Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making

Moral conflicts from the justice and care perspectives of japanese nurses: a qualitative content analysis

BACKGROUND

Healthcare professionals use the ethics of justice and care to construct moral reasoning. These ethics are conflicting in nature; different value systems and orders of justice and care are applied to the cause of actual moral conflict. We aim to clarify the structure and factors of healthcare professionals' moral conflicts through the lens of justice and care to obtain suggestions for conflict resolutions.

METHOD

Semi-structured interviews about experiences of moral conflict were conducted with Japanese nurses recruited using the snowball sampling method. Interviews were conducted based on the real-life moral conflict and choice interview. Interviews were recorded and transcribed verbatim, then analyzed based on the interpretive method of data analysis. Verbatim transcripts were read four times, first to get an overall sense of the conflict, then to understand the person's thoughts and actions that explain the conflict, and third and fourth to identify perspectives of justice and care, respectively. Each moral perspective was classified into categories according to Chally's taxonomy.

RESULTS

Among 31 responses, 2 that did not mention moral conflict were excluded, leaving 29 responses that were analyzed. These responses were classified into six cases with conflict between both justice and care perspectives or within one perspective, and into two cases without conflict between perspectives. The "rules" category of justice and the "welfare of others" category of care were included in many cases of conflict between two perspectives, and they frequently occurred in each perspective.

CONCLUSIONS

The nurses in this study suggest that they make moral judgments based on moral values that are intertwined with justice and care perspectives complex manner.Organizational, professional, and patient-related factors influenced conflicts between justice and care. Additionally, multiple overlapping loyalties created conflicts within justice perspectives, and multifaceted aspects of care-provider's responsibility and patient need created conflicts within care. Decision-making biased towards one perspective can be distorted. It is important to consider ethical issues from both perspectives to resolve conflicts, especially the effective use of the ethics of care is recommended.

Junior medical doctors' decision making when using advance care directives to guide treatment for people with dementia: a cross-sectional vignette study

Background

Junior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors’ decision-making processes when treating people with dementia who have advance care directives (ACDs), or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: (1) their legal compliance and decision-making process related to treatment decisions; (2) the factors influencing their clinical decision-making; and (3) the factors associated with accurate responses to one hypothetical vignette.

Method

A cross-sectional survey of junior doctors, including trainees, interns, registrars and residents, on clinical rotation in five public hospitals located in one Australian state. The anonymous, investigator-developed survey was conducted between August 2018 and June 2019. Two hypothetical vignettes describing patients with dementia presenting to hospital with an ACD and either: (1) bacterial pneumonia; or (2) suspected stroke were presented in the survey. Participants were asked to indicate whether they would commence treatment, given the ACD instructions described in each vignette.

Results

Overall, 116 junior doctors responded (35% consent rate). In Vignette 1, 58% of respondents (n = 67/116) selected the legally compliant option (i.e. not commence treatment). Participants who chose the legally compliant option perceived ‘following patient wishes’ (n = 32/67; 48%) and ‘legal requirements to follow ACDs’ (n = 32/67; 48%) as equally important reasons for complying with the ACD. The most common reason for not selecting the legally compliant option in Vignette 1 was the ‘ACD is relevant in my decision-making process, but other factors are more relevant’ (n = 14/37; 38%). In Vignette 2, 72% of respondents (n = 83/116) indicated they would commence treatment (i.e. not follow the ACD) and 18% (n = 21/116) selected they would not commence treatment. (i.e. follow the ACD). Similar reasons influenced participant decision-making in Vignette 2, a less legally certain scenario.

Conclusions

There are critical gaps in junior doctors’ compliance with the law as it relates to the implementation of ACDs. Despite there being differences in relation to the legal answer and its certainty, clinical and ethical factors guided decision-making over and above the law in both vignettes. More education and training to guide junior doctors’ clinical decision-making and ensure compliance with the law is required.

