Spouses' effectiveness as end-of-life health care surrogates: accuracy, uncertainty, and errors of overtreatment or undertreatment

Promoting Advance Care Planning for Persons with Dementia: Study Protocol for the LEAD (Life-Planning in Early Alzheimer's and Other Dementias) Clinical Trial

Due to the insidious progression of Alzheimer's disease and related dementias (ADRD), surrogate decision-makers typically make medical and long-term-care decisions for a care recipient, most often a family care partner. Unfortunately, many care recipient/care partner dyads have failed to engage in advance care planning or have lost the opportunity to do so due to the cognitive decline of the care recipient. To address this need, our team created a validated dementia-focused advance care planning tool known as the LEAD Guide (Life-Planning in Early Alzheimer's and Other Dementias). With funding from the National Alzheimer's Association and in consultation with our community advisory board, we developed a preliminary web-based intervention. This intervention integrates the LEAD Guide with self-paced educational modules that lead dyads through conversations and dementia-focused advance care planning processes. In this concept paper, we describe the aims of our funded R01 clinical trial (National Institute on Aging), where we aim to refine our preliminary web-based platform for use in a 5-month mixed-method NIH Stage-1 behavioral intervention. Using a sample of diverse community-based ADRD dyads (n = 60), we aim to: 1) describe the acceptability, usability, and feasibility of the intervention, 2) assess the initial efficacy of the intervention on the primary outcome (decision-making self-efficacy), and secondary outcomes (relationship quality, subjective well-being, anxiety) as perceived by both the care recipient and the care partner, and 3) examine advance care planning congruence as a mechanism of action. The LEAD clinical trial addresses public health challenges by guiding and supporting families through challenging advance care planning conversations, facilitating the transfer of knowledge regarding care preferences and values from the care recipient to the care partner, with the ultimate goal of improving the quality of life for both individuals with ADRD and their care partners.

How widowhood status relates to engagement in advance care planning among older adults: does race/ethnicity matter?

OBJECTIVES

This study investigated whether and to what extent widowhood status is related to engagement in advance care planning (ACP), and further whether race/ethnicity moderated the relation.

METHODS

We analyzed a total of 11,257 older Americans from the Health and Retirement Study using random-effect regression models after controlling for covariates and year-fixed effects.

RESULTS

We found that both being a widow/widower ever and having been widowed for a longer period of time were associated with a higher probability of engagement in ACP. Specifically, we found that a one-year increase in the number of years since spousal death was associated with 1.02 (p < 0.05, 95% CI = 1.00, 1.03) changes in the odds ratios of informal ACP; however, inclusion of a quadratic term indicated that this association reversed after the peak. Moreover, our findings suggested a moderating effect of race/ethnicity on the relations of the length of time since spousal loss with engagement in ACP. Specifically, the odds of widowed non-Hispanic Blacks discussing with someone the care or medical treatment (informal ACP) and having a living will (formal ACP) were 0.96 (p < 0.05, 95% CI = 0.93, 1.00) and 0.88 (p < 0.05, 95% CI = 0.79, 0.97) times that of non-widowed non-Hispanic Whites. Compared with their non-Hispanic White counterparts, widowed non-Hispanic Blacks were less likely to engage in ACP, and the negative relations were exacerbated when they became widows/widowers.

CONCLUSION

We elaborated on these findings and discussed their implications for understanding the moderating effect of race/ethnicity on the relation between late-life widowhood and engagement in ACP. In order to develop programs that enhance engagement in ACP and reduce racial/ethnic disparities, research must incorporate intersectionality theory with attention to motivations and decision-making style among diverse widows/widowers. The findings from this study could help inform policy makers when developing public health programs and health care reimbursement programs that enhance engagement in ACP among widows/widowers.

Making the Informal Formal: Discussing and Completing Advance Care Plans in Care Dyads with Cognitive Impairment

BACKGROUND

Discussing advance care planning (ACP) with care partners may be a steppingstone to the completion of advance directives (ADs) for persons with cognitive impairment (PwCIs).

OBJECTIVES

To examine whether PwCI-reported occurrence of and PwCI-care partner agreement about ACP discussions are associated with completion of ADs.

DESIGN AND SUBJECTS

We conducted a secondary, cross-sectional analysis of data from 1672 PwCI-care partner dyads in the BLINDED study. PwCIs were Medicare beneficiaries in the US, aged >65 years, and diagnosed with mild cognitive impairment or dementia. Care partners were identified by PwCIs as being most involved in their health care.

MEASUREMENTS

PwCIs' completion of ADs was determined by 1 or more affirmative responses to dichotomous indicators for formalizing a living will, medical directive, or durable power of attorney for health care. Discussion occurrence was based on PwCI reports and agreement between PwCI and care partner reports of prior conversations about PwCIs' ACP preferences between PwCIs and care partners.

RESULTS

In logistic regression models adjusted for PwCI and care partner characteristics, PwCIs who had (vs. had not) discussed ACP were 10% more likely to complete ADs. PwCIs from dyads agreeing (vs. disagreeing) a discussion occurred were 7% more likely to complete ADs. PwCIs from care dyads in agreement (vs. disagreement) about non-discussion were 11% less likely to formalize ADs.

CONCLUSIONS

Discussing ACP with care partners plays a direct, positive role in completing ADs among PwCIs. Health care providers who approach ACP as a dyadic, communicative decision-making process from the outset may facilitate PwCIs' uptake of ADs.

