Application of VIP Care in Patients with Advanced Tumors in the Western Region of China.

Objective: The objective of this study is to explore the application of a very important person (VIP) intervention mode in patients with advanced tumors in the western region of China.
Methods: One hundred and sixty-three patients were randomly divided into a control and experimental groups. The control group received routine care, and the experimental group received VIP future care. The willingness to end-of-life treatment, decision-making certainty, and quality of life were compared between the two groups before intervention (T0), after intervention (T1), and 1 month after intervention (T2).
Results: There were no significant differences in the basic data of the two groups. Unlike the control group, the experimental group preferred palliative care at the end of T1 (P < 0.05), and the acceptance rate of cardiopulmonary resuscitation and mechanical treatment decreased significantly. After the VIP intervention, the patient was transferred to the intensive care unit (ICU) (P < 0.05). After 1 month of intervention (T2), the results showed that the overall quality of life, physical discomfort, negative emotions, care and support, survival predicament, and lifetime value of the patients were significantly higher than those before the intervention (all P < 0.05). Decision certainty results showed that the differences between the T0, T1, and T2 time points and the interaction between groups and time were statistically significant, and the interaction was more significant at T2 (P < 0.05).
Conclusion: VIP future care can change patients' wishes for end-of-life care, improve patients' and quality of life, and increase patient decision-making certainty.

1. Introduction

According to the 2018 China Health and Family Planning Statistical Yearbook data, the malignant tumor has become the primary cause of death in China [1]. Guizhou and Sichuan are typical western cities. The 2017 Guizhou Provincial Tumor Registry Annual Report was released to show that the standard incidence rate of cancer in Guizhou's tumor follow-up registration areas was 157.47/100,000. The 2018 Sichuan Tumor Prevention and Control Status Report showed that the incidence rate of malignant tumors in Sichuan Province in 2015 was 251.55/100,000; i.e., an average of 25 people in 10,000 was diagnosed with malignant tumors [2]. From 2015 to 2018, the province's total cost of malignant tumor hospitalization was 26.1.54 billion yuan [3]. Patients with advanced tumors have a poor quality of life, with 65% to 85% of patients not having the opportunity to express their end-of-life treatment wishes before death [4, 5]. The appearance of malignant tumors significantly impacts the patient's physical mental health and quality of life, so most people will choose western medicine to relieve the pain caused by malignant tumors, mainly through oral opioids, such as morphine. However, it will also cause patients to have a variety of chest tightness, nausea and vomiting, severe constipation, and even hallucinations and mental abnormalities and other serious adverse reactions, and also have great drug resistance, dependence, and addiction to the drug [6]. Tumor patients are still plagued by tumor complications and treatment adverse reactions, most of whom have certain mental health disorders, dysfunctional abnormalities, physical defects, and social disorders and other postoperative complication-related problems, causing great trouble to the patient's life. Some patients with malignant tumors will have depression and insomnia due to the causes and psychological factors of the disease, and the long-term emotional depression seriously affects the body's immune system, so that the patient cannot achieve the expected treatment effect. At the same time, not all dying patients will choose excessive medical care, increasing pain and medical costs. The precare program (ACP) focuses on patients' terminal treatment and care wishes, promoting communication among dying patients, family members, and medical staff. The ultimate goal is to meet the wishes of dying patients for treatment and care. At present, the development model of ACP in the USA, Australia, and other European and American countries has been mature, while the development of ACP in most parts of China is still in the stage of theoretical research and concept promotion [7, 8]. It is necessary to learn from foreign models of ACP implementation and gradually form a localized ACP implementation model by combining China's unique medical system and cultural background [9]. In mainland China, investigations on the perceptions, attitudes and influencing factors of ACP among patients with advanced tumors, and their families and health-care workers are mainly limited, and there are few empirical studies on intervention models for patients with advanced tumors [10-15]. Based on evidence-based strategies and qualitative research, Deng Renli et al. [16] constructed a localized ACP intervention program “ very important person (VIP) for future care” to assist patients in expressing their end-of-life wishes, and the feasibility study of this intervention model has been completed in the eastern Chinese city of Zhuhai. Qiu Yeyin [17] and other scholars showed that in order to ensure the quality of life of patients with advanced tumors at the end of life, medical and nursing staff can use the “VIP for future care” intervention model to intervene in patients with ACP. At present, only the application of this model in eastern China has been reported, but due to the differences in culture, economy, and belief, the applicability of “VIP Future Nursing” intervention model in advanced cancer patients in the West still needs to be explored. Our group conducted a study on the applicability of the constructed VIP for future care intervention model to patients with advanced cancer in the western region of China from April 2020 to May 2021, and the results are reported below. All patients completed the study, and no patients dropped out of the study midway.

