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Voltz R, Meesters S, Ohler K, Weihrauch B, Kreische A, Niessen J, Heller A, Strupp J, Kremeike K. Top-down and bottom-up or participation through action? How to build a compassionate community - the experience of Caring Community Cologne. Palliat Care Soc Pract 2024; 18:26323524241238230. [PMID: 38529387 PMCID: PMC10962028 DOI: 10.1177/26323524241238230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/22/2024] [Indexed: 03/27/2024] Open
Affiliation(s)
- Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Strasse 62, Cologne D-50937, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
- Center for Health Services Research, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Sophie Meesters
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | | | | | - Anne Kreische
- Division of Health Planning and Promotion, Public Health Department Cologne, Cologne, Germany
| | - Johannes Niessen
- Division of Health Planning and Promotion, Public Health Department Cologne, Cologne, Germany
| | - Andreas Heller
- Institute of Pastoral Theology and Psychology, University of Graz, Austria
| | - Julia Strupp
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Kerstin Kremeike
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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Meier C, Vilpert S, Wieczorek M, Borasio GD, Jox RJ, Maurer J. Overestimation of Survival Rates of Cardiopulmonary Resuscitation Is Associated with Higher Preferences to Be Resuscitated: Evidence from a National Survey of Older Adults in Switzerland. Med Decis Making 2024; 44:129-134. [PMID: 38156651 PMCID: PMC10865767 DOI: 10.1177/0272989x231218691] [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: 07/31/2023] [Accepted: 11/06/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Many widely used advance directives templates include direct questions on individuals' preferences for cardiopulmonary resuscitation (CPR) in case of decision-making incapacity during medical emergencies. However, as knowledge of the survival rates of CPR is often limited, individuals' advance decisions on CPR may be poorly aligned with their preferences if false beliefs about the survival rates of CPR shape stated preferences for CPR. METHODS We analyzed nationally representative data from 1,469 adults aged 58+ y who responded to wave 8 (2019/2020) of the Swiss version of the Survey on Health, Ageing, and Retirement in Europe (SHARE) to assess the partial association between knowledge of CPR survival rates and stated preferences for CPR using multivariable probit regression models that adjust for social, health, and regional characteristics. Knowledge of CPR survival rates was assessed by asking how likely it is in general in Switzerland for a 70-y-old to survive until hospital discharge from a CPR performed outside of a hospital. Preferences for CPR were measured by asking respondents if they would wish to be resuscitated in case of cardiac arrest. RESULTS Only 9.3% of respondents correctly assessed the chances for a 70-y-old to survive until hospital discharge from a CPR performed outside of a hospital, while 65.2% indicated a preference to be resuscitated in case of a cardiac arrest. Respondents who correctly assessed CPR survival were significantly more likely to wish not to be resuscitated (average marginal effect: 0.18, P < 0.001). CONCLUSIONS Reducing misconceptions concerning the survival rates of CPR could change older adults' preferences for CPR and make them more likely to forgo such treatments. HIGHLIGHTS Many older adults in Switzerland overestimate the survival rates of cardiopulmonary resuscitation (CPR).The study reveals that individuals with accurate knowledge of CPR survival rates are more likely to refuse resuscitation in case of cardiac arrest.Overestimation of CPR survival rates may lead to a mismatch between individuals' preferences for CPR and their actual end-of-life care decisions.Improving the general population's knowledge of CPR survival rates is crucial to ensure informed decision making and effective advance care planning.
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Affiliation(s)
- Clément Meier
- Faculty of Biology and Medicine and the Faculty of Business and Economics, University of Lausanne, Switzerland
- Swiss Centre of Expertise in the Social Sciences, Lausanne, Switzerland
| | - Sarah Vilpert
- Swiss Centre of Expertise in the Social Sciences, Lausanne, Switzerland
- Faculty of Business and Economics, University of Lausanne, Switzerland
| | - Maud Wieczorek
- Swiss National Centre of Competence in Research LIVES – Overcoming Vulnerability: Life Course Perspectives, Lausanne and Geneva, Switzerland
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ralf J. Jox
- Palliative and Supportive Care Service, Chair in Geriatric Palliative Care, and Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Jürgen Maurer
- Faculty of Business and Economics, University of Lausanne, Switzerland
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Offermann J, Wilkowska W, Laurentius T, Bollheimer LC, Ziefle M. How age and health status impact attitudes towards aging and technologies in care: a quantitative analysis. BMC Geriatr 2024; 24:9. [PMID: 38172721 PMCID: PMC10765835 DOI: 10.1186/s12877-023-04616-4] [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: 05/26/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Increasing proportions of geriatric patients pose tremendous challenges for our society. Developments in assistive technologies have the potential to support older and frail people in aging and care. To reach a sustainable adoption of these technologies, the perceptions and wishes of future users must be understood. In particular, the relationships between individual health-related factors, and the perceptions of aging and using assistive technologies in severe health situations must be empirically examined. METHODS Addressing this research gap, our quantitative study (N = 570) investigates the impact of diverse future users' age and health status on their a) perceptions of aging, b) perceptions and acceptance of using assistive technologies in aging and care, as well as c) end-of-life decisions regarding technology usage. For this, four groups were segmented for the comparison of younger (< 50 years) healthy, younger chronically ill, older (50 + years) healthy, and older chronically ill participants. RESULTS The results revealed that health status is more decisive for age-related perceptions compared to age. The technology-related perceptions were slightly impacted by either chronological age or health status. The end-of-life decisions showed the most striking differences in the willingness to use assistive technologies, revealing older chronically ill participants to have more restrained attitudes towards technology usage than older healthy as well as all younger participants. CONCLUSIONS The findings suggest that the benefits of assistive technologies in private or professional care contexts should be communicated and implemented tailored to the respective user group's needs. Moreover, the results allow us to derive practical implications within the geriatric care context.
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Affiliation(s)
- Julia Offermann
- Chair for Communication Science & Human-Computer Interaction Center, RWTH Aachen University, Campus-Boulevard 57, 52074, Aachen, Germany.
| | - Wiktoria Wilkowska
- Chair for Communication Science & Human-Computer Interaction Center, RWTH Aachen University, Campus-Boulevard 57, 52074, Aachen, Germany
| | - Thea Laurentius
- Chair of Geriatrics & Department of Geriatric Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - L Cornelius Bollheimer
- Chair of Geriatrics & Department of Geriatric Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Martina Ziefle
- Chair for Communication Science & Human-Computer Interaction Center, RWTH Aachen University, Campus-Boulevard 57, 52074, Aachen, Germany
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Tomczyk M, Andorno R, Jox RJ. Should continuous deep sedation until death be legally regulated in Switzerland? An exploratory study with palliative care physicians. Palliat Care Soc Pract 2023; 17:26323524231219509. [PMID: 38152555 PMCID: PMC10752051 DOI: 10.1177/26323524231219509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023] Open
Abstract
Background In Switzerland, continuous deep sedation until death (CDSUD) is not legally regulated and the current clinical practice guidelines on palliative sedation from 2005 do not refer to it. In contrast, in France, a neighbouring country, CDSUD is regulated by a specific law and professional guidelines. International studies show that in culturally polymorphic countries, there are variations in the end-of-life practices between linguistic regions and that a linguistic region shares many cultural characteristics with the neighbouring country. Objectives This study aimed to explore the attitudes of palliative care physicians from the French-speaking part of Switzerland on the question of whether CDSUD should be legally regulated in the country, and to identify their arguments. Our study also aimed to assess whether a hypothetical Swiss law on CDSUD should be similar to the current legal regulation of this practice in France. Design We conducted a multicentre exploratory qualitative study based on face-to-face interviews with palliative care physicians in the French-speaking part of Switzerland. Methods We analysed the interview transcripts using thematic analysis, combining deductive and inductive coding. Results Most of the participants were opposed to having specific legal regulation of CDSUD in Switzerland. Their arguments were diverse: some focused on medical and epistemological aspects of CDSUD, whereas others emphasized the legal inconvenience of having such regulation. None had the opinion that, if CDSUD were legally regulated in Switzerland, the regulation should be similar to that in France. Conclusion This study allows to better understand why palliative care physicians in French-speaking Switzerland may be reluctant to have legal regulation of CDSUD. Further studies covering the whole country would be needed to gain a more complete picture of Swiss palliative care physicians on this question.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Av. de Provence 82, Lausanne CH-1007, Switzerland
| | - Roberto Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Ralf J. Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Meier C, Vilpert S, Wieczorek M, Borrat-Besson C, Jox RJ, Maurer J. Development and validation of a subjective end-of-life health literacy scale. PLoS One 2023; 18:e0292367. [PMID: 37831689 PMCID: PMC10575492 DOI: 10.1371/journal.pone.0292367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Abstract
Personal health literacy is the ability of an individual to find, understand, and use information and services to inform health-related decisions and actions for oneself and others. The end of life is commonly characterized by the occurrence of one or several diseases, the use of many different types of healthcare services, and a need to make complex medical decisions that may involve challenging tradeoffs, such as choices between quality and length of life. Although end-of-life care issues concern most people at some point in life, individuals' competencies to deal with those questions have rarely been explored. This study aims to introduce, develop, and validate an instrument to measure individuals' self-assessed competencies to deal with end-of-life medical situations, the Subjective End-Of-Life Health Literacy Scale (S-EOL-HLS), in a sample of older adults aged 50+ living in Switzerland who participated in wave 8 (2019/2020) of the Survey of Health, Ageing, and Retirement in Europe. The S-EOL-HLS uses a series of questions on self-rated difficulties in understanding end-of-life medical jargon, defining in advance which end-of-life medical treatments to receive or refuse, and communicating related choices. Aside from conducting exploratory and confirmatory factor analysis to evaluate the construct validity, we compared measurements from the S-EOL-HLS to respondents' general health literacy measured with the European Health Literacy Survey questionnaire. We obtained a three-factor model with acceptable fit properties (CFI = 0.993, TLI = 0.992, RMSEA = 0.083, SRMR = 0.061) and high reliability (α = 0.93). The partial associations between the health literacy scores from the two scales and respondents' sociodemographic characteristics were similar; however, individuals with higher end-of-life health literacy scores appeared to have more positive attitudes towards end-of-life care planning outcomes. The S-EOL-HLS demonstrates reliable and consistent results, making the instrument suitable for older adults in population surveys.
