This is the first study from Southern Thailand that surveyed the EoL care preferences of palliative cancer patients. The five most important components of EoL care discovered were: receiving the full truth about their illnesses, being relieved from distressing symptoms such as pain and shortness of breath, having loved ones around when needed, being mentally aware until the time of death, and feeling meaningful in life. Furthermore, the participants placed a high level of preference on receiving the full truth about their illnesses, disclosing the full truth about their illnesses to the family, passing away at home with loved ones around when needed, and being mentally aware until the time of death. These findings support those of prior reports from the United States of America [8, 9] and the EU  as well as a study conducted among Thai elderly patients from the Central and Northeastern regions of Thailand in 2017 . A reason for this might be the fact that most participants in this study were older adults with a mean age of 55.8 years. Also, knowing the full truth about one’s illnesses, being mentally aware until the time of death, preparing for death, and dying peacefully while feeling comfortable and without pain or suffering might be universal human need or basic core EoL care preferences among palliative cancer patients [4, 8, 9]. Therefore, there were no diversity and cultural difference.
Almost all participants identified ‘receiving the full truth about their illnesses’ as their number one need in regard to EoL care. Moreover, being mentally aware at the last hour of life was one of the five top EoL care preferences. This indicates that autonomy was of a critical importance to our palliative cancer patient population. However, since ‘disclosing the full truth regarding their illnesses to family members’ was a significant preference, it could be said that they were also likely to involve their family in the decision-making process related to their EoL care. This finding is consistent with those of a prior study on Northern Thai patients with a terminal illness; they desired that both physicians and relatives be involved in deciding the EoL care they received . Furthermore, this finding supports the report of a former study that Asian patients are more likely to have their family involved in medical decision-making rather than exercising full autonomy or decide only by themselves like most American and European patients do [1, 16, 17]. Concerning this matter and in light of this finding, Thai physicians should ask their patients whether they wish to receive information regarding their health conditions and treatment and to what extent, as well as whether they would like to be involved in making decisions related to their care or prefer that their families handle such matters . However, regarding resuscitation being administered or withheld for their relatives, this study showed the majority of participants failed to give an opinion either way. Then, all Thai palliative cancer patients should be promoted to exercise full autonomy and have a chance to adjudge the end-of-life procedures by themselves.
In relation to being relieved from distressing symptoms, the participants identified that ‘being free from symptoms such as pain and shortness of breath’, which cause considerable suffering, was the second important component of EoL care. Once more, this finding is consistent with those of a prior study. They found that even before the EoL stage, nearly half of their cancer patients reported moderate-to-severe pain; up to 30.0 % identified their pain level as severe, and an estimated 25.0 % died in pain . Therefore, all physicians should make the exploration and relief of their patients’ distress and suffering a priority of medical care. Moreover, knowledge regarding pain, basic end-of-life pain management, and symptom control should be offered to palliative cancer patients and their families [20,21,22].
Regarding passing away, a good death is one that is free from avoidable suffering, for the patient, their relatives, and caregivers alike; in general accord with the patient’s and family’s wishes; and reasonably consistent with clinical, cultural, and ethical standards [10, 23]. Prior studies have identified some factors that influence the passing away process; they are: the location of patient domicile, previous occupation, educational level, family income, family size, and dissatisfaction with life [13, 24]. Moreover, it is known that most elderly Thai patients prefer dying at home . However, this study revealed that only two-thirds of the participants agreed with passing away at home with loved ones around when needed and being mentally aware at the time of death, whereas one-third of them had no opinion on this matter. It seems that dying with meaning and being remembered after death may be more significant than the place of death for some patients . For cancer patients and their families, palliative home care might be difficult to manage due to factors such as the low level of home care support received by the public health system and weakened family networks [26, 27]. Hence, the choice to die in a hospital might be more preferable for the families of palliative cancer patients . However, the preference for dying at home is greater when the patient lives with a caregiver, and the family physician makes home visits . Therefore, both physicians and caregivers should pay attention to the patients’ desires regarding the care they wish to receive as well as respect their characterization of a meaningful death. Moreover, patient care during the last hour in hospitals should be modified in order to make it as similar to passing away at home as possible.
Towards achieving a good death, harmony regarding the concept of dying well and one’s attitude toward death and dying is important. Furthermore, a healthy interconnectedness among the family, caregivers, and healthcare providers should be the goal. These refer to the physical (symptom control), social (loved ones’ presence), emotional (sharing emotions), and spiritual (inner peace) dimensions of the process of dying. Moreover, the patient’s awareness until the last hour, acceptance of death, and ability to say goodbye to family and friends meaningfully as well as respecting the patient’s wishes should be ensured . For dying individuals, it will be meaningful to experience love and be understood from family. When healthcare professionals provide a compassionate and peaceful environment that facilitates acceptance and hope, the spiritual life of patients is enhanced [23, 29].
Finally, given the importance of family caregivers and healthcare providers in providing care and their impact on the patients’ dying process, it is necessary to reflect upon how their attitudes and prior experiences influence the care for the dying [24, 29]. Hence, a good relationship with family members and healthcare providers improves the patient’s level of self-satisfaction, makes the avoidance of death less likely and the acceptance of death more possible, and enhances their feeling of interconnectedness [13, 29]. These would go a long way in optimizing the terminally ill patients’ quality of life during their EoL period.
To our knowledge, this is the only study on this topic conducted in Southern Thailand during the past decade. However, the study was quantitative, and its sample size was small and restricted to only palliative cancer outpatients in lower Southern Thailand. Hence, its findings may not represent the situation of cancer patients in the whole country fairly. Even though no novel knowledge was obtained from this study, its findings confirmed that there were no differences in end-of-life care preferences between patients from the Southern, Northern and Central regions of Thailand. Henceforward, future studies should include a larger number of palliative cancer outpatients with gender and age-group differences from other hospitals in Thailand; in other words, multi-center research that aims to explore this research topic should be conducted. Moreover, such studies should employ a more qualitative approach or in-depth methodology that is adept at exploring specific disorders.