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Payne J, Sadeghi MA, Liu J, Siess S, Moyer A. The comprehensiveness and comprehensibility of publicly-available, state-approved advance directive documents. PSYCHOL HEALTH MED 2023; 28:3131-3148. [PMID: 35477323 DOI: 10.1080/13548506.2022.2067341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
The COVID-19 pandemic has increased attention to end-of-life decision-making and advance care planning. Advance directives (ADs) are documents that express an individual's wishes regarding their medical care if they are incapacitated and may appoint someone to make decisions for them. The purpose of the current study was to evaluate the comprehensiveness and comprehensibility of the widely available state-approved AD documents provided to the public online. Their content was coded using a grounded theory approach, and the reading level of the documents was assessed. Preferences related to important issues, such as pain relief, were commonly included (92.2% of forms), but other issues, such as whether someone would approve of artificial respiration (39.2%) or CPR (35.3%), were less often addressed. The average reading level of the forms (M = grade 7.64; SD = 1.28) was above the recommended 5th grade level. Overall, there was meaningful variability in the comprehensiveness and comprehensibility of AD documents, suggesting incompatibility for those recording their end-of-life preferences across states and the need for future work to increase their user-friendliness and ability to record authentic advance care wishes.
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Affiliation(s)
- Jackelyn Payne
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | | | - Jaimie Liu
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | - Samantha Siess
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | - Anne Moyer
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
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2
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Fleischmann C, Henking T, Neuderth S. [Knowledge and misconceptions on advance directives-results of a citizen survey]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:1172-1182. [PMID: 37592089 PMCID: PMC10539417 DOI: 10.1007/s00103-023-03751-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 07/10/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Advance directives (ADs) such as living wills or healthcare powers of attorney are important tools to anticipate medical treatment decisions when decision-making capacity is lost in the future. Although a rising number of citizens in Germany are creating such documents, little is known about their knowledge of the purpose, types, and use of ADs. After more than 10 years since legislation on ADs came into force, this study intends to measure the objective knowledge of citizens and detect deficits in knowledge. METHODS We conducted a cross-sectional quantitative survey of citizens aged 18+ in the city and county of Wuerzburg. The questionnaire included, among other things, possession, experience, and knowledge of ADs. Sampling was conducted via advertising and local networking. RESULTS Of the 282 participants who took part in the survey (Mage = 50 years, 2/3 female), 43.4% reported having created a minimum of one document. In the knowledge test, an average of 22/34 points was achieved. While questions about the specific application of ADs based on a case study were often answered correctly, we found deficits about the single document types. The results in the knowledge test and the variables on the subjective level of knowledge correlate positively. DISCUSSION The relatively high rate of ADs in this sample indicates their rapid dissemination during the past few years in Germany. Overall, the level of knowledge ADs appears to be low, revealing misconceptions about the creator's and involved people's rights and obligations. The measured knowledge level contradicts with the frequently expressed desire of citizens to preserve their autonomy by creating ADs for themselves.
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Affiliation(s)
- Carolin Fleischmann
- Institut für Angewandte Sozialwissenschaften, Technische Hochschule Würzburg-Schweinfurt, Münzstr. 12, 97070, Würzburg, Deutschland.
| | - Tanja Henking
- Institut für Angewandte Sozialwissenschaften, Technische Hochschule Würzburg-Schweinfurt, Münzstr. 12, 97070, Würzburg, Deutschland
| | - Silke Neuderth
- Institut für Angewandte Sozialwissenschaften, Technische Hochschule Würzburg-Schweinfurt, Münzstr. 12, 97070, Würzburg, Deutschland
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3
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Chen DR, Weng HC. Associations of health literacy, personality traits, and pro-individualism with the willingness to complete advance directives in Taiwan. BMC Palliat Care 2023; 22:91. [PMID: 37424005 DOI: 10.1186/s12904-023-01215-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Studies indicated that patients with advance directives (ADs) have a generally better quality of life near death. Yet, the concept of ADs is relatively new in East Asian countries. This study examined the associations between health literacy, pro-individualism in end-of-life (EOL) decisions (i.e., EOL pro-individualism), and master-persistence personality traits with the willingness to complete ADs. METHODS The data is from a representative data of 1478 respondents from the 2022 Taiwan Social Change Survey. Generalized structural equation modeling (GSEM) was used to conduct path analysis. RESULTS Nearly half of the respondents (48.7%) were willing to complete ADs. Health literacy has direct and indirect effects through EOL pro-individualism values on the willingness to complete ADs. Noncognitive factors such as mastery-persistence personality traits and EOL pro-individualism values enhanced the willingness to complete ADs. CONCLUSION A personalized communication strategy, mindful of personality dimensions and cultural values, can address individual fears and concerns, promoting the benefits of advance care planning (ACP). These influences can provide a roadmap for healthcare providers to customize their approach to ACP discussions, improving patient engagement in AD completion.
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Affiliation(s)
- Duan-Rung Chen
- Institute of Health Behaviors and Community Sciences, College of Public Health, National Taiwan University, Taipei, Taiwan.
- Population Health Research Center, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Hui-Ching Weng
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Pedrosa Carrasco AJ, Berlin P, Betker L, Riera-Knorrenschild J, von Blanckenburg P, Seifart C. Developing a care pathway for hospital-based advance care planning for cancer patients: A modified Delphi study. Eur J Cancer Care (Engl) 2022; 31:e13756. [PMID: 36268891 DOI: 10.1111/ecc.13756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/03/2022] [Accepted: 10/09/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective of this study is to develop a care pathway for a hospital-based advance care planning service for cancer patients. METHODS A web-based modified Delphi study consulted an expert panel consisting of a convenience sample of stakeholders including professionals with a special interest in advance care planning as well as a 'public and patient involvement group'. After generating ideas for core elements of a care pathway in the first round, numerical ratings and rankings informed the multi-professional research steering group's decision process eventually resulting in a final pathway. RESULTS The 41 participants in the Delphi study identified 177 potential core elements of the pathway in the first round. In two further rounds, consensus was reached on a final version of the pathway with 148 elements covering the 10 domains: prerequisites, organisation and coordination, identification and referral, provision of information, information sources, family involvement, advance care planning discussion, documentation, update and quality assurance. CONCLUSION We propose a care pathway for advance care planning for hospital patients with cancer based on the results of a Delphi study that reached consensus on an implementation strategy. Our study pioneers the standardisation of the process and provides input for further policy and research with the aim of aligning cancer patients' care with their preferences and values.
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Affiliation(s)
| | - Pia Berlin
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Liv Betker
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Jorge Riera-Knorrenschild
- Department of Haematology, Oncology and Immunology, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Pia von Blanckenburg
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Carola Seifart
- Research Group Medical Ethics, Philipps-University Marburg, Marburg, Germany
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5
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Chen LC, Tu IT, Yu IC, Tung TH, Huang HP, Lin YC, Beaton RD, Jane SW. The explorations of the awareness, contemplation, self-Efficacy, and readiness of advance care planning, and its predictors in Taiwanese patients while receiving hemodialysis treatment. Palliat Care 2022; 21:180. [PMID: 36242014 PMCID: PMC9561320 DOI: 10.1186/s12904-022-01063-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 09/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background End-stage renal disease (ESRD) is a major chronic illness worldwide, and Taiwan reports one of the highest incidence rates of ESRD with 529 cases per million population (pmp). A number of patients with ESRD patients might require lifelong hemodialysis (HD) or peritoneal dialyses (PD). Due to the progression of dialysis, patients are likely to experience other chronic comorbidities, anxiety and depression, frequent hospitalizations, and higher rates of mortality compared to patients with other types of chronic illnesses. As a result, dialysis patients are prone to experience advance care planning (ACP) needs, such as whether they withdraw from receiving dialysis while approaching their end-of-life (EOL). Yet, existing studies have shown that dialysis patients seldom receive timely consultation regarding ACP and there are limited studies examining ACP amongst Taiwan HD patients. Purpose The purpose of this study was to examine ACP awareness, contemplation, self-efficacy and readiness; and factors influencing ACP readiness. Design This cross-sectional descriptive study with convenience sampling was conducted in the out-patient HD unit at a regional teaching hospital in southern Taiwan. A total of 143 ESRD patients undergoing HD treatments were recruited. A 55-item ACP engagement survey containing the subscales of awareness, contemplation, self-efficacy, and readiness was employed. The data were analyzed with t-tests, one-way ANOVAs, Pearson’s correlations and multiple regressions. Results The results of our investigation revealed that approximately half of the participants (n = 67, 46.9%) were not informed of ACP. Although they reported considering their EOL, medical decisions and desired care, they demonstrated significantly low self-efficacy in discussing ACP (t= -5.272, p < 0.001). HD duration influenced all four ACP subscales; religious beliefs significantly influenced ACP-self-efficacy and readiness; and marital status, education, and primary decision-maker status significantly influenced ACP-readiness. The predictors of ACP-readiness were high self-efficacy and being the primary decision-maker (Adjusted R2 61%). Conclusion Most of the HD patients in this study had low ACP-awareness, contemplation, self-efficacy, and readiness, and most had not completed any ACP-related advance directives (AD). Healthcare professionals should proactively provide HD patients with ACP-related information and answer patients’ and medical decision-makers’ questions in a timely manner, thereby improving the quality of EOL care.
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Affiliation(s)
- Li-Chen Chen
- Department of Nursing, Chi-Mei Medical Center, Liouying, Tainan, Taiwan
| | - I-Te Tu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Liouying, Tainan, Taiwan
| | - I-Chen Yu
- Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan City, Taiwan.,Division of Nephrology, Department of Internal Medicine, Chang Gung Memorial Hospital, Lin-Ko, Taiwan
| | - Tao-Hsin Tung
- Evidence-based Medicine Center, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Hsiang-Ping Huang
- Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan City, Taiwan
| | - Yung-Chang Lin
- Division of Hematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Lin-Ko, Taiwan
| | - Randal D Beaton
- Psychosocial & Community Health and Health Services, Schools of Nursing and Public Health, University of Washington, Seattle, USA
| | - Sui-Whi Jane
- Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan City, Taiwan. .,Division of Hematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Lin-Ko, Taiwan.
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6
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Kim IJ. Exploring societal perspectives on priorities at the end of life in South Korea using Q-methodology. Jpn J Nurs Sci 2022; 19:e12495. [PMID: 35678103 DOI: 10.1111/jjns.12495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/10/2022] [Accepted: 05/02/2022] [Indexed: 11/29/2022]
Abstract
AIM To explore societal perspectives on priorities at the end of life in South Korea, an Asian country with high characteristics of Confucian culture. Based on this understanding, this study proposes strategies for establishing well-dying Confucian heritage cultures. METHODS Q-methodology, suitable for analyzing human subjectivity, was used in this study. Thirty-four Q-statements were extracted from the 170 Q population, which were gathered from literature reviews and online resources. Participants were 33 people expected to present diverse views of priorities at the end of their lives. The data were analyzed with principal component analysis and varimax rotations using the PQMethod software. RESULTS Four distinct perspectives on priorities at the end of life in South Korea were identified: "Emphasizing the right to self-determination," "Avoiding burdening the family," "Putting life first," and "Connotations with a complex perspective." CONCLUSIONS This study provides strategies for preparing various nursing interventions or policies for the establishment of a well-dying culture based on the four identified perspectives on priorities at the end of life, especially in countries with Confucian heritage cultures.
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Affiliation(s)
- Ick-Jee Kim
- Department of Nursing, Youngsan University, Yangsan, Gyeongsangnam-do, Republic of Korea
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Mentzelopoulos SD, Chen S, Nates JL, Kruser JM, Hartog C, Michalsen A, Efstathiou N, Joynt GM, Lobo S, Avidan A, Sprung CL. Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill. Crit Care 2022; 26:106. [PMID: 35418103 PMCID: PMC9009016 DOI: 10.1186/s13054-022-03971-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions.
