross-sectional survey of cancer patients and their families from 12 hospitals, physicians from 12 hospitals and the Korean Medical Association, and the general population, investigating their attitudes toward 10 good-death components.Three components-"not be a burden to the family," "presence of family," and "resolve unfinished business"-were considered the most important components by more than 2/3 of each of the three groups, and an additional three components-"freedom from pain," "feel that life was meaningful," and "at peace with God"-were considered important by all but the physicians group. Physicians considered "feel life was meaningful," "presence of family," and "not be a burden to family" as the core components of a good death, with "freedom from pain" as an additional component. "Treatment choices' followed, "finances in order," "mentally aware," and "die at home" were found to be the least important components among all four groups.While families strongly agreed that "presence of family" and "not be a burden to family" were important to a good death, the importance of other factors differed between the groups. Health care providers should attempt to discern each patient's view of a good death.

Little is known about people’s attitudes toward death. We aimed to examine attitudes toward death and to investigate their associations with health status in various participant groups. We administered nationwide questionnaires to a total of 4,107 individuals including general Korean population, cancer patients, family caregivers, and physicians. Association of attitudes toward five aspects of dying and death—the ending of life, fearing death because it is painful, anticipating an afterlife, preparing to practice charity and being remembered—and physical, mental, social, and spiritual health status were also analyzed. Attitudes differed. Most (63.4%-76.2%) accepted that death is the ending of life, 45.6%-58.8% feared a painful death, 47.6%-55.0% anticipated an afterlife, 88.5%-93.0% expected to forgive, and 89.9%-94.1% expected to be remembered after death. The general population, cancer patients, and family caregivers had similar attitudes but had more positive attitudes than physicians on the ending of life, fearing a painful death, and anticipating an afterlife. Accepting death as the ending of life and fear of death pain were inversely associated with mental, social, spiritual, or general health status, but participants anticipating an afterlife, expecting to forgive, or expecting to be remembered showed better social, spiritual, or general health status. This nationwide study of various participant groups shows that attitudes toward dying and death were associated with mental, social, spiritual, or general health, but not physical health status. These data suggest that sensitive and skillful discussions of death and dying might contribute to peaceful end of life.

Background: Accurate awareness of the prognosis is an important factor in the treatment decision of patients with advanced cancer; however, prognostic disclosure is still subject to debate because it can reduce patient’s satisfaction and increase depression. Aim: The purpose of this study is to assess whether patients’ prognostic awareness is associated with decreased quality of life (QoL) or increased depressive mood in patients with advanced cancer Design and Participants: In this cohort study, 386 patients with advanced cancer were recruited across 3 periods from December 2016 to August 2018. The outcome of this study was a change in QoL and depression according to the patients’ prognostic awareness at baseline, 3 months, and 6 months. Results: This study found significant differences in changes of QoL based on patients’ prognostic awareness. From baseline to 3 months, emotional functioning ( P = .039), pain ( P = .042), existential well-being ( P = .025), and social support ( P = .038) subscale scores improved significantly more in those with lack of prognostic awareness. Over 6 months, the group without prognostic awareness improved significantly in terms of physical functioning ( P = .037), emotional functioning ( P = .002), nausea/vomiting ( P = .048), and constipation ( P = .039) subscale scores and existential well-being scores ( P = .025). No significant difference between the groups was found in terms of depression. Conclusion: Accurate prognostic awareness may pose harm and may provide no additional benefits in terms of QoL and mood among patients with advanced cancer for a short period of time.

A caregiver's prognostic awareness can affect clinical decisions for the patient. The purpose of this study was to examine the impact of family caregivers' prognostic awareness on the quality of life (QOL) and emotional state of both patients with advanced cancer and their caregivers.This prospective cohort study was conducted from December of 2016 to January of 2018. A total of 159 patients with advanced cancer and an equal number of caregivers participated. The investigation tools used include the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C15-Palliative, the McGill Quality of Life Questionnaire, and the Patient Health Questionnaire-9, and evaluation was performed at baseline, 3 months, and 6 months. Covariance analysis with a general linear modeling was used to compare changes in quality of life scores according to the caregivers' awareness of the prognosis.Mean patient overall QOL score increased in the group of caregivers who were aware of prognosis and decreased in the caregivers who were not aware of the prognosis (p = 0.018). The changes over time in the patients' QOL scores associated with symptoms improved with caregiver awareness (pain, p = 0.017; dyspnea, p = 0.048; appetite loss, p = 0.045). The percentage of depressed patients was smaller after 3 months in the group with caregivers aware of the prognosis (baseline to 3 months p = 0.028). Caregivers who did not understand their patients' prognosis exhibited better existential well-being (p = 0.036), and the incidence of depression was lower in this group at 3 months (p = 0.024).Caregivers' prognostic awareness may improve the quality of life and mood in patients with advanced cancer; however, this awareness may harm the quality of life and mood of the caregivers. These results may aid in developing in-depth interventions regarding prognosis for both patients and their caregivers.

