Do advance directive attitudes and perceived susceptibility and end-of-life life-sustaining treatment preferences between patients with heart failure and cancer differ?

There is limited evidence on the relationships of preference for end-of-life life-sustaining treatments [LSTs] and diagnostic contexts like heart failure [HF] or cancer, and patient attitudes toward and perceived susceptibility to use advance directives [ADs]. Thus, this study aimed to compare attitudes and perceived susceptibility between HF patients and community-dwelling patients with cancer, and examine the associations of these variables with their preference for each LST (cardiopulmonary resuscitation [CPR], ventilation support, hemodialysis, and hospice care). Secondary data were obtained from 36 outpatients with HF (mean age, 65.44 years; male, 69.4%) and 107 cancer patients (mean age, 67.39 years; male, 32.7%). More patients with HF preferred CPR than cancer patients (41.7% and 15.9%, χ2 = 8.88, P = 0.003). Attitudes and perceived susceptibility were similar between the two diagnostic cohorts. HF patients and those with more positive attitudes had greater odds of preferring CPR (odds ratio [OR] = 3.02, confidence interval [CI] = 1.19, 7.70) and hospice care (OR = 1.14, CI = 1.06, 1.23), respectively. HF diagnosis and AD attitudes increased the preference for CPR and hospice care, respectively. This suggests that it is important to gain positive attitudes toward ADs and consider diagnostic context to facilitate informed decision-making for LSTs.

Involuntary Detention and Treatment: Are We Edging Toward a "Paradigm Shift"?

Recent challenges to conventional mental health laws concerning involuntary detention and treatment of persons with a mental disorder have led to proposals, or indeed an insistence, that fundamental reform is necessary. A key theme has been the need to eliminate unfair discrimination against people with a mental disorder because their human rights are not respected on an equal basis with other people. Some proposals depart radically from conventional assumptions concerning the justification of involuntary detention and treatment. One is a "fusion law," a generic law applying to all persons lacking the ability to make a treatment decision, whether resulting from a "mental" or "physical" illness. An authoritative interpretation of the UN Convention on the Rights of Persons with Disabilities (2006) goes so far as to maintain that involuntary interventions are a violation of the Convention.

Perspectiva Ética de la Rehabilitación Basada en la Comunidad (RBC) en el contexto Chileno / Ethical perspective of community based rehabilitation in the Chilean context / Perspectiva ètica de la rehabilitació basada en la comunitat en el context xilè

La estrategia de rehabilitación basada en la comunidad fue desarrollada para abordar una importante preocupación ética relacionada con la justicia social y la equidad. A continuación, en base una revisión de la literatura existente, se desarrollan cinco temas claves relacionados con la ética de dicha estrategia, destacando el aporte de Clarke, quien contempla argumentación crítica de cinco temas vinculados a la Rehabilitación basada en la comunidad, tales como; asociación de las partes interesadas, respeto a la cultura y experiencia local, equidad en el diseño del programa, empoderamiento comunitario y rendición de cuentas, se discuten dichas temáticas con el fin de comprender mejor el panorama de la rehabilitación, a partir de las sistematizaciones y experiencias en la población chilena

The community-based rehabilitation strategy was developed to address an important ethical concern related to social justice and equity. Then, based on a review of the existing literature, five key issues related to the ethics of this strategy are developed, highlighting the contribution of Clarke, who considers critical argumentation of five issues related to community-based rehabilitation, such as; Partnerships among stakeholders, Respect for culture and local experience, equity in program design, community empowerment and accountability, these topics are discussed in order to better understand the rehabilitation landscape in Chile, based on systematizations and experiences in the Chilean population

L'estratègia de rehabilitació basada en la comunitat va ser desenvolupada per a abordar una important preocupació ètica relacionada amb la justícia social i l'equitat. A continuació, en base una revisió de la literatura existent, es desenvolupen cinc temes claus relacionats amb l'ètica d'aquesta estratègia, destacant l'aportació de Clarke, qui contempla argumentació crítica de cinc temes vinculats a la rehabilitació basada en la comunitat: associació de les parts interessades, respecte a la cultura i experiència local, equitat en el disseny del programa, apoderament comunitari i rendició de comptes, es discuteixen aquestes temàtiques amb la finalitat de comprendre millor el panorama de la rehabilitació, a partir de les sistematitzacions i experiències en la població xilena

Mayo Clinic's 5-Step Policy for Responding to Bias Incidents.

Patient bias towards clinicians and employees in health care is common, but policy to address bias and to support staff is relatively limited. Creating a framework to address bias incidents is critical for cultivating environments that are safe for employees and patients. Mayo Clinic has created both policy to support staff and a reporting mechanism for accountability. Education, resources, and training are available and being disseminated to teach employees ways to respond to bias incidents.

