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Abstract

Background:

Patients with advanced cancer often experience symptoms between clinic visits, leading to emergency department admissions. Integrating patient-reported outcome measures into care could enhance symptom monitoring and support.

Aim:

This study assesses the feasibility and efficacy of the SUPPORT+ app for monitoring symptoms and providing timely interventions for patients with advanced cancer.

Design:

In this prospective feasibility study, patients used the SUPPORT+ app for weekly symptom monitoring over 16 weeks. Participants received self-management advice from the app and timely remote consultations from palliative care nurses. Assessments included questionnaires on psychological stress, app satisfaction, and palliative care knowledge, with medical records reviewed for emergency department visits and unplanned hospitalizations.

Setting and participants:

Patients with advanced cancer receiving community palliative care and owning smartphones were recruited from an outpatient palliative care clinic at a university hospital in Hong Kong.

Results:

A total of 109 patients were recruited, with 84 completing the study (retention rate: 78.4%). Over 90% reported their symptoms weekly. Significant increases were noted in advance directive completion (9.5% vs 22.6%, p = 0.047) and discussions on preferred places of dying (14.3% vs 28.6%, p = 0.044), alongside a decrease in depression scores (8.4–6.7, p = 0.024). Most participants found the app easy to use and reported positive health effects.

Conclusion:

The SUPPORT+ app demonstrated feasibility and acceptability in facilitating end-of-life communication, increasing advance directive completion, and potentially reducing depression in patients with advanced cancer. Further research, including randomized controlled trials, is needed to establish its efficacy.

Keywords

mobile applications community-based palliative care telemedicine patient-reported outcome measures cancer self-management

Introduction

Patients with advanced cancer often experience debilitating symptoms, yet these are frequently underreported.¹ The majority receive community-based care, where new or worsening symptoms may arise between visits. This gap in monitoring can lead to unnecessary emergency department (ED) visits and hospitalizations, placing additional strain on healthcare systems.^2
–5

There is a need to improve symptom monitoring and timely support for these patients. Patient-reported outcome measures (PROMs) integrated into care have demonstrated benefits, such as enhanced symptom tracking and reduced utilization.^6,7 Randomized trials showed web-based and real-time remote monitoring can improve quality of life, reduce distress, and prolong survival in cancer survivors.^8,9

The COVID-19 pandemic has accelerated digital health, with electronic PROMs (ePROMs) becoming more common. ePROMs can capture real-time symptoms, flag important issues, save clinician time, and prompt timely interventions.¹⁰ However, most cancer apps focus on biological monitoring, lifestyle modification, or patient education, with few enabling real-time patient reporting and healthcare professional response, especially for palliative care.^11,12

Hong Kong has a high smartphone adoption rate, with 97.1% in 2022 and 90.7% among the elderly population (age >65), making mobile symptom monitoring feasible.¹³ SUPPORT+ is an app developed by a multidisciplinary team including oncologists, palliative care specialists, nurses, and community leaders to enable advanced cancer patients to record symptoms, receive advice, and transfer data to healthcare professionals for early intervention. Details about the SUPPORT+ app are in Supplemental File 1.

This prospective study evaluates the feasibility and efficacy of the SUPPORT+ mobile app to enhance symptom monitoring and rapid clinical response for community-based palliative care in advanced cancer patients in Hong Kong.

Method

Study design

This was a single-arm, prospective study conducted at a university hospital in Hong Kong. Participants were asked to download the “SUPPORT+” mobile app and report their symptoms weekly for 16 weeks, with rapid clinical interventions provided as needed.

However, the absence of a comparison group in this study limits the ability to determine the true effectiveness of the intervention and establish causal relationships. Without a control group, results may be influenced by participant expectations or clinician bias, and findings may not be generalizable to broader populations.

Study participants

Eligible participants were patients with advanced cancer receiving regular follow-ups in the palliative care clinic. All participants were required to be smartphone owners, willing to receive notifications from the mobile app and report their symptoms on the app weekly for the 16-week study duration. Caregivers could assist in completing the weekly symptom diary if the patient was too weak. Patients were excluded if they were receiving inpatient care in hospice, had an Eastern Cooperative Oncology Group (ECOG) performance status of 3 or higher, or had a life expectancy of less than 3 months.

