Attitudes of physicians, nurses and relatives towards end-of-life decisions concerning nursing home patients with dementia

Commentary: Can an effective end-of-life intervention for advanced dementia be viewed as moral?

We comment on Dr. Terman's considerations on the moral justification of ceasing assisted feeding and hydration for people with advanced dementia. The core idea of his paper is that an advance directive can solve future dilemmas regarding assisted feeding. We submit that this static instrument is unfit for the complex and dynamic nature of assessing how to deal with refusals to eat, in particular for people with dementia. It overvalues the past in relation to the present situation and leaves no room for the possibility of changing wishes. Moreover, the perspectives of professional caregivers and families are not addressed because the focus is entirely on individual autonomy in early dementia. Multiple perspectives should be considered in interpreting directives and the actual situation in light of the patient's view of life in order to realistically account for what is morally justifiable in care in advanced dementia.

Family involvement in euthanasia or Physician Assisted Suicide and dementia: A systematic review

OBJECTIVE

To assess how families are involved in situations of euthanasia or physician assisted suicide (PAS) in dementia.

DESIGN

Systematic review searching literature in nine databases from inception up to October 2021. We included studies on family involvement in euthanasia from the perspective of persons with dementia and family caregivers. Themes were formulated through thematic analysis. The design was registered at Prospero (CRD42022298215).

RESULTS

We assessed 215 of 4038 studies in full text; 19 met the inclusion criteria of which 13 empirical studies. Themes included for people with dementia: being a burden; stage of dementia, and permissibility of euthanasia/PAS. Themes for family were the burden of care, responsibility toward the euthanasia or PAS wish, permissibility of euthanasia/PAS.

CONCLUSION

The wish for euthanasia/PAS arises in situations of burdensome care and fear of future deterioration. The family feels entrusted with the responsibility to enact upon the death wish. In shaping this responsibility, four roles of family can be distinguished: carer, advocate, supporter, and performer. Family as in need of support themselves is understudied.

Observation of Child Experience During Discontinuing of Medically Provided Nutrition and Hydration

CONTEXT

Ethical and professional guidelines support withholding/discontinuing medically provided nutrition and hydration (MPNH) for children in specific scenarios yet literature shows many providers do not support this practice. One reason clinicians continue MPNH is worry about child suffering.

OBJECTIVES

This study was designed to assess clinician observations of infant/child experience following withholding/discontinuing MPNH.

METHODS

This study is a national survey of clinicians who had personally medically-managed an infant/child during the process of withholding/discontinuing MPNH. Survey disseminated via Twitter, email, and Facebook. Descriptive and content analyses were performed.

RESULTS

Responses from 195 clinicians represented experiences with 900+ children, with over half of those experiences occurring within the prior year. Palliative care was consulted in 76% of cases. Most clinicians reported that in their patients, comfort (80/142, 56%) and peacefulness (89/143, 62%) increased during withholding/discontinuing MPNH, as did dry lips/mouth (109/143, 76%). Most observed decreased work of breathing (58/142, 63%) and respiratory secretions (90/142, 63%). The perceived need for pain medication typically remained unchanged (54/142, 38%). When asked to describe the dying process during withholding/ discontinuing MPNH, the most common response was "peaceful." Clinicians also observed increasing levels of parent relief (78/137, 57%), peace (77/137, 56%), as well as anxiety (74/137, 54%).

CONCLUSION

Respiratory, gastrointestinal symptoms, signs of peacefulness, and comfort improved for most infants and children during withholding/withdrawing MPNH. Aside from dry lips/mouth, fewer than 10% of children were perceived to have increased symptom distress. This study's findings are consistent with adult data and failed to detect a compelling reason to forgo withholding/discontinuing MPNH solely due to concern about child comfort.

Informal care-givers' attitudes towards medical assistance in dying for persons with dementia

Medical assistance in dying (MAID) is legal in Canada but cannot be accessed through an advance request. Some data suggest that informal care-givers of persons with dementia support the legalisation of advance requests for MAID. Opponents argue that care-givers' support is due to society's failure to address their well-documented burden and unmet needs. To our knowledge, this assumption has never been tested. To fill this knowledge gap, we conducted a survey among 204 Canadian informal care-givers of persons with dementia to (a) elicit their attitudes towards allowing no longer competent adults to access MAID through an advance request, and (b) test the hypothesis that attitudes are in part driven by the level of burden experienced by care-givers and unmet needs for support. Attitudes were elicited with a clinical vignette involving a woman with Alzheimer's disease who requests MAID while still competent, or through an advance request for the time after she would lose decisional capacity. Informal care-givers' support for MAID ranged from 60 per cent in the scenario where the person is still competent and likely has several more years to live, to 87 per cent when she is depicted as no longer competent, in severe distress and close to death. Quality-of-life considerations and the value of self-determination were key arguments in support of legalising advance requests for MAID. Using multivariable logistic regression, we found no evidence that burden and unmet support needs influence attitudes towards advance requests for MAID, after controlling for other determinants. These findings contribute new insights into people's attitudes towards the sensitive issue of whether MAID should be extended to persons with dementia-induced decisional incapacity.

Euthanasia in persons with advanced dementia: a dignity-enhancing care approach

In current Western societies, increasing numbers of people express their desire to choose when to die. Allowing people to choose the moment of their death is an ethical issue that should be embedded in sound clinical and legal frameworks. In the case of persons with dementia, it raises further ethical questions such as: Does the person have the capacity to make the choice? Is the person being coerced? Who should be involved in the decision? Is the person's suffering untreatable? The use of Advance Euthanasia Directives (AED) is suggested as a way to deal with end-of-life wishes of persons with dementia. However, in the Netherlands-the only country in which this practice is legal-the experiences of patients, doctors, and relatives have been far from satisfactory.Our paper analyses this complex ethical challenge from a Dignity-Enhancing Care approach, starting from the Dutch experiences with AED as a case. We first consider the lived experiences of the different stakeholders, seeking out a dialogical-interpretative understanding of care. We aim to promote human dignity as a normative standard for end-of-life care practices. Three concrete proposals are then presented in which this approach can be operationalised in order to deal respectfully with the end-of-life choices of persons with dementia.

Medical communication and decision-making about assisted hydration in the last days of life: A qualitative study of doctors experienced with end of life care

BACKGROUND

The impact of assisted hydration on symptoms and survival at the end of life is unclear. Little is known about optimal strategies for communicating and decision-making about this ethically complex topic. Hydration near end of life is known to be an important topic for family members, but conversations about assisted hydration occur infrequently despite guidance suggesting these should occur with all dying people.

AIM

To explore the views and experiences of doctors experienced in end-of-life care regarding communicating with patients and families and making decisions about assisted hydration at the end of life.

DESIGN

Qualitative study involving framework analysis of data from semi-structured interviews.

SETTING/PARTICIPANTS

Sixteen UK-based Geriatrics and Palliative Medicine doctors were recruited from hospitals, hospices and community services from October 2019 to October 2020.

