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Mishkin AD, Allen NC, Cheung SG, Faccini MC, Flicker LS, Shalev D. The Stresses of Surrogate Decision-Making: Contributing Factors and Clinicians' Role in Mitigation. Am J Hosp Palliat Care 2024; 41:895-905. [PMID: 37704184 PMCID: PMC10932874 DOI: 10.1177/10499091231198750] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Surrogate Decision-Makers (surrogates) are frequently employed in decision-making for critically ill adults. There are insufficient data considering the surrogate experience, stress, and potential for mitigation. METHODS An anonymous online survey queried (1) medical situation (2) total stress (3) demographics (4) potential factors, including sources of information about patient wishes, external sources of support or competing stressors, and their interactions with the medical team through the experience. RESULTS 108 respondents were included; 91 completed all items. Most respondents ranked their experience as a surrogate as one of the most stressful experiences of their lives; this was associated with whether it was an end-of-life decision (P = .003), Respondent Religion (P = .015), or religious or spiritual beliefs (P = .024), and having their own health problems (P = .008). On individual Likert responses, surrogates reported significant stress mitigation when they felt they had been helpful (P < .001), knew the patient's wishes (P = .0011), specifically discussed patient wishes (P < .001), or patient's wishes were documented (P < .001). Items about surrogate-team interaction also met significance, including the physician being communicative and available (P < .001), respectful (P = .007), honest (P < .001), and validating (P = .001). CONCLUSIONS Surrogate stress is an evolving area for research. Significant factors included relationship with the medical team, making this an important area for HPM to play a key role in mitigating surrogate stress.
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Affiliation(s)
- Adrienne D. Mishkin
- Blood and Marrow Transplantation and Cell Therapy Program, Division of Hematology & Oncology, Columbia University Irving Medical Center, New York, NY
- Department of Psychiatry, Columbia University Medical Center, New York, NY
| | - Nicole C. Allen
- Department of Psychiatry, Columbia University Medical Center, New York, NY
| | - Stephanie G. Cheung
- Department of Psychiatry, New York University Langone Medical Center, New York, NY
| | | | - Lauren S. Flicker
- Montefiore Einstein Center for Bioethics, Albert Einstein College of Medicine, Bronx, NY
| | - Daniel Shalev
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell, New York, NY
- Department of Psychiatry, Cornell, New York, NY
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Lee J, Kim SG, Lee SI, Youn H. Psychosocial Factors Associated With Thoughts Regarding Life-Sustaining Treatment for Oneself and Family Members. Psychiatry Investig 2024; 21:646-654. [PMID: 38960442 PMCID: PMC11222083 DOI: 10.30773/pi.2024.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/12/2024] [Accepted: 04/10/2024] [Indexed: 07/05/2024] Open
Abstract
OBJECTIVE This study aims to investigate the thoughts of the general population regarding life-sustaining treatment for both oneself and family members and to assess the factors associated with those thoughts. METHODS A total of 1,500 individuals participated in this study by completing a questionnaire consisting of self-reporting items with some instructions, basic demographic information, thoughts on life-sustaining treatment, and psychosocial scales. The disease status was calculated using the Charlson Comorbidity Index. The psychosocial scales included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Pittsburgh Sleep Quality Index, and Multidimensional Scale of Perceived Social Support. RESULTS The majority of participants did not want to receive life-sustaining treatment for both themselves and their families. However, more people wanted life-sustaining treatment for their family members (35.9%) than for themselves (21.6%). Among the basic demographic characteristics, there were significant differences in age, sex, marital status, living arrangements, occupational status, religion, and disease status. Regarding the psychosocial scales, there were significant differences in the PHQ-9 and GAD-7 scores between the group that preferred life-sustaining treatment for family members and the group that did not. CONCLUSION The findings suggest that life-sustaining treatment decisions for oneself and for one's family members can be different. We recommend a more clear expression of one's preferences regarding the last moments of one's life, including advance directives.
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Affiliation(s)
- Jeewon Lee
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Shin-Gyeom Kim
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Soyoung Irene Lee
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - HyunChul Youn
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
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Singh N, Giannitrapani KF, Gamboa RC, O’Hanlon CE, Fereydooni S, Holdsworth LM, Lindvall C, Walling AM, Lorenz KA. What Patients Facing Cancer and Caregivers Want From Communication in Times of Crisis: A Qualitative Study in the Early Months of the COVID-19 Pandemic. Am J Hosp Palliat Care 2024; 41:558-567. [PMID: 37390466 PMCID: PMC10315453 DOI: 10.1177/10499091231187351] [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] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Interpersonal communication is a cornerstone of patient-centered care. We aimed to identify what patients with cancer and caregivers may want from communication during a public health crisis. METHODS We interviewed 15 patients (8 Veteran, 7 non-Veteran) and caregivers from regionally, racially, and ethnically diverse backgrounds across the US about serious illness care and quality of care during the COVID-19 pandemic Using an iterative, inductive and deductive process, 2 coders analyzed content associated with the code "Communication," which appeared 71 times, and identified 5 themes. RESULTS Participants identified as White (10), Latino/a (3), Asian (1), and Black (1). (1) Help patients and caregivers prepare for care during crisis by communicating medical information directly and proactively. (2) Explain how a crisis might influence medical recommendations and impact on recovery from illness. (3) Use key messengers to improve communication between primary teams, patients, and caregivers. (4) Include caregivers and families in communication when they cannot be physically present. (5) Foster bidirectional communication with patients and families to engage them in shared decision-making during a vulnerable time. CONCLUSION Communication is critical during a public health crisis yet overwhelmed clinicians may not be able to communicate effectively. Communicating with caregivers and family, transparent and timely communication, ensuring diverse providers are on the same page, and effective listening are known gaps even before the COVID-19 pandemic. Clinicians may need quick interventions, like education about goals of care, to remind them about what seriously ill patients and their caregivers want from communication and offer patient-centered care during crises.
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Affiliation(s)
- Nainwant Singh
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Karleen F. Giannitrapani
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Raziel C. Gamboa
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | | | | | | | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare Center, Los Angeles, CA, USA
| | - Karl A. Lorenz
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
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Iunius LA, Vilpert S, Meier C, Jox RJ, Borasio GD, Maurer J. Advance Care Planning: A Story of Trust Within the Family. J Appl Gerontol 2024; 43:349-362. [PMID: 37984553 PMCID: PMC10875907 DOI: 10.1177/07334648231214905] [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: 04/11/2023] [Revised: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023] Open
Abstract
As the family usually plays a central role at the end of life, the quality of family relationships may influence how individuals approach advance care planning (ACP). Our study investigates the associations of trust in relatives with regard to end-of-life (EOL) issues-used as a proxy measure of family relationship quality-with individuals' engagement in EOL discussions, advance directive (AD) awareness, approval and completion, and designation of a healthcare proxy. Using nationally representative data of adults aged 55 years and over from wave 6 (2015) of the Survey of Health, Ageing, and Retirement in Europe (SHARE) in Switzerland (n = 1911), we show that complete trust in relatives is related to higher engagement in ACP. Subject to patient consent, the family should, therefore, be included in the ACP process, as such practice could enhance patient-centered EOL care and quality of life at the end of life.
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Affiliation(s)
- Lory A. Iunius
- Faculty of Business and Economics (HEC), University of Lausanne, Switzerland
| | - Sarah Vilpert
- Faculty of Business and Economics (HEC), University of Lausanne, Switzerland
- Swiss Centre of Expertise in the Social Sciences (FORS), Lausanne, Switzerland
| | - Clément Meier
- Faculty of Business and Economics (HEC), University of Lausanne, Switzerland
- Swiss Centre of Expertise in the Social Sciences (FORS), Lausanne, Switzerland
| | - Ralf J. Jox
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Switzerland
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Jürgen Maurer
- Faculty of Business and Economics (HEC), University of Lausanne, Switzerland
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Berlin P, Göggelmann L, Herzog S, Pedrosa Carrasco AJ, Hauck J, Timmesfeld N, Kruse J, Rief W, Riera Knorrenschild J, von Blanckenburg P, Seifart C. Cancer advance care planning: development of a screening tool. BMJ Support Palliat Care 2023:spcare-2022-003965. [PMID: 37979957 DOI: 10.1136/spcare-2022-003965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 09/05/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES Advance care discussions are a useful communication tools for medical preferences and beneficial for shared decision-making processes in hospital settings. The present study developed the first screening tool for need for advance care planning (ACP). METHODS In phase 1 (n=92), items were evaluated using feasibility analysis and item reduction. In phase 2 (n=201), reduced screening items were analysed for predictive value of need for ACP. Statistical analysis included receiver-operating characteristics analysis (area under the curve>0.80), optimal cut-off based on sensitivity and specificity, interpretation of OR and construct validity using correlation with death anxiety, communication avoidance within families and trust based on the relationship with the treating physician. RESULTS Participants in both phases were approximately 60 years old with non-curative prognosis. After item reduction, predictive values of four possible items with good item difficulty and discrimination were compared for mild, moderate and great levels of death anxiety. A two-item combination of I am burdened by thoughts of an unfavourable course of the disease and I am burdened by the feeling of being ill-prepared for the end of life showed best prediction of death anxiety and communication avoidance. Clinical cut-off at sum-score ≥6 was of high sensitivity (95%) and specificity (81%). Previous use of social support and readiness for ACP was related to higher chance of interest in ACP. CONCLUSION Screening for need of ACP is possible with two objective items and one subjective item. Positive screening therefore indicates when to offer ACP discussions and provides routine estimation of ACP need in clinical practice.
