Autonomy at the end of life: life-prolonging treatment in nursing homes--relatives' role in the decision-making process

BACKGROUND

The increasing number of elderly people in nursing homes with failing competence to give consent represents a great challenge to healthcare staff's protection of patient autonomy in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation. The lack of national guidelines and internal routines can threaten the protection of patient autonomy.

OBJECTIVES

To place focus on protecting patient autonomy in the decision-making process by studying how relatives experience their role as substitute decision-makers.

DESIGN

A qualitative descriptive design with analysis of the contents of transcribed in-depth interviews with relatives.

PARTICIPANTS

Fifteen relatives of 20 patients in 10 nursing homes in Norway.

RESULTS AND INTERPRETATIONS

The main findings reveal deficient procedures for including relatives in decision-making processes. Relatives have poor knowledge about the end of life, and there is little discussion about their role as substitute decision-makers for patients who are not competent to give consent. Few relatives understand the concept of patient autonomy. In Norway the treating physician is responsible for patient treatment. When relatives are included in discussions on treatment, they perceive themselves as responsible for the decision, which is a burden for them afterwards. This qualitative study describes relatives' experiences, thus providing important information on the improvement potential with the main objective of safeguarding patient autonomy and caring for relatives.

CONCLUSION

The study reveals failing procedures and thus a great potential for improvement. Both ethical and legal aspects must be addressed when considering patient autonomy.

Life-prolonging treatment in nursing homes: how do physicians and nurses describe and justify their own practice?

BACKGROUND

Making the right decisions, while simultaneously showing respect for patient autonomy, represents a great challenge to nursing home staff in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation to dying patents in end-of-life.

OBJECTIVES

To study how physicians and nurses protect nursing home patients' autonomy in end-of-life decisions, and how they justify their practice.

DESIGN

A qualitative descriptive design with analysis of the content of transcribed in-depth interviews with physicians and nurses.

PARTICIPANTS

Nine physicians and ten nurses in 10 nursing homes in Norway.

RESULTS AND INTERPRETATIONS

Assessment of the patient's competence to consent to treatment is almost absent. The physicians build their practice on the principles of beneficence and nonmaleficence. Nurses tend to trust the patients' rejection of life support, even when the patients have difficulty speaking or suffer from dementia. Relatives were, according to the health personnel, included in decision-making processes to a very limited extent. However, futile life support is sometimes provided contrary to the physicians' judgement of what constitutes the patient's best interest on occasions when they are pressurised by next of kin.

CONCLUSIONS

The study reveals a need to improve decision-making routines according to ethical ideals and legislation. Conflicts between relatives and healthcare professionals in the decision-making process deflect the focus from searching for the best possible treatment for the terminal patient. Further discussion is required as to whether the concept of autonomy is applicable in situations in which the patient is impaired and dying.

Nonverbal communication accuracy in married couples: relationship with marital complaints

Nonverbal communication abilities were examined as mediators of martial complaints for a sample of 48 recently married couples. Based on social penetration theory, we predicted that couples cohabiting longer would be better at decoding their partners' nonverbal expressions than couples cohabiting a shorter time, that individuals married to accurate nonverbal communicators would evidence fewer martial complaints, and that individuals with fewer marital complaints would be better nonverbal communicators. The data suggest that nonverbal decoding abilities do not covary with relationship length, although spouses were better at decoding their partners' expressions than were a panel of judges. In addition, nonverbal sensitivity to one's spouse did not covary with martial complaints, although an internal analysis suggests that wives' ability to decode husbands poorly encoded messages covaries negatively with both his and her complaints. Finally, husbands married to wives who are good encoders had fewer complaints, whereas the reverse was found to hold true for the relationship between husbands' encoding abilities on wives' complaints.

Ethical decision-making in nursing homes: Influence of organizational factors

In this article we report findings from a qualitative study that explored how doctors and nurses in nursing homes describe professional collaboration around dying patients. The study also examined the consequences this can have for the life-prolonging treatment of patients and the care of them and their relatives. Nine doctors and 10 nurses from 10 Norwegian nursing homes were interviewed about their experience of decision-making processes on life-prolonging treatment and care. The findings reveal that the frameworks for the professional collaboration and organization of physicians and nurses prevent patient treatment and care complying with ethical considerations and the law. These conditions have a challenging impact on the care of dying patients and their relatives.