Giving substance to 'the best interpretation of will and preferences'.

In General Comment No. 1, the UN Committee on the Rights of Persons with Disabilities calls for 'the best interpretation of will and preferences' to replace best interests determinations in decision-making law, but it has given little guidance on the content of this new standard. As a result, 'best interpretation' is sometimes treated as synonymous with 'true interpretation'. On this reading, 'the best interpretation of will and preferences' is just whatever interpretation most accurately represents the interpreted person's will and preferences. This article shows that the conflation of the word 'best' with the word 'true' must be avoided. Interpretative processes contribute to changes in the interpreted person, including changes in their will and preferences. There are both supportive and abusive forms of these contributions, but conflating 'best interpretation' with 'true interpretation' removes both from view. An alternative reading of 'best interpretation' should therefore be preferred: one that requires the process of interpretation to be responsive to both truth and the detailed substantive rights found in the UN Convention on the Rights of Persons with Disabilities.

The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department.

Physician Orders for Life-Sustaining Treatment forms convert patient wishes into physician orders to direct care patients receive near the end of life. Recent evidence of the challenges and opportunities for honoring patient end-of-life wishes in the emergency department (ED) is presented. The forms can be very helpful in directing whether cardiopulmonary resuscitation and intubation are desired in the first few minutes of a patient's presentation. After initial stabilization, understanding the intent of end-of-life orders and the scope of further interventions requires discussion with the patient or a surrogate. The emergency medicine provider must be committed both to honoring initial resuscitation orders and to the conversations required to narrow the gap between ED care and patient wishes so that people receive care best aligned with their wishes.

Ethics of dead participants: policy recommendations for biobank research.

Respecting people's consent choices for use of their material and data is a cornerstone of biobank ethics. Participation in biobanks is characteristically based on broad consent that presupposes an ongoing possibility of informing and interacting with participants over time. The death of a participant means the end of any interaction, but usually not the end of participation. Research on causes of death makes biobank material from deceased participants extremely valuable. But as new research questions and methods develop over time, the question arises whether stored biobank material from deceased persons still can be used on the basis of their broad consent. In this paper, we discuss policies for postmortem use of biobank material, including consent options, proxy consent and criteria for limitation of types of use and duration of storage. We conclude that the interests of participants in biobank research are best served by asking at enrolment if and how the biobank material may be used after death. We state that the use of biobank material from deceased participants should be delimited both by their consent and by the prevailing broad consent choices of living participants.Biobanks also need to inform participants at enrolment about the duration of storage of biobank material or at minimum have procedures for deciding how long material will be stored for and for which purpose. For older collections, in the absence of such information or consent options, relevant authorities should decide.

Making medical decisions for an incompetent older adult when both a proxy and an advance directive are available: which is more likely to reflect the older adult's preferences?

OBJECTIVES: To investigate which of two sources of information about an older adult's wishes-choices made in an advance directive or proxy's opinion-provides better insight into the older adult's preferences measured in hypothetical clinical situations involving decisional incapacity. METHODS: Secondary analyses of data collected from 157 community-dwelling, decisionally competent adults aged 70 years and over who attended a group information session on advance directives with their proxy. Older adults were invited to complete a directive introduced during the session, designed to express healthcare preferences. An average of 3 months later, older adults were asked during an interview whether they would want to receive each of four medical interventions and what their goals of care would be should they develop one of three sudden health events, assuming that they had severe dementia. Proxies were asked to guess the older adult's answers in each of the seven scenarios. RESULTS: Eighty per cent of the older adults completed the directive. Choices they made in the directive were more in line with the preferences they stated during the interview than were their proxies' guesses at their answers. However, concordance was relatively low, with percentages of agreement ranging from 43% to 83% across scenarios. CONCLUSIONS: Findings suggest that a directive might provide better insight into a person's wishes than the person's proxy, although neither source is perfect. A multifaceted decision-making model that includes both sources of information might better serve the interests of older adults who have lost the capacity to make decisions on their own. TRIAL REGISTRATION NUMBER: ISRCTN89993391; Post-results.

A qualitative analysis of student-written law and ethics cases: A snapshot of PY2 student experience.

