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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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Barć K, Finsel J, Helczyk O, Baader S, Aho‐Özhan H, Ludolph AC, Lulé D, Kuźma‐Kozakiewicz M. One third of physicians discuss exit strategies with patients with amyotrophic lateral sclerosis: Results from nationwide surveys among German and Polish neurologists. Brain Behav 2024; 14:e3243. [PMID: 38183365 PMCID: PMC10897500 DOI: 10.1002/brb3.3243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 01/08/2024] Open
Abstract
OBJECTIVE This paper examines neurologists' approaches to exit strategies (ESs), such as euthanasia and physician-assisted suicide, in patients with amyotrophic lateral sclerosis (PALS) in two European countries. METHODS In a nationwide anonymous survey, we collected responses from 237 Polish and 228 German neurologists, focusing on their practices and beliefs about ESs, as well as their viewpoints on life-sustaining measures (LSMs) (percutaneous endoscopic gastrostomy, non-invasive, and invasive ventilation). To analyze the data, we employed statistical methods, including Mann-Whitney U, Kruskal-Wallis, chi-square tests, Spearman's rank correlation, and multiple regression analysis. RESULTS One third of the neurologists initiated the discussion about ESs with PALS. Half were ready to have this conversation upon patient's request. Age, gender, religiousness, and nationality were closely associated with this approach. One in 9 neurologists received a request to terminate an LSM, whereas 1 in 10 to implement an ES. German neurologists and palliative care trainees acquired both demands more commonly. Neurologists quoted a low quality of life, decreased mood, and being a burden to the family/closest ones as primary reasons for a wish to hasten death among PALS. Although the majority expressed a willingness to terminate an LSM at a request of the patient, most opposed the legalization of euthanasia. Younger and less religious individuals were more likely to favor accepting euthanasia. CONCLUSION Neurologists vary significantly in their approaches to terminal care. Complex relationships exist among personal indices, shared beliefs, and current practices.
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Affiliation(s)
- Krzysztof Barć
- Department of NeurologyUniversity Clinical Centre of Medical University of WarsawWarsawPoland
| | - Julia Finsel
- Department of NeurologyUniversity of UlmUlmGermany
| | - Olga Helczyk
- Department of NeurologyUniversity of UlmUlmGermany
| | | | | | - Albert C. Ludolph
- Department of NeurologyUniversity of UlmUlmGermany
- German Centre of Neurodegenerative Diseases (DZNE)UlmGermany
| | | | - Magdalena Kuźma‐Kozakiewicz
- Department of NeurologyMedical University of WarsawWarsawPoland
- Neurodegenerative Diseases Research GroupMedical University of WarsawWarsawPoland
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3
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Dietrich CG, Schoppmeyer K. [Opportunities and risks of advance directives : An appraisal of the practice in Germany after legal regulation in 2009]. Schmerz 2024:10.1007/s00482-023-00771-0. [PMID: 38165491 DOI: 10.1007/s00482-023-00771-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Living wills/advance directives (AD) are an important tool for specifying patient wishes regarding medical care in the case of future inability to consent. Since 2009, German legislation defines framework conditions for the creation and validity of such directives in § 1901a BGB. METHODS An extensive literature search in an international and a German-language database was conducted to identify, analyze, and evaluate scientific articles on opportunities, risks, and problems in the creation and implementation of living wills. RESULTS Between 10 and 40% of patients have an AD. Among the stipulations in the AD, the demand for sufficient pain therapy is very important. However, numerous problems in the preparation and implementation of ADs reduce their value in everyday clinical practice. In particular, unclear conditions of validity, unspecific instructions for action, and lack of availability of the directives prevent practitioners from determining the patient's will. Other fundamental problems include frequent patient ambivalence and clinical ethical dissent. In addition, the framework condition of unlimited coverage set by the law carries the risk that changes of opinion in the course of life or disease are not taken into account. CONCLUSION Preparing an AD requires a high level of information, consultation, and time, as well as regular review or adjustment of its content. These factors are often not considered, thus complicating implementation and reducing the value of living wills. Possible solutions to these problems or alternative concepts for different patient settings are discussed in this review.
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Affiliation(s)
- Christoph G Dietrich
- Gastro-Praxis Wiesbaden im Medicum, Langenbeckplatz 2, 65189, Wiesbaden, Deutschland.
| | - Konrad Schoppmeyer
- Klinik für Innere Medizin II, Euregio-Klinik GmbH, Nordhorn, Deutschland, Albert-Schweitzer-Str. 10, 48527
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Primc N, Schwabe S, Poeck J, Günther A, Hasseler M, Rubeis G. A typology of nurses' interaction with relatives in emergency situations. Nurs Ethics 2023; 30:232-244. [PMID: 36314501 PMCID: PMC10014892 DOI: 10.1177/09697330221128902] [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: 11/05/2022]
Abstract
BACKGROUND In nursing homes, residents' relatives represent important sources of support for nurses. However, in the heightened stress of emergency situations, interaction between nurses and relatives can raise ethical challenges. RESEARCH OBJECTIVES The present analysis aimed at elaborating a typology of nurses' experience of ethical support and challenges in their interaction with relatives in emergency situations. RESEARCH DESIGN Thirty-three semi-structured interviews and six focus groups were conducted with nurses from different nursing homes in Germany. Data were analysed according to Mayring's method of qualitative content analysis. PARTICIPANTS AND RESEARCH CONTEXT Participants were licensed nurses working in nursing homes. ETHICAL CONSIDERATIONS Ethical approval was granted by Ostfalia University of Applied Sciences (02.07.2020) and the Ethics Committee of Hannover Medical School (Nr. 8866_BO_K_2020; 27.01.2020). Interviewees were anonymised and focus group were pseudonymised during transcription. All participants provided written consent. FINDINGS/RESULTS In emergency situations, relatives can represent important sources of support for nurses. However, they may also give rise to different challenges, relating to four ethical conflicts: (1) the challenge of meeting the information needs of relatives while providing appropriate care to all residents; (2) the challenge of managing relatives' demands for hospitalisation when hospitalisation is not deemed necessary by nurses; (3) the challenge of managing relatives' demands for lifesaving treatment when such treatment contradicts the will of the resident; and (4) the challenge of attempting to initiate hospitalisation when relatives oppose this course of action. Several external factors make these conflicts especially challenging for nurses: fear of legal consequences, a low staffing ratio, and a lack of qualified nursing staff. CONCLUSIONS Conflict between nurses and relatives typically revolves around hospitalisation and the initiation of lifesaving treatment. Whether nurses perceive interaction with relatives as supportive or conflictual essentially depends on the quality of the relationship, which may be negatively influenced by a number of external factors.
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Affiliation(s)
- Nadia Primc
- Institute of History and Ethics of Medicine, 9144University of Heidelberg, Heidelberg, Germany
| | - Sven Schwabe
- Institute for General Practice and Palliative Care, 9177Hannover Medical School, Hanover, Germany
| | - Juliane Poeck
- Institute of General Practice, 39065University Hospital Jena, Jena, Germany
| | - Andreas Günther
- Fire Department, 524823City of Braunschweig, Braunschweig Germany
| | - Martina Hasseler
- Faculty of Health Sciences, 120199Ostfalia University of Applied Sciences, Wolfenbüttel Germany
| | - Giovanni Rubeis
- Division Biomedical and Public Health Ethics, 467773Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
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Fischer J, Roßmeier C, Hartmann J, Tensil M, Jox RJ, Diehl-Schmid J, Riedl L. Inappropriate Involvement? Presenting Empirical Insight into the Preparation Phase of Advance Directives of Persons Living with Dementia Under German Legislation. J Aging Soc Policy 2023:1-16. [PMID: 36814064 DOI: 10.1080/08959420.2023.2182565] [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: 02/24/2023]
Abstract
The scholarly debate on advance directives (ADs) in the context of dementia is mainly built around ethical arguments. Empirical studies that shed light into the realities of ADs of persons living with dementia are few and far between and too little is known about the effect of national AD legislation on such realities. This paper offers insight into the preparation phase of ADs according to German legislation in the context of dementia. It presents results from a document analysis of 100 ADs and from 25 episodic interviews with family members. Findings show that drafting an AD involves family members and different professionals in addition to the signatory, whose cognitive impairment differed considerably at the time of preparing the AD. The involvement of family members and professionals is at times problematic, which prompts the question of how much and what kind of involvement of others turns an AD of a person living with dementia into an AD about a person living with dementia. The results invite policy makers to critically review legislation on ADs from the perspective of cognitively impaired persons, who might find it difficult to protect themselves from inappropriate involvement when completing an AD.
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Affiliation(s)
- Julia Fischer
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Carola Roßmeier
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Julia Hartmann
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Maria Tensil
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Janine Diehl-Schmid
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Lina Riedl
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
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Ye L, Jin G, Chen M, Xie X, Shen S, Qiao S. Prevalence and factors of discordance attitudes toward advance care planning between older patients and their family members in the primary medical and healthcare institution. Front Public Health 2023; 11:1013719. [PMID: 36908464 PMCID: PMC9996283 DOI: 10.3389/fpubh.2023.1013719] [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: 08/07/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Background This study aimed at investigating the prevalence and factors of the discordant attitudes toward advance care planning (ACP) among older patients and their family members toward patients' engagement in ACP in the primary medical and healthcare institution. Methods In a cross-sectional study, a total of 117 older patients and 117 family members from Jinhua Fifth Hospital in China were enrolled. The questionnaire included sociodemographic characteristics, functional capacity assessment, and attitudes toward patients' engagement in ACP. Functional capacity assessment scales included the Modified Barthel Index (MBI), the Short-Form Mini-Nutritional Assessment (MNA-SF), the 15-item Geriatric Depression Scale (GDS-15), the Mini-Mental State Examination (MMSE), the Clinical Frailty Scale (CFS), and the SARC-F questionnaire. Results The discordance attitudes toward patients' engagement in ACP between patients and family members accounted for 41(35.0%). In the multivariate logistic analysis, factors associated with higher odds of discordance attitudes toward patients' engagement in ACP included greater age differences between patients and family members (OR = 1.043, 95% CI: 1.007-1.081), lower educational level for family members (OR = 3.373, 95% CI: 1.239-9.181), the patient's higher GDS-15 score (OR = 1.437, 95% CI: 1.185-1.742), and patient's higher MNA-SF score (OR = 1.754, 95% CI: 1.316-2.338). Conclusion Older patients and their family members had little ACP knowledge, and factors that influence discordance attitudes toward patients' engagement in ACP included the age gaps between patients and family members, family members' educational level, patients' depressive symptoms, and patients' nutritional status.
