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Lee J, Kim SG, Lee SI, Youn H. Psychosocial Factors Associated With Thoughts Regarding Life-Sustaining Treatment for Oneself and Family Members. Psychiatry Investig 2024; 21:646-654. [PMID: 38960442 PMCID: PMC11222083 DOI: 10.30773/pi.2024.0032] [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: 01/30/2024] [Revised: 03/12/2024] [Accepted: 04/10/2024] [Indexed: 07/05/2024] Open
Abstract
OBJECTIVE This study aims to investigate the thoughts of the general population regarding life-sustaining treatment for both oneself and family members and to assess the factors associated with those thoughts. METHODS A total of 1,500 individuals participated in this study by completing a questionnaire consisting of self-reporting items with some instructions, basic demographic information, thoughts on life-sustaining treatment, and psychosocial scales. The disease status was calculated using the Charlson Comorbidity Index. The psychosocial scales included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Pittsburgh Sleep Quality Index, and Multidimensional Scale of Perceived Social Support. RESULTS The majority of participants did not want to receive life-sustaining treatment for both themselves and their families. However, more people wanted life-sustaining treatment for their family members (35.9%) than for themselves (21.6%). Among the basic demographic characteristics, there were significant differences in age, sex, marital status, living arrangements, occupational status, religion, and disease status. Regarding the psychosocial scales, there were significant differences in the PHQ-9 and GAD-7 scores between the group that preferred life-sustaining treatment for family members and the group that did not. CONCLUSION The findings suggest that life-sustaining treatment decisions for oneself and for one's family members can be different. We recommend a more clear expression of one's preferences regarding the last moments of one's life, including advance directives.
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Affiliation(s)
- Jeewon Lee
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Shin-Gyeom Kim
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Soyoung Irene Lee
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - HyunChul Youn
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
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da Silva MDAP, Corradi-Perini C. The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review. Indian J Palliat Care 2023; 29:234-242. [PMID: 37700891 PMCID: PMC10493695 DOI: 10.25259/ijpc_292_2022] [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: 12/08/2022] [Accepted: 01/27/2023] [Indexed: 09/14/2023] Open
Abstract
Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword 'clinical decision-making' AND 'terminal care' OR 'end-of-life care' and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.
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Affiliation(s)
| | - Carla Corradi-Perini
- Bioethics Graduate Program, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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Spronk B, Widdershoven G, Alma H. The Role of Worldview in Moral Case Deliberation: Visions and Experiences of Group Facilitators. JOURNAL OF RELIGION AND HEALTH 2021; 60:3143-3160. [PMID: 33830401 PMCID: PMC8484129 DOI: 10.1007/s10943-021-01246-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 06/12/2023]
Abstract
This study investigates the role of worldview in moral case deliberation (MCD). MCD is a form of clinical ethics support which aims to assist caregivers in reflection on moral dilemmas, experienced in daily practice. Bioethicists acknowledge that existential and religious aspects must be taken into account in the analysis of ethical questions, but it remains unclear how these elements are addressed in clinical ethics support. We investigated how facilitators of MCD address worldview in MCD. MCD facilitation is often done by spiritual caregivers, but not in their role as spiritual caregiver. Discussing worldview is no standard part of the procedure in MCD. This study was qualitative, focusing on the views and experiences of the facilitators of MCD. Semi-structured interviews (N = 12) were conducted with facilitators of MCD. Grounded theory was used for analysis. The results show that worldview plays both an explicit and an implicit role in the MCD process. The explicit role concerns the religious beliefs of patients and professionals. This calls for avoiding stereotyping and devoting attention to different visions. The implicit role comes to the fore in addressing core values and spiritual fulfillment. In order to clarify the fundamental nature of values, more explicit attention for worldview might be useful during MCD. However, this should be done with caution as the term 'worldview' might be interpreted by participants in terms of religious and personal beliefs, rather than as an invitation to reflect on one's view of the good life as a whole.
