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

Shared Decision-Making for Patients with Stroke in Neurocritical Care: A Qualitative Meta-Synthesis

Decision-making for patients with stroke in neurocritical care is uniquely challenging because of the gravity and high preference sensitivity of these decisions. Shared decision-making (SDM) is recommended to align decisions with patient values. However, limited evidence exists on the experiences and perceptions of key stakeholders involved in SDM for neurocritical patients with stroke. This review aims to address this gap by providing a comprehensive analysis of the experiences and perspectives of those involved in SDM for neurocritical stroke care to inform best practices in this context. A qualitative meta-synthesis was conducted following the methodological guidelines of the Joanna Briggs Institute (JBI), using the thematic synthesis approach outlined by Thomas and Harden. Database searches covered PubMed, CIHAHL, EMBASE, PsycINFO, and Web of Science from inception to July 2023, supplemented by manual searches. After screening, quality appraisal was performed using the JBI Appraisal Checklist. Data analysis comprised line-by-line coding, development of descriptive themes, and creation of analytical themes using NVivo 12 software. The initial search yielded 7,492 articles, with 94 undergoing full-text screening. Eighteen articles from five countries, published between 2010 and 2023, were included in the meta-synthesis. These studies focused on the SDM process, covering life-sustaining treatments (LSTs), palliative care, and end-of-life care, with LST decisions being most common. Four analytical themes, encompassing ten descriptive themes, emerged: prognostic uncertainty, multifaceted balancing act, tripartite role dynamics and information exchange, and influences of sociocultural context. These themes form the basis for a conceptual model offering deeper insights into the essential elements, relationships, and behaviors that characterize SDM in neurocritical care. This meta-synthesis of 18 primary studies offers a higher-order interpretation and an emerging conceptual understanding of SDM in neurocritical care, with implications for practice and further research. The complex role dynamics among SDM stakeholders require careful consideration, highlighting the need for stroke-specific communication strategies. Expanding the evidence base across diverse sociocultural settings is critical to enhance the understanding of SDM in neurocritical patients with stroke.Trial registration This study is registered with PROSPERO under the registration number CRD42023461608.

Advance Care Planning: A Story of Trust Within the Family

As the family usually plays a central role at the end of life, the quality of family relationships may influence how individuals approach advance care planning (ACP). Our study investigates the associations of trust in relatives with regard to end-of-life (EOL) issues-used as a proxy measure of family relationship quality-with individuals' engagement in EOL discussions, advance directive (AD) awareness, approval and completion, and designation of a healthcare proxy. Using nationally representative data of adults aged 55 years and over from wave 6 (2015) of the Survey of Health, Ageing, and Retirement in Europe (SHARE) in Switzerland (n = 1911), we show that complete trust in relatives is related to higher engagement in ACP. Subject to patient consent, the family should, therefore, be included in the ACP process, as such practice could enhance patient-centered EOL care and quality of life at the end of life.

COVID-19 vaccine hesitancy between family decision-makers and non-decision-makers among college teachers

BACKGROUND

Teachers with high educational levels significantly impact the health-related knowledge and attitudes of young students and their family members. This study aimed to investigate the coronavirus disease 2019 (COVID-19) vaccine hesitancy and associated factors, and compare the differences between decision-makers and non-decision-makers among college teachers.

METHODS

A cross-sectional online survey was administered across mainland China from 4 to 7 August 2021. Overall, 251 college teachers were included using snowball sampling. A multivariable logistic regression model was applied to explore the association between decision-makers and hesitancy to receive a COVID-19 vaccine.

RESULTS

Overall, 42.2% of the teachers were hesitant to being vaccinated against COVID-19. The hesitancy rate was lower among primary decision-makers than that among non-decision-makers (34.8% vs. 60.3%, p < .001). Primary decision-makers were less hesitant regarding COVID-19 vaccination than non-decision-makers (OR = 0.37, 95% CI 0.20-0.70); remarkably, whereas those engaged in nursing education versus non-medical related professional education (OR = 2.67, 95% CI 1.29-5.49), and partial versus full-course vaccination recipients (OR = 4.48, 95% CI: 1.76-11.42) were more likely to be hesitant regarding COVID-19 vaccination.