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Affiliation(s)
- Ling Ye
- Department of Geriatrics, Jinhua Fifth Hospital, Jinhua, China
| | - Genhong Jin
- Department of Geriatrics, Jinhua Fifth Hospital, Jinhua, China
| | - Min Chen
- Department of Geriatrics, Jinhua Fifth Hospital, Jinhua, China
| | - Xingyuan Xie
- Department of Geriatrics, Jinhua Fifth Hospital, Jinhua, China
| | - Shanshan Shen
- Department of Geriatrics, Zhejiang Hospital, Hangzhou, China
| | - Song Qiao
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
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Dying in the ICU : Changes in end of life decisions from 2011 to 2018 in the ICU of a communal tertiary hospital in Germany. DIE ANAESTHESIOLOGIE 2022; 71:930-940. [PMID: 35925156 DOI: 10.1007/s00101-022-01127-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/22/2022] [Accepted: 04/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND With modern intensive care medicine, even older patients and those with pre-existing conditions can survive critical illnesses and major operations; however, unreflected application of intensive care treatment might lead to a state called chronic critical illness. Today, withholding treatment and/or treatment withdrawal precede many deaths in the intensice care unit (ICU). We looked at changes in measures at the end of life and withholding or withdrawal of treatment in the ICU of a German tertiary hospital in 2017/2018 compared to 2011/2012. METHODS In this retrospective explorative study, we analyzed end of life practices in adult patients who died in an intermediate care unit (IMC)/ICU of Klinikum Hanau in 2017/2018. We compared these data with data from the same hospital in 2011/2012 RESULTS: Of the 1246 adult patients who died in Klinikum Hanau in 2017/2018, 433 (35%) died in an ICU or IMC unit. Deceased ICU patients were 74.0 ± 12.5 years and 86.6% were older than 60 years. At least one life-sustaining measure was withheld in 278 (76.2%) and withdrawn in 159 (46.3%) of patients. More than three quarters of patients (n = 276, 75.6%) had a do not resuscitate (DNR) order and in about half of the patients invasive ventilation (n = 175, 49.9%) or renal replacement therapy (n = 191, 52.3%) was limited. In 113 patients (31.0%) catecholamine treatment was withdrawn, in 72 (19.7%) patients invasive ventilation and in 49 (13.4%) patients renal replacement therapy. Compared to 2011/2012, we saw an increase by ~15% (absolute increase) in withholding and withdrawal of treatment and observed an effect of documents like advance directive or healthcare proxy. CONCLUSION In 76.2% of deceased ICU patients withholding treatment and in 43.6% treatment withdrawal preceded death. Compared to 2011/2012 treatment was withheld or withdrawn more often. Compared to 2011/2012, we saw an increase (~15% absolute) in withholding and withdrawal of treatment. After withholding or withdrawal of treatment, most patients died within 3 and 2 days, respectively.
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Barć K, Lulé D, Finsel J, Helczyk O, Baader S, Aho‐Özhan H, Ludolph AC, Kuźma‐Kozakiewicz M. Well-being on supportive techniques in amyotrophic lateral sclerosis: from neurologists' perspective. Ann Clin Transl Neurol 2022; 9:1874-1883. [PMID: 36448241 PMCID: PMC9735360 DOI: 10.1002/acn3.51663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/03/2022] [Accepted: 08/24/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To investigate intercultural neurologists' perception of well-being in patients with amyotrophic lateral sclerosis (ALS) using gastrostomy (PEG), non-invasive, and/or invasive ventilation (NIV/IV) and to analyse the determinants and impact on the management of the above medical interventions (MIs). METHODS The study was based on anonymous questionnaires addressing the clinical approach and personal attitude towards the use of PEG, NIV and IV in ALS patients completed by 465 neurologists: 228 from Germany and 237 from Poland. RESULTS The German and Polish neurologists estimated the quality of life in ALS patients using PEG and NIV as neutral, whilst low in individuals using IV. A regression model revealed an independent influence of palliative care training (PCT) and age on that attitude in the German group. Higher values of estimated patients' depressiveness on PEG, NIV and IV were found amongst the Polish neurologists. Marital status, experience in ALS and being a parent independently influenced the perception of patients' depressiveness in the German, whilst marital status, age and PCT were factors in the Polish group. Amongst German neurologists, a higher perception of patients' depressiveness in individuals using PEG, NIV and IV was linked to the later timing of the MIs discussion. In the Polish group, it was a lower estimation of QoL in patients using PEG. CONCLUSION Neurologists' perception of ALS patients' well-being on MIs reflects their demographic status, professional experience and potentially their cultural background. This perception plays an important role in the timing of MIs discussion, possibly influencing the decision-making process.
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Affiliation(s)
- Krzysztof Barć
- Department of NeurologyUniversity Clinical Centre of Medical University of WarsawWarsawPoland
| | | | - Julia Finsel
- Department of NeurologyUniversity of UlmUlmGermany
| | - Olga Helczyk
- Department of NeurologyUniversity of UlmUlmGermany
| | | | | | - Albert C. Ludolph
- Department of NeurologyUniversity of UlmUlmGermany,German Center of Neurodegenerative Diseases (DZNE)Ulm siteUlmGermany
| | - Magdalena Kuźma‐Kozakiewicz
- Department of NeurologyMedical University of WarsawWarsawPoland,Neurodegenerative Diseases Research GroupMedical University of WarsawWarsawPoland
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Marsch F, Spies CD, Francis RCE, Graw JA. Standardized High-Quality Processes for End-of-Life-Decision Making in the Intensive Care Unit Remain Robust during an Unprecedented New Pandemic-A Single-Center Experience. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15015. [PMID: 36429731 PMCID: PMC9690769 DOI: 10.3390/ijerph192215015] [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: 09/04/2022] [Revised: 10/25/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
Due to the global COVID-19 pandemic, a concomitant increase in awareness for end-of-life decisions (EOLDs) and advance care planning has been noted. Whether the dynamic pandemic situation impacted EOLD-processes on the intensive care unit (ICU) and patient-sided advance care planning in Germany is unknown. This is a retrospective analysis of all deceased patients of surgical ICUs of a university medical center from March 2020 to July 2021. All included ICUs had established standardized protocols and documentation for EOLD-related aspects of ICU therapy. The frequency of EOLDs and advance directives and the process of EOLDs were analyzed (No. of ethical approval EA2/308/20). A total number of 319 (85.5%) of all deceased patients received an EOLD. Advance directives were possessed by 83 (22.3%) of the patients and a precautionary power of attorney by 92 (24.7%) of the patients. There was no difference in the frequency of EOLDs and patient-sided advance care planning between patients with COVID-19 and non-COVID-19 patients. In addition, no differences in frequencies of do-not-resuscitate orders, withholding or withdrawing of intensive care medicine therapeutic approaches, timing of EOLDs, and participation of senior ICU attendings in EOLDs were noted between patients with COVID-19 and non-COVID-19 patients. Documentation of family conferences occurred more often in deceased patients with COVID-19 compared to non-COVID-19 patients (COVID-19: 80.0% vs. non-COVID-19: 56.8, p = 0.001). Frequency of EOLDs and completion rates of advance directives remained unchanged during the pandemic compared to pre-pandemic years. The EOLD process did not differ between patients with COVID-19 and non-COVID-19 patients. Institutional standard procedures might contribute to support the robustness of EOLD-making processes during unprecedented medical emergencies, such as new pandemic diseases.
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Affiliation(s)
- Fanny Marsch
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Claudia D. Spies
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Roland C. E. Francis
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Department of Anesthesiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Jan A. Graw
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Ulm, Ulm University, 89081 Ulm, Germany
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Silvestre M, Corradi S, De Luca BP, Stellacci A, Dell'Erba A, Marrone M. Advance Treatment Provision (DAT): Italian Legislation in the European Context. A Comparative Analysis. Front Public Health 2022; 10:826194. [PMID: 35462829 PMCID: PMC9019057 DOI: 10.3389/fpubh.2022.826194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/21/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Maria Silvestre
- Section of Legal Medicine, Interdisciplinary Department of Medicine (DIM), Bari, Italy
| | - Serena Corradi
- Section of Legal Medicine, Interdisciplinary Department of Medicine (DIM), Bari, Italy
| | - Benedetta Pia De Luca
- Section of Legal Medicine, Interdisciplinary Department of Medicine (DIM), Bari, Italy
| | - Alessandra Stellacci
- Section of Legal Medicine, Interdisciplinary Department of Medicine (DIM), Bari, Italy
| | - Alessandro Dell'Erba
- Section of Legal Medicine, Interdisciplinary Department of Medicine (DIM), Bari, Italy
| | - Maricla Marrone
- Section of Legal Medicine, Interdisciplinary Department of Medicine (DIM), Bari, Italy
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Allner M, Gostian M, Balk M, Rupp R, Allner C, Mantsopoulos K, Ostgathe C, Iro H, Hecht M, Gostian AO. Advance directives in patients with head and neck cancer - status quo and factors influencing their creation. Palliat Care 2022; 21:47. [PMID: 35395940 PMCID: PMC8991502 DOI: 10.1186/s12904-022-00932-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 03/10/2022] [Indexed: 12/24/2022] Open
Abstract
Background Advance Care Planning including living wills and durable powers of attorney for healthcare is a highly relevant topic aiming to increase patient autonomy and reduce medical overtreatment. Data from patients with head and neck cancer (HNC) are not currently available. The main objective of this study was to survey the frequency of advance directives (AD) in patients with head and neck cancer. Methods In this single center cross-sectional study, we evaluated patients during their regular follow-up consultations at Germany’s largest tertiary referral center for head and neck cancer, regarding the frequency, characteristics, and influencing factors for the creation of advance directives using a questionnaire tailored to our cohort. The advance directives included living wills, durable powers of attorney for healthcare, and combined directives. Results Four hundred and forty-six patients were surveyed from 07/01/2019 to 12/31/2019 (response rate = 68.9%). The mean age was 62.4 years (SD 11.9), 26.9% were women (n = 120). 46.4% of patients (n = 207) reported having authored at least one advance directive. These documents included 16 durable powers of attorney for healthcare (3.6%), 75 living wills (16.8%), and 116 combined directives (26.0%). In multivariate regression analysis, older age (OR ≤ 0.396, 95% CI 0.181–0.868; p = 0.021), regular medication (OR = 1.896, 95% CI 1.029–3.494; p = 0.040), and the marital status (“married”: OR = 2.574, 95% CI 1.142–5.802; p = 0.023; and “permanent partnership”: OR = 6.900, 95% CI 1.312–36.295; p = 0.023) emerged as significant factors increasing the likelihood of having an advance directive. In contrast, the stage of disease, the therapeutic regimen, the ECOG status, and the time from initial diagnosis did not correlate with the presence of any type of advance directive. Ninety-one patients (44%) with advance directives created their documents before the initial diagnoses of head and neck cancer. Most patients who decide to draw up an advance directive make the decision themselves or are motivated to do so by their immediate environment. Only 7% of patients (n = 16) actively made a conscious decision not create an advance directive. Conclusion Less than half of head and neck cancer patients had created an advance directive, and very few patients have made a conscious decision not to do so. Older and comorbid patients who were married or in a permanent partnership had a higher likelihood of having an appropriate document. Advance directives are an essential component in enhancing patient autonomy and allow patients to be treated according to their wishes even when they are unable to consent. Therefore, maximum efforts are advocated to increase the prevalence of advance directives, especially in head and neck cancer patients, whose disease often takes a crisis-like course. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00932-5.
