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Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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van Hamersveld-Kramer M, Perry SIB, Lodewijks E, Vasse E, de van der Schueren MAE. Decision-making regarding oral nutritional supplements for nursing home residents with advanced dementia: A cross-sectional pilot study. J Hum Nutr Diet 2021; 35:58-67. [PMID: 34694055 DOI: 10.1111/jhn.12955] [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: 08/02/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surrogate decision-making regarding oral nutritional supplements (ONS) for nursing home residents with advanced dementia is a complex process. In this cross-sectional study, we assessed whether Dutch dietitians, elderly care physicians (physicians) and surrogate decision-makers (SDMs) differ in the factors that they regard important when considering ONS. We also investigated differences in opinion regarding whether or not ONS is a life-prolonging measure. METHODS Through an online survey, 90 dietitians, 53 physicians and 70 SDMs of nursing home residents (all aged ≥ 65 years old with advanced dementia) rated the level of perceived influence of 11 pre-defined factors on their decision-making, ranked factors in order of importance and stated whether they considered ONS a life-prolonging measure or not. By statistical analysis, we tested differences in the mean sum of ranks for perceived influence differing between groups. We also tested differences in proportions between groups of those who considered ONS a life-prolonging measure. RESULTS Rating of perceived influence significantly differed for six factors. Quality of life was ranked as the most influential factor by all groups. Dietitians significantly differed in their opinion on the life-prolonging effect of ONS from physicians (odds ratio = 0.29, 95% confidence interval = 0.13-0.65), as well as from SDMs (odds ratio = 0.22, 95% confidence interval = 0.10-0.45). CONCLUSIONS Although all groups proclaimed quality of life to be first priority in decision-making, we found that Dutch dietitians, physicians and SDMs differed in what they regarded important when considering ONS for nursing home residents with advanced dementia. Regarding the life-prolonging effect of ONS, dietitians differed in opinion from physicians, as well as from SDMs.
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Affiliation(s)
| | - Sander I B Perry
- Department of Epidemiology and Data Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Eva Lodewijks
- Department of Dietetics, Florence Healthcare, Rijswijk, The Netherlands.,University Network for the Care Sector Zuid Holland, Leiden, The Netherlands
| | - Emmelyne Vasse
- Department of Dietetics, Gelderse Vallei Hospital, Ede, The Netherlands.,Dutch Malnutrition Steering Group, Amsterdam, The Netherlands
| | - Marian A E de van der Schueren
- Department of Nutrition, Dietetics and Lifestyle, HAN University of Applied Sciences, Nijmegen, The Netherlands.,Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
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Sharma-Virk M, van Erp WS, Lavrijsen JCM, Koopmans RTCM. Intensive neurorehabilitation for patients with prolonged disorders of consciousness: protocol of a mixed-methods study focusing on outcomes, ethics and impact. BMC Neurol 2021; 21:133. [PMID: 33752631 PMCID: PMC7983203 DOI: 10.1186/s12883-021-02158-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged disorders of consciousness (PDOC) are amongst the severest sequelae of acquired brain injury. Evidence regarding epidemiology and rehabilitation outcomes is scarce. These knowledge gaps and psychological distress in families of PDOC patients may complicate clinical decision-making. The complex PDOC care and associated moral dilemmas result in high workload in healthcare professionals. Since 2019, all PDOC patients in the Netherlands have access to intensive neurorehabilitation up to 2 years post-injury provided by one rehabilitation center and four specialized nursing homes. Systematic monitoring of quantitative rehabilitation data within this novel chain of care is done in a study called DOCTOR. The optimization of tailored PDOC care, however, demands a better understanding of the impact of PDOC on patients, their families and healthcare professionals and their views on rehabilitation outcomes, end-of-life decisions and quality of dying. The True Outcomes of PDOC (TOPDOC) study aims to gain insight in the qualitative outcomes of PDOC rehabilitation and impact of PDOC on patients, their families and healthcare professionals. METHODS Nationwide multicenter prospective cohort study in the settings of early and prolonged intensive neurorehabilitation with a two-year follow-up period, involving three study populations: PDOC patients > 16 years, patients' family members and healthcare professionals involved in PDOC care. Families' and healthcare professionals' views on quality of rehabilitation outcomes, end-of-life decisions and dying will be qualitatively assessed using comprehensive questionnaires and in-depth interviews. Ethical dilemmas will be explored by studying moral deliberations. The impact of providing care to PDOC patients on healthcare professionals will be studied in focus groups. DISCUSSION To our knowledge, this is the first nationwide study exploring quality of outcomes, end-of-life decisions and dying in PDOC patients and the impact of PDOC in a novel chain of care spanning the first 24 months post-injury in specialized rehabilitation and nursing home settings. Newly acquired knowledge in TOPDOC concerning quality of outcomes in PDOC rehabilitation, ethical aspects and the impact of PDOC will enrich quantitative epidemiological knowledge and outcomes arising from DOCTOR. Together, these projects will contribute to the optimization of centralized PDOC care providing support to PDOC patients, families and healthcare professionals.