CONCLUSION

Our findings indicate that a high proportion of college teachers in China are hesitant to receiving COVID-19 vaccination, and that primary decision-makers are less likely to exhibit hesitancy to being vaccinated against COVID-19 than non-decision-makers in their family. Family decision-makers among teachers can be considered a priority for COVID-19 vaccine promotion, thereby enhancing vaccine acceptance among vulnerable populations-including older adults and children-and preventing adverse outcomes.KEY MESSAGESQuestion: How prevalent is COVID-19 vaccine hesitancy among college teachers? Do differences exist between decision-makers and non-decision-makers?Findings: We found that a substantial proportion of college teachers are hesitant to being vaccinated against COVID-19, and that family decision-makers exhibited a lower hesitancy rate than non-decision-makers.Meaning: Our findings indicate that distinguishing between family decision-makers and non-decision-makers is necessary to facilitate vaccination promotion interventions among college teachers.

Impact of household decision makers' hesitancy to vaccinate children against COVID-19 on other household members: A family-based study in Taizhou, China

Background

Vaccination is the most effective means of preventing outbreaks of infectious diseases, and family ;decision makers play an important role in decision-making regarding family matters and may influence other family members to take an active role in vaccinating children against COVID-19.

Purpose

This study examined the influence of family decision makers on the hesitation of other family members to vaccinate their children against COVID-19.

Methods

A population-based, self-administered online questionnaire was administered in Taizhou, China, from September 1, 2021, to September 15, 2021. The questionnaire included demographic information, knowledge, attitudes, and perceptions about the COVID-19 vaccine as well as hesitation regarding the use of the COVID-19 vaccination in children. In total, 490 respondents were included in this study. Logistic regression was used to assess the factors associated with vaccine hesitancy.

Results

In total, 490 respondents from 190 households were interviewed. Of the 190 family decision makers, 43.7% (83/190) were hesitant to vaccinate their children against COVID-19. When family decision makers were hesitant to vaccinate children against COVID-19, 65.1% (82/126) of the other family members expressed similar hesitancy regarding vaccination. When family decision makers were not hesitant to vaccinate children, only 21.3% (37/174) of other family members were hesitant to do so. In the regression analysis, family decision makers' hesitation to vaccinate their children was associated with other family members' hesitation (OR=6.264, 95% CI:3.132-12.526). In addition, decision makers' perceptions of the safety of the vaccine (OR=0.422, 95% CI:0.215-0.826) and hesitation to vaccinate themselves (OR=8.967, 95% CI:4.745-16.948) influenced their hesitation to vaccinate their children.

Conclusion

The present study found that family decision makers' hesitation to vaccinate children against COVID-19 influenced other family members' hesitation to vaccinate children. In addition, family decision makers' perceptions of the safety of the vaccine and their hesitation to vaccinate themselves influenced other family members' hesitation to vaccinate their children.

Circumstances affecting patients' euthanasia or medically assisted suicide decisions from the perspectives of patients, relatives, and healthcare professionals: A qualitative systematic review

This study aims to explore circumstances affecting patients' euthanasia and medically assisted suicide (MAS) decisions from the perspectives of patients, relatives, and healthcare professionals. A qualitative systematic review was performed following PRISMA recommendations. The review protocol is registered in PROSPERO (CRD42022303034). Literature searches were conducted in MEDLINE, EMBASE, CINAHL Complete, Eric, PsycInfo, and citation pearl search in Scopus from 2012 to 2022. In total, 6840 publications were initially retrieved. The analysis included a descriptive numerical summary analysis and a qualitative thematic analysis of 27 publications, resulting in two main themes-Contexts and factors influencing actions and interactions, and Finding support while dealing with resistance in euthanasia and MAS decisions-and related sub-themes. The results illuminated the dynamics in (inter)actions between patients and involved parties that might both impede and facilitate patients' decisions related to euthanasia/MAS, potentially influencing patients' decision-making experiences, and the roles and experiences of involved parties.

