癌症告知策略的研究
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摘要
一、研究目的
癌症已经成为全球首要的疾病死亡原因，我国每年的发病率正逐年上升。由于癌症的治愈困难和预后差，使得向患者告知癌症诊断和病情不亚于向患者宣布“预期死亡”。这样，是否告知以及如何告知癌症病情一直是社会颇为争议的问题。在我国独特的文化背景下，临床医护人员通常是先将真实病情告知家属，再根据家属的意见决定是否告知患者。且家属普遍高估患者获知真实诊断的负性情绪，不主张将实情相告。近年来，越来越多的研究表明，医疗坏消息的告知是可行的，且癌症患者对知情权的呼声也越来越高，我国的这种告知模式正面临着严峻的挑战。并且，在癌症告知的过程中，人们对死亡有许多的不接受，达到或超过50％的治疗费用被用于延长晚期癌症患者痛苦的死亡过程。这些均不利于癌症患者在生命的最后阶段获得真正的舒适、尊严和满足，不利于卫生资源的有效利用。
本课题对此进行研究，为更好进行死亡教育和开展癌症告知奠定理论基础，让癌症患者理解生与死是人类自然生命的历程，既能善待生命，珍惜生命，又能勇敢正视疾病，坦然面对死亡；为更好尊重和满足癌症患者知情同意权，努力实现从“尊重家属的意见”到“尊重患者的权利”的转变提供科学依据；寻求最佳的告知人员、时间、内容、程度等，让癌症病情告知更温情、更人道、更科学、更理性，在“告诉事实”和“避免伤害”的冲突中取得最大的平衡；摸索出有效的护理干预措施，让患者在不多的时间内达到一种生存的相对较高质量；为制定科学的医疗服务政策和制度提出意见和建议，使得卫生事业的发展更有利于满足癌症患者的需求，更有利于社会公众的利益。
二、研究方法
本研究运用文献检索分析法、专家咨询法和专题小组讨论法等，探讨我国死亡观以及癌症告知的相关理论，研制不同人群死亡态度和癌症告知的问卷调查表。对某三级甲等医院医护人员634名、门诊患者307名、住院癌症患者302名、癌症患者家属305名，共计1548名不同人群进行现场调查；采用EpiData3．1软件，双录入法进行资料录入，用SPSS13．0软件进行数据分析。分析包括一般统计描述性分析、Wilcoxon检验或Kruskal-Wallis检验、χ~2检验、单因素Logistic回归分析、多因素Logistic回归分析、对应性分析等。全部检验均为双侧检验，P值＜0．05时有统计学意义。
三、研究内容
查阅国内外相关文献，结合专家小组讨论，基于中国传统文化的死亡观和现代的死亡观对我们现代医学的启示以及癌症告知策略的研究，从理论上探讨我国死亡观以及癌症告知策略的相关理论：探索不同人群(医护人员、普通患者、癌症患者和其家属)的死亡态度和癌症终末治疗态度，比较不同背景资料人群死亡态度和癌症终末治疗态度的差异及其影响因素，为更好开展癌症告知和进行死亡教育奠定理论基础；调查不同人群对癌症告知的态度，让医护人员和家属从“告知”与“不告知”的两难处境中解脱出来，为制定科学的医疗服务政策和制度奠定基础。比较不同背景资料人群对癌症告知策略的选择及其影响因素，探索适合癌症告知的人员、时间、地点、内容、方式和程度等，寻求科学的癌症病情告知策略；研究癌症患者和其家属在获知癌症诊断后心理变化，为科学开展护理干预提供依据；分析死亡态度和癌症告知态度之间的关联，摸索增进和完善癌症告知策略的途径。
四、研究结果
1．大部分患者既赞同无痛苦、有尊严地安乐死亡，又表现强烈对生的留念，希望医护人员和家属进行积极救治；能够接受死亡，但同时存在否认或侥幸心理。年龄、家庭住地、重病接触经历、丧礼经历及宗教信仰等因素对癌症患者的终末治疗和死亡态度的评分有一定影响(P＜0．01或P＜0．05)。
2．癌症患者家属赞成终末期淡化治疗，但对安乐死态度模糊；能够平静接受生命终结，但对死亡仍显忌讳。性别、婚姻、文化程度、丧亲经历、重病接触经历和宗教信仰等对癌症患者家属癌症终末治疗和死亡态度问题的评分有一定影响(P＜0．01或P＜0.05)。
3．医护人员对癌症终末期患者的治疗存在矛盾心理，对死亡持有回避和拒绝的态度；有危重患者接触史、丧亲经历者更倾向于不赞同“患者应坚强活下来”；有处置死亡经历者更倾向于赞同“减轻痛苦和提供尊严”、“建立治疗遗愿”(P＜0．01或P＜0．05)。
4．“临终关怀”和“安乐死”等生命伦理学观念已经能够被相对部分的人群所认可和接受；住地、年龄、性格、性别、家庭收入和住院经历等因素对普通门诊患者的终末治疗和死亡态度的评分有一定影响(P＜0．01或P＜0．05)。
5．医护人员较其他人群更倾向于不介意谈论死亡和对终末治疗更理性，家庭人均月收入是谈论死亡的危险因素，文化程度是理性治疗的危险因素，差异均有统计学意义(P＜0．01或P＜0．05)。
6．癌症患者非常希望了解真实病情，他们认为保护性医疗会导致对医护人员的不信任、让他们得不到真正的心理关怀；男性、既往有住院经历和丧礼经历的患者对待重症疾病的告知态度更积极。获知疾病时间≤1月者比＞1月者更倾向于对医护人员的欺骗产生不信任感；已婚者、男性比未婚者和女性更倾向于对隐瞒重症病情十分不满。
7．大多数家属主张在征求他们同意后，将真实病情告知癌症患者；Logistic回归分析显示，获知亲人患癌时间、文化程度、重病接触史、丧亲经历等因素对家属的癌症病情告知态度的评分具有一定影响(P＜0．01或P＜0．05)。
8．医务人员对癌症病情告知所持的态度较慎重，不十分赞同将真情完全告知患者，其告知意愿在一定程度上取决于患者的知情愿望，他们比较认同家属拥有决策权，且普遍认为患者不是充分知晓病情；Logistic回归分析显示，科室、职业、职称、文化程度、重病经历、住院经历、重病接触史、处理死亡经历是影响医护人员对癌症病情告知态度的主要因素(P＜0．01或P＜0．05)。
9．普通患者对癌症告知的态度比较模糊，对待癌症告知过程中医护人员、癌症患者和癌患家属三者之间的冲突，仍有相对部分的人群将矛头指向医护人员；住地和住院经历对普通患者的癌症病情告知态度的评分有一定影响(P＜0．01或P＜0．05)。
10．背景资料对不同人群的影响充满矛盾，仅不同角色人群的态度差异具有统计学意义(P＜0．01或P＜0．05)：癌症患者告知态度和知情愿望最积极，知情程度自评最高；家属并非告知主要障碍，普通患者和医护人员的告知态度最为保守。
11．大部分癌症患者主张在确诊时，有家人陪伴，由肿瘤专科医生面对面地直接将真实病情完全告知，并让患者获得治疗的希望。Logistic回归分析结果显示，女性、已婚、性格外向和介意谈论死亡者更支持家属参与告知；有既往住院经历和自觉病情较轻者更主张及时告知；文化程度高者更赞同医生直接告知。
12．癌症患者家属首要重视对患者的心理承受力的评估、十分强调自身在告知过程中的作用、特别讲求医护人员的告知艺术、比较赞同采取选择性部分告知。Logistic回归分析显示，性别、住地、职业、重病接触史、知情时间、丧亲经历、丧礼经历、宗教信仰以及谈论死亡的态度等因素对家属选择癌症告知策略具有一定影响(P＜0．01或P＜0．05)。
13．医护人员对癌症告知前准备的评分较高，比较赞同确诊时，在家属的情感支持下，在一个安静的私密环境中，由医护人员和家属组成的告知小组，共同商讨，进行有计划分步多次告知；Logistic回归分析显示，住院经历、重病经历、文化程度、家庭月收入、丧礼经历、危重病人接触史、处置死亡经历、职称和工作科室是医护人员癌症病情告知各项策略评价与选择的影响因素(P＜0．01或P＜0．05)。
