Geriatric palliative care: a view of its concept, challenges and strategies

In aging societies, the last phase of people’s lives changes profoundly, challenging traditional care provision in geriatric medicine and palliative care. Both specialties have to collaborate closely and geriatric palliative care (GPC) should be conceptualized as an interdisciplinary field of care and research based on the synergies of the two and an ethics of care.

Major challenges characterizing the emerging field of GPC concern (1) the development of methodologically creative and ethically sound research to promote evidence-based care and teaching; (2) the promotion of responsible care and treatment decision making in the face of multiple complicating factors related to decisional capacity, communication and behavioural problems, extended disease trajectories and complex social contexts; (3) the implementation of coordinated, continuous care despite the increasing fragmentation, sectorization and specialization in health care.

Exemplary strategies to address these challenges are presented: (1) GPC research could be enhanced by specific funding programs, specific patient registries and anticipatory consent procedures; (2) treatment decision making can be significantly improved using advance care planning programs that include adequate decision aids, including those that address proxies of patient who have lost decisional capacity; (3) care coordination and continuity require multiple approaches, such as care transition programs, electronic solutions, and professionals who act as key integrators.

IssuEs in Palliative care for people in advanced and terminal stages of Young-onset and Late-Onset dementia in GErmany (EPYLOGE): the study protocol

BACKGROUND

Scientific research on palliative care in dementia is still underdeveloped. In particular, there are no research studies at all on palliative care issues in young onset dementia (YOD), although significant differences compared to late onset dementia (LOD) are expected. Most studies have focused on persons with dementia in long term care (LTC) facilities but have neglected persons that are cared for at home. We hypothesize that unmet care needs exist in advanced and terminal stages of YOD and LOD and that they differ between YOD and LOD.

METHODS/DESIGN

The EPYLOGE-study (IssuEs in Palliative care for people in advanced and terminal stages of Young-onset and Late-Onset dementia in GErmany) aims to prospectively assess and survey 200 persons with YOD and LOD in advanced stages who are cared for in LTC facilities and at home. Furthermore, EPYLOGE aims to investigate the circumstances of death of 100 persons with YOD and LOD. This includes 1) describing symptoms and management, health care utilization, palliative care provision, quality of life and death, elements of advance care planning, family caregivers' needs and satisfaction; 2) comparing YOD and LOD regarding these factors; 3) developing expert-consensus recommendations derived from the study results for the improvement and implementation of strategies and interventions for palliative care provision; 4) and communicating the recommendations nationally and internationally in order to improve and adapt guidelines, to change current practice and to give a basis and perspectives for future research projects. The results will also be communicated to patients and their families in order to counsel and support them in their decision making processes and their dialogue with professional caregivers and physicians.

DISCUSSION

EPYLOGE is the first study in Germany that assesses palliative care and end-of-life issues in dementia. Furthermore, it is the first study internationally that focuses on the specific palliative care situation of persons with YOD and their families. EPYLOGE serves as a basis for the improvement of palliative care in dementia.

TRIAL REGISTRATION

The study is registered in ClinicalTrials.gov ( NCT03364179 ; Registered: 6. December 2017.

[Dementia from a palliative care perspective: why a disease-specific advance care planning is necessary]

Dementia from a palliative care perspective: why a disease-specific advance care planning is necessary Abstract. Palliative Care has to transform profoundly in the context of population aging in many countries around the globe. It has to collaborate increasingly with geriatric medicine and incorporate geriatric expertise. One of the pivotal challenges of geriatric palliative care is ethically appropriate decision making for patients who have lost decision-making capacity. While the traditional approach to advance directives (living wills) has demonstrably proven ineffective, the new approach that is currently being embraced, including in German-speaking countries, is the systemic process of advance care planning (ACP). In this article, ACP is first presented with its general aims, elements and effects. Second, it is shown why we need an adapted ACP program for people with dementia and what such a dementia-specific ACP must entail.

