Factors associated with good death of patients with advanced cancer: A prospective study in Japan

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We aimed to clarify factors associated with "good death" evaluated by the Good Death Scale (GDS) score among inpatients with advanced cancer in palliative care units (PCUs) in Japan. Methods: The study is a sub-analysis of a multicenter prospective cohort study conducted in Japan. All variables were recorded on a structured data collecting sheet designed for the study. We classified each patient into better GDS group or worse GDS group, and examined factors associated with better GDS using multivariate analysis. Results: Between January to December in 2017, 1896 patients were enrolled across 22 PCUs in Japan. Among them, a total of 1157 patients were evaluated. Five variables were significantly associated with a better GDS score in multivariate analysis: preferred place of death at PCU (odds ratio [OR] 2.85; 95% confidence interval [CI] 1.72–4.71; p < 0.01), longer survival time (OR 1.02; 95% CI 1.00–1.03; p < 0.01), not sudden death (OR 1.96; 95% CI 1.27–3.04; p < 0.01), better spiritual well-being Integrated Palliative Outcome Scale in the last 3 days in life (OR 0.53; 95% CI 0.42–0.68; p < 0.01) and better communication between patient and family (OR 0.81; 95% CI 0.66–0.98; p = 0.03). Conclusions: We clarified factors associated with "good death" using GDS among advanced cancer patients in Japanese PCUs. Recognition of factors associated with GDS could improve the quality of end-of-life care. Good death scale Palliative care End-of-life care Advanced cancer Palliative care unit Figures Figure 1 Key Message The multicenter prospective cohort study identified five factors associated with good death in patients admitted to palliative care units; preferred place of death at palliative care units, longer survival time, not sudden death, better spiritual well-being in the last 3 days in life, and better communication between patient and family. Introduction “Good death” is one of the primary goals of palliative care. There are various definitions for “good death” in different cultural contexts [ 1 ]. It is important for palliative care providers to identify what factors are associated with "good death" which refers to the quality of dying (QOD) for the patient with advanced cancer [ 2 – 11 ]. To date, many studies [12.13] have reported the factors associated with better QOD, such as preparing for death, dying comfortably, adequate symptom control, and clear decision-making. The Good Death Inventory (GDI) was developed to evaluate good death in Japanese patients with advanced cancer. The GDI was evaluated by the bereaved family member, using the 18 domains such as "environmental comfort," "life completion", and "dying in a favorite place" [ 2 – 4 ]. The survey of bereaved families using GDI is limited by the fact that some bereaved families may feel that responding using the GDI is painful or uncomfortable; this psychological stress may cause a low response rate to the questionnaires [ 6 ]. Meanwhile, the Good Death Scale (GDS) is an objective measure of good death developed in Taiwan. It has been verified to be reliable and valid in palliative care units (PCUs) in Taiwan [ 7 – 11 ]. To date, most previous studies have reported the QOD evaluated by patients or families, and few studies investigated QOD using GDS in Japan. In addition, there have been few studies about the factors associated with better GDS scores specifically. We considered that recognizing the factors associated with GDS could help improve the quality of end-of-life care. Thus, we aimed to clarify factors associated with better GDS score among patients with advanced cancer in PCUs in Japan. Methods Participants This study is a sub-analysis of a multicenter prospective cohort study conducted in Japan. The parent study is the East-Asian collaborative cross-cultural Study to Elucidate the Dying Process (EASED), which investigated the end-of-life care and dying process of patients with advanced cancer in PCUs nationwide in Japan. We enrolled consecutively newly admitted patients to the participating PCUs in the study duration. The inclusion criteria were as follows: (1) adult (age > = 18 years), (2) admitted to a participating PCU, and (3) suffering from locally extensive or metastatic cancer. The exclusion criteria were as follows: (1) refusal to enroll on the part of patients or their families, and (2) scheduled discharge within 7 days. All observations were performed in the course of routine clinical practice. Data collection We determined the measurement variables associated with GDS and the related demographics and clinical characteristics based on a relevant literature review. [ 2 – 4 , 7 – 11 ]. We prospectively recorded all variables on a data collecting sheet designed for this study on the first day of enrollment and at death. We collected and analyzed the following data: patients characteristics on admission (age, sex, marital status, living with family, children under age of 20 and preferred place of death) and data about death and symptoms in the last 3 days in life (sudden death, drowsiness, fatigue, dry mouth, spiritual well-being (SWB), end-of-life discussion with patient, communication between patients and families, hyperactive delirium, hallucination, dyspnea, respiratory secretion, intermit sedation, continuous deep sedation, hydration volume, days to death from last walking, eating and communicating and GDS). Measurements We analyzed the data of enrolled patients who died in PCUs, and we calculated survival time by subtracting the cases on the admission date from those on death date. If a physician answered ‘‘yes’’ to the question ‘‘Were you surprised by the timing of the death?’, we defined a priori that a patient had a sudden death [ 14 ]. As for end-of-life discussion, we determined whether the physicians informed the patients of the impending death, which was defined as the prediction of death within a few days [ 15 ]. We used the Integrated Palliative Outcome Scale (IPOS) to objectively assess patients’ symptoms (fatigue, drowsiness, dry mouth, SWB): 0, always; 1, most of the time; 2, sometimes; 3, occasionally; 4, not at all; 5, cannot assess because of unconsciousness. The Japanese version of IPOS has been reported to be a valid and reliable tool for assessing physical, psychological, spiritual and social symptoms, as well as assessing the outcomes of adult patients with cancer in Japan [16.17]. We used the Support Team Assessment Schedule (STAS) to assess communication between patients and families: 0, Communicating openly and honestly. Verbally and non-verbally.; 1, Communicating openly at some times or with some family members. Sometimes with partners or with some members of family members.; 2, Acknowledge condition but discussion does not satisfy either the patient or their family who feels full implications are not discussed. Maybe with partner but not family.; 3, Out of step, all discussions guarded.; 4, Pretending.; 8, Cannot assess. The Japanese version of STAS (STAS-J) has been reported to be verified as highly reliable [ 18 ]. We used the Memorial Delirium Assessment Scale (MDAS) to assess delirium by using items 9 (psychomotor activity); 0 (normal or psychomotor hypoactivity), 1 (mild), 2 (moderate), and 3 (severe) [ 19 ]. We assessed Hallucination using the Delirium Rating Scale-revised-98 (DRS-R-98), items 2 (perceptual disturbances and hallucinations); 0 (not present), 1 (mild perceptual disturbances), 2 (illusions present), and 3 (hallucinations present) [ 20 ]. Dyspnea was assessed as 0 (normal), 1 (exertional only) and 2 (at rest). We defined respiratory secretion as 0 (not audible), 1 (only audible at the head of the bed), 2 (clearly audible at the foot of the bed), and 3 (clearly audible at 6 m away from the foot of the bed) [ 21 ]. According to a previous study [ 22 ], we defined the last day of last walking as the day when the patients had Eastern Cooperative Oncology Group performance status (ECOG PS) 3 or less. We defined the last day of eating as the day when patients could eat more than a few bites and the last day of communicating was defined as the day when