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Affiliation(s)
- Moritz Allner
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany.
| | - Magdalena Gostian
- Department of Anesthesiology, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | - Matthias Balk
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Robin Rupp
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Clarissa Allner
- Emergency Medical Center, Department of Internal Medicine, Klinikum Fürth, Fürth, Germany
| | - Konstantinos Mantsopoulos
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), Erlangen-Nürnberg, Germany
| | - Heinrich Iro
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
| | - Markus Hecht
- Department of Radiation Oncology, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), Erlangen-Nürnberg, Germany
| | - Antoniu-Oreste Gostian
- Department of Otorhinolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität (FAU), 91054, Erlangen-Nürnberg, Germany
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12
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Potthoff S, Finke M, Scholten M, Gieselmann A, Vollmann J, Gather J. Opportunities and risks of self-binding directives: A qualitative study involving stakeholders and researchers in Germany. Front Psychiatry 2022; 13:974132. [PMID: 36339872 PMCID: PMC9633858 DOI: 10.3389/fpsyt.2022.974132] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/31/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Self-binding directives (SBDs) are a special type of psychiatric advance directive in which mental health service users can consent in advance to involuntary hospital admission and involuntary treatment during future mental health crises. This study presents opportunities and risks of SBDs reported by users with bipolar disorder, family members of people with bipolar disorder, professionals working with people with bipolar disorder and researchers with expertise in mental health ethics and law. METHODS Seventeen semi-structured interviews with users, family members and professionals, and one focus group with five researchers were conducted. The data was analyzed using qualitative content analysis. RESULTS Six opportunities and five risks of SBDs were identified. The opportunities were promotion of autonomy and self-efficacy of users, relief of responsibility for family members, early intervention, reduction of (perceived) coercion, positive impact on the therapeutic relationship and enhancement of professionals' confidence in decision-making. The risks were problems in the assessment of mental capacity, inaccurate information or misinterpretation, increase of coercion through misuse, negative impact on the therapeutic relationship due to noncompliance with SBDs, and restricted therapeutic flexibility and less reflection on medical decision-making. Stakeholders tended to think that the opportunities of SBDs outweigh their risks, provided that appropriate control and monitoring mechanisms are in place, support is provided during the drafting process and the respective mental healthcare setting is sufficiently prepared to implement SBDs in practice. CONCLUSIONS The fact that stakeholders consider SBDs as an opportunity to improve personalized crisis care for people with bipolar disorder indicates that a debate about the legal and clinical implementation of SBDs in Germany and beyond is necessary.
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Affiliation(s)
- Sarah Potthoff
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Marleen Finke
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Astrid Gieselmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.,Department of Psychiatry, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.,Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
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13
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Huemer M, Jahn-Kuch D, Hofmann G, Andritsch E, Farkas C, Schaupp W, Masel EK, Jost PJ, Pichler M. Trends and Patterns in the Public Awareness of Palliative Care, Euthanasia, and End-of-Life Decisions in 3 Central European Countries Using Big Data Analysis From Google: Retrospective Analysis. J Med Internet Res 2021; 23:e28635. [PMID: 34542419 PMCID: PMC8491122 DOI: 10.2196/28635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/25/2021] [Accepted: 07/05/2021] [Indexed: 12/25/2022] Open
Abstract
Background End-of-life decisions, specifically the provision of euthanasia and assisted suicide services, challenge traditional medical and ethical principles. Austria and Germany have decided to liberalize their laws restricting assisted suicide, thus reigniting the debate about a meaningful framework in which the practice should be embedded. Evidence of the relevance of assisted suicide and euthanasia for the general population in Germany and Austria is limited. Objective The aim of this study is to examine whether the public awareness documented by search activities in the most frequently used search engine, Google, on the topics of palliative care, euthanasia, and advance health care directives changed with the implementation of palliative care services and new governmental regulations concerning end-of-life decisions. Methods We searched for policies, laws, and regulations promulgated or amended in Austria, Germany, and Switzerland between 2004 and 2020 and extracted data on the search volume for each search term topic from Google Trends as a surrogate of public awareness and interest. Annual averages were analyzed using the Joinpoint Regression Program. Results Important policy changes yielded significant changes in search trends for the investigated topics. The enactment of laws regulating advance health care directives coincided with a significant drop in the volume of searches for the topic of euthanasia in all 3 countries (Austria: −24.48%, P=.02; Germany: −14.95%, P<.001; Switzerland: −11.75%, P=.049). Interest in palliative care increased with the availability of care services and the implementation of laws and policies to promote palliative care (Austria: 22.69%, P=.01; Germany: 14.39, P<.001; Switzerland: 17.59%, P<.001). The search trends for advance health care directives showed mixed results. While interest remained steady in Austria within the study period, it increased by 3.66% (P<.001) in Switzerland and decreased by 2.85% (P<.001) in Germany. Conclusions Our results demonstrate that legal measures securing patients’ autonomy at the end of life may lower the search activities for topics related to euthanasia and assisted suicide. Palliative care may be a meaningful way to raise awareness of the different options for end-of-life care and to guide patients in their decision-making process regarding the same.
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Affiliation(s)
- Matthias Huemer
- Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Daniela Jahn-Kuch
- Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Guenter Hofmann
- Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Andritsch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Clemens Farkas
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Walter Schaupp
- Institute of Moral Theology, University of Graz, Graz, Austria
| | - Eva Katharina Masel
- Clinical Division of Palliative Care, Department of Medicine I and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Philipp J Jost
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,Department of Internal Medicine III - Hematooncology, Technical University of Munich School of Medicine, Technical University of Munich, Munich, Germany
| | - Martin Pichler
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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14
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End-of-Life Decision-Making in Intensive Care Ten Years after a Law on Advance Directives in Germany. MEDICINA-LITHUANIA 2021; 57:medicina57090930. [PMID: 34577853 PMCID: PMC8468200 DOI: 10.3390/medicina57090930] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Mortality on Intensive Care Units (ICUs) is high and death frequently occurs after decisions to limit life-sustaining therapies. An advance directive is a tool meant to preserve patient autonomy by guiding anticipated future treatment decisions once decision-making capacity is lost. Since September 2009, advance directives are legally binding for the caregiver team and the patients' surrogate decision-maker in Germany. The change in frequencies of end-of-life decisions (EOLDs) and completed advance directives among deceased ICU patients ten years after the enactment of a law on advance directives in Germany is unknown. Materials and Methods: Retrospective analysis on all deceased patients of surgical ICUs of a German university medical center from 08/2008 to 09/2009 and from 01/2019 to 09/2019. Frequency of EOLDs and advance directives and the process of EOLDs were compared between patients admitted before and after the change in legislation. (No. of ethical approval EA2/308/20) Results: Significantly more EOLDs occurred in the 2019 cohort compared to the 2009 cohort (85.8% vs. 70.7% of deceased patients, p = 0.006). The number of patients possessing an advance directive to express a living or therapeutic will was higher in the 2019 cohort compared to the 2009 cohort (26.4% vs. 8.9%; difference: 17.5%, p < 0.001). Participation of the patients' family in the EOLD process (74.7% vs. 60.9%; difference: 13.8%, p = 0.048) and the frequency of documentation of EOLD-relevant information (50.0% vs. 18.7%; difference: 31.3%, p < 0.001) increased from 2009 to 2019. Discussion: During a ten-year period from 2009 to 2019, the frequency of EOLDs and the completion rate of advance directives have increased considerably. In addition, EOLD-associated communication and documentation have further improved.
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15
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Bonsignore A, Bragazzi NL, Basile C, Pelosi P, Gratarola A, Bonatti G, Patroniti N, Ciliberti R. Development and Validation of a Questionnaire investigating the Knowledge, Attitudes and Practices of Healthcare Workers in the Field of Anesthesiology concerning the Italian Law on Advance Healthcare Directives: a Pilot Study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021092. [PMID: 34487082 PMCID: PMC8477106 DOI: 10.23750/abm.v92i4.11314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 11/23/2022]
Abstract
Advance healthcare directives are legal documents, in which the patient, foreseeing a potential loss of capacity and autonomy, makes in advance decisions regarding future care and, in particular, end-of-life arrangements. In Italy, advance healthcare directives are regulated by the Law 219 of 22 December 2017. Objectives of the study were: i) to develop and validate a questionnaire dedicated to evaluate the knowledge of the Law in a sample of 98 anesthesiologists, and ii) to shed light on the process of health-related decision-making and its determinants (age, gender, doctor/training resident, religious beliefs). A second part of the survey not analyzed in the present study, aimed to assess, through two simulated clinical scenarios, how patient' directives, relatives and the medical staff could influence physicians' clinical decision. Overall Cronbach's alpha coefficient of the questionnaire resulted 0.83. Three factors explaining up to 38.4% of total variance (communication and relationship with the patient; critical life-threatening situations and binding nature of the advance directive for the physician; and involvement of patients). Most of the doctors (58.7%) did not fully know the recent legislative provision. The lack of knowledge is critical in view of the specificity of the clinical area investigated (anesthesiology and intensive care), which has to cope with ethical issues. An adequate revision and implementation of the traditional curricula could help medical students and trainees develop the aptitudes and skills needed in their future profession.
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Master JF, Wu B, Ni P, Mao J. The Compliance of End-of-Life Care Preferences Among Older Adults and Its Facilitators and Barriers: A Scoping Review. J Am Med Dir Assoc 2021; 22:2273-2280.e2. [PMID: 34087224 DOI: 10.1016/j.jamda.2021.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/11/2021] [Accepted: 05/03/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To explore the compliance of end-of-life (EOL) care preferences, and the facilitators and barriers of promoting quality of EOL care among older adults. DESIGN A scoping review was used to identify key themes in the compliance of EOL care preferences among older adults. SETTING AND PARTICIPANTS Studies published between 2009 and 2020 were identified from the Medline and Cochrane libraries. Eligible articles containing components related to the compliance of EOL care preferences among older adults were selected. MEASURES The eligible articles were thematically synthesized. Factors that affected the compliance of EOL care preferences among older adults were identified from the key components. RESULTS In total, 35 articles were included to identify the key components in the compliance of EOL care preferences: (1) supportive policy, (2) supportive environment, (3) cultural characteristics, (4) advance care planning (ACP), (5) the concordance of EOL care preferences between patients and surrogate decision makers, (6) prognosis awareness, and (7) patient's health status and the type of disease. Facilitators for the compliance of EOL care preferences included enactment of relevant policy, sufficient care institutions, the utilization of ACP, and poor health status. Barriers included lack of supportive policy, different culture, and low utilization of ACP. CONCLUSIONS/IMPLICATIONS The compliance of EOL care preferences was low among older adults. The compliance of EOL care preferences can be improved through relevant policy development and the utilization of ACP.
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Affiliation(s)
- Jie Fu Master
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bei Wu
- Rory Meyers College of Nursing and NYU Aging Incubator, New York University, New York, NY, USA
| | - Ping Ni
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Jing Mao
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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17
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In der Schmitten J, Jox RJ, Pentzek M, Marckmann G. Advance care planning by proxy in German nursing homes: Descriptive analysis and policy implications. J Am Geriatr Soc 2021; 69:2122-2131. [PMID: 33951187 DOI: 10.1111/jgs.17147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Legally recognized advance directives (ADs) have to be signed by the person to whom the decisions apply. In practice, however, there are also ADs written and signed by legal proxies (surrogates) on behalf of patients who lack decision-making capacity. Given their practical relevance and substantial ethical and legal implications, ADs by proxy (AD-Ps) have received surprisingly little scientific attention so far. OBJECTIVES To study the form, content, validity, and applicability of AD-Ps among German nursing home residents and develop policy implications. METHODS Secondary analysis of two independent cross-sectional studies in three German cities, comprising 21 nursing homes and 1528 residents. The identified AD-Ps were analyzed in parallel by three independent raters. Inter-rater agreement was measured using free-marginal multi-rater kappa statistics. RESULTS Altogether, 46 AD-Ps were identified and pooled for analysis. On average (range), AD-Ps were 1 (1-7) year(s) old, 0.5 (0.25-4) pages long, signed by 1 (0-5) person, with evidence of legal proxy involvement in 35%, and signed by a physician in 20% of cases. Almost all the AD-Ps reviewed aimed to limit life-sustaining treatment (LST), but had widely varying content and ethical justifications, including references to earlier statements (30%) or actual behavior (11%). The most frequent explicit directives were: do-not-hospitalize (67%), do-not-tube-feed (37%), do-not-attempt-resuscitation (20%), and the general exclusion of any LST (28%). Inter-rater agreement was mostly moderate (kappa ≥0.6) or strong (kappa ≥0.8). CONCLUSIONS Although AD-Ps are an empirical reality in German nursing homes, formal standards for such directives are lacking and their ethical justification based on substituted judgment or best interest standard often remains unclear. A qualified advance care planning process and corresponding documentation are required in order to safeguard the appropriate use of this important instrument and ensure adherence to ethico-legal standards.
