Advance directives and dementia.

Since the 1990 Patient Self-Determination Act, increasing numbers of adults are completing advance directives (ADs), but unfortunately many adults seen in a dementia evaluation program have not completed an AD. This article discusses the issue of individuals with dementia completing ADs. Situational factors that frame this issue are the stage of dementia, degree of certainty of an individual's wishes for end-of-life care, the decision-making act required by care providers, and the degree of contentment or distress experienced by an individual with dementia. Several investigators have demonstrated successful completion of ADs by individuals with mild and moderate dementia. A nurse's knowledge about the stages of dementia is essential to helping an individual through the AD decision-making process. Nurses caring for individuals with dementia should assess decision-making context; recognize the emotions of family, friends, and staff; understand the substance and logic of AD requests; and support individuals and their decisions.

Qualitative research and Alzheimer disease.

This article presents an overview of qualitative research methods and illustrates ways in which these methods may be useful in discovering unknowns that contribute to knowledge about Alzheimer disease. An observation of an elder with Alzheimer disease sets the scene for thinking about ways to explore, describe, and interpret human experiences and the context within which these experiences are perceived. The philosophical assumptions and standards for qualitative research methods are discussed. Two of the qualitative research approaches (ethnography and grounded theory) are presented using examples from published studies to illustrate the logical consistency of fit between purpose statement, data collection strategies, analysis structures, and results specific to the language, and guidelines and rules for each of these two approaches. Practical issues of data management, including the availability of qualitative computer packages and publication, are addressed briefly.

Peer review by nursing research committees in hospitals.

With the increasing amount of nursing research conducted in clinical settings, the value of peer review by nursing research committees (NRCs) in hospitals has come under greater scrutiny. Research facilitation has been the prevailing paradigm of NRCs for several decades. Reports of activities by NRCs in the literature appear to indicate a shift in that paradigm. The presence of clinical nurses with expert knowledge and advanced academic degrees who are serving as intra- and interdisciplinary scientific reviewers are leading a shift in the paradigm of NRCs toward activities that strengthen nursing science and nurse scientists. Eight strategies to support NRCs as review bodies for scientific merit are recommended.

Reaching consensus: the process of recommending treatment decisions for Alzheimer's patients.

Observational and interview data obtained from nurse caregivers and family members of patients with late-stage Alzheimer's disease were analyzed to explicate the nursing role in advance proxy planning. A four-phase model, Achieving Consensus: Decision Making to Determine Treatment Options for Patients with Alzheimer's Disease, was developed. Patient decline, family coping, professional development of nursing staff, and nursing unit philosophy were community characteristics found to be important antecedents to the process of reaching consensus. Achieving consensus constructs included interactive process components of patient, family, and staff adjustment, caring, and knowing. Timing and trust were influential catalysts to family and staff readiness factors for achieving consensus. Outcomes were the advice provided by staff and the family conference where treatment options were determined. Consequences included the advance proxy plan and patient care.

Working group recommendations: targeting criteria for geriatric evaluation and management research.

To maximize the cost effectiveness of geriatric evaluation and management (GEM) programs, criteria need to be established for selecting patients most likely to benefit. A working group was convened to define appropriate patient selection (targeting) criteria for each type of GEM program and to consider research questions for future targeting studies. The group outlined targeting criteria for the spectrum of GEM program types and locations. GEM program types included: inpatient GEM units; hospital geriatric consultation service; GEM programs in nursing homes; outpatient GEM programs for functionally impaired persons; and geriatric community outreach/screening programs for functionally independent elders. For each program type, the group outlined targeting criteria based on current literature and experience. Because research has not yet established the effectiveness of many of these patient targeting strategies, the group drafted a set of research questions, pertinent to targeting, that require attention: (1) For each identifiable population of elderly people, who are most likely to benefit from GEM? (2) How should these people best be identified/targeted? (3) What criteria should be used for targeting? (4) How and how often should population screening be performed to identify persons in need of GEM?