Ethical principles and dilemmas in the discourse of healthcare practitioners involved with end-of-life care based on the Advanced Directives Document

Introduction. The Advanced Directives Document (ADD) is an efficient tool to plan for future medical care in case of a potential loss of autonomy. Ethical dilemmas arise in end-of-life care, including the principle of respect for autonomy and potential beneficence involved in health care, leading to moral distress of practitioners. Objective. To identify the ethical principles and dilemmas arising from the discourse of healthcare practitioners involved with end-of-life care based on the ADD.   Methodology. Qualitative study with a hermeneutics approach based on 253 answers to the following exploratory question: Are you willing to respect the ADD of an unconscious patient when you think that the patient may benefit otherwise?   Results. Most practitioners acknowledge their respect for the ADD as an ethical obligation, whilst a minority consider it a legal right. For the large majority of practitioners, the ethical principles of respect for the ADD are recognized under the ethical theory of liberal individualism. Respect for autonomy is associated with the principle of non-maleficence and the value of human dignity. The principle of beneficence and the quality of life concept were presented as genuine moral dilemmas. A reversible clinical condition, the request for euthanasia, the family and the legibility of anticipated directives were submitted as apparent moral dilemmas. Conclusions. During the end-of-life decision making process, there are other valid ethical considerations beyond principlism. The dilemmas identified show the ethical complexity healthcare practitioners face based on the ADD.

Advance care planning and advance directives: an overview of the main critical issues

Advance care planning (ACP) is a process that guarantees the respect of the patient's values and priorities about his/her future care at the end of life. It consists of multiple conversations with the health professional that may lead to the completion of Advance Directives (AD), a set of legal documents helpful to clinicians and family members for making critical decisions on behalf of the patient, whereas he/she might become incapable. Over the past years, ACP has become particularly relevant for the growth of chronic diseases, the increase in life expectancy, and the growing attention paid to the patient's decisional autonomy. Several nations have introduced specific regulations of ACP and AD. However, their diffusion is accompanied by unforeseen limitations and issues, burdening their complete and systematic adoption. The present article describes several controversial aspects of ACP and some of the most significant challenges in end-of-life care.

The Advance Care Compass- A New Mechanics for Digitally Transforming Advance Directives

Advance directives allow people to declare their treatment preferences for a potential future state of incompetency. Covid-19, with its high numbers of quickly deteriorating patients requiring intensive care, has acutely demonstrated how helpful it would be for clinicians to have reliable, readily available, up-to-date information at hand to be able to act in accordance with what the individual patient would have wanted. Yet for the past few decades advance directives have fallen short of their potential, for various reasons. At worst, advance directives are perceived as unwieldy legal documents that put excessive demands on patients without providing useful guidance for better care. Recent efforts such as advance care planning have tried to remedy some of these shortcomings but have so far met with limited success. We suggest a new concept-the Advance Care Compass-that harnesses the potential of digitalization in healthcare to overcome many of difficulties encountered so far.

Improving the Care of Patients With Serious Illness: What Are the Palliative Care Education Needs of Internal Medicine Residents?

BACKGROUND

Hospitalized patients with serious illness have significant symptom burden and face complex medical decisions that often require goals of care discussions. Given the shortage of specialty palliative care providers, there is a pressing need to improve the palliative care skills of internal medicine (IM) residents, who have a central role in the care of seriously ill patients hospitalized at academic medical centers.

METHODS

We conducted an anonymous survey of IM residents at a large, urban, academic medical center to identify which aspects of palliative care trainees find most important and their knowledge gaps in palliative care. The survey measured trainees' self-assessed degree of importance and knowledge of core palliative care skills and evaluated frequency of completing advance care planning documentation.

RESULTS

Overall, 51 (23%) IM residents completed the survey. The majority of trainees considered multiple palliative care skills to be "very important/important": symptom management, prognostication, introducing the palliative care approach, discussing code status, and breaking serious news. Across these same skills, trainees reported variable levels of knowledge. In our sample, trainees reported completing healthcare proxy forms and Medical Orders for Life-Sustaining Treatment infrequently.

CONCLUSIONS

IM trainees rated core palliative care skills as important to their practice. Yet, they reported knowledge gaps across multiple core palliative care skills that should be addressed given their role as frontline providers for patients with serious illness.

