Ethical concerns of family caregivers to dementia patients

Ethical Concerns of Patients and Family Members Arising During Illness or Medical Care

Patients and family members (N = 671) were surveyed in five Mid-Atlantic U.S. hospitals to ascertain the number and kinds of ethical concerns they are presently experiencing or have previously experienced while being sick or receiving medical care. Seventy percent of participants had at least one (range 0-14) type of ethical concern or question. The most commonly experienced concerns pertained to being unsure how to plan ahead or complete an advance directive (29.4%), being unsure whether someone in the family was able to make their own decisions (29.2%), deciding about limiting life-sustaining treatments (28.6%), wondering about disclosing personal medical information to others in the family (26.4%) and not being sure whether to undergo treatment because of cost (26.2%). Most were interested to some degree in getting help from ethics consultants in the future (76.6%). Given this prevalence, common concerns might usefully be addressed systematically, rather than exclusively on a case-by-case basis.

Dementia and Ethics: The Views of Informal Carers

There has been little work on the ethical issues facing non-professionals who care for relatives or others with dementia. A qualitative pilot study was conducted in ten such individuals, eight of them women, caring for persons drawn mainly from one general practice. The interviews indicated that many of the dilemmas faced by carers are ethical and that the issues differ from those faced by professionals. Ethical issues are sometimes the most troublesome matter for carers. Unlike issues for professionals, they arise from a personal context and are shaped by long-term relationships.

Hopeful care for people with dementia

This study explores the notion of hopeful care and suggests that adult day care can support hope in people with dementia and their families. It evaluates how program services might contribute to the delivery of hopeful care. Data were analyzedfrom a sample of 175 pairs of people with dementia and theirfamily caregiversfrom 10 adult day centers who participated in the Robert Wood Johnson Foundation's Dementia Care and Respite Services program. Results of multivariate regressions indicate that variations in the way adult day services are operationalized appear to influence care receiver and caregiver outcomes theoretically linked to hopeful care.

The Shift in Existential Life Situations of Adult Children to Parents with Dementia Relocated to Nursing Homes

BACKGROUND

Previous research describes spouses and adult children of people with dementia as a homogeneous group using one term: family caregivers. Recent research shows that the needs and experiences of spouses and adult children differ, therefore they cannot be studied as a homogeneous group.

AIMS

The aim of the study was to describe the shift in existential life situations of adult children of a parent with dementia relocated to nursing homes.

DESIGN

This is a qualitative study with an interpretive approach.

METHODS

Face-to-face interviews were held with 11 adult children aged 48-65 years. The interviews lasted 30-60 minutes and data were analysed using interpretive content analysis.

FINDINGS

The adult children described how they experienced their life situation before and after their parents' relocation. Before relocation they described feelings of powerlessness, loneliness in their responsibilities, loss and guilt. After relocation they had feelings of freedom, ongoing responsibility, living with loss and having a new relationship with death.

CONCLUSION

The most important finding in our study was that adult children developed a different relationship with death than before the parent became affected by dementia. It is essential that healthcare staff understand and address the adult children's existential life situations and the suffering they are experiencing. Healthcare staff need to be conscious about adult children's needs for support to address their existential life situations before and after their parents relocate to nursing homes.

The Philosophical Foundation of Empowerment

Empowerment of the elderly within the health care system is a concept increasingly discussed in clinical and policy-making contexts. An examination of its current expressions and underlying philosophical principles reveals four different interpretations: empowerment as political activism and social process, empowerment as effective deliberation and moral reflection, empowerment as personal process. and empowerment as balance and interdependence. How empowerment is defined and expressed has distinct implications for the practitioner. who must be sensitive to tile underlying value conflicts that are at the core of decision making in the clinical or the public policy setting.

Searches for a Nursing Home: Personal and Situational Factors

Telephone and follow-up in-depth interviews were used to gather information from 25 sponsors (primary contact people or responsible parties) of nursing home residents to learn more about the nursing home search and selection process. Quantitative analyses revealed that sponsors who engaged in anticipatory action prior to the need for nursing home placement had lower personal competence scores than those sponsors who did not anticipate the need for nursing home care. As might be expected, sponsors who were involved in time-pressured searches had the highest stress scores. In-depth analyses of the qualitative data illuminated the diverse ways in which the situational factors (time-pressured versus non-time-pressured searches and antici patory versus nonanticipatory behavior) affected the personal factors (perceived competence and stress) to create idiosyncratic experiences for the sponsors. The findings show the value of offering professional assistance to individuals who are at the stage of seeking information about nursing homes.