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Affiliation(s)
- Manju Sharma-Virk
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands.
- PZC Dordrecht, Dordrecht, The Netherlands.
| | - Willemijn S van Erp
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
- Accolade Zorg, Bosch en Duin, The Netherlands
- Libra Revalidatie & Audiologie, Tilburg, The Netherlands
| | - Jan C M Lavrijsen
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
- Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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van Erp WS, Lavrijsen JCM, Vos PE, Laureys S, Koopmans RTCM. Unresponsive wakefulness syndrome: Outcomes from a vicious circle. Ann Neurol 2020; 87:12-18. [PMID: 31675139 PMCID: PMC6972677 DOI: 10.1002/ana.25624] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Willemijn S. van Erp
- Department of Primary and Community CareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenthe Netherlands
- Coma Science Group, GIGA Consciousness, University of LiègeLiègeBelgium
| | - Jan C. M. Lavrijsen
- Department of Primary and Community CareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenthe Netherlands
| | - Pieter E. Vos
- Department of NeurologySlingeland HospitalDoetinchemthe Netherlands
| | - Steven Laureys
- Coma Science Group, GIGA ConsciousnessUniversity of LiègeLiègeBelgium
| | - Raymond T. C. M. Koopmans
- Department of Primary and Community CareRadboud University Medical Center, Radboud Institute for Health Sciences, and Joachim en Anna Center for Specialized Geriatric CareNijmegenthe Netherlands
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Goudarzi F, Abedi H, Zarea K, Ahmadi F, Hosseinigolafshani SZ. The Resilient Care of Patients with Vegetative State at Home: a Grounded Theory. J Caring Sci 2018; 7:163-175. [PMID: 30283762 PMCID: PMC6163151 DOI: 10.15171/jcs.2018.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 04/18/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction: The care of patients in vegetative state at
home is difficult because they need continuous medical interventions and extensive care.
The present study aims to explain the process of home care of patients in vegetative state
at home. Methods: This study was a qualitative research with a
grounded theory approach. The participants were 22 people (included 17 family caregivers
and 5 professional caregivers) who were enrolled in a purposive sampling. Data was
gathered through unstructured interviews, observations and field notes. Data collection
was continued to saturation. Data analysis was performed through the Strauss and Corbin
1998 approach. The MAXQDA10 software was used to facilitate data analysis. Results: The data analysis led to emerge four main concepts
included "erosive care", "erosive expenditures", "seeking solver education" and "lasting
hope" as the axes of the study. Participants' experiences showed that the main concern of
family caregivers of vegetative patients was "playing an inevitable role in care", in
which they did not hesitate to make any effort, and they tolerated all the problems and
issues. Therefore, "resilient care" was extracted as the underlying idea of this
study. Conclusion: The process of resilient care of vegetative
patients at home showed planning by policy makers in health system is very important and
underscored the necessity for supporting families and family caregivers of these patients.
So some changes in the health system for this goal might include considering home care and
supporting them in various aspects, especially information, financial and emotional
dimensions.
