Dignity at stake: Caring for persons with impaired autonomy

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.

Dignity enhanced through faith & family support in palliative care: a qualitative study

BACKGROUND

Dignity is integral to palliative care. Illness can diminish it, causing hopelessness and the wish to hasten death. Yet, dignity is a complex multidimensional phenomenon, influenced by values and context. Understanding its varying interpretations can inform practice and policy. The aim of the study is to explore the understanding of dignity in adult patients with palliative care needs from a Lebanese perspective and how it is preserved during illness and while receiving health services.

DESIGN

Qualitative interview study underpinned with a social constructionist lens. Fourteen patients recruited from home-based hospice and outpatient clinics in Lebanon. Data analysed using reflexive thematic analysis.

RESULTS

Four themes were developed across all the interviews: (a) Dignity anchored through faith in God and religious practices; (b) Family support in maintaining physical, psychological wellbeing, and social connectedness; (c) Physical fitness, mental acuity, and healthy appearance through which patients may escape the stigma of disease, (d) accessible, equitable, and compassionate healthcare.

DISCUSSION

Dignity is elusive and difficult to define but faith and religious beliefs play a significant contribution in this study. For the participants, illness is seen as a natural part of life that does not necessarily diminish dignity, but it is the illness related changes that potentially affect dignity. Findings show the importance of family and children in preserving dignity during illness and how their active presence provide a sense of pride and identity. Participants aspired to restore physical, social, and mental well-being to reclaim their dignity and normalize their lives. Challenges related to physical appearance, memory loss, vitality, and social stigma associated with illness diminished dignity. Accessible, equitable and compassionate healthcare services are also crucial in preserving dignity. Participants valued clear communication, respect, and empathy from healthcare providers and identified affordability of care essential for maintaining dignity.

CONCLUSION

Faith in God, and strong family ties are dominant elements to maintaining dignity in the Lebanese context. Relational connectedness with family, children or God is also a need in maintaining dignity in other communal countries with variations in emphasis. The study indicates that religious and cultural context shapes the needs and perceptions of dignity during illness. These findings are likely to be transferable to many Middle Eastern countries but also countries with strong religious and family ties globally.

"It is very hard to just accept this" - a qualitative study of palliative care teams' ethical reasoning when patients do not want information

BACKGROUND

The aim of this study was to explore how palliative care staff reason about the autonomy challenge that arises when a patient who has first said he wants full information appears to change his mind and rejects being informed.

METHODS

The study had a qualitative and exploratory design. Participants (physicians, registred nurses, social workers, physiotherapists and occupational therapists) were recruited from palliative care teams in southern Sweden. Six separate focus group interviews with a total number of 33 participants were conducted. The teams were asked to discuss a fictional case of a man who first wants, then rejects, information about his situation. The interviews were audiotaped and transcribed verbatim. Reflexive thematic analysis following Braun and Clarke was undertaken to analyse data.

RESULTS

The analysis resulted in three themes: Patients have a right to reject information, Questioning whether this patient WANTS to reject information and There are other values at stake, too. Although participants endorsed a right to reject information, they were unsure whether this right was relevant in this situation, and furthermore felt that it should be balanced against counteracting factors. The effect of such balancing was that participants would aim to find a way to present relevant information to the patient, but in a probing and flexible way.

CONCLUSIONS

In their work with dying patients, palliative care staff meet many autonomy challenges. When faced with a choice to withhold information as per a patient's wishes, or to provide information with the patient's best interest in mind, staff find it hard to balance competing values. Staff also find it hard to balance their own interests against a purely professional stance. The overall strategy seems to be to look for caring ways to impart the information.

Dignity-preserving care of people with dementia in different nursing environments: a qualitative systematic review

AIMS

To systematically identify, evaluate and synthesize qualitative evidence about the dignity-related nursing experiences of people with dementia in families and nursing homes, summarize the similarities and differences and analyse the causes and influencing factors.

METHODS

A synthesis of qualitative studies retrieved from eight databases that were published before September 2022. Two reviewers independently screened and selected studies. Inclusion criteria were established according to the PICOS principle. Quality assessment was guided by Joanna Briggs Institute's Qualitative Assessment and Review Instrument and the structured topic synthesis method was used to summarise studies eligible for inclusion.

