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Barajas-Ochoa A, Mackie TI, Fofana B, Rosen Valverde JN. On legal guardianship: An exploratory assessment of knowledge, attitudes and practices of resident physicians. Med Teach 2024; 46:399-405. [PMID: 37722805 DOI: 10.1080/0142159x.2023.2256965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
BACKGROUND Clinicians encounter patients under legal guardianship. We aimed to assess the knowledge, attitudes and practices (KAP) on legal guardianship in residents. METHODS A KAP pilot survey about legal guardianship was developed by an interdisciplinary medicine-law-public health team and was distributed via institutional email to internal medicine, psychiatry, and neurology residents in a single academic institution. RESULTS Of the 172 invited residents, 105 (61%) responded and 102 surveys were included in the final analysis. Most respondents (58% women; internal medicine 73%, neurology 15%, psychiatry 12%) had attended 42 medical schools from 16 countries and had heard about guardianship (88%), but only 23% reported having received training on guardianship during medical school or residency. The vast majority (97%) understood the intended benefit of guardianship, but only 22.5% reported knowing that guardianship removed an individual's decision-making rights. Nearly half (47%) of respondents reported never having asked for documentation to prove that an individual was a patient's guardian, and only 15% expected to see a court order as proof of guardianship status. CONCLUSIONS Although most residents intuitively understood the intended benefit of guardianship, they did not understand its full implications for clinical practice. Training interventions are warranted.
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Affiliation(s)
- Aldo Barajas-Ochoa
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
- Division of Infectious Diseases, Department of Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Thomas I Mackie
- Department of Health Policy and Management, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Bintu Fofana
- Rutgers School of Public Health, Newark, NJ, USA
| | - Jennifer N Rosen Valverde
- Rutgers School of Public Health, Newark, NJ, USA
- Education and Health Law Clinic, Legal Director, H.E.A.L. Collaborative®, Rutgers University School of Law, Newark, NJ, USA
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2
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Fisher MC, Parrillo E, Petchler C, Kub J, Hughes MT, Sulmasy DP, Baker D, Nolan MT. "They Would Lift My Spirits": Sources of Support for Family Surrogate Decision-Makers at the End of Life. J Hosp Palliat Nurs 2023; 25:119-123. [PMID: 36907841 PMCID: PMC10175176 DOI: 10.1097/njh.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Surrogate decision-makers make critical decisions for loved ones at the end of life, and some experience lasting negative psychological outcomes. Understanding whom they rely on for support and the types of support they value may inform nursing care and that of other health team members who work with surrogates. The purpose of the study was to explore decision support and other types of support provided to surrogate decision-makers at the end of life of their loved one and perceived usefulness of the support. This secondary analysis of data from a mixed-methods study involved the examination of the transcripts of qualitative interviews with 13 surrogate decision-makers in the United States, conducted between 2010 and 2014. A constant comparative method was used to identify common themes surrounding surrogate decision support at the end of life. Surrogates valued advance directives and conversations with their loved one about treatment preferences. Surrogates described involving many different types of people in decision-making and other types of support. Finally, surrogates appreciated being reassured that they were doing a good job in making decisions and seemed to seek out this type of affirmation from various sources including the health care team, family, and friends. Nurses are well-positioned to provide this affirmation because of the time that they spend caring for the patient and family. Future research should further explore the concept of affirmation of surrogates in their role as a means of support as they make decisions for a loved one.
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Affiliation(s)
- Marlena C. Fisher
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Elaina Parrillo
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Claire Petchler
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Joan Kub
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
| | | | - Daniel P. Sulmasy
- The Kennedy Institute of Ethics, Georgetown University, 3700 O St NW, Washington, D.C., 20057, USA
| | - Deborah Baker
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
- Johns Hopkins Hospital, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Marie T. Nolan
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
- Conway School of Nursing, The Catholic University of America, Washington, DC
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3
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Torke AM, Varner-Perez SE, Burke ES, Taylor TA, Slaven JE, Kozinski KL, Maiko SM, Pfeffer BJ, Banks SK. Effects of Spiritual Care on Well-Being of Intensive Care Family Surrogates: A Clinical Trial. J Pain Symptom Manage 2023; 65:296-307. [PMID: 36526251 PMCID: PMC10129066 DOI: 10.1016/j.jpainsymman.2022.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022]
Abstract
CONTEXT Critical illness of a family member is associated with high emotional and spiritual distress and difficult medical decisions. OBJECTIVES To determine if a semistructured spiritual care intervention improves the well-being of family surrogate decision makers in intensive care (ICU) settings. METHODS This study is a randomized, allocation-concealed, parallel group, usual care-controlled, single-blind trial of patient/surrogate dyads in five ICUs in one Midwest, academic medical center. Patients were 18 and older admitted to the ICU and unable to make medical decisions. The intervention involved proactive contact from the chaplain, scheduled, semi-structured visits, weekly follow-up, and bereavement calls. The control group received usual care. The primary endpoint was the surrogate's anxiety (Generalized Anxiety Disorders-7 scale), six to eight weeks after discharge. RESULTS Of 192 patient/surrogate dyads enrolled, 128 completed outcome assessments. At follow-up, anxiety in the intervention group was lower than control (median score 1 (interquartile range 0,6) vs. 4 (1,9), P = 0.0057). The proportion of patients with a minimal clinically important difference (MCID) in anxiety of 2+ was 65.2% in the intervention group vs. 49.2% in control. The odds of an MCID remained higher in adjusted analysis (Odds Ratio 3.11, 95% confidence interval 1.18, 8.21; P = 0.0218) The adjusted odds of an MCID were higher for spiritual well-being (OR 3.79, CI 1.41,10.17; P = 0.0081). Satisfaction with spiritual care was also higher (adjusted mean 3.5 ± 0.4 vs. 2.9 ± 0.1); P < .0001). CONCLUSIONS Proactive, semistructured spiritual care delivered by chaplains improves well-being for ICU surrogates. Results provide evidence for inclusion of chaplains in palliative and intensive care teams.
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Affiliation(s)
- Alexia M Torke
- Indiana University School of Medicine (A.M.T., S.M.M., S.K.B.), Indianapolis, Indiana; Daniel F. Evans Center (A.M.T., S.E.V.P., S.M.M., B.J.P.), Indiana University Health, Indianapolis, Indiana; IU Center for Aging Research (A.M.T., S.E.V.P., E.S.B., T.A.T.), Regenstrief Institute, Indianapolis, Indiana.