Methods The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset. Results In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008]. Conclusions Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03971-9.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675, Athens, Greece.
| | - Su Chen
- D2, K Lab, Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care Medicine, The University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Christiane Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité University Medicine Berlin, Berlin, Germany.,Klinik Bavaria, Kreischa, Germany
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine, and Pain Therapy, Konstanz Hospital, Konstanz, Germany
| | - Nikolaos Efstathiou
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Suzana Lobo
- Critical Care Division - Faculty of Medicine São José do Rio Preto, São Paulo, Brazil
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Gloeckler S, Krones T, Biller-Andorno N. Advance care planning evaluation: a scoping review of best research practice. BMJ Support Palliat Care 2021:bmjspcare-2021-003193. [PMID: 34667065 DOI: 10.1136/bmjspcare-2021-003193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
Various indicators have been used to evaluate advance care planning, including completion rates, type of care received, and satisfaction. Recent consensus suggests, though, that receiving care consistent with one's goals is the primary outcome of advance care planning and assessment should capture this metric. Goal concordant care is challenging to measure, and there is little clarity about how best to do so. The aim of this scoping review is to explore what methods have been used to measure goal concordant care in the evaluation of advance care planning. PubMed, Embase, PsycINFO, CINAHL and Cochrane were searched in September 2020 to identify studies that aimed to track whether advance care planning affected the likelihood of patients receiving care that matched their preferred care. 135 original studies were included for review. Studies used retrospective chart review (36%, n=49), questionnaire (36%, n=48) and interview (31%, n=42), focusing on both patients and proxies. Studies considered both actual care received (55%, n=74) and hypothetical scenarios anticipating possible future care (49%, n=66); some studies did both. While the reviewed studies demonstrate the possibility of working towards a solid methodology, there were significant weaknesses. Notably, studies often lacked enough reporting clarity to be reproducible and, relatedly, key concepts, such as end-of-life or preferred care, were left undefined. The recommendations that follow from these findings inform future research approaches, supporting the development of a strong evidence base to guide advance care planning implementation in practice.
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Affiliation(s)
- Sophie Gloeckler
- Institute for Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- School of Nursing, Columbia University, New York, New York, USA
| | - Tanja Krones
- Institute for Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- Clinical Ethics, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Nikola Biller-Andorno
- Institute for Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
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Huemer M, Jahn-Kuch D, Hofmann G, Andritsch E, Farkas C, Schaupp W, Masel EK, Jost PJ, Pichler M. Trends and Patterns in the Public Awareness of Palliative Care, Euthanasia, and End-of-Life Decisions in 3 Central European Countries Using Big Data Analysis From Google: Retrospective Analysis. J Med Internet Res 2021; 23:e28635. [PMID: 34542419 PMCID: PMC8491122 DOI: 10.2196/28635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/25/2021] [Accepted: 07/05/2021] [Indexed: 12/25/2022] Open
Abstract
Background End-of-life decisions, specifically the provision of euthanasia and assisted suicide services, challenge traditional medical and ethical principles. Austria and Germany have decided to liberalize their laws restricting assisted suicide, thus reigniting the debate about a meaningful framework in which the practice should be embedded. Evidence of the relevance of assisted suicide and euthanasia for the general population in Germany and Austria is limited. Objective The aim of this study is to examine whether the public awareness documented by search activities in the most frequently used search engine, Google, on the topics of palliative care, euthanasia, and advance health care directives changed with the implementation of palliative care services and new governmental regulations concerning end-of-life decisions. Methods We searched for policies, laws, and regulations promulgated or amended in Austria, Germany, and Switzerland between 2004 and 2020 and extracted data on the search volume for each search term topic from Google Trends as a surrogate of public awareness and interest. Annual averages were analyzed using the Joinpoint Regression Program. Results Important policy changes yielded significant changes in search trends for the investigated topics. The enactment of laws regulating advance health care directives coincided with a significant drop in the volume of searches for the topic of euthanasia in all 3 countries (Austria: −24.48%, P=.02; Germany: −14.95%, P<.001; Switzerland: −11.75%, P=.049). Interest in palliative care increased with the availability of care services and the implementation of laws and policies to promote palliative care (Austria: 22.69%, P=.01; Germany: 14.39, P<.001; Switzerland: 17.59%, P<.001). The search trends for advance health care directives showed mixed results. While interest remained steady in Austria within the study period, it increased by 3.66% (P<.001) in Switzerland and decreased by 2.85% (P<.001) in Germany. Conclusions Our results demonstrate that legal measures securing patients’ autonomy at the end of life may lower the search activities for topics related to euthanasia and assisted suicide. Palliative care may be a meaningful way to raise awareness of the different options for end-of-life care and to guide patients in their decision-making process regarding the same.
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Affiliation(s)
- Matthias Huemer
- Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Daniela Jahn-Kuch
- Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Guenter Hofmann
- Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Andritsch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Clemens Farkas
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Walter Schaupp
- Institute of Moral Theology, University of Graz, Graz, Austria
| | - Eva Katharina Masel
- Clinical Division of Palliative Care, Department of Medicine I and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Philipp J Jost
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,Department of Internal Medicine III - Hematooncology, Technical University of Munich School of Medicine, Technical University of Munich, Munich, Germany
| | - Martin Pichler
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Abstract
Traditional healthcare services have demonstrated structural shortcomings in the delivery of patient care and enforced numerous elements of integration in the delivery of healthcare services. Integrated healthcare aims at providing all healthcare that makes humans healthy. However, with mainly chronically ill people and seniors, typically suffering from numerous comorbidities and diseases, being recruited for care, there is a need for a change in the healthcare service structure beyond direct-patient care to be compatible in peacetime and during public health emergencies. This article’s objective is to discuss the opportunities and obstacles for increasing the effectiveness of healthcare through improved integration. A rapid evidence review approach was used by performing a systematic followed by a non-systematic literature review and content analysis. The results confirmed that integrated healthcare systems play an increasingly important role in healthcare system reforms undertaken in European Union countries. The essence of these changes is the transition from the episodic treatment of acute diseases to the provision of coordinated medical services, focused on chronic cases, prevention, and ensuring patient continuity. However, integrated healthcare, at a level not yet fully defined, will be necessary if we are to both define and attain the integrated practice of both global health and global public health emergencies. This paper attains the necessary global challenges to integrate healthcare effectively at every level of society. There is a need for more knowledge to effectively develop, support, and disseminate initiatives related to coordinated healthcare in the individual healthcare systems.
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Dalmau-Bueno A, Saura-Lazaro A, Busquets JM, Bullich-Marín I, García-Altés A. Advance directives and real-world end-of-life clinical practice: a case-control study. BMJ Support Palliat Care 2021; 12:bmjspcare-2020-002851. [PMID: 33753359 PMCID: PMC9380474 DOI: 10.1136/bmjspcare-2020-002851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Advance directives (ADs) have been legally regulated to promote autonomy over health decisions among patients who later lose decision-making capacity. AIMS AND OBJECTIVES To analyse the differences in clinical practice at end of life among people who had completed an AD versus those who had not. METHODS Retrospective case-control study (1:2), matched by age, sex, year, cause of death and region of residence. The data sources used were the ADs registry, central registry of insured persons, hospital discharge, pharmacy and billing databases, and the mortality registry. Conditional logistic regression models (crude and adjusted by socioeconomic level) were performed. The outcome variable was the frequency of medical procedures performed during the last year of life. RESULTS 1723 people with ADs who died in Catalonia during 2014-2015 were matched with 3446 dead controls (without ADs). Thoracentesis was the procedure with the greatest reduction among women with an AD (adjusted OR (ORadj) 0.54, 95% CI: 0.32 to 0.89) in conjunction with artificial nutrition (ORadj 0.54, 95% CI: 0.31 to 0.95). Intubation was the procedure with the greatest reduction (ORadj 0.56, 95% CI: 0.33 to 0.94) among men. Slight differences could be seen in the case of cancer deaths. There were no relevant differences when adjusting by socioeconomic level. CONCLUSIONS ADs are an effective tool to adjust the realisation of some procedures at end of life. These results can help better plan for the treatment of patients with ADs, as well as increase the awareness among clinical personnel, families and the general population.
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Affiliation(s)
- Albert Dalmau-Bueno
- Catalan Health System Observatory, Agency for Health Quality and Assessment (AQuAS), Barcelona, Spain
| | | | - Josep Ma Busquets
- Ministry of Health, Government of Catalonia, Barcelona, Catalonia, Spain
| | | | - Anna García-Altés
- Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Emergency Healthcare Providers' Knowledge about and Attitudes toward Advance Directives: A Cross-Sectional Study between Nurses and Emergency Medical Technicians at an Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031158. [PMID: 33525577 PMCID: PMC7908551 DOI: 10.3390/ijerph18031158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 12/20/2022]
Abstract
This study aimed to explore and compare knowledge levels about advance directives (ADs) and life-sustaining treatment (LST) plans in end-of-life patients between emergency nurses and emergency medical technicians (EMTs). Using a cross-sectional study design and convenience sampling, 96 nurses and 68 EMTs were recruited from 12 emergency medical centers. A survey on knowledge about and attitudes toward ADs was performed using both online and offline methods between November and December 2019. Emergency healthcare providers were conceptually knowledgeable regarding ADs and LST, although approximately half or fewer had knowledge about ADs (such as the legal process for preparation, family or healthcare providers’ role, and the healthcare proxy). The knowledge levels of nurses and EMTs were moderate. Nurses had significantly greater knowledge relative to EMTs about ADs and LST. Positive attitudes of emergency healthcare providers were also moderately low, with nurses having less positive views than EMTs. Significant differences regarding ADs were found, with younger emergency healthcare providers having fewer career years, no personal end-of-life experiences, and less need for ADs having less knowledge. Emergency healthcare providers’ knowledge about and attitudes toward ADs were moderately low, with EMTs demonstrating a greater knowledge deficit and nurses exhibiting lower positive attitudes. Younger and novice providers had lower knowledge, but younger providers had more positive attitudes, implying that professional education and training should begin early in their careers to enhance their confidence for emergency delivery of advanced care planning.
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13
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Overview of the Motivation of Advance Care Planning: A Study from a Medical Center in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020417. [PMID: 33430302 PMCID: PMC7825806 DOI: 10.3390/ijerph18020417] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/25/2020] [Accepted: 01/04/2021] [Indexed: 01/08/2023]
Abstract
(1) Background: Since Taiwan's Patient Right to Autonomy Act took effect in 2019, up to ten thousand declarants have participated in advance care planning (ACP) and have signed advance directives (ADs). Relative to the entire population of Taiwan, only a small percentage have completed ACP. This study sought to understand the motivations of Taiwanese who have participated in ACP, so as to increase the percentage of individuals participating in ACP and signing ADs; (2) Objectives: To understand the motivations that drive Taiwanese individuals to participate in ACP discussions.; (3) Methods: A retrospective secondary data analysis was performed in this study. The participants consisted of declarants who completed their ACP at a medical center in Taiwan in 2019; (4) Results: During the study period, 946 individuals completed their ACP. Of those declarants, 66.7% were over 60 years of age; 66.5% completed the process in groups of three or more; 49.5% completed their ACP free of charge; and 35 declarants had designated a health care agent (HCA). The declarants' four main motivations for participating in ACP were "looking forward to dying with dignity," "making end-of-life preparations," "fear of being a social and economic burden on family members," and "reluctance to let family members take on the responsibility of making decisions." Furthermore, statistically significant differences were observed between the declarants in terms of gender, age, designation of an HCA, and motivations for participating in ACP. Females, declarants aged below 60 years, and declarants with a designated HCA tended to participate in ACP due to "reluctance to let family members to take on the responsibility of making decisions". Males, declarants aged above 60 years, and declarants without an HCA came for ACP because of "fear of being a social and economic burden on family members". (5) Conclusions: The main motivations of Taiwanese individuals who sought ACP were to die with dignity and to have an early understanding of end-of-life treatment and care models. Secondly, these individuals hoped that their families would not have to take on the responsibility of making decisions. They also did not want to impact their families socially and economically. In this regard, providing economic subsidies might enhance the Taiwanese public's intentions to seek ACP discussions on their own initiative.