14．普通公众对告知时家属的同意与参与较为认同。有危重病接触史者比无重病接触史者更赞同癌症告知时“有家属陪伴”以及“面对面直接口头交流”。体力劳动者比脑力劳动者更加主张癌症告知时“避免让与疾病不相关的人知道病情”。
15．经过一段时间的心理适应期，大多数患者和家属都可以平静地接受患癌现实；获知癌症诊断后，绝大多数癌症患者及其家属都存在不良情绪，且无论是癌症告知当时，还是经过一段时间之后，家属组均较患者组倾向于拥有更多的“不良情绪”；Logistic回归分析显示，年龄、性别、丧礼经历等是癌症患者及其家属产生不良情绪的影响因素(P＜0．01或P＜0．05)。
16．死亡态度和告知态度关系紧密：能够接受死亡的人更倾向于对癌症告知持积极态度，对接受死亡处于模糊态度者更倾向于癌症告知的含糊态度；持不接受死亡的态度者更倾向于不主张癌症告知。
五、研究结论与政策建议
1．向癌症患者及其家属告知真实病情是可行的；医护人员要特别注意让男性、已婚、有住院经历和丧礼经历的患者或家属享有充分的知情同意权，充分认识和理解癌症患者的矛盾心理，咨询他们对终末治疗的遗愿，护送他们在舒适、尊严和满足中走完人生的最后旅程。
2．对初期确诊的癌症患者，一定要遵循“不欺骗”原则；人性化癌症告知策略需要考虑患者的个人背景、个性特征、患病史和对待死亡的态度等；需要评估癌症患者的知情愿望，明确告知的对象；建立单独的谈话室，确保不被干扰的告知环境；需要家人的陪伴，提供情感的支持；需要医生充分履行告知的职责，及时告知病情诊断和变化；需要计划、分步、多次告知，并留下余地和希望；告知真实病情后，需要注意观察和疏导患者的不良情绪。
3．避免与家属之间的矛盾和冲突，构建和谐的医疗关系，医护人员应该重视家属的人文关怀，因人而异地对他们实施心理干预和健康教育。充分认识和理解癌患家属对癌症终末治疗和癌症告知的矛盾心理，征询家属的意见，尤其是对学历高、阅历深的家属，与他们或协商合作、或教育引导，且最好在家属经过一段时间的心理适应期之后，再向患者告知癌症真实病情，同时鼓励家属与患者沟通，为患者提供充分的心理和社会支持。
4．医护人员要努力克服在癌症告知认识上的误区，以优化生命全程为己任，积极开展癌症告知策略的研究，自觉加强与医疗有关的心理学、社会学以及人际交往等方面知识的学习与实践，加强同行交流与沟通，注重自身人生经历和工作经历的丰富和积累，努力培养对生死的自然达观态度，不断提高癌症的告知技巧；开展病人角色扮演等方式的教育，建立临终关怀病房和重症监护病房的常规培训制度等是增强医护人员对生命死亡认识和癌症告知责任感的可探索途径。
5．实现从“尊重家属的意见”到“尊重患者的权利”的转变，实现治疗向照料的转变，需要营造一个对死亡和癌症告知更加开明的氛围，需要早期针对性死亡教育的干预，需要城乡差别的不断缩小，需要社会经济和文化水平的发展和提高，需要社会各方共同努力，需要广大医护人员的积极引导。采用大众传媒多渠道地进行生命死亡教育能够改变人们对待癌症告知态度，改善患者对癌症的知情现状。人生经历少的、年轻的、农村的等特点的癌症患者医护人员进行死亡教育的重点人员。
6．“临终关怀”和“安乐死”等生命伦理学观念正逐步成为当今社会的主流思想，国家制定相关的政策和法规已经有了一定的认识基础；国家应大力开展具有中国特色的临终关怀以满足广大癌症患者的需求并加大宣传，努力促成全社会“无病则防，有病则治，治不好则临终关怀”的共识。
六、创新之处
1．本研究从死亡态度和癌症终末治疗态度这一崭新的角度，探寻癌症患者的病情告知策略。
2．在癌症患者知情同意的基础上，对癌症告知、癌症终末治疗和死亡态度等敏感问题进行调查。
3．本研究多维度研究癌症患者的病情告知态度和策略，普通门诊患者的调查是国内外空白。
Objectives
Cancer has become the world's foremost cause of death in illness and annual incidencerate is increasing year by year in China. Due to cancer cure difficulties and poor prognosis,made to inform patients of cancer diagnosis and condition inferior to that of "expecteddeath". Thus, it is a social condition rather than controversial issue of telling the cancerpatients the truth or not and how to tell. In the unique culture background of our country,medical staff usually tell the true condition of the patients to their families before making adecision of telling the patients or not according to their families' opinions. Moreover,families don't agree to tell the truth to the patients in consideration of the patients' strongnegative reaction to the true diagnosis. More and more studies have indicated that it isfeasible to tell the patients the medical bad news and the cancer patients' voice of right toknow is higher and higher. Under these circumstances, our country's disclosure mode isfacing severe challenges. What's more, people have many things unaccepted towards deathduring the process of cancer information, 50% or more medical expenditure are used in theprolongation of the painful dying process of the terminal cancer patients. These are neitherbeneficial for the cancer patients to get true comfort, dignity and satisfaction in the finalstages of life, nor for the effective use of health resources.