Factors associated with surrogate families’ life-sustaining treatment preferences for patients at home or in a geriatric health service facility: A cross-sectional study

Objective

Recently, end-of-life preference in palliative care has been gaining attention in Japan. The Ministry of Health, Labor, and Welfare established the Japanese basic policy in November 2018. Patients’ decision-making is recommended; however, patients with dementia or other disorders cannot make such decisions by themselves. Thus, healthcare providers may contact surrogates and consider their backgrounds for better decision-making. Hence, the preferences of home caregivers’ and geriatric health service facility (GHSF) residents’ families on patient life-sustaining treatment (LST) were investigated.

Method

This cross-sectional study involved home caregivers’ and GHSF residents’ families in Japan. We distributed 925 self-reported questionnaires comprising items, such as the number of people living together, care duration, comprehension of doctor's explanations, the Patient Health Questionnaire (PHQ)-9 and Short Form (SF)-8, and families’ LST preference for patients.

Results

In all, 619 valid responses were obtained [242 men and 377 women (309 in the HOME Caregivers Group, response rate = 61.1%; 310 in the GHSF Group, response rate = 74.0%)]. LST preference was significantly associated with sex, the number of people living together, care duration, and comprehension of doctors’ explanations in the HOME Caregivers Group but was not significantly associated with the GHSF Group. Furthermore, PHQ-9/SF-8 scores were not significantly associated with LST preference.

Significance of results

There were many differences in opinions about LST preference between home caregivers’ and GHSF residents’ families. The results suggested that the burden of nursing care was greater and harder in home caregiver families, and these factors may be related to the LST preference for a patient.

Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol

Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).

Advance Directives Completion among Older American Couples: A Dyadic Perspective on the Role of Cognitive Function and Other Factors

OBJECTIVE

Dyadic perspective is scarce in existing advance directive (AD) literature. Particularly, the significance of one's own and/or one's partner's cognitive function on AD remains unknown. This study investigates the relationship of cognitive function and other factors with AD completion within the spousal context.

METHODS

Data from the Health and Retirement Study (2014-2015) were used. Older heterosexual couples (age ≥65) married for 10+ years were asked if they had a living will and/or appointed a durable power of attorney for healthcare (DPAHC). Structural Equation Models examined the actor and partner effects of sociodemographic, health, and couple-level characteristics on wife's and husband's AD, respectively.

RESULTS

Moderate spousal interdependence was observed in living will (Kappa coefficient, k =0.60) and DPAHC (k=0.53). Older age and higher education were related to both spouses having AD. Less household wealth and being racial/ethnic minority were associated with a lower probability of having AD. Notable gender contrasts in actor and partner effects were found. Wife's higher level of cognitive function was associated with husband's AD completion. Contrarily, husband's lower level of cognitive function was associated with wife's AD completion. Retirement status had primarily actor effects for both husbands and wives. More chronic conditions were linked to husband's AD completion.

DISCUSSION

The spousal interdependence of AD warrants practitioner efforts to facilitate family-oriented end-of-life planning. Wives and husbands may have different thoughts regarding their spouse's cognitive capacity to surrogate. Facilitating couple-based discussions may be a feasible approach to promote engagement with AD among older adults.

Experience as an Informal Caregiver and Discussions Regarding Advance Care Planning in Japan

CONTEXT

Advance care planning (ACP) is vital for end-of-life care management. Experiences as informal family caregivers might act as a catalyst to promote ACP.

OBJECTIVES

We investigated the association between ACP discussions and caregiving experiences.

METHODS

A nationwide survey in Japan was conducted in December 2016 using a quota sampling method to select a sample representative of the general Japanese population. The responses of 3167 individuals aged 20-84 years (mean age: 50.9 ± 16.8) were analyzed. The outcome was measured by asking if respondents had ever engaged in ACP discussions. The exposure was measured by asking whether and for how long respondents had experience as informal caregivers for family members. We analyzed informal caregiving experience related to the occurrence of ACP discussions using multivariable logistic regression models that adjusted for possible covariates.

RESULTS

Respondents with informal caregiving experience had significantly higher odds of having ACP discussions than those without caregiving experience (adjusted odds ratio: 1.93, 95% CI = 1.63, 2.29). Stronger effects were identified in younger adults (aged 20-65 years) and those with a higher education level (education duration > 12 years) than in older adults (aged ≥65 years) and those with a lower education level, respectively.

CONCLUSION

Experiences as informal caregivers for family members may facilitate ACP discussions among Japanese adults, especially younger adults with higher educational attainment. Our findings may help health-care providers screen those at risk for inadequate ACP discussions, and informal caregiving experience should be considered when health-care providers initiate discussions of end-of-life care.

Communication with family concerning body donation in Hong Kong: what do we know?

This study aimed to examine three major issues: (a) The extent to which registered donors have communicated with family about body donation; (b) The differences in demographics, life and death attitudes, and quality of relationship with family members between those who communicated their body donation decision and those who did not; (c) The factors associated with the act of communicating with family about body donation. A survey was conducted of people who registered in a body donation programme in Hong Kong. A total of 1,070 registered donors completed an online questionnaire between August and September 2016. The majority of participants (80.1%) reported that they communicated with family members about body donation. About one-third only informed family members of their decisions after registration, and around 15.6% did not communicate with family members. Those who communicated with family were significantly older and married; they also indicated more positive life and death attitudes and a better quality of relationship with family members. Three factors were found to have significant associations with the act of communicating with family members about the decision to donate the body: (a) Age, (b) Quality of life, (c) Quality of relationship with family members. Communication with family members about body donation is still inadequate. Future body donation programmes may focus more on the way body donation decisions can be better communicated with family members. Special attention can be given to younger registered donors who find it difficult to communicate with the older generation, those who indicate more negative life and death attitudes, and who experienced a poorer quality of relationship with family members.