Adaptation of the Quality of Communication Questionnaire for Family Members and Its Validity Evidence for Use in Brazil

Assessment of communication between physicians and patients' family members is essential to improving healthcare quality. To adapt the Quality of Communication Questionnaire (QoC) for family members and to analyze its validity evidence for use in Brazil. Data were collected between 2017 and 2019, with family members of patients in intensive care (IC) and palliative care (PC) from five public hospitals in the South Brazil. The QoC was adapted for family members for use in Brazil, and its cross-cultural adaptation was carried out. The clarity and cultural appropriateness of the pre-final version were evaluated by 30 family members of patients in IC. The final version was responded by 198 family members of patients. All items were considered clear, and appropriate to Brazilian culture. The goodness of fit index for proposed model had CFI 0.96 (CI95%: 0.94 - 0.98), TLI 0.95 (CI95%: 0.92 - 0.97), RMSEA 0.07 (CI90%: 0.06 - 0.08), and χ²/df 2.18. Cronbach's alpha coefficient (α) among family members of patients in PC was 0.88 for the general communication (first subscale) and 0.80 for the end-of-life communication (second subscale). However, among family members of patients in IC, α was 0.86 for the first subscale and only 0.53 for the second subscale. The QoC for family members and its cross-cultural adaptation were carried out successfully. It has strong validity evidence among those with loved ones in PC, but only the QoC general communication subscale has strong validity evidence among those with loved ones in IC.

Role of patients' family members in end-of-life communication: an integrative review

OBJECTIVES

To synthesise empirical findings on the role of family in end-of-life (EOL) communication and to identify the communicative practices that are essential for EOL decision-making in family-oriented cultures.

SETTING

The EOL communication settings.

PARTICIPANTS

This integrative review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline. Relevant studies published between 1 January 1991 and 31 December 2021 were retrieved from four databases, including the PsycINFO, Embase, MEDLINE and Ovid nursing databases, using keywords with meanings of 'end-of-life', 'communication' and 'family'. Data were then extracted and coded into themes for analysis. The search strategy yielded 53 eligible studies; all 53 included studies underwent quality assessment. Quantitative studies were evaluated using the Quality Assessment Tool, and Joanna Briggs Institute Critical Appraisal Checklist was used for qualitative research.

PRIMARY AND SECONDARY OUTCOME MEASURES

Research evidence on EOL communication with a focus on family.

RESULTS

Four themes emerged from these studies: (1) conflicts in family decision-making in EOL communication, (2) the significance of timing of EOL communication, (3) difficulty in identification of a 'key person' who is responsible for decisions regarding EOL care and (4) different cultural perspectives on EOL communication.

CONCLUSIONS

The current review pointed towards the importance of family in EOL communication and illustrated that family participation likely leads to improved quality of life and death in patients. Future research should develop a family-oriented communication framework which is designed for the Chinese and Eastern contexts that targets on managing family expectations during prognosis disclosure and facilitating patients' fulfilment of familial roles while making EOL decision-making. Clinicians should also be aware of the significance of the role of family in EOL care and manage family members' expectations according to cultural contexts.

