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1.
Br J Nurs ; 30(19): 1144-1145, 2021 Oct 28.
Artigo em Inglês | MEDLINE | ID: mdl-34723663

RESUMO

Richard Griffith, Senior Lecturer in Health Law at Swansea University, considers an NHS Foundation Trust's challenge to the validity of a woman's advance decision to refuse treatment in the Court of Protection.


Assuntos
Diretivas Antecipadas , Recusa do Paciente ao Tratamento , Feminino , Humanos , Reino Unido
2.
Am J Manag Care ; 27(10): e361-e364, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34668679

RESUMO

OBJECTIVES: Advance care planning (ACP) consults have been credited with increasing the likelihood that patients will receive desired care at the end of life, including reduced hospitalization and spending. We aimed to investigate whether implementation of ACP consults leads to improved advance directive (AD) completion rates. STUDY DESIGN: Retrospective case-control evaluation. METHODS: Chart review was conducted among patients in hematology/oncology and primary care to compare AD completion rates of patients in each clinical area offered ACP consults between July 1, 2017, and June 30, 2018, and those not offered ACP consults prior to July 1, 2017. RESULTS: Completed ADs increased from historic rates of 1% to 65.9% of primary care patient records. Among hematology/oncology patients offered consults, completed ADs were present in 28.1% of patient records compared with historic rates of 3%. CONCLUSIONS: Patients offered ACP consults had significantly higher AD completion rates than those without consults in both primary care and hematology/oncology practices. The difference in ACP consult attendance between the primary care and hematology/oncology groups clearly suggests that further improvements can be made to assist patients in accessing AD education and completion support.


Assuntos
Planejamento Antecipado de Cuidados , Diretivas Antecipadas , Humanos , Atenção Primária à Saúde , Encaminhamento e Consulta , Estudos Retrospectivos
4.
Clin Geriatr Med ; 37(4): 605-610, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34600725

RESUMO

The overall rate of advance care planning (ACP) in the general population remains low. ACP is a dynamic process that needs to be refined over time. ACP documentation includes the naming of a health care proxy, preferences regarding life-sustaining treatment interventions, and other, more disease-specific, interventions, such as chemotherapy, hemodialysis, and surgeries. The process should start early in someone's adult life, with a broad scope of defining what matters most for that person. Over time, the initial ACP could be refined to include more specific limitations of certain medical procedures. ACP documents achieved more standardization in the last several years.


Assuntos
Planejamento Antecipado de Cuidados , Assistência Terminal , Diretivas Antecipadas , Documentação , Humanos
5.
BMC Med Ethics ; 22(1): 137, 2021 10 09.
Artigo em Inglês | MEDLINE | ID: mdl-34627232

RESUMO

BACKGROUND: Advance research directives (ARD) have been suggested as a means by which to facilitate research with incapacitated subjects, in particular in the context of dementia research. However, established disclosure requirements for study participation raise an ethical problem for the application of ARDs: While regular consent procedures call for detailed information on a specific study ("token disclosure"), ARDs can typically only include generic information ("type disclosure"). The introduction of ARDs could thus establish a double standard in the sense that within the context of ARDs, type disclosure would be considered sufficient, while beyond this context, token disclosure would remain necessary. MAIN BODY: This paper provides an ethical analysis of ARDs, taking into account the results of numerous empirical studies that have been performed so far. It will be argued that a revised understanding of informed consent can allow for context-sensitive disclosure standards. As a consequence, ARDs that include type disclosure can be acceptable under suitable circumstances. Such an approach raises a number of objections. A thorough examination shows, however, that they are not sufficient to justify a rejection of the approach. CONCLUSION: The approach presented in this paper avoids introducing a double standard. It is, therefore, more suitable for the implementation of ARDs than established approaches.


Assuntos
Diretivas Antecipadas , Consentimento Livre e Esclarecido , Revelação , Análise Ética , Humanos
6.
BMC Geriatr ; 21(1): 573, 2021 10 19.
Artigo em Inglês | MEDLINE | ID: mdl-34666711