Insufficient Advance Care Planning? Correlates of Planning Without Personal Conversations

Objectives

Advance care planning (ACP) typically comprises formal preparations (i.e., living will and/or durable power of attorney for health care) and informal discussions with family members and health care providers. However, some people complete formal documents without discussing them with others. If they become incapacitated, their appointed decision makers may lack guidance on how to interpret or enact their formal wishes. We document the prevalence and correlates of this partial approach to ACP.

Method

Using multinomial logistic regression models and data from a U.S. sample of 4,836 older adults in the 2018 wave of the National Health and Aging Trends Study (NHATS), this brief report evaluated associations between social integration indicators and the odds of completing (a) both discussions and formal plans (two-pronged ACP), (b) discussions only, (c) no ACP, and (d) formal ACP only (reference category). We adjust for demographic and health characteristics established as correlates of ACP.

Results

A minority (15%) of NHATS participants reported formal plans without having discussed them. Indicators of social isolation (e.g., smaller social networks and fewer social activities) increased the odds of engaging in formal planning only compared to two-pronged ACP. Socioeconomic disadvantage and probable dementia reduced the odds of having end-of-life conversations, whether as one’s only preparation or in tandem with formal preparations.

Discussion

Socially isolated persons are especially likely to do formal planning only, which is considered less effective than two-pronged ACP. Health care professionals should recognize that older adults with few kin may require additional support and guidance when doing ACP.

Factors Relating to Caregivers' Preference for Advance Care Planning of Patients in Japan: A Cross-Sectional Study

OBJECTIVES

The aim of this study was to examine the preferences of home caregivers on patient advance care planning (ACP), including life-sustaining treatment (LST) and the factors relating to these preferences.

BACKGROUND

Personalized ACP aims to respect the autonomy and choices of terminally ill patients regarding end-of-life care. However, there have been cases wherein doctors must instead discuss ACP with surrogates (including caregivers) for various reasons such as dementia, intractable neurologic diseases, and cerebrovascular accident.

METHODS

In this cross-sectional study, self-written questionnaires (filled by individuals themselves) were distributed to 506 in-home caregivers in 6 Japanese prefectures; the questionnaires contained items on caregiver and patient demographics, number of people living together in a caregiver's home (aside from patients), care duration, comprehension level of doctors' explanations regarding their patient's condition, patient diseases, whether caregivers have or have not told patients about their disease, level of nursing care, and caregiver LST preference (preferred or not preferred). The questionnaire package also contained the Burden Index of Caregiver-11, Patient Health Questionnaire-9, and Short Form-8 Health Survey.

RESULTS

Valid responses were obtained from 309 caregivers. More than half of them were not sure of their patient's LST preference. Sex, number of people living together in a care home, comprehension level of doctors' explanations, and care duration were found to be the significant factors relating to caregivers' LST preference (P < .05).

CONCLUSION

Health providers should be cognizant of the background factors relating to caregiver ACP preference when deciding on LST for terminal patients.

Epistemic burdens and the incentives of surrogate decision-makers

We aim to establish the following claim: other factors held constant, the relative weights of the epistemic burdens of competing treatment options serve to determine the options that patient surrogates pursue. Simply put, surrogates confront an incentive, ceteris paribus, to pursue treatment options with respect to which their knowledge is most adequate to the requirements of the case. Regardless of what the patient would choose, options that require more knowledge than the surrogate possesses (or is likely to learn) will either be neglected altogether or deeply discounted in the surrogate's incentive structure. We establish this claim by arguing that the relation between epistemic burdens and incentives in decision-making is a general feature of surrogate decision-making. After establishing the claim, we draw out some of the implications for surrogate decision-making in medicine and offer philosophical and psychological explanations of the phenomenon.

Choice of and comfort with health care proxy among older adults: Hierarchical compensation and perceived similarity in values

The purpose of this study was to investigate choice of and comfort with health care proxy among older adults (N = 240). Results indicated that choice of proxy follows a hierarchical compensation model. Perceived similarity regarding end-of-life preferences and political views were not associated with comfort with proxy; however, perceived similarity with regards to religious values was associated with comfort with proxy. Attempts to promote advance care planning and advance directives may benefit from emphasizing individuals' choice and autonomy but also their opportunity to designate a health care proxy who they feel represents their religious values.

How Social Network Size and Quality Affect End-of-Life Surrogate Preferences

Objective

Older adults typically choose their next-of-kin to serve as surrogate on their behalf should they become decisionally incapacitated at the end of life. However, some older adults do not choose their closest relative, even if they are married or parents. We compared the social networks of these latter persons to their peers who prefer a next-of-kin surrogate, anticipating differences in relationship quality and network size.

Methods

We used multinomial logistic regressions to investigate the quality and size of the social networks of 1,245 persons whose next of kin was a spouse and 723 persons whose next-of-kin was an adult child, and who participated in the 2005 National Social Life, Health and Aging Project.

Results

Twenty percent of those whose next-of-kin was a spouse and 32% of those whose next-of-kin was an adult child either bypassed that person in favor of a different surrogate, or preferred no surrogate at all. Low-quality next-of-kin relationships pushed older adults away from next-of-kin, and a greater number of high-quality relationships outside the immediate family pulled older adults toward a surrogate who was not next-of-kin.

Discussion

We discuss what is distinctive about the social networks of each group, and the implications for end-of-life support.

Association between social networks and discussions regarding advance care planning among Japanese older adults

Background

Older adults’ discussions with family, or with physicians, or with both, about advance care planning (ACP) are increasingly regarded as important for the management of end-of-life care, and yet the factors that induce older adults to engage in ACP discussions are poorly understood. For example, in older adults, is stronger connectedness with family and friends (stronger “networks”) associated with ACP discussions? By facilitating, or by impeding ACP discussions? We sought to evaluate the associations between ACP discussions and social networks in Japanese older adults.

