¿Qué conocen las enfermeras de Galicia sobre las voluntades anticipadas? / What do Galicia's nurses know about living wills?

Objetivo: Analizar el grado de conocimiento y la actitud sobre las voluntades anticipadas de las enfermeras que trabajan en 3 hospitales del Servizo Galego de Saúde (España). Método: Estudio descriptivo, transversal, multicéntrico. Se realizó un muestreo estratificado a enfermeras de los complejos hospitalarios Universitarios de Ourense, Ferrol y Vigo. Se calculó un tamaño muestral de 239 individuos. La recogida de los datos se realizó durante el primer semestre de 2018 mediante un cuestionario validado autocumplimentado («Cuestionario de conocimientos y actitudes de los profesionales sanitarios en el proceso de declaración de voluntades vitales»). Resultados: Participaron un total de 262 enfermeras. Un 50% cree que los profesionales sanitarios están obligados a informar sobre las voluntades anticipadas. Un 2% considera que tiene suficiente información sobre el tema, y así lo demuestran en las preguntas de conocimientos, donde entre un 61-93% fallan en las preguntas relacionadas con la documentación, uso y aspectos legales de las mismas. Un 84% considera que tiene la obligación de respetar los valores y creencias de los pacientes y un 89% que los pacientes tienen derecho a recibir y decidir sobre la atención idónea. Un 13% considera que los pacientes no están bien informados sobre voluntades anticipadas, y un 83% recomendaría a sus pacientes crónicos la realización del documento de voluntades anticipadas. Conclusiones: Las enfermeras tienen un gran desconocimiento sobre los aspectos legales y el uso de las voluntades anticipadas, lo que les hace sentirse poco capaces para informar a sus pacientes sobre las mismas. A pesar de la falta de conocimiento, su actitud es positiva y la mayoría manifiesta que las recomendaría a sus pacientes

Objective: To analyse the level of knowledge and attitudes concerning living wills of nurses working in 3 hospitals of Servizo Galego de Saúde (Spain). Method: Descriptive, cross-sectional, multi-centre study. Stratified sampling was carried out with nurses from the University Hospital Complexes of Ourense, Ferrol and Vigo. A sample size of 239 individuals was calculated. The data was collected during the first semester of 2018 using a validated self-administered questionnaire («Cuestionario de conocimientos y actitudes de los profesionales sanitarios en el proceso de declaración de voluntades vitales»). Results: A total of 262 nurses participated. Fifty percent believe that health professionals are obliged to inform about living wills. Two percent consider that they have enough information on the subject, and this is demonstrated in the knowledge questions, where between 61%-93% fail in the questions related to the documentation, use, and their legal aspects. Eighty-four percent consider that they have the obligation to uphold the values and beliefs of patients, and 89% that patients have the right to receive and decide on the right care. Thirteen percent consider that patients are not well informed about living wills, and 83% would recommend to chronic patients that they complete a living will. Conclusions: Nurses have a great lack of knowledge about the legal aspects and the use of living wills, which makes them feel unable to inform their patients about them. Despite of the lack of knowledge, their attitude is positive and most of them state that they would recommend them to their patients

Does implementation matter if comprehension is lacking? A qualitative investigation into perceptions of advance care planning in people with cancer.

PURPOSE: While advance care planning holds promise, uptake is variable and it is unclear how well people engage with or comprehend advance care planning. The objective of this study was to explore how people with cancer comprehended advance care plans and examine how accurately advance care planning documentation represented patient wishes. METHODS: This study used a qualitative descriptive design. Data collection comprised interviews and an examination of participants' existing advance care planning documentation. Participants included those who had any diagnosis of cancer with an advance care plan recorded: Refusal of Treatment Certificate, Statement of Choices, and/or Enduring Power of Attorney (Medical Treatment) at one cancer treatment centre. RESULTS: Fourteen participants were involved in the study. Twelve participants were female (86%). The mean age was 77 (range: 61-91), and participants had completed their advance care planning documentation between 8 and 72 weeks prior to the interview (mean 33 weeks). Three themes were evident from the data: incomplete advance care planning understanding and confidence, limited congruence for attitude and documentation, advance care planning can enable peace of mind. Complete advance care planning understanding was unusual; most participants demonstrated partial comprehension of their own advance care plan, and some indicated very limited understanding. Participants' attitudes and their written document congruence were limited, but advance care planning was seen as helpful. CONCLUSIONS: This study highlighted advance care planning was not a completely accurate representation of patient wishes. There is opportunity to improve how patients comprehend their own advance care planning documentation.