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Affiliation(s)
- Fateme Goudarzi
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran.,Department of Nursing, Nursing and Midwifery Faculty, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Heidarali Abedi
- Department of Nursing, Nursing and Midwifery Faculty, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran
| | - Kourosh Zarea
- Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Fazlollah Ahmadi
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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Span-Sluyter CAMFH, Lavrijsen JCM, van Leeuwen E, Koopmans RTCM. Moral dilemmas and conflicts concerning patients in a vegetative state/unresponsive wakefulness syndrome: shared or non-shared decision making? A qualitative study of the professional perspective in two moral case deliberations. BMC Med Ethics 2018; 19:10. [PMID: 29471814 PMCID: PMC5824545 DOI: 10.1186/s12910-018-0247-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background Patients in a vegetative state/ unresponsive wakefulness syndrome (VS/UWS) pose ethical dilemmas to those involved. Many conflicts occur between professionals and families of these patients. In the Netherlands physicians are supposed to withdraw life sustaining treatment once recovery is not to be expected. Yet these patients have shown to survive sometimes for decades. The role of the families is thought to be important. The aim of this study was to make an inventory of the professional perspective on conflicts in long-term care of patients in VS/UWS. Methods A qualitative study of transcripts on 2 Moral Deliberations (MD’s) in 2 cases of patients in VS/UWS in long-term care facilities. Results Six themes emerged: 1) Vision on VS/UWS; 2) Treatment and care plan; 3) Impact on relationships; 4) Feelings/attitude; 5) Communication; 6) Organizational aspects. These themes are related to professionals and to what families had expressed to the professionals. We found conflicts as well as contradictory feelings and thoughts to be a general feature in 4 of these themes, both in professionals and families. Conflicts were found in several actors: within families concerning all 6 themes, in nurse teams concerning the theme treatment and care plan, and between physicians concerning all 6 themes. Conclusions Different visions, different expectations and hope on recovery, deviating goals and contradictory feelings/thoughts in families and professionals can lead to conflicts over a patient with VS/UWS. Key factors to prevent or solve such conflicts are a carefully established diagnosis, clarity upon visions, uniformity in treatment goals and plans, an open and empathic communication, expertise and understanding the importance of contradictory feelings/thoughts. Management should bridge conflicts and support their staff, by developing expertise, by creating stability and by facilitating medical ethical discourses. Shared compassion for the patient might be a key to gain trust and bridge the differences from non-shared to shared decision making.
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Affiliation(s)
- Conny A M F H Span-Sluyter
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands. .,Novicare, Professionals in Elderly Care, Best, the Netherlands.
| | - Jan C M Lavrijsen
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands
| | | | - Raymond T C M Koopmans
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands.,Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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Birchley G, Jones K, Huxtable R, Dixon J, Kitzinger J, Clare L. Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty. BMC Med Ethics 2016; 17:46. [PMID: 27461340 PMCID: PMC4962460 DOI: 10.1186/s12910-016-0129-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/13/2016] [Indexed: 12/02/2022] Open
Abstract
Background In most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis. Methods To capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature. Results Initial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies. Conclusions Together these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0129-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK.
