The legal guardians' dilemma: Decision making associated with invasive non-life-saving procedures

Being a legal guardian - the nursing perspective

BACKGROUND

Surrogate decision making is common in public healthcare worldwide. In Israel any incompetent adult patient requires a Legal Guardian (LG), appointed by the court, for approval of invasive none-life saving procedures. Usually, the LG is a close family member of the patient. Nurses are the most available healthcare providers to the families and the LG during the process of appointment and afterwards. The patient's family is often anxious or even depressed, and thus the perceptions and behavior of nurses charged with providing support are crucial. In a previous study based on interviews of LGs we found that the most difficult issues for the LGs were decision related issues, family related issues and appointment bureaucracy issues.

OBJECTIVE

To qualitatively assess nurses attitudes regarding the difficulties that families and LGs face during and after appointments and to compare the findings to previously accessed LG attitudes.

RESEARCH DESIGN

After IRB approval, demographic and semi-structured questionnaires were used to assess the attitudes of a convenience sample of 34 nurses who were participating in a critical care training course (41 % of the respondents were from the ICU, 47 % from medical or surgical wards, and 12 % from other departments at secondary and tertiary hospitals in Israel.) regarding LGs difficulties. After reading and analyzing the responses provided by the nurses, the authors categorized the pertinent topics raised using content analysis. Nurses' perceptions were also compared to those of LGs reported in previous research by the authors.

RESULTS

Three main themes emerged: 1. Decision related issues; namely coping with the complexity of end of life decision issues; 2. Family related issues; namely, family dynamics related to the various decisions regarding LG identity and patient care; and 3. Bureaucracy issues; namely, the formal process related to LG appointment and decisions. Regarding the first two themes, the feelings of the nurse respondents were quite similar to those of LG respondents from our earlier research. The third theme - bureaucracy issues - was never mentioned by the nurses, as opposed to LGs who mentioned it frequently. This suggests that the nurses did not consider it to be an important issue.

CONCLUSIONS

The difficulties of decision making as well as family support and responsibility of LGs are well known by nurses. The appointment and bureaucracy issues were neglected by nurses, although they are very important to the LGs. Improvement of this parameter of care is needed. Possible directions for improvement include raising awareness of nurses regarding the appointment process and alleviation of bureaucracy. Further research is required to identify appropriate strategies for improving these aspects of care.

Attitudes of legal guardians in the ICU - a qualitative report

Decision-making in intensive care units (ICUs) is often made by surrogates, since patients are unconscious or incompetent. In Israel, Legal Guardians (LGs), appointed by the court, are required to make these decisions.

OBJECTIVE

To qualitatively assess the attitudes of LGs required to make decisions on behalf of their relatives.

RESEARCH DESIGN

Demographic and semi-structured questionnaires were used to assess the attitudes of LGs regarding difficulties, positive aspects and areas for improvement with regard to surrogate decision-making. The study sampled sixty-four LGs in two large Israeli hospitals. After reading and analysing the responses provided by the LGs, the authors categorised the pertinent topics raised using a thematic analysis.

RESULTS

Themes were: bureaucratic and legal issues, unclear or unknown patient preferences and fear of outcomes. Family and medical staff support was stated as the most beneficial. Suggestions for improvement included alleviation of bureaucracy and improved communication with the medical staff.

CONCLUSIONS

The importance of communication and bureaucratic difficulties, making the best decision for the patient and uncertainty regarding decision outcomes were found to be important issue for the LGs. The healthcare team should try and alleviate some of these burdens, mostly by improving communication with relatives, stressing and educating the importance of advance directives. Reporting the problems found in the decision making process of LGs to the legislators in order to revise and simplify the current legal requirements is advised.

Priority setting: the importance of incorporating opportunity costs

This article is a comment on Ofra Golan and Paul Hansen's framework for health technology prioritization that they suggest could be developed and used by the committee selecting new technologies for Israel's health basket. Although Golan and Hansen should be commended for the innovative way they have started to explore these issues, more work need to be done to take proper account of opportunity costs.

Know your patient: psychological drivers of decision making

This is a commentary on “Attitudes of legal guardians of ventilated ICU patients toward the process of decision making associated with invasive nonlife-saving procedures” by Michael Kuniavsky, Freda DeKeyser Ganz, David M Linton, and Sigal Sviri. Kuniavsky and colleagues report that decision-making for the seriously ill is difficult for the patients’ legal guardians, many of whom would be comfortable with doctors making the decisions. This commentary offers that accurate predictions about treatment choices may be derived by using assessments that characterize the key drivers of individual’s decision making, thus relieving some of decision makers' burdens. This approach could also usher in an era of assessing quality of care for the seriously ill by whether the care matches patient goals.