Factors Associated With The Perceptions of Physicians and Patients Regarding Disclosure of Death and Poor Prognosis in Zamboanga City Medical Center-Soliven 2016

FACTORS ASSOCIATED WITH THE PERCEPTIONS OF PHYSICIANS AND
PATIENTS REGARDING DISCLOSURE OF DEATH AND POOR

PROGNOSIS IN ZAMBOANGA CITY MEDICAL CENTER
A THESIS PRESENTED TO
THE FACULTY OF THE GRADUATE SCHOOL
ATENEO DE ZAMBOANGA UNIVERSITY
SCHOOL OF MEDICINE
ZAMBOANGA CITY
IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTERS IN PUBLIC HEALTH
BY
MARIA MONIQUE THERESITA M. SOLIVEN
APRIL 2016

APPROVAL SHEET
This research entitled FACTORS ASSOCIATED WITH THE PERCEPTIONS OF
PHYSICIANS AND PATIENTS REGARDING DISCLOSURE OF DEATH AND POOR
PROGNOSIS IN ZAMBOANGA CITY MEDICAL CENTER, prepared and submitted by
MARIA MONIQUE THERESITA M. SOLIVEN in partial fulfilment of the

requirements for the degree of MASTERS IN PUBLIC HEALTH, is hereby accepted.
_______________________________________
Fortunato L. Cristobal, MD, MPH, MHPEd
Adviser
Approved by the Oral Examination Committee with a grade of PASSED.
______________________________
Rosemarie S. Arciaga, MD, MSc
Chairperson
_______________________________
Servando D. Halili, Jr., MA, PhD
Member
__________________________
Jejunee P. Rivera, MD, MPH
Member
_____________________________________
Norvie T. Jalani, MD, MPH
Member
ACCEPTED in partial fulfilment of the requirements for the degree of Masters in Public
Health
____________________________________________
Fortunato L. Cristobal, MD, MPH, MHPEd
Dean, School of Medicine
Ateneo de Zamboanga University
ACKNOWLEDGEMENTS
All praises and thanks be to God Almighty, for the sustenance, strength, and guidance He
provided in the completion of this paper. To Him the researcher offers all glory and honor.
This paper would not have materialized without the immeasurable help provided by the
following:
To the Ateneo de Zamboanga University School of Medicine, for providing her with the
opportunity to carry out the schools mission to shed light on important public health issues that
would help provide solutions for the welfare of many.
To Dr. Fortunato Cristobal, her research adviser, for always believing in the potential of
this research endeavor, for his encouragement to take the courage of working on this topic, for
the invaluable guidance, and for tirelessly refining the details of this paper.
To the other members of the panel, Dr. Rosemarie Arciaga, Dr. Ben Halili, Dr. Jejunee
Rivera and Dr. Norvie Jalani for sharing their insightful comments and suggestions to further
improve this paper.
To Dr. Barbara Amity Flores, Family Medicine consultant from Veterans Memorial
Medical Center, for allowing her to conduct a similar study in a Zamboanga setting and for
providing invaluable knowledge and support during the course of the study.
To the administration and staff of Zamboanga City Medical Center headed by Dr. Romeo
Ong and Dr. Leila Estrella for allowing her to conduct the study in their prestigious institution.
To Dr. Frederick Iturralde, Dr. Rouella Balagot, Dr. Aisa Tahil and Dr. Felicita
Reluya for providing her with insights and sharing their experiences that provided depth and
substance to this paper.
To Dr. Norvie Jalani, who deserves to be thanked twice (or many times) for always
sharing her time, efforts and invaluable expertise in statistics.
To her classmates, Dr. Mark Feliciano and Dr. Nhaf Ali, for tirelessly assisting her
during data collection, Dr. Hissam Musanip and Dr. Monsie Guingona for enlightening her in
the data processing and analysis, and to ADZU-SOM Batch 2015 Dreamers for the endless
encouragement and support that led to the fruition of this paper.
ii
Lastly, the researcher thanks her family: her father, mother, and sisters, for the love,
material and moral support, relentless encouragement and understanding of the sacrifices needed
to complete this paper. To her grandfather and grandmother, whose dreams were to see the
researcher complete her masters in public health, your love and support were felt in every step of
this endeavor.
In all humility, the researcher dedicates this piece of work to Him and to the beautiful
people mentioned above.
MA. MONIQUE THERESITA M. SOLIVEN

April 2016, Zamboanga City Philippines
iii
ABSTRACT
This study aims to determine the physicians and patients perceptions on death and disclosure of
poor prognosis and determine the association to socio-demographic variables, illness severity
and physicians training profile to the respondents perceptions. A total of 42 resident physicians
and 240 patients responded to a Likert-type questionnaire regarding the general concept and
concerns of death and dying, preferences of disclosure practices and perceived roles of
physicians in end-of-life care. Descriptive statistics by means of frequency distribution was used
to analyze the Likert-type items. Multiple logistic regression was utilized to determine the
association of the outcome variables to the exposure variables. Physicians perceptions
generally coincide with patients perceptions on their views that death is a natural part of life;
that patients want to be given timely and detailed information about their prognosis; the more
appropriate person to deliver bad news; the role doctors play in caring for terminally-ill patients
and the need for physicians to be trained on how to conduct proper disclosure. However,
physicians have the misperception that patients do not want to be told about the news of poor
prognosis, when on the contrary, patients want to be informed. Another misperception of
physicians is the notion that hope is destroyed when a patient is told about poor prognosis. This
proves to be false for majority of the patient respondents. Association between physician
perceptions and socio-demographic and training profiles is significant for age group and
experience of difficulties in disclosure. Association between patient perceptions and sociodemographic profile and illness severity is significant for age group, Islam religion, Bisaya
ethnic group and severe illness. Knowing the perceptions would lead to effective communication
of death and dying which would allow patients to make more informed decisions, attain better
palliative care and have an opportunity to achieve proper closure.
iv
TABLE OF CONTENTS
Page
APPROVAL SHEET
i.
ACKNOWLEDGEMENT
ii.-iii.
ABSTRACT
iv.
LIST OF FIGURES
v.
LIST OF TABLES
v.-vi.
CHAPTER
1
THE PROBLEM AND ITS SETTING

a.) Background of the Study
3-5
b.) Related Literature
5-7
c.) Objectives
d.) Conceptual Framework
e.) Significance of the Study
10
f.) Scope and Delimitation of the Study
10-11
g.) Definition of Terms
11-12
METHODOLOGY
a.) Research Design
13
b.) Study Setting
13
c.) Respondents
13-14
d.) Study Population and Sampling Design
e.) Research Instrument
14-19
f.) Data Gathering Procedure
19-20
g.) Data Treatment
20-21
RESULTS, INTERPRETATION AND

DISCUSSION
14
22-56
SUMMARY, CONCLUSION AND

RECOMMENDATIONS
57-60
BIBLIOGRAPHY
61
APPENDIX
62-77
CURRICULUM VITAE
78
LIST OF FIGURES
Page
Figure 1. Conceptual Framework
LIST OF TABLES
Page
Table 1. Socio-demographic profile of study subjects in Zamboanga City
22
Medical Center, 2016
Table 2. Training profile among resident physicians in

Zamboanga City Medical Center, 2016
Table 3. Illness severity among patient respondents in
Table 4. Perceptions of resident physicians on death and disclosure of
prognosis
Table 5. Full model of variables associated with physicians perceptions
on patient preference to have disclosure done by a family
member
Table 5.1. Reduced model of variables associated with physicians
perceptions on patient preference to receive disclosure from a
family member
Table 6. Full model of variables associated with physicians perceptions
on the need for training on disclosure of poor prognosis and death
Table 6.1. Reduced model of variables associated with physicians
perceptions on the need for training on disclosure of poor
prognosis and death
Table 7. Summary Table of final models of variables associated with
physicians perceptions on death and disclosure of poor
prognosis
Table 8. Perceptions of patients on death and disclosure of poor prognosis
Table 9. Full model of variables associated with patients perceptions on
difficulty in discussing death and dying
Table 9.1 Reduced model of variables associated with patients
perceptions on difficulty in discussing death and dying
personal discomfort in discussing death and dying
perceptions on personal discomfort in discussing death and
dying
23
24
25
32-33
72
34
72
35
37
43
73
44
73

maintaining hope even in the face of poor prognosis
perceptions that hope is maintained even in the face of poor
prognosis
45
74
Table 12. Full model of variables associated with patients preference to

be informed of poor prognosis
preference to be informed of poor prognosis
have full disclosure of prognosis
preference to have full disclosure of poor prognosis
have disclosure of poor prognosis at the earliest possible time
preference to have disclosure of poor prognosis at the earliest
possible time
receive disclosure from a doctor
preference to receive disclosure from a doctor
receive disclosure from loved one or family member
preference to receive disclosure from a family member
collaborative decision-making for end-of-life care
46

perceptions on collaborative decision-making for end-of-life
care
Table 18. Summary Table of final models of variables associated with
patients perceptions on death and disclosure of poor prognosis
77
74
47
75
48
75
49
76
50
76
52
53
vi
CHAPTER 1
THE PROBLEM AND ITS SETTING
Background of the Study

Communicating particularly distressing news is considered demanding to both
physicians and patients. Disclosure of poor prognosis and death is both an important,
albeit a disputable, issue wherein in the past, a choice arises whether to tell the patient
about their prognosis or in recent times, it has been focused on what information to give
and how to convey it. Research reveals that majority of cancer patients in the Western
world prefer to receive detailed information about their condition and expected outcome,
however their information needs vary depending on the stage of their disease.
Nevertheless, terminally ill patients often have misunderstandings regarding the
prognosis of their illness as well as the goals of treatment. This may be attributed to
doctors disclosure practices wherein they are reluctant to communicate particularly
distressing news: doctors may avoid mentioning death or dying even when the patients
suffering is severe and prognosis is poor, they may become less detailed in providing
prognostic information or simply because of their concern that the information may be
contrary to the patients wishes by making them lose hope or that they become upset.
However, poor disclosure practices can have detrimental consequences for patients, their
families and friends, and the entire health care team, particularly on making appropriate
decisions for end-of-life care.
Both doctors and patients express that optimism and hope must be sustained while
in the process of honestly delivering distressing news of poor prognosis and death.

However, it has been stated that there is a delicate balance between realistically fostering
hope and unethically creating unrealistic expectations of longevity. Furthermore, hope is
a concept that can hold different meanings to each individual. In a similar way, prognosis
is a term often linked with life expectancy, encompasses the future course of the disease
and how this will impact on the quality of life of the patient.
Despite the issues surrounding the topic on disclosure of poor prognosis and death,
research is lacking in determining the perceptions of physicians and on the preferences of
patients on the disclosure of death and poor prognosis. Much of the literature has focused
on how to break bad news. There is a lack of evidence-based information on discussing
poor prognosis. Furthermore, there is an association on demographic, psychological,
disease variables, for example, age, sex, civil status, religiosity, educational level, anxiety
and disease status to patient preferences for prognostic information. However, these must
be further clarified within the context of the physicians perceptions.
This study aims to determine the physicians and the patients perceptions on the
issues of death and disclosure of poor prognosis. These issues include the following:
acceptance of death as a natural part of the circle of life, desire to accept news of poor
prognosis, preference to the more appropriate person to deliver bad news, desire whether
to be told of poor prognosis at the earliest possible time, desire to postpone the discussion
of death, and views on maintaining hope in the face of poor prognosis. Determining both
the physicians and the patients perceptions on the disclosure of death and poor prognosis
could contribute to a more effective and appropriate communication between the two
parties. Effective communication of death and dying could allow patients to make more
informed decisions, attain better palliative care and have an opportunity to achieve proper
closure.
Related Literature
One of the main goals of medicine is the prevention of disease and forestalling
death. Moreover, just as importantly, medicine also includes the relief of pain and
suffering and the promotion of a peaceful death (Callahan, 1998). For patients who are
terminally ill, it is imperative for the physician to initiate timely and sensitive discussions
on the patients end-of-life care as these discussions clarify treatment options, enhance
social support and eventually allow patients and their families to achieve meaningful
closure (Quill, 2000). However, physicians are oftentimes apprehensive or even unable to
disclose to patients that they are likely approaching the end of their lives. This is
attributed to medicines inherent prognostic uncertainty and of the physicians fears
that patients will perceive that they are giving up, thus, distressing patients by
eliminating hope (Quill, 2000). Eventually, physicians would resort to reporting fewer
facts and less detail on the prognostic information, which frequently lead to patients not
having a clear understanding of their illness, prognosis and goals of treatment. In the long
run, withholding information, albeit well intentioned in avoiding unnecessary emotional
stress, can derail appropriate treatment preferences and also delays patients and their
families in their capacity to cope (Hancock, 2007).
Physicians subscribe to the idea of full disclosure of poor prognosis (Marwit, et
al, 2002) but find it challenging to practice. Reasons include perceived lack of experience
and training, stress, lack of time, fear of negative impact on the patient, uncertainty of
prognostication, requests from family and friends to withhold information and feelings of

inadequacy and hopelessness due to the futility for a curative treatment (Hancock, 2007).
A physicians background and personality often determines how he or she conveys bad
news (Marwit, et al, 2002). More importantly, the physicians lack of awareness of
patients desires regarding disclosure of poor prognosis also proves to be a limitation in
the effective physician-patient communication (Flores, et al. 2011).
A reasonable body of literature addresses physicians perceptions and practices on
disclosure of poor prognosis. However, remarkably fewer studies have been done on
patients variables, particularly their preferences on communicating poor prognosis
(Marwit, et al, 2002). Attention to patient preferences, which includes advanced
planning, positive communication, treatment planning, patient satisfaction, and outcome,
highly improves the correspondence between patient-determined preference and
physician practice, making it easier to assist patients in the transition from chronic illness
to terminal status. The more a physician understands the patients life circumstances and
needs, the more likely he/she is to anticipate, discuss and ultimately accept the patients
disclosure preferences (Marwit, et al, 2002). When severity of illness and life expectancy
are openly discussed, less patient anxiety and more patient satisfaction were reported
(Flores, 2011).
It is also considered relevant to consider the demographic, personality, situational
and cultural factors of each patient (Marwit, et al, 2002), as these entail for a more
individualized approach in the disclosure of poor prognosis. Hagertys study in 2005
resulted in the majority of patients preferring a realistic and individualized approach and
detailed information when discussing prognosis. Socio-demographic variables of
patients age, gender, educational attainment, civil status, religious affiliation as well as
personality and situational variables such as previous experience with death, availability
of social support, and cultural factors must be taken into consideration before initiating
the discussion of poor prognosis (Marwit, et al, 2002).
A local study in 2011 was initiated by Flores et al in University of the Philippines
- Philippine General Hospital wherein it was found out that physicians perceptions
generally coincided with the patients preferences regarding: a) patients desire to accept
news of poor prognosis, b) the more appropriate person to deliver the bad news, and c)
the desire for disclosure but postponing discussions of death as much as possible. In
contrast, different responses were given with regards to death being a natural part of the
circle of life. Physicians had a more diverse response on maintaining hope in the face of
poor prognosis, contrary to the patients response that poor prognosis will not destroy
hope. Based on the socio-demographic factors, older patients prefer loved ones to deliver
the bad news. Male patients prefer not to know that they are terminally ill or dying. Those
who attained elementary education do not want disclosure of poor prognosis and are
more likely to postpone discussions of death. This study serves as a baseline for future
researchers on disclosure and end of life care. The researchers recommended using a
more appropriate method of qualitative hospice related studies using interview-type
survey or focused group discussion as well as further explanation of some of the answers
in the survey. It would also be beneficial to include patients from other clinical
departments (except for pediatrics department due to the use of a different protocol in
disclosure of poor prognosis).
General Objective:
To determine the perceptions and the associated physician and patient factors on the
disclosure of death and poor prognosis in Zamboanga City Medical Center
Specific Objectives
a. To determine resident physicians and patients perceptions on the following
themes on death and disclosure of poor prognosis:
general concept and concerns about death and dying;
preferences of patients on disclosure practices;
the perceived roles of the physician in end-of-life care
b. To determine the association of socio-demographic variables and training

experiences to physicians general concept and concerns about death and dying,
perceived preferences of patients on disclosure practices and the perceived roles
of the physician in end-of-life care;
c. To determine the association of socio-demographic variables and severity of

illness to the patients general concept and concerns about death and dying,
preferences of patients on disclosure practices and their perceived roles of the
physician in end-of-life care
Conceptual Framework
Figure 1. Conceptual Framework