"The Notion of Neutrality in Clinical Ethics Consultation"

Clinical ethics consultation (CEC), as an activity that may be provided by clinical ethics committees and consultants, is nowadays a well-established practice in North America. Although it has been increasingly implemented in Europe and elsewhere, no agreement can be found among scholars and practitioners on the appropriate role or approach the consultant should play when ethically problematic cases involving conflicts and uncertainties come up. In particular, there is no consensus on the acceptability of consultants making recommendations, offering moral advice upon request, and expressing personal opinions. We translate these issues into the question of whether the consultant should be neutral when performing an ethics consultation. We argue that the notion of neutrality 1) functions as a hermeneutical key to review the history of CEC as a whole; 2) may be enlightened by a precise assessment of the nature and goals of CEC; 3) refers to the normative dimension of CEC. Here, we distinguish four different meanings of neutrality: a neutral stance toward the parties involved in clinical decision making, toward the arguments offered to frame the discussion, toward the values and norms involved in the case, and toward the outcome of decision making, that is to say the final decision and action that will be implemented. Lastly, we suggest a non-authoritarian way to intend the term "recommendation" in the context of clinical ethics consultation.

Benefit in liver transplantation: a survey among medical staff, patients, medical students and non-medical university staff and students

Background

The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined.

Methods

This survey with 502 participants examines how urgency and benefit are weighted by different stakeholders (medical staff, patients on the liver transplant list or already transplanted, medical students and non-medical university staff and students).

Results

Liver transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care (ECOG 2). An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs.

Conclusions

The strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules.

[Provision of palliative care for people with advanced dementia]

As a result of a literature-based expert process, this review provides an overview about the principles of palliative care for people with advanced dementia that are relevant for clinical practice. In particular, the indications, impact and aims of palliative care for advanced dementia are described. Life-prolonging measures and management of symptoms at the end of life are discussed. Furthermore, the overview focuses on the legal basis of decision making.

Voluntary stopping of eating and drinking: is medical support ethically justified?

BACKGROUND

Physician-assisted dying has been the subject of extensive discussion and legislative activity both in Europe and North America. In this context, dying by voluntary stopping of eating and drinking (VSED) is often proposed, and practiced, as an alternative method of self-determined dying, with medical support for VSED being regarded as ethically and legally justified.

ARGUMENT

In our opinion, this view is flawed. First, we argue that VSED falls within the concept of suicide, albeit with certain unique features (non-invasiveness, initial reversibility, resemblance to the natural dying process). Second, we demonstrate, on the basis of paradigmatic clinical cases, that medically supported VSED is, at least in some instances, tantamount to assisted suicide. This is especially the case if a patient's choice of VSED depends on the physician's assurance to provide medical support.

CONCLUSION

Thus, for many jurisdictions worldwide, medically supported VSED may fall within the legal prohibitions on suicide assistance. Physicians, lawmakers, and societies should discuss specific ways of regulating medical support for VSED in order to provide clear guidance for both patients and healthcare professionals. Please see related article: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0951-0 .

"Hope for the best, prepare for the worst": A qualitative interview study on parents' needs and fears in pediatric advance care planning

BACKGROUND

Pediatric advance care planning is advocated by healthcare providers because it may increase the chance that patient and/or parent wishes are respected and thus improve end-of-life care. However, since end-of-life decisions for children are particularly difficult and charged with emotions, physicians are often afraid of addressing pediatric advance care planning.

AIM

We aimed to investigate parents' views and needs regarding pediatric advance care planning.

DESIGN

We performed a qualitative interview study with parents of children who had died from a severe illness. The interviews were analyzed by descriptive and evaluation coding according to Saldaña.

SETTING/PARTICIPANTS

We conducted semi-structured interviews with 11 parents of 9 children. Maximum variation was sought regarding the child's illness, age at death, care setting, and parent gender.

RESULTS

Parents find it difficult to engage in pediatric advance care planning but consider it important. They argue for a sensitive, individualized, and gradual approach. Hope and quality of life issues are primary. Parents have many non-medical concerns that they want to discuss. Written advance directives are considered less important, but medical emergency plans are viewed as necessary in particular cases. Continuity of care and information should be improved through regular pediatric advance care planning meetings with the various care providers. Parents emphasize the importance of a continuous contact person to facilitate pediatric advance care planning.

CONCLUSION

Despite a need for pediatric advance care planning, it is perceived as challenging. Needs-adjusted content and process and continuity of communication should be a main focus in pediatric advance care planning. Future research should focus on strategies that facilitate parent engagement in pediatric advance care planning to increase the benefit for the families.