This study focus on the above issues, building an academic foundation for the betterdeath education and cancer disclosure to make cancer patients understand that life anddeath are the natural course of human being, treat life, cherish life, but also bravely facedisease and death. Trying to supply a scientific evidence for the transition from "respectingthe families' opinion" to "respecting patients' right" so to better respect and satisfy thecancer patients' consent right; Seeking for the best disclosure staff, time, content and degree to make the cancer disclosure more warm, humanistic, scientific and rational, to geta best balance between "telling the truth" and "avoiding hurt"; seeking for the effectivecare interventions so to make the patients get a relatively higher life quality in the limitedlife; supplying opinions and suggestions for the constitution of the medical service policyand system to make the progress of health career more beneficial to cancer patients and thepublic Interests.
Methods
This research apply document retrieval, expert counseling and specialists paneldiscussion to discuss the death concept and relevant theories of cancer disclosure in ourcountry and develop questionnaires on death attitude and cancer disclosure of differentgroups of people. 634 medical staff, 307 non-cancer patients, 302 hospitalized cancerpatients, 305 relatives of cancer patients, together 1548 people of a level three group Ahospital were investigated on the spot; the data was recorded with software EpiData3.1and double-entry method and analyzed with SPSS13.0 software. Analysis includes generalstatistic description analysis, Wilcoxon test or Kruskal -Wallis test, x~2 test, Single-factorLogistic Regression Analysis, Multi-factors Logistic Regression Analysis andCorrespondence Analysis, etc. All tests are double-tailed tests and indicate a statisticsignificance when P＜0.05.
Contents
Combining the domestic and foreign literatures with the specialists panel discussion,based on the enlightenment of Chinese traditional cultural death attitude and modern deathattitude and the research of cancer informing strategy, in theory to probe into the deathattitude in our country and the relevant theories of cancer informing strategy; Probing intothe death attitude and treatment attitude towards terminal cancer in different groups ofpersons(medical personnel and non-caner patients, cancer patients and their families),comparing the differences and affected factors of death attitude and treatment attitudetowards terminal cancer in persons with different background, so to establish an academic foundation for better cancer disclosure and death education; Investigating the attitude ofdifferent people towards cancer disclosure to liberate the medical staff and family membersfrom the dilemma of telling or not and to establish a foundation of making scientificmedical service policy and institution. Comparing the choices and its affected factors ofcancer disclosure strategies in persons with different background, probing into the suitableperson, time, place, content, way, and degree and so on for cancer disclosure to get ascientific strategy of cancer disclosure; Investigating the psychological alteration of cancerpatients and their family members after getting a cancer diagnosis to provide evidence toscientific care intervention; Analyzing the relationship of the attitudes between death,terminal cancer treatment and cancer disclosure to probe into an approach to enhance andimprove the cancer disclosure strategies.
Results
1. Most patients approved dying painless and with dignity and comfort, at the same time,had a strong will to live and hoped for an active treatment from the medical staff andfamily members; they could accept the death, but had some sort of denying and suspecting.age, residence, history of contacting critical patients, experience of attending funeral andreligious belief were predictors of attitudes of the patients with cancer towards thetreatment of advanced cancer and death (P＜0.05 or P＜0.01).
2. The families of cancer patients assented to relegate medical therapy with an equivocalattitude to euthanasia; they showed avoidance to death despite that they could accept theend of life. Sex, marriage, education, bereavement experience, contacts to serious illness,religious belief were predictors of attitudes of the families of cancer patients towardsthe treatment of advanced cancer and death(P＜0.05 or P＜0.01).
3. Part of the medical staff showed ambivalent feelings about the treatment in the finalstage and showed evasion and rejection in attitude toward death. Those who had history ofcaring critical patient and experience of bereavement were tend to disapproving thatterminal-illed patients should live strongly. Those who have experience of death disposal were tend to approve of relieving the pain, providing dignity and establishing the last wishof treatment. (P＜0.05 or P＜0.01).
4. "Hospice care" and "euthanasia" and other bioethical concept had been able to berecognized and accepted by the most of people; residence, age, personality, gender, familyincome and hospital experience were predictors of the non-cancer patients' attitudestoward the treatment of terminal cancer and death(P＜0.05 or P＜0.01).
5. The medical staff prefer discussing death and rational treatment; family income permonth was risk factor for discussing death; education background was risk factor forrational treatment. All factors above based on the statistic evidence (P＜0.05 or P＜0.01).
6. Cancer patients generally expected to know the real state of the illness. They suggestedthat most of them didn't know their real condition completely and get the psychologicalsupport that they really wanted under the influence of protective medical care, which mightinduce their distrust of the medical staff. The patients' attitudes towards informingcritical illness were significantly affected by the gender, marriage status, personality,duration of cancer information, hospitalization experience and funeral experience, withsignificant statistical differences (P＜0.05 or P＜0.01).
7. Most family members believed that the medical staff should inform cancer patients abouttheir diseases after getting consent from their family members. The Logistic Regressionanalysis suggested that the time of being informed, education background, experiences oftaking care of critical patients and bereavement influenced the attitudes of family memberstowards the cancer disclosure (P＜0.05 or P＜0.01).
8. Some medical staff had a serious attitude towards cancer disclosure and didn't agree totell the truth totally, whose attitude was based on that of the patients in a sense, and agreedthe family members to determine the informing. Besides, most of them didn't think thepatients had gotten the disease thoroughly. Logistic regression analysis revealed thatdepartment, occupation, job title, education background, experience of serious illness andhospitalization, a history of exposure to serious illness and dealing with death were the main factors affecting medical staff's attitude towards cancer disclosure (P＜0.05 or P＜0.01).
9. Non-cancer Patients showed ambivalent feelings about cancer disclosure and directedagainst medical staff when medical staff, cancer patients and cancer patients' families hadconflict in the course of cancer disclosure. Their attitudes toward cancer-telling weresignificantly affected by their residence and hospitalization experience (P＜0.05 or P＜0.01).