| | - Kerry Jones
- Faculty of Health and Social Care, The Open University, Milton Keynes, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Jeremy Dixon
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Jenny Kitzinger
- Coma and Disorders of Consciousness Research Centre, Cardiff University, Cardiff, UK
| | - Linda Clare
- REACH: The Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
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van Erp WS, Lavrijsen JCM, Vos PE, Bor H, Laureys S, Koopmans RTCM. The vegetative state: prevalence, misdiagnosis, and treatment limitations. J Am Med Dir Assoc 2016; 16:85.e9-85.e14. [PMID: 25528282 DOI: 10.1016/j.jamda.2014.10.014] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/20/2014] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients in a vegetative state/unresponsive wakefulness syndrome (VS/UWS) open their eyes spontaneously, but show only reflexive behavior. Although VS/UWS is one of the worst possible outcomes of acquired brain injury, its prevalence is largely unknown. This study's objective was to map the total population of hospitalized and institutionalized patients in VS/UWS in the Netherlands: prevalence, clinical characteristics, and treatment limitations. METHODS Nationwide point prevalence study on patients in VS/UWS at least 1 month after acute brain injury in hospitals, rehabilitation centers, nursing homes, institutions for people with intellectual disability, and hospices; diagnosis verification by a researcher using the Coma Recovery Scale-revised (CRS-r); gathering of demographics, clinical characteristics, and treatment limitations. RESULTS We identified 33 patients in VS/UWS, 24 of whose diagnoses could be verified. Patients were on average 51 years old with a mean duration of VS/UWS of 5 years. The main etiology was hypoxia sustained during cardiac arrest and resuscitation. More than 50% of patients had not received rehabilitation services. Most were given life-sustaining treatment beyond internationally accepted prognostic boundaries regarding recovery of consciousness. Seventeen (39%) of 41 patients presumed to be in VS/UWS were found to be at least minimally conscious. CONCLUSIONS Results translate to a prevalence of 0.1 to 0.2 hospitalized and institutionalized VS/UWS patients per 100,000 members of the general population. This small figure may be related to the legal option to withhold or withdraw life-sustaining treatment, including artificial nutrition and hydration. On the other hand, this study shows that in certain cases, physicians continue life-prolonging treatment for up to 25 years. Patients have poor access to rehabilitation and are at substantial risk for misdiagnosis.
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Affiliation(s)
- Willemijn S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Liège, Belgium.
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pieter E Vos
- Department of Neurology, Singeland Ziekenhuis, Doetinchem, The Netherlands
| | - Hans Bor
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Liège, Belgium; University Hospital of Liège, Liège, Belgium; Belgian Funds for Scientific Research, Belgium
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Waalboog Foundation, Joachim and Anna, Centre for Specialised Geriatric Care, Nijmegen, The Netherlands
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Goudarzi F, Abedi H, Zarea K, Ahmadi F. Multiple Victims: The Result of Caring Patients in Vegetative State. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e23571. [PMID: 26328066 PMCID: PMC4553169 DOI: 10.5812/ircmj.23571] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 09/29/2014] [Accepted: 10/22/2014] [Indexed: 11/16/2022]
Abstract
Background: Having a patient in a vegetative state in the family is a complicated and stressful experience. Caring for such patients with complete disability at home is very challenging. Objectives: The present study aimed to explore the outcomes of caring for patients in a vegetative state for families and caregivers at home. Patients and Methods: In this qualitative study, 16 vegetative patients’ caregivers were selected through purposive sampling. Unstructured interviews and observations were used for data gathering. Data collection was continued until saturation of data and emergence of the main themes. Data analysis was performed by the content analysis method. Results: The analysis of the gathered data led to three themes: “lost main caregiver”, “affected caring partner” and “affected family”. Each theme had some subthemes and subcategories. Conclusions: The three emerged themes in this study showed that all the family members of vegetative patients, depending on their responsibilities, were affected by physical, mental, social and economic issues.
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Affiliation(s)
- Fateme Goudarzi
- Department of Nursing, Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Heidarali Abedi
- Faculty of Nursing and Midwifery, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, IR Iran
- Corresponding Author: Heidarali Abedi, Faculty of Nursing and Midwifery, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, IR Iran. Tel: +98-3135354058, Fax: +98-3135354065, E-mail:
| | - Kourosh Zarea
- Department of Nursing, Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Fazlollah Ahmadi
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran
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Clarke G, Harrison K, Holland A, Kuhn I, Barclay S. How are treatment decisions made about artificial nutrition for individuals at risk of lacking capacity? A systematic literature review. PLoS One 2013; 8:e61475. [PMID: 23613857 PMCID: PMC3628879 DOI: 10.1371/journal.pone.0061475] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 03/10/2013] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Worldwide, the number of individuals lacking the mental capacity to participate in decisions about their own healthcare is increasing. Due to the ageing global population and advancing medical treatments, there are now many more people living longer with neurological disorders, such as dementia, acquired brain injuries, and intellectual disabilities. Many of these individuals have feeding difficulties and may require artificial nutrition. However, little is known about the decision-making process; the evidence base is uncertain and often ethically complex. Using the exemplar of artificial nutrition, the objective of this review is to examine how treatment decisions are made when patients are at risk of lacking capacity. METHODS AND FINDINGS We undertook a systematic review according to PRISMA guidelines to determine who was involved in decisions, and what factors were considered. We searched PubMed, AMED, CINAHL, EMBASE, PsychINFO, and OpenSigle for quantitative and qualitative studies (1990-2011). Citation, reference, hand searches and expert consultation were also undertaken. Data extraction and quality assessment were undertaken independently and in duplicate. We utilised Thomas and Harden's 'Thematic Synthesis' for analysis. Sixty-six studies met inclusion criteria, comprising data from 40 countries and 34,649 patients, carers and clinicians. Six themes emerged: clinical indications were similar across countries but were insufficient alone for determining outcomes; quality of life was the main decision-making factor but its meaning varied; prolonging life was the second most cited factor; patient's wishes were influential but not determinative; families had some influence but were infrequently involved in final recommendations; clinicians often felt conflicted about their roles. CONCLUSIONS When individuals lack mental capacity, decisions must be made on their behalf. Dynamic interactive factors, such as protecting right to life, not unnecessarily prolonging suffering, and individual preferences, need to be addressed and balanced. These findings provide an outline to aid clinical practice and develop decision-making guidelines.
