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Background Cancer can cause undesired side effects that can significantly alter patients' perceived stress and mindfulness. The integration of nonpharmacologic, complementary health interventions, such as mindful breathing, is potentially useful in reducing stress and promoting the well-being of patients during treatment. Objectives This study examined the effects of a five-minute mindful breathing practice performed three times per day for three months on perceived stress and mindfulness among patients with cancer. Methods This longitudinal, randomized controlled study used a two-group, pre-/post-study design. Patients with distress scores of 4 or higher were randomized into two study arms. Participants in the intervention group were educated on mindfulness and guided on how to perform a five-minute mindful breathing practice. Perceived stress and mindfulness were assessed at baseline, one month postintervention, and three months postintervention. Findings Both groups had no significant difference in perceived stress and mindfulness scores at baseline. At three months, the intervention group reported a significant reduction in stress and an increase in mindfulness.

ContextThere has been increasing evidence of the role of mindfulness-based interventions in improving various health conditions. However, the evidence for the use of mindfulness in the palliative care setting is still lacking.ObjectivesThe objective of our study was to determine the efficacy of a single session of 20 min mindful breathing in alleviating multiple symptoms in palliative care.MethodsAdult palliative care in patients with at least one symptom scoring ≥5/10 based on the Edmonton Symptom Assessment Scale (ESAS) were recruited from September 2018 to December 2018. Recruited patients were randomly assigned to either 20 min mindful breathing and standard care or standard care alone.ResultsForty patients were randomly assigned to standard care plus a 20 min mindful breathing session (n=20) or standard care alone (n=20). There was statistically significant reduction of total ESAS score in the mindful breathing group compared with the control group at minute 20 (U=98, n 1 = n 2 = 20, mean rank 1 = 15.4, mean rank 2 = 25.6, median reduction 1 = 6.5, median reduction 2 = 1.5, z=−2.763, r=0.3, p=0.005).ConclusionOur results provided evidence that a single session of 20 min mindful breathing was effective in reducing multiple symptoms rapidly for palliative care patients.

To palliate suffering, understanding the circumstances leading to suffering and its amelioration could be helpful. Our study aimed to explore contributing and relieving factors of suffering in palliative care. Adult palliative care stage III or IV cancer in-patients were recruited from University of Malaya Medical Centre. Participants recorded their overall suffering score from 0 to 10 three times daily, followed by descriptions of their contributing and relieving factors. Factors of suffering were thematically analysed with NVIVO. Descriptive data were analysed with SPSS. 108 patients participated. The most common contributing factor of suffering was health factor (96.3%), followed by healthcare factor (78.7%), psychological factor (63.0%) and community factor (20.4%). The most common relieving factor was health factor (88.9%), followed by psychological factor (78.7%), community factor (75.9%) and healthcare factor (70.4%). Self-reported assessment of suffering offers a rapid approach to detect bothering issues that require immediate attention and further in-depth exploration.

Heart failure is the leading cause of morbidity and mortality worldwide. Standard treatment for heart failure includes pharmacotherapy and cardiac device implants. However, supportive approaches in managing dyspnea in heart failure are limited. This study aimed to test the efficacy of 20-minute mindful breathing in reducing dyspnea among patients admitted for acute decompensated heart failure. We conducted a parallel-group, non-blinded, randomized controlled trial of a single session of 20-minute mindful breathing plus standard care versus standard care alone among patients admitted for moderate to severe dyspnea due to acute decompensated heart failure, using the dyspnea score based on the Edmonton Symptom Assessment System (ESAS), at the Cardiology Unit of University Malaya Medical Centre in Malaysia. Thirty participants were randomly assigned to a single session of 20-minute mindful breathing plus standard care (n = 15) or standard care alone (n = 15), with no difference in their demographic and clinical characteristics. There was statistically significant reduction in dyspnea in the intervention group compared to the control group at minute 20 (U = 49.5, n1 = 15, n2 =15, median reduction in ESAS dyspnea score 1 = 2, median reduction in ESAS dyspnea score 2 = 0, mean rank 1 = 11.30, mean rank 2 = 19.70, z = −2.692, r = 0.4, P = 0.007). Our results provided evidence that a single session of 20-minute mindful breathing was efficacious in reducing dyspnea for patients admitted for acute decompensated heart failure.

Little is known regarding the educational needs and perspectives of people living with Parkinson’s disease (PD), particularly in Asia. To assess knowledge and perceptions regarding PD in a large multiethnic urban Asian cohort of patients and caregivers. We conducted a survey at a university hospital neurology clinic, using a novel Knowledge and Perception of Parkinson’s Disease Questionnaire (KPPDQ). The KPPDQ had satisfactory psychometric properties among patients and caregivers. Five hundred subjects were recruited with a 97% response rate (211 patients, 273 caregivers). Non-motor symptoms such as urinary problems, visual hallucinations and pain were relatively poorly recognized. Many (≈ 50–80%) respondents incorrectly believed that all PD patients experience tremor, that PD is usually familial, and that there is a cure for PD. About one-half perceived PD to be caused by something the patient had done in the past, and that PD medications were likely to cause internal organ damage. Issues of stigma/shame were relevant to one-third of patients, and 70% of patients perceived themselves to be a burden to others. Two-thirds of participants felt that PD imposed a heavy financial toll. Participants were about equally divided as to whether they would consider treatment with deep brain stimulation, tube feeding or invasive ventilation. Over three-quarters of patients expressed a preference to die at home. Important knowledge gaps, misperceptions and perspectives on PD were identified, highlighting the need for further efforts to raise awareness and provide accurate information regarding PD, and to address patient’s and caregivers’ needs and preferences.

