Impact of a decision aid on surrogate decision-makers' perceptions of feeding options for patients with dementia

A scoping review of decision-making tools to support substitute decision-makers for adults with impaired capacity

BACKGROUND

Substitute decision-makers (SDMs) make decisions that honor medical, personal, and end-of-life wishes for older adults who have lost capacity, including those with dementia. However, SDMs often lack support, information, and problem-solving tools required to make decisions and can suffer with negative emotional, relationship, and financial impacts. The need for adaptable supports has been identified in prior meta-analyses. This scoping review identifies evidence-based decision-making resources/tools for SDMs, outlines domains of support, and determines resource/tool effectiveness and/or efficacy.

METHODS

The scoping review used the search strategy: Population-SDMs for older adults who have lost decision-making capacity; Concept-supports, resources, tools, and interventions; Context-any context where a decision is made on behalf of an adult (>25 years). Databases included MEDLINE, Embase, CINAHL, PsycINFO, and Abstracts in Social Gerontology and SocIndex. Tools were scored by members on the research team, including patient partners, based on domains of need previously identified in prior meta-analyses.

RESULTS

Two reviewers independently screened 5279 citations. Articles included studies that evaluated a resource/tool that helped a family/friend/caregiver SDMs outside of an ICU setting. 828 articles proceeded onto full-text screening, and 25 articles were included for data extraction. The seventeen tools identified focused on different time points/decisions in the dementia trajectory, and no single tool encompassed all the domains of caregiver decision-making needs.

CONCLUSION

Existing tools may not comprehensively support caregiver needs. However, combining tools into a toolkit and considering their application relevant to the caregiver's journey may start to address the gap in current supports.

Resources to Support Decision-Making Regarding End-of-Life Nutrition Care in Long-Term Care: A Scoping Review

Resources are needed to aid healthcare providers and families in making end-of-life nutrition care decisions for residents living in long-term care settings. This scoping review aimed to explore what is reported in the literature about resources to support decision-making at the end of life in long-term care. Four databases were searched for research published from 2003 to June 2023. Articles included peer-reviewed human studies published in the English language that reported resources to support decision-making about end-of-life nutrition in long-term care settings. In total, 15 articles were included. Thematic analysis of the articles generated five themes: conversations about care, evidence-based decision-making, a need for multidisciplinary perspectives, honouring residents' goals of care, and cultural considerations for adapting resources. Multidisciplinary care teams supporting residents and their families during the end of life can benefit from resources to support discussion and facilitate decision-making.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Effectiveness of the SHARE Model in Improving the Knowledge of, Attitudes Toward, Intention to Provide, and Initiation of Hospice Care Among Caregivers of Terminally ill Patients With the Eight Major Non-Cancer Diseases

OBJECTIVES

To investigate the effects of a care intervention on the knowledge of, attitudes toward, intention to provide, and initiation of hospice care among caregivers of terminally ill patients with the eight major non-cancer diseases.

METHODS

A two-group pre-post-test randomized intervention design was adopted. The intervention group received the SHARE model intervention. The SHARE intervention was implemented once a week for 6 weeks, with each session lasting 20-60 min.

RESULTS

The intervention and control groups differed significantly in mean post-test scores for knowledge of hospice care (t = -4.973, p = .00) and intentions to provide hospice care (t = -2.424, p = .02). In the intervention group, pre- and post-test scores differed significantly for knowledge of hospice care (t = -6.201, p = .000), attitudes toward hospice care (t = -2.848, p = .008), and intentions to provide hospice care (t = -2.781, p = .009).

CONCLUSIONS

The SHARE intervention improved knowledge of hospice care, intentions to provide, and initiation of hospice care among the caregivers of terminally ill patients with non-cancer diseases.

Factors associated with the intention to engage in care planning among persons with mild cognitive impairment and dementia

This study examined factors associated with the intention to engage in advance care planning among persons with cognitive impairment. This cross-sectional study recruited 116 persons with cognitive impairment by convenience sampling from two teaching hospitals in Northern Taiwan from November 1, 2018, to December 31, 2020. Fewer than 50% of the participants intended to engage in advance care planning, and less than 10% signed the living will for hospice and palliative care. Multivariate linear regression determined factors influencing advance care planning intention included education level, a proxy signed do-not-resuscitate document, belief that family members would provide a signed do-not-resuscitate at their end-of-life, and necessity of explaining future care in advance. It is recommended to popularize advance care planning education and ensure the rights of persons with cognitive impairment to enable them to fully participate in their own care plans through family-centered advance care planning.

Decision Aid Interventions for Family Caregivers of Persons With Advanced Dementia in Decision-Making About Feeding Options: A Scoping Review

OBJECTIVES

We provided an overview of the literature on decision aid interventions for family caregivers of older adults with advanced dementia regarding decision making about tube feeding. We synthesized (1) the use of theory during the development, implementation, and evaluation of decision aids; (2) the development, content, and delivery of decision aid interventions; (3) caregivers' experience with decision aid interventions; and (4) the effect of decision aid interventions on caregivers' quality of decision-making about feeding options.

DESIGN

Scoping review.

METHODS

We conducted a scoping review of peer-reviewed studies published January 1, 2000-June 30, 2022, in MEDLINE, EMBASE, The Cochrane Library, CINAHL, and Web of Science databases. The process was guided by Arksey and O'Malley's methodological framework, which includes identifying the research question, choosing related studies, charting the data, and summarizing results. Empirical articles concerning the decision aid interventions about feeding options were selected.

RESULTS

Six publications reporting 4 unique decision aid interventions were included. All the interventions targeted caregivers of older adults with advanced dementia. Three decision aids were culturally adapted from existing decision aids. The Ottawa Decision Support Framework and the International Patient Decision Aid Standards Framework were used in these 6 publications. Interventions aimed to improve decision making regarding tube feeding for caregivers through static delivery methods. Caregivers rated these decision aids as helpful and acceptable. Decisional conflict and knowledge of feeding options were the most common outcomes evaluated. Reduction in decisional conflict and increase in knowledge were consistently found among dementia caregivers, but no intervention effects were found on preferences for the use of tube feeding.