Improving Medical-Legal Advance Care Planning

The importance of advance care planning (ACP) has been increasingly recognized by health systems. However, 46%-76% of patients report engaging in ACP with lawyers, whereas only a minority report doing so with physicians. In the U.S., ACP with lawyers focuses on advance directive documents, naturally occurs outside of health care contexts, and is often uninformed by the clinical context, such as one's prognosis and clinical trajectory. These forms are regularly stored at home or at a lawyer's office and not available at the bedside when needed in a medical crisis. Yet, in contrast to clinicians, lawyers hold sophisticated knowledge about their states' advance directive law. Lawyers may also understand clients' socioeconomic context and plans more broadly, which are known to be critical for contextualizing and personalizing patient care but are often not well captured in health care. Aligning medical and legal approaches to ACP is important to ensuring the quality and value of those efforts. As an important first step toward this goal, we convened an interprofessional panel of medical and legal experts to elucidate the state of medical-legal ACP and begin to identify strategies to improve and align practices within and across professions. This article describes the historical disconnects between the medical and legal practice of ACP, recommendations and products of the interprofessional panel, and recommendations for future medical-legal collaboration.

Variables that influence the medical decision regarding Advance Directives and their impact on end-of-life care

The objective of this study was to identify the variables that influence physicians to implement Advance Directives and assess their impact on end-of-life care. It is a narrative literature review of 25 articles published between 1997 and 2018, in the following databases: CAPES, EBSCOhost, BDTD, VHL, Google Scholar, MEDLINE^®/PubMed. The keywords utilized were: “advance directives”, “living wills”, “physicians”, “attitude”, “decision making”, “advance care planning”. The main factors that influenced physicians to implemente the directives were patients prognosis, medical paternalism, and patients understanding of their medical condition. Respect for autonomy, lack of knowledge and experience with directives, legal concerns, family influence, cultural and religious factors also contributed to medical decision. Most studies (86%) showed that having a directive led to lower rates of invasive interventions in the last days of patient´s life. Physicians were interested in respecting their patients’ autonomy and agreed that having an advance directive helped in the decision-making process; however, they stated other factors were also taken into account, mainly prognosis and reversibility conditions. Having directives contributed to reducing the use of life support therapies and adoption of comfort measures.

Reducing Avoidable Facility Transfers (RAFT): Outcomes of a Team Model to Minimize Unwarranted Emergency Care at Skilled Nursing Facilities

BACKGROUND

Acute health care interventions for residents of skilled nursing facilities (SNFs) are often unwarranted, unwanted, and/or harmful. We describe a provider-focused care model to reduce unwarranted or unwanted acute health care utilization.

OBJECTIVE

Assess the capability of the Reducing Avoidable Facility Transfers (RAFT) model to reduce unwanted and unwarranted acute health care utilization among residents in 3 rural SNFs between January 1, 2016 and June 30, 2017.

DESIGN

Prospective cohort, pre/post study.

SETTING

Three rural SNFs in collaboration with a geriatric practice in a tertiary academic medical center.

PARTICIPANTS

Post-acute care (PAC) and long-term care (LTC) residents of 3 rural SNFs.

INTERVENTION

RAFT includes the following components: (1) a small team of providers who manage longitudinal care and after hours call; (2) elicitation of advance care plans and preferences regarding acute care; (3) standardized communication process engaging the provider at the identification of an acute care event; (4) a biweekly case review of all emergency department (ED) transfers.

MEASURES

ED and hospital utilization.

RESULTS

RAFT demonstrated a 35% reduction in monthly ED transfers and a 30.5% reduction in monthly hospitalizations. These reductions were greatest for LTC residents.

CONCLUSIONS/IMPLICATIONS

The RAFT approach substantially reduced unwarranted ED and hospital utilization in this study. Results support replication and evaluation in a larger, more diverse setting and population.

Advance directives in France: do junior general practitioners want to improve their implementation and usage? A nationwide survey

Background

The doctor-patient relationship has evolved to respect “the autonomy and patients’ rights”. One of the cornerstones in such autonomy is the opportunity for patients to draw living wills, also known as advance directives (AD). However, information about AD available to patients remains scarce largely due to the lack of involvement of General practitioners for several reasons. The aim of our study was to evaluate current general practitioner residents’ (GPR) behavior concerning their role in informing their patients about AD.