Physicians and patients have their own perceptions on death and poor prognosis.
These perceptions may vary from one person to another due to their sociodemographic
profile, which includes: age, gender, civil status, religion, ethnic group and educational
attainment. The physicians perceptions may also be influenced or affected by his or her
level of training and experience in the care of patients with poor prognosis. The patients
perceptions may also be influenced by the severity of his or her illness. Determining the
perceptions and the associated physician and patient factors on the disclosure of death
and poor prognosis would help in the disclosure practices of physicians. By becoming
aware of ones own perceptions as well as being informed of the patients perceptions,
one can proceed in having the patients needs recognized, establish mutual goals, create a
collaborative relationship between the patient and the physician, and eventually prevents
delays in the patients and their families in their capacity to cope.
Significance of the Study
The existence of problems in the disclosure of poor prognosis largely contributes to

the failure to provide appropriate information about palliative care and prognosis causing
unnecessary pain and suffering. Studies show that clear understanding of the patients
perceptions and preferences in the disclosure of poor prognosis allow for physicians to
provide a more holistic approach in helping patients approach death in a peaceful manner.
This study is beneficial for primary health care physicians to initiate end-of-life
discussions earlier and more systematically which would allow patients to make more
informed decisions, achieve better palliation of symptoms and have more opportunity to
gain closure.
Scope and Delimitation of the Study

This study was conducted at the four (4) major departments of Zamboanga City
Medical Center (ZCMC) wherein the perceptions of patient respondents seen at both
inpatient and outpatient basis were studied. Patients from other clinical departments were
excluded, such as the patients in the pediatrics department due to the different protocol
for disclosure of poor prognosis. The parents, not the patients themselves, are the
recipients of prognostic information. Minor departments, such as radiology,
otorhinolaryngology, and ophthalmology were also not included in the study. The
perceptions of resident physician subjects who were employed at ZCMC at the time of
study from the four abovementioned departments were also determined. However, the
10
perceptions of the patients family members or primary caregivers on death and

disclosure of poor prognosis were not included in this study due to time constraints.
Definition of Terms
1. Perception- the process of assessing information in your surroundings; involves
becoming aware of ones environment in a way that is unique
(McGaan, 2016); organization, identification, and interpretation of
sensory information in order to represent and understand the
environment (Schacter, 2011)
2. Disclosure the release or divulgence of information
3. Prognosis a projection of the probable course and outcome of a particular
condition in terms of morbidity and mortality, based on stage and
symptoms, and previous experience with patients with the same
disease, with or without treatment
4. Poor Prognosis the prospect of survival and recovery from a disease is low (Law
and Howick, 2016)
5. Without higher education an individual who has not reached tertiary or
collegiate level in his or her schooling
6. With higher education an individual who has reached or completed tertiary or
collegiate level in his or her schooling
11
7. Mildly ill has a score of 25-49 according to the Duke University Severity
of Illness Scoring Key (DUSOI) (Parkerson et al, 1995)
8. Moderately ill has a score of 50-74 according to DUSOI.
9. Severely ill has a score of 75-100 according to DUSOI.
12
CHAPTER 2
METHODOLOGY
A. Research Design
This is an analytical cross-sectional study wherein the perceptions of physicians
and patients on death and disclosure of poor prognosis will be determined.
Association of patient perceptions to socio-demographic profiles age, gender, civil
status, religion, ethnic group and educational attainment of patients and severity of
illness as well as the association of physician perceptions to socio-demographic
profile and training profile will also be investigated.
B. Study Setting
This study was conducted at the wards and outpatient clinics in the four (4) major
departments in Zamboanga City Medical Center Internal Medicine, Family
Medicine, General Surgery and Obstetrics and Gynecology.
C. Respondents
The patient respondents are from Zamboanga City Medical Center (ZCMC) and
seen at both inpatient and outpatient basis in four (4) Major departments Internal
Medicine, Family Medicine, General Surgery and Obstetrics and Gynecology. The
patient is willing to participate in the study, gives his/her written consent and can
verbally communicate in Filipino. Patient subjects below 19 years old, illiterate, noncooperative and/or diagnosed with mental disorders are not included in the study.

13
Resident physician subjects are those currently employed at ZCMC from four (4)
abovementioned departments, are willing to participate and will give his/her written
consent to participate in the study. Resident physicians from other clinical
departments are excluded, such as the pediatrics residents and their patients due to the
different protocol for disclosure of poor prognosis. The parents, not the patients
themselves, are the recipients of prognostic information. Resident physician subjects
who neither is willing to participate nor gives his/her consent are excluded from the
study.
D. Study Population and Sampling Design

The sampling size requirement is 212 patients (or 53 patients per department),
determined using Epi Info Statcalc application with 4.0% confidence interval and 90%
power. Purposive sampling method was utilized for the patient respondents. A total
count of 42 resident physicians from the four major departments was included in the
study.
E. Research Instruments
Questionnaire Design
In the development of the questionnaires, the organization and the wording of the
questions were carefully considered because it was recognized that the topic of disclosure
of poor prognosis and death may be particularly sensitive.
14
1. Questionnaire for Patients

Part A of the questionnaire requested demographic information, including
variables that previous research (Flores et al, 2010) suggested might influence
perceptions on disclosure of death and poor prognosis. Questions about the patients age,
gender, religion, ethnic group and educational attainment were included.
Part B consisted of five questions regarding the patients illness: the first question
asked what their illness is, the second asks how long the patient knows about his illness,
third asks the degree of impairment in the patients daily activities, fourth asks the how
many times a year that the patient requires hospitalization and lastly, the fifth question
asks if there will be a likelihood for the improvement or the worsening of the patients
condition within the next year. These questions are essential in answering each
component of the Duke University Severity of Illness (DUSOI) Scale developed by
Parkerson et al in 1995, which would determine the severity of the patients illness.
Part C consisted of twelve statements regarding three main themes: general
concept and concerns about death and dying, preferences of patients on disclosure
practices, and the perceived roles of the physician in end-of-life care. Seven out of the 10
questions were taken from the validated survey questionnaire developed by Flores, et al
in 2010 in a similar study conducted at UP-PGH. Five of the remaining questions were
sourced from other studies through literature review. The questions on the extent of
disclosure and the need for physicians to undergo training in how to break bad news were
included from the questionnaire of Wittmann et al in 2010. With regards to the preference
of patients to have a collaborative role in medical decision making, the question was
lifted and paraphrased from the study of Elkin, et al in 2007. The question regarding
15
patients perceptions on the provision of holistic care from physicians was taken from a
2006 study conducted in Malaysia by Loh. In addition, 16 patients were interviewed to
gain more content, thus confirming the themes for the questionnaire and an additional
question on patients difficulty in discussing death was formulated. The patients
perceptions were measured using a 4-point Likert format with 1 indicating strongly
disagree, 2 is disagree, 3 is agree and 4 is strongly agree. Notably, there are no
options for a neutral response, which would lead the respondents to respond either
positively or negatively at varying degrees.
The initial format of the questionnaire underwent review and revisions by experts on
palliative care and hospice medicine. The survey tool for patients was translated to
Filipino for easier comprehension. Pretesting of the tool was conducted to determine
whether the questions were understandable, comprehensive and represents the content of
the study. To establish the tools reliability, a pilot test was carried out. Data was
collected from 30 subjects who were not included in the sample.
2. Duke University Severity of Illness Scale (DUSOI)

The Duke University Severity of Illness Checklist (DUSOI) is an instrument
designed by Parkerson et al to measure a patients severity of illness based on the
application of clinical judgment. This can be used directly by the provider at the time of
the patient encounter and also indirectly by medical record audit at a later date. The
parameters for judging severity include symptom status, complications, prognosis
without treatment and treatability. Symptom status is referred as the presence or absence
of symptoms and their level of severity on the day of the visit and during the preceding
16
week. Complication is defined as the presence of health problems which are secondary to
the problem being managed. Prognosis is assessed in terms of either the level of disability
or threat to life which a health problem holds for the patient during the next six months, if
untreated. Disability refers t o any limitation of a persons ability to function in everyday
life. Treatability is based upon the need for treatment and the expected response to
treatment. Studies have shown that the DUSOI tool makes it possible to examine
particular problems management for differential severity and the association of severity
to different management practices. It was also found out that the DUSOI is an acceptable
tool for use in general practice because of the large proportion of problems managed for
which the DUSOI ratings were completed. For example, in the scoring of the health
problem, Gout, the patients symptom score was 3 because gout was causing
moderate symptom severity; the complication score was 1 because the presence of
complications was questionable; the prognosis score was 3 because there was
major disability; and the treatability score was 2 because the expected response to
treatment was good. The total score was divided by 16 then multiplied by 100 to
generate a value between 0-100, as indicated by the bottom of the scoring form. A score
of between 0-24 indicates none or questionable illness, a score of 25-49 indicates mild
illness, 50-74 indicates moderate illness and a score of 75-100 indicates severe illness.
The score for gout is 56, which indicates moderate illness.
3. Questionnaire for Physicians
17
Part A of the questionnaire for physicians, like the questionnaire for patients, also
requested demographic information, such as the physicians age, gender, religion, and
ethnic group. The training profile of the resident physicians included their specialization,
year level, whether or not theyve had clinical experience in disclosure and if theyve had
and are still having difficulties in discussing death and disclosure of terminal illness or
poor prognosis.
Part B of the questionnaire also consisted of twelve statements regarding the three
main themes: general concept and concerns about death and dying, preferences of
patients on disclosure practices, and the perceived roles of the physician in end-of-life
care. Similar to the patient questionnaire, seven out of the 10 questions were taken from
the validated survey questionnaire developed by Flores, et al in 2010 in a similar study
conducted at UP-PGH. Five of the remaining questions were sourced from other studies
through literature review. The questions on the extent of disclosure and the need for
physicians to undergo training in how to break bad news were included from the
questionnaire of Wittmann et al in 2010. With regards to their perception that they must
have a collaborative role with patients in medical decision making, the question was
lifted and paraphrased from the study of Elkin, et al in 2007. The question regarding
physicians perceptions on the provision of holistic care from physicians was taken from
a 2006 study conducted in Malaysia by Loh. In addition, 4 senior resident physicians
were interviewed to gain more content, thus confirming the themes for the questionnaire
and an additional question on the physicians difficulty in discussing death and poor
prognosis was formulated. The physicians perceptions were similarly measured using a
4-point Likert-type items with 1 indicating strongly disagree, 2 is disagree, 3 is
18
agree and 4 is strongly agree. Likewise, there are no options for a neutral response,
which would lead the respondents to respond either positively or negatively at varying
degrees.
The initial format of the questionnaire also underwent review and revisions by
experts on palliative care and hospice medicine. Pretesting of the tool was conducted to
determine whether the questions were understandable, comprehensive and represents the
content of the study. To establish the tools reliability, a pilot test was carried out. Data
was collected from 5 subjects who were not included in the sample.
F. Data Gathering Procedure

Prior to the data gathering procedure, the researcher sought permission to the
Chief of Hospital of Zamboanga City Medical Center and distributed letters to the heads
of the major departments. Physician respondents were distributed self-administered
survey questionnaires in major departments. As for the patients, the questionnaires were
answered with the assistance of the researcher. This is due to the sensitive content of the
questionnaire and some of the respondents were diagnosed with critical diseases, and
therefore may need assistance in answering the questions. This allows the researcher to
adjust the questions according to verbal or nonverbal cues, builds trust and
understanding, thus, making the respondents more comfortable and more open in
answering the questions being posed, ensures that the respondents were selected carefully
and allows the adaptability to respondent differences. In order to answer the DUSOI
scale, both records review (clinical charts for admitted patients and outpatient forms for
walk-in patients) and interview were conducted in order to classify the patients according
19
to the severity of their illness. Once the questionnaires were answered, the corresponding
data were tallied and encoded using the spreadsheet program, Microsoft Excel.
G. Data Treatment
The data inputted in Microsoft Excel were checked and exported for analysis
using STATA software (ver. 13 for Windows). Patient socio-demographic profiles and
severity of illness and physician socio-demographic profiles and training profiles were
described using descriptive statistics frequencies and distributions. Descriptive statistics
are done for the Likert-type items, which are ordinal measurement scale items.
The four-point Likert-type items was collapsed and coded from 1-strongly
disagree, 2-disagree, 3-agree and 4-strongly agree into 0 for strongly disagree
and disagree and 1 for strongly agree and agree. For the patient group, each
survey question was analyzed by demographics such as age, gender, civil status, religion,
ethnic group, educational attainment and severity of illness. Similarly, for the physician
group, each survey question was also analyzed by demographics namely age, gender,
civil status, religion, ethnic group and the physicians training profile. Multiple logistic
regression was the statistical tool used to determine the association of the independent or
exposure variables to the dependent or outcome variables. Simple logistic regression was
done first, to determine the crude association of each exposure variable with the outcome
variable. All the variables with p-value <0.25 will be included in the full model. Walds
test and likelihood-ratio test were done to test if the exposure variable is associated with
the outcome variable. A final model is obtained which contains all the significant
20
exposure variables (p-value <0.05) along with the adjusted association of those variables
to the outcome variables.
Types of Data Included