CONCLUSIONS AND IMPLICATIONS

Decision aid interventions effectively improve decision-making regarding tube feeding among the target population. Cultural adaptation of an existing decision aid intervention is the main strategy. However, the lack of guidance of a cultural adaptation framework in this process may lead to difficulties explaining caregivers' behavioral changes. Moreover, merely providing information is not enough to change caregivers' preferences or behavior of use of tube feeding. A systematic approach to cultural adaptation and interactive intervention is needed in future studies.

Shared decision-making interventions for people with mental health conditions

BACKGROUND

One person in every four will suffer from a diagnosable mental health condition during their life. Such conditions can have a devastating impact on the lives of the individual and their family, as well as society.  International healthcare policy makers have increasingly advocated and enshrined partnership models of mental health care. Shared decision-making (SDM) is one such partnership approach. Shared decision-making is a form of service user-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision.  This review assesses whether SDM interventions improve a range of outcomes. This is the first update of this Cochrane Review, first published in 2010.

OBJECTIVES

To assess the effects of SDM interventions for people of all ages with mental health conditions, directed at people with mental health conditions, carers, or healthcare professionals, on a range of outcomes including: clinical outcomes, participation/involvement in decision-making process (observations on the process of SDM; user-reported, SDM-specific outcomes of encounters), recovery, satisfaction, knowledge, treatment/medication continuation, health service outcomes, and adverse outcomes.

SEARCH METHODS

We ran searches in January 2020 in CENTRAL, MEDLINE, Embase, and PsycINFO (2009 to January 2020). We also searched trial registers and the bibliographies of relevant papers, and contacted authors of included studies.  We updated the searches in February 2022. When we identified studies as potentially relevant, we labelled these as studies awaiting classification.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cluster-randomised controlled trials, of SDM interventions in people with mental health conditions (by Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

This updated review included 13 new studies, for a total of 15 RCTs. Most participants were adults with severe mental illnesses such as schizophrenia, depression, and bipolar disorder, in higher-income countries. None of the studies included children or adolescents.  Primary outcomes We are uncertain whether SDM interventions improve clinical outcomes, such as psychiatric symptoms, depression, anxiety, and readmission, compared with control due to very low-certainty evidence. For readmission, we conducted subgroup analysis between studies that used usual care and those that used cognitive training in the control group. There were no subgroup differences. Regarding participation (by the person with the mental health condition) or level of involvement in the decision-making process, we are uncertain if SDM interventions improve observations on the process of SDM compared with no intervention due to very low-certainty evidence. On the other hand, SDM interventions may improve SDM-specific user-reported outcomes from encounters immediately after intervention compared with no intervention (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) 0.26 to 1.01; 3 studies, 534 participants; low-certainty evidence). However, there was insufficient evidence for sustained participation or involvement in the decision-making processes. Secondary outcomes We are uncertain whether SDM interventions improve recovery compared with no intervention due to very low-certainty evidence. We are uncertain if SDM interventions improve users' overall satisfaction. However, one study (241 participants) showed that SDM interventions probably improve some aspects of users' satisfaction with received information compared with no intervention: information given was rated as helpful (risk ratio (RR) 1.33, 95% CI 1.08 to 1.65); participants expressed a strong desire to receive information this way for other treatment decisions (RR 1.35, 95% CI 1.08 to 1.68); and strongly recommended the information be shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58). The evidence was of moderate certainty for these outcomes. However, this same study reported there may be little or no effect on amount or clarity of information, while another small study reported there may be little or no change in carer satisfaction with the SDM intervention. The effects of healthcare professional satisfaction were mixed: SDM interventions may have little or no effect on healthcare professional satisfaction when measured continuously, but probably improve healthcare professional satisfaction when assessed categorically. We are uncertain whether SDM interventions improve knowledge, treatment continuation assessed through clinic visits, medication continuation, carer participation, and the relationship between users and healthcare professionals because of very low-certainty evidence. Regarding length of consultation, SDM interventions probably have little or no effect compared with no intervention (SDM 0.09, 95% CI -0.24 to 0.41; 2 studies, 282 participants; moderate-certainty evidence). On the other hand, we are uncertain whether SDM interventions improve length of hospital stay due to very low-certainty evidence. There were no adverse effects on health outcomes and no other adverse events reported.

AUTHORS' CONCLUSIONS

This review update suggests that people exposed to SDM interventions may perceive greater levels of involvement immediately after an encounter compared with those in control groups. Moreover, SDM interventions probably have little or no effect on the length of consultations.  Overall we found that most evidence was of low or very low certainty, meaning there is a generally low level of certainty about the effects of SDM interventions based on the studies assembled thus far. There is a need for further research in this area.

Decision aids for home and community care: a systematic review

OBJECTIVES

Decision aids (DAs) for clients in home and community care can support shared decision-making (SDM) with patients, healthcare teams and informal caregivers. We aimed to identify DAs developed for home and community care, verify their adherence to international DA criteria and explore the involvement of interprofessional teams in their development and use.

DESIGN

Systematic review reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Six electronic bibliographic databases (MEDLINE, Embase, CINAHL Plus, Web of Science, PsycINFO and the Cochrane Library) from inception to November 2019, social media and grey literature websites up to January 2021.

ELIGIBILITY CRITERIA

DAs designed for home and community care settings or including home care or community services as options.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently reviewed citations. Analysis consisted of a narrative synthesis of outcomes and a thematic analysis. DAs were appraised using the International Patient Decision Aid Standards (IPDAS). We collected information on the involvement of interprofessional teams, including nurses, in their development and use.

RESULTS

After reviewing 10 337 database citations and 924 grey literature citations, we extracted characteristics of 33 included DAs. DAs addressed a variety of decision points. Nearly half (42%) were relevant to older adults. Several DAs did not meet IPDAS criteria. Involvement of nurses and interprofessional teams in the development and use of DAs was minimal (33.3% of DAs).

CONCLUSION

DAs concerned a variety of decisions, especially those related to older people. This reflects the complexity of decisions and need for better support in this sector. There is little evidence about the involvement of interprofessional teams in the development and use of DAs in home and community care settings. An interprofessional approach to designing DAs for home care could facilitate SDM with people being cared for by teams.

PROSPERO REGISTRATION NUMBER

CRD42020169450.

