To what extent are the wishes of a signatory reflected in their advance directive: a qualitative analysis

[Advance care planning in the acute hospital: A qualitative analysis of terms and conditions]

Advance care planning in the acute hospital: A qualitative analysis of terms and conditions Abstract: Background: Advance Care Planning (ACP) is an internationally established concept aimed to facilitate anticipatory care planning in the event of future inability to consent. In Germany, ACP is currently not regularly offered to patients in acute care hospitals. Aim: We aimed to identify preconditions for implementation of ACP in acute care hospitals in Germany through review of the international literature and expert interviews. Methods: A systematic literature search was carried out in the databases MEDLINE and CINAHL for internationally used strategies for implementing ACP in acute care hospitals. Consecutively, a guide for interviews with experts to evaluate the strategies was developed. Interviews were analyzed by qualitative content analysis according to Mayring. Results: Out of 13 included publications, 17 preconditions were identified and assigned to 16 categories after evaluation by experts. In international ACP programs, it was described how to proceed and organize the ACP conversation. German experts emphasized that appropriate preconditions, such as sufficient time resources and training, must be granted, whereas the literature search revealed the conversation process and organization as important determinants. Conclusions: The implementation of ACP programs is conceivable, but requires specific conditions as legal regulation and defining and structuring of the processes.

Advance Directives in Portugal: A Qualitative Survey

(1) Background: Advance directives (ADs) in Portugal have been legalized since 2012. What has been observed over time, from the few studies carried out, is that despite the positive attitudes in the population, there is a low level of adherence to ADs. To try to understand the reasons for these data, the current study aimed to explore and describe the experiences of the Portuguese population regarding AD. (2) Methods: For this exploratory and descriptive qualitative study, the researchers conducted open (unstructured) interviews with a convenience sample aged over 18 years until data saturation was achieved. (3) Results: A total of fifteen interviews were conducted-eight with women and seven with men. The following four categories emerged from the content analysis of the interviews: (1) AD literacy, (2) AD relevance, (3) AD attitudes, and (4) conditionalities for compiling the ADs. (4) Conclusions: The study pointed out the good receptivity of the participants to the ADs; however, literacy on this subject was low, and identifying the conditionalities in the development of ADs could contribute to improvements in implementation in the population. The data from this study suggest the need to implement measures to increase the literacy of the Portuguese population on ADs and review the legal framework for improving the accessibility of the citizen population. There is also a need to continue researching and obtain more evidence about the ways in which the Portuguese population perceives ADs; thus, in this way, a society can better respond to its citizens' right to freely exercise their prospective autonomy at the end of their lives.

Perceptions, Attitudes, and Knowledge toward Advance Directives: A Scoping Review

(1) Background: Advance directives are an expression of a person's autonomy regarding end-of-life care. Several studies have shown that the level of completion in countries where advance directives are legalised is low. To better understand this phenomenon, it is important to know the perceptions, attitudes, and knowledge that the population has about this instrument. The aim of this article was to explore a population's perceptions and/or attitudes and/or knowledge toward advance directives. (2) Methods: A search was conducted in March 2023 in the ISI Web of Knowledge, Scopus, and PubMed databases using the following keywords: "advance care directives", "advance care planning", "perceptions", "attitudes", and "knowledge". Two hundred and twenty-four (224) articles were identified, and thirteen (13) were included for analysis. (3) Results: The selected articles point to a low level of knowledge toward advance directives: they recognise a strong positive attitude of the population toward the implementation of advance directives but a low level of achievement. (4) Conclusions: Studies on perceptions/attitudes/knowledge toward advance directives are important to understand the real needs of the population regarding this issue and to implement more adequate and effective promotion and dissemination measures.