Background: The prevalence of undertreated cancer pain remains high. Suboptimal pain control affects quality of life and results in psychological and emotional distress. Barriers to adequate pain control include fear of opioid dependence and its side effects. Aim: To investigate the attitudes and perceptions of morphine use in cancer pain in advanced cancer patients and their caregivers and to examine the influence of caregivers’ attitudes and perceptions on patients’ acceptance of morphine. Design: Qualitative study involving semi-structured individual interviews transcribed verbatim and analyzed thematically. Setting/Participants: A total of 18 adult opioid-naïve patients with advanced cancer and 13 caregivers ( n = 31) were recruited at a private tertiary hospital via convenience sampling. Results: Attitudes and perceptions of morphine were influenced by previous experiences. Prevalent themes were similar in both groups, including perceptions that morphine was a strong analgesic that reduced suffering, but associated with end-stage illness and dependence. Most participants were open to future morphine use for comfort and effective pain control. Trust in doctors’ recommendations was also an important factor. However, many preferred morphine as a last resort because of concerns about side effects and dependence, and the perception that morphine was only used at the terminal stage. Caregivers’ attitudes toward morphine did not affect patients’ acceptance of morphine use. Conclusion: Most participants were open to future morphine use despite negative perceptions as they prioritized optimal pain control and reduction of suffering. Focused education programs addressing morphine misperceptions might increase patient and caregiver acceptance of opioid analgesics and improve cancer pain control.

Background: We have found our 5-minute mindful breathing technique to be effective in reducing distress in palliative cancer patients. As palliative cancer patients tend to experience high levels of distress, the integration of this technique into a smartphone-based application could be a viable intervention option for these patients as well as their caregivers. Objective: We aim to further examine the efficacy of our mindful breathing module on distress reduction within the context of a smartphone-based application for palliative cancer patients and caregivers over a seven day period. We hypothesized that the intervention group (access to mindful breathing module) would have significantly greater distress regulation than the control group (access to soothing music) over seven days of using the smartphone-based application.Methods: 35 subjects were recruited from the palliative care ward at University Malaya Medical Centre (UMMC) and randomly assigned to either the control (access to soothing music) or intervention (access to mindful breathing module) group respectively. They then used and followed instructions as per the smartphone-based application for seven days. Results: While both groups reported a reduction in distress in using the application, there was no significant difference in reported distress levels between those who had access to the mindful breathing module and those who had access to only soothing music over the seven days. Our hypothesis was not supported. Conclusion: Although not significantly greater than the control group, the intervention group reported a reduction in distress using the smartphone application, which suggests that the integration of mindfulness and smartphone applications could potentially play a role in future distress reduction for patients and caregivers in view of its accessibility, ease of administration and anonymity.

Background:This study aimed to compare and correlate the post-bronchodilator forced expiratory volume in one second (PB-FEV1), exacerbation frequency, and scores of modified Medical Research Council (mMRC), COPD Assessment Tool (CAT), and St George’s Respiratory Questionnaire for COPD (SGRQ-c) of COPD patients. Methods:This was a post-hoc analysis of pooled data from two cross-sectional studies conducted from 1st June 2017 to 31st May 2018 at the respiratory clinic of University of Malaya Medical Center, and from 23rd January 2018 to 22nd January 2019 at the outpatient clinics of the Serian Divisional Hospital and Bau District Hospital in Malaysia, respectively. The parameters measured included PB-FEV1, exacerbation frequency, mMRC, CAT, and SGRQ-c. Descriptive, association and correlation statistics were used. Results:Of a total of 374 patients, the PB-FEV1 predicted was < 30% in 85 (22.7%), 30 – 49% in 142 (38.0%), 50 – 79% in 111 (29.7%), and ≥ 80% in 36 (9.6%) patients. Patients with PB-FEV1 < 30% predicted had significantly more COPD exacerbations than those with PB-FEV1 30 – 49% predicted (p < 0.001), 50 – 79% predicted (p < 0.001), and ≥ 80% predicted (p = 0.002). The scores of mMRC, CAT and SGRQ-c were not significantly higher in patients with more severe airflow limitation based on PB-FEV1 (p = 0.121 – 0.271). The PB-FEV1 predicted had significant small negative correlations with exacerbation frequency (r = - 0.182, p < 0.001), mMRC (r = - 0.121, p = 0.020), and SGRQ-c scores (r = - 0.114, p = 0.028). There was a moderate positive correlation between COPD exacerbation frequency and scores of mMRC, CAT, and SGRQ-c (r = 0.407 – 0.482, all p < 0.001). There were significant strong positive correlations between mMRC score with CAT (r = 0.727) and SGRQ-c scores (r = 0.847), and CAT score with SGRQ-c score (r = 0.851) (all p < 0.001). Conclusions:In COPD patients, different severity of airflow limitation was not associated with significant differences in the dyspnea symptom and HRQOL. Exacerbation was significantly more frequent in patients with very severe airflow limitation only. The correlation between airflow limitation with exacerbation, dyspnea symptom, and HRQOL was weak.