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Affiliation(s)
- Pia Berlin
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Lena Göggelmann
- Research Group Medical Ethics, Philipps-University Marburg, Marburg, Germany
| | - Svenja Herzog
- Research Group Medical Ethics, Philipps-University Marburg, Marburg, Germany
| | - Anna J Pedrosa Carrasco
- Research Group Medical Ethics, Philipps-University Marburg, Marburg, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Marburg, Germany
| | - Johannes Hauck
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Germany
| | - Johannes Kruse
- Clinic for Psychosomatic Medicine and Psychotherapy, University Hospital Giessen and Marburg, Giessen, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Jorge Riera Knorrenschild
- Department of Haematology, Oncology and Immunology, University Hospital of Giessen and Marburg, Marburg, Germany
| | - Pia von Blanckenburg
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Carola Seifart
- Research Group Medical Ethics, Philipps-University Marburg, Marburg, Germany
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Göcking B, Gloeckler S, Ferrario A, Brandi G, Glässel A, Biller-Andorno N. A case for preference-sensitive decision timelines to aid shared decision-making in intensive care: need and possible application. Front Digit Health 2023; 5:1274717. [PMID: 37881363 PMCID: PMC10595152 DOI: 10.3389/fdgth.2023.1274717] [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: 08/08/2023] [Accepted: 09/28/2023] [Indexed: 10/27/2023] Open
Abstract
In the intensive care unit, it can be challenging to determine which interventions align with the patients' preferences since patients are often incapacitated and other sources, such as advance directives and surrogate input, are integral. Managing treatment decisions in this context requires a process of shared decision-making and a keen awareness of the preference-sensitive instances over the course of treatment. The present paper examines the need for the development of preference-sensitive decision timelines, and, taking aneurysmal subarachnoid hemorrhage as a use case, proposes a model of one such timeline to illustrate their potential form and value. First, the paper draws on an overview of relevant literature to demonstrate the need for better guidance to (a) aid clinicians in determining when to elicit patient preference, (b) support the drafting of advance directives, and (c) prepare surrogates for their role representing the will of an incapacitated patient in clinical decision-making. This first section emphasizes that highlighting when patient (or surrogate) input is necessary can contribute valuably to shared decision-making, especially in the context of intensive care, and can support advance care planning. As an illustration, the paper offers a model preference-sensitive decision timeline-whose generation was informed by existing guidelines and a series of interviews with patients, surrogates, and neuro-intensive care clinicians-for a use case of aneurysmal subarachnoid hemorrhage. In the last section, the paper offers reflections on how such timelines could be integrated into digital tools to aid shared decision-making.
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Affiliation(s)
- Beatrix Göcking
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Sophie Gloeckler
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Andrea Ferrario
- Department of Management, Technology, and Economics, Swiss Federal Institute of Technology in Zurich, Zurich, Switzerland
- Mobiliar Lab for Analytics at ETH, Zurich, Switzerland
| | - Giovanna Brandi
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Andrea Glässel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
- School of Health Sciences, Institute of Public Health, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
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Bradley AS, Dalton A. Navigating ethical dilemmas in trauma, resuscitation, and critical care. Int Anesthesiol Clin 2023; 61:62-66. [PMID: 37551584 DOI: 10.1097/aia.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- A Steven Bradley
- Department of Anesthesiology and Critical Care, University of Chicago Medical Center, Chicago, IL
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Law S, Stergiopoulos V, Zaheer J, Nakhost A. "Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2023; 88:101873. [PMID: 36950980 DOI: 10.1016/j.ijlp.2023.101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 06/01/2023]
Abstract
In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.
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Affiliation(s)
- Samuel Law
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Psychiatry, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada.
| | - Vicky Stergiopoulos
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Addictions and Mental Health, Toronto, Ontario, Canada.
| | - Juveria Zaheer
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Addictions and Mental Health, Toronto, Ontario, Canada.
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Luo C, Zhang MX, Jiang E, Jin M, Tung TH, Zhu JS. The main decision-making competence for willingness-to-pay towards COVID-19 vaccination: a family-based study in Taizhou, China. Ann Med 2022; 54:2376-2384. [PMID: 36004802 PMCID: PMC9423852 DOI: 10.1080/07853890.2022.2114606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
PURPOSE This research aimed to explore individuals' willingness to pay (WTP) and studied the role of family decision makers in WTP for COVID-19 vaccines. METHODS A self-administered online questionnaire evaluating the willingness of community residents to pay for booster vaccination of COVID-19 vaccine was conducted among families in a community in Taizhou, China. The logistic regression model was performed to identify the factors associated with WTP for the COVID-19 vaccines, and all data were analysed by R software, version 4.1.0. RESULTS 44.2% and 43.7% of 824 community residents were willing to pay for the first two doses and the booster dose of the COVID-19 vaccine, respectively. Decision-makers were more willing to pay for both the first two doses and the boost dose of the COVID-19 vaccines, with OR (95%CI) being 1.75 (1.25-2.47) and 1.89 (1.34-2.67), respectively. Besides, participants' WTP for COVID-19 vaccines were also associated with their occupation and monthly household income. CONCLUSION This study found that family decision-makers were more willing to pay for both the first two doses and the booster dose of COVID-19 vaccines in Taizhou, China. To improve the WTP for COVID-19 vaccines, public policy programs need to conduct a comprehensive cost-benefit analysis and focus on the role of family decision makers in vaccination.Key MessagesA study evaluating the willingness of community residents to pay for booster vaccination of COVID-19 vaccine was conducted among families in a community in Taizhou, China.Family decision-makers were more willing to pay for both the first two doses and the booster dose of COVID-19 vaccines.To improve the WTP for COVID-19 vaccines, public policy programs need to conduct a comprehensive cost-benefit analysis and focus on the role of family decision-makers in vaccination.
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Affiliation(s)
- Chengwen Luo
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, Zhejiang, China
| | - Mei-Xian Zhang
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, Zhejiang, China
| | - Eva Jiang
- Gucheng Street Community Health Service Center, Linhai, Zhejiang, China
| | - Mindan Jin
- Gucheng Street Community Health Service Center, Linhai, Zhejiang, China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, Zhejiang, China
| | - Jian-Sheng Zhu
- Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, Zhejiang, China
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Tanaka M, Bito S, Enzo A, Okita T, Atsushi A. Cross-sectional survey of surrogate decision-making in Japanese medical practice. BMC Med Ethics 2021; 22:128. [PMID: 34560873 PMCID: PMC8464150 DOI: 10.1186/s12910-021-00698-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Instances of surrogate decision-making are expected to increase with the rise in hospitalised older adults in Japan. Few large-scale studies have comprehensively examined the entire surrogate decision-making process. This study aimed to gather information to assess the current state of surrogate decision-making in Japan. METHODS A cross-sectional survey was conducted using online questionnaires. A total of 1000 surrogate decision-makers responded to the questionnaire. We examined the characteristics of surrogate decision-makers and patients, content of surrogate decision-making meeting regarding life-sustaining treatment between the doctors and surrogate decision-makers, extent of involvement of the various parties in the surrogate decision-making process, judgement grounds for surrogate decision-making, and frequency of involvement in the surrogate decision-making process. RESULTS Of the participants, 70.5% were male and 48.3% were eldest sons. Only 7.6% of the patients had left a written record of their preferences and 48.8% of the surrogates reported no knowledge of the patient having expressed their prior intentions regarding medical care in any form. Respondents indicated that their family meetings with healthcare professionals mostly included the information recommended by guidelines in a surrogate decision-making meeting in Japan. Most participants reported a good understanding of the meeting content. Although many participants based their decisions on multiple grounds, surrogates' considerations may not adequately reflect respect for patient autonomy in Japan. Specifically, the eldest son considered his own preference more frequently than that of the other surrogate decision-makers. In 26.1% of the cases, either zero or one family meeting with healthcare professionals was held. In these cases, significantly fewer decisions involved the participation of healthcare professionals other than the doctor compared to cases with multiple meetings. CONCLUSIONS Surrogate decisions in Japan are most commonly made by eldest sons and may not frequently consider the perspectives of other surrogates. The finding that patient preferences were rarely known suggests a role for increased advance care planning.
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Affiliation(s)
- Masashi Tanaka
- Department of Clinical Epidemiology, National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan. .,Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan. .,KARADA Internal Medicine Clinic Shibuya, 1-23-13 Jinnan, Shibuya-ku, Tokyo, 150-0041, Japan.
| | - Seiji Bito
- Department of Clinical Epidemiology, National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Aya Enzo
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Takethoshi Okita
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Asai Atsushi
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
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Sellars M, Tran J, Nolte L, White B, Sinclair C, Fetherstonhaugh D, Detering K. Public knowledge, preferences and experiences about medical substitute decision-making: a national cross-sectional survey. BMJ Support Palliat Care 2021:bmjspcare-2020-002619. [PMID: 33722813 DOI: 10.1136/bmjspcare-2020-002619] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/01/2021] [Accepted: 02/12/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the Australian adult public's knowledge and experiences regarding substitute decision-making for medical decisions and their preferences for obtaining information about the substitute decision-maker (SDM) role. METHODS This is a national cross-sectional online survey of the Australian adult public. The survey examined participants' advance care planning (ACP) awareness and experience, SDM experiences and preferences for obtaining more information about SDM, and participant knowledge about SDM. RESULTS Of 1586 people who opened the survey, 1120 (70.6%) were included in the final sample. 13% (n=142) of participants indicated they had acted as an SDM. A median score of two correct responses out of five showed low to moderate knowledge about the SDM role among all participants, with only 33% reporting awareness of SDM laws existing in Australia. While most (59%) participants ranked a health professional as their preferred source of obtaining information about supporting SDMs, few participants who had been an SDM (n=64, 45%) reported obtaining any support in making medical decisions. The median SDM knowledge scores for people who had discussed ACP (3.0 vs 2.0, U=1 45 222, z=6.910, p<0.001), documented their ACP preferences (3.0 vs 2.0, U=71 984, z=4.087, p<0.001) or acted in the SDM role (3.0 vs 2.0, U=56 353, z=-3.694, p<0.001) were significantly higher compared with those who had not. CONCLUSIONS The Australian public may have low to moderate knowledge about the SDM role and access only minimal support when making challenging medical decisions.
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Affiliation(s)
- Marcus Sellars
- Department of Health Services Research & Policy, The Australian National University, Canberra, Australian Capital Territory, Australia
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Julien Tran
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Ben White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Craig Sinclair
- Australian Research Council Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, New South Wales, Australia
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Deirdre Fetherstonhaugh
- Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria, Australia
| | - Karen Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
- Faculty of Health, Arts and Innovation, Swinburne University, Melbourne, Victoria, Australia
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Lipnick D, Green M, Thiede E, Smith TJ, Lehman EB, Johnson R, La IS, Wiegand D, Levi BH, Van Scoy LJ. Surrogate Decision Maker Stress in Advance Care Planning Conversations: A Mixed-Methods Analysis From a Randomized Controlled Trial. J Pain Symptom Manage 2020; 60:1117-1126. [PMID: 32645452 PMCID: PMC8109394 DOI: 10.1016/j.jpainsymman.2020.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Spokespersons serving as surrogate decision makers for their loved ones report high levels of stress. Despite known benefits, advance care planning (ACP) conversations often do not occur. More information is needed to understand spokesperson stress during ACP. OBJECTIVES To explore if and how spokespersons perceive stress related to ACP conversations; compare factors related to stress; and assess whether ACP intervention impacted stress. METHODS Secondary and mixed-methods analysis with data transformation of semistructured interviews occurring during a 2 × 2 factorial (four armed) randomized controlled trial that compared standard online ACP to a comprehensive online ACP decision aid. Tools were completed by patients with advanced illness (n = 285) alone or with their spokesperson (n = 285). About 200 spokesperson interviews were purposively sampled from each of the four arms (50 per arm). RESULTS ACP conversations were reported as stressful by 54.41% (74 of 136) and nonstressful by 45.59% (62 of 136). Five themes impacting spokesperson stress were the nature of the relationship with their loved one; self-described personality and belief systems; knowledge and experience with illness and ACP conversations; attitude toward ACP conversations; and social support in caregiving and decision making. No significant differences in stress were associated with arm assignment. CONCLUSION Identifying what factors impact spokesperson stress in ACP conversations can be used to help design ACP interventions to more appropriately address the needs and concerns of spokespersons.
