When doctors and daughters disagree: twenty-two days and two blinks of an eye

Case report on the legal assurance of Advance Care Planning in collective culture

This case report shows that there is a lack of a legal framework in Japan to protect patients' right during the end‐of‐life period, which hinders the implementation of ACP in medical practice. This report suggests that legal support can contribute to the advancement of ACP while addressing cultural differences.

Advance Care Planning has been widely advocated in Japan, but it has not yet taken root. The collective decision making culture in Japan may unconsciously overpower or ignore the patients' wishes, hence legal support can mitigate its negative impacts on ACP.

Caregiver-provider communication about pain in persons with dementia

BACKGROUND

Pain in older persons with dementia is both under-detected and under-managed. Family caregivers can play an important role in addressing these deficiencies by communicating their care recipient's symptoms and behaviors to medical providers, but little is known about how caregivers and providers approach pain-related discussions in the context of dementia. The goal of this study was to explore how ambulatory care providers and family caregivers of persons with dementia view pain communication.

METHODS

In-depth, semi-structured interviews were conducted with family caregivers (n = 18) and healthcare providers involved in dementia care (n = 16). Interviews focused on three specific content areas: (1) caregivers' roles in communicating about pain in persons with dementia, (2) challenges experienced when communicating about pain in persons with dementia, and (3) strategies and recommendations for optimizing communication in this context. All interviews were audio-recorded, transcribed, and analyzed using the constant comparative method of data analysis.

RESULTS

Caregivers and providers described various roles that caregivers assumed in communication processes, such as serving as historians, interpreters, and advocates. They identified two key features of problematic communication-receipt of inadequate information and interpersonal conflict about the care recipient's pain-and articulated how ambiguity around pain and dementia, as well as preexisting beliefs and emotions, contributed to communication challenges. They also offered several suggestions to improve caregiver-provider communication processes, including the use of (1) written records to enhance the accuracy of caregivers' reports and ensure that providers had specific information to inform symptom management and treatment plans, (2) pain scales and follow-up discussions to establish baseline data and clarify treatment recommendations, and (3) collaboration and rapport-building strategies to validate the caregivers' contributions and maximize a team-based decision-making.

CONCLUSION

Receipt of inadequate information and interpersonal conflict are key challenges to caregiver-provider communication regarding pain in persons with dementia. Written records, pain scales, and rapport-building strategies may help to address these challenges.

Evaluation of a Collaborative Advance Care Planning Intervention among Older Adult Home Health Patients and Their Caregivers

Background: Caregivers are decision stakeholders; yet, few interventions have been developed to help patients and caregivers collaborate on advance care planning (ACP). Objective: To evaluate a theory-based ACP pilot intervention, Deciding Together, to improve decisional quality, readiness, collaboration, and concordance in ACP decisions for older adult home health (HH) patients and caregivers. Design: A one-group, pre- and posttest study using matched questionnaires was conducted. The intervention consisted of a clinical vignette, theoretically guided conversation prompts, and a shared decision-making activity. Setting/Subjects:N = 36 participants (n = 18 HH patients; n = 18 family and nonfamily caregivers) were purposively recruited from a HH agency to participate in the intervention at patients' homes. Measurements: Demographic and baseline measures were collected for relationship quality, health status, and previous ACP engagement. Outcome measures included perceptions of collaboration, readiness for ACP, concordance in life-sustaining treatment preferences (cardiopulmonary resuscitation, antibiotics, artificial nutrition and hydration, and mechanical ventilation), and decisional conflict. Descriptive statistics, Cohen's κ coefficients, paired t tests, McNemar's tests, and Wilcoxon signed-rank tests (and effect size estimates, r = z/√N) were calculated using R-3.5.1 (p < 0.05). Single value imputation was used for missing values. Results: While no significant differences were found for perceptions of collaboration, and readiness for ACP, patients (r = 0.38, p = 0.02) and caregivers (r = 0.38, p = 0.02) had reduced decisional conflict at posttest. Patients' and caregivers' agreement increased by 27.7% for an item assessing patients' preference for artificial nutrition and hydration (p = 0.03). Conclusions: This study suggests that collaborative ACP decision making may improve decisional conflict for older adult HH patients and their caregivers.

