Promoting advance care planning (ACP) in community health clinics in Israel: Perceptions of older adults with pro-ACP attitudes and their family physicians

OBJECTIVE

We examined barriers and facilitators to patient-family physician discussions in Israel about advance care planning, including preparation of an advance directive by adults over age 65, as part of a program in two community health clinics which afforded family physicians the opportunity to dedicate time to such discussions with patients. To the best of our knowledge, the program is the first of its kind in Israel.

METHOD

We used thematic analyses of qualitative data collected through 22 interviews with patients with pro-advanced care planning attitudes and three focus groups with eleven family physicians.

RESULTS

Overall, three themes in the interviews with patients and two themes in the focus groups with physicians emerged. The program gave people with pro-advanced care planning attitudes the opportunity to follow through with their ideas. We found that patients viewed their family physicians as facilitators and that the use of an information leaflet was an effective way to promote advance directives. Family physicians expressed positive attitudes toward assisting patients in the preparation of advance directives and welcomed an allotment of time for this endeavor as part of their schedule but expressed hesitation about assisting patients concerning legal and moral issues.

SIGNIFICANCE OF RESULTS

A pro-advanced care planning attitude is not enough for patients to complete the process of creating an advance directive; patients need active encouragement and intervention in order to turn their ideas into action. More patient and physician education are necessary to enable patients to protect their right to self-determination in end-of-life medical decision-making and to support physicians as facilitators of the process.

Just and inclusive end-of-life decision-making for long-term care home residents with dementia: a qualitative study protocol

BACKGROUND

Many people living with dementia eventually require care services and spend the remainder of their lives in long-term care (LTC) homes. Yet, many residents with dementia do not receive coordinated, quality palliative care. The stigma associated with dementia leads to an assumption that people living in the advanced stages of dementia are unable to express their end-of-life needs. As a result, people with dementia have fewer choices and limited access to palliative care. The purpose of this paper is to describe the protocol for a qualitative study that explores end-of-life decision-making processes for LTC home residents with dementia.

METHODS/DESIGN

This study is informed by two theoretical concepts. First, it draws on a relational model of citizenship. The model recognizes the pre-reflective dimensions of agency as fundamental to being human (irrespective of cognitive impairment) and thereby necessitates that we cultivate an environment that supports these dimensions. This study also draws from Smith's critical feminist lens to foreground the influence of gender relations in decision-making processes towards palliative care goals for people with dementia and reveal the discursive mediums of power that legitimize and sanction social relations. This study employs a critical ethnographic methodology. Through data collection strategies of interview, observation, and document review, this study examines decision-making for LTC home residents with dementia and their paid (LTC home workers) and unpaid (family members) care partners.

DISCUSSION

This research will expose the embedded structures and organizational factors that shape relationships and interactions in decision-making. This study may reveal new ways to promote equitable decision-making towards palliative care goals for LTC home residents with dementia and their care partners and help to improve their access to palliative care.

After providing end of life care to relatives, what care options do family caregivers prefer for themselves?

Objectives

We examined how caregivers who had cared for a relative at end of life (EoL) wished to be cared for in the event that they experienced advanced dementia or physical disability in the future, and what factors influenced their preferences for EoL care.

Methods

In this mixed-methods study, 83 participants, recruited from multiple sources in Israel, were interviewed concerning socio-demographic factors, health status, past experience with EoL, preference for extension of life vs. quality of life (QoL), willingness to be dependent on others, and preferences for EoL care.

Results

In case of advanced dementia, 58% preferred euthanasia or suicide; around a third chose those for physical disability. Care by family members was the least desired form of care in the advanced dementia scenario, although more desirable than institutional care in the physical disability scenario. QoL was rated as the highest factor impacting preferences for EoL care. Men demonstrated a higher preference than women for extension of life over QoL.

Conclusion

Our study points to the need for society to consider solutions to the request of participants to reject the type of EoL experienced by their relatives. Those solutions include investing in improving the quality of life at the end of life, and offering alternatives such as euthanasia, which a large proportion of our participants found ethically and medically appropriate within the current system of care in the event of severe physical disability, and more so in the event of advanced dementia.

Older Adults More Likely to Discuss Advance Care Plans With an Attorney Than With a Physician

Adults are encouraged to discuss their end-of-life health care preferences so that their wishes will be known and hopefully honored. The purpose of this study was to determine with whom older adults had communicated their future health care wishes and the extent to which respondents themselves were serving as a surrogate decision maker. Results from the cross-sectional online survey with 294 persons aged 50 and older reveal that among the married, over 80% had a discussion with their spouse and among those with an adult child, close to two thirds (64%) had. Over a third had discussed preferences with an attorney and 23% with a physician. Close to half were currently serving as a surrogate decision maker or had been asked to and had signed papers to formalize their role. 18% did not think that they were a surrogate but were not sure. More education is needed to emphasize the importance of advance care planning with a medical professional, especially for patients with advanced chronic illness. More education and research about the role of surrogate medical decision makers is called for.

Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes

As part of an intervention to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions, 1,877 resident records were reviewed for advance directive (AD) documentation. At the initial phases of the intervention, 50 percent of the records contained an AD. Of the ADs in the resident records, 55 percent designated a durable power of attorney for health care, most often a child (62 percent), other relative (14 percent), or spouse (13 percent). Financial power of attorney documents were sometimes found within the AD, even though these documents focused on financial decision making rather than health care decision making. Code status was the most prevalent health preference documented in the record at 97 percent of the records reviewed. The intervention used these initial findings and the philosophical framework of respect for autonomy to develop education programs and services on advance care planning. The role of the social worker within an interdisciplinary team is discussed.