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Affiliation(s)
- Daniella Lipnick
- Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Michael Green
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Elizabeth Thiede
- Penn State College of Nursing, University Park, Pennsylvania, USA
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Erik B Lehman
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Public Health Sciences at Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Rhonda Johnson
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - In Seo La
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Debra Wiegand
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Pediatrics, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Public Health Sciences at Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Hammami MM, Abuhdeeb K, Balkhi AA. Importance Hierarchy of Surrogate Medical Decision Making Determinants: A Q-Methodology Study in Middle Eastern and East Asian Men. Med Decis Making 2020; 40:1020-1033. [PMID: 33174512 DOI: 10.1177/0272989x20963042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Factors other than patient's preference may influence surrogate medical decision making in a culture- and viewpoint-dependent way. We explored the importance hierarchy of potential surrogate medical decision making determinants to Middle-Eastern (ME) and East-Asian (EA) men according to their norm-perception (N-viewpoint), preference as patients (P-viewpoint), and preference as surrogate decision-makers (S-viewpoint). METHODS Each respondent (120 ME, 120 EA) sorted 28 items reflecting potential determinants into a fixed distribution of importance hierarchy according to the three viewpoints. Latent decision making models were explored by by-person factor analysis (Q-methodology). RESULTS Six models were identified for each ME and EA viewpoint (total 36). Patient's health-related, patient's preference-related, and society's interests-related determinants were strongly embraced in 34, 3, and zero models and strongly discounted in 2, 5, and 21 models, respectively. Patient's religious/spiritual belief was strongly embraced in 6 EA models compared to 2 ME models and strongly discounted in 2 EA models compared to 5 ME models. Further, family-centric and surrogate's interest-related determinants were strongly embraced in 8 EA models compared to 1 ME model. They were also strongly embraced in 5 P-viewpoint compared to 2 S-viewpoint models and strongly discounted in 4 P-viewpoint compared to 11 S-viewpoint models. Despite the overall predominance of patient's health-related determinants and culture- and viewpoint-dependent differences, Q-methodology analysis identified relatively patient's preference-influenced, religious/spiritual beliefs-influenced, emotion-influenced, and familism-influenced models and showed notable overlap in models. CONCLUSIONS Patient's health was more important than other potential medical surrogate decision making determinants, including patient's preference, for both ME and EA men and in all viewpoints. The relative importance of some determinants was culture- and viewpoint- dependent and allowed description of different albeit overlapping models.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.,Alfaisal University College of Medicine, Riyadh, Saudi Arabia
| | - Kafa Abuhdeeb
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Areej Al Balkhi
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Lin CJ, Cheng YI, Garvie PA, D’Angelo LJ, Wang J, Lyon ME. The Effect of FAmily-CEntered (FACE ®) Pediatric Advanced Care Planning Intervention on Family Anxiety: A Randomized Controlled Clinical Trial for Adolescents With HIV and Their Families. JOURNAL OF FAMILY NURSING 2020; 26:315-326. [PMID: 33283612 PMCID: PMC8015181 DOI: 10.1177/1074840720964093] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Clinicians fear pediatric advance care planning (pACP) for adolescents is too distressing for families. Multisite longitudinal randomized controlled trial of adolescents with HIV tested the effect of FAmily-CEntered (FACE®) pACP intervention on families' anxiety and depression. One hundred five adolescent/family dyads were randomized to FACE® (n = 54 dyads) or control (n = 51 dyads). Families were 90% African American, 37% HIV-positive, and 22% less than high school educated. Families reported lower anxiety 3 months post-FACE® intervention than control (β = -4.71, 95% confidence interval [CI] = [-8.20, -1.23], p = .008). Male family members were less anxious than female family members (β = -4.55, 95% CI = [-6.96, -2.138], p ≤ .001). Family members living with HIV reported greater depressive symptoms than HIV-uninfected families (β = 3.32, 95% CI = [0.254, 6.38], p = .034). Clinicians can be assured this structured, facilitated FACE® pACP model minimized family anxiety without increasing depressive symptoms. Adolescent/family dyads should be invited to have access to, and provision of, evidence-based pACP as part of patient-centered/family-supported care in the HIV continuum of care.
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Affiliation(s)
| | - Yao I. Cheng
- Children’s National Hospital & Center for Translational Research, Washington, DC, USA
| | | | | | - Jichuan Wang
- Children’s National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, DC, USA
| | - Maureen E. Lyon
- Children’s National Hospital & Center for Translational Research, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, DC, USA
- Children’s National Research Institute, Washington, DC, USA
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15
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Development of a Japanese version of the Advance Care Planning Engagement Survey: Examination of its reliability and validity. Palliat Support Care 2020; 19:341-347. [PMID: 33118902 DOI: 10.1017/s1478951520001108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The importance of supporting advance care planning (ACP) by healthcare professionals is recognized worldwide, and assessing the outcomes, such as people's understanding and readiness for ACP, using an appropriate instrument is essential. We, therefore, developed a Japanese version of the Advance Care Planning Engagement Survey (ACP Engagement Survey; 15 items, 9 items, and 4 items), an international scale for assessing the progress of the ACP, and examined its validity and reliability. METHODS The ACP Engagement Survey was translated into Japanese, back-translated, and culturally adapted, and the final version was reviewed by the author of the original version. Data on basic demographic information and ACP-related experiences were simultaneously collected as external criteria in an online survey of older adults with chronic diseases. The Cronbach's alpha was calculated to assess its internal consistency, and a retest was performed three days later to calculate the intra-class correlation coefficients (ICCs). RESULTS A total of 200 respondents (mean age 70; 9.5% female) were included in the analysis. None of the items showed a ceiling effect, but several items did exhibit a floor effect. The factor structure was the same 2-factor structure as the original version, and both factors exhibited a high cumulative contribution rate. The Cronbach's alphas were 0.94 (15-item version), 0.91 (9-item version), and 0.95 (4-item version), and ICCs were of 0.88 (15-item version), 0.9 (9-item version), and 0.84 (4-item version). SIGNIFICANCE OF RESULTS The Japanese version of the ACP Engagement Survey was confirmed to have very good reliability regarding both internal consistency and test-retest reliability. Together with the result of the item analysis, we can conclude that the Japanese version of the ACP Engagement Survey is sufficiently reliable to be utilized in interventional studies, and it has acceptable content validity, construct validity, and criterion-related validity.
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Hammami MM, Al Balkhi A, De Padua SS, Abuhdeeb K. Factors underlying surrogate medical decision-making in middle eastern and east Asian women: a Q-methodology study. BMC Palliat Care 2020; 19:137. [PMID: 32873284 PMCID: PMC7466416 DOI: 10.1186/s12904-020-00643-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 08/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background It is not clear how lay people prioritize the various, sometimes conflicting, interests when they make surrogate medical decisions, especially in non-Western cultures. The extent such decisions are perspective-related is also not well documented. Methods We explored the relative importance of 28 surrogate decision-making factors to 120 Middle-Eastern (ME) and 120 East-Asian (EA) women from three perspectives, norm-perception (N), preference as patient (P), and preference as surrogate decision-maker (S). Each respondent force-ranked (one to nine) 28 opinion-items according to each perspective. Items’ ranks were analyzed by averaging-analysis and Q-methodology. Results Respondents’ mean (SD) age was 33.2 (7.9) years; all ME were Muslims, 83% of EA were Christians. “Trying everything possible to save patient,” “Improving patient health,” “Patient pain and suffering,” and/or “What is in the best interests of patient” were the three most-important items, whereas “Effect of caring for patient on all patients in society,” “Effect of caring for patient on patients with same disease,” and/or “Cost to society from caring for patient” were among the three least-important items, in each ME and EA perspectives. P-perspective assigned higher mean ranks to family and surrogate’s needs and burdens-related items, and lower mean rank to “Fear of loss” than S-perspective (p<0.001). ME assigned higher mean ranks to “Medical facts” and “Surrogate own wishes for patient” and lower mean rank to “Family needs” in all perspectives (p<0.001). Q-methodology identified models that were relatively patient’s preference-, patient’s religious/spiritual beliefs-, or emotion-dependent (all perspectives); medical facts-dependent (N- and S-perspectives), financial needs-dependent (P- and S-perspectives), and family needs-dependent (P-perspective). Conclusions 1) Patient’s health was more important than patient’s preference to ME and EA women; society interest was least important. 2) Family and surrogate’s needs/ burdens were more important, whereas fear of loss was less important to respondents as patients than as surrogate decision-makers. 3) Family needs were more important to EA than ME respondents, the opposite was true for medical facts and surrogate’s wishes for patient. 4) Q-methodology models that relatively emphasized various surrogate decision-making factors overlapped the ME and EA women’ three perspectives.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 MBC 03, Riyadh, 11211, Saudi Arabia. .,Alfaisal University College of Medicine, Riyadh, Saudi Arabia.
| | - Areej Al Balkhi
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 MBC 03, Riyadh, 11211, Saudi Arabia
| | - Sophia S De Padua
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 MBC 03, Riyadh, 11211, Saudi Arabia
| | - Kafa Abuhdeeb
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 MBC 03, Riyadh, 11211, Saudi Arabia
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Nagelschmidt K, Leppin N, Seifart C, Rief W, von Blanckenburg P. Systematic mixed-method review of barriers to end-of-life communication in the family context. BMJ Support Palliat Care 2020; 11:253-263. [DOI: 10.1136/bmjspcare-2020-002219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 11/03/2022]
Abstract
BackgroundCommunication about the end of life is especially important in the family context, as patients and their families are considered as the care unit in palliative care. Open end-of-life communication can positively affect medical, psychological and relational outcomes during the dying process for patient and family. Regardless of the benefits of end-of-life conversations, many patients and their family caregivers speak little about relevant end-of-life issues.AimTo identify barriers that hinder or influence the discussion of end-of-life issues in the family context.DesignA systematic mixed-method review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.Data sourcesA systematic search of PsycInfo, CINAHL, PubMed and Web of Science was conducted and extended with a hand search. Peer-reviewed primary studies reporting on the barriers to or difficulties in end-of-life conversations experienced by terminally ill patients and/or family caregivers were included in this review.Results18 qualitative and two quantitative studies met the inclusion criteria. The experiences of n=205 patients and n=738 family caregivers were analysed qualitatively; n=293 patients and n=236 caregivers were surveyed in the questionnaire studies. Five overarching categories emerged from the extracted data: emotional, cognitive, communicative, relational and external processes can hinder end-of-life communication within the family. The most frequently reported barriers are emotional and cognitive processes such as protective buffering or belief in positive thinking.ConclusionsResearch on end-of-life communication barriers in the family context is scarce. Further research should enhance the development of appropriate assessment tools and interventions to support families with the challenges experienced regarding end-of-life conversations.
