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1.
Rev Med Suisse ; 16(681): 307-309, 2020 Feb 12.
Artigo em Francês | MEDLINE | ID: mdl-32049451

RESUMO

Switzerland has a high rate of legal measures of constraint by international standard. Beside the incorporation of legal, medical and economic elements, the physician may be asked on what it means to be a care giver and to be free, because his decision could private his patient of a fundamental human right. The deprivation of freedom for purposes of assistance is helpful in some clinical situations but remains a controversial issue. We have to do our due diligence when assessing the patient, notably his capacity of discernment, and discuss with him and his relatives other treatments without legal constraint. The advance directives and the joint plan of crisis should be tools to increase patients' autonomy and to decrease the coercive measures.


Assuntos
Coerção , Tomada de Decisões , Hospitais Psiquiátricos , Direitos do Paciente/legislação & jurisprudência , Diretivas Antecipadas , Humanos , Transferência de Pacientes/legislação & jurisprudência , Médicos/psicologia , Suíça
2.
Einstein (Sao Paulo) ; 18: eRW4852, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31618287

RESUMO

The objective of this study was to identify the variables that influence physicians to implement Advance Directives and assess their impact on end-of-life care. It is a narrative literature review of 25 articles published between 1997 and 2018, in the following databases: CAPES, EBSCOhost, BDTD, VHL, Google Scholar, MEDLINE®/PubMed. The keywords utilized were: "advance directives", "living wills", "physicians", "attitude", "decision making", "advance care planning". The main factors that influenced physicians to implemente the directives were patients prognosis, medical paternalism, and patients understanding of their medical condition. Respect for autonomy, lack of knowledge and experience with directives, legal concerns, family influence, cultural and religious factors also contributed to medical decision. Most studies (86%) showed that having a directive led to lower rates of invasive interventions in the last days of patient´s life. Physicians were interested in respecting their patients' autonomy and agreed that having an advance directive helped in the decision-making process; however, they stated other factors were also taken into account, mainly prognosis and reversibility conditions. Having directives contributed to reducing the use of life support therapies and adoption of comfort measures.


Assuntos
Adesão a Diretivas Antecipadas/psicologia , Médicos/psicologia , Assistência Terminal , Diretivas Antecipadas , Atitude do Pessoal de Saúde , Tomada de Decisões , Humanos , Paternalismo , Autonomia Pessoal
3.
Rev Infirm ; 68(255): 34-36, 2019 Nov.
Artigo em Francês | MEDLINE | ID: mdl-31757328

RESUMO

In the context of the care of people at the end of life, the implementation of measures relating to advance healthcare directives still appears to be problematic. A nursing team in Saône-et-Loire carried out a research project on this issue and highlighted several obstacles: poor knowledge of the law, a lack of information among the general public, the sensitivity of the subject, etc. The project revealed avenues for further reflection now being explored.


Assuntos
Diretivas Antecipadas , Assistência Terminal , Humanos
4.
J Law Med ; 26(4): 896-921, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31682366

RESUMO

This article examines the evolution of advance care planning (ACP) in Singapore through the development of a less-formal, communications-based model - the Living Matters program - and its experience with local cultural and community responses to the process and its outcomes. Living Matters is, in practice, arguably a communitarian approach to ACP. The article then examines the challenges Living Matters poses to the overarching legal framework for ACP and suggests improvements to the proxy decision-making framework under the Mental Capacity Act (Singapore, cap 177A, 2010 rev ed), offering more flexible legal tools for ACP, and more regulatory support for the means to implement ACP outcomes effectively.