An Ethical Framework for Incorporating Digital Technology into Advance Directives: Promoting Informed Advance Decision Making in Healthcare

Despite the presumed value of advance directives, research to demonstrate impact has shown mixed results. For advance directives to serve their role promoting patient autonomy, it is important that patients be informed decision makers. The capacity to make decisions depends upon understanding, appreciation, reasoning, and communication. Advance directives are in part faulty because these elements are often limited. The present paper explores how the application of digital technology could be organized around a framework promoting these four elements. Given the state of digital advancements, there is great potential for advance directives to be meaningfully enhanced. The beneficial effects of incorporating digital technology would be maximized if they were organized around the aim of making advance directives not only documents for declaring preferences but also ethics-driven tools with decision aid functionality. Such advance directives would aid users in making decisions that involve complex factors with potentially far-reaching impact and would also elucidate the users' thought processes to aid those tasked with interpreting and implementing decisions based on an advance directive. Such advance directives might have embedded interactive features for learning; access to content that furthers one's ability to project oneself into possible, future scenarios; review of the logical consistency of stated preferences; and modes for effective electronic sharing. Important considerations include mitigating the introduction of bias depending on the presentation of information; optimizing interfacing with surrogate decision makers and treating clinicians; and prioritizing essential components to respect time constraints.

[Living wills of residents in nursing homes - which treatment situations and treatment measures are decreed?]

Einleitung  Die Möglichkeit, mittels Patientenverfügung Einfluss auf die spätere Behandlung im Falle der Einwilligungsunfähigkeit zu nehmen, gilt heutzutage als wichtiges Element zur Wahrung der Patientenautonomie am Lebensende. Behandlungsmaßnahmen bereits im Vorfeld einer Behandlung abzulehnen oder in diese einzuwilligen, ist für Bewohnende stationärer Pflegeeinrichtungen nicht nur vor dem Hintergrund der COVID-19-Pandemie von besonderer Bedeutung.

Methoden  Es wurde eine Vollerhebung aller Vorsorgedokumente von Bewohnenden in 13 stationären Pflegeeinrichtungen unterschiedlicher Größe und Trägerschaft in der Stadt und dem Landkreis Würzburg durchgeführt. Die Analyse der Dokumente erfolgte nach deduktiv-induktivem Vorgehen mittels kategorialer Zusammenfassungen und deskriptiver Häufigkeitsauszählungen.

Ergebnisse  In 265 erfassten Patientenverfügungen konnten 2072 Behandlungssituationen und 1673 medizinische Behandlungsmaßnahmen identifiziert werden. Bewohnende stimmen symptomlindernden und pflegerischen Maßnahmen größtenteils zu und lehnen lebensverlängernde bzw. -erhaltende Behandlungsmaßnahmen häufig ab, wobei letztgenannte zumeist auf bestimmte, festgelegte Behandlungssituationen beschränkt werden. Die Bezugnahme auf bestimmte Behandlungssituationen konnte beim Reanimationsversuch, sowohl in Form der Ablehnung wie der Einwilligung, in 88,6 % der Patientenverfügungen festgestellt werden. 62 % der Patientenverfügungen konnten einer Formularvorlage zugeordnet werden.

Diskussion  Die Untersuchung liefert Erkenntnisse über den Inhalt von Patientenverfügungen bei Bewohnenden stationärer Pflegeeinrichtungen. Sie gibt damit Hinweise auf medizinische Behandlungswünsche dieser Personengruppe im Falle der Einwilligungsunfähigkeit und zeigt auf, dass Behandlungsmaßnahmen (auch Reanimation) häufig in Bezug zu spezifischen Behandlungssituationen gesetzt werden.

Knowledge, Opinion, and Attitude About the Italian Law on Advance Directives: A Population-Based Survey

CONTEXT

Advance directives are legal documents which individuals draw up to declare their treatment preferences and to appoint well-informed proxies to safeguard patient autonomy in critical situations when that individual is temporarily or no longer able to communicate these preferences. On December 22, 2017, the Italian Parliament approved the first law on end of life ("Provisions for informed consent and advance directives" L.219/2017), after a heated public and political debate lasting almost 20 years.

OBJECTIVE

The aim of this study was to investigate the awareness, knowledge, opinions, and attitudes regarding Italian Law 219/2017 and advance directives among the Italian population 15 months after its entry into force.

METHODS

A nationwide population-based survey was conducted by a certified public opinion survey company. A sample size of 2000 interviews was planned. A structured questionnaire was developed to investigate awareness, opinions, and attitudes concerning the law by a multiprofessional research team. The agreed-on version was pretested on a sample of 70 selected participants.

