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White J, Falcioni D, Barker R, Bajic-Smith J, Krishnan C, Mansfield E, Hullick C. Persisting gaps in dementia carer wellbeing and education: A qualitative exploration of dementia carer experiences. J Clin Nurs 2024. [PMID: 39152552 DOI: 10.1111/jocn.17404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/30/2024] [Accepted: 08/02/2024] [Indexed: 08/19/2024]
Abstract
AIMS To explore the emotional wellbeing of dementia carers in the lead up to and during transition of a person living with dementia to a residential aged care facility. DESIGN An interpretative qualitative study. METHODS Semi-structured interviews were conducted with informal carers of person living with dementia between February and June 2023. Data were analysed using an inductive thematic approach and resulted in three themes. RESULTS The majority of carers were adult children (n = 19) and six were wives. Carers lived across metropolitan (n = 20) and regional settings (n = 5) in the most populous state of Australia. Three themes were identified which were attributed to different aspects of the carer role: (1) Carer emotional journey as dementia progresses - impacted by knowledge and lack of support; (2) Questioning decision making-underpinned by knowledge and confidence; and (3) Challenges in re-establishing identity - impacted by ongoing concerns. CONCLUSION As dementia progresses carers of person living with dementia consistently reported gaps in knowledge including how to access support. Specifically, this study identified the need for more to be done to help carers to develop the skills needed for their role, including participation in care planning and identifying care preferences for the future. Nurses can play a key role in promoting referral to services that support carers. Findings offer practical solutions to ameliorate carer stress and promote shared decision making. REPORTING METHOD This research was guided by the Consolidated Criteria for Reporting Qualitative Research.
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Affiliation(s)
- Jennifer White
- College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, Newcastle NSW, Australia
| | - Dane Falcioni
- College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, Newcastle NSW, Australia
| | - Roslyn Barker
- Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
| | | | - Chitra Krishnan
- Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
| | - Elise Mansfield
- College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, Newcastle NSW, Australia
| | - Carolyn Hullick
- Hunter Medical Research Institute, New Lambton Heights, Newcastle NSW, Australia
- Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
- Australian Commission of Safety and Quality in Health Care, Sydney, New South Wales, Australia
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Herington J, Kluger B. Parrots at the Bedside: Making Surrogate Decisions with Stochastic Strangers. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:32-34. [PMID: 38913490 PMCID: PMC11289735 DOI: 10.1080/15265161.2024.2353803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
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Rubin MA, Lewis A, Creutzfeldt CJ, Shrestha GS, Boyle Q, Illes J, Jox RJ, Trevick S, Young MJ. Equity in Clinical Care and Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2024:10.1007/s12028-024-02012-3. [PMID: 38872033 DOI: 10.1007/s12028-024-02012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/09/2024] [Indexed: 06/15/2024]
Abstract
People with disorders of consciousness (DoC) are characteristically unable to synchronously participate in decision-making about clinical care or research. The inability to self-advocate exacerbates preexisting socioeconomic and geographic disparities, which include the wide variability observed across individuals, hospitals, and countries in access to acute care, expertise, and sophisticated diagnostic, prognostic, and therapeutic interventions. Concerns about equity for people with DoC are particularly notable when they lack a surrogate decision-maker (legally referred to as "unrepresented" or "unbefriended"). Decisions about both short-term and long-term life-sustaining treatment typically rely on neuroprognostication and individual patient preferences that carry additional ethical considerations for people with DoC, as even individuals with well thought out advance directives cannot anticipate every possible situation to guide such decisions. Further challenges exist with the inclusion of people with DoC in research because consent must be completed (in most circumstances) through a surrogate, which excludes those who are unrepresented and may discourage investigators from exploring questions related to this population. In this article, the Curing Coma Campaign Ethics Working Group reviews equity considerations in clinical care and research involving persons with DoC in the following domains: (1) access to acute care and expertise, (2) access to diagnostics and therapeutics, (3) neuroprognostication, (4) medical decision-making for unrepresented people, (5) end-of-life decision-making, (6) access to postacute rehabilitative care, (7) access to research, (8) inclusion of unrepresented people in research, and (9) remuneration and reciprocity for research participation. The goal of this discussion is to advance equitable, harmonized, guideline-directed, and goal-concordant care for people with DoC of all backgrounds worldwide, prioritizing the ethical standards of respect for autonomy, beneficence, and justice. Although the focus of this evaluation is on people with DoC, much of the discussion can be extrapolated to other critically ill persons worldwide.
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Affiliation(s)
- Michael A Rubin
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Quinn Boyle
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Neurocritical Care, Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, USA.
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van Hamersveld-Kramer M, Perry SIB, Lodewijks E, Vasse E, de van der Schueren MAE. Decision-making regarding oral nutritional supplements for nursing home residents with advanced dementia: A cross-sectional pilot study. J Hum Nutr Diet 2021; 35:58-67. [PMID: 34694055 DOI: 10.1111/jhn.12955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surrogate decision-making regarding oral nutritional supplements (ONS) for nursing home residents with advanced dementia is a complex process. In this cross-sectional study, we assessed whether Dutch dietitians, elderly care physicians (physicians) and surrogate decision-makers (SDMs) differ in the factors that they regard important when considering ONS. We also investigated differences in opinion regarding whether or not ONS is a life-prolonging measure. METHODS Through an online survey, 90 dietitians, 53 physicians and 70 SDMs of nursing home residents (all aged ≥ 65 years old with advanced dementia) rated the level of perceived influence of 11 pre-defined factors on their decision-making, ranked factors in order of importance and stated whether they considered ONS a life-prolonging measure or not. By statistical analysis, we tested differences in the mean sum of ranks for perceived influence differing between groups. We also tested differences in proportions between groups of those who considered ONS a life-prolonging measure. RESULTS Rating of perceived influence significantly differed for six factors. Quality of life was ranked as the most influential factor by all groups. Dietitians significantly differed in their opinion on the life-prolonging effect of ONS from physicians (odds ratio = 0.29, 95% confidence interval = 0.13-0.65), as well as from SDMs (odds ratio = 0.22, 95% confidence interval = 0.10-0.45). CONCLUSIONS Although all groups proclaimed quality of life to be first priority in decision-making, we found that Dutch dietitians, physicians and SDMs differed in what they regarded important when considering ONS for nursing home residents with advanced dementia. Regarding the life-prolonging effect of ONS, dietitians differed in opinion from physicians, as well as from SDMs.
