Health-Care Provider Personal Religious Preferences and Their Perspectives on Advance Care Planning With Patients.

OBJECTIVE:: To understand how health-care providers' (HCPs) religious preferences influence their willingness to undertake advance care planning (ACP) with patients and their acceptance of other HCP's involvement. METHODS:: Online anonymous survey distributed to HCPs in hospital, ambulatory offices, and hospice settings in Dayton, Ohio. We evaluated the associations of HCP religion with their personal ACP, willingness to facilitate ACP, and acceptance of other HCPs' ACP participation. RESULTS:: 704 respondents: nurses (66.2%), physicians (18.8%), other HCPs (15.0%), white (88.9%), and primarily Catholic (23.3%) or Protestant (32.0%). "No religion" was marked by 13.9%. Respondents were favorable to ACP with patients. Religious respondents were more likely to have a living will ( P = .035) and health-care power of attorney ( P = .007) and more accepting of clergy as ACP decision coaches ( P = .030). HCP's religion was not associated with willingness to facilitate ACP discussions. There were minor differences between Catholics and Protestants. CONCLUSIONS:: Personal religious preference is associated with HCP's own ACP but had little relationship with their willingness to facilitate ACP conversations with patients or acceptance of other professional types of HCPs involvement in ACP conversations. Regardless of religious affiliation, HCPs have interest in undertaking ACP and endorse other HCPs ACP involvement. As results of this study suggest that personal religious affiliation is not a barrier for HCPs engaging in ACP with patients, attempts to overcome barriers to increasing ACP should be directed to other factors.

Atención clínica, toma de decisiones y soporte nutricional en pacientes con esclerosis lateral amiotrófica / Clinical care, decision making and nutritional support in patients with amyotrophic lateral sclerosis

Introducción: En los pacientes afectos de Esclerosis Lateral Amiotrófica, es indispensable ofertar una adecuada información, que conlleve una acertada toma de decisiones, debido a las situaciones de alta complejidad que presentan durante su enfermedad. Con esta idea de fondo, se creó en nuestro Hospital Universitario Puerta del Mar de Cádiz un equipo interdisciplinar e interniveles para la atención de pacientes con esta entidad. Objetivos: Comparar variables relacionadas con la evolución clínica y la de toma de decisiones antes y después de la creación del equipo. Material y Método: Estudio descriptivo, observacional. Se comparan variables, pre y post intervención, destacando: sintomatología que motiva la consulta o el ingreso, episodios de atención en el hospital, interconsultas a profesionales, registro en la historia clínica de haber proporcionado información sobre la posibilidad de expresar la Voluntad Vital Anticipada y/o la existencia de la misma, soporte nutricional recibido. Resultados: Se obtuvieron 15 pacientes en el primer grupo y 13 en el segundo. Existe mejora en los porcentajes obtenidos en todas las variables, destacando el registro de voluntades vitales, toma de decisiones y soporte nutricional. Discusión-Conclusiones: La creación de un equipo interdisciplinar que hace partícipe al paciente de todo su proceso, además de asegurar una adecuada toma de decisiones por parte del paciente, conlleva la mejora de los resultados de indicadores clínicos (AU)

Background: In cases of ALS, due to the highly complex situations arising during the disease, it is essential to provide adequate information to the patient, so they can make suitable decisions concerning quality of life and symptom management over the course of their disease. To this end, an interdisciplinary and interlevel team has been created in the Hospital Universitario Puerta del Mar of Cádiz to provide the best care for people living with ALS. Objectives: Compare variables related to the clinical outcome and decision in-making before and after the creation of the team. Methods: Descriptive and observational study. Variables under evaluation were compared pre- and post- intervention, including: symptoms at the admission or consultation stages, care taking episodes in the hospital, interdepartmental clinical issues, entries in the medical record of existence or prospect of completing the advance health care directive, decision-making and nutritional support. Result: For sake of comparison, two groups were formed, the first one was made of 15, whereas the second one composed of 13 patients. There was a significant improvement in all the variables under study. It is especially remarkable the advance in the living will records, decision-making and nutritional support. Discussion-Conclusion: The creation of an interdisciplinary team capable fo engaging the patient of ALS in the clinical issues and symptom management over the course of the disease, not only ensures an adequate decision-making by the patient, but improves the results of the corresponding clinical indicators (AU)

[Role of the family doctor in the completion and registration of advance directives documents]. / Papel del médico de familia en la cumplimentación y registro del documento de instrucciones previas.