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Affiliation(s)
- Benita Spronk
- Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Postbus 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1089 a, 1081 HV, Amsterdam, The Netherlands
| | - Hans Alma
- Department of Religion and Theology, Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV, Amsterdam, The Netherlands
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Labuschagne D, Torke A, Grossoehme D, Rimer K, Rucker M, Schenk K, Slaven JE, Fitchett G. Chaplaincy Care in the MICU: Examining the Association Between Spiritual Care and End-of-Life Outcomes. Am J Hosp Palliat Care 2021; 38:1409-1416. [PMID: 33464118 DOI: 10.1177/1049909120987218] [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: 11/16/2022] Open
Abstract
BACKGROUND Seriously ill patients admitted to the Intensive Care Unit (ICU) experience severe spiritual and existential distress. Patients' surrogate decision makers face the burden of making complex decisions about their loved ones' care. Experienced chaplains may play a role in assisting with decision-making, possibly by aligning patients' values and wishes with treatment plans and avoiding non-beneficial aggressive measures. OBJECTIVES To identify associations between chaplaincy care and length of stay (LOS) in the medical ICU (MICU). METHODS This was a retrospective observational study of usual spiritual care in the adult MICUs of 4 medical centers in the United States over a 3-month period. Inclusion criteria were death in the MICU or discharge to palliative care or hospice. Measures included medical, treatment, and spiritual care information. Through bivariate and multivariable analyses associations between spiritual care and LOS were examined. RESULTS In multivariable analysis of the 254 patients, receiving spiritual care was associated with an increased likelihood of being in a higher LOS tertile (adjusted odds ratio = 2.94, p < .001). In post hoc bivariate analysis, cases receiving spiritual care within the first 48 hours of MICU admission revealed a trend toward lower LOS (p = .181). CONCLUSION Spiritual care in the MICU was associated with longer LOS. Early intervention by chaplains who are well-integrated in the ICU may assist patients and their loved ones in coming to terms with grave illness and making difficult treatment decisions. Further well-designed studies of spiritual care interventions that may affect outcomes are needed.
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Affiliation(s)
| | - Alexia Torke
- Indiana University School of Medicine, Daniel F Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, IN, USA
| | - Daniel Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, OH, USA
| | - Katie Rimer
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Kristen Schenk
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
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Torke AM, Fitchett G, Maiko S, Burke ES, Slaven JE, Watson BN, Ivy S, Monahan PO. The Association of Surrogate Decision Makers' Religious and Spiritual Beliefs With End-of-Life Decisions. J Pain Symptom Manage 2020; 59:261-269. [PMID: 31539603 PMCID: PMC6989362 DOI: 10.1016/j.jpainsymman.2019.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/04/2019] [Accepted: 09/06/2019] [Indexed: 11/20/2022]
Abstract
CONTEXT Although religion and spirituality are important to surrogate decision makers, little is known about the role of religion in decision making regarding life-sustaining treatments. OBJECTIVES To determine the relationships between dimensions of religion and spirituality and medical treatment decisions made by surrogates. METHODS This prospective observational study enrolled patient/surrogate dyads from three hospitals in one metropolitan area. Eligible patients were 65 years or older and admitted to the medicine or medical intensive care services. Baseline surveys between hospital days 2 and 10 assessed seven dimensions of religion and spirituality. Chart reviews of the electronic medical record and regional health information exchange six months after enrollment identified the use of life-sustaining treatments and hospice for patients who died. RESULTS There were 291 patient/surrogate dyads. When adjusting for other religious dimensions, demographic, and illness factors, only surrogates' belief in miracles was significantly associated with a lower surrogate preference for do-not-resuscitate status (adjusted odds ratio [aOR] 0.39; 95% CI 0.19, 0.78). Among patients who died, higher surrogate intrinsic religiosity was associated with lower patient receipt of life-sustaining treatments within the last 30 days (aOR 0.66; 95% CI 0.45, 0.97). Belief in miracles (aOR 0.30; 95% CI 0.10, 0.96) and higher intrinsic religiosity (aOR 0.70; 95% CI 0.53, 0.93) were associated with lower hospice utilization. CONCLUSION Few religious variables are associated with end-of-life preferences or treatment. Belief in miracles and intrinsic religiosity may affect treatment and should be identified and explored with surrogates by trained chaplains or other clinicians with appropriate training.
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Affiliation(s)
- Alexia M Torke
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA; IU Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA; Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, Indiana, USA.
| | - George Fitchett
- Department of Religion, Health and Human Values, College of Health Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Saneta Maiko
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA; Indiana Conference, United Methodist Church, Greenwood, Indiana, USA
| | - Emily S Burke
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - James E Slaven
- IU Department of Biostatistics, IU School of Medicine, Indianapolis, Indiana, USA
| | | | - Steven Ivy
- Association for Clinical Pastoral Education, Decatur, Georgia, USA
| | - Patrick O Monahan
- IU Department of Biostatistics, IU School of Medicine, Indianapolis, Indiana, USA
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Abstract
Patient and family demands for the initiation or continuation of life-sustaining medically non-beneficial treatments continues to be a major issue. This is especially relevant in intensive care units, but is also a challenge in other settings, most notably with cardiopulmonary resuscitation. Differences of opinion between physicians and patients/families about what are appropriate interventions in specific clinical situations are often fraught with highly strained emotions, and perhaps none more so when the family bases their desires on religious belief. In this essay, I discuss non-beneficial treatments in light of these sorts of disputes, when there is a clash between the nominally secular world of fact- and evidence-based medicine and the faith-based world of hope for a miraculous cure. I ask the question whether religious belief can justify providing treatment that has either no or a vanishly small chance of restoring meaningful function. I conclude that non-beneficial therapy by its very definition cannot be helpful, and indeed is often harmful, to patients and hence cannot be justified no matter what the source or kind of reasons used to support its use. Therefore, doctors may legitimately refuse to provide such treatments, so long as they do so for acceptable clinical reasons. They must also offer alternatives, including second (and third) opinions, as well the option of transferring the care of the patient to a more accommodating physician or institution.