Can Neuroscience Contribute to Practical Ethics? A Critical Review and Discussion of the Methodological and Translational Challenges of the Neuroscience of Ethics

Neuroethics is an interdisciplinary field that arose in response to novel ethical challenges posed by advances in neuroscience. Historically, neuroethics has provided an opportunity to synergize different disciplines, notably proposing a two-way dialogue between an 'ethics of neuroscience' and a 'neuroscience of ethics'. However, questions surface as to whether a 'neuroscience of ethics' is a useful and unified branch of research and whether it can actually inform or lead to theoretical insights and transferable practical knowledge to help resolve ethical questions. In this article, we examine why the neuroscience of ethics is a promising area of research and summarize what we have learned so far regarding its most promising goals and contributions. We then review some of the key methodological challenges which may have hindered the use of results generated thus far by the neuroscience of ethics. Strategies are suggested to address these challenges and improve the quality of research and increase neuroscience's usefulness for applied ethics and society at large. Finally, we reflect on potential outcomes of a neuroscience of ethics and discuss the different strategies that could be used to support knowledge transfer to help different stakeholders integrate knowledge from the neuroscience of ethics.

[Resuscitation of elderly people : how to approach their preferences in advance]

Cardiopulmonary resuscitation (CPR) is a medical intervention whose practice is highly regulated. In Switzerland, when dealing with elderly patients, physicians decide whether resuscitation would be medically indicated in the case of a cardiorespiratory arrest and discuss it with the patient. The quality of the information provided by the physician during the first encounter with the patient may influence the latter's preferences. However, many studies emphasize the difficulties that hospital physicians face when engaging in this conversation. In order to promote a care provision that is both adequate and respectful of elderly patients, more attention should be devoted to the obstacles that hinder communication on this subject and to the resources available to physicians.

Medical indication regarding life-sustaining treatment for children: Focus groups with clinicians

BACKGROUND

Decisions about medical indication are a relevant problem in pediatrics. Difficulties arise from the high prognostic uncertainty, the decisional incapacity of many children, the importance of the family, and conflicts with parents. The objectivity of judgments about medical indication has been questioned. Yet, little is known about the factors pediatricians actually include in their decisions.

AIM

Our aims were to investigate which factors pediatricians apply in deciding about medical indication, and how they manage conflicts with parents.

DESIGN

We performed a qualitative focus group study with experienced pediatricians. The transcripts were subjected to qualitative content analysis.

SETTING/PARTICIPANTS

We conducted three focus groups with pediatricians from different specialties caring for severely ill children/adolescents. They discussed life-sustaining treatment in two case scenarios that varied according to diagnosis, age, and gender.

RESULTS

The decisions about medical indication were based on considerations relating to the individual patient, to the family, and to other patients. Individual patient factors included clinical aspects and benefit-burden considerations. Physicians' individual views and feelings influenced their decision-making. Different factors were applied or weighed differently in the two cases. In case of conflict with parents, physicians preferred solutions aimed at establishing consensus.

CONCLUSION

The pediatricians defined medical indication on a case-by-case basis and were influenced by emotional reasoning. In contrast to prevailing ethico-legal principles, they included the interests of other persons in their decisions. Decision-making strategies should incorporate explicit discussions of social aspects and physicians' feelings to improve the transparency of the decision-making process and reduce bias.

Choosing wisely at the end of life: the crucial role of medical indication

At the end of life, several treatments are administered routinely that lack medical indication and may cause significant harm to patients. Examples include artificial hydration and oxygen therapy in the dying phase, as well as enteral nutrition in advanced dementia. Medical indication is defined as the appropriateness of a therapeutic or diagnostic measure in the patient's concrete clinical situation, in light of the best available evidence. The decision about the absence or presence of a medical indication is a core competence of physicians. They have no obligation to perform or even mention measures that are not indicated. The decision about medical indication is a clinical compound decision, composed of both a factual, evidence-based judgement and a value judgement, which should always be patient-centred. Acknowledging the crucial role of medical indication in clinical decision making in medicine generally and at the end of life specifically opens up ways of enhancing patient-physician communication by clarifying roles, responsibilities and competencies. This may facilitate preventing overtreatment, improving patient wellbeing, and realising the patients' goals of care.

