Ethics and dementia: mapping the literature by bibliometric analysis

Ethical challenges in palliative sedation of adults: protocol for a systematic review of current clinical practice guidelines

INTRODUCTION

This study aims to identify the full spectrum of ethical challenges of all forms of palliative sedation for adults as presented in current clinical practice guidelines (CPGs) and to determine whether CPGs specify ethical challenges of this therapy for patients with cancer and non-cancer and, if so, how exactly they do this. To the best of our knowledge, no studies have yet investigated this topic. The purpose is purely descriptive; our aim is not to make any kind of normative judgements on these challenges. Nor is our aim to assess the quality of the CPGs.

METHODS AND ANALYSIS

We will perform a systematic review of CPGs on palliative sedation for adults via five electronic databases, grey literature search tools, citation tracking and contact with palliative care experts. Current CPGs accredited by an international, national or regional authority, published in English, German, French, Italian or Polish, from 2000 to the date of the search, will be subjected to content analysis at the textual, linguistic and thematic levels.

ETHICS AND DISSEMINATION

This is a protocol for a systematic review and no human will be involved in this research. Therefore, ethics approval and consent to participate are not applicable to this context. This study protocol is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis for Protocols criteria and registered on PROSPERO. Moreover, the integral version of this study protocol is published as a preprint on Research Square. The results of this study will be actively disseminated through peer-reviewed journals and books, international, national and local conference presentations, social media and media in general.

Thematic research clusters in very old populations (≥ 80 years): a bibliometric approach

Background

Population aging will be one of humanity’s major challenges in the decades to come. In addition to focusing on the pathologies causing the greatest mortality and morbidity in this population, such as dementia, health research in elderly people must consider a myriad of other interlinked factors, such as geriatric syndromes, social aspects, and factors related to preserving quality of life and promoting healthy aging. This study aims to identify the main subject areas attracting research attention with regard to very old (≥ 80 years) populations.

Methods

Documents assigned with the medical subject heading “Aged, 80 and over” were retrieved from MEDLINE and the Web of Science. This dataset was used to determine publication output by disease, geographic region, country, and discipline. A co-word analysis was undertaken to identify thematic research clusters.

Results

Since the mid-2000s, there has been a boom in scientific output focusing specifically on very old populations, especially in Europe (43.7% of the documents) but also in North America (30.5%) and Asia (26%); other regions made only nominal contributions (0.5 to 4.4%). The USA produced the most research, while the most growth over the study period occurred in Japan, Spain, and China. Four broad thematic clusters were identified: a) geriatric diseases, health services for the aged, and social and psychological issues of aging; b) cardiovascular diseases; c) neoplasms, and d) bacterial infections & anti-bacterial agents.

Conclusions

Scientific research in very old populations covers a wide variety of interrelated topics. In quantitative terms, the top subject areas have to do with cardiovascular and cerebrovascular diseases (including aortic valve stenosis and stroke), dementia, and neoplasms. However, other degenerative pathologies, geriatric syndromes, and different social and psychosocial aspects also attract considerable interest. It is necessary to promote more equal participation in global research on pathologies and topics related to very elderly populations, as the highest rates of population aging and the largest numbers of elderly people in the next decades will be in low- and middle-income countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02209-7.

Real-world ethics in palliative care: A systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice

BACKGROUND

Ethical issues arise daily in the delivery of palliative care. Despite much (largely theoretical) literature, evidence from specialist palliative care practitioners about day-to-day ethical challenges has not previously been synthesised. This evidence is crucial to inform education and adequately support staff.

AIM

To synthesise the evidence regarding the ethical challenges which specialist palliative care practitioners encounter during clinical practice.

DESIGN

Systematic review with narrative synthesis (PROSPERO registration CRD42018105365). Quality was dual-assessed using the Mixed-Methods Appraisal Tool. Tabulation, textural description, concept mapping and thematic synthesis were used to develop and present the narrative.

DATA SOURCES

Seven databases (MEDLINE, Philosopher's Index, EMBASE, PsycINFO, LILACS, Web of Science and CINAHL) were searched from inception to December 2019 without language limits. Eligible papers reported original research using inductive methods to describe practitioner-reported ethical challenges.

RESULTS

A total of 8074 records were screened. Thirteen studies from nine countries were included. Challenges were organised into six themes: application of ethical principles; delivering clinical care; working with families; engaging with institutional structures and values; navigating societal values and expectations; philosophy of palliative care. Challenges related to specific scenarios/contexts rather than the application of general ethical principles, and occurred at all levels (bedside, institution, society, policy).

