Preferences in end-of-life care of older persons: after-death interviews with proxy respondents

After providing end of life care to relatives, what care options do family caregivers prefer for themselves?

Objectives

We examined how caregivers who had cared for a relative at end of life (EoL) wished to be cared for in the event that they experienced advanced dementia or physical disability in the future, and what factors influenced their preferences for EoL care.

Methods

In this mixed-methods study, 83 participants, recruited from multiple sources in Israel, were interviewed concerning socio-demographic factors, health status, past experience with EoL, preference for extension of life vs. quality of life (QoL), willingness to be dependent on others, and preferences for EoL care.

Results

In case of advanced dementia, 58% preferred euthanasia or suicide; around a third chose those for physical disability. Care by family members was the least desired form of care in the advanced dementia scenario, although more desirable than institutional care in the physical disability scenario. QoL was rated as the highest factor impacting preferences for EoL care. Men demonstrated a higher preference than women for extension of life over QoL.

Conclusion

Our study points to the need for society to consider solutions to the request of participants to reject the type of EoL experienced by their relatives. Those solutions include investing in improving the quality of life at the end of life, and offering alternatives such as euthanasia, which a large proportion of our participants found ethically and medically appropriate within the current system of care in the event of severe physical disability, and more so in the event of advanced dementia.

A Philosophical View on the Experience of Dignity and Autonomy through the Phenomenology of Illness

In the context of the end of life, many authors point out how the experience of identity is crucial for the well-being of patients with advanced disease. They define this identity in terms of autonomy, control, or dependence, associating these concepts with the sense of personal dignity. From the perspective of the phenomenology of embodiment, Kay Toombs and other authors have investigated the ways disease can impact on the subjective world of patients and have stressed that a consideration of this personal world can promote understanding and recognition of their experience. Based on the findings of qualitative studies of the perception of dignity and autonomy in patients at the end of life, this analysis assesses concepts such as being-in-the-world in illness, embodiment, lived body versus objective body or the gaze of the other from a Toombsian phenomenological perspective.

Advance care planning dispositions: the relationship between knowledge and perception

BACKGROUND

Legal dispositions for advance care planning (ACP) are available but used by a minority of older adults in Switzerland. Some studies found that knowledge of and perception of those dispositions are positively associated with their higher usage. The objective of the present study is to test the hypothesis of an association between increased knowledge of ACP dispositions and a more positive perception of them.

METHODS

Data collected in 2014 among 2125 Swiss community-dwellers aged 71 to 80 of the Lausanne cohort 65+ (Lc65+), a population-based longitudinal study on aging and frailty. Data collection was conducted through a questionnaire on knowledge, use and perception of lasting power of attorney, advance directives and designation of a health care proxy. Covariables were extracted from the Lc65+ database. Bivariable and multivariable regression analyses assessed the association between level of knowledge and perception.

RESULTS

Half the participants did not know about legal dispositions for ACP; filing rates were 14% for advance directives, 11% for health care proxy and 6% for lasting power of attorney. Level of knowledge about the dispositions was associated with a more positive perception of them, even when adjusting for confounding factors.

CONCLUSION

Although the direction of the association's causality needs more investigation, results indicate that better knowledge on ACP dispositions could improve the perception older people have of them. Communication on dispositions should take into account individual knowledge levels and address commonly enunciated barriers that seem to diminish with increased knowledge.

Theories of Health Care Decision Making at the End of Life: A Meta-Ethnography

The aim of this meta-ethnography is to appraise the types and uses of theories relative to end-of-life decision making and to develop a conceptual framework to describe end-of-life decision making among patients with advanced cancers, heart failure, and amyotrophic lateral sclerosis (ALS) and their caregivers or providers. We used PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases to extract English-language articles published between January 2002 and April 2015. Forty-three articles were included. The most common theories included decision-making models ( n = 14) followed by family-centered ( n = 11) and behavioral change models ( n = 7). A conceptual framework was developed using themes including context of decision making, communication and negotiation of decision making, characteristics of decision makers, goals of decision making, options and alternatives, and outcomes. Future research should enhance and apply these theories to guide research to develop patient-centered decision-making programs that facilitate informed and shared decision making at the end of life among patients with advanced illness and their caregivers.

Death and the Oldest Old: Attitudes and Preferences for End-of-Life Care--Qualitative Research within a Population-Based Cohort Study

INTRODUCTION

Increasing longevity means more people will be dying in very old age, but little is known about the preferences of the 'oldest old' regarding their care at the end of life.

AIMS

To understand very old people's preferences regarding care towards the end of life and attitudes towards dying, to inform policy and practice.