Increasing advance care planning in the secondary care setting: A quality improvement project

BACKGROUND

Advance care plans (ACP) provide patients the opportunity to communicate their goals and wishes for future care.

LOCAL PROBLEM

A retrospective case note review of 50 inpatient deaths in 2017 confirmed a doctor had discussed expected death in 90%, however only 2% had an ACP.

METHODS

Patients appropriate for ACP were identified on a single geriatrics ward. Interventions were implemented with monthly data collection. Patients with an ACP were followed prospectively. The initiatives were subsequently applied across six geriatrics wards.

INTERVENTIONS

Interventions included improved identification of patients appropriate for ACP, doctor education and improved communication to general practitioners and healthcare providers.

RESULTS

Before initiation of interventions on the pilot ward, ACP was completed for 38% of appropriate patients; this increased to a mean of 78.6% over 4 months post-interventions. During the pilot, 44 patients had an ACP. Of those discharged, 75% avoided readmission over the following 6 months. After applying the interventions across all geriatric wards, ACPs increased to a mean of 81.2% and was maintained 12 months later at 72%.

CONCLUSIONS

The initiatives formed a structure to promote the use of ACP on the wards. Care plans focused on individualising care and effective communication resulted in reduction of readmissions.

Family Caregivers' Experiences With Health Care Workers in the Care of Older Adults With Activity Limitations

Importance

Family and unpaid caregivers often play an active role in managing the care of older adults with activity limitations.

Objective

To examine caregivers' experiences with older adults' health care workers.

Design, Setting, and Participants

This survey study constitutes a secondary analysis of a sample of 1916 family and unpaid caregivers to 1203 community-living older adults with activity limitations who participated in the 2017 National Health and Aging Trends Study. Data analysis was performed January to August 2019.

Exposures

Caregiver sociodemographic characteristics, caregiving intensity, and frequency speaking with or emailing older adults' health care workers.

Main Outcomes and Measures

Caregiver-reported experiences when interacting with older adults' health care workers in the prior year, including being listened to, being asked about understanding of treatments, and being asked about help needed in managing older adults' care.

Results

Caregivers (mean [SE] age, 59.4 [0.5] years; 63.7% women) assisting community-living older adults with activity limitations reported that they never (56.3%), sometimes or rarely (33.0%), or often (10.7%) spoke with or emailed older adults' health care workers in the prior year. Most caregivers who interacted with older adults' health care workers reported being always (70.6%) or usually (18.2%) listened to and always (54.4%) or usually (17.7%) being asked about their understanding of older adults' treatments. Fewer caregivers reported being always (21.3%) or usually (6.9%) asked whether they needed help managing older adults' care, and nearly one-half (45.0%) were never asked. Caregivers who interacted with older adults' health care workers often (vs sometimes or rarely) were more likely to report being always or usually listened to (94.8% vs 86.9%; P = .004), being asked about understanding treatments (80.1% vs 69.5%; P = .02), and being asked about needing help (40.8% vs 24.1%; P < .001). No other exposures were consistently associated with caregiver experiences. Measures of caregiving intensity, including caring for an older adult with dementia, were not associated with being listened to or asked about understanding, but were associated with being asked about needed help. Although caregivers of persons with dementia were more likely than caregivers of persons without dementia to report always being asked about needed help (26.9% vs 19.0%), a high percentage in both groups were never asked (41.2% vs 46.5%) (P = .007).

Conclusions and Relevance

These findings reinforce the need for strategies to better support family and unpaid caregivers, who are the main source of assistance to older adults with physical and/or cognitive limitations.

Nursing home resident deaths due to road trauma and the potential roles for nursing home providers to promote public safety

OBJECTIVE

This commentary aimed to determine whether nursing home (NH) providers have a responsibility for the safe mobility of residents outside the facility.

METHODS

The Safe System approach was applied to NH resident road safety, and fatality crash data involving NH residents were reviewed, to identify potential countermeasures to prevent injurious road crashes for older people living in a NH.

