Surrogate decision makers and proxy ownership: challenges of privacy management in health care decision making

Adaptation of the Quality of Communication Questionnaire for Family Members and Its Validity Evidence for Use in Brazil

Assessment of communication between physicians and patients' family members is essential to improving healthcare quality. To adapt the Quality of Communication Questionnaire (QoC) for family members and to analyze its validity evidence for use in Brazil. Data were collected between 2017 and 2019, with family members of patients in intensive care (IC) and palliative care (PC) from five public hospitals in the South Brazil. The QoC was adapted for family members for use in Brazil, and its cross-cultural adaptation was carried out. The clarity and cultural appropriateness of the pre-final version were evaluated by 30 family members of patients in IC. The final version was responded by 198 family members of patients. All items were considered clear, and appropriate to Brazilian culture. The goodness of fit index for proposed model had CFI 0.96 (CI95%: 0.94 - 0.98), TLI 0.95 (CI95%: 0.92 - 0.97), RMSEA 0.07 (CI90%: 0.06 - 0.08), and χ²/df 2.18. Cronbach's alpha coefficient (α) among family members of patients in PC was 0.88 for the general communication (first subscale) and 0.80 for the end-of-life communication (second subscale). However, among family members of patients in IC, α was 0.86 for the first subscale and only 0.53 for the second subscale. The QoC for family members and its cross-cultural adaptation were carried out successfully. It has strong validity evidence among those with loved ones in PC, but only the QoC general communication subscale has strong validity evidence among those with loved ones in IC.

Patient Portals to Support Care Partner Engagement in Adolescent and Adult Populations: A Scoping Review

IMPORTANCE

Family and other unpaid care partners may bridge accessibility challenges in interacting with the patient portal, but the extent and nature of this involvement is not well understood.

OBJECTIVE

To inform an emerging research agenda directed at more purposeful inclusion of care partners within the context of digital health equity by (1) quantifying care partners' uptake and use of the patient portal in adolescent and adult patients, (2) identifying factors involving care partners' portal use across domains of the System Engineering Initiative for Patient Safety model, and (3) assessing evidence of perceived or actual outcomes of care partners' portal use.

EVIDENCE REVIEW

Following Arksey and O'Malley's methodologic framework, a scoping review of manuscripts published February 1 and March 22, 2022, was conducted by hand and a systematic search of PubMed, PsycInfo, Embase, and Web of Science. The search yielded 278 articles; 125 were selected for full-text review and 41 were included.

FINDINGS

Few adult patient portal accounts had 1 or more formally registered care partners (<3% in 7 of 7 articles), but care partners commonly used the portal (8 of 13 contributing articles reported >30% use). Care partners less often authored portal messages with their own identity credentials (<3% of portal messages in 3 of 3 articles) than with patient credentials (20%-60% of portal messages in 3 of 5 articles). Facilitators of care partner portal use included markers of patient vulnerability (13 articles), care partner characteristics (15 articles; being female, family, and competent in health system navigation), and task-based factors pertaining to ease of information access and care coordination. Environmental (26 articles) and process factors (19 articles, eg, organizational portal registration procedures, protection of privacy, and functionality) were identified as influential to care partner portal use, but findings were nuanced and precluded reporting on effects. Care partner portal use was identified as contributing to both patient and care partner insight into patient health (9 articles), activation (7 articles), continuity of care (8 articles), and convenience (6 articles).

CONCLUSIONS AND RELEVANCE

In this scoping review, care partners were found to be infrequently registered for the patient portal and more often engaged in portal use with patient identity credentials. Formally registering care partners for the portal was identified as conferring potential benefits for patients, care partners, and care quality.

Ethical Dilemma: Healthcare Surrogate Refusal of Opioid Administration

It is morally distressing when a healthcare provider sees patients with undertreated pain but is unable to provide adequate relief because of a surrogate's refusal of such treatment. This issue might occur when there is no clear advanced directive that represents patients' wishes for treatment, and can be further complicated when patients are of minority cultural backgrounds. This article presents a case where the surrogate of a Korean-American woman with severe somatic pain from metastatic pancreatic cancer requested only acetaminophen be given to control the patient's pain. The ethical issues associated with surrogate misconceptions on therapeutic use of opioids are reviewed. This case highlights the ethical dilemma of withholding opioid treatment in a patient with advanced cancer. We conclude that the obligation to treat pain should be understood beyond the authority of surrogate refusal, in favor of patient quality of life, when an advance directive is not in place.

