Attitudes of patients with malignancies towards completion of advance directives

Stability of End-of-Life Care Wishes and Gender-Specific Characteristics of Outpatients with Advanced Cancer under Palliative Therapy: A Prospective Observational Study

INTRODUCTION

Early integration of palliative care and advance care planning (ACP) play an increasingly important role in the treatment of patients with advanced cancer. Advance directives (ADs) and patients' preferences regarding end-of-life (EoL) care are important aspects of ACP. In the outpatient setting, the prevalence of those documents and EoL care wishes is not well investigated, and changes in the longitudinal course are poorly understood.

METHODS

From June 2020 to August 2022, 67 outpatients with advanced solid tumors undergoing palliative cancer therapy were interviewed on the topic of ACP in a longitudinal course. From this database, the prevalence of ADs, healthcare proxy, EoL care wishes, and the need for counseling regarding these issues were collected. In addition, EoL care wishes were examined for their stability.

RESULTS

Fifty-one patients (76.1%) reported having ADs, and 41 patients (61.2%) reported having a healthcare proxy. Nineteen patients (37.3%) with ADs and 11 patients (68.7%) without ADs indicated a wish for counseling. Reported EoL care wishes remained stable over a period of approximately 6 months. Nevertheless, intraindividual changes occurred over time within the different EoL care preferences. The desire for resuscitation and dialysis were significantly higher in men than in women (resuscitation: 15 of 21 men [71.4%] versus 9 of 22 women [40.9%], odds ratio [OR] 3.611, 95% confidence interval [CI], 1.01-12.89, p = 0.048; dialysis: 16 of the 23 men [69.6%] versus 9 of the 25 women [36.0%], OR: 4.063, 95% CI: 1.22-13.58, p = 0.023).

CONCLUSION

Our results show a reasonably high percentage of ADs and healthcare proxies in our study cohort. The observed stability of EoL requests encourages the implementation of structured queries for ADs and healthcare proxy for outpatients undergoing palliative treatment. Our data suggest that gender-specific characteristics should be further investigated in this context.

Advance care planning by proxy in German nursing homes: Descriptive analysis and policy implications

BACKGROUND

Legally recognized advance directives (ADs) have to be signed by the person to whom the decisions apply. In practice, however, there are also ADs written and signed by legal proxies (surrogates) on behalf of patients who lack decision-making capacity. Given their practical relevance and substantial ethical and legal implications, ADs by proxy (AD-Ps) have received surprisingly little scientific attention so far.

OBJECTIVES

To study the form, content, validity, and applicability of AD-Ps among German nursing home residents and develop policy implications.

METHODS

Secondary analysis of two independent cross-sectional studies in three German cities, comprising 21 nursing homes and 1528 residents. The identified AD-Ps were analyzed in parallel by three independent raters. Inter-rater agreement was measured using free-marginal multi-rater kappa statistics.

RESULTS

Altogether, 46 AD-Ps were identified and pooled for analysis. On average (range), AD-Ps were 1 (1-7) year(s) old, 0.5 (0.25-4) pages long, signed by 1 (0-5) person, with evidence of legal proxy involvement in 35%, and signed by a physician in 20% of cases. Almost all the AD-Ps reviewed aimed to limit life-sustaining treatment (LST), but had widely varying content and ethical justifications, including references to earlier statements (30%) or actual behavior (11%). The most frequent explicit directives were: do-not-hospitalize (67%), do-not-tube-feed (37%), do-not-attempt-resuscitation (20%), and the general exclusion of any LST (28%). Inter-rater agreement was mostly moderate (kappa ≥0.6) or strong (kappa ≥0.8).

CONCLUSIONS

Although AD-Ps are an empirical reality in German nursing homes, formal standards for such directives are lacking and their ethical justification based on substituted judgment or best interest standard often remains unclear. A qualified advance care planning process and corresponding documentation are required in order to safeguard the appropriate use of this important instrument and ensure adherence to ethico-legal standards.

Advance Directives and Factors Associated with the Completion in Patients with Heart Failure

Advance directive (AD) has been underutilized among patients with heart failure (HF). This study was performed to explore the ADs and examine factors associated with the completion of an AD survey in patients with HF. In a descriptive, correlational study, data on end-of-life values, treatment directives, and proxy (Korean-Advance Directive (K-AD) questionnaire) and factors associated with K-AD completion were collected among HF patients during outpatient visits. Of 67 patients (age, 67 years; male, 61.2%), 52.2% completed all or part of the K-AD. Among values, comfortable death was the most preferred (n = 15) followed by avoiding family burden (n = 6). In those completers, preferences for hospice care, cardiopulmonary resuscitation, ventilation support, and hemodialysis were 68.6%, 42.9%, 28.6%, and 28.6%, respectively. Female sex (odds ratio (OR) = 0.167), poorer HF prognosis (OR = 0.156), and better functional status (OR = 0.905) were associated with less likelihood of completing the AD survey. The findings suggest that in-depth AD discussion needs to be started earlier in patients with HF to facilitate completion of AD, especially in female patients. Future research should investigate if early discussion of ADs as part of advance care planning with integration into standard care of HF facilitates the documentation of ADs.