10. Background information on the impact of different groups of people are full ofcontradictions, only the role of different groups has a statistically significant difference inattitudes (P＜0.05 or P＜0.01); cancer patients' informed attitudes and their desire ofinformed consent were most active, and self-evaluation of their conditions was the highest.family members are not the main obstacle to the truth disclosure, while the attitudes ofnon-cancer patients and medical staff are most conservative.
11. Most of the patients hoped to discuss with the professionals of cancer face to face oncediagnosed, besides, being ensured hopefully and accompanied by their relatives. Theresults of Logistic analysis showed that women, married, the patient with outgoingpersonality and minding talk about death supported for family members joining disclosure;the patient with previous hospital experience and less severe condition consciousnessapproved more timely truth-telling; the patient with higher education agreed on doctorsinforming directly.
12. The family members of cancer patients stressed the importance of psychologicalevaluation of the patients, and emphasized the role they played in the process of cancertelling. They also demanded the informing arts of medical staff and relatively agreed withthe selective inform pattern more. The results of Logistic analysis showed thatresidence, gender, occupation, experience of caring the serious illness, duration after beinginformed, experience of attending funeral and bereavement, religious belief and the attitudetowards talking about death were influential factors for the family members to choose the disclosure strategy(P＜0.05 or P＜0.01).
13. Medical staff got higher scores in preparation of cancer disclosure and highly agreedthat cancer patients should be informed with the emotional support of their families and ina quiet private environment once diagnosed and by a cancer disclosure group whichconsisted of the medical staff and patients' families and repeatedly informed the patients ina step by step plan. The results of Logistic analysis showed that experience ofserious illness and hospitalization, education background, family mensal income,experience of attending funeral and bereavement and dealing with death, job title anddepartment were influential factors for the medical staff's to evaluate and choose cancer-informing strategy (P＜0.05 or P＜0.01)
14. The general public agreed more with the families' consent and participation in cancerdisclosure. Noncancer patients with history of contact with severely ill patients far moreagreed on items of "allow family members to keep patients' company during disclosure"and " face-to-face disclosure " than those without such history; manual laborers far moreagreed on items of "do not allow disclosure to an outsider" than office workers.
15. After a period of psychological adjustment, most patients and their families couldcalmly accept the reality of cancer. After being informed of cancer diagnosis, most of thepatients and their families showed negative sentiment, and whether at the time of the cancerdisclosure, or after a period of time, the incidence of the adverse mood of the families ishigher than that of the patients themselves. The results of Logistic analysis suggested thatthe age, gender, funeral experiences were the influencing factors of the patients and theirfamilies to produce adverse mood (P＜0.05 or P＜0.01).
16. There was a close relationship between the attitude towards death and the attitudetowards disclosure: the people who could accept the deaths were more likely to have apositive attitude towards cancer disclosure, adversely, people who had a vague attitudetowards death were apt to have an ambiguous attitude towards cancer disclosure; the peoplewho couldn't accept death were more likely to deny cancer disclosure.
Conclusion
1. It is feasible to tell the patients and their family members the real condition; the medicalstaffs should especially think much of the full right of consent of those patients andfamilies who are male, married and experienced hospitalization and funeral experiences,fully realize and understand the cancer patients and their relatives' dilemma mood of theterminal cancer treatment, inquire their last wish for terminal treatment, see them off in thecomfortable, dignity and satisfactory dying process.
2. Principle of no cheating should be obeyed especially for those patients who are in theearly stage of diagnosis. Humanized cancer disclosure strategy should consider thepersonal background, personality, health history and the attitude towards death of thepatient, etc; and need to assess the desire to know of cancer patients, identify the patientsbeing informed; and need to establish a separate conversation room to ensure that theinterference is not exist in the cancer disclosure environment; need the accompaniment andemotional support of the family members; need the doctors' fully fulfillment of theirdisclosure responsibility and telling the disease diagnosis and changes in time; need todesigned, step-by-step and repeatedly inform, and reserve room for hope;need observe andevacuate the ill-natured emotion of patients after informed the real condition.
3. Medical staff should avoid conflicting with family members and develop the harmonicmedical relationship. Health professionals should pay attention to the families of thehumanistic care and actualize the psychological intervention and health education varyfrom person to person and should fully aware and understand the ambivalent mood aboutthe terminal cancer therapy and cancer disclosure of patients and families, Medical staffshould respect the opinions of the families, especially with high academic qualifications,more experienced, either consult and cooperate with them or educate and guide them, and itis better to give the family members a psychological adaptation period before telling thetrue condition of cancer to the patients, at the same time encourage families tocommunicate with patients, provide patients for adequate psychological and social support.
4. Medical staff should try to overcome the error in the understanding of cancer disclosureand be responsible for improving the quality of life, initiate the research of cancerdisclosure strategies, volunteer to study and practice the knowledge of psychology,sociology and communication, strengthen exchanges and communication betweencolleagues, pay attention to enriching and accumulating of their own life and workexperiences and manage to self-culture the natural and optimistic attitude towards life anddeath, continuously improve the cancer disclosure skills; the patients' roles playing, as wellas the establishment of the routing training systems of hospice care wards, ICU and so onare feasible ways for the medical staff to enhance the life and death cognition and thecancer disclosure responsibility.
5. The realization of the transition from "respect for the views of family members" to"respect the rights of people" and from "curative treatment" to "palliative care" need amore open atmosphere for death and cancer disclosure, and early intervention in thetargeted death education, and constant reduction of the difference between urban and ruralareas, and development and promotion of social economy and culture level, need in allsectors of the whole society to work together as well as need to guide actively by all themedical staff. Through carrying out the death and life education by the utilization of themass multi-channel approach, can change people's attitude towards cancer disclosure,improve patients' consent status. The cancer patients who are less experienced, young andrural are the emphasized person for death education.
6. "Hospice care" and "euthanasia" and other bioethical concept gradually become themainstream of today's society. So on this basic, the government can constitute relevantpolicies and regulations. The government should implement the Chinese characterizedhospice care to meet the cancer patients' need and vigorously publicize it, should makeeffort to achieve the consensus of "while anti-disease-free, treat the disease in time, hospicecare while no cure " in the whole society.
Innovation
1. This study was to explore truth-telling strategy by the approaching of the brand-newperspective of death attitude and the attitude of the treatment of terminal cancer.
2. On the basis of informed consent in cancer patients, the sensitive issues, such as theattitude towards cancer disclosure, the treatment of terminal cancer and death survey werecarried out
3. This study was conducted through multidimension, and the research on non-cancerpatients was filling the blank at home and abroad.