Localization of tones and noise in the horizontal plane by unrestrained house mice (Mus musculus)

House mice (Mus musculus, outbred strain NMRI) were trained to locate loudspeakers at the margin of a wire-mesh covered circular platform. Sound signals were tone bursts of 1, 15, 50 and 80 kHz and noise bursts (bandwidth 15–80 kHz). Localization acuity as represented by orientation angles (alpha) toward the speaker was determined at 5 radial distances from the centre of the platform. If the animals could localize under closed-loop conditions (with repetitive stimulation), the distributions of (alpha) showed a significant peak at the speaker position (0 degrees) and mean orientation angles (alpha) for the different stimuli all varied around 0 degrees. Distributions of (alpha) from open-loop tests were not peaked, i.e. mice did not localize the sound source. We calculated the median angle (beta) of the distributions of orientated runs and used (beta) as a measure for the accuracy of localization. Smallest values of beta were 12 degrees for 1 kHz, 15 degrees for 15 kHz, 9.5 degrees for 50 kHz, 8.5 degrees for 80 kHz tone bursts and 7 degrees for the noise bursts. The results are discussed in relation to possible localization mechanisms in mice.

Particle-size distribution of airborne poly- and perfluorinated alkyl substances

Eleven particle-size-segregated samples were taken to investigate the particle-size distribution of perfluoroalkyl substances (PFASs) using two five stage impactors in parallel. Samples were extracted with methanol and detected by HPLC/MS-MS. Investigation yielded reproducible results for the parallel samples over the entire sampling period. Particle-size distribution varied between perfluorooctane sulfonate (PFOS) and other perfluoroalkyl sulfonates (PFSAs), perfluorooctane carboxylate (PFOA) and other perfluoroalkyl carboxylates (PFCAs) and n-methyl-perfluorooctanesulfonamido ethanol (MeFOSE). Whereas PFOA and MeFOSE were predominantly observed in smallest size fraction (<0.14μm), maximum PFOS mass fractions were observed in the coarser size fractions between 1.38 and 3.81μm. The reason for this different behaviour remained unclear and indicated a complex atmospheric PFAS processing and sampling which should be further investigated and optimized, respectively.

Seasonal accumulation of persistent organic pollutants on a high altitude glacier in the Eastern Alps

The seasonal accumulations of perfluorinated substances (PFAS), polybrominated diphenyl ethers (PBDE) and polycyclic aromatic hydrocarbons (PAH) were measured in a 10 m shallow firn core from a high altitude glacier at Mt. Ortles (Italy, 3830 m above sea level) in South Tyrol in the Italian Eastern Alps. The most abundant persistent organic pollutants of each group were perfluorobutanoic acid (PFBA), perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA) (for PFASs); BDE 47, BDE 99, BDE 209 (for PBDEs) and phenanthrene (PHE), fluoranthene (FLA) and pyrene (PYR) (for PAHs). All compounds show different extents of seasonality, with higher accumulation during summer time compared to winter. This seasonal difference mainly reflects meteorological conditions with a low and stable atmospheric boundary layer in winter and strong convective activity in summer, transformation processes during the transport of chemicals and/or post-depositional alterations. Change in the composition of the water-soluble PFCAs demonstrates the influence of meltwater percolation through the firn layers.

Nonverbal communication accuracy in married couples: relationship with marital complaints

Nonverbal communication abilities were examined as mediators of martial complaints for a sample of 48 recently married couples. Based on social penetration theory, we predicted that couples cohabiting longer would be better at decoding their partners' nonverbal expressions than couples cohabiting a shorter time, that individuals married to accurate nonverbal communicators would evidence fewer martial complaints, and that individuals with fewer marital complaints would be better nonverbal communicators. The data suggest that nonverbal decoding abilities do not covary with relationship length, although spouses were better at decoding their partners' expressions than were a panel of judges. In addition, nonverbal sensitivity to one's spouse did not covary with martial complaints, although an internal analysis suggests that wives' ability to decode husbands poorly encoded messages covaries negatively with both his and her complaints. Finally, husbands married to wives who are good encoders had fewer complaints, whereas the reverse was found to hold true for the relationship between husbands' encoding abilities on wives' complaints.

Involving relatives in consultations for patients with long-term illnesses: Nurses and physicians' experiences

BACKGROUND

Due to the major changes occurring in the demographic composition of the world's population, the number of older individuals is increasing, which puts pressure on the healthcare systems in many different countries. The involvement of volunteers and family members may become necessary to fulfil a patient's needs for follow-up treatments and long-term care in their homes.