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Wang Y, Zhang Y, Hong Y, Zeng P, Hu Z, Xu X, Wang H. Advance directives and end-of-life care: knowledge and preferences of patients with brain Tumours from Anhui, China. BMC Cancer 2021; 21:25. [PMID: 33402101 PMCID: PMC7786498 DOI: 10.1186/s12885-020-07775-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 12/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Mainland China, advance directives (ADs) and end-of-life care for patients with tumours, especially patients with brain tumours who may have lost consciousness or the ability to speak at the early stage of their illness, have been poorly acknowledged. Thus, this study aimed to clarify the knowledge and preferences of ADs and end-of-life care in patients with brain tumours and to investigate predictors of patient preferences. METHODS This was a population-based cross-sectional survey that was conducted via face-to-face interviews. Information on sociodemographic factors, brain tumour illness, knowledge and preferences of the advanced decisions and end-of-life care of the patients was collected. RESULTS A total of 88.61% of participants had never heard of ADs, but 65.18% reported that they would like to make ADs. Knowledge of ADs, receiving surgical treatment or radiotherapy, being younger than 70 years old, being male, having educational qualifications of college or beyond, being childless, having medical insurance for nonworking or working urban residents and self-paying medical expenses were predictors of preference for making ADs. A total of 79.43% of participants wanted to discuss end-of-life arrangements with medical staff, and 63.29% of participants were willing to receive end-of-life care, even though it would not delay death. A total of 65.82% of patients with brain tumours wanted resuscitation, and as many as 45.45% of the patients thought that they did not need life support if they were in a persistent vegetative state. Brain primary tumours, being younger than 70 years old, male sex, educational qualification of junior middle school or below, having children, having new rural cooperative medical insurance and having medical expenses paid by children or spouses were predictors of choosing appropriate palliative care. CONCLUSIONS ADs and end-of-life care have been poorly acknowledged among patients with brain tumours in mainland China. Additional efforts should be encouraged amongst patients with primary brain tumours, those who are undergoing surgery and radiotherapy and those who have low socioeconomic status. A longitudinal and comprehensive study is encouraged to promote disease-specific ADs among Chinese patients with brain tumours.
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Affiliation(s)
- Yixin Wang
- Department of Oncology, Hefei Cancer Hospital; Chinese Academy of Sciences, Hefei, 230031, Anhui, China.,Anhui Provincial Key Laboratory of Medical Physics and Technology,Center of Medical Physics and Technology, HeFei Insititutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, Anhui, China.,University of Science and Technology of China, Hefei, 230026, China
| | - Yongkang Zhang
- Department of Oncology, Hefei Cancer Hospital; Chinese Academy of Sciences, Hefei, 230031, Anhui, China
| | - Yang Hong
- Department of Neurosurgry, The First Affliated Hospital of Anhui Medical University, Hefei, 230022, China
| | - Ping Zeng
- Department of Oncology, Hefei Cancer Hospital; Chinese Academy of Sciences, Hefei, 230031, Anhui, China
| | - Zongtao Hu
- Department of Oncology, Hefei Cancer Hospital; Chinese Academy of Sciences, Hefei, 230031, Anhui, China.,Anhui Provincial Key Laboratory of Medical Physics and Technology,Center of Medical Physics and Technology, HeFei Insititutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, Anhui, China
| | - Xiuli Xu
- Department of Oncology, Hefei Cancer Hospital; Chinese Academy of Sciences, Hefei, 230031, Anhui, China
| | - Hongzhi Wang
- Department of Oncology, Hefei Cancer Hospital; Chinese Academy of Sciences, Hefei, 230031, Anhui, China. .,Anhui Provincial Key Laboratory of Medical Physics and Technology,Center of Medical Physics and Technology, HeFei Insititutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, Anhui, China. .,University of Science and Technology of China, Hefei, 230026, China.
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15
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Karumathil AA, Tripathi R. Culture and Attitudes Towards Euthanasia: An Integrative Review. OMEGA-JOURNAL OF DEATH AND DYING 2020; 86:688-720. [PMID: 33377420 DOI: 10.1177/0030222820984655] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We examine and integrate last two decades of research on euthanasia from a cultural perspective. After an exhaustive search from Scopus and Web of Science, 40 studies matching our criteria are included in the review. We qualitatively summarize the literature country-wise and use text map of co-occurring terms in the titles, keywords, and abstracts of these articles to determine the similarities and differences among sub-themes in continental clusters. Research done in Asian, European, North American, and multi-cultural studies suggests that attributes unique to each culture are instrumental in shaping public attitudes towards euthanasia. We also find that some cultures, despite the prevalence of euthanasia, are underrepresented in empirical research. This review of literature on the cultural nuances in end-of-life decisions such as euthanasia is pertinent to social scientists, healthcare professionals and social workers in any given time, but more so during such critical events as worldwide COVID-19 pandemic.
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Affiliation(s)
- Anjana A Karumathil
- Department of Organizational Behaviour and Human Resources Management, Indian Institute of Management, Bangalore, India
| | - Ritu Tripathi
- Department of Organizational Behaviour and Human Resources Management, Indian Institute of Management, Bangalore, India
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16
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Kawakami A, Kwong EW, Lai CK, Song MS, Boo S, Yamamoto-Mitani N. Advance care planning and advance directive awareness among East Asian older adults: Japan, Hong Kong and South Korea. Geriatr Gerontol Int 2020; 21:71-76. [PMID: 33217170 DOI: 10.1111/ggi.14086] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 09/28/2020] [Accepted: 10/20/2020] [Indexed: 11/28/2022]
Abstract
AIM Population aging is a global phenomenon, and East Asian countries are no exception. However, the use of advance care planning (ACP) and advance directives (ADs) are not widespread in East Asia. This study aimed to examine the awareness of ACP/ADs and its related factors among community-dwelling older persons in Japan, Hong Kong and South Korea. METHODS This was a cross-sectional, cross-cultural questionnaire conducted among a convenience sample of community-dwelling persons. The questionnaire included information regarding awareness of ACP/ADs and personal information. Multiple logistic regression was used assess relationships between awareness of ACP/ADs and potential related factors. RESULTS The sample consisted of 404 community-dwelling older adults: 174 (43.0%) from Japan, 132 (32.7%) from Hong Kong and 98 (24.3%) from South Korea. In total, 122 participants (30.2%) had heard of ACP/ADs. Multiple logistic regression analysis revealed that an educational level >12 years was significantly associated with increased ACP/ADs awareness (adjusted odds ratio [AOR]: 2.19, 95% confidence interval (CI): 1.18-4.07, P = 0.01). The rate of those who have heard of ACP/ADs was significantly higher among Japanese than South Koreans were (AOR: 4.54, 95% CI: 1.64-12.58, P < 0.01), those from Hong Kong than South Korea (AOR: 5.15, 95% CI 1.89-14.0, P < 0.01) after some variables with significant differences among the three countries were controlled. CONCLUSIONS In particular, support tailored to the targets' educational levels will be required. It is also suggested that support is needed to enhance awareness of ACP/ADs in East Asia, although there is a difference in degree of awareness among the three countries. Geriatr Gerontol Int 2021; 21: 71-76.
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Affiliation(s)
- Aki Kawakami
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Enid Wy Kwong
- School of Nursing, Putian University, Putian, China.,School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Claudia Ky Lai
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong.,Division of Nursing Studies, School of Continuing Education, The Hong Kong Baptist University, Kowloon, Hong Kong
| | - Mi Sook Song
- College of Nursing Research Institute of Nursing Sciences, Ajou University, Suwon, South Korea
| | - Sunjoo Boo
- College of Nursing Research Institute of Nursing Sciences, Ajou University, Suwon, South Korea
| | - Noriko Yamamoto-Mitani
- Department of Gerontological Homecare & Long-term Care Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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17
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Seifart C, Koch M, Leppin N, Nagelschmidt K, Knorrenschild JR, Timmesfeld N, Rief W, von Blanckenburg P. Collaborative advance care planning in advanced cancer patients: col-ACP -study - study protocol of a randomised controlled trial. BMC Palliat Care 2020; 19:134. [PMID: 32838763 PMCID: PMC7445911 DOI: 10.1186/s12904-020-00629-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/06/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To assure patient-centred end-of-life care, palliative interventions need to account for patients' preferences. Advance care planning (ACP) is a structured approach that allows patients, relatives and physicians to discuss end-of-life decisions. Although ACP can improve several patient related outcomes, the implementation of ACP remains difficult. The col-ACP-study (collaborative advance care planning) will investigate a new ACP procedure (col-ACP-intervention (German: Hand-in-Hand Intervention)) in palliative cancer patients and their relatives that addresses individual values and targets barriers of communication before an ACP process. METHODS In a randomised controlled trial, 270 cancer patients without curative treatment options and their relatives will receive either 1) col-ACP 2) a supportive intervention (active control group) or 3) standard medical care (TAU). col-ACP comprises two steps: a) addressing various barriers of patients and relatives that discourage them from discussing end-of-life issues followed by b) a regular, structured ACP procedure. The col-ACP-intervention consists of 6 sessions. Primary endpoint is the patients' quality of life 16 weeks after randomisation. Secondary endpoints include measurements of distress; depression; communication barriers; caregivers' quality of life; existence of ACP or advance directives; the consistence of end of life care; and others. Patients will be followed up for 13 months. Multivariate analyses will be carried out. Qualitative evaluation of the intervention will be conducted. DISCUSSION Augmentation of a regular ACP program by a structured psycho-oncological intervention is an innovative approach to target barriers of communication about end-of-life issues. Study findings will help to understand the value of such a combined intervention in palliative care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03387436 (Date of registration: 01/02/2018, retrospectively registered.
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Affiliation(s)
- Carola Seifart
- Institutional Review Board, Clinical Ethics, Philipps-University Marburg, Marburg, Germany
| | - Martin Koch
- Institutional Review Board, Clinical Ethics, Philipps-University Marburg, Marburg, Germany
| | - Nico Leppin
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
| | - Katharina Nagelschmidt
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
| | - Jorge Riera Knorrenschild
- Department of Internal Medicine, Division Hematology and Oncology, University Clinic of Gießen and Marburg, Marburg, Germany
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University Bochum, Bochum, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
| | - Pia von Blanckenburg
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Gutenbergstraße 18, 35032, Marburg, Germany.
