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Arnfeldt CM, Groenvold M, Johnsen AT, Červ B, Deliens L, Dunleavy L, van der Heide A, Kars MC, Lunder U, Miccinesi G, Pollock K, Rietjens JAC, Seymour J. Development of an advance directive ’communication tool’ relevant for patients with advanced cancer in six European countries: Experiences from the ACTION trial. PLoS One 2022; 17:e0271919. [PMID: 35901043 PMCID: PMC9333298 DOI: 10.1371/journal.pone.0271919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 07/08/2022] [Indexed: 11/19/2022] Open
Abstract
Background The ACTION trial evaluated the effect of a modified version of the Respecting Choices´ advance care planning programme in patients with advanced cancer in six European countries. For this purpose, an advance directive acceptable for all six ACTION countries to be used for documenting the wishes and preferences of patients and as a communication tool between patients, their caregivers and healthcare staff, was needed. Aim To describe the development of a multinational cancer specific advance directive, the ´My Preferences form´, which was first based on the 2005 Wisconsin ‘Physician Orders of Life Sustaining Treatment´ Form, to be used within the ACTION trial. Methods Framework analysis of all textual data produced by members of the international project team during the development of the ACTION advance directives (e.g. drafts, emails, meeting minutes…). Setting/participants ACTION consortium members (N = 28) with input from clinicians from participating hospitals (N = 13) and ´facilitators´ (N = 8) who were going to deliver the intervention. Results Ten versions of the ACTION advance directive, the ´My Preferences form´, were developed and circulated within the ACTION consortium. Extensive modifications took place; removal, addition, modification of themes and modification of clinical to lay terminology. The result was a thematically comprehensive advance directive to be used as a communication tool across the six European countries within the ACTION trial. Conclusion This article shows the complex task of developing an advance directive suitable for cancer patients from six European countries; a process which required the resolution of several cross cultural differences in law, ethics, philosophy and practice. Our hope is that this paper can contribute to a deeper conceptual understanding of advance directives, their role in supporting decision making among patients approaching the end of life and be an inspiration to others wishing to develop a disease-specific advance directive or a standardised multinational advance directive.
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Affiliation(s)
- Caroline Moeller Arnfeldt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Palliative Care Research Unit, Department of Geriatrics and Palliative Medicine (GP), Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Palliative Care Research Unit, Department of Geriatrics and Palliative Medicine (GP), Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anna Thit Johnsen
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Branka Červ
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Ixelles, Belgium
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
| | | | - Marijke C. Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Urška Lunder
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Guido Miccinesi
- Center for Oncological Network, Study and Prevention of Cancer (ISPRO), Florence, Italy
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | | | - Jane Seymour
- Division of Nursing and Midwifery, Health Sciences School, University of Sheffield, Sheffield, United Kingdom
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Mosleh S, Alnajar M, Almalik MM. Nurses' perceived knowledge and benefits of artificial nutrition and hydration for patients nearing death: A survey among Jordanian nurses. Eur J Cancer Care (Engl) 2021; 30:e13394. [PMID: 33386666 DOI: 10.1111/ecc.13394] [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: 10/20/2019] [Revised: 07/23/2020] [Accepted: 11/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Existing research highlights the importance of nurses' knowledge and attitudes towards the provision of artificial nutrition and hydration (ANH) for patients with advanced cancer; however, the perspectives of Arabic and Islamic nurses have not yet been investigated. Therefore, we aimed to examine Jordanian nurses' knowledge, attitudes and perceived benefits in providing ANH for patients with advanced cancer. METHOD A descriptive cross-sectional design was employed. RESULTS Participants comprised 183 nurses (93.5% response rate). Around 80% received no training on ANH. Nurses had poor knowledge regarding ANH, with a mean score of 5.12 (SD=2.27) out of 15. Overall, nurses had positive attitudes towards ANH care (M = 3.09, SD = 0.29); however, the subscale analysis showed that nurses held inconspicuous beliefs about ANH benefits (M = 2.67, SD = 0.71) and strongly believed that ANH places a high burden on patients (M = 3.50, SD = 0.69). Nurses from government hospitals showed significantly higher ANH knowledge, as well as positive beliefs regarding ANH benefits, compared to less educated nurses. CONCLUSION Jordanian nurses have limited knowledge of ANH. Their positive attitude regarding ANH for terminally ill patients could be driven by cultural norms and beliefs, rather than education. Introducing ANH in nursing curricula and in-hospital services could have a positive impact on nurses' knowledge.