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Affiliation(s)
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Chair in Geriatric Palliative Care, Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michael Pentzek
- Institute of General Practice (ifam), Centre for Health and Society (chs), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig Maximilian University of Munich, Munich, Germany
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18
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Completion Rates of Advance Directives in a Trauma Emergency Room: Association with Age. Emerg Med Int 2021; 2021:5537599. [PMID: 33968449 PMCID: PMC8081623 DOI: 10.1155/2021/5537599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/29/2021] [Accepted: 04/05/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction An advance directive (AD) is a written legal document in which a person can express wishes and preferences for medical treatment for the moment when that person is no longer able to make medical decisions because of a serious illness or injury. While ADs have emerged in public, it is unclear, how many adults in Germany have completed an AD, and frequencies differ among different patient cohorts and medical settings. The aim of this study was to evaluate how many patients visiting a trauma emergency room (ER) in an academic teaching hospital had completed an AD. Furthermore, patient characteristics were compared between patients who had completed an AD and those who had not completed an AD. Methods. Patients with a traumatic injury or disease who attended the ER of an academic teaching hospital in the period from October 2015 to March 2016 (n = 499) were surveyed for completion rates of ADs. Results. Prior to their visit to the ER, 12.8% of the included patients possessed a completed AD. Patients with a completed AD had a higher age (median age: 54 (IQR: 34–66) vs. 35 (IQR: 25–50) p < 0.001) and were less often living in an urban residential location (UR) (UR: 23.5% vs. 39.4%, p=0.029). Groups did not differ between sex (p=0.115), frequencies of high school graduates (p=0.482), and possession of a private health insurance (p=0.072), disability insurance (p=0.291), or an accident insurance (p=0.790). Conclusion. Completion rates of ADs remain low among patients visiting an ER of an academic teaching hospital in Germany. Increasing age but not factors such as sex, educational background, or insurance status were associated with a higher frequency of completed ADs.
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19
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Sprung CL, Jennerich AL, Joynt GM, Michalsen A, Curtis JR, Efferen LS, Leonard S, Metnitz B, Mikstacki A, Patil N, McDermid RC, Metnitz P, Mularski RA, Bulpa P, Avidan A. The Influence of Geography, Religion, Religiosity and Institutional Factors on Worldwide End-of-Life Care for the Critically Ill: The WELPICUS Study. J Palliat Care 2021:8258597211002308. [PMID: 33818159 DOI: 10.1177/08258597211002308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the association between provider religion and religiosity and consensus about end-of-life care and explore if geographical and institutional factors contribute to variability in practice. MATERIALS AND METHODS Using a modified Delphi method 22 end-of-life issues consisting of 35 definitions and 46 statements were evaluated in 32 countries in North America, South America, Eastern Europe, Western Europe, Asia, Australia and South Africa. A multidisciplinary, expert group from specialties treating patients at the end-of-life within each participating institution assessed the association between 7 key statements and geography, religion, religiosity and institutional factors likely influencing the development of consensus. RESULTS Of 3049 participants, 1366 (45%) responded. Mean age of respondents was 45 ± 9 years and 55% were females. Following 2 Delphi rounds, consensus was obtained for 77 (95%) of 81 definitions and statements. There was a significant difference in responses across geographical regions. South African and North American respondents were more likely to encourage patients to write advance directives. Fewer Eastern European and Asian respondents agreed with withdrawing life-sustaining treatments without consent of patients or surrogates. While respondent's religion, years in practice or institution did not affect their agreement, religiosity, physician specialty and responsibility for end-of-life decisions did. CONCLUSIONS Variability in agreement with key consensus statements about end-of-life care is related primarily to differences among providers, with provider-level variations related to differences in religiosity and specialty. Geography also plays a role in influencing some end-of-life practices. This information may help understanding ethical dilemmas and developing culturally sensitive end-of-life care strategies.
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Affiliation(s)
- Charles L Sprung
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ann L Jennerich
- Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Andrej Michalsen
- Department of Anaesthesiology and Critical Care Medicine, Tettnang Hospital, Tettnang, Germany
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Linda S Efferen
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA
| | - Sara Leonard
- Department of Anaesthesia and Critical Care, King's College Hospital, London, UK
| | - Barbara Metnitz
- Austrian Centre for Documentation and Quality Assurance in Intensive Care Medicine, Vienna, Austria
| | - Adam Mikstacki
- Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland
| | - Namrata Patil
- Division of Thoracic Surgery and Division of Trauma, Burn and Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Robert C McDermid
- Division of Critical Care, University of Alberta, Edmonton, Alberta, Canada
| | - Philipp Metnitz
- Clinical Department of General Anaesthesiology, Emergency and Intensive Care Medicine, LKH-University Hospital of Graz, Medical University of Graz, Graz, Austria
| | - Richard A Mularski
- The Center for Health Research Kaiser Permanente Northwest, Portland, OR, USA
| | - Pierre Bulpa
- Intensive Care Unit of Mont-Godinne University Hospital, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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20
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Silies K, Schnakenberg R, Berg A, Kirchner Ä, Langner H, Köberlein-Neu J, Meyer G, Hoffmann F, Köpke S. Process evaluation of a complex intervention to promote advance care planning in community-dwelling older persons (the STADPLAN study)-study protocol. Trials 2020; 21:653. [PMID: 32678005 PMCID: PMC7366302 DOI: 10.1186/s13063-020-04529-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 06/18/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Process evaluation addresses the implementation, mechanisms of impact, and context of participants in complex interventions. The STADPLAN study assesses the effects of conversations on advance care planning (ACP) led by trained nurse facilitators. The complex intervention consists of several components that may lead to various changes in attitude and behavior regarding personal ACP activities. With the process evaluation, we aim to assess how changes were achieved in the STADPLAN intervention. METHODS The planned process evaluation study will be conducted alongside a cluster-randomized controlled trial on ACP in home care services (HCS). Trained nurse facilitators will deliver the ACP intervention consisting of an information brochure and two ACP conversations. A logic model depicts the assumed change processes of the intervention: the educational program enables nurses to conduct ACP conversations with patients and their caregivers. Patients gain knowledge and reflect upon and engage in their own ACP. Caregivers better understand patients' wishes and feel reassured in their role as surrogates. Designation of a surrogate and communication on ACP are facilitated. We will assess the effects of the educational program with questionnaires and a focus group including all participating nurses. We will measure ACP engagement, and prevalence of advance directives in patients, and ask for their experiences with the intervention. We will conduct semi-structured interviews with caregivers about their expectations and experiences regarding ACP in general and the intervention. We will address context factors, e.g., basic characteristics of the HCS (such as ownership, number of clients, staff and qualification). Analysis will be based upon the logic model, integrating qualitative and quantitative data. DISCUSSION The comprehensive process evaluation will provide essential information on the feasibility of implementation strategies and the clinical relevance of a nurse-led ACP intervention in home care recipients and its generalizability and transferability to other settings. TRIAL REGISTRATION German Clinical Trials Register: DRKS00016886 . Registered retrospectively on June 4, 2019, first participant included on May 29, 2019.
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Affiliation(s)
- Katharina Silies
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.
| | - Rieke Schnakenberg
- Department for Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany.
| | - Almuth Berg
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Änne Kirchner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Henriette Langner
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Rainer-Gruenter-Straße 21, 42119, Wuppertal, Germany
| | - Gabriele Meyer
- Medical Faculty, Institute for Health- and Nursing Science, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Falk Hoffmann
- Department for Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany
| | - Sascha Köpke
- Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.,Institute for Nursing Science, University of Cologne, Gleueler Straße 176 - 178, 50935, Köln, Germany
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21
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Panozzo L, Harvey P, Adams MJ, O’Connor D, Ward B. Communication of advance care planning decisions: a retrospective cohort study of documents in general practice. BMC Palliat Care 2020; 19:108. [PMID: 32664925 PMCID: PMC7359590 DOI: 10.1186/s12904-020-00613-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 07/02/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Doctors, particularly general practitioners, play a significant role in assisting patients to create advance care plans. When medically indicated, these documents are important tools to promote congruence between end-of-life care and patient's personal preferences. Despite this, little is known regarding the availability of these documents in hospitals. The aim of this study was to identify the proportion of people who died in hospital without an advance care plan and how many of these had advance care planning (ACP) documents in their general practice records. METHODS A retrospective cohort study was conducted of patient hospital records with manual linkage to general practice records. The large regional hospital in Victoria, Australia has a catchment population in excess of 300,000 people. The study sample was patients aged 75 years and over who died in the hospital between 1 January 2016 and 31 December 2017. The hospital records of these patients were examined to identify those which did not have a system alert for ACP documents on the file. Alerted ACP documents were limited to those legislated in the state of Victoria: advance care plan, Enduring Power of Attorney (Medical Treatment) or Enduring Power of Guardianship. Where no ACP document system alert was found in the hospital record, the patient's nominated general practice was consented to participate and the corresponding general practice record was examined. Data were analysed using descriptive statistics. RESULTS Of the 406 patients who died in hospital, 76.1% (309) did not have a system alert for any ACP document. Of the 309 hospital records without a system alert, 144 (46.7%) corresponding general practice records were examined. Of these, 14.6% included at least one ACP document, including four advance care plans, that were not available in hospital. CONCLUSIONS Unless ACP documents are consistently communicated from general practice, patient's preferences may be unknown during end-of-life care. It is important that both doctors and patients are supported to use connected electronic health records to ensure that documents are readily available to healthcare staff when they are required.
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Affiliation(s)
- Laura Panozzo
- School of Rural Health, Monash University, 26 Mercy Street, Bendigo, Victoria 3550 Australia
| | - Pam Harvey
- School of Rural Health, Monash University, 26 Mercy Street, Bendigo, Victoria 3550 Australia
- La Trobe Rural Health School, Edwards Road, Bendigo, Victoria 3550 Australia
| | - Meagan-Jane Adams
- Bendigo Health, 100 Barnard Street, Bendigo, Victoria 3550 Australia
| | - Dennis O’Connor
- School of Rural Health, Monash University, 26 Mercy Street, Bendigo, Victoria 3550 Australia
| | - Bernadette Ward
- School of Rural Health, Monash University, 26 Mercy Street, Bendigo, Victoria 3550 Australia
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Kim-Knauss Y, Lang FR. Late-Life Preparedness and Its Correlates: A Behavioral Perspective on Preparation. J Gerontol B Psychol Sci Soc Sci 2020; 76:1555-1564. [PMID: 32622349 DOI: 10.1093/geronb/gbaa088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The present study examined the extent of late-life preparedness and its correlates. In accordance with behavior theories, we postulated that those who have prior experience with caregiving and who perceive such activities as more useful and less risky are more likely to engage in late-life preparatory activities. Because the perceived distance until aging-related life challenges become prevalent may play a role in late-life preparedness, we hypothesized that the effects of the correlates would vary depending on one's subjective remaining life expectation (SRLE). METHODS Building upon cross-sectional data including 581 German adults from 18 to 93 years, we fitted a hurdle model that separately analyzes the presence and variety of self-reported action engagement to better handle the zero-inflated count measure of preparatory activities. RESULTS The results revealed that the effects of perceived utility, caregiving experience, and SRLE were significant for both the presence and variety of activities. SRLE was found to moderate the observed effects in the models: The effect of perceived utility on the presence of at least one late-life preparatory activity was larger for those with lower SRLE. In contrast, among those with higher SRLE, having provided care increased the variety of preparatory activities. DISCUSSION Findings suggest that some of the examined psychosocial factors are similarly associated with both the presence of at least one and the variety of late-life preparatory activities, although the extent of their effects varies depending on one's subjective life stage.
