Dignity in people with dementia: A concept analysis

Background: Dignity, an abstract and complex concept, is an essential part of humanity and an underlying guiding principle in healthcare. Previous literature indicates dignity is compromised in people with dementia (PwD), but those PwD maintain the capacity to live with dignity with appropriate external support. Alzheimer's disease and related dementias (ADRDs) lead to progressive functional decline and increased vulnerability and dependence, leading to heightened risks of PwD receiving inappropriate or insufficient care that diminishes dignity. Considering the increased disease prevalence and the continuously escalating costs of dementia care, establishing a productive value-based guideline may prevent suffering, maximize dignity, and thus promote quality of life (QoL).Aim: The goal of this project is to identify actionable targets for integrating dignity harmoniously and practically into care planning and management for PwD.Research Design: We conducted a concept analysis using Walker and Avant's eight-step process. A comprehensive literature search was conducted (PubMed and CINAHL) with the keywords "dignity," "dementia," "Alzheimer's disease," and "dementia care."Results: A total of 42 out of 4910 publications were included. The concept of dignity in PwD is operationalized as the promotion of worthiness and the accordance of respect that allows the presence and expression of a person's sense of self, regardless of physical, mental, or cognitive health. The concept has two subdimensions: absolute dignity which encompasses the inherent self and relative dignity characterized by its dynamic reflective nature. Worthiness and respect are the two main attributes, while autonomy is an underlying component of dignity. Specific antecedents of dignity in PwD are empowerment, non-maleficence, and adaptive environmental scaffolding. As a consequence of facilitating dignity in PwD, QoL may be enhanced.Conclusion: As a foundational and necessary humanistic value, incorporating dignity into dementia care can lead to efficient and effective care that optimizes QoL in PwD throughout their disease progression.

Social health markers in the context of cognitive decline and dementia: an international qualitative study

Background

Social health in the context of dementia has recently gained interest. The development of a social health conceptual framework at the individual and social environmental levels, has revealed a critical need for a further exploration of social health markers that can be used in the development of dementia intervention and to construct social health measures.

Objective

To identify social health markers in the context of dementia.

Method

This international qualitative study included six countries: Australia, Germany, Indonesia, Italy, Poland, and the Netherlands. Using purposive sampling, three to five cases per country were recruited to the study, with each case consisting of a person living with dementia, a primary informal caregiver, an active network member, and a health care professional involved in the care of the person with dementia. In-depth interviews, using an agreed topic guide, and content analysis were conducted to identify known and new social health markers. The codes were then categorized against our conceptual framework of social health.

Results

Sixty-seven participants were interviewed. We identified various social health markers, ranging from those that are commonly used in epidemiological studies such as loneliness to novel markers of social health at the individual and the social environmental level. Examples of novel individual-level markers were efforts to comply with social norms and making own choices in, for example, keeping contact or refusing support. At a social environmental level, examples of novel markers were proximity (physical distance) and the function of the social network of helping the person maintaining dignity.

Conclusions

The current study identified both well-known and novel social health markers in the context of dementia, mapped to the social health framework we developed. Future research should focus on translating these markers into validated measures and on developing social health focused interventions for persons with dementia.

A Principle-Based Approach to Visual Identification Systems for Hospitalized People with Dementia

A large proportion of hospital inpatients are affected by cognitive impairment, posing challenges in the provision of their care in busy, fast-paced acute wards. Signs and symbols, known as visual identifiers, are employed in many U.K. hospitals with the intention of helping healthcare professionals identify and respond to the needs of these patients. Although widely considered useful, these tools are used inconsistently, have not been subject to full evaluation, and attract criticism for acting as a shorthand for a routinized response. In order for visual identifiers to be used effectively in acute care settings, thorough consideration must be given to the ethical and legal issues that are engaged in this context, and their potential benefits and harms must be weighed and balanced. This paper proposes a set of legal and ethical principles that can be used to guide the implementation of visual identifiers. Together, these principles provide a framework applicable in the design and implementation phases to systematically identify relevant considerations arising from the use of these tools. We outline some tensions that arise between principles and conclude that selecting a preferred moral framework could help to guide decision-making, as does clarity around the purpose and objectives of the identifier.

The Moral and Gender Implications of Measures Used to Modulate the Mobility of People With Dementia Living in Residential Care Environments: A Scoping Review

BACKGROUND AND OBJECTIVES

Policies and measures often restrict the mobility of people with dementia living in residential care environments to protect them from harm. However, such measures can violate human rights and affect the quality of life. This review aims to summarize the literature on what is known about measures used to modulate the life-space mobility of residents with dementia living in a residential care environment. Furthermore, moral and sex and gender considerations were explored.

RESEARCH DESIGN AND METHODS

A scoping review framework was referenced to summarize the literature. A total of 5 databases were searched: PubMed, Embase, CINAHL, SCOPUS, and Web of Science. The studies for eligibility using the Rayyan screening tool.

RESULTS

A total of 30 articles met the inclusion criteria. A narrative description of the findings of the articles is presented across 3 themes: (1) measures and strategies used to modulate the life-space mobility; (2) moral aspects; and (3) sex and gender considerations.

DISCUSSION AND IMPLICATIONS

Various measures are used to modulate the life-space mobility of people with dementia living in residential care facilities. Research exploring the sex and gender differences of people with dementia is lacking. With a focus on human rights and quality of life, measures used to restrict or support mobility must support the diverse needs, capacity, and dignity of people with dementia. Noting the capacity and diversity of people with dementia will require society and public space to adopt strategies that promote safety and mobility to support the quality of life of people with dementia.

Healthcare Professionals' Perspectives on Dignity in Dementia: A Qualitative Analysis

In dementia care, the concept of dignity has garnered substantial attention from both researchers and policymakers. However, the concept often remains vague and open to interpretation, potentially leading to misunderstandings and suboptimal care for people with dementia. As healthcare professionals occupy a critical role in upholding dignity, exploring their viewpoints on this complex concept is paramount. In this study, we explore Danish healthcare professionals' views on the dignity of people with dementia and discuss these perspectives against existing theoretical accounts. We employed thematic analysis of data collected during facilitated discussions with a total of 99 healthcare professionals, including nurses and healthcare workers, during which we posed the question, "What is dignity to you?" and documented their perspectives. Through a systematic process of data coding and interpretation, we identified recurring patterns in their responses. This approach allowed us to uncover the depth and complexity of their viewpoints, providing valuable insights into the multifaceted nature of dignity as perceived by healthcare professionals. Our findings revealed that healthcare professionals possessed a nuanced understanding of dignity, recognizing both a subjective element and a universal aspect applicable to all individuals, aligning with theoretical interpretations. However, conceptual ambiguity remained a challenge.

Trust-building interventions to home-dwelling persons with dementia who resist care

BACKGROUND

Providing care for a home-dwelling person with dementia who resists care is an ethical and practical complex and challenging task. Faced with a growing number of persons with dementia, the healthcare professional's understanding of how to best care for and prevent unnecessary use of coercion with persons with dementia is of key importance.

RESEARCH AIM

The aim of this study was to explore the use of trust-building interventions in home-dwelling persons with dementia resisting care, as described by health professionals in documents of decisions of forced treatment and care.