In this study, the following data for the patient group were retrieved:
demographics such as age, gender, civil status, religion, ethnic group, educational level
and severity of illness; and dependent variables such as the patients perceptions on: the
general concept and concerns about death and dying, preferences of patients on
disclosure practices, patient-related concerns on death and dying, and the perceived roles
of the physician in end-of-life care. For the physician group, demographics such as age,
gender, civil status, religion, ethnic group, the training profile comprising of
specialization and year level in training, were retrieved. Dependent variables such as the
physicians perceptions on: the general concept and concerns about death and dying,
perceived preferences of patients on disclosure practices, patient-related concerns about
death and dying and the roles of the physicians in end-of-life care.
H. Ethical Considerations
The study was initiated only after the approval of the Research Ethics Board of the
Ateneo de Zamboanga University School of Medicine and the Zamboanga City Medical
Center Research Board of Ethics. Each respondent were informed that all data gathered in
relation to the study will be strictly confidential and will be used exclusively for the
purpose of the study only. Informed written consent was sought prior to the conduct of
the study. Participation was purely voluntary. Due to the sensitive content of the
questions, patients were asked to answer the questionnaire with the assistance of the
researcher, whereas the physicians were given self-administered questionnaires.
21
CHAPTER 3
RESULTS, INTERPRETATION AND DISCUSSION
A total of 42 resident physicians from the Family Medicine, Internal Medicine,
General Surgery and Obstetrics and Gynecology Departments and 240 patients seen both
at an inpatient and outpatient basis were included in the study. The succeeding tables will
show the socio-demographic profile of the two groups of respondents, the clinical
experience of resident physicians and the illness severity of the patient respondents.
Table 1. Socio-demographic profile of study subjects in
Demographic Profile
Age
Range
Mean Std. Dev
35 years old
36-50 years old
51-64 years old
65 years old
Gender
Male
Female
Civil Status
Single
Married or Cohabiting
Widow/Widower or Separated
Religion
Roman Catholic
Islam
Others (Protestant, none)
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Highest Educational Attainment
Some High School or Less
High School Graduate
Some College
College or More
Resident Physicians
n=42
n(%)
Patients
n=240
n(%)
26-42 years old

324.11
32 (76.19%)
10 (23.81%)
-
19-91 years old

4617.23
75 (31.25%)
69 (23.81%)
56 (23.33%)
40 (16.67%)
14 (33.3%)
28 (66.7%)
95 (60.4%)
145 (39.6%)
21 (50%)
21 (50%)
-
64 (26.67%)
144 (60.00%)
32 (13.33%)
10 (23.8%)
24 (57.1%)
8 (19.05%)
154 (64.17%)
68 (28.33%)
18 (7.50%)
8 (19.1%)
6 (14.3%)
21 (50%)
7 (17.7%)
96 (40%)
67 (27.9%)
54 (22.5%)
23 (9.6%)
134 (55.83%)
40 (16.67%)
36 (15.00%)
30 (12.50%)
22
Table 1 shows that the mean age for resident physicians was 32, the youngest was
26 and the oldest was 42. As for patients, the mean age was 46, the youngest was 19 and
the oldest was 91. Females outnumber males in both groups. Majority of the patient
respondents are married (60%). As for the physicians, half of the respondents were
married and half were single. Majority of the patient respondents were of the Catholic
faith (64.2%), while majority of the physicians belong to the faith of Islam (57.1%).
Zamboanguenos outnumber other ethnic gro ups among the patient respondents (40%).
On the other hand, majority of the resident physicians belong to the Tausug ethnic group
(50%). The highest level of education attained by majority of patient respondents reached
high school level (24.2%).
Table 2. Training profile among resident physicians in
Training Profile
Specialization
Family Medicine
Internal Medicine
General Surgery
Obstetrics and
Gynecology
Year Level in Training
1st Year
2nd Year
3rd Year
4th Year
5th Year
With clinical experience?
Yes
No
Encountered difficulties/problems with
disclosure?
Yes
No
Still have difficulties/problems with
disclosure?
Yes
No
Resident Physicians
n=42
n(%)
4 (9.5%)
17 (40.5%)
11 (26.2%)
10 (23.8%)
18 (43%)
14 (33.3%)
4 (9.5%)
5 (11.9%)
1 (2.4%)
41 (97.6%)
1 (2.4%)
32 (76.2%)
10 (23.8%)
16 (50%)
16 (50%)
23
Majority of the physician respondents were from the Internal Medicine

department, followed by residents from General Surgery, Obstetrics and Gynecology and
Family Medicine departments. Most of the residents were in their first and second year of
training at 43% and 33.3% respectively. Almost all of the physician respondents (97.6%)
have had clinical experience in the care of terminally ill and dying patients. Majority
(76.2%) have encountered difficulties or problems with disclosure of terminal illness or
death in the past. Of these, half of the respondent population still find it to be a problem.
Table 3. Illness severity among patient respondents in

Severity of Illness
Mildly Ill
Moderately Ill
Severely Ill
Total
n=240
n(%)
85 (35.4%)
120 (50%)
35 (14.6%)
Most of the patients were classified to be moderately ill, followed by mildly ill
and severely ill patients at 50%, 35.4% and 14.6% respectively. Patients were classified
according to the Duke University Severity of Illness Scale (DUSOI). See Appendix.
24
I. Perceptions of physicians on death and disclosure of poor prognosis

Table 4. Perceptions of resident physicians on death and disclosure of prognosis
4
1
3
2
Perceptions among
Strongly
Strongly
Agree
Disagree
Resident Physicians
Agree
Disagree
n(%)
n(%)
n=42
n(%)
n(%)
Theme A: General Concept and Concerns About Death and Dying
Death is a natural part
36 (85.7%) 6 (14.3%)
of life
Has difficulty in
discussing death and
3 (7.1%)
24(57.1%) 10(23.8%)
5 (11.9%)
dying
Has personal
discomfort in
6 (14.3%)
21(50%)
10(23.8%)
5 (11.9%)
discussing death and
dying
*Disclosure of poor
prognosis will destroy 16 (38.1%) 17(40.5%) 8(19.1%)
1(2.4%)
hope
Theme B.
Preferences of Patients on Physicians Disclosure
Practices
*Prefer not to know
about poor prognosis
2 (4.8%)
21(50%)
17(40.5%)
2 (4.8%)
Prefer to have full

disclosure of poor
prognosis
28 (66.7%)
10(23.8%)
2(4.8%)
2 (4.8%)
Important to know
prognosis early
26 (61.9%)
13(31%)
2(4.8%)
1 (2.4%)
Prefer disclosure from

a doctor
24 (57.1%)
16(38.1%)
1(2.4%)

a loved one
4 (9.5%)
17(40.5%)
18(42.9%)
1 (2.4%)
3 (7.1%)
Theme C. Perceived Roles of the Physician in End-of-Life Care

Collaborative
decision-making with
29 (69.1%) 10(23.8%) 2(4.8%)
1(2.4%)
patients
Doctors must provide
holistic care for their
38 (90.5%) 4(9.5%)
patients
Doctors must be
trained on proper
26 (61.9%) 12(28.6%) 3(7.1%)
1 (2.4%)
disclosure of death and
poor prognosis
*Reverse wording of questions

25
A. General concept and concerns about death and dying

This study revealed that physicians accept that death is a natural part of the cycle
of life with majority of the physicians strongly agreeing (85.7%), the rest agreeing
(14.3%) and none of the respondents disagreeing to the statement. This means that all
physicians are highly aware that death is a natural part of life. The study of Gibbins et al
in 2011 stated that death and dying happens in almost all areas of medicine and almost
all health care professionals will at some point care for dying patients. Resident
physicians are, therefore, aware that as doctors, they would be directly be caring patients
with incurable diseases, which would, more often than not, lead to death.
Despite this awareness, however, more than half of the physicians (57% agree,
14% strongly agree) admit to having difficulty in telling patients that they have terminal
illness or that they are dying. This is in concordance with a study describing that
discussing death is considered taboo within the hospital culture, with doctors wanting
to continue treating (even though they felt it was probably futile) and perceiving that
dying is a failure as there is nothing else to do. (Gibbins et al, 2011). Another study
stated three reasons why discussing prognosis remains to be a challenging task for
physicians: first, because the news of poor prognosis is emotionally difficult; second,
because there is a considerable prognostic uncertainty for seriously ill patients, and third,
physicians often rely on judgment and clinical experience in estimating prognosis
(Apatira et al, 2008). This leads to physicians having difficulties and becoming reluctant
in discussing poor prognosis to seriously ill patients.
Furthermore, more than half of the resident physicians have personal discomfort
when talking about death and dying, with half of the respondents agreeing and around 14
26
percent strongly agreeing. This discomfort may stem from the physicians own personal
experience in dealing with death, such as that of a loved one or a chronically ill patient
for which he or she has developed a close bond or the cultural influences on how he or
she handles topics on death. A study by Cassel, et al in 2006 showed that doctors may be
uncomfortable in discussing death because it evokes feelings of their own impotence and
it calls to mind their own mortality. Also, doctors may be concerned that the discussion
on the topic may shock or trouble their patients.
With regards to their views about maintaining hope in the face of poor prognosis,
majority of the physicians (40.5% agreed, 38.1% strongly agreed) believe that hope is
lost when patients are told that they are dying. This can be interpreted that physicians
perceive that when telling patients that they are dying automatically eliminates hope for a
cure. Previous research suggests that the reluctance of physicians to provide prognostic
information is their concern that their words may extinguish a patient and their families
sense of hope. However, evidence suggests that hope is maintained even with truthful
discussions that teach the patient that there is no chance for cure (Mack & Smith, 2012).
Studies also show that involving patients in the prognostic information and decisionmaking allowed for empowerment about medical care and overall well-being, which
makes it an important component of hope (Apatira et al, 2008).
B. Preferences of patients on physicians disclosure practices

It is widely accepted that it is the physicians duty to inform and educate patients
if they have severe illnesses with poor prognosis (Elkin et al, 2007). However, majority
of the physicians responded that patients prefer not to know about their poor prognosis
27
(50% agree, 4.8% strongly agree). This means that although physicians accept that
patients have the right to know about their prognosis, majority believe that patients
preference lean towards not knowing that they have an illness with poor prognosis. This
does not coincide with the local study done by Flores, et al in 2010, wherein results
revealed that 61% of the physicians perceive that patients wanted to know of their poor
prognosis.
With regards to the amount of prognostic information that patients require,
physicians affirm (66.7% strongly agree, 23.8% agree) that patients must be given full
disclosure of their condition. This means that physicians strongly believe that patients
would want all possible information about their diagnoses. A study by Wittmann et al in
2009 showed, however, that only 35% of the physicians believe that patients require full
disclosure of their prognosis, with majority or 65% believe that patients should be given
as much information as requested or partial disclosure. Various literature reveal that
physicians may have difficulty in practicing full disclosure because they are concerned of
the possible negative psychological effects on the patient. Still, studies have consistently
shown that selective and non-disclosure of poor prognosis led to even greater distress for
the patient and their families (Fallowfield et al, 1999) as compared to providing full
disclosure of the patients condition.
As to the timing of disclosure of poor prognosis, disclosure done at the earliest
possible time was deemed important by majority of the physician respondents (61.9%
strongly agreed, 31% agreed). This further coincides with the results of the local study
done by Flores wherein 95% of the physicians perceive that it is important to know the
prognosis early. This can be interpreted that physicians perceive that having discussions
28
of disclosure at the earliest possible time is important to enable patients and their families
in understanding and adjusting to their prognosis and allow them to better prepare for the
future.
With regards to the appropriate person to disclose the poor prognosis to the
patients, physicians believe (57.1% strongly agree, 38.1% agree) that patients would
prefer to receive disclosure from a doctor. This is consistent with the findings of Flores
local study wherein 89% agreed that disclosure from a doctor. This may be due to their
belief that doctors felt that they are qualified to provide information on the patients
condition. Physicians are approximately split in their beliefs when it comes to their
perception regarding patients preference to have disclosure done by a loved one or
trusted family member wherein 40.5% agree and 9.5% strongly agree, while 42.9%
disagree and 7.1% strongly disagree. Again, this coincides with the findings of Flores
wherein the physician respondents generally disagree that patients would want to receive
disclosure of poor prognosis from their loved ones. This may be due to the beliefs of
physicians that some misunderstandings regarding the prognostic information may occur
when the task of disclosure is passed on to the patients family members or loved ones.
However, the role of the patients family and loved ones are considered essential by the
physicians, as they are the ones who are more aware of the patients emotional,
psychological, social and spiritual conditions and should be seen as partners in providing
comfort for the patient (Young Ho Un et al, 2004).
29
C. Perceived roles of the physician in end-of-life care

When asked about the physicians perceptions on treatment decision-making, most
of the physicians believe (69.1% strongly agreed, 23.8% agreed) that both the doctor and
the patient must share in the crucial responsibility of making a decision on end-of-life
care. This means that physicians believe that a collaborative role of patients is essential as
compared to an active or a passive role in management decision-making. This is further
backed up by studies wherein shared decision making between the physician and the
patient is advocated, with empirical evidence that supports an association between more
collaborative decision making and higher patient satisfaction with the choice of treatment
and management and the medical decision-making process (Elkin et al, 2007).
This study also revealed that physicians believe providing holistic care for
patients who are terminally ill was important with majority of the physicians strongly
agreeing (90.5%), the rest agreeing (9.5%) and none of the respondents disagreeing to the
statement.
In a holistic approach to medicine, it is believed that the patients well-being
relies not just on the physical aspect of the illness, but must be interrelated with the
psychological, emotional, social, spiritual and environmental state (Strandberg et al,
2007). It is therefore of primary importance that doctors must be informed about a
patients whole life situation (von Bultzingslowen et al, 2006) particularly for patients
with poor prognosis.
The last statement revealed that majority of the physicians believe that training is
necessary for physicians in breaking bad news (61.9% strongly agreed, 28.6% agreed).
From this information as well as from other studies such as the study by Baile et al in
30
2000 stated that for many clinicians, it can be concluded that additional training in
disclosing unfavorable information to the patient could be useful in improving their
communication skills and increase their confidence in accomplishing this task.
Schildmann et al (2005) found that almost one-third or 63.2% of Foundation Year One
doctors have the opinion that they had received insufficient postgraduate training.
Moreover, techniques for disclosing information in a way that addresses the expectations
and emotions of the patients also seem to be strongly desired by physicians, but rarely
taught (Gibbins et al, 2011).
II. Association of socio-demographic factors and training profile to

physicians perceptions
The dependent variables or the responses of physicians to the statements regarding
the general concept and concerns about death and dying are the following: perceptions on
death as a natural part of life, difficulty and personal discomfort in discussing death and
dying and the maintaining hope in the face of poor prognosis. For the physicians
perceptions on patients preferences for disclosure, the statements are the following:
patients prefer to know about their prognosis, to have full disclosure, to receive
disclosure at the earliest possible time and to receive disclosure from an appropriate
person whether from a physician or a loved one. For the perceptions on the physicians
roles in end-of-life care, the statements are the following: doctors must collaborate with
patients in decision-making, that physicians must provide holistic care for patients and
that there is a need for physicians training for disclosure of poor prognosis. The
independent variables or factors measured are the sociodemographic variables, namely
age, gender, civil status, religion, ethnic group and training and clinical experience of
resident physicians, namely year level, specialization and experience in disclosure of
poor prognosis.
31
A. Factors associated with physicians general concept and concerns

about death and dying
Using simple logistic regression between the physicians general perceptions and the
socio-demographic factors, namely age, sex, civil status, religion, ethnic group, as well as
the clinical training factors, namely, specialization, year level and experiences in
disclosure of poor prognosis, did not yield any significant associations. There were also
no significant associations of the socio-demographic and training profile factors to
physicians perceived difficulty in disclosure of poor prognosis, personal discomfort in
discussing death and dying and the physicians views that hope is maintained even in the
face of poor prognosis.
B. Factors associated with physicians perceptions on the preferences of

patients on disclosure practices
Simple logistic regression showed that there were no significant associations between
the socio-demographic and training profile factors of physicians and their perceptions on
patients wanting to be informed of poor prognosis, preferring to have full disclosure,
perceived importance to know prognosis early and the patients preferences of receiving
disclosure from a doctor.
32
Table 5. Full model of variables associated with physicians perceptions on patient