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Affiliation(s)
| | - Sander I B Perry
- Department of Epidemiology and Data Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Eva Lodewijks
- Department of Dietetics, Florence Healthcare, Rijswijk, The Netherlands.,University Network for the Care Sector Zuid Holland, Leiden, The Netherlands
| | - Emmelyne Vasse
- Department of Dietetics, Gelderse Vallei Hospital, Ede, The Netherlands.,Dutch Malnutrition Steering Group, Amsterdam, The Netherlands
| | - Marian A E de van der Schueren
- Department of Nutrition, Dietetics and Lifestyle, HAN University of Applied Sciences, Nijmegen, The Netherlands.,Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
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Bosisio F, Sterie AC, Rubli Truchard E, Jox RJ. Implementing advance care planning in early dementia care: results and insights from a pilot interventional trial. BMC Geriatr 2021; 21:573. [PMID: 34666711 PMCID: PMC8524211 DOI: 10.1186/s12877-021-02529-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is particularly appropriate for persons with early dementia (PWED) since it promotes conversations about dementia-specific illness scenarios, addresses inconsistencies between advance directives and patients' observed behavior, emphasizes prospective and relational autonomy, and may be generally consistent with older persons' decision-making needs. However, despite evidence of its benefits, ACP is yet to become widely used among PWED. In this paper, we present a dementia-specific tool developed in Western Switzerland, discuss results of a pilot trial designed to promote ACP among PWED and their relatives, and discuss the feasibility and acceptability of the intervention and the study protocol in prevision of a large scale trial. METHODS This one-arm pre-post pilot trial consisted of four visits, with visits 2 and 3 being the ACP intervention. Quantitative outcome measures during visit 1 and 4 assessed the aptitude of the intervention to support PWED autonomy and relatives' knowledge of PWED's preferences. Feasibility was explored according to how the recruitment procedure unfurled and based on the necessary revisions to the study protocol and healthcare providers' reason for excluding a PWED from the study. Acceptability was assessed according to pre-post evaluations, difficulties regarding the intervention or trial participation, and pre-post qualitative interviews regarding participants' reasons to participate to the study, satisfaction with the tool and difficulties perceived. RESULTS The ACP intervention itself was well received by PWED and their relatives that expressed satisfaction with the procedure, especially regarding the opportunity to discuss a sensitive topic with the help of a facilitator. Five main challenges in terms of feasibility were 1) to locate eligible patients, 2) to tailor recruitment procedures to recruitment locations, 3) to adapt inclusion criteria to clinical routines, 4) to engage PWED and their relatives in ACP, and 5) to design a trial that does not burden PWED. Despite these challenges, the intervention increased the number of advance directives, the concordance between PWED's preferences and relatives' decision on their behalf, and relatives' perceived control over healthcare decisions. CONCLUSION Misconceptions about dementia and ACP, in the patient, relatives, and healthcare providers, combined with structural and institutional challenges, have the power to impede research and implementation of ACP in dementia care. For this reason, we conclude that a large scale trial to test a dementia-specific tool of ACP is currently not feasible in Western Switzerland and should be endorsed in a systemic approach of ACP. TRIAL REGISTRATION This trial was registered in the database clinicaltrial.gov with the number NCT03615027 .
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Affiliation(s)
- Francesca Bosisio
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland. .,Service of Palliative and Supportive Care, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland. .,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland.
| | - Anca-Cristina Sterie
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Service of Palliative and Supportive Care, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland
| | - Eve Rubli Truchard
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland
| | - Ralf J Jox
- Service of Palliative and Supportive Care, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.,Chair of Geriatric Palliative Care, Lausanne University Hospital and Lausanne University, Hôpital Nestlé, Lausanne, Switzerland.,Institute of Humanities in Medicine, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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Anantapong K, Davies N, Chan J, McInnerney D, Sampson EL. Mapping and understanding the decision-making process for providing nutrition and hydration to people living with dementia: a systematic review. BMC Geriatr 2020; 20:520. [PMID: 33267831 PMCID: PMC7709405 DOI: 10.1186/s12877-020-01931-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/25/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This systematic review aimed to explore the process of decision-making for nutrition and hydration for people living with dementia from the perspectives and experiences of all involved. METHODS We searched CINAHL, the Cochrane Library, EMBASE, MEDLINE and PsycINFO databases. Search terms were related to dementia, decision-making, nutrition and hydration. Qualitative, quantitative and case studies that focused on decision-making about nutrition and hydration for people living with dementia were included. The CASP and Murad tools were used to appraise the quality of included studies. Data extraction was guided by the Interprofessional Shared Decision Making (IP-SDM) model. We conducted a narrative synthesis using thematic analysis. PROSPERO registration number CRD42019131497. RESULTS Forty-five studies were included (20 qualitative, 15 quantitative and 10 case studies), comprising data from 17 countries and 6020 patients, family caregivers and practitioners. The studies covered a range of decisions from managing oral feeding to the use of tube feeding. We found that decisions about nutrition and hydration for people living with dementia were generally too complex to be mapped onto the precise linear steps of the existing decision-making model. Decision-making processes around feeding for people living with dementia were largely influenced by medical evidence, personal values, cultures and organizational routine. Although the process involved multiple people, family caregivers and non-physician practitioners were often excluded in making a final decision. Upon disagreement, nutrition interventions were sometimes delivered with conflicting feelings concealed by family caregivers or practitioners. Most conflicts and negative feelings were resolved by good relationship, honest communication, multidisciplinary team meetings and renegotiation. CONCLUSIONS The decision-making process regarding nutrition and hydration for people living with dementia does not follow a linear process. It needs an informed, value-sensitive, and collaborative process. However, it often characterized by unclear procedures and with a lack of support. Decisional support is needed and should be approached in a shared and stepwise manner.
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Affiliation(s)
- Kanthee Anantapong
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.
- Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand.
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Justin Chan
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Daisy McInnerney
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, Sterling Way, London, UK
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7
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Bronner K, Bodner L, Jox RJ, Marckmann G, Diehl-Schmid J, Hamann J. [Development of a decision aid for participative advance planning for people with dementia and their relatives]. DER NERVENARZT 2020; 91:1032-1039. [PMID: 32347327 PMCID: PMC7606278 DOI: 10.1007/s00115-020-00911-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with a diagnosis of dementia face various important social and health-related decisions. Due to the progression of the disease it seems crucial that patients try to deal with these decisions early in the course of the disease to have the opportunity to make decisions autonomously. Professional support can help to plan in advance according to the wishes and possibilities in an effective and individualized manner. MATERIAL AND METHODS The instrument was developed in a multiphase process based on advance care planning and shared decision-making. The prototype was pretested on 8 patient-relative dyads from a special outpatient department for early recognition and adapted as best as possible to their needs. Subsequently, in a pilot study the applicability of the decision aid was tested as an intervention in a further 19 patient-relative dyads with trained conversion attendants (diagnosis of Alzheimer's dementia or mixed form; mini mental state examination, MMSE (Mini-Mental-State-Test-Summenwert) >20 and <27). RESULTS The result was a written decision-making aid for people with early stage dementia and their relatives, which supports the decision-making process (health care proxy, advance directive, living and care, driving ability). The first results showed good acceptance and handling. Patients and relatives dealt with the individual topics to a high degree and found them to be highly relevant. CONCLUSION Despite positive feedback from the participants with respect to acceptance and applicability, there were major difficulties in recruiting. In the future, the systematic use of decision support as part of routine care could help to support the decision-making process in this patient group.