CONCLUSION

Palliative care practitioners encounter a broad range of contextual ethical challenges, many of which are not represented in palliative care ethics training resources, for example, navigating institutional policies, resource allocation and inter-professional conflict. Findings have implications for supporting ethical practice and training practitioners. The lack of low- and middle- income country data needs addressing.

A systematic review of ethical and legal issues in elder care

BACKGROUND

Ethical and legal issues are increasingly being reported by health caregivers; however, little is known about the nature of these issues in geriatric care. These issues can improve work and care conditions in healthcare, and consequently, the health and welfare of older people.

AIM

This literature review aims to identify research focusing on ethical and legal issues in geriatric care, in order to give nurses and other health care workers an overview of existing grievances and possible solutions to take care of old patients in a both ethical and legally correct way.

METHODS

Using a systematic approach based on Aveyard, a search of the PubMed, CINAHL, and Ethicshare databases was conducted to find out the articles published on ethical and legal issues in geriatric care.

ETHICAL CONSIDERATIONS

The approval for the study was obtained from UMIT-The Health and Life Sciences University, Austria.

RESULTS

Only 50 articles were included for systematic analysis reporting ethical and legal issues in the geriatric care. The results presented in this article showed that the main ethical issues were related to the older people's autonomy, respect for their needs, wishes and values, and respect for their decision-making. The main legal issues were related to patients' rights, advance directives, elderly rights, treatment nutrition dilemma, and autonomy.

CONCLUSION

Further education for professional caregivers, elderly people, and their families is needed on following topics: care planning, directive and living wills, and caregiver-family member relationships to guide and support the elderly people within their decision-making processes and during the end-of-life care.

Bibliometric networks and analytics on gerontology research

Purpose

The purpose of this paper is to bibliometrically analyze the gerontology-related research articles for a comprehensive understanding of the gerontology literature.

Design/methodology/approach

This study employed the approach of visual analytics on 32 journals with a total of 99,204 articles published after 2000 to identify the main subfields, keywords, and growth trend. The investigated journals are either open access online or listed in the Social Sciences Citation Index. In addition, the 200 most frequently cited papers were analyzed through bibliographic coupling, co-word, and co-citation analysis.

Findings

The selected most cited papers were mostly published before 2007, and psychiatry and psychology were the top research subfields. Dementia, older adult, and Alzheimer’s disease were the three most frequently occurring keywords, both in Author Keywords and KeyWords Plus. While coupling analysis yielded 12 research groups, co-word analysis classified the most frequently used 20 Author Keywords into two categories. Four research clusters were identified by the co-citation analysis.

Originality/value

This research provides a comprehensive view of the gerontology research as well as an understanding of the subfields and their interrelations. It also provides government departments with directions for formulating and executing policies affecting older people not only in setting academic and professional priorities but also in understanding the key topics related to older people.

Highlights in bioethics through 40 years: a quantitative analysis of top-cited journal articles

BACKGROUND

The field of bioethics is constantly evolving. To investigate trends in the field of bioethics, we conducted a quantitative analysis of the top-cited articles in bioethical journals over the past 40 years.

METHODS

Retrospective quantitative study of the 20 most cited bioethics articles published each year from 1975 to 2014 were conducted. Article samples were selected from a list of the most relevant 100 journals in the field of bioethics.

RESULTS

In total, 800 top-cited articles between 1975 and 2014 in the domain of bioethics were retrieved and analysed. More than half of them were composed by single authors, but multiauthorship became more prevalent with time. The majority (84.5%) of these highly cited articles originated from the USA (65.3%), UK or Canada, though the proportion of other countries increased in recent years. Almost half (44.6%) of the highly cited articles belonged to the subfield of clinical ethics, but other subfields such as research ethics, public health ethics and neuroethics became more prominent. Overall, the distribution of Thesaurus keywords and subfields became more diverse over time, and the number of journals publishing top-cited articles doubled. Furthermore, the empirical ethics approach increased over time in our sample of top-cited articles.

CONCLUSIONS

In sum, the forefront of bioethics is getting more diversified, collaborative and international. The presumed 'mainstream' becomes less dominant over time, as more highly cited articles come from new subfields, discuss new topics, use more Bioethics Thesaurus keywords, more authors participate and more countries other than the USA contribute to bioethics journals.

