Understanding Quality of Life among Adult Patients with Terminal Cancer in South Korea: An Integrative Review

Hyejin Kim; Jeonghyun Cho

doi:10.7475/kjan.2017.29.4.419

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Kim and Cho: Understanding Quality of Life among Adult Patients with Terminal Cancer in South Korea: An Integrative Review

Original Article

Korean J Adult Nurs 2017;29(4):419-431.

Published online: 9 August 2017

DOI: https://doi.org/10.7475/kjan.2017.29.4.419

Understanding Quality of Life among Adult Patients with Terminal Cancer in South Korea: An Integrative Review

Hyejin Kim, Ph.D., APRN-AGNP, BC¹, Jeonghyun Cho, Ph.D., RN^2,

¹School of Nursing, Emory University, Georgia, USA

²Department of Nursing, Inje University, Busan, Korea

Corresponding author: Cho, Jeonghyun Department of Nursing, Inje University, 75 Bokji-ro, Busanjin-gu, Busan 47392, Korea. Tel: +82-51-890-6233, Fax: +82-51-896-9840, E-mail: jhcho@inje.ac.kr

Received 16 June 201717 August 2017 Accepted 26 August 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Despite the importance of promoting quality of life (QOL) among patients with terminal cancer, a comprehensive understanding of QOL among this population is lacking in South Korea. Thus, the purpose of the integrative review was to identify patterns in studies about patient-reported QOL among Korean adult patients with a diagnosis of terminal cancer.

Methods

The integrative review method described by Whittemore and Knaf was used in this stuy. Twenty-five articles were selected for analysis.

Results

Most articles addressed factors that influenced QOL or validated an assessment instrument to measure QOL in patients with terminal cancer. Only one qualitative research article which described patients’ experiences of living with terminal cancer. Six other articles examined the effects of interventions on patients’ QOL but these did not provide detailed information about interventions. These articles seldom used robust designs and methods to test the interventions.

Conclusion

Findings from the review suggest conducting studies with qualitative methodologies to gain an in-depth understanding of QOL from patients’ perspectives. Additional studies with robust designs and methods are also neces-sary to develop and test theory-based, empirically-derived interventions that help maintain or promote QOL in patients with terminal cancer.

Keywords: Adult, Neoplasms, Quality of life, Review literature

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Appendix 1. List of Studies Included in an Integrative Review

1. Hwang IC, Keam B, Yun YH, Ahn HY, Kim YA. Quality of life changes and intensive care preferences in terminal cancer patients. Palliative & Supportive Care. 2015; 13(5):1309–16. https://doi.org/10.1017/S147895151400131X.

2. Hwang MS, Ryu HS. Effects of a palliative care program based on home care nursing. Journal of Korean Academy of Nursing. 2009; 39(4):528–38. https://doi.org/10.4040/jkan.2009.39.4.528.

3. Ju MJ, Sohn SK. Relationship between perceived family support and quality of life in hospitalized patients with terminal cancer. Asian Oncology Nursing. 2008; 8(1):32–9.

4. Kang J, Shin DW, Choi JY, Park CH, Baek YJ, Mo HN, et al. Addressing the religious and spiritual needs of dying patients by healthcare staff in Korea: patient perspectives in a multi-re-ligious Asian country. Psycho-oncology. 2012; 21(4):374–81. https://doi.org/10.1002/pon.1901.

5. Gang SG, Kim So, Kim SS, Park HM, Song GO, Won JH, et al. The effect of family support in the hospice facility. Korean Journal of Hospice Care. 2003; 3(1):31–41.

6. Gang SG, Kim So, Kim SS, Park HM, Song GO, Won JH, et al. The effect of faith in the terminal patients. Korean Journal of Hospice Care. 2002; 2(2):49–57.

7. Kim KU. Measurement of quality of life in patients with end- stage cancer. Cancer Nursing. 2014; 37(1):44–9. https://doi.org/10.1097/NCC.0b013e31827b5bdc.

8. Kim KU. Quality of life using Korean version of McMaster quality of life scale in hospice and palliative care patients. The Korean Journal of Hospice and Palliative Care. 2010; 13(4):225–31.