Exploring variables related to medical surrogate decision-making accuracy during the COVID-19 pandemic

OBJECTIVE

Surrogate medical decision making is common in the United States healthcare system. Variables that may influence surrogate decision making have been proposed. Little work has examined relations between these variables and outcomes of surrogate decision making. This study investigated whether surrogates' characteristics, including their knowledge of treatment options, and interpersonal factors predicted surrogates' accuracy and intervention selections. Specifically, predictor variables included: trust in the medical profession, trait-level anxiety, depression, anxiety about COVID-19, religiosity, perceived emotional support, understanding of treatment options, empathy, willingness to accept responsibility for medical decisions, reluctance to burden others, and perceived similarity between oneself and the patient.

METHODS

154 pairs of patients and their surrogates completed an online survey. Patients indicated preferred treatments in hypothetical decision scenarios. Surrogates indicated the treatment that they thought the patient would prefer.

RESULTS

When taken all together in a predictive model, the variables significantly predicted surrogates' accuracy, F (6) = 3.03, R² = .12, p = .008. Variables also predicted selection of intensive interventions, F (4) = 5.95, R² = .14, p = .00. Surrogates reporting greater anxiety about COVID-19 selected more intensive interventions.

CONCLUSIONS

Consistent with prior research, this study found that surrogates' characteristics influence the interventions they choose, with anxiety about COVID-19 having considerable bearing on their chosen interventions.

PRACTICE IMPLICATIONS

These findings can inform development of decision-making interventions to improve surrogates' accuracy. Providers may attend to variables highlighted by this study to support surrogates, particularly within the stressful context of COVID-19 and possible future pandemics.

Development of a core outcome set for the evaluation of interventions to enhance trial participation decisions on behalf of adults who lack capacity to consent: a mixed methods study (COnSiDER Study)

BACKGROUND

Trials involving adults who lack capacity to provide consent rely on proxy or surrogate decision-makers, usually a family member, to make decisions about participation. Interventions to enhance proxy decisions about trial participation are now being developed. However, a lack of standardised outcome measures limits evaluation of these interventions. The aim of this study was to establish an agreed standardised core outcome set (COS) for use when evaluating interventions to improve proxy decisions about trial participation.

METHODS

We used established methods to develop the COS including a consensus study with key stakeholder groups comprising those who will use the COS in research (researchers and healthcare professionals) and patients or their representatives. Following a scoping review to identify candidate items, we used a modified two-round Delphi survey to achieve consensus on core outcomes, with equivocal items taken to a consensus meeting for discussion. The COS was finalised following an online consensus meeting in October 2020.

RESULTS

A total of 28 UK stakeholders (5 researchers, 10 trialists, 3 patient/family representatives, 7 recruiters and 3 advisors/approvers) participated in the online Delphi survey to rank candidate items from the scoping review (n = 36) and additional items proposed by participants (n = 1). Items were broadly grouped into three categories: how family members make decisions, their experiences of making decisions, and the personal aspects that influence the decision. Following the Delphi survey, 27 items were included and ten items exhibited no consensus which required discussion at the consensus meeting. Sixteen participants attended the meeting, including additional patient/family representatives invited to increase representation from this key group (n = 2). We reached consensus for the inclusion of 28 outcome items, including one selected at the consensus meeting.

CONCLUSIONS

The study identified outcomes that should be measured as a minimum in all evaluations of interventions to enhance proxy decisions about trials. These relate to the process of decision-making, proxies' experience of decision-making, and factors that influence decision-making such as understanding. Further work with people with impairing conditions and their families is needed to explore their views about the COS and to identify appropriate outcome measures and timing of measurement.

TRIAL REGISTRATION

The study is registered on the COMET database ( https://www.comet-initiative.org/Studies/Details/1409 ).

Shared Decision Making in Cardiac Electrophysiology Procedures and Arrhythmia Management

Shared decision making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs.

Enteral tube feeding for people with severe dementia

BACKGROUND

The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing.

OBJECTIVES

To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), or controlled non-randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post-pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers.

DATA COLLECTION AND ANALYSIS

Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre-agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta-analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study.

MAIN RESULTS

We found no eligible RCTs. We included fourteen controlled, non-randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low-certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate-certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very-low certainty evidence).  Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low-certainty evidence. Five studies reported a variety of harm-related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia.

AUTHORS' CONCLUSIONS

We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here.

Decision-Making in People With Dementia or Mild Cognitive Impairment: A Narrative Review of Decision-Making Tools

OBJECTIVES

This review summarized the applicability of various decision-making tools for helping people with dementia or mild cognitive impairment (MCI) and their families make decisions.

DESIGN

This study was a narrative literature review. The protocol of this review was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42020182259).

SETTING AND PARTICIPANTS

People with dementia or MCI and their families were included in this study.

METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We searched the Cochrane Library, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Chinese Electronic Periodical Services databases from inception to May 2021. The Joanna Briggs Institute Critical Appraisal Checklists for a variety of study designs were used.

RESULTS

Topics related to decision-making were categorized as everyday activity decisions or medical treatment decisions. Various types of decision-making tools were identified, and we observed that decision aids can be modified and used for both everyday activity decisions and medical treatment decisions. In addition to highlighting decision aids for specific decisional issues and topics, we also elucidated other validated tools that can be used to facilitate the decision-making process.

CONCLUSIONS AND IMPLICATIONS

This study highlighted the topics involved in decision-making and using decision-making tools. The current review provides information that can help individuals and health care professionals choose optimal decision-making tools. On the basis of our findings, future studies can determine the most appropriate tools for intervention or outcome measures.

Nutrition and hydration for people living with dementia near the end of life: A qualitative systematic review

AIMS

To synthesize the qualitative evidence of the views and experiences of people living with dementia, family carers, and practitioners on practice related to nutrition and hydration of people living with dementia who are nearing end of life.

DESIGN

Systematic review and narrative synthesis of qualitative studies.

DATA SOURCES

MEDLINE, Embase, PsycINFO, CINAHL.

REVIEW METHODS

Databases were searched for qualitative studies from January 2000-February 2020. Quantitative studies, or studies reporting on biological mechanisms, assessments, scales or diagnostic tools were excluded. Results were synthesized using a narrative synthesis approach with thematic analysis.