RESEARCH DESIGN

A qualitative thematic document analysis inspired by critical realism was conducted.

PARTICIPANTS AND RESEARCH CONTEXT

Descriptions of trust-building interventions were extracted from 88 documents of forced treatment and care for home-dwelling persons with dementia, receiving home healthcare, in 2015 and 2016.

ETHICAL CONSIDERATIONS

Approved by the Regional Committee for Medical and Health Research Ethics, reference number 2017/788, and controlled by the Norwegian Centre for Research Data, reference number 54897. The study adhered to the guidelines of the Declaration of Helsinki.

FINDINGS

We found that "balancing safe care with the person's integrity" was an overarching theme that permeated the descriptions of trust-building interventions in the study. Three main themes were identified when the data were analyzed: safeguarding care, protecting integrity, and optimizing the environment.

DISCUSSION AND CONCLUSION

Health professionals balanced on a thin line between care and integrity when met with resistance from person with dementia. However, the trust-building interventions used in the most challenging situations did not differ from the interventions used in general in dementia care. Two knowledge gaps were identified: how to perform appropriate assessments of situations of home-dwelling persons with dementia when met with resistance to care, and whether environmental initiatives may also benefit home-dwelling persons with dementia who are not easily cared for.

Dignity as a Central Issue in Treating Patients with Dementia Associated with COVID-19 Infection

COVID-19 was initially considered a primary respiratory disorder associated with various short- and long-term complications, affecting many patients and imposing a significant burden. Patients who have dementia are especially vulnerable to the SARS-CoV2 infection, which is associated with an increased risk for neuropsychiatric complications. These patients need a unique approach to managing ethical issues related to the COVID-19 pandemic, including autonomy, veracity, non-maleficence, justice, compassion, and dignity. The latter is one of the most elusive and misunderstood concepts in medical ethics and is extremely important in debates surrounding the proper management of patients with dementia. However, it is often left out of ethical analysis, as most clinicians, when debating issues associated with clinical practice, often evaluate only the "classical" principles of biomedical ethics. In this article, we aim to assess the unique features of dignity in treating this group of patients during the COVID-19 pandemic. We will briefly analyze dignity as a bioethical concept. We will further explore its principal axes, namely compassion, creating a humane and purposeful environment, employing persuasion to meet the person's essential needs, exerting a certain degree of mild restraint to meet the person's critical needs, minimizing harm in terminal care, and justice, through the lens of people who had dementia during the COVID-19 pandemic. Applying this principle in clinical practice requires significant commitment from all healthcare workers. New approaches to the analysis of dignity, such as through the Ring Theory of Personhood, may facilitate its understanding by practitioners and aid its implementation in populations with multiple vulnerabilities, such as dementia patients, during an infectious outbreak that generates significant social and medical changes.

Do differences exist in cross-cultural caregivers' respect for the autonomy/dignity of people with dementia? Real-time field observations in nursing homes

BACKGROUND

Although published studies have examined the perceptions of caregivers who are attending to older adults with dementia concerning the values of human dignity and/or autonomy in institutional settings, none have explored the possible differences in actual behavior that relates to these values for caregivers from diverse ethno-cultural backgrounds.

AIMS

Explore how caregivers with varied cultural backgrounds may differ in their real-time behavior regarding the autonomy and dignity of older adults with dementia and thereby determine whether that real-time behavior reveals new aspects of respect and disrespect for both the autonomy and dignity of those older adults.

RESEARCH DESIGN AND METHODS

A qualitative research based on non-participatory observations, was meticulously recorded using a written journal and a rigorous microanalysis to analyze the collected data. We made 58 shift-based observations (morning and evening) of 29 caregivers from 3 ethno-cultural groups working in 3 nursing homes in Israel. These groups included Israeli-born Jews (Sabras), Israeli Arab-Muslims (Arabs), and immigrants from the Former Soviet Union (IFSU).

RESULTS

(1) IFSU caregivers demonstrated more respect for autonomy and dignity, but also demonstrated disrespect for these values. (2) the main difference between the IFSU caregivers and other caregiver groups pertained to respect for their autonomy. The main specific facets of autonomy where IFSU caregivers surpassed their colleagues were information provision and persuasion. (3) toward both autonomy and dignity of these older adults, previously unaccounted for in the models we used, were discovered among the varied groups of caregivers, with only minor gaps between these groups.

DISCUSSION AND IMPLICATIONS

This study-the first of its kind to focus on the real-time behaviors of caregivers from diverse ethno-cultural backgrounds-reveals the potential effects of culture on applying practices related to dignity and autonomy during daily care. The findings may have important implications for caregiver training in multicultural societies.

Informal caregivers and assistive technology in Norwegian nursing homes

Aim

To explore informal caregivers’ experiences and perspectives concerning assistive technology (AT) in two nursing homes, through the conceptual lens of person-centredness.

Background

The integration and use of AT and a person-centred approach to care are political intentions within healthcare services, both internationally and in Norway. In nursing homes, informal caregivers are often collaborators with the staff, and can be important partners concerning the implementation of AT in a person-centred way. However, there is little knowledge about the informal caregivers’ perspectives on the use of AT in nursing homes, or of whether or how they are included in the integration and use of AT.

Methods

The study had a qualitative design and comprised eleven informal caregivers of residents in two nursing homes in Norway. In-depth interviews were used for data collection. The data were analysed using content analysis. COREQ reporting guidelines were applied to ensure comprehensive reporting.

Results

Emerging themes highlighted the slow-going transition from old to new technology, and how the informal caregivers experienced that AT both promoted and degraded the dignity of their family members. Informal caregivers were positive to the use of technology, but have sparse knowledge and information about ATs in the nursing homes. They express a desire for AT to increase activity and safety, which promotes dignity, quality of life, and quality of the care for their family member. The informal caregivers want their family member to be seen, heard, and to get assistance on their own terms, even with regard to technology.

Conclusion

Before AT can be implemented, informal caregivers need to be informed and listened to and included in the processes. Through their stories, one can form an idea of how important a person-centred approach is to contributing to individually tailored and introduced AT in collaboration with the informal caregivers.

Is deception defensible in dementia care? A care ethics perspective

Deception is common in dementia care, although its moral legitimacy is questionable. This paper conceptually clarifies when does dementia care involve deception and argues that care ethics is an appropriate ethical framework to guide dementia care compared with the mainstream ethical theories that emphasize abilities. From a perspective of care ethics, this paper claims that morally defensible deception is context-specific, embodied as a caring process that needs to be identified through instant, creative and interactive care procedures. According to this argument, it further analyses and concludes the moral rationality of deception in five common cases. While deception is morally justified in many situations, another concern is that it is usually not the last resort but a means of convenience. As the ability to interact, autonomy and dignity of persons with dementia (PWDs) are generally ignored; nurses need more training and education to master the essential procedures to ensure that the value of authenticity and autonomy is maintained and considered throughout dementia care.

Iatrogenesis in the Context of Residential Dementia Care: A Concept Analysis

Background and Objectives

This concept analysis aims to explore iatrogenesis within the context of residential dementia care and to distinguish this phenomenon from similar phenomena, such as abuse and inadvertent harm.