Procedures

Eligible patients were invited to join the study and underwent baseline assessments, including demographic information, medical history, performance status, cancer type and metastasis, primary caregiver, current medications, and healthcare utilization (ED visits and hospitalizations in the past 3 months).

Participants then downloaded the SUPPORT+ app and received training. Over the 16-week study period, participants reported their symptoms weekly using the app. The app interface used the validated Integrated Palliative Care Outcome Scale (IPOS) to collect weekly symptom data from participants over the 16-week study period.¹⁴

Participants received weekly app reminders to record their symptoms. After reporting their symptom diary, participants received personalized self-management advice from the app.

Whenever a participant reported a severe symptom (score ⩾3), palliative care nurses would contact them within one business day to provide medical guidance, such as adjusting medications or arranging earlier appointments. Participants could also directly consult the nurses through the app during office hours.

Screenshots of the app are provided in Supplemental File 2.

Data collection and analysis

Participants completed assessments before and after the 16-week study period, including questionnaires on psychological stress, satisfaction with the mobile app, and palliative care knowledge. Medical records were reviewed for ED visits and unplanned hospitalizations.

The primary endpoint was the retention rate, measured by the completion of the IPOS questionnaire per week during the 16-week study period. We aimed for a retention rate of 70% to proceed to the next stage of a randomized controlled trial.

Secondary endpoints included psychological stress, advance care planning discussions, healthcare utilization, palliative care knowledge, and app satisfaction. Psychological stress was measured using the validated Hospital Anxiety and Depression Scale (HADS) Chinese version.¹⁵ HADS contains an Anxiety subscale (HADS-A) and a Depression subscale (HADS-D), each containing seven specific questions. All questions focus on feelings, states, or symptoms experienced during the past 1 week. A score of 0–7 is considered normal, 8–10 indicates borderline depression/anxiety and 11–21 indicates abnormal. Knowledge of palliative care was assessed using the validated “Palliative Care Knowledge Scale (PaCKS),” which contains 13 true/false items about various domains of palliative knowledge.¹⁶ Satisfaction with the mobile app was measured by the mHealth Satisfaction Questionnaire version 2, a 12-item scale developed using Rasch measurement theory.¹⁷

At week 16, end-of-life discussions and healthcare utilization in the past 3 months were reviewed in the medical records.

Categorical variables were analyzed using chi-square or Fisher’s exact tests, while continuous variables used Student’s t tests and Bonferroni correction for pre-post comparisons. The analyses of covariance (ANCOVAs) were used to compare the depression and anxiety scores at baseline and at week 16, with the corresponding baseline measure as the covariate. Statistical significance was set at p < 0.05, using R version 5.0 for Windows. The reporting of the study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement¹⁸ (Supplemental File 3).

Results

Patients’ demographics

A total of 109 patients with advanced cancer receiving palliative care were recruited between June 2022 and January 2023. The median age of the participants was 68.7 years (range: 41–98 years), and 60 participants (55.1%) were male. Seventy-seven participants (70.6%) reported their own symptoms themselves, while 32 (29.4%) had their caregivers report symptoms. Demographic and clinical characteristics of the participants at baseline are detailed in Table 1.

Table 1.

Clinical characteristics of the participants.

Clinical characteristics	Number	Percentage
Total number of patients recruited	109	100
Total number of patients screened and approached	241
Enrollment success rate	45.2%
Average number of recruitments per week	3.1
Total number of patients withdrawn	13	11.9
Died during study period	12	11.0
Completed 16-week study period	84
Reported symptoms weekly on the app	78
Retention rate	80.4%
Sex
Male	60	55.0
Female	49	45.0
Age (years)
Median	68.74	Range: 41–98
Age groups no. (%)
<70	59	54.1
70–79	24	22.0
80–89	20	18.3
⩾90	6	5.5
Users of the app
Patient	77	70.6
Carer	32	29.4
Relationship with the career users
Spouse	22	68.9
Children	10	31.3
Cancer type
GI cancer	38	34.9
Lung cancer	21	19.3
Breast cancer	8	7.3
Genitourinary cancer/Gynaecological cancer	16	14.7
Soft tissue sarcoma	4	3.7
Others	22	20.2
Any use of systemic treatment before
Yes	103	94.5
No	6	5.5
Marital status
Single	9	8.3
Married	68	62.4
Divorced	10	9.2
Widowed	22	20.2
Education level
Primary or below	40	36.7
Secondary	35	32.1
Diploma or above	34	31.2
ECOG performance status
0	5	4.6
1	79	72.5
2	25	22.3

ECOG: Eastern Cooperative Oncology Group.