RESULTS

Twenty studies were included; 15 explored the views of practitioners working with people living with dementia in long-term care settings or in hospitals. Four themes were developed: challenges of supporting nutrition and hydration; balancing the views of all parties involved with 'the right thing to do'; national context and sociocultural influences; and strategies to support nutrition and hydration near the end of life in dementia.

CONCLUSION

The complexity of supporting nutrition and hydration near the end of life for someone living with dementia relates to national context, lack of knowledge, and limited planning while the person can communicate.

IMPACT

This review summarizes practitioners and families' experiences and highlights the need to include people living with dementia in studies to help understand their views and preferences about nutrition and hydration near the end of life; and those of their families supporting them in the community. The review findings are relevant to multidisciplinary teams who can learn from strategies to help with nutrition and hydration decisions and support.

Development of a decision support intervention for family members of adults who lack capacity to consent to trials

BACKGROUND

Informed consent is required for participation in clinical trials, however trials involving adults who lack capacity to consent require different enrolment processes. A family member usually acts as a proxy to make a decision based on the patient's 'presumed will', but these decisions can be challenging and families may experience an emotional and decisional burden. Decisions made on behalf of others are conceptually different from those made for ourselves. Innovations have been developed to improve informed consent processes for research, including a number of decision aids, however there are no interventions for proxies who are faced with more complex decisions. This article outlines the development of a novel decision aid to support families making decisions about research participation on behalf of an adult who lacks capacity to consent.

METHODS

Decision support interventions should be developed using rigorous and evidence-based methods. This intervention was developed using MRC guidance for the development of complex interventions, and a conceptual framework for the development and evaluation of decision aids for people considering taking part in a clinical trial. The intervention was informed by a systematic review and analysis of existing information provision. Previous qualitative research with families who acted as proxies enabled the development of a theoretical framework to underpin the intervention. The intervention was iteratively developed with the involvement of lay advisors and relevant stakeholders.

RESULTS

Previous research, theoretical frameworks, and decision aid development frameworks were used to identify and develop the intervention components. The decision aid includes information about the proxy's role and utilises a values clarification exercise and decision support methods to enable a more informed and better-quality decision. Stakeholders, including those representing implementers and receivers of the intervention, contributed to the design and comprehensibility of the decision aid to ensure that it would be acceptable for use.

CONCLUSIONS

Frameworks for the development of decision aids for people considering participating in a clinical trial can be used to develop interventions for family members acting as proxy decision-makers. The decision support tool is acceptable to users. Feasibility testing and outcome measure development is required prior to any evaluation of its effectiveness.

Enhancing shared and surrogate decision making for people living with dementia: A systematic review of the effectiveness of interventions

BACKGROUND

Dementia can have a profound impact on decision making. People living with dementia (PLwD) often need to make decisions about health care, and, as dementia progresses, decisions may need to be made on their behalf. Specific interventions may support this process.

REVIEW QUESTION

What interventions are effective in improving shared decision making or surrogate decision making on the health care of PLwD?

METHODS

A narrative systematic review of existing literature was conducted. Seven databases, grey literature and key journals were searched. After exclusion by title, abstracts then full texts were reviewed collaboratively to manage any disagreements.

RESULTS

Eight studies met the inclusion criteria. Two articles, including one RCT, evaluated decision aids regarding the use of enteral feeding in advanced dementia. Six further articles, including five RCTs, were found which evaluated the effectiveness of interventions supporting patients or carers with advance care planning.

CONCLUSION

Decision-making interventions typically consist of multiple components which aim to establish preferences for future health care. Advance care planning interventions supported aspects of the decision-making processes but their impact on decision quality was rarely evaluated. Interventions did not increase the concordance of decisions with a person's values. The decision-specific interventions are unlikely to produce benefit in other decision contexts.

PATIENT INVOLVEMENT

Two caregivers, a public stakeholder group and a carer group were consulted in the design of the wider study to which this review relates. Six PLwD refined the research questions addressed in this paper.

Eating Problems in Advanced Dementia: Navigating Difficult Conversations

INTRODUCTION

The majority of older adults with advanced dementia (AD) develop difficulties with eating and swallowing, often prompting concerns about nutrition and quality of life. Employing a palliative approach requires providers to attain skills in addressing symptoms and communicating with family caregivers about the trajectory of AD and associated dysphagia, as well as to elicit goals of care. Research suggests internal medicine (IM) residents often perceive minimal education during training addressing skills needed to care for patients with AD.

METHODS

We developed and piloted a small-group interactive seminar utilizing a trigger video depicting a family meeting addressing eating problems in a patient with AD. Case-based learning, small-group discussion, and learner reflection were employed. We assessed the impact on 82 of the 106 IM, medicine-pediatrics, and neurology residents who participated in the seminar.

RESULTS

Participant evaluation indicated residents showed high satisfaction and perceived the educational content of the seminar to be robust and clinically relevant. We found statistically significant (p < .001) improvements in self-reported confidence in dementia-specific skills postseminar. Effect size was large to very large (Cohen's d = 1.3-1.7).

DISCUSSION

An interactive, case-based seminar utilizing a video depicting a realistic family meeting improved residents' self-efficacy in skills needed to address nutritional issues, engage in goals-of-care discussions, and reflect on concerns among caregivers of patients with AD. The seminar teaches important geriatric and palliative concepts meant to improve residents' ability to care for older adults with AD in their future careers.

Interventions to foster family inclusion in nursing homes for people with dementia: a systematic review

BACKGROUND

Family inclusion in nursing homes is central to the provision of individualized care for people with dementia. Although positive effects can be recognized, barriers have been identified that hamper family inclusion in nursing homes. Specifically for people with dementia, insight into the content of interventions to foster family inclusion is lacking.

METHODS

A systematic review was performed by systematically searching the databases PubMed, Cinahl, PsycInfo and Embase. Studies were eligible if they examined (1) nursing home settings, (2) interventions to foster the inclusion of family members from people with dementia, (3) were original research articles in which effects/experiences of/with these interventions were evaluated, and (4) were written in English, Dutch or German. Findings were summarized systematically.