Advance directives in Austrian intensive care units: An analysis of prevalence and barriers

Purpose

To investigate the prevalence of advance directives, healthcare proxies, and legal representatives in Austrian intensive care units (ICUs), and to explore barriers faced by adults engaged in the contemplation and documentation phase of the advance care planning process.

Methods

Two studies were conducted: (1) A 4-week multicenter study covering seven Austrian ICUs. A retrospective chart review of 475 patients who presented to the ICUs between 1 January 2019 and 31 January 2019 was conducted. (2) An interview and focus group study with 12 semi-structured expert interviews and three focus groups with 21 adults was performed to gain insights into potential barriers faced by Austrian adults planning medical decisions in advance.

Results

Of the 475 ICU patients, 3 (0.6%) had an advance directive, 4 (0.8%) had a healthcare proxy, and 7 (1.5%) had a legal guardian. Despite the low prevalence rates, patients and relatives reacted positively to the question of whether they had an advance directive. Patients older than 55 years and patients with children reacted significantly more positively than younger patients and patients without children. The interviews and focus groups revealed important barriers that prevent adults in Austria from considering planning in advance for potentially critical health states.

Conclusion

The studies show low prevalence rates of healthcare documents in Austrian ICUs. However, when patients were asked about an advance directive, reactions indicated positive attitudes. The gap between positive attitudes and actual document completion can be explained by multiple barriers that exist for adults in Austria when it comes to planning for potential future incapacity.

Determinants of completion of advance directives: a cross-sectional comparison of 649 outpatients from private practices versus 2158 outpatients from a university clinic

OBJECTIVES

To compare outpatients from private practices and outpatients from a university clinic regarding the determinants of completion of advance directives (AD) in order to generalise results of studies from one setting to the other. Five determinants of completion of AD were studied: familiarity with AD, source of information about AD, prior experiences with own life-threatening diseases or family members in need of care and motives in favour and against completion of AD.

DESIGN

Observational cross-sectional study.

SETTING

Private practices and a university clinic in Germany in 2012.

PARTICIPANTS

649 outpatients from private practices and 2158 outpatients from 10 departments of a university clinic.

OUTCOME MEASURES

Completion of AD, familiarity with AD, sources of information about AD (consultation), prior experiences (with own life-threatening disease and family members in need of care), motives in favour of or against completion of AD, sociodemographic data.

RESULTS

Determinants of completion of AD did not differ between outpatients from private practices versus university clinic outpatients. Prior experience with severe disease led to a significantly higher rate of completion of AD (33%/36% with vs 24%/24% without prior experience). Participants with completion of AD had more often received legal than medical consultation before completion, but participants without completion of AD are rather aiming for medical consultation. The motives in favour of or against completion of AD indicated inconsistent patterns.

CONCLUSIONS

Determinants of completion of AD are comparable in outpatients from private practices and outpatients from a university clinic. Generalisations from university clinic samples towards a broader context thus seem to be legitimate. Only one-third of patients with prior experience with own life-threatening diseases or family members in need of care had completed an AD as expression of their autonomous volition. The participants' motives for or against completion of AD indicate that ADs are considered a kind of 'negative autonomy' as instruments to prevent particular forms of therapy. Interactive, repeated and situation-based AD discussions might reach a higher percentage of patients and concurrently enable personal volitions and thereby strengthen individual 'positive autonomy'.

Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish

The Institute of Medicine and the American Heart Association have issued a "call to action" to expand the performance of cardiopulmonary resuscitation (CPR) in response to out-of-hospital cardiac arrest. Widespread advertising campaigns have been created to encourage more members of the lay public to undergo training in the technique of closed-chest compression-only CPR, based upon extolling the virtues of rapid initiation of resuscitation, untempered by information about the often distressing outcomes, and hailing the "improved" results when nonprofessional bystanders are involved. We describe this misrepresentation of CPR as a highly effective treatment as the fetishization of this valuable, but often inappropriately used, therapy. We propose that the medical profession has an ethical duty to inform the public through education campaigns about the procedure's limitations in the out-of-hospital setting and the narrow clinical indications for which it has been demonstrated to have a reasonable probability of producing favorable outcomes.

