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Näkki K, Mäki‐Petäjä‐Leinonen A, Ervasti K, Halkoaho A, Nurmi S, Solomon A, Suhonen N, Portaankorva AM, Krüger J, Solje E. Diverging medical and legal perceptions of the need for legal guardianship in people with dementia: A qualitative study. Eur J Neurol 2024; 31:e16334. [PMID: 38733099 PMCID: PMC11236050 DOI: 10.1111/ene.16334] [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: 03/19/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Dementia is assumed to alter mental capacity, which may necessitate legal guardianship. However, only limited research exists on how dementia affects mental capacity, and most studies have focused solely on a medical perspective and concentrate on memory functions. The aim of this qualitative study was to investigate physicians' and legal experts' perceptions on a broad range of cognitive and neuropsychiatric domains potentially affecting mental capacity and the need for guardianship in people with dementia. METHODS Physicians (N = 30) and legal experts (N = 20) participated in semi-structured individual interviews. The data were analyzed by using content analysis and further semi-quantified according to the cognitive and neuropsychiatric domains. RESULTS Physicians considered neuropsychiatric symptoms and executive dysfunction to be the most important deficits in the legal context, while legal experts highlighted episodic memory impairment and dyscalculia. Perceptions regarding the importance of several cognitive and neuropsychiatric symptoms varied between and within the professional groups. CONCLUSIONS Physicians and legal experts diverged in their perceptions of cognitive and neuropsychiatric domains affecting mental capacity and the need for guardianship. The evaluation and influence of medical evidence among legal experts heavily rely on subjective opinions. Given the substantial potential impact on patients' equal access to their rights, developing standardized guidelines is essential.
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Affiliation(s)
- Kaisa Näkki
- Center of Law and Welfare, Law SchoolUniversity of Eastern FinlandJoensuuFinland
| | | | - Kaijus Ervasti
- Center of Law and Welfare, Law SchoolUniversity of Eastern FinlandJoensuuFinland
| | - Arja Halkoaho
- Tampere University of Applied SciencesTampereFinland
| | - Sanna‐Maria Nurmi
- Institute of Clinical Medicine – NeurologyUniversity of Eastern FinlandKuopioFinland
| | - Alina Solomon
- Institute of Clinical Medicine – NeurologyUniversity of Eastern FinlandKuopioFinland
- Division of Clinical GeriatricsKarolinska InstitutetStockholmSweden
- Ageing Epidemiology Research UnitImperial College LondonLondonUK
| | - Noora‐Maria Suhonen
- Neurocenter, NeurologyOulu University HospitalOuluFinland
- Research Unit of Clinical MedicineNeurology, University of OuluOuluFinland
| | | | - Johanna Krüger
- Neurocenter, NeurologyOulu University HospitalOuluFinland
- Research Unit of Clinical MedicineNeurology, University of OuluOuluFinland
- Medical Research Center (MRC) OuluOulu University HospitalOuluFinland
| | - Eino Solje
- Institute of Clinical Medicine – NeurologyUniversity of Eastern FinlandKuopioFinland
- Neuro Center – NeurologyKuopio University HospitalKuopioFinland
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Lipanot BJ, Bosslet G. Five Questions to Help Prompt End-of-Life Planning in Neuromuscular Disease. Semin Respir Crit Care Med 2024. [PMID: 39029508 DOI: 10.1055/s-0044-1787994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
Patients with neuromuscular disease are living longer lives but continue to have significant and often unpredictable morbidity and mortality. End-of-life planning for these patients is thus an essential part of their medical care. This planning should include the following topics: health care surrogates, swallowing and nutrition, daytime respiratory support, and all aspects of when end of life is near. Adult-onset and early-onset diseases may require different approaches to these topics. All patients with neuromuscular disease will benefit from these discussions to best reach patient-centered goals. We present health care providers these five questions and explanations as a guide.