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18
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Psychological Attachment Orientations of Surrogate Decision-Makers and Goals-of-Care Decisions for Brain Injury Patients in ICUs. Crit Care Explor 2020; 2:e0151. [PMID: 32696015 PMCID: PMC7340333 DOI: 10.1097/cce.0000000000000151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Supplemental Digital Content is available in the text. To determine whether ICU surrogates with “insecure” psychologic attachment orientations are more prone to requesting tracheostomy and gastrostomy (i.e., life-sustaining therapy) for severe acute brain injury patients with poor prognosis compared to surrogates with “secure” orientations.
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Gerber K, Lemmon C, Williams S, Watt J, Panayiotou A, Batchelor F, Hayes B, Brijnath B. ‘There for me’: A qualitative study of family communication and decision-making in end-of-life care for older people. PROGRESS IN PALLIATIVE CARE 2020. [DOI: 10.1080/09699260.2020.1767437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Katrin Gerber
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | - Christel Lemmon
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | - Sue Williams
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | | | - Anita Panayiotou
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | - Frances Batchelor
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | | | - Bianca Brijnath
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
- Department of General Practice, Monash University, Melbourne, Australia
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Ullrich A, Theochari M, Bergelt C, Marx G, Woellert K, Bokemeyer C, Oechsle K. Ethical challenges in family caregivers of patients with advanced cancer - a qualitative study. BMC Palliat Care 2020; 19:70. [PMID: 32423444 PMCID: PMC7236546 DOI: 10.1186/s12904-020-00573-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 05/07/2020] [Indexed: 11/26/2022] Open
Abstract
Background Caring for patients with advanced or terminal diseases can confront family caregivers (FC) with ethical challenges. The present study aims at tracing paths connected to ethical challenges among FC of advanced cancer patients by exploring morally troubling situations and related burden, as well as strategies to handle the situation and experience of moral distress from the grieving FC’s perspective. Methods Within a qualitative design, interviews with 12 grieving FC were conducted using a semi-structured interview guide. Data were analysed using grounded theory and abductive reasoning. Results Core phenomena identified were two paths connected to ethical challenges among FC. Ethical challenges occurred in the context of difficult decision-making (Path 1) and in the context of lacking decision-making options when no decision was to be made by FC (Path 2). We found each path to be triggered by distinct sets of morally troubling situations that occurred during the patient’s disease trajectory. In the course of difficult decision-making (Path 1), detrimental external factors could add emotional stress, thus making the decision-making process burdensome. FC used various proactive strategies to overcome those detrimental factors and/or to make the decision. Decisions in conflict with FCs' own moral expectations and values led to moral distress, generating painful emotions. When no decision was to be made by FC (Path 2), FC felt powerless and overrun, which was associated with major emotionality in terms of anxiety and confusion. Either detrimental factors aggravated these feelings to paralyzing shock, or internal resources enabled FC to accept the situation. While acceptance prevented moral distress, paralyzing shock often caused a sense of not meeting their their own moral expectations and values, resulting in moral distress. In both paths, factors were identified that helped FC finding closure and prevented moral residue. Nevertheless, some FC experienced residual moral distress months after the morally troubling situation had occurred. Conclusion Findings provide first information towards understanding paths leading to ethical challenges in FC and can help clinicians to minimize associated emotional burden and moral distress.
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Affiliation(s)
- Anneke Ullrich
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Marianna Theochari
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Bergelt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriella Marx
- Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany.,Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Woellert
- Department of History and Ethics of Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karin Oechsle
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Aloiau A, Benton MJ, Mouchawar A, Segal DL. Impact of end-of-life planning on surrogate decision-maker anxiety in the US. Int J Palliat Nurs 2020; 26:75-82. [PMID: 32125916 DOI: 10.12968/ijpn.2020.26.2.75] [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: 11/11/2022]
Abstract
At the end of life, hospice patients frequently rely on surrogate decision makers (SDMs) for healthcare decisions, which creates anxiety among SDMs. This project evaluated whether an educational intervention to create a plan of care for hospice patients would reduce anxiety among SDMs. Before the intervention, immediately after the intervention, and 2 weeks following the intervention SDM anxiety was measured with the Geriatric Anxiety Scale, State Trait Anxiety Inventory-State Anxiety Scale, and one question about decision-making anxiety. Twelve patients (80±14.7 years) and 18 SDMs (60±12.9 years) completed the intervention. Immediately after the intervention SDMs showed a significant decrease (P=0.003) in anxiety. When anxiety was measured 2 weeks post-intervention, anxiety had increased again, and was no longer significantly different from pre-intervention levels. This project demonstrated that an educational intervention in the hospice setting can be effective in creating a short-term decrease to SDM anxiety levels.
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Affiliation(s)
| | | | - Alan Mouchawar
- Director Cardiac Anesthesia, Newport Harbor Anesthesia Consultants
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22
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Ten Koppel M, Pasman HRW, van der Steen JT, van Hout HPJ, Kylänen M, Van den Block L, Smets T, Deliens L, Gambassi G, Froggatt K, Szczerbińska K, Onwuteaka-Philipsen BD. Consensus on treatment for residents in long-term care facilities: perspectives from relatives and care staff in the PACE cross-sectional study in 6 European countries. BMC Palliat Care 2019; 18:73. [PMID: 31464624 PMCID: PMC6714096 DOI: 10.1186/s12904-019-0459-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 08/15/2019] [Indexed: 01/23/2023] Open
Abstract
Background In long-term care facilities often many care providers are involved, which could make it difficult to reach consensus in care. This may harm the relation between care providers and can complicate care. This study aimed to describe and compare in six European countries the degree of consensus among everyone involved in care decisions, from the perspective of relatives and care staff. Another aim was to assess which factors are associated with reporting that full consensus was reached, from the perspective of care staff and relatives. Methods In Belgium, England, Finland, Italy, the Netherlands and Poland a random sample of representative long-term care facilities reported all deaths of residents in the previous three months (n = 1707). This study included residents about whom care staff (n = 1284) and relatives (n = 790) indicated in questionnaires the degree of consensus among all involved in the decision or care process. To account for clustering on facility level, Generalized Estimating Equations were conducted to analyse the degree of consensus across countries and factors associated with full consensus. Results Relatives indicated full consensus in more than half of the residents in all countries (NL 57.9% - EN 68%), except in Finland (40.7%). Care staff reported full consensus in 59.5% of residents in Finland to 86.1% of residents in England. Relatives more likely reported full consensus when: the resident was more comfortable or talked about treatment preferences, a care provider explained what palliative care is, family-physician communication was well perceived, their relation to the resident was other than child (compared to spouse/partner) or if they lived in Poland or Belgium (compared to Finland). Care staff more often indicated full consensus when they rated a higher comfort level of the resident, or if they lived in Italy, the Netherland, Poland or England (compared to Finland). Conclusions In most countries the frequency of full consensus among all involved in care decisions was relatively high. Across countries care staff indicated full consensus more often and no consensus less often than relatives. Advance care planning, comfort and good communication between relatives and care professionals could play a role in achieving full consensus. Electronic supplementary material The online version of this article (10.1186/s12904-019-0459-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Ten Koppel
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands.
| | - H R W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands
| | - J T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, Leiden, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - H P J van Hout
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, Amsterdam, The Netherlands
| | - M Kylänen
- National Institute for Health and Welfare, Mannerheimintie, 166, Helsinki, Finland
| | - L Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, 103, Brussels, Belgium
| | - T Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, 103, Brussels, Belgium
| | - L Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, 103, Brussels, Belgium
| | - G Gambassi
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy
| | - K Froggatt
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, LA1 4YG, UK
| | - K Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, ul. Kopernika 7a, Krakow, Poland
| | - B D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands
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Hammami MM, Abuhdeeb K, Hammami MB, De Padua SJS, Al-Balkhi A. Prediction of life-story narrative for end-of-life surrogate's decision-making is inadequate: a Q-methodology study. BMC Med Ethics 2019; 20:28. [PMID: 31053127 PMCID: PMC6500001 DOI: 10.1186/s12910-019-0368-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/18/2019] [Indexed: 11/29/2022] Open
Abstract
Background Substituted judgment assumes adequate knowledge of patient’s mind-set. However, surrogates’ prediction of individual healthcare decisions is often inadequate and may be based on shared background rather than patient-specific knowledge. It is not known whether surrogate’s prediction of patient’s integrative life-story narrative is better. Methods Respondents in 90 family pairs (30 husband-wife, 30 parent-child, 30 sibling-sibling) rank-ordered 47 end-of-life statements as life-story narrative measure (Q-sort) and completed instruments on decision-control preference and healthcare-outcomes acceptability as control measures, from respondent’s view (respondent-personal) and predicted pair’s view (respondent-surrogate). They also scored their confidence in surrogate’s decision-making (0 to 4 = maximum) and familiarity with pair’s healthcare-preferences (1 to 4 = maximum). Life-story narratives’ prediction was examined by calculating correlation of statements’ ranking scores between respondent-personal and respondent-surrogate Q-sorts (projection) and between respondent-surrogate and pair-personal Q-sorts before (simulation) and after controlling for correlation with respondent-personal scores (adjusted-simulation), and by comparing percentages of respondent-surrogate Q-sorts co-loading with pair-personal vs. respondent-personal Q-sorts. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was determined by percent concordance. Results were compared among subgroups defined by intra-pair relationship, surrogate’s decision-making confidence, and healthcare-preferences familiarity. Results Mean (SD) age was 35.4 (10.3) years, 69% were females, and 73 and 80% reported ≥ very good health and life-quality, respectively. Mean surrogate’s decision-making confidence score was 3.35 (0.58) and 75% were ≥ familiar with pair’s healthcare-preferences. Mean (95% confidence interval) projection, simulation, and adjusted-simulation correlations were 0.68 (0.67–0.69), 0.42 (0.40–0.44), and 0.26 (0.24–0.28), respectively. Out of 180 respondent-surrogate Q-sorts, 24, 9, and 32% co-loaded with respondent-personal, pair-personal, or both Q-sorts, respectively. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was 47 and 52%, respectively. Surrogate’s decision-making confidence score correlated with adjusted-simulation’s correlation score (rho = 0.18, p = 0.01). There were significant differences among the husband-wife, parent-child, and sibling-sibling subgroups in percentage of respondent-surrogate Q-sorts co-loading with pair-personal Q-sorts (38, 32, 55%, respectively, p = 0.03) and percent agreement on healthcare-outcomes acceptability (55, 35, and 67%, respectively, p = 0.002). Conclusions Despite high self-reported surrogate’s decision-making confidence and healthcare-preferences familiarity, family surrogates are variably inadequate in simulating life-story narratives. Simulation accuracy may not follow the next-of-kin concept and is 38% based on shared background. Electronic supplementary material The online version of this article (10.1186/s12910-019-0368-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia. .,Alfaisal University College of Medicine, Riyadh, Saudi Arabia.