Planificación de decisiones anticipadas: un modelo de relación asistencial / No disponible

El modelo actual de relación asistencial entre una persona con un problema de salud y un profesional está basado en el consentimiento informado. Cuando una persona pierde su capacidad para tomar decisiones sobre su salud no puede participar en el consentimiento informado. Hace años en nuestro país se reguló legalmente el documento de voluntades anticipadas. Permite dar instrucciones sanitarias para que se utilicen cuando se ha perdido la capacidad. Pero esta regulación legal no es suficiente. La planificación de decisiones anticipadas (PDA) se define como un proceso deliberativo y estructurado mediante el cual una persona expresa sus valores, deseos y preferencias y, de acuerdo con estos y en colaboración con su entorno afectivo y su equipo sanitario de referencia, formula y planifica como quisiera que fuera la atención que debe recibir ante una situación de complejidad clínica o enfermedad grave que se prevé probable en un plazo de tiempo determinado y relativamente corto, o en situación de final de vida, especialmente en aquellas circunstancias en las que no esté en condiciones de decidir.La PAD se produce dentro de un proceso asistencial, requiere de la participación activa del paciente/familia y produce un plan específico de tratamiento, que puede incluir o no un documento de voluntades anticipadas legal. La PDA se ha mostrado útil para mejorar la atención centrada en el paciente al final de la vida, mejora el proceso asistencial, la satisfacción del paciente, familia y profesional y la continuidad asistencial. La demencia en fase avanzada ha de ser tratada con la metodología propia de la atención al final de la vida. En la práctica clínica los médicos consideran más importante la discusión con el paciente y las familias que se promueve desde la PDA, porque la comunicación permite tener oportunidades para reconocer sus valores tomar decisiones coherente con ellos, sobre la utilización de antibióticos y nutrición artificial en los últimos meses de vida, por ejemplo. En las personas con una enfermedad mental, el proceso de la PDA puede mejorar el empoderamiento, contribuir a una mejor y mayor conciencia de enfermedad y convertirse en una herramienta terapéutica. Actualmente existe una iniciativa del Gobierno de Cataluña que pretende mejorar la atención a las personas con enfermedades crónicas y de manera específica a aquellas personas con una enfermedad en fase avanzada. En el plan de intervención individualizado y compartido sobre estas personas está prevista la PDA

The current model of care between an individual with a health problem and a health care professional is based on informed consent. When a person loses his ability to take decisions about his health, he cannot participate in informed consent. Advance directive was legally regulated many years ago in our country. It allows for instructions on health for use when an individual has lost the ability to decide. But this legal regulation is insufficient. Advance Care Planning (ACP) is defined as a deliberative, structured process by which a person expresses his values, wishes and preferences and, according to these and in collaboration with their emotional environment and health reference team, formulates and plans what type of attention he would like to receive in a situation of clinical complexity or serious illness that is expected as probable within a certain relatively short period of time, or in a situation of end of life, especially in circumstances in which the individual is unable to decide. ACP occurs within a care process, requires the active participation of the patient / family and produces a specific treatment plan, which may include or not a living will. The ACP has proved useful to improve patient centered care at the end of life, improving the care process, patient, family and professional satisfaction and continuity of care. Advanced-stage dementia must be treated according to the methodology of care at the end of life. In clinical practice physicians consider decision making through discussion with the patient and families to be of great importance as promoted by the ACP. Good communication provides opportunities to recognize the person's values, take coherent decisions based on them with regard to, for example, the use of antibiotics and artificial nutrition in the last months of life. In individuals suffering from mental illness, the process of ACP can improve empowerment, contribute to a better and greater awareness of the disease and become a therapeutic tool. Currently, the Government of Catalonia aims to improve care for people with chronic diseases and specifically those with advanced disease. The personalized, shared plan of therapy for these people is contemplated in the ACP

La importancia del papel de enfermería ante las voluntades anticipadas / The important role of nursing in advance directives

