Nurses' perspectives on advance directives before the establishment of the new well-dying law in Korea: A mixed methods study

Recent Trends in the Withdrawal of Life-Sustaining Treatment in Patients with Acute Cerebrovascular Disease : 2017-2021

OBJECTIVE

The Act on Life-Sustaining Treatment (LST) decisions for end-of-life patients has been effective since February 2018. An increasing number of patients and their families want to withhold or withdraw from LST when medical futility is expected. This study aimed to investigate the status of the Act on LST decisions for patients with acute cerebrovascular disease at a single hospital.

METHODS

Between January 2017 and December 2021, 227 patients with acute cerebrovascular diseases, including hemorrhagic stroke (n=184) and ischemic stroke (n=43), died at the hospital. The study period was divided into the periods before and after the Act.

RESULTS

The duration of hospitalization decreased after the Act was implemented compared to before (15.9±16.1 vs. 11.2±18.6 days, p=0.127). The rate of obtaining consent for the LST plan tended to increase after the Act (139/183 [76.0%] vs. 27/44 [61.4%], p=0.077). Notably, none of the patients made an LST decision independently. Ventilator withdrawal was more frequently performed after the Act than before (52/183 [28.4%] vs. 0/44 [0%], p<0.001). Conversely, the rate of organ donation decreased after the Act was implemented (5/183 [2.7%] vs. 6/44 [13.6%], p=0.008). Refusal to undergo surgery was more common after the Act was implemented than before (87/149 [58.4%] vs. 15/41 [36.6%], p=0.021) among the 190 patients who required surgery.

CONCLUSION

After the Act on LST decisions was implemented, the rate of LST withdrawal increased in patients with acute cerebrovascular disease. However, the decision to withdraw LST was made by the patient's family rather than the patient themselves. After the execution of the Act, we also observed an increased rate of refusal to undergo surgery and a decreased rate of organ donation. The Act on LST decisions may reduce unnecessary treatments that prolong end-of-life processes without a curative effect. However, the widespread application of this law may also reduce beneficial treatments and contribute to a decline in organ donation.

Factors associated with attitudes toward advance directives in nurses and comparisons of the levels between emergency nurses and palliative care nurses

AIM

Little is known about attitudes toward advance directives and factors associated with them among emergency and palliative care nurses who often or daily face end-of-life circumstances. Thus, we aimed to compare the levels of attitudes toward advance directives, communication skills, knowledge about end-of-life care (knowledge), and awareness of the concept of a good death (good death awareness) between emergency and palliative care nurses, and to examine factors associated with attitudes toward advance directives in the total sample.

METHODS

In this cross-sectional, correlational study, data were collected from 153 nurses (59 emergency and 94 palliative care nurses) at three tertiary hospitals using online or offline surveys and were analyzed using t-tests and multiple linear regression analysis.

RESULTS

The levels of attitudes, communication skills, knowledge, and good death awareness were moderate in both groups. Attitudes in emergency compared to palliative care nurses were less positive (46.78 vs. 48.38; p = .044), and knowledge was significantly lower (13.64 vs. 15.00; p = .004). Communication skills and good death awareness between the two groups were similar. In the total sample, emergency practice (B = -1.59, p = .024), and lower levels of good death awareness (B = 0.30, p < .001), communication skills (B = 0.18, p = .001), and education (B = -2.84, p = .015) were associated with less positive attitudes (F = 9.52, p < .001; R²  = 0.35).

CONCLUSIONS

The findings demonstrate the need for improvements in attitudes, knowledge, communication skills, and good death awareness in both groups, especially emergency nurses. Two modifiable targets of interventions to improve nurses' attitudes were also noted.

A quantitative study of nurses perception to advance directive in selected private and public secondary healthcare facilities in Ibadan, Nigeria

Objectives

The study evaluated nurses’ perceptions on the benefits, drawbacks, and their roles in initiating and implementing advance directives (AD) at private and public secondary healthcare units.

Methods

The study adopted a cross-sectional, comparative-descriptive research design and was anchored on the structural functional theory. A total of 401 nurses (131 private and 270 public) were chosen on purpose. The data was collected between January and March 2018 among nurses at the selected hospitals. Analysis was done via SPSSv28.0.1.0.

Results

Compared to nurses working in private healthcare facilities (72.5%), the majority of nurses at the public healthcare facilities (75.2%) indicated a more favorable opinion of AD’s benefits and (61.9%) felt they had a substantial involvement in the development and execution of AD than their private counterpart (56.5%). Similarly, 60.7% of nurses employed by the government agreed that AD has some disadvantages compared to those employed by the private sector (58.8%). Significantly, Christian nurses are 0.53 times less likely than Muslims to contest AD’s benefits; 0.78 times less likely than Muslim to disagree that AD has flaws; and 1.30 times more likely than Muslim nurses to deny they contributed to the development and execution of AD, though not significant.

Conclusion

Making decisions at the end-of-life can be challenging, thus AD should be supported across the board in the healthcare industry. Nurses should be trained on their role in developing and implementing AD, as well as on its advantages and how to deal with its challenges.