RESULTS

Twenty-nine studies were included. Two interventions were targeted at creating family-staff partnerships from a two-way perspective. Other interventions focused on single components, such as including family members in formal decisions (n = 9), enabling them to make better informed decisions and/or participate more actively (n = 7), or providing psychoeducation for family members (n = 3). Within the interventions, family and staff members are often treated differently. Effects on actual increase in family inclusion remain unclear.

CONCLUSIONS

Very few interventions exist that try to enhance equal family-staff partnerships in nursing homes. Future interventions should pay specific attention to mutual exchange and reciprocity between family and staff. As little is known about promising (components of) interventions to foster family inclusion in nursing homes for people with dementia, more effectiveness research is needed.

Advance care planning information intervention for persons with mild dementia and their family caregivers: Impact on end-of-life care decision conflicts

Persons with dementia are at high risk for loss of decision-making ability due to increased cognitive decline as the disease progresses. Participation in advance care planning (ACP) discussions in the early stages of dementia is crucial for end-of-life (EoL) decision-making to ensure quality of EoL care. A lack of discussions about ACP and EoL care between persons with dementia and family caregivers (FCGs), can lead to decisional conflicts when persons with dementia are in the later stages of the disease. This study explored the effects of a family-centered ACP information intervention among persons with dementia and FCGs. The study was conducted in outpatient clinics in Taiwan. Participants were dyads (n = 40) consisting of persons diagnosed with mild cognitive impairment or mild dementia and their FCGs. A one-group, pretest–posttest, pre-experimental design was employed. The intervention was provided by an ACP-trained senior registered nurse and was guided by ACP manuals and family-centered strategies. Outcome data were collected with four structured questionnaires regarding knowledge of end-stage dementia treatment, knowledge of ACP, attitude towards ACP, and EoL decisional conflict about acceptance or refusal of cardiopulmonary resuscitation, ventilators, and tracheostomy. Paired t tests compared differences between pre-intervention data and 4-weeks’ post-intervention data. The intervention resulted in significant improvements among persons with dementia and FCGs for knowledge of end-stage dementia treatment (p = .008 and p < .001, respectively), knowledge of ACP (both p < .001), and significant reductions in decisional conflicts (both p < .001). Scores for positive and negative attitude toward ACP did not change for persons with dementia; however, there was a reduction in negative attitude for FCGs (p = .001). Clinical care for persons with dementia should incorporate ACP interventions that provide knowledge about EoL dementia care using family-centered care strategies that facilitate regular and continuous communication between FCGs, persons with dementia, and medical personnel to reduce decisional conflicts for EoL care.

Decision aids to support decision-making in dementia care: a systematic review

OBJECTIVES

We aimed to critically evaluate decision aids developed for practitioners and caregivers when providing care for someone with dementia or for use by people with dementia themselves. Decision aids may be videos, booklets, or web-based tools that explicitly state the decision, provide information about the decision, and summarize options along with associated benefits and harms. This helps guide the decision maker through clarifying the values they place on the benefits or harms of the options.

DESIGN

We conducted a systematic review of peer-reviewed literature in electronic databases (CINAHL, The Cochrane Library, EMBASE, MEDLINE, and PsychINFO) in March 2018. Reference lists were searched for relevant papers and citations tracked. Data were synthesized with meta-analysis and narrative synthesis. Papers were included if they met the following criteria: 1) the focus of the paper was on the evaluation of a decision aid; 2) the decision aid was used in dementia care; and 3) the decision aid was aimed at professionals, people with dementia, or caregivers.

RESULTS

We identified 3618 studies, and 10 studies were included, covering three topics across six decision aids: 1) support with eating/feeding options, 2) place of care, and 3) goals of care. The mode of delivery and format of the decision aids varied and included paper-based, video-based, and audio-based decision aids. The decision aids were shown to be effective, increasing knowledge and the quality of communication. The meta-analysis demonstrated that decisions are effective in reducing decisional conflict among caregivers (standardized mean difference = -0.50, 95% confidence interval [ - 0.97, - 0.02]).

CONCLUSION

Decision aids offer a promising approach for providing support for decision-making in dementia care. People are often faced with more than one decision, and decisions are often interrelated. The decision aids identified in this review focus on single topics. There is a need for decision aids that cover multiple topics in one aid to reflect this complexity and better support caregivers.

Perceptions of Gastrostomy Buttons Among Caregivers of Children With Special Health Care Needs

INTRODUCTION

Children with special health care needs (CSHCN) have chronic conditions that generally are classified as developmental disabilities. Children with developmental disabilities are at high risk of malnutrition. Gastrostomy buttons are frequently used to provide enteral nutrition for children with developmental disabilities.

OBJECTIVE

This study aimed to understand caregivers' perceptions regarding gastrostomy button placement for CSHCN.

METHODS

Caregivers (N = 257) were recruited from CSHCN peer support groups to complete an online survey regarding perceptions of gastrostomy button placement. Kolmogorov-Smirnov testing found that results were not normally distributed. Nonparametric testing with Spearman rank correlation was used to determine the relationship between Overall Satisfaction With Choice and all other perception variables.

RESULTS

The findings suggested overall satisfaction and willingness to accept gastrostomy button placement earlier.

CONCLUSION

Gastrostomy button placement has diverse effects for children with developmental disabilities and their families. Health care professionals must be knowledgeable about the positive and negative outcomes to effectively educate families as they consider gastrostomy placement.

Perspectives of people with dementia and carers on advance care planning and end-of-life care: A systematic review and thematic synthesis of qualitative studies

BACKGROUND:

Advance care planning aims to ensure that care received during serious and chronic illness is consistent with the person’s values, preferences and goals. However, less than 40% of people with dementia undertake advance care planning internationally.

AIM:

This study aims to describe the perspectives of people with dementia and their carers on advance care planning and end-of-life care.

DESIGN:

Systematic review and thematic synthesis of qualitative studies.

DATA SOURCES:

Electronic databases were searched from inception to July 2018.