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Affiliation(s)
- Clément Meier
- Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne, Lausanne, Switzerland
- Swiss Centre of Expertise in the Social Sciences (FORS), Lausanne, Switzerland
| | - Sarah Vilpert
- Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
- Swiss Centre of Expertise in the Social Sciences (FORS), Lausanne, Switzerland
| | - Maud Wieczorek
- Swiss Centre of Expertise in Life Course Research LIVES, Lausanne and Geneva, Geneva, Switzerland
| | | | - Ralf J. Jox
- Palliative and Supportive Care Service, Chair in Geriatric Palliative Care, and Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jürgen Maurer
- Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
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Yildiz B, Korfage IJ, Deliens L, Preston NJ, Miccinesi G, Kodba-Ceh H, Pollock K, Johnsen AT, van Delden JJM, Rietjens JAC, van der Heide A. Self-efficacy of advanced cancer patients for participation in treatment-related decision-making in six European countries: the ACTION study. Support Care Cancer 2023; 31:512. [PMID: 37552324 PMCID: PMC10409662 DOI: 10.1007/s00520-023-07974-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE Many patients prefer an active role in making decisions about their care and treatment, but participating in such decision-making is challenging. The aim of this study was to explore whether patient-reported outcomes (quality of life and patient satisfaction), patients' coping strategies, and sociodemographic and clinical characteristics were associated with self-efficacy for participation in decision-making among patients with advanced cancer. METHODS We used baseline data from the ACTION trial of patients with advanced colorectal or lung cancer from six European countries, including scores on the decision-making participation self-efficacy (DEPS) scale, EORTC QLQ-C15-PAL questionnaire, and the EORTC IN-PATSAT32 questionnaire. Multivariable linear regression analyses were used to examine associations with self-efficacy scores. RESULTS The sample included 660 patients with a mean age of 66 years (SD 10). Patients had a mean score of 73 (SD 24) for self-efficacy. Problem-focused coping (B 1.41 (95% CI 0.77 to 2.06)), better quality of life (B 2.34 (95% CI 0.89 to 3.80)), and more patient satisfaction (B 7.59 (95% CI 5.61 to 9.56)) were associated with a higher level of self-efficacy. Patients in the Netherlands had a higher level of self-efficacy than patients in Belgium ((B 7.85 (95% CI 2.28 to 13.42)), whereas Italian patients had a lower level ((B -7.50 (95% CI -13.04 to -1.96)) than those in Belgium. CONCLUSION Coping style, quality of life, and patient satisfaction with care were associated with self-efficacy for participation in decision-making among patients with advanced cancer. These factors are important to consider for healthcare professionals when supporting patients in decision-making processes.
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Affiliation(s)
- Berivan Yildiz
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Ida J Korfage
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Nancy J Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Guido Miccinesi
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Hana Kodba-Ceh
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anna Thit Johnsen
- Department of Psychology, University of Southern Denmark, Campusvej, 55, Odense, Denmark
- Department of Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Vilpert S, Meier C, Berche J, Borasio GD, Jox RJ, Maurer J. Older adults' medical preferences for the end of life: a cross-sectional population-based survey in Switzerland. BMJ Open 2023; 13:e071444. [PMID: 37487679 PMCID: PMC10373667 DOI: 10.1136/bmjopen-2022-071444] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVES Medical decision-making at the end of life is common and should be as patient-centred as possible. Our study investigates older adults' preferences towards three medical treatments that are frequently included in advance directive forms and their association with social, regional and health characteristics. SETTING A cross-sectional study using population-based data of wave 8 (2019/2020) of the Swiss component of the Survey of Health, Ageing and Retirement in Europe. PARTICIPANTS 1430 adults aged 58 years and older living in Switzerland. PRIMARY AND SECONDARY OUTCOME MEASURES Three questions on the preferences regarding cardiopulmonary resuscitation (CPR); life-prolonging treatment in case of high risk of permanent mental incapacity; reduced awareness (sedation) to relieve unbearable pain and symptoms. Their associations with individuals' social, regional and health characteristics. RESULTS Most older adults expressed a wish to receive CPR (58.6%) and to forgo life-prolonging treatment in case of permanent mental incapacity (92.2%). Most older adults also indicated that they would accept reduced awareness if necessary to receive effective treatment for pain and distressing symptoms (59.2%). Older adults' treatment preferences for CPR and life-prolonging treatment differed according to sex, age, partnership status, linguistic region and health status, while willingness to accept reduced awareness for effective symptom treatment was more similarly distributed across population groups. CONCLUSIONS Simultaneous preferences for CPR and refusal of life-prolonging treatment might appear to be conflicting treatment goals. Considering individuals' values and motivations can help clarify ambivalent treatment decisions. Structured advance care planning processes with trained professionals allows for exploring individuals' motivations and values and helps to identify congruent care and treatment goals.
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Affiliation(s)
- Sarah Vilpert
- Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
| | - Clément Meier
- Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Jeanne Berche
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ralf J Jox
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jürgen Maurer
- Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
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Bar-Sela G, Tur-Sinai A, Givon-Schaham N, Bentur N. Advance Care Planning and Attainment of Cancer Patients' End-of-Life Preferences: Relatives' Perspective. Am J Hosp Palliat Care 2023; 40:322-328. [PMID: 35587799 PMCID: PMC9941650 DOI: 10.1177/10499091221099921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The purpose of this study is to determine which element of advance care planning (ACP) - an advance directives (AD) document or an end-of-life discussion between patient and family (DwF), if any-improves the likelihood of cancer patients' attaining their preferences regarding treatments in the last month of life and dying in the place they prefer. METHODS First-degree relatives of deceased cancer patients, interviewed by telephone, were asked if the treatments the patients received in their last month of life and their place of death corresponded to the patients' preferences. Nominal logistic regression analyses were conducted in search of significant association between having an AD document and/or conducting a DwF and patients' treatment and place of death in accordance with their preferences. RESULTS 491 deceased patients were included in the study. Their average age was 68; 52% were women. According to 32% of the relatives, the patients' treatment in the last month of life was aligned with their preferences and 55% said the patients had died in their preferred place. Only 16.5% had an AD document, 58.5% only discussed their treatment preferences with relatives, and 25% did neither. DwF and ability to speak until last week of life were significantly related to receiving treatment consistent with patients' preferences. Dying where the patient prefers is significantly associated with having an AD and a DwF, with an AD yielding higher odds. CONCLUSION A multifaceted interconnection exists between the two elements of ACP in attaining cancer patients' wishes and abetting better end of life care.
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Affiliation(s)
- Gil Bar-Sela
- Oncology and Hematology Division, Emek Medical Center, Israel
| | - Aviad Tur-Sinai
- Department of Health Systems Management, The Max Stern Yezreel Valley College, Jezreel Valley, Israel,School of Nursing, University of Rochester Medical Center, New York
| | - Noa Givon-Schaham
- The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Netta Bentur
- The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Israel,Netta Bentur, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Riisfeldt TD. Overcoming Conflicting Definitions of "Euthanasia," and of "Assisted Suicide," Through a Value-Neutral Taxonomy of "End-Of-Life Practices". JOURNAL OF BIOETHICAL INQUIRY 2023; 20:51-70. [PMID: 36729348 PMCID: PMC10126086 DOI: 10.1007/s11673-023-10230-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 10/10/2022] [Indexed: 05/04/2023]
Abstract
The term "euthanasia" is used in conflicting ways in the bioethical literature, as is the term "assisted suicide," resulting in definitional confusion, ambiguities, and biases which are counterproductive to ethical and legal discourse. I aim to rectify this problem in two parts. Firstly, I explore a range of conflicting definitions and identify six disputed definitional factors, based on distinctions between (1) killing versus letting die, (2) fully intended versus partially intended versus merely foreseen deaths, (3) voluntary versus nonvoluntary versus involuntary decisions, (4) terminally ill versus non-terminally ill patients, (5) patients who are fully conscious versus those in permanent comas or persistent vegetative states, and (6) patients who are suffering versus those who are not. Secondly, I distil these factors into six "building blocks" and combine them to develop an unambiguous, value-neutral taxonomy of "end-of-life practices." I hope that this taxonomy provides much-needed clarification and a solid foundation for future ethical and legal discourse.
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Affiliation(s)
- Thomas D Riisfeldt
- Department of Philosophy, University of New South Wales, High St, Kensington, Sydney, New South Wales, 2052, Australia.
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Mazzola MA, Russell JA. Neurology ethics at the end of life. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:235-257. [PMID: 36599511 DOI: 10.1016/b978-0-12-824535-4.00012-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life (EOL). In many of these cases, there are conflicting opinions as to what is right and wrong originating from multiple sources. There is a particularly high prevalence of impaired patient judgment and decision-making capacity in this population that may result in a misrepresentation of their premorbid values and goals. Conflict may originate from a discordance between what is legal or from stakeholders who view and value life and existence differently from the patient, at times due to religious or cultural influences. Promotion of life, rather than preservation of existence, is the goal of many patients and the foundation on which palliative care is built. Those who provide EOL care, while being respectful of potential cultural, religious, and legal stakeholder perspectives, must at the same time recognize that these perspectives may conflict with the optimal ethical course to follow. In this chapter, we will attempt to review some of the more notable ethical challenges that may arise in the neurologically afflicted at the EOL. We will identify what we believe to be the most compelling ethical arguments both in support of and opposition to specific EOL issues. At the same time, we will consider how ethical analysis may be influenced by these legal, cultural, and religious considerations that commonly arise.