RESULTS

Viewing NH resident road safety through the Safe System approach identified actions that NH providers can take to actively contribute to: safe roads/roadsides for residents by better land use, infrastructure and design improvements; ensuring vehicles purchased and used for transporting residents have safety features; safe speed zones within and on nearby streets to NH; and safer road user behaviour through ensuring travel care plans for each resident.

CONCLUSION

Applying the Safe System approach has provided new and innovative insights into how road safety can be improved for NH residents.

Competing and conflicting interests in the care of critically ill patients

Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician's sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient's best interest and discusses steps that could help minimize the impact of these factors on patient care.

Advance directives: empowering patients at the end of life

Advance directives were conceived as a prospective means of empowering patients to direct their own end-of-life care. Unfortunately, these directives have been inadequately incorporated into healthcare decisions due to less-than-optimal execution and implementation. The authors explore challenges to implementing advance directives and propose potential solutions.

Alzheimer, dementia and the living will: a proposal

The world population aged significantly over the twentieth century, leading to an increase in the number of individuals presenting progressive, incapacitating, incurable chronic-degenerative diseases. Advances in medicine to prolong life prompted the establishment of instruments to ensure their self-determination, namely the living will, which allows for an informed person to refuse a type of treatment considered unacceptable according to their set of values. From the knowledge on the progression of Alzheimer disease, it is possible to plan the medical care, even though there is still no treatment available. Irreversible cognitive incapacity underlines the unrelenting loss of autonomy of the demented individual. Such a loss requires the provision of specific and permanent care. Major ethical issues are at stake in the physician-patient-family relationship, even when dementia is still at an early stage. The authors suggest that for an adequate health care planning in Alzheimer disease the living will can be presented to the patient in the early days of their geriatric care, as soon as the clinical, metabolic or even genetic diagnosis is accomplished. They also suggest that the appointment of a health care proxy should be done when the person is still in full enjoyment of his cognitive ability, and that the existence and scope of advance directives should be conveyed to any patient in the early stages of the disease. It follows that ethical guidelines should exist so that neurologists as well as other physicians that deal with these patients should discuss these issues as soon as possible after a diagnosis is reached.

Dialysis in the frail elderly--a current ethical problem, an impending ethical crisis

The current practice of hemodialysis for the frail elderly frequently ignores core bioethical principles. Lack of transparency and shared decision making coupled with financial incentives to treat have resulted in problems of overtreatment near the end of life. Imminent changes in reimbursement for hemodialysis will reverse the financial incentives to favor not treating high-risk patients. In this article, we describe what is empirically known about the approach to hemodialysis today, and how it violates four core ethical principles. We then discuss how the new financial system turns physician and organizational incentives upside down in ways that may exacerbate the ethical dilemmas, but in the opposite direction.

Advance care planning beyond advance directives: perspectives from patients and surrogates

CONTEXT

Advance care planning (ACP) has focused on documenting life-sustaining treatment preferences in advance directives (ADs). The ADs alone may be insufficient to prepare diverse patients and surrogates for complex medical decisions.

OBJECTIVES

To understand what steps best prepare patients and surrogates for decision making.

METHODS

We conducted 13 English/Spanish focus groups with participants from a Veterans Affairs and county hospital and the community. Seven groups included patients (n=38), aged ≥65 years, who reported making serious medical decisions. Six separate groups included surrogates (n=31), aged ≥18 years, who made decisions for others. Semistructured focus groups asked what activities best prepared the participants for decision making. Two investigators independently coded data and performed thematic content analysis. Disputes were resolved by consensus.

RESULTS

The mean±SD patient age was 78±8 years, and 61% were nonwhite. The mean±SD surrogate age was 57±10 years, and 91% were nonwhite. Qualitative analysis identified four overarching themes about how to best prepare for decision making: 1) identify values based on past experiences and quality of life, 2) choose surrogates wisely and verify that they understand their role, 3) decide whether to grant leeway in surrogate decision making, and 4) inform other family and friends of one's wishes to prevent conflict.

CONCLUSION

Beyond ADs, patients and surrogates recommend several additional steps to prepare for medical decision making including using past experiences to identify values, verifying that the surrogate understands their role, deciding whether to grant surrogates leeway, and informing other family and friends of one's wishes. Future ACP interventions should consider incorporating these additional ACP activities.