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Crowley DP, Doran DK. Advance healthcare directives: Knowledge and attitudes of Irish consultant physicians. Med Leg J 2022; 90:129-133. [PMID: 35624540 DOI: 10.1177/00258172221083444] [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]
Abstract
AIMS The Assisted Decision-Making (Capacity) Act 2015 provides a legislative framework for advance healthcare directives in Ireland. This study assessed Irish consultant physicians' knowledge of the provisions of the Act relating to advance healthcare directives, and their attitudes towards advance healthcare directives in general. METHODS Data were collected between May and October 2016. A questionnaire was distributed to all consultant physicians listed in the Irish Medical Directory under general internal medicine specialties. True/false questions assessed knowledge of the provisions of the Act. Likert-type questions assessed attitudes towards advance healthcare directives. RESULTS The overall response rate was 28.7% (238/830). Only 42.1% of respondents were aware of the provisions of the Act relating to advance healthcare directives. Of the seven questions that assessed knowledge of those provisions, the mean score was 3.31/7.78.7% agreed that advance healthcare directives are helpful when making treatment decisions for incapacitated patients. Only 15.7% regularly advise their patients to create advance healthcare directives. DISCUSSION Irish physicians are broadly supportive of advance healthcare directives but there are deficiencies in their knowledge of the law relating to them. Efforts should be made to educate physicians regarding the provisions of the Act prior to its commencement.
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Affiliation(s)
- Dr Patrick Crowley
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
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White BP, Willmott L, Feeney R, Neller P, Then SN, Bryant J, Waller A, Yates P. Limitations in health professionals' knowledge of end-of-life law: a cross-sectional survey. BMJ Support Palliat Care 2021:bmjspcare-2021-003061. [PMID: 34083318 DOI: 10.1136/bmjspcare-2021-003061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/19/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Insufficient knowledge about end-of-life law can impede the provision of safe and high-quality end-of-life care. Accurate legal knowledge across health professions is critical in palliative and end-of-life settings given the reliance on multidisciplinary care. Most research has focused on doctors, finding significant knowledge gaps. The limited evidence about other health professions also suggests legal knowledge deficits. OBJECTIVE To determine and compare levels of knowledge about end-of-life law across a broad sample of Australian health professionals and medical students, and to identify predictors of legal knowledge. METHODS An online pre-training survey was completed by participants enrolled in a national training programme on end-of-life law. The optional survey collected demographic data and measured baseline legal knowledge and attitudes towards end-of-life law. RESULTS Response rate was 67% (1653/2456). The final sample for analysis (n=1564, 95% of respondents), included doctors, medical students, nurses and a range of allied health professionals. Doctors and nurses had slightly higher levels of legal knowledge than did medical students and allied health professionals; all had critical knowledge gaps. Demographic and professional characteristics predicted knowledge levels, with experience of end-of-life law in practice, confidence applying law and recent continuing professional development being positively associated with legal knowledge. CONCLUSIONS This study provides new evidence about legal knowledge across a broad range of health professions. While knowledge levels varied somewhat across professions, knowledge gaps were observed in all professional groups. Education and training initiatives to enhance knowledge of end-of-life law should be tailored to meet the specific needs of each profession.