Advance care planning (ACP) in a healthy general population could improve the quality of care when a health problem arises.The purpose of this study was to evaluate the efficacy of video decision support aid in increasing the intention to document ACP in the general healthy population.In this randomized controlled trial, we enrolled 250 members of the general population (aged 20 years and older and determined to be healthy), stratified by age and sex. The intervention was a video that provided information about ACP and end-of-life care options such as cardiopulmonary resuscitation (CPR) and palliative care. An attention-control arm was given a booklet about advance directives. Primary outcome was a change in intention to document ACP. Secondary outcomes included the intention to refuse CPR at terminal status, CPR and palliative care knowledge score, and the Hospital Anxiety and Depression Scale.About 250 participants were randomly assigned, half to the video-assisted intervention group and half to the attention-control group. Within one week postintervention, the intention to document ACP was significantly higher in the video-assisted intervention arm (68.0% vs. 39.2%; P 0.001), and changes in the intention to document ACP were significantly greater in the video group than in the brochure group (P = 0.008; Δ = 14.4%). Palliative care knowledge score was also significantly increased in the video group (P = 0.036).A well-constructed video decision support intervention can increase the intention to document ACP in the general population that presumably had little opportunity to discuss ACP with physicians.

Appendix A. Factor analysis (Item discrimination, slope, and factor loading) and fit statistics (INFIT/OUTFIT) analysis; Table describing the result of factor analysis and fit statistics of 44 items. Appendix B. Quality Care Questionnaire â Palliative Care (QCQ-PC); Palliative care quality questionnaire validated in this paper. (DOCX 50 kb)

Background: Randomized controlled trials of decision aids for advance care planning (ACP) usually investigated patient groups' end-of-life (EOL) care preferences. This study evaluated the effectiveness of video decision-support materials for ACP in the general population to extend the potential application of ACP. Methods: This was a randomized, open-label, parallel-group, comparative effectiveness trial. We used computer-generated simple randomization (1:1) to randomize participants stratified by age and sex. Allocation was open-label. Participants assigned to the intervention arm viewed a 20-minute decision support video for ACP, and those in the attention-control arm received a 13-page brochure for advance directives. The primary outcome was change of ACP preference, established if the difference of changes between the two groups was greater than 15 percentage points (e.g., intervention 25%, attention-control 10%) at post-intervention compared with baseline assuming three different clinical conditions: healthy, diagnosed with a serious illness and diagnosed at EOL. Findings: From April 27 to May 25, 2018, we enrolled 250 of 832 contacted eligible participants (aged ≥20 years and healthy) and randomly assigned half to the video-assisted intervention group and half to the attention-control group. At post-intervention, ACP preference was significantly higher in the video-assisted intervention arm under all three hypothetical circumstances: healthy (p=0.008; Δ=14.4%); diagnosed with a serious illness (p=0.014; Δ=14.4%); diagnosed as at EOL (p=0.001; Δ=17.6%). A preference for no CPR at EOL significantly increased in the intervention group (p=0.024); in the subgroup with no ACP preference, preference for active treatment was significantly reduced in the intervention arm in two subsets (diagnosed with serious illness and EOL). Interpretation: A well-constructed, video-assisted decision support intervention can increase ACP preference in the general population that presumably had little opportunity to discuss ACP with medical staff. Funding Statement: Grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HC15C1391). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The protocol was approved by the institutional review board in Seoul National University Hospital Clinical Research Institute (IRB No 1804-083-937).

Purpose This clinical pilot study was performed to determine the effectiveness of dual-energy cone-beam computed tomography (DE-CBCT) in measuring bone mineral density (BMD). Materials and Methods The BMD values obtained using DE-CBCT were compared to those obtained using calibrated multislice computed tomography (MSCT). After BMD calibration with specially designed phantoms, both DE-CBCT and MSCT scanning were performed in 15 adult dental patients. Three-dimensional (3D) Digital Imaging and Communications in Medicine data were imported into a dental software program, and the defined regions of interest (ROIs) on the 3-dimensional surface-rendered images were identified. The automatically-measured BMD values of the ROIs (g/cm3), the differences in the measured BMD values of the matched ROIs obtained by DE-CBCT and MSCT 3D images, and the correlation between the BMD values obtained by the 2 devices were statistically analyzed. Results The mean BMD values of the ROIs for the 15 patients as assessed using DE-CBCT and MSCT were 1.09±0.07 g/cm3 and 1.13±0.08 g/cm3, respectively. The mean of the differences between the BMD values of the matched ROIs as assessed using DE-CBCT and calibrated MSCT images was 0.04±0.02 g/cm3. The Pearson correlation coefficient between the BMD values of DE-CBCT and MSCT images was 0.982 (r=0.982, P

Strong theoretical foundation and low computational complexity make representative-based clustering one of the most popular approaches for a clustering problem. Despite those superiorities, it presents two main drawbacks: the shape of clusters obtained is limited to convex shapes, and its performance is highly dependent on seeds initialization. To address these problems, the authors introduce MOSAIC, a novel agglomerative clustering algorithm, which greedily merges neighboring clusters maximizing a plug-in fitness function. The key idea is that by considering neighboring relationship computed using Gabriel Graphs among cluster, MOSAIC can derive non-convex shapes as the unions of small clusters previously generated by a representative-based clustering algorithm. The authors evaluate MOSAIC for traditional unsupervised clustering with k-means and DBSCAN, and also for supervised clustering. The experimental results show that compared to k-means stand-alone, their proposed post-processing techniques obtain higher quality clusters, whereas compared to DBSCAN results, MOSAIC is capable of identifying comparable arbitrary shape clusters, given a suitable fitness function. In addition, MOSAIC can cope with problems of clustering on high dimensional data. The authors also claim that MOSAIC can be employed as an effective post-processing clustering algorithm to further improve the quality of clustering.