Research Design and Methods

Walker and Avant's method for concept analysis was used to define critical attributes of iatrogenesis within residential dementia care, and to explore antecedents and consequences of its occurrence. A review of the literature about iatrogenesis in the context of residential dementia was conducted across 4 electronic databases. Texts about iatrogenesis in surgery, medicine, social work, psychology, and other relevant disciplines were also reviewed to provide additional context for the concept.

Results

Iatrogenesis takes a unique form in residential dementia care. The final definition of the concept proposed in this article is habituated, forceful, hands-on care provided to residents who exhibit responsive behaviors that result in emotional, physical, spiritual, social harm, and/or gradual functional decline, that is provided with the intention of supporting the resident's safety and dignity.

Discussion and Implications

The definition of iatrogenesis proposed in this article is an initial step toward developing evidence-based practice for the provision of nonconsensual assistance in residential dementia care. A theoretical definition like the one proposed in this article may serve as a starting point for the operationalization of the concept, which would promote future empirical research into staff and residents' experiences of health care-inflicted harms in this context. Theoretically, it contributes to critical conversations about the narratives, myths, and misperceptions that facilitate the provision of nonconsensual care.

Ethical considerations in design and implementation of home-based smart care for dementia

It has now become a realistic prospect for smart care to be provided at home for those living with long-term conditions such as dementia. In the contemporary smart care scenario, homes are fitted with an array of sensors for remote monitoring providing data that feed into intelligent systems developed to highlight concerning patterns of behaviour or physiological measurements and to alert healthcare professionals to the need for action. This paper explores some ethical issues that may arise within such smart care systems, focusing on the extent to which ethical issues can be addressed at the system design stage. Artificial intelligence has been widely portrayed as an ethically risky technology, posing challenges for privacy and human autonomy and with the potential to introduce and exacerbate bias and inequality. While broad principles for ethical artificial intelligence have become established, the mechanisms for governing ethical artificial intelligence are still evolving. In healthcare settings the implementation of smart technologies falls within the existing frameworks for ethical review and governance. Feeding into this ethical review there are many practical steps that designers can take to build ethical considerations into the technology. After exploring the pre-emptive steps that can be taken in design and governance to provide for an ethical smart care system, the paper reviews the potential for further ethical challenges to arise within the everyday implementation of smart care systems in the context of dementia, despite the best efforts of all concerned to pre-empt them. The paper concludes with an exploration of the dilemmas that may thus face healthcare professionals involved in implementing this kind of smart care and with a call for further research to explore ethical dimensions of smart care both in terms of general principles and lived experience.

Expanding role of nurses in management of dementia in geriatrics: improving well-being of geriatric patients through quality nursing care

The potential nurses role to include the recognition and management of dementia has been acknowledged. Practice Nurses are well-positioned to provide comprehensive dementia information and support so that people living with dementia are better equipped to self-manage their health and live well with dementia. However, treatment of geriatric dementia has become difficult owing to co-morbidities and cognitive and physical deterioration of these patients. Thus, geriatric dementia patients require special attention during care in homes and clinical settings. In modern medical practice, the role of nurse has become dynamic, ranging from education and personal care. The profession of nursing is considered as critical to meets the needs of the elderly population with dementia and ensure the delivery of high-quality care. Since nurses play such an important role in caring for these individuals, comprehensive reviews lack on their role and experience in geriatric dementia treatment and issues. This review summarizes the expanding role of nurses in the management of geriatric dementia in terms of nurse's knowledge, role, communication, attitude and maintaining patient's quality of life through diverse activities. Furthermore, we also explain the future direction for improving the nursing care to treat dementia in elderly population.

Dignity of older home-dwelling women nearing end-of-life: Informal caregivers' perception

BACKGROUND

Most older people wish to live in the familiar surroundings of their own home until they die. Knowledge concerning dignity and dignity loss of home-dwelling older women living with incurable cancer should be a foundation for quality of care within municipal healthcare services. The informal caregivers of these women can help increase the understanding of sources related to dignity and dignity loss.

AIM

The aim of this study was to explore informal caregivers' perceptions of sources related to dignity and dignity loss in end-of-life of older home-dwelling women with incurable cancer.

RESEARCH DESIGN AND METHOD

The study was founded upon Gadamer's philosophical hermeneutics. In-depth interviews with 13 informal caregivers were carried out, and four participant observations were performed during home meetings.

ETHICAL CONSIDERATION

The study was based on voluntary participation, informed consent, confidentiality and the opportunity to withdraw at any time. The Norwegian Social Science Data Services approved the study.

RESULTS

Three main sources important in preserving the older women's dignity were identified: maintaining one's self-concept, remaining hopeful and sustaining freedom of choice. We also identified three main sources that lead to dignity loss: Sensing loss of human value, experiencing absence of gentleness and feelings of being treated as an object.

DISCUSSION AND FINAL CONSIDERATIONS

On the individual level, the opportunity to maintain one's self-concept and control in life, preserved dignity, while feelings of existential loneliness led to dignity loss. On the relational level, being confirmed as worthy human beings promoted the women's dignity, whereas dignity loss was related to uncaring behaviours from healthcare professionals. On the societal level, individual decisions concerning travel situations and the place to stay when nearing end-of-life were of crucial importance. Constituting these women's living space, these perspectives should be emphasized in healthcare professionals' educational training and in the municipal end-of-life care of these patients.

Coping with Everyday Life for Home-Dwelling Persons with Dementia: A Qualitative Study

Aim

This study aimed to gain insight into factors that influence everyday coping strategies as described by persons with early to intermediate dementia.

Background

Living with dementia presents difficulties coping with everyday life. This study focuses on coping with everyday life for persons with mild to moderate dementia in order to facilitate their ability to live at home.

Design

A qualitative study.

Methods

Individual interviews with 12 persons with dementia were conducted in their own homes.

Findings

Coping with everyday life can be influenced by the experience of the diagnostic process and by information about dementia. It can also be affected by stigmatization of persons with dementia, as well as by challenges in everyday life. In addition, challenges in receiving help may include poor continuity of services and healthcare staff with limited competence. By contrast, person-centered care led to positive experiences that supported everyday coping skills. Most of the respondents wanted to participate in day care several days a week. Other positive experiences were making new friends and participating in meaningful activities; such experiences could enhance to coping strategies.

Conclusion

To strengthen everyday coping for persons with dementia living at home, there is a need for openness about the disease. Follow-up for persons with dementia must be carried out by reputable professionals trained and educated in dementia care. Finally, the municipalities must have contact persons, dementia coordinator/-team, who are available for persons with dementia at the time of diagnosis position and afterwards.

The compound role of a coordinator for home-dwelling persons with dementia and their informal caregivers: qualitative study

Background

As the number of persons with dementia is increasing, there has been a call for establishing sustainable clinical pathways for coordinating care and support for this group. The LIVE@Home.Path trial is a multicomponent, multi-disciplinary intervention combining learning, innovation, volunteer support and empowerment. To implement the intervention, a municipal coordinator has a crucial role. Implementation research on multicomponent interventions is complex and we conducted a qualitative study, aiming to explore the coordinator role and how a coordinator may empower persons with dementia in decision-making processes.

Methods

Qualitative program evaluation combined with a hermeneutic interpretive approach was chosen as methodological approach. Sixteen dyads, consisting of the person with dementia and their main informal caregiver received the intervention by two coordinators. Of these, six dyads, three informal caregivers alone and the two care coordinators along with their leader, in sum, eighteen persons, participated in in-depth or focus group interviews, sharing their experiences after 6 months intervention.