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Affiliation(s)
- Ben P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Rachel Feeney
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Penny Neller
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Shin-Ning Then
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jamie Bryant
- School of Medicine and Public Health, Health Behaviour Research Collaborative, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Amy Waller
- School of Medicine and Public Health, Health Behaviour Research Collaborative, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Patsy Yates
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
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Craig DP, Ray R, Harvey D, Shircore M. Factors Which Influence Hospital Doctors' Advance Care Plan Adherence. J Pain Symptom Manage 2020; 59:1109-1126. [PMID: 31846704 DOI: 10.1016/j.jpainsymman.2019.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
CONTEXT Advances in medicine have seen changes in mortality in Western countries. Simultaneously, countries such as Australia, Canada, U.S., New Zealand, U.K., and Germany have encouraged consumer-directed care and advance care plan (ACP) completion, giving patients a voice despite incapacity. Adhering to ACPs relies on the decision-making of treating doctors, making hospital doctors key partners, and their perspectives on ACP adherence critical. OBJECTIVES The aim of this review was to explore and map existing research on factors associated with hospital doctors adhering to adult patients' ACPs. METHODS A scoping review of English language publications within CINAHL, Emcare, Medline, PsycInfo, and Scopus was conducted, following PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. ACPs were defined as adult patient-generated, written health care directions or values statements. Studies of any design, which reported original research associated with hospital doctors adhering to ACPs, were included. RESULTS Twenty-seven publications were included in the final analysis. Results suggested ACPs were thought potentially useful; however, adherence has been associated with doctors' attributes (e.g., specialty, seniority), attitudes toward ACP (e.g., applicability), and legal knowledge. CONCLUSION Current literature suggests doctors hold largely positive attitudes toward ACPs that provide useful patient information that enables doctors to make appropriate treatment decisions. Doctors often perceive limitations to ACP applicability due to legal requirements or ambiguity of patient outcome goals.
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Affiliation(s)
- Denise Patricia Craig
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia.
| | - Robin Ray
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Desley Harvey
- College of Healthcare Sciences, James Cook University, Cairns, Queensland, Australia
| | - Mandy Shircore
- College of Business, Law and Governance, James Cook University, Cairns, Queensland, Australia
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Harvey P, Panozzo L, Adams MJ, O'Connor D, Ward B. Rural health services' relationships with patients: An enabler and a barrier to advance care planning. Aust J Rural Health 2019; 27:563-567. [PMID: 31809564 DOI: 10.1111/ajr.12542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/24/2019] [Accepted: 05/29/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The barriers and enablers to the uptake of advance care plans has been well documented but more so in metropolitan health services. Rural and regional areas have their own challenges of higher rates of chronic illness and an aging population when considering end of life care. This study aimed to explore the creation of advance care plans in a regional location that has service links to smaller health services. DESIGN A qualitative study involving thematic analysis of interview data. SETTING A regional local government area in Victoria, Australia. PARTICIPANTS Twelve representatives from rural and regional health services, including hospital, private practice and community organisation staff. MAIN OUTCOME MEASURES Barriers and enablers to the creation of advance care planning documents. RESULTS The data analysis yielded two main identified themes around Plan creation and communication of patient wishes: system and societal challenges to the creation and communication in advance care planning; and rural communities' expectation of the health service-patient relationship and advance care planning. CONCLUSION Although barriers to advance care planning are well known, rural and regional practitioners need to be aware of the effect long-term continuity of care from health practitioners and connections with health services has on advance care plan creation, and whether the paucity of written Plans effects end-of-life care. A potential solution was seen in the pending linkages to the national electronic patient record.