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Affiliation(s)
- Yaeji Kim-Knauss
- Institute of Psychogerontology, Friedrich-Alexander University of Erlangen-Nuremberg, Germany
| | - Frieder R Lang
- Institute of Psychogerontology, Friedrich-Alexander University of Erlangen-Nuremberg, Germany
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Ay E, Weigand MA, Röhrig R, Gruss M. Dying in the Intensive Care Unit (ICU): A Retrospective Descriptive Analysis of Deaths in the ICU in a Communal Tertiary Hospital in Germany. Anesthesiol Res Pract 2020; 2020:2356019. [PMID: 32190047 PMCID: PMC7068140 DOI: 10.1155/2020/2356019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Modern intensive care methods led to an increased survival of critically ill patients over the last decades. But an unreflected application of modern intensive care measures might lead to prolonged treatment for incurable diseases, and an inadaequate or too aggressive therapy can prolong the dying process of patients. In this study, we analysed end-of-life decisions regarding withholding and withdrawal of intensive care measures in a German intensive care unit (ICU) of a communal tertiary hospital. METHODS Patient datasets of all adult patients dying in an ICU or an intermediate care unit (IMC) in a tertiary communal hospital (Klinikum Hanau, Germany) between 01.01.2011 and 31.12.2012 were analysed for withholding and withdrawal of intensive care measures. RESULTS During the two-year period, 1317 adult patients died in Klinikum Hanau. Of these, 489 (37%) died either in an ICU/IMC unit. The majority of those deceased patients (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (. CONCLUSIONS About one-third of patients dying in the hospital died in ICU/IMC. At least one life-sustaining therapy was limited/withdrawn in more than 60% of those patients. Withholding of a therapy was more common than active therapy withdrawal. Ventilation and renal replacement therapy were withdrawn in less than 5% of patients, respectively.
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Affiliation(s)
- Esma Ay
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hanau GmbH, Leimenstrasse 20, Hanau D-63450, Germany
| | - Markus. A. Weigand
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, Heidelberg D-69120, Germany
| | - Rainer Röhrig
- Department of Medical Informatics, University Hospital RWTH Aachen, Aachen, Germany
| | - Marco Gruss
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hanau GmbH, Leimenstrasse 20, Hanau D-63450, Germany
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Feng C, Wu J, Li J, Deng HY, Liu J, Zhao S. Advance directives of lung cancer patients and caregivers in China: A cross sectional survey. Thorac Cancer 2019; 11:253-263. [PMID: 31851775 PMCID: PMC6996976 DOI: 10.1111/1759-7714.13237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/18/2019] [Indexed: 02/05/2023] Open
Abstract
Background This study aimed to investigate lung cancer patients and attitudes of their caregivers toward advance directives (ADs) in China. Methods A cross sectional study was conducted in the Department of Oncology outpatient clinic in West China Hospital, Sichuan University. A questionnaire was used to survey the attitudes of lung cancer patients and caregivers toward ADs. Results A total of 148 lung cancer patients and 149 caregivers were enrolled into the study. Of these, 94.6% and 89.9% of patients and caregivers had not heard of AD and none of those in the study had ever signed an AD. A total of 79.7% patients and 75.2% caregivers were willing to sign ADs after they were provided with information. Patients who preferred the end of life period to sign ADs were 5.4 times more likely to have ADs than patients who chose to sign ADs when their disease was diagnosed (P < 0.05, 95%CI [1.27–22.93]). Caregivers who were reluctant to undergo chemotherapy when diagnosed with cancer were 2.16 times more likely to sign ADs than those willing to receive chemotherapy (P < 0.05, 95%CI [1.20–3.90]). Conclusions In China, lung cancer patients and their caregivers showed lack of knowledge about ADs, and the completion rate of ADs was extremely low. However, participants were positive about ADs and public education on ADs may help to increase the completion rate of ADs in China.
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Affiliation(s)
- Chenchen Feng
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
| | - Juan Wu
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
| | - Junying Li
- Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Han Yu Deng
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jiewei Liu
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shuzhen Zhao
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
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Forero Villalobos JJ, Vargas Celis I, Bernales Silva M. Voluntades anticipadas: desafíos éticos en el cuidado del paciente. PERSONA Y BIOÉTICA 2019. [DOI: 10.5294/pebi.2019.23.2.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Las voluntades anticipadas en salud tienen como finalidad que la persona manifieste de manera anticipada su voluntad sobre los cuidados y el tratamiento de su salud, lo cual le permite expresar personalmente y de forma previa sus preferencias. Esta revisión de la literatura tiene por objetivo describir el concepto y la estructura de las voluntades anticipadas, así como los aspectos éticos involucrados durante el cuidado del paciente. Con las palabras clave “Advanced Health Care Directive” AND “Ethical Implication” y sus símiles en español (voluntades anticipadas, implicaciones éticas), se revisaron cinco bases de datos: ProQuest, Philosophy (JSTOR), PubMed, Web of Science y SciELO; las publicaciones se agruparon entre los años 2010 y 2018. Se obtuvieron 31 artículos de los cuales se realizó una lectura crítica. Los resultados de esta revisión fueron agrupados en las siguientes categorías: concepto, estructura, situaciones clínicas donde se aplican las voluntades anticipadas, fortalezas y limitaciones; así como los aspectos éticos involucrados. Actualmente, son más comunes las vivencias relacionadas con las situaciones al final de la vida, donde la persona pierde su capacidad de decidir y no puede manifestar sus deseos, por lo que es imposible conocer su voluntad. Gran parte de los profesionales de la salud no tienen capacitación adecuada sobre el desarrollo y la aplicación de las voluntades anticipadas, escenario que se convierte en una oportunidad para la investigación y profundización sobre el tema. Las voluntades anticipadas son una herramienta que proporciona al equipo de salud información fidedigna de los valores y deseos del paciente, por lo que es importante capacitar a estos profesionales para brindar una atención respetuosa y de calidad.
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Advance Directive Preferences Among Terminally Ill Older Patients and Its Facilitators and Barriers in China: A Scoping Review. J Am Med Dir Assoc 2019; 20:1356-1361.e2. [DOI: 10.1016/j.jamda.2019.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 05/05/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022]
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Hartog CS, Hoffmann F, Mikolajetz A, Schröder S, Michalsen A, Dey K, Riessen R, Jaschinski U, Weiss M, Ragaller M, Bercker S, Briegel J, Spies C, Schwarzkopf D. [Non-beneficial therapy and emotional exhaustion in end-of-life care : Results of a survey among intensive care unit personnel]. Anaesthesist 2018; 67:850-858. [PMID: 30209513 DOI: 10.1007/s00101-018-0485-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/20/2018] [Accepted: 08/27/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play a role in the context of EOLC. OBJECTIVE Is the working environment associated with perception of NBT or clinician burnout? MATERIAL AND METHODS Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis. RESULTS The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91 residents and 26 consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p ≤ 0.001) and the numbers of weekend working days per month (p = 0.012). Protective factors against burnout included intensive care specialization (p = 0.001) and emotional support within the team (p ≤ 0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p ≤ 0.001). DISCUSSION Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.
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Affiliation(s)
- Christiane S Hartog
- Klinik für Anästhesie m.S. operative Intensivmedizin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
- Klinik Bavaria Kreischa, Kreischa, Deutschland.
| | - F Hoffmann
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinik Jena, Jena, Deutschland
| | - A Mikolajetz
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinik Jena, Jena, Deutschland
| | - S Schröder
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Krankenhaus Düren, Düren, Deutschland
| | - A Michalsen
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Medizin Campus Bodensee - Klinik Tettnang, Tettnang, Deutschland
| | - K Dey
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Bundeswehrkrankenhaus Berlin, Berlin, Deutschland
| | - R Riessen
- Medizinische Klinik, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - U Jaschinski
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Augsburg, Deutschland
| | - M Weiss
- Klinik für Anästhesiologie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - M Ragaller
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Deutschland
| | - S Bercker
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - J Briegel
- Klinik für Anästhesiologie, Klinikum der Universität, LMU München, München, Deutschland
| | - C Spies
- Klinik für Anästhesie m.S. operative Intensivmedizin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - D Schwarzkopf
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinik Jena, Jena, Deutschland
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Ciliberti R, Gorini I, Gazzaniga V, De Stefano F, Gulino M. The Italian law on informed consent and advance directives: New rules of conduct for the autonomy of doctors and patients in end-of-life care. J Crit Care 2018; 48:178-182. [PMID: 30216936 DOI: 10.1016/j.jcrc.2018.08.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 08/10/2018] [Accepted: 08/27/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE Italy has long lacked a law regulating patients' informed consent and advance directives (ADs). All previous attempts to introduce a law on this matter failed to reach positive outcomes, and aroused heated ideological debate over the exact meaning of life and death. We report on the new law on informed consent and ADs approved by the Italian Parliament on 14th December 2017. MATERIALS AND METHODS We analyse the new law and discuss the main ethical points connected with it, in the Italian context and in comparison with the international situation. RESULTS The law provides for fundamental ethical principles and important guidelines: respect for patients' self-determination in all phases of life, option to refuse or interrupt life-sustaining treatments, including artificial nutrition and hydration, the legitimacy of end-of-life decisions, and the implementation of palliative care to ease suffering and pain. CONCLUSIONS The effects of the new law must be tested in the field. Its objectives will be achieved if, in clinical practice, ADs are able to satisfactorily represent informed personal preferences through patients' relationships with their physicians, as part of personalized advance care planning. Future studies are necessary to assess the impact of the new law in Italy.
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Affiliation(s)
- Rosagemma Ciliberti
- Department of Health Sciences, Section of Forensic Medicine and Bioethics, University of Genova, 12 Via De Toni, 16132 Genoa, Italy.
| | - Ilaria Gorini
- Department of Biotechnology and Life Sciences, University of Insubria, 9 Via O. Rossi, 21100 Varese, Italy.
| | - Valentina Gazzaniga
- Department of Medico-surgical Sciences and Biotechnologies, Sapienza University of Rome, 79 Corso della Repubblica, 04100 Latina, Italy.
| | - Francesco De Stefano
- Department of Health Sciences, Section of Forensic Medicine and Bioethics, University of Genova, 12 Via De Toni, 16132 Genoa, Italy.
| | - Matteo Gulino
- Department of Medico-surgical Sciences and Biotechnologies, Sapienza University of Rome, 79 Corso della Repubblica, 04100 Latina, Italy.