RESULTS

Participants reported clinical, practical and ethical challenges associated with this topic. The hospital setting provides barriers to high-quality communication with dying patients and their families about assisted hydration, which may contribute to the low incidence of documented assisted hydration-related conversations. Workplace culture in some hospices may make truly individualised decision-making about this topic more difficult. Lack of inclusion of patients in decision-making about assisted hydration appears to be common practice.

CONCLUSIONS

Proactive, routine discussion with dying people about hydration-related issues is indicated in all cases. There is room for debate regarding the limits of shared decision-making and the benefits of routine discussion of assisted hydration with all dying people. Clinicians have to navigate multiple barriers as they strive to provide individualised care.

Physicians' approach to end of life care: comparison of two tertiary care university hospitals in Lebanon

BACKGROUND

The care of terminally ill patients is fraught with ethical and medical dilemmas carried by healthcare professionals. The present study aims to explore the approaches of Lebanese attending physicians towards palliative care, end of life (EOL) care, and patient management in two tertiary care university hospitals with distinct medical culture.

METHODS

Four hundred attending physicians from the American University of Beirut Medical Center (AUBMC) and Hotel Dieu de France (HDF) were recruited. Participants were Medical Doctors in direct contact with adult patients that could be subject to EOL situations providing relevant demographic, educational, religious as well as personal, medical or patient-centric data.

RESULTS

The majority of physicians in both establishments were previously exposed to life-limiting decisions but remains uncomfortable with the decision to stop or limit resuscitation. However, physicians with an American training (AUBMC) were significantly more likely to exhibit readiness to initiate and discuss DNR with patients (p<0.0001). While the paternalistic medicinal approach was prevalent in both groups, physicians with a European training (HDF) more often excluded patient involvement based on family preference (p<0.0001) or to spare them from a traumatic situation (p=0.003). The majority of respondents reported that previous directives from the patient were fundamental to life-limiting decisions. However, the influence of patient and medical factors (e.g. culture, religion, life expectancy, age, socioeconomic status) was evidenced in the HDF group.

CONCLUSION

Early physician-initiated EOL discussions remain challenged in Lebanon. Paternalistic attitudes limit shared decision making and are most evident in European-trained physicians. Establishing a sound and effective framework providing legal, ethical and religious guidance is thus needed in Lebanon.

Discordance and concordance on perception of quality care at end of life between older patients, caregivers and clinicians: a scoping review

BACKGROUND

This scoping review aimed to investigate the presence of discordance or concordance in the perceptions of end-of-life (EOL) care quality between consumers (i.e. patients aged over 60 in their last years of life and/or their informal caregivers) and clinicians, to inform further improvements in end-of-life care service delivery.

METHODS

A scoping review of qualitative and quantitative studies was systematically undertaken by searching for English language publications in MEDLINE database and manual reference search of eligible articles. Thematic analysis was employed to identify and extract common concordance and discordance themes leading to the development of analytical constructs. Articles were eligible for inclusion if they reported on consumers' (i.e. older patients aged 60 + years in their final years of life and/or their informal caregivers) and clinicians' (doctors, nurses, social workers, etc.) perspectives on quality of medical, surgical or palliative/supportive care administered to older adults in the last year of life across all healthcare settings.

RESULTS

Of the 2736 articles screened, 21 articles were included. Four themes identified concordance between consumers' and clinicians' perceptions of care quality: holistic patient care; coordinated care that facilitated EOL; the role of family at EOL; and impact of prognostic uncertainty on care planning. Three themes emerged for discordance of perceptions: understanding the patient needs at EOL; capacity of healthcare system/providers to accommodate family needs; and knowledge and communication of active or palliative care at EOL.

CONCLUSIONS

While progress has been made on promoting patient autonomy and respecting the family role in representing patient's best interest, gaps remain in terms of care coordination, communication of prognosis, public understanding of the meaning of goals of care including de-escalation of management and enactment of advance care directives by clinicians for people with diminished decision capacity. Public understanding of the meaning of "comfort" care and the need to prevent over-treatment are essential for their satisfaction with care and their ability to embrace the concept of a good death.

Physicians' Characteristics and Attitudes Towards Medically Assisted Dying for Non-Competent Patients with Dementia

The federal and Quebec governments are both considering extending medical aid/assistance in dying (MAID) to non-competent patients who would have requested MAID prior to losing capacity. In 2016-2017, we surveyed 136 Quebec physicians (response rate: 25.5%) on their attitudes towards extending MAID to such patients. Complementing our published findings, we herein identify demographic and practice characteristics that distinguish physicians who reported being open to extending MAID to non-competent patients with dementia, or willing to administer MAID themselves should it be legal, from those who were not. We found that physicians who were older, had stronger religious beliefs, were trained in palliative care, practiced in a teaching hospital, and had not received assisted dying requests in the year preceding the survey held less favourable attitudes towards MAID for non-competent patients with dementia. These findings will inform current deliberations as to whether assistance in dying should be extended to non-competent patients in some circumstances.

Healthcare-providers experiences with Advance Care Planning and Goals of Patient Care medical treatment orders in Residential Aged Care Facilities; an explanatory descriptive study

OBJECTIVES

Advance Care Planning (ACP) is a process by which people communicate their healthcare preferences and values, planning for a time when they are unable to voice them. Within Residential Aged Care Facilities (RACF) both the completion and the clarity of ACP documents is variable and, internationally, medical treatment orders have been used to address these issues. In this study, Goals of Patient Care (GOPC) medical treatment orders were introduced alongside usual ACP in three RACF to improve healthcare decision-making for residents. This study explored the experiences of RACF healthcare-providers with ACP and GOPC medical treatment orders.

METHODS

The study was of Explanatory Descriptive design. Within three RACF where the GOPC medical treatment orders had been introduced, focus groups and interviews with healthcare-providers were performed. The transcribed interviews were analysed thematically.

RESULTS

Healthcare-providers reported support for ACP and GOPC but also discussed many problematic issues. Analysis of the data identified four main themes: Enablers, Barriers, Resident autonomy and Advance documentation (ACP and GOPC).

CONCLUSION

Healthcare-providers identified ACP and GOPC as positive tools for assisting with medical decision-making for residents. Although barriers exist in completion and activation of plans, healthcare-providers described them as progressing resident-centred care. Willingness to follow ACP instructions was reported to be reduced by lack of trust by clinicians. Families were also reported to change their views from those documented in family-completed ACP, attributed to poor understanding of their purpose. Participants reported that GOPC led to clearer documentation of residents' medical treatment-plans than relying on ACP documents alone. This article is protected by copyright. All rights reserved.

Assessing Public's Attitudes Towards Euthanasia and Assisted Suicide of Persons With Dementia Based on Their Advance Request: An Experimental Survey of US Public

OBJECTIVE

Advance request euthanasia and/or assisted suicide (AR-EAS) in persons with dementia is highly controversial. Results of typical public opinion surveys may not reflect the ethical and practical issues involved in the practice. We tested the impact of incorporating such issues in the assessment of public attitudes toward legalization of AR-EAS.