RESUMO

BACKGROUND: Advance care planning (ACP) is particularly appropriate for persons with early dementia (PWED) since it promotes conversations about dementia-specific illness scenarios, addresses inconsistencies between advance directives and patients' observed behavior, emphasizes prospective and relational autonomy, and may be generally consistent with older persons' decision-making needs. However, despite evidence of its benefits, ACP is yet to become widely used among PWED. In this paper, we present a dementia-specific tool developed in Western Switzerland, discuss results of a pilot trial designed to promote ACP among PWED and their relatives, and discuss the feasibility and acceptability of the intervention and the study protocol in prevision of a large scale trial. METHODS: This one-arm pre-post pilot trial consisted of four visits, with visits 2 and 3 being the ACP intervention. Quantitative outcome measures during visit 1 and 4 assessed the aptitude of the intervention to support PWED autonomy and relatives' knowledge of PWED's preferences. Feasibility was explored according to how the recruitment procedure unfurled and based on the necessary revisions to the study protocol and healthcare providers' reason for excluding a PWED from the study. Acceptability was assessed according to pre-post evaluations, difficulties regarding the intervention or trial participation, and pre-post qualitative interviews regarding participants' reasons to participate to the study, satisfaction with the tool and difficulties perceived. RESULTS: The ACP intervention itself was well received by PWED and their relatives that expressed satisfaction with the procedure, especially regarding the opportunity to discuss a sensitive topic with the help of a facilitator. Five main challenges in terms of feasibility were 1) to locate eligible patients, 2) to tailor recruitment procedures to recruitment locations, 3) to adapt inclusion criteria to clinical routines, 4) to engage PWED and their relatives in ACP, and 5) to design a trial that does not burden PWED. Despite these challenges, the intervention increased the number of advance directives, the concordance between PWED's preferences and relatives' decision on their behalf, and relatives' perceived control over healthcare decisions. CONCLUSION: Misconceptions about dementia and ACP, in the patient, relatives, and healthcare providers, combined with structural and institutional challenges, have the power to impede research and implementation of ACP in dementia care. For this reason, we conclude that a large scale trial to test a dementia-specific tool of ACP is currently not feasible in Western Switzerland and should be endorsed in a systemic approach of ACP. TRIAL REGISTRATION: This trial was registered in the database clinicaltrial.gov with the number NCT03615027 .


Assuntos
Planejamento Antecipado de Cuidados , Demência , Diretivas Antecipadas , Idoso , Idoso de 80 Anos ou mais , Comunicação , Demência/diagnóstico , Demência/terapia , Humanos , Estudos Prospectivos
7.
Medicina (Kaunas) ; 57(9)2021 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-34577853

RESUMO

Background and Objectives: Mortality on Intensive Care Units (ICUs) is high and death frequently occurs after decisions to limit life-sustaining therapies. An advance directive is a tool meant to preserve patient autonomy by guiding anticipated future treatment decisions once decision-making capacity is lost. Since September 2009, advance directives are legally binding for the caregiver team and the patients' surrogate decision-maker in Germany. The change in frequencies of end-of-life decisions (EOLDs) and completed advance directives among deceased ICU patients ten years after the enactment of a law on advance directives in Germany is unknown. Materials and Methods: Retrospective analysis on all deceased patients of surgical ICUs of a German university medical center from 08/2008 to 09/2009 and from 01/2019 to 09/2019. Frequency of EOLDs and advance directives and the process of EOLDs were compared between patients admitted before and after the change in legislation. (No. of ethical approval EA2/308/20) Results: Significantly more EOLDs occurred in the 2019 cohort compared to the 2009 cohort (85.8% vs. 70.7% of deceased patients, p = 0.006). The number of patients possessing an advance directive to express a living or therapeutic will was higher in the 2019 cohort compared to the 2009 cohort (26.4% vs. 8.9%; difference: 17.5%, p < 0.001). Participation of the patients' family in the EOLD process (74.7% vs. 60.9%; difference: 13.8%, p = 0.048) and the frequency of documentation of EOLD-relevant information (50.0% vs. 18.7%; difference: 31.3%, p < 0.001) increased from 2009 to 2019. Discussion: During a ten-year period from 2009 to 2019, the frequency of EOLDs and the completion rate of advance directives have increased considerably. In addition, EOLD-associated communication and documentation have further improved.


Assuntos
Diretivas Antecipadas , Tomada de Decisões , Cuidados Críticos , Morte , Alemanha , Humanos , Estudos Retrospectivos
8.
Praxis (Bern 1994) ; 110(12): 696-697, 2021 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-34521267

RESUMO

CME/Answers: Self-Determined Dying: The Challenge of Medical End-of-Life Decisions Abstract. Modern medical interventions make it possible today to postpone dying. Thus the process of dying confronts with numerous end-of-life decisions. The authority to make such decisions does not lie with the doctors. It is the unique right of the autonomous patient. This right can be experienced as freedom of choice, but also as an excessive demand. Doctors are responsible for supporting their patients in such a way that they become able to make relevant decisions concerning their dying process. In this context modern instruments such as advance directives or advance care planning play an important role. When patients are no longer able to decide for themselves, legal regulations define who is authorised to decide in their place.