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Affiliation(s)
- Pamela Harvey
- School of Rural Health, Monash University, Bendigo, Victoria, Australia
| | | | | | | | - Bernadette Ward
- School of Rural Health, Monash University, Bendigo, Victoria, Australia
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Shepherd J, Waller A, Sanson-Fisher R, Clark K, Ball J. Knowledge of, and participation in, advance care planning: A cross-sectional study of acute and critical care nurses' perceptions. Int J Nurs Stud 2018; 86:74-81. [PMID: 29966827 DOI: 10.1016/j.ijnurstu.2018.06.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Nurses have a core role in facilitating discussions and enacting decisions about end-of-life issues for patients in hospitals. Nurses' own knowledge and attitudes may influence whether they engage in meaningful end-of-life conversations with patients. AIMS To determine in a sample of nurses working in acute and critical care hospital wards: 1) their knowledge of advance care planning, including the authority of substitute decision-makers and legal validity of advance directives; 2) their own participation in advance care planning decision-making practices; and 3) associations between nurses' socio-demographic characteristics; clinical expertise; and knowledge and behaviour in relation to advance care planning practices. DESIGN Questionnaire-based, cross-sectional study. SETTING AND PARTICIPANTS The study was conducted with 181 registered and enrolled nurses employed in acute and critical care wards of three metropolitan hospitals in Australia. RESULTS Nurses were least knowledgeable about items relating to the authority of medical (56%) and financial (42%) substitute decision-makers. Few nurses had prepared advance directives (10%) or appointed medical (23%) or financial (27%) decision-makers, when compared to discussing end-of-life wishes (53%) or organ donation (75%). Overall, 15% of nurses had not engaged in any advance care planning practices. Nurses who had cared for 11-30 dying patients in the last six months were more likely to have an increased knowledge score. Older nurses were more likely to participate in a greater number of advance care planning practices and an increase in shifts worked per week led to a significant decrease in nurses' participation. CONCLUSION Nurses have a key role in providing advice and engaging dying patients and their families in advance care planning practices. Nurses' own knowledge and rates of participation are low. Further education and support is needed to ensure that nurses have an accurate knowledge of advance care planning practices, including how, when and with whom wishes should be discussed and can be enacted.
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Affiliation(s)
- Jan Shepherd
- University of Newcastle, University Dr, Callaghan, NSW, 2308, Australia.
| | - Amy Waller
- University of Newcastle, University Dr, Callaghan, NSW, 2308, Australia.
| | - Rob Sanson-Fisher
- University of Newcastle, University Dr, Callaghan, NSW, 2308, Australia; Hunter Medical Research Institute, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
| | - Katherine Clark
- Northern Sydney Local Health District, Royal North Shore Hospital Campus, Reserve Rd, St Leonards, NSW, 2065, Australia.
| | - Jean Ball
- Hunter Medical Research Institute, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
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White BP, Willmott L, Cartwright C, Parker M, Williams G, Davis J. Comparing doctors' legal compliance across three Australian states for decisions whether to withhold or withdraw life-sustaining medical treatment: does different law lead to different decisions? BMC Palliat Care 2017; 16:63. [PMID: 29179708 PMCID: PMC5704501 DOI: 10.1186/s12904-017-0249-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/16/2017] [Indexed: 11/23/2022] Open
Abstract
Background Law purports to regulate end-of-life care but its role in decision-making by doctors is not clear. This paper, which is part of a three-year study into the role of law in medical practice at the end of life, investigates whether law affects doctors’ decision-making. In particular, it considers whether the fact that the law differs across Australia’s three largest states – New South Wales (NSW), Victoria and Queensland – leads to doctors making different decisions about withholding and withdrawing life-sustaining treatment from adults who lack capacity. Methods A cross-sectional postal survey of the seven specialties most likely to be involved in end-of-life care in the acute setting was conducted between 18 July 2012 and 31 January 2013. The sample comprised all medical specialists in emergency medicine, geriatric medicine, intensive care, medical oncology, palliative medicine, renal medicine and respiratory medicine on the AMPCo Direct database in those three Australian states. The survey measured medical specialists’ level of legal compliance, and reasons for their decisions, concerning the withholding or withdrawal of life-sustaining treatment. Multivariable logistic regression was used to examine predictors of legal compliance. Linear regression was used to examine associations between the decision about life-sustaining treatment and the relevance of factors involved in making these decisions, as well as state differences in these associations. Results Response rate was 32% (867/2702). A majority of respondents in each state said that they would provide treatment in a hypothetical scenario, despite an advance directive refusing it: 72% in NSW and Queensland; 63% in Victoria. After applying differences in state law, 72% of Queensland doctors answered in accordance with local law, compared with 37% in Victoria and 28% in NSW (p < 0.001). Doctors reported broadly the same decision-making approach despite differences in local law. Conclusions Law appears to play a limited role in medical decision-making at the end of life with doctors prioritising patient-related clinical and ethical considerations. Different legal frameworks in the three states examined did not lead to different decisions about providing treatment. More education is needed about law and its role in this area, particularly where law is inconsistent with traditional practice. Electronic supplementary material The online version of this article (10.1186/s12904-017-0249-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ben P White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Australia.