preference to have disclosure done by a family member
Variables
Age Group
35 years old
36-54 years old
Gender
Male
Female
Civil Status
Single
Married
Religion
Roman Catholic
Islam
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Specialization
Family Medicine
Internal Medicine
General Surgery
Obstetrics & Gynecology
Year Level
1st year
2nd year
3rd year
4th year
5th year
Had no clinical experience in
the care of dying patients
Had no difficulties with
disclosure in the past
Dont have difficulties in
disclosure anymore
Patient prefers to have

disclosure done by a family
member
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
19 (45.2%)
2 (4.8%)
13 (31.0%)
8 (19.0%)
1.00
0.17
0.031, 0.939
0.042
7 (16.7%)
14 (33.3%)
7 (16.7%)
14 (33.3%)
1.00
1.00
0.277, 3.608
1.000
9 (21.4%)
12 (28.6%)
12 (28.6%)
9 (21.4%)
1.00
1.78
0.524, 6.035
0.356
5 (11.9%)
14 (33.3%)
2 (4.8%)
5 (11.9%)
10 (23.8%)
6 (14.3%)
1.00
1.40
0.33
0.318, 6.160
0.044, 2.523
0.656
0.287
3 (7.1%)
3 (7.1%)
15 (35.7%)
0 (0.0%)
5 (11.9%)
3 (23.8%)
6 (14.3%)
7 (11.9%)
1.00
1.67
4.17
1.00
0.195, 14.266
0.749, 23.179
-
0.641
0.103
-
1 (2.4%)
11 (26.2%)
4 (9.5%)
5 (11.9%)
3 (7.1%)
6 (14.3%)
6 (14.3%)
6 (14.3%)
1.00
2.00
5.50
2.50
0.150, 26.734
0.464, 65.162
0.194, 32.194
0.600
0.177
0.482
11 (26.2%)
6 (14.3%)
3 (7.1%)
1 (2.4%)
0 (0.0%)
7 (16.7%)
8 (19.0%)
1 (2.4%)
4 (9.5%)
1 (2.4%)
0.48
1.91
0.16
1
0.115, 1.976
0.164, 22.202
0.015, 1.732
-
0.308
0.605
0.131
-
1 (2.4%)
0 (0.0%)
1.00
6 (14.3%)
4 (9.5%)
1.70
0.402, 7.198
0.471
7 (16.7%)
9 (21.4%)
0.78
0.193, 3.127
0.723
* OR odds ratio; CI confidence interval
33
For the physicians perceptions on patient preference for a family member to do

disclosure, univariate analysis using simple logistic regression was done for each
exposure variable. These are included in the full model, as can be seen in Table 5.
Among the variables, the age group of 36-54 years old was statistically significant (pvalue=0.042). All variables having a p-value of <0.25 were selected as a candidate for
multivariate analysis as can be seen in the reduced model (Table 5.1, appendix).
B. Factors associated with physicians perceptions on their roles in

end-of-life care
Simple logistic regression showed that there were no significant associations
between the socio-demographic and training profile factors of physicians and their
perceptions on having collaborative decision-making with patients and that doctors must
provide holistic care for their patients.
34
Table 6. Full model of variables associated with physicians perceptions on the need
for training on disclosure of poor prognosis and death
Variables
Age Group
35 years old
36-54 years old
Physicians need training on

disclosure of poor prognosis
and death
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
29 (69.0%)
9 (21.4%)
3 (7.1%)
1 (2.4%)
1.00
0.93
0.088, 10.100
0.953
13 (31.0%)
25 (59.5%)
1 (2.4%)
3 (7.1%)
1.00
0.64
0.061, 6.791
0.712
19 (45.2%)
19 (45.2%)
2 (4.8%)
2 (4.8%)
1.00
1.00
0.127, 7.850
1.000
9 (21.4%)
22 (52.4%)
7 (16.7%)
1 (2.4%)
2 (4.8%)
1 (2.4%)
1.00
1.22
0.78
0.098, 15.230
0.041, 14.750
0.876
0.867
1 (2.4%)
0 (0.0%)
2 (4.8%)
1 (2.4%)
7 (16.7%)
6 (14.3%)
19 (45.2%)
6 (14.3%)
1.00
1.00
1.36
0.86
0.106, 17.417
0.044, 16.851
0.815
0.919
4 (9.5%)
10 (23.8%)
14 (33.3%)
10 (23.8%)
0 (0.0%)
0 (0.0%)
3 (7.1%)
1 (2.4%)
1.00
1.00
0.47
1.00
0.042, 5.166
-
0.534
-
17 (40.5%)
11 (26.2%)
4 (9.5%)
5 (11.9%)
1 (2.4%)
1 (2.4%)
3 (7.1%)
0 (0.0%)
0 (0.0%)
0 (0.0%)
1.00
0.09
1.00
1.00
1.00
0.005, 1.830
-
0.118
-
1 (2.4%)
0 (0.0%)
1.00

7 (16.7%)
3 (7.1%)
0.04
0.002, 0.704
0.028
Dont have difficulties in

disclosure anymore
15 (35.7%)
1(2.4%)
1.00
Gender
Male
Female
Civil Status
Single
Married
Religion
Roman Catholic
Islam
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Specialization
Family Medicine
Internal Medicine
General Surgery
Year Level
1st year
2nd year
3rd year
4th year
5th year
Had no clinical experience in
the care of dying patients
35
For the physicians perceptions on the need for training in disclosure of poor
prognosis and death, simple logistic regression was done for each exposure variable.
These variables are shown in the full model (Table 6). Among the variables, having no
difficulties in disclosure in the past was shown to be statistically significant (pvalue=0.028). All variables having a p-value of <0.25 were selected as candidates for
multivariate analysis as shown in the reduced model (table 6.1, appendix). The
components of the physicians training profile, namely year level in training and their
clinical experience with difficulties in disclosure, were included in the reduced model.
Table 7. Summary Table of Final models of regression analysis using the factors
associated with physicians perceptions on death and disclosure of poor prognosis
Dependent Variables
Factors
OR
95% CI
p-value
Prefers to receive disclosure

from a family member
36-54 years old

age group
0.17
0.031, 0.939
0.042

and death
Had no difficulties
in disclosure
0.08
0.007, 0.836
0.035
*Final model only includes variables with p-value <0.05 on logistic regression
Multiple logistic regression was done by using backward elimination of variables,
leaving age group as the lone statistically significant variable as seen in Table 7.
Physicians who belonged to the age group of 36-50 years old are 83% less likely to
perceive that patients would prefer to receive disclosure from a family member. This can
be interpreted that older physicians have gained more experience with disclosure and are
36
more likely to be in the senior year of their training, therefore, they perceive that the
patient would want to receive disclosure from a doctor and not from a family member. A
study done in Brazil showed that older and more experienced physicians are more likely
to be against openly discussing implications of poor prognosis (i.e. DNR status). As
physicians become older and gain more experience in handling patients, they are more
likely to do the disclosure themselves rather than having family members disclose poor
prognosis to terminally ill patients (Fumis et al, 2010).
Backward elimination of variables, left the variable, had no difficulties in disclosure
as the only statistically significant variable as seen in Table 7. Physicians who had no
difficulties in disclosure are 92% less likely to perceive that they needed training on
disclosure of poor prognosis and death. This may be attributed to the confidence that
these physicians have on their communication skills and probably personal experiences,
which makes it relatively easy for them to relate to patients, particularly those with poor
prognosis.
37
III. Perceptions of patients on death and disclosure of poor prognosis

Table 8. Perceptions of patients on death and disclosure of poor prognosis
4
Strongly
Agree
n(%)
1
Strongly
Agree
Disagree
Disagree
n(%)
n(%)
n(%)
Theme A: General Concept and Concerns About Death and Dying
Death is a natural part
175(72.9%)
34 (14.2%) 14 (5.8%)
17 (7.1%)
of life
Difficulty
in
50 (20.8%)
60 (25%)
81 (33.8%)
discussing death and 49(20.4%)
dying
Personal discomfort in
43 (17.9%) 71 (29.6%)
79 (32.9%)
discussing death and 47(19.6%)
dying
*Disclosure
will 10 (4.2%)
12 (5%)
35 (14.6%)
183(76.3%)
destroy hope
Theme B. Preferences of Patients on Physicians Disclosure Practices
*Prefer not to know
60 (25%)
17 (7.1%)
36 (15%)
127(52.9%)
about poor prognosis
Prefer to have full
30 (12.5%)
disclosure of poor 158(65.8%) 31 (12.9%) 21 (8.8%)
prognosis
Important to know
33 (13.8%)
115(47.8%)
46 (19.2%) 46 (19.2%)
prognosis early
161(67.1%)
41 (17.1%) 7 (2.9%)
31 (12.9%)
a doctor
30(12.5%)
48 (20%)
90 (37.5%)
72 (30%)
a loved one
Theme C. Perceived Roles of the Physician in End-of-Life Care
Collaborative
62 (25.8%)
47 (19.6%)
10 (4.2%)
decision-making with 121(50.4%)
patients
Doctors must provide
4 (1.7%)
1 (0.4%)
holistic care for their 194(80.8%) 41 (17.1%)
patients
Doctors
must
be
trained
on
proper
169(70.4%)
27 (11.3%) 16 (6.7%)
28 (11.7%)
disclosure of death and
poor prognosis
Perceptions among
Resident Physicians
n=240
*Reverse wording of questions
38
The dependent variables or the responses of patients to the statements regarding the
general concept and concerns about death and dying are the following: perceptions on
death as a natural part of life, difficulty and personal discomfort in discussing death and
dying and maintaining hope in the face of poor prognosis. For the patients preferences
for disclosure, the statements are the following: patients prefer to know about their
prognosis, to have full disclosure, to receive disclosure at the earliest possible time and to
receive disclosure from an appropriate person whether from a physician or a loved one.
For the patients perceptions on the physicians roles in end-of-life care, the statements
are the following: doctors must collaborate with patients in decision-making, that
physicians must provide holistic care for patients and that there is a need for physicians
training for disclosure of poor prognosis. The independent variables or factors measured
are the sociodemographic variables, namely age, gender, civil status, religion, ethnic
group and illness severity.
A. General concept and concerns about death and dying

This study revealed that patients accept that death is a natural part of the cycle of
life with majority of the patients strongly agreeing (72.9%) to the statement. This means
that all patients are highly aware that death is a natural part of life, viewing death as the
only sure thing that would happen. This coincides with a study done by Stromberg and
Jaarsma in 2007, wherein majority of the patient respondents described death as a
natural part of life, that it is a certainty; what is uncertain was not knowing how and
when death would occur.
Majority of the respondents say that they do not have difficulty in discussing
topics of death and dying (33.8% strongly disagreed, 25% disagreed. This means that
respondents can talk about death and dying relatively easily, however these feelings may
not necessarily translate into actual discussions about ones own death given the
variability in the responses. Additionally, patients also generally disagreed when asked
39
whether patients are uncomfortable when talking about death and dying (32.9% strongly
disagreed, 29.6% disagreed). During the 2012 British Social Attitudes survey, wherein
researchers sought to assess the publics attitudes on the issue on discussing and planning
for end of life care, it was found out that 70% of the respondents say that they feel
comfortable talking about death, which relatively coincides with the findings of this study.
The belief that hope is destroyed in the face of poor prognosis is strongly opposed
by most of the patients (76.3% strongly disagreed, 14.6% disagreed). This means that in
the event the patient has poor prognosis, hope is still maintained by many of the
respondents. In 2009, Manalo, an educator and a consultant for Community and Family
Medicine, stated that it is important to foster faith and hope in communicating poor
prognosis. A lot of Filipinos cope with their illness by praying and many believe that
hoping that whatever God's will, it is best for that individual. Hope is a reaction, which
reflects a traditional Filipino belief in combination with a Western philosophy towards
illness. Despite how poor the prognosis and severity of illness, one remains optimistic for
a cure (Giger and Davidhizar, 2003).
B. Preferences of patients on physicians disclosure practices

This study revealed that majority of the patients disagreed when asked if they
prefer not to know about their poor prognosis (52.9% strongly disagreed, 15% disagreed).
This means that patients prefer to be informed of their prognosis rather than resorting to
nondisclosure. Numerous studies have also shown that patients generally want to be wellinformed about their diagnosis, prognosis, and treatment options. A large study in UK by
Jenkins et al found that 87% of 2331 patients wanted detailed information about their
condition, including bad news.
40
With regards to the amount of prognostic information that patients require,

patients agreed that they would want to have full disclosure of their prognosis (65.8%
strongly agreed). This is consistent with the study done by Marwit and Datson in 2002
wherein a large percentage of participants expressed full disclosure levels preference.
Disclosure done at the earliest possible time was perceived as important by majority of
the respondents (47.8% strongly agreed). This coincides with a study done in 2008 by
Apatira, et al in California, USA revealed that timely discussion of prognosis is essential
for emotional and logistical preparation in the possibility of the patients death.
In terms of the appropriate person to disclose the poor prognosis, patients
preferred to receive disclosure from a doctor (67.1% strongly agreed, 17.1% agreed).
Studies done in the USA by Kutner et al in 1999 and Greisinger, et al in 1997 found that
most patients wanted to discuss their prognosis truthfully with their doctor, including the
impact of the illness on their daily lives. Another more recent study done in 2003 by
Fried et al showed that majority of palliative care patients and their caregivers would like
to have discussed life expectancy with their clinician. However, in some countries and
other cultural groups, the primary recipient of bad news is the family. For instance, a
study done by Uchitomi and Yamawaki pointed out that in Japan, all family members
are informed by physicians diagnosis, condition and therapeutic programs, before the
cancer patient is told the truth. Additionally, some patients would want disclosure to
come from a trusted family member who is more aware of the patients emotional,
psychological, social and physical conditions and could soften the impact and provide
comfort (Flores, 2011). Moreover, numerous studies have found that in instances wherein
family-oriented disclosure and decision-making dominates, many patients recognize the
41
propriety of nondisclosure and yet, they personally want to be involved in what is

going on and to decide for themselves (Hallenbeck & Arnold, 2007). This study revealed,
however, that most of the respondents do not prefer to receive disclosure from their loved
ones or families (30% strongly disagreed, 37.5% disagreed).
C. Perceived roles of the physician in end-of-life care