Chee-Shee Chai,1 Diana-Leh-Ching Ng,1 Wei-Jing Chua,2 Yu-Zhen Tung,2 Woweham Sindeh,3 Muhammad Amin Ibrahim,4 Siti Fatimah Badlishah Sham,5 Seng-Beng Tan2 1Department of Medicine, Faculty of Medicine and Health Science of University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia; 2Department of Medicine, Faculty of Medicine of University of Malaya, Kuala Lumpur, Malaysia; 3Department of Primary Care Medicine, Faculty of Medicine of University of Malaya, Kuala Lumpur, Malaysia; 4Department of Internal Medicine, Faculty of Medicine of University Technology MARA, Sungai Buloh, Selangor, Malaysia; 5Department of Primary Care Medicine, Faculty of Medicine of University Technology MARA, Sungai Buloh, Selangor, MalaysiaCorrespondence: Diana-Leh-Ching Ng, Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia, Tel +60 19-8198265, Email diananglehching@gmail.com Seng-Beng Tan, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, Tel +60 12-3263128, Email pramudita_1@hotmail.comPurpose: A different pattern of mental health issues was reported during the later stage of the COVID-19 pandemic; however, few studies have examined Malaysians’ knowledge, attitudes, and practices (KAP) prevalent during this time.Patients and Methods: A nationwide online cross-sectional study was conducted in Malaysia from June 1, 2021 to June 14, 2021, ie, 18-months from the first reported COVID-19 case in the country. Citizens aged 18 years and above were recruited by means of the snowball sampling method. ANOVA, Pearson correlation, and linear regression tests were used.Results: Of the 2168 respondents, most were young adults (62.7%), females (62.4%), tertiary educated individuals (84%), non-health care workers (85.9%), and individuals who knew someone diagnosed with COVID-19 (75.2%). The mean score for knowledge was 10.0 ± 1.52 (maximum score = 12); correct response rate for each question ranged from 54.2% to 99%. The mean score in terms of attitude was 1.3 ± 0.85 (maximum score = 2); 68.7% respondents agreed that control over COVID-19 would finally be achieved; and 62.3% believed that Malaysia could conquer COVID-19. The mean score for practices was 5.1 ± 1.10 (maximum score = 6); 81.5%, 88.1%, and 74.1% respondents avoided crowded places, confined spaces, and conversations in close physical proximity, respectively. Furthermore, 94.2% wore masks when leaving home; 89.0% practiced hand hygiene; and 83.8% adhering to COVID-19 warnings. Small but significant correlations were found between knowledge and attitude (r = 0.078, p < 0.001) as well as between knowledge and practices (r = 0.070, p = 0.001).Conclusion: Malaysians exhibited sound knowledge but negative attitudes and inadequate practices pertaining to COVID-19 during the pandemic’s later stage. At this phase, unlike at the early stage, the public’s sound knowledge ensured little improvement in their attitudes and practices. Therefore, health education at the later pandemic stage should focus on promoting positive attitudes and developing better practices.Keywords: knowledge, attitude, practices, COVID-19 pandemic, pandemic fatigue, late pandemic

Advancement in smartphone technology has brought about a steady rise in the global mobile phone usage. Smartphone addiction has been widely studied among adolescent and adult population, and little is known regarding its impact on patients who are diagnosed with major depressive disorder. This study examined the prevalence of smartphone addiction among depressed patients and the association between smartphone addiction and the severity of depression. A cross-sectional study was conducted on 140 patients who were diagnosed with major depressive disorder in the psychiatry department of University Malaya Medical Centre, Kuala Lumpur, Malaysia. Smartphone addiction was assessed with the smartphone addiction scale (SAS). The severity of depression was assessed using the clinician-rated Montgomery-Asberg Depression Rating Scale (MADRS). The prevalence of smartphone addiction was 58.6% (n = 82). This study found that (a) participants who spent more time on their smartphones were found to be at higher risk for smartphone addiction “overuse” subscale (p

Introduction and aim: Patient quality of life (QOL) while on long-term oral anticoagulant therapy has been receiving greater attention in recent years due to the increase in life expectancy brought about by advances in medical care. This study aimed to compare the QOL, treatment satisfaction, hospitalization and bleeding rate in patients on long-term warfarin versus direct oral anticoagulants (DOAC). Methods: This was a cross-sectional study of patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE) on long-term anticoagulant therapy attending the cardiology clinic and anticoagulation clinic of the University Malaya Medical Centre from July 1, 2016, to June 30, 2018. Patient QOL was assessed by using the Short Form 12 Health Survey (SF12), while treatment satisfaction was assessed by using the Perception of Anticoagulation Treatment Questionnaire 2 (PACT-Q2). Results: A total of 208 patients were recruited; 52.4% received warfarin and 47.6% received DOAC. There was no significant difference in QOL between warfarin and DOAC based on SF12 (physical QOL, P=0.083; mental QOL, P=0.665). Nevertheless, patients in the DOAC group were significantly more satisfied with their treatment compared to the warfarin group based on PACT-Q2 (P=0.004). The hospitalisation rate was significantly higher in the warfarin group than the DOAC group (15.6% versus 3.0%, P=0.002). Clinically relevant minor bleeds and severe bleeding events were non-significantly higher in the warfarin group than the DOAC group (66.7% versus 40.0%, P=0.069). Conclusion: Compared to warfarin, treatment of NVAF and VTE with DOAC showed comparable QOL, higher treatment satisfaction, lesser hospitalization, and a non-significant trend toward fewer bleeding episodes.