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18
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Silies K, Schnakenberg R, Berg A, Kirchner Ä, Langner H, Köberlein-Neu J, Meyer G, Hoffmann F, Köpke S. Process evaluation of a complex intervention to promote advance care planning in community-dwelling older persons (the STADPLAN study)-study protocol. Trials 2020; 21:653. [PMID: 32678005 PMCID: PMC7366302 DOI: 10.1186/s13063-020-04529-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 06/18/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Process evaluation addresses the implementation, mechanisms of impact, and context of participants in complex interventions. The STADPLAN study assesses the effects of conversations on advance care planning (ACP) led by trained nurse facilitators. The complex intervention consists of several components that may lead to various changes in attitude and behavior regarding personal ACP activities. With the process evaluation, we aim to assess how changes were achieved in the STADPLAN intervention. METHODS The planned process evaluation study will be conducted alongside a cluster-randomized controlled trial on ACP in home care services (HCS). Trained nurse facilitators will deliver the ACP intervention consisting of an information brochure and two ACP conversations. A logic model depicts the assumed change processes of the intervention: the educational program enables nurses to conduct ACP conversations with patients and their caregivers. Patients gain knowledge and reflect upon and engage in their own ACP. Caregivers better understand patients' wishes and feel reassured in their role as surrogates. Designation of a surrogate and communication on ACP are facilitated. We will assess the effects of the educational program with questionnaires and a focus group including all participating nurses. We will measure ACP engagement, and prevalence of advance directives in patients, and ask for their experiences with the intervention. We will conduct semi-structured interviews with caregivers about their expectations and experiences regarding ACP in general and the intervention. We will address context factors, e.g., basic characteristics of the HCS (such as ownership, number of clients, staff and qualification). Analysis will be based upon the logic model, integrating qualitative and quantitative data. DISCUSSION The comprehensive process evaluation will provide essential information on the feasibility of implementation strategies and the clinical relevance of a nurse-led ACP intervention in home care recipients and its generalizability and transferability to other settings. TRIAL REGISTRATION German Clinical Trials Register: DRKS00016886 . Registered retrospectively on June 4, 2019, first participant included on May 29, 2019.
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Affiliation(s)
- Katharina Silies
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.
| | - Rieke Schnakenberg
- Department for Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany.
| | - Almuth Berg
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Änne Kirchner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Henriette Langner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Rainer-Gruenter-Straße 21, 42119, Wuppertal, Germany
| | - Gabriele Meyer
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Falk Hoffmann
- Department for Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany
| | - Sascha Köpke
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.,Institute for Nursing Science, University of Cologne, Gleueler Straße 176 - 178, 50935, Köln, Germany
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19
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Schnakenberg R, Silies K, Berg A, Kirchner Ä, Langner H, Chuvayaran Y, Köberlein-Neu J, Haastert B, Wiese B, Meyer G, Köpke S, Hoffmann F. Study on advance care planning in care dependent community-dwelling older persons in Germany (STADPLAN): protocol of a cluster-randomised controlled trial. BMC Geriatr 2020; 20:142. [PMID: 32303198 PMCID: PMC7164271 DOI: 10.1186/s12877-020-01537-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/25/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In Germany, advance care planning (ACP) was first introduced by law in 2015. However, ACP is still uncommon in Germany and only few people have advance directive forms. This study aims to evaluate an ACP program in care dependent community-dwelling persons, compared to optimised usual care. METHODS A cluster-randomised controlled trial of 12 months duration will be conducted in 3 German study sites comparing the pretested ACP-counselling offered by trained nurses with a control group receiving optimised usual care. Using external concealed randomisation, 16 home care services each will be included in the intervention and the control group (30 participants per cluster; n = 960). Eligibility criteria for patients are: ≥60 years, somehow care dependent, adequate German language skills, assumed life-expectancy of ≥4 weeks, and cognitive ability for participation. ACP will be delivered by trained nurse facilitators of the respective home care services and communication will include proxy decision-makers. The primary endpoint will be patient activation, assessed by the Patient Activation Measure (PAM-13). Secondary endpoints include ACP-engagement, proportion of prepared advance directives, number and duration of hospitalisations, quality of life as well as depression and anxiety. Further, comprehensive economic and process evaluations will be conducted. DISCUSSION STADPLAN is the first study in Germany that assesses an adapted ACP intervention with trained nurses in home care services and the first international study focusing on cost effectiveness of ACP in community-dwelling older persons. The results will help to improve the understanding and communicating of patients' preferences regarding medical treatment and care and thereby contribute to patients' autonomy. TRIAL REGISTRATION German Clinical Trials Register: DRKS00016886 (Date of registration: 04.06.2019).
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Affiliation(s)
- Rieke Schnakenberg
- Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Katharina Silies
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Lübeck, Germany
| | - Almuth Berg
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Änne Kirchner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Henriette Langner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Yuliya Chuvayaran
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | | | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Gabriele Meyer
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Sascha Köpke
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Lübeck, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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20
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Druwé P, Benoit DD, Monsieurs KG, Gagg J, Nakahara S, Alpert EA, van Schuppen H, Élő G, Huybrechts SA, Mpotos N, Joly LM, Xanthos T, Roessler M, Paal P, Cocchi MN, Bjørshol C, Nurmi J, Salmeron PP, Owczuk R, Svavarsdóttir H, Cimpoesu D, Raffay V, Pachys G, De Paepe P, Piers R. Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians. J Am Geriatr Soc 2019; 68:39-45. [PMID: 31840239 DOI: 10.1111/jgs.16270] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/29/2019] [Accepted: 09/05/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE). SETTING Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39-45, 2019.
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Affiliation(s)
- Patrick Druwé
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - James Gagg
- Department of Emergency Medicine, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | | | - Hans van Schuppen
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gábor Élő
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Sofie A Huybrechts
- Department of Emergency Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Nicolas Mpotos
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Luc-Marie Joly
- Department of Emergency Medicine, Rouen University Hospital, Rouen, France
| | - Theodoros Xanthos
- European University, Nicosia, Cyprus, Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Markus Roessler
- Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Peter Paal
- Department of Anesthesiology and Critical Care Medicine, Hospitallers Brothers Hospital, Medical University Salzburg, Salzburg, Austria
| | - Michael N Cocchi
- Harvard Medical School, Department of Emergency Medicine and Department of Anesthesia Critical Care and Pain Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Conrad Bjørshol
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, The Regional Centre for Emergency Medical Research and Development (RAKOS), Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Radoslaw Owczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland
| | | | - Diana Cimpoesu
- University of Medicine and Pharmacy Gr.T. Popa and Emergency County Hospital Sf. Spiridon, Iasi, Romania
| | | | - Gal Pachys
- Emergency Department, Sourasky Medical Center, Tel Aviv, Israel
| | - Peter De Paepe
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
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Advance Directive Preferences Among Terminally Ill Older Patients and Its Facilitators and Barriers in China: A Scoping Review. J Am Med Dir Assoc 2019; 20:1356-1361.e2. [DOI: 10.1016/j.jamda.2019.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 05/05/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022]
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Arruda LMD, Abreu KPB, Santana LBC, Sales MVDC. Variables that influence the medical decision regarding Advance Directives and their impact on end-of-life care. EINSTEIN-SAO PAULO 2019; 18:eRW4852. [PMID: 31618287 PMCID: PMC6896595 DOI: 10.31744/einstein_journal/2020rw4852] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 05/30/2019] [Indexed: 11/05/2022] Open
Abstract
The objective of this study was to identify the variables that influence physicians to implement Advance Directives and assess their impact on end-of-life care. It is a narrative literature review of 25 articles published between 1997 and 2018, in the following databases: CAPES, EBSCOhost, BDTD, VHL, Google Scholar, MEDLINE®/PubMed. The keywords utilized were: “advance directives”, “living wills”, “physicians”, “attitude”, “decision making”, “advance care planning”. The main factors that influenced physicians to implemente the directives were patients prognosis, medical paternalism, and patients understanding of their medical condition. Respect for autonomy, lack of knowledge and experience with directives, legal concerns, family influence, cultural and religious factors also contributed to medical decision. Most studies (86%) showed that having a directive led to lower rates of invasive interventions in the last days of patient´s life. Physicians were interested in respecting their patients’ autonomy and agreed that having an advance directive helped in the decision-making process; however, they stated other factors were also taken into account, mainly prognosis and reversibility conditions. Having directives contributed to reducing the use of life support therapies and adoption of comfort measures.
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Quenot JP, Large A, Meunier-Beillard N, Pugliesi PS, Rollet P, Toitot A, Andreu P, Devilliers H, Marchalot A, Ecarnot F, Dargent A, Rigaud JP. What are the characteristics that lead physicians to perceive an ICU stay as non-beneficial for the patient? PLoS One 2019; 14:e0222039. [PMID: 31490986 PMCID: PMC6730882 DOI: 10.1371/journal.pone.0222039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 08/20/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose We sought to describe the characteristics that lead physicians to perceive a stay in the intensive care unit (ICU) as being non-beneficial for the patient. Materials and methods In the first step, we used a multidisciplinary focus group to define the characteristics that lead physicians to consider a stay in the ICU as non-beneficial for the patient. In the second step, we assessed the proportion of admissions that would be perceived by the ICU physicians as non-beneficial for the patient according to our focus group’s definition, in a large population of ICU admissions in 4 French ICUs over a period of 4 months. Results Among 1075 patients admitted to participating ICUs during the study period, 155 stays were considered non-beneficial for the patient, yielding a frequency of 14.4% [95% confidence interval (CI) 8.9, 19.9]. Average age of these patients was 72 ±12.8 years. Mortality was 43.2% in-ICU [95%CI 35.4, 51.0], 55% [95%CI 47.2, 62.8] in-hospital. The criteria retained by the focus group to define a non-beneficial ICU stay were: patient refusal of ICU care (23.2% [95%CI 16.5, 29.8]), and referring physician’s desire not to have the patient admitted (11.6% [95%CI 6.6, 16.6]). The characteristics that led physicians to perceive the stay as non-beneficial were: patient’s age (36.8% [95%CI 29.2, 44.4]), unlikelihood of recovering autonomy (61.9% [95%CI 54.3, 69.6]), prior poor quality of life (60% [95%CI 52.3, 67.7]), terminal status of chronic disease (56.1% [95%CI 48.3, 63.9]), and all therapeutic options have been exhausted (35.5% [95%CI 27.9, 43.0]). Factors that explained admission to the ICU of patients whose stay was subsequently judged to be non-beneficial included: lack of knowledge of patient’s wishes (52% [95%CI 44.1, 59.9]); decisional incapacity (sedation) (69.7% [95%CI 62.5, 76.9]); inability to contact family (34% [95%CI 26.5, 41.5]); pressure to admit (from family or other physicians) (50.3% [95%CI 42.4, 58.2]). Conclusions Non-beneficial ICU stays are frequent. ICU admissions need to be anticipated, so that patients who would yield greater benefit from other care pathways can be correctly oriented in a timely manner.
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Affiliation(s)
- Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand, University Hospital, Dijon, France
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
- * E-mail:
| | - Audrey Large
- Department of Intensive Care, François Mitterrand, University Hospital, Dijon, France
| | - Nicolas Meunier-Beillard
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
- DRCI, USMR, Francois Mitterrand University Hospital, Dijon, France
| | - Paul-Simon Pugliesi
- Department of Intensive Care, William Morey Hospital, Chalon sur Saône, France
| | - Pamina Rollet
- Department of Intensive Care, Nord Franche-Comté Hospital, Trevenans, France
| | - Amaury Toitot
- Department of Intensive Care, Nord Franche-Comté Hospital, Trevenans, France
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand, University Hospital, Dijon, France
| | - Hervé Devilliers
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
- Department of Internal Medicine, François Mitterrand University Hospital, Dijon, France
| | - Antoine Marchalot
- Department of Intensive Care, Dieppe General Hospital, Dieppe, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, France
| | - Auguste Dargent
- Department of Intensive Care, François Mitterrand, University Hospital, Dijon, France
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
| | - Jean-Philippe Rigaud
- Department of Intensive Care, Dieppe General Hospital, Dieppe, France
- Espace de Réflexion Ethique de Normandie, University Hospital Caen, France
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Tekpınar L, Uludağ A. Perspective of Doctors and Nurses on the Principle of Extended Autonomy in Konya, Turkey. OMEGA-JOURNAL OF DEATH AND DYING 2019; 83:884-897. [PMID: 31460839 DOI: 10.1177/0030222819872086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the support with legislation in Turkey regarding extended autonomy and advance directive, there is no clear provision and sufficient practice on the subject. Turkish doctors and nurses are generally unfamiliar with the conception of extended autonomy or advance directive, which raises dilemmas in terms of life-support choice, and this situation can even affect clinical decision-making processes. This study investigated the awareness level about extended autonomy and advance directive in Turkey and assessed doctors and nurses' attitudes toward patient autonomy. This was a quantitative descriptive study. It was found that the 46.8% of the respondents supported the principle of extended autonomy in health service delivery. However, 53.8% of the respondents had poor knowledge regarding advance directive. Majority (77.9%) of the respondents indicated that the legislative arrangements should be made concerning the principle of extended autonomy and the advance directive, which is its field of application.