With regards to end-of-life care, most of the patients perceive that both patients
and doctors must share in the responsibility as decision-makers (50.4% strongly agreed,
25.8% agreed). This can be interpreted that patients prefer to have an active, rather than a
passive role, in medical decision-making. According to a literature review conducted by
the Australian National Breast and Ovarian Cancer Centre in 2012, when discussing
prognosis, it is imperative that the physician has a collaborative relationship with the
patient particularly in making decisions for end-of-life care. Moreover, a collaborative
relationship between the physician and the patient showed that it instills hope for the
patient rather than an avoidant approach is utilized in discussing prognosis and end-oflife care (Haggerty, et al, 2003).
The holistic concept of medicine means that health should encompass the entirety
of the person, such as considering the psychological, physical, social and spiritual needs
of the patient (Strandberg, et al, 2007). The primary care physicians remain to be at the
forefront in leading the medical team in providing holistic care for the patient,
particularly those who have poor prognosis. Using the holistic approach can help patient
relieve of their suffering and maintain hope (Ngo-Metzger and August, 2008). According
to majority of the patient respondents, doctors must be able to provide holistic care for
42
their patients (80.8% strongly agreed, 17.1% agreed). This means that not only should
physicians cure the physical aspects of the illness, but must also integrate the whole being
of the patient. Moreover, patients perceive that given the challenging position faced by
physicians in dealing with dying patients, they feel that physicians should be better
equipped to handle such situations (Ngo-Metzger and August, 2008). As such, majority
of the patient respondents perceive that it is necessary for the physicians to be trained on
proper disclosure of death and poor prognosis (70.4% strongly agreed).
IV. Association of socio-demographic factors and severity of illness to

patients perceptions
A. Factors associated with patients general concept and concerns
about death and dying
Using simple logistic regression between the patients perceptions that death is a
natural part of life and the socio-demographic factors, namely age, sex, civil status,
religion, ethnic group, educational attainment as well as the severity of illness, did not
yield any significant associations.
For the patients perceived difficulty in discussing death and dying, univariate
analysis was done for each exposure variable and included in the full model of variables
as seen on Table 9. Among the variables, Islam was shown to be statistically significant
(p=0.022). No other variables were statistically significant, however, all qualified
variables (p-value <0.25) were selected and combined in the reduced model (see table 9.1,
appendix). With the reduced model, multiple logistic regression was done by using
backward elimination of variables.
43
Table 9. Full model of variables associated with patients perceptions on difficulty in

discussing death and dying
Variables
Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Gender
Male
Female
Civil Status
Single
Religion
Roman Catholic
Islam
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Educational Attainment
Without Higher Education
With Higher Education
Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Have difficulty in discussing

death and dying
Agree
Disagree
n(%)
n(%)
OR
95% CI
pvalue
35 (14.6%)
24 (10.0%)
25 (10.4%)
15 (6.3%)
40 (16.7%)
45 (18.8%)
31 (12.9%)
25 (10.4%)
1.00
0.61
0.92
0.69
0.311, 1.193
0.460, 1.847
0.313, 1.503
0.149
0.818
0.346
38 (15.8%)
61 (25.4%)
57 (23.8%)
84 (35.0%)
1.00
0.32
0.643, 1.844
0.750
26 (10.8%)
61 (25.4%)
12 (5.0%)
38 (15.8%)
83 (34.6%)
20 (8.3%)
1.00
1.07
0.88
0.590, 1.954
0.367, 2.098
0.815
0.768
56 (23.3%)
36 (15.0%)
7 (2.9%)
98 (40.8%)
32 (13.3%)
11 (4.6%)
1.00
1.97
1.11
1.104, 3.510
0.408, 3.036
0.022
0.833
35 (14.6%)
26 (10.8%)
28 (11.7%)
10 (4.2%)
61 (25.4%)
41 (17.1%)
26 (10.8%)
13 (5.4%)
1.00
1.10
1.88
1.34
0.580, 2.104
0.954, 3.692
0.533, 3.375
0.761
0.068
0.534
75 (31.3%)
24 (10.0%)
99 (41.3%)
42 (17.5%)
1.00
0.75
0.420, 1.353
0.344
36 (15.0%)
47 (19.6%)
16 (6.7%)
49 (20.4%)
73 (30.4%)
19 (7.9%)
0.88
1.15
0.498, 1.542
0.519, 2.531
0.647
0.736

For patients who perceived personal discomfort in discussing death and dying,
the full model of variables can be seen in Table 10. No significant variables were found
to be statistically significant. Age group, religion, ethnic group, educational attainment
and severity of illness were included in the reduced model for multiple logistic regression
as can be seen on table 10.1 (see appendix).
44
Table 10. Full model of variables associated with patients perceptions on personal
discomfort in discussing death and dying
Variables
Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Gender
Male
Female
Civil Status
Single
Religion
Roman Catholic
Islam
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Do not have personal discomfort

in discussing death and dying
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
24 (10.0%)
23 (9.6%)
26 (10.8%)
17 (7.0%)
51 (21.3%)
46 (19.2%)
30 (12.5%)
23 (9.6%)
1.00
1.06
1.84
1.57
0.529, 2.133
0.901, 3.765
0.711, 3.470
0.865
0.094
0.264
36 (15.0%)
54 (22.5%)
59 (24.6%)
61 (25.4%)
1.00
0.97
0.570, 1.659
0.919
22 (9.2%)
55 (22.9%)
13 (5.4%)
42 (17.5%)
89 (37.0%)
19 (7.9%)
1.00
1.18
1.31
0.637, 2.184
0.545, 3.130
0.599
0.549
51 (21.3%)
31 (12.9%)
8 (3.3%)
103 (42.9%)
37 (15.4%)
10 (4.2%)
1.00
1.69
1.62
0.944, 3.032
0.601, 4.341
0.077
0.341
31(12.9%)
26 (10.8%)
25 (10.4%)
8 (3.3%)
65 (27.0%)
41 (17.1%)
29 (12.1%)
15 (6.3%)
1.00
1.33
1.81
1.12
0.693, 2.551
0.911, 3.586
0.429, 2.917
0.391
0.090
0.819
70 (29.2%)
20 (8.3%)
104 (43.3%)
46 (19.2%)
1.00
0.65
0.352, 1.184
0.158
29 (12.0%)
44 (18.3%)
17 (7.1%)
56 (23.3%)
76 (31.6%)
18 (7.5%)
1.12
1.82
0.624, 2.001
0.819, 4.060
0.707
0.141
For patients perception that hope is maintained even in the face of poor prognosis,
the full model of variables is shown on table 11. Among the variables, the ethnic group
Bisaya is shown to be statistically significant (p-value = 0.043). Age group, gender,
ethnic group and illness severity were variables included in the reduced model for
multiple logistic regression which can be seen in table 11.1, appendix.
45

maintaining hope even in the face of poor prognosis
Variables
Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Gender
Male
Female
Civil Status
Single
Religion
Roman Catholic
Islam
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
*Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Hope is maintained even in

the face of poor prognosis
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
71 (27.9%)
63 (25.4%)
48 (20.0%)
36 (13.8%)
4 (3.3%)
6 (3.3%)
8 (3.3%)
4(2.9%)
1.00
0.59
0.34
0.51
0.160, 2.192
0.096, 1.186
0.120, 2.146
0.432
0.090
0.356
83 (33.8%)
135 (53.3%)
12 (23.8%)
10(35.0%)
1.00
1.95
0.807, 4.718
0.138
59 (24.6%)
131 (52.1%)
28 (10.4%)
5 (5.8%)
13 (7.1%)
4 (2.1%)
1.00
0.85
0.59
0.291, 2.505
0.148, 2.381
0.774
0.461
139 (56.7%)
62 (24.2%)
17 (6.3%)
15 (7.5%)
6 (4.2%)
1 (1.3%)
1.00
1.12
1.83
0.413, 3.010
0.228, 14.772
0.830
0.569
91 (35.4%)
57 (23.8%)
49 (19.2%)
21 (8.8%)
5 (4.6%)
10 (4.2%)
5 (3.3%)
2 (0.8%)
1.00
0.31
0.54
0.58
0.102, 0.963
0.149, 1.951
0.105, 3.181
0.043
0.346
0.528
157 (63.8%)
61 (23.3%)
17 (8.8%)
5 (4.2%)
1.00
1.32
0.467, 3.738
0.600
81 (30.4%)
106 (44.6%)
31 (12.1%)
4 (5.0%)
14 (5.4%)
4 (2.5%)
0.37
0.38
0.119, 1.179
0.090, 1.626
0.093
0.193
B. Factors associated with patients

practices
preferences on disclosure
For patients preference to be informed of poor prognosis, the full model of variables
can be seen in Table 12. Among the variables, the ethnic group Bisaya was shown to be
statistically significant (p-value=0.027). Age group, civil status, ethnic group, and
46
educational attainment were included in the reduced model for multiple logistic
regression (see table 12.1, appendix).
Table 12. Full model of variables associated with patients preference to be

informed of poor prognosis
Variables
*Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Gender
Male
Female
*Civil Status
Single
Religion
Roman Catholic
Islam
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
*Educational Attainment
Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Prefer to be informed of poor

prognosis
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
52 (21.7%)
41 (17.0%)
39 (16.3%)
31(12.9%)
23 (9.6%)
28 (11.7%)
17 (7.1%)
9 (3.8%)
1.00
0.65
1.01
1.52
0.326, 1.287
0.478, 2.152
0.626, 3.708
0.215
0.970
0.354
63 (26.3%)
100 (41.7%)
32 (13.3%)
45 (18.8%)
1.00
1.13
0.650, 1.960
0.667
39 (16.3%)
101 (42.0%)
23 (9.6%)
25 (10.4%)
43 (17.9%)
9 (3.8%)
1.00
1.51
1.64
0.813, 2.789
0.653, 4.110
0.193
0.293
106 (44.2%)
43 (17.9%)
14 (5.8%)
48 (20%)
25 (10.4%)
4 (1.7%)
1.00
0.78
1.58
0.428, 1.418
0.496, 5.068
0.414
0.437
73 (30.4%)
40 (16.7%)
33 (13.8%)
17 (7.1%)
23 (9.6%)
27 (11.3%)
21 (8.8%)
6 (2.5%)
1.00
0.47
0.50
0.89
0.237, 0.918
0.241, 1.018
0.315, 2.531
0.027
0.056
0.831
113 (47.1%)
50 (20.8%)
61 (25.4%)
16 (6.7%)
1.00
1.69
0.887, 3.210
0.111
29 (12.1%)
44 (18.3%)
17 (7.1%)
56 (23.3%)
76 (31.6%)
18 (7.5%)
1.16
1.13
0.642, 2.101
0.486, 2.625
0.620
0.776

For patients preference to receive full disclosure of poor prognosis, the full model of
variables is shown on table 13. There are no statistically significant variables in the full
47
model. The qualified variables for multiple regression are shown in the reduced model
(see table 13.1, appendix) which are ethnic group and educational attainment.
Table 13. Full model of variables associated with patients preference to have
full disclosure of prognosis
Variables
Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Gender
Male
Female
Civil Status
Single
Religion
Roman Catholic
Islam
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Prefer to have full disclosure of

poor prognosis
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
59 (24.6%)
57 (23.8%)
43 (17.9%)
30(12.5%)
16 (6.7%)
12 (5.0%)
13 (5.4%)
10 (4.2%)
1.00
1.29
0.90
0.81
0.560, 2.961
0.391, 2.059
0.329, 2.009
0.551
0.798
0.655
73 (30.4%)
116 (48.3%)
22 (9.2%)
29 (12.1%)
1.00
1.21
0.644, 2.256
0.559
49 (20.4%)
115 (47.9%)
25 (10.4%)
15 (6.3%)
29 (12.1%)
7 (2.9%)
1.00
1.21
1.09
0.598, 2.463
0.394, 3.027
0.591
0.864
121 (50.4%)
52 (21.7%)
16 (6.7%)
33 (13.8%)
16 (6.7%)
2 (0.8%)
1.00
0.89
2.18
0.449, 1.749
0.477, 9.971
0.728
0.314
81 (33.8%)
50 (20.8%)
40 (16.7%)
18 (7.5%)
15 (6.3%)
17 (7.1%)
14 (5.8%)
5 (2.1%)
1.00
0.54
0.53
0.67
0.251, 1.190
0.233, 1.202
0.215, 2.071
0.126
0.129
0.483
132 (55.0%)
57 (23.8%)
42 (17.5%)
9 (3.8%)
1.00
2.02
0.920, 4.414
0.080
68 (28.3%)
95 (39.6%)
26 (10.8%)
17 (7.1%)
25 (10.4%)
9 (3.8%)
0.95
0.72
0.476, 1.895
0.286, 1.822
0.884
0.491
For the timing of disclosure or the importance of knowing prognosis early, the full
model of variables are shown in table 14. Age groups of 51-64 years old and 65 years old
and above are shown to be statistically significant in the full model (p-value = 0.015).
48
The same goes with patients who received higher education (p-value = 0.019). The
variables eligible for multiple logistic regression were shown in the reduced model shown
in table 14.1, appendix. Age group, civil status, ethnic group and educational attainment
were included in the reduced model.
Table 14. Full model of variables associated with patients preference to have
disclosure of poor prognosis at the earliest possible time
Variables
*Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Gender
Male
Female
*Civil Status
Single
Religion
Roman Catholic
Islam
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Prefer to have disclosure of

poor prognosis at the earliest
possible time
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
58 (24.2%)
49 (20.4%)
32 (13.3%)
22 (9.2%)
17 (7.1%)
20 (8.3%)
24 (10.0%)
18 (7.5%)
1.00
0.72
0.39
0.36
0.339, 1.520
0.183, 0.833
0.157, 0.817
0.387
0.015
0.015
62 (25.8%)
99 (41.3%)
33 (13.8%)
46 (19.2%)
1.00
1.15
0.662, 1.982
0.627
46 (19.2%)
97 (40.4%)
18 (7.5%)
18 (7.5%)
47 (19.6%)
14 (5.8%)
1.00
0.81
0.50
0.423, 1.542
0.207, 1.220
0.517
0.129
103 (42.9%)
45 (18.8%)
13 (5.4%)
51 (21.3%)
23 (9.6%)
5 (0.2%)
1.00
0.97
1.29
0.529, 1.772
0.435, 3.808
0.918
0.648
69 (28.8%)
42 (17.5%)
34 (14.2%)
16 (6.7%)
27 (11.3%)
25 (10.4%)
20 (8.3%)
7 (2.9%)
1.00
0.66
0.67
0.89
0.338, 1.279
0.327, 1.352
0.331, 2.415
0.217
0.260
0.826
109 (45.4%)
52 (21.7%)
65 (27.1%)
14 (5.8%)
1.00
2.21
1.139, 4.308
0.019
54 (22.5%)
83 (34.6%)
24 (10.0%)
31 (12.9%)
37 (15.4%)
11 (4.6%)
1.29
1.25
0.716, 2.317
0.541, 2.899
0.399
0.599

For patients preference to receive disclosure from a doctor, the full model of
variables are shown in table 15. Among the variables, Bisaya ethnic group was shown to
49
be statistically significant (p-value = 0.042). The variables ethnic group and severity of
illness are included in the reduced model for multiple logistic regression, as can be seen
in Table 15.1, appendix.
Table 15. Full model of variables associated with patients preference to receive
disclosure from a doctor
Variables
Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Gender
Male
Female
Civil Status
Single
Religion
Roman Catholic
Islam
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
*Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Prefer to receive disclosure

from a doctor
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
65 (24.6%)
60 (23.8%)
45 (17.9%)
32 (12.5%)
10 (4.2%)
9 (3.8%)
11 (4.6%)
8 (3.3%)
1.00
1.03
0.63
0.62
0.390, 2.696
0.247, 1.606
0.222, 1.709
0.959
0.333
0.352
77 (32.0%)
125 (52.1%)
18 (7.5%)
20 (8.3%)
1.00
1.46
0.728, 2.933
0.286
54 (22.5%)
122 (50.8%)
26 (10.8%)
10 (4.2%)
22 (9.2%)
6 (2.5%)
1.00
1.03
0.80
0.455, 2.316
0.263, 2.447
0.949
0.699
132 (55.0%)
55 (22.9%)
15 (6.3%)
22 (9.2%)
13 (5.4%)
3 (1.3%)
1.00
0.71
0.83
0.332, 1.499
0.223, 3.117
0.364
0.786
87 (36.3%)
53 (22.1%)
43 (17.9%)
19 (7.9%)
9 (3.8%)
14 (5.8%)
11 (4.6%)
4 (1.7%)
1.00
0.39
0.40
0.49
0.159, 0.967
0.156, 1.050
0.137, 1.764
0.042
0.063
0.276
144 (60.0%)
58 (24.2%)
30 (12.5%)
8 (3.3%)
1.00
1.51
0.654, 3.489
0.334
70 (29.2%)
99 (41.3%)
33 (13.8%)
15 (6.3%)
21 (8.8%)
2 (0.8%)
1.01
3.54
0.487, 2.096
0.764,
16.367
0.978
0.106