| | - Shelley E Varner-Perez
- Daniel F. Evans Center (A.M.T., S.E.V.P., S.M.M., B.J.P.), Indiana University Health, Indianapolis, Indiana; IU Center for Aging Research (A.M.T., S.E.V.P., E.S.B., T.A.T.), Regenstrief Institute, Indianapolis, Indiana; Spiritual Care and Chaplaincy Department (S.E.V.P., B.J.P.), Indiana University Health, Indianapolis, Indiana
| | - Emily S Burke
- IU Center for Aging Research (A.M.T., S.E.V.P., E.S.B., T.A.T.), Regenstrief Institute, Indianapolis, Indiana
| | - Tracy A Taylor
- IU Center for Aging Research (A.M.T., S.E.V.P., E.S.B., T.A.T.), Regenstrief Institute, Indianapolis, Indiana
| | - James E Slaven
- Department of Biostatistics and Health Data Science (J.E.S.), Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Saneta M Maiko
- Indiana University School of Medicine (A.M.T., S.M.M., S.K.B.), Indianapolis, Indiana; Daniel F. Evans Center (A.M.T., S.E.V.P., S.M.M., B.J.P.), Indiana University Health, Indianapolis, Indiana
| | - Bruce J Pfeffer
- Daniel F. Evans Center (A.M.T., S.E.V.P., S.M.M., B.J.P.), Indiana University Health, Indianapolis, Indiana; Spiritual Care and Chaplaincy Department (S.E.V.P., B.J.P.), Indiana University Health, Indianapolis, Indiana
| | - Sarah K Banks
- Indiana University School of Medicine (A.M.T., S.M.M., S.K.B.), Indianapolis, Indiana
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4
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Kunzler BR, Smith TJ, Levi BH, Green MJ, Badzek L, Katsaros MG, Van Scoy LJ. The Value of Advance Care Planning for Spokespersons of Patients With Advanced Illness. J Pain Symptom Manage 2023; 65:471-478.e4. [PMID: 36690164 DOI: 10.1016/j.jpainsymman.2022.12.143] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/21/2023]
Abstract
CONTEXT Advance Care Planning (ACP) has fallen under scrutiny primarily because research has not consistently demonstrated patient-focused benefits. OBJECTIVES To better understand how spokespersons regard, engage with, and find value in ACP during decision-making for their loved ones. METHODS This qualitative analysis was part of a randomized controlled trial involving spokespersons of patients with advanced illness who had completed ACP. After making a medical decision on behalf of their loved one (or that loved one's death), semi-structured interviews explored spokespersons' experience of decision-making and if (and how) ACP played a role. Thematic analysis was conducted on interview transcripts. RESULTS From 120 interviews, five themes emerged: 1) Written advance directives (ADs) helped increase spokespersons' confidence that decisions were aligned with patient wishes (serving as a physical reminder of previous discussions and increasing clarity during decision-making and family conflict); 2) Iterative discussions involving ACP facilitated "In the moment" decision-making; 3) ADs and ACP conversations helped spokespersons feel more prepared for future decisions; 4) Spokespersons sometimes felt there was "no choice" regarding their loved one's medical care; and 5) Regrets and second-guessing were the most common negative emotions experienced by spokespersons. CONCLUSION Considering the recent debate about the utility of ACP and ADs, this analysis highlights the value of ACP for spokespersons involved in surrogate decision-making. Reframing the goals of ACP in terms of their benefit for spokespersons (and identifying appropriate outcome measures) may provide additional perspective on the utility of ACP.
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Affiliation(s)
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Pediatrics, Penn State College of Medicine (B.H.L.), Hershey, PA, USA
| | - Michael J Green
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Medicine, Penn State College of Medicine (M.J.G, L.J.V.S.), Hershey, PA, USA
| | - Laurie Badzek
- Penn State Ross and Carol Nese College of Nursing (L.B.), University Park, PA, USA
| | - Maria G Katsaros
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Medicine, Penn State College of Medicine (M.J.G, L.J.V.S.), Hershey, PA, USA; Department of Public Health Sciences, Penn State College of Medicine (L.J.V.S.), Hershey, PA, USA.
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5
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Abstract
According to a standard account of patient decision-making capacity (DMC), patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical condition and can comparatively evaluate all offered treatment options. We argue instead that some patient refusals can be capacitated, and therefore ethically authoritative, without meeting the strict criteria of this standard account-what we call comparative DMC. We describe how patients may possess burdens-based DMC for refusal if they have an overriding objection to at least one burden associated with each treatment option or goals-based DMC for refusal if they have an overriding goal that is inconsistent with treatment. The overridingness of a patient's objections to burdens, or of their commitment to a goal, can justify the moral authority of their refusal, even when a patient lacks some of the cognitive capacities that standard accounts of DMC involve.
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Affiliation(s)
- Mark Christopher Navin
- Oakland University
- Beaumont Hospital - Royal Oak
- Oakland University William Beaumont School of Medicine
| | - Abram L Brummett
- Beaumont Hospital - Royal Oak
- Oakland University William Beaumont School of Medicine
| | - Jason Adam Wasserman
- Beaumont Hospital - Royal Oak
- Oakland University William Beaumont School of Medicine
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6
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Kunzler BR, Foy AJ, Levi BH, Van Scoy LJ, Lehman EB, Smith TJ, Green MJ. Does Caregiver Participation in Advance Care Planning Using a Decision Support Tool Together With Patients Reduce Caregiver Strain, Burden and Anxiety Over Time? A Post-Hoc Analysis of a Randomized Controlled Trial. Am J Hosp Palliat Care 2021; 39:757-761. [PMID: 34414808 DOI: 10.1177/10499091211040233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT Surrogate decision makers experience significant amounts of anxiety, burden, and strain in their role as caregivers and decision makers for loved ones. OBJECTIVES To investigate longitudinally whether surrogate decision makers engaging in ACP together with their loved one reduces perceived anxiety, burden, and strain felt by surrogate decision makers. METHODS Post-hoc analysis of a randomized controlled trial evaluating caregivers' perceived self-efficacy to serve as surrogate decision makers. The trial employed a 2×2 study design of patient/caregiver dyads who engaged in advance care planning (ACP) using a standard living will form vs "Making Your Wishes Known" (MYWK), and having the patient engage in ACP alone vs together with the family caregiver. Surrogates completed validated survey instruments surveys longitudinally to compare levels of anxiety, burden, and strain. RESULTS 246 of 285 dyads completed the measures. No significant reductions in anxiety, burden, or strain were found longitudinally in surrogate decision makers using MYWK together with loved one's vs other control groups. Increases in strain and anxiety were seen across all study groups and increases in burden across 2/4 study groups. Strain and burden increased most in the MYWK Together arm (▴ = +2.22 and ▴ = +1.91 respectively). CONCLUSION Family caregivers who engaged in ACP together with patients using the decision support tool MYWK did not experience less strain, burden, or anxiety longitudinally compared to other study arms. These results may help inform the design of future studies and interventions that promote caregivers' involvement in ACP interventions.
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Affiliation(s)
| | - Andrew J Foy
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Michael J Green
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
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7
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Simmons DB, Levi BH, Green MJ, La IS, Lipnick D, Smith TJ, Thiede ER, Wiegand DL, Van Scoy L. What Surrogates Understand (and Don't Understand) About Patients' Wishes After Engaging Advance Care Planning: A Qualitative Analysis. Am J Hosp Palliat Care 2021; 39:427-432. [PMID: 34164999 DOI: 10.1177/10499091211026674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The goal of advance care planning (ACP) is to improve end-of-life decision-making for patients and their spokespersons, but multiple studies have failed to show substantial or consistent benefit from ACP. Understanding how and why ACP under-performs in the setting of complex medical decision-making is key to optimizing current, or designing new, ACP interventions. AIM To explore how ACP did or did not contribute to a spokespersons' understanding of patient wishes after engaging in ACP. DESIGN Thematic analysis of 200 purposively sampled interviews from a randomized control trial of an ACP decision aid. SETTING/PARTICIPANTS 200 dyads consisting of patients 18 years or older with advanced serious illness and their spokesperson at 2 tertiary care centers in Hershey, PA and Boston, MA. Participants were interviewed 1 month after completing ACP. RESULTS ACP helped participants: 1) express clear end-of-life wishes, 2) clarify values, and 3) recognize challenges associated with applying those wishes in complex situations. Shortcomings of ACP included 1) unknown prognostic information or quality-of-life outcomes to inform decision-making, 2) skepticism about patients' wishes, and 3) complicated emotions impacting end-of-life discussions. CONCLUSIONS Helping patients and their spokespersons better anticipate decision-making in the face of prognostic and informational uncertainty as well as the emotional complexities of making medical decisions may improve the efficacy of ACP interventions.