9. Kim KY, Choi YS, Kim DG, Suh SY. Symptoms and quality of life according to length of survival in hospice cancer patients. Korean Journal of Clinical Geriatrics. 2010; 11(2):143–53.

10. Kim SH, Chung BY, Xu Y. Evaluation of a home-based hospice and palliative care program in a community health center in Korea. Asian Nursing Research. 2009; 3(1):24–30. https://doi.org/10.1016/S1976-1317(09)60013-X.

11. Kim IH, Han YR. The effects of hospice care in public health centers on quality of life of terminal cancer patients and caregiver burden of families. Journal of Agricultural Medicine & Community Health. 2008; 33(1):59–70. https://doi.org/10.5393/jamch.2008.33.1.059.

12. Kim SH, Chung BY, Suh SR. Validation of the quality of life at the end of life among Korean middle and older adults with terminal illnesses. Journal of Korean Gerontological Nursing. 2007; 9(1):76–84.

13. Kim SH, Gu SK, Yun YH, Lee CG, Choi YS, Lee WS, et al. Validation study of the Korean version of the McGill Quality of Life Questionnaire. Palliative Medicine. 2007; 21(5):441–7. https://doi.org/10.1177/0269216307079816.

14. Kim KU, Yoon SJ, Lee JL, Ahn HS, Park HJ, Lee SI, et al. Validation of the Korean version of the McMaster Quality of Life Scale in terminal cancer patients. Journal of Palliative Care. 2006; 22(1):40–5.

15. Kwon IK, Hwang MS, Kwon KM. Quality of life of the terminal cancer patients receiving home care nursing. Journal of Korean Clinical Nursing Research. 2008; 14(2):103–14.

16. Lee MK, Lee WJ, Do YR, Lee KS, Jung KH, Heo DS, et al. Changes in health-related quality of life and quality of care among terminally ill cancer patients and survival prediction: multicenter prospective cohort study. Palliative & Supportive Care. 2015; 13(4):1103–11. https://doi.org/10.1017/S1478951514000960.

17. Lee YJ, Suh SY, Choi YS, Shim JY, Seo AR, Choi SE, et al. EORTC QLQ-C15-PAL quality of life score as a prognostic indicator of survival in patients with far advanced cancer. Supportive Care in Cancer. 2014; 22(7):1941–8. https://doi.org/10.1007/s00520-014-2173-8.

18. Lee MK, Baek SK, Kim SY, Heo DS, Yun YH, Park SR, et al. Awareness of incurable cancer status and health-related quality of life among advanced cancer patients: a prospective cohort study. Palliative Medicine. 2013; 27(2):144–54. https://doi.org/10.1177/0269216311429042.

19. Mo HN, Shin DW, Woo JH, Choi JY, Kang J, Baik YJ, et al. Is patient autonomy a critical determinant of quality of life in Korea? End-of-life decision making from the perspective of the patient. Palliative Medicine. 2012; 26(3):222–31. https://doi.org/10.1177/0269216311405089.

20. So WS, Cho KJ. A study on the effects of hospice care for the quality of life of the terminally-ill patients. The Journal of Nurses Academic Society. 1991; 21(3):418–35. https://doi.org/10.4040/jnas.1991.21.3.418.

21. Seon JJ, Lee ES, Kim SH, Park SJ. Changes in pain and quality of life of terminal cancer patients through hospice home care. Korean Journal of Hospice Care. 2003; 3(2):1–11.

22. Yeom CH, Jung GC, Song KJ. Changes of terminal cancer patients' health-related quality of life after high dose vitamin C administration. Journal of Korean Medical Science. 2007; 22(1):7–11. https://doi.org/10.3346/jkms.2007.22.1.7.

23. Yeom CH, Choi YS, Lee HR, Shim JY, Hong YS, Choe WS, et al. The comparison of the medical costs and quality of life in terminal cancer patients by the types of medical facilities. Journal of the Korean Academy of Family Medicine. 2000; 21(3):332–43.

24. Yun YH, Kwon YC, Lee MK, Lee WJ, Jung KH, Do YR, et al. Experiences and attitudes of patients with terminal cancer and their family caregivers toward the disclosure of terminal illness. Journal of Clinical Oncology. 2010; 28(11):1950–7. https://doi.org/10.1200/JCO.2009.22.9658.

