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Scherr BF, Buehler PK. [Ethical boundary decisions in intensive care medicine]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:967-975. [PMID: 39311946 PMCID: PMC11452514 DOI: 10.1007/s00108-024-01781-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/07/2024] [Indexed: 10/05/2024]
Abstract
BACKGROUND Ethical decision-making is a cornerstone of intensive care and emergency medicine. In acute scenarios, clinicians often face rapid, high-stakes decisions concerning life and death, made more challenging by time constraints and incomplete information. These decisions are further complicated by economic constraints, limited resources, and evolving technological capabilities. QUESTION What decision-making aids and factors can be employed in ethical borderline cases within intensive care medicine? RESULTS Fundamental ethical principles such as patient autonomy, beneficence, non-maleficence, and justice form the basis for medical treatment decisions. Evaluating the patient's will through advanced directives or proxy consensus is crucial, although advanced directives can be ambiguous. Assessing quality of life is increasingly important, with instruments such as the Clinical Frailty Scale (CFS) being utilized. For older patients, a holistic approach is recommended, focusing on overall health rather than chronological age. In patients with advanced underlying diseases, a multidisciplinary dialogue is essential. DISCUSSION Decision-making in intensive care medicine requires careful consideration of medical, ethical, and individual factors. Despite advances in artificial intelligence and prognostic models, human judgment remains crucial. During periods of resource scarcity, ethically sound triage protocols are required. The challenge lies in applying these principles and factors in clinical practice while respecting the individuality of each patient.
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Affiliation(s)
- Benedikt Florian Scherr
- Zentrum für Intensivmedizin, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Schweiz
| | - Philipp Karl Buehler
- Zentrum für Intensivmedizin, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Schweiz.
- University of Zurich, Zürich, Schweiz.
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2
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Daube D, Reifegerste D. [Digital information materials on dementia-an exploratory content analysis]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2024; 67:947-955. [PMID: 38806745 PMCID: PMC11282147 DOI: 10.1007/s00103-024-03893-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 05/07/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND A diagnosis of dementia places a heavy burden on those affected and their families. Often, difficult decisions must be made. Ideally, people with a new dementia diagnosis make informed decisions together with family members. Digital informational materials can be an important low-threshold resource for making informed decisions. They should provide comprehensive information about dementia, including both primary prevention (risk factors for the onset of dementia) and later treatment options. They should also cover precautionary measures that can make future decisions easier (e.g., advance directives, power of attorney). However, there is currently no comprehensive overview of the various online resources for dementia-related information. METHODS This study explores digital informational materials on dementia for different target groups in the German-speaking area using an innovative systematic search strategy. It examines how these materials are structured in terms of risk factors, treatment options, and decision support. This methodological approach is new, so it is described and discussed in detail. RESULTS The results show that most materials are intended for people with dementia and their families. Treatment measures are often discussed without explaining the risk factors they are meant to address. There is little focus on preventive measures that could support decision-making. DISCUSSION The unbalanced presentation could lead to certain measures being difficult to understand (for laypeople) or to misinterpretation of risk factors. Important implications are drawn from these findings.
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Affiliation(s)
- Dominik Daube
- Friedrich-Schiller-Universität Jena, Jena, Deutschland.
- Professur für Gesundheitskommunikation, Institute for Planetary Health Behaviour (IPB), Universität Erfurt, Nordhäuser Str. 63, 99089, Erfurt, Deutschland.
- Bernhard-Nocht-Institut für Tropenmedizin, Hamburg, Deutschland.
| | - Doreen Reifegerste
- Fakultät für Gesundheitswissenschaften, Universität Bielefeld, Bielefeld, Deutschland
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Wilson E, Palmer J, Armstrong A, Messer B, Presswood E, Faull C. End of life decision making when home mechanical ventilation is used to sustain breathing in Motor Neurone Disease: patient and family perspectives. BMC Palliat Care 2024; 23:115. [PMID: 38698397 PMCID: PMC11064348 DOI: 10.1186/s12904-024-01443-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Motor Neurone Disease (MND) leads to muscle weakening, affecting movement, speech, and breathing. Home mechanical ventilation, particularly non-invasive ventilation (NIV), is used to alleviate symptoms and support breathing in people living with MND. While home mechanical ventilation can alleviate symptoms and improve survival, it does not slow the progression of MND. This study addresses gaps in understanding end-of-life decision-making in those dependent on home mechanical ventilation, considering the perspectives of patients, family members, and bereaved families. METHODS A UK-wide qualitative study using flexible interviews to explore the experiences of people living with MND (n = 16), their family members (n = 10), and bereaved family members (n = 36) about the use of home mechanical ventilation at the end of life. RESULTS Some participants expressed a reluctance to discuss end-of-life decisions, often framed as a desire to "live for the day" due to the considerable uncertainty faced by those with MND. Participants who avoided end-of-life discussions often engaged in 'selective decision-making' related to personal planning, involving practical and emotional preparations. Many faced challenges in hypothesising about future decisions given the unpredictability of the disease, opting to make 'timely decisions' as and when needed. For those who became dependent on ventilation and did not want to discuss end of life, decisions were often 'defaulted' to others, especially once capacity was lost. 'Proactive decisions', including advance care planning and withdrawal of treatment, were found to empower some patients, providing a sense of control over the timing of their death. A significant proportion lacked a clear understanding of the dying process and available options. CONCLUSIONS The study highlights the complexity and evolution of decision-making, often influenced by the dynamic and uncertain nature of MND. The study emphasises the need for a nuanced understanding of decision-making in the context of MND.
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Affiliation(s)
- Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK.
| | - Jonathan Palmer
- University Hospitals, University Hospitals NHS Trust Plymouth, Plymouth, UK
| | - Alison Armstrong
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ben Messer
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Lank RJ, Morgenstern LB, Ortiz C, Case E, Zahuranec DB. Barriers to Surrogate Application of Patient Values in Medical Decisions in Acute Stroke: Qualitative Study in a Biethnic Community. Neurocrit Care 2024; 40:215-224. [PMID: 37131090 PMCID: PMC10620105 DOI: 10.1007/s12028-023-01724-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/27/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND The objective of this study was to identify barriers to surrogate decision-maker application of patient values on life-sustaining treatments after stroke in Mexican American (MA) and non-Hispanic White (NHW) patients. METHODS We conducted a qualitative analysis of semistructured interviews with stroke patient surrogate decision-makers completed approximately 6 months after hospitalization. RESULTS Forty-two family surrogate decision-makers participated (median age: 54.5 years; female: 83%; patients were MA [60%] and NHW [36%], and 50% were deceased at the time of the interview). We identified three primary barriers to surrogates' applications of patient values and preferences when making decisions on life-sustaining treatments: (1) a minority of surrogates had no prior discussion of what the patient would want in the event of a serious medical illness, (2) surrogates struggled to apply prior known values and preferences to the actual decisions made, and (3) surrogates felt guilt or burden, often even in the setting of some knowledge of patient values or preferences. The first two barriers were seen to a similar degree in MA and NHW participants, though guilt or burden was reported more commonly among MA (28%) than NHW (13%) participants. Maintaining patient independence (e.g., ability to live at home, avoid a nursing home, make their own decisions) was the most important priority for decision-making for both MA and NHW participants; however, MA participants were more likely to list spending time with family as an important priority (24% vs. 7%). CONCLUSIONS Stroke surrogate decision-makers may benefit from (1) continued efforts to make advance care planning more common and more relevant, (2) assistance in how to apply their knowledge of patient values to actual treatment decisions, and (3) psychosocial support to reduce emotional burden. Barriers to surrogate application of patient values were generally similar in MA and NHW participants, though the possibility of greater guilt or burden among MA surrogates warrants further investigation and confirmation.
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Affiliation(s)
- Rebecca J Lank
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Lewis B Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, School of Public Health, University of Michigan, Cardiovascular Center Rm 3392 1500 E Medical Center Dr., Ann Arbor, MI, USA
| | - Carmen Ortiz
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
| | - Erin Case
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, School of Public Health, University of Michigan, Cardiovascular Center Rm 3392 1500 E Medical Center Dr., Ann Arbor, MI, USA
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Xu R, Shi G, Zheng S, Tung TH, Zhang M. COVID-19 vaccine hesitancy between family decision-makers and non-decision-makers among college teachers. Ann Med 2023; 55:292-304. [PMID: 36594480 PMCID: PMC9815219 DOI: 10.1080/07853890.2022.2162114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Teachers with high educational levels significantly impact the health-related knowledge and attitudes of young students and their family members. This study aimed to investigate the coronavirus disease 2019 (COVID-19) vaccine hesitancy and associated factors, and compare the differences between decision-makers and non-decision-makers among college teachers. METHODS A cross-sectional online survey was administered across mainland China from 4 to 7 August 2021. Overall, 251 college teachers were included using snowball sampling. A multivariable logistic regression model was applied to explore the association between decision-makers and hesitancy to receive a COVID-19 vaccine. RESULTS Overall, 42.2% of the teachers were hesitant to being vaccinated against COVID-19. The hesitancy rate was lower among primary decision-makers than that among non-decision-makers (34.8% vs. 60.3%, p < .001). Primary decision-makers were less hesitant regarding COVID-19 vaccination than non-decision-makers (OR = 0.37, 95% CI 0.20-0.70); remarkably, whereas those engaged in nursing education versus non-medical related professional education (OR = 2.67, 95% CI 1.29-5.49), and partial versus full-course vaccination recipients (OR = 4.48, 95% CI: 1.76-11.42) were more likely to be hesitant regarding COVID-19 vaccination. CONCLUSION Our findings indicate that a high proportion of college teachers in China are hesitant to receiving COVID-19 vaccination, and that primary decision-makers are less likely to exhibit hesitancy to being vaccinated against COVID-19 than non-decision-makers in their family. Family decision-makers among teachers can be considered a priority for COVID-19 vaccine promotion, thereby enhancing vaccine acceptance among vulnerable populations-including older adults and children-and preventing adverse outcomes.KEY MESSAGESQuestion: How prevalent is COVID-19 vaccine hesitancy among college teachers? Do differences exist between decision-makers and non-decision-makers?Findings: We found that a substantial proportion of college teachers are hesitant to being vaccinated against COVID-19, and that family decision-makers exhibited a lower hesitancy rate than non-decision-makers.Meaning: Our findings indicate that distinguishing between family decision-makers and non-decision-makers is necessary to facilitate vaccination promotion interventions among college teachers.