El Documento de Voluntades Anticipadas permite al paciente involucrarse en las decisiones referidas a su tratamiento propiciando el principio de autonomía. Aunque los Documentos de Voluntades Anticipadas se han regulado legalmente a nivel estatal y autonómico, los profesionales enfermeros siguen teniendo un gran desconocimiento sobre los mismos. Debido a su contacto directo con el paciente, es importante que los profesionales de enfermería tengan un conocimiento actualizado sobre el tema para dar apoyo e información a los pacientes y así poder proporcionar una asistencia de calidad (AU)

The advance directives’ document involves patients in decisions related to their treatment; it promotes the principle of autonomy. Although advance directives’ document has been regulated legally at national state and local levels, nursing professionals still have a huge lack of this issue. How they work directly with patients, it is important nurses have update knowledge to give support and information to the patients, with the aim of providing a quality care (AU)

Conocimientos y actitudes de los profesionales sanitarios en el proceso de declaración de las voluntades vitales anticipadas / Knowledge and attitudes of health professionals to the living will declaration process

OBJETIVO: Identificar áreas de interés subyacentes en el proceso de Declaración de Voluntades Vitales Anticipadas (DVVA) y consensuar un cuestionario de conocimientos y actitudes dirigido a profesionales de la salud. DISEÑO: Estudio a través de técnica Delphi con método Rand. Dos fases: 1) propuestas de dimensiones: generación de ideas y posterior priorización de estas; 2) propuesta y priorización de ítems agrupados en bloques de conocimientos y actitudes. Desarrollado entre agosto de 2012 y enero de 2013. Emplazamiento: El trabajo se realizó por contacto inicial telefónico con panelistas y posteriormente vía correo electrónico. Los panelistas pertenecen al Sistema Sanitario Público Andaluz. PARTICIPANTES: Los criterios para la selección de los 8 componentes del panel fueron los conocimientos y la experiencia en el ámbito de la autonomía del paciente en Andalucía. RESULTADOS: Se identificó en Conocimientos: 1. °A) aspectos legales/generales; 2. °A) definición conceptual; 3. °A) documentación normalizada de las voluntades vitales anticipadas; 4. °A) experiencia práctica; 5. °A) procedimiento y registro de las DVVA. El segundo bloque fueron de Actitudes: 1. °B) actitudes del profesional en el momento de la aplicación del DVVA en la práctica clínica; 2. °B) actitudes del profesional ante escenarios éticos «complejos». Los 7 panelistas que finalmente participaron propusieron 165 ítems. Tras aplicar los criterios de priorización, puntuación y selección de escenarios, se identificaron 58 (35,2%) ítems como escenario adecuado. CONCLUSIONES: El cuestionario propuesto recoge amplias parcelas de conceptos y contenidos, y una vez validado ayudará a medir las intervenciones formativas realizadas en profesionales sanitarios para la mejora del conocimiento y las actitudes sobre el entorno de las DVVA

OBJECTIVE: To identify the underlying interests of the Living Will Declaration (LWD) process and to determine the consensus, using a questionnaire, of the knowledge and attitudes of health professionals. DESIGN: A study was performed in two phases using a Delphi technique with a Rand method.1. Dimensions proposed: generation of ideas and their subsequent prioritizing; 2. Proposal and prioritizing of items grouped into blocks of Knowledge and Attitudes, developed between August 2012 and January 2013. SETTING: The work was carried out by initial telephone contact with panellists, and then later by the panellists belonged to the Andalusia Public Health System. PARTICIPANTS: The criteria for selecting the eight components of the panel were knowledge and experience in the field of the freedom of the patient in Andalusia. RESULTS: The Knowledge identified included: 1 A) Legal and general aspects; 2 A) A conceptual definition; 3 A) Standardised LWD documents: 4 A) Practical experience; 5 A) Procedure and registering of the LWDs. The second block included Attitudes: 1 B) Attitudes of the professional in the application of LWDs in clinical practice, and 2 B) Attitudes of the professional in «complex» ethical scenarios The 7 panellists who finally took part proposed 165 items. After applying the prioritizing criteria, scores, and scenario selection, 58 (35.2%) items were identified as suitable scenarios. CONCLUSIONS: The proposed questionnaire included wide parcels of concepts and contents that, once validated, will help to measure the training interventions carried out on health professionals in order to improve knowledge and attitudes on the subject of LWDs