Primary outcome: Retention rate

During the 16-week study period, 12 participants died, and 13 participants withdrew from the study. Therefore, 84 participants completed the full study, and their data were analyzed. Among these 84 participants, 78 (80.4%) reported symptoms on the app every week. The overall retention rate for the study was 78.4%. Throughout the study, the app generated a total of 1035 alert triggers, averaging 9.6 alerts per participant.

Secondary outcomes

The secondary outcomes at week 0 and week 16 were summarized in Table 2.

Table 2.

Clinical outcomes at week 0 and week 16.

Items in clinical outcomes	Week 0		Week 16		p Value
Items in clinical outcomes	N	%	N	%	p Value
Depression and anxiety prevalence
HADS-Depression score: 1–7	30	35.7	46	54.8
HADS-Depression score: 8–10	29	34.5	23	27.3	0.003
HADS-Depression score: ⩾11	25	29.8	15	17.9
Mean score of HADS-Depression	8.4		6.7		0.024
HADS-Anxiety score: 1–7	71	84.5	67	79.8
HADS-Anxiety score: 8–10	11	13.1	15	17.8	0.568
HADS-Anxiety score: ⩾11	2	2.4	2	2.4
Mean score of HADS-Anxiety	5.6		5.8		0.952
End-of-life discussions
ACP discussion	30	35.7	44	52.4	0.067
Signing advance directive	8	9.5	19	22.6	0.047
Dying place discussion	12	14.3	24	28.6	0.044
Will signing	15	17.9	16	19.1	0.785
Healthcare utilization in past 3 months
Emergency room visit	8	9.5	4	4.8	0.275
Episode of hospitalization	7	8.3	4	4.8	0.372
Days of hospitalization	Mean: 6	Range: 1–21	Mean: 8	Range: 3–36	0.684
Palliative care knowledge
Mean	Mean: 8.8	Range: 2–12	Mean: 10.3	Range: 6–13	0.256

HADS: Hospital Anxiety and Depression Scale; ACP: Advance care planning; AD: Advanced directive.

Depression and anxiety prevalence

The percentage of participants with borderline or moderate depression (HADS-D score ⩾8) decreased from 64.3% at baseline to 45.2% at week 16 (p = 0.003). The mean HADS-D score decreased significantly from 8.4 to 6.7 (p = 0.024).

There was no significant change in the anxiety level, with 15.5% scoring ⩾8 on HADS-A at baseline and 20.2% at week 16 (p = 0.952). The mean score of anxiety was 5.6 at baseline and 5.8 at week 16.

The ANCOVA controlling for baseline levels of anxiety did not yield any significant effects with respect to the HAD-A (β = 0.1, SE = 0.45, t = 0.22, p = 0.83); while controlling for baseline levels of depression showed a significant reduction in the HADS-D (β = −0.95, SE = 0.37, t = −2.61, p = 0.01).

End-of-life discussions

The proportion of participants who had advance care planning discussions increased from 35.7% at baseline to 52.4% at week 16, although not statistically significant (p = 0.067). Signed advance directives increased significantly from 9.5% to 22.6% (p = 0.047). Discussions about preferred dying places increased from 14.3% to 28.6% (p = 0.044). Signed wills remained stable, changing from 17.9% to 19.1% (p = 0.785).

Healthcare utilization

The prevalence of ED admissions decreased from 9.5% at baseline to 4.8% at week 16 (p = 0.275), and that of hospital admissions decreased from 8.3% to 4.8% (p = 0.372). The median days of hospitalization increased from 6 to 8 days (p = 0.684).

Palliative care knowledge

The mean score of the PaCKS increased from 8.8 (range: 2–12) at baseline to 10.3 (range: 6–13) at week 16, but the change was not statistically significant (p = 0.256). Notably, 33 out of 84 participants (39.3%) exhibited improved palliative care knowledge.

Satisfaction with the app

Most of the participants expressed a high level of user acceptance and satisfaction with the app (Figure 1(a) and (b)). Seventy-eight participants (92.9%) found the app easy to use and acceptable time spent on the app. In addition, 60 (71.4%) said it positively influenced their health habits and lifestyle. However, 13 (15.6%) found the app boring, and 8 (9.5%) found it a disturbance.