Communication Capacity Scale (CCS) was 2 or less. Thus, we defined the last day as the admission date when the patient had ECOG PS 4, could eat a few bites, and had CCS 3 on admission. The Good Death Scale (GDS) [ 7 – 11 ] consists of 5 domains: awareness of dying (0, complete ignorance; 1, ignorance; 2, partial awareness; 3, complete awareness), acceptance of death (0, complete unacceptance; 1, unacceptance; 2, acceptance; 3, complete acceptance), honoring of the patient’ s wishes (0, no reference to the will of either the patient or the family; 1, following the family’ s will alone, 2, following the patient’ s will alone; 3, following the will of both), death timing (0, no preparation; 1, family alone had prepared; 2, patient alone had prepared; 3, both had prepared well), and the degree of physical comfort before death (0, a lot of suffering; 1, suffering; 2, a little suffering; 3, no suffering). The GDS was evaluated by the physicians after each patients’ death. The GDS has been translated into Japanese version [ 6 ]. However, the GDS has not been validated in Japan yet. The physicians assessed symptoms by direct observations at admission and in the last 3 days in life. If the patients had difficulties with verbal communication, the physicians assessed the patients’ status by proxy. Data analysis and statistics We performed all analyses using JMP version 16 for Windows (SAS, Cary, NC, USA). We classified the patients into two groups based on GDS score. According to previous studies [ 23 ], the cut-off point was set at 12-point. Therefore, the better GDS group had 12–15 points and the worse GDS group had 0–11 points. We excluded patients with missing values for any of the GDS items. We performed univariate logistic regression analysis for all variables to clarify the factors related to better GDS score. Finally, we used the variables with p values of < 0.05 for model fitting with multivariate logistic regression to clarify the factors associated with a better GDS score. We defined p values of < 0.05 as statistically significant. Results Patient characteristics From January 2017 to December 2017, a total of 1,896 patients were enrolled across 22 Japanese PCUs. After 263 ineligible patients were excluded because of their alive discharge, and 476 were excluded because of missing value for GDS scoring. Consequently, 1157 patients were evaluated (Fig. 1 ). These 1157 patients included 559 men (51.8%). The mean (standard deviation) age was 71.8 (12.0) years, and the most common primary cancer site was hepatobiliary/pancreatic (19.5%). The median survival time was 16.0 days (range 1–376). The better GDS group (GDS score: 12–15 points) comprised a total of 802 patients, while the worse GDS group (GDS score: 0–11 points) contained 355 patients. Table 1 showed the characteristics of the patients. Table 1 Baseline Characteristics of the Study Subjects (n = 1157) Characteristics Age [years, mean ± SD] 71.8 ± 12.0 Sex Male Female 559 (51.8) 558 (48.2) Primary cancer site Lung Gastroesophageal Colorectal Hepatobiliary/Pancreas Breast Gynecological Urological Head/Neck Others 193 (16.7) 171 (14.8) 152 (13.1) 226 (19.5) 77 (6.7) 78 (6.7) 83 (7.2) 49 (4.2) 128 (11.1) Living with family 851 (73.6) Children under the age of 20* 45 (3.9) Marital status* Married Widowed Unmarried Separated 707 (61.2) 247 (21.4) 126 (10.9) 76 (6.6) Median survival time [days, (range)] 16.0 (1-376) Abbreviations: SD, Standard Deviation; PCU, Palliative Care Unit *Missing value (n = 1) Factors associated with the better GDS score Table 2 showed the results of univariate analysis. 13 factors independently associated with the better GDS score: age (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.00-1.02; p = 0.01), sex (female vs. male) (OR 1.44; 95% CI 1.12–1.85; p < 0.01), preferred place of death (OR 2.42; 95% CI 1.68–3.47; p < 0.01), survival time (OR 2.42; 95% CI 1.68–3.47; p < 0.01), sudden death (No vs. Yes) (OR 2.11; 95% CI 1.56–2.87; p < 0.01), SWB IPOS in the last 3 days in life (OR 0.41; 95% CI 0.35–0.49; p < 0.01), end-of-life discussion with patients (Yes vs. No) (OR 1.83; 95% CI 1.01–3.33; p = 0.04), communication between patient and family STAS (OR 0.66; 95% CI 0.58–0.75; p < 0.01), fatigue IPOS in the last 3 days in life (OR 0.81; 95% CI 0.70–0.93; p < 0.01), hyperactive delirium severity in the last 3 days in life (OR 0.70; 95% CI 0.59–0.83; p < 0.01), dyspnea severity in the last 3 days in life (OR 0.77; 95% CI 0.67–0.88; p < 0.01), hydration volume (OR 1.00; 95% CI 1.00–1.00; p < 0.01), days to death from last walking (OR 1.01; 95% CI 1.00–1.02; p < 0.01). Table 2 Univariate logistic regression analysis: identification of factors associated with good death [Good Deats Scale ≥ 12] (n = 1157) Variables Odds ratio 95% confidence interval p value Age 1.01 1.00-1.02 0.01 Sex Female Male 1.44 Reference 1.12–1.85 < 0.01 Marital status Married Not married 1.22 Reference 0.94–1.57 0.13 Living with family Yes No 1.31 Reference 0.99–1.73 0.06 Children under age of 20 No Yes 1.26 Reference 0.67–2.34 0.48 Preferred place of death PCU Not PCU 2.42 Reference 1.68–3.47 < 0.01 Survival time 1.01 1.00-1.02 < 0.01 Sudden death No Yes 2.11 Reference 1.56–2.87 < 0.01 Spiritual well-being IPOS in the last 3 days in life 0.41 0.35–0.49 < 0.01 End-of-life discussion with patients Yes No 1.83 Reference 1.01–3.33 0.04 Communication between patient and family STAS 0.66 0.58–0.75 < 0.01 Fatigue IPOS in the last 3 days in life 0.81 0.70–0.93 < 0.01 Drowsiness IPOS in the last 3 days in life 1.05 0.90–1.22 0.54 Dry mouth IPOS in the last 3 days in life 1.03 0.87–1.21 0.74 Hyperactive delirium severity in the last 3 days in life 0.70 0.59–0.83 < 0.01 Hallucination severity in the last 3 days in life 0.89 0.77–1.03 0.13 Dyspnea severity in the last 3 days in life 0.77 0.67–0.88 < 0.01 Respiratory secretion severity in the last 3 days in life 0.93 0.80–1.06 0.28 Intermit sedation No Yes 1.25 Reference 0.93–1.68 0.14 Continuous sedation No Yes 1.11 Reference 0.76–1.61 0.60 Hydration volume 1.00 1.00–1.00 < 0.01 Days to death from last walking 1.01 1.00-1.02 < 0.01 Days to death from last eating 1.01 1.00-1.02 0.29 Days to death from last communicating 1.00 0.99–1.01 0.62 Abbreviations: PCU, Palliative Care Unit; STAS, Support Team Assessment Schedule; IPOS, Integrated Palliative Outcome Scale Table 3 listed the results of multivariate analyses, which clarified 5 variables significantly associated with the better GDS score: preferred place of death at PCU (OR 2.85; 95% CI 1.72–4.71; p < 0.01), longer survival time (OR 1.02; 95% CI 1.00–1.03; p < 0.01), not sudden death (OR 1.96; 95% CI 1.27–3.04; p < 0.01), better SWB IPOS in the last 3 days in life (OR 0.53; 95% CI 0.42–0.68; p < 0.01) and better communication between patient and family STAS-J (OR 0.81; 95% CI 0.66–0.98; p = 0.03). Table 3 Multivariate logistic regression analysis: identification of factors associated with good death [Good Deats Scale ≥ 12] (n = 1157) Variables Odds ratio 95% confidence interval p value Preferred place of death PCU Not PCU 2.85 Reference 1.72–4.71 < 0.01 Survival time 1.02 1.00-1.03 < 0.01 Sudden death No Yes 1.96 Reference 1.27–3.04 < 0.01 Spiritual well-being IPOS in the last 3 days in life 0.53 0.42–0.68 < 0.01 Communication between patient and family STAS 0.81 0.66–0.98 0.03 R 2 = 0.23 Abbreviations: PCU, Palliative Care Unit; IPOS, Integrated Palliative Outcome Scale Discussion To our knowledge, this study is the first to clarify factors associated with better GDS score in Japan. We found novel five factors associated with better GDS score in Japan: preferred place of death at PCU, longer survival time, not sudden death, better SWB in the last 3 days in life and better communication between patient and family. We firstly reported about the association of “better communication between patient and family STAS-J (Better communication)” and “not sudden death” with GDS. Based on these results, we believe that it was important to facilitate communication dying patients and their families at PCUs for good death. As for sudden death, it was very hard for health care providers to predict sudden death associated with worse GDS scores. Therefore, it was suggested that health care providers were