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Affiliation(s)
- Lütfiye Tekpınar
- Department of Health Management, Faculty of Economics and Administrative Sciences, Süleyman Demirel University, Isparta, Turkey
| | - Ayhan Uludağ
- Department of Health Management, Faculty of Health Sciences, Necmettin Erbakan University, Konya, Turkey
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Allen R, Cohn TM, Edozie C, Howard S, McCrink PR. Outcomes Comparison of Enculturating Advance Directives Process at a Health System. SAGE Open Nurs 2019; 5:2377960819828224. [PMID: 33415222 PMCID: PMC7774410 DOI: 10.1177/2377960819828224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/08/2019] [Accepted: 01/13/2019] [Indexed: 12/21/2022] Open
Abstract
The Center for Medicare and Medicaid Services requires organizations to comply with the Patient Self-Determination Act by having processes that inform patients about their rights to execute an advance directive (AD) and engage in shared decision-making. The aim of this study was to compare AD data from a previous study (1999-2002) to a postenculturation (2011-2015) of a structured process for documented patient's preferences. Second, to conduct a descriptive, bivariate analysis of the enculturated structured ADs process during 2011 and 2015. This descriptive, comparative analysis included 500 random patients from four hospitals, and the enculturated descriptive analysis included 302 patients from six hospitals. Comparisons showed less no ADs and a greater institutional ADs post compared with pre (p < .05). Fifty-four percent of patients from 2011 to 2015 had an AD, and none of them had resuscitative measures when Do-Not-Resuscitate status was ordered. This enculturated process which includes education for health-care professionals and the community facilitates optimal patient, family-centered care.
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Affiliation(s)
- Rose Allen
- Baptist Health South Florida, Miami, FL, USA
| | - Tanya M Cohn
- West Kendall Baptist Hospital, Miami, FL, USA.,Bethesda Hospitals, Boynton Beach, FL, USA
| | - Christine Edozie
- Homestead Hospital, FL, USA.,West Kendall Baptist Hospital, Miami, FL, USA
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Justinger C, Lang T, Serrano Contreras T, Schreiner M, Kehl F, Schön MR. [Patient advanced directives from the perspective of surgery patients-new aspects and aims : Living wills of patients before planned surgery]. Chirurg 2018; 90:299-306. [PMID: 30542807 DOI: 10.1007/s00104-018-0772-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient advance directives and other forms of precautionary medical provisions have arisen from patients' determination to influence and decide about medical treatment even in extreme situations. Although this topic is very present in the media, clinical experience indicates that the majority of patients are not yet aware of this subject. This current investigation aimed to collect data about the familiarity and degree of distribution of patient medical advance directives. Furthermore, it was examined how a routine question concerning patient's provisions in a preoperative setting is perceived by the patients and from which source information about this topic should be provided. METHODS Between April 2017 and October 2017 a total of 200 patients were randomly selected prior to planned surgery and interviewed anonymously using a standardized questionnaire. RESULTS Of the patients surveyed 78.8% stated that they knew about the possibility of patient advance directives. Of the patients interviewed 26.3% stated they had drawn up an advance directive, 20.7% had a precautionary power of attorney and 12.3% had signed a care directive. Among the influencing factors in drawing up an advance directive, age, as well as familial and disease-related causes, were identified as significant factors. The overwhelming majority of respondents (77.6%) wished to be approached on the subject of precautionary medical provisions before a planned operation. CONCLUSION Despite an increasing proportion of patients who have drawn up an advance directive, there is still a great need for information on the subject. Doctors should address patients on the topic before planned interventions.
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Affiliation(s)
- C Justinger
- Klinik für Allgemein- und Visceralchirurgie, Städtisches Klinikum Karlsruhe, Moltkestraße 90, 76133, Karlsruhe, Deutschland.
| | - T Lang
- Klinik für Allgemein- und Visceralchirurgie, Städtisches Klinikum Karlsruhe, Moltkestraße 90, 76133, Karlsruhe, Deutschland
| | | | - M Schreiner
- Klinik für Anästhesie und Intensivmedizin, Städtisches Klinikum Karlsruhe, Karlsruhe, Deutschland
| | - F Kehl
- Klinik für Anästhesie und Intensivmedizin, Städtisches Klinikum Karlsruhe, Karlsruhe, Deutschland
| | - M R Schön
- Klinik für Allgemein- und Visceralchirurgie, Städtisches Klinikum Karlsruhe, Moltkestraße 90, 76133, Karlsruhe, Deutschland
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Schnakenberg R, Radbruch L, Kersting C, Frank F, Wilm S, Becka D, Weckbecker K, Bleckwenn M, Just JM, Pentzek M, Weltermann B. More counselling for end-of-life decisions by GPs with own advance directives: A postal survey among German general practitioners. Eur J Gen Pract 2018; 24:131-137. [PMID: 29547013 PMCID: PMC5917308 DOI: 10.1080/13814788.2017.1421938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although general practitioners (GPs) are among the preferred contact persons for discussing end-of-life issues including advance directives (ADs), there is little data on how GPs manage such consultations. OBJECTIVES This postal survey asked German GPs about their counselling for end-of-life decisions. METHODS In 2015, a two-sided questionnaire was mailed to 959 GPs. GPs were asked for details of their consultations on ADs: frequency, duration, template use, and whether they have own ADs. Statistical analysis evaluated physician characteristics associated with an above-average number of consultations on AD. RESULTS The participation rate was 50.3% (n = 482), 70.5% of the GPs were male; the average age was 54 years. GPs had an average of 18 years of professional experience, and 61.4% serve more than 900 patients per three months. Most (96.9%) GPs perform consultations on living wills (LW) and/or powers of attorney (PA), mainly in selected patients (72.3%). More than 20 consultations each on LWs and PAs are performed by 60% and 50% of GPs, respectively. The estimated mean duration of consultations was 21 min for LWs and 16 min for PAs. Predefined templates were used in 72% of the GPs, 50% of GPs had their ADs. A statistical model showed that GPs with ADs and/or a qualification in palliative medicine were more likely to counsel ≥20 patients per year for each document. CONCLUSION The study confirmed that nearly all German GPs surveyed provide counselling on ADs. Physicians with ADs counsel more frequently than those without such documents.
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Affiliation(s)
- Rieke Schnakenberg
- a Institute of General Practice and Family Medicine, Medical Faculty , University of Bonn , Bonn , Germany
| | - Lukas Radbruch
- b Department of Palliative Medicine , University Hospital Bonn , Bonn , Germany
| | - Christine Kersting
- c General Medicine , Teaching Area RWTH Aachen University , Aachen , Germany
| | - Friederike Frank
- d Institute of General Practice, Medical Faculty , Heinrich Heine University Düsseldorf , Düsseldorf , Germany
| | - Stefan Wilm
- e Department of General Practice, Medical Faculty , Ruhr University of Bochum , Bochum , Germany
| | - Denise Becka
- f Institute for General Medicine , University of Duisburg-Essen , Essen , Germany
| | - Klaus Weckbecker
- a Institute of General Practice and Family Medicine, Medical Faculty , University of Bonn , Bonn , Germany
| | - Markus Bleckwenn
- a Institute of General Practice and Family Medicine, Medical Faculty , University of Bonn , Bonn , Germany
| | - Johannes M Just
- a Institute of General Practice and Family Medicine, Medical Faculty , University of Bonn , Bonn , Germany
| | - Michael Pentzek
- e Department of General Practice, Medical Faculty , Ruhr University of Bochum , Bochum , Germany
| | - Birgitta Weltermann
- c General Medicine , Teaching Area RWTH Aachen University , Aachen , Germany
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Druwé P, Monsieurs KG, Piers R, Gagg J, Nakahara S, Alpert EA, van Schuppen H, Élő G, Truhlář A, Huybrechts SA, Mpotos N, Joly LM, Xanthos T, Roessler M, Paal P, Cocchi MN, BjØrshol C, Pauliková M, Nurmi J, Salmeron PP, Owczuk R, Svavarsdóttir H, Deasy C, Cimpoesu D, Ioannides M, Fuenzalida PA, Kurland L, Raffay V, Pachys G, Gadeyne B, Steen J, Vansteelandt S, De Paepe P, Benoit DD. Perception of inappropriate cardiopulmonary resuscitation by clinicians working in emergency departments and ambulance services: The REAPPROPRIATE international, multi-centre, cross sectional survey. Resuscitation 2018; 132:112-119. [PMID: 30218746 DOI: 10.1016/j.resuscitation.2018.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/16/2018] [Accepted: 09/09/2018] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Cardiopulmonary resuscitation (CPR) is often started irrespective of comorbidity or cause of arrest. We aimed to determine the prevalence of perception of inappropriate CPR of the last cardiac arrest encountered by clinicians working in emergency departments and out-of-hospital, factors associated with perception, and its relation to patient outcome. METHODS A cross-sectional survey was conducted in 288 centres in 24 countries. Factors associated with perception of CPR and outcome were analyzed by Cochran-Mantel-Haenszel tests and conditional logistic models. RESULTS Of the 4018 participating clinicians, 3150 (78.4%) perceived their last CPR attempt as appropriate, 548 (13.6%) were uncertain about its appropriateness and 320 (8.0%) perceived inappropriateness; survival to hospital discharge was 370/2412 (15.3%), 8/481 (1.7%) and 8/294 (2.7%) respectively. After adjusting for country, team and clinician's characteristics, the prevalence of perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 [2.13-6.64]; P < .0001), a non-witnessed arrest (2.68 [1.89-3.79]; P < .0001), in older patients (2.94 [2.18-3.96]; P < .0001, for patients >79 years) and in case of a "poor" first physical impression of the patient (3.45 [2.36-5.05]; P < .0001). In accordance, non-shockable and non-witnessed arrests were both associated with lower survival to hospital discharge (0.33 [0.26-0.41]; P < 0.0001 and 0.25 [0.15-0.41]; P < 0.0001, respectively), as were older patient age (0.25 [0.14-0.44]; P < 0.0001 for patients >79 years) and a "poor" first physical impression (0.26 [0.19-0.35]; P < 0.0001). CONCLUSIONS The perception of inappropriate CPR increased when objective indicators of poor prognosis were present and was associated with a low survival to hospital discharge. Factoring clinical judgment into the decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.
