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Sullivan DR, Iyer AS, Enguidanos S, Cox CE, Farquhar M, Janssen DJA, Lindell KO, Mularski RA, Smallwood N, Turnbull AE, Wilkinson AM, Courtright KR, Maddocks M, McPherson ML, Thornton JD, Campbell ML, Fasolino TK, Fogelman PM, Gershon L, Gershon T, Hartog C, Luther J, Meier DE, Nelson JE, Rabinowitz E, Rushton CH, Sloan DH, Kross EK, Reinke LF. Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement. Am J Respir Crit Care Med 2022; 206:e44-e69. [PMID: 36112774 PMCID: PMC9799127 DOI: 10.1164/rccm.202207-1262st] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.
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Ilhan E, Pacey V, Brown L, Spence K, Gray K, Rowland JE, White K, Hush JM. Neonates as intrinsically worthy recipients of pain management in neonatal intensive care. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:65-72. [PMID: 33034802 DOI: 10.1007/s11019-020-09982-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 06/11/2023]
Abstract
One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.
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Affiliation(s)
- Emre Ilhan
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia.
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Ground Floor, 75 Talavera Road, Sydney, NSW, 2109, Australia.
| | - Verity Pacey
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Laura Brown
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Kaye Spence
- Children's Hospital at Westmead, Grace Centre for Newborn Intensive Care, Sydney, NSW, Australia
- School of Nursing and Midwifery, Western Sydney University, Parramatta, NSW, Australia
| | - Kelly Gray
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Jennifer E Rowland
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Karolyn White
- Research Ethics and Integrity, Macquarie University, Sydney, NSW, Australia
| | - Julia M Hush
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
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Spalding R. Accuracy in Surrogate End-of-Life Medical Decision-Making: A Critical Review. Appl Psychol Health Well Being 2020; 13:3-33. [PMID: 32829505 DOI: 10.1111/aphw.12221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/14/2020] [Accepted: 07/14/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Increasing age is accompanied by a greater need for medical decisions, due in part to age-related increases in chronic disease and disability. In later life, medical decisions about end-of-life care in particular are likely. However, a significant percentage of these decisions are made by surrogate decision-makers. "Surrogates" are most often instructed to use the substituted judgment standard and make decisions that patients would choose if they were able. Whether surrogates make decisions that adequately match patients' preferences is a concern. Surrogates are generally poor predictors of patient preferences (Shalowitz et al., 2006). However, no critical review of this literature has yet been published. METHOD A critical review was conducted to summarise and provide a methodological critique of 25 studies. RESULTS These studies generally concur that patient-surrogate agreement on medical decisions is poor. However, this conclusion is qualified by inconsistencies in methodological quality and the potentially limited generalisability of these findings. CONCLUSIONS Clinical research incorporating standardised hypothetical decision-making protocols, as well as triangulated data collection methods, would bolster confidence in future findings. Investigations prioritising the surrogate decision-making process, rather than solely the decisional outcome, could better identify ways to improve the decision-making process for incapacitated patients.
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Cresp SJ, Lee SF, Moss C. Experiences of substitute decision makers in making decisions for older persons diagnosed with major neurocognitive disorder at end of life: a qualitative systematic review protocol. ACTA ACUST UNITED AC 2017; 15:1770-1777. [DOI: 10.11124/jbisrir-2016-003252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Kuniavsky M, Kadmon I, Chinitz D. Being a legal guardian - the nursing perspective. Isr J Health Policy Res 2015; 4:59. [PMID: 26605040 PMCID: PMC4657348 DOI: 10.1186/s13584-015-0056-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 11/13/2015] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Michael Kuniavsky
- General ICU, Assaf Harofeh Medical Center, Beer Jaacov, 70300 Israel ; The Hebrew University School of Public Health and Community Medicine, Faculty of Medicine, Jerusalem, Israel
| | - Ilana Kadmon
- Hadassah-Hebrew University School of Nursing, Faculty of Medicine, Jerusalem, Israel
| | - David Chinitz
- The Hebrew University School of Public Health and Community Medicine, Faculty of Medicine, Jerusalem, Israel
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Carroll DW. Assessment of capacity for medical decision making. J Gerontol Nurs 2010; 36:47-52. [PMID: 20349850 DOI: 10.3928/00989134-20100303-03] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Accepted: 11/05/2009] [Indexed: 11/20/2022]
Abstract
Determination of a patient's capacity for medical decision making can be simple or complex, depending on the issue being considered; likewise, the degree of capacity required to make decisions varies with the complexity of the situation. A capacity examination is a focused and impartial evaluation of mental status and medical, surgical, psychiatric, and psychosocial histories. The examination is composed of several basic steps, beginning with an assessment of the patient's ability to communicate, followed by determination of his or her understanding of the proposed care, followed by the patient's rationale for decisions about that care. When a patient is deemed to lack capacity, mechanisms should be in place to ensure the patient receives the care needed. This article provides an overview of the concept of capacity, how it is determined, and how to proceed when the patient is found to lack it.
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Affiliation(s)
- David Wayne Carroll
- Department of Family Nursing, University of Texas Health Science Center at San Antonio, Texas 78229, USA.