Introduction The Spanish COPD guideline (GesEPOC) classifies COPD into four clinical phenotypes based on the exacerbation frequency and dominant clinical manifestations. In this study, we compared the disease-specific health-related quality of life (HRQoL) of patients with different clinical phenotypes. Methods This was a cross-sectional study of patients with COPD attending the respiratory medicine clinic of University of Malaya Medical Centre from 1 June 2017 to 31 May 2018. Disease-specific HRQoL was assessed by using the COPD Assessment Test (CAT) and St George's Respiratory Questionnaire for COPD (SGRQ-c). Results Of 189 patients, 28.6% were of non-exacerbator phenotype (NON-AE), 18.5% were of exacerbator with emphysema phenotype (AE NON-CB), 39.7% were of exacerbator with chronic bronchitis phenotype (AE CB), and 13.2% had asthma-COPD overlap syndrome phenotype (ACOS). The total CAT and SGRQ-c scores were significantly different between the clinical phenotypes (P

Background and Objective: Despite the increasing treatment options for patients with metastatic breast cancer (MBC), unmet needs remain common, especially in low and middle-income countries where resources are limited and MBC patients face many challenges. They often join support groups to cope with their unmet needs. Currently, many MBC patients connect with each other via online support group in view of the constant availability of support and rapid information exchange. The objective of this study is to determine the unmet needs of women with MBC from an online support group. Material and Methods: Messages in an online support group of twenty-two MBC patients over a period of three years from August 2016 till August 2019 were thematically analyzed. Results: Three themes were generated, (1) unmet information needs (2) unmet financial needs (3) unmet support needs. Women needed information on side effects of treatment, new treatment options and availability of clinical trials. Although Malaysia has universal health care coverage, access to treatment remains a major challenge. When treatment was not available in the public hospitals, or waiting lists were too long, women were forced to seek treatment in private hospitals, incurring financial catastrophe. Insufficient private insurance and inadequate social security payments force many women to consider stopping treatment. Women felt that they were not getting support from their clinicians in the public sector, who were quick to stop active treatment and advise palliation. On the other hand, clinicians in the private sector advise expensive treatment beyond the financial capability of the patients. Women with families also face the challenge of managing their family and household in addition to coping with their illness. Conclusions: There is a need for healthcare professionals, policy makers, and civil society to better address the needs of MBC patients through patient-centered, multidisciplinary and multi-organizational collaboration.

Background Coronavirus 2019 disease (COVID-19) is a highly infectious disease prompting extreme containment measures, including lockdown, travel restrictions, social distancing, and stringent personal hygiene. This study investigates the depression level and coping responses toward the lockdown, referred as the movement control order (MCO) during COVID-19 pandemic in Malaysia and its impact on quality of life. Method This cross-sectional study was conducted from April to May 2020. The outcomes were assessed using the Depression, Anxiety and Stress Scale–21, Coping Orientation to Problems Experienced Inventory, and World Health Organisation Quality of Life–BREF Scale (WHOQOL-BREF) in both English and validated Malay versions. Results Mild-to-severe depression was found in 28.2% (n = 149) of the 528 respondents. Respondents with mild-to-severe depression were significantly younger (33.09 ± 10.08 versus 36.79 ± 12.47 years), without partner (71.8% versus 45.6%), lived in the red zone (85.9% versus 71.0%), and had lower household income as defined in the category of B40 (51.7% versus 39.3%) compared to those without depression (all p p p Conclusion COVID-19 lockdown had adverse mental health effects. Our study highlighted that approximately one in three individual experienced mild-to-severe depression during the nationwide MCO. The varied impact of the pandemic on mental health could be due to different population characteristics and coping strategies used. Identifying those at higher risk to develop depression during MCO for COVID-19 pandemic could help mental healthcare service providers to plan services for those susceptible, thereby mitigating the pandemic’s effect on quality of life.

Objective Suffering is a common experience in palliative care. In our study, we aimed to determine the effect of 5-min mindfulness of love on suffering and the spiritual quality of life of palliative care patients. Methods We conducted a parallel-group, blinded, randomized controlled study at the University of Malaya Medical Centre (UMMC), Malaysia from February 2019 to April 2019. Sixty adult palliative care patients with an overall suffering score of 4/10 or above based on the Suffering Pictogram were recruited and randomly assigned to either the 5-min mindfulness of love group (N = 30) or the 5-min supportive listening group (N = 30). Results There were statistically significant improvements in the overall suffering score (mean difference = -2.9, CI = -3.7 to -2.1, t = -7.268, p = 0.000) and the total FACIT-Sp-12 score (mean difference = 2.9, CI = 1.5 to 4.3, t = 4.124, p = 0.000) in the intervention group compared to the control group. Conclusion The results provided evidence that 5-min mindfulness of love could affect the actual state of suffering and the spiritual quality of life of palliative care patients.