Method

We built a French nationwide survey from GPR class of 2012 to 2014.

Results

Two thousand three hundred ten residents completed our survey (21.1% of the total population of GPR during the period). 89.8% declared their willingness to offer patients the opportunity of writing AD. When asked about the usefulness of AD, 73.6% of residents responded that these are a suitable help for patients, but 19.7% considered that AD are essentially geared towards frail patients. Among residents who want to inform patients about AD (n = 2075), 14.7% wanted to involve all patients. Only 20.5% thought that elderly people should be systematically informed about AD. When the question involves other frail people in various disease areas, information seems relevant for 60.1% of GPR considering patient with cancer or malignant hematologic disease and for 56.2% about patients affected by neurodegenerative disease. When considering the routine use of AD, 20.5% of GPR would take them into account only if they are in agreement with the patient’s decision.

Conclusions

The results of the survey indicate that GPR would rather choose to decide who should be informed about AD, and when to take AD into account for ethical concerns.

Electronic supplementary material

The online version of this article (10.1186/s12910-019-0358-x) contains supplementary material, which is available to authorized users.

Treatment of Advanced Parkinson Disease and Related Disorders

PURPOSE OF REVIEW

Parkinson disease often spans decades of a patient's lifetime. Over time, nonmotor symptoms predominate and may limit dopaminergic therapy. Neurologists continue to play a vital role in treatment. In addition to balancing neurobehavioral complications of Parkinson disease with motor benefit, addressing nonmotor symptoms common in the advanced stage may improve quality of life and reduce symptom burden. Symptoms such as dysphagia, constipation, urinary dysfunction, orthostatic hypotension, and pain respond to nonpharmacologic and pharmacologic therapies.

RECENT FINDINGS

Evidence for treatment of many nonmotor symptoms is weak or lacking. The evidence for treatment of the atypical parkinsonian syndromes (progressive supranuclear palsy, multiple system atrophy, and corticobasal degeneration) in advanced stages is even more scant.

SUMMARY

Engaging palliative care physicians in the joint care of patients can provide patients with access to expertise in end-of-life issues. Neurologic illnesses have specific hospice criteria to guide clinicians for referrals. Evidence supports that assisting patients with advance directives can result in improved satisfaction with care and improved quality of life in the last weeks of life. Neurologists can remain engaged in their patients' care throughout the course of illness.

Comparing doctors' legal compliance across three Australian states for decisions whether to withhold or withdraw life-sustaining medical treatment: does different law lead to different decisions?

Background

Law purports to regulate end-of-life care but its role in decision-making by doctors is not clear. This paper, which is part of a three-year study into the role of law in medical practice at the end of life, investigates whether law affects doctors’ decision-making. In particular, it considers whether the fact that the law differs across Australia’s three largest states – New South Wales (NSW), Victoria and Queensland – leads to doctors making different decisions about withholding and withdrawing life-sustaining treatment from adults who lack capacity.

Methods

A cross-sectional postal survey of the seven specialties most likely to be involved in end-of-life care in the acute setting was conducted between 18 July 2012 and 31 January 2013. The sample comprised all medical specialists in emergency medicine, geriatric medicine, intensive care, medical oncology, palliative medicine, renal medicine and respiratory medicine on the AMPCo Direct database in those three Australian states. The survey measured medical specialists’ level of legal compliance, and reasons for their decisions, concerning the withholding or withdrawal of life-sustaining treatment. Multivariable logistic regression was used to examine predictors of legal compliance. Linear regression was used to examine associations between the decision about life-sustaining treatment and the relevance of factors involved in making these decisions, as well as state differences in these associations.

Results

Response rate was 32% (867/2702). A majority of respondents in each state said that they would provide treatment in a hypothetical scenario, despite an advance directive refusing it: 72% in NSW and Queensland; 63% in Victoria. After applying differences in state law, 72% of Queensland doctors answered in accordance with local law, compared with 37% in Victoria and 28% in NSW (p < 0.001). Doctors reported broadly the same decision-making approach despite differences in local law.

Conclusions

Law appears to play a limited role in medical decision-making at the end of life with doctors prioritising patient-related clinical and ethical considerations. Different legal frameworks in the three states examined did not lead to different decisions about providing treatment. More education is needed about law and its role in this area, particularly where law is inconsistent with traditional practice.