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Affiliation(s)
- Sultan Mosleh
- Faculty of Nursing, University of Mutah, AlKarak, Jordan.,Health Sciences Division, Higher Collages of Technology, United Arab Emirates
| | - Malek Alnajar
- Health Sciences Division, Higher Collages of Technology, United Arab Emirates
| | - Mona M Almalik
- Faculty of Nursing, University of Mutah, AlKarak, Jordan.,Health Sciences Division, Higher Collages of Technology, United Arab Emirates
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Anantapong K, Davies N, Chan J, McInnerney D, Sampson EL. Mapping and understanding the decision-making process for providing nutrition and hydration to people living with dementia: a systematic review. BMC Geriatr 2020; 20:520. [PMID: 33267831 PMCID: PMC7709405 DOI: 10.1186/s12877-020-01931-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/25/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This systematic review aimed to explore the process of decision-making for nutrition and hydration for people living with dementia from the perspectives and experiences of all involved. METHODS We searched CINAHL, the Cochrane Library, EMBASE, MEDLINE and PsycINFO databases. Search terms were related to dementia, decision-making, nutrition and hydration. Qualitative, quantitative and case studies that focused on decision-making about nutrition and hydration for people living with dementia were included. The CASP and Murad tools were used to appraise the quality of included studies. Data extraction was guided by the Interprofessional Shared Decision Making (IP-SDM) model. We conducted a narrative synthesis using thematic analysis. PROSPERO registration number CRD42019131497. RESULTS Forty-five studies were included (20 qualitative, 15 quantitative and 10 case studies), comprising data from 17 countries and 6020 patients, family caregivers and practitioners. The studies covered a range of decisions from managing oral feeding to the use of tube feeding. We found that decisions about nutrition and hydration for people living with dementia were generally too complex to be mapped onto the precise linear steps of the existing decision-making model. Decision-making processes around feeding for people living with dementia were largely influenced by medical evidence, personal values, cultures and organizational routine. Although the process involved multiple people, family caregivers and non-physician practitioners were often excluded in making a final decision. Upon disagreement, nutrition interventions were sometimes delivered with conflicting feelings concealed by family caregivers or practitioners. Most conflicts and negative feelings were resolved by good relationship, honest communication, multidisciplinary team meetings and renegotiation. CONCLUSIONS The decision-making process regarding nutrition and hydration for people living with dementia does not follow a linear process. It needs an informed, value-sensitive, and collaborative process. However, it often characterized by unclear procedures and with a lack of support. Decisional support is needed and should be approached in a shared and stepwise manner.
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Affiliation(s)
- Kanthee Anantapong
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.
- Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand.