Association Between Attitude Toward Death and Completion of Advance Directives

Advance directives provide health-care instruction for incapacitated individuals and authorize who may make health-care decisions for that individual. Identified factors do not explain all variance related to advance directive completion. This study was an analysis of an association between advance directive completion and death attitudes. Surveys that included the Death Attitude Profile—Revised were completed anonymously. Comparisons of means, chi-square, and logistic regression tests were conducted. Among individuals who did not consider themselves religious, the mean death avoidance attitude scores differed significantly among those with advance directives (mean = 1.93) and those without (mean = 4.05) as did the mean approach acceptance attitude scores of those with advance directives (mean = 5.73) and those without (mean = 3.71). Among individuals who do consider themselves religious, the mean escape acceptance attitude scores differed significantly among those with advance directives (mean = 5.11) and those without (mean = 4.15). The complicated relationships among religiosity, advance directives, and death attitudes warrant further study.

Nurses' knowledge of advance directives and perceived confidence in end-of-life care: a cross-sectional study in five countries

Nurses' knowledge regarding advance directives may affect their administration and completion in end‐of‐life care. Confidence among nurses is a barrier to the provision of quality end‐of‐life care. This study investigated nurses' knowledge of advance directives and perceived confidence in end‐of‐life care, in Hong Kong, Ireland, Israel, Italy and the USA using a cross‐sectional descriptive design (n = 1089). In all countries, older nurses and those who had more professional experience felt more confident managing patients' symptoms at end‐of‐life and more comfortable stopping preventive medications at end‐of‐life. Nurses in the USA reported that they have more knowledge and experience of advance directives compared with other countries. In addition, they reported the highest levels of confidence and comfort in dealing with end‐of‐life care. Although legislation for advance directives does not yet exist in Ireland, nurses reported high levels of confidence in end‐of‐life care.

An unequivocal good? Acknowledging the complexities of advance care planning

Over the past few decades advance care planning (ACP) has become the subject of debate, research and legislation in many countries. Encouraging people to express their preference for treatment in advance, ideally in written form, seems a natural way to identify what someone might have wanted when they can no longer participate in decision-making. The notion of ACP as an unequivocal good permeates much of the research and policy work in this area. For example, ACP is now actively encouraged in Australian federal and state government policies and the Victorian Government has recently published a practical ACP strategy for Victorian health services (2014-2018). However, advance care plan is ethically complex and the introduction of the Victorian health services strategy provides an opportunity to reflect on this complexity, particularly on the benefits and risks of ACP.

The impact of a tumor diagnosis on patients' attitudes toward advance directives

BACKGROUND

Although advance care planning and the completion of advance directives (ADs) are important tools to avoid unwanted aggressive care once patients have lost their decision-making capacity, only a minority of cancer patients are admitted with completed ADs, and little is known about patients' wishes regarding AD consultations.

METHODS

For 1 year, every new patient admitted to the hematology/oncology outpatient clinic of the University Hospital Regensburg received a self-administered questionnaire comprising a self-evaluation of AD knowledge and questions about preferences regarding consultation partners and the time of consultation. Disease-related data were collected from medical records. Statistics were calculated with SPSS.

RESULTS

Of the 500 questionnaires handed out, 394 (75%) were evaluable and analyzed. Twenty-eight percent of the participants had completed an AD (living will or health care proxy). Ninety-two percent of the participants without ADs had never received a consultation offer from any professional involved. Only 20% perceived a clear relation between cancer and AD consultations. More than 50% of the participants without ADs were in favor of consultations 'now' or 'in a few weeks', while more than 40% objected to AD consultations.

CONCLUSIONS

Oncology patients have a large unmet demand for AD consultations. However, a relevant percentage of these patients object to AD consultations. Structured and early AD consultation offers should be made, and early discussions about indications for aggressive treatment should take place.

Family structure, experiences with end-of-life decision making, and who asked about advance directives impacts advance directive completion rates

BACKGROUND

Advance directives are an important but underutilized resource. Reasons for this underutilization need to be determined.

OBJECTIVE

We investigated factors associated with completion of advance directives among inpatients.

DESIGN

We conducted prospective, structured interviews on family structure, health care, disease, and end-of-life experiences. We compared those with completed advance directives and those without.

SETTING/SUBJECTS

We interviewed 130 inpatients in an urban university hospital.

MEASUREMENTS

We used bivariate analysis and logistic regression to identify characteristics of patients with living wills and health care proxies versus patients without them.