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Affiliation(s)
- Katharina Bronner
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - Lea Bodner
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Ralf J Jox
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Georg Marckmann
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Janine Diehl-Schmid
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - Johannes Hamann
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland.
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Xie B, Tao C, Li J, Hilsabeck RC, Aguirre A. Artificial Intelligence for Caregivers of Persons With Alzheimer's Disease and Related Dementias: Systematic Literature Review. JMIR Med Inform 2020; 8:e18189. [PMID: 32663146 PMCID: PMC7471889 DOI: 10.2196/18189] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/20/2020] [Accepted: 06/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Artificial intelligence (AI) has great potential for improving the care of persons with Alzheimer's disease and related dementias (ADRD) and the quality of life of their family caregivers. To date, however, systematic review of the literature on the impact of AI on ADRD management has been lacking. OBJECTIVE This paper aims to (1) identify and examine literature on AI that provides information to facilitate ADRD management by caregivers of individuals diagnosed with ADRD and (2) identify gaps in the literature that suggest future directions for research. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic literature reviews, during August and September 2019, we performed 3 rounds of selection. First, we searched predetermined keywords in PubMed, Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, PsycINFO, IEEE Xplore Digital Library, and the ACM Digital Library. This step generated 113 nonduplicate results. Next, we screened the titles and abstracts of the 113 papers according to inclusion and exclusion criteria, after which 52 papers were excluded and 61 remained. Finally, we screened the full text of the remaining papers to ensure that they met the inclusion or exclusion criteria; 31 papers were excluded, leaving a final sample of 30 papers for analysis. RESULTS Of the 30 papers, 20 reported studies that focused on using AI to assist in activities of daily living. A limited number of specific daily activities were targeted. The studies' aims suggested three major purposes: (1) to test the feasibility, usability, or perceptions of prototype AI technology; (2) to generate preliminary data on the technology's performance (primarily accuracy in detecting target events, such as falls); and (3) to understand user needs and preferences for the design and functionality of to-be-developed technology. The majority of the studies were qualitative, with interviews, focus groups, and observation being their most common methods. Cross-sectional surveys were also common, but with small convenience samples. Sample sizes ranged from 6 to 106, with the vast majority on the low end. The majority of the studies were descriptive, exploratory, and lacking theoretical guidance. Many studies reported positive outcomes in favor of their AI technology's feasibility and satisfaction; some studies reported mixed results on these measures. Performance of the technology varied widely across tasks. CONCLUSIONS These findings call for more systematic designs and evaluations of the feasibility and efficacy of AI-based interventions for caregivers of people with ADRD. These gaps in the research would be best addressed through interdisciplinary collaboration, incorporating complementary expertise from the health sciences and computer science/engineering-related fields.
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Affiliation(s)
- Bo Xie
- School of Nursing, The University of Texas at Austin, Austin, TX, United States
- School of Information, The University of Texas at Austin, Austin, TX, United States
| | - Cui Tao
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Juan Li
- Department of Computer Science, North Dakota State University, Fargo, ND, United States
| | - Robin C Hilsabeck
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, TX, United States
| | - Alyssa Aguirre
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, TX, United States
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How Does Functional Neurodiagnostics Inform Surrogate Decision-Making for Patients with Disorders of Consciousness? A Qualitative Interview Study with Patients’ Next of Kin. NEUROETHICS-NETH 2020. [DOI: 10.1007/s12152-019-09425-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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10
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Miller LM, Whitlatch CJ, Lee CS, Caserta MS. Care Values in Dementia: Patterns of Perception and Incongruence Among Family Care Dyads. THE GERONTOLOGIST 2020; 59:509-518. [PMID: 29546327 DOI: 10.1093/geront/gny008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Persons with dementia (PWDs) often place greater importance on their care values (i.e., maintaining autonomy and social relations, choosing caregivers, avoiding being a burden) than family caregivers (CGs) perceive, which can detract from dementia care planning (e.g., care arrangements or surrogate decisions). Notable variability has been found across family care dyads (PWD and CG) in their perceptions of care values, suggesting that there may be multiple patterns of perception. The purpose of this study was to characterize distinct patterns of perception of care values in family care dyads. DESIGN AND METHODS Using cross-sectional data from 228 community-dwelling family care dyads, we quantified dyads' average perceptions and incongruence in perceptions of the importance of everyday care values using multilevel modeling. These scores were then used in a latent class analysis to identify distinct patterns of perception, with the dyad as the unit of analysis. RESULTS Two distinct patterns of care value perception were identified. 25% of dyads were labeled as "CG underestimating" due to lower average estimations of the importance of PWDs' care values, and a significant amount of dyadic incongruence. Underestimating dyads were characterized by a confirmed diagnosis of dementia, lower cognitive function, and younger age in PWDs, and higher relationship strain in the dyad. IMPLICATIONS Care dyads that fall into an underestimating pattern may be at greater risk for inadequate dementia care planning. Interventions to improve care planning in this higher-risk group may include care values identification with the PWD, strategies for alleviating relationship strain, early-stage planning, and disease education.
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Affiliation(s)
| | - Carol J Whitlatch
- Center for Research and Education, Benjamin Rose Institute on Aging, Cleveland, Ohio
| | - Christopher S Lee
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts
| | - Michael S Caserta
- College of Nursing and Center on Aging, The University of Utah, Salt Lake City
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11
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Daneau S, Bourbonnais A, Legault A. Surrogates' end-of-life decision-making process in nursing homes for residents with a neurocognitive disorder: An integrative review. Int J Older People Nurs 2019; 15:e12274. [PMID: 31612638 DOI: 10.1111/opn.12274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 08/16/2019] [Accepted: 08/27/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The goal of this review is to analyse articles on the experience of surrogates who find themselves making end-of-life decisions for a relative with a major neurocognitive disorder in a nursing home. DESIGN An integrative review of the literature based on Whittemore and Knafl's method. DATA SOURCES This review used the CINAHL, PubMed, PsycInfo, Embase and Web of Science databases. A complementary search was also conducted via citation pearl searching, and the reference lists from the selected articles were manually verified. REVIEW METHOD The quality of the selected articles was assessed using the Crow Critical Appraisal Tool, and the data were extracted systematically and were then organised according to Mishel's uncertainty in illness theory. The data that did not correspond to any concept of the theory were excluded at this stage. Analysis was conducted using the method put forward by Miles, Huberman and Saldaña. RESULTS A total of 18 articles were selected: 11 qualitative, 5 quantitative and 1 using a mixed method, as well as 1 ethical argument. The subjects arising from the analysis of the articles were the types of decisions made, the support available for the surrogates, the role and involvement of the surrogates in the process and the factors that influence the decisions. CONCLUSION The results of this integrative review stimulate reflection on the needs of family members involved in making decisions, as well as on the nursing practice and research. Published literature is mainly from North America, and thus, more research is needed to better understand the impact of cultural and ethnic differences in the process, which was poorly covered by the existing literature. Also, exploring nurses' involvement in supporting surrogates may eventually better equip nurses for their interventions with surrogates. IMPLICATIONS FOR PRACTICE Describing the illness progression and the signification of palliative care to the resident with a NCD and their surrogate decision makers, as well as discussing end-of-life care preferences as early as possible are all nursing interventions that could potentially enhance surrogates' end-of-life decision-making process.