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Affiliation(s)
- Philip M Rosoff
- Trent Center for Bioethics, Humanities and History of Medicine, Duke University Medical Center, 108 Seeley G. Mudd Building, Box 3040, 10 Bryan-Searle Drive, Durham, NC, 27710, USA. .,Departments of Pediatrics and Medicine, Duke University Medical Center, Durham, NC, USA.
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Duivenbode R, Hall S, Padela AI. Assessing Relationships Between Muslim Physicians’ Religiosity and End-of-Life Health-Care Attitudes and Treatment Recommendations: An Exploratory National Survey. Am J Hosp Palliat Care 2019; 36:780-788. [DOI: 10.1177/1049909119833335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Research demonstrates that the attitudes of religious physicians toward end-of-life care treatment can differ substantially from their nonreligious colleagues. While there are various religious perspectives regarding treatment near the end of life, the attitudes of Muslim physicians in this area are largely unknown. Objective: This article attempts to fill in this gap by presenting American Muslim physician attitudes toward end-of-life care decision-making and by examining associations between physician religiosity and these attitudes. Methods: A randomized national sample of 626 Muslim physicians completed a mailed questionnaire assessing religiosity and end-of-life care attitudes. Religiosity, religious practice, and bioethics resource utilization were analyzed as predictors of quality-of-life considerations, attitudes regarding withholding and withdrawing life-sustaining treatment, and end-of-life treatment recommendations at the bivariate and multivariable level. Results: Two-hundred fifty-five (41% response rate) respondents completed surveys. Most physicians reported that religion was either very or the most important part of their life (89%). Physicians who reported consulting Islamic bioethics literature more often had higher odds of recommending active treatment over hospice care in an end-of-life case vignette. Physicians who were more religious had higher odds of viewing withdrawal of life-sustaining treatment more ethically and psychologically challenging than withholding it and had lower odds of agreeing that one should always comply with a competent patient’s request to withdraw life-sustaining treatment. Discussion: Religiosity appears to impact Muslim physician attitudes toward various aspects of end-of-life health-care decision-making. Greater research is needed to evaluate how this relationship manifests itself in patient care conversations and shared clinical decision-making in the hospital.
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Affiliation(s)
- Rosie Duivenbode
- Initiative on Islam and Medicine, The University of Chicago, Chicago, IL, USA
| | - Stephen Hall
- Initiative on Islam and Medicine, The University of Chicago, Chicago, IL, USA
- Department of Medicine, Section of Emergency Medicine, The University of Chicago, Chicago, IL, USA
| | - Aasim I. Padela
- Initiative on Islam and Medicine, The University of Chicago, Chicago, IL, USA
- Department of Medicine, Section of Emergency Medicine, The University of Chicago, Chicago, IL, USA
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Abstract
In most children's hospitals, there are very few ethics consultations, even though there are many ethically complex cases. We hypothesize that the reason for this may be that hospitals develop different mechanisms to address ethical issues and that many of these mechanisms are closer in spirit to the goals of the pioneers of clinical ethics than is the mechanism of a formal ethics consultation. To show how this is true, we first review the history of collaboration between philosophers and physicians about clinical dilemmas. Then, as a case-study, we describe the different venues that have developed at one children's hospital to address ethical issues. At our hospital, there are nine different venues in which ethical issues are regularly and explicitly addressed. They are (1) ethics committee meetings, (2) Nursing Ethics Forum, (3) ethics Brown Bag workshops, (4) PICU ethics rounds, (5) Grand Rounds, (6) NICU Comprehensive Care Rounds, (7) Palliative Care Team (PaCT) case conferences, (8) multidisciplinary consults in Fetal Health Center, and (9) ethics consultations. In our hospital, ethics consults account for only a tiny percentage of ethics discussions. We suspect that most hospitals have multiple and varied venues for ethics discussions. We hope this case study will stimulate research in other hospitals analyzing the various ways in which ethicists and ethics committees can build an ethical environment in hospitals. Such research might suggest that ethicists need to develop a different set of "core competencies" than the ones that are needed to do ethics consultations. Instead, they should focus on their skills in creating multiple "moral spaces" in which regular and ongoing discussion of ethical issues would take place. A successful ethicist would empower everyone in the hospital to speak up about the values that they believe are central to respectful, collaborative practice and patient care. Such a role is closer to what the first hospital philosophers set out to do than in the role of the typical hospital ethics consultant today.
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Piccoli GB, Sofronie AC, Coindre JP. The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions. BMC Med Ethics 2017; 18:61. [PMID: 29121886 PMCID: PMC5680775 DOI: 10.1186/s12910-017-0219-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/31/2017] [Indexed: 12/16/2022] Open
Abstract
Background Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions. Case presentation Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy). In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”. Conclusions An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy. .,Nephrology, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
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