Honoring patient care preferences: surrogates speak

Perspectives of healthcare professionals and older patients on shared decision-making for treatment escalation planning in the acute hospital setting: a systematic review and qualitative thematic synthesis

Background

Shared Decision-Making (SDM) between patients and clinicians is increasingly considered important. Treament Escalation Plans (TEP) are individualised documents outlining life-saving interventions to be considered in the event of clinical deterioration. SDM can inform subjective goals of care in TEP but it remains unclear how much it is considered beneficial by patients and clinicians. We aimed to synthesise the existing knowledge of clinician and older patient (generally aged ≥65 years) perspectives on patient involvement in TEP in the acute setting.

Methods

Systematic database search was performed in MEDLINE, EMBASE, PsycInfo and CINAHL databases as well as grey literature from database inception to June 8, 2023, using the Sample (older patients, clinicians, acute setting; studies relating to patients whose main diagnosis was cancer or single organ failure were excluded as these conditions may have specific TEP considerations), Phenomenon of Interest (Treatment Escalation Planning), Design (any including interview, observational, survey), Evaluation (Shared Decision-Making), Research type (qualitative, quantitative, mixed methods) tool. Primary data (published participant quotations, field notes, survey results) and descriptive author comments were extracted and qualitative thematic synthesis was performed to generate analytic themes. Quality assessment was made using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess overall confidence in each thematic finding according to methodology, coherence, adequacy and relevance of the contributing studies. The study protocol was registered on PROSPERO, CRD42022361593.

Findings

Following duplicate exclusion there were 1916 studies screened and ultimately 13 studies were included, all from European and North American settings. Clinician-orientated themes were: treatment escalation is a medical decision (high confidence); clinicians want the best for their patients amidst uncertainty (high confidence); involving patients and families in decisions is not always meaningful and can involve conflict (high confidence); treatment escalation planning exists within the clinical environment, organisation and society (moderate confidence). Patient-orientated themes were: patients' relationships with Treatment Escalation Planning are complex (low confidence); interactions with doctors are important but communication is not always easy (moderate confidence); patients are highly aware of their families when considering TEP (moderate confidence).

Interpretation

Based on current evidence, TEP decisions appear dominated by clinicians' perspectives, motivated by achieving the best for patients and challenged by complex decisions, communication and environmental factors; older patients' perspectives have seldom been explored, but their input on decisions may be modest. Presenting the context and challenge of SDM during professional education may allow reflection and a more nuanced approach. Future research should seek to understand what approach to TEP decision-making patients and clinicians consider to be optimum in the acute setting so that a mutually acceptable standard can be defined in policy.

Funding

HCA International and the NIHR Imperial Biomedical Research Centre.

Systematic Review Revisited, 2010-2020: The Effect on Surrogates of Making Treatment Decisions for Others

Objectives: This study mapped research evidence spanning the last 10 years to identify the effect of being a surrogate decision maker for an incapacitated adult. Methods: A scoping review strategy was employed to allow for a focus on the breadth of the effect of surrogate decision making and to identify gaps in the existing research literature. Results: Surrogate decision making created emotional distress and burden for the majority of the SDMs. We found the negative effects on SDMs were linked to variety of stressors: fear of not knowing what the patient would want or being unable to fulfill the patient's actual or perceived wishes, feeling unprepared to assume the role of a SDM, and watching a loved one's health deteriorate over time. Discussion: Additional research is needed to elucidate the emotional burden of culturally diverse SDMs to determine their differences when compared to various groups.