Results

We found that the coordinators fulfilled three functions for the participating dyads: being a safety net, meaning that the dyads might have little needs at the moment, but found safety in a relation to someone who might help if the situation should change; being a pathfinder, meaning that they supported the dyads in finding their way through the complicated system of care and support services; being a source for emotional care and support, meaning that they listened, acknowledged and gave counsel in times of distress. The coordinators emphasized that a trusting leader and work environment was crucial for them to fulfill these functions. We also found that it was challenging for the coordinators to build a relation to the persons with dementia in order to pursue genuine empowerment in decision-making processes.

Conclusion

We found the framework for follow-up to be a feasible starting point for establishing empowering coordination and a sustainable care pathway for persons with dementia and their informal caregivers. More meeting points between coordinator and person with dementia should be pursued in order to fulfill the persons’ fundamental rights to participate in decision-making processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05913-z.

A concept analysis of dignity-protective continence care for care dependent older people in long-term care settings

Background

Although codes of conduct, guidelines and standards call for healthcare practitioners to protect patients’ dignity, there are widespread concerns about a lack of attention to the dignity of older people who need assistance with toileting, incontinence or bladder or bowel care in health or social care settings that provide long-term care. Incontinence and care dependence threatens patient dignity. The aim of this research was to explore, describe and explain the concept of dignity as it relates to continence care for older people requiring long-term care.

Methods

The first four steps of Rodgers evolutionary method of concept analysis were followed. First, a comprehensive and systematic search of databases and key guidelines about continence care was undertaken to identify empirical research about dignity and continence care in older people in facilities that provide permanent residential or inpatient care of older people for day-to-day living. Data were extracted on the authors, date, sample, country of origin, and key definitions, attributes, contexts and consequences from each included record. Findings were inductively analysed and grouped according to whether they were the key attributes and antecedents of dignity in relation to continence care or the consequences of undignified continence care.

Results

Of 625 articles identified, 18 were included in the final analysis. Fifty individual attributes were identified that were categorised in 6 domains (respect, empathy, trust, privacy, autonomy and communication). A further 15 were identified that related to the environment (6 physical and 9 social). Key consequences of undignified continence care were also identified and categorised into 3 levels of impact (resident/family member, staff or organisation).

Conclusions

This research resulted in a conceptual understanding of dignity that can be used as a value or guiding principle in an ethic of care for older people who need assistance with toileting, incontinence or bladder or bowel care in long-term care settings.

Home-dwelling persons with dementia's perception on care support: Qualitative study

Background

Over the last years, there has been a growth in care solutions aiming to support home-dwelling persons with dementia. Assistive technology and voluntarism have emerged as supplements to traditional homecare and daycare centers. However, patient participation is often lacking in decision-making processes, undermining ethical principles and basic human rights.

Research objective

This study explores the perceptions of persons with dementia toward assistive technology, volunteer support, homecare services, and daycare centers.

Research design

A hermeneutical approach was chosen for this study, using a semi-structured interview guide to allow for interviews in the form of open conversations.

Participants and research context

Twelve home-dwelling persons with dementia participated in the study. The participants were recruited through municipal daycare centers.

Ethical considerations

Interviews were facilitated within a safe environment, carefully conducted to safeguard the participants’ integrity. The Regional Committee for Medical and Health Research Ethics, Western Norway (Project number 2016/1630) approved the study.

Findings

The participants shared a well of reflections on experience and attitudes toward the aspects explored. They described assistive technology as possibly beneficial, but pointed to several non-beneficial side effects. Likewise, they were hesitant toward volunteer support, depending on how this might fit their individual preferences. Homecare services were perceived as a necessary means of care, its benefits ascribed to a variety of aspects. Similarly, the participants’ assessments of daycare centers relied on specific aspects, with high individual variety.

Discussion and conclusion

The study indicates that the margins between whether these specific care interventions were perceived as supportive or infringing may be small and details may have great effect on the persons’ everyday life. This indicates that patient participation in decision-making processes for this group is—in addition to be a judicial and ethical requirement—crucial to ensure adequate care and support.

Developing the New Interventions for independence in Dementia Study (NIDUS) theoretical model for supporting people to live well with dementia at home for longer: a systematic review of theoretical models and Randomised Controlled Trial evidence

PURPOSE

To build an evidence-informed theoretical model describing how to support people with dementia to live well or for longer at home.

METHODS

We searched electronic databases to August 2018 for papers meeting predetermined inclusion criteria in two reviews that informed our model. We scoped literature for theoretical models of how to enable people with dementia to live at home independently, with good life quality or for longer. We systematically reviewed Randomised Controlled Trials (RCTs) reporting psychosocial intervention effects on time lived with dementia at home. Two researchers independently rated risk of bias. We developed our theoretical model through discussions with experts by personal, clinical and academic experiences, informed by this evidence base.

RESULTS

Our scoping review included 52 studies. We divided models identified into: values and approaches (relational and recovery models; optimising environment and activities; family carer skills and support); care strategies (family carer-focused; needs and goal-based; self-management); and service models (case management; integrated; consumer-directed). The 11 RCTs included in our systematic review, all judged at low risk of bias, described only two interventions that increased time people with dementia lived in their own homes. These collectively encompassed all these components except for consumer-directed and integrated care. We developed and revised our model, using review evidence and expert consultation to define the final model.

CONCLUSIONS

Our theoretical model describes values, care strategies and service models that can be used in the design of interventions to enable people with dementia to live well and for longer at home.

TRIAL REGISTRATION

PROSPERO 2018 registration number: CRD42018099693 (scoping review). PROSPERO 2018 registration number: CRD42018099200 (RCT systematic review).

Health Outcome Prioritization in Alzheimer's Disease: Understanding the Ethical Landscape

BACKGROUND

Dementia has been described as the greatest global health challenge in the 21st Century on account of longevity gains increasing its incidence, escalating health and social care pressures. These pressures highlight ethical, social, and political challenges about healthcare resource allocation, what health improvements matter to patients, and how they are measured. This study highlights the complexity of the ethical landscape, relating particularly to the balances that need to be struck when allocating resources; when measuring and prioritizing outcomes; and when individual preferences are sought.

OBJECTIVE

Health outcome prioritization is the ranking in order of desirability or importance of a set of disease-related objectives and their associated cost or risk. We analyze the complex ethical landscape in which this takes place in the most common dementia, Alzheimer's disease.

METHODS

Narrative review of literature published since 2007, incorporating snowball sampling where necessary. We identified, thematized, and discussed key issues of ethical salience.

RESULTS

Eight areas of ethical salience for outcome prioritization emerged: 1) Public health and distributive justice, 2) Scarcity of resources, 3) Heterogeneity and changing circumstances, 4) Knowledge of treatment, 5) Values and circumstances, 6) Conflicting priorities, 7) Communication, autonomy and caregiver issues, and 8) Disclosure of risk.

CONCLUSION

These areas highlight the difficult balance to be struck when allocating resources, when measuring and prioritizing outcomes, and when individual preferences are sought. We conclude by reflecting on how tools in social sciences and ethics can help address challenges posed by resource allocation, measuring and prioritizing outcomes, and eliciting stakeholder preferences.