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White BP, Willmott L, Close E. Better Regulation of End-Of-Life Care: A Call For A Holistic Approach. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:683-693. [PMID: 36251135 PMCID: PMC9908626 DOI: 10.1007/s11673-022-10213-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/10/2022] [Indexed: 06/16/2023]
Abstract
Existing regulation of end-of-life care is flawed. Problems include poorly-designed laws, policies, ethical codes, training, and funding programs, which often are neither effective nor helpful in guiding decision-making. This leads to adverse outcomes for patients, families, health professionals, and the health system as a whole. A key factor contributing to the harms of current regulation is a siloed approach to regulating end-of-life care. Existing approaches to regulation, and research into how that regulation could be improved, have tended to focus on a single regulatory instrument (e.g., just law or just ethical codes). As a result, there has been a failure to capture holistically the various forces that guide end-of-life care. This article proposes a response to address this, identifying "regulatory space" theory as a candidate to provide the much-needed holistic insight into improving regulation of end-of-life care. The article concludes with practical implications of this approach for regulators and researchers.
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Affiliation(s)
- Ben P. White
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 Australia
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Kremeike K, Ullrich A, Schulz H, Rosendahl C, Boström K, Kaur S, Oubaid N, Plathe-Ignatz C, Leminski C, Hower K, Pfaff H, Hellmich M, Oechsle K, Voltz R. Dying in hospital in Germany - optimising care in the dying phase: study protocol for a multi-centre bottom-up intervention on ward level. BMC Palliat Care 2022; 21:67. [PMID: 35524257 PMCID: PMC9072764 DOI: 10.1186/s12904-022-00960-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 04/28/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hospitals are globally an important place of care for dying people and the most frequent place of death in Germany (47%), but at the same time, the least preferred one - for both patients and their relatives. Important indicators and outcome variables indexing quality of care in the dying phase are available, and various proposals to achieve corresponding quality objectives exist. However, they are not yet sufficiently adapted to the heterogeneous needs of individual hospital wards. METHODS This multi-centre single-arm pre-post study aims at the development and implementation of context-specific measures in everyday clinical practice, followed by evaluating this approach. Therefore, (1) already existing measures regarding optimal care in the dying phase are identified applying a systematic literature review as well as an online survey and a symposium with experts. Supported by the thereby generated collection of measures, (2) a stratified sample of ten teams of different wards from two university hospitals select suitable measures and implement them in their everyday clinical practice. Circumstances of patients' deaths on the selected wards are recorded twice, at baseline before application of the self-chosen measures and afterwards in a follow-up survey. Retrospective file analysis of deceased persons, quantitative staff surveys as well as qualitative multi-professional focus groups and interviews with relatives form the data basis of the pre-post evaluation. (3) Results are reviewed regarding their transferability to other hospitals and disseminated (inter-)nationally. DISCUSSION Measures that are easy to implement and appropriate to the specific situation are supposed to significantly improve the quality of care during the dying phase in hospitals and contribute to the well-being of dying patients and their relatives. Successful implementation of those measures requires consideration of the individual conditions and needs of patients and their relatives-but also of the health professionals-on the different hospital wards. Therefore, a bottom-up approach, in which the ward-specific situation is first analysed in detail and then the staff itself selects and implements measures to improve care, appears most promising for optimising care in the dying phase in hospitals. TRIAL REGISTRATION The study is registered in the German Clinical Trials Register ( DRKS00025405 ).
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Affiliation(s)
- Kerstin Kremeike
- Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - Anneke Ullrich
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Holger Schulz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carolin Rosendahl
- Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Kathleen Boström
- Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Sukhvir Kaur
- Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Nikolas Oubaid
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christina Plathe-Ignatz
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christin Leminski
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne, Eupenerstr. 129, 50933, Cologne, Germany
| | - Kira Hower
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne, Eupenerstr. 129, 50933, Cologne, Germany
| | - Holger Pfaff
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne, Eupenerstr. 129, 50933, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Karin Oechsle
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
- Center for Clinical Studies (ZKS), Faculty of Medicine and University Hospital, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
- Center for Health Services Research (ZVFK), Faculty of Medicine and University Hospital, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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Petri S, Zwißler B, In der Schmitten J, Feddersen B. [Advance Care Planning-further development of the patient advance directive : What the specialist in internal medicine must know]. Internist (Berl) 2022; 63:533-544. [PMID: 35441880 PMCID: PMC9020146 DOI: 10.1007/s00108-022-01333-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.
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Affiliation(s)
- S Petri
- Caritasverband der Erzdiözese München und Freising e. V., München, Deutschland
| | - B Zwißler
- Klinik für Anästhesiologie, Klinikum der Universität München, LMU München, München, Deutschland
| | - J In der Schmitten
- Institut für Allgemeinmedizin, Universitätsklinik Essen, Essen, Deutschland
| | - B Feddersen
- Klinik und Poliklinik für Palliativmedizin, SAPV, Klinikum der Universität München, LMU München, Schillerstr. 40/III, 80336, München, Deutschland.
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Yu WC, Huang CT, Sheng WH. Application of a pre-emptive question and answer platform to improve the level of satisfaction during family meetings in general medical wards. BMC Health Serv Res 2022; 22:499. [PMID: 35422016 PMCID: PMC9008296 DOI: 10.1186/s12913-022-07929-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/31/2022] [Indexed: 12/03/2022] Open
Abstract
Background A successful family meeting is key to family-centered care and may foster communication and improve the level of satisfaction of the family in terms of communication. In this study, we evaluated whether a proactive communication channel could improve the level of satisfaction of family members following a family meeting in a general medical ward setting. Methods We conducted a pre- and post-study to compare the level of satisfaction of a family with a family meeting before (N = 39) and after (N = 29) intervention in two general medical wards of a tertiary-care referral center. The intervention included a pre-emptive question and answer platform and a written response to family-raised queries in addition to a regular setting. Following each family meeting, family members were requested to fill a 10-item survey assessing their levels of satisfaction. Results The characteristics of the family members in terms of demographics, education levels, and previous experiences with family meetings in the pre- and post-intervention groups were similar. The scores in all the items that indicated the level of satisfaction significantly improved after intervention. The overall score for satisfaction increased from 85 (interquartile range, 80–95) to 98 (interquartile range, 93–100; P < 0.001). Conclusions Compared with conventional practice, the inclusion of a proactive communication platform along with a written response to raised queries as a part of family meetings improved the satisfaction levels of the family in terms of the content and process of the meeting in the general ward setting. Further studies are needed to delineate the optimal timing and use of such a communication modality. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07929-z.
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Im H, Choe HW, Oh SY, Ryu HG, Lee H. Changes in the incidence of cardiopulmonary resuscitation before and after implementation of the Life-Sustaining Treatment Decisions Act. Acute Crit Care 2022; 37:237-246. [PMID: 35280036 PMCID: PMC9184988 DOI: 10.4266/acc.2021.01095] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/13/2021] [Indexed: 11/30/2022] Open
Abstract
Background Methods Results Conclusions
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Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study. BMC Med Ethics 2022; 23:12. [PMID: 35172834 PMCID: PMC8851755 DOI: 10.1186/s12910-022-00752-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia. METHODS A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann-Whitney U test was used to analyse the differences between two groups and Kruskal-Wallis tests were used to analyse the differences between more than two groups. RESULTS Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that 'do-not-attempt cardiopulmonary resuscitations' orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient's wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation. CONCLUSIONS DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia's geographical location in Southern Europe.
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Kasuga H, Endo S, Masuishi Y, Hidaka T, Kakamu T, Saito K, Abe K, Fukushima T. Association between participation in sports club activities and decision-making preferences in end-of-life treatment among Japanese elderly people:a cross-sectional study. Fukushima J Med Sci 2021; 67:135-142. [PMID: 34744089 PMCID: PMC8784194 DOI: 10.5387/fms.2021-16] [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] [Indexed: 11/17/2022] Open
Abstract
Introduction: Decision-making regarding treatment at the end-of-life stage is an important issue for the elderly and their families. Such decision-making may be influenced by activities that promote communication and physical health. The purpose of this study was to examine the association between participation in sports club activities and decision-making regarding life-prolonging treatment among the general community-dwelling Japanese elderly. Methods: In this cross-sectional study, which used stratified random sampling, 1,603 elderly people aged 65 years or older as of January 2016, living in Fukushima prefecture, Japan were enrolled. Data was collected by a self-completed questionnaire (effective response rate: 53.4%). The association of sports club activity participation with a preference for accepting or declining life-prolonging treatment was analyzed by multinomial logistic regression analysis. Results: Of those participating in sports club activities, the results revealed an odds ratios of 1.812 for participants declining life-prolonging treatment (95% CI=1.325 to 2.477) and 1.948 for those who preferred life-prolonging treatment (95% CI=1.160 to 3.271). Conclusions: The present study suggests that participation in sports club activities is associated with articulating decisions about life-prolonging treatment in end-of-life care. Consideration of patient involvement in daily activities in non-medical settings may enhance decision-making for end-of-life care planning.
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Affiliation(s)
- Hideaki Kasuga
- Department of Hygiene and Preventive Medicine, Fukushima Medical University
| | - Shota Endo
- Department of Hygiene and Preventive Medicine, Fukushima Medical University
| | - Yusuke Masuishi
- Department of Hygiene and Preventive Medicine, Fukushima Medical University
| | - Tomoo Hidaka
- Department of Hygiene and Preventive Medicine, Fukushima Medical University
| | - Takeyasu Kakamu
- Department of Hygiene and Preventive Medicine, Fukushima Medical University
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Oncology and Palliative Care Nurses' Knowledge and Attitudes Toward Artificial Nutrition and Hydration for Patients at End of Life in Italy: A Cross-sectional Survey. Cancer Nurs 2021; 44:E99-E107. [PMID: 32195711 DOI: 10.1097/ncc.0000000000000803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nutrition is a basic patients' need and an important component of nursing. End-of-life cancer patients can experience difficulties in eating and drinking, sometimes requiring artificial nutrition and hydration (ANH). Nurses' knowledge and attitudes greatly influence nursing care. Nurses may lack knowledge of ANH. To date, no study has explored the knowledge and attitudes of oncology and palliative care nurses toward end-of-life ANH. OBJECTIVE To describe oncology and palliative care nurses' knowledge of and attitudes toward ANH. METHODS A multicenter cross-sectional study was conducted in 7 regions of Italy using the Italian version of the Questionnaire on Knowledge and Attitudes in Providing ANH for Terminal Cancer Patients. Attitudes were divided into benefits and burdens of providing ANH. Data were analyzed by descriptive statistics. RESULTS High percentages of oncology and palliative care nurses showed reasonable knowledge about ANH. More disagreement was evidenced about benefits and burdens of ANH, and lower importance was given to them. CONCLUSIONS Some misconceptions and a low level of awareness exist among some nurses about ANH. More nursing studies should be conducted and extended to different care settings. Moreover, guidelines should be reinforced with a nursing perspective to better define nurses' role in the decision-making process on ANH. IMPLICATIONS FOR PRACTICE This exploration of nurses' knowledge of and attitudes toward ANH in end-of-life cancer patients can contribute to an understanding of how nurses can be involved in better meeting cancer patients' nutritional needs at the end of life.