| | - Kafa Abuhdeeb
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
| | | | - Sophia J S De Padua
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
| | - Areej Al-Balkhi
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
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Bryant J, Turon H, Waller A, Freund M, Mansfield E, Sanson-Fisher R. Effectiveness of interventions to increase participation in advance care planning for people with a diagnosis of dementia: A systematic review. Palliat Med 2019; 33:262-273. [PMID: 30260290 DOI: 10.1177/0269216318801750] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Advance care planning involves considering, discussing and documenting future wishes in case a person is unable to make or communicate decisions. Given people with dementia are at high risk of future decisional incapacity, it is critical that advance care planning occurs early in the illness trajectory. Aim: To determine (1) the number of intervention studies published between 1997 and July 2017 that aimed to increase advance care planning for persons with dementia, (2) the methodological quality of studies and (3) the effectiveness of interventions in increasing advance care planning for persons with dementia. Design: Systematic review. Data sources: Medline, Cochrane, EMBASE, PsycINFO and CINAHL were searched for articles published from 1997 to July 2017. Studies were included if they utilised a methodologically robust study design and reported on an intervention designed to increase participation in advance care planning for persons with dementia that was targeted at the person with dementia and/or a carer/family member. Methodological quality was assessed independently by two authors. Results: Four studies met the criteria for inclusion. Methodological quality was variable. Two studies did not report analyses comparing advance care planning outcomes for intervention and control participants. A third study found no effect for a nurse-facilitator intervention. The fourth study found that a structured conversation about end-of-life care with a family member increased the likelihood of advance care orders being listed in residents’ records. Conclusion: There is little evidence about effective strategies to improve participation in advance care planning for persons with dementia. Methodologically rigorous intervention trials are needed to test interventions that encourage timely participation.
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Affiliation(s)
- Jamie Bryant
- 1 Health Behaviour Research Collaborative, The University of Newcastle, Newcastle, NSW, Australia
- 2 Priority Research Centre for Health Behaviour, The University of Newcastle, Newcastle, NSW, Australia
- 3 Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Heidi Turon
- 1 Health Behaviour Research Collaborative, The University of Newcastle, Newcastle, NSW, Australia
- 2 Priority Research Centre for Health Behaviour, The University of Newcastle, Newcastle, NSW, Australia
- 3 Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Amy Waller
- 1 Health Behaviour Research Collaborative, The University of Newcastle, Newcastle, NSW, Australia
- 2 Priority Research Centre for Health Behaviour, The University of Newcastle, Newcastle, NSW, Australia
- 3 Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Megan Freund
- 1 Health Behaviour Research Collaborative, The University of Newcastle, Newcastle, NSW, Australia
- 2 Priority Research Centre for Health Behaviour, The University of Newcastle, Newcastle, NSW, Australia
- 3 Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Elise Mansfield
- 1 Health Behaviour Research Collaborative, The University of Newcastle, Newcastle, NSW, Australia
- 2 Priority Research Centre for Health Behaviour, The University of Newcastle, Newcastle, NSW, Australia
- 3 Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Rob Sanson-Fisher
- 1 Health Behaviour Research Collaborative, The University of Newcastle, Newcastle, NSW, Australia
- 2 Priority Research Centre for Health Behaviour, The University of Newcastle, Newcastle, NSW, Australia
- 3 Hunter Medical Research Institute, Newcastle, NSW, Australia
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Not "Out of Sight, Out of Mind": Interventions to Relieve Suffering for Bereaved Families After an ICU Death. Crit Care Med 2019; 45:134-136. [PMID: 27984282 DOI: 10.1097/ccm.0000000000002119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Gul S, Turkman YE, Bakitas MA, Dionne-Odom JN. Surrogates' Perceptions of Service Quality While Making Decisions for ICU Patients. West J Nurs Res 2018; 41:1370-1384. [PMID: 30574823 DOI: 10.1177/0193945918820098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A qualitative secondary analysis was undertaken to identify aspects of health care service quality in an intensive care unit from the perspective of surrogate decision makers (N = 19) who were making decisions for relatives at end of life. Directed content analysis was guided by the Donabedian model of health care quality. Nineteen participants averaged 59 years old and were over half female (53%) and patients' spouses (53%) and adult children (32%). Salient aspects of quality service included surrogate perceptions that clinicians conveyed honesty about the patient's condition and in an easily understandable way; staff were sensitive and responsive to emotions and practical needs; clinicians demonstrated a clear, confident understanding of the patient's condition; and support by clinicians was given for surrogates' choices. Surrogates also commented on the hospital and intensive care unit environment, including cleanliness, comfort, privacy, and noise level. Further research is needed to explore how decision-support strategies might include service quality concepts.
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Affiliation(s)
- Senay Gul
- Hacettepe University, Ankara, Turkey
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27
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Jimenez G, Tan WS, Virk AK, Low CK, Car J, Ho AHY. Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons. J Pain Symptom Manage 2018; 56:436-459.e25. [PMID: 29807158 DOI: 10.1016/j.jpainsymman.2018.05.016] [Citation(s) in RCA: 295] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/16/2018] [Accepted: 05/18/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Advance care planning (ACP) involves important decision making about future medical needs. The high-volume and disparate nature of ACP research makes it difficult to grasp the evidence and derive clear policy lessons for policymakers and clinicians. AIM The aim of this study was to synthesize ACP research evidence and identify relevant contextual elements, program features, implementation principles, and impacted outcomes to inform policy and practice. DESIGN An overview of systematic reviews using the Cochrane Handbook of Systematic Reviews of Interventions was performed. Study quality was assessed using a modified version of the AMSTAR (A MeaSurement Tool to Assess Reviews) tool. DATA SOURCES MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE were searched for ACP-related research from inception of each database to April 2017. Searches were supplemented with gray literature and manual searches. Eighty systematic reviews, covering over 1660 original articles, were included in the analysis. RESULTS Legislations, institutional policies, and cultural factors influence ACP development. Positive perceptions toward ACP do not necessarily translate into more end-of-life conversations. Many factors related to patients' and providers' attitudes, and perceptions toward life and mortality influence ACP implementation, decision making, and completion. Limited, low-quality evidence points to several ACP benefits, such as improved end-of-life communication, documentation of care preferences, dying in preferred place, and health care savings. Recurring features that make ACP programs effective include repeated and interactive discussion sessions, decision aids, and interventions targeting multiple stakeholders. CONCLUSIONS Preliminary evidence highlights several elements that influence the ACP process and provides a variety of features that could support successful, effective, and sustainable ACP implementation. However, this evidence is compartmentalized and limited. Further studies evaluating ACP as a unified program and assessing the impact of ACP for different populations, settings, and contexts are needed to develop programs that are able to unleash ACP's full potential.
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Affiliation(s)
- Geronimo Jimenez
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Woan Shin Tan
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; NTU Institute of Health Technologies (HealthTech), Interdisciplinary Graduate School, Nanyang Technological University, Singapore, Singapore; Health Services and Outcomes Research Department, National Healthcare Group, Singapore, Singapore
| | - Amrit K Virk
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Chan Kee Low
- Economics Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore
| | - Josip Car
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Andy Hau Yan Ho
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Psychology Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore; Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
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28
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State of advance care planning research: A descriptive overview of systematic reviews. Palliat Support Care 2018; 17:234-244. [PMID: 30058506 DOI: 10.1017/s1478951518000500] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To provide an overview of the current state of research of advance care planning (ACP), highlighting most studied topics, publication time, quality of studies and reported outcomes, and to identify gaps to improve ACP receptivity, utilization, implementation, and outcomes. METHOD Cochrane methodology for conducting overviews of systematic reviews. Study quality was assessed using a modified version of the Assessing the Methodological Quality of Systematic Reviews tool. The following databases were searched from inception to April 2017: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE. Searches were supplemented with gray literature and manual searches. RESULT Eighty systematic reviews, covering 1,662 single articles, show that ACP-related research focuses on nine main topics: (1) ACP as part of end-of-life or palliative care interventions, (2) care decision-making; (3) communication strategies; (4) factors influencing ACP implementation; (5) ACP for specific patient groups, (6) ACP effectiveness; (7) ACP experiences; (8) ACP cost; and (9) ACP outcome measures. The majority of this research was published since 2014, its quality ranges from moderate to low, and reports on documentation, concordance, preferences, and resource utilization outcomes. SIGNIFICANCE OF RESULTS Despite the surge of ACP research, there are major knowledge gaps about ACP initiation, timeliness, optimal content, and impact because of the low quality and fragmentation of the available evidence. Research has mostly focused on discrete aspects within ACP instead of using a holistic evaluative approach that takes into account its intricate working mechanisms, the effects of systems and contexts, and the impacts on multilevel stakeholders. Higher quality studies and innovative interventions are needed to develop effective ACP programs and address research gaps.
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Fairlie DE. Specific Words and Experience Matter to Surrogates When Making End of Life Decisions. HEALTH COMMUNICATION 2018; 33:537-543. [PMID: 28278611 DOI: 10.1080/10410236.2017.1283560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This grant funded preliminary study investigated the relationship between end-of-life terminologies and decisional conflict in surrogate decision makers using a convenience sample of 234 adults aged 50 and older. Participants were randomized into two groups; each received a survey packet that varied only in the use of the words "Do Not Resuscitate (DNR)" and "Allow Natural Death (AND)." The Decisional Conflict Scale (DCS) was administered and demographic data were collected. No difference was found in the total DCS scores based on the AND and DNR versions. However, AND respondents perceived their decision as a good decision and were eight times more likely to sign the document than DNR participants. Experienced decision-makers evolved as a discrete group. They had lower mean total DCS scores and lower mean subscores, indicating that prior experience is an important aspect of end-of-life decision-making. Experienced AND participants were more likely to perceive their decision as good and were more likely to be sure of their decision, indicating that they respond more favorably to the words Allow Natural Death. Respondents to the DNR version were likely to not sign or postpone signing. Those who frequently attended religious services were twice as likely as those who rarely attend religious services of implementing their decision; whether the decision is to sign or not to sign the AND or DNR. Finally, participants were more likely to withdraw from the study when the term DNR was used. Recommendations for future research are presented.