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Justin Chan
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Daisy McInnerney
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, Sterling Way, London, UK
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Albanesi B, Marchetti A, D'Angelo D, Capuzzo MT, Mastroianni C, Artico M, Lusignani M, Piredda M, De Marinis MG. Exploring Nurses’ Involvement in Artificial Nutrition and Hydration at the End of Life: A Scoping Review. JPEN J Parenter Enteral Nutr 2020; 44:1220-1233. [DOI: 10.1002/jpen.1772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 12/10/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Beatrice Albanesi
- Department of Biomedicine and Prevention University of Rome “Tor Vergata Rome Italy
| | - Anna Marchetti
- Department of Biomedicine and Prevention University of Rome “Tor Vergata Rome Italy
| | - Daniela D'Angelo
- CNEC Center for Clinical Excellence and Quality of Care Istituto Superiore di Sanità Rome Italy
| | | | | | - Marco Artico
- Palliative Care and Pain Therapy Unit Azienda ULSS 4 Veneto Orientale San Donà di Piave Italy
| | - Maura Lusignani
- Biomedical Sciences for Health University of Milan Milan Italy
| | - Michela Piredda
- Research Unit Nursing Science Campus Bio‐Medico di Roma University Rome Italy
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Albanesi B, Marchetti A, Facchinetti G, Clari M, Dellafiore F, Piervisani L, Lusignani M, De Marinis MG, Piredda M. Cross-cultural adaptation and validation of questionnaire for knowledge, attitudes, and behavioral intentions in Italian nurses with regard to provision of artificial nutrition and hydration to patients terminally ill with cancer. Nutrition 2019; 72:110655. [PMID: 31918050 DOI: 10.1016/j.nut.2019.110655] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 09/20/2019] [Accepted: 11/02/2019] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Decision-making on artificial nutrition and hydration for patients terminally ill with cancer can be influenced by nurses' knowledge, attitudes, and behavioral intentions. A comprehensive 57-item questionnaire including six sections on the knowledge, attitudes, and behavioral intentions in providing artificial nutrition and hydration to patients terminally ill with cancer has been developed and used in Taiwan. However, the questionnaire needs further psychometric testing and adaptation for other cultures. This study aimed to cross-culturally adapt the questionnaire within the Italian cultural context and test its psychometric properties. METHODS The questionnaire was translated into Italian and cross-culturally adapted per the recommendations by Beaton. A panel of 10 experts assessed content validity. A multicenter cross-sectional study was conducted with 411 nurses to test its psychometric properties. Dimensionality and construct validity were assessed through exploratory and confirmatory factor analyses. Reliability was estimated by composite ω and traditional methods, such as the Kuder Richardson formula-20 and Cronbach's α coefficients. RESULTS The overall content validity index was 0.85. A confirmatory factor analysis was conducted for the knowledge section and the four attitudes sections. A preliminary analysis for the behavioral intentions section yielded non acceptable results. The internal consistency of the scales was adequate (range, 0.64-0.93). CONCLUSIONS This study constituted a notable advancement in the psychometric testing of the tool, and provides evidence that the Italian version of the questionnaire has acceptable psychometric characteristics for the sections on knowledge and attitudes.
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Affiliation(s)
- Beatrice Albanesi
- Department of Biomedicine and Prevention University of Rome 'Tor Vergata', Rome, Italy
| | - Anna Marchetti
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, Rome, Italy
| | - Gabriella Facchinetti
- Department of Biomedicine and Prevention University of Rome 'Tor Vergata', Rome, Italy
| | - Marco Clari
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Federica Dellafiore
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Loredana Piervisani
- Department of Biomedicine and Prevention University of Rome 'Tor Vergata', Rome, Italy
| | - Maura Lusignani
- Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | - Michela Piredda
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, Rome, Italy.
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Douglas JW, Lawrence JC, Turner LW, Knol LL, Ellis AC. Practitioner Knowledge, Personal Values, and Work Setting Influence Registered Dietitians' Feeding Tube Recommendations for Patients With Advanced Dementia. Nutr Clin Pract 2019; 35:634-641. [PMID: 30729569 DOI: 10.1002/ncp.10255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Current guidelines discourage tube-feeding older adults with advanced dementia (AD), as this practice does not improve nutrition status or survival and decreases quality of life in these patients. Because registered dietitians (RDs) often provide feeding recommendations for patients with AD, this study aimed to identify factors that influenced RDs' feeding tube recommendations for older adults with AD. METHODS A random sample of RDs who work with older adults in the United States completed a validated, electronic survey. Logistic regression analysis was used to identify factors related to the likelihood of RDs recommending a feeding tube for patients with AD. Independent variables included participant demographics and the 6 subscales of the Attitudes Toward Tube-Feeding in Advanced Dementia Questionnaire, which measured individual and environmental influences on RDs' recommendations. RESULTS Among the 662 RDs who responded, 72.2% were unlikely to recommend a feeding tube in patients with AD, and 15.4% were likely to do so (with the remaining being "neutral"). Factors associated with avoiding recommending a feeding tube include significantly higher total knowledge [odds ratio (OR) = 1.47, 95% CI (1.30, 1.66)] and personal values scores [OR = 7.51, 95% CI (3.96, 14.24)] and employment in long-term care settings [OR 3.29, 95% CI (1.38, 7.80)]. CONCLUSION In this survey, most RDs were likely to make recommendations that are consistent with current guidelines for tube feeding patients with AD. RDs who work outside the long-term care setting may benefit from additional training. Future research is needed to understand how personal values may influence recommendations.