25. Kim BH, Kang HJ. Experience of home-based hospice care of terminal-cancer patients. The Korean Journal of Hospice and Palliative Care. 2014; 17(4):223–31. https://doi.org/10.14475/kjhpc.2014.17.4.223.

Figure 1.

Process of data identification, screening, and evaluation.

Table 1.

Characteristics of Included Studies (N=25)

Variables	Categories	n(%)
Journal published	Domestic	13(52.0)
Journal published	International	12(48.0)
Year of publication	1990~1999	1(4.0)
	2000~2009	13(52.0)
	2010~2016	11(44.0)
Study design	Qualitative	1(4.0)
	Quantitative	19(76.0)
	Methodological	5(20.0)
Condition/setting	Hospital-based	18(72.0)
Condition/setting	Home-based	7(28.0)
QOL related domain^†	Individual factor	6(24.0)
	Symptom status	3(12.0)
	Functional status	2(8.0)
	General health perception	5(20.0)
	Environmental factor	11(44.0)
	Patient outcome	3(12.0)

^† Overlaps in count.

Table 2.

Description and Summary of the Selected Quantitative Studies

No.	Authors (year)	Purpose	Research design	Setting & sample	Instruments used for QOL	Major findings	Quality
1	Hwang et al.(2015)	Explore factors related to changes in preferences	Prospective cohort	Setting: 11 hospitals & National Cancer Center Sample: patients just diagnosed of terminal cancer (N=141)	EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire)	• Patients with stable physical function tended to accept ICU care. • Patients who reported poor performance, decreased QOL, or non-aggravated fatigue were more likely to change their preference to rejecting ICU care.	Fair
2	Hwang et al.(2009)	Develop and test a home care based palliative care program	Quasi-experiment al design with non-equivalent group pre and post test	Setting: home Sample: 46 (24 in experimental group, 22 in control group) Patients with terminal cancer and their families	Yun [16]'s tool developed to measure QOL of patients with terminal cancer	• The experimental group reported less pain, fewer symptoms, higher QOL, and lower family burden than the control group.	Good
3	Ju & Sohn (2008)	Examine the relationship between perceived family support and QOL in hospitalized patients with terminal cancer.	Cross-sectional	Setting: one hospital Sample: 104 terminal cancer inpatients	Yun [16]'s tool developed to measure QOL of patients with terminal cancer	• The levels of QOL were significantly associated with the number of children, effect of religion on the one' life, and perceived state of disease and pain. • There was a moderately positive correlation between patients' perceived family support and QOL.	Fair
4	Kang et al.(2012)	Examine the impact of addressing spiritual and religious needs on patients' QOL	Cross-sectional	Setting: 33 palliative care centers Sample: 94 terminal cancer patients receiving care from palliative care centers	EORTC-QLQ-C15-PAL and a patient version of the Good Death Inventory	• Patients with spiritual and religious needs addressed noted a significantly higher QOL than others when assessed using the EORTC QLQ-C15 PAL, despite no significant difference based on the Comprehensive QOL scale.	Good
5	Kang et al.(2003)	Examine the effects of family support on QOL	Longitudinal, retrospective cohort	Setting: a hospice Sample: 152 patients received hospice care (mostly patients with terminal cancer)	An investigator-developed instrument	• There were no differences in the QOL score between patients with and without family support in terms of physical, psychosocial, and spiritual aspects.	Fair
6	Kang et al.(2002)	Explore the influence of religion on QOL	Longitudinal, retrospective cohort	Setting: a hospice Sample: 75 patients who received hospice care (mostly patients with terminal cancer)	An investigator-developed instrument	• The patients who believed salvation reported a better spiritual QOL. Otherwise, there were no differences in physical and psychosocial QOL between patients who believed salvation and who did not.	Fair
7	Kim (2014)	Examine QOL in patients with terminal cancer using the Korean version of McMaster QOL	Methodological study	Setting: 4 general hospitals Sample: 52 patients with end-stage cancer	Korean version of McMaster QOL	• Patients who died within 21 days, had lower performance, and used a painkiller showed lower QOL than those who were alive at the end of the study, had higher performance, and did not use a painkiller respectively. Also, patients with fewer symptoms had higher QOL. • The number of symptoms besides pain had the largest effect on QOL, which was explained by the statistical power of 20%. Patients with fewer symptoms had higher QOL.	Fair