Electronic supplementary material

The online version of this article (10.1186/s12904-017-0249-1) contains supplementary material, which is available to authorized users.

The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study

OBJECTIVES

To determine the role played by law in medical specialists' decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed.

DESIGN

Cross-sectional postal survey of medical specialists.

SETTING

The two largest Australian states by population.

PARTICIPANTS

649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting.

MAIN OUTCOME MEASURES

Compliance with law and the impact of legal knowledge on compliance.

RESULTS

649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge.

CONCLUSIONS

Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care.

Advance Care Planning: Contemporary Issues and Future Directions

Advance care planning (ACP) is widely considered an essential step toward achieving end-of-life care that is consistent with the preferences of dying patients and their families. ACP comprises a living will and a durable power of attorney for health care (DPAHC); these tools enable patients to articulate and convey their treatment preferences when they are still cognitively intact. In this article, we describe the strengths, weaknesses, and correlates of ACP in the United States, with attention to race and socioeconomic disparities therein. We then discuss other public policies and community programs designed to increase both the number of older adults who articulate their preferences for end-of-life care, and efficacy of ACP for ensuring that patients' end-of-life treatment preferences are met. We describe the characteristics, strengths, and limitations of Physician Orders for Life Sustaining Treatment (POLSTs), and describe community programs, educational interventions, and public policies aimed toward increasing the prevalence and efficacy of end-of-life preparations. A key policy advance in the early 2010s has been Medicare coverage of one doctor-patient consultation session regarding end-of-life issues; we highlight the potentials and possible pitfalls of this policy. We conclude by identifying areas for future research, and highlighting practices from other nations that may help improve quality of end-of-life care in the United States.

Advance Directives and Operating: Room for Improvement?

Anesthesiologists and surgeons are frequently called on to perform procedures on critically ill patients with advanced directives. We assessed the attitudes of attending and resident surgeons and anesthesiologists at our institution regarding their understanding of and practice around the application of consenting critically ill patients with advance directives in the operating room. To do so, we deployed a survey after interdepartmental grand rounds, featuring a panel discussion of ethically complex cases featuring end-of-life issues.

Knowledge, attitudes, and influencing factors of cancer patients toward approving advance directives in China

Purpose

Many cancer patients do not have advance directives (ADs), which may lead to unwanted excessive or aggressive care when patients have lost decision-making capacity. The aim of this study was to investigate knowledge and attitudes of approving ADs and explore factors associated with willing to designate ADs among cancer patients in China.

Methods

We conducted semi-structured interview method investigating 753 in-patients with cancer in two cancer centers.

Results

Of those subjects, none of the cancer patients had an AD. Only 22.4 % (118 of 526) approved ADs. Comparing with the disapproved ADs group, the approved ADs group were more likely to discuss the AD with oncologist or nurse (χ² = 180.4, p < 0.001) in the cancer center (χ² = 244.1, p < 0.001), and they chose more comfort care (χ² = 18.8, p < 0.001). Most of cancer patients in the two groups wanted to die at home (72.8 %, 73.7 %, respectively). The older patients (OR, 1.04, 95 % CI, 1.02–1.07, p = 0.001), female (OR, 0.55, 95 % CI, 0.35–0.88, p = 0.013), with higher education levels (OR, 3.38, 95 % CI, 1.92–5.96, p < 0.001), with religious beliefs (OR, 2.91, 95 % CI, 1.71–4.94, p < 0.001), and with higher scores of ECOG (OR, 1.46, 95 % CI, 1.17–1.82, p = 0.001) were associated with desiring for ADs.

Conclusions

Our findings indicate that there was a dearth of knowledge and different attitudes toward approving ADs among cancer patients, and some factors of demographic and clinical characteristics influenced their willing to designate ADs. This research highlights the importance of propagandizing the ADs to the public, especially to the patients, and further discussing with them when the time is ripe.