DESIGN

Online survey (April 27-30, 2020) of 1,711 adults recruited via CloudResearch PrimePanel, matched to U.S. population in age, sex, race and/or ethnicity, education, household income, and political affiliation. After assessing initial attitudes toward legalization of AR-EAS, respondents viewed one of six randomly assigned scenarios depicting an ethical or practical issue in AR-EAS; acceptability of EAS in each scenario as well as general attitudes toward AR-EAS legalization were then elicited.

RESULTS

Approximately 54.4% initially agreed/strongly agreed with AR-EAS legalization; agreement was associated with lower dementia quality-of-life rating, younger age, not being religious, liberal politics, and $75,000-$99,999 income range. After viewing the scenarios, a minority in each scenario arm found the AR-EAS depicted acceptable (20.7%-39.1%; p<0.0001 for all six arms, in comparison with initial legalization question response). Support (agree/strongly agree) for AR-EAS legalization after reading specific scenarios was generally lower (range 36.5%-49.3%; p≤0.0002); change in support for legalization was associated with initial support for legalization, acceptability of AR-EAS in the scenarios, dementia quality-of-life ratings, and race.

CONCLUSION

Informing the public of the ethical and practical complexities in AR-EAS may have significant effects on their attitudes toward legalization. Future surveys should ensure that the public's views reflect sufficient exposure to these complexities.

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.

Which moral barriers and facilitators do physicians encounter in advance care planning conversations about the end of life of persons with dementia? A meta-review of systematic reviews and primary studies

IMPORTANCE AND OBJECTIVE

Conducting advance care planning (ACP) conversations with people with dementia and their relatives contributes to providing care according to their preferences. In this review, we identify moral considerations which may hinder or facilitate physicians in conducting ACP in dementia.

DESIGN

For this meta-review of systematic reviews and primary studies, we searched the PubMed, Web of Science and PsycINFO databases between 2005 and 30 August 2019. We included empirical studies concerning physicians' moral barriers and facilitators of conversations about end-of-life preferences in dementia care. The protocol was registered at Prospero (CRD42019123308).

SETTING AND PARTICIPANTS

Physicians and nurse practitioners providing medical care to people with dementia in long-term and primary care settings. We also include observations from patients or family caregivers witnessing physicians' moral considerations.

MAIN OUTCOMES

Physicians' moral considerations involving ethical dilemmas for ACP. We define moral considerations as the weighing by the professional caregiver of values and norms aimed at providing good care that promotes the fundamental interests of the people involved and which possibly ensues dilemmas.

RESULTS

Of 1347 studies, we assessed 22 systematic reviews and 51 primary studies as full texts. We included 11 systematic reviews and 13 primary studies. Themes included: (1) beneficence and non-maleficence; (2) respecting dignity; (3) responsibility and ownership; (4) relationship and (5) courage. Moral dilemmas related to the physician as a professional and as a person. For most themes, there were considerations that either facilitated or hindered ACP, depending on physician's interpretation or the context.

CONCLUSIONS

Physicians feel a responsibility to provide high-quality end-of-life care to patients with dementia. However, the moral dilemmas this may involve, can lead to avoidant behaviour concerning ACP. If these dilemmas are not recognised, discussed and taken into account, implementation of ACP as a process between physicians, persons with dementia and their family caregivers may fail.

End-of-Life Nutrition Considerations: Attitudes, Beliefs, and Outcomes

OBJECTIVE

To assess the physiological outcomes and interpersonal influences that should be considered when making the decision to provide artificial nutrition and hydration (AN&H) for patients in hospice/palliative programs.

METHODS

A systematic review was conducted using items from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 checklist. Distinct search strategies were employed to find primary research articles that addressed: General health outcomes of artificial nutrition and hydration interventions and nutrition therapy interventions (n = 16), nutrition-related symptoms in end-of-life care (n = 8), and the attitudes of patients and providers toward artificial nutrition and hydration (n = 21).

RESULTS

The effect of AN&H on health outcomes, quality-of-life measures and nutrition-related symptoms is limited and may vary by patient setting and diagnosis. In the absence of consistent evidence for specific health outcomes, decisions regarding AN&H should be made in context of the desires and beliefs of a patient, their family, and their medical providers. These beliefs may not be consistent with likely outcomes or may be inconsistent between individuals involved in the decision-making process, and individuals of different cultures or geographic regions may approach AN&H decisions from different perspectives. To help navigate the intersection of nutrition-related health outcomes and patient/provider beliefs, palliative care teams may employ a variety of strategies for approaching the decision-making process, and may benefit from specific involvement of a Registered Dietitian to help contribute to or lead these discussions.

Determining medical decision-making capacity in brain tumor patients: why and how?

Background

Brain tumor patients are at high risk of impaired medical decision-making capacity (MDC), which can be ethically challenging because it limits their ability to give informed consent to medical treatments or participation in research. The European Association of Neuro-Oncology Palliative Care Multidisciplinary Task Force performed a systematic review to identify relevant evidence with respect to MDC that could be used to give recommendations on how to cope with reduced MDC in brain tumor patients.

Methods

A literature search in several electronic databases was conducted up to September 2019, including studies with brain tumor and other neurological patients. Information related to the following topics was extracted: tools to measure MDC, consent to treatment or research, predictive patient- and treatment-related factors, surrogate decision making, and interventions to improve MDC.

Results

A total of 138 articles were deemed eligible. Several structured capacity-assessment instruments are available to aid clinical decision making. These instruments revealed a high incidence of impaired MDC both in brain tumors and other neurological diseases for treatment- and research-related decisions. Incapacity appeared to be mostly determined by the level of cognitive impairment. Surrogate decision making should be considered in case a patient lacks capacity, ensuring that the patient's "best interests" and wishes are guaranteed. Several methods are available that may help to enhance patients' consent capacity.

Conclusions

Clinical recommendations on how to detect and manage reduced MDC in brain tumor patients were formulated, reflecting among others the timing of MDC assessments, methods to enhance patients' consent capacity, and alternative procedures, including surrogate consent.

Conceptual framework for assisted dying for individuals with dementia: Views of experts not opposed in principle

Dementia is one of the prominent conditions for which an aging population has been seeking end-of-life solutions such as assisted dying. Individuals with dementia, however, are often unable to meet the eligibility criteria of being mentally competent and are thus discriminated against in relation to assisted dying laws. Provided that the assisted death directive is being made in sound mind, it is still of concern whether these advance directives can be appropriately framed and safeguarded to protect the wish of these vulnerable individuals while preventing harm. Therefore, to establish consensus views of experts on primary issues of, and concerns about, assisted dying for individuals with dementia as well as exploring tentative conceptual framework to safeguard practice and application, a three-round Delphi study was conducted. A core group of 12 experts from five countries was recruited comprising expertise in domains relevant to assisted dying and dementia. A semantic-thematic approach was applied to analyze the 119 generated statements. Evaluation of these research statements resulted in full consensus of 84 (70%) items. Our primary findings highlight seven core domains: applicability of assisted dying for dementia; ethical, practical, and pathological issues regarding the application of assisted dying; and ethical, legal, and professional recommendations for the ways forward. Despite the issues surrounding the provision of assisted death for individuals with dementia, our findings lead us to cautiously conclude that devising "adequate" safeguards is achievable. The result of this research may benefit future research and practice.