Psychometric Properties of the Chinese Version of the Surrogate Decision-Making Self-Efficacy Scale

Surrogate decision making for patients in the intensive care unit (ICU) can have negative physical and emotional health consequences for the decision-maker. Improving confidence and self-efficacy may reduce these consequences, but a valid instrument is necessary for reliable measurement. Using a cross-sectional design, the current study aimed to translate the Surrogate Decision-Making Self-Efficacy Scale (SDM-SES) into Chinese and evaluate its psychometric properties for surrogate decision-makers (SDMs) of patients in the ICU. The English version of the SDM-SES was translated into Chinese according to Brislin's translation guidelines and tested in 107 Chinese SDMs of patients in the ICU. Cronbach's alpha coefficient was 0.86, and a confirmatory factor analysis yielded acceptably high goodness-of-fit. Scores of the Chinese version of the SDM-SES were positively correlated with General Self-Efficacy Scale scores and 10-item Connor-Davidson Resilience Scale scores. This study indicates that the Chinese version of the SDM-SES has sufficient psychometric properties for assessing self-efficacy of SDMs for patients in the ICU. [Research in Gerontological Nursing, 14(1), 17-23.].

Are the "Right" People Selected for First Disclosures About Suicidal Thoughts? Exploring What We Know About Advance Care Planning in the Context of Safety Planning

Nominating primary confidants (i.e., safety plan nominees) is central to safety planning for suicide but there is a dearth of research about such confidants-a serious oversight given their high-leverage position to affect pathways into clinical care. Informed by advance care planning (ACP) work, this study examined differences between social network members who were and were not identified as primary confidants on attributes that could impact their effectiveness in a helping role. Using social network methodology, information was collected from 41 individuals with affective disorders about the 332 people and relationships in their networks. Logistic regression analysis revealed that being perceived as capable of managing stress and prioritizing the participant's best interests over one's own increased the odds of being a primary confidant. Clinicians working with suicidal individuals may benefit from integrating ACP principles-which recognize the thoughtful selection of nominees based on specific attributes-into their safety planning procedures.

Spiritual and Religious Coping of Medical Decision Makers for Hospitalized Older Adult Patients

BACKGROUND

Critically ill adult patients who face medical decisions often delegate others to make important decisions. Those who are authorized to make such decisions are typically family members, friends, or legally authorized representatives, often referred to as surrogates. Making medical decisions on behalf of others produces emotional distress. Spirituality and/or religion provide significant assistance to cope with this distress. We designed this study to assess the role of surrogates' spirituality and religion (S/R) coping resources during and after making medical decisions on behalf of critically ill patients. The study's aim was to understand the role that S/R resources play in coping with the lived experiences and challenges of being a surrogate.

METHODS

Semistructured interviews were conducted with 46 surrogates by trained interviewers. These were audio-recorded and transcribed by research staff. Three investigators conducted a thematic analysis of the transcribed interviews. The codes from inter-rater findings were analyzed, and comparisons were made to ensure consistency.

RESULTS

The majority (67%) of surrogates endorsed belief in God and a personal practice of religion. Five themes emerged in this study. Personal prayer was demonstrated as the most important coping resource among surrogates who were religious. Trusting in God to be in charge or to provide guidance was also commonly expressed. Supportive relationships from family, friends, and coworkers emerged as a coping resource for all surrogates. Religious and nonreligious surrogates endorsed coping strategies such as painting, coloring, silent reflection, music, recreation, and reading. Some surrogates also shared personal experiences that were transformative as they cared for their ill patients.

CONCLUSION

We conclude that surrogates use several S/R and other resources to cope with stress when making decisions for critically ill adult patients. The coping resources identified in this study may guide professional chaplains and other care providers to design a patient-based and outcome-oriented intervention to reduce surrogate stress, improve communication, increase patient and surrogate satisfaction, and increase surrogate integration in patient care. We recommend ensuring that surrogates have S/R resources actively engaged in making medical decisions. Chaplains should be involved before, during, and after medical decision making to assess and address surrogate stress. An interventional research-design project to assess the effect of spiritual care on surrogate coping before, during, and after medical decision making is also recommended.