RESULTS

Three key themes were extracted from 14 included studies; the living environment, relationship needs and self-awareness, which focused on improving the dementia-centred nursing environment, meeting the needs of the relationship-centred nursing network, and finally, improving the self-awareness of people with dementia to promote dignity.

CONCLUSION

This systematic review shows people with dementia need to integrate into society and maintain their dignity in a dementia-friendly environment that is respectful, inclusive environment that promotes freedom.

Dignity and the Importance of Acknowledgement of Personhood for People With Disability

Exploring the intricate relationship between individual and collective experiences, this study explores dignity from the perspectives of people with disability. Using an extreme citizen science approach, we engaged people with disability as active partners in gathering data through qualitative surveys and focus groups. Framework Analysis was employed to ensure the validity of findings while privileging the voices of people with lived experience of disability. Dignity was contingent on the acknowledgement of personhood and the delivery of human rights. Our research identified five key aspects to maintain and protect dignity: (1) acknowledging personhood; (2) recognising people with disability as decision-makers of their lives; (3) realising the right to access information; (4) maintaining the right to privacy; and (5) eliminating or minimising barriers to accessibility and inclusion. Undignified experiences that resulted from a lack of acknowledgement negatively affected participants' wellbeing, and healthcare settings were identified as particularly challenging environments for dignity. These findings have significant implications for healthcare systems and services within an international and interdisciplinary context. They emphasise the need for adaptable, flexible services, co-designed with people with lived experience of disability. Addressing organisational constraints, resource limitations, and expectations is paramount to ensuring dignity is maintained through the acknowledgement of personhood and safeguarding of human rights.

Valuing the individual - evaluating the Dignity Care Intervention

BACKGROUND

Palliative care needs in older persons can endanger their dignity. To provide dignity-conserving care to older persons, the Swedish Dignity Care Intervention (DCI-SWE) can be used. The DCI-SWE is built on Chochinov's dignity model and the original version, developed and tested in UK and Scotland.

AIM

To describe older persons' and their relatives' experiences of dignity and dignity-conserving care when using the DCI-SWE in municipal health care.

RESEARCH DESIGN

A mixed method study with convergent parallel design.

PARTICIPANTS AND RESEARCH CONTEXT

The DCI-SWE was used and evaluated in a Swedish municipality health care context. Older persons' (n=17) dignity-related distress and quality of life were assessed after the intervention. Interviews with older persons (n=10) and their relatives (n=8) were analysed using thematic analysis.

ETHICAL CONSIDERATIONS

The study followed the World Medical Association Declaration of Helsinki. Ethical approval was obtained from the Regional Ethical Review Board in Uppsala, Sweden (Reg No. 2014/312) and the National Swedish Ethical Review Authority (Reg. No. Ö 10-2019). Informed consent was collected from older persons and their relatives.

FINDINGS

The older persons' dignity-related distress did not significantly change over time (p = 0.44) neither was their overall quality of life (p = .64). Only psychological quality of life was decreased significantly (p = 0.01). The older persons and their relatives emphasized the importance of valuing the individual.

CONCLUSIONS

The DCI-SWE provides a forum to talk about dignity issues, but relevant competence, continuity and resources are needed. Psychological care actions and health care professionals' communication skills training are important. To fully evaluate, the DCI-SWE a larger sample and validated instruments are necessary.

Development and Psychometric Evaluation of the Elderly Dignity Questionnaire

Introduction: Respect for dignity is the core of nursing. Dignity assessment improves nurses’ understanding of the level of people’s need for it. Yet, there is no valid and reliable culturally-appropriate instrument for dignity assessment among elderly people in Iran. This study aimed to develop and evaluate the psychometric properties of the Elderly Dignity Questionnaire (EDQ).

Methods: The methodological study, EDQ items were generated based on the results of a qualitative study with conventional content analysis approach into dignity and the existing literature. For qualitative and quantitative face and content validity assessments, ten experts rated item then, item impact score and content validity ratio and index were calculated. Construct validity of EDQ was assessed via the exploratory factor analysis and using the data collected from 200 elderly people. Criterion validity was tested using the Rosenberg’s Self-Esteem Scale. Reliability testing was performed via the internal consistency and the test-retest stability assessments and data was collected from twenty elderly. Data were analyzed using SPSS software version 13.