2. Research Objects and Methods

A total of 163 patients with advanced cancer were admitted to the Oncology Department of the third Class General Hospital in western China from April 1, 2020, to May 31, 2021. There were 80 cases in the control group and 83 cases in the experimental group.

Inclusion criteria are as follows: (1) the subjects' age requirement: 18 years old or older; (2) patients with advanced cancer (the cancer was diagnosed as stages III and IV); (3) the Montreal Cognitive Assessment Scale (MoCA) [18] scored must be at least 26 points; (4) knowing the illness; and (5) unsigned advance directives (ADs).

Exclusion criteria are as follows: (1) the patient with mental disorders or diseases; (2) cannot tolerate long time communication; (3) patients who refused to participate in the study; (4) patients with incomplete clinical information; and (5) patients who survived less than one month. This study protocol has been reviewed and approved by the hospital ethics committee. Informed consent was obtained from all individual participants included in the study.

2.1. Method

2.1.1. Data Collection Method

The randomization tool in Medsci medical tools is used to randomly divide subjects into experimental and control groups according to odd and even numbers. (1) Control group: Nurses gave routine disease care and health education as per medical advice. Symptom management manual, emotional management manual, and late-life manual were issued to patients. (2) Experimental group: In addition to the intervention in the control group, the “VIP for future care” model was also applied.

On the first or second day of admission, “demographic data” and “baseline measurements of observational indicators” were taken from patients who met the inclusion criteria. The study subjects were screened according to the exclusion criteria. Patients were randomized using the random number table method, and the envelopes were sealed with random numbers; the envelopes were opened by study nurse 2 and the grouping was based on the random number in the envelope opened by the study nurse 2. The “VIP” three-phase intervention for the experimental group was completed by study nurse 2. Day 3: The study nurse 2 completes video, an approximately 4-minute one-on-one video presentation consisting of two parts, such as, the first part is an introduction to the three end-of-life treatment wishes (extended life care, primary medical care, and palliative care), and the second part is an introduction to ACP. Day 4: Study nurse 2 completes the illness experience, an approximately 40-minute “illness experience” interview (covering the experience in hospital, course of illness, pain, medication, psychological status, the experience of being rescued, and the knowledge of self-physical condition and prognosis). Day 5: Study nurse 2 completes the preference, an approximately 40-minute “end-of-life treatment wishes” interview (covering: who I want to help me make decisions, my treatment wishes, the late life I wanted, and the arrangements after my death). Day 6 and month 1: Study nurse 1 completed the observational measures for both time periods. A self-designed patient questionnaire was used to measure both groups of patients at baseline before the intervention (“T0”), after the intervention (within 24 hours of completion of the intervention, “T1”), and 1 month after the intervention, “T2”)for outcome effectiveness evaluation. The intervention was separated from the data collector and the collectors were not aware of the grouping of subjects. Both the experimental group and the control group completed the postintervention effect evaluation at T1, while 2 people in the control group withdrew from the study at T2 due to exacerbation, and 3 people in the experimental group withdrew due to exacerbation. 78 people in the control group completed the postintervention effect evaluation, and 80 people in the experimental group completed the effect evaluation.