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Willmott L, White B, Feeney R, Chambaere K, Yates P, Mitchell G. Intentional hastening of death through medication: A case series analysis of Victorian deaths prior to the Voluntary Assisted Dying Act 2017. Intern Med J 2021; 51:1650-1656. [PMID: 34139049 DOI: 10.1111/imj.15435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Voluntary assisted dying is lawful in Victoria in limited circumstances and commences in Western Australia in mid-2021. There is evidence that in rare cases unlawful assisted dying practices occur in Australia. AIMS To determine whether assisted dying practices occurred in Victoria in the 12 months prior to the commencement of the Voluntary Assisted Dying Act 2017 (Vic) ('VAD Act'), and to examine features of any identified cases. METHODS Exploratory case series of adult patients in Victoria who died between May 2018 and 18 June 2019 as a result of medication administered with the primary intention of hastening death. Cases were identified from a self-administered survey about medical end-of-life decisions for adult patients, completed by Victorian specialists treating adults at the end of life. We examined reported use of medication with the primary intention of hastening the patient's death; characteristics of assisted dying cases, including doctors' classification of such practices. RESULTS Nine cases met the inclusion criteria. Death did not occur immediately after providing medication with the intention of hastening death. In eight cases, it was framed as palliative or terminal sedation and/or continuous deep sedation. Most doctors used language that distanced their practices from assisted dying. CONCLUSIONS Unlawful assisted dying practices seem to have occurred in a small number of deaths in Victoria prior to commencement of the VAD Act. These practices typically occurred within the context of palliative or terminal sedation and may be difficult to distinguish from lawful palliative care practice. Some survey responses possibly reflect ambiguity in doctors' intentions when providing medication. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology
| | - Ben White
- Australian Centre for Health Law Research, Queensland University of Technology
| | - Rachel Feeney
- Australian Centre for Health Law Research, Queensland University of Technology
| | - Kenneth Chambaere
- Sociology & Ethics of the End of Life, End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Belgium
| | - Patsy Yates
- Head of the School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Geoffrey Mitchell
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Novel Beings and Assisted Nonexistence. Camb Q Healthc Ethics 2021; 30:543-555. [PMID: 34109930 DOI: 10.1017/s0963180120001085] [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: 11/06/2022]
Abstract
This article engages with the legal regulation of end-of-existence decisionmaking for novel beings, specifically assisted nonexistence for such entities. The author explains the concept of a legal model for assisted death by reference to the substantive features of legal regimes in three jurisdictions in which assisted suicide or euthanasia is lawful. He considers how these models might fit novel beings who may require or prefer assistance to end their own existence by reference to the constituent features-abstract legal ingredients-that models for assisted death share. The author argues that extant models may block some novel beings' access to end-of-existence assistance or fail to track what matters to them. He then examines the merits of adopting a universal model for assisted nonexistence, that is, a legal framework whose substantive features capture the end-of-existence concerns of both human and novel beings. Consideration of a unified legal framework may illuminate the discussion of assisted nonexistence for humans and novel beings. However, the paper proposes that whereas novel beings may have similar interests to humans, they may be relevantly different also. The prima facie case for adopting a one regime to rule us all approach to assisted nonexistence may be defeated by reasons for divergent regulation.
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Willmott L, White B, Feeney R, Chambaere K, Yates P, Mitchell G, Piper D. Collecting data on end-of-life decision-making: Questionnaire translation, adaptation and validity assessment. PROGRESS IN PALLIATIVE CARE 2021. [DOI: 10.1080/09699260.2021.1922795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Rachel Feeney
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Geoffrey Mitchell
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Donella Piper
- Business School, University of New England, Armidale, NSW, Australia
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Kim H, Im HS, Lee KO, Min YJ, Jo JC, Choi Y, Lee YJ, Kang D, Kim C, Koh SJ, Cheon J. Changes in decision-making process for life-sustaining treatment in patients with advanced cancer after the life-sustaining treatment decisions-making act. BMC Palliat Care 2021; 20:63. [PMID: 33906659 PMCID: PMC8080393 DOI: 10.1186/s12904-021-00759-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Cancer is a leading cause of death in Korea. To protect the autonomy and dignity of terminally ill patients, the Life-Sustaining Treatment Decision-Making Act (LST-Act) came into full effect in Korea in February 2018. However, it is unclear whether the LST-Act influences decision- making process for life-sustaining treatment (LST) for terminally ill cancer patients. Methods This was a retrospective study conducted with a medical record review of cancer patients who died at Ulsan University Hospital between July 2015 and May 2020. Patients were divided into two groups: those who died in the period before the implementation of the LST-Act (from July 2015 to October 2017, Group 1) and after the implementation of the LST-Act (from February 2018 to May 2020, Group 2). We measured the self-determination rate and the timing of documentation of do-not-resuscitate (DNR) or Physician Orders for Life-Sustaining Treatment (POLST) in both groups. Results A total of 1,834 patients were included in the analysis (Group 1, n = 943; Group 2, n = 891). Documentation of DNR or POLST was completed by patients themselves in 1.5 and 63.5 % of patients in Groups 1 and 2, respectively (p < 0.001). The mean number of days between documentation of POLST or DNR and death was higher in Group 2 than in Group 1 (21.2 days vs. 14.4 days, p = 0.001). The rate of late decision, defined as documentation of DNR or POLST within 7 days prior to death, decreased significantly in Group 2 (56.1 % vs. 47.6 %, p < 0.001). In the multivariable analysis, female patients (odds ratio [OR] 0.71, p = 0.002) and patients with more than 12 years of education (OR 0.70, p = 0.019) were significantly related to a reduced rate of late decision. More than 12 years of education (OR 0.53, p = 0.018) and referral to hospice palliative care (OR 0.40, p < 0.001) were significantly related to self-determination. Enforcement of LST-Act was related to a reduced rate of surrogate decision-making (OR 0.01, p < 0.001) and late decision (OR 0.51, p < 0.001). However, physicians with clinical experience of less than 3 years had a higher rate of surrogate decision-making (OR 5.08, p = 0.030) and late decision (OR 2.47, p = 0.021). Conclusions After the implementation of the LST-Act, the rate of self-determination increased and decisions for LST occurred earlier than in the era before the implementation of the LST-Act.
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Affiliation(s)
- Hyeyeong Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, 44033, Ulsan, Republic of Korea
| | - Hyeon-Su Im
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, 44033, Ulsan, Republic of Korea
| | - Kyong Og Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, 44033, Ulsan, Republic of Korea
| | - Young Joo Min
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, 44033, Ulsan, Republic of Korea
| | - Jae-Cheol Jo
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, 44033, Ulsan, Republic of Korea
| | - Yunsuk Choi
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, 44033, Ulsan, Republic of Korea
| | - Yoo Jin Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, 44033, Ulsan, Republic of Korea
| | - Daseul Kang
- Medical Information Center, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Changyoung Kim
- Medical Information Center, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Su-Jin Koh
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, 44033, Ulsan, Republic of Korea.
| | - Jaekyung Cheon
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, 44033, Ulsan, Republic of Korea. .,Department of Medical Oncology, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, 13496, Seongnam, Republic of Korea.
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Robijn L, Deliens L, Scherrens AL, Pauwels NS, Pype P, Rietjens J, Chambaere K. A systematic review of quality improvement initiatives for continuous sedation until death. Palliat Med 2021; 35:670-682. [PMID: 33722107 DOI: 10.1177/0269216321996990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Extensive debate surrounds the practice of continuous sedation until death within end-of-life care. AIM To provide insight into existing initiatives to support the practice of continuous sedation until death and assess their feasibility and effectiveness. DESIGN Systematic review and narrative synthesis, registered on PROSPERO (CRD42020149630). DATA SOURCES Records were searched through MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science from inception to April 16 2020. Peer-reviewed studies reporting original data on initiatives to support the practice of continuous sedation were included for review. RESULTS Twenty-one studies met the criteria and were included. Initiatives were focused on assessment tools of consciousness and discomfort (9), the use of guidelines and protocols (8), and expert consultation (3). All initiatives were reported as useful, acceptable, and feasible. Studies on the use of monitoring devices showed that a small proportion of patients were found to be awake, despite the patient being unresponsive according to the observer-based sedation scales. However, the wide range of values of these monitoring devices for comfortable and adequately sedated patients seems to hamper its overall implementation in daily clinical practice. Physicians reported changes in practice conform to guideline recommendations but the shift was modest at best. Expert consultation was regarded as supportive when sufficient expertise is lacking and helpful in avoiding possibly unnecessary sedations. CONCLUSIONS The reviewed initiatives may contribute to improvement of continuous sedation until death, though their evidence base is rather limited. More insight is needed into their feasibility, preconditions for effective implementation and impact in actual practice.