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Affiliation(s)
- Stéphanie Daneau
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada.,Research Chair in Nursing Care for Older People and their Families, Montréal, QC, Canada.,Department of Nursing, Université du Québec à Trois-Rivières, Drummondville, QC, Canada
| | - Anne Bourbonnais
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada.,Research Chair in Nursing Care for Older People and their Families, Montréal, QC, Canada.,Research Center of the Institut universitaire de gériatrie de Montréal, Montréal, QC, Canada
| | - Alain Legault
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada
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12
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Sellars M, Chung O, Nolte L, Tong A, Pond D, Fetherstonhaugh D, McInerney F, Sinclair C, Detering KM. Perspectives of people with dementia and carers on advance care planning and end-of-life care: A systematic review and thematic synthesis of qualitative studies. Palliat Med 2019; 33:274-290. [PMID: 30404576 PMCID: PMC6376607 DOI: 10.1177/0269216318809571] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND: Advance care planning aims to ensure that care received during serious and chronic illness is consistent with the person’s values, preferences and goals. However, less than 40% of people with dementia undertake advance care planning internationally. AIM: This study aims to describe the perspectives of people with dementia and their carers on advance care planning and end-of-life care. DESIGN: Systematic review and thematic synthesis of qualitative studies. DATA SOURCES: Electronic databases were searched from inception to July 2018. RESULTS: From 84 studies involving 389 people with dementia and 1864 carers, five themes were identified: avoiding dehumanising treatment and care (remaining connected, delaying institutionalisation, rejecting the burdens of futile treatment); confronting emotionally difficult conversations (signifying death, unpreparedness to face impending cognitive decline, locked into a pathway); navigating existential tensions (accepting inevitable incapacity and death, fear of being responsible for cause of death, alleviating decisional responsibility); defining personal autonomy (struggling with unknown preferences, depending on carer advocacy, justifying treatments for health deteriorations); and lacking confidence in healthcare settings (distrusting clinicians’ mastery and knowledge, making uninformed choices, deprived of hospice access and support at end of life). CONCLUSION: People with dementia and their carers felt uncertain in making treatment decisions in the context of advance care planning and end-of-life care. Advance care planning strategies that attend to people’s uncertainty in decision-making may help to empower people with dementia and carers and strengthen person-centred care in this context.
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Affiliation(s)
- Marcus Sellars
- 1 Advance Care Planning Australia, Austin Health, Melbourne, VIC, Australia.,2 Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Olivia Chung
- 1 Advance Care Planning Australia, Austin Health, Melbourne, VIC, Australia
| | - Linda Nolte
- 1 Advance Care Planning Australia, Austin Health, Melbourne, VIC, Australia
| | - Allison Tong
- 3 Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Dimity Pond
- 4 School of Medicine and Public Health (General Practice), The University of Newcastle, Callaghan, NSW, Australia
| | - Deirdre Fetherstonhaugh
- 5 Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, VIC, Australia
| | - Fran McInerney
- 6 Wicking Dementia Research and Education Centre, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Craig Sinclair
- 7 Rural Clinical School of Western Australia, University of Western Australia, Albany, WA, Australia
| | - Karen M Detering
- 1 Advance Care Planning Australia, Austin Health, Melbourne, VIC, Australia.,8 Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, VIC, Australia
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Wicki MT. Advance Care Planning for Persons with Intellectual Disabilities. GEROPSYCH-THE JOURNAL OF GERONTOPSYCHOLOGY AND GERIATRIC PSYCHIATRY 2018. [DOI: 10.1024/1662-9647/a000187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Abstract. As people live longer, they become more likely to die from prolonged, incurable, chronic illnesses occurring more frequently in old age. This study explores the usefulness, quality, and reliability of documented advance care planning interviews to determine the decision-making capacity of persons with intellectual disabilities (IDs). A volunteer sample of 60 persons rated the capacity to consent to treatment of four persons deciding on two end-of-life decisions. Sensitivity, specificity, and percent agreement were calculated. Interrater reliability was assessed using Fleiss’ κ and Krippendorff’s α. A Yates’ corrected χ2 was used to analyze differences in ratings between groups of raters. The sensitivity value was 62%; the specificity value was 95%. The percent agreement for all participants was 70%, Fleiss’ κ was 0.396, and Krippendorff’s α was 0.395. Of the participants, 72 found documented advance care planning discussions useful for diagnosing the decision-making capacity of people with IDs. The documented interviews helped to identify those persons with IDs who had the decision-making capacity. Documented interviews on end-of-life decisions could make a valuable contribution to fostering their self-determination in end-of-life issues.
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Affiliation(s)
- Monika T. Wicki
- Institute for Professionalization and System Development, University of Applied Sciences of Special Needs Education, Zurich, Switzerland
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14
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Xie B, Berkley AS, Kwak J, Fleischmann KR, Champion JD, Koltai KS. End-of-life decision making by family caregivers of persons with advanced dementia: A literature review of decision aids. SAGE Open Med 2018; 6:2050312118777517. [PMID: 29844911 PMCID: PMC5966844 DOI: 10.1177/2050312118777517] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/25/2018] [Indexed: 12/27/2022] Open
Abstract
Objectives: To investigate existing knowledge in the literature about end-of-life decision making by family caregivers of persons with dementia, focusing on decision aids for caregivers of persons with advanced dementia, and to identify gaps in the literature that can guide future research. Methods: A literature review through systematic searches in PubMed, CINAHL Plus with Full Text, and PsycINFO was conducted in February 2018; publications with full text in English and published in the past 10 years were selected in multiple steps. Results: The final sample included five decision aids with predominantly Caucasian participants; three of them had control groups, and three used audiovisual technology in presenting the intervention materials. No other technology was used in any intervention. Existing interventions lacked tailoring of information to caregivers’ preferences for different types and amounts of information necessary to make decisions consistent with patients’ values. Conclusion: Research is needed in exploring the use of technology in decision aids that could provide tailored information to facilitate caregivers’ decision making. More diverse samples are needed.