2.1.2. Observation Target

The observation target is to investigate the intention of terminal treatment, the quality of life (modified QOLC-E) and the certainty of patients' decision-making. The hospice treatment intention questionnaire includes the following: (a) Would you be willing to participate in an end-of-life treatment intentions discussion? (b) If you had to choose the future, would you choose? What would you want your doctor to do if your illness continued to get worse one day and your life was in danger? The intentional consistency questionnaire includes the following: whether you would be willing to receive CPR, mechanical ventilation, gastrointestinal nutrition, blood transfusions, surgery, hemodialysis, vasopressor, transfer to the ICU, intravenous nutrition and pain medication if your condition became severe or fell into a coma, and you need the following resuscitation measures to stay alive. The internal consistency of Cronbach's alpha coefficient of the patient intentions for end-of-life treatment questionnaire was 0.791, and the Cronbach's alpha coefficient of the patient intentions consistency questionnaire was 0.888 [17]. The patients' quality of survival was measured using the Chinese version of the modified quality of life questionnaire for end-of-life (mQOLC-E) [19, 20]. The scale consists of a 23-item pool with six dimensions: (1) negative emotions; (2) physical discomfort; (3) value of life; (4) survival dilemmas; (5) nursing care and support; and (6) food-related problems, based on a 4-point Likert scale with scores ranging from 1 to 4, with lower scores indicating higher quality of patient survival, and the Cronbach's alpha coefficient is 0.835. The patient decision certainty the “Sure-test” decisional conflict scale [20] was used, consisting of 4 items, each with a “yes” or “no” response. The higher the score, the higher the certainty of decision making, and the Cronbach's α coefficient was 0.64.

2.1.3. The Statistical Method

Data were entered in pairs using SPSS 23.0 software and analyzed for consistency. Check the raw data in time if there are errors, establish the corresponding database, and the SPSS 23.0 software system was applied for statistical analysis of all valid data. Count data were expressed by applying percentages and frequencies; measurement data were expressed by applying means and standard deviations; t-test, chi-square test or Wilcoxon rank sum test, and ANOVA were used for single factor analysis; the general linear model was used for multifactor analysis; and P < 0.05 was considered statistically significant difference.

3. Results

Comparison of general information. There was no significant difference in general data between the two groups (P > 0.05), and they are comparable as shown in Tables 1 and 2

Table 1

Comparison of general data 1 of advanced tumor patients between the two groups.

Group	Number of cases	Sex (example)		Age (−x ± s)	Marital status (example)				Educational status (example)
		Male	Female		Married/cohabiting	Unmarried	Widowed	Separation/divorce	Primary school or below	Middle school	Education degreeCollege degree or above
Control group	80	50	30	58.63 ± 10.497	54	3	12	11	6	29	12
Experimental group	83	58	25	57.05 ± 10.802	57	4	13	9	11	32	10
c 2/t value		0.992		0.945	0.409				1.956
P value		0.319		0.346	0.938				0.744

Table 2

Comparison of general data 2 of advanced tumor patients between the two groups.

Group	Religion		Inhabiting information		Medical burden		MoCA score (−x ± s )
	No	Buddhism	Solitary	Cohabitation with family members	Have health insurance	No health insurance
Control group	6	74	6	74	76	4	28.59 ± 1.628
Experimental group	8	75	8	75	80	3	28.71 ± 1.550
x 2/t value	0.237		0.237		0.19		-0.484
P value	0.626		0.626		0.663		0.629

Comparison of the end-of-life treatment intentions. There was no statistically significant difference between the two groups in the willingness to terminal treatment (P > 0.05) in T0. At T1, there was a difference in the choice of willingness for terminal treatment between the two groups, and the experimental group preferred palliative treatment (P < 0.05). After the intervention of VIP mode, the acceptance rate of CPR (cardiopulmonary resuscitation), mechanical ventilation, and transfer to ICU (intensive care unit) decreased, respectively. The difference was statistically significant(P < 0.05). There are no statistically significant difference in the comparison of end-of-life treatment wishes between the two groups in T2 (P > 0.05) (Table 3).

Table 3

Number of patients with advanced tumor in group 2 (person).