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Affiliation(s)
- Rong Xu
- Department of Nursing, Xiamen Medical College, Xiamen, Fujian, China
| | - Guifeng Shi
- Department of Preventive Health Care, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Shuo Zheng
- Department of Nursing, Weifang Nursing Vocational College, Qingzhou, Shandong, China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Meixian Zhang
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
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Deng JS, Ying CQ, Lin XQ, Huang CL, Zhang MX, Tung TH, Zhu JS. Impact of household decision makers' hesitancy to vaccinate children against COVID-19 on other household members: A family-based study in Taizhou, China. SSM Popul Health 2023; 24:101517. [PMID: 37767519 PMCID: PMC10520923 DOI: 10.1016/j.ssmph.2023.101517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/13/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Background Vaccination is the most effective means of preventing outbreaks of infectious diseases, and family ;decision makers play an important role in decision-making regarding family matters and may influence other family members to take an active role in vaccinating children against COVID-19. Purpose This study examined the influence of family decision makers on the hesitation of other family members to vaccinate their children against COVID-19. Methods A population-based, self-administered online questionnaire was administered in Taizhou, China, from September 1, 2021, to September 15, 2021. The questionnaire included demographic information, knowledge, attitudes, and perceptions about the COVID-19 vaccine as well as hesitation regarding the use of the COVID-19 vaccination in children. In total, 490 respondents were included in this study. Logistic regression was used to assess the factors associated with vaccine hesitancy. Results In total, 490 respondents from 190 households were interviewed. Of the 190 family decision makers, 43.7% (83/190) were hesitant to vaccinate their children against COVID-19. When family decision makers were hesitant to vaccinate children against COVID-19, 65.1% (82/126) of the other family members expressed similar hesitancy regarding vaccination. When family decision makers were not hesitant to vaccinate children, only 21.3% (37/174) of other family members were hesitant to do so. In the regression analysis, family decision makers' hesitation to vaccinate their children was associated with other family members' hesitation (OR=6.264, 95% CI:3.132-12.526). In addition, decision makers' perceptions of the safety of the vaccine (OR=0.422, 95% CI:0.215-0.826) and hesitation to vaccinate themselves (OR=8.967, 95% CI:4.745-16.948) influenced their hesitation to vaccinate their children. Conclusion The present study found that family decision makers' hesitation to vaccinate children against COVID-19 influenced other family members' hesitation to vaccinate children. In addition, family decision makers' perceptions of the safety of the vaccine and their hesitation to vaccinate themselves influenced other family members' hesitation to vaccinate their children.
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Affiliation(s)
- Jing-Shan Deng
- Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, China
| | - Chen-Qian Ying
- Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, China
| | - Xiao-Qing Lin
- Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, China
| | - Chun-Lian Huang
- Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, China
| | - Mei-Xian Zhang
- Evidence-based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, China
| | - Tao-Hsin Tung
- Evidence-based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, China
| | - Jian-Sheng Zhu
- Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, China
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Sledge R, Concepcion BP, Witten B, Klicko K, Schatell D. Kidney Failure Patients' Perceptions and Definitions of Health: A Qualitative Study. Kidney Med 2023; 5:100603. [PMID: 36925662 PMCID: PMC10011499 DOI: 10.1016/j.xkme.2023.100603] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Rationale & Objective Patients with kidney failure who have used multiple treatment modalities are a unique source of information for how different options may best fit their values. We aimed to understand how people interpret their health and kidney failure treatment experience to inform providers who facilitate shared decision-making conversations. Study Design This qualitative, interpretive phenomenological study explores how patients with kidney failure interpret health throughout their treatment trajectory. Setting & Participants We recruited a purposive sample of patients who had used 3 or more kidney failure treatment options, including transplant and dialysis from transplant clinics and online support groups, for semi-structured interviews. Eligible participants were over 18 and spoke English for a total of 7 current transplant, 10 current home dialysis, and 1 current in-center patient. Analytical Approach A 6-step iterative process of data analysis occurred concurrently with data collection. Results Half of the 18 participants were Black; 67% were women. Three interrelated themes emerged from interviews: ability to engage in meaningful activities; working for balance; and living in context. Participants evaluated health according to their ability to engage in meaningful activities while balancing their emotional and physical needs with their life goals. When their social and treatment environments supported their autonomy, participants also considered themselves healthy. Limitations The inclusion of only English-speaking patients limits the transferability of findings. A longitudinal design, repeated interviews, observation, and dyadic interviews would increase the health care providers' understanding and interpretation of health. Conclusions The themes demonstrated patients evaluated health based on ability to engage in meaningful activities while maintaining balance. The treatment context, particularly how health care providers responded to patients' physiological experience, autonomy, and power, influenced interpretation of patient treatment experiences. Integrating patient interpretations of health with quantitative measures of treatment effectiveness can help health care providers better partner with patients to provide effective care for kidney failure.
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Affiliation(s)
- Renata Sledge
- Department of Social Work, Fontbonne University, Saint Louis, Missouri
| | - Beatrice P. Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Beth Witten
- Medical Education Institute, Inc, Madison, Wisconsin
| | - Kristi Klicko
- Medical Education Institute, Inc, Madison, Wisconsin
| | - Dori Schatell
- Medical Education Institute, Inc, Madison, Wisconsin
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Luo C, Zhang MX, Jiang E, Jin M, Tung TH, Zhu JS. The main decision-making competence for willingness-to-pay towards COVID-19 vaccination: a family-based study in Taizhou, China. Ann Med 2022; 54:2376-2384. [PMID: 36004802 PMCID: PMC9423852 DOI: 10.1080/07853890.2022.2114606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/03/2022] [Accepted: 08/13/2022] [Indexed: 11/01/2022] Open
Abstract
PURPOSE This research aimed to explore individuals' willingness to pay (WTP) and studied the role of family decision makers in WTP for COVID-19 vaccines. METHODS A self-administered online questionnaire evaluating the willingness of community residents to pay for booster vaccination of COVID-19 vaccine was conducted among families in a community in Taizhou, China. The logistic regression model was performed to identify the factors associated with WTP for the COVID-19 vaccines, and all data were analysed by R software, version 4.1.0. RESULTS 44.2% and 43.7% of 824 community residents were willing to pay for the first two doses and the booster dose of the COVID-19 vaccine, respectively. Decision-makers were more willing to pay for both the first two doses and the boost dose of the COVID-19 vaccines, with OR (95%CI) being 1.75 (1.25-2.47) and 1.89 (1.34-2.67), respectively. Besides, participants' WTP for COVID-19 vaccines were also associated with their occupation and monthly household income. CONCLUSION This study found that family decision-makers were more willing to pay for both the first two doses and the booster dose of COVID-19 vaccines in Taizhou, China. To improve the WTP for COVID-19 vaccines, public policy programs need to conduct a comprehensive cost-benefit analysis and focus on the role of family decision makers in vaccination.Key MessagesA study evaluating the willingness of community residents to pay for booster vaccination of COVID-19 vaccine was conducted among families in a community in Taizhou, China.Family decision-makers were more willing to pay for both the first two doses and the booster dose of COVID-19 vaccines.To improve the WTP for COVID-19 vaccines, public policy programs need to conduct a comprehensive cost-benefit analysis and focus on the role of family decision-makers in vaccination.
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Affiliation(s)
- Chengwen Luo
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, Zhejiang, China
| | - Mei-Xian Zhang
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, Zhejiang, China
| | - Eva Jiang
- Gucheng Street Community Health Service Center, Linhai, Zhejiang, China
| | - Mindan Jin
- Gucheng Street Community Health Service Center, Linhai, Zhejiang, China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, Zhejiang, China
| | - Jian-Sheng Zhu
- Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, Zhejiang, China
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Bakke BM, Feuz MA, McMahan RD, Barnes DE, Li B, Volow AM, Powell J, Sudore RL. Surrogate Decision Makers Need Better Preparation for Their Role: Advice from Experienced Surrogates. J Palliat Med 2022; 25:857-863. [DOI: 10.1089/jpm.2021.0283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brian M. Bakke
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Mariko A. Feuz
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- Des Moines University College of Osteopathic Medicine, Des Moines, Iowa, USA
| | - Ryan D. McMahan
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Deborah E. Barnes
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aiesha M. Volow
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jana Powell
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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Tanaka M, Bito S, Enzo A, Okita T, Atsushi A. Cross-sectional survey of surrogate decision-making in Japanese medical practice. BMC Med Ethics 2021; 22:128. [PMID: 34560873 PMCID: PMC8464150 DOI: 10.1186/s12910-021-00698-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Instances of surrogate decision-making are expected to increase with the rise in hospitalised older adults in Japan. Few large-scale studies have comprehensively examined the entire surrogate decision-making process. This study aimed to gather information to assess the current state of surrogate decision-making in Japan. METHODS A cross-sectional survey was conducted using online questionnaires. A total of 1000 surrogate decision-makers responded to the questionnaire. We examined the characteristics of surrogate decision-makers and patients, content of surrogate decision-making meeting regarding life-sustaining treatment between the doctors and surrogate decision-makers, extent of involvement of the various parties in the surrogate decision-making process, judgement grounds for surrogate decision-making, and frequency of involvement in the surrogate decision-making process. RESULTS Of the participants, 70.5% were male and 48.3% were eldest sons. Only 7.6% of the patients had left a written record of their preferences and 48.8% of the surrogates reported no knowledge of the patient having expressed their prior intentions regarding medical care in any form. Respondents indicated that their family meetings with healthcare professionals mostly included the information recommended by guidelines in a surrogate decision-making meeting in Japan. Most participants reported a good understanding of the meeting content. Although many participants based their decisions on multiple grounds, surrogates' considerations may not adequately reflect respect for patient autonomy in Japan. Specifically, the eldest son considered his own preference more frequently than that of the other surrogate decision-makers. In 26.1% of the cases, either zero or one family meeting with healthcare professionals was held. In these cases, significantly fewer decisions involved the participation of healthcare professionals other than the doctor compared to cases with multiple meetings. CONCLUSIONS Surrogate decisions in Japan are most commonly made by eldest sons and may not frequently consider the perspectives of other surrogates. The finding that patient preferences were rarely known suggests a role for increased advance care planning.
