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Hoffman DN, Strand GR. 'Sit down and thrash it out': opportunities for expanding ethics consultation during conflict resolution in long-term care. New Bioeth 2024; 30:152-162. [PMID: 38509687 DOI: 10.1080/20502877.2024.2330275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
OBJECTIVE To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to assist with dispute resolution. DESIGN An online cross-sectional survey was distributed to the Society for Post-Acute and Long-Term Care Medicine (AMDA). RESULTS Two-thirds of participants, primarily medical directors, have rejected surrogate instructions and 71% have managed family conflict. Conflict over treatment decisions and issues interpreting advance directives were frequently reported. Half of facilities lack a formal dispute mediation policy. Only five respondents have called an ethics consult for assistance. CONCLUSION Ethically tense care conflicts commonly arise in long-term and post-acute care facilities. Few facility procedures incorporate ethics resources into actual practice. Recommendations are made to create actionable policy, increase access to ethics services, and support staff skill development in order to improve the end-of-life care experiences for patients, families, and care facility staff.
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Affiliation(s)
- David N Hoffman
- Bioethics Program, School of Professional Studies, Columbia University, New York, NY, USA
| | - Gianna R Strand
- Bioethics Program, School of Professional Studies, Columbia University, New York, NY, USA
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Fischer J, Roßmeier C, Hartmann J, Riedl L, Tensil M, Diehl-Schmid J, Jox RJ. Irrelevant Interests? A Qualitative Study Into How German Family Surrogates of Persons Living With Dementia Fulfill Their Legal Role as Advocates of an Advance Directive. THE GERONTOLOGIST 2024; 64:gnad119. [PMID: 37650918 DOI: 10.1093/geront/gnad119] [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: 02/21/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES German legislation establishes advance directives (ADs) as legally binding instruments that all involved parties need to adhere to. This applies also to family members who have been authorized as official surrogates of the AD's author. As surrogates, they are expected to make sure that the AD is being implemented. Our study aims at uncovering how family members experience their legally assigned role as an advocate of an AD. RESEARCH DESIGN AND METHODS We conducted 25 episodic interviews with family surrogates of persons living with dementia and used thematic analysis to make sense of our interview data. RESULTS Family surrogates expressed scepticism toward ADs as instruments for planning end-of-life care. They did not necessarily follow the decisions expressed in the AD. We found cases in which family surrogates intentionally refrained from bringing the ADs to the attention of health care providers as well as cases in which the ADs conflicted with self-related interests of family surrogates. DISCUSSION AND IMPLICATIONS Our findings lead us to critique the legal construction of family surrogates as advocates of the AD. Family members are directly and enduringly affected by the end-of-life care decisions that the AD sets out and are thus no neutral agents who have no stake in the matter. Expecting them to simply transmit decisions formulated in the AD means expecting them to render their own interests irrelevant-which, arguably, might be too much to ask.
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Affiliation(s)
- Julia Fischer
- Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, School of Medicine, Technical University of Munich, Munich, Germany
| | - Carola Roßmeier
- Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, School of Medicine, Technical University of Munich, Munich, Germany
- Clinical Center for Psychiatry, Psychotherapy, Psychosomatic Medicine, Geriatrics and Neurology, kbo-Inn-Salzach-Klinikum, Wasserburg am Inn, Germany
| | - Julia Hartmann
- Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, School of Medicine, Technical University of Munich, Munich, Germany
| | - Lina Riedl
- Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, School of Medicine, Technical University of Munich, Munich, Germany
| | - Maria Tensil
- Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, School of Medicine, Technical University of Munich, Munich, Germany
| | - Janine Diehl-Schmid
- Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, School of Medicine, Technical University of Munich, Munich, Germany
- Clinical Center for Psychiatry, Psychotherapy, Psychosomatic Medicine, Geriatrics and Neurology, kbo-Inn-Salzach-Klinikum, Wasserburg am Inn, Germany
| | - Ralf J Jox
- Chair in Geriatric Palliative Care, Institute of Humanities in Medicine and Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Switzerland