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Affiliation(s)
- David B Simmons
- Department of Pastoral Care, Penn State Milton S. Hershey Medical Center, Hershey, PA.,Department of Medicine, Penn State College of Medicine, Hershey, PA
| | - Benjamin H Levi
- Penn State College of Medicine, Hershey, PA.,Penn State Milton S. Hershey Medical Center, Hershey, PA.,Department of Humanities, Penn State College of Medicine, Hershey, PA.,Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Michael J Green
- Department of Medicine, Penn State College of Medicine, Hershey, PA.,Penn State College of Medicine, Hershey, PA.,Penn State Milton S. Hershey Medical Center, Hershey, PA.,Department of Humanities, Penn State College of Medicine, Hershey, PA
| | - In Seo La
- College of Nursing Science, Kyung Hee University, Seoul, South Korea
| | | | | | | | - Debra L Wiegand
- University of Maryland-Baltimore Department of Nursing, Baltimore, MD
| | - Lauren Van Scoy
- Department of Medicine, Penn State College of Medicine, Hershey, PA.,Penn State College of Medicine, Hershey, PA.,Penn State Milton S. Hershey Medical Center, Hershey, PA.,Department of Humanities, Penn State College of Medicine, Hershey, PA.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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Bartlett S, Fettig LP, Baenziger PH, DiOrio EN, Herget KM, D'Cruz L, Coughlin JR, Lake M, Truong A, Comer AR. Indiana Medical Resident's Knowledge of Surrogate Decision Making Laws. Int Q Community Health Educ 2021; 42:272684X211004737. [PMID: 33752546 DOI: 10.1177/0272684x211004737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION During the care of incapacitated patients, physicians, and medical residents discuss treatment options and gain consent to treat through healthcare surrogates. The purpose of this study is to ascertain medical residents' knowledge of healthcare consent laws, application during clinical practice, and appraise the education residents received regarding surrogate decision making laws. METHODS Beginning in February of 2018, 35 of 113 medical residents working with patients within Indiana completed a survey. The survey explored medical residents' knowledge of health care surrogate consent laws utilized in Indiana hospitals and Veterans Affairs (VA) hospitals via clinical vignettes. RESULTS Only 22.9% of medical residents knew the default state law in Indiana did not have a hierarchy for settling disputes among surrogates. Medical residents correctly identified which family members could participate in medical decisions 86% of the time. Under the Veterans Affairs surrogate law, medical residents correctly identified appropriate family members or friends 50% of the time and incorrectly acknowledged the chief decision makers during a dispute 30% of the time. All medical residents report only having little or some knowledge of surrogate decision making laws with only 43% having remembered receiving surrogate decision making training during their residency. CONCLUSIONS These findings demonstrate that medical residents lack understanding of surrogate decision making laws. In order to ensure medical decisions are made by the appropriate surrogates and patient autonomy is upheld, an educational intervention is required to train medical residents about surrogate decision making laws and how they are used in clinical practice.
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Affiliation(s)
- Stephanie Bartlett
- Indiana University School of Health and Human Sciences, Indianapolis, Indiana, United States
| | - Lyle P Fettig
- Indiana University School of Medicine, Eskenazi Health, Indianapolis, Indiana, United States
| | - Peter H Baenziger
- Ascension's Peyton Manning Children's Hospital, Indianapolis, Indiana, United States
| | | | - Kayla M Herget
- St. Vincent Hospital, Indianapolis, Indiana, United States
| | - Lynn D'Cruz
- Indiana University School of Health and Human Sciences, Indianapolis, Indiana, United States
| | - Johanna R Coughlin
- Indiana University Health, Indianapolis, Indiana, United States
- Witham Hospital, Lebanon, Indiana, United States
| | - Mikaela Lake
- Lake Erie College of Osteopathic Medicine, Bradenton, Florida, United States
| | - Amy Truong
- Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, United States
| | - Amber R Comer
- Health Sciences, Indiana University, Indianapolis, Indiana, United States
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9
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de Cola B, Dallery J. Delay discounting rate by a surrogate decision maker depends on the smoking status of the recipient. Exp Clin Psychopharmacol 2021; 29:73-81. [PMID: 32105134 PMCID: PMC7483137 DOI: 10.1037/pha0000356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The tendency to devalue future rewards is known as delay discounting. Discounting is measured using a series of intertemporal choices between smaller, sooner outcomes and larger, later outcomes. We used a surrogate delay discounting task to explore whether such choices would differ if a hypothetical recipient was a smoker or was an individual with good health habits. Across three studies, the descriptions of the recipient included only information about smoking status (n = 66), smoking status and equal annual income (n = 47), and smoking status and equal weekly expenditures (n = 42). Higher rates of delay discounting for the smoker recipient compared to the nonsmoker recipient were observed across all three studies. These results parallel previous findings showing group differences in discounting between actual smokers and nonsmokers. We discuss the similarities between the present results and previous studies in light of an extension of Bem's (1967) self-perception theory, which posits that choices in laboratory-based delay discounting tasks are informed by observation of real-world intertemporal choice. The theory asserts that there is no fundamental difference between a first-person account of such knowledge and a third-person account. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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10
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Thiede E, Levi BH, Lipnick D, Johnson R, Seo La I, Lehman EB, Smith T, Wiegand D, Green M, Van Scoy LJ. Effect of Advance Care Planning on Surrogate Decision Makers' Preparedness for Decision Making: Results of a Mixed-Methods Randomized Controlled Trial. J Palliat Med 2020; 24:982-993. [PMID: 33373538 DOI: 10.1089/jpm.2020.0238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Advance care planning (ACP) is intended to help patients and their spokespersons prepare for end-of-life decision making, yet little is known about what factors influence the extent to which spokespersons feel prepared for that role. Objective: To examine spokespersons' perceived preparedness for surrogate decision making after engaging in ACP. Design: Mixed methods experimental design with qualitative thematic analysis and data transformation (creating categorical data from rich qualitative data) of interviews collected during a randomized controlled trial (2012-2017). Setting/Participants: Two tertiary care medical centers (Hershey, PA and Boston, MA). Of 285 dyads (patients with advanced illness and their spokespersons) enrolled in the trial, 200 spokesperson interviews were purposively sampled and 198 included in the analyses. Main Outcomes and Measures: Interviews with spokespersons (four weeks post-intervention) explored spokespersons' perceived preparedness for surrogate decision making, occurrence of ACP conversations, and spokespersons' intentions regarding future surrogate decisions. Data transformation was used to categorize participants' responses into three categories: Very Prepared, Very Unprepared, or In Between Prepared and Unprepared. Themes and categories were compared across arms. Results: About 72.72% of spokespersons (144/198) reported being Very Prepared and 27.28% (54/198) reported being Very Unprepared or In Between with no differences in preparedness across study arms. Occurrence of post-intervention ACP conversations did not influence perceived preparedness; however, spokespersons who used an ACP decision aid reported more conversations. Four themes emerged to explain spokespersons' perceived preparedness: (1) perceptions about ACP; (2) level of comfort with uncertainty; (3) relational issues; and (4) personal characteristics. Regarding future intentions, it emerged that spokespersons believed their knowledge of patient wishes, as well as other personal, relational, situational, and emotional factors would influence their surrogate decisions. Conclusions: Factors extrinsic to specific ACP interventions influence how prepared spokespersons feel to act as spokespersons. Understanding these factors is important for understanding how to improve concordance between patients' stated end-of-life wishes and surrogate decisions. Trial Registration: NCT02429479.