Freedom of choice and decision-making in health and social care

People with dementia represent a significant and growing proportion of patients, but little is known about their involvement in making choices about their health or social care. This study explored the experiences of French older patients with dementia and their caregivers about their participation in decision-making. Individual semi-directive interviews were conducted with patients ( n= 21) and their primary carer focusing on a recently made decision (to accept professional help at home, to attend a day centre, or to move into residential care). Five aspects of decision-making were explored: information received; being listened to; expression of opinion; time allowed to reflect on decision; and possibility of changing one's mind. Carers tended to be more satisfied than patients on most criteria. Many patients felt they had not been listened to sufficiently, and had limited freedom to participate in decision-making. Continuing education may help professionals to improve their ability to involve patients with dementia in decision-making concerning their care arrangements.

Conceptualization of science using collaboration and competences

Purpose

The purpose of this paper is to propose an approach for conceptualizing science based on collaboration and competences of researchers.

Design/methodology/approach

The research is conducted by exploratory analysis of collaboration and competences using case studies from humanistic, engineering, natural sciences and a general topic.

Findings

The findings show that by applying the proposed approach on bibliographic data that readily exist for many national sciences as well as for international scientific communities, one can obtain useful new insights into the research. The approach is demonstrated with the following exploratory findings: identification of important connections and individual researchers that connect the community of anthropologists; collaboration of technical scientists in the community of anthropologists caused by an interdisciplinary research project; connectivity, interdisciplinary and structure of artificial intelligence, nanotechnology and a community based on a general topic; and identifying research interest shift described with concretization and topic-shift.

Practical implications

As demonstrated with the practical implementation (http://scienceatlas.ijs.si/), users can obtain information of the most relevant competences of a researcher and his most important collaborators. It is possible to obtaining researchers, community structure and competences of an arbitrary research topic.

Social implications

The map for collaboration and competences of a complete science can be a crucial tool for policy-making. Social scientists can use the results of the proposed approach to better understand and direct the development of science.

Originality/value

Originality and value of the paper is in combining text (competences) and network (research collaboration and co-authoring) approaches for exploring science. Additional values give the results of analysis that demonstrate the approach.

Mapping the scientific research on wine and health (2001-2011)

There have been a substantial number of studies suggesting possible health benefits from polyphenols in wine, especially red wine. These hypothetical effects, in addition to those of alcohol, are attributed by many to antioxidant and anti-inflammatory effects of the polyphenols. The aim of this paper was to map the scientific research on wine and health by using bibliographic analyses of papers published during the period 2002-2011. Papers were published in 535 different journals and in 106 different subject categories, the most productive journals being the Journal of Agricultural and Food Chemistry, Food Chemistry and Molecular Nutrition, and Food Research, and the most productive subject category being food science and technology. Institutions in the main network of collaboration between centers were primarily located in France, Italy, and the United State. The number of papers on the medicinal use of wine has been dramatically rising in recent years because of the increased awareness of its importance in modern society. We emphasize the large distribution of information among numerous journals and the multidisciplinary nature of the topic. In the network of co-words, we observe the central role played by the terms "resveratrol", "wine", and "polyphenols".

A Bibliometric Analysis of an International Research Ethics Trainee Program

We used bibliometric analysis to evaluate the citations associated with publications by trainees in the Fogarty International Center's International Research Ethics Education and Curriculum Development program. Papers published between 2004 and 2008 were identified for analysis. The outcome measures were total citations, h-index, and i-10. A total of 328 manuscripts were identified, with a yearly average of 66 publications and 363 citations. The median number of citations per paper is 3 (IQR Q1–Q3:6). 12.6% (n = 53) of papers were cited over 10 times and the h-index is 22, indicating that 22 papers had been cited at least 22 times. The data indicate that trainees have been productive and contributed to the scholarly literature. Future studies to benchmark this performance with other bioethics education programs are required to make interpretation of citation analysis more meaningful.

The full spectrum of ethical issues in dementia care: systematic qualitative review

BACKGROUND

Integrating ethical issues in dementia-specific training material, clinical guidelines and national strategy plans requires an unbiased awareness of all the relevant ethical issues.

AIMS

To determine systematically and transparently the full spectrum of ethical issues in clinical dementia care.

METHOD

We conducted a systematic review in Medline (restricted to English and German literature published between 2000 and 2011) and Google books (with no restrictions). We applied qualitative text analysis and normative analysis to categorise the spectrum of ethical issues in clinical dementia care.

