The limits of proxy decision making: overtreatment

Decision-making for people with dementia and advanced kidney disease: a secondary qualitative analysis of interviews from the Conservative Kidney Management Assessment of Practice Patterns Study

OBJECTIVE

To explore dialysis decision-making for adults who lack capacity due to cognitive impairment, a common and under-recognised condition in those with advanced chronic kidney disease (CKD).

DESIGN

Secondary analysis of qualitative data collected during the Conservative Kidney Management Assessment of Practice Patterns Study programme of research was performed. Sixty semistructured interviews were conducted with multiprofessional team members from UK renal centres. Staff were asked about local facilities, the value of conservative kidney management (CKM), when and with whom CKM was discussed and how CKM could be improved. Thematic analysis was employed to identify, characterise and report on themes that emerged from the data, focused on the specific issues experienced by people with dementia.

SETTING

A purposive sample of nine UK renal centres differing in the scale of their CKM programmes.

PARTICIPANTS

Clinical directors of renal centres identified staff involved in CKM. Staff were asked to participate if they had experience of low clearance clinics or of caring for patients with advanced CKD (estimated glomerular filtration rate <20mL/min/1.73² or >65 years with end-stage kidney disease).

RESULTS

Two overarching themes were identified: factors taken into consideration during decision-making, and the process of decision-making itself. Comorbidity, social support, quality of life and the feasibility of dialysis were reported as factors pertinent to clinicians' decisions regarding suitability. The majority of renal centres practised multidisciplinary 'best interests' decision-making for those without capacity. Attitudes to advance care planning were divided.

CONCLUSIONS

In view of the prevalence of cognitive impairment among those with advanced CKD, we suggest consideration of routine assessment of cognition and capacity. In the UK, dialysis is initiated and continued for individuals with dementia and services should be adapted to meet the needs of this population.

Decision-making on behalf of people living with dementia: how do surrogate decision-makers decide?

BACKGROUND

For people living with dementia, the capacity to make important decisions about themselves diminishes as their condition advances. As a result, important decisions (affecting lifestyle, medical treatment and end of life) become the responsibility of someone else, as the surrogate decision-maker. This study investigated how surrogate decision-makers make important decisions on behalf of a person living with dementia.

METHODS

Semi-structured interviews were conducted with 34 family members who had formally or informally taken on the role of surrogate decision-maker. Thematic analysis of interviews was undertaken, which involved identifying, analysing and reporting themes arising from the data.

RESULTS

Analysis revealed three main themes associated with the process of surrogate decision-making in dementia: knowing the person's wishes; consulting with others and striking a balance. Most participants reported that there was not an advance care plan in place for the person living with dementia. Even when the prior wishes of the person with dementia were known, the process of decision-making was often fraught with complexity.

DISCUSSION

Surrogate decision-making on behalf of a person living with dementia is often a difficult process. Advance care planning can play an important role in supporting this process. Healthcare professionals can recognise the challenges that surrogate decision-makers face and support them through advance care planning in a way that suits their needs and circumstances.

An ethical façade? Medical students' miscomprehensions of substituted judgment

Background

We studied how well first-year medical students understand and apply the concept of substituted judgment, following a course on clinical ethics.

Method

Students submitted essays on one of three ethically controversial scenarios presented in class. One scenario involved a patient who had lost decisional capacity. Through an iterative process of textual analysis, the essays were studied and coded for patterns in the ways students misunderstood or misapplied the principle of substituted judgment.

Results

Students correctly articulated course principles regarding patient autonomy, substituted judgment, and non-imposition of physician values. However, students showed misunderstanding by giving doctors the responsibility of balancing the interests of the patient against the interests of the family, by stating doctors and surrogates should be guided primarily by a best-interest standard, and by suggesting that patient autonomy becomes the guiding principle only when patients can no longer express their wishes.

Conclusion

Students did not appear to internalize or correctly apply the substituted judgment standard, even though they could describe it accurately. This suggests the substituted judgment standard may run counter to students' moral intuitions, making it harder to apply in clinical practice.

Identification of high-risk subgroups in very elderly intensive care unit patients

Introduction

Current prognostic models for intensive care unit (ICU) patients have not been specifically developed or validated in the very elderly. The aim of this study was to develop a prognostic model for ICU patients 80 years old or older to predict in-hospital mortality by means of data obtained within 24 hours after ICU admission. Aside from having good overall performance, the model was designed to reliably and specifically identify subgroups at very high risk of dying.

Methods

A total of 6,867 consecutive patients 80 years old or older from 21 Dutch ICUs were studied. Data necessary to calculate the Glasgow Coma Scale, Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II (SAPS II), Mortality Probability Models II scores, and ICU and hospital survival were recorded. Data were randomly divided into a developmental (n = 4,587) and a validation (n = 2,289) set. By means of recursive partitioning analysis, a classification tree predicting in-hospital mortality was developed. This model was compared with the original SAPS II model and with the SAPS II model after recalibration for very elderly ICU patients in the Netherlands.

Results

Overall performance measured by the area under the receiver operating characteristic curve and by the Brier score was similar for the classification tree, the original SAPS II model, and the recalibrated SAPS II model. The tree identified most patients with very high risk of mortality (9.2% of patients versus 8.9% for the original SAPS II and 5.9% for the recalibrated SAPS II had a risk of more than 80%). With a cut-point at a risk of 80%, the positive predictive values were 0.88 for the tree, 0.83 for the original SAPS II, and 0.87 for the recalibrated SAPS II.

Conclusion

Prognostic models with good overall performance may also reliably identify subgroups of very elderly ICU patients who have a very high risk of dying before hospital discharge. The classification tree has the advantage of identifying the separate factors contributing to bad outcome and of using few variables. Up to 9.5% of patients were found to have a risk to die of more than 85%.

Transferring dying nursing home residents to the hospital: DON perspectives on the nurse's role in transfer decisions

This qualitative study elicits factors that influence decision-making by nurses about transferring a dying resident from the nursing home to the hospital. Focus groups with directors of nursing (DONs) from long-term care facilities revealed those decisions are influenced by knowledge (or lack thereof) of resident or family preferences, nurse interactions with physicians, nursing home technological and personnel resources, and nurse concerns about institutional liability. DONs can improve transfer decisions by communicating with all parties, clarifying nursing home processes for end-of-life care, and scheduling early and thorough conversations with residents and families about end-of-life care. DONs can implement improvements through staff education on communication issues, rigorous evaluation and performance outcome measures related to patient transfer, and conveyance to staff of the institution's mission and the nursing service's values.