required to focus on bereavement care after patients’ sudden death. In previous reports [ 10 ], dedicated family care was associated with better GDS score, using the social context of Taiwan. Because better communication is essential for dedicated family care [ 24 ], “better communication between patient and family STAS-J (Better communication)” may be an outcome associated with better GDS score. In addition, since the GDS construct dominants are "propriety" and "timeliness", it is possible that good communication with the family was associated with an increase in the GDS. Since “sudden death”, which was unexpected by the physicians, is related to the dominant "awareness" and "timeliness" of the GDS components, it is expected that “not sudden death” was associated with better GDS. Hiratsuka et al [25.26]. reported that three domains of GDS [acceptance/timeliness/comfort] were significantly related to SWB in the last 3 days in life because fear to death, including spiritual distress, was related to GDS as death approaches. Previous studies [8.10.27] showed that patients in the PCUs had better GDS score than those in other wards. The primary mission of the PCUs is to relieve the suffering of dying patients; the ability to relieve physical and psychological suffering is a factor that leads to better GDS [ 10 ]. Furthermore, it is possible that good deaths in the PCUs were associated with GDS, since past studies in Japan have reported that " dying in a favorite place" is associated with good deaths [2.3.4]. These suggests that achieving the wish of patients admitted to the PCUs to die in the PCUs is a factor that is associated with better GDS. Cheng et al [ 23 ]. reported that admission to PCUs for more than 7 days is a factor that is associated with better GDS score, which is similar to the conclusion in this study that “longer survival time” is associated with better GDS. This study has some limitations. First, the GDS score is assessed by only the attending physician. The GDS is a scale that relies on objective measures of evaluation, and results may vary depending on the physician or medical staff member who evaluates them. Second, this study included only patients admitted to PCUs in Japan; thus, the external validity is limited. The patients admitted to PCUs have different GDS scores compared to patients in general wards [7.9.23], and thus the factors related to GDS scores may also be different. Japanese culture and view of life and death differs from other cultures in some respects, and results may differ if the cultural context changes. Further research on factors related to “good death” across countries and types of wards is needed. Third, the GDS has been translated into Japanese [ 6 ], but it has not been validated in Japan. There was a possibility that GDS does not capture good death in Japanese patients with advanced cancer. Further research for validation of GDS in Japanese patients with advanced cancer is needed. Conclusion We clarified factors associated with good death using the GDS among patients with advanced cancer in Japan. Providing an environment that facilitates communication between the patients and their families at the place the patient wants leads to a "good death." Abbreviations Communication Capacity Scale (CCS) Confidence interval (CI) Delirium Rating Scale-revised-98 (DRS-R-98) East-Asian collaborative cross-cultural Study to Elucidate the Dying Process (EASED) Eastern Cooperative Oncology Group performance status (ECOG PS) Good Death Inventory (GDI) Good Death Scale (GDS) Integrated Palliative Outcome Scale (IPOS) Japanese version of STAS (STAS-J) Memorial Delirium Assessment Scale (MDAS) Odds ratio (OR) Palliative care unit (PCU) Quality of dying (QOD) Support Team Assessment Schedule (STAS) Spiritual well-being (SWB) Declarations Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author Contributions: Tomoo Ikari: Conceptualization, project implementation writing draft, and writing review and editing Yusuke Hiratsuka: Conceptualization, project administration, formal analysis, data curation, methodology, investigation, writing draft, and writing review and editing Shao-Yi Cheng: Investigation, supervision and writing review and editing Mitsunori Miyashita: Supervision and writing review and editing Tatsuya Morita: Investigation, supervision and writing review and editing Masanori Mori: Conceptualization, investigation, methodology, project administration, resources, supervision, and writing review and editing Yu Uneno: Investigation and writing review and editing Koji Amano: Investigation and writing review and editing Yuko Uehara: Investigation and writing review and editing Takashi Yamaguchi: Investigation and writing review and editing Isseki Maeda: Investigation and writing review and editing Akira Inoue: Investigation and writing review and editing Ethics approval: This study was conducted in accordance with the ethical standards of the Declaration of Helsinki. The ethical guidelines for medical and health research involving human subjects presented by the Japanese Ministry of Health, Labor, and Welfare, and was approved by the local Institutional Review Boards of all participating institutions. Japanese law does not require individual informed consent from participants in a non-invasive observational trial such as the present study. Consent to participate: We used an opt-out method rather than acquiring written or oral informed consent; all patients could find information on the study through the instructions posted on the ward or institutional website, and they had the opportunity to decline participation. Consent to publish: All authors read and approved the final manuscript. References Morita T, Oyama Y, Cheng SY, et al. Palliative care physicians’ attitudes toward patient autonomy and a good death in East Asian countries. J Pain Symptom Manage. 2015;50:190–199. e191. Hirai K, Miyashita M, Morita T, et al. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 17 Aug, 2022 Reviews received at journal 11 Aug, 2022 Reviewers agreed at journal 01 Aug, 2022 Reviewers invited by journal 28 Jul, 2022 Editor assigned by journal 25 Jul, 2022 Submission checks completed at journal 21 Jul, 2022 First submitted to journal 16 Jul, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1864957","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":122808122,"identity":"26019cfb-f2d0-46b4-8def-acb6f0c15af8","order_by":0,"name":"Tomoo Ikari","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tomoo","middleName":"","lastName":"Ikari","suffix":""},{"id":122808123,"identity":"6ebf8bc8-fc42-4190-851b-99919da60e13","order_by":1,"name":"Yusuke Hiratsuka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYBACA2YoDSZ5GBjkQPSBB4S0HEBoMTAGa0nAp4UBTUtiA4iBT4s5O+/Dzx/+HDbmb+BOfPCG4U/6/LDDD4G22MnpNmDXYtnMbixxsO2wmcQB3s2GcxgMcjfeTjMAakk2NjuAw2GH2RgkDjYctmE4wLtNmgekZXYCSMuBxG24tTD/OPDnsI38Ad7tv4Fa0g1np38gpIVN4gDbYTMDoC3MQC0J8tI5BG1hszjblm5seJh3s+QcA2PDDdI5BQcSDPD45fwx5hsVf6wN5x3v3fjhTYWcvPzs9M0fPlTYyeHSggDgZACMHoMDUAbxQL6BFNWjYBSMglEwEgAA/ble+otweFYAAAAASUVORK5CYII=","orcid":"","institution":"Tohoku University School of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yusuke","middleName":"","lastName":"Hiratsuka","suffix":""},{"id":122808124,"identity":"26a6a642-11a0-4c71-aa9a-7d53dc095ea2","order_by":2,"name":"Shao-Yi Cheng","email":"","orcid":"","institution":"National Taiwan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shao-Yi","middleName":"","lastName":"Cheng","suffix":""},{"id":122808125,"identity":"04123843-7529-49a7-9e1f-826f75e377fd","order_by":3,"name":"Mitsunori Miyashita","email":"","orcid":"","institution":"Tohoku University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mitsunori","middleName":"","lastName":"Miyashita","suffix":""},{"id":122808126,"identity":"796d6b75-3c28-432b-ae22-63fa9719c540","order_by":4,"name":"Tatsuya Morita","email":"","orcid":"","institution":"Seirei Mikatahara General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tatsuya","middleName":"","lastName":"Morita","suffix":""},{"id":122808127,"identity":"7d3eb344-5359-4bd0-80ee-0bbcd1e46e69","order_by":5,"name":"Masanori Mori","email":"","orcid":"","institution":"Seirei Mikatahara