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Affiliation(s)
- Joy W Douglas
- Department of Human Nutrition and Hospitality Management , Tuscaloosa, Alabama, USA
| | - Jeannine C Lawrence
- Department of Human Nutrition and Hospitality Management , Tuscaloosa, Alabama, USA
| | - Lori W Turner
- Department of Health Science, University of Alabama, Tuscaloosa, Alabama, USA
| | - Linda L Knol
- Department of Human Nutrition and Hospitality Management , Tuscaloosa, Alabama, USA
| | - Amy C Ellis
- Department of Human Nutrition and Hospitality Management , Tuscaloosa, Alabama, USA
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Douglas JW, Turner LW, Knol LL, Ellis AC, Godfrey AC, Lawrence JC. The Attitudes Toward Tube-Feeding in Advanced Dementia (ATT-FAD) Questionnaire: A Valid and Reliable Tool. J Nutr Gerontol Geriatr 2018; 37:183-203. [PMID: 30513275 DOI: 10.1080/21551197.2018.1518797] [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: 10/27/2022]
Abstract
Registered Dietitians (RDs) should participate in interdisciplinary feeding discussions for patients with advanced dementia, but research on how RDs make such feeding recommendations is scarce. This study developed and validated a theory-based questionnaire to assess the knowledge, beliefs, and attitudes of RDs regarding feeding tube use among older adults with advanced dementia. The instrument was drafted based on the Social Ecological Model, and face and content validity were established through an expert panel review. Pilot testing with 70 RDs provided an initial measure of internal consistency reliability and reduced the number of items in the survey. Efficacy testing with 662 RDs allowed for a second analysis of internal consistency reliability and eliminated additional items. Construct validity was then established using validation by extreme groups and exploratory factor analysis, yielding six subscales, each with adequate internal consistency and test-retest correlation coefficients: (I) Total Knowledge, (II) Knowledge Self-Efficacy, (III) Religion/Spirituality/Culture, (IV) Personal Values, (V) Perceived Organization and Training, and (VI) Perceived Policy. The survey, based on the Social Ecological Model, was deemed a valid and reliable tool to assess RDs' knowledge and attitudes regarding feeding tube use among older adults with advanced dementia.
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Affiliation(s)
- Joy W Douglas
- a Department of Human Nutrition and Hospitality Management , The University of Alabama , Tuscaloosa , AL , USA
| | - Lori W Turner
- b Department of Health Science , The University of Alabama , Tuscaloosa , AL , USA
| | - Linda L Knol
- a Department of Human Nutrition and Hospitality Management , The University of Alabama , Tuscaloosa , AL , USA
| | - Amy C Ellis
- a Department of Human Nutrition and Hospitality Management , The University of Alabama , Tuscaloosa , AL , USA
| | - Ann C Godfrey
- c Department of Educational Studies in Psychology, Research Methodology, and Counseling (ESPRMC) , The University of Alabama , Tuscaloosa , AL , USA
| | - Jeannine C Lawrence
- a Department of Human Nutrition and Hospitality Management , The University of Alabama , Tuscaloosa , AL , USA
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van der Steen JT, Di Giulio P, Giunco F, Monti M, Gentile S, Villani D, Finetti S, Pettenati F, Charrier L, Toscani F. Pneumonia in Nursing Home Patients With Advanced Dementia: Decisions, Intravenous Rehydration Therapy, and Discomfort. Am J Hosp Palliat Care 2017; 35:423-430. [PMID: 28532225 PMCID: PMC5794105 DOI: 10.1177/1049909117709002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Comfort may be an appropriate goal in advanced dementia. Longitudinal studies on physician decision-making and discomfort assessed by direct observation are rare, and intravenous rehydration therapy is controversial. METHODS To assess treatment decisions and discomfort in patients with advanced dementia and pneumonia and to compare by intravenous rehydration therapy, we used data from the observational multicenter Italian End of Life Observatory-Prospective Study On DEmentia patients Care. We analyzed 109 episodes of pneumonia, which involved decisions in 77 nursing home patients with Functional Assessment Staging Tool stage 7. We assessed decisions, decision-making, and treatments every fortnight. Trained observers assessed discomfort with the Discomfort Scale-Dementia Alzheimer Type (DS-DAT). RESULTS Most decisions referred to