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Affiliation(s)
- Benjamin J Lipanot
- Division of Pulmonary, Critical Care, Allergy, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Gabriel Bosslet
- Division of Pulmonary, Critical Care, Allergy, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Garg M, Oliva J, Lu A, Martin M, Hooper S. Hospital-Based Medical-Legal Partnerships for Complex Care Patients: Intersectionality and Ethics Considerations. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2024; 51:764-770. [PMID: 38477278 PMCID: PMC10937167 DOI: 10.1017/jme.2023.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Health systems are integrating medical-legal partnerships (MLPs) into clinical care and increasingly center "complex care" patients. These patients have intersecting medical and social needs and often face systemic inequities that exacerbate their chronic health conditions. This paper describes a role for MLPs in hospital quality initiatives; examines the ethics of MLPs assisting with guardianship and institutionalization of hospital patients including marginalized groups; and advocates for MLP interventions designed to address intersectional and ethical concerns.
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Affiliation(s)
- Megha Garg
- THE UNIVERSITY OF CALIFORNIA SCHOOL OF MEDICINE, SAN FRANCISCO, CA, USA
- SAN FRANCISCO VETERANS AFFAIRS MEDICAL CENTER, SAN FRANCISCO, CA, USA
| | | | - Alice Lu
- THE UNIVERSITY OF CALIFORNIA SCHOOL OF MEDICINE, SAN FRANCISCO, CA, USA
| | - Marlene Martin
- THE UNIVERSITY OF CALIFORNIA SCHOOL OF MEDICINE, SAN FRANCISCO, CA, USA
| | - Sarah Hooper
- THE UNIVERSITY OF CALIFORNIA COLLEGE OF LAW, SAN FRANCISCO, CA, USA
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Barajas-Ochoa A, Mackie TI, Fofana B, Rosen Valverde JN. On legal guardianship: An exploratory assessment of knowledge, attitudes and practices of resident physicians. MEDICAL TEACHER 2024; 46:399-405. [PMID: 37722805 DOI: 10.1080/0142159x.2023.2256965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
BACKGROUND Clinicians encounter patients under legal guardianship. We aimed to assess the knowledge, attitudes and practices (KAP) on legal guardianship in residents. METHODS A KAP pilot survey about legal guardianship was developed by an interdisciplinary medicine-law-public health team and was distributed via institutional email to internal medicine, psychiatry, and neurology residents in a single academic institution. RESULTS Of the 172 invited residents, 105 (61%) responded and 102 surveys were included in the final analysis. Most respondents (58% women; internal medicine 73%, neurology 15%, psychiatry 12%) had attended 42 medical schools from 16 countries and had heard about guardianship (88%), but only 23% reported having received training on guardianship during medical school or residency. The vast majority (97%) understood the intended benefit of guardianship, but only 22.5% reported knowing that guardianship removed an individual's decision-making rights. Nearly half (47%) of respondents reported never having asked for documentation to prove that an individual was a patient's guardian, and only 15% expected to see a court order as proof of guardianship status. CONCLUSIONS Although most residents intuitively understood the intended benefit of guardianship, they did not understand its full implications for clinical practice. Training interventions are warranted.
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Affiliation(s)
- Aldo Barajas-Ochoa
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
- Division of Infectious Diseases, Department of Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Thomas I Mackie
- Department of Health Policy and Management, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Bintu Fofana
- Rutgers School of Public Health, Newark, NJ, USA
| | - Jennifer N Rosen Valverde
- Rutgers School of Public Health, Newark, NJ, USA
- Education and Health Law Clinic, Legal Director, H.E.A.L. Collaborative®, Rutgers University School of Law, Newark, NJ, USA
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Largent EA, Peterson A, Karlawish J. Supported decision making: Facilitating the self-determination of persons living with Alzheimer's and related diseases. J Am Geriatr Soc 2023; 71:3566-3573. [PMID: 37698156 PMCID: PMC10841214 DOI: 10.1111/jgs.18596] [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: 07/06/2023] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 09/13/2023]
Abstract
Decision-making capacity describes the ability to make a particular decision at a given time. People with Mild Cognitive Impairment (MCI) and mild stage dementia typically experience an associated erosion of their decisional abilities. Many could be said to have marginal capacity. These individuals are in a liminal space between adequate and inadequate capacity. Too often, marginal capacity is overlooked as a category: individuals are classified either as having capacity and being able to make decisions independently or as lacking capacity and needing a surrogate to make decisions for them. These approaches can, respectively, result in under- or overprotection of individuals with marginal capacity. A promising alternative approach is supported decision making. In supported decision making, a person with marginal capacity identifies a trusted person or network of persons to aid them in making their own decisions. Supported decision making is recognized by law in a growing number of states; it is important for geriatricians to be familiar with the concept, as they are increasingly likely to encounter it in their practice. Even in states where supported decision making is not formally recognized, it can be practiced informally, helping patients, care partners, and clinicians strike an appropriate balance between respecting autonomy and recognizing vulnerability. In this article, we describe supported decision making, discuss its ethical and legal foundations, and identify steps by which geriatricians can incorporate it into their practice.