General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Masanori","middleName":"","lastName":"Mori","suffix":""},{"id":122808128,"identity":"ce9a8af2-89ed-487d-b5a9-12ab7a50b211","order_by":6,"name":"Yu Uneno","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Uneno","suffix":""},{"id":122808129,"identity":"98784b73-52d7-4ac6-87f0-71e43a9d357c","order_by":7,"name":"Koji Amano","email":"","orcid":"","institution":"National Cancer Center Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Koji","middleName":"","lastName":"Amano","suffix":""},{"id":122808130,"identity":"bbbd8e32-2bef-4663-bb8f-17b2a440810f","order_by":8,"name":"Yuko Uehara","email":"","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuko","middleName":"","lastName":"Uehara","suffix":""},{"id":122808131,"identity":"b69f9a37-95dc-4377-b478-931146ad4d29","order_by":9,"name":"Takashi Yamaguchi","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Yamaguchi","suffix":""},{"id":122808132,"identity":"f92f5f51-6387-474a-8f30-692191262498","order_by":10,"name":"Isseki Maeda","email":"","orcid":"","institution":"Senri-Chuo Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Isseki","middleName":"","lastName":"Maeda","suffix":""},{"id":122808133,"identity":"7620be95-b950-40d8-9ade-98d359fdf5c5","order_by":11,"name":"Akira Inoue","email":"","orcid":"","institution":"Tohoku University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Akira","middleName":"","lastName":"Inoue","suffix":""}],"badges":[],"createdAt":"2022-07-16 15:44:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1864957/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1864957/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":24357663,"identity":"c16632a1-491f-4d0c-96c5-59b51daa24c6","added_by":"auto","created_at":"2022-07-26 17:50:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":51085,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants selection flow\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-1864957/v1/c4dbb92970bb9443b854121f.png"},{"id":24357686,"identity":"b58f80ba-ed11-4ded-9e43-655d4456ef9d","added_by":"auto","created_at":"2022-07-26 17:50:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":561956,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1864957/v1/a544c025-6bff-46f2-91f5-eebaa9d559a3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors associated with good death of patients with advanced cancer: A prospective study in Japan","fulltext":[{"header":"Key Message","content":"\u003cp\u003eThe multicenter prospective cohort study identified five factors associated with good death in patients admitted to palliative care units; preferred place of death at palliative care units, longer survival time, not sudden death, better spiritual well-being in the last 3 days in life, and better communication between patient and family.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003e\u0026ldquo;Good death\u0026rdquo; is one of the primary goals of palliative care. There are various definitions for \u0026ldquo;good death\u0026rdquo; in different cultural contexts [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is important for palliative care providers to identify what factors are associated with \"good death\" which refers to the quality of dying (QOD) for the patient with advanced cancer [\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To date, many studies [12.13] have reported the factors associated with better QOD, such as preparing for death, dying comfortably, adequate symptom control, and clear decision-making.\u003c/p\u003e \u003cp\u003eThe Good Death Inventory (GDI) was developed to evaluate good death in Japanese patients with advanced cancer. The GDI was evaluated by the bereaved family member, using the 18 domains such as \"environmental comfort,\" \"life completion\", and \"dying in a favorite place\" [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The survey of bereaved families using GDI is limited by the fact that some bereaved families may feel that responding using the GDI is painful or uncomfortable; this psychological stress may cause a low response rate to the questionnaires [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Meanwhile, the Good Death Scale (GDS) is an objective measure of good death developed in Taiwan. It has been verified to be reliable and valid in palliative care units (PCUs) in Taiwan [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To date, most previous studies have reported the QOD evaluated by patients or families, and few studies investigated QOD using GDS in Japan. In addition, there have been few studies about the factors associated with better GDS scores specifically. We considered that recognizing the factors associated with GDS could help improve the quality of end-of-life care. Thus, we aimed to clarify factors associated with better GDS score among patients with advanced cancer in PCUs in Japan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThis study is a sub-analysis of a multicenter prospective cohort study conducted in Japan. The parent study is the East-Asian collaborative cross-cultural Study to Elucidate the Dying Process (EASED), which investigated the end-of-life care and dying process of patients with advanced cancer in PCUs nationwide in Japan.\u003c/p\u003e \u003cp\u003eWe enrolled consecutively newly admitted patients to the participating PCUs in the study duration. The inclusion criteria were as follows: (1) adult (age\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;18 years), (2) admitted to a participating PCU, and (3) suffering from locally extensive or metastatic cancer. The exclusion criteria were as follows: (1) refusal to enroll on the part of patients or their families, and (2) scheduled discharge within 7 days. All observations were performed in the course of routine clinical practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eWe determined the measurement variables associated with GDS and the related demographics and clinical characteristics based on a relevant literature review. [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe prospectively recorded all variables on a data collecting sheet designed for this study on the first day of enrollment and at death. We collected and analyzed the following data: patients characteristics on admission (age, sex, marital status, living with family, children under age of 20 and preferred place of death) and data about death and symptoms in the last 3 days in life (sudden death, drowsiness, fatigue, dry mouth, spiritual well-being (SWB), end-of-life discussion with patient, communication between patients and families, hyperactive delirium, hallucination, dyspnea, respiratory secretion, intermit sedation, continuous deep sedation, hydration volume, days to death from last walking, eating and communicating and GDS).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMeasurements\u003c/h2\u003e \u003cp\u003eWe analyzed the data of enrolled patients who died in PCUs, and we calculated survival time by subtracting the cases on the admission date from those on death date.\u003c/p\u003e \u003cp\u003eIf a physician answered \u0026lsquo;\u0026lsquo;yes\u0026rsquo;\u0026rsquo; to the question \u0026lsquo;\u0026lsquo;Were you surprised by the timing of the death?\u0026rsquo;, we defined a priori that a patient had a sudden death [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs for end-of-life discussion, we determined whether the physicians informed the patients of the impending death, which was defined as the prediction of death within a few days [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe used the Integrated Palliative Outcome Scale (IPOS) to objectively assess patients\u0026rsquo; symptoms (fatigue, drowsiness, dry mouth, SWB): 0, always; 1, most of the time; 2, sometimes; 3, occasionally; 4, not at all; 5, cannot assess because of unconsciousness. The Japanese version of IPOS has been reported to be a valid and reliable tool for assessing physical, psychological, spiritual and social symptoms, as well as assessing the outcomes of adult patients with cancer in Japan [16.17].