Assuntos
Planejamento Antecipado de Cuidados , Médicos , Diretivas Antecipadas , Morte , Humanos , Autonomia Pessoal
9.
BMC Palliat Care ; 20(1): 138, 2021 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-34503479

RESUMO

BACKGROUND: Advance care planning involves the discussion and documentation of an individual's values and preferences to guide their future healthcare should they lose capacity to make or communicate treatment decisions. Advance care planning can involve the individual's completion of an Advance Care Directive (ACD), a legislated and common-law instrument which may include appointment of a substitute decision-maker and binding refusals of treatment. In South Australia, ACDs intersect in the acute-care context with the Resuscitation Plan 7-Step Pathway (7-SP), an integrated care plan written for and by clinicians, designed to organise and improve patients' end-of-life care through the use of structured documentation. Here, we examine the perspectives of healthcare professionals (HCPs) within a hospital setting on the practical integration of ACDs and the 7-SP, exploring the perceived role, function, and value of each as they intersect to guide end-of-life care in an Australian hospital setting. METHODS: Qualitative data were collected via eight focus groups with a total of 74 HCPs (acute care, and oncology specialists; medical intern; general and emergency nurses; social workers) across two hospitals. Audio recordings were transcribed and thematically analysed. RESULTS: HCPs viewed ACDs as a potentially valuable means of promoting patient autonomy, but as rarely completed and poorly integrated into hospital systems. Conversely, the process and documentation of the 7-SP was perceived as providing clarity about clinicians' responsibilities, and as a well-understood, integrated resource. Participants sometimes exhibited uncertainty around which document takes precedence if both were present. Sometimes, the routinisation of the 7-SP meant it was understood as the 'only way' to determine patient wishes and provide optimal end-of-life care. When this occurs, the perceived authority of ACDs, or of patients' choice not to participate in end-of-life discussions, may be undermined. CONCLUSIONS: The intersection of ACDs and the 7-SP appears problematic within acute care. Clinicians' uncertainty as to whether an ACD or 7-SP takes precedence, and when it should do so, suggests a need for further clarity and training on the roles of these documents in guiding clinical practice, the legislative context within which specific documentation is embedded, and the dynamics associated with collaborative decision-making in end-of-life care.


Assuntos
Planejamento Antecipado de Cuidados , Diretivas Antecipadas , Austrália , Documentação , Hospitais , Humanos
10.
Acta Biomed ; 92(4): e2021092, 2021 09 02.
Artigo em Inglês | MEDLINE | ID: mdl-34487082

RESUMO

Advance healthcare directives are legal documents, in which the patient, foreseeing a potential loss of capacity and autonomy, makes in advance decisions regarding future care and, in particular, end-of-life arrangements. In Italy, advance healthcare directives  are regulated by the Law 219 of 22 December 2017. Objectives of the study were: i) to develop and validate a questionnaire dedicated to evaluate the knowledge of the Law in a sample of 98 anesthesiologists, and ii) to shed light on the process of health-related decision-making and its determinants (age, gender, doctor/training resident, religious beliefs). A second part of the survey  not analyzed  in the present study, aimed to assess, through two simulated clinical scenarios, how patient' directives, relatives and the medical staff could influence physicians' clinical decision. Overall Cronbach's alpha coefficient of the questionnaire resulted 0.83. Three factors explaining up to 38.4% of total variance (communication and relationship with the patient; critical life-threatening situations and binding nature of the advance directive for the physician; and involvement of patients). Most of the doctors (58.7%) did not fully know the recent legislative provision. The lack of knowledge is critical in view of the specificity of the clinical area investigated (anesthesiology and intensive care), which has to cope with ethical issues. An adequate revision and implementation of the traditional curricula could help medical students and trainees develop the aptitudes and skills needed in their future profession.


Assuntos
Anestesiologia , Conhecimentos, Atitudes e Prática em Saúde , Diretivas Antecipadas , Pessoal de Saúde , Humanos , Itália , Projetos Piloto , Inquéritos e Questionários
11.
J Clin Ethics ; 32(3): 241-246, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34548433

RESUMO

The topic of withholding the Heimlich maneuver as part of a do-not-attempt-to-resuscitate (DNAR) order or an advance directive has not been widely discussed in the clinical ethics literature. This discussion addresses a request by family members to withhold the Heimlich maneuver from a patient in a long-term care facility. A request to forgo the Heimlich maneuver seems to have prima facie categorical similarities to justifications for withholding life-saving treatments such as cardiopulmonary resuscitation (CPR). Further examination reveals significant distinctions. Such distinctions call into question the ethical appropriateness of including the Heimlich maneuver among interventions to be withheld as part of end-of-life care planning, and encourages a broader discussion of an increasingly uncritical deference to autonomy in end-of-life decision making. Most notably, the Heimlich maneuver is the only intervention known to effectively relieve the distressing symptoms of accidental choking. The Heimlich maneuver serves a palliative function and is the standard of care for accidental choking. The Heimlich maneuver should not be conflated with other life-prolonging interventions that may be withheld as part of end-of-life care planning.