treatment with antibiotics (90%; 98 of 109) and intravenous rehydration therapy (53%; 58 of 109), but hospitalization was rare (1%). Selecting decisions with antibiotics, with rehydration therapy, the prognosis was more frequently <15 days (34% vs 5% without rehydration therapy; P = .001), and a goal to reduce symptoms/suffering was more common (96% vs 74%; P = .005) while there was no difference in striving for life prolongation (a minority). With rehydration therapy, the decision was more often discussed with family rather than communicated only. Mean DS-DAT scores over time proximate to the first decision ranged between 9.2 and 10.5. CONCLUSIONS Italian nursing home patients with advanced dementia and pneumonia frequently received invasive rehydration therapy in addition to antibiotics, however, mostly with a palliative intent. Discomfort was high overall and symptom relief may be improved. Relations between invasive rehydration therapy and discomfort need further study.
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Affiliation(s)
- Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands
- Jenny T. van der Steen, PhD, Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, PO Box 9600, 2300 RC Leiden, the Netherlands.
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
- IRCCS Mario Negri Institute, Milano, Italy
| | - Fabrizio Giunco
- Istituto “L. Palazzolo”–Fondazione Don Gnocchi, Milano, Italy
| | - Massimo Monti
- Geriatric Institute “Pio Albergo Trivulzio”–Milano, Italy
| | - Simona Gentile
- Rehabilitation and Alzheimer’s Disease Evaluation Unit, “Ancelle della Carità” Hospital, Cremona, Italy
| | - Daniele Villani
- Neurorehabilitation and Alzheimer’s Disease Evaluation Unit, “Figlie di San Camillo” Hospital, Cremona, Italy
| | - Silvia Finetti
- Lino Maestroni Foundation–Palliative Medicine Research Institute, Cremona, Italy
| | - Francesca Pettenati
- Lino Maestroni Foundation–Palliative Medicine Research Institute, Cremona, Italy
| | - Lorena Charrier
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Franco Toscani
- Lino Maestroni Foundation–Palliative Medicine Research Institute, Cremona, Italy
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Forbat L, Kunicki N, Chapman M, Lovell C. How and why are subcutaneous fluids administered in an advanced illness population: a systematic review. J Clin Nurs 2017; 26:1204-1216. [PMID: 27982484 DOI: 10.1111/jocn.13683] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To identify the mechanisms of subcutaneous fluid administration in advanced illness. BACKGROUND Hydration at end of life is a fundamental issue in quality care internationally. Decision-making regarding the provision of artificial hydration in advanced illness is complicated by a paucity of evidence-based guidance. Despite considerable attention given to the topic including two recent Cochrane reviews, there has been no focus in systematically identifying papers that report the mechanisms for delivering hydration subcutaneously. Consequently, there is a need to produce guidance on the site, mode, volume and rate of infusion, based on empirical evidence. DESIGN Systematic review of papers reporting empirical research data. METHODS Key databases (CENTRAL, Medline, EMBASE, Web of Science, CINAHL) were searched in September 2015, with no date limitations. Inclusion criteria focused on hypodermoclysis in adults within an advanced illness population. Selected studies were reviewed for quality and a risk-of-bias assessment was conducted for the included studies. RESULTS Fourteen papers were included in the analysis; most (n = 8) were conducted in hospices with others (n = 6) in long-stay units with a population affected by chronic conditions associated with ageing. Studies were of moderate or high quality. The site and mode of infusion were not well described in these papers, and rates of infusion varied widely allowing for little clear consensus to guide clinical practice in the administration of subcutaneous fluids. CONCLUSIONS Studies under-report the mechanisms by which artificial hydration is provided, creating a paucity of evidence-based guidance by which to practice. There is a need for evidence generated from nonmalignant populations to ensure applicability to the large number of people with other advanced illness. RELEVANCE TO CLINICAL PRACTICE In the absence of sufficiently powered robust evidence, the mode of delivery of artificial hydration at end of life remains in the gloaming between evidence and unfounded habit.
