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Mangal AL, Mücke M, Rolke R, Appelmann I. Advance directives in amyotrophic lateral sclerosis - a systematic review and meta-analysis. BMC Palliat Care 2024; 23:191. [PMID: 39075493 PMCID: PMC11285133 DOI: 10.1186/s12904-024-01524-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 07/16/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease of the upper and lower motoneuron. It is associated with a life expectancy of 2-4 years after diagnosis. Individuals experience paralysis, dysphagia, respiratory failure and loss of communicative function, rendering advance care planning (ACP) critically important. This systematic review primarily aimed to internationally compare the application of advance directives (AD) and ACP in ALS. Its secondary aim was to identify ACP preferences, identify fields for future research and to generate recommendations for improving patient care through ACP. METHODS We conducted a systematic literature review and meta-analysis. Five electronic databases (Embase, Medline, Scopus, PsycInfo and CENTRAL) were searched for qualitative and quantitative primary literature from 1999 to 2024. Cross-references were used to identify additional publications. Study selection was performed based on inclusion criteria. Number and content of AD were extracted systematically. After statistical analysis consecutive meta-analysis was performed for international differences and changes over time. Quality assessment of studies was performed using the MMAT (Mixed Methods Appraisal Tool). PROSPERO Registration (June 07, 2021) : CRD42021248040. RESULTS A total of 998 records was screened of which 26 were included in the synthesis. An increase in publication numbers of 88.9% was observed from 1999 to 2024. Results regarding use and content of AD were heterogeneous and international differences were detected. AD were signed in 60.4% of records (1,629 / 2,696 patients). The number of AD decreased over time when separating the review period in two decades (1st 1999-2011: 78% vs. 2nd 2012-2024: 42%). Study quality was superior in qualitative and mixed method designs compared to quantitative studies. CONCLUSION Further prospective studies should include detailed analyses on preferences regarding ventilation and artificial nutrition in ALS and should encompass countries of the global south. Despite the complexity of ACP with regard to individual patient needs, ACP should be part of each individual support plan for ALS patients and should specifically comprise a discussion on the preferred place of death. The available disease-specific AD documents should be preferred.
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Affiliation(s)
- Anne Lisa Mangal
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Martin Mücke
- Department of Digitalization and General Practice, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Roman Rolke
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Iris Appelmann
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, Aachen, 52074, Germany.
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Erdmann A, Spoden C, Hirschberg I, Neitzke G. Talking about the end of life: communication patterns in amyotrophic lateral sclerosis – a scoping review. Palliat Care Soc Pract 2022; 16:26323524221083676. [PMID: 35309870 PMCID: PMC8928370 DOI: 10.1177/26323524221083676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/04/2022] [Indexed: 11/26/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) leads to death on average 2–4 years after the onset of symptoms. Although many people with the disease decide in favour of life-sustaining measures, some consider hastening death. The objectives of this review are to provide an insight into the following questions: (1) How do people with amyotrophic lateral sclerosis (PALS), their families and health care professionals (HCPs) communicate about life-sustaining and life-shortening options? (2) What are the challenges for all involved in decision making and communication about this topic? To answer these questions, we searched eight databases for publications in English and German on end-of-life issues of PALS. We included texts published between 2008 and 2018, and updated our search to May 2020. Sources were analysed in MAXQDA using deductively and inductively generated codes. After the final analysis, 123 full texts were included in this review. We identified a wide range of communicative challenges and six different and, in part, opposite communication patterns: avoiding or delaying communication on end-of-life issues, openly considering dying and actively seeking assistance, ignoring or disregarding patients’ wishes, discussing and respecting the patients’ wishes, engaging in advance care planning and avoiding or delaying advance care planning. The literature reveals a very heterogeneous response to end-of-life issues in ALS, despite several good-practice suggestions, examples and guidelines. We derive a strong need for harmonization and quality assurance concerning communication with PALS. Avoiding or delaying communication, decision making and planning, as well as ignoring or disregarding the patient’s will by HCP can be judged as a violation of the ethical principles of autonomy and non-maleficence.