Autonomy, Personal Empowerment, and Quality of Life in Long-Term Care

The philosophical principle of autonomy provides a conceptual framework within which an understanding of quality of life for the elderly can be developed. This structure provides the basis for designing interventions to enhance the quality of life of older persons by maintaining their autonomy in spite of long-term care service needs. Such programs should encourage proactive strategies to anticipate and plan for potential health crises, promote empowerment of the elderly, expand knowledge, and clarify personal and familial values regarding service options. Examples of the kinds of programs needed to enhance autonomy in community-based and institutional long-term care settings are presented to illustrate how independence can be supported even under conditions of increasing frailty and service needs. These applied approaches to enhancing personal autonomy give explicit recognition to the importance of ethical concepts in developing and implementing long-term care services to improve the elderly's quality of life.

Older adults' evaluations of middle-aged children's attempts to initiate discussion of care needs

We explored how older adults evaluated the strategies used by an adult child to initiate discussion of future care needs, and subsequently, whether these judgments affected older adults' willingness to engage in discussions about eldercare if approached in a similar fashion by one of their own children. One hundred and thirty older adults were randomly assigned to read one of four scripts depicting efforts by a middle-aged daughter to raise the topic of future care needs with her mother by implementing a variety of facework behaviors. Scripts manipulated the degree to which the daughter conveyed respect for her mother's desires for autonomy (negative face) and connection (positive face). The daughter's facework significantly predicted older parents' evaluation of her as supportive, which in turn predicted their willingness to discuss future care needs with one of their own children if they were to approach the conversation in a similar way.

Attitudes toward decision making and aging, and preparation for future care needs

Adult children are the primary source of informal eldercare in the United States. Unfortunately, however, families rarely prepare for an aging parent's future care needs. This is problematic, as advance preparation may reduce depression and anxiety in older adults and be helpful for adult children. Given the importance of preparation prior to parental dependency, we examined factors associated with preparation for caregiving. Using survey methodology, we studied 2 groups of people: Functionally independent parents at least 60 years of age, and adult children at least 40 years of age. Several variables appeared to be associated with awareness of care needs, gathering information, and discussion of possible care arrangements. Most notably, attitudes regarding shared autonomy and aging anxiety were positively associated with each of these stages of preparation. Other findings suggest that being concerned about possible negative effects of caregiving and perceiving the future as limited may also be associated with preparation for caregiving. The results provide gerontologists, interventionists, and families with insight into attitudes that may inhibit or facilitate preparation for future caregiving needs.

Ethics and dementia: mapping the literature by bibliometric analysis

OBJECTIVES

This paper reports on a bibliometric analysis of keywords in the literature on ethics and dementia during the period 1980-2000.

METHODS

Keywords were drawn from titles, abstracts and keyword fields of 14 bibliographic databases and clustered in to 19 categories. These categories were then examined for their frequency and co-occurrences. The strength of relationships between these categories is mapped using the metaphor of the 'night sky' showing constellations of issues and changes over time.

RESULTS

Four categories appear consistently and frequently in the literature: professional care, end-of-life issues, decision-making and treatment. Other issues come and go (such as quality-of-life issues) while others appear to respond to outside events (e.g. feeding issues). The research literature is based predominantly on surveys or studies soliciting responses to predefined issues. Little research has been undertaken to establish the range of ethical issues for either family members or professionals.

DISCUSSION

We discuss the domination of the literature by four categories of ethical issues, the new and emerging areas of ethical interest and those areas that are triggered by external events such as legal cases. We also discuss some of the limitations of the study and note some omissions in the literature.

CONCLUSION

During the period 1980-2000 the research literature has been dominated by surveys and studies soliciting views on predefined issues with relatively few in-depth, open-ended qualitative studies.

Ethical issues in family care of older persons with dementia: implications for family therapists

Despite a considerable literature on family care of the elderly, comparatively little attention has been devoted to the ethical dimensions of caring for frail and dependent older family members. Nor is there an extensive literature available to guide family therapists or others in the helping professions who work with families experiencing ethical dilemmas and issues associated with caring for elderly loved ones. The purpose of this paper is to highlight some of the ethical dilemmas families face in caring for an elderly loved one, and to identify several ethical principles that can be used to address these dilemmas. There is an explicit focus on families caring for aged parents afflicted with a dementia such as Alzheimer's disease.

Dementia and ethics: the views of informal carers

There has been little work on the ethical issues facing non-professionals who care for relatives or others with dementia. A qualitative pilot study was conducted in ten such individuals, eight of them women, caring for persons drawn mainly from one general practice. The interviews indicated that many of the dilemmas faced by carers are ethical and that the issues differ from those faced by professionals. Ethical issues are sometimes the most troublesome matter for carers. Unlike issues for professionals, they arise from a personal context and are shaped by long-term relationships.

Carers, ethics and dementia: a survey and review of the literature

BACKGROUND

Much has been written on ethical issues in dementia, but usually from the point of view of the various professionals involved. Whilst there has been an increasing amount of interest in the psychosocial problems that face the carers of people with dementia, the ethical nature of some of these problems has largely been ignored.