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Affiliation(s)
- Masashi Tanaka
- Department of Clinical Epidemiology, National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan. .,Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan. .,KARADA Internal Medicine Clinic Shibuya, 1-23-13 Jinnan, Shibuya-ku, Tokyo, 150-0041, Japan.
| | - Seiji Bito
- Department of Clinical Epidemiology, National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Aya Enzo
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Takethoshi Okita
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Asai Atsushi
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, 2-1 Seiryotyou, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
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Aldolaim S. Ethical Dilemma: Healthcare Surrogate Refusal of Opioid Administration. Pain Manag Nurs 2021; 22:806-810. [PMID: 34226149 DOI: 10.1016/j.pmn.2021.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/09/2021] [Accepted: 05/28/2021] [Indexed: 11/30/2022]
Abstract
It is morally distressing when a healthcare provider sees patients with undertreated pain but is unable to provide adequate relief because of a surrogate's refusal of such treatment. This issue might occur when there is no clear advanced directive that represents patients' wishes for treatment, and can be further complicated when patients are of minority cultural backgrounds. This article presents a case where the surrogate of a Korean-American woman with severe somatic pain from metastatic pancreatic cancer requested only acetaminophen be given to control the patient's pain. The ethical issues associated with surrogate misconceptions on therapeutic use of opioids are reviewed. This case highlights the ethical dilemma of withholding opioid treatment in a patient with advanced cancer. We conclude that the obligation to treat pain should be understood beyond the authority of surrogate refusal, in favor of patient quality of life, when an advance directive is not in place.
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Affiliation(s)
- Sadeg Aldolaim
- From the Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
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Rosenwohl-Mack S, Dohan D, Matthews T, Batten JN, Dzeng E. Understanding Experiences of Moral Distress in End-of-Life Care Among US and UK Physician Trainees: a Comparative Qualitative Study. J Gen Intern Med 2021; 36:1890-1897. [PMID: 33111237 PMCID: PMC7592132 DOI: 10.1007/s11606-020-06314-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Moral distress is a state in which a clinician cannot act in accordance with their ethical beliefs because of external constraints. Physician trainees, who work within rigid hierarchies and who lack clinical experience, are particularly vulnerable to moral distress. We examined the dynamics of physician trainee moral distress in end-of-life care by comparing experiences in two different national cultures and healthcare systems. OBJECTIVE We investigated cultural factors in the US and the UK that may produce moral distress within their respective healthcare systems, as well as how these factors shape experiences of moral distress among physician trainees. DESIGN Semi-structured in-depth qualitative interviews about experiences of end-of-life care and moral distress. PARTICIPANTS Sixteen internal medicine residents in the US and fourteen junior doctors in the UK. APPROACH The work was analyzed using thematic analysis. KEY RESULTS Some drivers of moral distress were similar among US and UK trainees, including delivery of potentially inappropriate treatments, a poorly defined care trajectory, and involvement of multiple teams creating different care expectations. For UK trainees, healthcare team hierarchy was common, whereas for US trainees, pressure from families, a lack of guidelines for withholding inappropriate treatments, and distress around physically harming patients were frequently cited. US trainees described how patient autonomy and a fear of lawsuits contributed to moral distress, whereas UK trainees described how societal expectations around resource allocation mitigated it. CONCLUSION This research highlights how the differing experiences of moral distress among US and UK physician trainees are influenced by their countries' healthcare cultures. This research illustrates how experiences of moral distress reflect the broader culture in which it occurs and suggests how trainees may be particularly vulnerable to it. Clinicians and healthcare leaders in both countries can learn from each other about policies and practices that might decrease the moral distress trainees experience.
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Affiliation(s)
- Sarah Rosenwohl-Mack
- Department of Family Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Dohan
- Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Thea Matthews
- Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | | | - Elizabeth Dzeng
- Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA.
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13
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Rath KA, Tucker KL, Lewis A. Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting. Am J Hosp Palliat Care 2021; 39:79-85. [PMID: 34002621 DOI: 10.1177/10499091211017872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient's wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions. METHODS Case report and discussion of the associated ethical issues. RESULTS We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team. CONCLUSION It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.
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Affiliation(s)
- Kelly A Rath
- Department of Neurocritical Care, Gardner Neuroscience Institute, University of Cincinnati, OH, USA
| | - Kristi L Tucker
- Section on Neurocritical Care, Department of Neurology, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
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14
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Silies KT, Köpke S, Schnakenberg R. Informal caregivers and advance care planning: systematic review with qualitative meta-synthesis. BMJ Support Palliat Care 2021; 12:bmjspcare-2021-003095. [PMID: 33952583 DOI: 10.1136/bmjspcare-2021-003095] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/23/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Advance care planning (ACP) is a communication process about a person's values, life goals and preferences for current and future treatment and care. It can improve end-of-life care experiences for care recipients as well as for family caregivers. Knowledge about caregivers' needs might support implementation of ACP interventions suitable to both care recipients and their caregivers. OBJECTIVE To explore the experiences and attitudes of informal family caregivers, and their knowledge, regarding ACP. METHODS A systematic literature search was conducted (participants: family caregivers; intervention: advance care planning; databases: MEDLINE, PsycINFO, CINAHL, Cochrane Library). Thematic synthesis was applied to qualitative and mixed methods studies; quantitative studies were described in relation to the themes of the meta-synthesis. RESULTS 57 studies were included, of these 51 in the meta-synthesis. Three themes emerged: (1) caregiver's individual conceptualisation of ACP, (2) caregiver's relationships and (3) ACP process. These themes were incorporated into a longitudinal perspective on the caregiver's ACP trajectory, encompassing the phases (A) life before, (B) ACP process, (C) utilisation of ACP and (D) life after. The implications for ACP activities are described according to each phase. CONCLUSION For the benefit of care recipients, healthcare professionals should carefully consider caregivers' conceptualisations of ACP as well as the relationships within the family. They need to be skilled communicators, sensitive to individual needs and equipped with sufficient time resources to tailor ACP interventions to their clients' unique situation. Thus, they will support decision-making according to care recipients' wishes, caregivers' end-of-life experience and their life after bereavement. PROSPERO REGISTRATION NUMBER CRD42018082492.
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Affiliation(s)
| | - Sascha Köpke
- Institute of Nursing Science, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Rieke Schnakenberg
- Department for Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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15
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Grounds for surrogate decision-making in Japanese clinical practice: a qualitative survey. BMC Med Ethics 2021; 22:5. [PMID: 33435976 PMCID: PMC7805133 DOI: 10.1186/s12910-020-00573-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 12/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background In the coming years, surrogate decision-making is expected to become highly prevalent in Japanese clinical practice. Further, there has been a recent increase in activities promoting advance care planning, which potentially affects the manner in which judgements are made by surrogate decision-makers. This study aims to clarify the grounds on which surrogate decision-makers in Japan base their judgements. Methods In this qualitative study, semi-structured interviews were conducted to examine the judgement grounds in surrogate decision-making for critical life-sustaining treatment choices in acute care hospitals. Results A total of 228 participants satisfied the inclusion criteria, and 15 were selected for interviews. We qualitatively analysed the content of 14 interview transcripts, excluding one that did not meet the inclusion criteria. Based on this analysis, we extracted 4 core categories, 17 categories, 35 subcategories, and 55 codes regarding judgement grounds in surrogate decision-making. The four core categories were as follows: patient preference-oriented factor (Type 1), patient interest-oriented factor (Type 2), family preference-oriented factor (Type 3), and balanced patient/family preference-oriented factor (Type 4). The Type 4 core category represented attempts to balance the preferences of the patient with those of the surrogate decision-maker. Conclusions Surrogate decision-makers based their decisions on important aspects related to a patient’s life, and they considered not only the patient’s preferences and best interests but also their own preferences. As the need for surrogate decisions will increase in the future, decision-makers will need to consider judgement grounds from a more diverse perspective.
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16
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Thiede E, Levi BH, Lipnick D, Johnson R, Seo La I, Lehman EB, Smith T, Wiegand D, Green M, Van Scoy LJ. Effect of Advance Care Planning on Surrogate Decision Makers' Preparedness for Decision Making: Results of a Mixed-Methods Randomized Controlled Trial. J Palliat Med 2020; 24:982-993. [PMID: 33373538 DOI: 10.1089/jpm.2020.0238] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Advance care planning (ACP) is intended to help patients and their spokespersons prepare for end-of-life decision making, yet little is known about what factors influence the extent to which spokespersons feel prepared for that role. Objective: To examine spokespersons' perceived preparedness for surrogate decision making after engaging in ACP. Design: Mixed methods experimental design with qualitative thematic analysis and data transformation (creating categorical data from rich qualitative data) of interviews collected during a randomized controlled trial (2012-2017). Setting/Participants: Two tertiary care medical centers (Hershey, PA and Boston, MA). Of 285 dyads (patients with advanced illness and their spokespersons) enrolled in the trial, 200 spokesperson interviews were purposively sampled and 198 included in the analyses. Main Outcomes and Measures: Interviews with spokespersons (four weeks post-intervention) explored spokespersons' perceived preparedness for surrogate decision making, occurrence of ACP conversations, and spokespersons' intentions regarding future surrogate decisions. Data transformation was used to categorize participants' responses into three categories: Very Prepared, Very Unprepared, or In Between Prepared and Unprepared. Themes and categories were compared across arms. Results: About 72.72% of spokespersons (144/198) reported being Very Prepared and 27.28% (54/198) reported being Very Unprepared or In Between with no differences in preparedness across study arms. Occurrence of post-intervention ACP conversations did not influence perceived preparedness; however, spokespersons who used an ACP decision aid reported more conversations. Four themes emerged to explain spokespersons' perceived preparedness: (1) perceptions about ACP; (2) level of comfort with uncertainty; (3) relational issues; and (4) personal characteristics. Regarding future intentions, it emerged that spokespersons believed their knowledge of patient wishes, as well as other personal, relational, situational, and emotional factors would influence their surrogate decisions. Conclusions: Factors extrinsic to specific ACP interventions influence how prepared spokespersons feel to act as spokespersons. Understanding these factors is important for understanding how to improve concordance between patients' stated end-of-life wishes and surrogate decisions. Trial Registration: NCT02429479.