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Affiliation(s)
- Anke Erdmann
- Institute for Experimental Medicine, Medical Ethics Working Group, Kiel University, 24105 Kiel, Germany
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Celia Spoden
- German Institute for Japanese Studies, Tokyo, Japan
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Irene Hirschberg
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Gerald Neitzke
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
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3
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Erdmann A, Spoden C, Hirschberg I, Neitzke G. The wish to die and hastening death in amyotrophic lateral sclerosis: A scoping review. BMJ Support Palliat Care 2021; 11:271-287. [PMID: 33397660 PMCID: PMC8380909 DOI: 10.1136/bmjspcare-2020-002640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/05/2020] [Accepted: 11/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) develops into a life-threatening condition 2 to 4 years after the onset of symptoms. Although many people with the disease decide in favour of life-sustaining measures, thoughts about hastening death are not uncommon. OBJECTIVES Our aim was to examine the scope of literature on the wish to die in ALS and provide an insight into determinants and motives for different end-of-life options. METHODS We searched eight databases for English and German publications on death wishes in ALS for the period from 2008 to 2018 and updated the search up to May 2020. After the screening process, 213 full texts were included for the final analysis. We analysed the texts in MAXQDA, using deductively and inductively generated codes. RESULTS We identified end-of-life considerations, ranging from wishes to die without hastening death, to options with the possibility or intention of hastening death. Besides physical impairment, especially psychosocial factors, socio-demographic status and socio-cultural context have a great impact on decisions for life-shortening options. There is huge variation in the motives and determinants for end-of-life considerations between individuals, different societies, healthcare and legal systems. CONCLUSIONS For a variety of reasons, the information and counselling provided on different options for sustaining life or hastening death is often incomplete and insufficient. Since the motives and determinants for the wish to hasten death are extremely diverse, healthcare professionals should investigate the reasons, meaning and strength of the desire to die to detect unmet needs and examine which interventions are appropriate in each individual case.
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Affiliation(s)
- Anke Erdmann
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
- Institute for Experimental Medicine, Medical Ethics Working Group, Kiel University, Kiel, Germany
| | - Celia Spoden
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Irene Hirschberg
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Gerald Neitzke
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
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Genuis SK, Luth W, Campbell S, Bubela T, Johnston WS. Communication About End of Life for Patients Living With Amyotrophic Lateral Sclerosis: A Scoping Review of the Empirical Evidence. Front Neurol 2021; 12:683197. [PMID: 34421792 PMCID: PMC8371472 DOI: 10.3389/fneur.2021.683197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/09/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Communication about end of life, including advance care planning, life-sustaining therapies, palliative care, and end-of-life options, is critical for the clinical management of amyotrophic lateral sclerosis patients. The empirical evidence base for this communication has not been systematically examined. Objective: To support evidence-based communication guidance by (1) analyzing the scope and nature of research on health communication about end of life for amyotrophic lateral sclerosis; and (2) summarizing resultant recommendations. Methods: A scoping review of empirical literature was conducted following recommended practices. Fifteen health-related and three legal databases were searched; 296 articles were screened for inclusion/exclusion criteria; and quantitative data extraction and analysis was conducted on 211 articles with qualitative analysis on a subset of 110 articles that focused primarily on health communication. Analyses summarized article characteristics, themes, and recommendations. Results: Analysis indicated a multidisciplinary but limited evidence base. Most reviewed articles addressed end-of-life communication as a peripheral focus of investigation. Generic communication skills are important; however, substantive and sufficient disease-related information, including symptom management and assistive devices, is critical to discussions about end of life. Few articles discussed communication about specific end-of-life options. Communication recommendations in analyzed articles draw attention to communication processes, style and content but lack the systematized guidance needed for clinical practice. Conclusions: This review of primary research articles highlights the limited evidence-base and consequent need for systematic, empirical investigation to inform effective communication about end of life for those with amyotrophic lateral sclerosis. This will provide a foundation for actionable, evidence-based communication guidelines about end of life. Implications for research, policy, and practice are discussed.