癌症已经成为全球首要的疾病死亡原因，我国每年的发病率正逐年上升。由于癌症的治愈困难和预后差，使得向患者告知癌症诊断和病情不亚于向患者宣布“预期死亡”。这样，是否告知以及如何告知癌症病情一直是社会颇为争议的问题。在我国独特的文化背景下，临床医护人员通常是先将真实病情告知家属，再根据家属的意见决定是否告知患者。且家属普遍高估患者获知真实诊断的负性情绪，不主张将实情相告。近年来，越来越多的研究表明，医疗坏消息的告知是可行的，且癌症患者对知情权的呼声也越来越高，我国的这种告知模式正面临着严峻的挑战。并且，在癌症告知的过程中，人们对死亡有许多的不接受，达到或超过50％的治疗费用被用于延长晚期癌症患者痛苦的死亡过程。这些均不利于癌症患者在生命的最后阶段获得真正的舒适、尊严和满足，不利于卫生资源的有效利用。
本课题对此进行研究，为更好进行死亡教育和开展癌症告知奠定理论基础，让癌症患者理解生与死是人类自然生命的历程，既能善待生命，珍惜生命，又能勇敢正视疾病，坦然面对死亡；为更好尊重和满足癌症患者知情同意权，努力实现从“尊重家属的意见”到“尊重患者的权利”的转变提供科学依据；寻求最佳的告知人员、时间、内容、程度等，让癌症病情告知更温情、更人道、更科学、更理性，在“告诉事实”和“避免伤害”的冲突中取得最大的平衡；摸索出有效的护理干预措施，让患者在不多的时间内达到一种生存的相对较高质量；为制定科学的医疗服务政策和制度提出意见和建议，使得卫生事业的发展更有利于满足癌症患者的需求，更有利于社会公众的利益。
二、研究方法
本研究运用文献检索分析法、专家咨询法和专题小组讨论法等，探讨我国死亡观以及癌症告知的相关理论，研制不同人群死亡态度和癌症告知的问卷调查表。对某三级甲等医院医护人员634名、门诊患者307名、住院癌症患者302名、癌症患者家属305名，共计1548名不同人群进行现场调查；采用EpiData3．1软件，双录入法进行资料录入，用SPSS13．0软件进行数据分析。分析包括一般统计描述性分析、Wilcoxon检验或Kruskal-Wallis检验、χ~2检验、单因素Logistic回归分析、多因素Logistic回归分析、对应性分析等。全部检验均为双侧检验，P值＜0．05时有统计学意义。
三、研究内容
查阅国内外相关文献，结合专家小组讨论，基于中国传统文化的死亡观和现代的死亡观对我们现代医学的启示以及癌症告知策略的研究，从理论上探讨我国死亡观以及癌症告知策略的相关理论：探索不同人群(医护人员、普通患者、癌症患者和其家属)的死亡态度和癌症终末治疗态度，比较不同背景资料人群死亡态度和癌症终末治疗态度的差异及其影响因素，为更好开展癌症告知和进行死亡教育奠定理论基础；调查不同人群对癌症告知的态度，让医护人员和家属从“告知”与“不告知”的两难处境中解脱出来，为制定科学的医疗服务政策和制度奠定基础。比较不同背景资料人群对癌症告知策略的选择及其影响因素，探索适合癌症告知的人员、时间、地点、内容、方式和程度等，寻求科学的癌症病情告知策略；研究癌症患者和其家属在获知癌症诊断后心理变化，为科学开展护理干预提供依据；分析死亡态度和癌症告知态度之间的关联，摸索增进和完善癌症告知策略的途径。
四、研究结果
1．大部分患者既赞同无痛苦、有尊严地安乐死亡，又表现强烈对生的留念，希望医护人员和家属进行积极救治；能够接受死亡，但同时存在否认或侥幸心理。年龄、家庭住地、重病接触经历、丧礼经历及宗教信仰等因素对癌症患者的终末治疗和死亡态度的评分有一定影响(P＜0．01或P＜0．05)。
2．癌症患者家属赞成终末期淡化治疗，但对安乐死态度模糊；能够平静接受生命终结，但对死亡仍显忌讳。性别、婚姻、文化程度、丧亲经历、重病接触经历和宗教信仰等对癌症患者家属癌症终末治疗和死亡态度问题的评分有一定影响(P＜0．01或P＜0.05)。
3．医护人员对癌症终末期患者的治疗存在矛盾心理，对死亡持有回避和拒绝的态度；有危重患者接触史、丧亲经历者更倾向于不赞同“患者应坚强活下来”；有处置死亡经历者更倾向于赞同“减轻痛苦和提供尊严”、“建立治疗遗愿”(P＜0．01或P＜0．05)。
4．“临终关怀”和“安乐死”等生命伦理学观念已经能够被相对部分的人群所认可和接受；住地、年龄、性格、性别、家庭收入和住院经历等因素对普通门诊患者的终末治疗和死亡态度的评分有一定影响(P＜0．01或P＜0．05)。
5．医护人员较其他人群更倾向于不介意谈论死亡和对终末治疗更理性，家庭人均月收入是谈论死亡的危险因素，文化程度是理性治疗的危险因素，差异均有统计学意义(P＜0．01或P＜0．05)。
6．癌症患者非常希望了解真实病情，他们认为保护性医疗会导致对医护人员的不信任、让他们得不到真正的心理关怀；男性、既往有住院经历和丧礼经历的患者对待重症疾病的告知态度更积极。获知疾病时间≤1月者比＞1月者更倾向于对医护人员的欺骗产生不信任感；已婚者、男性比未婚者和女性更倾向于对隐瞒重症病情十分不满。
7．大多数家属主张在征求他们同意后，将真实病情告知癌症患者；Logistic回归分析显示，获知亲人患癌时间、文化程度、重病接触史、丧亲经历等因素对家属的癌症病情告知态度的评分具有一定影响(P＜0．01或P＜0．05)。
8．医务人员对癌症病情告知所持的态度较慎重，不十分赞同将真情完全告知患者，其告知意愿在一定程度上取决于患者的知情愿望，他们比较认同家属拥有决策权，且普遍认为患者不是充分知晓病情；Logistic回归分析显示，科室、职业、职称、文化程度、重病经历、住院经历、重病接触史、处理死亡经历是影响医护人员对癌症病情告知态度的主要因素(P＜0．01或P＜0．05)。
9．普通患者对癌症告知的态度比较模糊，对待癌症告知过程中医护人员、癌症患者和癌患家属三者之间的冲突，仍有相对部分的人群将矛头指向医护人员；住地和住院经历对普通患者的癌症病情告知态度的评分有一定影响(P＜0．01或P＜0．05)。
10．背景资料对不同人群的影响充满矛盾，仅不同角色人群的态度差异具有统计学意义(P＜0．01或P＜0．05)：癌症患者告知态度和知情愿望最积极，知情程度自评最高；家属并非告知主要障碍，普通患者和医护人员的告知态度最为保守。
11．大部分癌症患者主张在确诊时，有家人陪伴，由肿瘤专科医生面对面地直接将真实病情完全告知，并让患者获得治疗的希望。Logistic回归分析结果显示，女性、已婚、性格外向和介意谈论死亡者更支持家属参与告知；有既往住院经历和自觉病情较轻者更主张及时告知；文化程度高者更赞同医生直接告知。
12．癌症患者家属首要重视对患者的心理承受力的评估、十分强调自身在告知过程中的作用、特别讲求医护人员的告知艺术、比较赞同采取选择性部分告知。Logistic回归分析显示，性别、住地、职业、重病接触史、知情时间、丧亲经历、丧礼经历、宗教信仰以及谈论死亡的态度等因素对家属选择癌症告知策略具有一定影响(P＜0．01或P＜0．05)。
13．医护人员对癌症告知前准备的评分较高，比较赞同确诊时，在家属的情感支持下，在一个安静的私密环境中，由医护人员和家属组成的告知小组，共同商讨，进行有计划分步多次告知；Logistic回归分析显示，住院经历、重病经历、文化程度、家庭月收入、丧礼经历、危重病人接触史、处置死亡经历、职称和工作科室是医护人员癌症病情告知各项策略评价与选择的影响因素(P＜0．01或P＜0．05)。