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Affiliation(s)
- Elizabeth Thiede
- College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Benjamin H Levi
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Pediatrics, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Daniella Lipnick
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Rhonda Johnson
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - In Seo La
- School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Erik B Lehman
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Theresa Smith
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Pediatrics, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Debra Wiegand
- School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Michael Green
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Lauren Jodi Van Scoy
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Humanities and College of Medicine, Penn State University, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
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Hammami MM, Abuhdeeb K, Balkhi AA. Importance Hierarchy of Surrogate Medical Decision Making Determinants: A Q-Methodology Study in Middle Eastern and East Asian Men. Med Decis Making 2020; 40:1020-1033. [PMID: 33174512 DOI: 10.1177/0272989x20963042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Factors other than patient's preference may influence surrogate medical decision making in a culture- and viewpoint-dependent way. We explored the importance hierarchy of potential surrogate medical decision making determinants to Middle-Eastern (ME) and East-Asian (EA) men according to their norm-perception (N-viewpoint), preference as patients (P-viewpoint), and preference as surrogate decision-makers (S-viewpoint). METHODS Each respondent (120 ME, 120 EA) sorted 28 items reflecting potential determinants into a fixed distribution of importance hierarchy according to the three viewpoints. Latent decision making models were explored by by-person factor analysis (Q-methodology). RESULTS Six models were identified for each ME and EA viewpoint (total 36). Patient's health-related, patient's preference-related, and society's interests-related determinants were strongly embraced in 34, 3, and zero models and strongly discounted in 2, 5, and 21 models, respectively. Patient's religious/spiritual belief was strongly embraced in 6 EA models compared to 2 ME models and strongly discounted in 2 EA models compared to 5 ME models. Further, family-centric and surrogate's interest-related determinants were strongly embraced in 8 EA models compared to 1 ME model. They were also strongly embraced in 5 P-viewpoint compared to 2 S-viewpoint models and strongly discounted in 4 P-viewpoint compared to 11 S-viewpoint models. Despite the overall predominance of patient's health-related determinants and culture- and viewpoint-dependent differences, Q-methodology analysis identified relatively patient's preference-influenced, religious/spiritual beliefs-influenced, emotion-influenced, and familism-influenced models and showed notable overlap in models. CONCLUSIONS Patient's health was more important than other potential medical surrogate decision making determinants, including patient's preference, for both ME and EA men and in all viewpoints. The relative importance of some determinants was culture- and viewpoint- dependent and allowed description of different albeit overlapping models.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.,Alfaisal University College of Medicine, Riyadh, Saudi Arabia
| | - Kafa Abuhdeeb
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Areej Al Balkhi
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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12
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Yamaguchi H, Sato K, Kawahito K, Miyatake A, Kondo K, Inaba K, Inaba K, Kawaminami S, Tabata R, Yuasa S, Okura Y, Tuchiya A, Suzuki Y, Tani K. Japanese elderly individuals wish for enteral tube feeding more strongly for their parents than for themselves. J Med Invest 2019; 66:258-263. [PMID: 31656285 DOI: 10.2152/jmi.66.258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
[Introduction] The purpose of this study was to investigate the differences in the preference of enteral tube feeding between elderly inhabitants of Mugi town, Tokushima Prefecture, Japan, and their parents in various physical conditions. [Methods] This population-based questionnaire survey studied 300 randomly selected participants aged 65-80 years. Respondents were to consider a situation where eating was difficult, and were questioned on their desire for tube feeding, using a visual analogue scale (VAS) ranging from "do not want tube feeding (0)" to "want tube feeding (100)." [Results] Valid responses of 103 (34.4%) participants were analyzed. Under conditions of being "healthy," "bedridden," "with dementia," and "bedridden and with dementia," the median (IQR) of the VAS values for the desire for tube feeding were 31.8 (3.3 to 83.8), 19.3 (2.4 to 52.3), 5.2 (0.7 to 18.9), 4.0 (0.3 to 15.2) for respondents and 55.2 (11.6 to 92.2), 48.7 (5.5 to 85.5), 9.0 (1.2 to 46.8), 5.1 (0.1 to 36.5) for parents, respectively. The VAS values for the parents were significantly higher (p=0.001, 0.002, 0.001, and 0.01, respectively for the four conditions described) for the same items. [Conclusion] Surrogate decisions made by family members often differ from what the patients would have desired. J. Med. Invest. 66 : 258-263, August, 2019.
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Affiliation(s)
- Harutaka Yamaguchi
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Koj Sato
- Medical student, Tokushima University, Tokushima, Japan
| | | | | | | | - Keisuke Inaba
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kaori Inaba
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shingo Kawaminami
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Ryo Tabata
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shino Yuasa
- Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Yoshihiro Okura
- Department of General Medicine and Primary Care, Tokushima University Hospital, Tokushima, Japan
| | - Atsushi Tuchiya
- Department of Civil and Environmental Studies, Tokushima University Graduate School of Integrated Arts and Sciences, Tokushima, Japan
| | - Yoshihiro Suzuki
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kenji Tani
- Department of General Medicine and Primary Care, Tokushima University Hospital, Tokushima, Japan
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13
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Song MK, Ward SE, Hepburn K, Paul S, Kim H, Shah RC, Morhardt DJ, Medders L, Lah JJ, Clevenger CC. Can Persons with Dementia Meaningfully Participate in Advance Care Planning Discussions? A Mixed-Methods Study of SPIRIT. J Palliat Med 2019; 22:1410-1416. [PMID: 31373868 DOI: 10.1089/jpm.2019.0088] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Despite the importance of persons with dementia (PWDs) engaging in advance care planning (ACP) at a time when they are still competent to appoint a surrogate decision maker and meaningfully participate in ACP discussions, studies of ACP in PWDs are rare. Objective: We conducted an intervention development study to adapt an efficacious ACP intervention, SPIRIT (sharing patient's illness representations to increase trust), for PWDs in early stages (recent Montreal Cognitive Assessment [MoCA] score ≥13) and their surrogates and assess whether SPIRIT could help PWDs engage in ACP. Design: A formative expert panel review of the adapted SPIRIT, followed by a randomized trial with qualitative interviews, was conducted. Patient-surrogate dyads were randomized to SPIRIT in person (in a private room in a memory clinic) or SPIRIT remote (via videoconferencing from home). Setting/Subjects: Twenty-three dyads of PWDs and their surrogates were recruited from an outpatient brain health center. Participants completed preparedness outcome measures (dyad congruence on goals of care, patient decisional conflict, and surrogate decision-making confidence) at baseline and two to three days post-intervention, plus a semistructured interview. Levels of articulation of end-of-life wishes of PWDs during SPIRIT sessions were rated (3 = expressed wishes very coherently, 2 = somewhat coherently, and 1 = unable to express coherently). Results: All 23 were able to articulate their end-of-life wishes very or somewhat coherently during the SPIRIT session; of those, 14 PWDs had moderate dementia. While decision-making capacity was higher in PWDs who articulated their wishes very coherently, MoCA scores did not differ by articulation levels. PWDs and surrogates perceived SPIRIT as beneficial, but the preparedness outcomes did not change pre-post. Conclusions: SPIRIT engaged PWDs and surrogates in meaningful ACP discussions, but requires testing of efficacy and long-term outcomes.
