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Advanced care plans (ACPs) are designed to convey the wishes of patients with regards to their care in the event of incapacity. There are a number of prerequisites for creation of an effective ACP. First, the patient must be aware of their condition, their prognosis, the likely trajectory of the illness, and the potential treatment options available to them. Second, patient input into ACP must be free of any coercive factors. Third, the patient must be able to remain involved in adapting their ACP as their condition evolves. Continued use of familial determination and collusion within the local healthcare system, however, has raised concerns that the basic requirements for effective ACP cannot be met.
To assess the credibility of these concerns, we employed a video vignette approach depicting a family of three adult children discussing whether or not to reveal a cancer diagnosis to their mother. Semistructured interviews with 72 oncology patients and 60 of their caregivers were conducted afterwards to explore the views of the participants on the different positions taken by the children.
Collusion, family-centric decision making, adulteration of information provided to patients, and circumnavigation of patient involvement appear to be context-dependent. Patients and families alike believe that patients should be told of their conditions. However, the incidence of collusion and familial determination increases with determinations of a poor prognosis, a poor anticipated response to chemotherapy, and a poor premorbid health status. Financial considerations with respect to care determinations remain secondary considerations.
Significance of results:
Our data suggest that ACPs can be effectively constructed in family-centric societies so long as healthcare professionals continue to update and educate families on the patient's situation. Collusion and familial intervention in the decision-making process are part of efforts to protect the patient from distress and are neither solely dependent on cultural nor an “all-or-nothing” phenomenon. The response of families are context-dependent and patient-specific, weighing the patient's right to know and prepare and the potential distress it is likely to cause. In most cases, the news is broken gently over time to allow the patient to digest the information and for the family to assess how well they cope with the news. Furthermore, the actions of families are dependent upon their understanding of the situation, highlighting the need for continued engagement with healthcare professionals.
The manner in which personhood or “what makes you who you are” is conceived is key to the provision of patient-centered care and maintenance of the dignity and quality of life of terminally ill patients. However, there is little agreement on how this pivotal concept ought to be defined. Some have argued in favor of an innate concept of personhood, while others see an individual as a reflection of their familial identity or their conscious function, and all share a common position that personhood is unchanging, and hinges upon the central theme of their respective concepts. The present paper aims to explore a more clinically influenced perspective of personhood.
We report the case of a 42-year-old Malay Singaporean who had been a caregiver for her husband throughout his cancer and then became a cancer patient herself after his passing. This case explores her changing and multifaceted conceptions of personhood throughout her life and illness, and discussions about end-of-life care.
The patient reports a concept of personhood that encompasses the innate, individual, relational, and societal aspects, which are interlinked and vary in terms of depth and conviction according to the various times in her life and illness.
Significance of results:
Our findings support the ring theory of personhood, which provides a clinically supported model of the conception of personhood that is context dependent and encompasses the four abovementioned aspects.
The traditional relationship between patient and physician in East Asian society has often been described as “paternalistic.” However, in an increasingly Westernized world, our knowledge of how patients perceive the role of the physician in their decision making regarding treatment is lacking.
This article is part of a larger pilot study exploring the patient–physician dynamic on decision making among Southeast Asian palliative cancer patients. We explore: (1) influence of physicians, (2) the effect of symptom control and quality of life, and (3) dynamics and communication of physicians.
An interviewer-administered questionnaire was distributed, with 18 questions related to physician–patient interactions asked. Most questions followed a three point scale: “agree,” “neutral,” and “disagree,” and spontaneous answers beyond this framework were recorded.
Thirty patients from the palliative care service were interviewed, including inpatients at Singapore General Hospital and those attending outpatient clinics at the National Cancer Centre.
Patients said that they themselves and their physicians were the main influences (80% each), over family members (48.3%). Some patients (26.7%) felt that symptoms were not well controlled, and 42.9% identified low mood or anxiety. Some patients (44.8%) felt that their condition had an effect on decision making. Most patients (89.3%) had a good relationship with the staff, with >80% being comfortable with discussions held. However, 20.7% of patients felt dissatisfied with the information provided, and 62.1% of patients wanted full disclosure of information.
Significance of results:
Patients appeared to place highest regard in both autonomy and physician input in making decisions, accompanied by an increased desire for more information. These reflect deviation away from traditional thinking of paternalistic doctoring in East Asia.
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