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Florack J, Abele C, Baisch S, Forstmeier S, Garmann D, Grond M, Hornke I, Karakaya T, Karneboge J, Knopf B, Lindl G, Müller T, Oswald F, Pfeiffer N, Prvulovic D, Poth A, Reif A, Schmidtmann I, Theile-Schürholz A, Ullrich H, Haberstroh J. Project DECIDE, part II: decision-making places for people with dementia in Alzheimer's disease: supporting advance decision-making by improving person-environment fit. BMC Med Ethics 2023; 24:26. [PMID: 37118723 PMCID: PMC10148477 DOI: 10.1186/s12910-023-00905-0] [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: 02/24/2023] [Accepted: 03/29/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND The UN Convention on the Rights of Persons with Disabilities, and the reformed guardianship law in Germany, require that persons with a disability, including people with dementia in Alzheimer's disease (PwAD), are supported in making self-determined decisions. This support is achieved through communication. While content-related communication is a deficit of PwAD, relational aspects of communication are a resource. Research in supported decision-making (SDM) has investigated the effectiveness of different content-related support strategies for PwAD but has only succeeded in improving understanding, which, although one criterion of capacity to consent, is not sufficient to ensure overall capacity to consent. The aim of the 'spatial intervention study' of the DECIDE project is to examine an innovative resource-oriented SDM approach that focuses on relational aspects. We hypothesise that talking to PwAD in their familiar home setting (as opposed to a clinical setting) will reduce the complexity of the decision-making process and enhance overall capacity to consent. METHODS People with a suspected or confirmed diagnosis of dementia in Alzheimer's disease will be recruited from two memory clinics (N = 80). We will use a randomised crossover design to investigate the intervention effect of the decision-making place on capacity to consent. Besides reasoning capacity, which is part of overall capacity to consent and will be the primary outcome, various secondary outcomes (e.g., other aspects of capacity to consent, subjective task complexity, decisional conflict) and suspected moderating or mediating variables (e.g., meaning of home, demographic characteristics) will be assessed. DISCUSSION The results of the study will be used to develop a new SDM strategy that is based on relational resources for PwAD. If a change in location achieves the anticipated improvement in capacity to consent, future research should focus on implementing this SDM strategy in a cost-effective manner in clinical practice. TRIAL REGISTRATION DRKS00030799 .
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Affiliation(s)
- Janina Florack
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany.
- Klinikum Siegen, Siegen, Germany.
| | - Christina Abele
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stefanie Baisch
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | - Simon Forstmeier
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | - Daniel Garmann
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- Klinikum Siegen, Siegen, Germany
| | | | | | - Tarik Karakaya
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Jonas Karneboge
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | | | - Gregor Lindl
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Tanja Müller
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | - Frank Oswald
- Goethe University Frankfurt, Frankfurt Am Main, Germany
| | - Nathalie Pfeiffer
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | | | - Aoife Poth
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Andreas Reif
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Irene Schmidtmann
- University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Anna Theile-Schürholz
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | | | - Julia Haberstroh
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
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Schneider B, S Müller R, Sperling U. Voluntarily Stopping Eating and Drinking (VSED). GEROPSYCH 2021. [DOI: 10.1024/1662-9647/a000252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Abstract. Most cases of voluntarily stopping eating and drinking (VSED) occur in the context of severe underlying diseases with concomitant dwindling needs for food and fluids. In these cases, VSED resembles the rejection of a medical treatment. While this is the leading difference to suicide, however, there are also situations within VSED in which aspects of suicide prevention must be considered. After defining the relevant terms and presenting a literature review, we outline options of dealing with different death wishes and provide recommendations oriented toward the possibilities of suicide prevention in the context of abstaining from food and fluids.
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Affiliation(s)
- Barbara Schneider
- Department of Addictive Behaviors, Psychiatry and Psychotherapy, LVR-Klinik Köln, Germany
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt/Main, Germany
| | - Ronja S Müller
- Institute of Ophthalmology, University College London, UK
| | - Uwe Sperling
- Geriatric Center, University Medical Center Mannheim, Germany
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Hotzy F, Cattapan K, Orosz A, Dietrich B, Steinegger B, Jaeger M, Theodoridou A, Bridler R. Psychiatric advance directives in Switzerland: Knowledge and attitudes in patients compared to professionals and usage in clinical practice. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 68:101514. [PMID: 32033691 DOI: 10.1016/j.ijlp.2019.101514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Psychiatric advance directives (PAD) were shown to be effective in the reduction of coercion and strengthening of the patients` autonomy. Therefore, the Swiss legislation was revised and stipulates that PAD must be taken into account during involuntary hospitalization. This study aimed to analyze knowledge on and attitudes towards this instrument in patients and healthcare practitioners and their usage in clinical practice. METHODS We developed a structured questionnaire and included patients (n = 110), psychiatrists (n = 205), psychologists (n = 85), nurses (n = 268) and peers (n = 16) to rate their knowledge on and attitudes towards PAD. We registered the existing PAD in patients and peers. The response rate varied between 17% (nurses), 19% (psychologists) 21% (psychiatrists), 33% (peers) and 56% (patients). RESULTS Only 7% of the participating patients had a PAD. Compared to the other groups, patients had the least knowledge on PAD. Psychiatrists were significantly more critical towards PAD. Concerns that PAD impede necessary and adequate treatment, restrict professionals and result in conflicts between patients and HCP were most frequently named as reason for critical attitudes. CONCLUSIONS Although being explicitly mentioned in the Swiss legislation the usage of PAD is small. Proactive information and training of psychiatrists might be helpful for a reduction of skeptical attitudes. This might improve the attitudes and lead to active support of patients during the preparation of PAD.