OBJECTIVE

To review the literature on ethical issues in dementia from the perspective of the main, non-professional carers of people with dementia.

METHOD

A systematic literature search using Medline, Clinpsych and CINAHL databases between 1982 and 2000. A pilot study of carers.

RESULTS

The lay perspective provides both a wide variety of issues and unique approaches. Although in the literature quantitative research answers some questions, it is qualitative research that deepens our understanding of the issues from the perspective of carers.

CONCLUSION

It is particularly qualitative research that brings out the ethical issues for carers, which tend to be more varied than the ethical issues raised in the professional literature. Awareness of such issues could inform and shape the support given to carers.

Caring for Family Caregivers and the Cognitively Impaired Care-Receiver

Research validating the role of the family as caregivers has been well documented for the past quarter century. Although family caregiving is not new, today's new technology has increased both the complexity and the time span of care. Hence, caring for chronically ill or physically or mentally incapacitated older family members has become a normal family function. Subsequently, the focus and findings of numerous studies centered on the identification of "caregiver burden, " "caregiver stress, " and "caregiver strain. " This article provides interventions to assist the nurse in caring for family caregivers, as well as care receivers.

The influence of autonomy and paternalism on communicative behaviors in mother-daughter relationships prior to dependency

Parents and their adult children rarely have discussions regarding caregiving preferences, especially before the onset of dependency. Families develop decision-making practices during caregiving, ideally, ones that maintain the care recipient's autonomy. Maintaining autonomy is essential because limiting autonomy leads to potentially negative health consequences. This study examined the attitudes of older, independent mothers and their adult daughters (n = 36 dyads) as well as their communication behaviors during decision making. All the mothers and daughters (100%) held strong beliefs in shared autonomy. Mothers (55.6%) and daughters (58.3%) were about evenly split in their strength of belief in independent autonomy. More mothers (63.9%) held strong beliefs in paternalism than did daughters (36.1%). In their conversations, daughters talked more when the mother and daughter held stronger beliefs in paternalism. These findings suggest that an individual's attitudes toward paternalism influence who controls conversations between parents and their adult children regarding caregiving, even before the parent has begun to show any signs of dependency. Once caregiving begins, it can be too late to change already ingrained patterns of decision making. Although this study takes a step toward establishing an understanding of how families develop decision-making processes utilized during caregiving, the sample size and composition limit generalizability. Future studies should follow families, as the parents make the transition from independence to dependence, to develop a better understanding of the factors involved in successfully making such a critical transition in the family's life.

Daughters-in-law as caregivers: how and why do they come to care?

This exploratory qualitative study examines the family dynamics and socio-structural factors which explain how and why some women become caregivers to in-laws. As well, it explores prevailing attitudes about care by in-laws. Material is drawn retrospectively from three previous studies of caregivers in Montreal, Quebec, including 10 semi-structured interviews with daughters-in-law and 72 interviews with spousal and child caregivers. An exploratory framework of the factors which are determinant in becoming a daughter-in-law caregiver is proposed which includes such elements as: social and cultural norms regarding family responsibility for eldercare; social and cultural norms regarding the place and the rights of the elderly; rules of family relations, couple dynamics, gender dynamics and family availability.

Characteristics of psychogeriatric patient visits to a general hospital emergency room

OBJECTIVE

This study describes psychogeriatric patients who visit the Emergency Room (ER) in a teaching hospital with a comprehensive psychogeriatric service.

METHOD

A survey assessing demographic and clinical characteristics was completed for every psychiatric ER patient during a 2-year period.

RESULTS

One hundred and seventy-three ER patients aged over 60 (mean age 71.2) were assessed. Fifty-three percent were previously known to the psychogeriatric service. The majority of these previously known psychogeriatric patients who used the ER suffered from mood disorders. The majority of new psychogeriatric patients seen in the ER had an organic brain syndrome (OBS).

CONCLUSIONS

Few OBS patients who visited the ER were previously known to the psychogeriatric service, but many new OBS patients accessed the psychogeriatric service via the ER. For patients with mood disorders, particularly if suicidal, the ER was used as part of their service delivery system.

Addressing the needs of informal carers: a neglected area of nursing practice

The British government's philosophy of maintaining dependency groups in the community, coupled with the rising numbers of frail elderly and dwindling pool of informal carers, has highlighted the need for appropriate professional interventions in this area. However, a failure to adequately conceptualize the needs of carers has, in the past, resulted in interventions often being inappropriate, irrelevant or unavailable. This paper advocates a major role for the nursing profession in redressing this balance. Using the findings of a postal survey on the problems and satisfactions of caring, the authors suggest how nurses might modify their current practice to maximize their contribution to this important but neglected area of their work.