Figure 1.

(a) Satisfaction: What do you think about using the health app? (b) Satisfaction: How did you experience the health app?

Discussion

Main findings/results of the study

This study demonstrated that a mobile app-based palliative care programme is a feasible and effective approach for symptom management and end-of-life planning in patients with advanced cancer. The programme achieved a retention rate of 78.4%, with 90.5% of participants reporting symptoms on a weekly basis. The use of the mobile app was associated with reduced levels of depression, increased end-of-life discussions, and trends towards lower healthcare utilization and improved palliative care knowledge. Participants reported high satisfaction with the app, particularly regarding its ability to facilitate symptom monitoring and enable rapid clinical interventions. However, limitations of the study include the absence of a control group and the lack of assessment of health-related quality of life (HRQoL).

What this study adds

The retention rate of this study (78.4%) falls within the range of other ePRO studies, which have reported adherence rates ranging from 41% to 83%.^19
–21 For instance, the ePRO system at Memorial Sloan Kettering achieved a 51.3% response rate on weekends and 58.4% on weekdays, while the eRAPID programme in the UK reported a commendable adherence rate of 72.2%.^20,21 These figures suggested that our mobile app-based approach not only meets but potentially exceeds the engagement levels seen in similar interventions, highlighting its acceptability among patients facing advanced cancer.

As the demand for effective palliative care solutions increases due to the ageing population and rising cancer incidence, mobile health technologies are becoming indispensable. They facilitate the delivery of home-based palliative care, allowing healthcare providers to support patients directly in their environments. In Hong Kong, where palliative care coverage is relatively good, there remain significant gaps in symptom monitoring and timely management between clinic visits.^22,23

Moreover, our results suggest a promising reduction in the prevalence of depression among participants who used the mobile app, although anxiety levels did not show a significant change. This improvement may be linked to the inclusion of cognitive behavioural therapy (CBT) elements in the app, particularly through “Auntie Care,” a virtual support tool that provides personalized interactions and emotional encouragement. Auntie Care responds to the patients with tailored conversations based on the severity of their symptoms, fostering connection, and delivering supportive dialogue to alleviate psychological distress. This aligns with previous research, including a review of 38 studies, showing that CBT-based mobile apps help users engage with their environment and reframe negative thoughts.²⁴ Additionally, our findings support existing evidence on mobile health applications in cancer survivors, as systematic reviews and meta-analyses have shown app-based interventions can enhance quality of life, improve self-efficacy, and reduce symptoms of anxiety, depression, and distress.²⁵

This study did not assess the app’s impact on HRQoL, which is a critical measure for evaluating patient-centred outcomes in palliative care. The lack of such assessments restricts our ability to fully gauge the intervention’s effectiveness in improving this vital aspect of patient well-being. Future research should incorporate comprehensive HRQoL measures, such as the EORTC-CTC-Q30 or EORTC QLQ-C15-PAL, to better understand the efficacy of mobile health interventions on patients’ quality of life.

The study did not find significant differences in ED visits or hospitalizations, likely due to complex factors that influence the need for inpatient care among palliative care patients in Hong Kong, such as elective admission for palliative interventions, cultural preferences, caregiver knowledge and resource limitations.

While there is growing interest in ACP and AD in Hong Kong, the completion rate remains low, at only 0.5% of the general population.²⁶ This low rate can be attributed to various cultural and societal factors, including a strong emphasis on family values, taboos surrounding death, and limited patient involvement in end-of-life decision-making.^27
–29 Our findings suggested that the mobile app-based intervention effectively facilitated improved ACP and communication, addressing some of the identified barriers. The ability to communicate with healthcare providers through the app likely encouraged more open discussions about end-of-life preferences and the documentation of these wishes. This study highlights the potential for larger future studies to explore the use of mobile app systems to promote ACP discussions.

In summary, this study not only reinforces the feasibility and acceptability of a mobile app-based approach for palliative care but also highlights its potential to improve symptom management, enhance psychological well-being, and promote advance care planning discussions. As digital health tools continue to evolve, there is a compelling need for larger-scale studies to explore their long-term impacts and to assess their effectiveness across diverse patient populations and settings.