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Affiliation(s)
- Lenzo Robijn
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Luc Deliens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Anne-Lore Scherrens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Nele S Pauwels
- Ghent University, Knowledge Management Center Ghent, Ghent, Belgium
| | - Peter Pype
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Judith Rietjens
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Kenneth Chambaere
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
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Jennings N, Chambaere K, Chamely S, Macpherson CC, Deliens L, Cohen J. Palliative and End-of-Life Care in a Small Caribbean Country: A Mortality Follow-back Study of Home Deaths. J Pain Symptom Manage 2020; 60:1170-1180. [PMID: 32650139 DOI: 10.1016/j.jpainsymman.2020.06.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 11/28/2022]
Abstract
CONTEXT Empirical information on circumstances of dying from advanced illness in developing countries remains sparse. Evidence indicates that out-of-hospital end-of-life care can have significant benefits such as increased satisfaction for the patient and caregivers and cost-effective for a health-care system. Services that are aimed to deliver care at private homes may be a good model for low- and middle-income countries or other low-resourced settings. OBJECTIVES To examine specialized, generalist, and informal palliative care provision and to describe the end-of-life care goals and treatments received. METHOD A mortality follow-back study with data obtained from general practitioners certifying a random sample of death certificates of adult decedents who died between March and August 2018. The questionnaire inquired about the characteristics of care and treatment preceding death. RESULTS Three hundred nine questionnaires were mailed, and the response rate was 31% (N = 96), of which 76% were nonsudden deaths. Of these cases, 27.4% received no palliative care, 39.7% received it from a general practitioner, and 6.8% from a specialized palliative care service. Comfort maximization (60.3%) was the main goal of care in the last week of life, and analgesics (53.4%) were the predominant treatment for achieving this goal. In addition, 60.3% received informal palliative care from a family member. CONCLUSION The largest part of end-of-life care at home in Trinidad and Tobago is provided by family members, whereas professional caregivers feature less prominently. To ensure quality in end-of-life care, better access to analgesics is needed, and adequate support and education for family members as well as general practitioners are highly recommended.
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Affiliation(s)
- Nicholas Jennings
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; St. George's University, Bioethics Department, St. George's Grenada.
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Stacey Chamely
- Independent researcher, San Fernando, Trinidad and Tobago
| | - Cheryl C Macpherson
- Bioethics Division, St. George's University School of Medicine and Windward Islands Research and Education Foundation, St. George's, Grenada
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
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Douplat M, Fraticelli L, Claustre C, Peiretti A, Serre P, Bischoff M, Jacquin L, Freyssenge J, Schott AM, Tazarourte K, Frugier S, Khoury CEL, Grezard M, Antoine JD, Dumont O, Lhuillier E, Pierro L, Blain S, Prost C, Sen-Brachet P, Khaldi A. Management of decision of withholding and withdrawing life-sustaining treatments in French EDs. Scand J Trauma Resusc Emerg Med 2020; 28:52. [PMID: 32513282 PMCID: PMC7282105 DOI: 10.1186/s13049-020-00744-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature.
Study objective
We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France.
Method
In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process.
Results
There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives.
Conclusion
The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.
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Park SY, Lee B, Seon JY, Oh IH. A National Study of Life-Sustaining Treatments in South Korea: What Factors Affect Decision-Making? Cancer Res Treat 2020; 53:593-600. [PMID: 33227190 PMCID: PMC8053857 DOI: 10.4143/crt.2020.803] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/21/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE This cross-sectional study investigated the status of life-sustaining treatment (LST) practices and identified characteristics and factors influencing decision-making practices. Materials and Methods The National Agency for Management of Life-sustaining Treatment retains records provided by doctors regarding patients subject to LST implementation. A total of 71,327 patients receiving LST were identified. We analyzed all nationally reported data between February 2018 and October 2019. Indicators such as the proportion of deaths, records for decision to terminate LST, implementation of LST records, and registration of Advance Statements on LST were analyzed. RESULTS A total of 67,252 (94.3%) end-of life decisions were implemented in South Korea. The proportion of deaths preceded by a LST plan, non-self-determination LST decision, and any advance statements was 33.5% (23,891/71,327), 66.5% (47,436/71,327), and 1.2% (890/71,327), respectively. The logistic regression model revealed that self-determination to terminate LST was more frequent for men than for women and higher for those aged 30-69. Disability (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.56 to 0.61), living in non-metropolitan areas (OR, 0.84; 95% CI, 0.81 to 0.86), and disease comorbidity was independently associated with a low level of self-determination. CONCLUSION After the implementation of the new LST Act, about a third of patients in end-of-life process made decisions regarding their medical LST. However, family members still play a major role in LST decisions where the patient's intention cannot be verified. Decisions related to LST are predominantly made when death is imminent. Thus, it is necessary to increase awareness of end-of-life LST decision-making among medical staff and the public.
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Affiliation(s)
- So-Youn Park
- Department of Medical Education and Medical Humanities, Kyung Hee University School of Medicine, Seoul, Korea
| | - Bomyee Lee
- Department of Medical Education and Medical Humanities, Graduate School, Kyung Hee University, Seoul, Korea
| | - Jeong Yeon Seon
- Department of Preventive Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - In-Hwan Oh
- Department of Preventive Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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Levoy K, Tarbi EC, De Santis JP. End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model. Nurs Outlook 2020; 68:784-807. [PMID: 32943221 PMCID: PMC7704858 DOI: 10.1016/j.outlook.2020.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 06/26/2020] [Accepted: 07/10/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research. PURPOSE To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model. METHOD Walker and Avant's approach to concept analysis. FINDINGS End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences). DISCUSSION Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
| | - Elise C Tarbi
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Joseph P De Santis
- University of Miami School of Nursing and Health Studies, Coral Gables, FL
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Mehlis K, Bierwirth E, Laryionava K, Mumm F, Heussner P, Winkler EC. Late decisions about treatment limitation in patients with cancer: empirical analysis of end-of-life practices in a haematology and oncology unit at a German university hospital. ESMO Open 2020; 5:e000950. [PMID: 33109628 PMCID: PMC7592262 DOI: 10.1136/esmoopen-2020-000950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/25/2022] Open
Abstract
Background Decisions to limit treatment (DLTs) are important to protect patients from overtreatment but constitute one of the most ethically challenging situations in oncology practice. In the Ethics Policy for Advance Care Planning and Limiting Treatment study (EPAL), we examined how often DLT preceded a patient’s death and how early they were determined before (T1) and after (T2) the implementation of an intrainstitutional ethics policy on DLT. Methods This prospective quantitative study recruited 1.134 patients with haematological/oncological neoplasia in a period of 2×6 months at the University Hospital of Munich, Germany. Information on admissions, discharges, diagnosis, age, DLT, date and place of death, and time span between the initial determination of a DLT and the death of a patient was recorded using a standardised form. Results Overall, for 21% (n=236) of the 1.134 patients, a DLT was made. After implementation of the policy, the proportion decreased (26% T1/16% T2). However, the decisions were more comprehensive, including more often the combination of ‘Do not resuscitate’ and ‘no intense care unit’ (44% T1/64% T2). The median time between the determination of a DLT and the patient’s death was similarly short with 6 days at a regular ward (each T1/T2) and 10.5/9 (T1/T2) days at a palliative care unit. For patients with solid tumours, the DLTs were made earlier at both regular and palliative care units than for the deceased with haematological neoplasia. Conclusion Our results show that an ethics policy on DLT could sensitise for treatment limitations in terms of frequency and extension but had no significant impact on timing of DLT. Since patients with haematological malignancies tend to undergo intensive therapy more often during their last days than patients with solid tumours, special attention needs to be paid to this group. To support timely discussions, we recommend the concept of advance care planning.
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Affiliation(s)
- Katja Mehlis
- Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany.
| | - Elena Bierwirth
- Institut für physikalische und rehabilitative Medizin, Klinikum Ingolstadt GmbH, Ingolstadt, Germany
| | - Katsiaryna Laryionava
- Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | - Friederike Mumm
- Department of Medicine III, University Hospital Munich, Munich, Germany
| | - Pia Heussner
- Zentrum Innere Medizin, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Germany
| | - Eva C Winkler
- Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
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Tanaka M, Kodama S, Lee I, Huxtable R, Chung Y. Forgoing life-sustaining treatment - a comparative analysis of regulations in Japan, Korea, Taiwan, and England. BMC Med Ethics 2020; 21:99. [PMID: 33066771 PMCID: PMC7563900 DOI: 10.1186/s12910-020-00535-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Regulations on forgoing life-sustaining treatment (LST) have developed in Asian countries including Japan, Korea and Taiwan. However, other countries are relatively unaware of these due to the language barrier. This article aims to describe and compare the relevant regulatory frameworks, using the (more familiar) situation in England as a point of reference. We undertook literature reviews to ascertain the legal and regulatory positions on forgoing LST in Japan, Korea, Taiwan, and England. MAIN TEXT Findings from a literature review are first presented to describe the development of the regulatory frameworks surrounding the option of forgoing LST in each country. Based on the findings from the four countries, we suggest five ethically important points, reflection on which should help to inform the further development of regulatory frameworks concerning end-of-life care in these countries and beyond. There should be reflection on: (1) the definition of - and reasons for defining - the 'terminal stage' and associated criteria for making such judgements; Korea and Taiwan limit forgoing LST to patients in this stage, but there are risks associated with defining this too narrowly or broadly; (2) foregoing LST for patients who are not in this stage, as is allowed in Japan and England, because here too there are areas of controversy, including (in England) whether the law in this area does enough to respect the autonomy of (now) incapacitated patients; (3) whether 'foregoing' LST should encompass withholding and withdrawing treatment; this is also an ethically disputed area, particularly in the Asian countries we examine; (4) the family's role in end-of-life decision-making, particularly as, compared with England, the three Asian countries traditionally place a greater emphasis on families and communities than on individuals; and (5) decision-making with and for those incapacitated patients who lack families, surrogate decision-makers or ADs. CONCLUSION Comparison of, and reflection on, the different legal positions that obtain in Japan, Korea, Taiwan, and England should prove informative and we particularly invite reflection on five areas, in the hope the ensuing discussions will help to establish better end-of-life regulatory frameworks in these countries and elsewhere.