The attitude of professionals about living wills (advance directives) is not homogenous and varies depending on the specialty, experience and beliefs. Many doctors are still afraid of inconveniencing patients. The situation confronting the professional in an acute care hospital with a relatively unknown patient in a palliative care unit is not the same as consulting a family doctor who is caring for the patient holistically. Primary care has a unique position to approach the life and values of our patients and their families and not just the disease, which makes it the right place to guide and advise the patient on the preparation and registration of living wills.

Embracing a broad spirituality in end of life discussions and advance care planning.

Advance care planning for end of life typically focuses on the mechanics of completing living wills and durable power of attorney documents. Even when spiritual aspects of end of life care are discussed, the dominant assumptions are those of traditional religious systems. A broad view of spirituality is needed, one that may involve traditional religious beliefs but also includes personal understandings of what is holy or sacred. Embracing this broad practice of spirituality will help both familial and professional caregivers honor an essential aspect of end of life discussions and promote greater discernment of the deep meaning in advance care documents.

[Ethical issues of artificial nutritional support]. / Ethische Fragen der künstlichen Ernährung.

This review article discusses some ethical issues of clinical nutrition according to the Beauchamp and Childress principles of bioethics: "respect for autonomy, nonmaleficence, beneficence, and justice".

Pathways from religion to advance care planning: beliefs about control over length of life and end-of-life values.

PURPOSE OF THE STUDY: To evaluate the extent to which religious affiliation and self-identified religious importance affect advance care planning (ACP) via beliefs about control over life length and end-of-life values. DESIGN AND METHODS: Three hundred and five adults aged 55 and older from diverse racial and socioeconomic groups seeking outpatient care in New Jersey were surveyed. Measures included discussion of end-of-life preferences; living will (LW) completion; durable power of attorney for healthcare (DPAHC) appointment; religious affiliation; importance of religion; and beliefs about who/what controls life length, end-of-life values, health status, and sociodemographics. RESULTS: Of the sample, 68.9% had an informal discussion and 46.2% both discussed their preferences and did formal ACP (LW and/or DPAHC). Conservative Protestants and those placing great importance on religion/spirituality had a lower likelihood of ACP. These associations were largely accounted for by beliefs about God's controlling life length and values for using all available treatments. IMPLICATIONS: Beliefs and values about control account for relationships between religiosity and ACP. Beliefs and some values differ by religious affiliation. As such, congregations may be one nonclinical setting in which ACP discussions could be held, as individuals with similar attitudes toward the end of life could discuss their treatment preferences with those who share their views.

[Preventive crisis management in general outpatient palliative care - prospectively cross-sectional study of General Practitioners in Eastern Bavaria]. / Vorbeugendes Krisenmanagement in der allgemeinen ambulanten Palliativversorgung. Prospektive Querschnittstudie bei Hausärzten in Ostbayern.

BACKGROUND: General out-patient palliative care (GOPC) must be integrated into the care of patients with life-limiting diseases. Aim of the study was to evaluate experiences of general practitioners concerning advance directives and palliative emergency sheets. METHODS: A self-provided survey was mailed to all general practitioners in Regensburg (cross-sectional study). Main outcome measures included responses regarding a palliative emergency sheet (PES) and a palliative emergency plan (PEP). The investigation period was four months. The analysis was performed using defined criteria (e. g. professional experience concerning palliative care patients, patients treated in nursing homes, patients with dementia). RESULTS: Sixty-nine questionnaires from 259 were analysed (response rate 27 %). 86 % of respondents named practical experience in the care of palliative patients, 46 % named theoretical knowledge in this field. 41 % and 40 % consider creating an advance directive for their practical work as important/very important (p = 0.004 concerning the treatment of more than five palliative care patients per three months). 52 % and 49 % regard a PES or a PEP to be relevant (PES median: 6.5, SD ± 2.7; PEP median: 6.5 SD ± 2.9; inter-group analysis p < 0.05). 94 % of respondents name the general practitioner to be suitable for creating an advance directive. CONCLUSION: In Germany, GOPC in end-of-life care is very important. This study shows that advance directives were declared as an important instrument for patients? autonomy. The sense of PES and PEP to ensure patients? autonomy, especially for acute emergency medical palliative care, must be better recognized. However, the increase in acceptance in the GOPC for such instruments must be disclosed. Further studies to investigate this problem are necessary.