INTRODUCTION: This study was designed to better understand pharmacy students' experiences and recognition of legal and ethical tensions existing in pharmacy practice as demonstrated in student-written law and ethics cases. METHODS: A qualitative analysis of 132 student-written cases representing the team efforts of 1053 students over a 12-year time period was conducted. Student-written cases were coded and analyzed thematically. RESULTS: Our results demonstrate the types of ethical and legal issues our students have experienced in pharmacy practice during the first five quarters of their professional education. Our data highlight three themes: 1) ethical dilemmas presented when the law is misapplied; 2) ethical dilemmas presented when an institutional policy or law was viewed as insufficient; and 3) ethical dilemmas presented as provider distress. The third theme was further subdivided into five subthemes. CONCLUSION: The themes that emerged from this study represent some of the ethical dilemmas that second professional year students have encountered and how these dilemmas may intersect with legal boundaries. Educators can use cases demonstrating these themes to reinforce law and ethics education in the curriculum, thus helping prepare students for pharmacy practice. This article recommends how and when to use case examples.

[Coercive Interventions in Psychiatry: Prevention and Patients' Preferences]. / Psychiatrische Zwangsmaßnahmen: Prävention und Präferenzen aus Patientenperspektive.

Objective This study explores patients' preferences and measures of prevention of coercive methods in psychiatric treatment. Methods Structured interviews of 90 patients with psychotic disorders were undertaken, most of whom had previously experienced coercive methods. Results Participants saw preventive potential in a wider availability of individual non-pharmacological therapy, improvement of staff professional competence and communication skills, high staff-to-patient ratios and retreat facilities. The majority of participants preferred forced medication and manual restraint in case of self-endangerment, and forced medication and mechanical restraint in the event of endangerment of others. Conclusion Patients' suggestions relating to prevention of coercion are in line with most expert's opinions. In case coercive methods are required, manual restraint and application of forced medication is accepted as the treatment of choice according to most patients in case of self-endangerment.

The impact of a liberalisation law on legally induced abortion hospitalisations.

OBJECTIVES: Legal abortion based purely in maternal option without fetal/maternal pathology was liberalised in Portugal in 2007 and since then abortion rates have increased substantially. The aim of this paper was to study the impact of the liberalisation of abortion by maternal request on total legal abortion related hospitalisation trends. STUDY DESIGN: We considered hospitalisations of legal abortion (ICD-9-CM codes 635.x) with discharges from 2000 to 2014. Data was obtained from a Portuguese administrative database, which contains all registered public hospitalisations in mainland Portugal. Performed legal abortions during the same period were obtained from INE (National Statistics Institute). Hospitalisations per abortion were calculated by dividing the number of legal abortions hospitalisations per the number of legal abortions, mean ages, number of hospitalisations per age group, complications, admission type and length of stay were also analysed, throughout the study period. RESULTS: Hospitalisations rose during the study period, (from 618 episodes in 2000 to 1,259 in 2014, with a peak of 1,603 in 2010). Since the liberalisation law was passed there was a significant decrease in the number of hospitalisations per abortion: from 1.07 in 2000 to 0.11 in 2014 (p<0.001). Furthermore, the mean age maintained stable since liberalisation (30.8 years before 2007 and 31.0 after). Abortion related hospitalisations are more frequent in women aged 25-39. A significant decrease from the emergent to the scheduled type of admission occurred from 2000 to 2014 (from 83.5% to 56.7% of emergent admissions) (p<0.001). Complications remained stable between 2000 and 2014 and delayed or excessive haemorrhage was the most frequent (4.6%). CONCLUSIONS: Since the liberalisation, hospitalisations per abortion have decreased, reflecting the major impact that the liberalisation of legal abortion by maternal request had on abortion trends nationwide. Before the liberalisation, each abortion led to approximately one hospitalisation while after the liberalisation this trend shifted to approximately 10% of the number of abortions. Legal abortion related hospitalisations are more frequent in women aged between 25 and 39 years old, an older age group when compared to the one registered in all cases of legal abortions, reflecting the differences between those hospitalised and those who are not. Our study shows the impact that legal abortion by maternal request liberalisation law can bring to abortion and to hospitalisation trends.

Patient Engagement Advisory Committee. Final rule.

The Food and Drug Administration (FDA) is amending the standing advisory committees' regulations to add the Patient Engagement Advisory Committee.

[The suitability of therapeutic effort: An end-of-life strategy]. / Adecuación del esfuerzo terapéutico, una estrategia al final de la vida.

End-of-life treatment and attention to the needs of relatives are not adequate for several reasons: Society denies or hides the death; it is very difficult to predict it accurately; treatment is frequently fragmented between different specialists, and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts with decisions made at the end of life, particularly the suitability of therapeutic effort. The attitude of professionals on the adequacy of therapeutic effort is not homogenous, and varies depending on the specialty, experience, and beliefs. Many doctors are still afraid of inconveniencing patients. Primary care is in a privileged 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.