Physicians' experiences with euthanasia: a cross-sectional survey amongst a random sample of Dutch physicians to explore their concerns, feelings and pressure

Background

Physicians who receive a request for euthanasia or assisted suicide may experience a conflict of duties: the duty to preserve life on the one hand and the duty to relieve suffering on the other hand. Little is known about experiences of physicians with receiving and granting a request for euthanasia or assisted suicide. This study, therefore, aimed to explore the concerns, feelings and pressure experienced by physicians who receive requests for euthanasia or assisted suicide.

Methods

In 2016, a cross-sectional study was conducted. Questionnaires were sent to a random sample of 3000 Dutch physicians. Physicians who had been working in adult patient care in the Netherlands for the last year were included in the sample (n = 2657). Half of the physicians were asked about the most recent case in which they refused a request for euthanasia or assisted suicide, and half about the most recent case in which they granted a request for euthanasia or assisted suicide.

Results

Of the 2657 eligible physicians, 1374 (52%) responded. The most reported reason not to participate was lack of time. Of the respondents, 248 answered questions about a refused euthanasia or assisted suicide request and 245 about a granted EAS request. Concerns about specific aspects of the euthanasia and assisted suicide process, such as the emotional burden of preparing and performing euthanasia or assisted suicide were commonly reported by physicians who refused and who granted a request. Pressure to grant a request was mostly experienced by physicians who refused a request, especially if the patient was ≥80 years, had a life-expectancy of ≥6 months and did not have cancer. The large majority of physicians reported contradictory emotions after having performed euthanasia or assisted suicide.

Conclusions

Society should be aware of the impact of euthanasia and assisted suicide requests on physicians. The tension physicians experience may decrease their willingness to perform euthanasia and assisted suicide. On the other hand, physicians should not be forced to cross their own moral boundaries or be tempted to perform euthanasia and assisted suicide in cases that may not meet the due care criteria.

Fodder for Despair, Masquerading as Hope: Diagnosing the Postures of Hope(lessness) at the End of Life

Hope is needed for persons confronting the limits of human life, antagonised by the threats of death. It is needed also for those health and medical professionals constrained by the institution of medicine, determined by market metaphors and instrumental reasoning. Yet, despair can masquerade as hope for such persons when functional hoping for particular outcomes or aims proves futile and aimless. The following will examine such masquerades, while giving attention to particular expressions of autonomy, which persist as fodder for despair in our late modern milieu. The late classical account of Hercules and his death, as well as contemporary reasons for soliciting medical assistance in dying, will focus on the diagnostics of despair, while a Christian account practicing presence, and of hope as a concrete posture enfleshed by habits of patience, among other virtues, will point toward counter-narratives that might sustain persons in times of crisis and enable persons’ flourishing as human beings, even unto death.

Cross-cultural adaptation and validation of questionnaire for knowledge, attitudes, and behavioral intentions in Italian nurses with regard to provision of artificial nutrition and hydration to patients terminally ill with cancer

OBJECTIVES

Decision-making on artificial nutrition and hydration for patients terminally ill with cancer can be influenced by nurses' knowledge, attitudes, and behavioral intentions. A comprehensive 57-item questionnaire including six sections on the knowledge, attitudes, and behavioral intentions in providing artificial nutrition and hydration to patients terminally ill with cancer has been developed and used in Taiwan. However, the questionnaire needs further psychometric testing and adaptation for other cultures. This study aimed to cross-culturally adapt the questionnaire within the Italian cultural context and test its psychometric properties.

METHODS

The questionnaire was translated into Italian and cross-culturally adapted per the recommendations by Beaton. A panel of 10 experts assessed content validity. A multicenter cross-sectional study was conducted with 411 nurses to test its psychometric properties. Dimensionality and construct validity were assessed through exploratory and confirmatory factor analyses. Reliability was estimated by composite ω and traditional methods, such as the Kuder Richardson formula-20 and Cronbach's α coefficients.

RESULTS

The overall content validity index was 0.85. A confirmatory factor analysis was conducted for the knowledge section and the four attitudes sections. A preliminary analysis for the behavioral intentions section yielded non acceptable results. The internal consistency of the scales was adequate (range, 0.64-0.93).

CONCLUSIONS

This study constituted a notable advancement in the psychometric testing of the tool, and provides evidence that the Italian version of the questionnaire has acceptable psychometric characteristics for the sections on knowledge and attitudes.

The experiences of family members witnessing the diminishing drinking of a dying relative: An adapted meta-narrative literature review

BACKGROUND

Addressing the concerns of family members is an important aspect of palliative and end-of-life care. One aspect that commonly causes family caregivers concern is the decline of patients' oral fluid intake in the last few days of life.

AIM

To map the narratives in which family members' experiences of witnessing the diminishing drinking of a dying relative have been researched, review the findings within each narrative and consider directions for future research.

DESIGN

An adapted meta-narrative review approach.

DATA SOURCES

The Cumulative Index of Nursing and Applied Health Literature, Medline, PsycINFO, Psycharticles and Scopus databases were searched for relevant research published between January 1982 and December 2017. Quality was assessed using the Quality Assessment and Review Instrument.

RESULTS

A total of 22 papers met the inclusion criteria. No study focused specifically on the experiences of family members when witnessing the diminishing drinking of dying relatives. However, research about diminishing drinking was identified within studies broadly focusing on cancer cachexia, clinical decision-making about hydration and/or nutrition and support in a hospice context. The research indicates that family members' experiences of diminishing drinking vary with their views about the significance of drinking, dying well and their expectations of themselves and healthcare professionals.

CONCLUSION

While some understanding of the topic can be inferred from research in related areas, there is a paucity of information specifically about family members' experiences when witnessing the diminishing drinking of a dying relative.

Are Informal Caregivers of Persons With Dementia Open to Extending Medical Aid in Dying to Incompetent Patients? Findings From a Survey Conducted in Quebec, Canada

Euthanasia is a controversial and complex issue, especially when involving incompetent patients. On December 10, 2015, Quebec became the first Canadian province to give access to medical aid in dying (MAiD) (ie, euthanasia performed by a physician) to competent patients who satisfy strictly defined criteria. Less than 2 years later, Quebec is considering extending MAiD to incompetent patients who made an advance request. With the objective of contributing scientific data to current societal debates, we conducted a survey among 471 informal caregivers of persons with dementia, reached through Alzheimer Societies. We used a series of vignettes featuring a person with Alzheimer disease to investigate respondents' attitudes towards MAiD. The response rate was 69%. Two-thirds [68%; 95% confidence interval, 63%-73%] found it acceptable to extend MAiD to an incompetent patient at an advanced stage of Alzheimer disease who had made a written request while competent, and 91% (95% confidence interval, 87%-94%) found it acceptable at the terminal stage. Self-determination was the most widely endorsed argument in favor of access to MAiD for incompetent patients. Findings suggest strong support among informal caregivers for extending MAiD to incompetent patients, provided they are terminally-ill and had made a written request before losing capacity.