8	Kim (2010)	Test an instrument to measure patients' QOL in hospice and palliative care	Methodological study	Setting: 7 hospice and palliative care centers Sample: 70 terminal cancer patients (N=70)	Korean version of McMaster QOL Scale	• Based on examinations on validity and reliability, the Korean version of McMaster QOL Scale was a valid, reliable, and efficient tool to measure QOL in Korean patients with terminal cancer.	Fair
9	Kim et al.(2010)	Explore the relationship between survival duration and symptoms and QOL	Retrospective cohort	Setting: 6 hospitals Sample: 137 terminal cancer inpatients	MDASI-K (Korean version of MD Anderson Symptom Inventory)	• Deterioration of functioning was associated with the decreased survival period. The prevalence and severity of symptoms as well as QOL significantly differed depending on the survival period. Symptoms and QOL worsened as the survival duration decreased.	Fair
10	Kim et al.(2009)	Evaluate the effects of a home based palliative care program consisting of physical/medical care, psychological support, counseling, and education	Cross-sectional	Setting: home Sample: 76 terminally ill patients (30 in experimental group, 46 in control group), mostly diagnosed with terminal cancer	A revised Korean version of the QOL at the End-of-Life (QUAL-E)	• The experimental group showed significantly higher QOL in a physical aspect only.	Good
11	Kim & Han (2008)	Examine the effects of hospice care offered by public health centers on QOL in patients with terminal cancer and caregiver burden	Quasi-experiment al design with one-group pre and posttest	Setting: home Sample: 32 terminal cancer patients and 32 caregivers	Cancer-Quality of Life instrument developed by Lee [17]	• After the intervention, patients' QOL scores increased significantly, compared with those before the intervention. • After the intervention, caregivers' burden decreased significantly.	Fair
12	Kim et al.(2007a)	Develop and test the QUAL-E	Methodological study	Setting: home Sample: 76 patients with terminal cancer	QUAL-E	• The final instrument consisted of five domains, such as physical symptoms, social relationships, preparation, control, and completion, which was explained at 69% of the total variance. • Overall Cronbach's ⍺ coefficient was 0.84.	Fair
13	Kim et al.(2007b)	Examine the reliability and validity of the Korean version of McGill QOL Questionnaire	Methodological study	Setting: 1 outpatient clinic and 6 hospitals Sample: 140 patients diagnosed of terminal cancer	McGill QOL Questionnaire	• The Korean version of McGill QOL was proved to be a valid, reliable, and efficient tool to measure health-related QOL in Korean patients with terminal cancer.	Good
14	Kim et al.(2006)	Develop a Korean version of the McMaster QOL Scale	Methodological study	Setting: 20 hospices and palliative care centers Sample: 70 Patients diagnosed with terminal cancer, 70 family members, 28 nurses, 7 physicians	McMaster QOL Scale	• The K-McMaster QOL Scale was a valid, reliable, and efficient instrument to measure health-related QOL in Korean patients with terminal cancer.	Fair
15	Kwon et al.(2008)	Identify factors that affect QOL	Cross-sectional	Setting: home Sample: 72 patients with terminal cancer who were receiving home care	Yun [16]'s tool developed to measure QOL of patients with terminal cancer	• QOL was negatively associated with three types of pain, physical functioning, and symptom experiences. • Mild pain, physical functioning, and family coping were significantly associated with QOL, with statistical explanation of 26.7%.	Good
16	Lee et al.(2015)	Examine changes in health-related QOL and quality of care and investigate influences of QOL and quality of care on survival at the end of life	Prospective cohort	t Setting: 11 hospitals and National Cancer Center Sample: 463 patients with a recent diagnosis of end-stage cancer	EORTC QLQ-C30	• In light of QOL, patients presented worsening emotional and cognitive functioning over 3 months of the study period, whereas they reported increasing dyspnea, constipation, and pain. • Patients with poor global QOL, problematic appetite loss, and lower ECOG-PS scores were more likely to have a shorter period of survival.	Good