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Affiliation(s)
- Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Sandra E Ward
- School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kenneth Hepburn
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Hyejin Kim
- Red Cross College of Nursing, Chung-Ang University, Seoul, Korea
| | - Raj C Shah
- Family Medicine and Rush Alzheimer's Disease Center, University of Chicago, Chicago, Illinois
| | - Darby J Morhardt
- Department of Preventive Medicine, Cognitive Neurology and Alzheimer's Disease Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Laura Medders
- Emory Integrated Memory Care Clinic, Emory Healthcare, Atlanta, Georgia
| | - James J Lah
- Department of Neurology, School of Medicine, Emory University, Atlanta, Georgia
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Batteux E, Ferguson E, Tunney RJ. On the Likelihood of Surrogates Conforming to the Substituted Judgment Standard When Making End-of-Life Decisions for Their Partner. Med Decis Making 2019; 39:651-660. [PMID: 31354033 PMCID: PMC6794635 DOI: 10.1177/0272989x19862800] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/14/2019] [Indexed: 11/16/2022]
Abstract
A considerable proportion of end-of-life decisions are made by the patient's next-of-kin, who can be asked to follow the substituted judgment standard and decide based on the patient's wishes. The question of whether these surrogate decision makers are actually able to do so has become an important issue. In this study, we examined how the likelihood of surrogates conforming to the substituted judgment standard varies with individual differences in mortality acceptance and confidence in their decision making. We recruited 153 participants in romantic relationships between 18 and 80 years old from the general population. We asked them to make hypothetical end-of-life decisions for themselves and on behalf of their partner, as well as predict what their partner would do, and complete a series of questionnaires. Participants predicted that their partner would make similar decisions to their own but were more likely to accept a life-saving treatment that could result in reduced quality of life on their partner's behalf than for themselves. Decisions made by older adults were more likely to conform to the substituted judgment standard, which is encouraging given that they are more likely to be confronted with these decisions in real life, although this was not due to differences in mortality acceptance. Older adults were also more likely to have had previous discussions with their partner and thereby know that person's wishes and feel confident that they made the right decision, but these factors did not affect their likelihood of conforming to the substituted judgment standard. This shows that encouraging discussions about end of life among families would ease the decision process, but more work is needed to ensure that surrogates can adhere to the substituted judgment standard.
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15
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Elizari Urtasun L. Conflict between Children's Autonomy and Protection in Healthcare. Comparative Study between Spanish and Belgian Law. Eur J Health Law 2019; 26:1-19. [PMID: 31349214 DOI: 10.1163/15718093-12264429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This article addresses the autonomy of children and adolescents in healthcare decisions, focusing on those ones that might entail a risk to the child's life or health, especially when a medical intervention is refused. In these cases, a conflict between the recognition of the autonomy of the child and his or her protection arises, and various legal systems solve it in different ways. This study examines this issue from a comparative perspective between Belgian and Spanish laws, taking into account that the latter was rewritten in 2015 to leave out all underage patients' decisions that could constitute a risk for their life or health.
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16
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Cohen AB, Benjamin AZ, Fried TR. End-of-Life Decision Making and Treatment for Patients with Professional Guardians. J Am Geriatr Soc 2019; 67:2161-2166. [PMID: 31301189 DOI: 10.1111/jgs.16072] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/01/2019] [Accepted: 06/10/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Concerns have repeatedly been raised about end-of-life decision making when a patient with diminished capacity is represented by a professional guardian, a paid official appointed by a judge. Such guardians are said to choose high-intensity treatment even when it is unlikely to be beneficial or to leave pivotal decisions to the court. End-of-life decision making by professional guardians has not been examined systematically, however. DESIGN Retrospective cohort study. SETTING Inpatient and outpatient facilities in the Department of Veterans Affairs (VA) Connecticut Healthcare System. PARTICIPANTS Decedent patients represented by professional guardians who received care at Connecticut VA facilities from 2003 to 2013 and whose care in the last month of life was documented in the VA record. MEASUREMENTS Through chart reviews, we collected data about the guardianship appointment, the patient's preferences, the guardian's decision-making process, and treatment outcomes. RESULTS There were 33 patients with professional guardians who died and had documentation of their end-of-life care. The guardian sought judicial review for 33%, and there were delays in decision making for 42%. In the last month of life, 29% of patients were admitted to the intensive care unit, intubated, or underwent cardiopulmonary resuscitation; 45% received hospice care. Judicial review and high-intensity treatment were less common when information about the patient's preferences was available. CONCLUSION Rates of high-intensity treatment and hospice care were similar to older adults overall. Because high-intensity treatment was less likely when the guardian had information about a patient's preferences, future work should focus on advance care planning for individuals without an appropriate surrogate. J Am Geriatr Soc 67:2161-2166, 2019.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Andrea Z Benjamin
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Clinical Epidemiology Research Center, Veterans Affairs (VA) Connecticut Health System, West Haven, Connecticut
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17
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Scheunemann LP, Khalil R, Rajagopal PS, Arnold RM. Development and Pilot Testing of a Simulation to Study How Physicians Facilitate Surrogate Decision Making Based on Critically Ill Patients' Values and Preferences. J Pain Symptom Manage 2019; 57:216-223.e8. [PMID: 30408496 PMCID: PMC6348012 DOI: 10.1016/j.jpainsymman.2018.10.513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 11/22/2022]
Abstract
CONTEXT There are no evidence-based programs to train physicians to facilitate shared decision making based on incapacitated intensive care unit patients' values and preferences. OBJECTIVES The objective of this study was to develop a high-fidelity simulation to fill this gap. METHODS Case development involved six steps: 1) drafting a case about an elderly patient receiving prolonged mechanical ventilation; 2) engaging an expert advisory board to optimize case content; 3) revising the case based on advisory board input; 4) training actors to portray the case patient's daughter; 5) obtaining physician feedback on the simulation; and 6) revising the case based on their feedback. We conducted a cross-sectional pilot study with 50 physicians to assess feasibility and acceptability, defined a priori as an enrollment rate >40 physicians/year, study procedures <75 minutes/participant, >95% actor adherence to standardization rules, and high physician ratings of realism and acceptability. RESULTS Advisory panel feedback yielded two modifications: 1) refocusing the case on decision making about tracheostomy and percutaneous gastrostomy and 2) making the patient's values more authentic. Physician feedback yielded two additional modifications: 1) reducing how readily the actor divulged the patient's values and 2) making her more emotional. All 50 physicians enrolled in the pilot study over 11 months completed study procedures in <75 minutes. Actor adherence to standardization rules was 95.8%. Physicians' mean ratings of realism and acceptability were 8.4 and 9.1, respectively, on a 10-point scale. CONCLUSION Simulation is feasible, is acceptable, and can be adequately standardized to study physicians' skills for facilitating surrogate decision making based on an incapacitated intensive care unit patient's values and preferences.
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Affiliation(s)
- Leslie P Scheunemann
- Division of Geriatric Medicine and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | - Ramy Khalil
- St. Clair Hospital, Pittsburgh, Pennsylvania, USA
| | - Padma S Rajagopal
- Division of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Palliative and Supportive Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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18
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Abstract
A qualitative secondary analysis was undertaken to identify aspects of health care service quality in an intensive care unit from the perspective of surrogate decision makers (N = 19) who were making decisions for relatives at end of life. Directed content analysis was guided by the Donabedian model of health care quality. Nineteen participants averaged 59 years old and were over half female (53%) and patients' spouses (53%) and adult children (32%). Salient aspects of quality service included surrogate perceptions that clinicians conveyed honesty about the patient's condition and in an easily understandable way; staff were sensitive and responsive to emotions and practical needs; clinicians demonstrated a clear, confident understanding of the patient's condition; and support by clinicians was given for surrogates' choices. Surrogates also commented on the hospital and intensive care unit environment, including cleanliness, comfort, privacy, and noise level. Further research is needed to explore how decision-support strategies might include service quality concepts.