Background The Spanish chronic obstructive pulmonary disease (COPD) guideline phenotypes patients according to the exacerbation frequency and COPD subtypes. In this study, we compared the patients’ health-related quality of life (HRQoL) according to their COPD phenotypes. Methods This was a cross-sectional study of COPD patients who attended the outpatient clinic of the Serian Divisional Hospital and Bau District Hospital from 23th January 2018 to 22th January 2019. The HRQoL was assessed using modified Medical Research Council (mMRC), COPD Assessment Test (CAT), and St George’s Respiratory Questionnaire for COPD (SGRQ-c). Results Of 185 patients, 108 (58.4%) were non-exacerbators (NON-AE), 51 (27.6%) were frequent exacerbators (AE), and the remaining 26 (14.1%) had asthma-COPD overlap (ACO). Of AE patients, 42 (82.4%) had chronic bronchitis and only 9 (17.6%) had emphysema. Of the 185 COPD patients, 65.9% had exposure to biomass fuel and 69.1% were ex- or current smokers. The scores of mMRC, CAT, and SGRQ-c were significantly different between COPD phenotypes (p p p = 0.003; p p p AE patients had significantly higher score in each item of CAT and component of SGRQ-c compared to those with NON-AE (all p p = 0.003–0.016; p = p = p Conclusions The HRQoL of COPD patients was significantly different across different COPD phenotypes. HRQoL was worst in AE, followed by ACO and NON-AE. This study supports phenotyping COPD patients based on their exacerbation frequency and COPD subtypes. The treatment of COPD should be personalised according to these two factors.

Palliative care providers find meaning in their work, even though stress, burnout, and compassion fatigue can be a concern. In this study, we aimed to explore the experiences of well-being of palliative care providers in Malaysia. Data collected using semistructured interviews were thematically analyzed. Eighteen palliative care providers participated: 9 doctors and 9 nurses. Five subthemes were generated: (1) values and strengths, (2) coping and work-life balance, (3) social support and spirituality, (4) passion and satisfaction, and (5) learning, growth, and transformation. These subthemes were further categorized into 2 themes: resilience and reward. The results may inform the development of interventions in the promotion and sustenance of well-being of palliative care providers.

We present a case of a 64-year-old woman with stage 1 breast cancer. She underwent a modified radical mastectomy, followed by chemotherapy. She reported physical and psychosocial suffering due to her disease and treatment. Four weekly sessions of guided 30-min mindful breathing were delivered by the palliative care team to ease her suffering. The patient reported feelings of calmness, peace and relaxation after each session, with decrease in suffering, negative emotions and physical discomfort. This is the first report on the use of guided 30-min mindful breathing in palliating suffering of a patient with cancer.

ObjectivesSuffering is common among patients with advanced cancer. The practice of mindfulness during patient care can potentially reduce suffering. We aimed to examine the efficacy of mindfulness-based supportive therapy (MBST) on reducing suffering in patients with advanced cancer.MethodsWe conducted a parallel-group, single-blinded, randomised controlled trial at the University of Malaya Medical Centre, Malaysia. Seventy-three patients with advanced cancer with an overall suffering score ≥4/10 based on the Suffering Pictogram were recruited and randomly assigned into either the MBST group (n=34) or the control group (n=39).ResultsThere was a statistically significant reduction in the overall suffering score in the MBST group compared with the control group (U=432.5, median1=−2.0, median2=−1.0, z=−2.645, p=0.008). There was also significant improvement in the total Hospital Anxiety and Depression Scale score (U=483.5, median1=−4.0, median2=−3.0, z=−1.994, p=0.046), and the total Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being score (U=252.0, median1=+14.5, median2=+5.0, z=−4.549, p=0.000) in the MBST group compared with the control group.ConclusionsThe results provided evidence that the practice of MBST during patient care could promote positive psychosocial outcomes.

Bee Kim Tan,1,2 Seng Beng Tan,3 Li-Chia Chen,4 Kian Meng Chang,5 Siew Siang Chua,1,6 Sharmini Balashanker,7 Habiba Nazeera Begum Kamarul Jaman,5 Syed Carlo Edmund,8 Ping Chong Bee3 1Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 2Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia; 3Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 4Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK; 5Department of Hematology, Ampang Hospital, Ampang, Selangor, Malaysia; 6School of Pharmacy, Faculty of Health and Medical Sciences, Taylor’s University, Lakeside Campus, Subang, Selangor, Malaysia; 7School of Pharmacy, University of Nottingham Malaysia Campus, Semenyih, Selangor, Malaysia; 8Clinical Research Center, Ampang Hospital, Ampang, Selangor, Malaysia Purpose: Poor adherence to tyrosine kinase inhibitors (TKIs) could compromise the control of chronic myeloid leukemia (CML) and contributes to poorer survival. Little is known about how medication-related issues affect CML patients’ adherence to TKI therapy in Malaysia. This qualitative study aimed to explore these issues.Patients and methods: Individual face-to-face, semistructured interviews were conducted at the hematology outpatient clinics of two medical centers in Malaysia from August 2015 to January 2016. CML patients aged ≥18 years who were prescribed a TKI were invited to participate in the study. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed.Results: Four themes were identified from 18 interviews: 1) concerns about adverse reactions to TKIs, 2) personal beliefs regarding the use of TKIs, 3) mismanagement of TKIs in daily lives, and 4) financial burden in accessing treatment. Participants skipped their TKIs due to ineffective emesis control measures and perceived wastage of medication from vomiting. Participants also modified their TKI therapy due to fear of potential harm from long-term use, and stopped taking their TKIs based on belief in curative claims of traditional medicines and misconception about therapeutic effects of TKIs. Difficulty in integrating the dosing requirements of TKIs into daily lives led to unintentional skipping of doses, as well as the risk of toxicities from inappropriate dosing intervals or food interactions. Furthermore, financial constraints also resulted in delayed initiation of TKIs, missed clinic appointments, and treatment interruptions.Conclusion: Malaysian CML patients encountered a range of medication-related issues leading to a complex pattern of nonadherence to TKI therapy. Further studies should investigate whether regular contact with patients to improve understanding of treatment rationale, to elicit and address patients’ concerns about adverse reactions, and to empower patients with skills to self-manage their medications might promote better adherence to TKIs and improve CML patients’ outcome. Keywords: medication-related issues, adherence, tyrosine kinase inhibitors, chronic myeloid leukemia, qualitative study, thematic analysis