The Utility of a Personal Values Report for Medical Decision-Making

Our aim was to determine if a patient's Personal Values Report (PVR) has a positive impact on a doctor's decisions regarding treatment. We conducted a prospective cohort study delivering a short, web-based hypothetical case-centred questionnaire to intensive care doctors practising in Australia and New Zealand. One hundred and twenty-four intensive care consultants and registrars agreed to participate in an online questionnaire in two routine mailings between November 2013 and February 2014. We evaluated the effect of a PVR on clinical decision-making in a case-based scenario. In addition, participants rated the utility of the PVR on their decision-making process. Participants were presented with a difficult scenario in a frail elderly man where death was almost inevitable without aggressive support but survival with severe disability was possible with significant intervention. Most doctors (52.4%) elected to continue ventilation and admit to ICU. After the PVR was made available, only 8.1% of doctors continued to choose to admit the patient to the ICU. In all cases where admission to the ICU was chosen after seeing the PVR, the admission to the ICU was stated to be to permit family to arrive before withdrawing support (an approach which was consistent with the values stated in the PVR). One hundred and twenty-one of the 124 participants (97.6%) agreed or strongly agreed that the PVR helped them get an understanding of the patient's wishes, whereas none of the participants (0%) were unsure, disagreed or strongly disagreed with this statement. The remaining 2.4% did not answer the question. It is surmised that PVRs pre-written by patients are potentially an effective and valuable tool for use in helping doctors make decisions regarding patient care.

Dilemmas in end-stage heart failure

Heart failure (HF), a complex clinical syndrome due to structural or functional disorder of the heart, is a major global health issue, with a prevalence of over 5.8 million in the USA alone, and over 23 million worldwide. As a leading cause of hospitalizations among patients aged 65 years or older, HF is a major consumer of healthcare resources, creating a substantial strain on the healthcare system. This paper discusses the epidemiology of HF, financial impact, and multifaceted predicaments in end-stage HF care. A search was conducted on the U.S. National Library of Medicine website (www.pubmed.gov) using keywords such as end-stage heart failure, palliative care, ethical dilemmas. Despite the poor prognosis of HF (worse than that for many cancers), many HF patients, caregivers, and clinicians are unaware of the poor prognosis. In addition, the unpredictable clinical trajectory of HF complicates the planning of end-of-life care, such as palliative care and hospice, leading to underutilization of such resources. In conclusion, ethical dilemmas in end-stage HF are numerous, embroiling not only the patient, but also the caregiver, healthcare team, and society.

[Knowledge and attitudes of health professionals to the living will declaration process]

OBJECTIVE

To identify the underlying interests of the Living Will Declaration (LWD) process and to determine the consensus, using a questionnaire, of the knowledge and attitudes of health professionals.

DESIGN

A study was performed in two phases using a Delphi technique with a Rand method. 1. Dimensions proposed: generation of ideas and their subsequent prioritizing; 2. Proposal and prioritizing of items grouped into blocks of Knowledge and Attitudes, developed between August 2012 and January 2013.

SETTING

The work was carried out by initial telephone contact with panellists, and then later by the panellists belonged to the Andalusia Public Health System.

PARTICIPANTS

The criteria for selecting the eight components of the panel were knowledge and experience in the field of the freedom of the patient in Andalusia.

RESULTS

The Knowledge identified included: 1 A) Legal and general aspects; 2 A) A conceptual definition; 3 A) Standardised LWD documents: 4 A) Practical experience; 5 A) Procedure and registering of the LWDs. The second block included Attitudes: 1 B) Attitudes of the professional in the application of LWDs in clinical practice, and 2 B) Attitudes of the professional in «complex» ethical scenarios The 7 panellists who finally took part proposed 165 items. After applying the prioritizing criteria, scores, and scenario selection, 58 (35.2%) items were identified as suitable scenarios.

CONCLUSIONS

The proposed questionnaire included wide parcels of concepts and contents that, once validated, will help to measure the training interventions carried out on health professionals in order to improve knowledge and attitudes on the subject of LWDs.

Advance directives: empowering patients at the end of life

Advance directives were conceived as a prospective means of empowering patients to direct their own end-of-life care. Unfortunately, these directives have been inadequately incorporated into healthcare decisions due to less-than-optimal execution and implementation. The authors explore challenges to implementing advance directives and propose potential solutions.