Revealing and Receiving Sexual Health Information

This investigation applies communication privacy management theory to examine sexual health disclosures from the perspectives of disclosers and confidants. A Qualtrics survey distributed through Amazon Mechanical Turk yielded 161 participants who disclosed sexual health information to a partner and 130 who received a disclosure. Accounts of the conversations were analyzed with content analysis to describe the linkage rules of the disclosures. Motivation to reveal or conceal, risks and benefits, and gender hypotheses and research questions were ascertained using descriptive statistics and tests of difference. Linkage rules for the majority of participants indicate that disclosures are made in a straightforward style before a sexual episode or on the day of diagnosis. Disclosures were perceived to be of above average quality and resulted in increased relational closeness. Tentative results suggest there may be disclosure differences based on privacy orientation. There were no significant differences based on type of diagnosis or gender.

Enhancing Family-Centered Care in Cardiothoracic Surgery

The psychological impact of critical illness is far reaching, affecting patients and their loved ones. Family members face a multitude of stressors, ranging from concerns about death or permanent disability to stress over health care costs and lost wages. Patients are at risk for developing post-intensive care syndrome. Professional groups and patient safety organizations have crafted family-centered care (FCC) models that support hospitalized patients and their families. There is a paucity of data on use of FCC in cardiothoracic intensive care units. This article discusses FCC models and why they are beneficial to the needs of families of postoperative cardiothoracic surgery patients.

Family Caregivers' Experiences With Health Care Workers in the Care of Older Adults With Activity Limitations

IMPORTANCE

Family and unpaid caregivers often play an active role in managing the care of older adults with activity limitations.

OBJECTIVE

To examine caregivers' experiences with older adults' health care workers.

DESIGN, SETTING, AND PARTICIPANTS

This survey study constitutes a secondary analysis of a sample of 1916 family and unpaid caregivers to 1203 community-living older adults with activity limitations who participated in the 2017 National Health and Aging Trends Study. Data analysis was performed January to August 2019.

EXPOSURES

Caregiver sociodemographic characteristics, caregiving intensity, and frequency speaking with or emailing older adults' health care workers.

MAIN OUTCOMES AND MEASURES

Caregiver-reported experiences when interacting with older adults' health care workers in the prior year, including being listened to, being asked about understanding of treatments, and being asked about help needed in managing older adults' care.

RESULTS

Caregivers (mean [SE] age, 59.4 [0.5] years; 63.7% women) assisting community-living older adults with activity limitations reported that they never (56.3%), sometimes or rarely (33.0%), or often (10.7%) spoke with or emailed older adults' health care workers in the prior year. Most caregivers who interacted with older adults' health care workers reported being always (70.6%) or usually (18.2%) listened to and always (54.4%) or usually (17.7%) being asked about their understanding of older adults' treatments. Fewer caregivers reported being always (21.3%) or usually (6.9%) asked whether they needed help managing older adults' care, and nearly one-half (45.0%) were never asked. Caregivers who interacted with older adults' health care workers often (vs sometimes or rarely) were more likely to report being always or usually listened to (94.8% vs 86.9%; P = .004), being asked about understanding treatments (80.1% vs 69.5%; P = .02), and being asked about needing help (40.8% vs 24.1%; P < .001). No other exposures were consistently associated with caregiver experiences. Measures of caregiving intensity, including caring for an older adult with dementia, were not associated with being listened to or asked about understanding, but were associated with being asked about needed help. Although caregivers of persons with dementia were more likely than caregivers of persons without dementia to report always being asked about needed help (26.9% vs 19.0%), a high percentage in both groups were never asked (41.2% vs 46.5%) (P = .007).

CONCLUSIONS AND RELEVANCE

These findings reinforce the need for strategies to better support family and unpaid caregivers, who are the main source of assistance to older adults with physical and/or cognitive limitations.