Physician-assisted suicide, euthanasia and palliative sedation: attitudes and knowledge of medical students

OBJECTIVES

In November 2015, the German Federal Parliament voted on a new legal regulation regarding assisted suicide. It was decided to amend the German Criminal Code so that any "regular, repetitive offer" (even on a non-profit basis) of assistance in suicide would now be considered a punishable offense. On July 2, 2015, a date which happened to be accompanied by great media interest in that it was the day that the first draft of said law was presented to Parliament, we surveyed 4th year medical students at the Technical University Munich on "physician-assisted suicide," "euthanasia" and "palliative sedation," based on a fictitious case vignette study.

METHOD

The vignette study described two versions of a case in which a patient suffered from a nasopharyngeal carcinoma (physical suffering subjectively perceived as being unbearable vs. emotional suffering). The students were asked about the current legal norms for each respective course of action as well as their attitudes towards the ethical acceptability of these measures.

RESULTS

Out of 301 students in total, 241 (80%) participated in the survey; 109 answered the version 1 questionnaire (physical suffering) and 132 answered the version 2 questionnaire (emotional suffering). The majority of students were able to assess the currently prevailing legal norms on palliative sedation (legal) and euthanasia (illegal) correctly (81.2% and 93.7%, respectively), while only a few students knew that physician-assisted suicide, at that point in time, did not constitute a criminal offense. In the case study that was presented, 83.3% of the participants considered palliative sedation and the simultaneous withholding of artificial nutrition and hydration as ethically acceptable, 51.2% considered physician-assisted suicide ethically legitimate, and 19.2% considered euthanasia ethically permissible. When comparing the results of versions 1 and 2, a significant difference could only be seen in the assessment of the legality of palliative sedation: it was considered legal more frequently in the physical suffering version (88.1% vs. 75.8%).

CONCLUSION

The majority of the students surveyed wrongly assumed that physician-assisted suicide is a punishable offense in Germany. However, a narrow majority considered physician-assisted suicide ethically acceptable in the case study presented. Compared to euthanasia, more than twice as many participants considered physician-assisted suicide acceptable. There was no significant difference between personal attitudes towards palliative sedation, physician-assisted suicide or euthanasia in light of physical or emotional suffering. Educational programs in this field should be expanded both qualitatively and quantitatively, especially considering the relevance of the subject matter, the deficits within the knowledge of legal norms and the now even higher complexity of the legal situation due to the new law from December 2015.

[Changing the therapeutic goal in critically ill patients. Ethical analysis of a surgical case]

We report on a 32-year-old patient, who developed septic shock, toxic shock-like syndrome, and multiple organ failure following nectrotizing fasciitis. Amputations had to be performed on all extremities. Subsequently, she developed secondary sclerosing cholangitis. Treatment goals had to be reassessed, since long-term survival seemed doubtful and, in the best case, burdened with severe handicap. We discuss the evaluation of the treatment goals, utilizing a structured model of goal-setting. In the first step the treatment goal is identified based on the patient's wishes. This goal's realistic achievability is verified considering scientific evidence and medical experience. The benefit of the aspired goal is set in relation to risks and burden of the necessary treatment measures in a third step. The resulting benefit-risk ratio must be evaluated by the patient or her representative. Treatment goals have to be reevaluated if the assessment of achievability or the benefit-risk ratio are disadvantageous. In this case, the initial therapeutic goal was retained. After an extraordinarily prolonged and complex therapy including reconstructive surgery the patient is now living independently at home.

Persistent vegetative state and minimally conscious state: a systematic review and meta-analysis of diagnostic procedures

BACKGROUND

Acute brain damage can cause major disturbances of consciousness, ranging all the way to the persistent vegetative state (PVS), which is also known as "unresponsive wakefulness syndrome". PVS can be hard to distinguish from a state of minimal preserved consciousness ("minimally conscious state," MCS); the rate of misdiagnosis is high and has been estimated at 37-43%. In contrast, PVS is easily distinguished from brain death. We discuss the various diagnostic techniques that can be used to determine whether a patient is minimally conscious or in a persistent vegetative state.

METHODS

This article is based on a systematic review of pertinent literature and on a quantitative meta-analysis of the sensitivity and specificity of new diagnostic methods for the minimally conscious state.