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Laryionava K, Pfeil TA, Dietrich M, Reiter-Theil S, Hiddemann W, Winkler EC. The second patient? Family members of cancer patients and their role in end-of-life decision making. BMC Palliat Care 2018; 17:29. [PMID: 29454337 PMCID: PMC5816525 DOI: 10.1186/s12904-018-0288-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Family members are important companions of severely ill patients with cancer. However, studies about the desirability and difficulties of integrating relatives in the decision-making process are rare in oncology. This qualitative study explores the family role in decisions to limit treatment near the end of life from the professionals' point of view. METHODS Qualitative in-depth interviews were conducted with oncologists (n = 12) and nurses (n = 6) working at the Department of Hematology/Oncology at the University Hospital in Munich, Germany. The data were analyzed using a descriptive qualitative methodology and discussed from a medical ethics perspective. RESULTS Four major themes played a central role in the perception of the medical staff in regard to family members. (1) Family impact on patients' treatment preferences. (2) Strong family wish for further treatment. (3) Emotional distress of the family related to the involvement in end-of-life decision-making. (4) Importance of knowing family structures. CONCLUSIONS The important role of the family members in patients' disease process is recognized by oncologists and oncology nurses. However, this does not seem to lead to an early involvement of the family members. Developing and establishing a systematic assessment of family members' needs and wishes in order to provide a specific-tailored support should become a priority for interdisciplinary clinical research in the near future.
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Affiliation(s)
- Katsiaryna Laryionava
- National Center for Tumor Diseases, Department of Medical Oncology, Programme for Ethics and Patient-Oriented Care in Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Timo A Pfeil
- Department of Internal Medicine III (Haematology and Oncology), University Hospital Grosshadern, Munich, Germany
| | - Mareike Dietrich
- National Center for Tumor Diseases, Department of Medical Oncology, Programme for Ethics and Patient-Oriented Care in Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Stella Reiter-Theil
- Department Clinical Ethics, Psychiatric Hospitals of the University Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wolfgang Hiddemann
- Department of Internal Medicine III (Haematology and Oncology), University Hospital Grosshadern, Munich, Germany
| | - Eva C Winkler
- National Center for Tumor Diseases, Department of Medical Oncology, Programme for Ethics and Patient-Oriented Care in Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
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Schmidhuber M, Haeupler S, Marinova-Schmidt V, Frewer A, Kolominsky-Rabas PL. Advance Directives as Support of Autonomy for Persons with Dementia? A Pilot Study among Persons with Dementia and Their Informal Caregivers. Dement Geriatr Cogn Dis Extra 2017; 7:328-338. [PMID: 29118785 PMCID: PMC5662977 DOI: 10.1159/000479426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Advance directives could be an important instrument to support a person's will once he/she is not able to consent anymore - if composed competently. A survey was conducted to identify the level of knowledge concerning possibilities and limits of advance directives. METHODS The study was conducted as part of the Bavarian Dementia Survey (BayDem). Data were collected from January 2014 to December 2015 by structured face-to-face interviews. Study participants were persons with dementia and their informal caregivers (n = 74). RESULTS In total, 66% reported having written an advance directive. Concerning the participants' knowledge about possibilities and limitations of advance directives, a lack of knowledge was noted about the possibility to revoke an advance directive. Furthermore, 70% of informal caregivers and 56% of persons with dementia were not aware of the possibility to include dementia-specific terms in the advance directive. CONCLUSION It is necessary to optimize structures for public information and education concerning the topic of advance directives for persons with dementia.
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Affiliation(s)
- Martina Schmidhuber
- Institute for History of Medicine and Medical Ethics, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sandra Haeupler
- Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Velislava Marinova-Schmidt
- Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Andreas Frewer
- Institute for History of Medicine and Medical Ethics, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Peter L. Kolominsky-Rabas
- Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Luck T, Rodriguez FS, Wiese B, van der Leeden C, Heser K, Bickel H, In der Schmitten J, Koenig HH, Weyerer S, Mamone S, Mallon T, Wagner M, Weeg D, Fuchs A, Brettschneider C, Werle J, Scherer M, Maier W, Riedel-Heller SG. Advance directives and power of attorney for health care in the oldest-old - results of the AgeQualiDe study. BMC Geriatr 2017; 17:85. [PMID: 28407800 PMCID: PMC5390475 DOI: 10.1186/s12877-017-0482-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 04/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Completion of advance directives (ADs) and power of attorney (POA) documents may protect a person's autonomy in future health care situations when the individual lacks decisional capacity. As such situations become naturally much more common in old age, we specifically aimed at providing information on (i) the frequency of ADs/POA in oldest-old individuals and (ii) factors associated with having completed ADs/POA. METHODS We analyzed data of oldest-old primary care patients (85+ years; including community-dwelling and institutionalized individuals) within the German AgeQualiDe study. Patients were initially recruited via their general practitioners (GPs). We calculated frequencies of ADs and POA for health care with 95% confidence intervals (CI) and used multivariable logistic regression analysis to evaluate the association between having ADs and POA and participants' socio-demographic, cognitive, functional, and health-related characteristics. RESULTS Among 868 GP patients participating in AgeQualiDe (response = 90.9%), n = 161 had dementia and n = 3 were too exhausted/ill to answer the questions. Out of the remaining 704 (81.1%) dementia-free patients (mean age = 88.7 years; SD = 3.0), 69.0% (95%-CI = 65.6-72.4) stated to having ADs and 64.6% (95%-CI = 61.1-68.2) to having a POA for health care. Individual characteristics did not explain much of the variability of the presence/absence of ADs and POA (regression models: Nagelkerke's R2 = 0.034/0.051). The most frequently stated reasons for not having ADs were that the older adults trust their relatives or physicians to make the right decisions for them when necessary (stated by 59.4% and 44.8% of those without ADs). Among the older adults with ADs, the majority had received assistance in its preparation (79.0%), most frequently from their children/grandchildren (38.3%). Children/grandchildren were also the most frequently stated group of designated persons (76.7%) for those with a POA for health care. CONCLUSIONS Our findings suggest a high dissemination of ADs and POA for health care in the oldest-old in Germany. Some adults without ADs/POA perhaps would have completed advance care documents, if they had had received more information and support. When planning programs to offer advanced care planning to the oldest old, it might be helpful to respond to these specific needs, and also to be sensitive to attitudinal differences in this target group.
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Affiliation(s)
- Tobias Luck
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany.
| | - Francisca S Rodriguez
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany.,LIFE - Leipzig Research Center for Civilization Diseases, Universität Leipzig, Leipzig, Germany.,Edward R. Roybal Institute on Aging, University of Southern California, Los Angeles, USA
| | - Birgitt Wiese
- Work Group Medical Statistics and IT-Infrastructure, Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Carolin van der Leeden
- Department of Primary Medical Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathrin Heser
- Department of Psychiatry, University of Bonn, Bonn, Germany
| | - Horst Bickel
- Department of Psychiatry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jürgen In der Schmitten
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Hans-Helmut Koenig
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Siegfried Weyerer
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Silke Mamone
- Work Group Medical Statistics and IT-Infrastructure, Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Tina Mallon
- Department of Primary Medical Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Wagner
- Department of Psychiatry, University of Bonn, Bonn, Germany.,DZNE, German Center for Neurodegenerative Diseases, Bonn, Germany
| | - Dagmar Weeg
- Department of Psychiatry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Angela Fuchs
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Brettschneider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Werle
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Martin Scherer
- Department of Primary Medical Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Maier
- Department of Psychiatry, University of Bonn, Bonn, Germany.,DZNE, German Center for Neurodegenerative Diseases, Bonn, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
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Schweda M, Schicktanz S, Raz A, Silvers A. Beyond cultural stereotyping: views on end-of-life decision making among religious and secular persons in the USA, Germany, and Israel. BMC Med Ethics 2017; 18:13. [PMID: 28212642 PMCID: PMC5316158 DOI: 10.1186/s12910-017-0170-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 01/24/2017] [Indexed: 11/24/2022] Open
Abstract
Background End-of-life decision making constitutes a major challenge for bioethical deliberation and political governance in modern democracies: On the one hand, it touches upon fundamental convictions about life, death, and the human condition. On the other, it is deeply rooted in religious traditions and historical experiences and thus shows great socio-cultural diversity. The bioethical discussion of such cultural issues oscillates between liberal individualism and cultural stereotyping. Our paper confronts the bioethical expert discourse with public moral attitudes. Methods The paper is based on a qualitative study comprising 12 focus group discussions with religious and secular persons in the USA, Germany, and Israel (n = 82). Considering the respective socio-political and legal frameworks, the thematic analysis focuses on moral attitudes towards end-of-life decision making and explores the complex interplay between individual preferences, culture, and religion. Results Our findings draw attention to the variety and complexity of cultural and religious aspects of end-of-life decision making. Although there is local consensus that goes beyond radical individualism, positions are not neatly matched with national cultures or religious denominations. Instead, the relevance of the specific situatedness of religious beliefs and cultural communities becomes visible: Their status and role in individual situations, for example, as consensual or conflicting on the level of personal perspectives, family relationships, or broader social contexts, e.g., as a majority or minority culture within a political system. Conclusions As the group discussions indicate, there are no clear-cut positions anchored in “nationality,” “culture,” or “religion.” Instead, attitudes are personally decided on as part of a negotiated context representing the political, social and existential situatedness of the individual. Therefore, more complex theoretical and practical approaches to cultural diversity have to be developed.
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Affiliation(s)
- Mark Schweda
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Humboldtallee 36, 37073, Göttingen, Germany
| | - Silke Schicktanz
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Humboldtallee 36, 37073, Göttingen, Germany.
| | - Aviad Raz
- Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Be'er-Sheva, 84105, Israel
| | - Anita Silvers
- Department of Philosophy, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA, 94132, USA
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Alonso A, Dörr D, Szabo K. Critical appraisal of advance directives given by patients with fatal acute stroke: an observational cohort study. BMC Med Ethics 2017; 18:7. [PMID: 28152998 PMCID: PMC5288941 DOI: 10.1186/s12910-016-0166-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/30/2016] [Indexed: 11/25/2022] Open
Abstract
Background Advance directives (AD) imply the promise of determining future medical treatment in case of decisional incapacity. However, clinical practice increasingly indicates that standardized ADs often fail to support patients’ autonomy. To date, little data are available about the quality and impact of ADs on end-of-life decisions for incapacitated acute stroke patients. Methods We analyzed the ADs of patients with fatal stroke, focusing on: (a) their availability and type, (b) stated circumstances to which the AD should apply, and (c) stated wishes regarding specific treatment options. Results Between 2011 and 2014, 143 patients died during their hospitalization on our stroke unit. Forty-two of them (29.4%) had a completed and signed, written AD, as reported by their family, but only 35 ADs (24.5%) were available. The circumstances in which the AD should apply were stated by 21/35 (60%) as a “terminal condition that will cause death within a relatively short time” or an ongoing “dying process.” A retrospective review found only 16 of 35 ADs (45.7%) described circumstances that, according to the medical file, could have been considered applicable by the treating physicians. A majority of patients objected to cardiopulmonary resuscitation (22/35, 62.9%), mechanical ventilation (19/35, 54.3%), and artificial nutrition (26/35, 74.3%), while almost all (33/35, 94.3%) directed that treatment for alleviation of pain or discomfort should be provided at all times even if it could hasten death. Conclusions The prevalence of ADs among patients who die from acute stroke is still low. A major flaw of the ADs in our cohort was their attempt to determine single medical procedures without focusing on a precise description of applicable scenarios. Therefore, less than half of the ADs were considered applicable for severe acute stroke. These findings stress the need to foster educational programs for the general public about advance care planning to facilitate the processing of timely, comprehensive, and individualized end-of-life decision-making.