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Quail P, Keller H, Vucea V, Heckman G, Sasan M, Boscart V, Ramsey C, Garland A. A Qualitative Study of Nursing Home Staff Lived Experience With Advance Care Planning. J Am Med Dir Assoc 2023; 24:1761-1766. [PMID: 37536660 DOI: 10.1016/j.jamda.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE Advance care planning (ACP) within nursing homes (NHs) is an integral component of resident-centered care yet remains an ongoing area for improvement. This study explored health care providers' experiences when facilitating ACP discussions with residents and their families. DESIGN Interpretive description was used to explore meanings and generate knowledge that is applicable for clinical contexts. SETTING AND PARTICIPANTS A purposive sample of 27 staff members (2 directors of care, 3 assistant directors of care, 1 nurse practitioner, 11 registered nurses, 3 registered practical nurses, and 7 social workers) from 29 NHs located across 3 Canadian provinces that participated in cluster-randomized intervention study to improve ACP. METHODS Semistructured interviews were conducted between January and July 2020. Interpretive description methods were used for analysis. RESULTS Three themes were identified. "Navigating Relational Tensions During ACP with Families" captures the relational tensions that participants experienced while navigating ACP processes with residents and their families. The second theme, "Where's the Doctor?" highlights the general lack of physician involvement in ACP discussions and the subsequent pressures faced by participants when supporting residents and families. The last theme, "Crises Change the Best Laid Plans," illustrates the challenges participants face when trying to adhere to existing care plans during residents' medical crises. CONCLUSION AND IMPLICATIONS Participants' experiences indicate that current ACP processes in NHs do not meet the needs of residents, families, or care teams. Additional support from physicians and changes to structural processes are needed to support resident-centered end-of-life planning within this care context.
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Affiliation(s)
- Patrick Quail
- Department of Family Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada.
| | - Heather Keller
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Vanessa Vucea
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - George Heckman
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Mehar Sasan
- McMaster University, Hamilton, Ontario, Canada
| | - Veronique Boscart
- Conestoga College, Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Clare Ramsey
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan Garland
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Clavien C, Ehlers U, J Jox R, Karzig I, Krones T, Loupatzatzis B, Monteverde S, Theile G. Advance Care Planning in Switzerland: Chances and challenges of delivering high-quality ACP in a small high-income, multilingual, federally organized country. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:115-120. [PMID: 37438170 DOI: 10.1016/j.zefq.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 07/14/2023]
Abstract
We describe the development of ACP in Switzerland during the last decade in the German- and French-speaking cantons and on the national level. In 2013, a revision of the Swiss civil law came into force, declaring advance directives (ADs) as binding. Since then, ACP has been researched and implemented primarily by universities and university hospitals. Despite the foundation of the national association "ACP Swiss" in 2020, several national initiatives, and a roadmap for a national implementation, many challenges and barriers still remain. There is, however, reasonable hope to implement high-quality ACP throughout Switzerland within the next ten years.
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Affiliation(s)
| | - Ulrike Ehlers
- Saint Gallen Cantonal Hospital, Saint Gallen, Switzerland
| | - Ralf J Jox
- University of Lausanne, Lausanne, Switzerland
| | | | - Tanja Krones
- University Hospital Zurich, Zurich, Switzerland.
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Götze K, Feddersen B, In der Schmitten J, Marckmann G. Advance Care Planning in Germany. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:127-132. [PMID: 37393112 DOI: 10.1016/j.zefq.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 04/29/2023] [Accepted: 05/10/2023] [Indexed: 07/03/2023]
Abstract
Advance Care Planning (ACP) defined as a comprehensive concept requiring a cultural change following implementation at the individual, institutional and regional level in order to achieve care consistency with care preferences when individuals are incapable of participating in critical decisions was first implemented in two regional projects (LIMITS and beizeiten begleiten, North Rhine Westphalia) in Germany in the 2000s. Based on the positive evaluation of beizeiten begleiten, legislation of 2015 (§ 132g, Social Code Book V) allows nursing homes and care homes for persons with disabilities to offer qualified ACP facilitation covered by the statutory health insurance. However, trainers for ACP facilitators need no specific qualification, and the training program for ACP facilitators is only broadly defined, which resulted in great heterogeneity of ACP facilitator qualifications. Furthermore, neither the institutional nor the regional implementation are sufficiently considered in this legislation, i.e. essential components of a successful implementation of ACP are missing. Nevertheless, a growing number of initiatives, research projects and a professional national society for ACP, engage in approaches to advance institutional and regional implementation, and to offer ACP to other target groups beyond the legal framework.