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Affiliation(s)
- Bo Xie
- School of Nursing, The University of Texas at Austin, Austin, TX, USA.,School of Information, The University of Texas at Austin, Austin, TX, USA
| | - Amy S Berkley
- School of Nursing, The University of Texas at Austin, Austin, TX, USA
| | - Jung Kwak
- School of Nursing, The University of Texas at Austin, Austin, TX, USA
| | | | | | - Kolina S Koltai
- School of Information, The University of Texas at Austin, Austin, TX, USA
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15
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Convey H, Holt J, Summers B. Proxy decision making and dementia: Using Construal Level Theory to analyse the thoughts of decision makers. J Adv Nurs 2018. [DOI: 10.1111/jan.13563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Helen Convey
- School of Healthcare; University of Leeds; Leeds UK
| | - Janet Holt
- School of Healthcare; University of Leeds; Leeds UK
| | - Barbara Summers
- Centre for Decision Research; Leeds University Business School; University of Leeds; Leeds UK
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16
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[Quality of dying processes after commencement of the German Living Will Act : Experiences of a surgical intensive care unit]. Chirurg 2018; 88:244-250. [PMID: 27995297 DOI: 10.1007/s00104-016-0345-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is so far no information on how the third act on amendment of the German guardianship law from 29 July 2009 has affected dying processes of critically ill patients. METHODS This retrospective study analyzed the patterns of dying processes in postoperative critically ill patients treated from 2009 to 2012 (period II after the commencement of the German Living Will Act) and 10 years before (period I, 1999-2002). Independent associations were calculated by logistic regression. RESULTS In the observation period II (n = 137 dying patients) time until death significantly decreased to 19.3 days (95% CI 14.8-23.8, p = 0.008) vs. 29.2 days (95% CI 23.7-34.6) in period I (n = 163). In period II respect of the patient's will preceded death in 42.3% of the dying patients (period I: 8.6%, p < 0.001). Simultaneously, the frequency of patients with a severe preoperative comorbidity (failure of more than one organ) increased (26.8% of dying patients vs. 5.5% in period I, p = 0.001). The treatment during period II was, in addition to high age and a severe comorbidity, a significant independent predictor for the possibility that respect of the patient's will preceded death (odds ratio 7.42; 95% CI 3.77-14.60). CONCLUSION Independent of various covariables, treatment after the commencement of the German Living Will Act was associated with a broader and earlier respect of the patient's will, thereby shortening the time until death.
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17
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Gil E, Agmon M, Hirsch A, Ziv M, Zisberg A. Dilemmas for guardians of advanced dementia patients regarding tube feeding. Age Ageing 2018; 47:138-143. [PMID: 29040344 DOI: 10.1093/ageing/afx161] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 09/23/2017] [Indexed: 02/03/2023] Open
Abstract
Background advanced dementia is an incurable illness, its last stage marked by inability to eat. Tube feeding was deemed a helpful solution at this stage, but in recent years its inefficiency has been proved, and it is no longer practiced in many countries around the world. In Israel, however, the procedure is still accepted. In the gastroenterology department at the Bnai Zion Medical Center, a serious interaction is ongoing with patients' legal guardians, where detailed information is given about the inefficiency of the tube procedure. Nevertheless, the great majority of guardians choose to have it performed. Purpose to probe the considerations underlying the decision for gastrostomy, despite the data and the recommendations. Method qualitative research, including participant observation at the clinic and in-depth interviews with guardians. Findings the families of most patients did not discuss end-of-life issues with them. The overwhelming preference for using the technology was interpreted as life-saving, in contrast to comfort feeding, which was deemed euthanasia. The reasons given for the decision to tube feed were drawn from a range of outlooks: religion, the patient's earlier survival capacity, and pragmatic considerations involving relations with nursing home staff. Conclusion study of the decision-making process of advanced dementia patients' guardians sheds light on the layers of meaning of the Israeli discourse regarding end-of-life issues.
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Affiliation(s)
- Efrat Gil
- Geriatric Unit, Bnai Zion MC, Haifa, Israel
- Technion Israel Institute of Technology Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Maayan Agmon
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Ayal Hirsch
- Gastroenterology Institute, Bnai Zion MC, Haifa, Israel
| | - Miriam Ziv
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Anna Zisberg
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
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18
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Peixoto RI, da Silveira VM, Zimmermann RD, de M Gomes A. End-of-life care of elderly patients with dementia: A cross-sectional study of family carer decision-making. Arch Gerontol Geriatr 2017; 75:83-90. [PMID: 29197715 DOI: 10.1016/j.archger.2017.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/20/2017] [Accepted: 11/23/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Dementia syndromes pose a major worldwide challenge to public health. In terminal stage of dementia, carers are responsible for decision making in end-of-life treatment and there may be multiple factors that contribute to the choice of a palliative or invasive treatment. AIM To identify possible factors that influence the decision-making of family caregivers on implementing invasive or palliative interventions for people with end stage dementia. DESIGN A structured interview with family caregivers of elderly patients addressing aspects of the following categories: elderly with dementia, caregiver, medical treatment history. Statistical analysis was performed to test whether there was a significant association between the carer's decision (invasive or palliative treatment) and the collected variables. SETTINGAND PARTICIPANTS The study was conducted in three hospitals in Brazil. Participants were family caregivers of inpatients with end stage dementia RESULTS: Most of caregivers chose not to perform invasive procedures. The factors with the greatest association with the decision for invasive care were: elderly with tracheostomy, dementia diagnosis for less than 2 years, caregiver's age less than 50 years, history of hospital admission in the last year, affirmation that interviewee would be surprised with the death of the elderly within 1year and the denial that health care team has already explained about treatment options. CONCLUSION There were identified several factors related to the carer, the elderly person and their medical treatment that may influence the choice between palliative and invasive care for the elderly person with dementia.
