Values underlying end-of-life decisions: a qualitative approach

The moderating role of subjective nearness-to-death in the association between health worries and death anxieties from COVID-19

The purpose of this study was to examine whether subjective nearness-to-death moderated the association between health worries and death anxiety due to the COVID-19 outbreak among older adults in Israel. Using an online survey, 277 participants were recruited and completed self-reported questionnaires, which included background characteristics, exposure to COVID-19 risk experiences, self-rated health, subjective nearness-to-death, health worries regarding COVID-19, and death anxiety. Findings revealed that subjective nearness-to-death moderated the association between health worries and death anxiety. The importance and significance of subjective perceptions concerning the distance from death as far, which may serve as a resilient resource, is discussed.

An evolutionary concept analysis of "patients' values"

BACKGROUND

Patients' values are everywhere and nowhere in nursing: frequently invoked and associated with effective nursing care but seldom explicitly defined or subject to dedicated analysis. Clarification of the concept of patients' values is pivotal because respecting and supporting patients' values are widely recognized as crucial for ethical nursing care. Despite this and the pervasive employment of the term patients' values in theories, approaches, and clinical guidelines, the concept remains ambiguous.

PURPOSE

We sought to understand the key elements of the concept by investigating its use in theoretical and empirical literature.

METHOD

This study used Rodgers' evolutionary concept analysis approach.

FINDINGS

We found that values are core individual beliefs that function in hierarchical systems; however, in the context of disease, the priority assigned to values by the individual may change. This is important, given that values play a foundational role in health-related decisions, such as in the context of chronic diseases.

DISCUSSION

Values are influenced by both individual intrinsic needs and the social context, but importantly, are involved in guiding decision-making. The attributes of the values may vary according to the context of the disease, the type of disease, and the decision at hand.

Experiences and Motivations Underlying Wishes to Die in Older People Who Are Tired of Living: A Research Area in its Infancy

The wish to die in older people who are tired of living and the possibilities to organize death are currently being discussed within the debate on self-determination and physician-assisted suicide. Until now insight into the experiences and thoughts of people who are tired of life but not suffering from a severe depression or a life-threatening disease is lacking. Studies focussing specifically on this topic are rare. This review provides an overview of this research area in its infancy. The existential impact of age-related loss experiences play an important role in developing a wish to die. Other influencing factors are: personal characteristics, biographical factors, social context, perceptions and values. Further research to experiences and motivations underlying these specific age-related wishes to die and the existential impact of the loss-experiences seems necessary to deepen the understanding of this group of older people and for the development of policy and good care.

Choosing between life and death: patient and family perceptions of the decision not to resuscitate the terminally ill cancer patient

In keeping with the pre-eminent status accorded autonomy within Australia, Europe, and the United States, medical practice requires that patients authorize do-not-resuscitate (DNR) orders, intended to countermand the default practice in hospitals of instituting cardiopulmonary-resuscitation (CPR) on all patients experiencing cardio-pulmonary arrest. As patients typically do not make these decisions proactively, however, family members are often asked to act as surrogate decision-makers and decide on the patient's behalf. Although the appropriateness of patients or their families having to decide about the provision of CPR has been challenged, there has been little examination of how patients and their families talk about and negotiate such decisions, particularly in the context of the patient's imminent death. In this article, part of a larger study analysing interviews with 28 patients (13 female) with cancer within weeks of their death, and 20 others (predominantly family) attending, we argue that a common assumption underpinning participants' talk about the DNR decision (i.e. forgoing CPR) is that it requires a choice between life and death. Using illustrative examples, we demonstrate that in making decisions about CPR, patients and their families are implicitly required to make moral judgements about the value of the patient's life, including their relationships with significant others. We identify some implications of these empirical observations for the development of ethically appropriate policies and practices regarding patient autonomy and surrogacy at the end of life.