Temperamento e hipertensión arterial. Divertimento / Temperament and arterial hypertension. Divertissement

No disponible

Sufrimiento insoportable y voluntad de vivir: primeros resultados de un estudio en Gipuzkoa / No disponible

Este artículo introductorio presenta los resultados de un estudio con144 personas, entre ellas 120 enfermos con distintas patologías (31,7% con supervivencia estimada inferior a un año), realizado fundamentalmente en el Hospital Donostia de junio a octubre del 2005, con el objetivo principal de averiguar las percepciones y valores de los entrevistados antela experiencia del sufrimiento propio. La metodología empleada, esencialmente narrativa, propicia un encuentro que proporciona cierto alivio al paciente y aporta al profesional claves para una intervención que mejore la relación asistencial. Además de confirmar resultados anteriores, el estudio ha detectado que la experiencia del sufrimiento es multifactorial y varía de enfermo a enfermo, pero que sigue estando presente en la experiencia de una parte considerable de pacientes. Introducir la narración en la práctica clínica aumenta el autoconocimiento del profesional y hace posible alcanzar algunos de los más valiosos fines de la medicina paliativa. El sufrimiento es un fenómeno relacional, pero también lo es la voluntad de vivir, que se manifiesta en el recurso del paciente a su red de relaciones familiares y asistenciales, así como al consuelo religioso y a la resignación u otros fenómenos de aguante (AU)

This paper introduces the results of a qualitative study based on interviews with 144 subjects, amongst them 120 patients with diverse pathologies(317% with an estimated survival of 1 year). The study was conducted mainly in Hospital Donostia (Spain) from June to October 2005, its main goal being to identify perceptions and values about the patients' experience of suffering. In addition to confirming previous results, the study proved that the experience of suffering was variable amongst patients, and originated in multiple factors. Suffering is a relational phenomenon, and so is the will to live, which makes itself visible in the patient's recourse to his or her family and healthcare relationships network, as well as to spiritual comfort and resignation, or other forms of enduring. The methodology employed, essentially narrative, allowed face-to-face encounters between patients and professionals, which provided wellbeing to patients and some clues to professionals so as to improve their relationship. Introducing narratives in clinical practice enhances professional self-knowledge, and attains some of the most valuable goals of palliative medicine (AU)

Living will, resuscitation preferences, and attitudes towards life in an aged population.

BACKGROUND: The growth of life-sustaining medical technology and greater attention to medical care at the end of life have provoked interest in issues related to advance care planning. OBJECTIVE: To investigate how having a living will (LW), resuscitation preferences, health condition, and life attitudes are related in home-dwelling elderly people. METHODS: In a cross-sectional descriptive study, detailed assessments were made of 378 home-dwelling elderly individuals participating in a cardiovascular prevention study (DEBATE Study). The participants were inquired about a preexistence of a written document (LW) concerning life-sustaining care, preferences of cardiopulmonary resuscitation (CPR) in their current situation, and attitudes towards life. General health, physical and cognitive functioning, the presence of depression, and quality of life were also assessed. RESULTS: Forty-four of the 378 participants (12%) had a LW. As compared with those without one (n = 334), there were more women [82% (36/44) vs. 63% (210/334)] and widows [57% (25/44) vs. 41% (135/334)] among those with a LW. They were also more educated and considered their health to be better. Despite having a LW, 46% (20/44) of them preferred CPR in their current condition, a proportion not statistically different from the 58% (194/334) of the individuals without a LW. In the whole sample, 39% (149/378) of the individuals preferred to forgo CPR. As compared with those preferring CPR, they were older, more often women, and widowed. Participants preferring to forgo CPR had a poorer quality of life, were more lonely, and showed signs of depression more often than those preferring CPR. The preference to forgo CPR was related to attitudes towards life regardless of physical or cognitive functioning. CONCLUSIONS: Having a LW does not reduce the reported preference of CPR which is related more to current mental status and life attitudes. In-depth assessment of the patient's preferences should be performed in any comprehensive care plan.