"Yes they have the right to know, but…": Young Adult Women Managing Private Health Information as Dependents

This study explored how young adult women manage privacy regarding their health information as dependents on a parent's insurance policy. Under current and proposed health care reform in the United States, young adults between the ages of 18 and 26 years can remain on a parent's policy as a dependent, which can improve young adult's access to health care services. Although dependent expansion provisions can improve coverage for young adults, it may also threaten their privacy by giving a parent access to adult-child's private health information. Using Communication Privacy Management, this study investigated how dependent young adult women conceptualize and negotiate information ownership with parents in a forced disclosure situation. Results revealed young adult women either felt they alone should own and control their health information or believed a parent as the policy hold should have access to the information. However, all preferred to be in control of the disclosure and used core and catalyst criteria to manage the privacy dilemma current health care policy creates. Specifically, the threat of a parent seeing an adult-child used a stigmatized health service motivated young adult women to engage in deception, pay out of pocket for services covered by insurance, and put off or avoid health care. Results of this study complicate assumptions about privacy management and demonstrate how health care policy affects family communication.

An environmental scan of shared access to patient portals

We sought to understand the comprehensiveness of consumer-oriented information describing the availability of shared access to adult patient portals from publicly reported information on institutional websites of 20 large and geographically diverse health systems. All 20 health systems reported that they offer patients the ability to share access to their patient portal account with a family member or friend; however, the comprehensiveness of information regarding registration procedures, features, and terminology varied widely. Half of the systems (n = 10) reported having shared access available on their patient portal registration webpage. Few systems (n = 2) reported affording patients the ability to differentiate specific role-based privileges. No systems reported uptake of shared access among adult patients, which was variably described as "proxy," "caregiver," "parental," or "delegate" access. Findings suggest that engaging families through health information technology will require greater efforts to promote awareness and differentiate privileges that respect patients' choice and control in information-sharing preferences.

The decision partner in healthcare decision-making: A concept analysis

BACKGROUND

The decision partner concept emerged to describe someone who contributes to healthcare decision-making with a patient. There is a need for greater precision and consensus surrounding its conceptual definition and use in broader populations.

OBJECTIVE

To define and describe the decision partner concept within the context of healthcare decision-making.

DESIGN

A concept analysis.

DATA SOURCES

We searched the following databases for articles published between 1990-2017: PsychINFO, PubMed, Embase, and CINAHL. We included qualitative, quantitative, or mixed methods studies that used the term decision partner in the context of healthcare decision-making.

METHODS

We applied the Walker and Avant method to identify the antecedents, attributes, related concepts, consequences, and empirical referents of the concept, with major themes identified.

RESULTS

From the 112 articles included in this concept analysis, 6 defining attributes of decision partner were identified: (1) has a relationship with the patient, (2) demonstrates a willingness to participate in decision-making, (3) articulates a clear understanding of both the patient's health condition and the decisions that must be made, (4) demonstrates decision-making self-efficacy; (5) exemplifies an emotional capacity to participate in decision-making, and (6) willing to fulfill several supportive roles including patient advocate and the "hub of information".

CONCLUSIONS

A unifying definition and discussion of the decision partner concept has been developed. Our findings: (1) offer insights into refining the concept across various diseases and healthcare encounters, (2) contribute to developing theoretical models and empirical research to refine antecedents, attributes, consequences, (3) serve as a foundation to develop instruments to measure the concept and (4) highlight the need to design interventions that include and support decision partners in healthcare decision-making.

The Influence of Everyday Interpersonal Communication on the Medical Encounter: An Extension of Street's Ecological Model

Street's ecological model has shaped the research-examining communication during medical encounters for over a decade. Although the model accounts for the variety of contexts that shape the conversations in which patients and health-care providers engage, the model does not adequately address the way that everyday conversations about health carry over into patient-provider interactions. In this essay, we propose an extension of Street's model that adds the context of everyday communication about health as a contributing factor in the medical encounter. We support the need for this extension by discussing research that points to the ways these conversations with our social network influence communication during the medical encounter and propose new areas for research based on this extension.