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Affiliation(s)
- Rafaella I Peixoto
- Department of Geriatrics, Hospital das Clínicas, Universidade Federal de Pernambuco, Brazil.
| | - Vera M da Silveira
- Programa de pós-graduação em Gerontologia, Universidade Federal de Pernambuco, Brazil
| | - Rogério D Zimmermann
- Programa de pós-graduação em Gerontologia, Universidade Federal de Pernambuco, Brazil
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19
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Barker S, Lynch M, Hopkinson J. Decision making for people living with dementia by their carers at the end of life: a rapid scoping review. Int J Palliat Nurs 2017; 23:446-456. [DOI: 10.12968/ijpn.2017.23.9.446] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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20
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Shanley C, Fetherstonhaugh D, McAuliffe L, Bauer M, Beattie E. Providing support to surrogate decision-makers for people living with dementia: Healthcare professional, organisational and community responsibilities. HEALTH & SOCIAL CARE IN THE COMMUNITY 2017; 25:1563-1570. [PMID: 28569431 DOI: 10.1111/hsc.12456] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 06/07/2023]
Abstract
The prevalence of dementia will continue to increase with the ageing of the population. Many people living with dementia will reach a stage where surrogate decision-makers-mostly family carers-will need to make a range of decisions on their behalf. The aim of this study was to learn from surrogate decision-makers how they can be most effectively supported in this role. The study employed a qualitative design using semi-structured face-to-face or telephone interviews with a purposive sample of 34 surrogate decision-makers of people living with dementia. Transcripts of participant interviews were reviewed using a thematic approach to analysis. Four main themes were identified from this analysis: needing greater community awareness of dementia and its impact; intervening early in cognitive decline; relying on health professionals for ongoing support; and seeking and using support from wherever is relevant for each person. Based on this analysis and a review of the literature, we propose a wholistic set of recommendations for the support of surrogate decision-makers. Healthcare professionals need to help family carers understand the likely trajectory of dementia, including the significance of surrogate decision-making. They can support the person living with dementia and their surrogates to undertake advance care planning and they can act as empathic guides during this process. Health and community care organisations need to provide a "key worker" model wherever possible so that the person living with dementia and their surrogate decision-maker do not have to seek support from multiple staff members or organisations. Carer support programmes can routinely include information and resources about surrogate decision-making. Community and government organisations can help people prepare for the possibility of becoming surrogate decision-makers by promoting a greater public awareness and understanding of both dementia and advance care planning.
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Affiliation(s)
- Christopher Shanley
- Centre for Applied Nursing Research, Western Sydney University and Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Deirdre Fetherstonhaugh
- Australian Centre for Evidence Based Aged Care (ACEBAC), La Trobe University, Melbourne, Victoria, Australia
| | - Linda McAuliffe
- Australian Centre for Evidence Based Aged Care (ACEBAC), La Trobe University, Melbourne, Victoria, Australia
| | - Michael Bauer
- Australian Centre for Evidence Based Aged Care (ACEBAC), La Trobe University, Melbourne, Victoria, Australia
| | - Elizabeth Beattie
- Dementia Collaborative Research Centre (DCRC)-Carers and Consumers, Queensland University of Technology, Brisbane, Queensland, Australia
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21
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Fetherstonhaugh D, McAuliffe L, Shanley C, Bauer M, Beattie E. "Did I make the right decision?": The difficult and unpredictable journey of being a surrogate decision maker for a person living with dementia. DEMENTIA 2017; 18:1601-1614. [PMID: 28766384 DOI: 10.1177/1471301217721862] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many people living with dementia eventually lose the capacity to make their own decisions and will rely on another person – a surrogate decision maker – to make decisions on their behalf. It is important – especially with the increasing prevalence of dementia – that the role of surrogate decision maker is understood and supported. This qualitative study explored the experiences of 34 surrogate decision makers of persons living with dementia in Australia. Face-to-face and telephone interviews were conducted over six months in 2014. Five themes were identified: becoming the only – or main – surrogate decision maker; growing into the role of surrogate decision maker; dealing with the stress of making decisions; having to challenge healthcare professionals; and getting support – or not – from family members. An overarching construct tying the themes together is the description of the participants’ experience as being on a difficult and unpredictable journey. Healthcare professionals can provide support by acting as empathic guides on this journey.
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Affiliation(s)
| | | | - Christopher Shanley
- Western Sydney University, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia
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22
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Lamahewa K, Mathew R, Iliffe S, Wilcock J, Manthorpe J, Sampson EL, Davies N. A qualitative study exploring the difficulties influencing decision making at the end of life for people with dementia. Health Expect 2017. [PMID: 28640487 PMCID: PMC5750695 DOI: 10.1111/hex.12593] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Dementia is a progressive neurodegenerative condition characterized by declining functional and cognitive abilities. The quality of end of life care for people with dementia in the UK can be poor. Several difficult decisions may arise at the end of life, relating to the care of the person with dementia, for example management of comorbidities. Objective To explore difficulties in decision making for practitioners and family carers at the end of life for people with dementia. Design Qualitative methodology using focus groups and semi‐structured interviews and thematic analysis methods. Settings and participants Former (n=4) and current (n=6) family carers of people with experience of end of life care for a person with dementia were recruited from an English dementia voluntary group in 2015. A further 24 health and care professionals were purposively sampled to include a broad range of expertise and experience in dementia end of life care. Results Four key themes were identified as follows: challenges of delivering coherent care in dynamic systems; uncertainty amongst decision makers; internal and external conflict amongst decision makers; and a lack of preparedness for the end of life. Overarching difficulties such as poor communication, uncertainty and conflict about the needs of the person with dementia as well as the decision maker's own role can characterize decision making at the end of life. Conclusions This study suggests that decision making at the end of life for people with dementia has the potential to be improved. More planning earlier in the course of dementia with an on‐going approach to conversation may increase preparedness and family carers’ expectations of end of life.
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Affiliation(s)
- Kethakie Lamahewa
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rammya Mathew
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Jane Wilcock
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, UK.,Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, UK
| | - Nathan Davies
- Research Department of Primary Care and Population Health, University College London, London, UK
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23
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Fetherstonhaugh D, McAuliffe L, Bauer M, Shanley C. Decision-making on behalf of people living with dementia: how do surrogate decision-makers decide? JOURNAL OF MEDICAL ETHICS 2017; 43:35-40. [PMID: 27780889 DOI: 10.1136/medethics-2015-103301] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 09/12/2016] [Accepted: 10/04/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND For people living with dementia, the capacity to make important decisions about themselves diminishes as their condition advances. As a result, important decisions (affecting lifestyle, medical treatment and end of life) become the responsibility of someone else, as the surrogate decision-maker. This study investigated how surrogate decision-makers make important decisions on behalf of a person living with dementia. METHODS Semi-structured interviews were conducted with 34 family members who had formally or informally taken on the role of surrogate decision-maker. Thematic analysis of interviews was undertaken, which involved identifying, analysing and reporting themes arising from the data. RESULTS Analysis revealed three main themes associated with the process of surrogate decision-making in dementia: knowing the person's wishes; consulting with others and striking a balance. Most participants reported that there was not an advance care plan in place for the person living with dementia. Even when the prior wishes of the person with dementia were known, the process of decision-making was often fraught with complexity. DISCUSSION Surrogate decision-making on behalf of a person living with dementia is often a difficult process. Advance care planning can play an important role in supporting this process. Healthcare professionals can recognise the challenges that surrogate decision-makers face and support them through advance care planning in a way that suits their needs and circumstances.