14．普通公众对告知时家属的同意与参与较为认同。有危重病接触史者比无重病接触史者更赞同癌症告知时“有家属陪伴”以及“面对面直接口头交流”。体力劳动者比脑力劳动者更加主张癌症告知时“避免让与疾病不相关的人知道病情”。
15．经过一段时间的心理适应期，大多数患者和家属都可以平静地接受患癌现实；获知癌症诊断后，绝大多数癌症患者及其家属都存在不良情绪，且无论是癌症告知当时，还是经过一段时间之后，家属组均较患者组倾向于拥有更多的“不良情绪”；Logistic回归分析显示，年龄、性别、丧礼经历等是癌症患者及其家属产生不良情绪的影响因素(P＜0．01或P＜0．05)。
16．死亡态度和告知态度关系紧密：能够接受死亡的人更倾向于对癌症告知持积极态度，对接受死亡处于模糊态度者更倾向于癌症告知的含糊态度；持不接受死亡的态度者更倾向于不主张癌症告知。
五、研究结论与政策建议
1．向癌症患者及其家属告知真实病情是可行的；医护人员要特别注意让男性、已婚、有住院经历和丧礼经历的患者或家属享有充分的知情同意权，充分认识和理解癌症患者的矛盾心理，咨询他们对终末治疗的遗愿，护送他们在舒适、尊严和满足中走完人生的最后旅程。
2．对初期确诊的癌症患者，一定要遵循“不欺骗”原则；人性化癌症告知策略需要考虑患者的个人背景、个性特征、患病史和对待死亡的态度等；需要评估癌症患者的知情愿望，明确告知的对象；建立单独的谈话室，确保不被干扰的告知环境；需要家人的陪伴，提供情感的支持；需要医生充分履行告知的职责，及时告知病情诊断和变化；需要计划、分步、多次告知，并留下余地和希望；告知真实病情后，需要注意观察和疏导患者的不良情绪。
3．避免与家属之间的矛盾和冲突，构建和谐的医疗关系，医护人员应该重视家属的人文关怀，因人而异地对他们实施心理干预和健康教育。充分认识和理解癌患家属对癌症终末治疗和癌症告知的矛盾心理，征询家属的意见，尤其是对学历高、阅历深的家属，与他们或协商合作、或教育引导，且最好在家属经过一段时间的心理适应期之后，再向患者告知癌症真实病情，同时鼓励家属与患者沟通，为患者提供充分的心理和社会支持。
4．医护人员要努力克服在癌症告知认识上的误区，以优化生命全程为己任，积极开展癌症告知策略的研究，自觉加强与医疗有关的心理学、社会学以及人际交往等方面知识的学习与实践，加强同行交流与沟通，注重自身人生经历和工作经历的丰富和积累，努力培养对生死的自然达观态度，不断提高癌症的告知技巧；开展病人角色扮演等方式的教育，建立临终关怀病房和重症监护病房的常规培训制度等是增强医护人员对生命死亡认识和癌症告知责任感的可探索途径。
5．实现从“尊重家属的意见”到“尊重患者的权利”的转变，实现治疗向照料的转变，需要营造一个对死亡和癌症告知更加开明的氛围，需要早期针对性死亡教育的干预，需要城乡差别的不断缩小，需要社会经济和文化水平的发展和提高，需要社会各方共同努力，需要广大医护人员的积极引导。采用大众传媒多渠道地进行生命死亡教育能够改变人们对待癌症告知态度，改善患者对癌症的知情现状。人生经历少的、年轻的、农村的等特点的癌症患者医护人员进行死亡教育的重点人员。
6．“临终关怀”和“安乐死”等生命伦理学观念正逐步成为当今社会的主流思想，国家制定相关的政策和法规已经有了一定的认识基础；国家应大力开展具有中国特色的临终关怀以满足广大癌症患者的需求并加大宣传，努力促成全社会“无病则防，有病则治，治不好则临终关怀”的共识。
六、创新之处
1．本研究从死亡态度和癌症终末治疗态度这一崭新的角度，探寻癌症患者的病情告知策略。
2．在癌症患者知情同意的基础上，对癌症告知、癌症终末治疗和死亡态度等敏感问题进行调查。
3．本研究多维度研究癌症患者的病情告知态度和策略，普通门诊患者的调查是国内外空白。
Objectives
Cancer has become the world's foremost cause of death in illness and annual incidencerate is increasing year by year in China. Due to cancer cure difficulties and poor prognosis,made to inform patients of cancer diagnosis and condition inferior to that of "expecteddeath". Thus, it is a social condition rather than controversial issue of telling the cancerpatients the truth or not and how to tell. In the unique culture background of our country,medical staff usually tell the true condition of the patients to their families before making adecision of telling the patients or not according to their families' opinions. Moreover,families don't agree to tell the truth to the patients in consideration of the patients' strongnegative reaction to the true diagnosis. More and more studies have indicated that it isfeasible to tell the patients the medical bad news and the cancer patients' voice of right toknow is higher and higher. Under these circumstances, our country's disclosure mode isfacing severe challenges. What's more, people have many things unaccepted towards deathduring the process of cancer information, 50% or more medical expenditure are used in theprolongation of the painful dying process of the terminal cancer patients. These are neitherbeneficial for the cancer patients to get true comfort, dignity and satisfaction in the finalstages of life, nor for the effective use of health resources.