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | | | - Malcolm Parker
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Gail Williams
- School of Public Health, University of Queensland, Brisbane, Australia
| | - Juliet Davis
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Australia
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White BP, Willmott L, Williams G, Cartwright C, Parker M. The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study. JOURNAL OF MEDICAL ETHICS 2017; 43:327-333. [PMID: 27531924 DOI: 10.1136/medethics-2016-103543] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/20/2016] [Accepted: 07/15/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine the role played by law in medical specialists' decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed. DESIGN Cross-sectional postal survey of medical specialists. SETTING The two largest Australian states by population. PARTICIPANTS 649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting. MAIN OUTCOME MEASURES Compliance with law and the impact of legal knowledge on compliance. RESULTS 649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge. CONCLUSIONS Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care.
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Affiliation(s)
- Benjamin P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gail Williams
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
| | - Colleen Cartwright
- ASLaRC, Southern Cross University, Tweed Heads, New South Wales, Australia
| | - Malcolm Parker
- University of Queensland, Brisbane, Queensland, Australia
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Le Guen J, Boumendil A, Guidet B, Corvol A, Saint-Jean O, Somme D. Are elderly patients' opinions sought before admission to an intensive care unit? Results of the ICE-CUB study. Age Ageing 2016; 45:303-9. [PMID: 26758531 DOI: 10.1093/ageing/afv191] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/23/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND demand for intensive care of the very elderly is growing, but few studies report inclusion of their opinions in the admission decision-making process. Whether or not to refer a very elderly patient to intensive care unit is a difficult decision that should take into account individual wishes, out of respect for the patient's decision-making autonomy. METHODS in 15 emergency departments, patients over 80 years old who had a potential indication for admission to intensive care, and that were capable of expressing their opinion were included. Frequency of opinions sought before referral decision and individual and organisational factors associated were recorded and analysed. RESULTS a total of 2,115 patients were included. Only 270 (12.7%) of them were asked for their opinion, and there were marked variations between study centres (minimum: 1.1% and maximum: 53.6%). A history of dementia reduced the probability of a patient being asked for his or her opinion (OR 0.47, 95% CI: 0.25-0.83). Patients' opinion was most often sought when their functional autonomy was conserved (OR 2.10, 95% CI: 1.39-3.21) and when a relative had been questioned (OR 5.46, 95% CI: 3.8-7.88). Older attending physicians were less likely to ask for the patient's opinion (older physician versus younger physician, OR 0.48, 95% CI: 0.35-0.66). CONCLUSIONS elderly patients are therefore rarely asked for their opinion prior to intensive care admission. Our results indicate that respect of the decision-making autonomy of elderly subjects in the admission process to an intensive care unit should be reinforced.