17	Lee et al.(2014)	Examine if patient-reported QOL predicts survival	Retrospective cohort	Setting: 6 hospitals Sample: 162 patients diagnosed of terminal cancer	EORTC QLQ-C15~PAL	• The physical functioning domain of the EORTC QLQ-C15~PAL was associated with survival. Other six domains were associated with survival after controlling for global health status, emotional functioning, fatigue, nausea/vomiting, appetite, and constipation.	Good
18	Lee et al.(2013)	Examine if awareness of disease status affects QOL during palliative chemotherapy.	Prospective cohort	Setting: 2 hospitals and the Korea National Cancer Center Sample: 98 patients with advanced cancer starting palliative chemotherapy	EORTC QLQ-C30	• Patients who acknowledged their incurable status presented better QOL, emotional and social functioning, and decreased fatigue, appetite loss, constipation, financial difficulty, and anxiety, compared with patients unaware of their incurable status.	Good
19	Mo et al.(2011)	Investigate if autonomy influences QOL or quality of death	Cross-sectional	Setting: 33 inpatient palliative care centers Sample: 93 patients with terminal cancer	EORTC QLQ-C15~PAL	• Patients who fully engaged in the decision-making process presented lower QOL, especially emotional functioning, than those who did not.	Good
20	So & Cho (1991)	Examine the effects of hospice care on QOL	Quasi-experiment al design with one-group pre and post test	Setting: 2 hospitals Sample: 32 patients with terminal cancer	An investigator-developed instrument	• Overall QOL was better post hospice care than pre hospice care. • The most effective aspect of the hospice care was spiritual aspect, and the least was physical aspect.	Fair
21	Sun et al.(2003)	Examine the effect of home hospice care on the pain relief and QOL	Quasi-experiment al design with one-group pre and post test	Setting: home Sample: 41 patients with terminal cancer	A modified version of Cho [18]'s QOL instrument	• After receiving the home hospice care, patients presented significantly improved QOL, compared to that before the intervention. • After receiving the home hospice care, patients showed better QOL in social, emotional, and spiritual aspects, while they presented worse QOL in the physical aspect.	Fair
22	Yeom et al.(2007)	Examine the effects of high dose vitamin C administration on QOL	n n Quasi-experiment al design with non-equivalent group pre and post test	Setting: 1 outpatient clinic Sample: 39 outpatients with terminal cancer	EORTC QLQ-C30	• With the administration of vitamin C, the global health and functional status (physical, role, emotional, cognitive, and social function) scored increased, and symptom scores (fatigue, nausea/vomiting, pain, sleep problem, and decreased appetite) decreased. However, there were no significant changes in dyspnea, constipation, diarrhea, and financial impact.	Fair
23	Yeom et al.(2000)	Compare the medical costs and QOL in patients with terminal cancer by the types of medical facilities	Cross-sectional	Setting: Home hospice, charity hospital hospice unit, university hospital hospice unit, and hospital non-hospice unit Sample: 159 patients with terminal cancer	An investigator-developed instrument	• Home hospice and the charity hospital hospice unit presented lower medical costs than the university hospital. • The ADL status, level of pain, and frequency of depression in patients receiving home hospice were lower than those in patients receiving care in charity and university hospital hospice unit.	Fair
24	Yun et al.(2010)	Explore the experiences of patients with cancer and their family caregivers regarding acknowledgment of terminal cancer	r Cross-sectional	Setting: 11 hospitals and National Cancer Center Sample: 481 terminally ill cancer patients and 381 family caregivers	EORTC QLQ-C30	• The patient group was more likely than the caregiver group to prefer that patients be informed of their terminal status. • Patients informed of their terminal status had a significantly better QOL than patients who guessed it from their worsening condition.	Good

Table 3.

Description and Summary of the Selected Qualitative Studies

No.	Authors (year)	Purpose	Research design	Method	Setting & sample	Major findings	Quality
25	Kim & Kang (2014)	Explore terminal cancer patients' experiences of home-based hospice care	Phenomenology	Semi-structured individual interviews	Setting: home Sample: 10 patients with terminal cancer who received home-based hospice care services	The main themes were worsening QOL, appreciation, acceptance of their remaining lives, being prepared for death with religion, and negative coping.	Fair

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