This study focus on the above issues, building an academic foundation for the betterdeath education and cancer disclosure to make cancer patients understand that life anddeath are the natural course of human being, treat life, cherish life, but also bravely facedisease and death. Trying to supply a scientific evidence for the transition from "respectingthe families' opinion" to "respecting patients' right" so to better respect and satisfy thecancer patients' consent right; Seeking for the best disclosure staff, time, content and degree to make the cancer disclosure more warm, humanistic, scientific and rational, to geta best balance between "telling the truth" and "avoiding hurt"; seeking for the effectivecare interventions so to make the patients get a relatively higher life quality in the limitedlife; supplying opinions and suggestions for the constitution of the medical service policyand system to make the progress of health career more beneficial to cancer patients and thepublic Interests.
Methods
This research apply document retrieval, expert counseling and specialists paneldiscussion to discuss the death concept and relevant theories of cancer disclosure in ourcountry and develop questionnaires on death attitude and cancer disclosure of differentgroups of people. 634 medical staff, 307 non-cancer patients, 302 hospitalized cancerpatients, 305 relatives of cancer patients, together 1548 people of a level three group Ahospital were investigated on the spot; the data was recorded with software EpiData3.1and double-entry method and analyzed with SPSS13.0 software. Analysis includes generalstatistic description analysis, Wilcoxon test or Kruskal -Wallis test, x~2 test, Single-factorLogistic Regression Analysis, Multi-factors Logistic Regression Analysis andCorrespondence Analysis, etc. All tests are double-tailed tests and indicate a statisticsignificance when P＜0.05.
Contents
Combining the domestic and foreign literatures with the specialists panel discussion,based on the enlightenment of Chinese traditional cultural death attitude and modern deathattitude and the research of cancer informing strategy, in theory to probe into the deathattitude in our country and the relevant theories of cancer informing strategy; Probing intothe death attitude and treatment attitude towards terminal cancer in different groups ofpersons(medical personnel and non-caner patients, cancer patients and their families),comparing the differences and affected factors of death attitude and treatment attitudetowards terminal cancer in persons with different background, so to establish an academic foundation for better cancer disclosure and death education; Investigating the attitude ofdifferent people towards cancer disclosure to liberate the medical staff and family membersfrom the dilemma of telling or not and to establish a foundation of making scientificmedical service policy and institution. Comparing the choices and its affected factors ofcancer disclosure strategies in persons with different background, probing into the suitableperson, time, place, content, way, and degree and so on for cancer disclosure to get ascientific strategy of cancer disclosure; Investigating the psychological alteration of cancerpatients and their family members after getting a cancer diagnosis to provide evidence toscientific care intervention; Analyzing the relationship of the attitudes between death,terminal cancer treatment and cancer disclosure to probe into an approach to enhance andimprove the cancer disclosure strategies.
Results
1. Most patients approved dying painless and with dignity and comfort, at the same time,had a strong will to live and hoped for an active treatment from the medical staff andfamily members; they could accept the death, but had some sort of denying and suspecting.age, residence, history of contacting critical patients, experience of attending funeral andreligious belief were predictors of attitudes of the patients with cancer towards thetreatment of advanced cancer and death (P＜0.05 or P＜0.01).
2. The families of cancer patients assented to relegate medical therapy with an equivocalattitude to euthanasia; they showed avoidance to death despite that they could accept theend of life. Sex, marriage, education, bereavement experience, contacts to serious illness,religious belief were predictors of attitudes of the families of cancer patients towardsthe treatment of advanced cancer and death(P＜0.05 or P＜0.01).
3. Part of the medical staff showed ambivalent feelings about the treatment in the finalstage and showed evasion and rejection in attitude toward death. Those who had history ofcaring critical patient and experience of bereavement were tend to disapproving thatterminal-illed patients should live strongly. Those who have experience of death disposal were tend to approve of relieving the pain, providing dignity and establishing the last wishof treatment. (P＜0.05 or P＜0.01).
4. "Hospice care" and "euthanasia" and other bioethical concept had been able to berecognized and accepted by the most of people; residence, age, personality, gender, familyincome and hospital experience were predictors of the non-cancer patients' attitudestoward the treatment of terminal cancer and death(P＜0.05 or P＜0.01).
5. The medical staff prefer discussing death and rational treatment; family income permonth was risk factor for discussing death; education background was risk factor forrational treatment. All factors above based on the statistic evidence (P＜0.05 or P＜0.01).
6. Cancer patients generally expected to know the real state of the illness. They suggestedthat most of them didn't know their real condition completely and get the psychologicalsupport that they really wanted under the influence of protective medical care, which mightinduce their distrust of the medical staff. The patients' attitudes towards informingcritical illness were significantly affected by the gender, marriage status, personality,duration of cancer information, hospitalization experience and funeral experience, withsignificant statistical differences (P＜0.05 or P＜0.01).
7. Most family members believed that the medical staff should inform cancer patients abouttheir diseases after getting consent from their family members. The Logistic Regressionanalysis suggested that the time of being informed, education background, experiences oftaking care of critical patients and bereavement influenced the attitudes of family memberstowards the cancer disclosure (P＜0.05 or P＜0.01).
8. Some medical staff had a serious attitude towards cancer disclosure and didn't agree totell the truth totally, whose attitude was based on that of the patients in a sense, and agreedthe family members to determine the informing. Besides, most of them didn't think thepatients had gotten the disease thoroughly. Logistic regression analysis revealed thatdepartment, occupation, job title, education background, experience of serious illness andhospitalization, a history of exposure to serious illness and dealing with death were the main factors affecting medical staff's attitude towards cancer disclosure (P＜0.05 or P＜0.01).
9. Non-cancer Patients showed ambivalent feelings about cancer disclosure and directedagainst medical staff when medical staff, cancer patients and cancer patients' families hadconflict in the course of cancer disclosure. Their attitudes toward cancer-telling weresignificantly affected by their residence and hospitalization experience (P＜0.05 or P＜0.01).