Results: Factor analysis loaded the forty items on six factors. factor six was combined with factor five due to its limited number of items. The five factors were labeled as roles and responsibilities (twelve items), familial and social relationships (seven items), self-dignity (ten items), authorization (four items), independence, and integrity (seven items). The Cronbach’s alpha and the intraclass correlation coefficient of EDQ were 0.91 and 0.86, respectively.

Conclusion: This study confirms EDQ’s validity and reliability. Thus, this questionnaire can be used for dignity in the elderly.

Meaning of Respect for Older People in Family Relationships

Background: Older people have various physical and mental health needs and often receive help from their family members to perform their daily life activities. This research aimed to explore the meaning of respect for older people in family relationships. Methods: A qualitative study using a content analysis approach was conducted. Semi-structured interviews were performed with sixteen older people and four family members. Results: Three main categories were developed: “respect for personal interests”, “kind and sincere respect” and “respect for autonomy”. Understanding of the meaning of respect for older people was influenced by special expectations from family members in terms of meeting personal needs, consideration of preferences and interests and empowerment and support to help preserve older people’s independence and autonomy. Conclusions: Family members should be informed and educated with regard to their expected roles in family relationships, and should consider respect as an important factor affecting older people’s well-being.

Reflections of the collaborative care planning as a person-centred practice

The ageing population is increasing worldwide with an increase in chronic disorders. At the same time, person‐centred care has become a policy within both health and social care. To facilitate coordination and collaboration and integrate the older adult's perspective in the decision‐making process the collaborative care planning process with the development of a written care plan can be used. In this study, the result of an interpreted analysis of four empirical studies of the collaborative care planning as a person‐centred practice will be discussed and reflected on. A framework based on the French philosopher Paul Ricoeur's little ethics was used in the synthesis of the studies. The findings revealed two common threads: personhood and power asymmetry. Both challenges in achieving a person‐centred collaborative care planning. Ricoeur's dialogical thinking and description of a person served as an underpinning in discussing and reflecting upon the findings of the interpreted synthesis. Collaborative care planning is a complex process. However, Ricoeur's philosophy contributed to a greater understanding of the collaborative care planning as a person‐centred practice and accentuated that ethics, human values, and the older adults and care partners perspectives need to be given the same importance and considerations as the medical and social sciences perspectives for the collaborative care planning process to truly become person‐centred.

Nursing support for older people's autonomy in residential care: An integrative review

BACKGROUND

Nurses play a crucial role in enabling older people's autonomy in residential care. However, there is a lack of synthesised knowledge about how nurses can support older people.

OBJECTIVE

The aim of this study was to identify and synthesise nursing support for older people's autonomy in residential care.

METHODS

An integrative review was carried out by searching the CINAHL, Philosopher's index, PubMed, SocINDEX, Scopus and Web of Science databases, supplemented by manual searches. The searches focused on peer-reviewed scientific empirical research papers published in English, without date limitations. The constant comparison method was used for the analysis.

RESULTS

The review identified 24 papers, and these showed that older people's autonomy was based on dignity. Nurses protected older people's autonomy in eight different ways. They protected their right to make their own decisions, acted as advocates, respected their wishes, provided opportunities for autonomy, fostered independence, gave information to residents and relatives, provided individualised care practices and protected older people's safety. However, there were also barriers that needed to be overcome.

CONCLUSIONS

Nurses used multiple, individually tailored activities to support older people's autonomy, but they also had different reasons for supporting or hindering it. Work and leadership structures are needed to ensure that older people's autonomy is driven by ethical practices.

IMPLICATIONS FOR PRACTICE

The results of this review can help nurses who provide residential care for older people to recognise the different nursing activities that can be used to support older people's autonomy and to develop strategies to apply them in different daily care situations. However, further research is needed to determine how these activities can be realised in daily care and how they cover different aspects of older people's lives in residential care.