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Affiliation(s)
- Gemma Clarke
- CLAHRC End of Life Care, University of Cambridge, Cambridge, United Kingdom.
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Lavrijsen J, van den Bosch H, Vegter J. Bone fractures in the long-term care of a patient in a vegetative state: A risk to conflicts. Brain Inj 2009; 21:993-6. [PMID: 17729051 DOI: 10.1080/02699050701528447] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE This case report shows how recurrent bone fractures can increase the tension in the relationship between family and caregivers in the long-term care of a patient in a vegetative state (VS). The aim of this report is to prevent conflict situations elsewhere by informing the family in time about the risk of fractures in a situation of severe osteoporosis. RESULTS A second opinion and a density test of the bone contributed to the acceptance of the family of that risk in the daily nursing care, after all adjustments to prevent fractures and to adapt the environment were undertaken. CONCLUSIONS The registration of immobility and the risk of fractures in the problem list is recommended, particularly in the emotional context of the long-term care of a vegetative state. This should be part of the multidisciplinary care plan, in which regular evaluations and communication with family are essential.
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Affiliation(s)
- Jan Lavrijsen
- Nursing Home Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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12
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Lavrijsen JCM, van den Bosch JSG, Koopmans RTCM, van Weel C. Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes. J Neurol Neurosurg Psychiatry 2005; 76:1420-4. [PMID: 16170089 PMCID: PMC1739352 DOI: 10.1136/jnnp.2004.058198] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To establish the prevalence of vegetative state in Dutch nursing homes, describe the patient characteristics, and highlight the possible influence of medical decisions at the end of life. DESIGN A cross-sectional survey. The vegetative state was defined according to the Multi Society Task Force on PVS. All Dutch nursing homes were approached to provide data on patients in a vegetative state. In cases of doubt, the researcher discussed the diagnosis with the patient's physician and, if necessary, examined the patient. Information on patients in a vegetative state in care between 2000 and September 2003 and end of life decisions for them were also recorded. RESULTS All nursing homes and physicians participated. After assessment of 12 doubtful patients, 32 met the criteria of vegetative state lasting longer than one month, a prevalence of 2/1,000,000. Of these, 30 patients' data were analysed: age 9-90 years; 73% female; duration of vegetative state 2 months-20 years (26 surviving >1 year, 13 >5 years). Stroke was the commonest cause. Between 2000 and September 2003, there were 76 patients in a vegetative state in care of whom 34 died of complications and nine after withdrawal of artificial nutrition and hydration. CONCLUSIONS The prevalence of vegetative state in Dutch nursing homes has been established for the first time. The figures are lower than suggested in the literature. The study included a heterogeneous group of patients, of which a substantial number survived for many years. The results cannot be explained by a policy of systematically withdrawing artificial nutrition and hydration.
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Affiliation(s)
- Inez de Beaufort
- Erasmus Medical Center of Erasmus University, Rotterdam, The Netherlands
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