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Affiliation(s)
- Patrick Druwé
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
| | | | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - James Gagg
- Department of Emergency Medicine, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | | | - Hans van Schuppen
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gábor Élő
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Kralove Region and University Hospital Hradec Kralove, Czech Republic
| | - Sofie A Huybrechts
- Department of Emergency Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Nicolas Mpotos
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Luc-Marie Joly
- Department of Emergency Medicine, Rouen University Hospital, Rouen, France
| | - Theodoros Xanthos
- European University, Nicosia, Cyprus, Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Markus Roessler
- Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Peter Paal
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Michael N Cocchi
- Harvard Medical School, Department of Emergency Medicine and Department of Anesthesia, Critical Care and Pain Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, USA
| | - Conrad BjØrshol
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, The Regional Centre for Emergency Medical Research and Development (RAKOS), Department of Clinical Medicine, University of Bergen, Norway
| | - Monika Pauliková
- Department of Anesthesiology and Intensive Care, East Slovak Institute of Oncology, Košice, Slovakia
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | | | - Radoslaw Owczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland
| | | | - Conor Deasy
- Department of Emergency Medicine, Cork University Hospital, Cork, Republic of Ireland
| | - Diana Cimpoesu
- University of Medicine and Pharmacy Gr.T. Popa and Emergency County Hospital Sf. Spiridon, Iasi, Romania
| | | | | | - Lisa Kurland
- Department of Medical Sciences, Örebro University and Department of Clinical Research and Education, Karolinska Institute, Stockholm, Sweden
| | - Violetta Raffay
- Municipal Institute for Emergency Medicine, Novi Sad, Serbia
| | - Gal Pachys
- Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Bram Gadeyne
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Johan Steen
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Stijn Vansteelandt
- Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium; Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter De Paepe
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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Turner AM, Osterhage K, Loughran J, Painter I, Demiris G, Hartzler AL, Phelan EA. Emergency information management needs and practices of older adults: A descriptive study. Int J Med Inform 2018; 111:149-158. [PMID: 29425626 DOI: 10.1016/j.ijmedinf.2017.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 09/08/2017] [Accepted: 12/04/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To better understand how older adults currently manage emergency information, the barriers and facilitators to planning and management of emergency information, as well as the potential role of information technology to facilitate emergency planning and management. INTRODUCTION Older adults face a much higher risk of sudden illness/injury and are the age group with the largest percentages of emergent and urgent healthcare visits. Emergency information (health information needed in an emergency situation such as emergency contact information, diagnoses, and advance directives) needs to be maintained and easily accessible to ensure older adults get appropriate care and treatment consistent with their wishes in emergency situations. Current health information technologies rarely take into consideration the emergency information needs of older adults, their caregivers, and emergency responders. METHODS As part of a larger study we performed in-depth interviews with 90 older adults living in a variety of residential settings (independent living, retirement communities, assisted living) regarding how they manage information about their health. Interview sessions included photos of important health information artifacts. Interviews were transcribed and coded. RESULTS Analysis of in-depth interviews revealed that emergency information is a type of health information that older adults frequently manage. Participants differed in whether they practice emergency planning (e.g. the preparation and continued management of emergency information), and in whether they involve others in emergency information and emergency planning. Despite its importance, emergency information was often not up-to-date and not always kept in locations readily apparent to emergency responders. CONCLUSION Emergency information, such as emergency contact information, diagnoses, and advance directives, is a type of health information that older adults manage. Considering emergency information in the design of health information technologies for older adults could address some of the barriers and support the facilitators to emergency planning and information management.
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Affiliation(s)
- Anne M Turner
- University of Washington, Northwest Center for Public Health Practice, 1107 NE 45th St., Suite 400, Seattle, WA, 98105, USA; Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA; Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, 850 Republican Street, Box 358047, Seattle, WA, 98195, USA, USA.
| | - Katie Osterhage
- University of Washington, Northwest Center for Public Health Practice, 1107 NE 45th St., Suite 400, Seattle, WA, 98105, USA; Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA.
| | - Julie Loughran
- University of Washington, Northwest Center for Public Health Practice, 1107 NE 45th St., Suite 400, Seattle, WA, 98105, USA; Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA.
| | - Ian Painter
- University of Washington, Northwest Center for Public Health Practice, 1107 NE 45th St., Suite 400, Seattle, WA, 98105, USA; Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA.
| | - George Demiris
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, 850 Republican Street, Box 358047, Seattle, WA, 98195, USA, USA; Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Box 357260, University of Washington, Seattle, WA, 98195, USA, USA.
| | - Andrea L Hartzler
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, 850 Republican Street, Box 358047, Seattle, WA, 98195, USA, USA.
| | - Elizabeth A Phelan
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA, USA; Division of Gerontology and Geriatric Medicine, School of Medicine, University of Washington, Harborview Medical Center, 325 9th Ave, Box 359755, Seattle, WA, 98104, USA, USA.
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Quenot JP, Ecarnot F, Meunier-Beillard N, Dargent A, Large A, Andreu P, Rigaud JP. What are the ethical questions raised by the integration of intensive care into advance care planning? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S46. [PMID: 29302602 DOI: 10.21037/atm.2017.08.08] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A major goal of intensive care units (ICUs) is to offer optimal management, but for many patients admitted to the ICU, they are unlikely to yield any lasting benefit. In this context, the ICU physician remains a key intermediary, particularly when a decision regarding possible limitation or withdrawal of life-sustaining therapy becomes necessary. The possibility of admission to the ICU, and the type of care the patient would like to receive there, should be integrated into the healthcare project in agreement with the patient, regardless of the stage of disease that the patient suffers from. These dispositions should be recorded in the patient's file, and should respect the progressive nature of both the disease itself, and the discussions necessary in such complex situations. The ICU physician can serve as a valuable consultant for the treating physician, in particular to guide patient choices when formalizing their healthcare preferences in the form of advance care planning (ACP) or advance directives (AD). Ideally, the best time to address this issue is before the patient's clinical situation deteriorates towards an acute emergency, and providing complete and transparent information to inform the patient's choices.
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Affiliation(s)
- Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France
| | | | - Auguste Dargent
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Audrey Large
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
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Kermel-Schiffman I, Werner P. Knowledge regarding advance care planning: A systematic review. Arch Gerontol Geriatr 2017; 73:133-142. [DOI: 10.1016/j.archger.2017.07.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/20/2017] [Accepted: 07/20/2017] [Indexed: 11/26/2022]
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Impact of a stay in the intensive care unit on the preparation of Advance Directives: Descriptive, exploratory, qualitative study. Anaesth Crit Care Pain Med 2017; 37:113-119. [PMID: 28826983 DOI: 10.1016/j.accpm.2017.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Our objective was to assess, through a qualitative, exploratory study, the thought processes of patients regarding the formulation of advance directives (AD) after a stay in the ICU. METHODS The study was conducted from May to July 2016 using telephone interviews performed by four senior ICU physicians. Inclusion criteria were: patients discharged from ICU to home>3 months earlier. Semi-directive interviews with patients focused on 5 main points surrounding AD. RESULTS In total, among 159 eligible patients, data from 94 (59%) were available for analysis. Among all those interviewed, 83.5% had never heard of "advance directives". Only 2% had executed AD before ICU admission, and 7% expressed a desire to prepare AD further to their ICU stay. Among the barriers to preparation of AD, lack of information was the main reason cited for not executing AD. Patients noted the following in their AD: withdrawal of life-support in case of vegetative/minimally conscious state or when there is no longer any hope, in case of uncontrollable pain, and if impossible to wean from mechanical ventilation. CONCLUSION The ideal time to engage patients in these discussions is most likely well before an acute health event occurs, although this warrants further investigation both before and after ICU admissions.
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Peicius E, Blazeviciene A, Kaminskas R. Are advance directives helpful for good end of life decision making: a cross sectional survey of health professionals. BMC Med Ethics 2017; 18:40. [PMID: 28583175 PMCID: PMC5460321 DOI: 10.1186/s12910-017-0197-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 05/15/2017] [Indexed: 11/25/2022] Open
Abstract
Background This paper joins the debate over changes in the role of health professionals when applying advance directives to manage the decision-making process at the end of life care. Issues in relation to advance directives occur in clinical units in Lithuania; however, it remains one of the few countries in the European Union (EU) where the discussion on advance directives is not included in the health-care policy-making agenda. To encourage the discussion of advance directives, a study was designed to examine health professionals’ understanding and preferences related to advance directives. In addition, the study sought to explore the views of health care professionals of the application of Advance Directives (AD) in clinical practice in Lithuania. Methods A cross-sectional survey was conducted by interviewing 478 health professionals based at major health care centers in Kaunas district, Lithuania. The design of the study included the use of a questionnaire developed for this study and validated by a pilot study. The collected data were analyzed using standard descriptive statistical methods. Results The analysis of knowledge about AD revealed some statistically significant differences when comparing the respondents’ profession and gender. The analysis also indicated key emerging themes among respondents including tranquility of mind, the longest possible life expectancy and freedom of choice. Further, the study findings revealed that more than half of the study participants preferred to express their will while alive by using advance directives. Conclusions The study findings revealed a low level of knowledge on advance directives among health professionals. Most health professionals agreed that AD’s improved end-of-life decision making while the majority of physicians appreciated AD as the best tool for sharing responsibilities in clinical practice in Lithuania. More physicians than nurses preferred the presence of advance directives to support their decision making in end-of-life situations.
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Affiliation(s)
- Eimantas Peicius
- Department of Social Sciences and Humanities, Medical Academy Lithuanian University of Health Sciences, Mickevičiaus g. 9, Kaunas, LT-44307, Lithuania
| | - Aurelija Blazeviciene
- Department of Nursing and Care, Medical Academy Lithuanian University of Health Sciences, Mickevičiaus g. 9, Kaunas, LT-44307, Lithuania.
| | - Raimondas Kaminskas
- Department of Social Sciences and Humanities, Medical Academy Lithuanian University of Health Sciences, Mickevičiaus g. 9, Kaunas, LT-44307, Lithuania
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White BP, Willmott L, Williams G, Cartwright C, Parker M. The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study. JOURNAL OF MEDICAL ETHICS 2017; 43:327-333. [PMID: 27531924 DOI: 10.1136/medethics-2016-103543] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/20/2016] [Accepted: 07/15/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine the role played by law in medical specialists' decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed. DESIGN Cross-sectional postal survey of medical specialists. SETTING The two largest Australian states by population. PARTICIPANTS 649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting. MAIN OUTCOME MEASURES Compliance with law and the impact of legal knowledge on compliance. RESULTS 649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge. CONCLUSIONS Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care.
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Affiliation(s)
- Benjamin P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gail Williams
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
| | - Colleen Cartwright
- ASLaRC, Southern Cross University, Tweed Heads, New South Wales, Australia
| | - Malcolm Parker
- University of Queensland, Brisbane, Queensland, Australia
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Luck T, Rodriguez FS, Wiese B, van der Leeden C, Heser K, Bickel H, In der Schmitten J, Koenig HH, Weyerer S, Mamone S, Mallon T, Wagner M, Weeg D, Fuchs A, Brettschneider C, Werle J, Scherer M, Maier W, Riedel-Heller SG. Advance directives and power of attorney for health care in the oldest-old - results of the AgeQualiDe study. BMC Geriatr 2017; 17:85. [PMID: 28407800 PMCID: PMC5390475 DOI: 10.1186/s12877-017-0482-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 04/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Completion of advance directives (ADs) and power of attorney (POA) documents may protect a person's autonomy in future health care situations when the individual lacks decisional capacity. As such situations become naturally much more common in old age, we specifically aimed at providing information on (i) the frequency of ADs/POA in oldest-old individuals and (ii) factors associated with having completed ADs/POA. METHODS We analyzed data of oldest-old primary care patients (85+ years; including community-dwelling and institutionalized individuals) within the German AgeQualiDe study. Patients were initially recruited via their general practitioners (GPs). We calculated frequencies of ADs and POA for health care with 95% confidence intervals (CI) and used multivariable logistic regression analysis to evaluate the association between having ADs and POA and participants' socio-demographic, cognitive, functional, and health-related characteristics. RESULTS Among 868 GP patients participating in AgeQualiDe (response = 90.9%), n = 161 had dementia and n = 3 were too exhausted/ill to answer the questions. Out of the remaining 704 (81.1%) dementia-free patients (mean age = 88.7 years; SD = 3.0), 69.0% (95%-CI = 65.6-72.4) stated to having ADs and 64.6% (95%-CI = 61.1-68.2) to having a POA for health care. Individual characteristics did not explain much of the variability of the presence/absence of ADs and POA (regression models: Nagelkerke's R2 = 0.034/0.051). The most frequently stated reasons for not having ADs were that the older adults trust their relatives or physicians to make the right decisions for them when necessary (stated by 59.4% and 44.8% of those without ADs). Among the older adults with ADs, the majority had received assistance in its preparation (79.0%), most frequently from their children/grandchildren (38.3%). Children/grandchildren were also the most frequently stated group of designated persons (76.7%) for those with a POA for health care. CONCLUSIONS Our findings suggest a high dissemination of ADs and POA for health care in the oldest-old in Germany. Some adults without ADs/POA perhaps would have completed advance care documents, if they had had received more information and support. When planning programs to offer advanced care planning to the oldest old, it might be helpful to respond to these specific needs, and also to be sensitive to attitudinal differences in this target group.