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Affiliation(s)
- Elizabeth Thiede
- College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Benjamin H Levi
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Pediatrics, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Daniella Lipnick
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Rhonda Johnson
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - In Seo La
- School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Erik B Lehman
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Theresa Smith
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Pediatrics, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Debra Wiegand
- School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Michael Green
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Lauren Jodi Van Scoy
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
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Levoy K, Tarbi EC, De Santis JP. End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model. Nurs Outlook 2020; 68:784-807. [PMID: 32943221 PMCID: PMC7704858 DOI: 10.1016/j.outlook.2020.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 06/26/2020] [Accepted: 07/10/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research. PURPOSE To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model. METHOD Walker and Avant's approach to concept analysis. FINDINGS End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences). DISCUSSION Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
| | - Elise C Tarbi
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Joseph P De Santis
- University of Miami School of Nursing and Health Studies, Coral Gables, FL
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18
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Spalding R, Edelstein B. Factors predicting collaborative willingness of surrogates making medical decisions on the Physician Order for Scope of Treatment (POST). Aging Ment Health 2020; 24:1543-1552. [PMID: 31496268 DOI: 10.1080/13607863.2019.1660854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: The Physician's Order for Scope of Treatment (POST) indicates patient preferences regarding cardiopulmonary resuscitation (CPR), levels of care, and fluids/nutrition provision decisions. When patients become incapacitated, 'surrogates' often collaborate with physicians on POST decisions. Surrogates may vary in their willingness to collaborate, which can be problematic when physicians expect shared decision-making. No research has yet investigated collaborative decision-making among surrogates on the POST. This study investigated how six psychological variables predicted participants' desires for collaboration when completing an online decision-making task.Methods: Participants served as hypothetical surrogates and made decisions for another person on the three sections of the West Virginia POST. One-hundred-and-seventy-two adults were recruited from Amazon Mechanical Turk.Results: The six variables contributed significantly to the prediction of collaborative willingness, F (6, 163) = 5.29, p < .001, R2= 0.19. Two variables uniquely contributed: confidence and consideration of future consequences. The model most strongly predicted collaborative willingness for the CPR decision.Conclusion: This study provides a novel examination of under-researched areas: surrogate collaborative willingness and the POST. Differing risks associated with the three POST decisions may influence how surrogates value collaboration. Ways to enhance collaborative willingness when making POST decisions are discussed.
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Affiliation(s)
- Rachael Spalding
- Department of Psychology, West Virginia University, Morgantown, WV, USA
| | - Barry Edelstein
- Department of Psychology, West Virginia University, Morgantown, WV, USA
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19
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What would people think? Perceived social norms, willingness to serve as a surrogate, and end-of-life treatment decisions. Palliat Support Care 2020; 19:46-54. [PMID: 32665048 DOI: 10.1017/s1478951520000401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Population aging has increased the prevalence of surrogate decision making in healthcare settings. However, little is known about factors contributing to the decision to become a surrogate and the surrogate medical decision-making process in general. We investigated how intrapersonal and social-contextual factors predicted two components of the surrogate decision-making process: individuals' willingness to serve as a surrogate and their tendency to select various end-of-life treatments, including mechanical ventilation and palliative care options. METHOD An online sample (N = 172) of adults made hypothetical surrogate decisions about end-of-life treatments on behalf of an imagined person of their choice, such as a parent or spouse. Using self-report measures, we investigated key correlates of willingness to serve as surrogate (e.g., decision-making confidence, willingness to collaborate with healthcare providers) and choice of end-of-life treatments. RESULTS Viewing service as a surrogate as a more typical practice in healthcare was associated with greater willingness to serve. Greater decision-making confidence, greater willingness to collaborate with patients' physicians, and viewing intensive, life-sustaining end-of-life treatments (e.g., mechanical ventilation) as more widely accepted were associated with choosing more intensive end-of-life treatments. SIGNIFICANCE OF RESULTS The current study's consideration of both intrapersonal and social-contextual factors advances knowledge of two key aspects of surrogate decision making - the initial decision to serve as surrogate, and the surrogate's selection of various end-of-life treatment interventions. Providers can use information about the role of these factors to engage with surrogates in a manner that better facilitates their decision making. For instance, providers can be sensitive to potential cultural differences in surrogate decision-making tendencies or employing decision aids that bolster surrogates' confidence in their decisions.
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20
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Abshire MA, Nolan MT, Dy SM, Gallo JJ. What matters when doctors die: A qualitative study of family perspectives. PLoS One 2020; 15:e0235138. [PMID: 32574209 PMCID: PMC7310709 DOI: 10.1371/journal.pone.0235138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/09/2020] [Indexed: 11/19/2022] Open
Abstract
Background The challenges of supporting the end-of-life preferences of patients and their families have often been attributed to poor understanding of the patient’s condition. Understanding how physicians, as patients, communicate their end-of-life care preferences to their families may inform shared decision making at end of life. Objectives The purpose of this study was to understand what matters to families of physicians when decision making with and for a physician who is approaching the end of life. Design Cross-sectional qualitative design. Participants We conducted interviews with family members of deceased physicians. Approach We analyzed the data using the constant comparison method to identify themes. Key results Family members (N = 26) rarely were unclear about the treatment preferences of physicians who died. Three overarching themes emerged about what matters most to physicians’ families: (1) honoring preferences for the context of end-of-life care; (2) supporting the patient’s control and dignity in care; and, (3) developing a shared understanding of preferences. Families struggled to make decisions and provide the care needed by the physicians at the end of life, often encountering significant challenges from the healthcare system. Conclusions Even when disease and prognosis are well understood as in this group of physicians, families still experienced difficulties in end-of-life decision making. These findings highlight the need to specifically address preferences for caregiver, care setting and symptom management in shared end-of-life decision making conversations with patients and families.
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Affiliation(s)
- Martha A. Abshire
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
- * E-mail:
| | - Marie T. Nolan
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
| | - Sydney M. Dy
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Joseph J. Gallo
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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21
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Gonzales NR, Reynolds AS. Our patients are dying. Neurology 2020; 94:813-814. [DOI: 10.1212/wnl.0000000000009395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Batteux E, Ferguson E, Tunney RJ. A mixed methods investigation of end-of-life surrogate decisions among older adults. BMC Palliat Care 2020; 19:44. [PMID: 32241277 PMCID: PMC7119279 DOI: 10.1186/s12904-020-00553-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/23/2020] [Indexed: 11/15/2022] Open
Abstract
Background A large number of end-of-life decisions are made by a next-of-kin for a patient who has lost their decision-making capacity. This has given rise to investigations into how surrogates make these decisions. The experimental perspective has focused on examining how the decisions we make for others differ from our own, whereas the qualitative perspective has explored surrogate insights into making these decisions. Methods We conducted a mixed methods study to bring these two perspectives together. This is crucial to comparing decision outcomes to the decision process. We asked older adult partners to make end-of-life decisions for each other. They then took part in a semi-structured interview about their decision process. Transcripts were analysed using thematic analysis. Results 24 participants took part in the study. Surrogates were more likely to take a life-saving treatment at the risk of a diminished quality of life for their partner than for themselves. This was consistent with their transcripts which showed that they wanted to give their partner a better chance of living. Although there was evidence of surrogate inaccuracy in the decision task, participants overwhelmingly reported their intention to make a decision which aligns with the substituted judgment standard. However, uncertainty about their wishes pushed them to consider other factors. Conclusions Taking a mixed methods approach allowed us to make novel comparisons between decision outcome and process. We found that the intentions of surrogates broadly align with the expectations of the substituted judgment standard and that previous discussions with their partner helps them to make a decision.
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Affiliation(s)
- Eleonore Batteux
- Department of Clinical, Health and Educational Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
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23
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Cholbi M. Holding On and Letting Go: Anticipatory Grief and Surrogate Choices at the End of Life. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:42-43. [PMID: 31746712 DOI: 10.1080/15265161.2019.1674414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Abstract
End-of-life decision making frequently involves a complex balancing of clinical, cultural, social, ethical, religious and economic considerations. Achieving a happy balance of these sometimes-competing interests, however, can be particularly fraught in a family-centric society like Singapore where the family unit often retains significant involvement in care determinations necessitating careful consideration of the family's position during the decision-making process. While various decision-making tools such as relational autonomy, best interests principle and welfare-based models have been proposed to help navigate such difficult decision-making processes, their application in practical terms, however, is dubious at best. This case report is presented to highlight these issues and explore the utility of these frameworks within the Singapore end-of-life care context when the interests of the family may be dissonant from those of the patient.