Methods

In July 2016 we conducted a cross-sectional survey on 355 community-dwelling patients aged ≥65 years visiting community hospital clinics in Fukushima, Japan. We used the Lubben Social Network Scale (LSNS-6, the shortest available LSNS scale) to assess social networks and recorded two components of social network structure, marital status (dichotomized as “married” vs. “single / other”) and living status (“living with others” vs. “living alone”). One item asked if patients had had ACP discussions. We analyzed the LSNS-6 social network and marital and living status data in relation to the occurrence of ACP discussions using multiple logistic regression models with adjustments for possible confounding factors.

Results

Respondents’ social network was “limited” in 16% of cases; 61% had had ACP discussions. Respondents with a limited social network had a significantly lower tendency to have had ACP discussions than respondents with an “adequate” social network (adjusted odds ratio [AOR]: 0.35; 95% confidence interval [CI]: 0.18–0.66; P < 0.001). Marital status and living status were not significantly associated with ACP discussion.

Conclusions

Among Japanese older adults, weaker social networks may be associated with a lower tendency to discuss ACP. Our findings may help practitioners to quickly screen populations at risk for inadequate ACP discussion by using the LSNS-6.

Centenarians' End-of-Life Thoughts and Plans: Is Their Social Network on the Same Page?

OBJECTIVES

To explore how centenarians think about and plan for the end of life (EOL) and to what extent their primary contacts (proxy informants) are aware of these thoughts.

DESIGN

Population-based study with semistructured in-person interviews.

SETTING

Defined geographical region approximately 60 km around Heidelberg, Germany.

PARTICIPANTS

Subsample drawn from the larger study of centenarians (N = 78) with data on centenarians' EOL thoughts from the centenarian and the proxy informant.

MEASUREMENTS

Centenarians reported on their thoughts about the EOL, perception of the EOL as threatening, longing for death, engagement in any EOL planning, and type of EOL plan (will, living will, healthcare surrogate) in place. Proxy respondents answered the same set of questions based on what they thought the centenarians' perspective was.

RESULTS

In nearly half of cases, proxies misjudged whether the centenarian thought about EOL. Although only few centenarians perceived the EOL as threatening, and approximately one-quarter reported longing for death, proxies overestimated centenarians' reports on the former and underestimated the latter. Proxies reported more centenarian EOL planning than centenarians themselves.

CONCLUSION

Even though enrolled proxies were mostly persons very close to the centenarian, many of them did not seem to be well informed about the centenarians' thoughts and plans regarding the EOL, suggesting a lack of communication between centenarians and social network members in this respect. Healthcare professionals should be aware that, even for very old adults approaching the end of their lives, discussions about EOL and EOL planning may need to be actively encouraged and supported.

Advance Directives Information Delivery in Medicare/Medicaid-Funded Agencies: An Exploratory Study

To encourage citizens to plan their end-of-life care to protect their autonomy, Congress passed the Patient Self-Determination Act (PSDA) in 1990. Under the PSDA, all Medicare/Medicaid-funded agencies are required to ask if all the patients, upon admission, have advance directives (ADs). If they have not formulated an AD, agencies need to inform that they have a right to do so and provide them with the written information. Although this is required by law, there is no universal procedure or set standard approach to deliver the information to patients in these agencies. It is often unclear who provides and explains information on ADs, and what materials are provided. The purpose of this study was to understand the procedures and challenges presented in the delivery of information about ADs in agencies in response to the PSDA requirements. Using a case study approach, semi-structured interviews with personnel in nine agencies were analyzed and three overarching themes were identified: organizational procedures, staff interactions, and staff perceptions. The findings indicated that there is a need for AD-specific training for staff responsible for delivering AD information to their clients. Implementation of a formalized procedure/guidelines for information delivery would be helpful to maintain quality standards across agencies.

Planning for Future Care and the End of Life: A Qualitative Analysis of Gay, Lesbian, and Heterosexual Couples

Two key components of end-of-life planning are (1) informal discussions about future care and other end-of-life preferences and (2) formal planning via living wills and other legal documents. We leverage previous work on the institutional aspects of marriage and on sexual-minority discrimination to theorize why and how heterosexual, gay, and lesbian married couples engage in informal and formal end-of-life planning. We analyze qualitative dyadic in-depth interviews with 45 midlife gay, lesbian, and heterosexual married couples ( N = 90 spouses). Findings suggest that same-sex spouses devote considerable attention to informal planning conversations and formal end-of-life plans, while heterosexual spouses report minimal formal or informal planning. The primary reasons same-sex spouses give for making end-of-life preparations are related to the absence of legal protections and concerns about discrimination from families. These findings raise questions about future end-of-life planning for same- and different-sex couples given a rapidly shifting legal and social landscape.

How Surrogates Decide: A Secondary Data Analysis of Decision-Making Principles Used by the Surrogates of Hospitalized Older Adults

BACKGROUND

Many hospitalized adults do not have the capacity to make their own health care decisions and thus require a surrogate decision-maker. While the ethical standard suggests that decisions should focus on a patient's preferences, our study explores the principles that surrogates consider most important when making decisions for older hospitalized patients.

OBJECTIVES

We sought to determine how frequently surrogate decision-makers prioritized patient preferences in decision-making and what factors may predict their doing so.

DESIGN AND PARTICIPANTS

We performed a secondary data analysis of a study conducted at three local hospitals that surveyed surrogate decision-makers for hospitalized patients 65 years of age and older.