"Let him speak:" a descriptive qualitative study of the roles and behaviors of family companions in primary care visits among older adults with cognitive impairment

OBJECTIVE

Cognitive impairment poses communication challenges in primary care. Although family "companions" commonly attend primary care visits of older adults with cognitive impairment, little is known about how their involvement affects communication. Therefore, we sought to understand how companion involvement affects the quality of primary care visit communication for older adults with cognitive impairment.

METHODS

Cross-sectional, descriptive qualitative study participants were as follows: (1) English-speaking adults age 65 or older with mild, moderate, or severe cognitive impairment; (2) family members or other unpaid companions who accompany older adults to primary care visits; and (3) primary care clinicians. Twenty semi-structured and in-depth qualitative interviews of older adults and their companions (N = 20 dyads) and two focus groups (N = 10 primary care clinicians) were conducted. Interviews and focus groups were transcribed and analyzed thematically.

RESULTS

Family companions commonly facilitate communication by advocating for patients, ensuring the accuracy of information exchange and understanding, and preserving rapport. Significant communication challenges were also identified, including patient and companion role ambiguity, competing visit agendas, and primary care clinician confusion regarding the most accurate source of information. Patients, companions, and clinicians each identified strategies to improve communication, chief among them being to identify, differentiate, and respect both patient and companion priorities and perspectives.

CONCLUSIONS

Family companions actively participate in primary care visits of older adults with cognitive impairment in ways that promote and inhibit effective communication. Findings suggest the need for strategies that more effectively and purposefully involve family in the care of primary care patients with cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

Development and Initial Validation of the Caregiver Perceptions About Communication With Clinical Team Members (CAPACITY) Measure

Despite the important role that family caregivers play managing the care of persons with complex health needs, little is known about how caregivers perceive themselves to be recognized and valued by health care professionals. Our objective was to develop and validate a novel measure, the CAregiver Perceptions About CommunIcation with Clinical Team members (CAPACITY) instrument. Questions focus on perceived quality of communication with the health care team and the extent to which caregivers believe that the health care team considers their capacity and preferences in decision making. A confirmatory factor analysis supported a two-factor solution addressing communication and capacity. Internal consistency reliability was .90 for the communication domain and .93 for the capacity domain. Correlations between these two subscales and individual difference measures provided evidence of convergent and discriminant validity. The CAPACITY instrument may be a useful performance measure that quantifies the extent to which caregivers' experience person- and family-centered health care.

Family Communication about End-of-Life Decisions and the Enactment of the Decision-Maker Role

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.

"Taking over somebody's life": Experiences of surrogate decision-makers in the surgical intensive care unit

BACKGROUND

Impaired capacity of patients necessitates the use of surrogates to make decisions on behalf of patients. Little is known about surrogate decision-making in the surgical intensive care unit, where the decline to critical illness is often unexpected. We sought to explore surrogate experiences with decision-making in the surgical intensive care unit.

METHODS

This qualitative study was performed at 2 surgical intensive care units at a single, tertiary, academic hospital Surrogate decision-makers who had made a major medical decision for a patient in the surgical intensive care unit were identified and enrolled prospectively. Semistructured telephone interviews following an interview guide were conducted within 90 days after hospitalization until thematic saturation. Recordings were transcribed, coded inductively, and analyzed utilizing an interpretive phenomenologic approach.

RESULTS

A major theme that emerged from interviews (N = 19) centered on how participants perceived the surrogate role, which is best characterized by 2 archetypes: (1) Preferences Advocates, who focused on patients' values; and (2) Clinical Facilitators, who focused on patients' medical conditions. The primary archetype of each surrogate influenced how they defined their role and approached decisions. Preferences Advocates framed decisions in the context of patients' values, whereas Clinical Facilitators emphasized the importance of clinical information.

CONCLUSION

The experiences of surrogates in the surgical intensive care unit are related to their understanding of what it means to be a surrogate and how they fulfill this role. Future work is needed to identify and manage the informational needs of surrogate decision-makers.

Ethical frameworks for surrogates' end-of-life planning experiences

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.