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Affiliation(s)
- Emily A Largent
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Andrew Peterson
- Department of Philosophy, Institute for Philosophy and Public Policy, George Mason University, Fairfax, Virginia, USA
| | - Jason Karlawish
- Department of Medicine, Department of Medical Ethics and Health Policy, Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Tannou T, Gzil F, Kennelly SP, Tournoy J, Frisardi V, Soysal P. How do geriatricians evaluate decision-making ability for older adults with cognitive impairment? Results from an European survey. Eur Geriatr Med 2023; 14:953-960. [PMID: 37603190 DOI: 10.1007/s41999-023-00852-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/01/2023] [Indexed: 08/22/2023]
Abstract
CONTEXT The assessment of decision-making ability of older adults with cognitive impairment is a complex challenge that geriatricians often face in relation to risk-taking situations (driving, aging in place, financial decisions, etc.). However, there are no clear and consensual practice guidelines. An overview of current practices and needs seemed necessary. METHODS We co-created and conducted an online survey to describe practice and knowledge, among European geriatricians. The survey was structured in 3 parts: a description of the professional's practice regarding cognitive impairment, a specific questionnaire about everyday risky decision-making evaluation and an investigation of the clinician's knowledge about relevant ethical and legal recommendations. Each part consisted of both multiple choice and open questions, analyzed through descriptive statistics and qualitative analysis methods. RESULTS Based on the responses of 123 geriatricians across Europe, our survey showed that clinical interview is the cornerstone of geriatric assessment of decision-making ability of patients with mild to moderate dementia. When faced with risk-taking dilemma situations, geriatricians tend to favor a context of safety above autonomy, but they can support risky decision-making if it is consistent with the patient's previous lifestyle, depending on the degree of risk to self and others, on the decision-making ability assessed, and if there is some form of shared decision-making. CONCLUSION Assessing decision-making ability is challenging for geriatricians, who in our study relied more on their clinical interview and global cognitive tests than more in-depth evaluations. Supporting independent decision-making, when associated with risk-taking, requires better detection and anticipation shared with the patient environment.
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Affiliation(s)
- Thomas Tannou
- CIUSS Centre-Sud de l'ile de Montréal, Centre de Recherche de l'institut Universitaire de Gériatrie de Montréal, 4565 Rue Queen Mary, Montréal, QC, H3W1W5, Canada.
- Université de Franche-Comté, UR LINC, 25000, Besançon, France.
| | - Fabrice Gzil
- École des Hautes Études en Santé Publique, 35000, Rennes, France
- Espace de Réflexion Éthique d'Ile-de-France, 75000, Paris, France
- Centre de Recherche en Épidémiologie et Santé des Populations, UMR 1018 Inserm/Université Paris Saclay, 94800, Villejuif, France
| | - Seán P Kennelly
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Jos Tournoy
- Gerontology and Geriatrics Unit, Department of Public Health and Primary Care, KU Leuven-University of Leuven, Louvain, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Louvain, Belgium
| | - Vincenza Frisardi
- Neuromotor Department, Geriatric Unit, AUSL-IRCCS Reggio Emilia (RE), Louvain, Italy
| | - Pinar Soysal
- Department of Geriatric Medicine, Faculty of Medicine, Bezmialem Vakif University, Adnan Menderes Bulvarı (Vatan Street), Fatih, 34093, Istanbul, Turkey
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Martin M, Kendall S, Uveges MK. Traumatic Brain Injury, Dysphagia, and the Ethics of Oral Intake. AACN Adv Crit Care 2023; 34:255-262. [PMID: 37644626 DOI: 10.4037/aacnacc2023789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Michael Martin
- Michael Martin is Professional Development Director, Tufts Medical Center, Boston Dispensary Building, 29 Bennet St, Boston, MA 02111
| | - Sarah Kendall
- Sarah Kendall is Professional Development Director, Tufts Medical Center, Boston, Massachusetts
| | - Melissa Kurtz Uveges
- Melissa Kurtz Uveges is Assistant Professor, Boston College, Connell School of Nursing, Chestnut Hill, Massachusetts
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Tang HW, Sakurai Y, Chong YE. Aging and the Law in Singapore and Japan: Adult Guardianship and Other Alternatives. J Aging Soc Policy 2023:1-20. [PMID: 37703224 DOI: 10.1080/08959420.2023.2255484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 05/05/2023] [Indexed: 09/15/2023]
Abstract