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Affiliation(s)
- Senay Gul
- Hacettepe University, Ankara, Turkey
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19
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Dionne-Odom JN, Ejem D, Azuero A, Taylor RA, Rocque GB, Turkman Y, Thompson MA, Knight SJ, Martin MY, Bakitas MA. Factors Associated with Family Caregivers' Confidence in Future Surrogate Decision Making for Persons with Cancer. J Palliat Med 2018; 21:1705-1712. [PMID: 30129873 DOI: 10.1089/jpm.2018.0148] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Improving family caregiver preparation for surrogate decision making is a critical priority. Objective: Determine a parsimonious set of intrapersonal factors associated with family caregivers' confidence in making future medical decisions for their relatives with cancer. Methods: Cross-sectional mail survey. Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers from communities of eight U.S. cancer centers. Participants completed validated measures of their social and mental health, self-care behaviors, coping styles, and surrogate decision-making confidence. Using linear modeling, the Bayesian information criterion was used to identify factors associated with decision-making confidence. A bootstrap approach was used to conduct penalized inference on the selected model coefficients. Model fit validation was assessed with a random forest ensemble. Results: Caregivers (n = 294) were on average 65.5 years old, mostly female (72.8%), and care recipients' spouse/partner (60.2%). The parsimonious set of factors associated with low caregiver decision-making confidence included less engagement in spiritual growth self-care, more use of avoidant coping, low emotional social support, and younger care recipient age (in-sample R2 = 0.22). These factors were also identified by a random forest approach. After overfitting adjustment (shrunken R2 = 0.09), the strongest associations with low surrogate decision-making confidence were low spiritual growth self-care (adjusted standardized B = 0.17, p = 0.005) and high use of avoidant coping (adjusted standardized B = -0.12, p = 0.049). Discussion: Identifying strategies to enhance spiritual growth and reduce avoidant coping may be promising targets for interventions to improve family caregivers' confidence in future surrogate decision making.
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Affiliation(s)
- J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard A Taylor
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yasemin Turkman
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Moneka A Thompson
- Department of Pastoral Care, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sara J Knight
- Department of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle Y Martin
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
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20
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Fried TR, Zenoni M, Iannone L, O'Leary J, Fenton BT. Engagement in Advance Care Planning and Surrogates' Knowledge of Patients' Treatment Goals. J Am Geriatr Soc 2017; 65:1712-1718. [PMID: 28317097 DOI: 10.1111/jgs.14858] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES A key objective of advance care planning (ACP) is improving surrogates' knowledge of patients' treatment goals. Little is known about whether ACP outside of a trial accomplishes this. The objective was to examine patient and surrogate reports of ACP engagement and associations with surrogate knowledge of goals. DESIGN Cohort study SETTING: Primary care in a Veterans Affairs Medical Center. PARTICIPANTS 350 community-dwelling veterans age ≥55 years and the individual they would choose to make medical decisions on their behalf, interviewed separately. MEASUREMENTS Treatment goals were assessed by veterans' ratings of 3 health states: severe physical disability, cognitive disability, and pain, as an acceptable or unacceptable result of treatment for severe illness. Surrogates had knowledge if they correctly predicted all 3 responses. Veterans and surrogates were asked about living will and health care proxy completion and communication about life-sustaining treatment and quality versus quantity of life (QOL). RESULTS Over 40% of dyads agreed that the veteran had not completed a living will or health care proxy and that there was no QOL communication. For each activity, sizeable proportions (18-34%) disagreed about participation. In dyads who agreed QOL communication had occurred, 30% of surrogates had knowledge, compared to 21% in dyads who agreed communication had not occurred and 15% in dyads who disagreed (P = .01). This relationship persisted in multivariable analysis. Agreement about other ACP activities was not associated with knowledge. CONCLUSION Disagreement about ACP participation was common. Agreement about communication regarding QOL was modestly associated with surrogate knowledge of treatment goals. Eliciting surrogates' perspectives is critical to ACP. Even dyads who agree about participation may need additional support for successful engagement.
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Affiliation(s)
- Terri R Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Maria Zenoni
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lynne Iannone
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Program on Aging, Yale School of Medicine, New Haven, Connecticut
| | - John O'Leary
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Program on Aging, Yale School of Medicine, New Haven, Connecticut
| | - Brenda T Fenton
- Pain Research, Informatics, Multi-Morbidities and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
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21
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Siddiqui S. A Physician's Moral Dilemma in the Emergency Department: Going Against a Patient's Perceived Wishes. J Emerg Med 2016; 51:748-749. [PMID: 27658555 DOI: 10.1016/j.jemermed.2016.07.084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/01/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES We describe a case where a patient at the end of life with an advanced medical directive in place presents to the ED in distress. CASE REPORT Our case is of a middle aged male with advanced cancer who presents in the ED with his family in respiratory distress requiring intubation. Even though his advanced medical directive states not for prolonged life sustaining support his wife and daughters plead with the physicians to save his life in order to end his suffering as well as prepare them for a more peaceful death. CONCLUSION We discuss the ethical and moral distress faced by ED physicians in such acute scenarios where a patient's perceived wishes are not in line with their families' pleas.
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Affiliation(s)
- Shahla Siddiqui
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore and Department of Anaesthesia and Intensive Care, Khoo Teck Puat Hospital, Singapore
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22
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Abstract
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.
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Abstract
Unrepresented patients lack the capacity to make medical decisions for themselves, have no clear documentation of preferences for medical treatment, and have no surrogate decision maker or obvious candidate for that role. There is no consensus about who should serve as the decision maker for these patients, particularly regarding whether to continue or to limit life-sustaining treatment. Several authors have argued that ethics committees should play this role rather than the patient's treating physician, a common current default. We argue that concerns about the adequacy of physicians as surrogates are either empirically unfounded or apply equally to ethics committees. We suggest that physicians should be the primary decision maker for the unrepresented because of their fiduciary duties toward their patients. As part of the process of fulfilling these duties, they should seek the advice of third parties such as ethic committees; but final end-of-life decision-making for the unrepresented should rest with the treating physician.
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Chiarchiaro J, Schuster RA, Ernecoff NC, Barnato AE, Arnold RM, White DB. Developing a simulation to study conflict in intensive care units. Ann Am Thorac Soc 2015; 12:526-32. [PMID: 25643166 DOI: 10.1513/AnnalsATS.201411-495OC] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Although medical simulation is increasingly being used in healthcare education, there are few examples of how to rigorously design a simulation to evaluate and study important communication skills of intensive care unit (ICU) clinicians. OBJECTIVES To use existing best practice recommendations to develop a medical simulation to study conflict management in ICUs, then assess the feasibility, acceptability, and realism of the simulation among ICU clinicians. METHODS The setting was a medical ICU of a tertiary care, university hospital. Participants were 36 physicians who treat critically ill patients: intensivists, palliative medicine specialists, and trainees. Using best-practice guidelines and an iterative, multidisciplinary approach, we developed and refined a simulation involving a critically ill patient, in which the patient had a clear advance directive specifying no use of life support, and a surrogate who was unwilling to follow the patient's preferences. ICU clinicians participated in the simulation and completed surveys and semistructured interviews to assess the feasibility, acceptability, and realism of the simulation. MEASUREMENTS AND MAIN RESULTS All participants successfully completed the simulation, and all perceived conflict with the surrogate (mean conflict score, 4.2 on a 0-10 scale [SD, 2.5; range, 1-10]). Participants reported high realism of the simulation across a range of criteria, with mean ratings of greater than 8 on a 0 to 10 scale for all domains assessed. During semistructured interviews, participants confirmed a high degree of realism and offered several suggestions for improvements. CONCLUSIONS We used existing best practice recommendations to develop a simulation model to study physician-family conflict in ICUs that is feasible, acceptable, and realistic.
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Routh R, Mcneill C, Jackson GA. Use of power of attorney in Scotland. Scott Med J 2015; 61:119-123. [PMID: 26631049 DOI: 10.1177/0036933015619314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Power of Attorney as a form of surrogate decision making was introduced within the Adults with Incapacity, Scotland Act (2000) to help individuals who lack mental capacity due to illnesses like dementia. Even after a decade, little was known if it has been useful. We sought to find out how useful the power of attorney document has been so far in supporting people when they lose their capacity and identify any barriers. METHODS AND RESULTS We did a survey and approached a random sample of 5000 attorneys in Scotland. A total of 1226 attorneys responded; 59% of the respondents had never used their powers but still considered it useful for 'peace of mind'. For the majority, the costs of arranging a power of attorney ranged in between £150 and £300. CONCLUSIONS The study confirms that power of attorney is useful to safeguard interests of people when they lose capacity. Costs remain a big barrier. Further studies are required to understand the long-term impact of providing financial support to arrange a power of attorney at an early stage on reducing delayed discharges in hospitals.