Analyzing the Housing Consumer Preferences via Analytic Hierarchy Process (AHP) in Dubai, United Arab Emirates

Dubai was one of the top three real estate destinations in the world for investment in 2020. This paper aims to understand the order of preference for various housing determinants by housing consumers in Dubai. As a methodology, a survey was conducted on Dubai residents, and Analytic Hierarchy Process (AHP) was performed to identify the housing determinants and consumers’ preferences. In addition, the respondents’ demographic characteristics identified priorities by income, place of residence, age, gender, and type of house. The results showed that housing consumers place importance on housing price and rent (0.0918), and the investment value (0.0866). However, there was no serious consideration for social and psychological factors, other than safety (0.0730). Regarding gender, men place more importance on the housing price and rent (0.113), and the investment value (0.110). In comparison, women place more importance on factors such as the convenience of transportation (0.104), safety (0.093), and residential environment (0.082). In the age groups, the interest in the educational environment (0.081) among the 40-year-olds was relatively high. In terms of monthly income, the higher the income, the higher the interest in investment value (0.086).

Associations Between Family Member Involvement and Outcomes of Patients Admitted to the Intensive Care Unit: Retrospective Cohort Study

BACKGROUND

Little is known about family member involvement, by relationship status, for patients treated in the intensive care unit (ICU).

OBJECTIVE

Using documentation of family interactions in clinical notes, we examined associations between child and spousal involvement and ICU patient outcomes, including goals of care conversations (GOCCs), limitations in life-sustaining therapy (LLST), and 3-month mortality.

METHODS

Using a retrospective cohort design, the study included a total of 858 adult patients treated between 2008 and 2012 in the medical ICU at a tertiary care center in northeastern United States. Clinical notes generated within the first 48 hours of admission to the ICU were used with standard machine learning methods to predict patient outcomes. We used natural language processing methods to identify family-related documentation and abstracted sociodemographic and clinical characteristics of the patients from the medical record.

RESULTS

Most of the 858 patients were White (n=650, 75.8%); 437 (50.9%) were male, 479 (55.8%) were married, and the median age was 68.4 (IQR 56.5-79.4) years. Most patients had documented GOCC (n=651, 75.9%). In adjusted regression analyses, child involvement (odds ratio [OR] 0.81; 95% CI 0.49-1.34; P=.41) and child plus spouse involvement (OR 1.28; 95% CI 0.8-2.03; P=.3) were not associated with GOCCs compared to spouse involvement. Child involvement was not associated with LLST when compared to spouse involvement (OR 1.49; 95% CI 0.89-2.52; P=.13). However, child plus spouse involvement was associated with LLST (OR 1.6; 95% CI 1.02-2.52; P=.04). Compared to spouse involvement, there were no significant differences in the 3-month mortality by family member type, including child plus spouse involvement (OR 1.38; 95% CI 0.91-2.09; P=.13) and child involvement (OR 1.47; 95% CI 0.9-2.41; P=.12).

CONCLUSIONS

Our findings demonstrate that statistical models derived from text analysis in the first 48 hours of ICU admission can predict patient outcomes. Early child plus spouse involvement was associated with LLST, suggesting that decisions about LLST were more likely to occur when the child and spouse were both involved compared to the involvement of only the spouse. More research is needed to further understand the involvement of different family members in ICU care and its association with patient outcomes.

Acquiescence is Not Agreement: The Problem of Marginalization in Pediatric Decision Making

Although parents are the default legal surrogate decision-makers for minor children in the U.S., shared decision making in a pluralistic society is often much more complicated, involving not just parents and pediatricians, but also grandparents, other relatives, and even community or religious elders. Parents may not only choose to involve others in their children's healthcare decisions but choose to defer to another; such deference does not imply agreement with the decision being made and adds complexity when disagreements arise between surrogate decision-makers for minor children and their physicians. I argue that clinicians and ethicists have a duty to consider voices marginalized by hierarchical structures, including but not limited to gender-based inequalities. This approach involves negotiating potential conflicts: between respecting differences of culture and religion, on one hand, and assuring that the wishes of those who are most invested in children's lives are considered, on the other.

The Meaning of Words and Why They Matter During End-of-Life Conversations

Effective communication during end-of-life is crucial for health care delivery, but misinterpretation can influence how the quality of the care is rendered and perceived.