Informal caregivers are at risk of being overwhelmed by various sources of suffering while caring for their significant others. It is, therefore, important for caregivers to take care of themselves. In the self-care context, mindfulness has the potential to reduce caregiver suffering. We studied the effect of a single session of 20-minute mindful breathing on the perceived level of suffering, together with the changes in bispectral index score (BIS) among palliative care informal caregivers. This was a randomized controlled study conducted at the University of Malaya Medical Centre, Malaysia. Forty adult palliative care informal caregivers were recruited and randomly assigned to either 20-minute mindful breathing or 20-minute supportive listening. The changes in perceived suffering and BIS were measured preintervention and postintervention. The reduction in suffering score in the intervention group was significantly more than the control group at minute 20 ( U = 124.0, n1= n2= 20, mean rank1= 24.30, mean rank2= 16.70, z = −2.095, P = .036). The reduction in BIS in the intervention group was also significantly greater than the control group at minute 20 ( U = 19.5, n1= n2= 20, mean rank1= 29.52, mean rank2= 11.48, z = −4.900, P < .0001). Twenty minutes of mindful breathing was more efficacious than 20 minutes of supportive listening in the reduction in suffering among palliative care informal caregivers.

Introduction and aim Patient quality of life (QOL) while on long-term oral anticoagulant therapy has been receiving greater attention in recent years due to the increase in life expectancy brought about by advances in medical care. This study aimed to compare the QOL, treatment satisfaction, hospitalization and bleeding rate in patients on long-term warfarin versus direct oral anticoagulants (DOAC). Methods This was a cross-sectional study of patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE) on long-term anticoagulant therapy attending the cardiology clinic and anticoagulation clinic of the University Malaya Medical Centre from July 1, 2016, to June 30, 2018. Patient QOL was assessed by using the Short Form 12 Health Survey (SF12), while treatment satisfaction was assessed by using the Perception of Anticoagulation Treatment Questionnaire 2 (PACT-Q2). Results A total of 208 patients were recruited; 52.4% received warfarin and 47.6% received DOAC. There was no significant difference in QOL between warfarin and DOAC based on SF12 (physical QOL, P=0.083; mental QOL, P=0.665). Nevertheless, patients in the DOAC group were significantly more satisfied with their treatment compared to the warfarin group based on PACT-Q2 (P=0.004). The hospitalisation rate was significantly higher in the warfarin group than the DOAC group (15.6% versus 3.0%, P=0.002). Clinically relevant minor bleeds and severe bleeding events were non-significantly higher in the warfarin group than the DOAC group (66.7% versus 40.0%, P=0.069). Conclusion Compared to warfarin, treatment of NVAF and VTE with DOAC showed comparable QOL, higher treatment satisfaction, lesser hospitalization, and a non-significant trend toward fewer bleeding episodes.

ContextNumerous studies have shown that gratitude can reduce stress and improve quality of life.ObjectiveOur study aimed to examine the effect of mindful gratitude journaling on suffering, psychological distress and quality of life of patients with advanced cancer.MethodsWe conducted a parallel-group, blinded, randomised controlled trial at the University of Malaya Medical Centre, Malaysia. Ninety-two adult patients with advanced cancer, and an overall suffering score ≥4/10 based on the Suffering Pictogram were recruited and randomly assigned to either a mindful gratitude journaling group (N=49) or a routine journaling group (N=43).ResultsAfter 1 week, there were significant reductions in the overall suffering score from the baseline in both the intervention group (mean difference in overall suffering score=−2.0, 95% CI=−2.7 to −1.4, t=−6.125, p=0.000) and the control group (mean difference in overall suffering score=−1.6, 95% CI=−2.3 to −0.8, t=−4.106, p=0.037). There were also significant improvements in the total Hospital Anxiety and Depression Scale score (mean difference=−3.4, 95% CI=−5.3 to −1.5, t=−3.525, p=0.000) and the total Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being score (mean difference=7.3, 95% CI=1.5 to 13.1, t=2.460, p=0.014) in the intervention group after 7 days, but not in the control group.ConclusionThe results provide evidence that 7 days of mindful gratitude journaling could positively affect the state of suffering, psychological distress and quality of life of patients with advanced cancer.Trial registration numberThe trial was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN1261800172191) and conducted in accordance with the Declaration of Helsinki.

Context Dyspnea is a common and distressing symptom in respiratory diseases. Despite advances in the treatment of various lung diseases, the treatment modalities for dyspnea remain limited. Objectives This study aims to examine the effect of 20-minute mindful breathing on the rapid reduction of dyspnea at rest in patients with lung cancer, chronic obstructive pulmonary disease, and asthma. Methods We conducted a parallel-group, nonblinded, randomized controlled trial of standard care plus 20-minute mindful breathing vs. standard care alone for patients with moderate to severe dyspnea due to lung disease, named previously, at the respiratory unit of University Malaya Medical Centre in Malaysia, from August 1, 2017, to March 31, 2018. Results Sixty-three participants were randomly assigned to standard care plus a 20-minute mindful breathing session (n = 32) or standard care alone (n = 31), with no difference in their demographic and clinical characteristics. There was statistically significant reduction in dyspnea in the mindful breathing group compared with the control group at minute 5 (U = 233.5, n1 = 32, n2 = 31, mean rank1 = 23.28, mean rank2 = 37.72, z = −3.574, P Conclusion Our results provide evidence that a single session of 20-minute mindful breathing is effective in reducing dyspnea rapidly for patients with lung cancer, chronic obstructive pulmonary disease, and asthma.