For patients preference to receive disclosure from a loved one or a family
member, the full model of variables are shown in table 16. Among the variables, severe
illness was shown to be statistically significant (p-value=0.008). The qualified variables
50
for multiple logistic regression are civil status, ethnic group and severity of illness. These
make up the reduced model as can be seen in Table 16.1, appendix.
Table 16. Full model of variables associated with patients preference to receive
disclosure from loved one or family member
Variables
Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Gender
Male
Female
*Civil Status
Single
Religion
Roman Catholic
Islam
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
*Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Prefer to receive disclosure from

a doctor
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
26 (24.6%)
20 (23.8%)
18 (17.9%)
14 (12.5%)
49 (6.7%)
49 (5.0%)
38 (5.4%)
26 (4.2%)
1.00
0.77
0.89
1.01
0.380, 1.556
0.428, 1.862
0.454, 2.270
0.466
0.762
0.971
29 (30.4%)
49 (48.3%)
66 (9.2%)
96 (12.1%)
1.00
1.16
0.666, 2.025
0.597
23 (20.4%)
37 (47.9%)
18 (10.4%)
41 (6.3%)
107 (12.1%)
14 (2.9%)
1.00
0.62
2.29
0.327, 1.161
0.965, 5.444
0.134
0.060
48 (50.4%)
22 (21.7%)
8 (6.7%)
106 (13.8%)
46 (6.7%)
10 (0.8%)
1.00
1.06
1.77
0.573, 1.947
0.656, 4.756
0.364
0.260
28 (33.8%)
26 (20.8%)
17 (16.7%)
7 (7.5%)
68 (6.3%)
41 (7.1%)
37 (5.8%)
16 (2.1%)
1.00
1.54
1.12
1.06
0.796, 2.979
0.541, 2.300
0.394, 2.863
0.199
0.767
0.905
60 (55.0%)
18 (23.8%)
114 (17.5%)
48 (3.8%)
1.00
0.71
0.381, 1.332
0.288
20 (28.3%)
41 (39.6%)
17 (10.8%)
65 (7.1%)
79 (10.4%)
18 (3.8%)
1.69
3.07
0.901, 3.158
1.337, 7.046
0.102
0.008
51
C. Factors associated with patients perceptions on physicians roles in

end-of-life care
Simple logistic regression between the patients perceptions that physicians must
provide holistic care for patients and the socio-demographic factors, namely age, sex,
civil status, religion, ethnic group, educational attainment as well as the severity of illness,
did not yield any significant associations. There were also no significant associations of
the socio-demographic profile and severity of illness to patients perception that doctors
need training on proper disclosure of poor prognosis.
For patients perceptions on having collaborative decision-making with doctors for
end-of-life care the full model is shown on table 17. Being married or cohabiting was
shown to be statistically significant (p-value=0.024). Those who belonged to the religion
Islam were also significantly associated with patients perceptions to having collaborative
decision-making (p-value = 0.006). Those who belong to the Tausug ethnic group and
other ethnic groups (i.e. Ilonggo, Samal, etc.) are also statistically significant (p-values =
0.038; 0.021, respectively). The variables qualified for multiple logistic regression are
age group, civil status, religion and ethnic group. These are included in the reduced
model as seen on Table 17.1, appendix.
52

Variables
*Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Gender
Male
Female
*Civil Status
Single
*Religion
Roman Catholic
Islam
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Have collaborative decisionmaking for end-of-life care

Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
61 (25.4%)
54 (22.5%)
42 (17.5%)
27 (11.3%)
14 (5.8%)
15 (6.3%)
14 (5.8%)
13 (5.4%)
1.00
0.83
0.69
0.48
0.367, 1.867
0.298, 1.592
0.198, 1.150
0.646
0.383
0.099
75 (31.3%)
109 (45.4%)
20 (8.3%)
36 (15.0%)
1.00
0.81
0.434, 1.502
0.499
56 (23.3%)
105 (43.8%)
23 (9.6%)
8 (3.3%)
39 (16.3%)
9 (3.8%)
1.00
0.38
0.37
0.168, 0.879
0.125, 1.063
0.024
0.065
126 (52.5%)
44 (18.3)
14 (5.8%)
28 (11.7%)
24 (10.0%)
4 (1.7%)
1.00
0.41
0.78
0.214, 0.776
0.238, 2.542
0.006
0.677
80 (33.3%)
53 (22.1%)
37 (15.4%)
14 (5.8%)
16 (6.7%)
14 (5.8%)
17 (7.1%)
9 (3.8%)
1.00
0.78
0.44
0.31
0.341, 1.680
0.198, 0.955
0.115, 0.841
0.494
0.038
0.021
131 (54.5%)
53 (22.1%)
43 (17.9%)
13 (5.4%)
1.00
1.34
0.666, 2.688
0.413
20 (8.3%)
41 (17.1%)
17 (7.1%)
65 (27.1%)
79 (32.9%)
18 (7.5%)
0.95
0.83
0.488, 1.835
0.334, 2.074
0.869
0.693
53
The final models from multiple logistic regression are summarized in table 18. A
total of eight perceptions were shown to have significant associations with
sociodemographic factors and illness severity.
Table 18. Summary Table of Final models of regression analysis using the factors
associated with patients perceptions on death and disclosure of poor prognosis
Dependent Variables
Factors
OR
95% CI
p-value
No difficulty in discussing
death and dying
Islam religion
1.97
1.104, 3.511
0.022
No personal discomfort in
51-64 age group

Islam religion
2.15
2.03
1.023, 4.517
1.097, 3.764
0.043
0.024

Bisaya ethnic group
0.31
0.102, 0.963
0.043
Prefers to know about poor

prognosis
Bisaya ethnic group
0.47
0.237, 0.918
0.027
Prefers to have disclosure of

prognosis at the earliest
possible time
51-64 age group

65 age group
0.39
0.36
0.183, 0.833
0.157, 0.817
0.015
0.015

from a doctor
Bisaya ethnic group
0.39
0.159, 0.967
0.042

from a family member
Severe illness
3.07
1.337, 7.046
0.008
Have collaborative decisionmaking in end-of-life care
65 age group
Islam religion
0.32
0.71
0.122, 0.814
0.213, 2.373
0.017
0.001
*Final model only includes variables with p-value <0.05 on logistic regression
54
For the perceptions of having difficulty in discussing death and dying, multiple
logistic regression was done by using backward elimination of variables. This leaves
Islam as the only statistically significant variable. Muslim patients are almost twice as
likely to perceive not having difficulties when talking about death and dying as compared
to patients who belonged to other religious affiliations. This coincides with the teachings
of Islam, wherein it is believed that death marks the transition from one state of
existence to the next and that death is something to be accepted as part of the overall
divine plan. Furthermore, death is not considered to be a taboo topic in Muslim society
and it is something that is encouraged to be reflected upon frequently (Aziz, 1998).
For the patients personal discomfort in discussing death and dying, the 51-64
years old age group and those belonging to the religion of Islam were twice as likely to
be personally comfortable in discussing death and dying. This can be interpreted as
Muslim patients aged 51-64 years old are more likely to be comfortable in discussing
death and dying. Again, this coincides with the teachings of Islam wherein death is not
something to be feared but welcomed, as it is part of a divine plan. Older Muslim patients
are more likely to subscribe to this belief. Older age can be translated to a more
developed spirituality anchored by the teachings of Islam. This coincides with the finding
that Muslim patients who belong to the age group 51-64 years old are more likely to be
more comfortable in discussing death and dying.
Patients who belong to the Bisaya ethnic group are shown to be 69% less likely to
maintain hope in the face of poor prognosis. In addition, they are 53% less likely to want
to be informed of poor prognosis and are 61% less likely to prefer to receive disclosure
from a doctor. In general, patients from various ethnic groups and cultural backgrounds
55
differ in their perceptions in maintaining hope and preferences in the way prognostic
information is delivered (Abrahm et al, 2014). In some Filipino cultures, discussion about
death and dying are avoided because these exchanges demonstrate a lack of respect for
the belief that individual fate is determined by God (Searight and Gafford, 2005).
Patients who belong to the 51-64 years old age group and those who are 65 years
old and above are shown to be 61% and 64% less likely to prefer to have disclosure at the
earliest possible time, respectively. This can be interpreted that older patients prefer a
gradual approach to disclosure of poor prognosis. This can be attributed by some of the
older patients who feared the emotional burdens associated with knowing prognosis
when they are told of poor prognosis immediately. However, studies have shown that
older patients, particularly the elderly, prefer to discuss prognosis at the earliest possible
time as it will help in preparing themselves and their families, provide for their own
emotional and spiritual needs and making health and medical-related decisions (Ahalt et
al, 2012).
Patients categorized as having severe illness are three times more likely to prefer
to receive disclosure from a family member. In many Asian cultures, illness is considered
a family event rather than an individual occurrence. These patients rely on trusted
family members to disclose their prognosis, as they are the ones who can, and are
expected to provide emotional and spiritual support in times of distress (Searight &
Gafford, 2005).
Muslim patients belonging to the age group of 65 years old and above are shown to
be significantly associated with patients perceptions for a collaborative decision-making

56
with doctors for end-of-life care. Muslim patients are 29% less likely to collaborate with
physicians in decision-making for end-of-life care, choosing instead to let their families
make the decision for them. Additionally, elderly patients are 68% less likely to do
collaborative decision-making as well, relaying the task to their families instead. This is
due to the elderlies desire of greater family involvement (Hanson and Winzelberg, 2013).
Furthermore, in collectivist Asian and Muslim cultures, illness is considered a shared
family affair. Consequently, decision-making is centered on family most of the time
(OKelly et al, 2011).
57
CHAPTER 4
SUMMARY, CONCLUSION AND RECOMMENDATIONS
On the theme of general concept and concerns on death and dying, physicians
strongly agree that death is a natural part of life and agree that they have difficulties and
personal discomforts in discussing death and dying. They also agree that disclosure of
poor prognosis will destroy hope. For the preferences of patients on disclosure practices,
physicians agree that patients do not want to be informed of poor prognosis. However,
they strongly agree that patients would prefer full disclosure from a doctor at the earliest
possible time as opposed to receiving disclosure from a family member. Physicians also
strongly agree that collaborative decision-making, holistic care and the need to undergo
training were all essential roles of physicians in end-of-life care. Physicians between 3654 years old are less likely to perceive that patients would prefer to receive disclosure
from a family member. Those who do not have difficulties in disclosure are also less
likely to perceive the need for further training.
Patient respondents also strongly agree that death is a natural part of life, but
disagree that they have difficulty and have personal discomforts in discussing death and
dying. They also strongly disagree that disclosure of poor prognosis will destroy hope.
For their preferences on disclosure practices, patients strongly disagree that they do not
want to be informed of poor prognosis. They also strongly agree that they would prefer
full disclosure from a doctor at the earliest possible time as opposed to receiving
disclosure from a family member. The patients also strongly agree that collaborative
decision-making, holistic care and the need to undergo training were all essential roles of
57
physicians in end-of-life care. Islam religion was found to be significantly associated

with patients perceptions. Muslim patients are less likely to have difficulty in discussing
death and poor prognosis. Furthermore, older Muslim patients are also less likely to have
personal discomfort in discussing death. However, they are less likely to have
collaborative decision-making in end-of-life care. Patients who belong in the Bisaya
ethnic group are less likely to maintain hope in the face of poor prognosis, prefer not to
know about poor prognosis and prefer not to receive disclosure from a doctor. Patients
aged 51 years old and above are less likely to prefer receiving disclosure at the earliest
possible time. Patients with severe illness more likely prefer to receive disclosure from a
family member.
Physicians perceptions generally coincide with patients perceptions on their
views that death is a natural part of life; that patients want to be given timely and detailed
information about their prognosis; the more appropriate person to deliver bad news; the
role doctors play in caring for terminally ill patients and the need for physicians to be
trained on how to conduct proper disclosure. However, physicians have the
misperception that patients do not want to be told about the news of poor prognosis, when
on the contrary, patients want to be told rather than not knowing that they are terminally
ill. This reluctance and apprehension cause patients to frequently have misunderstandings
about their illness, which would contribute to anxiety and depression. Another
misperception of physicians is the notion that hope is destroyed when a patient is told
about his or her poor prognosis. This proves to be false for majority of the patient
respondents, as they feel that hope is maintained and not destroyed even when faced with
poor prognosis.
58
The results of the associations of sociodemographic profiles and severity of