RESULTS:

From 84 studies involving 389 people with dementia and 1864 carers, five themes were identified: avoiding dehumanising treatment and care (remaining connected, delaying institutionalisation, rejecting the burdens of futile treatment); confronting emotionally difficult conversations (signifying death, unpreparedness to face impending cognitive decline, locked into a pathway); navigating existential tensions (accepting inevitable incapacity and death, fear of being responsible for cause of death, alleviating decisional responsibility); defining personal autonomy (struggling with unknown preferences, depending on carer advocacy, justifying treatments for health deteriorations); and lacking confidence in healthcare settings (distrusting clinicians’ mastery and knowledge, making uninformed choices, deprived of hospice access and support at end of life).

CONCLUSION:

People with dementia and their carers felt uncertain in making treatment decisions in the context of advance care planning and end-of-life care. Advance care planning strategies that attend to people’s uncertainty in decision-making may help to empower people with dementia and carers and strengthen person-centred care in this context.

Fact Box decision support tools reduce decisional conflict about antibiotics for pneumonia and artificial hydration in advanced dementia: a randomized controlled trail

Background

fact Boxes are decision support tools that can inform about treatment effects.

Objectives

to test whether Fact Box decision support tools impacted decisional conflict, knowledge and preferences about the use of antibiotics and artificial hydration in advanced dementia.

Design

randomized controlled trial.

Setting

Swiss-German region of Switzerland.

Subjects

two hundred thirty-two participants (64 physicians, 100 relatives of dementia patients, 68 professional guardians) randomly allocated to intervention (N = 114) or control (N = 118).

Intervention

two-page Fact Box decision support tools on antibiotics for pneumonia and artificial hydration in advanced dementia (at 1-month).

Methods

participants were mailed questionnaires at baseline and one month later that asked questions about treatments based on hypothetical scenarios. The primary outcome was change in decisional conflict (DCS-D; range 0 < 100) about treatment decisions. Secondary outcomes included knowledge about treatments (range 0 < 7) and preferences to forego treatments.

Results

participants were: mean age, 55.6 years; female, 62.8%. Relative to control participants, intervention participants experienced less decisional conflict about using antibiotics (unstandardized beta (b) = -8.35, 95% Confidence Interval (CI), -12.43, -4.28) and artificial hydration (b = -6.02, 95% CI, -9.84, -2.20) at 1-month compared to baseline. Intervention participants displayed greater knowledge about the use of antibiotics (b = 2.24, 95% CI, 1.79, 2.68) and artificial hydration (b = 3.01, 95% CI, 2.53, 3.49), and were significantly more likely to prefer to forego antibiotics (odds ratio, 2.29, 95% CI, 1.08, 4.84) but not artificial hydration.

Conclusions

fact Box decision support tools reduced decisional conflict, increased knowledge and promoted preferences to forego antibiotics in advanced dementia among various decision-makers.

Trial registration

FORSbase (12091).

What Matters to Persons With Dementia at the End of Life: Perspectives of Proxy Decision Makers

For substituted decision makers for the growing number of persons with dementia (PWDs), understanding the PWD's values is a prerequisite for making end-of-life (EOL) decisions congruent with the PWD's wishes. The current qualitative study explored PWD health care proxies' perspectives on values that are important to PWDs at end of life and challenges in making EOL decisions that reflect PWDs' values. Semistructured interviews were conducted with 20 PWD proxies, and data were analyzed using the content analysis, an inductive approach to identify themes. Three main themes emerged: (1) what matters to PWDs at end of life, (2) uncertainty about the PWD's current wishes and EOL trajectory poses challenges, and (3) the role of health care professionals' empathic and clear communication. Together, these findings suggest proxies' efforts to understand and respect PWDs' wishes at end of life and communication strategies that health care providers can use to help PWD proxies cope with uncertainty and challenges in EOL decision making.

End-of-life decision making by family caregivers of persons with advanced dementia: A literature review of decision aids

Objectives:

To investigate existing knowledge in the literature about end-of-life decision making by family caregivers of persons with dementia, focusing on decision aids for caregivers of persons with advanced dementia, and to identify gaps in the literature that can guide future research.

Methods:

A literature review through systematic searches in PubMed, CINAHL Plus with Full Text, and PsycINFO was conducted in February 2018; publications with full text in English and published in the past 10 years were selected in multiple steps.

Results:

The final sample included five decision aids with predominantly Caucasian participants; three of them had control groups, and three used audiovisual technology in presenting the intervention materials. No other technology was used in any intervention. Existing interventions lacked tailoring of information to caregivers’ preferences for different types and amounts of information necessary to make decisions consistent with patients’ values.

Conclusion:

Research is needed in exploring the use of technology in decision aids that could provide tailored information to facilitate caregivers’ decision making. More diverse samples are needed.

Shared decision-making when choosing the feeding method of patients with severe dementia: a systematic review

Abstract Objectives: To evaluate whether the use of a support tool for shared decision-making in the choice of feeding method for patients with severe dementia can benefit the patient/caregiver dyad, and to evaluate the quality of the decision-making process. Method: A search was performed in the Medline, LILACS, IBECS, SciELO, WHOLIS databases for randomized controlled trials, whether double-blind or otherwise, and quasi-experimental, cohort, case-control, or cross-sectional observational studies in Portuguese, Spanish, English and French. Results: Eight articles were found that showed that the use of a decision support tool, as an aid for the shared decision-making method, is beneficial as it reduces decisional conflict and increases the knowledge of caregivers about the subject. The quality of the decision-making process is unsatisfactory due to the low frequency of discussions between caregivers and the health team and the poor evaluation of caregivers about the participation of the team in the decision-making process. Conclusion: Decision support tools provide benefits for caregivers/patients undergoing the difficult task of deciding about feeding methods. Findings suggest that the current quality of decision-making is inadequate.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values.

OBJECTIVES

To assess the effects of decision aids in people facing treatment or screening decisions.

SEARCH METHODS

Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008.

SELECTION CRITERIA

We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence.

MAIN RESULTS

We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup.

AUTHORS' CONCLUSIONS

Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.

Social Ecological Perspectives of Tube-Feeding Older Adults with Advanced Dementia: A Systematic Literature Review

Dementia is a progressive, debilitating disease that often results in weight loss, malnutrition, and dehydration. Feeding tubes are often prescribed; however, this practice can lead to complications. The purpose of this systematic review was to examine the use of feeding tubes in elderly demented patients from a social ecological perspective. Results indicated that family members often receive inadequate decision-making education. Many health care professionals lack knowledge of evidence-based guidelines pertaining to feeding tube use. Organizational and financial reimbursement structures influence feeding tube use. Feeding practices for patients with advanced dementia is a complex issue, warranting approaches that target each level of the Social Ecological Model.