Could Caregivers' Stressful Care Experiences Be Related to Their Attitudes towards Advance Care Planning? A Cross-Sectional Descriptive Study

Previous research has shown that care experiences influence the willingness for advance care planning (ACP). Family caregivers have increased contact with medical providers and procedures in the process of caring, and they have also witnessed the disability and suffering of patients. However, few studies have focused on family caregivers to understand their attitudes towards ACP. The aim of this cross-sectional study was to acknowledge family caregivers' attitudes towards ACP and the related factors, especially care stress and experiences during the care process. We interviewed 291 family caregivers, and the demographics of the caregivers and care recipients, the clinical condition of care recipients, and the caregivers' stress and care experiences were collected via anonymous questionnaires. Multiple logistic regression was performed to determine the factors associated with the attitudes towards ACP. We found that the caregiver having private health insurance (p < 0.001) and a completed DNR (p < 0.001) and the experience of recipients admitted to the ICU (p = 0.019) are associated with caregiver's positive attitudes towards ACP. The greater the stress of conflict within a family over care decisions, the more participants think that ACP is important (p = 0.011). It is suggested that (1) in a family-centered culture, a public strategy for promoting ACP could be to emphasize the benefits of ACP in reducing family conflicts, and (2) when people make financial plans, they should also be provided with information about ACP to enable them to form a more integral plan for their future.

Quality of Communication Questionnaire for Patients Hospitalized in Intensive and Palliative Care: Validity Evidence for Use in Brazil

The Quality of Communication Questionnaire (QoC) was culturally adapted for Brazil due to its importance and use in several studies and different scenarios. The objective of this study was to evaluate the validity evidence of the Brazilian version of the QoC. A validation study was carried out involving 253 patients admitted to five public hospitals in Southern Brazil. Data were analyzed using descriptive analysis, Cronbach's alpha (α) to assess internal consistency, exploratory factor analysis, and goodness-of-fit index. One hundred and three patients were in intensive care (IC), and 150 were in palliative care (PC). The participants' mean age was 51 years (SD = 14.2). QoC,and its general communication subscale, and end-of-life communication subscale means were 5.5 (SD = 1.6), 8.8 (SD = 1.5), and 5.5 (SD = 1.6) respectively. Among patients in IC, QoC Cronbach's alpha was .75, and .84 in the general communication subscale and .51 in the end-of-life communication subscale. Among patients in PC, QoC Cronbach's alpha was .83, and .88 in the general communication subscale, and .71 in the end-of-life communication subscale. The root mean square error of approximation was .07 (90% CI: .04 - .08); Tucker-Lewis index was .97 (95% CI: .95 - .98); comparative fit index was .98 (95% CI: .97 - .99), and χ²/df ratio was 1.33 (χ²[53] = 70.858, p = .05). The authors conclude that the general communication subscale of QoC Brazilian version has good validity evidence for patients in IC and PC, whereas the end-of-life communication subscale is only valid for patient in PC.

This Is Us: An Analysis of Mediated Family Communication at End-of-Life

Death is a ubiquitous theme in television dramas and we argued that mediated depictions of end-of-life experiences have the potential to provide glimpses into the ways in which characters experience real-life issues and can serve as conversation starters within family viewers. The study aimed to identify how a popular television drama, This is Us, depicted end-of-life communication. Analysis of season one revealed 54 conversations about end-of-life, two explicit death scenes, and three implied death scenes. Results also illustrate how the storyline within the show clearly depicts the impact end-of-life has on the family system, emphasizing the ongoing interdependence, hierarchy, and boundary (re)negotiation as a result of death. Findings advance understanding of how mediated narratives can illustrate end-of-life scenarios and conversations within the family system and can provide observational opportunities for modeling end-of-life communication behaviors within their families.

Nobody Wants to Talk About Dying: Facilitating End-of-Life Discussions

BACKGROUND

This educational study investigated the association between nursing staff and end-of-life discussions in an assisted living facility. Although mandated, these conversations often are deficient due to health care providers' limited knowledge on advance care documents.