illness to patient perceptions can help improve disclosure practices, provide
empowerment for decision-making on medical care and improve overall well-being. A
one-size-fits-all type of disclosure practice may not benefit all patients. Efforts to
individualize disclosure practices must be tailored to a patients specific characteristics.
Disclosure of poor prognosis and impending death is a vital skill, as it is essential in
helping patients and families move toward closure and help facilitate discussion of
treatment preferences.
The limitations of this study are the restriction to the population of a single
institution and the sensitive nature of the topic on death and dying particularly for
respondents who are severely ill. Although the questionnaires for the patient
respondents were answered with the assistance of the researcher and that it was
also repeatedly clarified that the questions were hypothetical (that is,
hypothetically that the respondent has a terminal illness), the topic of death and
dying itself brought about some intense emotions such as feelings of sadness and
fear to some of the respondents, particularly those who are severely ill.
It is recommended that these results be kept in mind when disclosing poor
prognosis. The misperceptions of physicians regarding patients preference to be
informed of poor prognosis as and that poor prognosis destroys hope, must also be
corrected. This study can be used as a baseline when conducting similar researches. The
researcher recommends determining the perceptions of the patients relatives or
significant others, as they play an essential part in the patients emotional, psychological,
59
social and spiritual conditions and should be seen as partners in providing comfort for the
patient. Further explanation of answers could be followed through and other related
issues could be elicited and pursued. In order to explore the perspectives of patients and
physicians on death and disclosure of poor prognosis further, the use of a more
appropriate method of qualitative research technique such as conducting in-depth
interviews or focus group discussions among selected respondents can provide more
robust information.
60
BIBLIOGRAPHY
Bruera, E., Sweeney, C., et al (2001). Patient Preferences Versus Physician
Perceptions of Treatment Decisions in Cancer Care. American Society of Clinical
Oncology.
Callahan, D. (1998). Managed Care and the Goals of Medicine. Journal of the
American Geriatrics Society, 385-388.
Elkin, E., Kim, S., et al. (2007). Desire for Information and Involvement in Treatment
Decisions: Elderly Cancer Patients Preferences and Their Physicians
Perceptions. Journal of Clinical Oncology, 5275-5281.
Flores, A., Nicodemus, L. and Medina, Jr. M. (2011). Primary Health Care Provider
Perception versus Patients Preferences on Death and Disclosure of Poor
Prognosis. The Filipino Family Physician, 8-16.
Friedrichsen, M., Lindholm, A., & Milberg, A. (2011). Experiences of truth
disclosure in terminally ill cancer patients in palliative home care. Palliative and
Supportive Care Pall Supp Care, 173-180.
Grunfeld, E., Maher, E.J., et al. (2006). Advanced Breast Cancer Patients Perceptions of
Decision Making for Palliative Chemotherapy. Journal of Clinical Oncology, 10901099.
Hagerty, R. (2005). Communicating With Realism and Hope: Incurable Cancer Patients'
Views on the Disclosure of Prognosis. Journal of Clinical Oncology, 1278-1288.
Hancock, K., Clayton, J., et al (2007). Truth-telling in discussing prognosis in advanced
life-limiting illnesses: A systematic review. Palliative Medicine, 507-517.
Huang, H., Cheng, S., Yao, C., Hu, W., Chen, C., & Chiu, T. (2015). Truth Telling and
Treatment Strategies in End-of-Life Care in Physician-Led Accountable Care
Organizations. Medicine.
Lee, S.M., & Hawkins, R., (2015) Disclosure Preferences Towards Terminally Ill
Patients in Singapore: Are We Ready to Confront the Elephant in the Room?
Austral-Asian Journal of Cancer. 9-17.
Marwit, S., & Datson, S. (2002). Disclosure Preferences About Terminal Illness: An
Examination Of Decision-Related Factors. Death Studies, 1-20.
Miyata, H. (2005). Disclosure preferences regarding cancer diagnosis and prognosis: To
tell or not to tell? Journal of Medical Ethics, 447-451.
Quill, T. (2000). Initiating End-of-Life Discussions With Seriously Ill Patients. JAMA,
2502-2502.
Tang, S., & Lee, S. (2003). Cancer diagnosis and prognosis in Taiwan: Patient
preferences versus experiences. Psycho-Oncology, 1-13.
Wei, S., Chen, F., Chen, H., et al (2015). Patients' and Family Members' DecisionMaking and Information Disclosure Preferences in a Single-Center Survey in
China: A Pilot Study. American Journal of Hospice and Palliative Medicine.
61
APPENDIX A
Pahintulot Para sa Pasyente
Ako, si _____________________________ (pangalan), _____ (edad) taong gulang, ay
malayang makikibahagi sa pananaliksik na pinamagatang Perceptions of Physicians
and Patients on the Disclosure of Death and Poor Prognosis in Zamboanga City
Medical Center na nasa pangunahing pamamahala ni Dr. Ma. Monique Theresita M.
Soliven. Naipaliwanag sa akin at naunawaan ko ang mga sumusunod:
Ang layunin ng pagsusuri na ito ay malaman ang mga saloobin ng mga
pasyenteng katulad ko sa pagtanggap ng balita ukol sa maselan na paksa ng kamatayan.
Inaasahan na ang kalalabasan ng pagsusuri na ito ay makatutulong sa mga doctor upang
mas mapabuti ang pangangalaga ng mga pasyente, lalo na sa mga malulubha na ang sakit
o nalalapit nang mamatay.
Ako ay isa sa napiling pasyente na sasagot ng isang questionnaire ukol sa
nabanggit na paksa.
Hindi kinakailangan mag follow-up matapos masagutan ang questionnaire.
Walang anumang gamot ang ibibigay o ipapainom sa akin sa pananaliksik na ito.
Wala akong matatanggap na kabayaran sa aking pagsali.
Lahat ng impormasyon patungkol sa akin ay mananatiling lihim sa kaalaman ng
ibang tao. Ang mga resulta ng pananaliksik na ito ay maaaring ilahad sa mga talakayan o
pahayagan liban sa personal na impormasyon ukol sa akin.
Kusang-loob akong nakikibahagi sa pananaliksik na ito at maaari kong itigil ang
aking pakikipagbahagi sa kahit na anong oras o sa kahit na anong dahilan.
Para sa karagdagang kaalaman, maaari akong makipag-ugnayan kay Dra. Soliven
sa numerong ito 09153734644.
Walang mali o tamang sagot sa questionnaire na papasagutan sa akin. Ang
kinakailangan lamang dito ay ang aking tapat na opinyon sa mga paksang bahagi ng
pananaliksik na ito.
Lagda:
________________________
Pangalan: ________________________
Petsa:
________________________
Ang pahintulot na ito ay nakuha ni :____________________________________

Pangalan at Lagda
Date: ___________________________________
62
Survey form number:
Date of Survey:
Department:
Patient
( ) In-Patient
( ) Out-
( ) Family Medicine ( ) Internal Medicine ( ) General Surgery ( ) Obstetrics &

Gynecology
( ) Orthopedics
( ) ENT
Pangalan (opsyonal):
Status Sibil: ( ) Single ( ) Kasal
( ) Ophthalmology
Edad:
(
Kasarian:
) Live-In
( ) Lalaki ( ) Babae
( ) Hiwalay ( ) Biyudo/Biyuda
Tirahan:
_______________________________________________________________________
Relihiyon:
(
(
(
(
(
) Kristiyano
( ) Muslim
) Katoliko
) Protestante
) Ibang Relihiyon (isulat): __________
) Walang Relihiyon
Grupong Etniko:
( ) Chavacano
( ) Bisaya
( ) Tausug
( ) Iba (isulat): ____
Nakumpleto sa Pag-aaral: ( ) Elementary level ( ) Elementary graduate

( ) High School Level ( ) High School Graduate
( ) College Level
( ) College graduate ( ) Hindi Nakapag-aral ( ) Iba (isulat): ___
Trabaho: ____________________________________________________
Ano ang iyong sakit? __________________________________________
Gaano katagal mo na alam ang tungkol sa iyong sakit?
( ) Wala pang isang araw ( ) 1- 6 na araw
( ) 1 3 linggo
( ) 6 na buwan 1 taon
( ) lampas pa sa 1 taon
( ) 1-6 na buwan
Kinakailangan ba na tulungan ka sa pang-araw-araw mong gawain?

( ) hindi
( ) nangangailangan
( ) madalas na
( ) ganap na
nangangailangan ng
ng kaunting tulong
nangangailangan ng
nangangailangan
tulong
tulong
ng tulong
Gaano kadalas sa isang taon mong kailangang pumunta sa ospital para
magpagamot?
( ) hindi kinakailangan
( )1o2
( ) Madaming beses
Magkakaroon ba ng pagpapabuti ng iyong kondisyon sa loob ng isang taon?
( ) maaaring mapapabuti
( ) maaaring walang
( ) maaaring lumala
pagbabago
63
SCORING:
0-24 None, Questionable
25-49 - Mild
50-74 - Moderate
75-100 - Severe
DUSOI Severity Score: ________
64
Panuto: Maglagay ng check mark () sa ilalim ng hanay na tumutugma sa pinakaangkop na pahayag. Walang tama o maling sagot.
PAHAYAG
HIGIT NA
SUMASANGAYON
SUMASANGAYON
HINDI
SUMASANGAYON
HIGIT NA
HINDI
SUMASANGAYON
1. Naniniwala ako na ang kamatayan ay

natural na bahagi ng buhay ng isang
tao.
2. Nahihirapan akong pag-usapan ang
tungkol sa kamatayan.
3. Hindi ako komportableng pag-usapan
ang tungkol sa kamatayan.
4. Mas nakakabuti sa akin na hindi
malaman na ako ay may malubhang
sakit at malapit nang mamatay.
5. Mas gugustuhin ko na ipahayag sa
akin ang buong katototohanan
tungkol sa aking kondisyon.
6. Mas gusto ko na ang aking doktor
ang magsabi sa akin na ako ay
malubha na at nalalapit nang
mamatay.
65
7. Mas gusto ko na ang aking kamaganak o mahal sa buhay ang

magbabalita sa akin na ako ay
malubha na at nalalapit nang
mamatay.
8. Importante na ipagbigay-alam sa akin
agad ng aking doctor kung malubha
na ang aking sakit at nalalapit nang
mamatay.
9. Ako at ang aking doktor ang dapat
magpapasya tungkol sa aking
matatanggap na pagpapagamot.
10. Hindi ako mawawalan ng pag-asa
kahit na malaman ko na ako ay

malubha na at malapit nang mamatay.
11. Isa sa mga tungkulin ng mga doctor
ay ang pagkakaroon ng malasakit sa
mga pasyenteng malubha na ang sakit
at nalalapit nang mamatay.
12. Kailangang sumailalim sa edukasyon
at pagsasanay ang mga doktor sa
pagbabalita at pakikipag-usap sa
mga pasyenteng malubha na ang sakit
at nalalapit nang mamatay.
MARAMING SALAMAT PO!
66
APPENDIX B
Ateneo de Zamboanga University

School of Medicine
4th Floor, LRC Building, Ateneo de Zamboanga University Campus,

La Purisima street, Zamboanga City, Philippines

Title of the Study:
PERCEPTIONS OF PHYSICIANS AND PATIENTS ON THE

DISCLOSURE OF DEATH AND POOR PROGNOSIS IN
ZAMBOANGA CITY MEDICAL CENTER

Proponents Name: Maria Monique Theresita M. Soliven

Address: #8 Cana Hills, Luyahan, Brgy. Pasonanca, Zamboanga City, Philippines
Contact Number: 09153734644

Brief Description of Research Project:

A clear understanding of the patients preferences in the disclosure of poor prognosis allow for
physicians to provide a more holistic approach in helping patients approach death in a peaceful
manner. This study is beneficial for primary health care physicians to initiate end-of-life
discussions earlier and more systematically which would allow patients to make more informed
decisions, achieve better palliation of symptoms and have more opportunity to gain closure.
This research project is a cross-sectional study will be conducted to determine the perceptions
of physicians and patients on the disclosure of death and poor prognosis in four (4) major
departments, namely Family Medicine, Internal Medicine, General Surgery and Obstetrics and
Gynecology in Zamboanga City Medical Center (ZCMC) using a self-administered validated
questionnaire for the physician respondents and a researcher-assisted validated questionnaire
for the patient respondents.

This study will be conducted from December 01, 2015 to April 25, 2016.

67
Informed Consent for Resident Physicians

I, __________________________ (Name/Initials),_______ (Age) ________(Gender), of
(Department) ________________________ give my consent to participate in the study
entitled Perceptions of Physicians and Patients on the Disclosure of Death and Poor
Prognosis in Zamboanga City Medical Center (ZCMC) under the supervision of Ma.
Monique Theresita M. Soliven, MD. I fully understand my contribution and what is
expected from me in this study. The following have been explained well to me prior to
my signing this consent:
The objective of the study is to determine the perspectives of patients and resident
physicians on the disclosure of death and poor prognosis. This is a cross-sectional study.
The target populations are patients seen at ZCMC and Resident Physicians currently
rotating in the departments of ZCMC during the months of December 2015 to January
2016.
I am one of the Physician Residents selected to answer the survey questionnaire to
be answered as honestly and judiciously as possible.
There will be no clinic visits or follow-ups required in this study. I am to submit
my accomplished survey questionnaire as soon as I finish answering it.
There will be no diagnostic tests or any medications involved in this study.
There will be no compensation for participating in this study.
All records or information revealed in this study will be kept strictly confidential.
However, the results may be published in journals or used as future reference if needed.
Results of the study may be shared with the respondents upon request.
My participation is voluntary and I can withdraw any time for any reason without
any
repercussions to my training.
I can call or ask questions anytime regarding this study. The contact person
should I need more information about the study is Ma. Monique Theresita Soliven at
mobile number 09153734644 or via email thru moritzmsoliven@gmail.com.
Name and Signature of Resident Physician:

________________________________________
Department: ________________________
Date: ______________________________
Informed Consent obtained by:____________________________________

Name and Signature
Date: ___________________________________

68
Survey form number: ________________________ Date of Survey: ___________________

Name (optional): _____________________________ Age: Gender: ( ) Male ( ) Female
Civil Status: ( ) Single ( ) Married ( ) Separated
( ) Widow/Widower
Address:
____________________________________________________________________________
Religion:
Ethnic Group:
( ) Christian
( ) Muslim
( ) Chavacano
( ) Catholic
( ) Bisaya
( ) Protestant
( ) Tausug
( ) Others (specify): ______________
( ) Others (specify): ________
( ) No Religion
Specialization:
( ) Family Medicine
( ) Internal Medicine ( ) General Surgery
( ) Obstetrics & Gynecology ( )ENT
( ) Orthopedics
( ) Ophthalmology
Year Level:
( ) 1st year
( ) 2nd year
( ) 3rd year
( ) 4th 5th year
1. Have you had clinical experience in the care of dying patients:

Yes
No
2. Have you ever encountered difficulties/problems with disclosure of a terminal
illness/poor prognosis/death to a patient in the past?
Yes
No
a. If you answered yes, is it still a problem for you now?
Yes

No
69
Instructions: Please put a check mark () under the column that corresponds to what
you consider as most appropriate for each phrase. There are no right or wrong answers.
STATEMENTS
4
STRONGL
Y AGREE
3
AGREE
2
DISAGREE
1
STRONGL
Y
DISAGREE
1. I accept that death is a natural

part of the cycle of life.
2. I have difficulty in telling my
patients directly they are
going to die.
3. I have personal discomfort in
telling patients that they are
dying.
4. Majority of patients do not
want to know that they are
terminally-ill or that they are
dying.
5. I believe that patients should
have full disclosure of their
disease so that they will be
prepared for the future.
6. Majority of the patients prefer
doctors to disclose poor
prognosis because they can
provide the facts about the
patients illness/condition
7. Majority of patients prefer to
receive disclosure of poor
prognosis from a trusted
family member or a loved
one because they know how
to approach the patient best.
70
8. It is important for patients to

be told about his/her terminal
condition immediately or at
the earliest possible time so
that they will be able to make
timely decisions about their
future.
9. I believe that doctors and
patients must share the
responsibility in decisionmaking for end-of-life care
for the patient.
10. I believe that hope is
destroyed when physicians
tell patients that they are
dying.
11. Health professionals must
provide holistic care for their
patients.
12. Training is necessary for
physicians in the proper
disclosure of death and poor
prognosis in order to provide
better care for terminally-ill
patients.
THANK YOU VERY MUCH
71
APPENDIX C
Table 5.1. Reduced model of variables associated with physicians perceptions on patient
preference to receive disclosure from a family member
Variables
Age Group
35 years old
36-54 years old
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Specialization
Family Medicine
Internal Medicine
General Surgery
Year Level
1st year
2nd year
3rd year
4th year
5th year
Patient prefers to have

disclosure done by a family
member
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
19 (45.2%)
2 (4.8%)
13 (31.0%)
8 (19.0%)
1.00
0.17
0.031, 0.939
0.042
3 (7.1%)
3 (7.1%)
15 (35.7%)
0 (0.0%)
5 (11.9%)
3 (23.8%)
6 (14.3%)
7 (11.9%)
1.00
1.67
4.17
1.00
0.195, 14.266
0.749, 23.179
-
0.641
0.103
-
1 (2.4%)
11 (26.2%)
4 (9.5%)
5 (11.9%)
3 (7.1%)
6 (14.3%)
6 (14.3%)
6 (14.3%)
1.00
2.00
5.50
2.50
0.150, 26.734
0.464, 65.162
0.194, 32.194
0.600
0.177
0.482
11 (26.2%)
6 (14.3%)
3 (7.1%)
1 (2.4%)
0 (0.0%)
7 (16.7%)
8 (19.0%)
1 (2.4%)
4 (9.5%)
1 (2.4%)
0.48
1.91
0.16
1
0.115, 1.976
0.164, 22.202
0.015, 1.732
-
0.308
0.605
0.131
-
Table 6.1. Reduced model of variables associated with physicians perceptions on the need
for training on disclosure of poor prognosis and death
Variables
Year Level
1st year
2nd year
3rd year
4th year
5th year

and death
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
17 (40.5%)
11 (26.2%)
4 (9.5%)
5 (11.9%)
1 (2.4%)
1 (2.4%)
3 (7.1%)
0 (0.0%)
0 (0.0%)
0 (0.0%)
1.00
0.09
1.00
1.00
1.00
0.005, 1.830
-
0.118
-
7 (16.7%)
3 (7.1%)
0.04
0.002, 0.704
0.028
72
Table 9.1 Reduced model of variables associated with patients perceptions on difficulty in
Variables
Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Religion
Roman Catholic
Islam
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Do not have difficulty in

Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
35 (14.6%)
24 (10.0%)
25 (10.4%)
15 (6.3%)
40 (16.7%)
45 (18.8%)
31 (12.9%)
25 (10.4%)
1.00
0.64
1.06
0.83
0.318, 1.271
0.513, 2.176
0.370, 1.875
0.200
0.881
0.660
56 (23.3%)
36 (15.0%)
7 (2.9%)
98 (40.8%)
32 (13.3%)
11 (4.6%)
1.00
2.38
1.14
0.662, 8.586
0.399, 3.237
0.184
0.812
35 (14.6%)
26 (10.8%)
28 (11.7%)
10 (4.2%)
61 (25.4%)
41 (17.1%)
26 (10.8%)
13 (5.4%)
1.00
1.10
0.84
0.85
0.559, 2.184
0.203, 3.428
0.270, 2.696
0.774
0.802
0.788
Table 10.1 Reduced model of variables associated with patients perceptions on personal
discomfort in discussing death and dying
Variables
Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Religion
Roman Catholic
Islam
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Do not have personal discomfort

in discussing death and dying
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
24 (10.0%)
23 (9.6%)
26 (10.8%)
17 (7.0%)
51 (21.3%)
46 (19.2%)
30 (12.5%)
23 (9.6%)
1.00
0.96
1.83
1.70
0.457, 2.010
0.845, 3.982
0.711, 4.075
0.911
0.125
0.232
51 (21.3%)
31 (12.9%)
8 (3.3%)
103 (42.9%)
37 (15.4%)
10 (4.2%)
1.00
1.99
1.69
0.529, 7.482
0.592, 4.853
0.309
0.326
31(12.9%)
26 (10.8%)
25 (10.4%)
8 (3.3%)
65 (27.0%)
41 (17.1%)
29 (12.1%)
15 (6.3%)
1.00
1.16
1.10
0.72
0.578, 2.346
0.259, 4.680
0.216, 2.422
0.671
0.897
0.600
70 (29.2%)
20 (8.3%)
104 (43.3%)
46 (19.2%)
1.00
0.69
0.362, 1.309
0.255
29 (12.0%)
44 (18.3%)
17 (7.1%)
56 (23.3%)
76 (31.6%)
18 (7.5%)
0.95
1.38
0.507, 1.779
0.590, 3.252
0.873
0.455
73
Table 11.1 Reduced model of variables associated with patients perceptions that hope is
maintained even in the face of poor prognosis
Variables
*Age Group
35 years old
36-54 years old
51-64 years old
65 years old
*Gender
Male
Female
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
*Illness Severity
Mild Illness
Moderate Illness
Severe Illness

Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
71 (27.9%)
63 (25.4%)
48 (20.0%)
36 (13.8%)
4 (3.3%)
6 (3.3%)
8 (3.3%)
4(2.9%)
1.00
0.75
0.47
0.62
0.192, 2.935
0.124, 1.791
0.136, 2.799
0.432
0.090
0.356
83 (33.8%)
135 (53.3%)
12 (23.8%)
10(35.0%)
1.00
1.66
0.651, 4.220
0.138
91 (35.4%)
57 (23.8%)
49 (19.2%)
21 (8.8%)
5 (4.6%)
10 (4.2%)
5 (3.3%)
2 (0.8%)
1.00
0.34
0.45
0.54
0.107, 1.067
0.120, 1.710
0.093, 3.180
0.064
0.242
0.499
81 (30.4%)
106 (44.6%)
31 (12.1%)
4 (5.0%)
14 (5.4%)
4 (2.5%)
0.42
0.50
0.126, 1.405
0.112, 2.258
0.160
0.370

Table 12.1 Reduced model of variables associated with patients preference to be informed
of poor prognosis
Variables
*Age Group
35 years old
36-54 years old
51-64 years old
65 years old
*Civil Status
Single
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Prefer to be informed of poor

prognosis
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
52 (21.7%)
41 (17.0%)
39 (16.3%)
31(12.9%)
23 (9.6%)
28 (11.7%)
17 (7.1%)
9 (3.8%)
1.00
0.59
0.86
1.24
0.267, 1.301
0.360, 2.072
0.405, 3.774
0.191
0.742
0.709
39 (16.3%)
101 (42.0%)
23 (9.6%)
25 (10.4%)
43 (17.9%)
9 (3.8%)
1.00
2.00
1.80
0.965, 4.129
0.565, 5.742
0.062
0.320
73 (30.4%)
40 (16.7%)
33 (13.8%)
17 (7.1%)
23 (9.6%)
27 (11.3%)
21 (8.8%)
6 (2.5%)
1.00
0.51
0.46
0.94
0.251, 1.030
0.211, 0.983
0.320, 2.741
0.060
0.045
0.906
113 (47.1%)
50 (20.8%)
61 (25.4%)
16 (6.7%)
1.00
1.69
0.849, 3.380
0.135
74
Table 13.1 Reduced model of variables associated with patients preference to have full
Variables
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Prefer to have full disclosure of

poor prognosis
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
81 (33.8%)
50 (20.8%)
40 (16.7%)
18 (7.5%)
15 (6.3%)
17 (7.1%)
14 (5.8%)
5 (2.1%)
1.00
0.58
0.51
0.72
0.266, 1.277
0.223, 1.170
0.231, 2.264
0.117
0.112
0.578
132 (55.0%)
57 (23.8%)
42 (17.5%)
9 (3.8%)
1.00
2.00
0.903, 4.444
0.088
Table 14.1 Reduced model of variables associated with patients preference to have
disclosure of poor prognosis at the earliest possible time
Variables
Age Group
35 years old
36-54 years old
51-64 years old
65 years old
Civil Status
Single
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Prefer to have disclosure of

poor prognosis at the
earliest possible time
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
58 (24.2%)
49 (20.4%)
32 (13.3%)
22 (9.2%)
17 (7.1%)
20 (8.3%)
24 (10.0%)
18 (7.5%)
1.00
0.80
0.41
0.33
0.355, 1.797
0.175, 0.940
0.117, 0.914
0.587
0.035
0.033
46 (19.2%)
97 (40.4%)
18 (7.5%)
18 (7.5%)
47 (19.6%)
14 (5.8%)
1.00
0.72
0.74
0.542, 2.417
0.402, 3.636
0.723
0.735
69 (28.8%)
42 (17.5%)
34 (14.2%)
16 (6.7%)
27 (11.3%)
25 (10.4%)
20 (8.3%)
7 (2.9%)
1.00
0.68
0.50
0.86
0.337, 1.372
0.229, 1.080
0.307, 2.390
0.217
0.078
0.767
109 (45.4%)
52 (21.7%)
65 (27.1%)
14 (5.8%)
1.00
1.93
0.957, 3.904
0.066
75
Table 15.1 Reduced model of variables associated with patients preference to receive
disclosure from a doctor
Variables
Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Prefer to receive disclosure

from a doctor
Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
87 (36.3%)
53 (22.1%)
43 (17.9%)
19 (7.9%)
9 (3.8%)
14 (5.8%)
11 (4.6%)
4 (1.7%)
1.00
0.38
0.39
0.44
0.152, 0.942
0.149, 1.023
0.120, 1.640
0.037
0.056
0.223
70 (29.2%)
99 (41.3%)
33 (13.8%)
15 (6.3%)
21 (8.8%)
2 (0.8%)
0.98
3.71
0.461, 2.072
0.795,
17.324
0.953
0.095
Table 16.1 Reduced model of variables associated with patients preference to receive
disclosure from a family member
Variables
*Civil Status
Single
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
*Illness Severity
Mild Illness
Moderate Illness
Severe Illness
Prefer to receive disclosure from

a doctor
Agree
Disagree
n(%)
n(%)
OR
95% CI
pvalue
23 (20.4%)
37 (47.9%)
18 (10.4%)
41 (6.3%)
107 (12.1%)
14 (2.9%)
1.00
0.61
1.93
0.316, 1.166
0.791, 4.693
0.134
0.149
28 (33.8%)
26 (20.8%)
17 (16.7%)
7 (7.5%)
68 (6.3%)
41 (7.1%)
37 (5.8%)
16 (2.1%)
1.00
1.57
1.27
1.12
0.793, 3.118
0.592, 2.712
0.394, 3.170
0.195
0.542
0.833
20 (28.3%)
41 (39.6%)
17 (10.8%)
65 (7.1%)
79 (10.4%)
18 (3.8%)
1.39
2.41
0.722, 2.685
1.014, 5.729
0.323
0.046
76
Table 17.1 Reduced model of variables associated with patients perceptions on

Variables
*Age Group
35 years old
36-54 years old
51-64 years old
65 years old
*Civil Status
Single
*Religion
Roman Catholic
Islam
*Ethnic Group
Zamboangueno
Bisaya
Tausug
Others
Have collaborative decisionmaking for end-of-life care

Agree
Disagree
n(%)
n(%)
OR
95% CI
p-value
61 (25.4%)
54 (22.5%)
42 (17.5%)
27 (11.3%)
14 (5.8%)
15 (6.3%)
14 (5.8%)
13 (5.4%)
1.00
0.88
0.66
0.31
0.348, 2.203
0.248, 1.738
0.099, 0.995
0.779
0.397
0.049
56 (23.3%)
105 (43.8%)
23 (9.6%)
8 (3.3%)
39 (16.3%)
9 (3.8%)
1.00
0.50
0.77
0.199, 1.239
0.213, 2.777
0.133
0.689
126 (50.4%)
44 (21.7%)
14 (6.7%)
28 (13.8%)
24 (6.7%)
4 (0.8%)
1.00
0.31
0.80
0.079, 1.257
0.227, 2.793
0.102
0.722
80 (33.8%)
53 (20.8%)
37 (16.7%)
14 (7.5%)
16 (6.3%)
14 (7.1%)
17 (5.8%)
9 (2.1%)
1.00
0.78
1.14
0.49
0.332, 1.852
0.247, 5.235
0.138, 1.721
0.580
0.869
0.264
77
CURRICULUM VITAE
Name:
Age:
Sex:
Civil Status:
Date of Birth:
Address:
Religion:
Father:
Mother:
Maria Monique Theresita Mercado Soliven

27
Female
Single
January 7, 1989
#8 Cana Hills, Luyahan Drive, Barangay Pasonanca, Zamboanga City
Roman Catholic
Pedro Rufo N. Soliven
Ma. Theresa M. Soliven
EDUCATIONAL BACKGROUND
DOCTOR OF MEDICINE
School: Ateneo de Zamboanga University School of Medicine
Place: La Purisima Street, Zamboanga City
Year of Graduation: 2015
Awards Received:
Best Group Comprehensive Health Plan (Team Mirangan)
Susana Gan Suanty Community Commitment Award
Best Individual Research Award
COLLEGE
Degree: Bachelor of Science Major in Biology Medical Track
School: Ateneo de Manila University
Place: Katipunan Avenue, Quezon City
HIGH SCHOOL
School: Ateneo de Zamboanga University
ELEMENTARY
School: Ateneo de Zamboanga University
Award Received: Graduating with Honors

78

Factors Associated With The Perceptions of Physicians and Patients Regarding Disclosure of Death and Poor Prognosis in Zamboanga City Medical Center-Soliven 2016

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FACTORS ASSOCIATED WITH THE PERCEPTIONS OF PHYSICIANS AND

PATIENTS REGARDING DISCLOSURE OF DEATH AND POOR

MASTERS IN PUBLIC HEALTH

MARIA MONIQUE THERESITA M. SOLIVEN

MARIA MONIQUE THERESITA M. SOLIVEN in partial fulfilment of the

Approved by the Oral Examination Committee with a grade of PASSED.

MA. MONIQUE THERESITA M. SOLIVEN

THE PROBLEM AND ITS SETTING

b.) Related Literature

d.) Conceptual Framework

e.) Significance of the Study

f.) Scope and Delimitation of the Study

g.) Definition of Terms

b.) Study Setting

d.) Study Population and Sampling Design

e.) Research Instrument

f.) Data Gathering Procedure

g.) Data Treatment

RESULTS, INTERPRETATION AND

SUMMARY, CONCLUSION AND

Medical Center, 2016

Table 2. Training profile among resident physicians in

Table 11. Full model of variables associated with patients perceptions on

Table 12. Full model of variables associated with patients preference to

Table 17.1 Reduced model of variables associated with patients

Background of the Study

general concept and concerns about death and dying;

preferences of patients on disclosure practices;

the perceived roles of the physician in end-of-life care

b. To determine the association of socio-demographic variables and training

c. To determine the association of socio-demographic variables and severity of

Figure 1. Conceptual Framework

Significance of the Study

The existence of problems in the disclosure of poor prognosis largely contributes to

Scope and Delimitation of the Study

perceptions of the patients family members or primary caregivers on death and

D. Study Population and Sampling Design

1. Questionnaire for Patients

2. Duke University Severity of Illness Scale (DUSOI)

3. Questionnaire for Physicians

F. Data Gathering Procedure

Types of Data Included

26-42 years old

19-91 years old

Majority of the physician respondents were from the Internal Medicine

Table 3. Illness severity among patient respondents in

I. Perceptions of physicians on death and disclosure of poor prognosis

Prefer to have full

Prefer disclosure from

Prefer disclosure from

Theme C. Perceived Roles of the Physician in End-of-Life Care

*Reverse wording of questions

A. General concept and concerns about death and dying

B. Preferences of patients on physicians disclosure practices

C. Perceived roles of the physician in end-of-life care

II. Association of socio-demographic factors and training profile to

A. Factors associated with physicians general concept and concerns

B. Factors associated with physicians perceptions on the preferences of

Table 5. Full model of variables associated with physicians perceptions on patient

Patient prefers to have

* OR odds ratio; CI confidence interval

For the physicians perceptions on patient preference for a family member to do

B. Factors associated with physicians perceptions on their roles in

Survey form number: ______ Date of Survey: _