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Affiliation(s)
- Shelagh K. Genuis
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Westerly Luth
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Sandra Campbell
- John W. Scott Health Sciences Library, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Tania Bubela
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Wendy S. Johnston
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Andersen PM, Kuźma-Kozakiewicz M, Keller J, Maksymowicz-Śliwińska A, Barć K, Nieporęcki K, Finsel J, Vazquez C, Helczyk O, Linse K, Häggström AC, Stenberg E, Semb O, Ciećwierska K, Szejko N, Uttner I, Herrmann A, Petri S, Meyer T, Ludolph AC, Lulé D. Caregivers' divergent perspectives on patients' well-being and attitudes towards hastened death in Germany, Poland and Sweden. Amyotroph Lateral Scler Frontotemporal Degener 2021; 23:252-262. [PMID: 34187249 DOI: 10.1080/21678421.2021.1936064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: During the course of amyotrophic lateral sclerosis (ALS), patients and their families are faced with existential decisions concerning life-prolonging and -shortening measures. Correct anticipation of patient's well-being and preferences is a prerequisite for patient-centered surrogate decision making. Methods: In Germany (N = 84), Poland (N = 77) and Sweden (N = 73) patient-caregiver dyads were interviewed. Standardized questionnaires on well-being (ADI-12 for depressiveness; ACSA for global quality of life) and wish for hastened death (SAHD) were used in ALS patients. Additionally, caregivers were asked to fill out the same questionnaires by anticipating patients' perspective (surrogate perspective). Results: Caregivers significantly underestimated patients' well-being in Germany and Poland. For Swedish caregivers, there were just as many who underestimated and overestimated well-being. The same was true for wish for hastened death in all three countries. For Swedish and Polish patients, caregivers' estimation of well-being was not even associated with patients' responses and the same was true for estimation of wish for hastened death in all three countries. Older caregivers and those with the most frequent encounter with the patient were the closest in their rating of well-being and wish for hastened death to the patients' actual state, while caregivers with chronic disease him/herself were more likely to underestimate patient's well-being. Discussion: Despite distinct cultural differences, there was a clear discrepancy between patients' and caregivers' perspective on patients' well-being and preferences towards life in all three countries. This possible bias in caregivers' judgment needs to be taken into account in surrogate decision making.
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Affiliation(s)
- Peter M Andersen
- Institute of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Magdalena Kuźma-Kozakiewicz
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland.,Neurodegenerative Diseases Research Group, Medical University of Warsaw, Warsaw, Poland
| | - Jürgen Keller
- Department of Neurology, University of Ulm, Ulm, Germany
| | | | - Krzysztof Barć
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | | | - Julia Finsel
- Department of Neurology, University of Ulm, Ulm, Germany
| | | | - Olga Helczyk
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Katharina Linse
- Department of Neurology, Technische Universität Dresden, and German Center for Neurodegenerative Diseases (DZNE), Dresden, Germany
| | | | - Erica Stenberg
- Institute of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Olof Semb
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | | | - Natalia Szejko
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Ingo Uttner
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Andreas Herrmann
- Department of Neurology, Technische Universität Dresden, and German Center for Neurodegenerative Diseases (DZNE), Dresden, Germany
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Thomas Meyer
- Department of Neurology, Charité CVK, Berlin, Germany
| | - Albert C Ludolph
- Department of Neurology, University of Ulm, Ulm, Germany.,German Center for Neurodegenerative Diseases (DZNE), Ulm, Germany
| | - Dorothée Lulé
- Department of Neurology, University of Ulm, Ulm, Germany
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Hauswirth AG, George HC, Lomen-Hoerth C. ALS patient and caregiver attitudes toward physician-hastened death in California. Muscle Nerve 2021; 64:428-434. [PMID: 34076273 DOI: 10.1002/mus.27343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION/AIMS Since 2016, six states have legalized physician-hastened death (PHD). Neuromuscular disorders, including amyotrophic lateral sclerosis (ALS), are common diagnoses for patients who use PHD, but how patients with ALS view PHD in California has not been systematically studied. We aimed to quantify how many patients with ALS and their caregivers have considered PHD and to assess reasons to consider using or not using it. METHODS This is a cross-sectional study at one ALS center surveying patients with ALS and their caregivers. Data on disease characteristics, demographics, quality of life, and depression were also collected. Descriptive statistics were used to analyze the data. Qualitative data were also collected and analyzed. Patients were followed up longitudinally to assess if they died or if they used PHD. RESULTS A small majority of ALS patients surveyed had considered or would consider using PHD (16/30). Patients most commonly described having intolerable symptoms, being a burden on their loved ones, and losing independence as reasons to consider using PHD. Many patients shared that "their life has purpose" and "they are making the most of their lives" as to why they are not considering PHD. Considering PHD was not related to disease severity or depression. On longitudinal follow-up, 10 of the 30 patients have died, and none have used PHD. DISCUSSION Pursuing PHD is a personal decision for each individual patient. This study shows that considering PHD is relatively common in ALS patients, independent of disease severity or presence of depression.
