Advance care planning and advance directives: an overview of the main critical issues

Characteristics associated with the intention to complete advance directives and end-of-life preferences in Brazilians with heart failure

OBJECTIVE

To identify characteristics associated with an intention to complete advance directives (ADs) and end-of-life treatment preferences for outpatients with heart failure (HF).

METHODS

A cross-sectional, analytical study. Sociodemographic and clinical data were collected from 108 patients with HF in an outpatient clinic in São Paulo, SP, Brazil. Quality of life (QoL) was assessed using the Minnesota Living with Heart Failure Questionnaire; knowledge about HF and the intention to complete ADs were assessed using a script. The relationships among variables were assessed through the chi-square and Mann-Whitney tests, with p < 0.05 considered significant.

RESULTS

The intention to complete ADs was significantly associated with reporting adherence to pharmacological recommendations (99% vs. 88.1%, p = 0.02), worse QoL (29.7 ± 18.2 vs. 20.9 ± 11.0; p = 0.0336), perceived knowledge about HF (89.7% vs. 63.6%, p = 0.0495), not wishing the healthcare providers would decide about treatment (27.3% vs. 2.15, p = 0.0026), and considering ADs useful (91.8% vs. 27.3%, p < 0.001). End-of-life treatment preferences included living as long as possible (50.5%), not being sedated (37.1%), and staying close to family and friends for as long as possible (32.0%).

CONCLUSIONS

Characteristics associated with an intention to complete ADs and end-of-life treatment preferences were identified in patients with HF.

IMPLICATIONS FOR NURSING PRACTICE

These results can help facilitate patients' completion of their ADs or activate their intention to maximize opportunities to exercise autonomy.

ICU stays that are judged to be non-beneficial: A qualitative study of the perception of nursing staff

INTRODUCTION

Non-beneficial stays in the intensive care unit (ICU) may have repercussions for patients and their families, but can also cause suffering among the nursing staff. We aimed explore the perceptions of nursing staff in the ICU about patient stays that are deemed to be "non-beneficial" for the patient, to identify areas amenable to intervention, with a view to improving how the nursing staff perceive the patient pathway before, during and after intensive care.

METHODS

Multicentre, qualitative study using individual, semi-structured interviews. All qualified nurses and nurses' aides who were full-time employees in the ICU of three participating centres were invited to participate. Interviews were recorded, transcribed and analyzed using textual content analysis.

RESULTS

A total of 21 interviews were performed from February 2020 to October 2021, at which point saturation was reached in the data. Average age of participants was 38.5±7.5 years, and they had an average of 10.7±7.4 years of experience working in the ICU. Four major themes emerged from the interviews, namely: (1) the work is oriented towards life-threatening emergencies, technical procedures and burdensome care; (2) a range of specific criteria and circumstances influence the decisions to admit patients to ICU; (3) there are significant organisational, physical and psychological repercussions associated with a non-beneficial stay in the ICU; (4) respondents made some proposals for improvements to the patient care pathway.

CONCLUSION

Nursing staff have a similar perception to physicians regarding admission decisions and non-beneficial ICU stays. The possibility of future ICU admission needs to be anticipated, discussed systematically with patients and integrated into healthcare goals that are consistent with the patient's wishes and preferences, in multi-professional collaboration including nursing and medical staff.

Insights into Advance Care Planning in Africa

Advance Care Planning is an important element of palliative care whose relevance has over the years shifted from focusing on patients at end of life to being applicable at any stage of an individual's health. It is said to be beneficial not only to the patient but also to the general health care system. It may facilitate a peaceful death in addition to minimizing unnecessary costs and the use of resources yet its use among health care workers in Africa is not well researched. This study therefore aimed to explore the use of Advance Care Planning among health care providers in sub-Saharan Africa. It was a survey that targeted health care professionals across Sub-Saharan Africa who were either current staff or alumni of Hospice Africa Uganda (HAU) between 2012 and 2023. These were conveniently sampled from HAU data base. An electronic survey was sent out, data was collected into an excel sheet and it was analysed descriptively. Responses to the survey came from nine out of 37 countries with PC services across Africa and there was a 14% response rate. 83% of the respondents had insight into Advance Care Planning and a surprise finding was that 40% had cared for patients with ACP. The majority (96%) would respect Advance Care Plans of their patients. These findings gave some insights into the use of ACP although the results cannot be generalised to a wider demography of healthcare providers.

Taiwanese Older Adults Prefer to Use Antibiotics and Intravenous Infusion at the End of Life based on a Cartoon Version of the Life Support Preferences Questionnaire

Asians believe discussing death-related topics is inauspicious and may bring bad luck. It is critical to explore the end-of-life care preferences of the Asian elderly with less-threatening tools. The study examined older adults' preferences regarding end-of-life treatments by applying a cartoon version of the Life Support Preferences Questionnaire (LSPQ). A cross-sectional survey was conducted to understand older adults' preferences for end-of-life treatments. A total of 342 older adults participated in the study, comprising 268 elderly patients from a veterans hospital located in northern Taiwan and 74 elderly family members of the patients. Regardless of scenario, cardiopulmonary resuscitation (CPR) had the lowest score, indicating that older adults considered it a less desirable medical treatment. By contrast, antibiotics and intravenous infusions had the highest scores, indicating that older adults tended to prefer them. End-of-life care preferences were significantly different in genders. CPR and surgical preferences of older adults differed significantly with education level. Different demographic characteristics had different end-of-life treatment preferences, and future research may develop advance care planning programs for different attributes. This cartoon version of the LSPQ can help healthcare professionals to understand older adults' preferences for end-of-life care and warrants further empirical research.

Anticipating need for intensive care in the healthcare trajectory of patients with chronic disease: A qualitative study among specialists

Introduction

We investigated the reflections and perceptions of non-ICU physicians about anticipating the need for ICU admission in case of acute decompensation in patients with chronic disease.

Methods

We performed a qualitative multicentre study using semi-structured interviews among non-ICU specialist physicians. The interview guide, developed in advance, focused on 3 questions: (1) What is your perception of ICU care? (2) How do you think advance directives can be integrated into the patient’s healthcare goals? and (3) How can the possibility of a need for ICU admission be integrated into the patient’s healthcare goals? Interviews were recorded, transcribed and analysed by thematic analysis. Interviews were performed until theoretical saturation was reached.

Results

In total, 16 physicians (8 women, 8 men) were interviewed. The main themes related to intensive care being viewed as a distinct specialty, dispensing very technical care, and with major human and ethical challenges, especially regarding end-of-life issues. The participants also mentioned the difficulty in anticipating an acute decompensation, and the choices that might have to be made in such situations. The timing of discussions about potential decompensation of the patient, the medical culture and the presence of advance directives are issues that arise when attempting to anticipate the question of ICU admission in the patient’s healthcare goals or wishes.

Conclusion

This study describes the perceptions that physicians treating patients with chronic disease have of intensive care, notably that it is a distinct and technical specialty that presents challenging medical and ethical situations. Our study also opens perspectives for actions that could promote a pluridisciplinary approach to anticipating acute decompensation and ICU requirements in patients with chronic disease.

Case report on the legal assurance of Advance Care Planning in collective culture

This case report shows that there is a lack of a legal framework in Japan to protect patients' right during the end‐of‐life period, which hinders the implementation of ACP in medical practice. This report suggests that legal support can contribute to the advancement of ACP while addressing cultural differences.

Advance Care Planning has been widely advocated in Japan, but it has not yet taken root. The collective decision making culture in Japan may unconsciously overpower or ignore the patients' wishes, hence legal support can mitigate its negative impacts on ACP.