Dignifying and undignifying aspects of care for people with dementia: a narrative review

Background

The progressive disease trajectory makes people with dementia increasingly vulnerable and gradually more dependent on others which can lead to admission to a nursing home. Special interest in dignity in people with dementia has led to a growing body of knowledge towards promoting or hindering their dignity.

Aim

The aim of this narrative review was to synthesise dignifying and undignifying aspects of formal and informal care for people with dementia within nursing homes.

Method

The electronic databases CINAHL, SCOPUS, PSycInfo and PubMed were systematically searched with the terms ‘dementia’ and ‘dignity’, complemented with the use of snowballing and reference check. A total of 789 unique items were found. The search and selection process was structured by the PRISMA framework, and both authors formulated the criteria of eligibility. A methodological check was performed using the critical appraisal tool of Hawker. This process led to inclusion of 29 articles which were reviewed with the help of the guidelines for narrative synthesis by Popay et al.

Findings

The emerged dignifying and undignifying aspects of formal and informal care are characterised by either a successful or unsuccessful process of adjustment towards changing abilities, preferences and care needs of people with dementia. Three themes appeared as undignifying aspects of care: ‘Stigmatisation and objectivation’, ‘Scarcity and hastiness’ and ‘Impending estrangement and misunderstanding’. Four themes were identified as dignifying aspect of care: ‘Personalisation’, ‘Respect, attentiveness and encouragement’, ‘Attention for physical care and bodily gestures’, and ‘Foster belonging’. Literature synthesis showed mostly relational aspects of care concerning dignity in people with dementia. Formal and informal caregivers are important in maintaining and promoting their dignity.

Concept analysis of dignity-centered care for people with chronic progressive disease

AIM

This concept analysis describes attributes, antecedents, and consequences of dignity-centered care for people with chronic progressive disease.

METHODS

Rodgers' method of concept analysis was used to clarify the concept's defining attributes. Databases searched were PubMed, MEDLINE, EMBASE, CINAHL, and Ichushi-Web by NPO Japan Medical Abstracts Society, in English and Japanese, from 1976 to 2017. The combination of MESH and keywords used were (dignity), and (care), and (chronic disease) or (chronic illness).

RESULTS

Three antecedents were identified: loss of physical function and reduced psychological capacity, independence and role; living with uncertainty of illness; and multi-faceted distress. There were four attributes identified: bolstering self-esteem, reducing multi-faceted distress, continued relationship, and protecting individual's rights. Four consequences were identified: improved self-esteem, relief from multi-faceted distress, deepening the purpose and meaning of life, and maintaining and/or improving the quality of life.

CONCLUSION

Dignity-centered care is defined as: care that results in improvement of self-esteem, deepens purpose and meaning of life, maintains and improves quality of life and provides relief from multi-faceted distress. This happens through protecting the individual's rights, bolstering self-esteem and reducing multi-faceted distress through continued relationships with family, friends, and providers. There is a need for continued involvement with those individuals who have lost physical function, psychological capacity, autonomy, and role. They live with uncertainty of illness and exhibit multi-faceted distress. This concept is a fulcrum for patient and nurse reciprocity enabling both to realize greater integrity and respect, and is useful for nursing practice and research.

"We live as good a life as we can, in the situation we're in" - the significance of the home as perceived by persons with dementia

BACKGROUND

The coming years will see more persons with dementia living longer at home. However, "the home" is a complex concept with a multitude of meanings, varying among individuals and raising ethical and practical dilemmas in the support provided for this group. This study aims to increase the understanding of experiences and attitudes among persons with dementia related to living at home.

METHODS

Qualitative interviews were conducted with 12 persons, 69 to 89 years old, with a dementia diagnosis and living at home. Using a hermeneutical approach, the interviews were analysed as single texts, as parts of a set of texts and as a whole single text. The writings of care philosopher Kari Martinsen on "The home" were chosen as a framework for the theoretical interpretation of the findings.

RESULTS

The participants experienced a vital interconnectedness between the home and their lives, placing their home as a core foundation for life. Through stories of persisting love, they illuminated how their lived lives functioned as a foundation for their homes. Further, they described how progressing dementia disturbed rhythms of life at home, forcing them to adapt and change their routines and rhythms in life. Finally, in the hope of an enhanced future home the participants showed an acceptance of, but also a reluctance to, the prospect of having to move out of their homes at some future point.

CONCLUSION

The study suggests that the participants' home generated existential meaning for the participating persons with dementia. Their experience of being at home was based on a variety of individual factors working together in various ways. These findings imply a need to understand what factors are important for the individual, as well as how these factors interact in order to provide support for this group of people.

Dignity work of older women caring for a husband with dementia at home

In this study, we explored perceptions of dignity, and sources preserving dignity of six older Norwegian women caring for a home-dwelling husband with dementia. Through hermeneutic interpretation of in-depth interviews, "having personal integrity," "mastering everyday life," and "giving of one self" were identified as crucial intrapersonal aspects of dignity - while "acknowledging worthiness and uniqueness of each human being" was found to be an essential interpersonal aspect. Nine dignity-preserving sources identified suggests that the wives engaged in "dignity work" to preserve their own dignity as a caregiver, as well as to safeguard the dignity of their husbands who were vulnerable to dignity loss.

Ethical practice in dementia care

This article draws on a range of case study examples from dementia care and explains how ethical theory can be applied to enhance professional practice. Ethical concepts are critically examined in this context and tensions between them are explored. The article demonstrates how an established ethical framework can assist with application in practice situations. It also argues that cultivating virtues, such as courage and receptivity, is an essential aspect of providing ethical nursing care for people with dementia.

Considering axiological integrity: a methodological analysis of qualitative evidence syntheses, and its implications for health professions education

Qualitative evidence synthesis (QES) is a suite of methodologies that combine qualitative techniques with the synthesis of qualitative knowledge. They are particularly suited to medical education as these approaches pool findings from original qualitative studies, whilst paying attention to context and theoretical development. Although increasingly sophisticated use is being made of qualitative primary research methodologies in health professions education (HPE) the use of secondary qualitative reviews in HPE remains underdeveloped. This study examined QES methods applied to clinical humanism in healthcare as a way of advancing thinking around the use of QES in HPE in general. A systematic search strategy identified 49 reviews that fulfilled the inclusion criteria. Meta-study was used to develop an analytic summary of methodological characteristics, the role of theory, and the synthetic processes used in QES reviews. Fifteen reviews used a defined methodology, and 17 clearly explained the processes that led from data extraction to synthesis. Eight reviews adopted a specific theoretical perspective. Authors rarely described their reflexive relationship with their data. Epistemological positions tended to be implied rather than explicit. Twenty-five reviews included some form of quality appraisal, although it was often unclear how authors acted on its results. Reviewers under-reported qualitative approaches in their review methodologies, and tended to focus on elements such as systematicity and checklist quality appraisal that were more germane to quantitative evidence synthesis. A core concern was that the axiological (value) dimensions of the source materials were rarely considered let alone accommodated in the synthesis techniques used. QES can be used in HPE research but only with careful attention to maintaining axiological integrity.

Informal use of restraint in nursing homes: A threat to human rights or necessary care to preserve residents' dignity?