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Affiliation(s)
- Anna G Hauswirth
- University of California, San Francisco, School of Medicine, San Francisco, California, USA.,Internal Medicine Department, Kaiser San Francisco, San Francisco, California, USA
| | - Hannah C George
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Catherine Lomen-Hoerth
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
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7
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Silva-Moraes MH, Bispo-Torres AC, Barouh JL, Lucena PH, Armani-Franceschi G, Dorea-Bandeira I, Vieira F, Miranda-Scippa Â, Quarantini LC, Lucena R, Bandeira ID. Suicidal behavior in individuals with amyotrophic lateral sclerosis: A systematic review. J Affect Disord 2020; 277:688-696. [PMID: 32911219 DOI: 10.1016/j.jad.2020.08.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/01/2020] [Accepted: 08/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Amyotrophic Lateral Sclerosis (ALS) leads to a drastic reduction in quality of life, generating intense psychological distress and predisposing those affected to mental illness and, in more severe cases, suicidal behavior. OBJECTIVE This is a systematic review aiming to estimate the frequency of wish to die, suicide ideation and suicide in individuals with ALS using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). METHODS The following databases were used: Pubmed/MEDLINE, PsycINFO, Embase, SciELO, Biblioteca Virtual de Saúde (BVS), and Cochrane Library. The choice of appropriate descriptors, or their equivalents, to define the search terms was based on the technical and scientific vocabulary of each database. RESULTS 13 articles were included in the present systematic review, of which three were cross-sectional studies, nine were cohort-type and there was one case-control study. The studies show that individuals with ALS have a higher risk of suicide in relation to the general population, and there is evidence that this risk is even higher in the early stages of the disease. Major Depressive Disorder was the most prevalent mental disorder in the studies included. This mental health concern is often undertreated, leading to the increased susceptibility of this population to suicide. LIMITATIONS In general, the study samples represent a highly heterogeneous population while many instruments used in the data collection were not uniform. CONCLUSIONS The high degree of psychological vulnerability of this population, associated with a greater predisposition to suicidal behavior, should be minimized through public health measures.
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Affiliation(s)
| | | | - Judah L Barouh
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil; Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Harvard University, Boston, United States
| | - Pedro H Lucena
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | | | - Ingrid Dorea-Bandeira
- Faculdade de Tecnologia e Ciências, Salvador, Brazil; Laboratório de Neuropsicofarmacologia, Serviço de Psiquiatria do Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Flavia Vieira
- Laboratório de Neuropsicofarmacologia, Serviço de Psiquiatria do Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil; Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Praça XV de Novembro, s/n - Largo do Terreiro de Jesus, Salvador, Bahia, Brazil
| | - Ângela Miranda-Scippa
- Departamento de Neurociências e Saúde Mental, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Lucas C Quarantini
- Departamento de Neurociências e Saúde Mental, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil; Laboratório de Neuropsicofarmacologia, Serviço de Psiquiatria do Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Rita Lucena
- Departamento de Neurociências e Saúde Mental, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Igor D Bandeira
- Laboratório de Neuropsicofarmacologia, Serviço de Psiquiatria do Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil; Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Praça XV de Novembro, s/n - Largo do Terreiro de Jesus, Salvador, Bahia, Brazil.