Advance directives in nursing homes: prevalence, validity, significance, and nursing staff adherence

BACKGROUND

The German Advance Directives Act of 2009 confirms that advance directives (ADs) are binding. Little is known, however, about their prevalence in nursing homes, their quality, and whether they are honored.

METHODS

In 2007, we carried out a cross-sectional survey in all 11 nursing homes of a German city in the state of North Rhine-Westphalia (total nursing home population, 1089 residents). The ADs were formally analyzed and assessed by 3 raters with respect to 5 clinical decision-making scenarios. The specifications of the ADs were compared with what the nurses reported that they would do in each scenario.

RESULTS

11% of the nursing home residents had a personal AD, and a further 1.4% an AD by proxy. 52% of the 119 ADs that we analyzed contained no documentation of the patient's decision-making capacity and/or voluntariness, and only 3% contained documentation of a medical consultation. Most ADs failed to state what should be done in case the patient acutely became incapable of consenting to treatment (inter-rater agreement [IRA] >83%). For the case of permanent decisional incapacity, many ADs contained ambiguous information (IRA<43%). 23 directives stated that the patient should not have cardiopulmonary resuscitation in case an arrest occurred in the patient's current clinical condition, but the nurses reported a corresponding do-not-resuscitate agreement for only 9 of these 23 patients.

CONCLUSION

In 2007, ADs were rare in these German nursing homes, and most of the existing ones were invalid, of little meaning, and/or disregarded by the nursing staff. There is little reason to believe that the Advance Directives Act of 2009 will bring about any major change in this miserable status quo. Advance care planning, a system-oriented concept still uncommon in Germany, could give new impulses to promote a cultural change in this respect.

Uncertainty and decision making for residents with dementia

Uncertainty is a significant barrier confronting surrogate decision makers(SDMs) who make treatment decisions for nursing home (NH) residents with dementia. The study purpose is to describe uncertainty among SDMs of NH residents with dementia and to identify factors associated with greater Uncertainty. We employed a nonexperimental, cross-sectional design using mailed survey and recruited 155 SDM participants from eight NHs in New England. The survey contained the Mishel Uncertainty in Illness Scale For Family Members. Independent variables included resident and SDM sociodemographic characteristics, Advance Directives, Credible Authority, Social Support, and Perceived Self-Efficacy for Surrogate Decision Making. Results of a simultaneous multiple regression analysis identified Perceived Self-Efficacy,Social Support, and Close Relative explained 22% of the Uncertainty variance.These findings suggest that close family relatives who serve as SDMs for NH residents with dementia may benefit from increasing social support and enhancing SDMs’ self-efficacy for decision making.

Nurses' perspectives on feeding decisions for nursing home residents with advanced dementia

AIM

To develop a broad understanding of nursing beliefs, knowledge and roles in feeding decisions for nursing home residents with advanced dementia.

BACKGROUND

Concern is growing about the common use of feeding tubes in nursing home residents with advanced dementia. Nurses can play an important role in providing information and guiding family members through difficult feeding decisions. Little is known about nurses' perspectives on feeding decisions.

DESIGN

Qualitative descriptive.

METHODS

In-depth semi-structured interviews of 11 licensed nurses who were experienced in caring for nursing home residents with dementia.

RESULTS

Analysis of the interview transcripts revealed three themes: insufficient empirical information, ambiguous role in feeding decisions and uncertainty about moral agency in decisions about the placement of feeding tubes.

CONCLUSIONS

Despite views that family members would benefit from guidance in decisions regarding the placement of feeding tubes, nurses were, nevertheless, reluctant to become involved in these difficult decisions.

RELEVANCE TO CLINICAL PRACTICE

If nurses are to guide family members in decisions about the use of feeding tubes, they need more education about evidence-based practice as well as support in exercising their nursing responsibilities.

Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting

BACKGROUND

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program was designed to ensure the full range of patient treatment preferences are honored throughout the health care system. Data are lacking about the use of POLST in the hospice setting.

OBJECTIVE

To assess use of the POLST by hospice programs, attitudes of hospice personnel toward POLST, the effect of POLST on the use of life-sustaining treatments, and the types of treatments options selected by hospice patients.

DESIGN

A telephone survey was conducted of all hospice programs in three states (Oregon, Wisconsin, and West Virginia) to assess POLST use. Staff at hospices reporting POLST use (n = 71) were asked additional questions about their attitudes toward the POLST. Chart reviews were conducted at a subsample of POLST-using programs in Oregon (n = 8), West Virginia (n = 5), and Wisconsin (n = 2).

RESULTS

The POLST is used widely in hospices in Oregon (100%) and West Virginia (85%) but only regionally in Wisconsin (6%). A majority of hospice staff interviewed believe the POLST is useful at preventing unwanted resuscitation (97%) and at initiating conversations about treatment preferences (96%). Preferences for treatment limitations were respected in 98% of cases and no one received unwanted cardiopulmonary resuscitation (CPR), intubation, intensive care, or feeding tubes. A majority of hospice patients (78%) with do-not-resuscitate (DNR) orders wanted more than the lowest level of treatment in at least one other category such as antibiotics or hospitalization.

CONCLUSIONS

The POLST is viewed by hospice personnel as useful, helpful, and reliable. It is effective at ensuring preferences for limitations are honored. When given a choice, most hospice patients want the option for more aggressive treatments in selected situations.