Background Informal (unpaid) caregivers provide care that goes beyond customary and normative support, and endure ‘silent suffering’ often unrecognised by healthcare providers. Understanding factors that contribute to the wellbeing of informal caregivers can further the capacity of healthcare workers to promote caregivers’ wellbeing. Methods We performed a qualitative study of semi-structured face-to-face interviews in Malaysia. Transcripts were read repeatedly for familiarisation, followed by coding and thematic analysis. NVivo11 software was used to analyse data. Results The five main themes shown to promote the wellbeing of informal caregivers are: acceptance, appreciation, hope, happiness and support. Finding acceptance mirrors the seven stages of grief – shock, denial, anger, bargaining, depression, testing and acceptance – and seems to be born out of having no other choice. This lack of choice is rationalised in three non–mutually exclusive ways: understanding that death is an inevitability of life, trust in the sovereignty of a higher power or god, and seeing death as the ultimate freedom from suffering. Caregivers were appreciative of healthcare providers, the time they had with their loved ones, the opportunity to give back to their loved ones, and were also grateful to god. Of note, skills traditionally seen as ‘soft’ by medical practitioners, were most appreciated – professionalism, providing education, responsiveness to requests and humanity. The hope seen in preserving wellbeing is built on having accepted their situation and shapes hope for realistic goals. Without acceptance, unrealistic hope would only frustrate and be detrimental to their wellbeing. Happiness is protective against negative rumination and is derived from the patients themselves, relationships and moments of respite. Support systems comprised spiritual or religious groups, family and friends, each catering to slightly different needs. Conclusion Awareness of these five factors that promote caregiver wellbeing should inform clinical practice and holistic care.

Alleviation of suffering in palliative care needs a combination of good symptom control and psychosocial care. The capacity of mindfulness to promote psychological flexibility opens up possibilities of creating a paradigm shift that can potentially change the landscape of psychosocial care. In this review, we attempt to introduce 4 methods to establish mindfulness based on ‘The Discourse on the Foundations of Mindfulness’, a core text of Theravada Buddhism, followed by a brief comparison of the concepts and practices of mindfulness in different cultures and religions in Southeast Asia. Next, 2 mindfulness-based interventions specifically designed for palliative psychosocial care – mindfulness-based supportive therapy (MBST) and mini-mindfulness meditation (MMM) are introduced. We hypothesise that mindful practices, tailored to the palliative setting, can promote positive psychosocial outcomes. Key words: End-of-life care, Mindful, Satipatthana, Spiritual care, Spirituality

Palliative cancer patients suffer from high levels of distress. There are physiological changes in relation to the level of perceived distress.To study the efficacy of 5 minutes of mindful breathing (MB) for rapid reduction of distress in a palliative setting. Its effect to the physiological changes of the palliative cancer patients was also examined.This is a randomized controlled trial. Sixty palliative cancer patients were recruited. They were randomly assigned to either 5 minutes of MB or normal listening arms. The changes of perceived distress, blood pressure, pulse rate, breathing rate, galvanic skin response, and skin surface temperature of the patients were measured at baseline, after intervention, and 10 minutes post-intervention.There was significant reduction of perceived distress, blood pressure, pulse rate, breathing rate, and galvanic skin response; also, significant increment of skin surface temperature in the 5-minute MB group. The changes in the 5-minute breathing group were significantly higher than the normal listening group.Five-minute MB is a quick, easy to administer, and effective therapy for rapid reduction of distress in palliative setting. There is a need for future study to establish the long-term efficacy of the therapy.

Although suffering in palliative care has received increasing attention over the past decade, the psychological processes that underpin suffering remain relatively unexplored.ObjectiveTo understand the psychological processes involved in the experiencing of suffering at the end phase of life.MethodsSemistructured interviews were conducted with 20 palliative care inpatients from an academic medical centre in Kuala Lumpur, Malaysia. The transcripts were thematically analysed with NVIVO9.Results5 themes of psychological processes of suffering were generated: (1) perceptions, (2) cognitive appraisals, (3) hope and the struggles with acceptance, (4) emotions and (5) clinging. A model of suffering formation was constructed.ConclusionThe findings may inform the development of mechanism-based interventions in the palliation of suffering.