Consensus on treatment for residents in long-term care facilities: perspectives from relatives and care staff in the PACE cross-sectional study in 6 European countries

Background

In long-term care facilities often many care providers are involved, which could make it difficult to reach consensus in care. This may harm the relation between care providers and can complicate care. This study aimed to describe and compare in six European countries the degree of consensus among everyone involved in care decisions, from the perspective of relatives and care staff. Another aim was to assess which factors are associated with reporting that full consensus was reached, from the perspective of care staff and relatives.

Methods

In Belgium, England, Finland, Italy, the Netherlands and Poland a random sample of representative long-term care facilities reported all deaths of residents in the previous three months (n = 1707). This study included residents about whom care staff (n = 1284) and relatives (n = 790) indicated in questionnaires the degree of consensus among all involved in the decision or care process. To account for clustering on facility level, Generalized Estimating Equations were conducted to analyse the degree of consensus across countries and factors associated with full consensus.

Results

Relatives indicated full consensus in more than half of the residents in all countries (NL 57.9% - EN 68%), except in Finland (40.7%). Care staff reported full consensus in 59.5% of residents in Finland to 86.1% of residents in England. Relatives more likely reported full consensus when: the resident was more comfortable or talked about treatment preferences, a care provider explained what palliative care is, family-physician communication was well perceived, their relation to the resident was other than child (compared to spouse/partner) or if they lived in Poland or Belgium (compared to Finland). Care staff more often indicated full consensus when they rated a higher comfort level of the resident, or if they lived in Italy, the Netherland, Poland or England (compared to Finland).

Conclusions

In most countries the frequency of full consensus among all involved in care decisions was relatively high. Across countries care staff indicated full consensus more often and no consensus less often than relatives. Advance care planning, comfort and good communication between relatives and care professionals could play a role in achieving full consensus.

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0459-9) contains supplementary material, which is available to authorized users.

The involvement of family in the Dutch practice of euthanasia and physician assisted suicide: a systematic mixed studies review

BACKGROUND

Family members do not have an official position in the practice of euthanasia and physician assisted suicide (EAS) in the Netherlands according to statutory regulations and related guidelines. However, recent empirical findings on the influence of family members on EAS decision-making raise practical and ethical questions. Therefore, the aim of this review is to explore how family members are involved in the Dutch practice of EAS according to empirical research, and to map out themes that could serve as a starting point for further empirical and ethical inquiry.

METHODS

A systematic mixed studies review was performed. The databases Pubmed, Embase, PsycInfo, and Emcare were searched to identify empirical studies describing any aspect of the involvement of family members before, during and after EAS in the Netherlands from 1980 till 2018. Thematic analysis was chosen as method to synthesize the quantitative and qualitative studies.

RESULTS

Sixty-six studies were identified. Only 14 studies had family members themselves as study participants. Four themes emerged from the thematic analysis. 1) Family-related reasons (not) to request EAS. 2) Roles and responsibilities of family members during EAS decision-making and performance. 3) Families' experiences and grief after EAS. 4) Family and 'the good euthanasia death' according to Dutch physicians.

CONCLUSION

Family members seem to be active participants in EAS decision-making, which goes hand in hand with ambivalent feelings and experiences. Considerations about family members and the social context appear to be very important for patients and physicians when they request or grant a request for EAS. Although further empirical research is needed to assess the depth and generalizability of the results, this review provides a new perspective on EAS decision-making and challenges the Dutch ethical-legal framework of EAS. Euthanasia decision-making is typically framed in the patient-physician dyad, while a patient-physician-family triad seems more appropriate to describe what happens in clinical practice. This perspective raises questions about the interpretation of autonomy, the origins of suffering underlying requests for EAS, and the responsibilities of physicians during EAS decision-making.

Is Every Life Worth Saving: Does Religion and Religious Beliefs Influence Paramedic's End-of-Life Decision-making? A Prospective Questionnaire-based Investigation

Background:

Paramedics, arriving on emergency cases first, have to make end-of-life decisions almost on a daily basis. Faith shapes attitudes toward the meaning and worth of life itself and therefore influences decision-making.

Objective:

The objective of this study was to detect whether or not religious and spiritual beliefs influence paramedics in their workday life concerning end-of-life decisions, and whether it is legally possible for them to act according to their conscience.

Methods and Design:

This is a literature review of prior surveys on the topic using five key words and questionnaire-based investigation using a self-administered online survey instrument.

Settings/Participants:

Paramedics all over Germany were given the opportunity to participate in this online questionnaire-based study.

Measurements:

Two databases were searched for prior studies for literature review. Participants were asked about their religiosity, how it affects their work, especially in end-of-life situations, how experienced they are, and whether or not they have any legal latitude to withhold resuscitation.

Results:

A total of 429 paramedics answered the questionnaire. Religious paramedics would rather hospitalize a patient holding an advance directive than leave him/her at home (P = 0.036) and think death is less a part of life than the nonreligious (P = 0.001). Otherwise, the Spearman's rho correlation was statistically insignificant for all tests regarding resuscitation.

Conclusions:

The paramedic's religiosity is not the prime factor in his/her decision-making regarding resuscitation.

Nurses' perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada

We conducted a survey in a random sample of 514 Quebec nurses caring for the elderly to assess their attitudes towards extending medical aid in dying to incompetent patients and to explore associated factors. Attitudes were measured using clinical vignettes featuring a hypothetical patient with Alzheimer disease. Vignettes varied according to the stage of the disease (advanced or terminal) and the presence or absence of a written request. Of the 291 respondents, 83.5% agreed with the current legislation that allows physicians to administer aid in dying to competent patients who are at the end of life and suffer unbearably. A similar proportion (83%, p = 0.871) were in favor of extending medical aid in dying to incompetent patients who are at the terminal stage of Alzheimer disease, show signs of distress, and have made a written request before losing capacity.

Should Medical Assistance in Dying Be Extended to Incompetent Patients With Dementia? Research Protocol of a Survey Among Four Groups of Stakeholders From Quebec, Canada

BACKGROUND

Alzheimer's disease and related disorders affect a growing number of people worldwide. Quality of life is generally good in the early stages of these diseases. However, many individuals fear living through the advanced stages. Such fears are triggering requests for medical assistance in dying (MAiD) by patients with dementia. Legislation was recently passed in Canada and the province of Quebec allowing MAiD at the explicit request of a patient who meets a set of eligibility criteria, including competence. Some commentators have argued that MAiD should be accessible to incompetent patients as well, provided appropriate safeguards are in place. Governments of both Quebec and Canada are currently considering whether MAiD should be accessible through written requests made in advance of loss of capacity.

OBJECTIVE

Aimed at informing the societal debate on this sensitive issue, this study will compare stakeholders' attitudes towards expanding MAiD to incompetent patients with dementia, the beliefs underlying stakeholders' attitudes on this issue, and the value they attach to proposed safeguards. This paper describes the study protocol.