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Ang K, Lim MY, Srinivasan S. Ethical and legal issues of tracheostomy ventilation in patients with amyotrophic lateral sclerosis. PROCEEDINGS OF SINGAPORE HEALTHCARE 2019. [DOI: 10.1177/2010105819828753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Doctors owe a legal duty of care to patients, of which legal standard of care, especially on advice, evolves over time. With the modified Montgomery test, informed consent involves a process of best interests decision-making accompanied by disclosure of relevant information in a comprehensible fashion, to the patient. Ethical issues confronting treatment decision and advice are also manifold and have to be confronted. For example, in amyotrophic lateral sclerosis (ALS), an incurable disease, death is usually due to respiratory failure. Tracheostomy ventilation (TV) may be the only alternative to death, yet patients on TV may be subject to the relentless progression of ALS resulting in a locked-in state. Through a case vignette of invasive ventilation for ALS, we examine the ethical and legal issues regarding choice of assisted ventilation in these patients, especially for TV, to ensure reasoned and defensible methodology in patient care. We also include a tracheostomy counselling info kit applicable for use prior to tracheostomy insertion.
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Affiliation(s)
- Kexin Ang
- Department of Neurology, National Neuroscience Institute, Singapore
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Ohnsorge K, Rehmann-Sutter C, Streeck N, Gudat H. Wishes to die at the end of life and subjective experience of four different typical dying trajectories. A qualitative interview study. PLoS One 2019; 14:e0210784. [PMID: 30653575 PMCID: PMC6336242 DOI: 10.1371/journal.pone.0210784] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 12/21/2018] [Indexed: 12/11/2022] Open
Abstract
RESEARCH AIMS The motivations that lead to wishes to die (WTD) in palliative care patients with cancer are relatively well studied. But little is known about WTD in other pathologies and the relation between subjective understandings of dying trajectories and a WTD. We investigated the WTD of palliative patients in four different dying trajectories: neurological diseases, organ failure, frailty due to age, and cancer. STUDY POPULATION 62 palliative cancer (n = 30) and non-cancer (n = 32) patients (10 neurological disease; 11 organ failure; 11 frailty), their families and health professionals in different palliative care settings (248 interviews). STUDY DESIGN AND METHODS Qualitative semi-structured interviews. Data analysis through Interpretive Phenomenological Analysis and Grounded Theory. RESULTS In addition to personal motivations, we found that people dealing with similar trajectories were often confronted with similar questions and concerns due to similar challenges. For four trajectories we show typical patterns, similarities and differences that should be considered when talking with patients about their WTD. These illness-related considerations do not explain the WTD completely, but give important information on the challenges for particular patient groups that might experience a WTD. In all patient groups, there were clear moments that triggered a WTD: for neurological patients it was experiencing breathlessness, high-dependency care, or when considering tube feeding or respiratory support; for persons with organ failure it was an acute burdensome crisis; for patients with cancer after the initial diagnosis, it was the first relapse or the move into advanced palliative care; for elderly frail persons it was the move into care facilities, or the loss of important relationships or capabilities. The feeling of being a burden to others was reported in all patient groups. INTERPRETATION WTD can be triggered within disease trajectories by specific conditions and transitional points that affect agency and self-understanding. A better understanding of the concerns and challenges of a particular dying trajectory as well as its characteristic trigger points can facilitate early and comprehensive communication about patients' WTD, and the underlying motivations and protective factors.
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Affiliation(s)
- Kathrin Ohnsorge
- Hospiz im Park, Hospital for Palliative Care, Arlesheim, Switzerland
| | | | - Nina Streeck
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Heike Gudat
- Hospiz im Park, Hospital for Palliative Care, Arlesheim, Switzerland
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10
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Therapeutic decisions in ALS patients: cross-cultural differences and clinical implications. J Neurol 2018; 265:1600-1606. [PMID: 29728768 DOI: 10.1007/s00415-018-8861-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Quantitative analysis of decision-making on therapeutic options in different sociocultural context in amyotrophic lateral sclerosis (ALS). METHODS ALS patients (n = 244) were consecutively recruited in Germany (n = 83), Poland (n = 83), and Sweden (n = 78) in a prospective cross-cultural study ( www.NEEDSinALS.com ). They were interviewed on preferences for therapeutic techniques including invasive (IV) and non-invasive ventilation (NIV), as well as percutaneous endoscopic gastrostomy (PEG) and on hypothetical termination of these using quantitative questions. Using standardized questionnaires, religiousness, personal values, quality of life, and depressiveness were assessed. RESULTS NIV was most frequently used in Germany and PEG in Sweden. Swedish patients were most liberal on initiation and termination of PEG, NIV and IV. Polish patients were mostly undecided and were least likely to consider discontinuing supportive management. Current use was partly associated with age, gender and state of physical function; also, financial support explained some variance. Future preferences on therapeutic options from the patient's perspective were also closely associated with cultural factors. The more oriented towards traditional and conservative values, the less likely patients were to decide for invasive therapeutic devices (IV, PEG), the least likely to have ideations to discontinue any device and the more likely to have an undecided attitude. CONCLUSIONS Current use of therapeutic options is determined by medical condition in analogy to clinical guidelines. For future considerations, other factors such as cultural background are crucial, yielding hurdles to be regarded in the implementation of advanced directives in a multicultural environment.