[Discontinuing parenteral nutrition, patient self-determination and legal sanctions in treatment limitations. On the legal questions of physician-assisted death]. / Einstellung von Sondenernährung, Patientenverfügung und gerichtliche Genehmigung der Therapiebegrenzung. Zu Rechtsfragen ärztlicher Sterbehilfe.

Since the Federal High Court decided the "Case of Kempten" in 1994, German Law allows discontinuation of life-sustaining treatment even when the patient's life could be extended by a number of months. Unfortunately, the court gives little normative criteria regarding the conditions under which "helping to die" is legal. Instead of such criteria, the will of the patient is underlined as being decisive. Therefore, the legal problems have shifted to the determination of the patient's will and substituted consent; written living will, power of attorney and consent of the court have become more important within the law of euthanasia. Along with a general description of the legal limits of euthanasia, the scope of application of these civil law institutes will be discussed.

Roles for the church in improving end-of-life care: perceptions of Christian clergy and laity.

Although faith communities may seem to be logical places to discuss death and dying, few churches are engaged in extensive efforts to improve end-of-life care. To explore the meaning of a good death and potential roles for faith communities in this effort, the authors held focus groups involving 121 clergy and congregants affiliated with Christian churches in Honolulu. Participants' definitions of a good death were similar to those articulated in other studies, for example, pain is managed, inappropriate prolongation of dying is avoided, the family is present and supportive, conflicts are resolved, and spiritual/existential issues are addressed. Participants identified a number of roles for the church: (a) to help congregants prepare for death, both spiritually and practically; (b) to facilitate resolution of conflict and forgiveness; (c) to clarify if or how church theology should guide attitudes and practices related to death and dying; (d) to administer the appropriate rituals; and (e) to provide outreach to sick, dying, and bereaved members. A number of participants noted that attention to spiritual issues at life's end would be important to all people, and churches wanting to increase membership should expand offerings in this area. These findings suggest that faith communities can have a major impact on improving end-of-life care and that pastoral education include attention to these issues.

End-of-life decisions in HIV-positive patients: the role of spiritual beliefs.

OBJECTIVE: To describe the role of spiritual beliefs in HIV-positive patients' end-of-life decisions. DESIGN: Inperson, cross-sectional survey. SETTING: An HIV/AIDS floor of an urban, university teaching hospital. PATIENTS: Ninety hospitalized HIV-positive patients. MAIN OUTCOME MEASURES: Prior discussions about advance directives, possession of a living will (written advance directive), fear of death, professions of hope and purpose in life, religious beliefs and practices, guilt about HIV infection, and perception of HIV as punishment. RESULTS: Of 104 eligible patients, 90 agreed to be interviewed. Twenty-four per cent of patients had discussed their resuscitation status with a physician and 17% possessed a living will; 44% of patients felt guilty about their HIV infection, 32% expressed fear of death, and 26% felt their disease was some form of punishment. Prior discussions about resuscitation status were less likely in those who perceived HIV as punishment (P=0.009) and more likely in those who believed in God's forgiveness (P=0.043). A living will was more common in those who prayed daily (P=0.025) and in those whose belief in God helped them when thinking about death (P=0.065). Fear of death was more likely in those who perceived HIV as punishment (P=0.01) or felt guilty about having HIV (P=0.039), and less likely in those who read the Bible frequently (P=0.01) or attended church regularly (P=0.015). Outcome measures did not vary significantly according sex, race, HIV risk factors, or education level. CONCLUSIONS: In this HIV-positive population, spiritual beliefs and religious practices appeared to play a role in end-of-life decisions. Discussions about end-of-life decisions may be facilitated by a patient's belief in a forgiving God and impeded by a patient's interpretation of HIV infection as punishment. Health-care providers need to recognize patients' spiritual beliefs and incorporate them into discussions about terminal care.

The right to die: a case for reform.

The debate over patients' right to die is a complex one. Here one nurse looks at the statutory requirements and ethical considerations and makes a case for the development of living wills.