\u003c/p\u003e \u003cp\u003eWe used the Support Team Assessment Schedule (STAS) to assess communication between patients and families: 0, Communicating openly and honestly. Verbally and non-verbally.; 1, Communicating openly at some times or with some family members. Sometimes with partners or with some members of family members.; 2, Acknowledge condition but discussion does not satisfy either the patient or their family who feels full implications are not discussed. Maybe with partner but not family.; 3, Out of step, all discussions guarded.; 4, Pretending.; 8, Cannot assess. The Japanese version of STAS (STAS-J) has been reported to be verified as highly reliable [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe used the Memorial Delirium Assessment Scale (MDAS) to assess delirium by using items 9 (psychomotor activity); 0 (normal or psychomotor hypoactivity), 1 (mild), 2 (moderate), and 3 (severe) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. We assessed Hallucination using the Delirium Rating Scale-revised-98 (DRS-R-98), items 2 (perceptual disturbances and hallucinations); 0 (not present), 1 (mild perceptual disturbances), 2 (illusions present), and 3 (hallucinations present) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDyspnea was assessed as 0 (normal), 1 (exertional only) and 2 (at rest). We defined respiratory secretion as 0 (not audible), 1 (only audible at the head of the bed), 2 (clearly audible at the foot of the bed), and 3 (clearly audible at 6 m away from the foot of the bed) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to a previous study [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], we defined the last day of last walking as the day when the patients had Eastern Cooperative Oncology Group performance status (ECOG PS) 3 or less. We defined the last day of eating as the day when patients could eat more than a few bites and the last day of communicating was defined as the day when Communication Capacity Scale (CCS) was 2 or less. Thus, we defined the last day as the admission date when the patient had ECOG PS 4, could eat a few bites, and had CCS 3 on admission.\u003c/p\u003e \u003cp\u003eThe Good Death Scale (GDS) [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] consists of 5 domains: awareness of dying (0, complete ignorance; 1, ignorance; 2, partial awareness; 3, complete awareness), acceptance of death (0, complete unacceptance; 1, unacceptance; 2, acceptance; 3, complete acceptance), honoring of the patient\u0026rsquo; s wishes (0, no reference to the will of either the patient or the family; 1, following the family\u0026rsquo; s will alone, 2, following the patient\u0026rsquo; s will alone; 3, following the will of both), death timing (0, no preparation; 1, family alone had prepared; 2, patient alone had prepared; 3, both had prepared well), and the degree of physical comfort before death (0, a lot of suffering; 1, suffering; 2, a little suffering; 3, no suffering). The GDS was evaluated by the physicians after each patients\u0026rsquo; death. The GDS has been translated into Japanese version [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the GDS has not been validated in Japan yet.\u003c/p\u003e \u003cp\u003eThe physicians assessed symptoms by direct observations at admission and in the last 3 days in life. If the patients had difficulties with verbal communication, the physicians assessed the patients\u0026rsquo; status by proxy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis and statistics\u003c/h2\u003e \u003cp\u003eWe performed all analyses using JMP version 16 for Windows (SAS, Cary, NC, USA).\u003c/p\u003e \u003cp\u003eWe classified the patients into two groups based on GDS score. According to previous studies [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], the cut-off point was set at 12-point. Therefore, the better GDS group had 12\u0026ndash;15 points and the worse GDS group had 0\u0026ndash;11 points. We excluded patients with missing values for any of the GDS items. We performed univariate logistic regression analysis for all variables to clarify the factors related to better GDS score. Finally, we used the variables with \u003cem\u003ep\u003c/em\u003e values of \u0026lt;\u0026thinsp;0.05 for model fitting with multivariate logistic regression to clarify the factors associated with a better GDS score. We defined \u003cem\u003ep\u003c/em\u003e values of \u0026lt;\u0026thinsp;0.05 as statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eFrom January 2017 to December 2017, a total of 1,896 patients were enrolled across 22 Japanese PCUs. After 263 ineligible patients were excluded because of their alive discharge, and 476 were excluded because of missing value for GDS scoring. Consequently, 1157 patients were evaluated (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These 1157 patients included 559 men (51.8%). The mean (standard deviation) age was 71.8 (12.0) years, and the most common primary cancer site was hepatobiliary/pancreatic (19.5%). The median survival time was 16.0 days (range 1\u0026ndash;376). The better GDS group (GDS score: 12\u0026ndash;15 points) comprised a total of 802 patients, while the worse GDS group (GDS score: 0\u0026ndash;11 points) contained 355 patients. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e showed the characteristics of the patients.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics of the Study Subjects (n\u0026thinsp;=\u0026thinsp;1157)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge [years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e559 (51.8)\u003c/p\u003e \u003cp\u003e558 (48.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary cancer site\u003c/p\u003e \u003cp\u003eLung\u003c/p\u003e \u003cp\u003eGastroesophageal\u003c/p\u003e \u003cp\u003eColorectal\u003c/p\u003e \u003cp\u003eHepatobiliary/Pancreas\u003c/p\u003e \u003cp\u003eBreast\u003c/p\u003e \u003cp\u003eGynecological\u003c/p\u003e \u003cp\u003eUrological\u003c/p\u003e \u003cp\u003eHead/Neck\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193 (16.7)\u003c/p\u003e \u003cp\u003e171 (14.8)\u003c/p\u003e \u003cp\u003e152 (13.1)\u003c/p\u003e \u003cp\u003e226 (19.5)\u003c/p\u003e \u003cp\u003e77 (6.7)\u003c/p\u003e \u003cp\u003e78 (6.7)\u003c/p\u003e \u003cp\u003e83 (7.2)\u003c/p\u003e \u003cp\u003e49 (4.2)\u003c/p\u003e \u003cp\u003e128 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving with family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e851 (73.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildren under the age of 20*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status*\u003c/p\u003e \u003cp\u003eMarried\u003c/p\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003cp\u003eSeparated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e707 (61.2)\u003c/p\u003e \u003cp\u003e247 (21.4)\u003c/p\u003e \u003cp\u003e126 (10.9)\u003c/p\u003e \u003cp\u003e76 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian survival time [days, (range)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.0 (1-376)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eAbbreviations: SD, Standard Deviation; PCU, Palliative Care Unit\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*Missing value (n\u0026thinsp;=\u0026thinsp;1)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with the better GDS score\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e showed the results of univariate analysis. 