RESULTS

Twenty-one percent of patients had a living will and 35% had a health care proxy. Patients with completed living wills were older (p≤0.0046), had more comorbidities (p=0.018), were widowed (p=0.02), and were more often admitted with chronic disease (p=0.009) compared to those without living wills. Patients with health care proxies were older (p<0.001), had religious affiliations (p=0.04), more children (p=0.03), and more often widowed (p≤0.001) than those without health care proxies. Patients were 10.8 times (95% confidence interval [CI] 4.59-25.3), 46.5 times (95% CI 15.1-139.4), and 68.6 times (95% CI 13.0-361.3) more likely to complete a living will when asked by medical staff, legal staff, or family and friends, respectively, than those not asked. Patients with health care proxies were 1.68 times (95% CI 0.81-3.47), 4.34 times (95% CI 1.50-12.6), and 18.0 times (95% CI 2.03-158.8) more likely to have been asked by the same groups. Patients with experience in end-of-life decision-making were 2.54 times more likely to possess a living will (95%CI 1.01-6.42) and 3.53 times more likely to possess a health care proxy (95% CI 1.51-8.25) than those without experiences.

CONCLUSIONS

Having been asked about advance directives by medical staff, legal staff, or family and friends increases the likelihood that patients will possess an advance directive. Those with prior experience with end-of-life decision-making are more likely to possess an advance directive. Family structure and health care utilization also impacts possession of advance directives.

Study of the factors influencing the preparation of advance directives

The aim of the study is to analyze the factors influencing the decision to prepare advance directives (AD) related to socio-demographic situation, health status, degree of dependence, healthcare characteristics and psychosocial aspects. This is a case-control study conducted using a personal interview. We compared 123 subjects who had completed AD with 123 subjects who had not and who belonged to two health centers in the Albacete Health District. Study variables included self-perceived health, functional status, morbidity, socio-demographic characteristics, use of health services, attitudes toward AD and psychosocial aspects. We found a predominance of women (64.2%) among those who prepared AD, with a mean age of 53.3 years. Preparing AD was associated with secondary or higher education (OR=2.5), a lifestyle other than living with a partner and with children (OR=2.5), chronic medication use (OR=3.2), higher than average number of specialist visits (OR=4.0), a longer-term relationship with the family physician (OR=3.5), a family history of having AD (OR=17.3) and with lower levels of social interaction (OR=3.0). The results suggest that several factors, resulting from both the socio-demographic situation and health or functional status, can affect the decision to formalize AD.

Advance directives: prevalence and attitudes of cancer patients receiving radiotherapy

PURPOSE

Advance directives (AD) are becoming increasingly widespread. We examine the prevalence of AD and the factors associated with AD in tumor patients during radiotherapy.

METHODS

A standardized questionnaire was handed out to all tumor patients on 9 random days with an interval of at least 12 weeks. The data were analyzed in a bivariate and multivariate way.

RESULTS

Of 1,208 questionnaires, 658 were completed and returned (54.5%). Of respondents, 23.6% had already signed an AD, 53.3% thought they were likely to sign an AD, 9.0% did not want to sign an AD, and 4.9% were not familiar with advance directives. Patients who have signed an AD and those who are likely to sign one think that ADs facilitate the physician's decision-making process (97.7% cf. 94.5%) and that they ease the burden on relatives (98.5% cf. 98.8%). Regardless of an AD having been signed, every second respondent was of the opinion that AD facilitates consultations rather than serving as a directive (55.1% cf. 57.3%). Patients likely to sign an AD are significantly younger compared to those unlikely to do so and have suffered from their tumor disease for a shorter period of time.

CONCLUSIONS

Of advance directives is widely accepted among the tumor patients surveyed. Advanced directives are not exclusively seen as instruments for surrogate decision making, but also as mediums to improve communication. Training of physicians and additional offers for patients could increase the actual number of ADs and perhaps improve physicians and relatives understanding of patients needs and wishes.

Attitudes towards palliative care in primary metastatic cancer: a survey among oncologists

Oncologists differ widely in their attitudes towards palliative care and services. These attitudes depend on a number of individual and society-based variables. It is recommended that palliative care be started early in the disease trajectory of patients with a life-threatening disease but in Austria we lack data on oncologists' adherence to this recommendation. We surveyed 785 oncologists in Austria by presenting the clinical course of a hypothetical patient with primary metastatic breast cancer from diagnosis until death. The majority of oncologists would involve palliative care services when the patient's Karnofsky index (KI) was < 50, and hospice services when the KI was < 40. Special training in palliative care was significantly associated with early use of hospice services. Reasons for not involving palliative care and hospice services earlier than indicated were systematically evaluated and included, among others, "fear of destroying the patient's hopes" (36% of respondents with regard to palliative services, 57% with regard to hospices). Overall, 67% of the oncologists would inform the patient about the malignant nature of her disease and the anticipated limitation of her life expectancy at the time of diagnosis. Issuing an advance directive would be discussed by only 25% at that time. Our data show that oncologists involve palliative care services at an advanced stage of disease in patients with primary metastatic cancer and that information about malignancy and the incurable nature of the disease is not uniformly provided at the time of diagnosis.