METHODS

Data will be collected via a questionnaire mailed to random samples of community-dwelling seniors, relatives of persons with dementia, physicians, and nurses, all residing in Quebec (targeted sample size of 385 per group). Participants will be recruited through the provincial health insurance database, Alzheimer Societies, and professional associations. Attitudes towards MAiD for incompetent patients with dementia will be elicited through clinical vignettes featuring a patient with Alzheimer's disease for whom MAiD is considered towards the end of the disease trajectory. Vignettes specify the source of the request (from the patient through an advance request or from the patient's substitute decision-maker), manifestations of suffering, and how close the patient is to death. Arguments for or against MAiD are used to elicit the beliefs underlying respondents' attitudes.

RESULTS

The survey was launched in September 2016 and is still ongoing. At the time of submission, over 850 respondents have returned the questionnaire, mostly via mail.

CONCLUSIONS

This study will be the first in Canada to directly compare views on MAiD for incompetent patients with dementia across key stakeholder groups. Our findings will contribute valuable data upon which to base further debate about whether MAiD should be accessible to incompetent patients with dementia, and if so, under what conditions.

Effects of facilitated family case conferencing for advanced dementia: A cluster randomised clinical trial

Background

Palliative care planning for nursing home residents with advanced dementia is often suboptimal. This study compared effects of facilitated case conferencing (FCC) with usual care (UC) on end-of-life care.

Methods

A two arm parallel cluster randomised controlled trial was conducted. The sample included people with advanced dementia from 20 Australian nursing homes and their families and professional caregivers. In each intervention nursing home (n = 10), Palliative Care Planning Coordinators (PCPCs) facilitated family case conferences and trained staff in person-centred palliative care for 16 hours per week over 18 months. The primary outcome was family-rated quality of end-of-life care (End-of-Life Dementia [EOLD] Scales). Secondary outcomes included nurse-rated EOLD scales, resident quality of life (Quality of Life in Late-stage Dementia [QUALID]) and quality of care over the last month of life (pharmacological/non-pharmacological palliative strategies, hospitalization or inappropriate interventions).

Results

Two-hundred-eighty-six people with advanced dementia took part but only 131 died (64 in UC and 67 in FCC which was fewer than anticipated), rendering the primary analysis under-powered with no group effect seen in EOLD scales. Significant differences in pharmacological (P < 0.01) and non-pharmacological (P < 0.05) palliative management in last month of life were seen. Intercurrent illness was associated with lower family-rated EOLD Satisfaction with Care (coefficient 2.97, P < 0.05) and lower staff-rated EOLD Comfort Assessment with Dying (coefficient 4.37, P < 0.01). Per protocol analyses showed positive relationships between EOLD and staff hours to bed ratios, proportion of residents with dementia and staff attitudes.

Conclusion

FCC facilitates a palliative approach to care. Future trials of case conferencing should consider outcomes and processes regarding decision making and planning for anticipated events and acute illness.

Trial registration

Australian New Zealand Clinical Trial Registry ACTRN12612001164886

Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty

Background

In most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis.

Methods

To capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature.

Results

Initial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies.

Conclusions

Together these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury.

Electronic supplementary material

The online version of this article (doi:10.1186/s12910-016-0129-x) contains supplementary material, which is available to authorized users.

End of life care: The experiences of advance care planning amongst family caregivers of people with advanced dementia – A qualitative study

Background

End of life decisions for people with advanced dementia are reported as often being difficult for families as they attempt to make appropriate and justified decisions.

Aim

To explore the experiences of advance care planning amongst family caregivers of people with advanced dementia.

Design

Qualitative research including a series of single cases (close family relatives).

Methods

A purposive sample of 12 family caregivers within a specialist dementia unit was interviewed about their experiences of advance care planning between August 2009 and February 2010.

Results/Findings

Family caregivers need encouragement to ask the right questions during advance care planning to discuss the appropriateness of nursing and medical interventions at the end of life.

Conclusions

Advance care planning can be facilitated with the family caregiver in the context of everyday practice within the nursing home environment for older people with dementia.

Nursing staff and euthanasia in the Netherlands. A nation-wide survey on attitudes and involvement in decision making and the performance of euthanasia

OBJECTIVES

To give insight into Dutch nursing staff's attitudes and involvement regarding euthanasia.

METHODS

The sample was recruited from a nation-wide existent research panel of registered nurses and certified nursing assistants. Descriptive analyses and multivariate logistic regression analyses were performed.

RESULTS

587 respondents (response of 65%) completed the questionnaire. The majority (83%) state that physicians have to discuss the decision about euthanasia with the nurses involved. Besides, 69% state that a physician should discuss a euthanasia request with nurses who have regular contact with a patient. Nursing staff who have religious or other beliefs that they consider important for their attitude towards end-of-life decisions, and staff working in a hospital or home care, are most likely to have this opinion. Being present during the euthanasia is quite unusual: only a small group (7%) report that this has ever been the case in their entire working life. Seven% (incorrectly) think they are allowed to administer the lethal drugs.

CONCLUSION

The majority want to be involved in decision-making processes about euthanasia. Not all are aware that they are not legally allowed to administer the lethal drugs.

PRACTICE IMPLICATIONS

Nursing staff should be informed of relevant existing legislation and professional guidelines.

Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies

AIM

The aim of the present study was to investigate the proportion of physicians and nurses who agree with the administration of antibiotic therapy (AT), artificial hydration (AH), and artificial nutrition (AN) in patients with advanced dementia and different life expectancies. Furthermore, we aimed at analyzing the correlates of the opinion according to which medical treatments should no longer be given to advanced dementia patients once their life expectancy falls.

METHODS

End-of-life decisions and opinions were measured with a questionnaire that was sent to geriatric units, hospices and nursing homes in three different regions of Italy. Multivariate logistic regressions were carried out to ascertain the correlates of the agreement with the administration of AH, AT or AN.

RESULTS

When the patient's life expectancy was 1-6 months, 83% of respondents agreed with AH, 79% with AT and 71% with AN. When the life expectancy was less than 1 month, a large proportion of respondents still agreed with AH and AT (73% and 61%), whereas less than one in two respondents (48%) agreed with AN.

CONCLUSIONS

The findings of the present study showed that AN creates more ethical dilemmas in the clinical management of end of life than other treatments, such as AH or AT. Opinions on whether or not these practices are appropriate at the end of life were related with feelings, thoughts and ethical issues that played a different part for physicians and nurses. Geriatr Gerontol Int 2017; 17: 487-493.

Antibiotic use and associated factors in patients with dementia: a systematic review

BACKGROUND

Infections frequently occur in patients with dementia and antibiotics are often prescribed, but may also be withheld.

OBJECTIVES

The aim of this systematic review is to provide a systematic overview of the prevalence of antibiotic use, and factors associated with prescribing antibiotics in patients with dementia.

DATA SOURCES

A systematic search of MEDLINE, EMBASE, PSYCINFO, CINAHL, and the Cochrane library databases until February 13, 2014 was performed, using both controlled terms and free-text terms.