13 factors independently associated with the better GDS score: age (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.00-1.02; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), sex (female vs. male) (OR 1.44; 95% CI 1.12\u0026ndash;1.85; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), preferred place of death (OR 2.42; 95% CI 1.68\u0026ndash;3.47; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), survival time (OR 2.42; 95% CI 1.68\u0026ndash;3.47; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), sudden death (No vs. Yes) (OR 2.11; 95% CI 1.56\u0026ndash;2.87; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), SWB IPOS in the last 3 days in life (OR 0.41; 95% CI 0.35\u0026ndash;0.49; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), end-of-life discussion with patients (Yes vs. No) (OR 1.83; 95% CI 1.01\u0026ndash;3.33; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04), communication between patient and family STAS (OR 0.66; 95% CI 0.58\u0026ndash;0.75; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), fatigue IPOS in the last 3 days in life (OR 0.81; 95% CI 0.70\u0026ndash;0.93; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), hyperactive delirium severity in the last 3 days in life (OR 0.70; 95% CI 0.59\u0026ndash;0.83; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), dyspnea severity in the last 3 days in life (OR 0.77; 95% CI 0.67\u0026ndash;0.88; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), hydration volume (OR 1.00; 95% CI 1.00\u0026ndash;1.00; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), days to death from last walking (OR 1.01; 95% CI 1.00\u0026ndash;1.02; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate logistic regression analysis: identification of factors associated with good death [Good Deats Scale\u0026thinsp;\u0026ge;\u0026thinsp;12] (n\u0026thinsp;=\u0026thinsp;1157)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% confidence interval\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00-1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.12\u0026ndash;1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMarried\u003c/p\u003e \u003cp\u003eNot married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.94\u0026ndash;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiving with family\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99\u0026ndash;1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChildren under age of 20\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.26\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67\u0026ndash;2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreferred place of death\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePCU\u003c/p\u003e \u003cp\u003eNot PCU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.42\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.68\u0026ndash;3.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurvival time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00-1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSudden death\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.11\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.56\u0026ndash;2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpiritual well-being IPOS in the last 3 days in life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.35\u0026ndash;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEnd-of-life discussion with patients\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.83\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.01\u0026ndash;3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommunication between patient and family STAS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.58\u0026ndash;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFatigue IPOS in the last 3 days in life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.70\u0026ndash;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDrowsiness IPOS in the last 3 days in life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u0026ndash;1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDry mouth IPOS in the last 3 days in life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.87\u0026ndash;1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHyperactive delirium severity in the last 3 days in life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.59\u0026ndash;0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHallucination severity in the last 3 days in life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.77\u0026ndash;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDyspnea severity in the last 3 days in life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67\u0026ndash;0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespiratory secretion severity in the last 3 days in life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.80\u0026ndash;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntermit sedation\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.93\u0026ndash;1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContinuous sedation\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.76\u0026ndash;1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHydration volume\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u0026ndash;1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDays to death from last walking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00-1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDays to death from last eating\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00-1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDays to death from last communicating\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99\u0026ndash;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: PCU, Palliative Care Unit; STAS, Support Team Assessment Schedule; IPOS, Integrated Palliative Outcome Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e listed the results of multivariate analyses, which clarified 5 variables significantly associated with the better GDS score: preferred place of death at PCU (OR 2.85; 95% CI 1.72\u0026ndash;4.71; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), longer survival time (OR 1.02; 95% CI 1.00\u0026ndash;1.03; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), not sudden death (OR 1.96; 95% CI 1.27\u0026ndash;3.04; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), better SWB IPOS in the last 3 days in life (OR 0.53; 95% CI 0.42\u0026ndash;0.68; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and better communication between patient and family STAS-J (OR 0.81; 95% CI 0.66\u0026ndash;0.98; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression analysis: identification of factors associated with good death [Good Deats Scale\u0026thinsp;\u0026ge;\u0026thinsp;12] (n\u0026thinsp;=\u0026thinsp;1157)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% confidence interval\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreferred place of death\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePCU\u003c/p\u003e \u003cp\u003eNot PCU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.85\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.72\u0026ndash;4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurvival time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00-1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSudden death\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.96\u003c/p\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.27\u0026ndash;3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpiritual well-being IPOS in the last 3 days in life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.42\u0026ndash;0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommunication between patient and family STAS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.66\u0026ndash;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eR\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.23\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: PCU, Palliative Care Unit; IPOS, Integrated Palliative Outcome Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this study is the first to clarify factors associated with better GDS score in Japan. We found novel five factors associated with better GDS score in Japan: preferred place of death at PCU, longer survival time, not sudden death, better SWB in the last 3 days in life and better communication between patient and family.\u003c/p\u003e \u003cp\u003eWe firstly reported about the association of \u0026ldquo;better communication between patient and family STAS-J (Better communication)\u0026rdquo; and \u0026ldquo;not sudden death\u0026rdquo; with GDS. Based on these results, we believe that it was important to facilitate communication dying patients and their families at PCUs for good death. As for sudden death, it was very hard for health care providers to predict sudden death associated with worse GDS scores. Therefore, it was suggested that health care providers were required to focus on bereavement care after patients\u0026rsquo; sudden death.