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Göcking B, Gloeckler S, Ferrario A, Brandi G, Glässel A, Biller-Andorno N. A case for preference-sensitive decision timelines to aid shared decision-making in intensive care: need and possible application. Front Digit Health 2023; 5:1274717. [PMID: 37881363 PMCID: PMC10595152 DOI: 10.3389/fdgth.2023.1274717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/28/2023] [Indexed: 10/27/2023] Open
Abstract
In the intensive care unit, it can be challenging to determine which interventions align with the patients' preferences since patients are often incapacitated and other sources, such as advance directives and surrogate input, are integral. Managing treatment decisions in this context requires a process of shared decision-making and a keen awareness of the preference-sensitive instances over the course of treatment. The present paper examines the need for the development of preference-sensitive decision timelines, and, taking aneurysmal subarachnoid hemorrhage as a use case, proposes a model of one such timeline to illustrate their potential form and value. First, the paper draws on an overview of relevant literature to demonstrate the need for better guidance to (a) aid clinicians in determining when to elicit patient preference, (b) support the drafting of advance directives, and (c) prepare surrogates for their role representing the will of an incapacitated patient in clinical decision-making. This first section emphasizes that highlighting when patient (or surrogate) input is necessary can contribute valuably to shared decision-making, especially in the context of intensive care, and can support advance care planning. As an illustration, the paper offers a model preference-sensitive decision timeline-whose generation was informed by existing guidelines and a series of interviews with patients, surrogates, and neuro-intensive care clinicians-for a use case of aneurysmal subarachnoid hemorrhage. In the last section, the paper offers reflections on how such timelines could be integrated into digital tools to aid shared decision-making.
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Affiliation(s)
- Beatrix Göcking
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Sophie Gloeckler
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Andrea Ferrario
- Department of Management, Technology, and Economics, Swiss Federal Institute of Technology in Zurich, Zurich, Switzerland
- Mobiliar Lab for Analytics at ETH, Zurich, Switzerland
| | - Giovanna Brandi
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Andrea Glässel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
- School of Health Sciences, Institute of Public Health, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
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An Ethics Early Action Protocol to Promote Teamwork and Ethics Efficacy. Dimens Crit Care Nurs 2021; 40:226-236. [PMID: 34033444 DOI: 10.1097/dcc.0000000000000482] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Moral dilemmas and ethical conflicts occur in critical care. Negative consequences include misunderstandings, mistrust, patient and family suffering, clinician moral distress, and patient safety concerns. Providing an opportunity for team-based ethics assessments and planning could improve communication and reduce moral distress. OBJECTIVES The aims of this study were to explore whether an early action ethics intervention affects intensive care unit (ICU) clinicians' moral distress, ethics self-efficacy, and perceptions of hospital climate and to compare nurses' and physicians' scores on moral distress, ethics self-efficacy, and ethical climate at 3 time points. METHODS Intensive care unit nurses and physicians were asked to complete surveys on moral distress, ethics self-efficacy, and ethical climate before implementing the ethics protocol in 6 ICUs. We measured responses to the same 3 surveys at 3 and 6 months after the protocol was used. RESULTS At baseline, nurses scored significantly higher than physicians in moral distress and significantly lower in ethics self-efficacy. Plot graphs revealed that nurses' and physicians' outcome scores trended toward one another. At 3 and 6 months post intervention, nurse and physician scores changed differently in moral distress and ethics self-efficacy. When examining nurse and physician scores separately over time, we found nurses' scores in moral distress and moral distress frequency decreased significantly over time and ethics self-efficacy and ethics climate increased significantly over time. Physicians' scores did not change significantly. DISCUSSION This study indicates that routine, team-based ethics assessment and planning opens a space for sharing information, which could decrease nurses' moral distress and increase their ethics self-efficacy. This, in turn, can potentially promote teamwork and reduce burnout.