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Affiliation(s)
- Miho Tanaka
- Japan Medical Association Research Institute, 2-28-16 Honkomagome, Bunkyo-ku, Tokyo, 113-8621 Japan
| | - Satoshi Kodama
- Graduate School of Letters, Kyoto University, Yoshida Honmachi, Sakyo-ku, Kyoto, 606-8501 Japan
| | - Ilhak Lee
- College of Medicine, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722 South Korea
| | - Richard Huxtable
- Centre for Ethics in Medicine, Population Health Sciences, Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Yicheng Chung
- Tokyo Branch of Otani University, Shin Buddhist Comprehensive Research Institute, 2-19-11 Yushima, Bunkyo-ku, Tokyo, 113-0034 Japan
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Balslev van Randwijk C, Opsahl T, Assing Hvidt E, Bjerrum L, Kørup AK, Hvidt NC. Association Between Danish Physicians' Religiosity and Spirituality and Their Attitudes Toward End-of-Life Procedures. JOURNAL OF RELIGION AND HEALTH 2020; 59:2654-2663. [PMID: 32441014 DOI: 10.1007/s10943-020-01026-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Several studies in different countries have investigated the influence of physician characteristics (such as ethnicity, gender and personal values) on attitudes in end-of-life (EOL) decision-making. While patients and relatives formally decide about issues related to EOL, the physician often ends up with a pivotal role in the decision-making process. Consequently, the influence of the personal beliefs and values of physicians on decisions in EOL care is central in the clinical encounter. The aim of this study was to investigate whether the religious and spiritual characteristics of Danish physicians are associated with their attitudes toward certain EOL decisions, particularly concerning euthanasia (E), physician-assisted suicide (PAS), sedation into unconsciousness in dying patients (SUDP), and withdrawal of life support. The study is based on a questionnaire that was mailed to 1485 physicians in the Region of Southern Denmark. We found that being more religious meant being more likely to object to E/PAS, with gender also being a significant factor, in that females were more likely to object to E/PAS than males. Being more religious also meant being more likely to object to SUDP. In a medical practice, revolving around patient-centered care, and often linked with ideals of value neutrality, it is important to gain an understanding of the influences of personal values of physicians on attitudes toward several areas of clinical decision-making. This study contributes to the knowledge of, and possible reflections upon, the impact of physicians' personal beliefs and values on their attitudes toward important decisions in their patients' lives.
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Affiliation(s)
- Christian Balslev van Randwijk
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
- University College Capital, Copenhagen, Denmark
| | - Tobias Opsahl
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark.
| | | | - Lars Bjerrum
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Alex Kappel Kørup
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
- Department of Mental Health Vejle, University of Southern Denmark, Vejle, Denmark
| | - Niels Christian Hvidt
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
- Academy of Geriatric Cancer Research, Odense University Hospital, Odense, Denmark
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Siddiqui S, Zhang WW, Platzbecker K, Douglas MJ, Rock LK, Eikermann M. Ethical, legal, and communication challenges in managing goals-of-care discussions in chronically critically ill patients. J Crit Care 2020; 63:231-237. [PMID: 32962879 DOI: 10.1016/j.jcrc.2020.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/14/2020] [Accepted: 08/31/2020] [Indexed: 11/24/2022]
Abstract
Clinicians should expect controversial goals of care discussions in the surgical intensive care from time to time. Differing opinions about the likelihood of meaningful recovery in patients with chronic critical illness often exist between intensive care unit providers of different disciplines. Outcome predictions presented by health-care providers are often reflections of their own point of view that is influenced by provider experience, profession, and personal values, rather than the consequence of reliable scientific evaluation. In addition, family members of intensive care unit patients often develop acute cognitive, psychologic, and physical challenges. Providers in the surgical intensive care unit should approach goals-of-care discussions in a structured and interprofessional manner. This best practice paper highlights medical, legal and ethical implications of changing goals of care from prioritizing cure to prioritizing comfort and provides tools that help physicians become effective leaders in the multi-disciplinary management of patients with challenging prognostication.
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Affiliation(s)
- Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Wei Wei Zhang
- Division of Trauma and Critical Care Surgery, Rutgers Health University Hospital and Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Katharina Platzbecker
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Molly J Douglas
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Banner University Medical Center and The University of Arizona College of Medicine - Tucson, Tucson, AZ, USA
| | - Laura K Rock
- Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Klinik für Anästhesiologie, Universitätsklinikum Essen, Essen, Germany
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Borrat-Besson C, Vilpert S, Borasio GD, Maurer J. Views on a "Good Death": End-of-Life Preferences and Their Association With Socio-Demographic Characteristics in a Representative Sample of Older Adults in Switzerland. OMEGA-JOURNAL OF DEATH AND DYING 2020; 85:409-428. [PMID: 32727297 DOI: 10.1177/0030222820945071] [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] [Indexed: 01/11/2023]
Abstract
The current study explores the end-of-life (EOL) preferences of a national representative sample of adults aged 55 and older in Switzerland and shows how these preferences vary by respondents' sociodemographic characteristics and the linguistic region in which they live. Many of the presented EOL attributes are considered as (very) important by a large majority of the older population in Switzerland with significant variations across sociodemographic groups. Specifically, gender is related to psychosocial aspects of EOL, age to the importance attached to avoiding being a burden on the society, and education levels to preferences regarding overtreatment and advance care planning. The results highlight the importance of a personalized, holistic and interdisciplinary approach to EOL and EOL care, since social, psychological, organizational and physical aspects of EOL are rated as (very) important with significant differences in EOL preferences across sociodemographic groups.
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Affiliation(s)
- Carmen Borrat-Besson
- Swiss Centre of Expertise in the Social Sciences (FORS), University of Lausanne, Switzerland
| | - Sarah Vilpert
- Swiss Centre of Expertise in the Social Sciences (FORS), University of Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital, Switzerland.,University of Lausanne, Switzerland
| | - Jürgen Maurer
- Department of Economics, Faculty of Business and Economics (HEC), University of Lausanne, Switzerland
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Counting Cases of Termination of Life without Request: New Dances with Data. Camb Q Healthc Ethics 2020; 29:395-402. [PMID: 32484146 DOI: 10.1017/s0963180120000122] [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: 11/07/2022]
Abstract
This paper explores the common argument proposed by opponents of the legalization of euthanasia that permitting ending a patient's life at their request will lead to the eventual legalization of terminating life without request. The author's examination of data does not support the conclusion that a causal connection exists between legalizing ending of life on request and an increase in the number of cases without request.
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Cayetano-Penman J, Malik G, Whittall D. Nurses' Perceptions and Attitudes About Euthanasia: A Scoping Review. J Holist Nurs 2020; 39:66-84. [PMID: 32448052 DOI: 10.1177/0898010120923419] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Nurses have a critical role in providing holistic care for people with life-limiting conditions. However, they experience internal moral conflict and powerlessness when patients request them to assist in the dying process. A scoping review was undertaken to determine what is known about nurses' perceptions and attitudes of euthanasia. Review Methods: Several databases were searched that yielded both qualitative and quantitative primary peer-reviewed research studies that focused on nurses, their perceptions and attitudes about euthanasia. Descriptive and explorative analyses of the data set from the research studies were undertaken. Results: A total of 23 studies were included in the review. Opinions about euthanasia were mixed. Two key concepts emerged from the review: some nurses were positive and/or supportive of euthanasia, while some were negative and/or unsupportive of euthanasia. The main factors associated with being positive and/or supportive were because of (a) extreme uncontrollable pain, unbearable suffering, or other distressing experiences of the patient, (b) legality of euthanasia, and (c) right of the patient to die. The factors that determined nurses' negative and/or unsupportive attitude included (a) religion, (b) moral/ethical dilemmas, (c) role of gender of the health professional, and, (d) poor palliative care. Conclusions: The matter of euthanasia has challenged nurses considerably in their aim to deliver holistic care. There were several crucial factors influencing nurses' perceptions and attitudes, and these were affected by their personal, professional and transpersonal perspectives. The potential implications to nurses relate to education, practice, and research. Nurses need to be informed of existing legislation and provided in-depth education and professional guidelines to help direct action. Further research is needed to explore the impact on nurses' emotional well-being, clarify their role/s and determine the support they might require when involved with euthanasia.
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Wicki MT. Medical end‐of‐life decisions for people with intellectual disabilities in Switzerland: Third survey. JOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES 2020. [DOI: 10.1111/jppi.12340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Monika T. Wicki
- University of Applied Sciences of Special Needs Education Zurich Switzerland
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Ethical content of expert recommendations for end-of-life decision-making in intensive care units: A systematic review. J Crit Care 2020; 58:10-19. [PMID: 32278227 DOI: 10.1016/j.jcrc.2020.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/24/2020] [Accepted: 03/29/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE Intensive care unit health care professionals must be skilled in providing end-of-life care. Crucial in this kind of care is end-of-life decision-making, which is a complex process involving a variety of stakeholders and requiring adequate justification. The aim of this systematic review is to analyse papers tackling ethical issues in relation to end-of-life decision-making in intensive care units. It explores the ethical positions, arguments and principles. METHODS A literature search was conducted in bibliographic databases and grey literature sources for the time period from 1990 to 2019. The constant comparative method was used for qualitative analysis of included papers in order to identify ethical content including ethical positions, ethical arguments, and ethical principles used in decision-making process. RESULTS In the 15 included papers we have identified a total of 43 ethical positions. Ten positions were identified as substantive, 33 as procedural. Twelve different ethical principles emerged from the ethical arguments. The most frequently used principles are the principles of beneficence, autonomy and nonmaleficence. CONCLUSIONS We have demonstrated that recommendations and guidelines designed specifically by intensive or critical care experts for intensive care units promote similar ethical positions, with minimal dissenting positions.
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Kim JS, Yoo SH, Choi W, Kim Y, Hong J, Kim MS, Park HY, Keam B, Heo DS. Implication of the Life-Sustaining Treatment Decisions Act on End-of-Life Care for Korean Terminal Patients. Cancer Res Treat 2020; 52:917-924. [PMID: 32204581 PMCID: PMC7373872 DOI: 10.4143/crt.2019.740] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/20/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose Life-sustaining treatment (LST) decisions for patients and caregivers at the end-of-life (EOL) process are supported by the “Act on Hospice and Palliative Care and Decisions on LST for Patients at the EOL,” enforced in February 2018. It remains unclear whether the act changes EOL decisions and LST implementation in clinical practice. For this study, we investigated patients’ decision-making regarding LSTs during the EOL process since the act’s enforcement. Materials and Methods Retrospective reviews were conducted on adult patients who were able to decide to terminate LST and died at Seoul National University Hospital between February 5, 2018, and February 5, 2019. We examined demographics, who made the decisions, the type and date of documentation confirming patient's LST, and whether the LST was withheld or withdrawn. Results Of 809 patients who were enrolled, 29% (n=231) completed forms regarding LST themselves, and 71% (n=578) needed family members to decide. The median time from confirmation of the EOL process to death and from the Advance Statement to death were 2 and 5 days, respectively (both ranges, 0 to 244). In total, 90% (n=727) of patients withheld treatment, and 10% (n=82)withdrew it. We found a higher withdrawal rate when family members made the decisions (13.3% vs. 1.7%, p < 0.001). Conclusion After the act’s enforcement, withdrawing LSTs became lawful and self-determination rates increased. Family members still make 71% of decisions regarding LSTs, but these are often inconsistent with the patients’ wishes; thus, further efforts are needed to integrate the new act into clinical practice.