Use of restraint in nursing homes is highly controversial and fundamentally transgresses human rights and freedom of movement and choice. While different forms of formal restraint use in nursing homes are broadly delineated, the use of informal restraint is less understood. The aim of this article is to identify different kinds of informal restraint, and how staff use informal restraint under which circumstances. This article illuminates informal restraint use based on an ethnographic study in four nursing homes in the Western part of Norway. We have identified five different forms of informal restraint use which are as follows: (1) diversion of residents' attention; (2) white lies; (3) persuasion and interpersonal pressure; (4) offers and finally (5) threats. These different forms of informal restraint are actions by staff against residents' will, limiting residents' freedom of movement and their personal preferences. In addition, we have identified 'grey-zone restraint' which comprises actions by staff towards residents which lie in-between formal and informal restraint. The use of informal restraint can be explained by institutional circumstances such as location, architecture and institutional collectivist constraints in relation to care work. Moreover, and paradoxically, informal restraint can be explained as a consequence of neo-liberal policies with establishment of extended premises for freedom of movement and practices of resident preferences in nursing homes. Informal restraint practices call into question whether these practices are compatible with fundamental human rights and the preservation of residents' dignity.

How to respond to resistiveness towards assistive technologies among persons with dementia

It is a common experience among care professionals that persons with dementia often say 'no' to conventional caring measures such as taking medication, eating or having a shower. This tendency to say 'no' may also concern the use of assistive technologies such as fall detectors, mobile safety alarms, Internet for social contact and robots. This paper provides practical recommendations for care professionals in home health care and social care about how to respond to such resistiveness towards assistive technologies. Apart from the option of accepting the 'no', it discusses a number of methods for influencing persons with dementia in order to overcome the 'no'. These methods range from various non-coercive measures-including nudging-to coercion. It is argued that while conventional caring measures like those mentioned are essential for survival, health or hygiene, assistive technologies are commonly merely potentially beneficial supplements. With this in mind, it is concluded that care professionals should be more restrictive in using methods of influence involving some degree of pressure regarding assistive technologies than regarding conventional caring measures.

Human dignity and autonomy in the care for patients with dementia: differences among formal caretakers from various cultural backgrounds

OBJECTIVES

To explore whether gaps exist between caretakers from different ethno-cultural groups (Israeli-born Jews [Sabras], Israeli Arabs [Arabs], and migrants from Russia [Russians]) regarding their perceptions of autonomy and human dignity of patients with dementia.

DESIGN

A mixed-methods research scheme was used, comprised of qualitative and quantitative methods, utilizing semi-structured interviews and self-reported questionnaires. Twenty formal caretakers participated in the qualitative portion, and approximately 200 caretakers were included in the quantitative portion. All participants were recruited from three nursing homes and one hospital in the Galilee region (Israel).

RESULTS

The qualitative portion of the study yielded eight themes encapsulated in the concept of autonomy and ten themes entailed within human dignity, in the context of care for patients with dementia. By utilizing these themes in the quantitative portion, substantial differences in nursing homes were found in the attitudes to autonomy and dignity of patients with dementia between Russian and Arab as well as Sabra caretakers (index score for autonomy: 2.97, 4.07, and 4, respectively; index score for dignity: 3.17, 4.1, and 4.07). A multi-variable regression, focusing on caretakers from nursing homes, showed the most significant influencing variables on the indexes of autonomy and dignity were ethno-culture Arab/Russian (0.84, 0.62) and the patient's family (0.29, 0.30). Regarding the autonomy index, being a female caretaker also had a significant influence (0.24). In the hospital, no influence emerged for the ethno-culture variables, and neither type of institution showed any influence of religion or religiousness as well as societal or community norms.

CONCLUSIONS

Contrary to past research, in nursing homes, significant differences were found between certain ethno-cultural groups (Arabs and Russians) regarding their stance toward the dignity and autonomy of patients with dementia. Arab caretakers' fostering of more encompassing conceptions of dignity and autonomy, irrespective of institutional setting, provides better grounds for person-centered care.

The Experience of Relations in Persons with Dementia: A Systematic Meta-Synthesis

BACKGROUND

Dementia influences a person's experience of social relationships, as described in several studies. In this systematic meta-synthesis of qualitative studies, we aim to interpret and synthesize the experiences of persons with dementias and their relations with others.

SUMMARY

Living with dementia changes life, leading to new social roles and different social statuses. Persons with dementia experience being disconnected and dependent on others, feeling like being a burden, and being a person who is treated in paternalistic ways. Family, friends and others with dementia might play significant roles in their ability to maintain a meaningful life. Key Messages: Three categories emerged from the data, change in life, change in relations, and maintenance of meaningful aspects in life; these categories are intertwined and essential in sustaining a lifeline for persons with dementia. The comprehensive meaning of the material is understood as the expression: Living a meaningful life in relational changes.

Human capabilities in advanced dementia: Nussbaum's approach

AIMS AND OBJECTIVES

To explore how Martha Nussbaum's approach to human capabilities can apply to dignity in the lives of people with advanced dementia living in nursing homes.

BACKGROUND

Challenges experienced when supporting people with advanced dementia who express problematic behaviours include understanding their needs and ensuring a dignified life for them.

DESIGN AND METHODS

Data were gathered using an ethnographic approach based on participatory observation. Nussbaum's capability approach was then used as a framework for the analysis. Four women diagnosed with advanced dementia who also expressed problematic behaviours were recruited from a nursing home in Northern Sweden. The data collection was performed during 2015.

FINDINGS

Individuals with advanced dementia had difficulties in participating in the planning of their lives and achieving the human capability of practical reasoning. They were also at risk of being placed outside the social group, thus hindering them from attaining the human capability of affiliation. A dignified life for individuals with advanced dementia requires nursing staff to be present and to provide adapted support to ensure that the individual can actually pursue human capabilities.

CONCLUSION

Creating opportunities for the human capabilities of practical reasoning and affiliation is essential as they permeate all other human capabilities. For these individuals, it was crucial not only to create opportunities for human capabilities but also to attend to their expressions and needs and to guide and steer them towards a dignified life.

IMPLICATIONS FOR PRACTICE

The normative structure of the capability approach described by Nussbaum can ensure that nursing staffs move beyond fulfilling patients' basic needs to consider other capabilities vital for a dignified life.

Factors Associated with the Quality of Life of People with Dementia and with Quality of Life-Improving Interventions: Scoping Review

Objectives

To synthesise current research exploring the factors and interventions associated with the quality of life of people with dementia.

Background

Dementia is a progressive condition affecting an estimated 40 million people worldwide. The illness has a significant impact on the lives of the persons affected and their loved ones, and may thus impair the quality of life of both. As it progresses, dementia weakens the patients’ ability to express their own views about their quality of life and the factors associated with it.

Design

Scoping review.

Data sources

Electronic database search of MEDLINE, CINAHL, PsycINFO, Joanna Briggs Institute Library, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), EMBASE, Medic published up to March 2016; and incremental hand search. Review method: Systematic or other kinds of reviews and single studies were included for the review if they met the inclusion criteria. Results: A total of 20 reviews and 7 primary studies were retained for synthesis. Key findings were abstracted and a themes matrix was generated to identify patterns of meaning. The factors associated with the quality of life of people with dementia were sociodemographic factors, factors related to dementia and social and caring environment. Interventions supporting quality of life focused on the activation of people with dementia. Conclusions: This scoping review identified a large body of knowledge exploring the factors and interventions associated with the quality of life of people with dementia. The interventions were heterogeneous and the sample sizes small, which is why more research is needed.