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Affiliation(s)
- Tobias Luck
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany.
| | - Francisca S Rodriguez
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany.,LIFE - Leipzig Research Center for Civilization Diseases, Universität Leipzig, Leipzig, Germany.,Edward R. Roybal Institute on Aging, University of Southern California, Los Angeles, USA
| | - Birgitt Wiese
- Work Group Medical Statistics and IT-Infrastructure, Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Carolin van der Leeden
- Department of Primary Medical Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathrin Heser
- Department of Psychiatry, University of Bonn, Bonn, Germany
| | - Horst Bickel
- Department of Psychiatry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jürgen In der Schmitten
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Hans-Helmut Koenig
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Siegfried Weyerer
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Silke Mamone
- Work Group Medical Statistics and IT-Infrastructure, Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Tina Mallon
- Department of Primary Medical Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Wagner
- Department of Psychiatry, University of Bonn, Bonn, Germany.,DZNE, German Center for Neurodegenerative Diseases, Bonn, Germany
| | - Dagmar Weeg
- Department of Psychiatry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Angela Fuchs
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Brettschneider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Werle
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Martin Scherer
- Department of Primary Medical Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Maier
- Department of Psychiatry, University of Bonn, Bonn, Germany.,DZNE, German Center for Neurodegenerative Diseases, Bonn, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
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Alonso A, Dörr D, Szabo K. Critical appraisal of advance directives given by patients with fatal acute stroke: an observational cohort study. BMC Med Ethics 2017; 18:7. [PMID: 28152998 PMCID: PMC5288941 DOI: 10.1186/s12910-016-0166-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/30/2016] [Indexed: 11/25/2022] Open
Abstract
Background Advance directives (AD) imply the promise of determining future medical treatment in case of decisional incapacity. However, clinical practice increasingly indicates that standardized ADs often fail to support patients’ autonomy. To date, little data are available about the quality and impact of ADs on end-of-life decisions for incapacitated acute stroke patients. Methods We analyzed the ADs of patients with fatal stroke, focusing on: (a) their availability and type, (b) stated circumstances to which the AD should apply, and (c) stated wishes regarding specific treatment options. Results Between 2011 and 2014, 143 patients died during their hospitalization on our stroke unit. Forty-two of them (29.4%) had a completed and signed, written AD, as reported by their family, but only 35 ADs (24.5%) were available. The circumstances in which the AD should apply were stated by 21/35 (60%) as a “terminal condition that will cause death within a relatively short time” or an ongoing “dying process.” A retrospective review found only 16 of 35 ADs (45.7%) described circumstances that, according to the medical file, could have been considered applicable by the treating physicians. A majority of patients objected to cardiopulmonary resuscitation (22/35, 62.9%), mechanical ventilation (19/35, 54.3%), and artificial nutrition (26/35, 74.3%), while almost all (33/35, 94.3%) directed that treatment for alleviation of pain or discomfort should be provided at all times even if it could hasten death. Conclusions The prevalence of ADs among patients who die from acute stroke is still low. A major flaw of the ADs in our cohort was their attempt to determine single medical procedures without focusing on a precise description of applicable scenarios. Therefore, less than half of the ADs were considered applicable for severe acute stroke. These findings stress the need to foster educational programs for the general public about advance care planning to facilitate the processing of timely, comprehensive, and individualized end-of-life decision-making.
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Affiliation(s)
- A Alonso
- Department of Neurology, Medizinische Fakultät Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - D Dörr
- Clinical Ethics Committee, Medizinische Fakultät Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - K Szabo
- Department of Neurology, Medizinische Fakultät Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Elmeadawy S, Fitzner C, Elsner F, Dietrich CG. Wissen, Haltung und Meinung von Patienten zum neuen Patientenverfügungsgesetz. Schmerz 2017; 31:54-61. [DOI: 10.1007/s00482-016-0124-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Spranzi M, Fournier V. The near-failure of advance directives: why they should not be abandoned altogether, but their role radically reconsidered. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2016; 19:563-568. [PMID: 27151078 DOI: 10.1007/s11019-016-9704-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Advance directives (ADs) have been hailed for two decades as the best way to safeguard patients' autonomy when they are totally or partially incompetent. In many national contexts they are written into law and they are mostly associated with end-of-life decisions. Although advocates and critics of ADs exchange relevant empirical and theoretical arguments, the debate is inconclusive. We argue that this is so for good reasons: the ADs' project is fraught with tensions, and this is the reason why they are both important and deeply problematic. We outline six such tensions, and conclude with some positive suggestions about how to better promote patients' autonomy in end-of-life decision. We argue that ADs should continue to be an option but they cannot be the panacea that they are expected to be.
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Affiliation(s)
- Marta Spranzi
- University of Versailles-St-Quentin-en-Yvelines (UVSQ), Versailles, France
- Centre d'éthique clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Véronique Fournier
- Centre d'éthique clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Survey on German Palliative Care Specialists' Experiences with Advance Directives. Pain Ther 2016; 6:17-28. [PMID: 27900726 PMCID: PMC5447540 DOI: 10.1007/s40122-016-0063-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction Advance directives (AD) play a central role in end-of-life treatments, intensive care, and palliative care. However, little is known about the experiences of healthcare professionals with ADs. This study reports on palliative care professionals’ views on advance directives (AD). Methods A questionnaire was handed out to attendants of a palliative care symposium. Results Complete answers were obtained from 126 physicians and 276 nurses. Almost all physicians and nurses had treated patients with an AD, and the majority more than 10 patients. The most frequent refusal by the patients was resuscitation (87.8%) followed by intensive care (79.1%), artificial ventilation, and nutrition. The most frequent wish was pain therapy (92.3%) followed by allowing the natural course of the illness (64.4%). The wish for hospice treatment (44.8%) or spiritual care (39.3%) was less frequent. Discussion The results hint at fears and deficits in the care of patients at the end of life. Often the quality of life and not the quantity of days remaining is in the center of a patient’s will and points to the growing importance of palliative care. Conclusion ADs are well established among palliative care professionals and regarded as helpful for patients at the end of life.
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Otte IC, Elger B, Jung C, Bally KW. The utility of standardized advance directives: the general practitioners' perspective. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2016; 19:199-206. [PMID: 26860626 PMCID: PMC4880623 DOI: 10.1007/s11019-016-9688-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Advance directives (AD) are written documents that give patients the opportunity to communicate their preferences regarding treatments they do or do not want to receive in case they become unable to make decisions. Commonly used pre-printed forms have different formats. Some offer space for patients to (a) appoint a surrogate decision maker, and/or (b) to determine future medical treatments and/or (c) give a statement of personal values. So far it is unknown which forms GPs preferably use and why they decide to do so. 23 semi-structured interviews with GPs were analysed using content analysis. Interviewees mainly use short templates (to appoint surrogate decision makers) and medium length templates with checkboxes to indicate patients' preferences in regards to life prolonging measures. Especially when patients faced the progression of a disease, participants use the latter version. Only then, the interviewees remarked, patients are capable to rate concrete situations reliably. GPs also realize the importance of the verbal assessment of patients' preferences; however they rarely keep a written form of the conversation. Some GPs hand out one or more templates and ask their patients to read and think about them at home with the option to talk to them about it later on, while others prefer their patients to fill them out alone at home. Regardless of template usage, most GPs emphasize that ADs require regular updates. GPs tend to see standardized advance directives mainly as a tool to start a conversation with their patients and to identify their real preferences and values. When the patient is still not facing the progression of an already existing disease it could be sufficient to only appoint a surrogate decision maker instead of creating a full AD. However, in all other situations, appointing a surrogate decision maker should be backed up by a written statement of a patient's general values. Patients and their relatives should always have the opportunity to ask their GP for medical advice when drafting an AD. It is crucial to regularly verify and update existing ADs within the course of a disease.
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Affiliation(s)
- Ina Carola Otte
- Institute of Biomedical Ethics, University of Basel, Basel, Switzerland
- Institute of Primary Health Care, University of Basel, Basel, Switzerland
| | - Bernice Elger
- Institute of Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Corinna Jung
- Institute of Primary Health Care, University of Basel, Basel, Switzerland
| | - Klaus Walter Bally
- Institute of Primary Health Care, University of Basel, Basel, Switzerland.
- Facharzt für Allgemeine Medizin FMH, Universitäres Zentrum für Hausarztmedizin beider Basel, St. Johanns-Parkweg 2, 4056, Basel, Switzerland.
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Zheng RJ, Fu Y, Xiang QF, Yang M, Chen L, Shi YK, Yu CH, Li JY. Knowledge, attitudes, and influencing factors of cancer patients toward approving advance directives in China. Support Care Cancer 2016; 24:4097-103. [PMID: 27209478 PMCID: PMC4993803 DOI: 10.1007/s00520-016-3223-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/17/2016] [Indexed: 02/05/2023]
Abstract
Purpose Many cancer patients do not have advance directives (ADs), which may lead to unwanted excessive or aggressive care when patients have lost decision-making capacity. The aim of this study was to investigate knowledge and attitudes of approving ADs and explore factors associated with willing to designate ADs among cancer patients in China. Methods We conducted semi-structured interview method investigating 753 in-patients with cancer in two cancer centers. Results Of those subjects, none of the cancer patients had an AD. Only 22.4 % (118 of 526) approved ADs. Comparing with the disapproved ADs group, the approved ADs group were more likely to discuss the AD with oncologist or nurse (χ2 = 180.4, p < 0.001) in the cancer center (χ2 = 244.1, p < 0.001), and they chose more comfort care (χ2 = 18.8, p < 0.001). Most of cancer patients in the two groups wanted to die at home (72.8 %, 73.7 %, respectively). The older patients (OR, 1.04, 95 % CI, 1.02–1.07, p = 0.001), female (OR, 0.55, 95 % CI, 0.35–0.88, p = 0.013), with higher education levels (OR, 3.38, 95 % CI, 1.92–5.96, p < 0.001), with religious beliefs (OR, 2.91, 95 % CI, 1.71–4.94, p < 0.001), and with higher scores of ECOG (OR, 1.46, 95 % CI, 1.17–1.82, p = 0.001) were associated with desiring for ADs. Conclusions Our findings indicate that there was a dearth of knowledge and different attitudes toward approving ADs among cancer patients, and some factors of demographic and clinical characteristics influenced their willing to designate ADs. This research highlights the importance of propagandizing the ADs to the public, especially to the patients, and further discussing with them when the time is ripe.