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Affiliation(s)
- Kornelia Götze
- Institute of General Practice, Center for Health and Society, Medical Faculty, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany.
| | - Berend Feddersen
- Department of Palliative Medicine, Ludwig Maximilians University, Munich University Hospital, Munich, Germany
| | - Jürgen In der Schmitten
- Institute of Family Medicine/General Practice, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig Maximilians University Munich, Munich, Germany
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Götze K, Bausewein C, Feddersen B, Fuchs A, Hot A, Hummers E, Icks A, Kirchner Ä, Kleinert E, Klosterhalfen S, Kolbe H, Laag S, Langner H, Lezius S, Meyer G, Montalbo J, Nauck F, Reisinger C, Rieder N, Schildmann J, Schunk M, Stanze H, Vogel C, Wegscheider K, Zapf A, Marckmann G, in der Schmitten J, Albert A, Alheid C, Bausewein C, Bruene M, Calles C, Camci H, Daubmann A, Dahlke S, Enger S, Feddersen B, Felder G, Fluck C, Freienstein A, Freytag T, Fuchs A, Icks A, in der Schmitten J, Hensel L, Hummers E, Hot A, Kirchner Ä, Kleinert E, Klosterhalfen S, Kolbe H, Laag S, Langner H, Lezius S, Marckmann G, Meyer G, Montalbo J, Nauck F, Nguyen T, Nowak A, Ossenberg M, Reisinger C, Reuter S, Rieder N, Riester T, Rosu I, Rösgen H, Salanta K, Sassi Z, Schildmann J, Schulenberg T, Schunk M, Sommer D, Stanze H, Stöhr A, Theuerkauf A, Thilo N, Tönjann J, Partowinia-Peters M, Prommersberger S, Przybylla S, Vogel C, Vomhof M, Wilken J, Zapf A, Zimprich J. Effectiveness of a complex regional advance care planning intervention to improve care consistency with care preferences: study protocol for a multi-center, cluster-randomized controlled trial focusing on nursing home residents (BEVOR trial). Trials 2022; 23:770. [PMID: 36096948 PMCID: PMC9465132 DOI: 10.1186/s13063-022-06576-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background According to recent legislation, facilitated advance care planning (ACP) for nursing home (NH) residents is covered by German sickness funds. However, the effects of ACP on patient-relevant outcomes have not been studied in Germany yet. This study investigates whether implementing a complex regional ACP intervention improves care consistency with care preferences in NH residents. Methods This is a parallel-group cluster-randomized controlled trial (cRCT) with 48 NHs (≈ 3840 resident beds) between 09/2019 and 02/2023. The intervention group will receive a complex, regional ACP intervention aiming at sustainable systems redesign at all levels (individual, institutional, regional). The intervention comprises comprehensive training of ACP facilitators, implementation of reliable ACP processes, organizational development in the NH and other relevant institutions of the regional healthcare system, and education of health professionals caring for the residents. Control group NHs will deliver care as usual. Primary outcome is the hospitalization rate during the 12-months observation period. Secondary outcomes include the rate of residents whose preferences were known and honored in potentially life-threatening events, hospital days, index treatments like resuscitation and artificial ventilation, advance directives, quality of life, psychological burden on bereaved families, and costs of care. The NHs will provide anonymous, aggregated data of all their residents on the primary outcome and several secondary outcomes (data collection 1). For residents who have given informed consent, we will evaluate care consistency with care preferences and further secondary outcomes, based on chart reviews and short interviews with residents, surrogates, and carers (data collection 2). Process evaluation will aim to explain barriers and facilitators, economic evaluation the cost implications. Discussion This study has the potential for high-quality evidence on the effects of a complex regional ACP intervention on NH residents, their families and surrogates, NH staff, and health care utilization in Germany. It is the first cRCT investigating a comprehensive regional ACP intervention that aims at improving patient-relevant clinical outcomes, addressing and educating multiple institutions and health care providers, besides qualification of ACP facilitators. Thereby, it can generate evidence on the potential of ACP to effectively promote patient-centered care in the vulnerable population of frail and often chronically ill elderly. Trial registration ClinicalTrials.gov ID NCT04333303. Registered 30 March 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06576-3.
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Cohen AB, DeMartino ES. How should advance care planning be done when a surrogate is making decisions? J Am Geriatr Soc 2021; 69:2103-2105. [PMID: 34002373 DOI: 10.1111/jgs.17222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Andrew B Cohen
- Section of Geriatrics, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Erin S DeMartino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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