Dignity and autonomy in the care for patients with dementia: Differences among formal caretakers of varied cultural backgrounds and their meaning

BACKGROUND

A key message in the World Health Organization report on dementia (2012) emphasizes this disease as a top priority in public health and the need to improve professional attitudes to patients with dementia, while acknowledging that the workforce in dementia care is becoming increasingly diverse culturally.

AIMS

To trace whether there are substantial gaps between formal caretakers from different cultural groups (Israeli born Jews [Sabras], Israeli Arabs [Arabs] and migrants from Russia [Russians]) regarding their stances on the human dignity and autonomy of patients with dementia, as well as understand the meaning of these gaps.

DESIGN & METHOD

quantitative analysis utilizing questionnaires that were filled-out by approximately 200 caretakers from the different cultural groups, working in a nursing home or a hospital.

RESULTS

In nursing homes, substantial differences were found in the attitudes to human dignity and autonomy of patients with dementia between Russian and Arab as well as Sabra caretakers. In the hospital, there was no influence for the ethno-culture variable on dignity or autonomy.

CONCLUSION

Contrary to past research, in nursing homes, significant differences were found between certain ethno-cultural groups (Arabs and Russians) regarding their stance towards the dignity of patients with dementia. Arab caretakers hold a conception of dignity and autonomy that resonates strongly with person-centered care and outweighs institutional settings as well as may be related to the fostering of virtues.

Autonomy and dignity of patients with dementia: Perceptions of multicultural caretakers

Background:

A key message in the World Health Organization’s report on dementia emphasizes the need to improve public and professional attitudes to dementia and its understanding, while acknowledging the fact that the workforce in dementia care is becoming increasingly diverse culturally.

Objectives:

To explore possible differences among formal caretakers from varied cultural background in their attitudes toward the autonomy and human dignity of patients with dementia.

Research design:

Semi-structured interviews and content analysis, utilizing two fictional vignettes for eliciting caretakers’ attitudes toward dignity and autonomy of their patients.

Participants and context:

A total of 20 formal caretakers of patients with dementia from three different cultural groups in Israel (“Sabras,” “Arabs,” and “Russians”), working in nursing homes and a hospital.

Ethical consideration:

Approvals of relevant research ethics committees were obtained and followed.

Findings:

In comparison with the other groups, most Arab caretakers offer markedly richer perceptions of human dignity and autonomy. Their human dignity’s conceptualization emphasizes “person-centered approach,” and their perception of patients’ autonomy includes provision of explanations and preservation and encouragement of independence.

Discussion:

The differences found in the attitudes toward the meaning of autonomy and human dignity between the Arab caretakers and the other caretakers stand in contrast to previous studies regarding human dignity, emphasizing the common nature of these attitudes. Offering a linkage (theoretical and empirical) between the Arab perceptions of dignity and autonomy, the study strengthen and further the importance attributed in existing literature to person-centered care in enhancing the quality of care for patients with dementia.

Conclusion:

The conceptualization of human dignity may vary among different cultural groups. It may also influence the extent to which the caretaker holds a full-fledged perception of the patients’ autonomy.

Dignity in long-term care: An application of Nordenfelt's work

BACKGROUND

The concept of dignity is recognised as a fundamental right in many countries. It is embedded into law, human rights legislation and is often visible in organisations' philosophy of care, particularly in aged care. Yet, many authors describe difficulties in defining dignity and how it can be preserved for people living in long term care.

OBJECTIVES

In this article, Nordenfelt's 'four notions of dignity' are considered, drawing on research literature addressing the different perspectives of those who receive, observe or deliver care in the context of the long-term care environment.

METHODS

A review of the literature was undertaken using the terms 'nursing homes', 'residential care' or 'long-term care'. The terms were combined and the term 'human dignity' was added. A total of 29 articles met the inclusion criteria from the United Kingdom (14), United States (2), Australia (1), Sweden (3), Hong Kong (2), Norway (3), Nordic (1), Taiwan (1), Netherlands (1). Ethical Considerations: Every effort has been made to ensure an unbiased search of the literature with the intention of an accurate interpretation of findings.

DISCUSSION

The four notions of dignity outlined by Nordenfelt provide a comprehensive description of the concept of dignity which can be linked to the experiences of people living in long-term care today and provide a useful means of contextualising the experiences of older people, their families and significant others and also of staff in long-term care facilities. Of particular interest are the similarities of perspectives of dignity between these groups. The preservation of dignity implies that dignity is a quality inherent in us all. This links directly to the exploration and conclusions drawn from the literature review. Conversely, promoting dignity implies that dignity is something that can be influenced by others and external factors. Hence, there are a number of implications for practice.

CONCLUSION

We suggest that two of Nordenfelt's notions, 'dignity of identity' and 'dignity of Menschenwüde', are a common thread for residents, family members and staff when conceptualising dignity within long-term care environments.

Residents’ and caregivers’ views on spiritual care and their understanding of spiritual needs in persons with dementia: A meta-synthesis

Aims

To synthesize research that investigated how residents and caregivers view spiritual care, come to understand the spiritual needs of people with dementia, and how caregivers provide care congruent with peoples’ needs.

Methods and study design

Meta-synthesis using Noblit and Hare’s meta-ethnography. A synthesis of eight qualitative, empirical, primary studies that explored spiritual care in the context of dementia care was performed.

Findings

Spiritual care for persons with dementia was described in the forms of (i) performing religious rituals that provides a sense of comfort and(ii) coming to know the person, which provides opportunities to understand a person's meaning and purpose, and (iii) attending to basic needs provides an opportunity to appreciate others’ vulnerability and humanness.

Conclusions

Spiritual care intended to help persons with dementia to express their faith and religious beliefs, and help persons with dementia experience meaning in life, connectedness to self, God/deity and other persons.

Living well with dementia: enhancing dignity and quality of life, using a novel intervention, Dignity Therapy

AIMS AND OBJECTIVES

To assess the feasibility, acceptability and potential effectiveness of Dignity Therapy to improve the quality of life and reduce psychological and spiritual distress in older people with early stage dementia.

BACKGROUND

Dementia is a syndrome with several causes that leads to a progressive decline in multiple areas of functioning. The maintenance of dignity and enhancement of quality of life are key elements of care. Meaningful communication may become more difficult with condition progression. Improvements in communication may have positive effects on the person's quality of life. Dignity Therapy is a short psychotherapeutic intervention that uses a trained therapist to take the person with dementia through a guided interview process, producing a 'generativity' document that creates a lasting, written legacy during a time when they are still able to communicate well.

DESIGN AND METHOD

This was a feasibility mixed method study. Dignity Therapy was undertaken with patients diagnosed as having early stage dementia. Data were gathe-red from pre- and post-Dignity Therapy interviews, a focus group, interviews with key stakeholders, and three outcome measures: The Herth Hope Index; The Patient Dignity Inventory; Perceived Quality of Life/Satisfaction with Quality Life Ratings.