Assuntos
Planejamento Antecipado de Cuidados , Diretivas Antecipadas , Tomada de Decisões , Humanos , Procurador , Singapura
6.
Z Gerontol Geriatr ; 52(8): 774-781, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31628610

RESUMO

Advance directives and durable powers of attorney are two increasingly used tools for patients' precedent autonomy; however, their combined use, as recommended by major institutions in Germany, might in reality result in various discrepancies between the wording and interpretation of the directive and the surrogate's understanding of the patient's relevant will. In one of the possible conflict constellations, the surrogate wants to overrule a relevant and unambiguous advance directive by reference to a privileged access to the patient's "real" treatment preferences or the presumed will of the patient. Such cases, which must be strictly distinguished from cases with real or alleged leeway for interpretation in the advance directive, can lead to normative uncertainty as well as to substantial psychological distress for all persons involved. Based on an exemplary real clinical case from 2015 (which did not go to court) legal, ethical and pragmatic aspects of the described constellation are discussed. Ethically, caution should be exercised against a relapse into a masked treatment paternalism, which currently seems to be partly caused by judicial exegesis.


Assuntos
Diretivas Antecipadas , Cônjuges , Alemanha , Humanos
7.
Gerokomos (Madr., Ed. impr.) ; 30(3): 119-123, sept. 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-185317

RESUMO

Introducción: Visto el escaso número de declaraciones de voluntades anticipadas presentadas, las diferencias entre modelos de documentos en las distintas comunidades autónomas, la falta de difusión, la importancia y beneficios que aportaría que el número de declarantes aumentara… nos preguntamos: ¿por qué la declaración de voluntades anticipadas es una gran desconocida? Objetivos: Conocer si la población sabe de la existencia de la declaración de voluntades anticipadas. Saber si tiene intención de realizarla. Metodología: Tras una búsqueda bibliográfica previa se realizó un estudio observacional descriptivo transversal de un total de 1.652personas de entre 18 y 79 años de todo el territorio nacional. Para la recogida de información, se elaboró un cuestionario de diseño propio, anónimo y específico que se difundió a través de internet mediante correo electrónico, mensajería instantánea y redes sociales. Se utilizó el análisis estadístico multivariante IBM SPSS Statistics 19. Resultados: Casi un 90% de los encuestados ha pensado alguna vez en su propia muerte. Un poco más del 50% conocía qué eran las voluntades anticipadas. El 90% afirmaba que el documento tenía gran utilidad. Solo un 3% había registrado el documento. Conclusiones: La realización de las voluntades anticipadas es sin duda de vital importancia para la población anciana, aunque no por eso deja de serlo para la sociedad en su conjunto, ya que realmente ni la enfermedad ni la muerte entienden de edad. Con este documento se asegurará el respeto en cualquier situación, y a lo largo de toda la vida, de la autonomía y la libertad para decidir de cada individuo


Introduction: Considering the small number of Living Will declarations made; the differences between the documents of each Autonomous Community, the lack of publicity about its existence; and the importance and the benefits that could bring an increase in the number of deponents… we wonder: ¿Why are the Living Will Declarations still unknown? Aim: To know if the public is aware of the existence of the Living Will Declarations. To know if there are persons with the intention to make use of it. Methodology: After a previous bibliographical research, a transversal descriptive observational study of a total of 1652 people between 18 and 79 years of the whole national territory was carried out. For the collection of information, a selfdesigned, anonymous and specific questionnaire was developed and disseminated through the web via email, instant messaging and social networks. A multivariate statistical analysis IBM SPSS Statistics 19. Results: Almost 90% of respondents have thought about their own death. A little over 50% knew what the anticipated Wills were. 90% said that the document was very useful. Only 3% had registered the document. Conclusion: The use of anticipated wills is undoubtedly of vital importance for the elderly population, and also for the society as a whole, since neither illness nor death take age into account. If this document is taken into account, it will ensure respect in any situation and for each individual to decide over its freedom and autonomy


Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Testamentos Quanto à Vida , Diretivas Antecipadas , Autonomia Pessoal , Inquéritos e Questionários , Eutanásia , Internet , Rede Social , Análise Multivariada
8.
Surg Clin North Am ; 99(5): 1019-1027, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31446907

RESUMO

Shared decision making requires the exchange of information from the patient and the surgeon (and ideally involves the expertise of the entire multidisciplinary team) to determine the medical and/or surgical treatment that best aligns with the patient's goals and values. Should the surgical patient wish to transition to end-of-life care, the transition to comfort-focused care is within the scope of practice for surgeons. Incorporating the expertise of other health care professionals is an important consideration for whole-patient care. Integrating primary palliative care into surgical practice can help mitigate unnecessary suffering and allow a smoother transition to comfort-focused care.