Assuntos
Obstrução das Vias Respiratórias , Reanimação Cardiopulmonar , Manobra de Heimlich , Diretivas Antecipadas , Humanos , Suspensão de Tratamento
12.
Praxis (Bern 1994) ; 110(11): 601-607, 2021 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-34465189

RESUMO

CME: Self-Determined Dying: The Challenge of Medical End-of-Life Decisions Abstract. Modern medical interventions make it possible today to postpone dying. Thus the process of dying confronts with numerous end-of-life decisions. The authority to make such decisions does not lie with the doctors. It is the unique right of the autonomous patient. This right can be experienced as freedom of choice, but also as an excessive demand. Doctors are responsible for supporting their patients in such a way that they become able to make relevant decisions concerning their dying process. In this context modern instruments such as advance directives or advance care planning play an important role. When patients are no longer able to decide for themselves, legal regulations define who is authorised to decide in their place.


Assuntos
Planejamento Antecipado de Cuidados , Médicos , Diretivas Antecipadas , Morte , Humanos , Autonomia Pessoal
13.
BMC Health Serv Res ; 21(1): 901, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34470636

RESUMO

BACKGROUND: Advance Care Planning (ACP) has emerged to improve end-of-life processes and experiences. However, the available evidence presents the gloomy picture of increasing number of older people living with chronic diseases and the mismatch between their preferences for and the actual place of death. The study aimed to investigate the efficacy of normalisation of an Advance Care Planning (NACP) service delivered by specially trained Registered Nurses (RNs) in hospital and community settings. METHODS: A quasi-experimental study was conducted involving 16 sites (eight hospital and eight community sites) in Australia. Patients who were aged ≥18 years, who had at least one of nine chronic conditions, and who did not have an Advance Care Directive (ACD) were offered the NACP service. ACP was normalised as part of routine service on admission. The intervention, NACP, was a series of facilitated conversations about the components of ACP. The primary outcomes which included the completion of ACDs, and/or appointment of an Enduring Guardian (EG), were assessed in both intervention and control sites at pre and post intervention stages. Numbers of patients who completed an ACD or appointed an EG were described by count (percentage). ACD completion was compared between intervention and control sites using a logistic mixed effects regression model. The model includes fixed effects for treatment group, period, and their interaction, as well as random site level intercepts. Secondary model included potentially confounding variables as covariates, including age, sex and chronic diseases. RESULTS: The prevalence of legally binding ACDs in intervention sites has increased from five to 85 (from 0.85% in pre to 17.6% in post), whereas it has slightly decreased from five to 2 (from 1.2% in pre and to 0.49% in post) in control sites (the difference in these changes being statistically significant p < 0.001). ACD completion rate was 3.6% (n = 4) in LHD1 and 1.2% (n = 3) in LHD2 in hospital whereas it was 53% (n = 26) in LHD1 and 80% (n = 52) in LHD2 in community. CONCLUSIONS: The study demonstrated that NACP service delivered by ACP RNs was effective in increasing completion of ACDs (interaction odds ratio = 50) and was more effective in community than hospital settings. Involvement of various healthcare professionals are warranted to ensure concordance of care. TRIAL REGISTRATION: The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ) on 03/10/2018. The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx.


Assuntos
Planejamento Antecipado de Cuidados , Adolescente , Adulto , Diretivas Antecipadas , Idoso , Austrália/epidemiologia , Doença Crônica , Hospitais , Humanos , Ensaios Clínicos Controlados não Aleatórios como Assunto
14.
Tijdschr Gerontol Geriatr ; 52(2)2021 Jun 09.
Artigo em Holandês | MEDLINE | ID: mdl-34498437