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25
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How Surrogate Decision-Makers for Patients With Chronic Critical Illness Perceive and Carry Out Their Role. Crit Care Med 2019; 46:699-704. [PMID: 29462004 DOI: 10.1097/ccm.0000000000003035] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Family members commonly make medical decision for patients with chronic critical illness. This study examines how family members approach this decision-making role in real time. DESIGN Qualitative analysis of interviews with family members in the intervention arm of a randomized controlled communication trial. SETTINGS Medical ICUs at four U.S. hospitals. PARTICIPANTS Family members of patients with chronic critical illness (adults mechanically ventilated for ≥ 7 d and expected to remain ventilated and survive for ≥ 72 hr) who participated in the active arm of a communication intervention study. INTERVENTIONS Family members participated in at least two content-guided, informational, and emotional support meetings led by a palliative care physician and nurse practitioner. MEASUREMENTS AND MAIN RESULTS Grounded theory was used for qualitative analysis of 66 audio recordings of meetings with 51 family members. Family members perceived their role in four main ways: voice of the patient, advocate for the patient, advocate for others, and advocate for oneself. Their decision-making was characterized by balancing goals, sharing their role, keeping perspective, remembering previous experiences, finding sources of strength, and coping with various burdens. CONCLUSIONS Family members take a multifaceted approach as they participate in decision-making. Understanding how surrogates perceive and act in their roles may facilitate shared decision-making among clinicians and families during critical care.
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Nagai H. Blood ties and trust: a comparative history of policy on family consent in Japan and the United States. Monash Bioeth Rev 2019; 34:226-238. [PMID: 28432652 DOI: 10.1007/s40592-017-0069-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Informed consent honors the autonomous decisions of patients, and family consent places importance on decisions made by their families. However, there is little understanding of the relationship between these two medical decision-making approaches. Both approaches exist in Japan as part of its truth disclosure policy. What is the status of family consent in the United States, from which Japan introduced informed consent? This paper compares the situation in the United States with that in Japan, where family consent has been combined with informed consent. It then explains the history of policy development through which family consent was added to informed consent in the United States. Based on this analysis, the paper suggests that the relationship between informed consent and family consent in the United States was established on the basis of a family model that places more importance on trust-based relationships than it does on blood ties.
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Affiliation(s)
- Hiroyuki Nagai
- Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
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Bibas L, Peretz-Larochelle M, Adhikari NK, Goldfarb MJ, Luk A, Englesakis M, Detsky ME, Lawler PR. Association of Surrogate Decision-making Interventions for Critically Ill Adults With Patient, Family, and Resource Use Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e197229. [PMID: 31322688 PMCID: PMC6646989 DOI: 10.1001/jamanetworkopen.2019.7229] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Physicians often rely on surrogate decision-makers (SDMs) to make important decisions on behalf of critically ill patients during times of incapacity. It is uncertain whether targeted interventions to improve surrogate decision-making in the intensive care unit (ICU) reduce nonbeneficial treatment and improve SDM comprehension, satisfaction, and psychological morbidity. OBJECTIVE To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) to determine the association of such interventions with patient- and family-centered outcomes and resource use. DATA SOURCES A search was conducted of MEDLINE, Embase, and other relevant databases for potentially relevant studies from inception through May 30, 2018. STUDY SELECTION Randomized clinical trials studying interventions that were targeted at SDMs or family members of critically ill adults in the ICU were included. Key search terms included surrogate or substitute decision-maker, critically ill, randomized controlled trials, and their respective related terms. DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent, blinded reviewers independently screened citations and extracted data. Random effects models with inverse variance weighting were used to pool outcomes data when possible and otherwise present findings qualitatively. MAIN OUTCOMES AND MEASURES Outcomes of interest were divided into 3 categories: (1) patient-related clinical outcomes (mortality, length of stay [LOS], duration of life-sustaining therapies), (2) SDM and family-related outcomes (comprehension, major change in goals of care, incident psychological comorbidities [posttraumatic stress disorder, anxiety, depression], and satisfaction with care), and (3) use of resources (cost of care and health care resource use). RESULTS Of 3735 studies screened, 13 RCTs were included, comprising a total of 10 453 patients. Interventions were categorized as health care professional led (n = 6), ethics consultation (n = 3), palliative care consultation (n = 2), and media (n = 1 pamphlet and 1 video). No association with mortality was observed (risk ratio, 1.03; 95% CI, 0.98-1.08; P = .22). Intensive care unit LOS was significantly shorter among patients who died (mean difference, -2.11 days; 95% CI, -4.16 to -0.07; P = .04), but not in the overall population (mean difference, -0.79 days; 95% CI, -2.33 to 0.76 days; P = .32). There was no consistent difference in SDM-related outcomes, including satisfaction with care or perceived quality of care (n = 6 studies) and incident psychological comorbidities (depression: ratio of means, -0.11; 95% CI, -0.29 to 0.08; P = .26; anxiety: ratio of means, -0.08; 95% CI, -0.25 to 0.08; P = .31; or posttraumatic stress disorder: ratio of means: -0.04; 95% CI, -0.21 to 0.13; P = .65). Among 6 trials reporting effects on health care resource use, only 1 nurse-led intervention observed a significant reduction in costs ($75 850 control vs $51 060 intervention; P = .04). CONCLUSIONS AND RELEVANCE Systematic interventions aimed at improving surrogate decision-making for critically ill adults may reduce ICU LOS among patients who die in the ICU, without influencing overall mortality. Better understanding of the complex processes related to surrogate decision-making is needed.
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Affiliation(s)
- Lior Bibas
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Maude Peretz-Larochelle
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Neill K. Adhikari
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael J. Goldfarb
- Division of Cardiology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Adriana Luk
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Michael E. Detsky
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Sinai Health System, Toronto, Ontario, Canada
| | - Patrick R. Lawler
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Heart and Stroke/Richard Lewar Centre of Excellence, University of Toronto, Toronto, Ontario, Canada
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Not "Out of Sight, Out of Mind": Interventions to Relieve Suffering for Bereaved Families After an ICU Death. Crit Care Med 2019; 45:134-136. [PMID: 27984282 DOI: 10.1097/ccm.0000000000002119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
In this issue of the Hastings Center Report, Daniel Brudney suggests that clinicians have an overly deferential attitude toward their patients' surrogate decision-makers that is rooted in a wrongful investment of moral authority. He maintains that surrogate decision-makers have no moral right to decide for their loved ones and that their value in the decision-making process is limited to their knowledge of their loved one's preferences. If operationalized, Brudney's framework would ease the way for clinicians to remove a surrogate who cannot provide information relevant to the patient's preferences and to resort to a paternalistic model of decision-making. Brudney fails to consider that the value of the surrogate does not flow from the surrogate, but rather from the patient's moral claim to have decisions made for him or her by a loved one. This claim recognizes that surrogates have intrinsic value through their relationship to and knowledge of the patient. Bioethics consultation services can assist clinical teams in engaging with the human crowd that surrounds each patient and navigating conflicting values and goals. This relational approach embraces the "mire and blood" that is endemic to relationships and clinical encounters.
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Seaman JB, Arnold RM, Buddadhumaruk P, Shields AM, Gustafson RM, Felman K, Newdick W, SanPedro R, Mackenzie S, Morse JQ, Chang CCH, Happ MB, Song MK, Kahn JM, Reynolds CF, Angus DC, Landefeld S, White DB. Protocol and Fidelity Monitoring Plan for Four Supports. A Multicenter Trial of an Intervention to Support Surrogate Decision Makers in Intensive Care Units. Ann Am Thorac Soc 2018; 15:1083-1091. [PMID: 30088971 PMCID: PMC6322040 DOI: 10.1513/annalsats.201803-157sd] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Individuals acting as surrogate decision makers for critically ill patients frequently struggle in this role and experience high levels of long-term psychological distress. Prior interventions designed to improve the sharing of information by the clinical team with surrogate decision makers have demonstrated little effect on surrogates' outcomes or clinical decisions. In this report, we describe the study protocol and corresponding intervention fidelity monitoring plan for a multicenter randomized clinical trial testing the impact of a multifaceted surrogate support intervention (Four Supports) on surrogates' psychological distress, the quality of decisions about goals of care, and healthcare use. We will randomize the surrogates of 300 incapacitated critically ill patients at high risk of death and/or severe long-term functional impairment to receive the Four Supports intervention or an education control. The Four Supports intervention adds to the intensive care unit (ICU) team a trained interventionist (family support specialist) who delivers four types of protocolized support-emotional support; communication support; decisional support; and, if indicated, anticipatory grief support-to surrogates through daily interactions during the ICU stay. The primary outcome is surrogates' symptoms of anxiety and depression at 6-month follow-up, measured with the Hospital Anxiety and Depression Scale. Prespecified secondary outcome measures are the Patient Perception of Patient Centeredness Scale (modified for use with surrogates) and Impact of Event Scale scores at 3- and 6-month follow-up, respectively, together with ICU and hospital lengths of stay and total hospital cost among decedents. The fidelity monitoring plan entails establishing and measuring adherence to the intervention using multiple measurement methods, including daily checklists and coding of audiorecorded encounters. This approach to intervention fidelity may benefit others designing and testing behavioral interventions in the ICU setting. Clinical trial registered with www.clinicaltrials.gov (NCT01982877).