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Affiliation(s)
- Rajdeep Routh
- ST6 Trainee, Old Age Psychiatry, NHS Greater Glasgow & Clyde, UK
| | - Catriona Mcneill
- Clinical Studies Officer (Glasgow), Scottish Dementia Clinical Research Network, UK
| | - Graham A Jackson
- Alzheimer Scotland Professor of Dementia Care, University of the West of Scotland, Alzheimer Scotland Centre for Policy and Practice, UK
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Abstract
Resolution of long-standing debates about the role and impact of advance directives - living wills and powers of attorney for health care - has been hampered by a dearth of appropriate data, in particular data that compare the process and outcomes of end-of-life decision making on behalf of patients with and without advance directives. Drawing on a large ethnographic study of patients in two intensive care units in a large urban teaching hospital, this article compares aspects of the medical decision-making process and outcomes by advance-directive status. Controlling for demographic characteristics and severity of illness, the study finds few significant differences between patients without advance directives and those who claim to have them. Surprisingly, these few differences hold only for those whose directives are in their hospital chart. There are no significant differences between those with no directive and those claiming to have a copy at home or elsewhere. The article considers the implications if directives seemingly must be in hand to show even modest effects. Do advance directives direct? The intensive care unit data provide far more support for the growing body of literature that casts doubt on their impact than studies that promote the use of them.
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Sur MD, Angelos P. Ethical Issues in Surgical Critical Care: The Complexity of Interpersonal Relationships in the Surgical Intensive Care Unit. J Intensive Care Med 2015; 31:442-50. [PMID: 25990272 DOI: 10.1177/0885066615585953] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/13/2015] [Indexed: 11/16/2022]
Abstract
A major challenge in the era of shared medical decision making is the navigation of complex relationships between the physicians, patients, and surrogates who guide treatment plans for critically ill patients. This review of ethical issues in adult surgical critical care explores factors influencing interactions among the characters most prominently involved in health care decisions in the surgical intensive care unit: the patient, the surrogate, the surgeon, and the intensivist. Ethical tensions in the surgeon-patient relationship in the elective setting may arise from the preoperative surgical covenant and the development of surgical complications. Unlike that of the surgeon, the intensivist's relationship with the individual patient must be balanced with the need to serve other acutely ill patients. Due to their unique perspectives, surgeons and intensivists may disagree about decisions to pursue life-sustaining therapies for critically ill postoperative patients. Finally, although surrogates are asked to make decisions for patients on the basis of the substituted judgment or best interest standards, these models may underestimate the nuances of postoperative surrogate decision making. Strategies to minimize conflicts regarding treatment decisions are centered on early, honest, and consistent communication between all parties.
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Affiliation(s)
- Malini D Sur
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, USA
| | - Peter Angelos
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, USA Bucksbaum Institute for Clinical Excellence, The University of Chicago Medicine, Chicago, IL, USA
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Escher M, Perrier A, Rudaz S, Dayer P, Perneger TV. Doctors' decisions when faced with contradictory patient advance directives and health care proxy opinion: a randomized vignette-based study. J Pain Symptom Manage 2015; 49:637-45. [PMID: 25131892 DOI: 10.1016/j.jpainsymman.2014.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 06/27/2014] [Accepted: 07/06/2014] [Indexed: 11/18/2022]
Abstract
CONTEXT Sometimes a written advance directive contradicts the opinion of a health care proxy. How this affects doctors' decision making is unknown. OBJECTIVES To quantify the influence of contradictory instructions on doctors' decisions. METHODS All the generalists and internists in French-speaking Switzerland were mailed the questionnaire. Respondents (43.5%) evaluated three vignettes that described medical decisions for incapacitated patients. Each vignette was produced in four versions: one with an advance directive, one with a proxy opinion, one with both, and one with neither (control). In the first vignette, the directive and proxy agreed on the recommendation to forgo a medical intervention; in the second, the advance directive opposed, but the proxy favored the intervention; and in the third, the roles were reversed. Each doctor received one version of each vignette, attributed at random. The outcome variables were the doctor's decision to forgo the medical intervention and the rating of the decision as difficult. RESULTS Written advance directives and proxy opinions significantly influenced doctors' decision making. When both were available and concordant, they reinforced each other (odds ratio [OR] of forgoing intervention 35.7, P < 0.001 compared with no instruction). When the directive and proxy disagreed, the resulting effect was to forgo the intervention (ORs 2.1 and 2.2 for the two discordant vignettes, both P < 0.001). Discordance between instructions was associated with increased odds of doctors rating the decision as difficult (both ORs 2.0, P ≤ 0.001). CONCLUSION Contradictions between advance directives and proxy opinions result in a weak preference for abstention from treatment and increase the difficulty of the decision.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland.
| | - Arnaud Perrier
- Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Sandrine Rudaz
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland
| | - Thomas V Perneger
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
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van Rookhuijzen AE, Touwen DP, de Ruijter W, Engberts DP, van der Mast RC. Deliberating clinical research with cognitively impaired older people and their relatives: an ethical add-on study to the protocol "Effects of Temporary Discontinuation of Antihypertensive Treatment in the Elderly (DANTE) with Cognitive Impairment". Am J Geriatr Psychiatry 2014; 22:1233-40. [PMID: 23973250 DOI: 10.1016/j.jagp.2013.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 03/26/2013] [Accepted: 04/08/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To explore the decision-making process involving elderly subjects with mild cognitive impairment and a relative when asked to participate in a clinical trial. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, we investigated the decision-making process during the informed consent conversations between the researchers of a clinical trial and 18 persons aged 75 years and older, with a Mini-Mental State Examination score ≥21 and ≤27. This assessment was performed by both observation and a standardized interview with the older person and a close relative who could act as a proxy (surrogate) decision maker, if necessary. The informed consent conversation and procedure took place at the home of the potential participants. MEASUREMENTS Videotapes or audiotapes were transcribed and analyzed by using coding schemes. RESULTS The participants were able to formulate substantial reasons why they would want to participate in the clinical trial. Willingness to help others and contribute to medical knowledge, combined with the absence of substantial risks, were predominant reasons for participation. Most older subjects did consult their relatives, who generally considered them capable of deciding for themselves. CONCLUSIONS Notwithstanding their (mild) cognitive impairment, these older subjects were able to formulate substantiated reasons for participation in a clinical trial. Thus, it is plausible that they were capable of making this decision themselves, which was affirmed by their relatives. Recognition of the desire to contribute unselfishly to research that might benefit others has important implications for future clinical research conducted in older people with mild cognitive impairment.
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Affiliation(s)
| | - Dorothea P Touwen
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Wouter de Ruijter
- Department of Public Health and Primary Health Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Dick P Engberts
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Roos C van der Mast
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
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Cox CE, White DB, Abernethy AP. A universal decision support system. Addressing the decision-making needs of patients, families, and clinicians in the setting of critical illness. Am J Respir Crit Care Med 2014; 190:366-73. [PMID: 25019639 DOI: 10.1164/rccm.201404-0728cp] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the setting of a complex critical illness, preference-sensitive decision making-choosing between two or more reasonable treatment options-can be difficult for patients, families, and clinicians alike. A common challenge to making high-quality decisions in this setting is a lack of critical information access and sharing among participants. Decision aids-brochures, web applications, and videos-are a major focus of current research because mounting evidence suggests they can improve decision-making quality and enhance collaborative shared decision making. However, many decision aids have important limitations, including a relatively narrow capacity for personalization, an inability to gather and generate clinical data, a focus on only a single disease or treatment, and high developmental costs. To address these issues and to help guide future research, we propose a model of "universal" electronic decision support that can be easily adapted by clinicians and patients/families for whatever decision is at hand. In this scalable web-based platform, a general shared decision-making core structure would accommodate simple, interchangeable disease and treatment information modules. The format and content of the system could be adapted to decisional participants' unique characteristics, abilities, and needs. Universal decision support can better standardize a decisional approach and also allow a unique degree of personalization within a framework of shared decision making. We also discuss potential criticisms of this approach as well as strategies that can overcome them in a critical illness setting.