Strengths and limitations

The strengths of this study included the use of the validated IPOS and the assessment of a broad range of important outcomes. However, the single-arm, prospective design without a control group limited the ability to draw definitive conclusions about the intervention’s efficacy. The 16-week duration may have been insufficient to capture long-term effects, and excluding patients with worse performance status limits the generalizability of the findings. In addition, the absence of HRQoL measurements and qualitative data on user experiences could have enriched our understanding of the intervention’s impact.

Moreover, recruitment was slow, with only 12–13 participants successfully enrolled per month, largely due to technological literacy barriers, particularly among older adults. Although participants reported symptoms via the app, engagement with self-management advice was inconsistent, and some patients hesitated to download the app due to privacy concerns. These challenges highlight the need to improve technological accessibility and user experience in future app designs, emphasizing the importance of robust privacy measures and intuitive features to encourage broader adoption.

Conclusion

The study shows the feasibility of using a mobile app for symptom monitoring and rapid clinical response to enhance community-based palliative care for advanced cancer patients. The findings underscore the promise of leveraging mobile technologies to support this population, warranting further research with a randomized controlled trial to establish the benefits.

Supplemental Material

sj-pdf-1-pcr-10.1177_26323524251351036 – Supplemental material for Use of mobile app “SUPPORT+” to enhance community palliative care in patients with advanced cancer: A prospective study

Supplemental material, sj-pdf-1-pcr-10.1177_26323524251351036 for Use of mobile app “SUPPORT+” to enhance community palliative care in patients with advanced cancer: A prospective study by Wing-Lok Chan, Yin-Ling Tai, Wai-Kwan Steven Siu, Holly Li-Yu Hou, Kwok-Keung Yuen and Victor Ho-Fun Lee in Palliative Care and Social Practice

Footnotes

The authors would like to acknowledge the SUPPORT+ Committee for their advice and support in the development of the mobile app.

Author’s note

The authors were fully responsible for all content and editorial decisions,were involved at all stages of development,and approved the final version. All authors certify that they comply with the ethical guidelines for authorship and publishing in Palliative Care and Social Practice .

ORCID iDs

Wing-Lok Chan

Victor Ho-Fun Lee

Ethical considerations

The study complies with the Declaration of Helsinki and was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB) (UW-22-015).

Consent to participate

All participants provided written informed consent.

Author contributions

Wing-Lok Chan: Conceptualization;Data curation;Formal analysis;Funding acquisition;Investigation;Methodology;Project administration;Supervision;Validation;Writing – original draft.

Yin-Ling Tai: Data curation;Project administration.

Wai Kwan Steven Siu: Supervision.

Holly Li-Yu Hou: Formal analysis;Investigation.

Kwok-Keung Yuen: Project administration;Supervision.

Victor Ho-Fun Lee: Supervision.

Funding

The author(s) disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: The development of the SUPPORT+ mobile app was funded by the BOCHK Centenary Charity Programme. Otherwise,the author(s) received no financial support for the research,authorship,and/or publication of this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Data availability statement

All requests for data access should be addressed to the Chief Investigator at winglok@hku.hk and will be reviewed by all authors.

Supplemental material

Supplemental material for this article is available online.

References

Teunissen

Wesker

Kruitwagen

, et al. Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manage 2007; 34: 94–104.

Henson

Maddocks

Evans

, et al. Palliative care and the management of common distressing symptoms in advanced cancer: pain, breathlessness, nausea and vomiting, and fatigue. J Clin Oncol 2020; 38: 905–914.

Nene

Brennan

Castillo

, et al. Cancer-related emergency department visits: comparing characteristics and outcomes. West J Emerg Med 2021; 22: 1117–1123.

Majka

Trueger

NS.

Emergency department visits among patients with cancer in the US. JAMA Netw Open 2023; 6(1): e2253797.

Alishahi Tabriz

Turner

Hong

, et al. Trends and characteristics of potentially preventable emergency department visits among patients with cancer in the US. JAMA Netw Open 2023; 6: e2250423.

Churruca

Pomare

Ellis

, et al. Patient-reported outcome measures (PROMs): a review of generic and condition-specific measures and a discussion of trends and issues. Health Expect 2021; 24: 1015–1024.

Di Maio

Basch

Denis

, et al. The role of patient-reported outcome measures in the continuum of cancer clinical care: ESMO Clinical Practice Guideline. Ann Oncol 2022; 33: 878–892.

Basch

Deal

Kris

, et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. J Clin Oncol 2016; 34: 557–565.