FINDINGS

This study demonstrated that Dignity Therapy is feasible, acceptable and potentially effective for older people with dementia. Three overarching themes emerged: A life in context, A key to connect and Personal legacy.

CONCLUSIONS

We recommend that this feasibility study forms the basis for further study, advocating the prospective benefits to patients with dementia, families and nursing practice.

IMPLICATIONS FOR PRACTICE

Dignity Therapy, as a psychosocial intervention, has the potential to improve the quality of life and enhance person centred care for people with dementia.

'This is my story, how I remember it': In-depth analysis of Dignity Therapy documents from a study of Dignity Therapy for people with early stage dementia

Dementia is a progressive condition that impacts on individuals, families and care professionals. Maintaining quality of life through engagement with the person with dementia is an important part of their care. Dignity Therapy is an interactive, psychotherapeutic intervention that uses a trained dignity therapist to guide the person with dementia through an interview that then creates a written legacy called a generativity document. This can provide knowledge to inform care, as the condition progresses. Generativity documents were analysed using framework analysis. Main themes from the analysis were origin of values, essence and affirmation of self, forgiveness and resolution and existentialism/ meaning of life. These themes provide evidence of the type, scope and contribution that information generated from Dignity Therapy can make to the care and support of people with dementia. They provide information about the values, self-identity and the people and events that have been important to them and influenced their lives.

Dignity as honour-wound: an experiential and relational view

In this paper, we draw on a phenomenological-philosophical foundation to clarify the meaning of dignity as a coherent phenomenon. Consistent with an evocation of its central meanings, we then introduce and delineate seven kinds of dignity that are intertwined and interrelated. We illustrate how these kinds of dignity can provide a useful template to think about its qualities, its 'rupture' and its 'restoration' in human life, particularly in relation to health and social care contexts. We then consider the implications of these relational and experiential views for current debates about the notion of dignity: Is dignity a useless concept? Is dignity objective or subjective? What are the useful ways of characterizing different varieties of dignity? We conclude by pointing to a metaphor that may hold the sense and meaning of our deepest human dignity: The gathering of both value and vulnerability, in which human value does not depend on the eradication of human vulnerability, but occurs within its very context.

‘I don't know if you want to know this’: carers’ understandings of intimacy in long-term relationships when one partner has dementia

This article explores experiences of relational intimacy (including sexual intimacy) in long-term relationships when one partner has dementia. An emerging body of research focuses on living with dementia, but work on relationships between people with dementia and their family and loved ones tends to focus on understanding the experience of caring, and on constructs like ‘care burden’. Research concerned with the lived experience of relationships themselves is less frequent, and very little published work focuses on experiences of sex and intimacy. This qualitative study explores how six participants experience their intimate relationships with their partners with dementia. Semi-structured interviews provided a rich source of data which were analysed using Interpretive Phenomenological Analysis. Three master themes emerged from our analysis: ‘everydayness’, ‘absent presence’ and ‘I don't know if you want to know this…’. Participants explored how living with dementia constructed specific, everyday relational challenges, and disrupted everyday intimacies. Intimacy, including sexual intimacy, remains an important element of older couple relationships. Relational experiences present specific and difficult to articulate experiences for the partners of people living with dementia – particularly experiences related to sex and sexuality. Representations of older adults (particularly older adults with a long-term illness) as relatively asexual beings can make elements of these relational challenges particularly difficult to express.

Relational interactions preserving dignity experience: Perceptions of persons living with dementia

BACKGROUND

Dignity experience in the daily lives of people living with dementia is influenced by their relational interactions with others. However, literature reviews show that knowledge concerning crucial interactional qualities, preserving their sense of dignity, is limited.

AIM

The aim of this study was to explore and describe crucial qualities of relational interactions preserving dignity experience among people with dementia, while interacting with family, social network, and healthcare professionals.

METHODOLOGY

The study was founded upon Gadamer's philosophical hermeneutics, and an exploratory design employing qualitative research interviews was conducted.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 11 individuals diagnosed with mild to moderate dementia, living in their own homes, were recruited from two Hospital Memory Clinics in Norway.

ETHICAL CONSIDERATIONS

In recruiting persons with dementia as study participants, sensitivity toward their life history, autonomy, integrity, relationships, and dignity is essential. These standards, and the ethical principles of moral sensitivity to their vulnerability, doing no harm, showing justice, and respecting their personal utility, guided our research.

RESULTS

Three main interactional qualities preserving the participants' dignity experience were found: Experiencing love and confirmation; experiencing social inclusion and fellowship; experiencing humane warmth and understanding within a caring culture, while being met as an equal human being. A total of 10 sub-qualities were identified within these 3 main qualities.

DISCUSSION AND FINAL CONSIDERATIONS

Dignity experience among the participants was preserved when certain interactional qualities were present in their interactions with family, social network, and healthcare professionals. While supporting some of the findings of previous studies, this study adds new knowledge on the subject. Knowledge of relational interactions toward preserving dignity experience should be a fundamental part of future dementia care practice. Based on the results of this study, an empirical-theoretical model was developed for this purpose.

Relatives’ participation in everyday care in special care units for persons with dementia

Background:

Research concerning relatives’ participation in the everyday care related to persons living in special care units for persons with dementia is limited.

Research questions:

To examine relatives’ participation in their near one’s everyday care, the level of burden experienced and important factors for participation, in this special context.

Design:

The study had a cross-sectional design, and data collection was carried out by means of a study-specific questionnaire.

Participants and context:

A total of 233 relatives from 23 different special care units participated.

Ethical consideration:

The study was approved by the Norwegian Social Science Data Services.

Results:

A great majority of relatives reported that they visited weekly and were the resident’s spokesperson, but seldom really participated in decisions concerning their everyday care. Participation was seldom reported as a burden.

Discussion:

This study indicated that relatives were able to make a difference to their near one’s everyday life and ensure quality of care based on their biographical expertise, intimate knowledge about and emotional bond with the resident. Since knowing the resident is a prerequisite for providing individualised care that is in line with the resident’s preferences, information concerning these issues is of utmost importance.

Conclusion:

This study prompts reflection about what it is to be a spokesperson and whether everyday care is neglected in this role. Even though relatives were satisfied with the care provided, half of them perceived their participation as crucial for the resident’s well-being. This indicated that relatives were able to offer important extras due to their biographical expertise, intimate knowledge about and emotional bond with the resident. Good routines securing that written information about the residents’ life history and preferences is available and used should be implemented in practice.

Crucial dimensions constituting dignity experience in persons living with dementia

Dignity is seen as an essential need, fundamental right, and inherent quality of each human being. There is however, a need for increased knowledge on crucial dimensions constituting dignity experience in persons living with dementia. This study explored personal dimensions of life which persons with dementia perceived crucial for experiencing dignity in their daily lives. Based on the findings of eight empirical sub-dimensions, three main dimensions crucial for constituting dignity experience, were identified through hermeneutical interpretation: A historical dignity-dimension, acknowledging one’s own life-projects and life-history; an intrapersonal dignity-dimension, recognizing one’s own human worth, and living according to internal values; and an interpersonal dignity-dimension, experiencing being part of a caring and confirming communion. Knowledge of dignity preservation should be a crucial foundation for future dementia care.