RESULTS

The sample included 2000 valid interviews; 70.1% of respondents declared they had heard about the law on informed consent and advance directives. Respondents were asked to express their overall opinion on the law's utility and importance: 88% declared that the law was quite or very important and 76% had a positive attitude toward making/registering advance directives.

CONCLUSION

The principles of Italian Law 219/2017 are aligned with the ethical sentiment of the vast majority of the Italian population. It is crucial to stimulate discussion to increase knowledge and awareness to increase the number of advance directives.

Qu’écrivent les personnes atteintes d’hémopathies malignes dans leurs directives anticipées ? Analyse qualitative de 35 écrits

En France, les directives anticipées (DA) se sont vues reconnaître un statut légal en 2005, renforcé en 2016, toutefois une minorité de personnes fait le choix d’en rédiger. Dans le contexte de la maladie grave, quel est leur contenu ? Quelles informations relatives à leur prise en charge ou leur fin de vie y déposent-elles ? L’objectif de cette recherche qualitative est d’analyser le contenu des DA rédigées par des patients atteints d’hémopathies malignes afin de mieux comprendre leur appropriation. L’étude s’est déroulée en deux étapes sur une durée totale de huit ans et deux mois : un travail préliminaire, rétrospectif et monocentrique et une seconde étape prospective et multicentrique dans six sites français. L’analyse qualitative des DA a été accomplie par un binôme composé d’un hématologue sénior et d’un chercheur en sciences humaines et sociales. Une analyse thématique a été réalisée avec identification des principaux messages et mots clés. Les 35 DA collectées sont investies de trois façons différentes : l’appropriation est 1) purement juridique avec une citation de la loi in extenso sans personnalisation de l’écrit ; 2) centrée sur les actes et traitements médicaux souhaités ou refusés ; 3) un moyen de transmettre des messages personnels à l’attention de leurs proches comme leur confiance, l’amour qu’il leur porte ou les modalités d’obsèques souhaitées. En conclusion, nos résultats objectivent que la rédaction de DA ne se limite pas aux patients en fin de vie et qu’au-delà de la transmission d’informations relatives aux actes ou traitements médicaux, les patients les utilisent pour y déposer des messages personnels à leurs proches. Ce nouveau rôle des DA pourrait favoriser la communication intrafamiliale même si ce n’est pas leur finalité première. Faire évoluer les DA vers un concept plus large, comme une planification anticipée des soins, pourrait être un moyen de repenser l’outil et de toucher un plus grand nombre de personnes.

[Advance care planning: A qualitative investigation on patients' perspectives with advanced heart failure]

BACKGROUND

The Hospice and Palliative Care Act (2015) promotes advance care planning (ACP) for patients in nursing homes, but chronically ill patients living at home can also benefit from ACP.

OBJECTIVE

The aim of the study was to analyze the perception of ACP consultations by patients with advanced heart failure.

MATERIAL AND METHODS

Patients (70 years and older) with advanced heart failure participated in two physician-led ACP consultations. Afterwards, two evaluative interviews were conducted with each participant. All consultations and interviews were analyzed by grounded theory considering the coding paradigm. Finally, an empirical grounded typology was conducted.

RESULTS

A total of 30 patients participated in at least 1 ACP consultation, whereas 18 persons completed an interview. Successful ACP consultations depend not only on the discussion but also on the patient's requirements: willingness to discuss ACP, their illness, death and dying, and the experienced and preferred role in healthcare decision-making. From the patient's viewpoint ACP consultation can result in an advance directive, but an informed rejection of ACP or the creation of new assumptions for the future are also possible outcomes.

CONCLUSION

The ACP discussions should to be aligned to patients' preferences in terms of communication and content. It is important to accept a rejection of dealing with ACP or conducting an advance directive. The patients' view needs to be integrated into future research.

Advance directives from haematology departments: the patient's freedom of choice and communication with families. A qualitative analysis of 35 written documents

BACKGROUND

In France, advance directives are favourably perceived by most of the population, although the drafting rate is low. This ambivalence is challenging because advance directives are meant to promote the autonomy and freedom of choice of patients. The purpose of this study was to analyse the content of advance directives written by patients suffering from malignant haemopathies to better understand how patients put them into practice. These could be relevant as early as the initial diagnosis of haematological malignancies because of the uncertain course of the disease.