METHODS

Qualitative data collection for n = 42 population-based cohort study participants aged 95-101 (88% women, 42% in long-term-care): topic-guided interviews with n = 33 participants and n = 39 proxy informants, most with both (n = 30: 4 jointly + separate interviews for 26 dyads).

RESULTS

Death was a part of life: these very old people mainly live day-to-day. Most were ready to die, reflecting their concerns regarding quality of life, being a nuisance, having nothing to live for and having lived long enough. Contrasting views were rare exceptions but voiced firmly. Most were not worried about death itself, but concerned more about the dying process and impacts on those left behind; a peaceful and pain-free death was a common ideal. Attitudes ranged from not wanting to think about death, through accepting its inevitable approach to longing for its release. Preferring to be made comfortable rather than have life-saving treatment if seriously ill, and wishing to avoid hospital, were commonly expressed views. There was little or no future planning, some consciously choosing not to. Uncertainty hampered end-of-life planning even when death was expected soon. Some stressed circumstances, such as severe dependency and others' likely decision-making roles, would influence choices. Carers found these issues harder to raise but felt they would know their older relatives' preferences, usually palliative care, although we found two discrepant views.

CONCLUSIONS

This study's rare data show ≥95-year-olds are willing to discuss dying and end-of-life care but seldom do. Formal documentation of wishes is extremely rare and may not be welcome. Although being "ready to die" and preferring a palliative approach predominated, these preferences cannot be assumed.

Decisions in complex clinical situations: Prevalence and factors associated in general public

Many studies have focused on advanced directives. However, the type of treatment that citizens would choose in critical health situations and whether their decision varies with their sociodemographic characteristics and their experiences of life both within and outside the family context, are unknown. This study analyzes the factors associated with choosing or refusing life support treatment in hypothetical situations of differing clinical complexity. This transversal descriptive study was carried out by questionnaires given to 1051 participants from primary care centres. The Life Support Preferences Questionnaire (LSPQ) used to assess preferences of life-sustaining treatment, describes six scenarios with different prognoses. Analysis of the sociodemographic characteristics and life experiences of the subjects led to the following findings. In situations of very severe prognosis, treatment is mostly rejected. When there is chance of recovery, treatment is mostly accepted, especially in the least aggressive cases and when deciding for another person. A greater propensity to reject treatment was observed among subjects over 55 years, those in poor health and those who had observed a terminal illness in a family member. Practising Catholics are more likely to accept treatment in all medical situations described. Preferences for life support treatment are linked to sociodemographic characteristics and life experiences of patients. Physicians should bear in mind these characteristics when confronted with critical clinical situations, involving difficult decisions.

Culture and end of life care: a scoping exercise in seven European countries

AIM

Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries.

METHODS

We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes.

RESULTS

A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities.

CONCLUSION

This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.

Researching the end-of-life in old age: cultural, ethical and methodological issues

Increased life expectancy has strengthened the association between old age and death, with significant implications for gerontology and for the generation of knowledge through research. The global rise in chronic disease has had a significant impact on the duration and shape of dying trajectories in old age and their variations. This development poses ethical and methodological challenges for researchers, not least because it is often difficult to establish whether an older person is ‘dying from’ as opposed to ‘living with’ one or more diseases. This paper reports a comprehensive literature review of empirical research on the end-of-life in old age, and has two inter-related themes. It explores the social and cultural contexts of death and critically analyses the methods and ethical approaches adopted by researchers. Cross-cultural studies and studies in which cultural factors were of prime interest were selected with a view to examining the concept of a ‘good death’ in old age. The paper discusses the evidence of cultural similarities and differences and the impact of social and cultural change on ideas concerning a good death. It identifies contemporary influences and pressures on end-of-life care for older people and discusses the significance of communication and the roles of families and service providers. The paper concludes by identifying substantive and methodological lessons for researchers in gerontology and suggests ways in which the impact of research might be enhanced.

Preferences of elderly cancer patients in their advance directives

Efforts to improve the quality of end-of-life decision-making have emphasized the principle of individual autonomy to better ensure that patients receive care consistent with their preferences. Advance directives (ADs) can be vehicles for in-depth and ongoing discussions among health care professionals, patients, and families. The aim of our study was to identify preferences and values expressed in ADs of 50 elderly patients with cancer. Main concerns of the patients were resuscitation and introduction of artificial nutrition. Very few patients had unrealistic expectation. Preferences about patient's symptom management were quite different from one to another. Content of ADs not only involved life-sustaining technology, but also psychosocial items and religious beliefs and values. All patients designated at least one surrogate. In conclusion, ADs should not be considered simply as another questionnaire, but more as a process to improve communication.