RESULTS

The literature review retrieved 92 references that together mentioned a spectrum of 56 ethical issues in clinical dementia care. The spectrum was structured into seven major categories that consist of first- and second-order categories for ethical issues.

CONCLUSIONS

The systematically derived spectrum of ethical issues in clinical dementia care presented in this paper can be used as training material for healthcare professionals, students and the public for raising awareness and understanding of the complexity of ethical issues in dementia care. It can also be used to identify ethical issues that should be addressed in dementia-specific training programmes, national strategy plans and clinical practice guidelines. Further research should evaluate whether this new genre of systematic reviews can be applied to the identification of ethical issues in other cognitive and somatic diseases. Also, the practical challenges in addressing ethical issues in training material, guidelines and policies need to be evaluated.

Publications on dementia in Medline 1974-2009: a quantitative bibliometric study

OBJECT

The aim is to describe the development of the scientific literature on dementia.

METHODS

We present a quantitative, bibliometric study of the literature on dementia, based on Medline, covering 36 years (1974-2009). Two samples of references to dementia papers were retrieved: The main sample based on the MeSH term Dementia holds more than 88,500 references. We have compared the annual additions of references on dementia with the addition to total Medline. Changes of 'the Dementia to Medline ratio' (%) give the best information on the development.

RESULTS

Publications on dementia increased 5.6 times faster than Medline. Most of this relative acceleration took place during 1980-1997, when the references on dementia increased from 0.17 to 0.78%. During the recent 12 years, the publications on dementia have been keeping pace with Medline and have stabilized around 0.8%.

CONCLUSIONS

We have shown a large increase of the literature on dementia, relative both to the development of all medical research and to all psychiatric research. The bibliometric approach may be questioned as quantitative methods treat articles as being of equal value, what is not true. If, for example, during a certain period, the research output is 'inflated' by a great number of repetitive papers, the quantitative method will give an unfair picture of the development. Our relative method, however, will give relevant results as, at each point of time, the proportion of 'valuable research' ought to be about the same in the dementia group as in total Medline.

Framing the structure of global open innovation research

This study proposes a way of mapping open innovation research structure by quantitatively analyzing open innovation research papers retrieved from Web of Science database. A total of 130 papers are retrieved in this study and 62 papers which contain keywords are chosen for research structure visualization. Open innovation research networks are quantitatively investigated by combining network theory and keyword co-occurrence. Contour maps of open innovation are also created on the basis of networks for visualization. The networks and contour maps can be expressed differently by choosing different information as the main actors, such as the paper author, the institute, the country or the author-keywords, to reflect open innovation research structures in micro, meso, and macro-levels, respectively. The quantitative ways of exploring open innovation research structure are investigated to unveil important or emerging open innovation components as well as to demonstrate visualization of the structure of global open innovation research. The quantitative method provided in this project shows a possible way of visualizing and evaluating research community structure and thus a computerized calculation is possible for potential quantitative applications on open innovation research management, e.g. R&D resource allocation, research performance evaluation, and science map.

Quantitative mapping of scientific research-The case of electrical conducting polymer nanocomposite

This study aims to understand knowledge structure both quantitatively and visually by integrating keyword analysis and social network analysis of scientific papers. The methodology proposed in this study is capable of creating a three-dimensional "Research focus parallelship network" and a "Keyword Co-occurrence Network", together with a two-dimensional knowledge map. The network and knowledge map can be depicted differently by choosing different information for the network actor, i.e. country, institute, paper and keyword, to reflect knowledge structures from macro, to meso, to micro-levels. A total of 223 highly cited papers published by 142 institutes and 26 countries are analyzed in this study. China and the US are the two countries located at the core of knowledge structure and China is ranked no. 1. This quantitative exploration provides a way to unveil important or emerging components in scientific development and also to visualize knowledge; thus an objective evaluation of scientific research is possible for quantitative technology management.

Quantitative mapping of patented technology - The case of electrical conducting polymer nanocomposite

This study aims to obtain global technology evolution by constructing and analyzing patent citation network and patent citation map for the field of electrical conducting polymer nanocomposite. A total of 1421 patents are retrieved from USPTO patent database and patent citation network is established by combing both patent citation and social network analysis. Network properties, e.g. Degree Centrality, Betweenness Centrality, and Closeness Centrality, are calculated for representing several technology evolution mechanisms that first proposed in this study. Also, a distance-based patent citation map is constructed by calculating relative distances and positions of patents in the patent citation network. Quantitative ways of exploring technology evolution are investigated in this study to unveil important or emerging techniques as well as to demonstrate dynamics and visualization of technology evolutions.