METHOD

All staff underwent end-of-life training to identify their own reservations that prevent involvement with advance directive completion, develop advance directive competency, recognize the ramifications when advance directives are not documented, and role-play to experience different character viewpoints.

RESULTS

The group discussions and interview data were summarized into four main themes: not qualified to broach the end-of-life documents; reluctance to get involved; right place, right time, and right words; and who wants to think about death? Eleven subthemes that detailed descriptions from each category also were identified.

CONCLUSION

Staff acknowledged the value of in-service education to alleviate their uncertainty on the subject matter, gaining confidence, proficiency, and perspectives with end-of-life planning. [J Contin Educ Nurs. 2021;52(6):287-293.].

Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting

BACKGROUND

There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient's wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions.

METHODS

Case report and discussion of the associated ethical issues.

RESULTS

We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team.

CONCLUSION

It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.

Barriers in implementing the dying patient law: the Israeli experience - a qualitative study

Background

Coping with end-of-life issues is a major challenge for governments and health systems. Despite progress in legislation, many barriers exist to its full implementation. This study is aimed at identifying these end-of-life barriers in relation to Israel.

Methods

Qualitative in-depth interviews using professionals and decision makers in the health-care and related systems (n = 37) were carried out, along with two focus groups based on brainstorming techniques consisting of nurses (n = 10) and social workers (n = 10). Data was managed and analyzed using Naralyzer software.

Results

Qualitative analysis showed identification of six primary barriers: 1) law, procedures, and forms; 2) clinical aspects; 3) human aspects; 4) knowledge and skills of medical teams; 5) communication; and 6) resource allocation. These were further divided into 44 sub area barriers.

Conclusions

This study highlights the role of the family doctor in end-of-life by training physicians in decision-making workshops and increasing their knowledge in the field of palliative medicine. Effectively channeling resources, knowledge, and support for medical teams, by accounting for the structure and response of the units for home treatment will improve patient’s access to information on and support for end-of-life laws, as well as reduce legislative barriers in other countries that face the same issues.

Dying on television versus dying in intensive care units following withdrawal of life support: how normative frames may traumatise the bereaved

While treatment is often withdrawn from patients in intensive care units (ICUs), few people outside the healthcare profession have witnessed a death under such circumstances. Family members who have made the decision to withdraw treatment may have expectations about the dying process, what constitutes a good death and how they should behave in an ICU based on popular prime-time television series. An inductive comparative thematic coding strategy is therefore used to examine how death following treatment withdrawal as depicted in a US medical drama (Grey's Anatomy) differs from realities observed for 6 months fieldwork at an ICU in Canada. Three common frames (privacy, emotional control and memorialising) help patients' intimates normalise the unfamiliar experience and guide their behaviour during the event. However, discrepancies between media representations and experiences in the ICU, especially around the frames of timing of death and the physicality of the unbounded body (incontinence and agonal breathing), can traumatise them. The bereaved may be left viewing ventilator withdrawal and dying as chaotic processes and believing their loved one suffered through a bad death. Understanding these normative and discrepant frames should help healthcare professionals better prepare the public to witness death.

The decision partner in healthcare decision-making: A concept analysis

BACKGROUND

The decision partner concept emerged to describe someone who contributes to healthcare decision-making with a patient. There is a need for greater precision and consensus surrounding its conceptual definition and use in broader populations.

OBJECTIVE

To define and describe the decision partner concept within the context of healthcare decision-making.

DESIGN

A concept analysis.

DATA SOURCES

We searched the following databases for articles published between 1990-2017: PsychINFO, PubMed, Embase, and CINAHL. We included qualitative, quantitative, or mixed methods studies that used the term decision partner in the context of healthcare decision-making.

METHODS

We applied the Walker and Avant method to identify the antecedents, attributes, related concepts, consequences, and empirical referents of the concept, with major themes identified.