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Affiliation(s)
- Ru-Jun Zheng
- West China Nursing School and Business School, Sichuan University, Chengdu, 610041, People's Republic of China.,Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yan Fu
- Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Qiu-Fen Xiang
- Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Mei Yang
- Cancer Research Center, Tumor Hospital of Xinjiang, Xinjiang Medical University, Urumuqi, 830000, People's Republic of China
| | - Lin Chen
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ying-Kang Shi
- Institute of Hospital Administration,West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Chun-Hua Yu
- Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
| | - Jun-Ying Li
- Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Gigon F, Merlani P, Ricou B. Advance Directives and Communication Skills of Prehospital Physicians Involved in the Care of Cardiovascular Patients. Medicine (Baltimore) 2015; 94:e2112. [PMID: 26656337 PMCID: PMC5008482 DOI: 10.1097/md.0000000000002112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Fabienne Gigon
- From the Intensive Care Unit, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (FG, BR) and Intensive Care Medicine, Ospedale Regionale di Lugano, Lugano, Switzerland (PM)
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Pollock K, Wilson E. Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03310] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAdvance care planning (ACP) enables patients to consider, discuss and, if they wish, document their wishes and preferences for future care, including decisions to refuse treatment, in the event that they lose capacity to make decisions for themselves. ACP is a key component of UK health policy to improve the experience of death and dying for patients and their families. There is limited evidence about how patients and health professionals understand ACP, or when and how this is initiated. It is evident that many people find discussion of and planning for end of life care difficult, and tend to avoid the topic.AimTo investigate how patients, their relatives and health professionals initiate and experience discussion of ACP and the outcomes of advance discussions in shaping care at the end of life.Design and data collectionQualitative study with two workstreams: (1) interviews with 37 health professionals (general practitioners, specialist nurses and community nurses) about their experiences of ACP; and (2) longitudinal case studies of 21 patients with 6-month follow-up. Cases included a patient and, where possible, a nominated key relative and/or health professional as well as a review of medical records. Complete case triads were obtained for 11 patients. Four cases comprised the patient alone, where respondents were unable or unwilling to nominate either a family member or a professional carer they wished to include in the study. Patients were identified as likely to be within the last 6 months of life. Ninety-seven interviews were completed in total.SettingGeneral practices and community care settings in the East Midlands of England.FindingsThe study found ACP to be uncommon and focused primarily on specific documented tasks involving decisions about preferred place of death and cardiopulmonary resuscitation, supporting earlier research. There was no evidence of ACP in nearly half (9 of 21) of patient cases. Professionals reported ACP discussions to be challenging. It was difficult to recognise when patients had entered the last year of life, or to identify their readiness to consider future planning. Patients often did not wish to do so before they had become gravely ill. Consequently, ACP discussions tended to be reactive, rather than pre-emptive, occurring in response to critical events or evidence of marked deterioration. ACP discussions intersected two parallel strands of planning: professional organisation and co-ordination of care; and the practical and emotional preparatory work that patients and families undertook to prepare themselves for death. Reference to ACP as a means of guiding decisions for patients who had lost capacity was rare.ConclusionsAdvance care planning remains uncommon, is often limited to documentation of a few key decisions, is reported to be challenging by many health professionals, is not welcomed by a substantial number of patients and tends to be postponed until death is clearly imminent. Current implementation largely ignores the purpose of ACP as a means of extending personal autonomy in the event of lost capacity.Future workAttention should be paid to public attitudes to death and dying (including those of culturally diverse and ethnic minority groups), place of death, resuscitation and the value of anticipatory planning. In addition the experiences and needs of two under-researched groups should be explored: the frail elderly, including those who manage complex comorbid conditions, unrecognised as vulnerable cases; and those patients affected by stigmatised conditions, such as substance abuse or serious mental illness who fail to engage constructively with services and are not recognised as suitable referrals for palliative and end of life care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Higginson IJ, Gomes B, Calanzani N, Gao W, Bausewein C, Daveson BA, Deliens L, Ferreira PL, Toscani F, Gysels M, Ceulemans L, Simon ST, Cohen J, Harding R. Priorities for treatment, care and information if faced with serious illness: a comparative population-based survey in seven European countries. Palliat Med 2014; 28:101-10. [PMID: 23703237 DOI: 10.1177/0269216313488989] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Health-care costs are growing, with little population-based data about people's priorities for end-of-life care, to guide service development and aid discussions. AIM We examined variations in people's priorities for treatment, care and information across seven European countries. DESIGN Telephone survey of a random sample of households; we asked respondents their priorities if 'faced with a serious illness, like cancer, with limited time to live' and used multivariable logistic regressions to identify associated factors. SETTING/PARTICIPANTS Members of the general public aged ≥ 16 years residing in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain. RESULTS In total, 9344 individuals were interviewed. Most people chose 'improve quality of life for the time they had left', ranging from 57% (95% confidence interval: 55%-60%, Italy) to 81% (95% confidence interval: 79%-83%, Spain). Only 2% (95% confidence interval: 1%-3%, England) to 6% (95% confidence interval: 4%-7%, Flanders) said extending life was most important, and 15% (95% confidence interval: 13%-17%, Spain) to 40% (95% confidence interval: 37%-43%, Italy) said quality and extension were equally important. Prioritising quality of life was associated with higher education in all countries (odds ratio = 1.3 (Flanders) to 7.9 (Italy)), experience of caregiving or bereavement (England, Germany, Portugal), prioritising pain/symptom control over having a positive attitude and preferring death in a hospice/palliative care unit. Those prioritising extending life had the highest home death preference of all groups. Health status did not affect priorities. CONCLUSIONS Across all countries, extending life was prioritised by a minority, regardless of health status. Treatment and care needs to be reoriented with patient education and palliative care becoming mainstream for serious conditions such as cancer.
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Affiliation(s)
- Irene J Higginson
- 1King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, London, UK
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in der Schmitten J, Lex K, Mellert C, Rothärmel S, Wegscheider K, Marckmann G. Implementing an advance care planning program in German nursing homes: results of an inter-regionally controlled intervention trial. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:50-7. [PMID: 24612497 PMCID: PMC3950824 DOI: 10.3238/arztebl.2014.0050] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 10/07/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Advance Care Planning (ACP) is a systematic approach to ensure that effective advance directives (ADs) are developed and respected. We studied the effects of implementing a regional ACP program in Germany. METHODS In a prospective, inter-regionally controlled trial focusing on nursing homes (n/hs), we compared the number, relevance and validity of new ADs completed in the intervention region versus the control region. Intervention n/h residents and their families were offered professional facilitation including standardized documentation. RESULTS Data from 136 residents of three intervention n/hs were compared with data from 439 residents of 10 control n/hs over a study period of 16.5 months. In the intervention region, 49 (36.0%) participating residents completed a new AD over the period of the study, compared to 18 (4.1%) in the control region; these ADs included 30 ADs by proxy in the intervention region versus 10 in the control region. Proxies were designated in 94.7% versus 50.0% of cases, the AD was signed by a physician in 93.9% versus 16.7%, and an emergency order was included in 98.0% versus 44.4%. Resuscitation status was addressed in 95.9% versus 38.9% of cases (p<0.01 for all of the differences mentioned above). In the intervention region, new ADs were preceded by an average of 2.5 facilitated conversations (range, 2–5) with a mean total duration of 100 minutes (range, 60–240 minutes). CONCLUSION The implementation of an ACP program in German nursing homes led, much more frequently than previously reported, to the creation of advance directives with potential relevance to medical decision-making. Future research should assess the effect of such programs on clinical and structural outcomes.
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Affiliation(s)
| | - Katharina Lex
- Institute for Patient Safety, Rheinische Friedrich-Wilhelms-Universität Bonn
| | - Christine Mellert
- Department of General Practice, Düsseldorf University, University Hospital
| | - Sonja Rothärmel
- Faculty of Social Work, Catholic University of Eichstätt-Ingolstadt
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine at the Ludwig Maximilians University Munich
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Gysels M, Evans N, Meñaca A, Higginson IJ, Harding R, Pool R. Diversity in defining end of life care: an obstacle or the way forward? PLoS One 2013; 8:e68002. [PMID: 23844145 PMCID: PMC3700860 DOI: 10.1371/journal.pone.0068002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 05/28/2013] [Indexed: 12/05/2022] Open
Abstract
Aim The terms used to describe care at the end of life (EoL), and its definitions, have evolved over time and reflect the changes in meaning the concept has undergone as the field develops. We explore the remit of EoL care as defined by experts in EoL care, from across Europe and beyond, to understand its current usage and meanings. Method A qualitative survey attached to a call for expertise on cultural issues in EoL care was sent to experts in the field identified through the literature, European EoL care associations, and conferences targeted at EoL care professionals. Respondents were asked to identify further contacts for snowball recruitment.The responses were analysed using content and discourse analysis. Results Responses were received from 167 individuals (33% response rate), mainly from academics (39%) and clinical practitioners working in an academic context (23%) from 19 countries in Europe and beyond. 29% of respondents said explicitly that there was no agreed definition of EoL care in practice and only 14% offered a standard definition (WHO, or local institution). 2% said that the concept of EoL care was not used in their country, and 5% said that there was opposition to the concept for religious or cultural reasons. Two approaches were identified to arrive at an understanding of EoL care: exclusively by drawing boundaries through setting time frames, and inclusively by approaching its scope in an integrative way. This led to reflections about terminology and whether defining EoL care is desirable. Conclusion The global expansion of EoL care contributes to the variety of interpretations of what it means. This complicates the endeavour of defining the field. However, when diversity is taken seriously it can open up new perspectives to underpin the ethical framework of EoL care.
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Affiliation(s)
- Marjolein Gysels
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.
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Coleman AME. Physician attitudes toward advanced directives: a literature review of variables impacting on physicians attitude toward advance directives. Am J Hosp Palliat Care 2012; 30:696-706. [PMID: 23125398 DOI: 10.1177/1049909112464544] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To review physician's attitudes as well as the variables that may impact on physicians' attitude toward advance directives (ADs). METHOD Literature review of 17 published articles, covering the period 1989 to 2011. FINDINGS Physicians overall have a positive attitude toward patients' AD. However, other factors affect this "general positive attitude." These factors influence the attitude-behavior relationship of physicians, and hence their actual practice in relation to patients' AD. CONCLUSION The findings from this review are of importance in explaining the differences in the attitude of physicians toward AD and their compliance. This raises the issue of consideration of other ethical paradigms/theories in the clinical context other than the framework of "principlism-"based autonomy, on which AD leans on. This is important in light of the pluralism of ethical theories.
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Gristina GR, Martin E, Ranieri VM. Regulation of advance directives in Italy: a bad law in the making. Intensive Care Med 2012; 38:1897-900. [PMID: 22854978 DOI: 10.1007/s00134-012-2656-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 07/12/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE The Advance Directives (ADs) have been adopted in many countries to defend patients' autonomy. In Italy, the role of ADs has recently been the subject of heated debate involving political parties and the Roman Catholic Church. In February 2009, the conservative government coalition presented a bill of law on this issue. It has been passed by the Low Chamber and is now being discussed in the Senate. The purpose of the article is to highlight any possible bill's contradiction with Italian Constitution, Italian Code of Medical Ethics (ICME), and Oviedo Convention contents, relevant for intensivists. METHODS Analysis of bill's content in the light of Italian Constitution, ICME, Oviedo Convention articles and in comparison with French legislation regarding end of life (Leonetti law). RESULTS In the Authors' point of view the bill's articles -limit the moral and judicial importance of four main issues as informed consent, permanent incapacity, artificial nutrition/hydration, and withdraw/withhold treatments. CONCLUSIONS In the Authors' opinion the ADs must represent informed preferences made freely by patients within the relationship with their physicians, as part of an advance care planning. When this relationship develops in accordance with the ICME rules, it contains all of the ethical/professional dimensions to legitimate right choices in each case. The law should draw inspiration from ICME principles, assigning them a juridical power, acknowledging their validity in legitimating end-of-life decisions, and defining a framework of juridical legitimacy for these decisions without infringing on patients' right to autonomy with prescriptions on the care.
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