Dementia, goals of care, and personhood: a study of surrogate decision makers' beliefs and values

Surrogate decision makers for persons with advanced dementia play a key role in making decisions about medical treatments for their loved ones. We conducted in-depth interviews of 20 surrogates to examine their goals of care preferences and beliefs about personhood. All surrogates believed the goal of comfort was important, and 30.0% believed that curing physical problems was important. Significant proportions of surrogates acknowledged dementia-related changes in patients' ability to reason, communicate, and relate to others. Qualitative findings demonstrated diverse beliefs regarding the impact of dementia on factors related to personhood, for example, dignity, respect from others, and having a life worth living. In conclusion, the surrogates we interviewed expressed diverse preferences regarding goals of care and diverse assessments about the impact of dementia on personhood.

Mild cognitive impairment: conceptual, assessment, ethical, and social issues

Mild cognitive impairment (MCI) is defined as a condition characterized by newly acquired cognitive decline to an extent that is beyond that expected for age or educational background, yet not causing significant functional impairment. The concept of MCI has received considerable attention in the literature over the past few years, and aspects related to its definition, prevalence, and evolution have been extensively studied and reviewed.

Here we attempt to synthesize the implications of the current status of this entity, focusing on the conceptual, methodological, and, in particular, the social and ethical aspects of MCI which have attracted less attention. We discuss the weaknesses of the concept of MCI, which is heterogeneous in etiology, manifestations, and outcomes, and suggest that the emergence of the syndrome at this stage reflects industrial interests related to possible development of drugs for this disorder. On the other hand, the formal diagnosis of MCI, with its implications that the person may develop dementia, may have a grave impact on the psychological state of the individual, at a stage when prediction of outcome is tenuous and possibilities of useful interventions are meager. We present suggestions for the direction of future research in these areas.

Changes in the quantity and level of evidence of palliative and hospice care literature: the last century

PURPOSE

To objectively quantify the literature and the clinical trial basis for palliative and hospice practice given a perception that its evidence base is not well developed.

METHODS

Using Ovid Medline, the study looked at cumulative and absolute numbers of articles in the general medical literature and the palliative and hospice care literature. The same comparisons were made exploring clinical trials from 1902 to 2005. Data were collated in five year groups from 1970 onward using a highly specific search phrase.

RESULTS

The proportion of all Ovid Medline publications relating to palliative and hospice care rose from 0.08% in 1970 to 0.38% of the literature in 2005. In the same time, clinical trials increased from 0.96% to 7.22% of the palliative care literature published. By 2005, one in every 122 clinical trials published in the literature as a whole was in palliative or hospice care. The rate of growth in palliative care clinical trials as a proportion of all palliative and hospice publications was on average 1.4 times greater than in the corresponding general literature. More than one half of these studies were reported in just 43 journals, most of which were not specialist palliative and hospice care journals.

DISCUSSION

Given the diversity of journals in which clinical studies related to hospice and palliative care appear, there is a key challenge for clinicians in finding ways that will allow currency of practice in a broad and rapidly changing field.

[Ethics and dementia: a three years' experience of a French "Alzheimer's ethico-clinic workshop"]

There is a growing interest concerning ethical questions. This ethical need is the more important in the field of dementia. Indeed, the ethical concerns related to this field are highly specific, which leaves some of our questions without pertinent answers.

METHODS

After three years of experience, it is a good time to assess the Alzheimer ethico-clinic workshop created by a French memory centre (in Grenoble) and encouraged by the French national Alzheimer disease plan.

RESULTS

Since their implementation, we have recorded 24 monthly coordination meetings, 10 of which have been held through videoconferences with various participants. Most of the time during the workshops, clinical situations that are experienced in our daily activities are brought up by one of us and then exposed for collective discussion. If no practical situation is available, we organize the meetings through critical readings of texts of law or through comments on articles dealing with Ethics. We retain four main ethical topics: the information given to the patient and his family, the acceptance of the person, the balance of benefits/risks and one's individual ethics as opposed to the ethics of a group. At this point in time, we are pleased with the organization of these workshops and feel that they meet our expectations. Thanks to the diverse experiences and activities of each participant, the discussions on Ethics are of high quality.