Adherencia terapéutica / Therapeutic adherence

Se define en este trabajo el concepto de adherencia terapéutica, que implica una activa y voluntaria colaboración con el plan de cuidado de la salud, e incorpora las creencias y actitudes del paciente como factores relevantes que deben tenerse en cuenta. Se resalta que la diferencia principal entre adherencia y cumplimiento es que la adherencia requiere la conformidad del paciente respecto a las recomendaciones. Con respecto a la magnitud del problema, se cita que en los países desarrollados la adherencia terapéutica en los pacientes que padecen enfermedades crónicas es del 50%, y después de 6 meses de haber comenzado un tratamiento, el número de pacientes que deja de tomar la medicación varía entre el 30 y el 80%. Se describen los distintos tipos de incumplimiento en función del periodo de seguimiento: incumplimiento parcial y/o esporádico, descanso farmacológico o vacaciones terapéuticas, cumplimiento de bata blanca e incumplimiento absoluto. Asimismo, se revisan las principales causas del incumplimiento, siendo las más importantes la falta de información y la falta de apoyo en el cambio de comportamiento que se requiere en la mayoría de patologías, en especial en ancianos y enfermos crónicos. A continuación se describen los métodos que se usan para medir la adherencia, tanto los directos como los indirectos (entre los cuales hay métodos objetivos y subjetivos). Por ultimo, se abordan los distintos métodos que pueden servir para mejorar la adherencia y las distintas intervenciones para mejorar el cumplimiento (AU)

Defined in this work the concept of therapeutic adherence, which requires active and voluntary collaboration with the plan of health care, and incorporates beliefs and attitudes of the patient and factors to be taken into consideration. It is remarkable that the major difference between adherence and compliance is that the adherence requires agreement of the patient with regard to the recommendations. In relation to the magnitude of the problem is mentioned in the developed countries adherence to treatment in patients with chronic diseases is 50%, and after 6 months of the beginning of treatment, ranges from 30 to 80% the number of patients stop taking the medication. Describes the different kinds of failure on the basis of the follow-up: «partial failure and/or sporadic», «rest pharmacological or therapeutics holidays», «white coat compliance» and «complete failure». Reviews the main causes of the failure, being the most important the lack of information and the lack of support in the change of behavior that is required for the majority of pathology, especially in the elderly and the chronic ill. The following are methods for measuring the adherence, both direct and indirect (in which there are objective methods and subjective). Finally, it's raised the various methods that can be used to improve adherence and interventions to improve compliance (AU)

Advance directives in home health and hospice agencies: United States, 2007.

This report provides nationally representative data on policies, storage, and implementation of advance directives (ADs) in home health and hospice (HHH) agencies in the United States using the National Home and Hospice Care Survey. Federally mandated ADs policies were followed in >93% of all agencies. Nearly all agencies stored ADs in a file at the agency, but only half stored them at the patient's residence. Nearly all agencies informed staff about the AD, but only 77% and 72% of home health agencies informed the attending physician and next-of-kin, respectively. Home health and hospice agencies are nearly universally compliant with ADs policies that are required in order to receive Medicare and Medicaid payments, but have much lower rates of adoption of ADs policies beyond federally mandated minimums.

Increasing use of artemisinin-based combination therapy for treatment of malaria infection in Nigerian hospitals / Aumento del uso de tratamientos combinados con artemisina para el tratamiento de la infección de malaria en hospitales nigerianos

Objectives: This study aimed at describing the pattern of outpatient antimalarial drug prescribing in a secondary and a tertiary hospital, and to assess adherence to the National Antimalarial Treatment Guideline (ATG). Methods: An audit of antimalarial prescription files from the two health facilities for a period of six months in 2008 was conducted. Semi structured questionnaires were used to collect information from the doctors and pharmacists on their awareness and knowledge of the National Antimalarial Treatment Guideline. Results: Artemisinin-based combination therapies (ACTs) were the most prescribed antimalarials. Overall, 81.4% of the total prescriptions contained ACTs, out of which 56.8% were artemether-lumefantrine. However, adherence to the drugs indicated by national guideline within the DU90% was 38.5% for the tertiary and 66.7 % for the secondary hospital. The standard practice of prescribing with generic name was still not adhered to as evidenced in the understudied hospitals. The percentage of health care providers that were aware of the ATG was 88.2% for doctors and 85.1% for pharmacists. However, 13.3% and 52.2% of doctors and pharmacists respectively could not properly list the drugs specified in the guideline. Amodiaquine was the most commonly preferred option for managing children aged 0-3 months with malaria infection against the indicated oral quinine. Conclusion: This study showed an increased use of artemisinin-based combination therapy for the treatment of uncomplicated malaria compared previous reports in Nigeria. This study also highlights the need for periodic in-service quality assurance among health professionals with monitoring of adherence to and assessment of knowledge of clinical guidelines to ensure the practice of evidence based medicine (AU)