Assuntos
Cuidados Paliativos , Assistência Terminal , Diretivas Antecipadas , Tomada de Decisões , Coração Auxiliar , Humanos , Obstrução Intestinal/terapia , Assistência Terminal/métodos
9.
Surg Clin North Am ; 99(5): 859-865, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31446914

RESUMO

Surgeons, anesthesiologists, and nurses are frequently asked to operate on patients with an existing Do Not Resuscitate (DNR) order, resulting in confusion about the proper approach. We discuss the origins of decisions not to attempt resuscitation, the special circumstances surrounding the need for resuscitation intraoperatively, and reasons to suspend, or not suspend, the DNR order during the perioperative period. DNR should be part of a comprehensive discussion of a patient and family's goals of care. A clear understanding of those goals will lead the care team to a better understand the role of perioperative resuscitation for that individual patient.


Assuntos
Diretivas Antecipadas , Ordens quanto à Conduta (Ética Médica) , Reanimação Cardiopulmonar , Parada Cardíaca/terapia , Humanos , Salas Cirúrgicas , Cuidados Paliativos
10.
Anesthesiol Clin ; 37(3): 453-474, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31337478

RESUMO

Understanding geriatric physiology is critical for successful perioperative management of older surgical patients. The frailty syndrome is evolving as an important, potentially modifiable process capturing a patient's biologic age and is more predictive of adverse perioperative outcomes than chronologic age. Use of frailty in risk stratification and perioperative decision-making allows providers to effectively diagnose, risk stratify, and treat patients in the perioperative setting. Further study is needed to develop a universal definition of frailty, to identify comprehensive yet feasible screening tools that allow for accurate detection of frailty in the perioperative setting, and to refine treatment programs for frail surgical patients.


Assuntos
Envelhecimento/patologia , Fragilidade/fisiopatologia , Diretivas Antecipadas , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Idoso Fragilizado , Fragilidade/diagnóstico , Cirurgia Geral , Avaliação Geriátrica , Humanos
11.
Artigo em Alemão | MEDLINE | ID: mdl-31344743

RESUMO

It is legally required to determine and respect patient preferences and wishes as much as possible under the circumstances given. This also applies to emergency medicine and intensive care, particularly if a patient is unconscious and is not able to give his consent by him-/herself. According to German law, patients' explicit written statements (advance directive, living will) are mandatory. If no advance directive is available, or if the directive does not match the current medical circumstances, other (oral) statements of the individual patient have to be scrutinized to identify presumed wishes and establish presumed consent. Such wishes are equally binding. The article explicates the role of legal proxies (legal guardians, patient representatives) in determining patients' wishes. Detailed instructions and recommendations are given to medical staff on how to support legal representatives and next of kin with respect to shared decision-making and the process of determining patient preferences. This way, patient autonomy and patients' rights can be protected best.


Assuntos
Diretivas Antecipadas , Direitos do Paciente , Tomada de Decisões , Humanos , Testamentos Quanto à Vida
12.
Artigo em Alemão | MEDLINE | ID: mdl-31344744

RESUMO

Patients' rights need to be protected, particularly if the patient is unconscious or otherwise unable to consent. According to German law, a legal proxy is mandatory. Spouses and adult children do not automatically function as legal proxies. There are two alternative ways to become a legal proxy: a patient representative (Bevollmächtigter) is authorized by a written power of attorney (Vorsorgevollmacht), signed by the patient. If there is no power of attorney, a legal guardian (Betreuer) has to be appointed by a guardianship court. Both representatives and guardians are obliged to support the patient and are only allowed to make medical decisions, if the patient is currently unable to give his/her consent. The legal proxy is obligated to take into account advance directives, other patient preferences and presumed wishes. Recommendations and examples are given on how to apply these documents in medical practice and how to deal with legal representatives and guardians.