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Affiliation(s)
| | - Robert M. Arnold
- Department of General Internal Medicine, Section of Palliative Care and Medical Ethics, School of Medicine
- UPMC Palliative and Supportive Institute, Pittsburgh, Pennsylvania
| | | | | | | | - Kristyn Felman
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | - Wendy Newdick
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | - Rachel SanPedro
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | | | - Jennifer Q. Morse
- School of the Health Sciences, Chatham University, Pittsburgh, Pennsylvania
| | - Chung-Chou H. Chang
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
- Department of General Internal Medicine and
| | | | - Mi-Kyung Song
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia and
| | - Jeremy M. Kahn
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | - Charles F. Reynolds
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
| | - Seth Landefeld
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Douglas B. White
- CRISMA Center, Department of Critical Care Medicine, School of Medicine
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Petrillo LA, McMahan RD, Tang V, Dohan D, Sudore RL. Older Adult and Surrogate Perspectives on Serious, Difficult, and Important Medical Decisions. J Am Geriatr Soc 2018; 66:1515-1523. [PMID: 29972594 PMCID: PMC6167167 DOI: 10.1111/jgs.15426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/09/2018] [Accepted: 04/06/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To elicit decisions that diverse older adults and surrogates perceive as serious, difficult, or important and explore what helped them make those decisions. DESIGN Focus groups (N=13) in which participants were asked to recall serious, difficult, or important medical decisions and what helped them make those decisions. SETTING Clinics, support groups and senior centers. PARTICIPANTS Diverse English- and Spanish-speaking older adults (age: mean 78, range 64-89) and surrogates (age: mean 57, range 33-76) (29% African American, 26% white, 26% Asian or Pacific Islander, 19% Hispanic) (N=69). MEASUREMENTS We used thematic analysis to analyze transcripts. RESULTS We identified 168 decisions. Older adults from all racial and ethnic groups frequently recalled cancer treatment decisions and decisions about chronic illness management. Surrogates described decisions about transitions in care and medical crises. Older adults valued self-sufficiency and maximizing survival and relied on personal experiences as often as medical advice. In all racial and ethnic groups, surrogates valued avoiding suffering for loved ones. CONCLUSION Diverse older adults and surrogates perceive life-threatening illness and day-to-day decisions about chronic disease to be serious, difficult, and important. The surrogates' goal of avoiding suffering of older adults may differ from older adults' priorities of self-sufficiency and maximizing survival. Clinicians should support older adults and surrogates in identifying important and difficult decisions and learn about the values and information sources they bring to decision-making. With this knowledge, clinicians can customize decision support and achieve person-centered care.
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Affiliation(s)
- Laura A Petrillo
- Division of Palliative Care and Geriatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan D McMahan
- School of Medicine, University of California, San Francisco, San Francisco, California
| | - Victoria Tang
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Daniel Dohan
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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Frey R, Herzog SM, Hertwig R. Deciding on behalf of others: a population survey on procedural preferences for surrogate decision-making. BMJ Open 2018; 8:e022289. [PMID: 30049700 PMCID: PMC6067368 DOI: 10.1136/bmjopen-2018-022289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To assess people's procedural preferences for making medical surrogate decisions, from the perspectives of both a potential surrogate and an incapacitated patient. DESIGN Computer-assisted telephone interviews. Respondents were randomly assigned either the role of an incapacitated patient or that of a potential surrogate for an incapacitated family member. They were asked to rate six approaches to making a surrogate decision: patient-designated surrogate, discussion among family members, majority vote of family members' individual judgements, legally assigned surrogate, population-based treatment indicator and delegating the decision to a physician. SETTING Germany and German-speaking and French-speaking parts of Switzerland. PARTICIPANTS 2010 respondents were quota sampled from a panel (representative for the German and German-speaking and French-speaking Swiss populations, respectively, in terms of age, sex and regions). MAIN OUTCOME MEASURES Endorsement of each approach (rated on a scale from 1 to 10). Degree to which preferences overlap between the perspective of potential surrogates and potential patients. RESULTS Respondents' endorsement of the six different approaches varied markedly (from Mdn=9.3 to Mdn=2.6). Yet the preferences of respondents taking the perspective of incapacitated patients corresponded closely with those of respondents taking the perspective of a potential surrogate (absolute differences ranging from 0.1 to 1.3). The preferred approaches were a patient-designated surrogate (Mdn=9.3) and all family members making a collective decision by means of group discussion (Mdn=9.3). The two least-preferred approaches were relying on a statistical prediction rule (Mdn=3.0) and delegating the decision to a physician (Mdn=2.6). CONCLUSIONS Although respondents taking the perspective of an incapacitated patient preferred a patient-designated surrogate, few people have designated such a surrogate in practice. Policy-makers may thus consider implementing active choice, that is, identifying institutional settings in which many people can be reached (eg, when obtaining a driver's licence) and requesting them to complete advance directives and to designate a specific surrogate. Moreover, potential patients and surrogates alike highly valued shared surrogate decisions among family members. Policy-makers may consider acknowledging this possibility explicitly in future legislation, and caregivers and physicians may consider promoting shared surrogate decisions in practice.
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Affiliation(s)
- Renato Frey
- Center for Cognitive and Decision Sciences, Department of Psychology, University of Basel, Basel, Switzerland
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - Stefan M Herzog
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - Ralph Hertwig
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
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de Vries K, Drury-Ruddlesden J. Advance care planning for people with dementia: Ordinary everyday conversations. DEMENTIA 2018; 18:3023-3035. [PMID: 29566541 DOI: 10.1177/1471301218764169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Advance care planning for people with dementia has become a focus of dementia care policies in developed countries. In New Zealand, the framework for dementia care relies on the person with dementia having a level of competence to enable them to participate in the planning process. For people with dementia, it may be too late to initiate these discussions in terms of decision-making capacity. Consequently, decisions about end-of-life care for people with dementia are typically made by a family member who acts as a surrogate decision maker on behalf of the person with dementia. An exploratory qualitative study of 23 people who had been carers or provided support for a family member with dementia who had died within five years of the interview was undertaken. The overarching theme, ‘ordinary everyday conversations’, describes how informal conversations and discussions within the family relating to preferences at the end of life had been embedded in interactions within the families over years. Sub-themes revealed three important components enabling adherence to the prior wishes of the person with dementia through these conversations: knowing the person and belief in ‘doing the right thing’; the importance of Wills and Enduring Power of Attorney; and negotiating unexpected encounters. There is potential for families to be well prepared for the time when they may need to make decisions for the person with dementia based on ordinary everyday conversation that take place within families and throughout life. This study also suggests that more innovative approaches to making a Will may provide an important vehicle for expressing advanced care wishes.
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Affiliation(s)
- Kay de Vries
- Faculty of Health and Life Sciences, School of Nursing and Midwifery, De Montfort University, The Gateway, Leicester, UK
| | - Jenny Drury-Ruddlesden
- Faculty of Health, Graduate School of Nursing, Midwifery and Health, Victoria University Wellington, Wellington, New Zealand
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[Quality of dying processes after commencement of the German Living Will Act : Experiences of a surgical intensive care unit]. Chirurg 2018; 88:244-250. [PMID: 27995297 DOI: 10.1007/s00104-016-0345-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is so far no information on how the third act on amendment of the German guardianship law from 29 July 2009 has affected dying processes of critically ill patients. METHODS This retrospective study analyzed the patterns of dying processes in postoperative critically ill patients treated from 2009 to 2012 (period II after the commencement of the German Living Will Act) and 10 years before (period I, 1999-2002). Independent associations were calculated by logistic regression. RESULTS In the observation period II (n = 137 dying patients) time until death significantly decreased to 19.3 days (95% CI 14.8-23.8, p = 0.008) vs. 29.2 days (95% CI 23.7-34.6) in period I (n = 163). In period II respect of the patient's will preceded death in 42.3% of the dying patients (period I: 8.6%, p < 0.001). Simultaneously, the frequency of patients with a severe preoperative comorbidity (failure of more than one organ) increased (26.8% of dying patients vs. 5.5% in period I, p = 0.001). The treatment during period II was, in addition to high age and a severe comorbidity, a significant independent predictor for the possibility that respect of the patient's will preceded death (odds ratio 7.42; 95% CI 3.77-14.60). CONCLUSION Independent of various covariables, treatment after the commencement of the German Living Will Act was associated with a broader and earlier respect of the patient's will, thereby shortening the time until death.
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The Experience of Surrogate Decision Makers on Being Approached for Consent for Patient Participation in Research. A Multicenter Study. Ann Am Thorac Soc 2018; 14:238-245. [PMID: 27849142 DOI: 10.1513/annalsats.201606-425oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Recruitment in critical care research differs from other contexts in important ways: patients lack decision-making capacity, uncertainty exists regarding patient prognosis, and critical illnesses are often associated with appreciable morbidity and mortality. OBJECTIVES We aimed to describe the experiences of surrogate decision makers (SDMs) in being approached for consent for critically ill patients to participate in research. METHODS A multicenter, qualitative study involving semistructured interviews with 26 SDMs, who provided or declined surrogate consent for research participation, at 5 Canadian centers nested within a multicenter observational study of research recruitment practices. Transcripts were reviewed by three qualitative researchers, and data were analyzed using grounded theory and a narrative critical analysis. MEASUREMENTS AND MAIN RESULTS SDMs were guided by an overarching desire for the patient to live. Surrogate research decision-making involved three sequential stages: (1) being approached; (2) reflecting on participation; and (3) making a decision. In stage 1, SDMs identified factors (their expectations, how they were approached, the attributes of the person approaching, and study risks and benefits) that characterized their consent encounter and affirmed a preference to be approached in person. If SDMs perceived the risk of participation to be too high or felt patients may not benefit from participation, they did not contemplate further. In stage 2, SDMs who knew the patient's wishes or had a deeper understanding of research prioritized the patient's wishes and the perceived benefits of participation. Without this information, SDMs prioritized obtaining more and better care for the patient, considered what was in their mutual best interests, and valued healthcare professional's knowledge. Trust in healthcare professionals was essential to proceeding further. In stage 3, SDMs considered six factors in rendering decisions. CONCLUSIONS SDMs engaged in three sequential stages and considered six factors in making surrogate decisions for research participation. Surrogates' assessments of the risks and benefits of participation and their trust in healthcare professionals were critical factors in research decision-making. By conceptualizing surrogate decision-making for research in stages, future research can develop and test procedures to enhance the surrogate research decision-making process.
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Abstract
Determining effective decision support strategies that enhance quality of end-of-life decision making in the intensive care unit is a research priority. This systematic review identified interventional studies describing the effectiveness of decision support interventions administered to critically ill patients or their surrogate decision makers. We conducted a systematic literature search using PubMed, CINAHL, and Cochrane. Our search returned 121 articles, 22 of which met the inclusion criteria. The search generated studies with significant heterogeneity in the types of interventions evaluated and varied patient and surrogate decision-maker outcomes, which limited the comparability of the studies. Few studies demonstrated significant improvements in the primary outcomes. In conclusion, there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers. Additional research is needed to develop and evaluate innovative decision support interventions for end-of-life decision making in the intensive care unit.