AIM

This study aimed to explore how nurses and physicians experienced and addressed ethical challenges when they dealt with relatives in what have traditionally been one-on-one consultations at two Norwegian hospital outpatient clinics.

RESEARCH DESIGN AND METHODS

A total of eight nurses and two physicians from two different hospitals participated in individual in-depth interviews. The transcribed interviews were analysed using an eclectic approach called 'bricolage' inspired by Kvale and Brinkmann. We combined cross-case thematic and theoretical normative analyses.

ETHICAL CONSIDERATIONS

The principles of voluntariness, confidentiality, withdrawal and anonymity were respected throughout the research process. In addition, the Norwegian Social Science Data Services approved this study.

FINDINGS

The findings showed that respect for a patient's autonomy was used as an argument for delimiting the relatives' access to the patient's consultations. We found that there were insufficient routines in place for inviting and involving relatives in the patient consultations in the outpatient clinics.

DISCUSSION

The traditional Western attitudes towards the principles of patient autonomy will likely be challenged due to the growing need for family involvement in the care of a patient in the future.

CONCLUSION

This study's description of the nurses and physicians' interpretations of 'patient autonomy' as a phenomenon uncover the need for systematic ethical deliberation in the clinical setting. On an organisational level, there is a strong indication of the need to discuss the routines that are in place to invite the next of kin to participate in such patient's healthcare consultations.

Profile of forensic psychiatric inpatients referred to the Free State Psychiatric Complex, 2004–2008

<p><strong>Introduction:</strong> An accused found unfit to stand trial and/or not responsible for his/her actions because of mental illness, is declared a state patient by the court. <strong></strong></p><p><strong>Aim:</strong> The aim of the study was to analyse the biographical data and relevant particulars of forensic psychiatric inpatients who were admitted to the Free State Psychiatric Complex (FSPC) according to section 42 of the Mental Health Care Act (no. 17 of 2002), from 2004 to 2008. Study design A descriptive, retrospective study was conducted. Method One hundred and twenty forensic psychiatric inpatients admitted to the FSCP in the terms of section 42 of the Mental Health Care Act in the period 2004–2008, were included in the study.</p><p><strong>Results:</strong> The majority (95.8%) of the offenders were male, unmarried (83.8%) and unemployed (81.5%). The median age was 32.5 years. Most of the offenses against persons were of a sexual nature (45.8%). More than half (55.5%) of the forensic inpatients were diagnosed with schizophrenia, followed by mental retardation (10%) and bipolar mood disorder. Eighty percent (80%) of these patients were found not competent to stand trial and unaccountable. Fifty percent (50%) of the participants received treatment for a mental illness prior to the crime, and were also known to have poor compliance and defaulted from treatment in the past.</p><p><strong>Conclusion:</strong> The findings of this study can contribute to implement effective management and training programmes for the benefit of state patients.</p>

Next of kin's protracted challenges with access to relevant information and involvement opportunities

Background

Next of kin are considered a resource for both the patient and the health service. Need for information varies with severity and duration of health changes. A clear requirement is about what to expect upon homecoming, and what supportive services are available. The picture of relatives’ access to involvement and information is still somewhat unclear.

Objective

To investigate what information, knowledge, and involvement next of kin considered important for managing their caring role and collaboration with their close relatives who experienced events that led to chronic illness.

Design, setting, and methods

A qualitative exploratory design. Seventeen informants were recruited through various courses offered to relatives. Data were collected in 2017 from individual interviews, analyzed in an interpretative tradition, and involved qualitative content analysis.

Results

The results reflect a long intervening period in between the activating incident and a clarification of the situation. This period was characterized by unpreparedness for duration of anxiety and amount of energy involved in balancing the relationship. Further, the interviewees saw retrospectively that information about disease and treatment was available, but they had to find such resources themselves. Information about how to handle the situation was almost absent. Ultimately, they were disappointed over not being involved.

Conclusion

Previously provided prospective information about the embedded anxiety in the situation and consequences for relationships, involvement in patients’ services, and better communication about existing services seem to be significant. Health care professionals, especially in outpatient care, may improve their services by debating how they can implement family-oriented care in personalized treatment as usual. Focus on prospective information, early involvement, and relevant information about existing resources may empower relatives and relieve the experience of care burden.

Surface stabilization determines a classical versus non-classical nucleation pathway during particle formation

In the bottom-up synthesis of nanoparticles, the degree of surface stabilization by the surfactant decides a classical or non-classical formation pathway.