Differences between COPD patients and their families regarding willingness toward life-sustaining treatments

BACKGROUND/PURPOSE

Patients with chronic obstructive pulmonary disease (COPD) receive more life-sustaining treatments (LSTs) than those with other diseases. The aims of this study were to explore the willingness of COPD patients and their families to consent to LSTs and compare the differences between their levels of willingness.

METHODS

A cross-sectional survey was conducted, and structured questionnaires were used for data collection.

RESULTS

A total of 219 valid samples were collected, including 109 patients and 110 families. Sixty percent of family members indicated that they did not know the intentions of the patient. Families were significantly more willing for patients to receive LSTs than the patients themselves. The level of willingness of patients and families varied according to the situation and LST interventions. When patients were in a vegetative state or medical treatments were futile, the willingness of COPD patients and their families to receive LSTs significantly decreased. Endotracheal intubation and external defibrillation were the least likely to be requested, whereas the willingness to receive medication injections and noninvasive ventilation was greatest.

CONCLUSION

Communication between families and patients on the issue of LST should be facilitated. Adequate information on the patient's condition and possible LSTs should be provided to avoid COPD patients receiving inappropriate LSTs.

Family Communication about End-of-Life Decisions and the Enactment of the Decision-Maker Role

End-of-life (EOL) decisions in families are complex and emotional sites of family interaction necessitating family members coordinate roles in the EOL decision-making process. How family members in the United States enact the decision-maker role in EOL decision situations was examined through in-depth interviews with 22 individuals who participated in EOL decision-making for a family member. A number of themes emerged from the data with regard to the enactment of the decision-maker role. Families varied in how decision makers enacted the role in relation to collective family input, with consulting, informing and collaborating as different patterns of behavior. Formal family roles along with gender- and age-based roles shaped who took on the decision-maker role. Additionally, both family members and medical professionals facilitated or undermined the decision-maker’s role enactment. Understanding the structure and enactment of the decision-maker role in family interaction provides insight into how individuals and/or family members perform the decision-making role within a cultural context that values autonomy and self-determination in combination with collective family action in EOL decision-making.

Ethical frameworks for surrogates' end-of-life planning experiences

BACKGROUND

Despite the growing body of knowledge about surrogate decision making, we know very little about the use of ethical frameworks (including ethical theories, principles, and concepts) to understand surrogates' day-to-day experiences in end-of-life care planning for incapacitated adults.

OBJECTIVES AND METHODS

This qualitative systematic review was conducted to identify the types of ethical frameworks used to address surrogates' experiences in end-of-life care planning for incapacitated adults as well as the most common themes or patterns found in surrogate decision-making research.

FINDINGS

Seven research papers explicitly identified ethical theories, principles, or concepts, such as autonomy, substituted judgment, and best interest standards as guidelines for the research. Surrogate decision making themes included the responsibilities and goals of being a surrogate, factors influencing surrogates' decision making, outcomes for surrogates, and an overarching theme of "wanting to do the right thing" for their loved one and/or themselves.

DISCUSSION

Understanding the complexity of surrogates' experiences of end-of-life care planning is beyond the scope of conventional ethical frameworks.

CONCLUSION

Ethical frameworks that address individuality and contextual variations related to decision making may more appropriately guide surrogate decision-making research that explores surrogates' end-of-life care planning experiences.

The Role of Relationship Biography in Advance Care Planning

Objective: We examine the ways that romantic relationship biographies are related to whether, how, and with whom individuals complete advance care planning (ACP), preparations for end-of-life medical care. Method: Data are from an Internet survey of 2,144 adults aged 18 to 64, all of whom were either married to or cohabiting with an opposite-sex partner. Results: Cohabitors were less likely than married people to complete ACP. Relationship quality was an important influence on ACP, but did not account for the differences between married and cohabiting persons. Differences were largely explained by the age composition of the groups. Discussion: Couples who foresee a long and stable future together are those most likely to engage in end-of-life planning, a preventative health behavior with long-term consequences for well-being.