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Affiliation(s)
- Julien Le Guen
- Service de Gériatrie, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Ariane Boumendil
- Institut national de la santé et de la recherche médicale UMRS-707, Université Pierre et Marie Curie, Paris, France
| | - Bertrand Guidet
- Service de Réanimation Médicale, Hôpital Saint Antoine, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Aline Corvol
- Centre de recherche sur l'action politique en Europe (CRAPE) UMR 6051, CNRS, Université Rennes 1, Rennes, France Service de Gériatrie, CHU de Rennes, Université Rennes 1, Faculté de médecine, Rennes, France
| | - Olivier Saint-Jean
- Service de Gériatrie, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Dominique Somme
- Service de Gériatrie, CHU de Rennes, Université Rennes 1, Faculté de médecine, Rennes, France
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Cartwright CM, White BP, Willmott L, Williams G, Parker MH. Palliative care and other physicians' knowledge, attitudes and practice relating to the law on withholding/withdrawing life-sustaining treatment: Survey results. Palliat Med 2016; 30:171-9. [PMID: 26001394 DOI: 10.1177/0269216315587996] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND To effectively care for people who are terminally ill, including those without decision-making capacity, palliative care physicians must know and understand the legal standing of Advance Care Planning in their jurisdiction of practice. This includes the use of advance directives/living wills and substitute decision-makers who can legally consent to or refuse treatment if there is no valid advance directive. AIM This study aimed to investigate the knowledge, attitudes and practices of medical specialists most often involved in end-of-life care in relation to the law on withholding/withdrawing life-sustaining treatment from adults without decision-making capacity. DESIGN/PARTICIPANTS A pre-piloted survey was posted to specialists in palliative, emergency, geriatric, renal and respiratory medicine; intensive care; and medical oncology in three Australian States. Surveys were analysed using SPSS 20 and SAS 9.3. RESULTS The overall response rate was 32% (867/2702) - 52% from palliative care specialists. Palliative care specialists and geriatricians had significantly more positive attitudes towards the law (χ42(2) = 94.352; p < 0.001) and higher levels of knowledge about the withholding/withdrawing life-sustaining treatment law (χ7(2) = 30.033; p < 0.001) than did the other specialists, while still having critical gaps in their knowledge. CONCLUSION A high level of knowledge of the law is essential to ensure that patients' wishes and decisions, expressed through Advance Care Planning, are respected to the maximum extent possible within the law, thereby according with the principles and philosophy of palliative care. It is also essential to protect health professionals from legal action resulting from unauthorised provision or cessation of treatment.
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Affiliation(s)
- Colleen Maria Cartwright
- ASLaRC Aged Services Unit, Southern Cross University, Gold Coast, QLD, Australia Cartwright Consulting Australia, Miami, QLD, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD, Australia
| | - Gail Williams
- School of Population Health, The University of Queensland, Brisbane, QLD, Australia
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Periyakoil VS, Neri E, Fong A, Kraemer H. Do unto others: doctors' personal end-of-life resuscitation preferences and their attitudes toward advance directives. PLoS One 2014; 9:e98246. [PMID: 24869673 PMCID: PMC4037207 DOI: 10.1371/journal.pone.0098246] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 04/30/2014] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE High-intensity interventions are provided to seriously-ill patients in the last months of life by medical sub-specialists. This study was undertaken to determine if doctors' age, ethnicity, medical sub-specialty and personal resuscitation and organ donation preferences influenced their attitudes toward Advance Directives (AD) and to compare a cohort of 2013 doctors to a 1989 (one year before the Patient Self Determination Act in 1990) cohort to determine any changes in attitudes towards AD in the past 23 years. DESIGN Doctors in two academic medical centers participated in an AD simulation and attitudes survey in 2013 and their responses were compared to a cohort of doctors in 1989. OUTCOMES Resuscitation and organ donation preferences (2013 cohort) and attitudes toward AD (1989 and 2013 cohorts). RESULTS In 2013, 1081 (94.2%) doctors of the 1147 approached participated. Compared to 1989, 2013 cohort did not feel that widespread acceptance of AD would result in less aggressive treatment even of patients who do not have an AD (p<0.001, AUC = 0.77); had greater confidence in their treatment decisions if guided by an AD (p<.001, AUC = 0.58) and were less worried about legal consequences of limiting treatment when following an AD (p<.001, AUC = 0.57). The gender (p = 0.00172), ethnicity (χ2 14.68, DF = 3,p = .0021) and sub-specialty (χ2 28.92, p = .004, DF = 12) influenced their attitudes towards AD. 88.3% doctors chose do-not-resuscitate status and wanted to become organ donors. Those less supportive of AD were more likely to opt for "full code" even if terminally ill and were less supportive of organ donation. CONCLUSIONS Doctors' attitudes towards AD has not changed significantly in the past 23 years. Doctors' gender, ethnicity and sub-specialty influence their attitudes towards AD. Our study raises questions about why doctors continue to provide high-intensity care for terminally ill patients but personally forego such care for themselves at the end of life.