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Wang LH, Elliott MA, Jung Henson L, Gerena-Maldonado E, Strom S, Downing S, Vetrovs J, Kayihan P, Paul P, Kennedy K, Benditt JO, Weiss MD. Death with dignity in Washington patients with amyotrophic lateral sclerosis. Neurology 2016; 87:2117-2122. [PMID: 27770068 DOI: 10.1212/wnl.0000000000003335] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/28/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To describe the amyotrophic lateral sclerosis (ALS) patients who sought medication under the Washington State Death with Dignity (DWD) Act since its inception in 2009. METHODS Chart review at 3 tertiary medical centers in the Seattle/Puget Sound region and comparison to publicly available data of ALS and all-cause DWD cohorts from Washington and Oregon. RESULTS In Washington State, 39 patients with ALS requested DWD from the University of Washington, Virginia Mason, and Swedish Medical Centers beginning in 2009. The median age at death was 65 years (range 46-86). Seventy-seven percent of the patients used the prescriptions. All of the patients who used the medications passed away without complications. The major reasons for patients to request DWD as reported by participating physicians were loss of autonomy and dignity and decrease in enjoyable activities. Inadequate pain control, financial cost, and loss of bodily control were less commonly indicated. These findings were similar to those of the 92 patients who sought DWD in Oregon. In Washington and Oregon, the percentage of patients with ALS seeking DWD is higher compared to the cancer DWD cohort. Furthermore, compared to the all-cause DWD cohort, patients with ALS are more likely to be non-Hispanic white, married, educated, enrolled in hospice, and to have died at home. CONCLUSIONS Although a small number, ALS represents the disease with the highest proportion of patients seeking to participate in DWD. Patients with ALS who choose DWD are well-educated and have access to palliative or life-prolonging care. The use of the medications appears to be able to achieve the patients' goals without complications.
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Affiliation(s)
- Leo H Wang
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT.
| | - Michael A Elliott
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Lily Jung Henson
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Elba Gerena-Maldonado
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Susan Strom
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Sharon Downing
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Jennifer Vetrovs
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Paige Kayihan
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Piper Paul
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Kate Kennedy
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Joshua O Benditt
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
| | - Michael D Weiss
- From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT
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Gould RL, Coulson MC, Brown RG, Goldstein LH, Al-Chalabi A, Howard RJ. Psychotherapy and pharmacotherapy interventions to reduce distress or improve well-being in people with amyotrophic lateral sclerosis: A systematic review. Amyotroph Lateral Scler Frontotemporal Degener 2015; 16:293-302. [PMID: 26174444 DOI: 10.3109/21678421.2015.1062515] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Our objective was to systematically review and critically evaluate the evidence for psychotherapy and pharmacotherapy interventions for reducing distress or improving well-being in people with amyotrophic lateral sclerosis (pwALS). Online bibliographic databases and clinical trial registers were searched and an assessment of study quality was conducted. Seven thousand two hundred and twenty-three studies were identified, of which five met inclusion criteria (four completed and one in progress). All studies examined psychotherapeutic interventions, and no studies investigated pharmacotherapy. Two studies adopted a randomized controlled trial design, one a controlled trial design and two a cohort design. Sample sizes were small in all studies (overall n = 145). The quality of completed studies was generally poor, with evidence that all were at potential risk of bias in numerous areas. Improvements in well-being were found with expressive disclosure (compared to no disclosure), cognitive behavioural therapy/counselling (compared to non-randomized pharmacotherapy) and hypnosis in the short term only, while no improvements were seen with a life review intervention. In conclusion, there is currently insufficient evidence to recommend the use of specific psychotherapy interventions for reducing distress or improving well-being in pwALS, and no evidence to support pharmacotherapy interventions. Research is urgently needed to address these significant gaps in the literature.