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How Surrogates Decide: A Secondary Data Analysis of Decision-Making Principles Used by the Surrogates of Hospitalized Older Adults. J Gen Intern Med 2017; 32:1285-1293. [PMID: 28840485 PMCID: PMC5698224 DOI: 10.1007/s11606-017-4158-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 05/19/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
Abstract
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.
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Patient-family EoL communication and its predictors: Reports from caregivers of Latino patients in the rural U.S.-Mexico border region. Palliat Support Care 2017; 16:520-527. [PMID: 29072148 DOI: 10.1017/s147895151700092x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Family caregivers play an important role in end-of-life (EoL) decision making when the patient is unable to make his/her own decisions. While communication about EoL care between patients and family is perhaps a first step toward advance care planning (ACP)/EoL decisions, not every culture puts great value on open communication about this topic. The aims of the present study were to explore EoL communication and the aspects of communication among caregivers of Latino patients in the rural United States (U.S.)-Mexico border region. METHOD This study analyzed data from a hospice needs assessment collected from 189 family caregivers of Latino patients at a home health agency in a rural U.S.-Mexico border region. Bivariate tests and logistic regression were used to address our aims. RESULTS About half of the family caregivers (n = 96, 50.8%) reported to have ever engaged in EoL discussion with patients. Significant predictors of EoL discussion included life-sustaining treatment preference (odds ratio [OR] = 0.44, p < 0.05); knowledge of an advance directive (AD) (OR = 5.50, p < 0.01); and distrust of physicians (OR = 0.29, p < 0.01). Caregivers who preferred extending the life of their loved one even if he/she had to rely on life supports were less likely to engage in EoL communication. Also, caregivers who worried that physicians might want to stop treatments (i.e., "pull the plug") too soon were less likely to do so. Conversely, caregivers who had knowledge about ADs were more likely to engage in EoL communication. SIGNIFICANCE OF RESULTS EoL communication is a complex process influenced by individual, social, and cultural values and the beliefs of both the patient and his/her family. Inclusion of family caregivers in the ACP process and facilitating culturally tailored EoL communication between patients and family caregivers is important.
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O’Hare AM, Szarka J, McFarland LV, Vig EK, Sudore RL, Crowley S, Reinke LF, Trivedi R, Taylor JS. "Maybe They Don't Even Know That I Exist": Challenges Faced by Family Members and Friends of Patients with Advanced Kidney Disease. Clin J Am Soc Nephrol 2017; 12:930-938. [PMID: 28356337 PMCID: PMC5460720 DOI: 10.2215/cjn.12721216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/21/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Family members and friends of patients with advanced chronic illness are increasingly called on to assist with ever more complex medical care and treatment decisions arising late in the course of illness. Our goal was to learn about the experiences of family members and friends of patients with advanced kidney disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS As part of a study intended to identify opportunities to enhance advance care planning, we conducted semistructured interviews at the Veterans Affairs Puget Sound Health Care System with 17 family members and friends of patients with advanced kidney disease. Interviews were conducted between April of 2014 and May of 2016 and were audiotaped, transcribed, and analyzed inductively using grounded theory to identify emergent themes. RESULTS The following three themes emerged from interviews with patients' family members and friends: (1) their roles in care and planning were fluid over the course of the patient's illness, shaped by the patients' changing needs and their readiness to involve those close to them; (2) their involvement in patients' care was strongly shaped by health care system needs. Family and friends described filling gaps left by the health care system and how their involvement in care and decision-making was at times constrained and at other times expected by providers, depending on system needs; and (3) they described multiple sources of tension and conflict in their interactions with patients and the health care system, including instances of being pitted against the patient. CONCLUSIONS Interviews with family members and friends of patients with advanced kidney disease provide a window on the complex dynamics shaping their engagement in patients' care, and highlight the potential value of offering opportunities for engagement throughout the course of illness.
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Affiliation(s)
- Ann M. O’Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Hospital and Specialty Medicine Service, and
- Departments of Medicine and
| | - Jackie Szarka
- Center of Innovation for Veteran-Centered and Value-Driven Care
| | | | - Elizabeth K. Vig
- Geriatrics and Extended Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Departments of Medicine and
| | - Rebecca L. Sudore
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Susan Crowley
- Veterans Affairs Westhaven and Yale University, New Haven, Connecticut
| | - Lynn F. Reinke
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Hospital and Specialty Medicine Service, and
| | - Ranak Trivedi
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
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Family Communication about End-of-Life Decisions and the Enactment of the Decision-Maker Role. Behav Sci (Basel) 2017; 7:bs7020036. [PMID: 28590407 PMCID: PMC5485466 DOI: 10.3390/bs7020036] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/12/2017] [Accepted: 06/02/2017] [Indexed: 11/18/2022] Open
Abstract
End-of-life (EOL) decisions in families are complex and emotional sites of family interaction necessitating family members coordinate roles in the EOL decision-making process. How family members in the United States enact the decision-maker role in EOL decision situations was examined through in-depth interviews with 22 individuals who participated in EOL decision-making for a family member. A number of themes emerged from the data with regard to the enactment of the decision-maker role. Families varied in how decision makers enacted the role in relation to collective family input, with consulting, informing and collaborating as different patterns of behavior. Formal family roles along with gender- and age-based roles shaped who took on the decision-maker role. Additionally, both family members and medical professionals facilitated or undermined the decision-maker’s role enactment. Understanding the structure and enactment of the decision-maker role in family interaction provides insight into how individuals and/or family members perform the decision-making role within a cultural context that values autonomy and self-determination in combination with collective family action in EOL decision-making.
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Storytelling in the Early Bereavement Period to Reduce Emotional Distress Among Surrogates Involved in a Decision to Limit Life Support in the ICU: A Pilot Feasibility Trial. Crit Care Med 2017; 45:35-46. [PMID: 27618273 DOI: 10.1097/ccm.0000000000002009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Surrogate decision makers involved in decisions to limit life support for an incapacitated patient in the ICU have high rates of adverse emotional health outcomes distinct from normal processes of grief and bereavement. Narrative self-disclosure (storytelling) reduces emotional distress after other traumatic experiences. We sought to assess the feasibility, acceptability, and tolerability of storytelling among bereaved surrogates involved in a decision to limit life support in the ICU. DESIGN Pilot single-blind trial. SETTING Five ICUs across three hospitals within a single health system between June 2013 and November 2014. SUBJECTS Bereaved surrogates of ICU patients. INTERVENTIONS Storytelling and control conditions involved printed bereavement materials and follow-up assessments. Storytelling involved a single 1- to 2-hour home or telephone visit by a trained interventionist who elicited the surrogate's story. MEASUREMENTS AND MAIN RESULTS The primary outcomes were feasibility (rates of enrollment, intervention receipt, 3- and 6-mo follow-up), acceptability (closed and open-ended end-of-study feedback at 6 mo), and tolerability (acute mental health services referral). Of 53 eligible surrogates, 32 (60%) consented to treatment allocation. Surrogates' mean age was 55.5 (SD, 11.8), and they were making decisions for their parent (47%), spouse (28%), sibling (13%), child (3%), or other relation (8%). We allocated 14 to control and 18 to storytelling, 17 of 18 (94%) received storytelling, 14 of 14 (100%) and 13 of 14 (94%) control subjects and 16 of 18 (89%) and 17 of 18 (94%) storytelling subjects completed their 3- and 6-month telephone assessments. At 6 months, nine of 13 control participants (69%) and 16 of 17 storytelling subjects (94%) reported feeling "better" or "much better," and none felt "much worse." One control subject (8%) and one storytelling subject (6%) said that the study was burdensome, and one control subject (8%) wished they had not participated. No subjects required acute mental health services referral. CONCLUSION A clinical trial of storytelling in this study population is feasible, acceptable, and tolerable.
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Lilley EJ, Morris MA, Sadovnikoff N, Luxford JM, Changoor NR, Bystricky A, Bader AM, Cooper Z. "Taking over somebody's life": Experiences of surrogate decision-makers in the surgical intensive care unit. Surgery 2017; 162:453-460. [PMID: 28549520 DOI: 10.1016/j.surg.2017.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/28/2017] [Accepted: 03/09/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Impaired capacity of patients necessitates the use of surrogates to make decisions on behalf of patients. Little is known about surrogate decision-making in the surgical intensive care unit, where the decline to critical illness is often unexpected. We sought to explore surrogate experiences with decision-making in the surgical intensive care unit. METHODS This qualitative study was performed at 2 surgical intensive care units at a single, tertiary, academic hospital Surrogate decision-makers who had made a major medical decision for a patient in the surgical intensive care unit were identified and enrolled prospectively. Semistructured telephone interviews following an interview guide were conducted within 90 days after hospitalization until thematic saturation. Recordings were transcribed, coded inductively, and analyzed utilizing an interpretive phenomenologic approach. RESULTS A major theme that emerged from interviews (N = 19) centered on how participants perceived the surrogate role, which is best characterized by 2 archetypes: (1) Preferences Advocates, who focused on patients' values; and (2) Clinical Facilitators, who focused on patients' medical conditions. The primary archetype of each surrogate influenced how they defined their role and approached decisions. Preferences Advocates framed decisions in the context of patients' values, whereas Clinical Facilitators emphasized the importance of clinical information. CONCLUSION The experiences of surrogates in the surgical intensive care unit are related to their understanding of what it means to be a surrogate and how they fulfill this role. Future work is needed to identify and manage the informational needs of surrogate decision-makers.