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Affiliation(s)
- Christopher E Cox
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine
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Abstract
Rid and Wendler propose the development of a Patient Preference Predictor (PPP), an actuarial model for predicting incapacitated patient's life-sustaining treatment preferences across a wide range of end-of-life scenarios. An actuarial approach to end-of-life decision making has enormous potential, but transferring the logic of actuarial prediction to end-of-life decision making raises several conceptual complexities and logistical problems that need further consideration. Actuarial models have proven effective in targeted prediction tasks, but no evidence supports their effectiveness in the kind of broad spectrum prediction task that is the proposed goal of the PPP. We argue that a more focused approach, targeting specific medical conditions and generating treatment predictions based on the preferences of individuals with actual disease experience, is both more firmly grounded in past research and is a more prudent initial strategy for exploring the efficacy of actuarial prediction in end-of-life decision making.
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Affiliation(s)
- Peter H Ditto
- *4001 Social and Behavioral Sciences Gateway, Department of Psychology and Social Behavior, University of California, Irvine, CA 92697-7085, USA.
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Escher M, Perneger TV, Rudaz S, Dayer P, Perrier A. Impact of advance directives and a health care proxy on doctors' decisions: a randomized trial. J Pain Symptom Manage 2014; 47:1-11. [PMID: 23742734 DOI: 10.1016/j.jpainsymman.2013.03.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 03/02/2013] [Accepted: 03/19/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Advance directives or proxy designations are widely recommended, but how they affect doctors' decision making is not well known. OBJECTIVES The aim of this study was to quantify the influence of advance directives and proxy opinions on doctors' decisions. METHODS We mailed to all the generalists and internists in French-speaking Switzerland (N = 1962) three vignettes describing difficult decisions involving incapacitated patients. In each case, the advance directive requested that further care be withheld. One vignette tested the impact of a written advance directive vs. a proxy. Another compared the impact of a handwritten directive vs. a formalized document. The third vignette compared the impact of a family member vs. a doctor as a proxy. Each vignette was prepared in three or four versions, including a control version in which no directive or proxy was present. Vignettes were randomly allocated to respondents. We used logistic regression to predict the decision to forgo a medical intervention. RESULTS Compared with the control condition, the odds of forgoing a medical intervention were increased by the written advance directive (odds ratio [OR] 7.3; P < 0.001), the proxy (OR 7.9; P < 0.001), and the combination of the two (OR 35.7; P < 0.001). The handwritten directive had the same impact (OR 13.3) as the formalized directive (OR 13.8). The effect of proxy opinion was slightly stronger when provided by a doctor (OR 11.3) rather than by family (OR 7.8). CONCLUSION Advance directives and proxy opinions are equally effective in influencing doctors' decisions, but having both has the strongest effect. The format of the advance directive and the identity of the proxy have little influence on decisions.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland.
| | - Thomas V Perneger
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Sandrine Rudaz
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland
| | - Arnaud Perrier
- Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
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Abstract
Recalcitrant disputes among health care providers and patients or their families may signal deep cultural differences about what interventions are needed or about clinicians's professional duties. These issues arose in relation to a mother's request for hymenoplasty or revirgination for her minor daughter to enable an overseas, forced marriage and protect her from an honor killing. The American College of Obstetrics and Gynecology committee recommends against members performing a hymenoplasty or other female genital cosmetic surgeries due to a lack of data concerning their safety and efficacy. A key issue in such cases is how to determine what is in the minor's best interest and the scope of health care moral or professional's duties. The Best Interests Standard can serve as a powerful moral tool for resolving cross-cultural disputes and identifying needed policy.
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Affiliation(s)
- Loretta M Kopelman
- *Kennedy Institute of Ethics, Healy Hall, Georgetown University, Washington, DC 20057, USA.
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Braun UK, Naik AD, McCullough LB. Reconceptualizing the experience of surrogate decision making: reports vs genuine decisions. Ann Fam Med 2009; 7:249-53. [PMID: 19433843 PMCID: PMC2682974 DOI: 10.1370/afm.963] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 08/26/2008] [Accepted: 09/22/2008] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND We propose a reconceptualization of surrogate decision making when patients lack an advance directive stating their preferences about life-sustaining treatment. This reconceptualization replaces the current 2-standard model of substituted judgment (based on the patient's prior preferences and values) and best interests (an assessment of how best to protect and promote the patient's health-related and other interests). METHODS We undertook a conceptual analysis based on the ethics of informed consent, a qualitative study of how surrogates of seriously ill patients experience the surrogate's role, and descriptions of decision making. RESULTS When the surrogate can meet the substituted judgment standard, the experience of the surrogate should be understood as providing a report, not making a decision. Surrogate decisions based on the best interest standard are experienced as genuine decisions, and the label "surrogate decision making" should be reserved to characterize only these experiences. CONCLUSIONS Physicians should identify clinically reasonable options and elicit the surrogate's sense of decision-making burden. Some surrogates will be able to make reports, and the physician should make a clear recommendation that implements the patient's reported preference. Some surrogates will confront genuine decisions, which should be managed by negotiating treatment goals. Requests by the surrogate that everything be done may represent a psychosocially burdensome decision, and support should be provided to help the surrogate work through the decision-making process.
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Affiliation(s)
- Ursula K Braun
- Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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Braun UK, Beyth RJ, Ford ME, McCullough LB. Voices of African American, Caucasian, and Hispanic surrogates on the burdens of end-of-life decision making. J Gen Intern Med 2008; 23:267-74. [PMID: 18172738 DOI: 10.1007/s11606-007-0487-7] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 06/07/2007] [Accepted: 12/06/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND End-of-life decisions are frequently made by patients' surrogates. Race and ethnicity may affect such decision making. Few studies have described how different racial/ethnic groups experience end-of-life surrogate decision making. OBJECTIVES To describe the self-reported experience the self-reported experience of African-American, Caucasian, and Hispanic surrogate decision makers of seriously ill patients and to examine the relationship of race, ethnicity, and culture to that experience. DESIGN Purposive sample to include racial/ethnic minorities in a qualitative study using focus group interviews. PARTICIPANTS The participants of the study were 44 experienced, mostly female, surrogate decision makers for older veterans. APPROACH Transcripts were qualitatively analyzed to identify major themes, with particular attention to themes that might be unique to each of the three groups. RESULTS The experience of burden of end-of-life decision making was similar in all three groups. This burden in its medical, personal, and familial dimensions is compounded by uncertainty about prognosis and the patient's preferences. Racial/ethnic variations of responses to this burden concerned the physician-family relationship, religion and faith, and past experiences with race/ethnicity concordant versus non-concordant physicians. CONCLUSIONS Regardless of race/ethnicity, surrogates for seriously ill patients appeared to experience increased significant, multidimensional burdens of decision making under conditions of uncertainty about a patient's preferences. This aspect of the burden of surrogate decision making may not be fully appreciated by physicians. Physicians should identify and be especially attentive to strategies used by surrogates, which may vary by race/ethnicity, to reduce the uncertainty about a patient's preferences and thus the burden of surrogate decision making to assist them in this difficult process.
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