Assuntos
Diretivas Antecipadas , Tutores Legais , Adulto , Criança , Tomada de Decisões , Feminino , Humanos , Masculino , Direitos do Paciente
13.
Rev. enferm. UFSM ; 9: [20], jul. 15, 2019.
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1024454

RESUMO

Objetivo: compreender como os médicos e cuidadores familiares entendem a aplicabilidade das Diretivas Antecipadas de Vontade no cuidado em final de vida. Método: pesquisa qualitativa, descritiva e exploratória, realizada com sete médicos de um hospital universitário do sul do Brasil e sete cuidadores familiares de pacientes em fase final de vida, no período de outubro a dezembro de 2014, a partir de entrevistas semiestruturadas, submetidas à análise textual discursiva. Resultados: emergiram duas categorias: Diretivas Antecipadas de Vontade: o direito à autonomia pessoal e conflitos e dilemas na aplicabilidade das Diretivas Antecipadas de Vontade. Conclusão: as Diretivas Antecipadas de Vontade estão relacionadas ao respeito da autonomia pessoal, respaldo profissional e redução das angústias e sofrimentos dos cuidados familiares diante dos processos decisórios que envolvem o fim de vida. Entretanto, constitui-se como uma prática cercada por medos e receios à sua aplicabilidade e ao cumprimento pelo profissional


Aim: to understand how family caregivers and physicians understand the applicability of the Advance Directives of Will in the care at the end of life. Method: qualitative, descriptive and exploratory research, carried out with seven physicians from a university hospital in the south of Brazil and seven family caregivers of patients in the final phase of life, from October to December 2014, through semi-structured interviews, with the discursive textual analysis. Results: two categories emerged: Early Directives of Will: the right to personal autonomy and conflicts and dilemmas in the applicability of Advance Directives of Will. Conclusion: Advance Directives are related to respect for personal autonomy, professional support and reduction of distress and suffering of family care in the decision-making processes that involve the end of life. However, it is a practice surrounded by fears of its applicability and compliance by the professional.


Objetivo: comprender cómo los médicos y cuidadores familiares entienden la aplicabilidad de las Directivas Anticipadas de Voluntad en el cuidado al final de la vida. Método: investigación cualitativa, descriptiva, exploratoria realizada con siete médicos de un hospital universitario del sur de Brasil y siete cuidadores familiares de pacientes en fase final de la vida, entre octubre y diciembre de 2014, a partir de entrevistas semiestructuras, las cuales fueron sometidas a análisis textual discursiva. Resultados: se identificó dos categorías: Directivas Anticipadas de Voluntad: el derecho a la autonomía personal y conflictos; y dilemas en la aplicabilidad de las Directivas Anticipadas de Voluntad. Conclusión: las Directivas Anticipadas de Voluntad están relacionadas al respeto a la autonomía personal, a el respaldo profesional y a la reducción de las angustias y sufrimientos de los cuidados familiares delante de los procesos decisorios relacionados al fin de vida. Sin embargo, se constituye como una práctica rodeada por miedos y temores a su aplicabilidad y al cumplimiento por el profesional.


Assuntos
Humanos , Diretivas Antecipadas , Doente Terminal , Medicina
14.
Isr J Health Policy Res ; 8(1): 48, 2019 06 03.
Artigo em Inglês | MEDLINE | ID: mdl-31159870