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Affiliation(s)
- Liz Forbat
- Centre of Palliative Care Research, Calvary Health Care and Australian Catholic University, Canberra, ACT, Australia
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Douglas JW, Lawrence JC, Turner LW. Social Ecological Perspectives of Tube-Feeding Older Adults with Advanced Dementia: A Systematic Literature Review. J Nutr Gerontol Geriatr 2017; 36:1-17. [PMID: 28140779 DOI: 10.1080/21551197.2016.1277174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Dementia is a progressive, debilitating disease that often results in weight loss, malnutrition, and dehydration. Feeding tubes are often prescribed; however, this practice can lead to complications. The purpose of this systematic review was to examine the use of feeding tubes in elderly demented patients from a social ecological perspective. Results indicated that family members often receive inadequate decision-making education. Many health care professionals lack knowledge of evidence-based guidelines pertaining to feeding tube use. Organizational and financial reimbursement structures influence feeding tube use. Feeding practices for patients with advanced dementia is a complex issue, warranting approaches that target each level of the Social Ecological Model.
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Affiliation(s)
- Joy W Douglas
- a Department of Human Nutrition and Hospitality Management , The University of Alabama , Tuscaloosa , Alabama , USA
| | - Jeannine C Lawrence
- a Department of Human Nutrition and Hospitality Management , The University of Alabama , Tuscaloosa , Alabama , USA
| | - Lori W Turner
- b College of Human Environmental Sciences , The University of Alabama , Tuscaloosa , Alabama , USA
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Hanson E, Hellström A, Sandvide Å, Jackson GA, MacRae R, Waugh A, Abreu W, Tolson D. The extended palliative phase of dementia – An integrative literature review. DEMENTIA 2016; 18:108-134. [PMID: 27460046 DOI: 10.1177/1471301216659797] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article presents an integrative literature review of the experience of dementia care associated with the extended palliative phase of dementia. The aim was to highlight how dementia is defined in the literature and describe what is known about the symptomatology and management of advanced dementia regarding the needs and preferences of the person with dementia and their family carer/s. There was no consistent definition of advanced dementia. The extended palliative phase was generally synonymous with end-of-life care. Advanced care planning is purported to enable professionals to work together with people with dementia and their families. A lack of understanding of palliative care among frontline practitioners was related to a dearth of educational opportunities in advanced dementia care. There are few robust concepts and theories that embrace living the best life possible during the later stages of dementia. These findings informed our subsequent work around the concept, ‘Dementia Palliare’.
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Affiliation(s)
- Elizabeth Hanson
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Amanda Hellström
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Åsa Sandvide
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
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12
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Pengo V, Zurlo A, Voci A, Valentini E, De Zaiacomo F, Catarini M, Iasevoli M, Maggi S, Pegoraro R, Manzato E, Giantin V. Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies. Geriatr Gerontol Int 2016; 17:487-493. [PMID: 27004847 DOI: 10.1111/ggi.12746] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/23/2015] [Accepted: 12/22/2015] [Indexed: 11/30/2022]
Abstract
AIM The aim of the present study was to investigate the proportion of physicians and nurses who agree with the administration of antibiotic therapy (AT), artificial hydration (AH), and artificial nutrition (AN) in patients with advanced dementia and different life expectancies. Furthermore, we aimed at analyzing the correlates of the opinion according to which medical treatments should no longer be given to advanced dementia patients once their life expectancy falls. METHODS End-of-life decisions and opinions were measured with a questionnaire that was sent to geriatric units, hospices and nursing homes in three different regions of Italy. Multivariate logistic regressions were carried out to ascertain the correlates of the agreement with the administration of AH, AT or AN. RESULTS When the patient's life expectancy was 1-6 months, 83% of respondents agreed with AH, 79% with AT and 71% with AN. When the life expectancy was less than 1 month, a large proportion of respondents still agreed with AH and AT (73% and 61%), whereas less than one in two respondents (48%) agreed with AN. CONCLUSIONS The findings of the present study showed that AN creates more ethical dilemmas in the clinical management of end of life than other treatments, such as AH or AT. Opinions on whether or not these practices are appropriate at the end of life were related with feelings, thoughts and ethical issues that played a different part for physicians and nurses. Geriatr Gerontol Int 2017; 17: 487-493.