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Affiliation(s)
- Dawn E Fairlie
- a School of Health Sciences, Department of Nursing , College of Staten Island, City University of New York
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30
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Yap SY. Use of the welfare-based model in the application of palliative sedation. Asian Bioeth Rev 2018; 10:93-101. [PMID: 33717279 PMCID: PMC7747338 DOI: 10.1007/s41649-018-0050-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 10/26/2022] Open
Affiliation(s)
- Su Yan Yap
- Palliative Care Services, Department of Geriatric Medicine, Changi General Hospital, Singapore
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31
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Laryionava K, Pfeil TA, Dietrich M, Reiter-Theil S, Hiddemann W, Winkler EC. The second patient? Family members of cancer patients and their role in end-of-life decision making. BMC Palliat Care 2018; 17:29. [PMID: 29454337 PMCID: PMC5816525 DOI: 10.1186/s12904-018-0288-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Family members are important companions of severely ill patients with cancer. However, studies about the desirability and difficulties of integrating relatives in the decision-making process are rare in oncology. This qualitative study explores the family role in decisions to limit treatment near the end of life from the professionals' point of view. METHODS Qualitative in-depth interviews were conducted with oncologists (n = 12) and nurses (n = 6) working at the Department of Hematology/Oncology at the University Hospital in Munich, Germany. The data were analyzed using a descriptive qualitative methodology and discussed from a medical ethics perspective. RESULTS Four major themes played a central role in the perception of the medical staff in regard to family members. (1) Family impact on patients' treatment preferences. (2) Strong family wish for further treatment. (3) Emotional distress of the family related to the involvement in end-of-life decision-making. (4) Importance of knowing family structures. CONCLUSIONS The important role of the family members in patients' disease process is recognized by oncologists and oncology nurses. However, this does not seem to lead to an early involvement of the family members. Developing and establishing a systematic assessment of family members' needs and wishes in order to provide a specific-tailored support should become a priority for interdisciplinary clinical research in the near future.
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Affiliation(s)
- Katsiaryna Laryionava
- National Center for Tumor Diseases, Department of Medical Oncology, Programme for Ethics and Patient-Oriented Care in Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Timo A Pfeil
- Department of Internal Medicine III (Haematology and Oncology), University Hospital Grosshadern, Munich, Germany
| | - Mareike Dietrich
- National Center for Tumor Diseases, Department of Medical Oncology, Programme for Ethics and Patient-Oriented Care in Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Stella Reiter-Theil
- Department Clinical Ethics, Psychiatric Hospitals of the University Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wolfgang Hiddemann
- Department of Internal Medicine III (Haematology and Oncology), University Hospital Grosshadern, Munich, Germany
| | - Eva C Winkler
- National Center for Tumor Diseases, Department of Medical Oncology, Programme for Ethics and Patient-Oriented Care in Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
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Green MJ, Van Scoy LJ, Foy AJ, Stewart RR, Sampath R, Schubart JR, Lehman EB, Dimmock AEF, Bucher AM, Lehmann LS, Harlow AF, Yang C, Levi BH. A Randomized Controlled Trial of Strategies to Improve Family Members' Preparedness for Surrogate Decision-Making. Am J Hosp Palliat Care 2017; 35:866-874. [PMID: 29186982 DOI: 10.1177/1049909117744554] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate 2 strategies for preparing family members for surrogate decision-making. DESIGN A 2 × 2 factorial, randomized controlled trial testing whether: (1) comprehensive online advance care planning (ACP) is superior to basic ACP, and (2) having patients engage in ACP together with family members is superior to ACP done by patients alone. SETTING Tertiary care centers in Hershey, Pennsylvania, and Boston, Massachusetts. PARTICIPANTS Dyads of patients with advanced, severe illness (mean age 64; 46% female; 72% white) and family members who would be their surrogate decision-makers (mean age 56; 75% female; 75% white). INTERVENTIONS Basic ACP: state-approved online advance directive plus brochure. Making Your Wishes Known (MYWK): Comprehensive ACP decision aid including education and values clarification. MEASUREMENTS Pre-post changes in family member self-efficacy (100-point scale) and postintervention concordance between patients and family members using clinical vignettes. RESULTS A total 285 dyads enrolled; 267 patients and 267 family members completed measures. Baseline self-efficacy in both MYWK and basic ACP groups was high (90.2 and 90.1, respectively), and increased postintervention to 92.1 for MYWK ( P = .13) and 93.3 for basic ACP ( P = .004), with no between-group difference. Baseline self-efficacy in alone and together groups was also high (90.2 and 90.1, respectively), and increased to 92.6 for alone ( P = .03) and 92.8 for together ( P = .03), with no between-group difference. Overall adjusted concordance was higher in MYWK compared to basic ACP (85.2% vs 79.7%; P = .032), with no between-group difference. CONCLUSION The disconnect between confidence and performance raises questions about how to prepare family members to be surrogate decision-makers.
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Affiliation(s)
- Michael J Green
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,4 Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Renee R Stewart
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Ramya Sampath
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Jane R Schubart
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,6 Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Erik B Lehman
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Anne E F Dimmock
- 2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Ashley M Bucher
- 4 Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Lisa S Lehmann
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,7 National Center for Ethics in Health Care, Veterans Administration, Washington, DC, USA
| | - Alyssa F Harlow
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Chengwu Yang
- 8 Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York, NY, USA
| | - Benjamin H Levi
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,9 Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
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Githaiga JN, Swartz L. Socio-cultural contexts of end- of- life conversations and decisions: bereaved family cancer caregivers' retrospective co-constructions. BMC Palliat Care 2017; 16:40. [PMID: 28806952 PMCID: PMC5557528 DOI: 10.1186/s12904-017-0222-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 07/31/2017] [Indexed: 11/27/2022] Open
Abstract
Background End-of-life communication becomes increasingly difficult in terminal cancer, which inevitably entails conversations around dying and death. In resource-limited areas, the context of end-of-life communication is usually home-based palliative care comprising mostly women in the family who play critical roles as informal caregivers. This article examined the content and contexts of family end-of-life conversations and decisions based on the retrospective accounts of a sample of bereaved women family cancer caregivers in Nairobi, Kenya. Method An interpretative phenomenological analysis approach was utilized to explore pertinent end-of-life communication themes. Four mini focus group interviews with a total of 13 participants [n = 5; n = 3; n = 3; n = 2] were conducted. Results Two end-of-life themes, advance directives as preparedness for death, and initiating death talk were examined. Findings (a) illustrate the role of family dynamics in influencing the nature of end-of-life conversations and decisions (b) demonstrate the transitional nature of family caregiver roles, and (c) underscore the paradox of the critical role played by family members in palliative care versus their ill preparedness in dealing with end-of-life issues. Conclusions Findings are relevant in informing palliative psychosocial interventions and specifically the concerns and decisions of cancer patients and their families. This prompts further engagement with the question of how to equip family caregivers in resource-limited contexts for end of life care. Methodologically, these results demonstrate the possibility of simultaneous elucidation of individual experiences, interactive co-constructions and the socio-cultural contexts of experiences and meaning making processes in IPA research.
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Affiliation(s)
- Jennifer Nyawira Githaiga
- Department of Psychology, Stellenbosch University, Private Bag X1, Matieland, Stellenbosch, 7602, South Africa.
| | - Leslie Swartz
- Department of Psychology, Stellenbosch University, Private Bag X1, Matieland, Stellenbosch, 7602, South Africa
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Family Communication about End-of-Life Decisions and the Enactment of the Decision-Maker Role. Behav Sci (Basel) 2017; 7:bs7020036. [PMID: 28590407 PMCID: PMC5485466 DOI: 10.3390/bs7020036] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/12/2017] [Accepted: 06/02/2017] [Indexed: 11/18/2022] Open
Abstract
End-of-life (EOL) decisions in families are complex and emotional sites of family interaction necessitating family members coordinate roles in the EOL decision-making process. How family members in the United States enact the decision-maker role in EOL decision situations was examined through in-depth interviews with 22 individuals who participated in EOL decision-making for a family member. A number of themes emerged from the data with regard to the enactment of the decision-maker role. Families varied in how decision makers enacted the role in relation to collective family input, with consulting, informing and collaborating as different patterns of behavior. Formal family roles along with gender- and age-based roles shaped who took on the decision-maker role. Additionally, both family members and medical professionals facilitated or undermined the decision-maker’s role enactment. Understanding the structure and enactment of the decision-maker role in family interaction provides insight into how individuals and/or family members perform the decision-making role within a cultural context that values autonomy and self-determination in combination with collective family action in EOL decision-making.
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Storytelling in the Early Bereavement Period to Reduce Emotional Distress Among Surrogates Involved in a Decision to Limit Life Support in the ICU: A Pilot Feasibility Trial. Crit Care Med 2017; 45:35-46. [PMID: 27618273 DOI: 10.1097/ccm.0000000000002009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Surrogate decision makers involved in decisions to limit life support for an incapacitated patient in the ICU have high rates of adverse emotional health outcomes distinct from normal processes of grief and bereavement. Narrative self-disclosure (storytelling) reduces emotional distress after other traumatic experiences. We sought to assess the feasibility, acceptability, and tolerability of storytelling among bereaved surrogates involved in a decision to limit life support in the ICU. DESIGN Pilot single-blind trial. SETTING Five ICUs across three hospitals within a single health system between June 2013 and November 2014. SUBJECTS Bereaved surrogates of ICU patients. INTERVENTIONS Storytelling and control conditions involved printed bereavement materials and follow-up assessments. Storytelling involved a single 1- to 2-hour home or telephone visit by a trained interventionist who elicited the surrogate's story. MEASUREMENTS AND MAIN RESULTS The primary outcomes were feasibility (rates of enrollment, intervention receipt, 3- and 6-mo follow-up), acceptability (closed and open-ended end-of-study feedback at 6 mo), and tolerability (acute mental health services referral). Of 53 eligible surrogates, 32 (60%) consented to treatment allocation. Surrogates' mean age was 55.5 (SD, 11.8), and they were making decisions for their parent (47%), spouse (28%), sibling (13%), child (3%), or other relation (8%). We allocated 14 to control and 18 to storytelling, 17 of 18 (94%) received storytelling, 14 of 14 (100%) and 13 of 14 (94%) control subjects and 16 of 18 (89%) and 17 of 18 (94%) storytelling subjects completed their 3- and 6-month telephone assessments. At 6 months, nine of 13 control participants (69%) and 16 of 17 storytelling subjects (94%) reported feeling "better" or "much better," and none felt "much worse." One control subject (8%) and one storytelling subject (6%) said that the study was burdensome, and one control subject (8%) wished they had not participated. No subjects required acute mental health services referral. CONCLUSION A clinical trial of storytelling in this study population is feasible, acceptable, and tolerable.