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Affiliation(s)
- Rebecca L Gould
- a Department of Old Age Psychiatry , Institute of Psychiatry, King's College London , London , UK
| | - Mark C Coulson
- b Department of Psychology , School of Science and Technology, Middlesex University , London , UK
| | - Richard G Brown
- c Department of Psychology , Institute of Psychiatry, King's College London , London , UK
| | - Laura H Goldstein
- c Department of Psychology , Institute of Psychiatry, King's College London , London , UK
| | - Ammar Al-Chalabi
- d Department of Basic and Clinical Neuroscience , Institute of Psychiatry, Psychology & Neuroscience, King's College London , London , UK
| | - Robert J Howard
- a Department of Old Age Psychiatry , Institute of Psychiatry, King's College London , London , UK
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13
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Connolly S, Galvin M, Hardiman O. End-of-life management in patients with amyotrophic lateral sclerosis. Lancet Neurol 2015; 14:435-42. [PMID: 25728958 DOI: 10.1016/s1474-4422(14)70221-2] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Most health-care professionals are trained to promote and maintain life and often have difficulty when faced with the often rapid decline and death of people with terminal illnesses such as amyotrophic lateral sclerosis (ALS). By contrast, data suggest that early and open discussion of end-of-life issues with patients and families allows time for reflection and planning, can obviate the introduction of unwanted interventions or procedures, can provide reassurance, and can alleviate fear. Patients' perspectives regarding end-of-life interventions and use of technologies might differ from those of the health professionals involved in their care, and health-care professionals should recognise this and respect the patient's autonomy. Advance care directives can preserve autonomy, but their legal validity and use varies between countries. Clinical management of the end of life should aim to maximise quality of life of both the patient and caregiver and, when possible, incorporate appropriate palliation of distressing physical, psychosocial, and existential distress. Training of health-care professionals should include the development of communication skills that help to sensitively manage the inevitability of death. The emotional burden for health-care professionals caring for people with terminal neurological disease should be recognised, with structures and procedures developed to address compassion, fatigue, and the moral and ethical challenges related to providing end-of-life care.
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Affiliation(s)
- Sheelah Connolly
- Academic Unit of Neurology, Trinity College Dublin, Trinity Biomedical Sciences Institute, 152-160 Pearse Street, Dublin 2, Republic of Ireland.
| | - Miriam Galvin
- School of Nursing and Human Sciences, Dublin City University, Glasnevin, Dublin 9, Republic of Ireland
| | - Orla Hardiman
- Academic Unit of Neurology, Trinity College Dublin, Trinity Biomedical Sciences Institute, 152-160 Pearse Street, Dublin 2, Republic of Ireland; Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Republic of Ireland
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14
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Levitsky GN, Levitsky AS, Gilod VM. Mental disorders in patients with lateral amyotrophic sclerosis and their family members. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:64-67. [DOI: 10.17116/jnevro20151152164-67] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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15
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Pagnini F, Phillips D, Langer E. A mindful approach with end-of-life thoughts. Front Psychol 2014; 5:138. [PMID: 24600429 PMCID: PMC3930860 DOI: 10.3389/fpsyg.2014.00138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/03/2014] [Indexed: 12/14/2022] Open
Affiliation(s)
- Francesco Pagnini
- Department of Psychology, Catholic University of Milan Milan, Italy ; Department of Psychology, Harvard University Cambridge, MA, USA ; Niguarda Ca' Granda Hospital Milan, Italy
| | - Deborah Phillips
- Department of Psychology, Catholic University of Milan Milan, Italy ; Department of Psychology, Harvard University Cambridge, MA, USA ; Niguarda Ca' Granda Hospital Milan, Italy
| | - Ellen Langer
- Department of Psychology, Catholic University of Milan Milan, Italy ; Department of Psychology, Harvard University Cambridge, MA, USA ; Niguarda Ca' Granda Hospital Milan, Italy
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16
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Lulé D, Nonnenmacher S, Sorg S, Heimrath J, Hautzinger M, Meyer T, Kübler A, Birbaumer N, Ludolph AC. Live and let die: existential decision processes in a fatal disease. J Neurol 2014; 261:518-25. [PMID: 24413639 DOI: 10.1007/s00415-013-7229-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 12/08/2013] [Accepted: 12/19/2013] [Indexed: 12/14/2022]