Voluntades anticipadas como referente ético de conocimiento en los enfermeros que laboran en servicios de oncología

El propósito del presente artículo es identificar los conocimientos sobre la Voluntad Anticipada (VA) en enfermeros que laboran en servicios de oncología. Para ello, se utilizó como metodología un estudio observacional con intención analítica que midió el nivel de conocimiento a través de un cuestionario autodiligenciado. En él participaron 50 enfermeros, seleccionados por muestreo no probabilístico. Así, se analizaron las variables cualitativas con distribuciones de frecuencia, y las cuantitativas con estadística descriptiva y análisis bivariado. El nivel de conocimiento se categorizó así: 0 a 10 puntos (nivel bajo), 11 a 20 puntos (nivel medio), 21 a 30 puntos (nivel alto). Los resultados de la investigación arrojaron como dato que, para un grupo donde el 86 % eran mujeres, con promedio de edad de 37 años, el promedio de años de experiencia como enfermeros fue de 11.5 años. Por otra parte, el promedio de años de experiencia en el área de oncología fue de 6.2 años. De los que hacían parte de este último promedio, el 48 % tenían diplomado en oncología y el 46 % especialización. El 70 % de los participantes tenía un conocimiento medio, el 26 % un conocimiento alto, y el 4 %un nivel bajo. Cabe mencionar que solo el nivel de formación de postgrado se relacionó de manera significativa con el nivel de conocimientos. Como conclusión, se encontró que los profesionales en enfermería poseen un nivel de conocimiento medio sobre la legislación que aborda las voluntades anticipadas en Colombia y esto está relacionado con el nivel de formación.

Factors Associated with Advance Directives Documentation: A Nationwide Cross-Sectional Survey of Older Adults in Korea

Advance directives (ADs) can support autonomy in making healthcare decisions and minimize unnecessary discomfort during the treatment process at the end of life (EOL). This study aimed to investigate the factors that influence AD documentation among community-dwelling older adults. We used data from the National Survey of Older Koreans which was conducted nationwide in 2020. Data from participants aged 65 years or older were extracted using stratified multistage cluster sampling and the survey was conducted through one-on-one interviews. A total of 9920 older adults were included in this study: 421 respondents (4.7%) claimed that they had prepared for AD. Multivariable logistic regression analysis showed that being 75 years or older, having higher educational attainment, higher income, having any chronic disease(s), being screened for dementia in the past, being against futile life-sustaining treatment, taking a lecture on death and being registered for organ donation were positively associated with AD. Furthermore, when health was rated as average, it was associated with reduced odds of AD documentation compared when health was rated as good. These results suggest that more targeted efforts are required to promote EOL discussions among older adults.

Decision-making preferences on end-of-life care for older people: Exploration and comparison of Japan, the Hong Kong SAR and South Korea in East Asia

AIMS AND OBJECTIVES

The aim of this study was to examine and compare decision-making preferences on end-of-life care for older people in Japan, the Hong Kong SAR and South Korea.

BACKGROUND

Cultural values and beliefs influence decision-making on end-of-life care.

DESIGN

A cross-sectional design was adopted.

METHODS

Community-dwelling people aged ≥65 with additional requirements were recruited in 2016-2017 in the three regions. Their decision-making preferences on end-of-life care were assessed using Pang et al.'s questionnaire. These preferences and their sociodemographic and personal experience variables were compared and analysed using univariate and multiple logistic regressions. The STROBE checklist was followed.

RESULTS

This study involved 415 participants. In all three regions, the most preferred decision maker and person with whom to discuss end-of-life care issues was a family member. Participants in the Hong Kong SAR were less likely to select a family member as their preferred decision maker than those in Japan (adjusted odds ratio = 0.129). Koreans were less likely to discuss end-of-life care issues with medical professionals than people in Japan (adjusted odds ratio = 0.278). More than 70% of the participants in each region indicated that they would not prefer to leave an advance directive to decide their end-of-life care.

CONCLUSION

Older Asians prefer to make their own decisions after consulting others. Family members play an important role in helping older people plan their preferred end-of-life care arrangements, even acting as decision makers when older people become incapable of deciding for themselves.

RELEVANCE TO CLINICAL PRACTICE

Sufficient information should be provided to older people and their families for the older people to determine their preferred care. Helping families to understand and support the planned care and advance directives is a strategy for maximising family compliance with the care. Continuous efforts should be made to promote advance care planning and advance directives.

Implementing advance directives-An international literature review of important considerations for nurses

AIM(S)

To review the global literature on the implementation of advance health care directives to date, and the experiences of the health care professionals who must initiate the discussions around advance care planning, as well as support patients' ultimate decisions.

BACKGROUND

Ireland's Assisted Decision-Making (Capacity) Act 2015 legalizes advance health care directives. It promotes the autonomy of the person and enables them to have treatment in accordance with their will and preferences. However, there is professional uncertainty on how to support and integrate assisted decision-making.

EVALUATION

16 studies featuring the views of health care professionals are included and evaluated using a framework of 'benefits versus challenges'.

KEY ISSUE(S)

Four themes clearly emerge during the review process: the concept of capacity and who decides; autonomy versus paternalism-conflict among the health care professional/patient/family caregiver triad; barriers to advance directives; and timing issues.

CONCLUSION(S)

Significant benefits of advance health care directives exist for all parties including less stress for patients and families alike, less burden and less residual guilt for surviving relatives, and an over-arching prevention of 'crisis' decision-making.

IMPLICATIONS FOR NURSING MANAGEMENT

This review highlights the central role of the nurse in empowering patients to express their wills and preferences, supporting patients' capacity to make decisions about their own care, initiating end-of-life care discussions and advocating to have advance health care directives acknowledged. Moreover, it identifies the challenges ahead for all nurse managers in implementing this new mandate.