Medical Foster Homes: Can the Adult Foster Care Model Substitute for Nursing Home Care?

OBJECTIVE

To compare characteristics, healthcare use, and costs of care of veterans in the rapidly expanding Veterans Health Administration (VHA) medical foster home (MFH) with those of three other VHA long-term care (LTC) programs.

DESIGN

Descriptive, unmatched study.

SETTING

VHA MFHs, home-based primary care (HBPC), community living centers (CLCs), and community nursing homes (CNHs).

PARTICIPANTS

Veterans newly enrolled in one of the four LTC settings in calendar years 2010 or 2011.

MEASUREMENTS

Using VA and Medicare data from fiscal years 2010 and 2011, demographic characteristics, healthcare use, and costs of 388 veterans in MFHs were compared with 26,037 of those in HBPC, 5,355 in CLCs, and 5,517 in CNHs in the year before and the year after enrollment.

RESULTS

Veterans enrolled in the MFH program were more likely to be unmarried than those in other LTC programs and had higher levels of comorbidity and frailty than veterans receiving HBPC but had similar levels of comorbidity, frailty, and healthcare use as those in CLCs and CNHs. MFH veterans incurred lower costs than those in CNHs and CLCs.

CONCLUSION

MFHs served a distinct subset of veterans with levels of comorbidity and frailty similar to those of veterans cared for in CLCs and CNHs at costs that were comparable to or lower than those of the VHA. Propensity-matched comparisons will be necessary to confirm these findings.

Effectiveness of interventions to indirectly support food and drink intake in people with dementia: Eating and Drinking Well IN dementiA (EDWINA) systematic review

Background

Risks and prevalence of malnutrition and dehydration are high in older people but even higher in older people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions aiming to improve, maintain or facilitate food/drink intake indirectly, through food service or dining environment modification, education, exercise or behavioural interventions in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia).

Methods

We comprehensively searched Medline and twelve further databases, plus bibliographies, for intervention studies with ≥3 cognitively impaired adult participants (any type/stage). The review was conducted with service user input in accordance with Cochrane Collaboration’s guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data. Meta-analysis (statistical pooling) was not appropriate so data were tabulated and synthesised narratively.

Results

We included 56 interventions (reported in 51 studies). Studies were small and there were no clearly effective, or clearly ineffective, interventions. Promising interventions included: eating meals with care-givers, family style meals, soothing mealtime music, constantly accessible snacks and longer mealtimes, education and support for formal and informal care-givers, spaced retrieval and Montessori activities, facilitated breakfast clubs, multisensory exercise and multicomponent interventions.

Conclusions

We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. A variety of promising indirect interventions need to be tested in large, high-quality RCTs, and may be approaches that people with dementia and their formal or informal care-givers would wish to try.

Trial registration

The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007611).

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0256-8) contains supplementary material, which is available to authorized users.

Survival in older adults with dementia and eating problems: To PEG or not to PEG?

BACKGROUND & AIMS

Despite guidelines, long-term enteral nutrition (EN) through percutaneous endoscopic gastrostomy (PEG) is often prescribed to older individuals with dementia and eating problems (refusal to eat or dysphagia). The aim of this prospective observational non-randomized un-blinded study was to assess the role of this procedure on risk of mortality.

METHODS

184 demented malnourished patients (58 M, age 82.2 ± 7.7) with eating problems, discharged from a hospital ward in Italy, were enrolled. Information on dementia type and staging (FAST and CDR scores), Charlson Comorbidity Score and setting of living (community vs nursing home) was collected. After an 18-month follow-up, a telephonic interview with caregivers was planned to assess mortality. Survival of patients discharged on EN by PEG vs oral nutrition (ON) was analyzed by Kaplan-Meier method. Multivariable Cox proportional regression models were also built to test the effects of EN over mortality.

RESULTS

EN was prescribed in 54 patients (15 M). At follow-up, mortality was higher in EN than in ON group (70% vs 40%, p = 0.0002). Survival was significantly shorter in the EN group (log-rank 17.259, p < 0.0001; average length 0.66 ± 0.09 vs 1.28 ± 0.08 years, p < 0.0001). At multivariate Cox proportional regression model, EN was a significant predictor of death (HR 1.82, 95% CI 1.09-3.02, p = 0.02) independent of age, dementia type, FAST, CDR, Charlson score and setting of living in the whole cohort, but not in those with CDR score ranking 4-5.

CONCLUSIONS

In elderly individuals with dementia and eating problems, long-term PEG feeding increases the risk of mortality and should be discouraged.

Person-centered Feeding Care: A Protocol to Re-introduce Oral Feeding for Nursing Home Patients with Tube Feeding

BACKGROUND

Although the literature on nursing home (NH) patients with tube feeding (TF) has focused primarily on the continuation vs. discontinuation of TF, the reassessment of these patients for oral feeding has been understudied. Re-assessing patients for oral feeding may be better received by families and NH staff than approaches focused on stopping TF, and may provide an opportunity to address TF in less cognitively impaired patients as well as those with end-stage conditions. However, the literature contains little guidance on a systematic interdisciplinary team approach to the oral feeding reassessment of patients with TF, who are admitted to NHs.

METHODS

This project had two parts that were conducted in one 170-bed intermediate/skilled, Medicare-certified NH in Honolulu, Hawai'i. Part 1 consisted of a retrospective observational study of characteristics of TF patients versus non-tube fed patients at NH admission (2003-2006) and longitudinal follow-up (through death or 6/30/2011) with usual care of the TF patients for outcomes of: feeding and swallowing reassessment, goals of care reassessment, feeding status (TF and/or per oral (PO) feedings), and hospice status. Part 2 involved the development of an interdisciplinary TF reassessment protocol through working group discussions and a pilot test of the protocol on a new set of patients admitted with TF from 2011-2014.