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Yamamoto S, Arao H, Masutani E, Aoki M, Kishino M, Morita T, Shima Y, Kizawa Y, Tsuneto S, Aoyama M, Miyashita M. Decision Making Regarding the Place of End-of-Life Cancer Care: The Burden on Bereaved Families and Related Factors. J Pain Symptom Manage 2017; 53:862-870. [PMID: 28189769 DOI: 10.1016/j.jpainsymman.2016.12.348] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/21/2016] [Accepted: 12/20/2016] [Indexed: 11/21/2022]
Abstract
CONTEXT Decision making regarding the place of end-of-life (EOL) care is an important issue for patients with terminal cancer and their families. It often requires surrogate decision making, which can be a burden on families. OBJECTIVES To explore the burden on the family of patients dying from cancer related to the decisions they made about the place of EOL care and investigate the factors affecting this burden. METHODS This was a cross-sectional mail survey using a self-administered questionnaire. Participants were 700 bereaved family members of patients with cancer from 133 palliative care units in Japan. The questionnaire covered decisional burdens, depression, grief, and the decision-making process. RESULTS Participants experienced emotional pressure as the highest burden. Participants with a high decisional burden reported significantly higher scores for depression and grief (both P < 0.001). Multiple regression analyses revealed that higher burden was associated with selecting a place of EOL care that differed from that desired by participants (P < 0.001) and patients (P = 0.034), decision making without knowing the patient's wishes and values (P < 0.001) and without participants sharing their wishes and values with the patient's doctors and/or nurses (P = 0.022), and making the decision because of a due date for discharge from a former facility or hospital (P = 0.005). CONCLUSION Decision making regarding the place of EOL care was recalled as burdensome for family decision makers. An early decision-making process that incorporates sharing patients' and family members' values that are relevant to the desired place of EOL care is important.
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Affiliation(s)
- Sena Yamamoto
- Department of Nursing, Social Medical Corporation Hakuaikai Sagara Hospital, Kagoshima, Japan
| | - Harue Arao
- Division of Health Sciences, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Eiko Masutani
- Division of Health Sciences, Osaka University Graduate School of Medicine, Suita, Japan
| | - Miwa Aoki
- Faculty of Nursing, University of Kochi, Kochi, Japan
| | - Megumi Kishino
- Department of Nursing, Kobe University Hospital, Kobe, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara Hospital, Hamamatsu, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satoru Tsuneto
- Department of Palliative Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Maho Aoyama
- Community Health Nursing, Course of Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
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Sipples R, Taylor R, Kirk-Walker D, Bagcivan G, Dionne-Odom JN, Bakitas M. Perioperative Palliative Care Considerations for Surgical Oncology Nurses. Semin Oncol Nurs 2017; 33:9-22. [DOI: 10.1016/j.soncn.2016.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Kim H, Deatrick JA, Ulrich CM. Ethical frameworks for surrogates' end-of-life planning experiences. Nurs Ethics 2016; 24:46-69. [PMID: 27005954 DOI: 10.1177/0969733016638145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the growing body of knowledge about surrogate decision making, we know very little about the use of ethical frameworks (including ethical theories, principles, and concepts) to understand surrogates' day-to-day experiences in end-of-life care planning for incapacitated adults. OBJECTIVES AND METHODS This qualitative systematic review was conducted to identify the types of ethical frameworks used to address surrogates' experiences in end-of-life care planning for incapacitated adults as well as the most common themes or patterns found in surrogate decision-making research. FINDINGS Seven research papers explicitly identified ethical theories, principles, or concepts, such as autonomy, substituted judgment, and best interest standards as guidelines for the research. Surrogate decision making themes included the responsibilities and goals of being a surrogate, factors influencing surrogates' decision making, outcomes for surrogates, and an overarching theme of "wanting to do the right thing" for their loved one and/or themselves. DISCUSSION Understanding the complexity of surrogates' experiences of end-of-life care planning is beyond the scope of conventional ethical frameworks. CONCLUSION Ethical frameworks that address individuality and contextual variations related to decision making may more appropriately guide surrogate decision-making research that explores surrogates' end-of-life care planning experiences.
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Abstract
OBJECTIVE No prior studies on hospice utilization have captured information about the amount of time between when one first learns of hospice as a potential option for care and when he/she actually enrolls. Little is in fact known about this decision-making process. The present study examines hospice enrollment by exploring relationships between hospice decision time and known barriers to care. METHOD This was an exploratory cross-sectional study. Pearson's r was employed to identify bivariate relationships between barriers to care and decision time for hospice care. Independent-sample t tests and ANOVA were utilized to consider differences in decision time across key variables. RESULTS Some 90 hospice patients, or their primary decision maker, participated in the study from a not-for-profit hospice located in the southern United States. Decision time was correlated with referral source, use of disease-directed treatment, functional status (on the Palliative Performance Scale [PPS]), age, diagnosis, income, race, and spirituality-suggesting that decision time is a pertinent variable when examining hospice utilization. Differences in decision time were found across diagnosis, race, income, and referral source. SIGNIFICANCE OF RESULTS This study provides implications for policy and practice, particularly for clinicians faced with initial conversations about hospice care. Differences in decision time highlight ongoing needs related to overcoming healthcare disparities, the important role of including families in initial conversations, and the potential need for varied approaches to talking about hospice care based upon diagnosis. Results also highlight the need for policies supportive of concurrent care, where hospice can be accessed alongside curative care.
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Affiliation(s)
- Gary Mitchell
- Dementia Care Advisor, Four Seasons Health Care, Northern Ireland
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Mayer PA, Esplin B, Burant CJ, Wilson BM, Krall ML, Daly BJ, Gatliff J. In My Best Interest. Am J Hosp Palliat Care 2015; 34:160-165. [PMID: 26494828 DOI: 10.1177/1049909115609576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Advance directives (ADs) have traditionally been viewed as clear instructions for implementing patient wishes at times of compromised decision-making capacity (DMC). However, whether individuals prefer ADs to be strictly followed or to serve as general guidelines has not been studied. The Veterans Administration's Advance Directive Durable Power of Attorney for Health Care and Living Will (VA AD) provides patients the opportunity to indicate specific treatment preferences and to indicate how strictly the directive is to be followed. OBJECTIVE To describe preferences for life-sustaining treatments (LSTs) in various illness conditions as well as instructions for the use of VA ADs. DESIGN/SETTING A descriptive study was performed collecting data from all ADs entered into the medical record at 1 VA Medical Center between January and June 2014. MEASUREMENTS Responses to VA AD with emphasis on health care agents (HCAs) and LW responses. RESULTS Veterans were more likely to reject LST when death was imminent (74.6%), when in a coma (71.1%), if they had brain damage (70.6%), or were ventilator dependent (70.4%). A majority (67.4%) of veterans preferred the document to be followed generally rather than strictly. Veterans were more likely to want VA ADs to serve as a general guide when a spouse was named HCA. CONCLUSION Most of the sampled veterans rejected LST except under conditions of permanent disability. A majority intend VA ADs to serve as general guidelines rather than strict, binding instructions. These findings have significant implications for surrogate decision making and the use of ADs more generally.
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Affiliation(s)
- Patricia A Mayer
- 1 Cleveland Fellowship in Advanced Bioethics, Cleveland, OH, USA
| | - Bryn Esplin
- 1 Cleveland Fellowship in Advanced Bioethics, Cleveland, OH, USA
| | - Christopher J Burant
- 2 Frances Payne Bolton School of Nursing at Case Western Reserve University, Cleveland, OH, USA.,3 Statistics Resource Center, Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Brigid M Wilson
- 4 Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | | | - Barbara J Daly
- 6 Clinical Ethics, University Hospitals Case Medical Center, Cleveland, OH, USA.,7 School of Nursing and School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jason Gatliff
- 5 Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,8 Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,9 Clinical Ethics Consultation, Center for Biomedical Ethics, MetroHealth Medical Center, Cleveland, OH, USA
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Pattison N, O’Gara G, Wigmore T. Negotiating Transitions: Involvement of Critical Care Outreach Teams in End-of-Life Decision Making. Am J Crit Care 2015; 24:232-40. [PMID: 25934720 DOI: 10.4037/ajcc2015715] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Little research has examined the involvement of critical care outreach teams in end-of-life decision making. OBJECTIVE To establish how much time critical care outreach teams spend with patients who are subsequently subject to limitation of medical treatment and end-of-life decisions and how much influence the teams have on those decisions. METHODS A single-center retrospective review, with qualitative analysis, in a large cancer center. Data from all patients referred emergently for critical care outreach from October 2010 to October 2011 who later had limitation of medical treatment or end-of-life care were retrieved. Findings were analyzed by using SPSS 19 and qualitative free-text analysis. RESULTS Of 890 patients referred for critical care outreach from October 2010 to October 2011, 377 were referred as an emergency; 108 of those had limitation of medical treatment and were included in the review. Thirty-five patients (32.4%) died while hospitalized. As a result of outreach intervention and a decision to limit medical treatment, 56 (51.9%) of the 108 patients received a formal end-of-life care plan (including care pathways, referral to palliative care team, hospice). About a fifth (21.5%) of clinical contact time is being spent on patients who subsequently are subject to limitation of medical treatment. Qualitative document analysis showed 5 emerging themes: difficulty of discussions about not attempting cardiopulmonary resuscitation, complexities in coordinating multiple teams, delays in referral and decision making, decision reversals and opaque decision making, and technical versus ethical imperatives. CONCLUSION A considerable amount of time is being spent on these emergency referrals, and decisions to limit medical treatment are common. The appropriateness of escalation of levels of care is often not questioned until patients become critically or acutely unwell, and outreach teams subsequently intervene.