Item		T0				T1				T2
		Control group	Experimental group	X 2	P	Control group	Experimental group	X 2	P	Control group	Experimental group	X 2	P
		n = 80	n = 83			n = 80	n = 83			n = 80	n = 83
Would you be willing to do CPR?	Willingness	31	35	0.733	0.693	48	22	18.662	0.000∗	25	26	0.047	0.977
	Unwillingness	36	32			26	49			44	44
	Leave out of consideration	13	16			6	12			9	10
Would you be willing to accept mechanical ventilation?	Willingness	27	29	0.06	0.971	34	18	8.517	0.014∗	17	25	1.986	0.37
	Unwillingness	42	42			40	59			54	50
	Leave out of consideration	11	12			6	6			7	5
Would you be willing to be transferred to intensive care?	Willingness	28	26	0.253	0.881	28	13	8.824	0.012∗	27	26	1.565	0.667
	Unwillingness	35	38			45	64			44	49
	Leave out of consideration	17	19			7	6			7	5

∗Compared with control group, P < 0.05.

There was no significant difference in the quality of life evaluation between the 2 groups before intervention (P > 0.05). The independent sample t-test was conducted with the extracted six public factor S1~S6, which represented six dimensions. The results showed that except for physical discomfort and food problems (T2), the dimensions of overall quality of life, physical discomfort, negative emotion, care and support, survival predicament, and life value of patients were significantly higher than those before intervention (all P < 0.05) (Table 4)

Table 4

Comparison of quality of life scores between the two groups after 1 month of intervention (T2) (score, −x ± s).

Variable	Control group (`x ± s)	Experimental group (`x ± s)	t	P
Body	−0.286 ± 0.730	−0.369 ± 0.728	0.717	0.474
Appetite	−0.026 ± 0.947	0.071 ± 1.123	-0.588	0.557
Concern	−0.099 ± 0.718	−0.425 ± 0.780	2.695	0.008∗
Emotion	0.297 ± 1.258	−0.296 ± 0.811	3.509	<0.001∗
Dilemma	0.198 ± 1.204	−0.383 ± 0.810	3.552	<0.001∗
Worth	0.043 ± 1.002	−0.350 ± 0.679	2.883	0.005∗

The ACP intervention can improve the decision certainty of patients. According to the general linear pattern test results, factor analysis of decision certainty: the differences between patient groups were statistically significant; the differences between T0, T1, and T2 were statistically significant; and there are significant interaction effects at T2 (P < 0.05). (Table 5 and Figure 1)

Table 5

Comparison of decision determination scores between the two groups of advanced tumor patients (score, −x ± s).

Group	T0		T1		T2
	Cases	Sure score (`x ± s)	Cases	Sure score (`x ± s)	Cases	Sure score (`x ± s)
Control group	80	1.56 ± 0.653	80	1.78 ± 0.449	78	3.41 ± 0.780
Experimental group	83	1.58 ± 0.607	83	1.80 ± 0.435	80	3.71 ± 0.620
Interblock(95% CI)	-0.016 (-0.211~0.179)		-0.020 (-0.157~0.117)		-0.302 (-0.524~ -0.080)
P	0.514		0.586		0.000∗
Time(95% CI)	T0 vs.T1 -0.215 (-0.35~ -0.08)		T1 vs.T2 -1.778 (-1.191~ -1.65)		T0 vs.T2 -1.993(-2.13~ -1.86)
P	<0.001∗		<0.001∗		<0.001∗

∗Compared with control group, P < 0.05.

Figure 1

Interaction between groups and time.