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Affiliation(s)
- Deirdre Fetherstonhaugh
- Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria, Australia
| | - Linda McAuliffe
- Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria, Australia
| | - Michael Bauer
- Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria, Australia
| | - Chris Shanley
- Centre for Applied Nursing Research, Western Sydney University, Penrith South, New South Wales, Australia
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Butler JM, Hirshberg EL, Hopkins RO, Wilson EL, Orme JF, Beesley SJ, Kuttler K, Brown SM. Preliminary Identification of Coping Profiles Relevant to Surrogate Decision Making in the ICU. PLoS One 2016; 11:e0166542. [PMID: 27835704 PMCID: PMC5105941 DOI: 10.1371/journal.pone.0166542] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 10/31/2016] [Indexed: 11/19/2022] Open
Abstract
Objective The Intensive Care Unit (ICU) is a stressful environment for families of critically ill patients and these individuals are at risk to develop persistent psychological morbidity. Our study objective was to identify individual differences in coping with stress and information presentation preferences of respondents exposed to a simulated ICU experience. Methods Participants were recruited from a university and two community populations. Participants completed questionnaires that measured demographic information and characteristics that may be relevant to an individual’s ICU experience. Quality of life was measured by the EQ-5D, personality dimensions were examined with the abbreviated Big Five inventory, coping with stress was assessed with Brief COPE. Shared decision making preferences were assessed by the Degner Control Preferences Scale (CPS) and information seeking style was assessed with the Miller Behavioral Style Scale (MBSS). Social support was examined using an abbreviated version of the Social Relationship Index. Participants also completed a vignette-based simulated ICU experience, in which they made a surrogate decision on behalf of a loved one in the ICU. Results Three hundred forty-three participants completed the study. Three distinct coping profiles were identified: adaptive copers, maladaptive copers, and disengaged copers. Profiles differed primarily on coping styles, personality, quality of their closest social relationship, and history of anxiety and depression. Responses to the simulated ICU decision making experience differed across profiles. Disengaged copers (15%) were more likely to elect to refuse dialysis on behalf of an adult sibling compared to adaptive copers (7%) or maladaptive copers (5%) (p = 0.03). Notably, the MBSS and the CPS did not differ by coping profile. Conclusion Distinct coping profiles are associated with differences in responses to a simulated ICU experience. Tailoring communication and support to specific coping profiles may represent an important pathway to improving ICU experience for patients and families.
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Affiliation(s)
- Jorie M. Butler
- Geriatric Research Education and Clinical Center (GRECC), George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Department of Internal Medicine, Division of Geriatrics, University of Utah, Salt Lake City, Utah, United States of America
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- * E-mail:
| | - Eliotte L. Hirshberg
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Department of Internal Medicine, Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah, United States of America
| | - Ramona O. Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah, United States of America
| | - Emily L. Wilson
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
| | - James F. Orme
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Department of Internal Medicine, Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Sarah J. Beesley
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Department of Internal Medicine, Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Kathryn Kuttler
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Homer Warner Center for Informatics Research, Murray, Utah, United States of America
| | - Samuel M. Brown
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Department of Internal Medicine, Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah, United States of America
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Kim H, Deatrick JA, Ulrich CM. Ethical frameworks for surrogates' end-of-life planning experiences. Nurs Ethics 2016; 24:46-69. [PMID: 27005954 DOI: 10.1177/0969733016638145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the growing body of knowledge about surrogate decision making, we know very little about the use of ethical frameworks (including ethical theories, principles, and concepts) to understand surrogates' day-to-day experiences in end-of-life care planning for incapacitated adults. OBJECTIVES AND METHODS This qualitative systematic review was conducted to identify the types of ethical frameworks used to address surrogates' experiences in end-of-life care planning for incapacitated adults as well as the most common themes or patterns found in surrogate decision-making research. FINDINGS Seven research papers explicitly identified ethical theories, principles, or concepts, such as autonomy, substituted judgment, and best interest standards as guidelines for the research. Surrogate decision making themes included the responsibilities and goals of being a surrogate, factors influencing surrogates' decision making, outcomes for surrogates, and an overarching theme of "wanting to do the right thing" for their loved one and/or themselves. DISCUSSION Understanding the complexity of surrogates' experiences of end-of-life care planning is beyond the scope of conventional ethical frameworks. CONCLUSION Ethical frameworks that address individuality and contextual variations related to decision making may more appropriately guide surrogate decision-making research that explores surrogates' end-of-life care planning experiences.
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Davies N, Mathew R, Wilcock J, Manthorpe J, Sampson EL, Lamahewa K, Iliffe S. A co-design process developing heuristics for practitioners providing end of life care for people with dementia. BMC Palliat Care 2016; 15:68. [PMID: 27484683 PMCID: PMC4969644 DOI: 10.1186/s12904-016-0146-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The end of life for someone with dementia can present many challenges for practitioners; such as, providing care if there are swallowing difficulties. This study aimed to develop a toolkit of heuristics (rules-of-thumb) to aid practitioners making end-of-life care decisions for people with dementia. METHODS An iterative co-design approach was adopted using a literature review and qualitative methods, including; 1) qualitative interviews and focus groups with family carers and 2) focus groups with health and care professionals. Family carers were recruited from a national charity, purposively sampling those with experience of end-of-life care for a person with dementia. Health and care professionals were purposively sampled to include a broad range of expertise including; general practitioners, palliative care specialists, and geriatricians. A co-design group was established consisting of health and social care experts and family carers, to synthesise the findings from the qualitative work and produce a toolkit of heuristics to be tested in practice. RESULTS Four broad areas were identified as requiring complex decisions at the end of life; 1) eating/swallowing difficulties, 2) agitation/restlessness, 3) ending life-sustaining treatment, and 4) providing "routine care" at the end of life. Each topic became a heuristic consisting of rules arranged into flowcharts. Eating/swallowing difficulties have three rules; ensuring eating/swallowing difficulties do not come as a surprise, considering if the situation is an emergency, and considering 'comfort feeding' only versus time-trialled artificial feeding. Agitation/restlessness encourages a holistic approach, considering the environment, physical causes, and the carer's wellbeing. Ending life-sustaining treatment supports practitioners through a process of considering the benefits of treatment versus quality-of-life and comfort. Finally, a heuristic on providing routine care such as bathing, prompts practitioners to consider adapting the delivery of care, in order to promote comfort and dignity at the end of life. CONCLUSIONS The heuristics are easy to use and remember, offering a novel approach to decision making for dementia end-of-life care. They have the potential to be used alongside existing end-of-life care recommendations, adding more readily available practical assistance. This is the first study to synthesise experience and existing evidence into easy-to-use heuristics for dementia end-of-life care.