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Tarsney PS, Sandel ME, Doyle CK, Shapiro SP, Hutchison PJ, Mukherjee D. Putting the Pieces Together: Advance Directives in the Rehabilitation Setting. PM R 2021; 12:73-81. [PMID: 31774628 DOI: 10.1002/pmrj.12295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Preya S Tarsney
- Department of Physical Medicine & Rehabilitation, Northwestern University Feinberg School of Medicine and Shirley Ryan AbilityLab, Chicago, IL
| | - M Elizabeth Sandel
- Department of Physical Medicine and Rehabilitation, University of California, Davis School of Medicine, Sacramento, CA
| | - Cavan K Doyle
- Director of Clinical Ethics at AMITA Health and Neiswanger Institute for Bioethics & Healthcare Leadership, Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | | | - Paul J Hutchison
- Division of Pulmonary and Critical Care, Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Debjani Mukherjee
- Department of Physical Medicine & Rehabilitation, Northwestern University Feinberg School of Medicine and Shirley Ryan AbilityLab, Chicago, IL
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Maffoni M, Argentero P, Giorgi I, Giardini A. Healthcare professionals' perceptions about the Italian law on advance directives. Nurs Ethics 2019; 27:796-808. [PMID: 31631774 DOI: 10.1177/0969733019878831] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the variegated legislative framework on advance directives, the first specific regulation in Italy on this issue came into force only in 2018. RESEARCH OBJECTIVE This qualitative study aimed to investigate the implications of the new Italian law on advance directives in clinical practice from the perspective of those who deal with this delicate ethical issue on an everyday basis, that is, Italian healthcare professionals. RESEARCH DESIGN A qualitative research design using semi-structured audio-recorded interviews was adopted. The data collection and analysis were performed according to the Grounded Theory approach. PARTICIPANTS Nineteen healthcare professionals (16 nurses, 3 physicians) working in a palliative care unit of a research and clinical institute in Italy. ETHICAL CONSIDERATIONS The study is part of the WeDistress HELL Project (WEllness and DISTRESS in HEalth care professionals dealing with end of Life and bioethicaL issues) approved by the Ethical Committee of ICS Maugeri - Institute of Pavia (Italy). FINDINGS The authors identified a main overall category, 'Pros and Cons of the Italian law on advance directives', composed of six constituent categories: Positive welcome, Self-determination and protection, Prompts for future betterment, Uncertainties, Lack of knowledge, and Neutrality and no suggestions. DISCUSSION The Italian law n. 219/2017 on advance directives was seen as a legal instrument possessing both strengths and weaknesses, but able to guarantee the patient's self-determination and support healthcare professionals in providing care according to patients' wishes. CONCLUSION An understanding of the healthcare providers' perspective may support the discussion on advance directives and bridge the gaps that currently persist in handling ethical issues.
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Affiliation(s)
- Marina Maffoni
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Ines Giorgi
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit - Institute of Pavia, Italy
| | - Anna Giardini
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit - Institute of Montescano, Italy
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Lennard C. Best interest versus advance decisions to refuse treatment in advance care planning for neurodegenerative illness. ACTA ACUST UNITED AC 2019; 27:1261-1267. [PMID: 30457382 DOI: 10.12968/bjon.2018.27.21.1261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article describes the role of nurses assisting people with degenerative illness in advance care planning (ACP) for a time when they may lose decision-making capacity. It looks at the concept of advance decisions to refuse treatment (ADRT), as defined in the Mental Capacity Act 2005 , exploring the legal, ethical and philosophical ramifications of carrying out, or overriding, formerly expressed wishes of someone who has subsequently lost decision-making capacity. It uses an illustrative composite case study of an individual with Huntington's disease whose prognosis includes future deterioration in swallowing, together with consideration of whether to have or refuse a percutaneous endoscopic gastrostomy. The author, who as part of his role cares for people with neurodegenerative conditions, including Huntington's disease, discusses the difficulties and dilemmas that nurses experience with ADRTs, drawing on personal experience. He suggests that, rather than focusing on ADRTs, ACP may be most effective in preparing people and their surrogates to make real-time decisions, based on a shared understanding of the individual's values.