The perceptions of do-not-resuscitate policies of dying patients with cancer

Patients in hospitals must authorize do-not-resuscitate (DNR) orders or the default cardiopulmonary resuscitation (CPR) occurs. Using discursive analysis, we examined the speech of 28 cancer patients, judged as within 3 months of death, to determine how they justified preferences for DNR orders. Most saw these as a positive outcome of not interfering with a natural death with the decision being personal and the legal right of a competent autonomous person. If surrogates were required, they needed knowledge of the medical facts and the patient's wishes. The doctor was crucial, while family although likely to be supportive may be burdened by the responsibility. Some favored an early DNR discussion, but the majority favored a later discussion when it was applicable. At interview, 58% patients had a DNR order, rising to 82% by the time of death. Written orders were favored, yet 9 of 21 who did not want CPR had no DNR order. Hope was mentioned spontaneously by 25 patients, both as a thing over which patients had little control and as the desire of a positive future outcome. If doctors' and patients' assessments of eligibility for DNR orders do not coincide, the process and documentation of decision-making needs revision.

The implications of dying cancer patients' talk on cardiopulmonary resuscitation and do-not-resuscitate orders

Current medical emphasis on autonomy requires that patients be primary in authorizing do-not-resuscitate (DNR) orders, countermanding provision of cardiopulmonary resuscitation (CPR) on terminally ill patients. The assumptions that patients make regarding CPR and DNR orders will influence their choices about them. Using discursive analysis, the authors examined the speech of 28 patients dying of cancer regarding the appropriateness of refraining from CPR or of instituting DNR orders. Most participants identified CPR as inappropriate in their circumstances, favoring institution of DNR orders. However, a minority drew on dominant construals of DNR orders and CPR to locate themselves outside the category of suitable candidates for DNR orders, thus justifying a preference for CPR--even though some had current DNR orders. Doctors' and patients' assessments of eligibility for DNR orders might not coincide, and when patient autonomy is presumed by patients to be determinant, discrepancies between patient expectations and instituted medical practice are inevitable.

Social work and end-of-life care: reviewing the past and moving forward

This paper reviews the professional literature with respect to the social work profession's involvement in end-of-life care. The search process was conducted by entering key words in various combinations to electronic databases. Eligible articles were required to address one of the following: roles and activities of social workers in providing end-of-life care; core principles valued by social workers in the provision of end-of-life care; and barriers to provision of effective end-of-life care. The literature from 1990 through July 2004 was searched most rigorously. Based on this review, suggestions for where the profession of social work should focus its energies are offered. These key areas include focusing on generating empirically-based knowledge for practice and policy analysis and developing a system of social work education that addresses the unique knowledge and skills needed to participate in end-of-life practice as competent and informed professional practitioners. Current initiatives with regard to critical areas are summarized.

Death and dying from old people's point of view. A literature review

Providing high-quality end-of-life care to older people is a requirement especially for countries with a high proportion of old and very old people. This calls for an understanding of older people's view of death and dying, and one way forward is to investigate the current knowledge base. This study aimed at reviewing the literature of empirical studies about older people's view of death and dying, whether in a terminal phase of life or not. A total of 33 publications were included, identified in a stepwise literature search done in Medline, CINAHL and PsychInfo, using the terms "death", "attitude to death", "death" and "dying" in combination with "aged". Very few studies focused solely on the oldest old. The designs were mainly cross-sectional, quantitative or qualitative, using personal interviews. Some common themes of importance for further research were revealed, such as older people's readiness to talk about death and dying, conceptions of death, after-death and dying, and were seemingly related to anxiety about death, the impact on and of those close by, having both negative and positive connotations, especially related to balancing closeness, being a burden and dependency, death anxiety and its possible antecedents, the fine line between natural sadness and suffering from depression, and worry about the end-of-life phase. The lack of studies dealing with older people's view of death and dying, and the heterogeneity with regard to research questions and samples implies that findings may serve mainly as inspiration for further research.

Thinking ahead: factors associated with executing advance directives

This article examines why older adults do or do not execute advance directives. METHODS. Secondary data analysis was conducted on data from the Charlotte County (Florida) Healthy Aging Study, on 451 adults who were relatively healthy and affluent. Exploratory logistic regressions were conducted on the probability that respondents had executed advance directives. RESULTS. Findings indicated that increasing age and higher income were the most consistent indicators of having executed an advance directive. Also, individuals reporting taking more prescription medications were more likely to have all the advance directives, except the durable power of attorney for health care. Reporting more negative life events was predictive of having executed the durable power of attorney for health care. DISCUSSION. These findings suggest that in addition to awareness of advance directives, demographic, health, and situational factors may affect the willingness of older adults to execute advance directives. Further research should examine other, more representative, samples to confirm these findings.