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Affiliation(s)
- Nathan Davies
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - Rammya Mathew
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Jane Wilcock
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, WC2B 6NR, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, 6th Floor, Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, Sterling Way, London, N18 1QX, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Steve Iliffe
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
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Michael N, O'Callaghan C, Clayton JM. Exploring the utility of the vignette technique in promoting advance care planning discussions with cancer patients and caregivers. PATIENT EDUCATION AND COUNSELING 2016; 99:1406-1412. [PMID: 27021780 DOI: 10.1016/j.pec.2016.03.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 01/26/2016] [Accepted: 03/19/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE We aimed to specifically examine patients' and caregivers' perspectives about the use of the vignette technique (VT) integrating clinical scenarios, as a potential tool for facilitating advance care planning (ACP) discussions. METHODS Secondary analysis of data from three studies that incorporated the VT, focusing on statements specific to use of the VT and using a qualitative descriptive design informed by grounded theory. RESULTS Data from 85 participants were analyzed. Participants varied in their personal identification with scenarios, with caregivers being more accurate. Scenarios prompted consideration and participation in ACP discussions, sometimes steering conversations in directions that participants were ready to consider. However, scenarios also risked evoking distress in participants who may have chosen to avoid discussions. CONCLUSIONS For some patients, scenarios of possible clinical outcomes may provide a neutral platform to promote ACP conversations in a non-threatening manner and allow for exploration of ACP domains to greater depth. PRACTICE IMPLICATIONS Vignettes may be used in staff training through role-play or case discussions; as part of face-to-face interventions to improve knowledge and information processing and to facilitate the initiation of sensitive conversations. Its use in audio-visual formats may further enhance end-of-life dialogue and warrants further consideration.
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Affiliation(s)
- Natasha Michael
- Palliative Care Service, Cabrini Health, Melbourne, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Peter MacCallum Cancer Centre, Melbourne, Australia.
| | - Clare O'Callaghan
- Palliative Care Service, Cabrini Health, Melbourne, Australia; Peter MacCallum Cancer Centre, Melbourne, Australia; St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Josephine M Clayton
- HammondCare Palliative and Supportive Care Service, Greenwich Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
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Birnbacher D. Patientenverfügungen und Advance Care Planning bei Demenz und anderen kognitiven Beeinträchtigungen. Ethik Med 2016. [DOI: 10.1007/s00481-016-0388-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Advance (Meta-) Directives for Patients with Dementia who Appear Content: Learning from a Nationwide Survey. J Am Med Dir Assoc 2016; 17:294-9. [DOI: 10.1016/j.jamda.2016.01.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 11/18/2022]
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Abstract
BACKGROUND Infections frequently occur in patients with dementia and antibiotics are often prescribed, but may also be withheld. OBJECTIVES The aim of this systematic review is to provide a systematic overview of the prevalence of antibiotic use, and factors associated with prescribing antibiotics in patients with dementia. DATA SOURCES A systematic search of MEDLINE, EMBASE, PSYCINFO, CINAHL, and the Cochrane library databases until February 13, 2014 was performed, using both controlled terms and free-text terms. RESULTS Thirty-seven articles were included. The point prevalence of antibiotic use in patients with dementia ranged from 3.3 to 16.6%. The period prevalence ranged from 4.4 to 88% overall, and from 23.5 to 94% in variable time frames before death; the median use was 52% (median period 14 days) and 48% (median period 22 days), respectively. Most patients with lower respiratory tract infections or urinary tract infections (77-91%) received antibiotic treatment. Factors associated with antibiotic use related to patients, families, physicians, and the healthcare context. More severe dementia and a poor prognosis were associated with less antibiotic use in various countries. Associations with aspiration and illness severity differed by country. CONCLUSIONS AND IMPLICATIONS Antibiotic use in patients with dementia is substantial, and probably highly associated with the particular healthcare context. Future studies may report antibiotic use by infection type and stage of dementia, and compare cross-nationally.
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Kuehlmeyer K, Schuler AF, Kolb C, Borasio GD, Jox RJ. Evaluating Nonverbal Behavior of Individuals with Dementia During Feeding: A Survey of the Nursing Staff in Residential Care Homes for Elderly Adults. J Am Geriatr Soc 2015; 63:2544-2549. [DOI: 10.1111/jgs.13822] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Katja Kuehlmeyer
- Institute for Ethics, History and Theory of Medicine; Ludwig-Maximilians Universität München; Munich Germany
| | - Anna F. Schuler
- Institute for Ethics, History and Theory of Medicine; Ludwig-Maximilians Universität München; Munich Germany
| | - Christian Kolb
- Institute of Psychogerontology; Friedrich Alexander Universität; Erlangen-Nuremberg Germany
| | - Gian Domenico Borasio
- Chair in Palliative Medicine; Centre Hospitalier Universitaire Vaudois; Université de Lausanne; Lausanne Switzerland
| | - Ralf J. Jox
- Institute for Ethics, History and Theory of Medicine; Ludwig-Maximilians Universität München; Munich Germany
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Jox RJ, Kuehlmeyer K, Klein AM, Herzog J, Schaupp M, Nowak DA, Koenig E, Müller F, Bender A. Diagnosis and Decision Making for Patients With Disorders of Consciousness: A Survey Among Family Members. Arch Phys Med Rehabil 2015; 96:323-30. [DOI: 10.1016/j.apmr.2014.09.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/04/2014] [Accepted: 09/23/2014] [Indexed: 01/09/2023]
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Abstract
PURPOSE OF REVIEW This review aims to consider the philosophical literature from the last 18 months relevant to dementia. Philosophical thought should underpin and strengthen developments in clinical practice. For instance, deepening our thoughts about personhood should support the development of person-centred care. RECENT FINDINGS There is relatively little work written by philosophers about dementia. But much of the writing by health and social care researchers and much empirical work in this field throws up philosophical issues. These do not solely concern personal identity, personhood and selfhood, even if the literature frequently refers to these topics. Instead we see, first, that there are other issues (around citizenship, rights, the nature of mind, of normality and of ageing) which deserve further philosophical attention and, secondly, that the discussions about personhood have moved beyond the concern that our persistence over time as individuals depends on memory to encompass a broader view which emphasizes instead the ability of people to continue to construct their life-worlds through their persisting meaningful relationships. SUMMARY Real interaction with people with dementia creates an increasingly nuanced account of the life-worlds of people with dementia, which should stimulate both philosophical work and clinical practice.
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