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Affiliation(s)
- A Alonso
- Department of Neurology, Medizinische Fakultät Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - D Dörr
- Clinical Ethics Committee, Medizinische Fakultät Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - K Szabo
- Department of Neurology, Medizinische Fakultät Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Spranzi M, Fournier V. The near-failure of advance directives: why they should not be abandoned altogether, but their role radically reconsidered. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2016; 19:563-568. [PMID: 27151078 DOI: 10.1007/s11019-016-9704-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Advance directives (ADs) have been hailed for two decades as the best way to safeguard patients' autonomy when they are totally or partially incompetent. In many national contexts they are written into law and they are mostly associated with end-of-life decisions. Although advocates and critics of ADs exchange relevant empirical and theoretical arguments, the debate is inconclusive. We argue that this is so for good reasons: the ADs' project is fraught with tensions, and this is the reason why they are both important and deeply problematic. We outline six such tensions, and conclude with some positive suggestions about how to better promote patients' autonomy in end-of-life decision. We argue that ADs should continue to be an option but they cannot be the panacea that they are expected to be.
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Affiliation(s)
- Marta Spranzi
- University of Versailles-St-Quentin-en-Yvelines (UVSQ), Versailles, France
- Centre d'éthique clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Véronique Fournier
- Centre d'éthique clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Lotz JD, Jox RJ, Meurer C, Borasio GD, Führer M. Medical indication regarding life-sustaining treatment for children: Focus groups with clinicians. Palliat Med 2016; 30:960-970. [PMID: 26847523 PMCID: PMC5117124 DOI: 10.1177/0269216316628422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Decisions about medical indication are a relevant problem in pediatrics. Difficulties arise from the high prognostic uncertainty, the decisional incapacity of many children, the importance of the family, and conflicts with parents. The objectivity of judgments about medical indication has been questioned. Yet, little is known about the factors pediatricians actually include in their decisions. AIM Our aims were to investigate which factors pediatricians apply in deciding about medical indication, and how they manage conflicts with parents. DESIGN We performed a qualitative focus group study with experienced pediatricians. The transcripts were subjected to qualitative content analysis. SETTING/PARTICIPANTS We conducted three focus groups with pediatricians from different specialties caring for severely ill children/adolescents. They discussed life-sustaining treatment in two case scenarios that varied according to diagnosis, age, and gender. RESULTS The decisions about medical indication were based on considerations relating to the individual patient, to the family, and to other patients. Individual patient factors included clinical aspects and benefit-burden considerations. Physicians' individual views and feelings influenced their decision-making. Different factors were applied or weighed differently in the two cases. In case of conflict with parents, physicians preferred solutions aimed at establishing consensus. CONCLUSION The pediatricians defined medical indication on a case-by-case basis and were influenced by emotional reasoning. In contrast to prevailing ethico-legal principles, they included the interests of other persons in their decisions. Decision-making strategies should incorporate explicit discussions of social aspects and physicians' feelings to improve the transparency of the decision-making process and reduce bias.
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Affiliation(s)
- Julia Desiree Lotz
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Christine Meurer
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Gian Domenico Borasio
- Palliative Care Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Monika Führer
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
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Survey on German Palliative Care Specialists' Experiences with Advance Directives. Pain Ther 2016; 6:17-28. [PMID: 27900726 PMCID: PMC5447540 DOI: 10.1007/s40122-016-0063-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction Advance directives (AD) play a central role in end-of-life treatments, intensive care, and palliative care. However, little is known about the experiences of healthcare professionals with ADs. This study reports on palliative care professionals’ views on advance directives (AD). Methods A questionnaire was handed out to attendants of a palliative care symposium. Results Complete answers were obtained from 126 physicians and 276 nurses. Almost all physicians and nurses had treated patients with an AD, and the majority more than 10 patients. The most frequent refusal by the patients was resuscitation (87.8%) followed by intensive care (79.1%), artificial ventilation, and nutrition. The most frequent wish was pain therapy (92.3%) followed by allowing the natural course of the illness (64.4%). The wish for hospice treatment (44.8%) or spiritual care (39.3%) was less frequent. Discussion The results hint at fears and deficits in the care of patients at the end of life. Often the quality of life and not the quantity of days remaining is in the center of a patient’s will and points to the growing importance of palliative care. Conclusion ADs are well established among palliative care professionals and regarded as helpful for patients at the end of life.
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Zhang Q, Xie C, Xie S, Liu Q. The Attitudes of Chinese Cancer Patients and Family Caregivers toward Advance Directives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13080816. [PMID: 27529264 PMCID: PMC4997502 DOI: 10.3390/ijerph13080816] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/05/2016] [Accepted: 08/08/2016] [Indexed: 11/25/2022]
Abstract
Advance directives (ADs) have been legislated in many countries to protect patient autonomy regarding medical decisions at the end of life. China is facing a serious cancer burden and cancer patients’ quality at the end of life should be a concern. However, limited studies have been conducted locally to gather information about attitudes toward ADs. The purpose of this study was to investigate the attitudes of Chinese cancer patients and family caregivers toward ADs and to explore the predictors that are associated with attitudes. The study indicated that although there was low awareness of ADs, most cancer patients and family caregivers had positive attitudes toward ADs after related information was explained to them. Participants preferred to discuss ADs with medical staff when they were diagnosed with a life-threatening disease. Preferences for refusing life-sustaining treatment and choosing Hospice-Palliative Care (HPC) at the end of life would increase the likelihood of agreeing with ADs. This suggests that some effective interventions to help participants better understand end-of-life treatments are helpful in promoting ADs. Moreover, the development of HPC would contribute to Chinese cancer patients and family caregivers agreeing with ADs.
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Affiliation(s)
- Qiu Zhang
- Department of Health Service Management, Public Health School of Sun Yat-sen University, Guangzhou 510060, China.
| | - Chuanbo Xie
- State Key Laboratory of Oncology in South China, Department of Preventive Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.
| | - Shanghang Xie
- State Key Laboratory of Oncology in South China, Department of Preventive Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.
| | - Qing Liu
- State Key Laboratory of Oncology in South China, Department of Preventive Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China.
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Zheng RJ, Fu Y, Xiang QF, Yang M, Chen L, Shi YK, Yu CH, Li JY. Knowledge, attitudes, and influencing factors of cancer patients toward approving advance directives in China. Support Care Cancer 2016; 24:4097-103. [PMID: 27209478 PMCID: PMC4993803 DOI: 10.1007/s00520-016-3223-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/17/2016] [Indexed: 02/05/2023]
Abstract
Purpose Many cancer patients do not have advance directives (ADs), which may lead to unwanted excessive or aggressive care when patients have lost decision-making capacity. The aim of this study was to investigate knowledge and attitudes of approving ADs and explore factors associated with willing to designate ADs among cancer patients in China. Methods We conducted semi-structured interview method investigating 753 in-patients with cancer in two cancer centers. Results Of those subjects, none of the cancer patients had an AD. Only 22.4 % (118 of 526) approved ADs. Comparing with the disapproved ADs group, the approved ADs group were more likely to discuss the AD with oncologist or nurse (χ2 = 180.4, p < 0.001) in the cancer center (χ2 = 244.1, p < 0.001), and they chose more comfort care (χ2 = 18.8, p < 0.001). Most of cancer patients in the two groups wanted to die at home (72.8 %, 73.7 %, respectively). The older patients (OR, 1.04, 95 % CI, 1.02–1.07, p = 0.001), female (OR, 0.55, 95 % CI, 0.35–0.88, p = 0.013), with higher education levels (OR, 3.38, 95 % CI, 1.92–5.96, p < 0.001), with religious beliefs (OR, 2.91, 95 % CI, 1.71–4.94, p < 0.001), and with higher scores of ECOG (OR, 1.46, 95 % CI, 1.17–1.82, p = 0.001) were associated with desiring for ADs. Conclusions Our findings indicate that there was a dearth of knowledge and different attitudes toward approving ADs among cancer patients, and some factors of demographic and clinical characteristics influenced their willing to designate ADs. This research highlights the importance of propagandizing the ADs to the public, especially to the patients, and further discussing with them when the time is ripe.
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Affiliation(s)
- Ru-Jun Zheng
- West China Nursing School and Business School, Sichuan University, Chengdu, 610041, People's Republic of China.,Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yan Fu
- Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Qiu-Fen Xiang
- Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Mei Yang
- Cancer Research Center, Tumor Hospital of Xinjiang, Xinjiang Medical University, Urumuqi, 830000, People's Republic of China
| | - Lin Chen
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ying-Kang Shi
- Institute of Hospital Administration,West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Chun-Hua Yu
- Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
| | - Jun-Ying Li
- Department of Thoracic Cancer and Cancer Research Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Alonso A, Ebert AD, Dörr D, Buchheidt D, Hennerici MG, Szabo K. End-of-life decisions in acute stroke patients: an observational cohort study. BMC Palliat Care 2016; 15:38. [PMID: 27044257 PMCID: PMC4820928 DOI: 10.1186/s12904-016-0113-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 03/23/2016] [Indexed: 11/11/2022] Open
Abstract
Background Crucial issues of modern stroke care include best practice end-of-life-decision (EOLD)-making procedures and the provision of high-quality palliative care for dying stroke patients. Methods We retrospectively analyzed records of those patients who died over a 4-year period (2011–2014) on our Stroke Unit concerning EOLD, focusing on the factors that most probably guided decisions to induce limitation of life-sustaining therapy and subsequently end-of-life-care procedures thereafter. Results Of all patients treated at our Stroke Unit, 120 (2.71 %) died. In 101 (86.3 %), a do-not-resuscitate-order (DNRO) was made during early treatment. A decision to withdraw/withhold further life supportive therapy was made in 40 patients (34.2 %) after a mean of 5.0 days (range 0–29). Overall patient death occurred after a mean time of 7.0 days (range 1–30) and 2.6 days after therapy restrictions. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke were possible indicators of decisions to therapeutic withdrawing/withholding. Proceedings of EOL care in these patients were heterogeneous; in most cases monitoring (95 %), medical procedures (90 %), oral medication (88 %), parenteral nutrition (98 %) and antibiotic therapy (86 %) were either not ordered or withdrawn, however IV fluids were continued in all patients. Conclusions A high percentage of stroke patients were rated as terminally ill and died in the course of caregiving. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke facilitated decisions to change therapeutic goals thus initiating end-of-life-care. However, there is further need to foster research on this field in order to ameliorate outcome prognostication, to understand the dynamics of EOLD-making procedures and to educate staff to provide high-quality patient-centred palliative care in stroke medicine. Electronic supplementary material The online version of this article (doi:10.1186/s12904-016-0113-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angelika Alonso
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
| | - Anne D Ebert
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Dorothee Dörr
- Health Care Ethics Committee, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Michael G Hennerici
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
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Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, Soeters P, Weimann A, Bischoff SC. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr 2016; 35:545-56. [PMID: 26923519 DOI: 10.1016/j.clnu.2016.02.006] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 01/28/2016] [Accepted: 02/05/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient. METHODS The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members. RESULTS The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.