Comparative adult guardianship law and other alternatives, especially in an Asian context, is an under-investigated area. This paper attempts to fill the gap in the literature by comparing the adult guardianship law and other alternatives from the perspectives of Singapore and Japan. The central argument of this paper is that in order for the law of adult guardianship to be widely adopted in Asian societies like Singapore and Japan - where much of adult guardianship related issues are governed by informal familial arrangements; this would require governments to do more than the mere enacting of adult guardianship legislation. To encourage widespread adoption, governments must embark on a robust public awareness campaign to promote the adult guardianship scheme, provide institutional support, and simplify the process for people wishing to sign up to the scheme and enact the appropriate safeguards against abuse. Such conditions are present in Singapore, whereas in Japan, these are lacking which explains the lower take-up rate with Japanese people preferring informal arrangements. Another key difference between Singapore and Japan is that the former relies primarily on family and relatives to act as adult guardians, while the court in the latter jurisdiction insists on the appointment of professionals like lawyers to act as adult guardians. It is surmised that this factor explains the lower take-up rate of formal adult guardianship in Japan as compared to Singapore due to the costs involved in engaging professional guardians. This paper also explores the alternatives to adult guardianship in both systems. Alternatives to formal adult guardianship is important because there will be a substantial portion of the population of older adults who would prefer these alternatives for various reasons.
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Affiliation(s)
- Hang Wu Tang
- Yong Pung How School of Law, Singapore Management University, Singapore, Singapore
| | - Yukio Sakurai
- The Collaboration researcher, Yokohama National University, Yokohama, Japan
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Wang L, Morphew J, Vitale C, Mullan P, Zietlow K. Guardianship: The Implications of Resident Physician Perceptions of Caring for Incapacitated Older Adults Without Advocates. Gerontol Geriatr Med 2023; 9:23337214231218581. [PMID: 38107507 PMCID: PMC10725095 DOI: 10.1177/23337214231218581] [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: 07/31/2023] [Revised: 11/06/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023] Open
Abstract
As the incidence of dementia rises, increased utilization of surrogate decision-makers, including legal guardians, is anticipated. This manuscript presents an analysis of resident physicians' experiences and perceptions regarding requirements, roles, and responsibilities of caring for older adults in need of, or already under, legal guardianship. This is a cross-sectional study, conducted at a tertiary academic medical center. A survey was sent, via Qualtrics, to all emergency medicine, family medicine, internal medicine, general surgery, and medicine-pediatric resident physicians. Eighty-eight out of three hundred thirty-three (26.4%) eligible residents physicians completed the survey. Most (98.9%) reported caring for patients under guardianship, yet many resident physicians reported significant uncertainty regarding the roles and responsibilities of guardianship, including its potential benefits and limitations. They also displayed misconceptions and overconfidence about guardians' abilities to facilitate disposition, ensure financial security, and assign code status, among other matters. Our study highlights the importance of structured and directed education on the topic of guardianship for medical trainees.
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Affiliation(s)
- Linda Wang
- Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jared Morphew
- VDepartment of Family & Community Medicine and Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Caroline Vitale
- Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
- Geriatric Research Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Patricia Mullan
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Kahli Zietlow
- Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
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Chodos AH, Hooper S. Context, humility, and caution in guardianship determination. J Am Geriatr Soc 2022; 70:3058-3060. [DOI: 10.1111/jgs.18067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Anna H. Chodos
- Division of Geriatrics, Department of Medicine University of California San Francisco California USA
| | - Sarah Hooper
- Medical‐Legal Partnership for Seniors, Atlantic Institute UCSF and UC Hastings Consortium on Law, Science & Health Policy San Francisco California USA
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