\u003c/p\u003e \u003cp\u003eIn previous reports [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], dedicated family care was associated with better GDS score, using the social context of Taiwan. Because better communication is essential for dedicated family care [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], \u0026ldquo;better communication between patient and family STAS-J (Better communication)\u0026rdquo; may be an outcome associated with better GDS score. In addition, since the GDS construct dominants are \"propriety\" and \"timeliness\", it is possible that good communication with the family was associated with an increase in the GDS. Since \u0026ldquo;sudden death\u0026rdquo;, which was unexpected by the physicians, is related to the dominant \"awareness\" and \"timeliness\" of the GDS components, it is expected that \u0026ldquo;not sudden death\u0026rdquo; was associated with better GDS.\u003c/p\u003e \u003cp\u003eHiratsuka et al [25.26]. reported that three domains of GDS [acceptance/timeliness/comfort] were significantly related to SWB in the last 3 days in life because fear to death, including spiritual distress, was related to GDS as death approaches. Previous studies [8.10.27] showed that patients in the PCUs had better GDS score than those in other wards. The primary mission of the PCUs is to relieve the suffering of dying patients; the ability to relieve physical and psychological suffering is a factor that leads to better GDS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, it is possible that good deaths in the PCUs were associated with GDS, since past studies in Japan have reported that \" dying in a favorite place\" is associated with good deaths [2.3.4]. These suggests that achieving the wish of patients admitted to the PCUs to die in the PCUs is a factor that is associated with better GDS. Cheng et al [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. reported that admission to PCUs for more than 7 days is a factor that is associated with better GDS score, which is similar to the conclusion in this study that \u0026ldquo;longer survival time\u0026rdquo; is associated with better GDS.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, the GDS score is assessed by only the attending physician. The GDS is a scale that relies on objective measures of evaluation, and results may vary depending on the physician or medical staff member who evaluates them. Second, this study included only patients admitted to PCUs in Japan; thus, the external validity is limited. The patients admitted to PCUs have different GDS scores compared to patients in general wards [7.9.23], and thus the factors related to GDS scores may also be different. Japanese culture and view of life and death differs from other cultures in some respects, and results may differ if the cultural context changes. Further research on factors related to \u0026ldquo;good death\u0026rdquo; across countries and types of wards is needed. Third, the GDS has been translated into Japanese [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], but it has not been validated in Japan. There was a possibility that GDS does not capture good death in Japanese patients with advanced cancer. Further research for validation of GDS in Japanese patients with advanced cancer is needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe clarified factors associated with good death using the GDS among patients with advanced cancer in Japan. Providing an environment that facilitates communication between the patients and their families at the place the patient wants leads to a \"good death.\"\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCommunication Capacity Scale (CCS)\u003c/p\u003e\n\u003cp\u003eConfidence interval (CI)\u003c/p\u003e\n\u003cp\u003eDelirium Rating Scale-revised-98 (DRS-R-98)\u003c/p\u003e\n\u003cp\u003eEast-Asian collaborative cross-cultural Study to Elucidate the Dying Process (EASED) Eastern Cooperative Oncology Group performance status (ECOG PS)\u003c/p\u003e\n\u003cp\u003eGood Death Inventory (GDI)\u003c/p\u003e\n\u003cp\u003eGood Death Scale (GDS)\u003c/p\u003e\n\u003cp\u003eIntegrated Palliative Outcome Scale (IPOS)\u003c/p\u003e\n\u003cp\u003eJapanese version of STAS (STAS-J)\u003c/p\u003e\n\u003cp\u003eMemorial Delirium Assessment Scale (MDAS)\u003c/p\u003e\n\u003cp\u003eOdds ratio (OR)\u003c/p\u003e\n\u003cp\u003ePalliative care unit (PCU)\u003c/p\u003e\n\u003cp\u003eQuality of dying (QOD)\u003c/p\u003e\n\u003cp\u003eSupport Team Assessment Schedule (STAS)\u003c/p\u003e\n\u003cp\u003eSpiritual well-being (SWB)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTomoo Ikari: Conceptualization, project implementation writing draft, and writing review and editing\u003c/p\u003e\n\u003cp\u003eYusuke Hiratsuka: Conceptualization, project administration, formal analysis, data curation, methodology, investigation, writing draft, and writing review and editing\u003c/p\u003e\n\u003cp\u003eShao-Yi Cheng: Investigation, supervision and writing review and editing\u003c/p\u003e\n\u003cp\u003eMitsunori Miyashita: Supervision and writing review and editing\u003c/p\u003e\n\u003cp\u003eTatsuya Morita: Investigation, supervision and writing review and editing\u003c/p\u003e\n\u003cp\u003eMasanori Mori: Conceptualization, investigation, methodology, project administration, resources, supervision, and writing review and editing\u003c/p\u003e\n\u003cp\u003eYu Uneno: Investigation and writing review and editing\u003c/p\u003e\n\u003cp\u003eKoji Amano: Investigation and writing review and editing\u003c/p\u003e\n\u003cp\u003eYuko Uehara: Investigation and writing review and editing\u003c/p\u003e\n\u003cp\u003eTakashi Yamaguchi: Investigation and writing review and editing\u003c/p\u003e\n\u003cp\u003eIsseki Maeda: Investigation and writing review and editing\u003c/p\u003e\n\u003cp\u003eAkira Inoue: Investigation and writing review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical standards of the Declaration of Helsinki. The ethical guidelines for medical and health research involving human subjects presented by the Japanese Ministry of Health, Labor, and Welfare, and was approved by the local Institutional Review Boards of all participating institutions. Japanese law does not require individual informed consent from participants in a non-invasive observational trial such as the present study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used an opt-out method rather than acquiring written or oral informed consent; all patients could find information on the study through the instructions posted on the ward or institutional website, and they had the opportunity to decline participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMorita T, Oyama Y, Cheng SY, et al. Palliative care physicians\u0026rsquo; attitudes toward patient autonomy and a good death in East Asian countries. J Pain Symptom Manage. 2015;50:190\u0026ndash;199. e191.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirai K, Miyashita M, Morita T, et al. Good death in Japanese cancer care: a qualitative study. J Pain Symptom Manage. 2006; 31: 140\u0026ndash;147.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyashita M, Sanjo M, Morita T, et al. Good death in cancer care: a nationwide quantitative study. Ann Oncol. 2007; 18: 1090\u0026ndash;1097.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyashita M, Morita T, Sato K, et al. Good death inventory: a measure for evaluating good death from the bereaved family member's perspective. J Pain Symptom Manage. 2008; 35: 486\u0026ndash;498.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJ. Randall Curtis, Donald L. Patrick, Ruth A. Engelberg et al. A Measure of the Quality of Dying and Death: Initial Validation Using After-Death Interviews with Family Members. J Pain Symptom Manage. 2002; 24: 17\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKodama M, Kobayashi M, Katayama K, et al. Development and Linguistic Validation of the Japanese Version of the Good Death Scale (in Japanese). Palliat Care Res. 2017; 12: 311\u0026ndash;316.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng SY, Lin WY, Cheng YH, et al. Cancer patient autonomy and quality of dying-a prospective nationwide survey in Taiwan. Psychooncology. 