RESULTS

From the 112 articles included in this concept analysis, 6 defining attributes of decision partner were identified: (1) has a relationship with the patient, (2) demonstrates a willingness to participate in decision-making, (3) articulates a clear understanding of both the patient's health condition and the decisions that must be made, (4) demonstrates decision-making self-efficacy; (5) exemplifies an emotional capacity to participate in decision-making, and (6) willing to fulfill several supportive roles including patient advocate and the "hub of information".

CONCLUSIONS

A unifying definition and discussion of the decision partner concept has been developed. Our findings: (1) offer insights into refining the concept across various diseases and healthcare encounters, (2) contribute to developing theoretical models and empirical research to refine antecedents, attributes, consequences, (3) serve as a foundation to develop instruments to measure the concept and (4) highlight the need to design interventions that include and support decision partners in healthcare decision-making.

A psychometric study of the decisional conflict scale in surrogate decision makers

OBJECTIVE

To assess the psychometric properties of the 16-item Decisional Conflict Scale (DCS) in surrogate decision makers.

METHODS

With a sample of 472 surrogates from intensive care units in five academic medical centers across the United States, we performed the analysis in five phases to 1) model the congeneric structure with confirmatory factor analysis and assess 2) internal consistency reliability, 3) the unidimensional or global assessment, 4) factorial invariance across surrogate gender, and 5) individual item influence on the domains.

RESULTS

The congeneric model fit the data, with all factor loadings (0.577-0.955) statistically significant at p < 0.05. All subdomains had acceptable internal consistency (0.751-0.981). The bifactor model supported the sub-domains or the global construct as appropriate measurement models. The DCS demonstrated invariance for use across surrogate genders. The most difficult item for surrogates to complete was "This decision is easy for me to make" [MNSQ Infit/Outfit: 2.37/3.27] and the easiest item was "I have enough advice to make a choice" [0.70/0.67].

CONCLUSIONS

Overall, the DCS demonstrated good fit, and can be considered a valid and reliable tool to use with the surrogate population.

PRACTICE IMPLICATIONS

Measuring surrogate decisional conflict could be especially useful to determine how to improve the decision-making process.

Palliative Sedation for the Terminally Ill Patient

Palliative sedation (PS) is performed in the terminally ill patient to manage one or more refractory symptoms. Proportional PS, which means that drugs can be titrated to the minimum effective dose, is the form most widely used. From a quarter to a third of all terminally ill patients undergo PS, with a quarter of these requiring continuous deep sedation. The prevalence of PS varies according to the care setting and case mix. The most frequent refractory physical symptoms are delirium and dyspnea, but PS is also considered for existential suffering or psychological distress, which is an extremely difficult and delicate issue to deal with. Active consensus from the patient and advanced care planning is recommended for PS. The decision-making process concerning the continuation or withdrawal of other treatments is not the same as that used for PS. The practice differs totally from euthanasia in its intentions, procedures, and results. The most widely used drugs are midazolam and haloperidol for refractory delirium, but chlorpromazine and other neuroleptics are also effective. In conclusion, some patients experience refractory symptoms during the last hours or days of life and PS is a medical intervention aimed at managing this unbearable suffering. It does not have a detrimental effect on survival.

Family Communication at the End of Life

People often feel awkward and ill at ease when faced with the opportunity for communication at the end of life, thus the overall theme for the articles in this special issue is the creation of more awareness and knowledge regarding the depth, breadth, and importance of current research exploring family communication at the end of life. This introductory essay attempts to accomplish the following: (1) discuss the importance of talk regarding death; (2) highlight the formative role of family interactions on the death and dying process; and (3) outline the articles in this special issue. Scholars contributing to this special issue on “Family Communication at the End of Life” have provided evidence that communication is important between and for terminally ill individuals, family members, and healthcare/palliative care specialists. Overall, research exploring communication at the end of life is especially relevant because every person experiences the death and loss of loved ones, and ultimately faces the reality of their own death.