RESULTS

We identified and evaluated 20 clinical studies involving a total of 906 patients with either PVS or MCS. The reported sensitivities and specificities of the various techniques used to diagnose MCS vary widely. The sensitivity and specificity of functional MRI-based techniques are 44% and 67%, respectively (with corresponding 95% confidence intervals of 19%-72% and 55%-77%); those of quantitative EEG are 90% and 80%, respectively (95% CI, 69%-97% and 66%-90%). EEG, event-related potentials, and imaging studies can also aid in prognostication. Contrary to prior assumptions, 10% to 24% of patients in PVS can regain consciousness, sometimes years after the event, but only with marked functional impairment.

CONCLUSION

The basic diagnostic evaluation for differentiating PVS from MCS consists of a standardized clinical examination. In the future, modern diagnostic techniques may help identify patients who are in a subclinical minimally conscious state.

Pediatric advance care planning from the perspective of health care professionals: a qualitative interview study

BACKGROUND

Pediatric advance care planning differs from the adult setting in several aspects, including patients' diagnoses, minor age, and questionable capacity to consent. So far, research has largely neglected the professionals' perspective.

AIM

We aimed to investigate the attitudes and needs of health care professionals with regard to pediatric advance care planning.

DESIGN

This is a qualitative interview study with experts in pediatric end-of-life care. A qualitative content analysis was performed.

SETTING/PARTICIPANTS

We conducted 17 semi-structured interviews with health care professionals caring for severely ill children/adolescents, from different professions, care settings, and institutions.

RESULTS

Perceived problems with pediatric advance care planning relate to professionals' discomfort and uncertainty regarding end-of-life decisions and advance directives. Conflicts may arise between physicians and non-medical care providers because both avoid taking responsibility for treatment limitations according to a minor's advance directive. Nevertheless, pediatric advance care planning is perceived as helpful by providing an action plan for everyone and ensuring that patient/parent wishes are respected. Important requirements for pediatric advance care planning were identified as follows: repeated discussions and shared decision-making with the family, a qualified facilitator who ensures continuity throughout the whole process, multi-professional conferences, as well as professional education on advance care planning.

CONCLUSION

Despite a perceived need for pediatric advance care planning, several barriers to its implementation were identified. The results remain to be verified in a larger cohort of health care professionals. Future research should focus on developing and testing strategies for overcoming the existing barriers.

Determination of Death: A Discussion on Responsible Scholarship, Clinical Practices, and Public Engagement

The concept and determination of death by neurological or cardio-circulatory criteria play a crucial role for medical practice, society, and the law. Academic debates on death determination have regained momentum, and recent cases involving the neurological determination of death ("brain death") in the United States have sparked sustained public debate. The determination of death by neurological criterion (irreversible cessation of the whole brain or of the brain stem) is medically practiced in at least 80 countries. However, academic debates persist about the conceptual and scientific validity of death determined by neurological criterion. The cardio-circulatory criterion, which permits organ donation following cardio-circulatory arrest, has also recently been challenged. Given the presence of academic debates, several questions ensue about the responsible conduct of clinicians and scholars involved in clinical practices and academic research. This article identifies tension points for responsible practices in the domains of scholarship, clinical practice, and public discourse and formulates suggestions to stimulate further dialogue on responsible practices and to identify questions in need of further research.

A European survey on attitudes towards pain and end-of-life issues in locked-in syndrome

OBJECTIVES

Patients with locked-in syndrome often self-report a higher quality of life than generally expected. This study reports third-person attitudes towards several salient issues on locked-in syndrome.

METHODS

Close-ended survey among conference attendees from 33 European countries. Analysis included chi-square tests and logistic regressions.

RESULTS

From the 3332 respondents (33% physicians, 18% other clinicians, 49% other professions; 47% religious), 90% agreed that patients with locked-in syndrome can feel pain. The majority (75%) disagreed with treatment withdrawal, but 56% did not wish to be kept alive if they imagined themselves in this condition (p < 0.001). Religious and southern Europeans opposed to treatment withdrawal more often than non-religious (p < 0.001) and participants from the North (p = 0.001). When the locked-in syndrome was compared to disorders of consciousness, more respondents endorsed that being in a chronic locked-in syndrome was worse than being in a vegetative state or minimally conscious state for patients (59%) than they thought for families (40%, p < 0.001).

CONCLUSIONS

Personal characteristics mediate opinions about locked-in syndrome. The dissociation between personal preferences and general opinions underlie the difference in perspective in disability. Ethical responses to dilemmas involving patients with locked-in syndrome should consider the diverging ethical attitudes of stakeholders.