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Affiliation(s)
- Florian Hotzy
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry, Zuerich, Switzerland.
| | - Katja Cattapan
- Sanatorium Kilchberg/Zuerich, Private Hospital of Psychiatry, Kilchberg, Switzerland; University Hospital of Psychiatry, University of Bern, Bern, Switzerland.
| | - Ariane Orosz
- Sanatorium Kilchberg/Zuerich, Private Hospital of Psychiatry, Kilchberg, Switzerland; University Hospital of Psychiatry, University of Bern, Bern, Switzerland.
| | - Bianca Dietrich
- Sanatorium Kilchberg/Zuerich, Private Hospital of Psychiatry, Kilchberg, Switzerland; Department of Psychology, Otto-Friedrich-University, Markusstr. 8a, 96045 Bamberg, Germany
| | - Brigitt Steinegger
- Sanatorium Kilchberg/Zuerich, Private Hospital of Psychiatry, Kilchberg, Switzerland.
| | - Matthias Jaeger
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry, Zuerich, Switzerland; Psychiatry Baselland, Liestal, Switzerland.
| | - Anastasia Theodoridou
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry, Zuerich, Switzerland.
| | - René Bridler
- Sanatorium Kilchberg/Zuerich, Private Hospital of Psychiatry, Kilchberg, Switzerland.
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Gather J, Vollmann J. Physician-assisted suicide of patients with dementia. A medical ethical analysis with a special focus on patient autonomy. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:444-453. [PMID: 23850340 DOI: 10.1016/j.ijlp.2013.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
For many years there has been a controversial international debate on physician-assisted suicide (PAS). While proponents of PAS regularly refer to the unbearable suffering and the right of self-determination of incurably ill patients, critics often warn about the diverse risks of abuse. In our article, we aim to present ethical arguments for and against PAS for patients in an early stage of dementia. Our focus shall be on ethical questions of autonomy, conceptual and empirical findings on competence and the assessment of mental capacity to make health care decisions. While the capacity to make health care decisions represents an ethically significant precondition for PAS, it becomes more and more impaired in the course of the dementia process. We present conditions that should be met in order to ethically justify PAS for patients with dementia. From both a psychiatric and an ethical perspective, a thorough differential diagnosis and an adequate medical and psychosocial support for patients with dementia considering PAS and their relatives should be guaranteed. If, after due deliberation, the patient still wishes assistance with suicide, a transparent and documented assessment of competence should be conducted by a professional psychiatrist.
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Affiliation(s)
- Jakov Gather
- Department of Psychiatry, LWL University Hospital, Ruhr-University Bochum, Germany.
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Vollmann J. [Compulsory treatment in psychiatry: an ethical analysis of the new legal regulations for clinical practice]. DER NERVENARZT 2013; 85:614-20. [PMID: 23979362 DOI: 10.1007/s00115-013-3866-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The new legal regulations of compulsory treatment in Germany require a change in clinical psychiatric practice as well as an ethical analysis of the consequences for those involved. MATERIALS AND METHODS The new legal regulations are reported and via ethical analysis new problematic fields, such as consequences of the new law are identified and discussed in the context of psychiatry and law. RESULTS The main ethical identified problems are care of mentally ill with mental competence who refuse medical treatment, the different normative assessment of compulsory treatment and mechanical fixation, the ambivalent role of the conversation between psychiatrist and patient in order to change the natural will of the patient to avoid compulsory measures, the ethical consequences of questionable financial incentives in the context of compulsory treatment and the contradictive legal regulations in the field. CONCLUSIONS The ethical analysis of the new law on compulsory treatment in Germany shows chances for improvement of clinical psychiatric practice as well as normative problematic regulations and fields of conflicts.
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Affiliation(s)
- J Vollmann
- Institut für Medizinische Ethik und Geschichte der Medizin, Ruhr-Universität Bochum, Markstr. 258a, 44799, Bochum, Deutschland,
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Müller S, Walter H, Kunze H, Konrad N, Heinz A. [Compulsory treatment under legal uncertainty: part 2: consequences of legal uncertainty in clinical practice - suggestions for improvement]. DER NERVENARZT 2013; 83:1150-5. [PMID: 22911323 DOI: 10.1007/s00115-012-3628-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The current legal uncertainty on compulsory treatment of mentally ill patient incapable of giving consent favors the practice of defensive treatment, such as the increased use of isolation and fixation instead of medication. Such a stance runs the risk of acute or chronic health damage for patients. The dissent between legal practitioners and psychiatrists on compulsory treatment is obviously based on a different understanding of autonomy and its prerequisites. We advocate an individual centered, preferably open form of treatment by medicinal and milieu therapeutic approaches in association with intensified relationships with the aim to restore or improve the ability for self-determination. We also call upon the legislative authorities to establish legal certainty. It is decisive that the characteristics of mental diseases and the possibilities of modern treatment are taken into consideration in order to suitably respect patient autonomy without neglecting the necessary help.
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Affiliation(s)
- S Müller
- Klinik für Psychiatrie und Psychotherapie, Forschungsbereich Mind & Brain, Charité - Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Deutschland.
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