Abstract
Decisions and determinants of decisions to prolong or shorten life in the course of fatal diseases like ALS are poorly understood. Decisions and desire for hastened death of N = 93 ALS patients were investigated in a prospective longitudinal approach three times in the course of 1 year. Determinants of decisions were evaluated: quality of life (QoL), depression, feeling of being a burden, physical function, social support and cognitive status. More than half of patients had a positive attitude towards life-sustaining treatments and they had a low desire for hastened death. Of those with undecided or negative attitude, 10 % changed attitudes towards life-sustaining treatments in the course of 1 year. Patients' desire to hasten death was low and decreased significantly within 1 year despite physical function decline. Those with a high desire for hastened death decided against invasive therapeutic treatments. QoL, depression and social support were not predictors for vital decisions and remained stable. Feeling of being a burden was a predictor for decisions against life-supporting treatments. Throughout physical function loss, decisions to prolong life are flexibly adapted while desire to shorten life declines. QoL was stable and not a predictor for vital decisions, even though anticipated low QoL has been reported to be the reason to request euthanasia. In contrast, feeling of being a burden in decision making needs more attention in clinical counselling. Considering a patient's possible adaptation processes in the course of a fatal disease is necessary.
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Affiliation(s)
- Dorothée Lulé
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany,
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17
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Eisen A, Krieger C. Ethical considerations in the management of amyotrophic lateral sclerosis. Prog Neurobiol 2013; 110:45-53. [DOI: 10.1016/j.pneurobio.2013.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 04/26/2013] [Accepted: 05/17/2013] [Indexed: 12/11/2022]
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18
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Stutzki R, Weber M, Reiter-Theil S. Finding their voices again: a media project offers a floor for vulnerable patients, clients and the socially deprived. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2013; 16:739-750. [PMID: 23404541 PMCID: PMC3832779 DOI: 10.1007/s11019-013-9468-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
'DU bist Radio' (DBR) is an award winning [DBR has been awarded with the "Catholic Media Award of the German Bishops Conference, Prädikat WERTvoll" (2011), the Suisse "Media Prize Aargau/Solothurn" (2010), the German "Alternative Media Award" (2009) and was nominated for the "Prix Europa" (2009)] monthly radio format that goes on air on three Swiss radio stations. The purpose of this program which was first broadcast in 2009 is the development of a new media format which--without applying any journalistic (or other) filter and influence--conveys authenticity of expression amongst society's most vulnerable fellow citizens such as patients, clients and the socially deprived. So-called marginal groups are encouraged to speak for themselves, as a possible paradigm case for encouraging the inclusion of patients' and relatives' "unfiltered" voices in general and in clinical ethics as well. Before handing over the microphone to the groups in focus, a team of journalists, educated in medical ethics, over a period of 4 days, teaches them on-site radio skills and craft. Once this task is completed and the actual production of the broadcast begins, the media crew does not exert any influence whatsoever on the content of the 1-h program. Thus, the final product is solely created and accounted for by the media-inexperienced participants, leading to unforeseen and often surprising results. It is discussed that the DBR approach of fostering authenticity of expression can serve as an enhancement to today's respect and autonomy oriented field of medical ethics.
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Affiliation(s)
- Ralf Stutzki
- Clinical Ethics, University Hospital Basel/Psychiatric Hospitals of the University Basel, IBMB, University of Basel, Schanzenstrasse 13, 4056, Basel, Switzerland,
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Stutzki R, Weber M, Reiter-Theil S, Simmen U, Borasio GD, Jox RJ. Attitudes towards hastened death in ALS: A prospective study of patients and family caregivers. Amyotroph Lateral Scler Frontotemporal Degener 2013; 15:68-76. [DOI: 10.3109/21678421.2013.837928] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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