Role of advance directives in palliative care units: a prospective study

Advance directives (ADs) might be useful in achieving improved communication and satisfaction with decision making at the end-of-life. Our aims were to better characterise patients with advanced oncological disease who decided to complete ADs and to measure the effect of ADs completion on the satisfaction level with end-of-life care from both patients and their relatives. A prospective study was conducted in three palliative care units. Patients with advanced cancer were included if they met the following criteria: an estimated life expectancy of <6 months, fluency in French, Mini Mental State Examination >20 and not yet completed ADs. All the patients received information about ADs and decided whether to complete ADs or not. The level of satisfaction with involvement in the decision process concerning end-of-life care was assessed by means of a written questionnaire. In all, 53 of 228 patients were included, and 12 decided to complete ADs. Patients who completed ADs had statistically less depression one week after inclusion (P = 0.030), had a lower anxiety score on the second week and had a lower depression score on the third week. There was a trend towards a higher satisfaction level with the involvement of the patients in end-of-life care for those completing ADs (P = 0.878). In conclusion, each patient with an advanced progressive disease should be informed about ADs and be encouraged to complete the ADs with the aim to ease many fears as well as to improve communication.

Voices of African American, Caucasian, and Hispanic surrogates on the burdens of end-of-life decision making

BACKGROUND

End-of-life decisions are frequently made by patients' surrogates. Race and ethnicity may affect such decision making. Few studies have described how different racial/ethnic groups experience end-of-life surrogate decision making.

OBJECTIVES

To describe the self-reported experience the self-reported experience of African-American, Caucasian, and Hispanic surrogate decision makers of seriously ill patients and to examine the relationship of race, ethnicity, and culture to that experience.

DESIGN

Purposive sample to include racial/ethnic minorities in a qualitative study using focus group interviews.

PARTICIPANTS

The participants of the study were 44 experienced, mostly female, surrogate decision makers for older veterans.

APPROACH

Transcripts were qualitatively analyzed to identify major themes, with particular attention to themes that might be unique to each of the three groups.

RESULTS

The experience of burden of end-of-life decision making was similar in all three groups. This burden in its medical, personal, and familial dimensions is compounded by uncertainty about prognosis and the patient's preferences. Racial/ethnic variations of responses to this burden concerned the physician-family relationship, religion and faith, and past experiences with race/ethnicity concordant versus non-concordant physicians.

CONCLUSIONS

Regardless of race/ethnicity, surrogates for seriously ill patients appeared to experience increased significant, multidimensional burdens of decision making under conditions of uncertainty about a patient's preferences. This aspect of the burden of surrogate decision making may not be fully appreciated by physicians. Physicians should identify and be especially attentive to strategies used by surrogates, which may vary by race/ethnicity, to reduce the uncertainty about a patient's preferences and thus the burden of surrogate decision making to assist them in this difficult process.

Completion of a Durable Power of Attorney for Health Care: What Does Cognition Have to Do With It?

PURPOSE

This study examined the association between cognitive functioning and completion of a durable power of attorney for health care.

DESIGN AND METHODS

Participants were from the Second Longitudinal Study on Aging (LSOA II), a nationally representative sample of community-dwelling persons who were at least 70 years of age at the time of participation. The sample included 325 older adult respondents (144 men, 181 women) with a mean age of 80.7 years (SE = 0.36) and a mean educational attainment of 11.6 years (SE = 0.18). Researchers measured each respondent's cognitive functioning during follow-up by using an adapted Telephone Interview of Cognitive Status, and a proxy informant indicated whether the respondent completed a durable power of attorney for health care.

RESULTS

A durable power of attorney for health care was completed by 60.8% (SE = 2.51) of respondents prior to their death. Logistic regression demonstrated that respondents with the first quartile of global cognitive functioning were 76% less likely to have completed a durable power of attorney (adjusted odds ratio = 0.24, 95% confidence interval = 0.09-0.60) than those with the fourth quartile of cognitive functioning.

IMPLICATIONS

The factors associated with completion of durable power of attorney for health care by older adults with lower levels of cognitive functioning should be investigated further. Such data could be used to inform interventions to increase the completion rates of durable power of attorney for health care among this particular group of older adults.

The end of life: a qualitative study of the perceptions of people over the age of 80 on issues surrounding death and dying

This study explored how elderly people living in the community perceive issues around death, dying, and the end of life using a qualitative grounded theory approach. Forty individuals aged between 80 and 89 years who were living alone in the community were interviewed and were identified through purposive and random sampling. The results revealed that issues associated with end of life included fear of how they would die, fear of becoming a burden to others, wanting to prepare for and have a choice with regard to where and when they die, and issues relating to assisted dying. The study demonstrated that issues relating to the end of life are a major concern for older people, but are seldom addressed by professionals. Listening to and understanding the views and experiences of the older age group regarding end-of-life care is needed if adequate person-centered care is to be delivered to this ever-growing population group.