MAIN MEASURES

Surrogates rated the importance of 16 decision-making principles and selected the one that was most important. We divided the surrogates into two groups: those who prioritized patient preferences and those who prioritized patient well-being. We analyzed the two groups for differences in knowledge of patient preferences, presence of advance directives, and psychological outcomes.

KEY RESULTS

A total of 362 surrogates rated an average of six principles as being extremely important in decision-making; 77.8% of surrogates selected a patient well-being principle as the most important, whereas only 21.1% selected a patient preferences principle. Advance directives were more common to the patient preferences group than the patient well-being group (61.3% vs. 44.9%; 95% CI: 1.01-3.18; p = 0.04), whereas having conversations with the patient about their health care preferences was not a significant predictor of surrogate group identity (81.3% vs. 67.4%; 95% CI: 0.39-1.14; p = 0.14). We found no differences between the two groups regarding surrogate anxiety, depression, or decisional conflict.

CONCLUSIONS

While surrogates considered many factors, they focused more often on patient well-being than on patient preferences, in contravention of our current ethical framework. Surrogates more commonly prioritized patient preferences if they had advance directives available to them.

Surrogate inaccuracy in predicting older adults' desire for life-sustaining interventions in the event of decisional incapacity: is it due in part to erroneous quality-of-life assessments?

BACKGROUND

Family members are often called upon to make decisions for an incapacitated relative. Yet they have difficulty predicting a loved one's desire to receive treatments in hypothetical situations. We tested the hypothesis that this difficulty could in part be explained by discrepant quality-of-life assessments.

METHODS

The data come from 235 community-dwelling adults aged 70 years and over who rated their quality of life and desire for specified interventions in four health states (current state, mild to moderate stroke, incurable brain cancer, and severe dementia). All ratings were made on Likert-type scales. Using identical rating scales, a surrogate chosen by the older adult was asked to predict the latter's responses. Linear mixed models were fitted to determine whether differences in quality-of-life ratings between the older adult and surrogate were associated with surrogates' inaccuracy in predicting desire for treatment.

RESULTS

The difference in quality-of-life ratings was a significant predictor of prediction inaccuracy for the three hypothetical health states (p < 0.01) and nearly significant for the current health state (p = 0.077). All regression coefficients were negative, implying that the more the surrogate overestimated quality of life compared to the older adult, the more he or she overestimated the older adult's desire to be treated.

CONCLUSION

Discrepant quality-of-life ratings are associated with surrogates' difficulty in predicting desire for life-sustaining interventions in hypothetical situations. This finding underscores the importance of discussing anticipated quality of life in states of cognitive decline, to better prepare family members for making difficult decisions for their loved ones.

TRIAL REGISTRATION NUMBER

ISRCTN89993391.

Engagement in Advance Care Planning and Surrogates' Knowledge of Patients' Treatment Goals

OBJECTIVES

A key objective of advance care planning (ACP) is improving surrogates' knowledge of patients' treatment goals. Little is known about whether ACP outside of a trial accomplishes this. The objective was to examine patient and surrogate reports of ACP engagement and associations with surrogate knowledge of goals.

DESIGN

Cohort study SETTING: Primary care in a Veterans Affairs Medical Center.

PARTICIPANTS

350 community-dwelling veterans age ≥55 years and the individual they would choose to make medical decisions on their behalf, interviewed separately.

MEASUREMENTS

Treatment goals were assessed by veterans' ratings of 3 health states: severe physical disability, cognitive disability, and pain, as an acceptable or unacceptable result of treatment for severe illness. Surrogates had knowledge if they correctly predicted all 3 responses. Veterans and surrogates were asked about living will and health care proxy completion and communication about life-sustaining treatment and quality versus quantity of life (QOL).

RESULTS

Over 40% of dyads agreed that the veteran had not completed a living will or health care proxy and that there was no QOL communication. For each activity, sizeable proportions (18-34%) disagreed about participation. In dyads who agreed QOL communication had occurred, 30% of surrogates had knowledge, compared to 21% in dyads who agreed communication had not occurred and 15% in dyads who disagreed (P = .01). This relationship persisted in multivariable analysis. Agreement about other ACP activities was not associated with knowledge.

CONCLUSION

Disagreement about ACP participation was common. Agreement about communication regarding QOL was modestly associated with surrogate knowledge of treatment goals. Eliciting surrogates' perspectives is critical to ACP. Even dyads who agree about participation may need additional support for successful engagement.

Withdrawal of life-sustaining treatment: patient and proxy agreement: a secondary analysis of "contracts, covenants, and advance care planning"

BACKGROUND

Families of critically ill patients often make difficult decisions related to end-of-life (EOL) care including the withdrawal of life-sustaining therapies.

OBJECTIVES

This study explored patient and proxy decisions related to mechanical ventilator withdrawal in scenarios characterizing 3 distinct disease trajectories (cancer, stroke, and heart failure [HF]) with different prognoses. The relationship between patient directives, modification of directives, prognosis, trust, and EOL decisions were examined.

METHODS

This secondary analysis of data obtained in the "Contracts, Covenants, and Advance Care Planning" study included a sample of 110 subjects with 50 patient-proxy pairs. Patient and proxy agreement was assessed in response to questions regarding mechanical ventilator withdrawal while considering directives or modification of directives in 3 different scenarios.

