At Taipei City Hospital Zhongxing Branch, a data-driven study was conducted to evaluate the accuracy of attending physicians' judgments regarding patients' end-of-life stages and the reasons behind these judgments. The hospital is actively promoting the concept of a good death to over 6,000 healthcare workers. This study, which spans different hospital branches and various diseases, is the first of its kind in Asia and has received support from the Hospice Foundation of Taiwan's 2022 Palliative Care Advocacy, Education, and Research Program.
Mr. Lu, who was in his 70s, was admitted to the hospital due to a brain hemorrhage and unexpectedly discovered that his cancer, which had been stable for seven years, had metastasized to his brain, lungs, and liver. Initially, chemotherapy and medication stabilized his condition, and his prognosis was quite optimistic. Unfortunately, during the pandemic, Mr. Lu contracted COVID-19, which drastically weakened his immune system, leading to the deterioration of his condition and his premature death.
Ms. Chen, aged 49, had been battling breast cancer for four years, having experienced multiple recurrences and metastasis to her lungs and liver. Although her tumor initially shrank, and her attending physician believed that she could live for 1 to 3 years with injections and oral medication, Ms. Chen refused to continue aggressive treatment and passed away a year later.
In Mr. Lu's case, external infection factors played a role, while in Ms. Chen's case, it was the patient's refusal of aggressive treatment. Both of them passed away sooner than their attending physicians had anticipated, but fortunately, they had engaged in Advance Care Planning (ACP) during their treatment process, and made the difficult decisions about their end-of-life care ahead of time. Thus, after activating their Advance Directives (AD), they were able to die in the manner they wished.
Physicians Being Overly Optimistic Can Create Blind Spots in Hospice Initiation Strategies
"End-of-life discussions are crucial for patients to understand their prognosis and make care decisions that truly reflect their desires," said Dr. Tai-Yin Wu, Deputy Director of Taipei City Hospital Zhongxing Branch. Initiating these conversations early not only helps patients pass away peacefully but also provides their families with an opportunity to heal from trauma and find the strength to move forward.
In most clinical settings, the attending physician controls the activation button and decides whether to involve hospice care. However, this strategy has its blind spots because not every physician can clearly explain the direction of medical treatment and prognosis or accurately identify the timeline of death every time. This often prevents them from stepping back to a guiding role and introducing social workers, psychologists, nurses, and chaplains to facilitate end-of-life discussions.
"Physicians naturally hope their treatments will be effective, but this expectation can lead them to make overly optimistic judgments," said Dr. Wu. The progression of terminal illnesses and patterns of medical care differ, making accurate prognostication challenging. Additionally, a physician's professional training and experience can affect their accuracy. If physicians are overly optimistic and hospice care is introduced too late, patients may not pass away peacefully, families may struggle to cope with grief, and numerous medical disputes could arise.
Dr. Kuang-Yu Hsu, Director of the Division of Hospice Palliative Care at Zhongxing Branch, added that predicting death timelines is difficult, and communicating about them is equally challenging. Patients' fear of death and society's high expectations for longevity can make healthcare staff apprehensive about the reactions that may follow from stating that "death is near." This may cause team members to resist crossing medical hierarchies and passively leave end-of-life communication to the attending physician.
Asia's First Large-Scale, Cross-Hospital, Cross-Disease End-of-Life Prediction Study
Dr. Tai-Yin Wu’s research project-- Physicians Are Over Optimistic in Recognizing Inpatients' Survival and Palliative Care Needs: A Large Scale Multi-center Study in Taiwan--received funding from the Hospice Foundation of Taiwan's 2022 Palliative Care Advocacy, Education, and Research Program. This study aims to use data to evaluate the accuracy of physicians' judgments regarding end-of-life stages and identify the related causes.