End-of-life decisions: family views on advance directives

A cross-sectional survey was administered to family members of patients who died at 1 of the 5 Catholic institutions comprising Mercy Health Partners, a health care system in Ohio, to determine their opinions about patient and family participation in decisions about end-of-life care. Among 165 respondents, 118 (86%) of 138 agreed that the family was encouraged to join in decisions and 133 (91%) of 146 that their family member's health care choices were followed. Most agreed that nurses answered their questions (93%, 141/151) and that the doctor communicated well with family members (83%, 128/155). Seventy percent (107/152) indicated that their family member had at least 1 advance directive. There were no differences in whether health care choices were followed when patients with formal advance directives (92%, 92/100) were compared with patients without formal advance directives (88%, 35/40). A unique survey instrument can be used to measure family perceptions and opinions of participation in decisions about end-of-life care.

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

OBJECTIVE

For many nursing home patients in the advanced stages of dementia, a decision to start or forgo treatment has to be taken at the end of their life. It is very important for the peace of mind of all involved in such decision-making that there is agreement on which decision is in the best interest of the patient. It is thus important to investigate the attitude of physicians, nurses and relatives towards medical end-of-life decisions concerning patients with dementia, so that the policy in nursing homes can be tuned to stimulate dialogue and understanding between all parties.

METHODS

Fifteen statements about artificial nutrition and hydration (ANH), advance directives, hastening death, self-determination and euthanasia, and nursing home policy were presented to physicians, nurses and relatives of nursing home patients suffering from dementia.

RESULTS

In general, physicians, nurses and relatives agree on many aspects of end-of-life decision-making for nursing home patients with dementia. However, on some issues the outcomes of the decision-making may differ. Relatives attach more importance to advance directives than physicians, and have more permissive attitudes towards hastening death.

CONCLUSION

Although physicians, nurses and relatives are all guided by the best interest of the patient, it seems that differences in religious beliefs, perspective of the patient, and responsibility can lead to different attitudes towards end-of-life decisions.

PRACTICE IMPLICATIONS

Physicians should discuss end-of-life decisions more openly. Physicians should be aware of the influences on attitudes and incorporate them into communication about end-of-life decisions.

Frequency and determinants of advance directives concerning end-of-life care in The Netherlands

In the USA, the use of advance directives (ADs) has been studied extensively, in order to identify opportunities to increase their use. We investigated the prevalence of ADs and the factors associated with formulation of an AD in The Netherlands, using samples of three groups: the general population up to 60 years of age, the general population over 60 years of age, and the relatives of patients who died after euthanasia or assisted suicide. The associated factors were grouped into three components: predisposing factors (e.g. age, gender), enabling factors (e.g. education) and need factors (e.g. health-related factors). We found that living wills had been formulated by 3% of younger people, 10% of older people, and 23% of the relatives of a person who died after euthanasia or assisted suicide. Most living wills concerned a request for euthanasia. In all groups, 26-29% had authorized someone to make decisions if they were no longer able to do so themselves. Talking to a physician about medical end-of-life treatment occurred less frequently, only 2% of the younger people and 7% of the older people had done so. Most people were quite confident that the physician would respect their end-of-life wishes, but older people more so than younger people. In a multivariate analysis, many predisposing factors were associated with the formulation of an AD: women, older people, non-religious people, especially those who lived in an urbanized area, and people with less confidence that the physician would respect their end-of-life wishes were more likely to have formulated an AD. Furthermore, the enabling factor of a higher level of education, the need factor of contact with a medical specialist in the past 6 months, and the death of a marital partner were associated with the formulation of an AD.

Striving for quality or length at the end-of-life: attitudes of the Dutch general public

Questionnaires were mailed to 1777 members of the Dutch public (response: 78%), measuring to what extent respondents appreciate life-prolonging treatment, even if it would seriously impair their quality of life. The association between these attitudes and personal characteristics and initiatives to engage in advance care planning was analyzed. About one third of the respondents prefers quality of life at the expense of survival, another third prefers length of life regardless of impaired quality, whereas the remaining third did not express a clear attitude towards quality or length of life. People who were younger, male, having children, having religious beliefs, and without a history of serious illness were more likely to strive for length, whereas the reverse associations were found for striving for quality. The latter was related to undertaking initiatives to engage in advance care planning. Awareness of differences in attitudes towards life-prolonging treatment within the public may improve communication about appropriate end-of-life care.