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Affiliation(s)
- Jung Sun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Wonho Choi
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Yejin Kim
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Jinui Hong
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Min Sun Kim
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea.,Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
| | - Hye Yoon Park
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea.,Department of Psychiatry, Seoul National University Hospital, Seoul, Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Dae Seog Heo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
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Jahn-Kuch D, Domke A, Bitsche S, Stöger H, Avian A, Jeitler K, Posch N, Siebenhofer A. End-of-life decision making by Austrian physicians - a cross-sectional study. BMC Palliat Care 2020; 19:4. [PMID: 31901225 PMCID: PMC6942327 DOI: 10.1186/s12904-019-0509-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 12/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Austria has recently been embroiled in the complex debate on the legalization of measures to end life prematurely. Empirical data on end-of-life decisions made by Austrian physicians barely exists. This study is the first in Austria aimed at finding out how physicians generally approach and make end-of-life therapy decisions. METHODS The European end-of-life decisions (EURELD) questionnaire, translated and adapted by Schildmann et al., was used to conduct this cross-sectional postal survey. Questions on palliative care training, legal issues, and use of and satisfaction with palliative care were added. All Austrian specialists in hematology and oncology, a representative sample of doctors specialized in internal medicine, and a sample of general practitioners, were invited to participate in this anonymous postal survey. RESULTS Five hundred forty-eight questionnaires (response rate: 10.4%) were evaluated. 88.3% of participants had treated a patient who had died in the previous 12 months. 23% of respondents had an additional qualification in palliative medicine. The cause of death in 53.1% of patients was cancer, and 44.8% died at home. In 86.3% of cases, pain relief and / or symptom relief had been intensified. Further treatment had been withheld by 60.0%, and an existing treatment discontinued by 49.1% of respondents. In 5 cases, the respondents had prescribed, provided or administered a drug which had resulted in death. 51.3% of physicians said they would never carry out physician-assisted suicide (PAS), while 30.3% could imagine doing so under certain conditions. 38.5% of respondents supported the current prohibition of PAS, 23.9% opposed it, and 33.2% were undecided. 52.4% of physicians felt the legal situation with respect to measures to end life prematurely was ambiguous. An additional qualification in palliative medicine had no influence on measures taken, or attitudes towards PAS. CONCLUSIONS The majority of doctors perform symptom control in terminally ill patients. PAS is frequently requested but rarely carried out. Attending physicians felt the legal situation was ambiguous. Physicians should therefore receive training in current legislation relating to end-of-life choices and medical decisions. The data collected in this survey will help political decision-makers provide the necessary legal framework for end-of-life medical care.
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Affiliation(s)
- D Jahn-Kuch
- Palliative Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - A Domke
- Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Graz, Austria
| | - S Bitsche
- Palliative Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - H Stöger
- Palliative Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - A Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - K Jeitler
- Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Graz, Austria.,Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - N Posch
- Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Graz, Austria
| | - A Siebenhofer
- Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Graz, Austria. .,Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt am Main, Germany.
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Petri S, Zwißler B, in der Schmitten J, Feddersen B. Behandlung im Voraus Planen – Weiterentwicklung der Patientenverfügung. Anaesthesist 2019; 69:78-88. [DOI: 10.1007/s00101-019-00697-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Haltaufderheide J, Nadolny S, Gysels M, Bausewein C, Vollmann J, Schildmann J. Outcomes of clinical ethics support near the end of life: A systematic review. Nurs Ethics 2019; 27:838-854. [PMID: 31742473 DOI: 10.1177/0969733019878840] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Clinical ethics support services have been advocated in recent decades. In clinical practice, clinical ethics support services are often requested for difficult decisions near the end of life. However, their contribution to improving healthcare has been questioned and demands for evaluation have been put forward. Research indicates that there are considerable challenges associated with defining adequate outcomes for clinical ethics support services. In this systematic review, we report findings of qualitative studies and surveys, which have been conducted to evaluate clinical ethics support services near the end of life. METHODS Electronic databases and other sources were queried from 1970 to May 2018. Two authors screened studies independently. Methodological quality of studies was assessed. For each arm of the review, an individual synthesis was performed. Prospero ID: CRD42016036241. ETHICAL CONSIDERATIONS Ethical approval is not needed as it is a systematic review of published literature. RESULTS In all, 2088 hits on surveys and 2786 on qualitative studies were found. After screening, nine surveys and four qualitative studies were included. Survey studies report overall positive findings using a very wide and heterogeneous range of outcomes. Negative results were reported only occasionally. However, methodological quality and conceptual justification of used outcomes was often weak and limits generalizability of results. CONCLUSION Evidence points to positive outcomes of clinical ethics support services. However, methodological quality needs to be improved. Further qualitative or mixed-method research on evaluating clinical ethics support services may contribute to the development of evaluating outcomes of clinical ethics support services by means of broaden the range of appropriate (process-oriented) outcomes of (different types of) clinical ethics support services.
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Affiliation(s)
| | - Stephan Nadolny
- Bielefeld University of Applied Sciences, Germany; Martin Luther University Halle-Wittenberg, Germany; University of Applied Sciences for Diakonia, Germany
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de Nooijer K, Pivodic L, Deliens L, Miccinesi G, Vega Alonso T, Moreels S, Van den Block L. Primary palliative care for older people in three European countries: a mortality follow-back quality study. BMJ Support Palliat Care 2019; 10:462-468. [PMID: 31619438 PMCID: PMC7691801 DOI: 10.1136/bmjspcare-2019-001967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/23/2019] [Accepted: 10/02/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Many older people with serious chronic illnesses experience complex health problems for which palliative care is indicated. We aimed to examine the quality of primary palliative care for people aged 65-84 years and those 85 years and older who died non-suddenly in three European countries. METHODS This is a nationwide representative mortality follow-back study. General practitioners (GPs) belonging to epidemiological surveillance networks in Belgium (BE), Italy (IT) and Spain (ES) (2013-2015) registered weekly all deaths in their practices. We included deaths of people aged 65 and excluded sudden deaths judged by GPs. We applied a validated set of quality indicators. RESULTS GPs registered 3496 deaths, of which 2329 were non-sudden (1126 aged 65-84, 1203 aged 85+). GPs in BE (reference category) reported higher scores than IT across almost all indicators. Differences with ES were not consistent. The score in BE particularly differed from IT on GP-patient communication (aged 65-84: 61% in BE vs 20% in IT (OR=0.12, 95% CI 0.07 to 0.20) aged 85+: 47% in BE vs 9% in IT (OR=0.09, 95% CI 0.05 to 0.16)). Between BE and ES, we identified a large difference in involvement of palliative care services (aged 65-84: 62% in BE vs 89% in ES (OR=4.81, 95% CI 2.41 to 9.61) aged 85+: 61% in BE vs 77% in ES (OR=3.1, 95% CI 1.71 to 5.53)). CONCLUSIONS Considerable country differences were identified in the quality of primary palliative care for older people. The data suggest room for improvement across all countries, particularly regarding pain measurement, GP-patient communication and multidisciplinary meetings.
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Affiliation(s)
- Kim de Nooijer
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Guido Miccinesi
- Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, Florence, Italy
| | - Tomas Vega Alonso
- Public Health Directorate, Regional Ministry of health (Direccion General de Salud Publica, Conselleria de Sanidad), Castille and Leon, Valladolid, Spain
| | - Sarah Moreels
- Epidemiology and Public Health, Health Services Research, Sciensano, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Dierickx S, Onwuteaka-Philipsen B, Penders Y, Cohen J, van der Heide A, Puhan MA, Ziegler S, Bosshard G, Deliens L, Chambaere K. Commonalities and differences in legal euthanasia and physician-assisted suicide in three countries: a population-level comparison. Int J Public Health 2019; 65:65-73. [DOI: 10.1007/s00038-019-01281-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/12/2019] [Accepted: 06/28/2019] [Indexed: 01/22/2023] Open
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Wendrich-van Dael AE, Pivodic L, Cohen J, Deliens L, Van den Block L, Chambaere K. End-of-Life Decision Making for People Who Died of Dementia: A Mortality Follow-Back Study Comparing 1998, 2007, and 2013 in Flanders, Belgium. J Am Med Dir Assoc 2019; 20:1347-1349. [PMID: 31147288 DOI: 10.1016/j.jamda.2019.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/05/2019] [Accepted: 04/07/2019] [Indexed: 11/30/2022]
Affiliation(s)
| | - Lara Pivodic
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
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Andreasen P, Finne-Soveri UH, Deliens L, Van den Block L, Payne S, Gambassi G, Onwuteaka-Philipsen BD, Smets T, Lilja E, Kijowska V, Szczerbińska K. Advance directives in European long-term care facilities: a cross-sectional survey. BMJ Support Palliat Care 2019; 12:bmjspcare-2018-001743. [PMID: 31113800 PMCID: PMC9380512 DOI: 10.1136/bmjspcare-2018-001743] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/05/2019] [Accepted: 04/23/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND End-of-life care practices in long-term care facilities (LTCFs) are the focus of growing attention in Europe, due to rapidly increasing number of older persons living in LTCFs. The knowledge about end-of-life discussions or existence of written advance directives in the European LTCFs is scarce. This study's aim is to investigate the prevalence of written advance directives and their sociodemographic associates, among recently deceased LTCF residents, in six European countries. METHODS Data from the European Union-funded PACE database were collected from 322 LTCFs in six European countries in 2014. The assessments were performed by using two questionnaires designed for LTCF administrative staff and for staff member.LTCFs were selected within each country by using proportional stratified random sampling procedure. Facilities with certain types and sizes were included from each country.Multilevel multivariate analyses were performed to evaluate associations between written advance directives and selected predictors. RESULTS In total, 32.5 % of the 1384 deceased LTCF residents had a written advance directive with a range from 0% to 77 % between countries. The proportion of the most common advance directive, 'Do not resuscitate in case of cardiac or respiratory arrest (DNR)', varied correspondingly from 0% to 75%.LTCF type (OR 2.86 95% CI 1.59 to 5.23) and capability of expressing at the time of admission (OR 3.26 95% CI 2.26 to 4.71) were the independent predictors for advance directive. Residents living in LTCFs where physician was available were less likely to have advance directive compared with residents from LTCFs where physician was not available. CONCLUSION Extensive differences for prevalence of written advance directive exist between countries among older LTCF residents in Europe. Timely and appropriate response to LTCF resident's health needs and preferences efforts advance care planning.