PROSPECTIVES

As a place of shared discussions/thoughts, these ethical workshops could constitute a reference to be used when making decisions in complex situations. Other than the importance of the ethical questions that are raised, it should encourage open-minded attitudes and enrich the actions of each of us by making us more aware of the ethical concerns in daily situations. Finally, these workshops could be a field of research for theses, dissertations and answer the training and research needs of a memory centre.

Three decades of suicide and life-threatening behavior: a bibliometric study

The purpose of this study is to quantify certain characteristics of the articles published in Suicide and Life-Threatening Behavior in three 5-year periods, namely, 1971-1975, 1984-1988, and 1997-2001. The characteristics in question include geographic origin of articles, number of authors per article, number of references listed per article, and number of times an article is cited in the literature. Changes across the three periods in terms of distribution of subjects/participants by age group and gender are also examined. The discussion focuses on explanations for the trends and characteristics that are described.

Genetic research into Alzheimer's disease: a European focus group study on ethical issues

BACKGROUND

Nowadays, there is an increasing interest in the heritable aspects of Alzheimer's Disease (AD). The ethical implications of this kind of research are also attracting attention. However, relatively few open-ended qualitative studies have been carried out to study these aspects.

OBJECTIVE

To explore and analyse ethical issues raised by genetic research into AD.

METHODS

A modified focus group technique.

RESULTS

Participants stressed the importance of relatives in genetic research and suggested a family consent procedure. The consent procedure ought to be more uniform within Europe and should allow for variation in the types of research being done. The long-term results of genetic research into AD are expected to be positive while the short-term results seem likely to be negative. The perception of AD as a disease could be changed by the results from genetic research into AD, and this could have effects at the individual level (feelings of guilt and responsibility for one's own health).

CONCLUSIONS

(1) The role of the family in genetic AD research differs from its role in other biomedical research into AD. The development of a family consent procedure might solve some informed consent problems. (2) Negative social consequences of genetic AD research are expected in the short term, but there are hopes of positive consequences in the long term.

Trends in scientific activity addressing transmissible spongiform encephalopathies: a bibliometric study covering the period 1973-2002

BACKGROUND

The purpose of this study is to analyse the trends in scientific research on transmissible spongiform encephalopathies by applying bibliometric tools to the scientific literature published between 1973 and 2002.

METHODS

The data for the study were obtained from Medline database, in order to determine the volume of scientific output in the above period, the countries involved, the type of document and the trends in the subject matters addressed. The period 1973-2002 was divided in three sub-periods.

RESULTS

We observed a significant growth in scientific production. The percentage of increase is 871.7 from 1973 to 2002. This is more evident since 1991 and particularly in the 1996-2001 period. The countries found to have the highest output were the United States, the United Kingdom, Japan, France and Germany. The evolution in the subject matters was almost constant in the three sub-periods in which the study was divided. In the first and second sub-periods, the subject matters of greatest interest were more general, i.e Nervous system or Nervous system diseases, Creutzfeldt-Jakob disease, Scrapie, and Chemicals and Drugs, but in the last sub-period, some changes were observed because the Prion-related matters had the greatest presence. Collaboration among authors is small from 1973 to 1992, but increases notably in the third sub-period, and also the number of authors and clusters formed. Some of the authors, like Gajdusek or Prusiner, appear in the whole period.

CONCLUSION

The study reveals a very high increase in scientific production. It is related also with the beginnings of research on bovine spongiform encephalopathy and variant Creutzfeldt-Jakob disease, with the establishment of progressive collaboration relationships and a reflection of public health concerns about this problem.

Awareness in dementia: ethical and legal issues in relation to people with dementia

Our improved understanding of the experience of people with dementia provides a new impetus to address legal and ethical issues. This paper explores emerging issues in relation to awareness in dementia and its impact on legal and ethical matters. The different approaches and principles demonstrated in relation to ethical issues are discussed, with an exploration of the concepts of beneficence, non-maleficence, autonomy, and paternalism. Application of these concepts is discussed in relation to advance directives, capacity, and decision making, participation in research and treatment, including informed consent, and truth telling. The tensions that exist between the imperatives of doing no harm and of maintaining autonomy in addressing legal and ethical issues are highlighted, and attention drawn to the manner in which the attribution of unawareness is used to justify withholding autonomy. The review emphasizes the importance of considering competency and awareness as being multi-faceted, to be understood in the context of social interaction.