METHODS

This was a multicentre, qualitative, descriptive study. The advance directives written by patients with malignant haemopathies treated in one of the six French hospital departments were included in the study from 01/06/2008 to 15/04/2016. A thematic analysis of the advance directives was performed by two researchers: a senior haematologist and a research assistant.

RESULTS

The median age of the patients was 69. Most were women (sex ratio: 0.59), living as a couple (57%), with lymphoid pathologies (66%), who were still alive two years after the instructions were written (63%) and had nominated a health care proxy (88.6%). Free texts (62.9%) were richer in content than pre-defined forms. The advance directives were used in three ways: for a purely legal purpose, to focus on medical treatments or actions, or to communicate a message to the family. Three main themes emerged: (1) refusal of medical treatment (100%), in which patients express refusal of life-sustaining care (97.1%). The actual treatments or the moment when they should be limited or stopped were not always mentioned in detail. (2) A desire for effective pain relief to avoid suffering (57.1%) and (3) messages for their family (34.3%), such as funeral arrangements (17.1%) and messages of love or trust (14.3%).

CONCLUSIONS

Patients who write advance directives are not necessarily at the end of their lives. Their content mainly conveys treatment wishes, although patients also use them to pass on personal messages to their close family. This emerging role of advance directives to communicate messages within the family should be valued, even if it is not their original purpose.

Failure of the Current Advance Care Planning Paradigm: Advocating for a Communications-Based Approach

The purpose of advance care planning (ACP) is to allow an individual to maintain autonomy in end-of-life (EOL) medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives (ADs). However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has been the development of Physician Orders for Life Sustaining Treatment (POLST). POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient.

Critical appraisal of advance directives given by patients with fatal acute stroke: an observational cohort study

Background

Advance directives (AD) imply the promise of determining future medical treatment in case of decisional incapacity. However, clinical practice increasingly indicates that standardized ADs often fail to support patients’ autonomy. To date, little data are available about the quality and impact of ADs on end-of-life decisions for incapacitated acute stroke patients.

Methods

We analyzed the ADs of patients with fatal stroke, focusing on: (a) their availability and type, (b) stated circumstances to which the AD should apply, and (c) stated wishes regarding specific treatment options.

Results

Between 2011 and 2014, 143 patients died during their hospitalization on our stroke unit. Forty-two of them (29.4%) had a completed and signed, written AD, as reported by their family, but only 35 ADs (24.5%) were available. The circumstances in which the AD should apply were stated by 21/35 (60%) as a “terminal condition that will cause death within a relatively short time” or an ongoing “dying process.” A retrospective review found only 16 of 35 ADs (45.7%) described circumstances that, according to the medical file, could have been considered applicable by the treating physicians. A majority of patients objected to cardiopulmonary resuscitation (22/35, 62.9%), mechanical ventilation (19/35, 54.3%), and artificial nutrition (26/35, 74.3%), while almost all (33/35, 94.3%) directed that treatment for alleviation of pain or discomfort should be provided at all times even if it could hasten death.

Conclusions

The prevalence of ADs among patients who die from acute stroke is still low. A major flaw of the ADs in our cohort was their attempt to determine single medical procedures without focusing on a precise description of applicable scenarios. Therefore, less than half of the ADs were considered applicable for severe acute stroke. These findings stress the need to foster educational programs for the general public about advance care planning to facilitate the processing of timely, comprehensive, and individualized end-of-life decision-making.

Survey on German Palliative Care Specialists' Experiences with Advance Directives

Introduction

Advance directives (AD) play a central role in end-of-life treatments, intensive care, and palliative care. However, little is known about the experiences of healthcare professionals with ADs. This study reports on palliative care professionals’ views on advance directives (AD).

Methods

A questionnaire was handed out to attendants of a palliative care symposium.