The study traces back to 2015, when Dr. Sheng-Jean Huang, a prominent advocate for palliative care in Taiwan, was the Superintendent of Taipei City Hospital. He actively promoted the concept of a dignified death across seven hospital branches, reaching over 6,000 healthcare workers. Starting in March 2016, nurses at Taipei City Hospital’s seven branches were required to use the Taiwan Palliative Care Screening Tool (TW-PCST) to assess all inpatients based on disease severity, comorbidities, functional status, and deterioration. If the score was 4 or higher, the attending physician had to answer three questions: (1) "Would you be surprised if this patient dies within the next 6 to 12 months?", (2) "Is the patient in the terminal stage?", and (3) "Does the patient need palliative care?" Based on these responses, a decision would be made about involving palliative care. Dr. Tai-Yin Wu noted that Taipei City Hospital still actively requires all physicians to complete these assessments within three days.
Taipei City Hospital's Big Data Center meticulously recorded these assessments. In 2019, Dr. Tai-Yin Wu began collaborating with the hospital’s Chief Data Officer to analyze data from patients who died during their hospitalization between 2016 and 2020. The analysis examined the relationship between physicians’ responses to the three assessment questions and the patients' actual survival periods. This cross-hospital, cross-disease study is the first of its kind in Asia, as previous research generally focused on single diseases or specialties, aiming to improve the accuracy of end-of-life predictions.
Disease Types and Gender May Impact End-of-Life Prediction Accuracy
Dr. Tai-Yin Wu presented findings from the study indicating that only 88% of patients were accurately identified by their attending physicians as being in the last 6 to 12 months of life. The key factor influencing this accuracy was the physician's experience; those with more extensive experience tended to make more accurate predictions. Physicians with specialized training in palliative care, who had shadowed in hospice wards or conducted home palliative visits, were better at assessing patients' remaining lifespans.
The type of disease also influenced the accuracy of predictions. Malignant diseases like cancer had more predictable progression, allowing physicians to more accurately confirm that patients were entering the terminal stage and to connect them with palliative care resources early. Conversely, patients with non-malignant diseases had more variable survival times. For instance, cancer patients approached the end of life twice as quickly as non-cancer patients in cases where physicians predicted death within a year. Organ failure patients might die 2 to 5 years later, while dementia patients could live for 8 to 9 more years, making it more challenging to determine the optimal time for palliative care intervention.
The study also highlighted that gender differences affected both the acceptance of palliative care and the assessment of end-of-life stages. Women were generally more receptive to palliative care, while men were more likely to continue ineffective treatments until the final two weeks of life. Dr. Wu noted that these differences might be linked to societal expectations based on gender roles. Men, often seen as the primary earners in their families, are expected to fight for survival, leading families to invest more in prolonging their lives. Although women typically carry a smaller economic burden, some chose to forgo aggressive treatment to avoid placing emotional and financial strain on their families.
Dr. Tai-Yin Wu emphasized that there are no right or wrong choices in these decisions. However, during family meetings, the palliative care team must carefully understand the underlying reasons for these choices and appropriately connect resources to ensure that patients' true wishes are honored.
The Importance of Deeply Rooted Palliative Education
Dr. Tai-Yin Wu emphasizes that relying solely on attending physicians to initiate palliative care is insufficient, calling for improved strategies. An effective immediate strategy is to have nurses directly initiate end-of-life conversations after assessing patients with high TW-PCST scores, rather than passively waiting for physician judgments. Additionally, physicians need to be informed about the accuracy of their death predictions. For example, Taipei City Hospital has been providing feedback to physicians on death cases since 2018, helping them understand discrepancies in end-of-life assessments and build more interpretive experience.
"The most crucial aspect is embedding palliative care education and training deeply within domestic medical education," Dr. Wu stated. Just as geriatric medicine has become a mandatory part of clinical medical education, physician training is gradually evolving. Encouraging physicians to pursue further training in palliative care, in addition to specializing in palliative care, will enhance the implementation of palliative care in clinical settings. This will provide patients with more or adequate time for end-of-life discussions and ensure a meaningful conclusion to their lives.