RESULTS

Patient and proxy agreement ranged from 48% (n = 24 pairs) to 94% (n = 47 pairs). Agreement was lowest in HF (uncertain prognosis) when the directive indicated "do nothing" or "did not indicate any preference." Modified directives yielded 48% (n = 24 pairs) to 84% (n = 42 pairs) agreement. Changing directives from "do nothing" to "more hopeful" in HF (uncertain prognosis) had the highest agreement among modified scenarios. Despite wide variability in agreement, patients reported a high level of trust in their proxies' decisions.

DISCUSSION

This study highlighted differences in patient and proxy agreement about withdrawal of mechanical ventilation. Critical care nurses provide a key role in supporting EOL decisions. Encouraging ongoing communication about preferences and understanding the role of disease process and prognosis in decision making are paramount. Future research needs to explore factors that may improve patient and proxy agreement in EOL decisions and ways critical care nurses can support patients and proxies in these decisions, ultimately improving EOL care.

End of life care: The experiences of advance care planning amongst family caregivers of people with advanced dementia – A qualitative study

Background

End of life decisions for people with advanced dementia are reported as often being difficult for families as they attempt to make appropriate and justified decisions.

Aim

To explore the experiences of advance care planning amongst family caregivers of people with advanced dementia.

Design

Qualitative research including a series of single cases (close family relatives).

Methods

A purposive sample of 12 family caregivers within a specialist dementia unit was interviewed about their experiences of advance care planning between August 2009 and February 2010.

Results/Findings

Family caregivers need encouragement to ask the right questions during advance care planning to discuss the appropriateness of nursing and medical interventions at the end of life.

Conclusions

Advance care planning can be facilitated with the family caregiver in the context of everyday practice within the nursing home environment for older people with dementia.

Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names

Background

Confusion between look-alike and sound-alike (LASA) medication names (such as mercaptamine and mercaptopurine) accounts for up to one in four medication errors, threatening patient safety. Error reduction strategies include computerized physician order entry interventions, and ‘Tall Man’ lettering. The purpose of this study is to explore the medication name designation process, to elucidate properties that may prime the risk of confusion.

Methods and Findings

We analysed the formal and semantic properties of 7,987 International Non-proprietary Names (INNs), in relation to naming guidelines of the World Health Organization (WHO) INN programme, and have identified potential for errors. We explored: their linguistic properties, the underlying taxonomy of stems to indicate pharmacological interrelationships, and similarities between INNs. We used Microsoft Excel for analysis, including calculation of Levenshtein edit distance (LED). Compliance with WHO naming guidelines was inconsistent. Since the 1970s there has been a trend towards compliance in formal properties, such as word length, but longer names published in the 1950s and 1960s are still in use. The stems used to show pharmacological interrelationships are not spelled consistently and the guidelines do not impose an unequivocal order on them, making the meanings of INNs difficult to understand. Pairs of INNs sharing a stem (appropriately or not) often have high levels of similarity (<5 LED), and thus have greater potential for confusion.

Conclusions

We have revealed a tension between WHO guidelines stipulating use of stems to denote meaning, and the aim of reducing similarities in nomenclature. To mitigate this tension and reduce the risk of confusion, the stem system should be made clear and well ordered, so as to avoid compounding the risk of confusion at the clinical level. The interplay between the different WHO INN naming principles should be further examined, to better understand their implications for the problem of LASA errors.

Surrogate utility estimation by long-term partners and unfamiliar dyads

To what extent are people able to make predictions about other people's preferences and values?We report two experiments that present a novel method assessing some of the basic processes in surrogate decision-making, namely surrogate-utility estimation. In each experiment participants formed dyads who were asked to assign utilities to health related items and commodity items, and to predict their partner's utility judgments for the same items. In experiment one we showed that older adults in long-term relationships were able to accurately predict their partner's wishes. In experiment two we showed that younger adults who were relatively unfamiliar with one another were also able to predict other people's wishes. Crucially we demonstrated that these judgments were accurate even after partialling out each participant's own preferences indicating that in order to make surrogate utility estimations people engage in perspective-taking rather than simple anchoring and adjustment, suggesting that utility estimation is not the cause of inaccuracy in surrogate decision-making. The data and implications are discussed with respect to theories of surrogate decision-making.

'Deferred or chickened out?' Decision making among male carers of people with dementia

In this paper, we present new insight into the ways in which carers of people with dementia make decisions in the context of seemingly declining autonomy and freedom associated with the condition. Our focus is on the ways in which carers reflect on decisions made in different temporal contexts (day-to-day, medium- and long term). Drawing on data and analysis from in-depth interviews with male informal carers of women with mild to moderate dementia living in the northwest of England, we outline how the decision-making process is dependent on the temporality of the decisions. Arguably unsurprisingly, we found that short-term or 'day-to-day' decisions were made with input from those cared for, while longer term decisions were deferred until a point when necessity meant carers had to make decisions themselves. However, and importantly, carers were aware of the implications of how they were making decision, including the potential impact in terms of partial withdrawal, or even full denial, of autonomy of those they care for. Consequently, we argue that carers adopt a form of practised autonomy to negotiate the complexity of everyday decision making while managing longer term uncertainty and anxiety.

Health Care Communication and Agreement and Disagreement About Symptoms Within the Context of Multimorbidity

Informal caregivers for older adults often act as medical 'proxies' based on their assumed knowledge of the care recipient's illness-related symptoms. Differences between symptom descriptions given by care recipients and caregivers, however, raise questions about the validity of proxy reports. Community-dwelling caregivers and their care recipients with chronic, multi-morbid conditions revealed similar numbers of symptoms reported as well as average symptom distress. Dyads with care recipients who scored higher on negative affect were more likely to have significantly lower. Results suggested the possibility of identifying and intervening with dyads who may be 'at-risk' for divergent symptom reporting. This awareness may increase the ability to engage in informed and shared medical decision making throughout the illness trajectory.