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Affiliation(s)
- Valentina Pengo
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
| | - Anna Zurlo
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
| | - Alberto Voci
- Department of Philosophy, Sociology, Education and Applied Psychology, University of Padova, Padova, Italy
| | - Elisabetta Valentini
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
| | | | | | - Mario Iasevoli
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
| | - Stefania Maggi
- Aging Section, Institute of Neurosciences, Italian Research Council, Padova, Italy
| | | | - Enzo Manzato
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy.,Aging Section, Institute of Neurosciences, Italian Research Council, Padova, Italy
| | - Valter Giantin
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
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Critical decisions for older people with advanced dementia: a prospective study in long-term institutions and district home care. J Am Med Dir Assoc 2015; 16:535.e13-20. [PMID: 25843621 DOI: 10.1016/j.jamda.2015.02.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 02/16/2015] [Accepted: 02/16/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe and compare the decisions critical for survival or quality of life [critical decisions (CDs)] made for patients with advanced dementia in nursing homes (NHs) and home care (HC) services. DESIGN Prospective cohort study with a follow-up of 6 months. SETTING Lombardy Region (NHs) and Reggio-Emilia and Modena Districts (HC), Italy. PARTICIPANTS Patients (496 total; 315 in NHs and 181 in HC) with advanced dementia (Functional Assessment Staging Tool score ≥ 7) and expected survival ≥ 2 weeks. MEASUREMENTS At baseline, the patients' demographic data, date of admission and of dementia diagnosis, type of dementia, main comorbidities, presence of pressure sores, ongoing treatments, and current prescriptions were abstracted from clinical records. At baseline and every 15 days thereafter, information regarding the patients' general condition and CDs (deemed critical by the doctor or team) was collected by an interview with the doctor. For each CD, the physician reported the problem that led to the decision, that was eventually made, the purpose of the decision, whether the decision had been discussed with and/or communicated to the family, who made the final decision, whether the decision was maintained after 1 week, whether it corresponded to what the doctor would have judged appropriate, and the expected survival of the patient (≤ 15 days). RESULTS For 267 of the 496 patients (53.8%; 60.3% in NHs and 42.5% at home), 644 CDs were made; for 95 patients, more than 1 CD was made. The problems that led to a CD were mainly infections (respiratory tract and other infections; 46.6%, 300/644 CDs); nutritional/hydration problems (20.6%; 133 CDs); and the worsening of a pre-existing disease (9.3%; 60 CDs). The most frequent type of decision concerned the prescription of antibiotics (overall 41.1%, 265/644; among NH patients 44.6%, 218/488; among HC patients, 30.2%, 47/156). The decision to hospitalize the patient was more frequently reported for HC than NH patients (25.5% vs 3.1%). The most frequent purposes of the CDs in both settings were reducing symptoms or suffering (more so in NHs; 81.1% vs 57.0% in HC) and prolonging survival (NH 27.5%; HC 23.1%; multiple purposes were possible). For 26 decisions (3.8%), the purpose was to ease death or not to prolong life. CONCLUSIONS Decisions critical for the survival or quality of life of patients with advanced dementia were made for approximately one-half of the patients during a 6-month time frame, and such decisions were made more frequently in NHs than in HC. HC patients were more frequently hospitalized, and a sizeable minority of these patients were treated with the goal of prolonging survival. Italian patients with advanced dementia may benefit from the implementation of palliative care principles, and HC patients may benefit from the implementation of measures to avoid hospitalizing patients near the end of life.
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