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Affiliation(s)
- Natalie Pattison
- Natalie Pattison is a senior clinical nursing research fellow, Geraldine O’Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England
| | - Geraldine O’Gara
- Natalie Pattison is a senior clinical nursing research fellow, Geraldine O’Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England
| | - Timothy Wigmore
- Natalie Pattison is a senior clinical nursing research fellow, Geraldine O’Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England
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Cowey E, Smith LN, Stott DJ, McAlpine CH, Mead GE, Barber M, Walters M. Impact of a clinical pathway on end-of-life care following stroke: a mixed methods study. Palliat Med 2015; 29:249-59. [PMID: 25249241 DOI: 10.1177/0269216314551378] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Death after stroke is common, but little is known about end-of-life care processes in acute stroke units. AIM (1) To identify family and health-care worker perceptions of an end-of-life care pathway for patients who die after acute stroke. (2) To determine whether patients with fatal stroke judged to require an end-of-life care pathway differ from patients with fatal stroke who die without introduction of such a pathway. DESIGN Mixed methods study integrating qualitative semistructured interviews with quantitative casenote review. SETTING/PARTICIPANTS In four Scottish acute stroke units, 17 relatives of deceased stroke patients and 23 health-care professionals were interviewed. Thematic analysis used a modified grounded theory approach. Multivariate analysis was performed on casenote data, identified prospectively from 100 consecutive stroke deaths. RESULTS Deciding pathway use was a consultative process, occurring within normal working hours. Families were commonly involved and could veto or trigger aspects of end-of-life care. Families sometimes felt responsible for decisions such as pathway use, resuscitation or hydration. Families were often led to expect their relative's death early in the post-stroke period. Prolonged dying processes, particularly where patients had severe dysphagia, added to distress for families. Preferences for place of care were discussed infrequently. No link was found between demographic or clinical characteristics and care pathway use. CONCLUSION Distressing stroke-related clinical problems dominated relatives' concerns rather than use of the end-of-life care pathway. At times, relatives felt primarily responsible for key aspects of decision-making. Relatives often felt unprepared for a prolonged dying process after stroke, particularly where patients had persistent major swallowing difficulties.
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Affiliation(s)
- Eileen Cowey
- Nursing & Health Care School, University of Glasgow, Glasgow, UK
| | - Lorraine N Smith
- Nursing & Health Care School, University of Glasgow, Glasgow, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Christine H McAlpine
- Department of Medicine for the Elderly, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Gillian E Mead
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Mark Barber
- Department of Medicine for the Elderly, Monklands Hospital, NHS Lanarkshire, Airdrie, UK
| | - Matthew Walters
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Family communication and decision making at the end of life: A literature review. Palliat Support Care 2014; 13:815-25. [DOI: 10.1017/s1478951514000388] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:Patients and families coping with a terminal illness are faced with a number of decisions over the course of their disease. The role that family communication plays in the process of decision making is an important one. The objectives for this review are to examine the current state of empirical literature on the relationship between family communication and decision making about end-of-life care, to identify gaps, and to discuss implications for policy, practice, and future research.Method:Articles were identified using systematic keyword searches within the following relevant databases: Academic Search Complete, CINAHL Plus, Communications and Mass Media Complete, ERIC, PsychINFO, MEDLINE, SocINDEX, and ProQuest.Results:The three bodies of relevant literature that emerged during this review include: (1) the importance of family communication at the end of life (EoL); (2) family decision making at the EoL; and (3) the interrelationship of communication (both within the family and with healthcare professionals) and decision making at the EoL. While the literature highlights the role of communication between medical professionals and the patient or family members, there is very little focus on the process of how family communication among the family members themselves contributes to decision making at the end of life.Significance of results:Barriers to end-of-life care are important considerations for helping patients to access timely and appropriate services. Understanding the pertinent role of family communication as it relates to the decision for EoL care is the first step in working to provide another avenue for overcoming these barriers.
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Ying I, Levitt Z, Jassal SV. Should an elderly patient with stage V CKD and dementia be started on dialysis? Clin J Am Soc Nephrol 2013; 9:971-7. [PMID: 24235287 DOI: 10.2215/cjn.05870513] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The burden of cognitive impairment appears to increase with progressive renal disease, such that the prevalence of dementia among those starting dialysis, or those already established on dialysis, is high. The appropriateness of dialysis initiation in this population has been questioned, and current Renal Physician Association guidelines suggest forgoing dialysis in individuals who have dementia and lack awareness of self and environment. Patients are, however, also entitled to equal rights and respect, equal access to health care services, and an opportunity to engage in shared decision-making processes, particularly if there is concern over reversibility of disease. This article discusses, on the basis of principles of beneficence and nonmaleficence, the arguments in favor of and against dialysis use, and the process of determining an appropriate care plan. Factors discussed include the current societal trend toward a technological imperative, premature fatalism, survival benefits, and the implications of providing care to patients who are unable to express their tolerance for symptoms associated with the treatment or lack of treatment.
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Affiliation(s)
- Irene Ying
- Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada, †Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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Rhee JJ, Zwar NA, Kemp LA. Why Are Advance Care Planning Decisions Not Implemented? Insights from Interviews with Australian General Practitioners. J Palliat Med 2013; 16:1197-204. [DOI: 10.1089/jpm.2013.0156] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joel J. Rhee
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Nicholas A. Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Lynn A. Kemp
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
- Centre for Health Equity Training Research and Evaluation (CHETRE), University of New South Wales, Sydney, Australia
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Final decisions: how hospice enrollment prompts meaningful choices about life closure. Palliat Support Care 2013; 12:211-21. [PMID: 23942112 DOI: 10.1017/s1478951512001113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The purpose of this study was to explore and describe decisions that faced newly enrolled hospice patients and their caregivers after hospice enrollment. METHOD An exploratory, descriptive, cross-sectional design was employed using qualitative methods. In-depth in-person interviews were conducted with current hospice patients (n = 35) and caregivers (n = 45) from 53 families. RESULTS The decision to enroll in hospice was a critical juncture on the trajectory of a terminal illness that allowed patients and their families an opportunity to consider subsequent tasks that were important for life closure. A typology of five decisions is presented: (1) operationalized advance care planning (ACP): a renewed focus on decisions about care at life's end; (2) surrogate decision-making: caregivers begin making both informal and formal decisions for the dying person; (3) meaning-making: the foreshortened time brings into focus decisions about seeing special people, attending events, and creating memories; (4) Location of death: decisions about whether the person wants to and can remain at home to die; and (5) final acts: decisions about funeral arrangements, wills, and leaving a legacy become central. ACP was found to exist on a continuum that ranged from absent ACP, dormant ACP, simplified ACP to activated ACP. Hospice enrollment became a catalyst for reactivating discussion of end-of-life choices. SIGNIFICANCE OF RESULTS Hospice enrollment prompts the need to consider subsequent important choices that contribute to meaningful life closure, are central to the completion of a family relationship, and may influence adaptation in bereaved caregivers. It is important for clinicians to recognize that well-timed encouragement to consider and explore the use of hospice services, although it may indeed diminish hope for cure or recovery, simultaneously offers an opportunity to engage with important and time-sensitive developmental tasks.
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Barnato AE, Arnold RM. The effect of emotion and physician communication behaviors on surrogates' life-sustaining treatment decisions: a randomized simulation experiment. Crit Care Med 2013; 41:1686-91. [PMID: 23660727 PMCID: PMC3687021 DOI: 10.1097/ccm.0b013e31828a233d] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Surrogate decision makers for critically ill patients experience strong negative emotional states. Emotions influence risk perception, risk preferences, and decision making. We sought to explore the effect of emotional state and physician communication behaviors on surrogates' life-sustaining treatment decisions. DESIGN 5 × 2 between-subject randomized factorial experiment. SETTING Web-based simulated interactive video meeting with an intensivist to discuss code status. SUBJECTS Community-based participants 35 and older who self-identified as the surrogate for a parent or spouse recruited from eight U.S. cities through public advertisements. INTERVENTIONS Block random assignment to emotion arousal manipulation and each of the four physician communication behaviors. MEASUREMENTS AND MAIN RESULTS Surrogate's code status decision (cardiopulmonary resuscitation vs do not resuscitate/allow natural death). Two hundred fifty-six of 373 respondents (69%) logged-in and were randomized: average age was 50; 70% were surrogates for a parent; 63.5% were women; 76% were white, 11% black, and 9% Asian; and 81% were college educated. When asked about code status, 56% chose cardiopulmonary resuscitation. The emotion arousal manipulation increased the score on depression-dejection scale (β = 1.76 [0.58 - 2.94]) but did not influence cardiopulmonary resuscitation choice. Physician attending to emotion and framing the decision as the patient's rather than the surrogate's did not influence cardiopulmonary resuscitation choice. Framing no cardiopulmonary resuscitation as the norm rather than cardiopulmonary resuscitation resulted in fewer surrogates choosing cardiopulmonary resuscitation (48% vs 64%, odds ratio, 0.52 [95% CI, 0.32-0.87]), as did framing the alternative to cardiopulmonary resuscitation as "allow natural death" rather than do not resuscitate (49% vs 61%, odds ratio, 0.58 [95% CI, 0.35-0.96]). CONCLUSIONS Experimentally induced emotional state did not influence code status decisions, although small changes in physician communication behaviors substantially influenced this decision.
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Affiliation(s)
- Amber E Barnato
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Abstract
Objective. Making surrogate decisions on behalf of incapacitated patients can raise difficult questions for relatives, physicians, and society. Previous research has focused on the accuracy of surrogate decisions (i.e., the proportion of correctly inferred preferences). Less attention has been paid to the procedural satisfaction that patients’ surrogates and patients attribute to specific approaches to making surrogate decisions. The objective was to investigate hypothetical patients’ and surrogates’ procedural satisfaction with specific approaches to making surrogate decisions and whether implementing these preferences would lead to tradeoffs between procedural satisfaction and accuracy. Methods. Study 1 investigated procedural satisfaction by assigning participants (618 in a mixed-age but relatively young online sample and 50 in an older offline sample) to the roles of hypothetical surrogates or patients. Study 2 (involving 64 real multigenerational families with a total of 253 participants) investigated accuracy using 24 medical scenarios. Results. Hypothetical patients and surrogates had closely aligned preferences: Procedural satisfaction was highest with a patient-designated surrogate, followed by shared surrogate decision-making approaches and legally assigned surrogates. These approaches did not differ substantially in accuracy. Limitations are that participants’ preferences regarding existing and novel approaches to making surrogate decisions can only be elicited under hypothetical conditions. Conclusions. Next to decision making by patient-designated surrogates, shared surrogate decision making is the preferred approach among patients and surrogates alike. This approach appears to impose no tradeoff between procedural satisfaction and accuracy. Therefore, shared decision making should be further studied in representative samples of the general population, and if people’s preferences prove to be robust, they deserve to be weighted more strongly in legal frameworks in addition to patient-designated surrogates.
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Affiliation(s)
- Renato Frey
- Center for Cognitive and Decision Sciences, University of Basel, Switzerland (RF)
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany (RF, RH, SMH)
| | - Ralph Hertwig
- Center for Cognitive and Decision Sciences, University of Basel, Switzerland (RF)
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany (RF, RH, SMH)
| | - Stefan M. Herzog
- Center for Cognitive and Decision Sciences, University of Basel, Switzerland (RF)
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany (RF, RH, SMH)
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