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Affiliation(s)
- Vyjeyanthi S. Periyakoil
- Stanford University School of Medicine, Palo Alto, California, United States of America
- Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, California, United States of America
| | - Eric Neri
- Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Ann Fong
- Stanford Hospital and Clinics, Palo Alto, California, United States of America
| | - Helena Kraemer
- Stanford University School of Medicine, Palo Alto, California, United States of America
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De Vleminck A, Houttekier D, Pardon K, Deschepper R, Van Audenhove C, Vander Stichele R, Deliens L. Barriers and facilitators for general practitioners to engage in advance care planning: a systematic review. Scand J Prim Health Care 2013; 31:215-26. [PMID: 24299046 PMCID: PMC3860298 DOI: 10.3109/02813432.2013.854590] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of this systematic review is to identify the perceived factors hindering or facilitating GPs in engaging in advance care planning (ACP) with their patients about care at the end of life. DESIGN Studies from 1990 to 2011 were found in four electronic databases (PubMed, CINAHL, EMBASE, PsycINFO); by contacting first authors of included studies and key experts; and searching through relevant journals and reference lists. Studies were screened, graded for quality, and analysed independently by two authors; those reporting the perception by GPs of barriers and facilitators to engagement in ACP were included. RESULTS Eight qualitative studies and seven cross-sectional studies were included for data extraction. All barriers and facilitators identified were categorized as GP characteristics, perceived patient factors, or health care system characteristics. Stronger evidence was found for the following barriers: lack of skills to deal with patients' vague requests, difficulties with defining the right moment, the attitude that it is the patient who should initiate ACP, and fear of depriving patients of hope. Stronger evidence was found for the following facilitators: accumulated skills, the ability to foresee health problems in the future, skills to respond to a patient's initiation of ACP, personal convictions about who to involve in ACP, and a longstanding patient-GP relationship and the home setting. CONCLUSION Initiation of ACP in general practice may be improved by targeting the GPs' skills, attitudes, and beliefs but changes in health care organization and financing could also contribute.
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Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Belgium
| | - Dirk Houttekier
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Belgium
| | - Reginald Deschepper
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Belgium
| | - Chantal Van Audenhove
- LUCAS (Center for Care Research and Consultancy), Catholic University of Louvain, Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Belgium
- Heymans Institute, Ghent University, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Belgium
- Department of Public and Occupational Health, and EMGO+ Institute for Health and Care Research, and VU University Medical Centre, The Netherlands
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Silvester W, Fullam RS, Parslow RA, Lewis VJ, Sjanta R, Jackson L, White V, Gilchrist J. Quality of advance care planning policy and practice in residential aged care facilities in Australia. BMJ Support Palliat Care 2012; 3:349-57. [PMID: 24644755 PMCID: PMC3756507 DOI: 10.1136/bmjspcare-2012-000262] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP. DESIGN Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures. SETTING 19 selected RACFs in Victoria. PARTICIPANTS 12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour. RESULTS Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support. CONCLUSIONS Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained.