4. Discussion

Acceptance of cardiopulmonary resuscitation, mechanical ventilation, and transfer to the intensive care unit decreased in patients in stage T1 after the VIP model intervention. There was no statistically significant difference (P > 0.05) in the comparison of patients' end-of-life treatment intentions between the two groups in T2. The results of Michael et al. [21] suggested that the need for patients' end-of-life treatment intentions increased after the interview intervention but did not change the written signature of end-of-life treatment intentions. El-Jawahri et al. [22] used the ACP decision aid video tool in patients with advanced heart failure and found that patients' end-of-life care was more concerned with comfort and less receptive to CPR and intubation. It is clear that whether ACP intervention has changed the intention of hospice treatment has different results in different studies. This may be related to the manner in which ACP intervention was conducted, the study population, or the fact that repeated measurements caused control patients also to begin to prepare for hospice care, thus interfering with the results of the experiment. Huiying et al. [23] noted that elderly terminally ill patients receive various treatments to prolong life, which can lead to patients being overtreated and increasing patient distress. In this study, a series of interventions were conducted to make the patients' true wishes for treatment and care clear and to express their true end-of-life wishes to their families and health-care workers with a correct understanding of the disease and end-of-life treatment measures. After knowing the patient's true end-of-life wishes, the family has a certain psychological basis to wisely choose the treatment and care measures that meet the patient's wishes at the end of life, which can maintain the patient's dignity and autonomy, and also avoid overmedication. This study suggests that there is statistical significance after the VIP model intervention (T1) and no statistical significance at T2, which suggests whether the end-of-life treatment wishes should be signed in a timely manner after the intervention and that uncertainty increases as time passes and the patient's treatment wishes slowly fade and are forgotten. Researchers also suggest that researchers maintain continuous communication with patients and their families to help patients make firm choices. The timing of signing the letter of willingness for hospice treatment is worth discussing in the next step.

The VIP intervention model improves the quality of survival of patients with advanced cancer. Except for two items of physical discomfort and food concerns, the other dimensions of survival quality and their overall survival quality were higher in the postintervention (T1) patients than in the preintervention, and the difference was statistically significant when comparing before and after (both P < 0.05). It suggests that the VIP intervention model can help end-stage patients to choose a lifestyle that meets their wishes in advance of their waking hours, thus improving their quality of survival [24]. Compared with before intervention, there was no significant difference in the scores of physical discomfort and food attention, which may be related to the end stage of the disease. The patient's condition worsens at the end stage, severe pain and cachexia often make the patient miserable, and the quality of life drops sharply. The purpose of nursing and treatment of advanced cancer patients is not to eradicate the disease but also to minimize the suffering of patients and improve their quality of life. In this study, nurses took the initiative to communicate disease-related information with patients. They encouraged patients to participate in disease decision-making to understand ACP-related knowledge gradually. The “VIP for future care” intervention model encourages patients to express their treatment wishes on their own, and nurses dynamically assess patients' psychological feelings and needs, take the initiative to give care, eliminate doubts, improve negative emotions, and enhance family and social support, thus improving patients' quality of life.

This study showed that the decision-making certainty of patients increased after the “VIP for future care” mode intervention, which was related to the interaction between time and the “VIP for future care” mode intervention. Nair R et al. [25] suggested that patients' decision satisfaction was improved after ACP intervention, and decision confidence increased from 72% to 93%; Michael et al. [22] and Rocque et al. [26] suggested that ACP intervention increased patients' decision certainty, which is consistent with the results of this study. It is possible that the “VIP for future care” model intervention provided more opportunities for direct communication between nurses and patients because the patients were at the end stage of the disease, which helped the patients to face the disease correctly and clarify their real treatment and care wishes and end-of-life treatment measures so that the patients could get clearer decision support.

To sum up, ACP intervention is very important for patients with advanced cancer. By fully understanding patients' end-of-life wishes, it respects and guarantees patients' autonomy, and jointly helps patients to pass the end-of-life stage with dignity, which is important to improve the quality of life and death of patients with end-stage cancer. The data comparison shows that the intervention model of “VIP for future care” can change patients' end-of-life treatment wishes, improve patients' quality of life, and increase patients' decision-making certainty. It is also applicable in the western region of China and is suggested to be used in the whole country. There are also some shortcomings and limitations in this study. Due to time, manpower, financial, and other reasons, the number of researchers is small, and the sample size is large. There are great differences in the size of hospitals in different regions, and there may be deviations in the results, and no follow-up has been carried out. It is suggested to prolong the follow-up time after discharge. Future multicenter, large sample and prospective randomized controlled trials still need further confirmation.

5. Conclusion

VIP future care can change patients' wishes for end-of-life care, improve patients' and quality of life, and increase patient decision-making certainty.