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Affiliation(s)
- Chris Lennard
- Registered mental health nurse, Pirton Grange Specialist Care Centre, Pirton, Worcestershire
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Taneja R, Faden LY, Schulz V, Rawal A, Miller K, Bishop KA, Lingard L. Advance care planning in community dwellers: A constructivist grounded theory study of values, preferences and conflicts. Palliat Med 2019; 33:66-73. [PMID: 30284950 DOI: 10.1177/0269216318803487] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Most laypeople have not engaged in any advance care planning. Yet they are expected to articulate choices for life-sustaining interventions when they need admission to an acute care hospital in Canada. Aim: To describe how laypeople understand and make decisions for life-sustaining interventions when engaging in advance care planning. Design: Semi-structured interviews using constructivist grounded theory methodology and purposive sampling. Setting: Mid-size Canadian urban community Participants: In total, 20 healthy laypeople, 55 years and older, participated in in-depth semi-structured face-to-face interviews. Theoretical sampling was used to explore findings from the first round of interviews. Ten participants were invited for repeat interviews. Results: Four major themes were identified. Most participants claimed at the outset that they had engaged in advance care planning, but they were unfamiliar with contemporary life-sustaining interventions and had not factored these into their decisions. Participants’ confidence in their substitute decision makers precluded them from having explicit discussions with these individuals. Participants expressed their values and preferences in terms of unacceptable functional outcomes from serious illness, rather than desired interventions. The process of articulating their preferences within the interviews was subject to decision conflicts, which in turn helped them re-evaluate and refine their decisions. Conclusion: Advance care planning for the healthy older adult is challenging. Meaningful engagement may lead to conflicts in decision-making. Efforts to improve engagement must reflect what patients know and understand, their focus on unacceptable negative outcomes rather than interventions, and the need for iterative discussions with health-care providers.
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Affiliation(s)
- Ravi Taneja
- 1 Division of Critical Care Medicine, University of Western Ontario, London, ON, Canada.,2 Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Lisa Y Faden
- 3 Centre for Education Research & Innovation, University of Western Ontario, London, ON, Canada
| | - Valerie Schulz
- 1 Division of Critical Care Medicine, University of Western Ontario, London, ON, Canada.,2 Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Asha Rawal
- 1 Division of Critical Care Medicine, University of Western Ontario, London, ON, Canada
| | - Kristina Miller
- 4 Faculty of Health Sciences, University of Western Ontario, London, ON, Canada
| | - Kristen A Bishop
- 4 Faculty of Health Sciences, University of Western Ontario, London, ON, Canada
| | - Lorelei Lingard
- 3 Centre for Education Research & Innovation, University of Western Ontario, London, ON, Canada
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Abstract
This series on palliative care is developed in collaboration with the Hospice and Palliative Nurses Association (HPNA; http://hpna.advancingexpertcare.org). The HPNA aims to guide nurses in preventing and relieving suffering and in giving the best possible care to patients and families, regardless of the stage of disease or the need for other therapies. The HPNA offers education, certification, advocacy, leadership, and research.
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Pope TM. Legal Briefing: New Penalties for Disregarding Advance Directives and Do-Not-Resuscitate Orders. THE JOURNAL OF CLINICAL ETHICS 2017. [DOI: 10.1086/jce2017281074] [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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Terry P. When Patients and Surrogates Disagree About Advance Directives. Chest 2016; 149:1576-7. [DOI: 10.1016/j.chest.2016.02.678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 02/23/2016] [Accepted: 02/23/2016] [Indexed: 11/27/2022] Open
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Bruce CR, Bibler T, Childress AM, Stephens AL, Pena AM, Allen NG. Response. Chest 2016; 149:1577-8. [DOI: 10.1016/j.chest.2016.02.677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 02/26/2016] [Accepted: 02/29/2016] [Indexed: 11/26/2022] Open
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