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Affiliation(s)
- William Silvester
- Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
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Bond CJ, Lowton K. Geriatricians' views of advance decisions and their use in clinical care in England: qualitative study. Age Ageing 2011; 40:450-6. [PMID: 21429949 DOI: 10.1093/ageing/afr025] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND an anticipatory decision document records a person's wishes regarding medical treatment at a time when they have capacity to make choices, to be enacted when this capacity is lost. In England and Wales an advance decision to refuse treatment (ADRT, or advance decision), a legally binding document, is currently rarely used. A disparity is suggested to exist between physicians' support for anticipatory decisions in principle and their lack of impact on decision-making in practice. OBJECTIVE to elicit geriatricians' views on advance decisions and their use in decision-making in England. DESIGN a qualitative approach was taken. Semi-structured interviews were conducted with 10 geriatricians. An inductive approach was used for data analysis. RESULTS geriatricians held positive views on anticipatory decisions in principle. In practice, they reported being highly likely to follow a decision which was in line with their clinical view. They would also favour an ADRT which was prescriptive in terms of the situation and treatment to which it applied. However, geriatricians expressed concerns in relation to patient understanding of the role and limits of these documents. Participants expressed discomfort in following an ADRT which, in their professional opinion, did not represent the patient's best interests, despite it being a legally binding document. A conflict between doctors' beneficence and patients' autonomy was apparent, with geriatricians differing in their views on how ADRTs should fit into medical decision-making; particularly how far anticipatory decisions can represent ongoing patient autonomy. CONCLUSION despite their status in law, an ADRT which conflicts with a geriatrician's clinical opinion may not be implemented, in breach of the Mental Capacity Act. To avoid this, they must be seated within wider advance care planning.
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Mancini ME, Soar J, Bhanji F, Billi JE, Dennett J, Finn J, Ma MHM, Perkins GD, Rodgers DL, Hazinski MF, Jacobs I, Morley PT. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S539-81. [PMID: 20956260 DOI: 10.1161/circulationaha.110.971143] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Soar J, Mancini ME, Bhanji F, Billi JE, Dennett J, Finn J, Ma MHM, Perkins GD, Rodgers DL, Hazinski MF, Jacobs I, Morley PT. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010; 81 Suppl 1:e288-330. [PMID: 20956038 PMCID: PMC7184565 DOI: 10.1016/j.resuscitation.2010.08.030] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol,United Kingdom.
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Wilson E, Seymour JE, Perkins P. Working with the Mental Capacity Act: findings from specialist palliative and neurological care settings. Palliat Med 2010; 24:396-402. [PMID: 20176617 DOI: 10.1177/0269216309360739] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Since October 2007 staff across health and social care services in England and Wales have been guided by the Mental Capacity Act (2005) in the provision of care for those who may lack capacity to make some decisions for themselves. This paper reports on the findings from a study with 26 staff members working in three palliative and three neurological care centres. Semistructured interviews were used to gain an understanding of their knowledge of the Mental Capacity Act, the issue of capacity itself and the documentation processes associated with the introduction of the Act and in line with advance care planning. Within this setting advance care planning is a key part of care provision and the mental capacity of service users is a regular issue. Findings show that staff generally had a good understanding of issues around capacity but felt unclear about some of the terminology related to the Mental Capacity Act, impacting on their confidence to discuss issues with service users and complete the documentation. Many felt the Act and its associated documentation had aided record-keeping in an area staff already delivered well in practice. Advance care planning in the context of the Mental Capacity Act is not as well embedded in practice as providers would like and consideration needs to be given to how and when staff should approach these issues with service users.