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Affiliation(s)
- Paula Andreasen
- The Department of Welfare, The Ageing, Disability and Functioning Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Ulla Harriet Finne-Soveri
- The Department of Welfare, The Ageing, Disability and Functioning Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Luc Deliens
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Sheila Payne
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, Lancashire, UK
| | - Giovanni Gambassi
- Department of Internal Medicine, Istituto di Medicina Interna e Geriatria, Universita Cattolica del Sacro Cuore, Roma, Italy
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Expertise Center of Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Tinne Smets
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Eero Lilja
- The Department of Welfare, The Equality and Inclusion Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Violetta Kijowska
- Department of Sociology of Medicine, Medical Faculty, Jagiellonian University Medical College, Krakow, Poland
| | - Katarzyna Szczerbińska
- Laboratory for Research on Aging Society, Department of Sociology of Medicine, Medical Faculty, Jagiellonian University Medical College, Kraków, Poland
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Dolja-Gore X, Harris ML, Kendig H, Byles JE. Factors associated with length of stay in hospital for men and women aged 85 and over: A quantile regression approach. Eur J Intern Med 2019; 63:46-55. [PMID: 30803835 DOI: 10.1016/j.ejim.2019.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 01/31/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Explore characteristics of hospital use for adults aged 85 and over in their last year of life and examine factors associated with cumulative overnight length of stay (LOS). DATA SOURCE/STUDY SETTING NSW 45 and Up Study linked with hospital data. STUDY DESIGN Longitudinal cohort study. METHODS Quantile regression models were performed for men and women (N = 3145) to examine heterogeneity in predictors of overnight hospital admissions. Coefficients were estimated at the 25th, 50th, 75th and 90th percentiles of the LOS distribution. PRINCIPAL FINDINGS 86% had at least one hospitalisation in their last year of life, with 60% dying in hospital. For men, first admission for organ failure was associated with a 26 day increase at the 90th LOS percentile, and a 0.22 day increase at the 10th percentile compared to men with cancer. Women admitted with influenza had decreased LOS of 20.5 days at the 75th percentile and 6 to 8 fewer days at the lower percentiles compared to those women with cancer. CONCLUSIONS Poor health behaviours were a major driver of highest LOS among older men, pointing to opportunities to achieve health care savings through prevention. For older women, influenza was associated with shorter LOS, which could be an indicator of the high and rapid mortality rates at older ages, and may be easily prevented. Other factors associated with LOS among women, included where they lived before they were admitted, and discharge destination.
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Affiliation(s)
- Xenia Dolja-Gore
- Research Centre for Generational Health and Ageing, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
| | - Melissa L Harris
- Research Centre for Generational Health and Ageing, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
| | - Hal Kendig
- Centre for Research on Ageing, Health and Wellbeing, College of Medicine, Biology and Environment, Australian National University, Mills Road, Acton, ACT, Australia; ARC Centre of Excellence in Population Ageing Research, Australia.
| | - Julie E Byles
- Research Centre for Generational Health and Ageing, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; ARC Centre of Excellence in Population Ageing Research, Australia.
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Ramos JGR, Vieira RD, Tourinho FC, Ismael A, Ribeiro DC, de Medeiro HJ, Forte DN. Withholding and Withdrawal of Treatments: Differences in Perceptions between Intensivists, Oncologists, and Prosecutors in Brazil. J Palliat Med 2019; 22:1099-1105. [PMID: 30973293 DOI: 10.1089/jpm.2018.0554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Legal concerns have been implicated in the occurrence of variability in decisions of limitations of medical treatment (LOMT) before death. Objective: We aimed to assess differences in perceptions between physicians and prosecutors toward LOMT. Measurements: We sent a survey to intensivists, oncologists, and prosecutors from Brazil, from February 2018 to May 2018. Respondents rated the degree of agreement with withholding or withdrawal of therapies in four different vignettes portraying a patient with terminal lung cancer. We measured the difference in agreement between respondents. Results: There were 748 respondents, with 522 (69.8%) intensivists, 106 (14.2%) oncologists, and 120 (16%) prosecutors. Most respondents agreed with withhold of chemotherapy (95.2%), withhold of mechanical ventilation (MV) (90.2%), and withdrawal of MV (78.4%), but most (75%) disagreed with withdrawal of MV without surrogate's consent. Prosecutors were less likely than intensivists and oncologists to agree with withhold of chemotherapy (95.7% vs. 99.2% vs. 100%, respectively, p < 0.001) and withhold of MV (82.4% vs. 98.3% vs. 97.9%, respectively, p < 0.001), whereas intensivists were more likely to agree with withdrawal of MV than oncologists (87.1% vs. 76.1%, p = 0.002). Moreover, prosecutors were more likely to agree with withholding of active cancer treatment than with withholding of MV [difference (95% confidence interval, CI) = 13.2% (5.2 to 21.6), p = 0.001], whereas physicians were more likely to agree with withholding than with withdrawal of MV [difference (95% CI) = 10.9% (7.8 to 14), p < 0.001]. Conclusions: This study found differences and agreements in perceptions toward LOMT between prosecutors, intensivists, and oncologists, which may inform the discourse aimed at improving end-of-life decisions.
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Affiliation(s)
- João Gabriel Rosa Ramos
- Intensive Care Unit, Hospital Sao Rafael, Salvador, Brazil.,Palliative Care Team, Hospital Sao Rafael, Salvador, Brazil.,Clinica Florence Hospice and Rehabilitation Center, Salvador, Brazil
| | | | | | - Andre Ismael
- Prosecution Service at Distrito Federal e Territorios, Brasilia, Brazil
| | | | | | - Daniel Neves Forte
- Teaching and Research on Palliative Care Program, Hospital Sirio-Libanes, Sao Paulo, Brazil
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Gielen J, Van Den Branden S, Broeckaert B. Attitudes of European Physicians toward Euthanasia and Physician-Assisted Suicide: A Review of the Recent Literature. J Palliat Care 2019. [DOI: 10.1177/082585970802400307] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Joris Gielen
- Interdisciplinary Centre for the Study of Religion and World Views, Catholic University Leuven, Leuven, Belgium
| | - Stef Van Den Branden
- Interdisciplinary Centre for the Study of Religion and World Views, Catholic University Leuven, Leuven, Belgium
| | - Bert Broeckaert
- Interdisciplinary Centre for the Study of Religion and World Views, Catholic University Leuven, Leuven, Belgium
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48
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Luna F, Van Delden JJ. Is Physician-Assisted Death Only for Developed Countries? Latin America as a Case Study. J Palliat Care 2019. [DOI: 10.1177/082585970402000307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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49
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Roest B, Trappenburg M, Leget C. The involvement of family in the Dutch practice of euthanasia and physician assisted suicide: a systematic mixed studies review. BMC Med Ethics 2019; 20:23. [PMID: 30953490 PMCID: PMC6451224 DOI: 10.1186/s12910-019-0361-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/27/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Family members do not have an official position in the practice of euthanasia and physician assisted suicide (EAS) in the Netherlands according to statutory regulations and related guidelines. However, recent empirical findings on the influence of family members on EAS decision-making raise practical and ethical questions. Therefore, the aim of this review is to explore how family members are involved in the Dutch practice of EAS according to empirical research, and to map out themes that could serve as a starting point for further empirical and ethical inquiry. METHODS A systematic mixed studies review was performed. The databases Pubmed, Embase, PsycInfo, and Emcare were searched to identify empirical studies describing any aspect of the involvement of family members before, during and after EAS in the Netherlands from 1980 till 2018. Thematic analysis was chosen as method to synthesize the quantitative and qualitative studies. RESULTS Sixty-six studies were identified. Only 14 studies had family members themselves as study participants. Four themes emerged from the thematic analysis. 1) Family-related reasons (not) to request EAS. 2) Roles and responsibilities of family members during EAS decision-making and performance. 3) Families' experiences and grief after EAS. 4) Family and 'the good euthanasia death' according to Dutch physicians. CONCLUSION Family members seem to be active participants in EAS decision-making, which goes hand in hand with ambivalent feelings and experiences. Considerations about family members and the social context appear to be very important for patients and physicians when they request or grant a request for EAS. Although further empirical research is needed to assess the depth and generalizability of the results, this review provides a new perspective on EAS decision-making and challenges the Dutch ethical-legal framework of EAS. Euthanasia decision-making is typically framed in the patient-physician dyad, while a patient-physician-family triad seems more appropriate to describe what happens in clinical practice. This perspective raises questions about the interpretation of autonomy, the origins of suffering underlying requests for EAS, and the responsibilities of physicians during EAS decision-making.
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Affiliation(s)
- Bernadette Roest
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512HD Utrecht, The Netherlands
| | - Margo Trappenburg
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512HD Utrecht, The Netherlands
| | - Carlo Leget
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512HD Utrecht, The Netherlands
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Caruso R, Rocco G, Dellafiore F, Brognoli G, Magon A, Conte G, Pittella F, Stievano A. ‘Nosce te ipsum’: An Italian national survey to explore choice's differences in End of Life (EoL) care between healthcare professionals and general public. Appl Nurs Res 2019; 46:8-15. [DOI: 10.1016/j.apnr.2019.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 11/18/2018] [Accepted: 01/20/2019] [Indexed: 11/16/2022]
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