Maguire

McCann

Kotronoulas

, et al. Real time remote symptom monitoring during chemotherapy for cancer: European multicentre randomised controlled trial (eSMART). BMJ 2021; 374: n1647.

10.

Vercell

Gasteiger

Yorke

, et al. Patient-facing cancer mobile apps that enable patient reported outcome data to be collected: a systematic review of content, functionality, quality, and ability to integrate with electronic health records. Int J Med Inform 2023; 170: 104931.

11.

Fahner

Beunders

AJM

Van der Heide

, et al. Interventions guiding advance care planning conversations: a systematic review. J Am Med Dir Assoc 2019; 20: 227–248.

12.

Ostherr

Killoran

Shegog

, et al. Death in the digital age: a systematic review of information and communication technologies in end-of-life care. J Palliat Med 2016; 19: 408–420.

13.

Census and Statistics Department, Hong Kong Special Administrative Region. Thematic Household Survey Report – Report No. 77 – Information technology usage and penetration, https://www.censtatd.gov.hk/en/data/stat_report/product/C0000031/att/B11302772023XXXXB0100.pdf on (2023, accessed 30 July 2024).

14.

Long

VJE

Cheung

, et al. Validity and reliability of the English and translated Chinese versions of the Integrated Palliative care Outcome Scale (IPOS) in Singapore. BMC Palliat Care 2021; 20: 40.

15.

Leung

Wing

Kwong

, et al. Validation of the Chinese-Cantonese version of the hospital anxiety and depression scale and comparison with the Hamilton Rating Scale of Depression. Acta Psychiatr Scand 1999; 100: 456–461.

16.

Kozlov

Carpenter

Rodebaugh

TL.

Development and validation of the Palliative Care Knowledge Scale (PaCKS). Palliat Support Care 2017; 15: 524–534.

17.

Melin

Bonn

Pendrill

, et al. A questionnaire for assessing user satisfaction with mobile health apps: development using Rasch measurement theory. JMIR Mhealth Uhealth 2020; 8: e15909.

18.

von Elm

Altman

Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147(8): 573–577

19.

Mir

Ferrua

Fourcade

, et al. Digital remote monitoring plus usual care versus usual care in patients treated with oral anticancer agents: the randomized phase 3 CAPRI trial. Nat Med 2022; 28: 1224–1231.

20.

Absolom

Warrington

Hudson

, et al. Phase III randomized controlled trial of eRAPID: eHealth intervention during chemotherapy. J Clin Oncol 2021; 39: 734–747.

21.

Basch

Schrag

Henson

, et al. Effect of electronic symptom monitoring on patient-reported outcomes among patients with metastatic cancer: a randomized clinical trial. JAMA 2022; 327: 2413–2422.

22.

Lam

WM.

Palliative care in Hong Kong. HK Pract 2019; 41:39–46

23.

Hausner

Kevork

Pope

, et al. Factors associated with discharge disposition on an acute palliative care unit. Support Care Cancer 2018; 26: 3951–3958.

24.

Shahsavar

Choudhury

Effectiveness of evidence based mental health apps on user health outcome: a systematic literature review. PLoS One 2025; 20(3): e0319983.

25.

Qin

Chen

Sun

, et al. Effect of mobile phone app-based interventions on quality of life and psychological symptoms among adult cancer survivors: systematic review and meta-analysis of randomized controlled trials. J Med Internet Res 2022; 24: e39799.

26.

Chan

CWH

Wong

MMH

Choi

, et al. Prevalence, perception, and predictors of advance directives among Hong Kong Chinese: a population-based survey. Int J Environ Res Public Health 2019; 16: 365.

27.

Pun

JKH

Cheung

Chow

JCH

, et al. Chinese perspective on end-of-life communication: a systematic review. BMJ Support Palliat Care. Epub ahead of print 9 July 2020. DOI: 10.1136/bmjspcare-2019-002166.

28.

Cheng

Shek

Man

, et al. Dealing with death taboo: discussion of do-not-resuscitate directives with Chinese patients with noncancer life-limiting illnesses. Am J Hosp Palliat Care 2019; 36: 760–766.

29.

Chung

Wong

Kiang

, et al. Knowledge, attitudes, and preferences of advance decisions, end-of-life care, and place of care and death in Hong Kong: a population-based telephone survey of 1067 adults. J Am Med Dir Assoc 2017; 18: 367.e19–367.e27.

Supplementary Material

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