RESUMO

To anticipate future suffering due to dementia a growing number of people draft written advance euthanasia directives (AED). In actual practice the number of cases of euthanasia in advanced dementia is very limited. Dementia case managers are often closely involved since an early stage of the disease in the support and guidance of people with dementia and are well positioned to talk about the AED. This study aims to acquire insights into the way case managers deal with AEDs of people suffering from dementia. This qualitative study consists of two focus groups of ten case managers in total. Involvement of case managers was found to extend beyond discussing merely AEDs, to also the broader discussion of euthanasia and 'future euthanasia wishes' of patients with dementia. A thematic analysis of how case managers proceed with future euthanasia wishes yielded five themes: 1) Scenarios in practice; 2) Introduction of a written euthanasia directive as a conversation topic; 3) Guidance and support of the client and caregiver; 4) Cooperation with other health care workers; 5) Experienced dilemmas. The insights, provided by this study, into the role of case managers regarding the guidance of people with dementia and a future euthanasia wish contributes to a further optimization of the multidisciplinary collaboration between general practitioners and dementia case managers. Further research into the added value of this collaboration in dealing with these complicated issues around euthanasia in dementia care, is recommended.


Assuntos
Gerentes de Casos , Demência , Eutanásia , Diretivas Antecipadas , Humanos , Percepção
15.
J Law Med ; 28(3): 655-662, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34369122

RESUMO

Advance planning is increasingly being used in mental health care, particularly in the context of potential compulsory treatment. A variety of advance planning instruments may be used in health care settings and there has been confusion about the most appropriate language to describe them. This adds to confusion about whether an instrument is binding on health professionals or consumers and how the instrument might be disseminated. This column provides an overview and critique of current provisions in Australian law and of the key terms used.


Assuntos
Planejamento Antecipado de Cuidados , Serviços de Saúde Mental , Diretivas Antecipadas , Atitude do Pessoal de Saúde , Austrália , Humanos , Saúde Mental
16.
Asian J Psychiatr ; 64: 102802, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34388669

RESUMO

BACKGROUND: Dementias are a group of gradually progressing neurodegenerative conditions, leading to significant impairment in cognition, functioning, decision-making, capacity and autonomy. With the rise of human rights and patient-centred perspectives in psychogeriatric management, physician-assisted suicide (PAS) has emerged as an important and integral part of end-of-life care in advanced dementias. METHODS: With only few original studies in the area, this paper takes a narrative and critical approach to review the global legislations, treatment decisions, debates as well as perspectives from patients, families and medical professionals. RESULTS: PAS and euthanasia are legally allowed in countries like Belgium, Netherlands, Switzerland and few states of the United States (U.S.). Germany has fewer clearer legislations in this regard. The Oregon state requirement and care criteria of the Dutch euthanasia act form the basis of most such laws. Even in the presence of these provisions, PAS is fraught with multiple medical, ethical, moral and legal dilemmas and physicians as well as caregivers are quite heterogenous in their outlook. While right to live with dignity and need to end incurable suffering form the main arguments for PAS, several arguments against it are possibility of undue influence, impaired judgement leading to biased decision-making such as depression and suicidality, inappropriate assessment of capacity, and that all deaths are not necessarily painful. These dilemmas are critically discussed in light of autonomy, decision-making and advanced directives in people living with dementia as well as the rationality of ending life and 'right to live vs right to die'. Based on the findings, certain balanced strategies are highlighted for the health professionals. CONCLUSION: The 'slippery slope' of PAS needs to be carefully evaluated from a social justice and human rights perspective to improve dignified end-of-life care in dementia. Considerations are also discussed from India, a rapidly-ageing nation with no current provisions for PAS.


Assuntos
Demência , Eutanásia , Médicos , Suicídio Assistido , Diretivas Antecipadas , Demência/terapia , Humanos , Estados Unidos
17.
Artigo em Inglês | MEDLINE | ID: mdl-34360232

RESUMO

While advance directives (ADs) are considered to be part of government's healthcare agenda, there has not been any public consultation for legislation, nor investigation regarding the public's views about ADs in the Chinese culture of Macao. The current study explored the Macao Chinese people's willingness to make ADs. Data were collected from 724 residents aged 18 years and above. Results showed that 533 respondents (73.6%) claimed that they were willing to complete an AD if the document was recognized legally. The experience of caring for relatives or friends with terminal illnesses, palliative care as the preferred end-of-life treatment option, and scoring higher in the Hospice Care Attitude Scale were the predictors of willingness to make ADs. Results of the study suggested that there was a relatively high number of people who would consider setting up ADs. Our study recommends that healthcare professionals should equip themselves to raise ADs-related discussions with patients. Moreover, the Macao Government is responsible for facilitating the introduction and implementation of ADs in order to improve overall end-of-life care quality in Macao.


Assuntos
Diretivas Antecipadas , Cuidados Paliativos , China , Humanos , Macau , Prevalência
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