RESULTS

Thirty-seven articles were included. The point prevalence of antibiotic use in patients with dementia ranged from 3.3 to 16.6%. The period prevalence ranged from 4.4 to 88% overall, and from 23.5 to 94% in variable time frames before death; the median use was 52% (median period 14 days) and 48% (median period 22 days), respectively. Most patients with lower respiratory tract infections or urinary tract infections (77-91%) received antibiotic treatment. Factors associated with antibiotic use related to patients, families, physicians, and the healthcare context. More severe dementia and a poor prognosis were associated with less antibiotic use in various countries. Associations with aspiration and illness severity differed by country.

CONCLUSIONS AND IMPLICATIONS

Antibiotic use in patients with dementia is substantial, and probably highly associated with the particular healthcare context. Future studies may report antibiotic use by infection type and stage of dementia, and compare cross-nationally.

First Do No Harm: Euthanasia of Patients with Dementia in Belgium

In Memory of Ed Pellegrino. Euthanasia in Belgium is not limited to terminally ill patients. It may be applied to patients with chronic degenerative diseases. Currently, people in Belgium wish to make it possible to euthanize incompetent patients who suffer from dementia. This article explains the Belgian law and then explores arguments for and against euthanasia of patients with dementia. It probes the dementia paradox by elucidating Dworkin's distinction between critical and experiential interests, arguing that at the end-of-life this distinction is not clearcut. It argues against euthanasia for patients with dementia, for respecting patients' humanity and for providing them with more care, compassion, and good doctoring.

Advance Directives and Communication Skills of Prehospital Physicians Involved in the Care of Cardiovascular Patients

Advance directives (AD) were developed to respect patient autonomy. However, very few patients have AD, even in cases when major cardiovascular surgery is to follow. To understand the reasons behind the low prevalence of AD and to help decision making when patients are incompetent, it is necessary to focus on the impact of prehospital practitioners, who may contribute to an increase in AD by discussing them with patients. The purpose of this study was to investigate self-rated communication skills and the attitudes of physicians potentially involved in the care of cardiovascular patients toward AD.Self-administered questionnaires were sent to general practitioners, cardiologists, internists, and intensivists, including the Quality of Communication Score, divided into a General Communication score (QOCgen 6 items) and an End-of-life Communication score (QOCeol 7 items), as well as questions regarding opinions and practices in terms of AD.One hundred sixty-four responses were received. QOCgen (mean (±SD)): 9.0/10 (1.0); QOCeol: 7.2/10 (1.7). General practitioners most frequently start discussions about AD (74/149 [47%]) and are more prone to designate their own specialty (30/49 [61%], P < 0.0001). Overall, only 57/159 (36%) physicians designated their own specialty; 130/158 (82%) physicians ask potential cardiovascular patients if they have AD and 61/118 (52%) physicians who care for cardiovascular patients talk about AD with some of them.The characteristics of physicians who do not talk about AD with patients were those who did not personally have AD and those who work in private practices.One hundred thirty-three (83%) physicians rated the systematic mention of patients' AD in the correspondence between physicians as good, while 114 (71%) at the patients' first registration in the private practice.Prehospital physicians rated their communication skills as good, whereas end-of-life communication was rated much lower. Only half of those surveyed speak about AD with cardiovascular patients. The majority would prefer that physicians of another specialty, most frequently general practitioners, initiate conversation about AD. In order to increase prehospital AD incidence, efforts must be centered on improving practitioners' communication skills regarding death, by providing trainings to allow physicians to feel more at ease when speaking about end-of-life issues.

Pragmatic cluster randomised controlled trial of facilitated family case conferencing compared with usual care for improving end of life care and outcomes in nursing home residents with advanced dementia and their families: the IDEAL study protocol

BACKGROUND

Care for people with advanced dementia requires a palliative approach targeted to the illness trajectory and tailored to individual needs. However, care in nursing homes is often compromised by poor communication and limited staff expertise. This paper reports the protocol for the IDEAL Project, which aims to: 1) compare the efficacy of a facilitated approach to family case conferencing with usual care; 2) provide insights into nursing home- and staff-related processes influencing the implementation and sustainability of case conferencing; and 3) evaluate cost-effectiveness.

DESIGN/METHODS

A pragmatic parallel cluster randomised controlled trial design will be used. Twenty Australian nursing homes will be randomised to receive either facilitated family case conferencing or usual care. In the intervention arm, we will train registered nurses at each nursing home to work as Palliative Care Planning Coordinators (PCPCs) 16 h per week over 18 months. The PCPCs' role will be to: 1) use evidence-based 'triggers' to identify optimal time-points for case conferencing; 2) organise, facilitate and document case conferences with optimal involvement from family, multi-disciplinary nursing home staff and community health professionals; 3) develop and oversee implementation of palliative care plans; and 4) train other staff in person-centred palliative care. The primary endpoint will be symptom management, comfort and satisfaction with care at the end of life as rated by bereaved family members on the End of Life in Dementia (EOLD) Scales. Secondary outcomes will include resident quality of life (Quality of Life in Late-stage Dementia [QUALID]), whether a palliative approach is taken (e.g. hospitalisations, non-palliative medical treatments), staff attitudes and knowledge (Palliative Care for Advanced Dementia [qPAD]), and cost effectiveness. Processes and factors influencing implementation, outcomes and sustainability will be explored statistically via analysis of intervention 'dose' and qualitatively via semi-structured interviews. The pragmatic design and complex nature of the intervention will limit blinding and internal validity but support external validity.

DISCUSSION

The IDEAL Project will make an important contribution to the evidence base for dementia-specific case conferencing in nursing homes by considering processes and contextual factors as well as overall efficacy. Its strengths and weaknesses will both lie in its pragmatic design.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12612001164886. Registered 02/11/2012.

Health care professionals' perspectives of advance care planning for people with dementia living in long-term care settings: A narrative review of the literature

This paper provides an overview of the evidence on the perspective of health care professionals (HCPs) in relation to advance care planning (ACP) for people with dementia, residing in long-term care settings. A narrative approach was adopted to provide a comprehensive synthesis of previously published literature in the area. A systematic literature search identified 14 papers for inclusion. Following review of the studies four themes were identified for discussion; Early integration and planning for palliative care in dementia; HCPs ethical and moral concerns regarding ACP; Communication challenges when interacting with the person with dementia and their families and HCPs need for education and training. Despite evidence, that HCPs recognise the potential benefits of ACP, they struggle with its implementation in this setting. Greater understanding of dementia and the concept of ACP is required to improve consistency in practice. Synthesising the existing evidence will allow for further understanding of the key issues, potentially resulting in improved implementation in practice.

Euthanasia and physician-assisted suicide in dementia: A qualitative study of the views of former dementia carers

BACKGROUND

Despite media and academic interest on assisted dying in dementia, little is known of the views of those directly affected.

AIM

This study explored the views of former carers on assisted dying in dementia.

DESIGN

This was a qualitative study using thematic analysis.

SETTING/PARTICIPANTS

A total of 16 former carers of people with dementia were recruited through national dementia charities and participated in semi-structured interviews.

RESULTS

While many supported the individual's right to die, the complexity of assisted dying in dementia was emphasized. Existential, physical, psychological and psychosocial aspects of suffering were identified as potential reasons to desire an assisted death. Most believed it would help to talk with a trained health professional if contemplating an assisted death.