RESULTS

Part 1: Of 238 admitted patients, 13.4% (32/238) had TF. Prior stroke and lack of DNR status was associated with increased likelihood of TF. Of the 32 patients with TF at NH admission, 15 could communicate and interact (mild, moderate or no cognitive impairment with prior stroke or pneumonia); while 17 were nonverbal and/or bedbound patients (advanced cognitive impairment or terminal disease). In the more cognitively intact group, 9/15 (60%) were never reassessed for tolerance of oral diets and 10/15 (66.7%) remained with TF without any oral feeding until death. Of the end-stage group, 13/17 (76.5%) did not have goals of care reassessed and remained with TF without oral feeding until death. Part 2: The protocol pilot project included all TF patients admitted to the facility in 2011-2014 (N=33). Of those who were more cognitively intact (n=22), 21/22 (95.5%) had swallowing reassessed, 11/22 (50%) resumed oral feedings but 11 (50%) failed reassessment and continued exclusive TF. Of those with end-stage disease (n=11), 100% had goals of care reassessed and 9 (81.8%) families elected individualized oral feeding (with or without TF).

CONCLUSION

Using findings from our retrospective study of usual care, our NH's interdisciplinary team developed and pilot-tested a protocol that successfully reintroduced oral feedings to tube-fed NH patients who previously would not have resumed oral feeding.

Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units

In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.

Tools to Promote Shared Decision Making in Serious Illness: A Systematic Review

IMPORTANCE

Serious illness impairs function and threatens survival. Patients facing serious illness value shared decision making, yet few decision aids address the needs of this population.

OBJECTIVE

To perform a systematic review of evidence about decision aids and other exportable tools that promote shared decision making in serious illness, thereby (1) identifying tools relevant to the treatment decisions of seriously ill patients and their caregivers, (2) evaluating the quality of evidence for these tools, and (3) summarizing their effect on outcomes and accessibility for clinicians.

EVIDENCE REVIEW

We searched PubMed, CINAHL, and PsychInfo from January 1, 1995, through October 31, 2014, and identified additional studies from reference lists and other systematic reviews. Clinical trials with random or nonrandom controls were included if they tested print, video, or web-based tools for advance care planning (ACP) or decision aids for serious illness. We extracted data on the study population, design, results, and risk for bias using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Each tool was evaluated for its effect on patient outcomes and accessibility.

FINDINGS

Seventeen randomized clinical trials tested decision tools in serious illness. Nearly all the trials were of moderate or high quality and showed that decision tools improve patient knowledge and awareness of treatment choices. The available tools address ACP, palliative care and goals of care communication, feeding options in dementia, lung transplant in cystic fibrosis, and truth telling in terminal cancer. Five randomized clinical trials provided further evidence that decision tools improve ACP documentation, clinical decisions, and treatment received.

CONCLUSIONS AND RELEVANCE

Clinicians can access and use evidence-based tools to engage seriously ill patients in shared decision making. This field of research is in an early stage; future research is needed to develop novel decision aids for other serious diagnoses and key decisions. Health care delivery organizations should prioritize the use of currently available tools that are evidence based and effective.

The effect of prognostic data presentation format on perceived risk among surrogate decision makers of critically ill patients: a randomized comparative trial

PURPOSE

The purpose of this study is to determine whether varying the format used to present prognostic data alters the perception of risk among surrogate decision makers in the intensive care unit (ICU).

METHODS

This was a prospective randomized comparative trial conducted in a 23-bed adult tertiary ICU. Enrolled surrogate decision makers were randomized to 1 of 2 questionnaires, which presented hypothetical ICU scenarios, identical other than the format in which prognostic data were presented (eg, frequencies vs percentages). Participants were asked to rate the risk associated with each prognostic statement.

RESULTS

We enrolled 141 surrogate decision makers. The perception of risk varied significantly dependent on the presentation format. For "quantitative data," risks were consistently perceived as higher, when presented as frequencies (eg, 1 in 50) compared with equivalent percentages (eg, 2%). Framing "qualitative data" in terms of chance of "death" rather than "survival" led to a statistically significant increase in perceived risks. Framing "quantitative" data in this way did not significantly affect risk perception.

CONCLUSION

Data format had a significant effect on how surrogate decision makers interpreted risk. Qualitative statements are interpreted widely and affected by framing. Where possible, multiple quantitative formats should be used for presenting prognostic information.

Percutaneous endoscopic gastrostomy (PEG) tubes are placed in elderly adults in Japan with advanced dementia regardless of expectation of improvement in quality of life

BACKGROUND

The Japan Geriatrics Society published a guideline on the decision-making process for health care for the elderly in June 2012, noting that withholding or withdrawing feeding tubes are treatment options that should be discussed during the decision-making process. Arguments against the guideline posit that the insertion of a percutaneous endoscopic gastrostomy (PEG) tube feeding may improve quality of life (QOL) for elderly adults and their relatives.

OBJECTIVES

The aim of the present study was to explore (a) expected outcomes with PEG tube placement and (b) outcomes from PEG tube feeding in long-term care settings among elderly adults with advanced dementia in Japan.

DESIGN

This study was conducted using a cross-sectional study design.

SETTING

A total of 381 hospitals and 985 long-term care facilities provided sets of completed questionnaires.

PARTICIPANTS

There were 1 199 hospital patients and 2 160 long-term care patients aged 65 years or older with PEG tube placement included in the analysis.

MEASUREMENTS

The nurses or physicians at each hospital provided information on the level of dementia at the time of PEG tube placement and on the expected outcomes of PEG tube feeding for elderly hospital patients. The nurses or other direct care workers at each facility provided information on the level of dementia and outcomes from PEG tube feeding for the long-term care patients.

RESULTS

In the hospital patient group, 62.9% of patients had advanced dementia. PEG tube feeding was expected to prolong survival for 51.1% of hospital patients with advanced dementia. Improved QOL was expected for 39.1% of them. In the long-term care patient group, 61.7% of patients had advanced dementia. The rate of patients enjoying their own lives was lower in long-term care patients who had advanced dementia (4.2%) than in the other patients (16.4%). Approximately 60% of relatives reported satisfaction with the QOL of the patients, both in the long-term care patients with advanced dementia and the other patients.

CONCLUSION

Our results question the assumption that PEG tube feeding may improve QOL among elderly adults with advanced dementia. The national health policy should explore an approach to help patients, relatives, and practitioners make decisions about feeding options.