Objetivos: Este estudio trató de describir el patrón de prescripción ambulatoria de antimaláricos en un hospital secundario y terciario, y evaluar el cumplimiento de la Guía Nacional de Tratamiento Antimalárico (ATG). Métodos: Se realizó un audit de los archivos de prescripción de antamaláricos en dos establecimientos sanitarios de un periodo de seis meses en 2008. Se utilizaron cuestionarios semi-estructurados para recoger informaciones del conocimiento de médicos y farmacéuticos de la Guía Nacional de Tratamiento Antimalárico. Resultados: Los tratamientos de combinación con artemisina (TCA) fueron los antimaláricos más prescritos. Del total de prescripciones, el 81,4% TCA, de las cuales el 56,8% eran artemeter-lumefantrina. Sin embargo, el cumplimiento de los medicamentos indicados en las guías nacionales con el DU90% fue del 38,5% en el hospital terciario y del 66,7% en el secundario. La práctica de prescripción por nombre genérico todavía no era seguida en ninguno de los hospitales. El porcentaje de profesionales sanitarios que conocía las TCA era del 88,2% de los médicos y del 85,1% de los farmacéuticos. Sin embargo, el 13,3% y el 52,2% de médicos y farmacéuticos, respectivamente, no pudo enunciar adecuadamente la lista de medicamentos especificados en la guía. La amodiaquina fue la opción más frecuentemente preferida para tratar a niños de 0-3 meses con infección de malaria, en lugar de la indicada quinina oral. Conclusión: Este estudio mostró un aumento del uso de regímenes de combinación con artemisina para tratamiento de malaria no complicada en comparación con anteriores informes de Nigeria. Este estudio también remarca la necesidad de un periódico aseguramiento de la calidad interno entre los profesionales sanitarios, monitorizando el cumplimiento y el conocimiento de las guías clínicas para asegurar la práctica basada en la evidencia (AU)

Do-not-resuscitate. Orders in surgery: decreasing the confusion.

Patients have the right to make decisions regarding their medical care, including the right to refuse treatment or to issue do-not-resuscitate orders as part of an advance directive. Health care providers must comply with the patient's wishes regarding care. Automatic suspension or continuation of a do-not-resuscitate order for a patient undergoing surgery cannot be justified. Surgical team members should consult with the patient and, if necessary, with an ethics expert or committee to determine whether the do-not-resuscitate order is to be maintained or completely or partially suspended during anesthesia and surgery. All surgical departments should have a written policy and procedure concerning the treatment of patients with do-not-resuscitate orders.

"Do-Not-Attempt-Resuscitation"-orders in ICCUs: a survey of attitudes and experiences of nurses in Norway.

OBJECTIVE: A "Do-Not-Attempt-Resuscitation" (DNAR)-order can be ordered for a critically ill coronary patient. One question that arises is whether the patient should be informed about the DNAR-decision? The purpose of the present study was to investigate attitudes and experiences towards DNAR-orders of nurses working in Intensive Coronary Care Units (ICCUs) in Norway. METHODS: A web-based questionnaire. RESULTS: The response rate was 60% (176/295). A total of 74% of the respondents thought the patient should be informed about a DNAR-order. Given a mentally competent and conscious patient, 50% answered that they "to a relatively high" or "a very high degree" had experienced non-informed patients with a DNAR-order. CONCLUSION: The study revealed a positive attitude among respondents to inform patients about a DNAR-order. However, one half of the respondents had experienced that this information was not given. There may be several explanations for this discrepancy. Patients are treated individually and the right to know does not mean that every patient would want to know or needs to know. The timing of the information and the opportunity to provide it can also be a problem for such critically ill patients in the ICCU.