Factors Related to the Differential Preference for Cardiopulmonary Resuscitation Between Patients With Terminal Cancer and That of Their Respective Family Caregivers

There is little information regarding concordance between preferences for end-of-life care of terminally ill patients with cancer and those of their family caregivers. A cross-sectional exploration of cardiopulmonary resuscitation (CPR) preference in 361 dyads was conducted. Patients or family caregivers who were willing to approve CPR were compared with dyads who did not support CPR. The patient's quality of life was more associated with family caregiver's willingness than patient's willingness. A patient was more likely to prefer CPR than their caregiver in dyads of females and emotionally stable patients. A family caregiver showed stronger support for CPR if the patient had controlled pain or stable health and the family caregiver had not been counseled for CPR. Communications should be focused on these individuals to improve the planning of end-of-life care.

Does End-of-Life Planning Help Partners Become Better Surrogates?

PURPOSE OF THE STUDY

This study investigates the role of surrogates' involvement in their partners' end-of-life care planning, focusing on the relationship between the extent and type of end-of-life planning in which surrogates have been involved and the accuracy of their substituted judgments.

DESIGN AND METHODS

The data come from an internet survey collected by Knowledge Networks and the National Center for Family and Marriage Research. The national sample is comprised of 1,075 opposite-sex American couples aged 18-64. A series of multilevel negative binomial regression analyses were conducted.

RESULTS

Surrogates' involvement in multiple types of planning helped them to make accurate substituted judgments, whereas surrogates' involvement in informal discussions helped them to make accurate estimations primarily when they wanted limited care for themselves.

IMPLICATIONS

This study highlights the importance of engaging in both advance directives and informal discussion. The findings also suggest that surrogates who want extensive care for themselves may need extra attention when practitioners assist them in making a substituted judgment.

Family relationships and advance care planning: do supportive and critical relations encourage or hinder planning?

OBJECTIVES

The effectiveness of advance care planning (ACP) may depend on family members' understanding of patient preferences. However, we know of no studies that explore the association between family relationship dynamics and ACP. ACP includes a living will, durable power of attorney for health care (DPAHC) appointment, and discussions. We evaluated the effects of three aspects of family relations--general family functioning, support and criticism from spouse, and support and criticism from children--on both overall ACP and specific DPAHC designations.

METHOD

Using multinomial logistic regression models and data from a sample of 293 older adults, we estimated the effects of family relationship quality on the likelihood of completing ACP and appointing a spouse or adult child as DPAHC. Analyses controlled for demographic and health characteristics.

RESULTS

Better overall family functioning increased the odds of ACP. Higher levels of spousal support increased the odds of holding informal discussions, whereas spousal criticism reduced the odds of naming one's spouse as DPAHC. Both criticism and emotional support from children increased the odds that a child was named as DPAHC.

DISCUSSION

Family dynamics affect ACP in complex ways and should be considered when patients and their families discuss end-of-life care and make DPAHC designations.

Honoring patient care preferences: surrogates speak

A growing body of evidence has pointed to the stressful experience surrounding surrogate decision-making on behalf of incapacitated patients. This study (N = 59) asked surrogates to speak about their experiences immediately after having made a life-sustaining treatment decision. Grounded theory analysis revealed four themes: (1) the emotional impact of the decision-making process on the surrogate; (2) the difficulty of watching a loved one's health deteriorate; (3) the importance of having a Living Will (LW) or other written/verbal instructions; and (4) the reliance on spirituality as a means of coping with the surrogate experience. Findings of this study suggest that engaging surrogates at the time of patient admission may be essential in order to clarify patient preferences and strengthen communication between surrogates and the interdisciplinary healthcare team.

An assessment of social diffusion in the Respecting Choices advance care planning program

This study examines the potential social diffusion effects of the Respecting Choices advance care planning program administered in La Crosse, Wisconsin, since 1991. The program produces educational materials for patients, trains facilitators to help patients prepare for end of life, and ensures that advance directives are connected to patients' medical records. Using data from a survey of more than 5,000 White Wisconsin high school graduates in their mid-60s, we found that participants who were living in the La Crosse area were significantly less likely than their peers living elsewhere to have executed a living will or appointed a health care power of attorney. This pattern may reflect psychological reactance, where individuals reject a message or lesson when they perceive compliance as a threat to their autonomy. There was no evidence of social diffusion effects; participants who lived in the La Crosse region themselves or who had social network members residing in the area were no more likely than those with no known ties to the region to have engaged in advance care planning. Future studies should explore the processes through which individuals learn and share with others their knowledge of advance care planning.

Ethical aspects of using GPS for tracking people with dementia: recommendations for practice

BACKGROUND

Problems with out-of-home mobility are among the more common behavioral disturbances in dementia. Today people with dementia can be aided by easily accessible assistive technologies, such as tracking devices using Global Positioning Systems (GPS). Attitudes toward these technologies are still inconclusive and their use with people with dementia raises ethical concerns. The lack of ethical consensus on the use of GPS for people with dementia underlines the need for clearer policies and practical guidelines.

METHODS

Here we summarize qualitative and quantitative findings from a larger research project on the ethical aspects of using GPS for tracking people with dementia.

RESULTS

The findings are formulated in a list of recommendations for policy-makers as well as for professional and family caregivers. Among other points, the recommendations indicate that the preferences and best interests of the people with dementia should be central to the difficult decisions required in dementia care. Further, no-one should be coerced into using tracking technology and, where possible, people with dementia must be involved in the decision-making and their consent sought.