CONCLUSION

Health workers should be mindful of the holistic experience of dementia at the end of life. The psychological and existential aspects of suffering should be addressed, as well as relief of physical pain. Further research is required.

Old age and forgoing treatment: a nationwide mortality follow-back study in the Netherlands

BACKGROUND

The ageing of the population raises the need to study forgoing treatment decisions among older people.

AIM

To describe the incidence and decision-making of forgoing treatment and identify age-related differences.

METHODS

A nationwide study of a stratified sample from the Statistics Netherlands death registry to which all deaths were reported in 2010. All attending physicians of those deaths received a questionnaire about end-of-life decisions. 6600 cases were studied. We examined three age groups: 17-64, 65-79, and 80 and above. Logistic regression analyses were performed to identify age-related differences controlling for other patient characteristics.

RESULTS

Forgoing treatment occurred in 37% of the total population, with a significant increase in the incidence across age. The most common treatments withheld/withdrawn were artificial hydration/nutrition, medication and antibiotics. Age-related differences were found, especially for withholding artificial hydration/nutrition among patients aged 65-79 (OR 2.04), and for withdrawing medication (OR 2.51) and antibiotics (OR 2.10) among the oldest when compared to the youngest patients. The most common reason for making the decision was 'no chance of improvement'. The likelihood of forgoing treatment due to 'loss of dignity' was higher for the oldest (OR 2.32), as well as due to the request/wish of the patient (OR 1.97), when compared to the youngest patients.

CONCLUSIONS

Forgoing treatment occurred in a substantial proportion of older people, and more often than in younger age groups. The avoidance of burdensome treatment solely to prolong life suggests a better acceptance that these patients are nearing death.

Depression of Family Caregivers Is Associated with Disagreements on Life-Sustaining Preferences for Treating Patients with Dementia

Background

Family caregivers may not agree with patients with dementia regarding attitudes toward end-of-life preferences, and the effects of this type of disagreement are not well understood. This study sought to identify such a disagreement and its predictors.

Methods

A cross-sectional sample of 84 family caregivers and patients with dementia was recruited from memory clinics. We used the Mini-Mental State Examination, Neuropsychiatric Inventory, Clinical Dementia Rating, and Katz index of independence in activities of daily living to assess patient symptoms, functions, and severity of dementia. Caregivers completed questionnaires on perceived patient end-of-life care preferences, caregiver end-of-life care preferences for patients, Zarit Burden Interview (ZBI), Center for Epidemiological Studies–Depression Scale (CES-D), and knowledge of clinical complications of advanced dementia.

Results

The self-disclosure rates of patient preferences were 34.5% for tube feeding, 39.3% for cardiopulmonary resuscitation, and 45.2% for mechanical ventilation. For patients who had disclosed preferences, the disagreement rate between them and their caregivers was 48.3% for tube feeding, 48.5% for cardiopulmonary resuscitation, and 60.3% for mechanical ventilation. Caregiver depression (i.e., CES-D ≥16) was associated with disagreements on cardiopulmonary resuscitation (adjusted odds ratio (aOR) = 6.6, 95% CI = 1.4–31.1, P = 0.01) and mechanical ventilation (aOR = 14, 95% CI = 2.2–87.2, P = 0.005) preferences.

Conclusion

The preferences of end-of-life issues differed greatly between dementia patients and their caregivers. Depression in caregivers is associated with such discrepancy.

Findings on Advance Care Plans among Cognitively Impaired Older Adults

Cognitively impaired and cognitively intact older adults seemingly differ regarding engagement in aspects of advance care plans (ACPs). Through informant reports in the Canadian Study on Health and Aging, we examined differences between deceased cognitively impaired and intact older adults in components of ACPs: (1) discussions/arrangements for end-of-life care; (2) creation of legal documents; and in ACP outcomes, (3) location of death; and (4) dying in accordance with wishes. Cognitively impaired older adults were more likely to have made arrangements for a substitute decision-maker (OR = 1.90) and to have created legal documents (OR = 2.64 for health care preferences, OR = 2.00 for naming a decision-maker). They were less likely to have discussed preferences for end-of-life care (OR = 0.62). These findings suggest that ACPs differ for cognitively impaired persons, indicating a need for further investigation. This is a step towards understanding this complex process in a particularly vulnerable population.

Attitudes of belgian students of medicine, philosophy, and law toward euthanasia and the conditions for its acceptance

Euthanasia is legal in Belgium if due care criteria are met, which is judged by committees including physicians, ethicists, and jurists. We examined whether students in these disciplines differ in how they judge euthanasia as an acceptable act. A cross-sectional, anonymous e-mail survey revealed that they have similar attitudes and accept its legalization. Therefore, joint decision-making of physicians, ethicists, and lawyers regarding euthanasia seems to have a common attitudinal base in Belgium. However, they differ to some extent regarding the conditions they put forward for euthanasia being acceptable. Philosophy of life (religion) was an independent predictor of these attitudes.

Assisted dying in dementia: a systematic review of the international literature on the attitudes of health professionals, patients, carers and the public, and the factors associated with these

BACKGROUND

Assisted death and dementia is a controversial topic that, in recent years, has been subject to considerable clinical, ethical and political debate.

OBJECTIVE

This paper reviews the international literature on attitudes towards assisted dying in dementia and considers the factors associated with these.

DESIGN

A systematic literature search was conducted in Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, PsychINFO and Web of Science between 1992 and August 2013. Electronic and hand searches identified 118 potential relevant studies. Eighteen studies met the full inclusion criteria and were screened using a quality assessment tool.

RESULTS

Health professionals hold more restrictive views towards assisted dying, which appear less affected by their cultural background, than the public, patients and carers. However, opinions within each population vary according to dementia severity and issues of capacity, as well as differing according to factors such as age, ethnicity, gender and religion of those surveyed. There also appears to be a trend towards more accepting attitudes over time.

CONCLUSIONS

Sociodemographic factors can influence attitudes towards assisted dying. The impact of these, however, may also differ according to the population surveyed. The findings from this review can contribute to current debates and inform clinical practice and future research in this area.

[The attitude among nursing professionals and students when facing death: a review of the scientific literature of the last decade]

Nursing professionals are integral members of the healthcare team and they maintain the most direct and prolonged contact with patients experiencing a terminal illness. This integrative review of the literature sought to investigate the attitude towards death among nursing professionals and students. Data were collected through searches in Lilacs, Medline, PsycINFO and CINAHL databases using the key words "nurses" and "attitude to death" in the period from 2000 to 2011. Of the 1376 articles identified, 262 were selected for data extraction and 35 were downloaded in full, constituting the corpus of research. The results showed a predominance of articles published in Brazilian journals. Studies indicate that the subject of death and dying has been neglected in training institutions, which causes hardship among professionals and nursing students when faced with the issue in practice, in addition to inappropriate conduct when dealing with patients who are experiencing the end of life process. In conclusion, the need for future research that may provide more detailed clarifications on the subject and seek strategies to address the lack of preparation and support of the nursing staff when they cope with death and dying was emphasized.