End-of-life decisions: influence of advance directives on patient care.

The patient records of 160 older adults who died in a community hospital were reviewed to determine the use of advance directives and evaluate their effect on the care decisions made by health care providers. Findings confirmed that the use of advance directives has not changed during the past 15 years. The documents did not seem to influence health care providers' decisions about the hospital unit in which patients were treated, the use of life-sustaining treatments, or the initiation of comfort care plans. The presence of a living will seemed to influence health care providers' decisions to write do-not-resuscitate orders more often and to use cardiopulmonary resuscitation less often for patients possessing the document. Recommendations for future research include implementation and evaluation of educational initiatives for both health care consumers and health care providers.

Respecting the wishes of patients in intensive care units.

This study examined why intensive care unit (ICU) nurses experience difficulties in respecting the wishes of patients in end-of-life care in Japan. A questionnaire survey was conducted with ICU nurses working in Japanese university hospitals. The content of their narratives was analyzed concerning the reasons why the nurses believed that patients' wishes were not respected. The most commonly stated reason was that patients' wishes were impossible to realize, followed by the fact that decision making was performed by others, regardless of whether the patients' wishes were known, if the death was sudden, and time constraints. Many nurses wanted to respect the wishes of dying patients, but they questioned how patients die in ICUs and were therefore faced with ethical dilemmas. However, at the same time, many of the nurses realized that respecting patients' wishes about end-of-life care in an ICU would be difficult and that being unable to respect these wishes would often be unavoidable. The results thus suggest that there has been insufficient discussion about respecting the wishes of patients undergoing intensive care.

Patient safety: honoring advanced directives.

Healthcare providers typically think of patient safety in the context of preventing iatrogenic injury. Prevention of falls and medication or treatment errors is the typical focus of adverse event analyses. If healthcare providers are committed to honoring the wishes of patients, then perhaps failures to honor advanced directives should be viewed as reportable medical errors.

The state of advance care planning: one decade after SUPPORT.

The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) was a landmark study regarding end-of-life decision making and advance care planning. Phase I of the study looked at the state of end of life in various hospitals, and phase II implemented a nurse-facilitated intervention designed to improve advance care planning, patient-physician communication, and the dying process. The observational phase found poor quality of care at the end of life and the intervention failed to improve the targeted outcomes. The negative findings brought public attention to the need to improve care for the dying and spawned a wealth of additional research on decision-making at the end of life. In the decade since SUPPORT, researchers have defined the attributes of a "good death," addressed the role of advance directives in advance care planning, and studied the use of surrogate decision-making at the end of life. This rekindled the discussion on advance care planning and challenged health care providers to design more flexible approaches to end of life care.

Managed death in a PACE: pathways in present and advance directives.

OBJECTIVES: To test the effect of an innovative method of documenting present and advance health care wishes on the rates of completion and the qualitative choices of health care wishes. DESIGN: Interventional prospective cohort (pre- and post-). SETTING: Program for All-inclusive Care of the Elderly (PACE) site in St. Louis, MO. PARTICIPANTS: Enrolled PACE participants. INTERVENTION: A documentation tool that captures both present and advance directives in a framework of "pathways," blending goals of care with typical procedure-oriented directives. MEASUREMENTS: Data from medical records to calculate rates of health care wishes (HCW) completion, proportions of qualitative choices, and compliance with wishes at death. RESULTS: Baseline prevalences of present directives (PD) and advance directives (AD) were 77% and 36%, respectively, while Do Not Resuscitate (DNR) wishes were documented in 48% of PD and 26% of AD. After implementation of the Pathways Tool, completion rates increased to 99% for both PD and AD. Documented DNR wishes decreased to 38% of PD and increased to 66% of AD. Qualitative choices for care (Longevity vs Function vs Palliation) changed toward a palliation pathway for AD (from 9% to 53%). The rate of dying at home increased from 24% to 65%. Compliance with end-of-life wishes increased from 72% to 96%. These are statistically significant. CONCLUSION: Introduction of a novel pathways method of documenting HCW in a PACE site was associated with increased completion, preferences toward less invasive levels of care at life's end, and increased compliance with participants' wishes and deaths at home. Future research to validate the methodology employed in this intervention should be conducted in other long-term care settings.