IntroductionAlthough psychological distress is highly prevalent, palliative cancer patients are mostly too lethargic to undergo many sessions of the conventional psychotherapy.ObjectivesThe study aims to develop a brief, quick and easy to administer psychological intervention for rapid reduction of distress in palliative care patients.MethodsIn phase I, an expert panel of multidisciplinary team was formed. The theory of mindfulness-based intervention was simplified into a 5-minute mindful breathing technique that can be learnt and practiced by palliative care patients.In phase II, the efficacy of 5-minute mindful breathing was investigated in a pilot test that comprised of nine palliative cancer patients and eleven care takers.In Phase III, the efficacy of 5-minute mindful breathing was further examined in a non-blinded, randomized controlled trial (RCT) that included 60 cancer patients under palliative care. Apart from perceived distress, physiological measures were assessed.ResultsThe effect of 5-minute mindful breathing in rapidly reducing distress among palliative care patients was confirmed in both the pilot test (Tan et al., 2015) and RCT (Ng et al., 2016). The finding was further supported by the significant physiological changes associated with distress reduction such as decreased breathing rate, blood pressure, pulse rate, galvanic skin and increased skin surface temperature (Ng et al., 2016) with the 5-minute mindful breathing.ConclusionThe 5-minute mindful breathing is a quick and easy to administer intervention that is useful for reducing acute suffering or distress in palliative care patients.Disclosure of interestThe authors have not supplied their declaration of competing interest.

This is a 4 week, randomized, double-blind, placebo-controlled study to examine the effects of methylphenidate as add-on therapy to mirtazapine compared to placebo for treatment of depression in terminally ill cancer patients. It involved 88 terminally ill cancer patients from University of Malaya Medical Centre, Kuala Lumpur, Malaysia. They were randomized and treated with either methylphenidate or placebo as add on to mirtazapine. The change in Montgomery-Åsberg Depression Rating Scale (MADRS) score from baseline to day 3 was analyzed by linear regression. Changes of MADRS and Clinical Global Impression-Severity Scale (CGI-S) over 28 days were analyzed using mixed model repeated measures (MMRM). Secondary analysis of MADRS response rates, defined as 50% or more reduction from baseline score. A significantly larger reduction of Montgomery-Åsberg Depression Rating Scale (MADRS) score in the methylphenidate group was observed from day 3 (B=4.14; 95% CI=1.83-6.45). Response rate (defined as 50% or more reduction from baseline MADRS score) in the methylphenidate treated group was superior from day 14. Improvement in Clinical Global Impression-Severity Scale (CGI-S) was greater in the methylphenidate treated group from day 3 until day 28. The drop-out rates were 52.3% in the methylphenidate group and 59.1% in the placebo group (relative risk=0.86, 95%CI=0.54-1.37) due to cancer progression. Nervous system adverse events were more common in methylphenidate treated subjects (20.5% vs 9.1%, p=0.13). In conclusions, methylphenidate as add on therapy to mirtazapine demonstrated an earlier antidepressant response in terminally ill cancer patients, although at an increased risk of the nervous system side effects.

Background Inner peace is a state of mind that is free from suffering. Despite facing life-limiting diseases, it is still possible for patients to experience moments of inner peace in the midst of their pain and illnesses. The authors conduct this study to find out these moments of inner peace and the various paths eading to inner peace in palliative care patients. Purpose The purpose of this study is to (1) understand the types of inner peace in palliative care patients, to (2) understand the paths leading to inner peace in palliative care patients and to (3) construct a theory of inner peace in palliative care patients. Method Grounded theory is used in gathering, synthesising, analysing and conceptualising the data to achieve the above purpose. Results Regarding the types of inner peace, the study reveals four categories: (1) physical peace, (2) psychological peace, (3) social peace and (4) spiritual peace. Regarding the paths leading to inner peace, six categories are revealed: (1) self awareness, (2) positive thought, (3) positive emotion, (4) positive behaviour, (5) positive attitude and (6) self regulation. Conclusion The former categorisation of the types of inner peace enables us to understand inner peace in a systematic manner. It helps clinician in recognising the types of inner peace in patients. The latter categorisation gives us a deeper understanding of the various paths leading to inner peace. It provides a guide in developing various mechanism-based approaches that help patients to achieve inner peace. From these two findings, the authors construct a model of inner peace that can be generalised to all patients in the field of medicine. This model of inner peace can help clinician to facilitate patients in achieving inner peace in spite of their illnesses.

Introduction University Malaya Medical Centre is the main teaching hospital of University Malaya and admitted over 45000 inpatients in 2009. Palliative care services have gradually evolved since 2002. Services are currently provided by a team of medical specialists who manage an eight bedded inpatient ward, a hospital inpatient consultation team and weekly outpatient service. Method The palliative care database was reviewed retrospectively for the year 2010–2011 and basic demographic data, types of referrals, diagnostic categories and outcomes of care were collected and compared with the National Council for Palliative Care (NCPC) Minimum Data Set (MDS) report for the year 2009-2010. Only the hospital consultation and inpatient data is presently held within the database. Results A total of 856 (new, continuing and re-referred) inpatients were seen by the palliative care service. 44% were male (n=336) and 56% were female (n=428) and there were a considerably greater proportion of patients aged 65-74 compared with the NCPC data. Among new referrals, cancer diagnoses comprised 80% of referrals (n=591) compared with 19% (n=142) non-cancer diagnoses and 10 unrecorded diagnoses (1%). Proportionally more patients with breast cancer (17.6% vs 9%), motor neuron disease (9.8% vs 2%), chronic renal problems (21.8% vs 7%) and other heart/circulatory conditions (21.8% vs 12%) were seen compared with the NCPC MDS. More than half the patients seen by the palliative care team were discharged from hospital. Discussion The data demonstrates referral patterns and potential areas for further development. The need for more accurate evidence reflecting activity levels, outcomes and quality markers will be valuable in monitoring and planning future services as well as allocating resources in order to best meet the needs of the population. Further research into the local population is yet untapped and presents a huge opportunity for further work.