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Affiliation(s)
- Eleanor Wilson
- Sue Ryder Care Centre for Palliative and End of Life Studies, School of Nursing, Midwifery and Physiotherapy, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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Colbert CY, Mirkes C, Ogden PE, Herring ME, Cable C, Myers JD, Ownby AR, Boisaubin E, Murguia I, Farnie MA, Sadoski M. Enhancing competency in professionalism: targeting resident advance directive education. J Grad Med Educ 2010; 2:278-82. [PMID: 21975633 PMCID: PMC2941387 DOI: 10.4300/jgme-d-10-00003.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 02/12/2010] [Accepted: 04/22/2010] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Education about advance directives typically is incorporated into medical school curricula and is not commonly offered in residency. Residents' experiences with advance directives are generally random, nonstandardized, and difficult to assess. In 2008, an advance directive curriculum was developed by the Scott & White/Texas A&M University System Health Science Center College of Medicine (S&W/Texas A&M) internal medicine residency program and the hospital's legal department. A pilot study examining residents' attitudes and experiences regarding advance directives was carried out at 2 medical schools. METHODS In 2009, 59 internal medicine and family medicine residents (postgraduate year 2-3 [PGY-2, 3]) completed questionnaires at S&W/Texas A&M (n = 32) and The University of Texas Medical School at Houston (n = 27) during a validation study of knowledge about advance directives. The questionnaire contained Likert-response items assessing attitudes and practices surrounding advance directives. Our analysis included descriptive statistics and analysis of variance (ANOVA) to compare responses across categories. RESULTS While 53% of residents agreed/strongly agreed they had "sufficient knowledge of advance directives, given my years of training," 47% disagreed/strongly disagreed with that statement. Most (93%) agreed/strongly agreed that "didactic sessions on advance directives should be offered by my hospital, residency program, or medical school." A test of responses across residency years with ANOVA showed a significant difference between ratings by PGY-2 and PGY-3 residents on 3 items: "Advance directives should only be discussed with patients over 60," "I have sufficient knowledge of advance directives, given my years of training," and "I believe my experience with advance directives is adequate for the situations I routinely encounter." CONCLUSION Our study highlighted the continuing need for advance directive resident curricula. Medical school curricula alone do not appear to be sufficient for residents' needs in this area.
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Affiliation(s)
- Colleen Y. Colbert
- Corresponding author: Colleen Y. Colbert, PhD, Scott & White Healthcare, 2401 South 31st Street, Temple, TX 76508, 254.724.8882,
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Villars H, Oustric S, Andrieu S, Baeyens JP, Bernabei R, Brodaty H, Brummel-Smith K, Celafu C, Chappell N, Fitten J, Frisoni G, Froelich L, Guerin O, Gold G, Holmerova I, Iliffe S, Lukas A, Melis R, Morley JE, Nies H, Nourhashemi F, Petermans J, Ribera Casado J, Rubenstein L, Salva A, Sieber C, Sinclair A, Schindler R, Stephan E, Wong RY, Vellas B. The primary care physician and Alzheimer's disease: an international position paper. J Nutr Health Aging 2010; 14:110-20. [PMID: 20126959 DOI: 10.1007/s12603-010-0022-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.
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Affiliation(s)
- H Villars
- Gérontopôle, Alzheimer's Disease Research and Clinical Center, Toulouse University Hospital, Toulouse, France.
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Simón-Lorda P, Tamayo-Velázquez MI, Vázquez-Vicente A, Durán-Hoyos A, Pena-González J, Jiménez-Zurita P. [Knowledge and attitudes of medical staff in two health districts concerning living wills]. Aten Primaria 2008. [PMID: 18358157 DOI: 10.1157/13116148] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To explore the knowledge and attitudes of physicians towards advance directives in 2 healthcare areas. To compare the outcomes of both areas. To compare the outcomes of primary healthcare and specialised healthcare. DESIGN A cross sectional, descriptive study by means of a self-administered questionnaire. SETTING North-Málaga and North-Almería healthcare areas, Spain. PARTICIPANTS Physicians of primary and specialised healthcare. MEASUREMENTS AND MAIN RESULTS Knowledge and attitudes towards advance directives. 194 (63.19%) questionnaires were filled out by the physicians from both healthcare districts. Mean age (standard deviation) 42.54 (80.85); 65.5% of participants were men and 33.5% were women; 51.55% from primary care and 48.45% from specialised healthcare. CONCLUSIONS Polled physicians revealed a positive attitude towards the usefulness of advance directives for the patient's relatives and for healthcare professionals. They also show a positive attitude towards the use and respect of advance directives. They show a high predisposition to registry their advance directive, but a low predisposition to do so in a short term.
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