2016; 25: 179\u0026ndash;186.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeung KK, Tsai JS, Cheng SY, et al. Can a good death and quality of life be achieved for patients with terminal cancer in a palliative care unit? J Palliat Med. 2010; 13: 1433\u0026ndash;1438.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng SY, Dy S, Huang SB, et al. Comparison of proxy ratings of main family caregivers and physicians on the quality of dying of terminally ill cancer patients. Jpn J Clin Oncol. 2013; 43: 795\u0026ndash;804.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng SY, Dy S, Fang PH, et al. Evaluation of inpatient multidisciplinary palliative care unit on terminally ill cancer patients from providers\u0026rsquo; perspectives: a propensity score analysis. Jpn J Clin Oncol. 2013; 43: 161\u0026ndash;169.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen SY, Hu XY, Liu WJ. Good death study of elderly patients with terminal cancer in Taiwan. J Palliat Med. 2008; 22: 626\u0026ndash;632.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKastbom L, Milberg A, Karlsson M. A good death from the perspective of palliative cancer patients. Support Care Cancer. 2017;25:933\u0026ndash;939.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrikorian A, Maldonado C, Pastrana T. Patient\u0026rsquo;s perspectives on the notion of a good death: a systematic review of the literature. J Pain Symptom Manage. 2020;59:152\u0026ndash;164.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBruera S, Chisholm G, Dos Santos R, et al. Frequency and factors associated with unexpected death in an acute palliative care unit: expect the unexpected. J Pain Symptom Manage. 2015;49:822\u0026ndash;827.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamaguchi T, Maeda I, Hatano Y, et al. Communication and Behavior of Palliative Care Physicians of Patients With Cancer Near End of Life in Three East Asian Countries. J Pain Symptom Manage. 2021; 61:315\u0026ndash;322.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSakurai H, Miyashita M, Imai K, et al. Validation of the integrated palliative care outcome scale (IPOS)\u0026mdash;Japanese version. Jpn J Clin Oncol 2019; 49:257\u0026ndash;262.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSakurai H, Miyashita M, Morita T, et al. Comparison between patient-reported and clinician-reported outcomes: Validation of the Japanese version of the Integrated Palliative care Outcome Scale for staff. Palliat Support Care 2021; 5:1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyashita M, Yasuda M, Baba R, et al. Inter-rater reliability of proxy simple symptom assessment scale between physician and nurse: a hospital-based palliative care team setting. Eur J Cancer Care 2010; 19:124\u0026ndash;130.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBreitbart W, Rosenfeld B, Roth A, et al. The Memorial Delirium Assessment Scale. J Pain Symptom Manag. 1997; 13:128\u0026ndash;137.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982; 5: 649\u0026ndash;655.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDowning GM, Wainwright W, Victoria Hospice Society (2006) Medical care of the dying, 4th ed. Victoria, BC\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiratsuka Y, Yamaguchi T, Maeda I, et al. The Functional Palliative Prognostic Index: a scoring system for functional prognostication of patients with advanced cancer. Support Care Cancer. 2020; 28:6067\u0026ndash;6074..\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng SY, Dy S, Hu WY, et al. Factors affecting the improvement of quality of dying of terminally ill patients with cancer through palliative care: a ten-year experience. J Palliat Med. 2012; 15: 854\u0026ndash;862.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlenys C, Kristian P, Rowan H, et al. Communication between family carers and health professionals about end-of-life care for older people in the acute hospital setting: a qualitative study. BMC Palliat Care 2015; 14: 35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiratsuka Y, Sang-Yeon Suh, Maeda I, et al. Factors influencing spiritual well-being in terminally ill cancer inpatients in Japan. Support Care Cancer 2021; 29: 2795\u0026ndash;2802.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiratsuka Y, Suh SY, Kim SH, et al. Factors related to spiritual well-being in the last days of life in three East Asian countries: An international multicenter prospective cohort study. Palliat Med. 2021 35:1564\u0026ndash;1577.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaw ST, Chih HW, Tai YC, et al. Fear of Death and Good Death Among the Young and Elderly with Terminal Cancers in Taiwan. J Pain Symptom Manage 2005; 29: 344\u0026ndash;351. \u003cb\u003eStatements \u0026amp; Declarations\u003c/b\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Good death scale, Palliative care, End-of-life care, Advanced cancer, Palliative care unit ","lastPublishedDoi":"10.21203/rs.3.rs-1864957/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1864957/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e \u003cp\u003eIt is important for palliative care providers to identify what factors are associated with \"good death\" for patients with advanced cancer. We aimed to clarify factors associated with \"good death\" evaluated by the Good Death Scale (GDS) score among inpatients with advanced cancer in palliative care units (PCUs) in Japan.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThe study is a sub-analysis of a multicenter prospective cohort study conducted in Japan. All variables were recorded on a structured data collecting sheet designed for the study. We classified each patient into better GDS group or worse GDS group, and examined factors associated with better GDS using multivariate analysis.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eBetween January to December in 2017, 1896 patients were enrolled across 22 PCUs in Japan. Among them, a total of 1157 patients were evaluated. Five variables were significantly associated with a better GDS score in multivariate analysis: preferred place of death at PCU (odds ratio [OR] 2.85; 95% confidence interval [CI] 1.72\u0026ndash;4.71; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), longer survival time (OR 1.02; 95% CI 1.00\u0026ndash;1.03; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), not sudden death (OR 1.96; 95% CI 1.27\u0026ndash;3.04; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), better spiritual well-being Integrated Palliative Outcome Scale in the last 3 days in life (OR 0.53; 95% CI 0.42\u0026ndash;0.68; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and better communication between patient and family (OR 0.81; 95% CI 0.66\u0026ndash;0.98; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eWe clarified factors associated with \"good death\" using GDS among advanced cancer patients in Japanese PCUs. Recognition of factors associated with GDS could improve the quality of end-of-life care.\u003c/p\u003e","manuscriptTitle":"Factors associated with good death of patients with advanced cancer: A prospective study in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-07-26 17:50:43","doi":"10.21203/rs.3.rs-1864957/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-08-17T10:32:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-08-11T12:42:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cd1784b5-39da-411c-bbd6-e044024e245f","date":"2022-08-01T08:36:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-07-28T13:12:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-07-25T16:17:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-07-21T07:28:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2022-07-16T15:31:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2593d16a-ade6-434b-afb3-8f1d54710844","owner":[],"postedDate":"July 26th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-09-12T12:44:25+00:00","versionOfRecord":[],"versionCreatedAt":"2022-07-26 17:50:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1864957","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1864957","identity":"rs-1864957","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}