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Affiliation(s)
- Elizabeth J Lilley
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
| | - Megan A Morris
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nicholas Sadovnikoff
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jamahal M Luxford
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia
| | - Navin R Changoor
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Anna Bystricky
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Angela M Bader
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA
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Berger JT. The Limits of Surrogates’ Moral Authority and Physician Professionalism:Can the Paradigm of Palliative Sedation Be Instructive? Hastings Cent Rep 2017; 47:20-23. [DOI: 10.1002/hast.665] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Withdrawal of life-sustaining treatment: patient and proxy agreement: a secondary analysis of "contracts, covenants, and advance care planning". Dimens Crit Care Nurs 2016; 34:91-9. [PMID: 25650494 DOI: 10.1097/dcc.0000000000000097] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Kim H, Deatrick JA, Ulrich CM. Ethical frameworks for surrogates' end-of-life planning experiences. Nurs Ethics 2016; 24:46-69. [PMID: 27005954 DOI: 10.1177/0969733016638145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the growing body of knowledge about surrogate decision making, we know very little about the use of ethical frameworks (including ethical theories, principles, and concepts) to understand surrogates' day-to-day experiences in end-of-life care planning for incapacitated adults. OBJECTIVES AND METHODS This qualitative systematic review was conducted to identify the types of ethical frameworks used to address surrogates' experiences in end-of-life care planning for incapacitated adults as well as the most common themes or patterns found in surrogate decision-making research. FINDINGS Seven research papers explicitly identified ethical theories, principles, or concepts, such as autonomy, substituted judgment, and best interest standards as guidelines for the research. Surrogate decision making themes included the responsibilities and goals of being a surrogate, factors influencing surrogates' decision making, outcomes for surrogates, and an overarching theme of "wanting to do the right thing" for their loved one and/or themselves. DISCUSSION Understanding the complexity of surrogates' experiences of end-of-life care planning is beyond the scope of conventional ethical frameworks. CONCLUSION Ethical frameworks that address individuality and contextual variations related to decision making may more appropriately guide surrogate decision-making research that explores surrogates' end-of-life care planning experiences.
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Narang AK, Wright AA, Nicholas LH. Trends in Advance Care Planning in Patients With Cancer: Results From a National Longitudinal Survey. JAMA Oncol 2016; 1:601-8. [PMID: 26181909 DOI: 10.1001/jamaoncol.2015.1976] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Advance care planning (ACP) may prevent end-of-life (EOL) care that is nonbeneficial and discordant with patient wishes. Despite long-standing recognition of the merits of ACP in oncology, it is unclear whether participation in ACP by patients with cancer has increased over time. OBJECTIVES To characterize trends in durable power of attorney (DPOA) assignment, living will creation, and participation in discussions of EOL care preferences and to explore associations between ACP subtypes and EOL treatment intensity as reflected in EOL care decisions and terminal hospitalizations. DESIGN, SETTING, AND PARTICIPANTS We analyzed prospectively collected survey data from 1985 next-of-kin surrogates of Health and Retirement Study (HRS) participants with cancer who died between 2000 and 2012, including data from in-depth "exit" interviews conducted with the surrogates after the participant's death. The HRS is a nationally representative, biennial, longitudinal panel study of US residents older than 50 years. Trends in ACP subtypes were tested, and multivariable logistic regression models examined for associations between ACP subtypes and measures of treatment intensity. MAIN OUTCOMES AND MEASURES Trends in the surrogate-reported frequency of DPOA assignment, living will creation, and participation in discussions of EOL care preferences; associations between ACP subtypes and both surrogate-reported EOL care decisions and terminal hospitalizations. RESULTS From 2000 to 2012, there was an increase in DPOA assignment (52% to 74%, P = .03), without significant change in use of living wills (49% to 40%, P = .63) or EOL discussions (68% to 60%, P = .62). Surrogate reports that patients received "all care possible" at EOL increased during the period (7% to 58%, P = .004), and rates of terminal hospitalizations were unchanged (29% to 27%, P = .70). Limiting or withholding treatment was associated with living wills (adjusted odds ratio [AOR], 2.51; 95% CI, 1.53-4.11; P < .001) and EOL discussions (AOR, 1.93; 95% CI, 1.53-3.14; P = .002) but not with DPOA assignment. CONCLUSIONS AND RELEVANCE Use of DPOA increased significantly between 2000 and 2012 but was not associated with EOL care decisions. Importantly, there was no growth in key ACP domains such as discussions of care preferences. Efforts that bolster communication of EOL care preferences and also incorporate surrogate decision makers are critically needed to ensure receipt of goal-concordant care.
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Affiliation(s)
- Amol K Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts3Harvard Medical School, Boston, Massachusetts
| | - Lauren H Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland5Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Kon AA, Davidson JE, Morrison W, Danis M, White DB. Shared Decision Making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement. Crit Care Med 2016; 44:188-201. [PMID: 26509317 PMCID: PMC4788386 DOI: 10.1097/ccm.0000000000001396] [Citation(s) in RCA: 321] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Shared decision making is endorsed by critical care organizations; however, there remains confusion about what shared decision making is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define shared decision making, recommend when shared decision making should be used, identify the range of ethically acceptable decision-making models, and present important communication skills. DESIGN The American College of Critical Care Medicine and American Thoracic Society Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of American College of Critical Care Medicine and American Thoracic Society were included in the statement. MAIN RESULTS Six recommendations were endorsed: 1) DEFINITION: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient's values, goals, and preferences. 2) Clinicians should engage in a shared decision making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their "default" approach a shared decision making process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable, including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies. CONCLUSIONS Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.
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Affiliation(s)
- Alexander A. Kon
- Naval Medical Center San Diego, San Diego, CA
- University of California San Diego, San Diego, CA
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Miller JJ, Morris P, Files DC, Gower E, Young M. Decision conflict and regret among surrogate decision makers in the medical intensive care unit. J Crit Care 2015; 32:79-84. [PMID: 26810482 DOI: 10.1016/j.jcrc.2015.11.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/30/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Family members of critically ill patients in the intensive care unit face significant morbidity. It may be the decision-making process that plays a significant role in the psychological morbidity associated with being a surrogate in the ICU. We hypothesize that family members facing end-of-life decisions will have more decisional conflict and decisional regret than those facing non-end-of-life decisions. METHODS We enrolled a sample of adult patients and their surrogates in a tertiary care, academic medical intensive care unit. We queried the surrogates regarding decisions they had made on behalf of the patient and assessed decision conflict. We then contacted the family member again to assess decision regret. RESULTS Forty (95%) of 42 surrogates were able to identify at least 1 decision they had made on behalf of the patient. End-of-life decisions (defined as do not resuscitate [DNR]/do not intubate [DNI] or continuation of life support) accounted for 19 of 40 decisions (47.5%). Overall, the average Decision Conflict Scale (DCS) score was 21.9 of 100 (range 0-100, with 0 being little decisional conflict and 100 being great decisional conflict). The average DCS score for families facing end-of-life decisions was 25.5 compared with 18.7 for all other decisions. Those facing end-of-life decisions scored higher on the uncertainty subscale (subset of DCS questions that indicates level of certainty regarding decision) with a mean score of 43.4 compared with all other decisions with a mean score of 27.0. Overall, very few surrogates experienced decisional regret with an average DRS score of 13.4 of 100. CONCLUSIONS Nearly all surrogates enrolled were faced with decision-making responsibilities on behalf of his or her critically ill family member. In our small pilot study, we found more decisional conflict in those surrogates facing end-of-life decisions, specifically on the subset of questions dealing with uncertainty. Surrogates report low levels of decisional regret.
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Affiliation(s)
- Jesse J Miller
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
| | - Peter Morris
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
| | - D Clark Files
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
| | - Emily Gower
- Wake Forest School of Medicine, Department of Epidemiology and Ophthalmology, Winston Salem, NC 27012.
| | - Michael Young
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
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Smart CM, Giacino JT. Exploring caregivers’ knowledge of and receptivity toward novel diagnostic tests and treatments for persons with post-traumatic disorders of consciousness. NeuroRehabilitation 2015; 37:117-30. [DOI: 10.3233/nre-151244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Colette M. Smart
- JFK-Johnson Rehabilitation Institute and the New Jersey Neuroscience Institute, JFK Medical Center, Edison, NJ, USA
- Department of Psychology, University of Victoria, Victoria, BC, Canada
| | - Joseph T. Giacino
- JFK-Johnson Rehabilitation Institute and the New Jersey Neuroscience Institute, JFK Medical Center, Edison, NJ, USA
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, USA
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How clinicians discuss critically ill patients' preferences and values with surrogates: an empirical analysis. Crit Care Med 2015; 43:757-64. [PMID: 25565458 DOI: 10.1097/ccm.0000000000000772] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although shared decision making requires clinicians to discuss the patient's values and preferences, little is known about the extent to which this occurs with surrogates in ICUs. We sought to assess whether and how clinicians talk with surrogates about incapacitated patients' preferences and values. DESIGN Prospective, cross-sectional study. SETTING Five ICUs of two hospitals. SUBJECTS Fifty-four physicians and 159 surrogates for 71 patients. INTERVENTIONS We audio-recorded 71 conferences in which clinicians and surrogates discussed life-sustaining treatment decisions for an incapacitated patient near the end of life. Two coders independently coded each instance in which clinicians or surrogates discussed the patient's previously expressed treatment preferences or values. They subcoded for values that are commonly important to patients near the end of life. They also coded treatment recommendations by clinicians that incorporated the patient's preferences or values. MEASUREMENTS AND MAIN RESULTS In 30% of conferences, there was no discussion about the patient's previously expressed preferences or values. In 37%, clinicians and surrogates discussed both the patient's treatment preferences and values. In the remaining 33%, clinicians and surrogates discussed either the patient's treatment preferences or values, but not both. In more than 88% of conferences, there was no conversation about the patient's values regarding autonomy and independence, emotional well-being and relationships, physical function, cognitive function, or spirituality. On average, 3.8% (SD, 4.3; range, 0-16%) of words spoken pertained to patient preferences or values. CONCLUSIONS In roughly a third of ICU family conferences for patients at high risk of death, neither clinicians nor surrogates discussed patients' preferences or values about end-of-life decision making. In less than 12% of conferences did participants address values of high importance to most patients, such as cognitive and physical function. Interventions are needed to ensure patients' values and preferences are elicited and integrated into end-of-life decisions in ICUs.
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