The Human Rights of Older People With Mental Health Conditions and Psychosocial Disability to a Good Death and Dying Well

The perspectives of hospital doctors about end-of-life care in people with mental illness: an observational pilot study

BACKGROUND

Negative attitudes towards people living with mental illness (PLWMI), defined here as mentalism, are a major contribution to health care inequity, which may extend into end-of-life care. There is a clear need for investigation of the attitudes of doctors towards PLWMI at the end of life as doctors may lead processes of care that contribute to this inequity.

AIMS

The aim of this pilot study is to examine the perspectives of hospital-based doctors regarding end-of-life care and medical decision-making in PLWMI.

METHODS

A survey was created to explore whether mentalism is present in the perspectives of hospital doctors regarding end-of-life care for PLWMI. The survey included demographic characteristics of participants and questions comprising statements and vignettes that required agree/disagree responses. Descriptive statistics were used to summarise responses, and chi-square tests examined associations with demographic variables.

RESULTS

The survey was commenced by 48 hospital-based doctors and completed by 45. Descriptive statistics indicated that mentalism is present in the attitudes of hospital doctors regarding end-of-life care of PWLMI, with 47 of 48 participants (98%) endorsing at least one mentalist response. One significant association found that psychiatrists and psychiatry trainees were less likely to endorse a stereotype response in one vignette.

CONCLUSIONS

This preliminary study addresses a gap within the literature on the potential contribution of mentalist attitudes in doctors to the poorer end-of-life care outcomes for PLWMI. The findings highlight the need for further study of this topic and suggest a role for targeted medical education in the pursuit of health care equality for PLWMI.

A palliative care goals model for people with dementia and their family: Consensus achieved in an international Delphi study

BACKGROUND

Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life.

AIM

To develop a multidimensional international palliative care goals model in dementia for use in practice.

DESIGN

International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified.

SETTING/PARTICIPANTS

Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study.

RESULTS

Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves.

CONCLUSION

A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research.

Ageism, human rights and ethical aspects of end-of-life care for older people with serious mental illness

There are many complex concepts to consider during end-of-life discussions and advance care planning, especially when vulnerable populations such as older individuals with serious mental illness are involved. This article aims to summarize some of these important concepts, such as the effects of ageism, preservation of human rights and dignity, supported or shared decision making and palliative approaches. It emerged from a study that found two thirds of 100 participants 60 years of age and older with serious mental illness had end-of-life decision-making capacity. This finding highlighted the individual and contextual nature of decision-making capacity, the importance of consideration of individual values and protection of human dignity during end-of-life care. Healthcare providers have a duty to initiate end-of-life and advance care discussions, to optimize decision-making capacity, and to protect autonomous decision-making. Chronological age or diagnostic categories should never be used as reasons for discrimination and all patients should receive end-of-life care in keeping with their preferences and values.

Review of Religious Variables in Advance Care Planning for End-of-Life Care: Consideration of Faith as a New Construct

Religion and spirituality have long been considered important social determinants of human health, and there exists an extensive body of research to support such. End-of-life (EOL) may raise complex questions for individuals about religious and spiritual (R/S) values guiding advance care planning (ACP) and EOL care decisions, including the provision of spiritual care. This commentary will review the history and current national trends of ACP activities for EOL, principally within the United States. It will describe the relationship of religious variables and the attributes of selected research instruments used to study religious variables on ACP and EOL preferences. The review also summarizes unique ACP challenges for patients with neurocognitive disorders and severe mental illness. Findings disclose that higher levels of religiosity, reliance on religious coping, conservative faith traditions, and "belief in God's control over life's length and divine intervention have lower levels of ACP and more intensive EOL care preferences, although the provision of spiritual spiritual care at EOL mitigates intensive EOL care. Based upon the curated evidence, we propose an epistemological justification to consider "faith" as a separately defined religious variable in future ACP and EOL research. This review is relevant to geriatric psychiatrists and gerontological health care professionals, as they may be part of multidisciplinary palliative care teams; provide longitudinal care to patients with neurocognitive disorders and severe mental illness; and may provide diagnostic, emotional, and therapeutic services for patients and families who may struggle with EOL care decisions.

Mental Health Promotion and Risk Reduction Strategies for Mental Disorders in Older Persons: Why Should Governments and Policymakers Care?

There is no health without mental health. These are both indispensable human rights and are prerequisite to living ones life with dignity. Unfortunately, mental health systems have been in crisis, with burden of mental illness being among the ten leading healthcare-related issues worldwide, with no measurable reduction in such for over 30 years. Concurrently, the demographic clock continues to tick. Toadys 703 million people aged 65 or older are projected to reach 1.5 billion by the year 2050. Of these, 20% will suffer with serious mental health conditions. At the heart of the global crisis for older people is ageism, frequently intersecting with ableism, mentalism, sexism, and racism. These biases result in the violation of older peoples human rights every day, with the resultant poor quality of life and premature death. They are compounded by major gaps in legislation, policies, and practices, rendering the central transformative promise of the UNs 2030 Agenda to Leave No One Behind a very elusive goal. Evidence-based interventions designed to prevent or reduce the risk of common mental health conditions and psychosocial disability are already available. All governments and policymakers have a major role to play in the promotion of good mental health and the prevention of mental illness by integrating these into public health and general social policy. This requires adopting, implementing, and scaling up of evidence-based, cost-effective interventions to reduce the risk of the development of mental disorders and providing access to adequate treatment when needed for older persons. All governments and policymakers also have a pivotal role to play in leading and supporting a UN convention on the human rights of older people. A UN convention would help combat ageism at the national and international levels by ensuring integration of monitoring and enforcement mechanisms to effectively implement policies and laws that could address discrimination, inequity, and the protection of human rights of older people, including their mental health.

Human Rights and Empowerment in Aged Care: Restraint, Consent and Dying with Dignity

The aged care system in Australia is in crisis and people living with dementia are especially vulnerable to breaches of human rights to autonomy, dignity, respect, and equitable access to the highest quality of health care including meeting needs on account of disability. To be powerful advocates for themselves and others, people with dementia and the wider community with vested interests in quality aged care must be informed about their rights and what should be expected from the system. Prior to the Australian Royal Commission into Aged Care Quality and Safety, the Empowered Project was established to empower and raise awareness amongst people with dementia and their families about changed behaviours, chemical restraint, consent, end of life care, and security of tenure. A primary care-embedded health media campaign and national seminar tour were undertaken to meet the project aims of awareness-raising and empowerment, based on 10 Essential Facts about changed behaviours and rights for people with dementia, established as part of the project. Knowledge translation was assessed to examine the need and potential benefit of such seminars. We demonstrated that this brief educational engagement improved community knowledge of these issues and provided attendees with the information and confidence to question the nature and quality of care provision. With the completion of the Royal Commission and corresponding recommendations with government, we believe the community is ready to be an active player in reframing Australia’s aged care system with a human rights approach.