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Affiliation(s)
- Christiane Druml
- UNESCO Chair on Bioethics at the Medical University of Vienna, Collections and History of Medicine - Josephinum, Medical University of Vienna, Waehringerstrasse 25, A-1090 Vienna, Austria.
| | - Peter E Ballmer
- Department of Medicine, Kantonsspital Winterthur, Brauerstrasse 15, Postfach 834, 8401 Winterthur, Switzerland.
| | - Wilfred Druml
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Frank Oehmichen
- Department of Early Rehabilitation, Klinik Bavaria Kreischa, An der Wolfsschlucht 1-2, 01731 Kreischa, Germany.
| | - Alan Shenkin
- Department of Clinical Chemistry, University of Liverpool, Duncan Building, Daulby Street, Liverpool L69 3GA, UK.
| | - Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Jean Leven Building, 6th Floor, Tel Aviv, Israel.
| | - Peter Soeters
- Department of Surgery, Academic Hospital Maastricht, Peter Debeyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
| | - Arved Weimann
- Department of General Surgery and Surgical Intensive Care, St Georg Hospital, Delitzscher Straße 141, 04129 Leipzig, Germany.
| | - Stephan C Bischoff
- Department of Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599 Stuttgart, Germany.
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Kuehlmeyer K, Schuler AF, Kolb C, Borasio GD, Jox RJ. Evaluating Nonverbal Behavior of Individuals with Dementia During Feeding: A Survey of the Nursing Staff in Residential Care Homes for Elderly Adults. J Am Geriatr Soc 2015; 63:2544-2549. [DOI: 10.1111/jgs.13822] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Katja Kuehlmeyer
- Institute for Ethics, History and Theory of Medicine; Ludwig-Maximilians Universität München; Munich Germany
| | - Anna F. Schuler
- Institute for Ethics, History and Theory of Medicine; Ludwig-Maximilians Universität München; Munich Germany
| | - Christian Kolb
- Institute of Psychogerontology; Friedrich Alexander Universität; Erlangen-Nuremberg Germany
| | - Gian Domenico Borasio
- Chair in Palliative Medicine; Centre Hospitalier Universitaire Vaudois; Université de Lausanne; Lausanne Switzerland
| | - Ralf J. Jox
- Institute for Ethics, History and Theory of Medicine; Ludwig-Maximilians Universität München; Munich Germany
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Raz A, Jordan I, Schicktanz S. Exploring the positions of German and Israeli patient organizations in the bioethical context of end-of-life policies. HEALTH CARE ANALYSIS 2015; 22:143-59. [PMID: 22729899 DOI: 10.1007/s10728-012-0213-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient organizations are increasingly involved in national and international bioethical debates and health policy deliberations. In order to examine how and to what extent cultural factors and organizational contexts influence the positions of patient organizations, this study compares the positions of German and Israeli patient organizations (POs) on issues related to end-of-life medical care. We draw on a qualitative pilot study of thirteen POs, using as a unit of analysis pairs comprised of one German PO and one Israeli PO that were matched on the basis of organizational category. Bioethical positions that emanated from the interviews concerned advance directives--general views, recent legal framework, and formalization; as well as active and passive euthanasia, withholding and withdrawing of treatment, and physician-assisted suicide. In addition to the unifying, within-country impact of cultural factors, we found that constituency-based organizations and partner organizations in both countries often share common views, whereas disease-based support organizations have very heterogeneous positions. We conclude by discussing how organizational contexts provide a source of uniformity as well as diversity in the positions of POs.
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Affiliation(s)
- Aviad Raz
- Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Beer-Sheva, Israel,
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Inthorn J, Schicktanz S, Rimon-Zarfaty N, Raz A. "What the patient wants…": Lay attitudes towards end-of-life decisions in Germany and Israel. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2015; 18:329-340. [PMID: 25344758 DOI: 10.1007/s11019-014-9606-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
National legislation, as well as arguments of experts, in Germany and Israel represent opposite regulatory approaches and positions in bioethical debates concerning end-of-life care. This study analyzes how these positions are mirrored in the attitudes of laypeople and influenced by the religious views and personal experiences of those affected. We qualitatively analyzed eight focus groups in Germany and Israel in which laypeople (religious, secular, affected, and non-affected) were asked to discuss similar scenarios involving the withholding or withdrawing of treatment, physician-assisted suicide, and euthanasia. In both countries, respect for patient autonomy and patients' wishes to die with dignity found broad consent. Laypeople argued in favor of accepting such wishes when they were put down in an advance directive. Laypeople in non-religious groups in both countries argued on the basis of a respect for autonomy for the possibility of euthanasia in severe cases but, at the same time, cautioned against its possible misuse. National contrast was apparent in the moral reasoning of lay respondents concerning the distinction between withholding and withdrawing treatment. The modern religious laypeople in Israel, especially, argued strongly, on the basis of the halakhic tradition, against allowing the withdrawal of treatment in accord with a patient's wish. We conclude by discussing the emergent notion of shared responsibility and views of professional responsibility, which we connect through relevant cultural themes such as religion and national culture.
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Affiliation(s)
- Julia Inthorn
- Department of Medical Ethics and History of Medicine, University Medical Center Goettingen, Humboldtallee 36, 37073, Goettingen, Germany,
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Jox RJ, Ney L. [Changing the therapeutic goal in critically ill patients. Ethical analysis of a surgical case]. Unfallchirurg 2015; 117:399-405. [PMID: 24831869 DOI: 10.1007/s00113-013-2455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We report on a 32-year-old patient, who developed septic shock, toxic shock-like syndrome, and multiple organ failure following nectrotizing fasciitis. Amputations had to be performed on all extremities. Subsequently, she developed secondary sclerosing cholangitis. Treatment goals had to be reassessed, since long-term survival seemed doubtful and, in the best case, burdened with severe handicap. We discuss the evaluation of the treatment goals, utilizing a structured model of goal-setting. In the first step the treatment goal is identified based on the patient's wishes. This goal's realistic achievability is verified considering scientific evidence and medical experience. The benefit of the aspired goal is set in relation to risks and burden of the necessary treatment measures in a third step. The resulting benefit-risk ratio must be evaluated by the patient or her representative. Treatment goals have to be reevaluated if the assessment of achievability or the benefit-risk ratio are disadvantageous. In this case, the initial therapeutic goal was retained. After an extraordinarily prolonged and complex therapy including reconstructive surgery the patient is now living independently at home.
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Affiliation(s)
- R J Jox
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, Lessingstraße 2, 80336, München, Deutschland,
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Évolution des droits de patients en fin de vie. Presse Med 2015; 44:392-400. [DOI: 10.1016/j.lpm.2015.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 02/11/2015] [Accepted: 02/16/2015] [Indexed: 11/18/2022] Open
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Sprung CL, Truog RD, Curtis JR, Joynt GM, Baras M, Michalsen A, Briegel J, Kesecioglu J, Efferen L, De Robertis E, Bulpa P, Metnitz P, Patil N, Hawryluck L, Manthous C, Moreno R, Leonard S, Hill NS, Wennberg E, McDermid RC, Mikstacki A, Mularski RA, Hartog CS, Avidan A. Seeking Worldwide Professional Consensus on the Principles of End-of-Life Care for the Critically Ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) Study. Am J Respir Crit Care Med 2014; 190:855-66. [DOI: 10.1164/rccm.201403-0593cc] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Pfirstinger J, Kattner D, Edinger M, Andreesen R, Vogelhuber M. The impact of a tumor diagnosis on patients' attitudes toward advance directives. Oncology 2014; 87:246-56. [PMID: 25139124 DOI: 10.1159/000363508] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/05/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although advance care planning and the completion of advance directives (ADs) are important tools to avoid unwanted aggressive care once patients have lost their decision-making capacity, only a minority of cancer patients are admitted with completed ADs, and little is known about patients' wishes regarding AD consultations. METHODS For 1 year, every new patient admitted to the hematology/oncology outpatient clinic of the University Hospital Regensburg received a self-administered questionnaire comprising a self-evaluation of AD knowledge and questions about preferences regarding consultation partners and the time of consultation. Disease-related data were collected from medical records. Statistics were calculated with SPSS. RESULTS Of the 500 questionnaires handed out, 394 (75%) were evaluable and analyzed. Twenty-eight percent of the participants had completed an AD (living will or health care proxy). Ninety-two percent of the participants without ADs had never received a consultation offer from any professional involved. Only 20% perceived a clear relation between cancer and AD consultations. More than 50% of the participants without ADs were in favor of consultations 'now' or 'in a few weeks', while more than 40% objected to AD consultations. CONCLUSIONS Oncology patients have a large unmet demand for AD consultations. However, a relevant percentage of these patients object to AD consultations. Structured and early AD consultation offers should be made, and early discussions about indications for aggressive treatment should take place.
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Affiliation(s)
- Jochen Pfirstinger
- Department of Hematology and Medical Oncology, University Hospital Regensburg, Regensburg, Germany
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Advance health care directives and "public guardian": the Italian supreme court requests the status of current and not future inability. BIOMED RESEARCH INTERNATIONAL 2014; 2014:576391. [PMID: 24729977 PMCID: PMC3963218 DOI: 10.1155/2014/576391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/29/2014] [Accepted: 02/01/2014] [Indexed: 11/17/2022]
Abstract
Advance health care decisions animate an intense debate in several European countries, which started more than 20 years ago in the USA and led to the adoption of different rules, based on the diverse legal, sociocultural and philosophical traditions of each society. In Italy, the controversial issue of advance directives and end of life's rights, in the absence of a clear and comprehensive legislation, has been over time a subject of interest of the Supreme Court. Since 2004 a law introduced the “Public Guardian,” aiming to provide an instrument of assistance to the person lacking in autonomy because of an illness or incapacity. Recently, this critical issue has once again been brought to the interest of the Supreme Court, which passed a judgment trying to clarify the legislative application of the appointment of the Guardian in the field of advance directives.
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in der Schmitten J, Lex K, Mellert C, Rothärmel S, Wegscheider K, Marckmann G. Implementing an advance care planning program in German nursing homes: results of an inter-regionally controlled intervention trial. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:50-7. [PMID: 24612497 PMCID: PMC3950824 DOI: 10.3238/arztebl.2014.0050] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 10/07/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Advance Care Planning (ACP) is a systematic approach to ensure that effective advance directives (ADs) are developed and respected. We studied the effects of implementing a regional ACP program in Germany. METHODS In a prospective, inter-regionally controlled trial focusing on nursing homes (n/hs), we compared the number, relevance and validity of new ADs completed in the intervention region versus the control region. Intervention n/h residents and their families were offered professional facilitation including standardized documentation. RESULTS Data from 136 residents of three intervention n/hs were compared with data from 439 residents of 10 control n/hs over a study period of 16.5 months. In the intervention region, 49 (36.0%) participating residents completed a new AD over the period of the study, compared to 18 (4.1%) in the control region; these ADs included 30 ADs by proxy in the intervention region versus 10 in the control region. Proxies were designated in 94.7% versus 50.0% of cases, the AD was signed by a physician in 93.9% versus 16.7%, and an emergency order was included in 98.0% versus 44.4%. Resuscitation status was addressed in 95.9% versus 38.9% of cases (p<0.01 for all of the differences mentioned above). In the intervention region, new ADs were preceded by an average of 2.5 facilitated conversations (range, 2–5) with a mean total duration of 100 minutes (range, 60–240 minutes). CONCLUSION The implementation of an ACP program in German nursing homes led, much more frequently than previously reported, to the creation of advance directives with potential relevance to medical decision-making. Future research should assess the effect of such programs on clinical and structural outcomes.
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Affiliation(s)
| | - Katharina Lex
- Institute for Patient Safety, Rheinische Friedrich-Wilhelms-Universität Bonn
| | - Christine Mellert
- Department of General Practice, Düsseldorf University, University Hospital
| | - Sonja Rothärmel
- Faculty of Social Work, Catholic University of Eichstätt-Ingolstadt
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine at the Ludwig Maximilians University Munich
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