Results

Complete answers were obtained from 126 physicians and 276 nurses. Almost all physicians and nurses had treated patients with an AD, and the majority more than 10 patients. The most frequent refusal by the patients was resuscitation (87.8%) followed by intensive care (79.1%), artificial ventilation, and nutrition. The most frequent wish was pain therapy (92.3%) followed by allowing the natural course of the illness (64.4%). The wish for hospice treatment (44.8%) or spiritual care (39.3%) was less frequent.

Discussion

The results hint at fears and deficits in the care of patients at the end of life. Often the quality of life and not the quantity of days remaining is in the center of a patient’s will and points to the growing importance of palliative care.

Conclusion

ADs are well established among palliative care professionals and regarded as helpful for patients at the end of life.

The utility of standardized advance directives: the general practitioners' perspective

Advance directives (AD) are written documents that give patients the opportunity to communicate their preferences regarding treatments they do or do not want to receive in case they become unable to make decisions. Commonly used pre-printed forms have different formats. Some offer space for patients to (a) appoint a surrogate decision maker, and/or (b) to determine future medical treatments and/or (c) give a statement of personal values. So far it is unknown which forms GPs preferably use and why they decide to do so. 23 semi-structured interviews with GPs were analysed using content analysis. Interviewees mainly use short templates (to appoint surrogate decision makers) and medium length templates with checkboxes to indicate patients' preferences in regards to life prolonging measures. Especially when patients faced the progression of a disease, participants use the latter version. Only then, the interviewees remarked, patients are capable to rate concrete situations reliably. GPs also realize the importance of the verbal assessment of patients' preferences; however they rarely keep a written form of the conversation. Some GPs hand out one or more templates and ask their patients to read and think about them at home with the option to talk to them about it later on, while others prefer their patients to fill them out alone at home. Regardless of template usage, most GPs emphasize that ADs require regular updates. GPs tend to see standardized advance directives mainly as a tool to start a conversation with their patients and to identify their real preferences and values. When the patient is still not facing the progression of an already existing disease it could be sufficient to only appoint a surrogate decision maker instead of creating a full AD. However, in all other situations, appointing a surrogate decision maker should be backed up by a written statement of a patient's general values. Patients and their relatives should always have the opportunity to ask their GP for medical advice when drafting an AD. It is crucial to regularly verify and update existing ADs within the course of a disease.

Advance Directives and Communication Skills of Prehospital Physicians Involved in the Care of Cardiovascular Patients

Advance directives (AD) were developed to respect patient autonomy. However, very few patients have AD, even in cases when major cardiovascular surgery is to follow. To understand the reasons behind the low prevalence of AD and to help decision making when patients are incompetent, it is necessary to focus on the impact of prehospital practitioners, who may contribute to an increase in AD by discussing them with patients. The purpose of this study was to investigate self-rated communication skills and the attitudes of physicians potentially involved in the care of cardiovascular patients toward AD.Self-administered questionnaires were sent to general practitioners, cardiologists, internists, and intensivists, including the Quality of Communication Score, divided into a General Communication score (QOCgen 6 items) and an End-of-life Communication score (QOCeol 7 items), as well as questions regarding opinions and practices in terms of AD.One hundred sixty-four responses were received. QOCgen (mean (±SD)): 9.0/10 (1.0); QOCeol: 7.2/10 (1.7). General practitioners most frequently start discussions about AD (74/149 [47%]) and are more prone to designate their own specialty (30/49 [61%], P < 0.0001). Overall, only 57/159 (36%) physicians designated their own specialty; 130/158 (82%) physicians ask potential cardiovascular patients if they have AD and 61/118 (52%) physicians who care for cardiovascular patients talk about AD with some of them.The characteristics of physicians who do not talk about AD with patients were those who did not personally have AD and those who work in private practices.One hundred thirty-three (83%) physicians rated the systematic mention of patients' AD in the correspondence between physicians as good, while 114 (71%) at the patients' first registration in the private practice.Prehospital physicians rated their communication skills as good, whereas end-of-life communication was rated much lower. Only half of those surveyed speak about AD with cardiovascular patients. The majority would prefer that physicians of another specialty, most frequently general practitioners, initiate conversation about AD. In order to increase prehospital AD incidence, efforts must be centered on improving practitioners' communication skills regarding death, by providing trainings to allow physicians to feel more at ease when speaking about end-of-life issues.