CONCLUSIONS

The decision whether, when and how to use GPS for tracking people with dementia should be made at the time of diagnosis jointly by the person with dementia, his/her family and professional caregivers. This decision should be made in formal structured meetings facilitated by a professional team.

[The surrogate for inpatients]

The French legal framework of the surrogate has been defined by a law passed in 2002 concerning the patients' rights, in response to the absence of prior rights of the incompetent patient. The surrogate is designated only by a competent major patient. In the case of competent patient, the surrogate may support the patient throughout the course of care, including during the hospitalizations or consultations. In the case of incompetent patient, the surrogate must be involved in the decision-making process. A poor designation and a lack of the surrogate's involvement emerge from different French studies since 2002, especially in the end-of-life decisions, despite a specific law passed in 2005, which reinforced the surrogate's role in this context. The evolution of the patients' rights, in France as in most of the industrialized countries, should lead to specific actions to improve the surrogate's involvement, in the respect of the ethical principles of autonomy, beneficence and non-maleficence.

Who should make the decision on the use of GPS for people with dementia?

OBJECTIVES

In recent years advanced technologies, such as Global Positioning Systems (GPS), allow for tracking of human spatial activity and provide the ability to intervene to manage that activity. The purpose of this study is to examine the issue of who should decide about the use of electronic tracking using GPS for people with dementia.

METHODS

Based on quantitative data collected from 296 participants comprising cognitively intact elderly, family caregivers of people with dementia, social workers, other professionals, and social work students, study participants were asked to rate nine different potential decision-makers to make this decision.

RESULTS

The results show that figures inside the family, particularly the spouse or the most involved family caregiver, were perceived more important in the decision-making process than figures outside the family, whereas the person with dementia was ranked third in the order of the figures. Since the decision to use GPS for tracking raises the ethical dilemma of personal safety versus autonomy and privacy of people with dementia, the findings seem to indicate that the reluctance of professional caregivers to assist family caregivers to make this decision is experienced as frustrating.

CONCLUSIONS

The findings imply that in order to reach a balance between the wishes and interests of both people with dementia and their family caregivers, there is a need for more active involvement of the professional caregivers to facilitate the family decision-making process.

Older adults' preferences for independent or delegated end-of-life medical decision making

OBJECTIVE

This study assesses the proportions of participants who prefer independent or delegated medical decision making at the end of life and examines the relationships of personal beliefs, affiliative beliefs, and end-of-life planning behaviors to decision-making preference.

METHOD

Data are drawn from the Wisconsin Longitudinal Study, a sample of nearly 4,500 healthy White Midwestern high school graduates in their mid-60s.

RESULTS

Four fifths of participants wanted to make decisions independently. Valuing independence, being less avoidant of thoughts of death, and valuing quality of life over length of life had strong associations with a preference for independent decision making. Those concerned about burdening a caregiver wanted to make independent decisions. Persons who both executed a living will and appointed a durable power of attorney for health care preferred independent decision making.

DISCUSSION

Older adults cite personal and affiliative beliefs, not lack of autonomy, as reasons for their choice to decide independently or delegate.

Clinical decision making in palliative care and end of life care

Clinical decision making involves a consideration of multiple factors; clinical options are constructed based on the objective clinical data and evidence-based standards. Technologic advances have led not only to life saving interventions, but also to the use of these technologies when benefit to the patient was unclear or unexamined. The cases of Karen Quinlan, Nancy Cruzan, and Terri Schiavo provide a framework for examining the evolution of clinical decision making, including when to use or not to use technologies such as ventilators and artificial nutrition and hydration, and the role of specific questions in the process. Advance directives are a means to convey patient preferences, however, in the absence of advance directives, skilled questioning can elicit patient preferences. Nurses' roles in clinical decision making are often nebulous but can be enhanced by understanding these interrelated processes, as well as by knowing the policies and procedures of their institutions.

End-of-life concerns and care preferences: congruence among terminally ill elders and their family caregivers

This study examined the end-of-life challenges, concerns, and care preferences of terminally ill elders and their family caregivers, with a focus on areas of congruence and incongruence. Ten elders and 10 family caregivers participated in separate, semi-structured, face-to-face interviews. Data analysis included team coding and thematic analysis, guided by an a priori set of categories based on the study questions. Shared challenges and concerns included experiencing decline, managing pain and discomfort, and living with uncertainty. There was also congruence regarding end-of-life care preferences, specifically the importance of quality care, treatment with dignity and respect, and avoiding unnecessary life-sustaining treatment. Areas of incongruence included the elders' difficulties in accepting dependence, their fears of becoming a burden, and desire to be prepared for death. Family caregivers were most concerned with providing adequate care to meet the elders' physical and spiritual care needs. Open family communication was associated with greater congruence. The authors discuss implications of these findings for research and intervention.

Do Older Adults Know Their Spouses' End-of-Life Treatment Preferences?

When terminally ill patients become mentally incapacitated, the patient's surrogate often makes treatment decisions in collaboration with health care providers. We examine how surrogates' errors in reporting their spouse's preferences are affected by their gender, status as durable power of attorney for health care (DPAHC), whether the surrogate and spouse held discussions about end-of-life preferences, and the spouse's health status. We apply structural equation models to data from 2,750 married couples in their mid 60s who participated in the 2004 wave of the Wisconsin Longitudinal Study. Surrogates reported their spouse's preferences incorrectly 13 and 26 percent of the time in end-of-life scenarios involving cognitive impairment and physical pain, respectively. Surrogates projected their own preferences onto the spouse. Similar patterns emerged regardless of surrogate gender, surrogate status as DPAHC, marital discussions about end-of-life, or spousal health status. We discuss implications for the process of surrogate decision-making and for future research.