10. Background information on the impact of different groups of people are full ofcontradictions, only the role of different groups has a statistically significant difference inattitudes (P＜0.05 or P＜0.01); cancer patients' informed attitudes and their desire ofinformed consent were most active, and self-evaluation of their conditions was the highest.family members are not the main obstacle to the truth disclosure, while the attitudes ofnon-cancer patients and medical staff are most conservative.
11. Most of the patients hoped to discuss with the professionals of cancer face to face oncediagnosed, besides, being ensured hopefully and accompanied by their relatives. Theresults of Logistic analysis showed that women, married, the patient with outgoingpersonality and minding talk about death supported for family members joining disclosure;the patient with previous hospital experience and less severe condition consciousnessapproved more timely truth-telling; the patient with higher education agreed on doctorsinforming directly.
12. The family members of cancer patients stressed the importance of psychologicalevaluation of the patients, and emphasized the role they played in the process of cancertelling. They also demanded the informing arts of medical staff and relatively agreed withthe selective inform pattern more. The results of Logistic analysis showed thatresidence, gender, occupation, experience of caring the serious illness, duration after beinginformed, experience of attending funeral and bereavement, religious belief and the attitudetowards talking about death were influential factors for the family members to choose the disclosure strategy(P＜0.05 or P＜0.01).
13. Medical staff got higher scores in preparation of cancer disclosure and highly agreedthat cancer patients should be informed with the emotional support of their families and ina quiet private environment once diagnosed and by a cancer disclosure group whichconsisted of the medical staff and patients' families and repeatedly informed the patients ina step by step plan. The results of Logistic analysis showed that experience ofserious illness and hospitalization, education background, family mensal income,experience of attending funeral and bereavement and dealing with death, job title anddepartment were influential factors for the medical staff's to evaluate and choose cancer-informing strategy (P＜0.05 or P＜0.01)
14. The general public agreed more with the families' consent and participation in cancerdisclosure. Noncancer patients with history of contact with severely ill patients far moreagreed on items of "allow family members to keep patients' company during disclosure"and " face-to-face disclosure " than those without such history; manual laborers far moreagreed on items of "do not allow disclosure to an outsider" than office workers.
15. After a period of psychological adjustment, most patients and their families couldcalmly accept the reality of cancer. After being informed of cancer diagnosis, most of thepatients and their families showed negative sentiment, and whether at the time of the cancerdisclosure, or after a period of time, the incidence of the adverse mood of the families ishigher than that of the patients themselves. The results of Logistic analysis suggested thatthe age, gender, funeral experiences were the influencing factors of the patients and theirfamilies to produce adverse mood (P＜0.05 or P＜0.01).
16. There was a close relationship between the attitude towards death and the attitudetowards disclosure: the people who could accept the deaths were more likely to have apositive attitude towards cancer disclosure, adversely, people who had a vague attitudetowards death were apt to have an ambiguous attitude towards cancer disclosure; the peoplewho couldn't accept death were more likely to deny cancer disclosure.
Conclusion
1. It is feasible to tell the patients and their family members the real condition; the medicalstaffs should especially think much of the full right of consent of those patients andfamilies who are male, married and experienced hospitalization and funeral experiences,fully realize and understand the cancer patients and their relatives' dilemma mood of theterminal cancer treatment, inquire their last wish for terminal treatment, see them off in thecomfortable, dignity and satisfactory dying process.
2. Principle of no cheating should be obeyed especially for those patients who are in theearly stage of diagnosis. Humanized cancer disclosure strategy should consider thepersonal background, personality, health history and the attitude towards death of thepatient, etc; and need to assess the desire to know of cancer patients, identify the patientsbeing informed; and need to establish a separate conversation room to ensure that theinterference is not exist in the cancer disclosure environment; need the accompaniment andemotional support of the family members; need the doctors' fully fulfillment of theirdisclosure responsibility and telling the disease diagnosis and changes in time; need todesigned, step-by-step and repeatedly inform, and reserve room for hope;need observe andevacuate the ill-natured emotion of patients after informed the real condition.
3. Medical staff should avoid conflicting with family members and develop the harmonicmedical relationship. Health professionals should pay attention to the families of thehumanistic care and actualize the psychological intervention and health education varyfrom person to person and should fully aware and understand the ambivalent mood aboutthe terminal cancer therapy and cancer disclosure of patients and families, Medical staffshould respect the opinions of the families, especially with high academic qualifications,more experienced, either consult and cooperate with them or educate and guide them, and itis better to give the family members a psychological adaptation period before telling thetrue condition of cancer to the patients, at the same time encourage families tocommunicate with patients, provide patients for adequate psychological and social support.
4. Medical staff should try to overcome the error in the understanding of cancer disclosureand be responsible for improving the quality of life, initiate the research of cancerdisclosure strategies, volunteer to study and practice the knowledge of psychology,sociology and communication, strengthen exchanges and communication betweencolleagues, pay attention to enriching and accumulating of their own life and workexperiences and manage to self-culture the natural and optimistic attitude towards life anddeath, continuously improve the cancer disclosure skills; the patients' roles playing, as wellas the establishment of the routing training systems of hospice care wards, ICU and so onare feasible ways for the medical staff to enhance the life and death cognition and thecancer disclosure responsibility.
5. The realization of the transition from "respect for the views of family members" to"respect the rights of people" and from "curative treatment" to "palliative care" need amore open atmosphere for death and cancer disclosure, and early intervention in thetargeted death education, and constant reduction of the difference between urban and ruralareas, and development and promotion of social economy and culture level, need in allsectors of the whole society to work together as well as need to guide actively by all themedical staff. Through carrying out the death and life education by the utilization of themass multi-channel approach, can change people's attitude towards cancer disclosure,improve patients' consent status. The cancer patients who are less experienced, young andrural are the emphasized person for death education.
6. "Hospice care" and "euthanasia" and other bioethical concept gradually become themainstream of today's society. So on this basic, the government can constitute relevantpolicies and regulations. The government should implement the Chinese characterizedhospice care to meet the cancer patients' need and vigorously publicize it, should makeeffort to achieve the consensus of "while anti-disease-free, treat the disease in time, hospicecare while no cure " in the whole society.
Innovation
1. This study was to explore truth-telling strategy by the approaching of the brand-newperspective of death attitude and the attitude of the treatment of terminal cancer.
2. On the basis of informed consent in cancer patients, the sensitive issues, such as theattitude towards cancer disclosure, the treatment of terminal cancer and death survey werecarried out
3. This study was conducted through multidimension, and the research on non-cancerpatients was filling the blank at home and abroad.
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