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Elliott BA, Gessert CE, Peden-McAlpine C. Family decision-making in advanced dementia: narrative and ethics. Scand J Caring Sci 2009; 23:251-8. [PMID: 19645802 DOI: 10.1111/j.1471-6712.2008.00613.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traditionally, family members become decision-makers for ageing parents with cognitive impairment. Our understanding of how families negotiate the ethical issues in this decision-making is still developing. AIM To describe and understand the ethical thinking used in end-of-life decision-making by family surrogates on behalf of their cognitively impaired elders. METHODS Qualitative research with eight focus groups that included 39 family members of severely impaired nursing home residents in Minnesota. Transcripts were analysed using a thematic approach. FINDINGS The family surrogates described their decision-making as a process based in the families' stories and as extensions of the elders' identities. Four themes emerged from the analysis of the families' decision-making: (i) acquisition of decision-making authority, (ii) decision-making for short-term or long-term time frames, (iii) justifying the decisions and (iv) advocacy for the elders. CONCLUSIONS The families in these focus groups used the elders' life stories to frame their decisions for care. Providers working in primary care settings who work with families in making care decisions for cognitively impaired elderly patients may find narrative ethics more pertinent than principle-based ethics in understanding families' perspectives and priorities, while also recognizing their decision-making transition from using the principle of autonomy to that of beneficence.
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Affiliation(s)
- Barbara A Elliott
- University of Minnesota Medical School Duluth, Duluth, MN 55812, USA.
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Torke AM, Alexander GC, Lantos J. Substituted judgment: the limitations of autonomy in surrogate decision making. J Gen Intern Med 2008; 23:1514-7. [PMID: 18618201 PMCID: PMC2518005 DOI: 10.1007/s11606-008-0688-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Revised: 04/30/2008] [Accepted: 05/21/2008] [Indexed: 11/29/2022]
Abstract
Substituted judgment is often invoked as a guide for decision making when a patient lacks decision making capacity and has no advance directive. Using substituted judgment, doctors and family members try to make the decision that the patient would have made if he or she were able to make decisions. However, empirical evidence suggests that the moral basis for substituted judgment is unsound. In spite of this, many physicians and bioethicists continue to rely on the notion of substituted judgment. Given compelling evidence that the use of substituted judgment has insurmountable flaws, other approaches should be considered. One approach provides limits on decision making using a best interest standard based on community norms. A second approach uses narrative techniques and focuses on each patient's dignity and individuality rather than his or her autonomy.
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Affiliation(s)
- Alexia M Torke
- Indiana University Center for Aging Research, Indianapolis, IN, USA.
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Eliott J, Olver I. Autonomy and the Family as (In)Appropriate Surrogates for DNR Decisions: A Qualitative Analysis of Dying Cancer Patients’ Talk. THE JOURNAL OF CLINICAL ETHICS 2007. [DOI: 10.1086/jce200718302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Broström L, Johansson M, Nielsen MK. "What the patient would have decided": a fundamental problem with the substituted judgment standard. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2007; 10:265-78. [PMID: 17120112 DOI: 10.1007/s11019-006-9042-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Accepted: 10/13/2006] [Indexed: 05/12/2023]
Abstract
Decision making for incompetent patients is a much-discussed topic in bioethics. According to one influential decision making standard, the substituted judgment standard, the decision that ought to be made for the incompetent patient is the decision the patient would have made, had he or she been competent. Although the merits of this standard have been extensively debated, some important issues have not been sufficiently explored. One fundamental problem is that the substituted judgment standard, as commonly formulated, is indeterminate in content and thus offers the surrogate little or no guidance. What the standard does not specify is just how competent one should imagine the patient to be, and what else one ought to envision about the patient's hypothetical outlook and the circumstances surrounding his or her decision making. The article discusses this problem of underdetermined decision conditions.
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Affiliation(s)
- Linus Broström
- Department of Medical Ethics, Lund University, BMC C13, Lund, 221 84, Sweden.
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Abstract
The decision to provide or withhold artificial feeding in patients with advanced dementia presents a multifaceted ethical dilemma. This article analyses the issues of rights regarding such patients and explores the ethical principles of beneficence, non-maleficence, respect/autonomy, justice and veracity. Evidence points strongly to hand-feeding being the method of choice for these patients (Finucane et al, 1999; Li, 2002). However, for each case there is no right or wrong answer and the physical and psychological wellbeing of the individual patient must be taken into account.
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Enes SPD, de Vries K. A survey of ethical issues experienced by nurses caring for terminally ill elderly people. Nurs Ethics 2004; 11:150-64. [PMID: 15030023 DOI: 10.1191/0969733004ne680oa] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study examined the ethical issues experienced by nurses working in a small group of elderly persons' care settings in the UK, using a survey questionnaire previously used in other countries for examining the cultural aspects of ethical issues. However 'culture' relates not only to ethnicity but also the organizational culture in which care is delivered. Nurses working in elderly persons' care settings described a range of issues faced when caring for elderly terminally ill people, which illustrated the different needs of patients, relatives, professionals and society. These issues related to the unique needs of elderly people (such as dementia sufferers) and could have an impact on patients' quality of death.
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