RESUMO

In most countries there is a mismatch between demand for intensive care unit (ICU) beds and ICU bed availability. Because of a policy of low ICU-bed reimbursement this mismatch is much more profound in Israel, which arguably has the lowest number of ICU beds/1000 population of OECD countries. Increasing demand for mechanical ventilation has led to an ever-rising presence of ventilated patients in medical departments, which may reach up to 15% or more of medical beds, especially during winter months, posing serious challenges such as: delivery of adequate treatment, guaranteeing patient safety, nosocomial infections, emergence and spread of resistant organisms, dissatisfaction among family members and medical and nursing staff, as well as enormous direct and indirect expenses.This paper assumes that no change in ICU reimbursement will occur in the near future. We, therefore, describe a number of policy issues that should ideally be addressed together in order to cope realistically with the increase in mechanically ventilated patients in medical departments. First, all medical departments should operate a 5-bed augmented care room with one dedicated nurse per shift. Medical residents should receive a mandatory 3-month ICU rotation in their first year of residency, and attending physicians should receive adequate training in mechanical ventilation and vasopressor support, point-of-care ultrasound and central venous catheterization. Second, family physicians should be required to discuss and fill relevant forms with advance directives for elderly and/or chronically ill patients. Third, rules for terminal extubation should be established, even if only applied infrequently. Finally, co-payment should be considered for families of patients demanding all possible medical treatment in spite of contrary medical advice, considering these patients' terminal status.Implementation of these recommendations will require policy decision making in the Ministry of Health, Scientific Council of the Israeli Medical Association, the professional societies (for internal medicine and family practice) and finally by the leadership of individual hospitals.


Assuntos
Unidades de Terapia Intensiva , Respiração Artificial , Diretivas Antecipadas , Idoso , Hospitais , Humanos , Israel
15.
Clin Rehabil ; 33(10): 1571-1585, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31169031

RESUMO

OBJECTIVE: To clarify the concept of best interests, setting out how they should be ascertained and used to make healthcare decisions for patients who lack the mental capacity to make decisions. CONTEXT: The legal framework is the Mental Capacity Act (MCA) 2005, which applies to England and Wales. THEORY: Unless there is a valid and applicable Advance Decision, an appointed decision-maker needs to decide for those without capacity. This may be someone appointed by the patient through a Lasting Power of Attorney, or a Deputy appointed by the court. Otherwise the decision-maker is usually the responsible clinician. Different approaches exist to surrogate decision-making cross-nationally. In England and Wales, decision-making is governed by the MCA 2005, which uses a person-centred, flexible best interests (substituted interests) approach. OBSERVATIONS: The MCA is often not followed in healthcare settings, despite widespread mandatory training. The possible reasons include its focus on single decisions, when multiple decisions are made daily, the potential time involved and lack of clarity about who is the responsible decision-maker. SOLUTION: One solution is to decide a strategic policy to cover more significant (usually health-related) decisions and to separate these from day-to-day relational decisions covering care and activities. Once persistent lack of capacity is confirmed, an early meeting should be arranged with family and friends, to start a process of sharing information about the patient's medical condition and their values, wishes, feelings and beliefs with a view to making timely treatment decisions in the patient's best interests.


Assuntos
Tomada de Decisões , Competência Mental , Procurador , Diretivas Antecipadas , Tomada de Decisão Clínica , Humanos , Relações Profissional-Família
16.
BMC Health Serv Res ; 19(1): 362, 2019 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-31174530

RESUMO

BACKGROUND: Advance care planning (ACP) is the process of ongoing communication among patients, family and health care professionals regarding what plans for future care are preferred in the event that patients become unable to make their own decisions. Clinicians play an important role in ACP as both initiators and decision coaches. However, lack of training for clinicians has frequently been reported as the reason for low involvement in ACP discussions - hence the present review evaluates the effectiveness of ACP training programs for healthcare professionals to guide the development of novel training programs for them in the future. METHODS: A literature search for intervention studies was conducted independently by two reviewers in July 2018. Participants included all healthcare professionals working with adult patients suffering from terminal illness. The primary outcomes were the professionals' knowledge of and attitudes towards ACP, and self-perceived competence in ACP conversations. The Effective Public Health Practice Project appraisal tool was used to examine the quality of the studies included. RESULTS: A total of 4025 articles were identified, and ten eligible articles, covering 1081 participants, were included in the review. However, there is a lack of high quality randomized controlled trials of providing ACP training for nurses working in non-palliative care hospital settings. The overall quality of the intervention studies was moderate. All the studies included used instructional sessions in their interventions, while some contained group discussion, role-play and the use of advanced technology. The training programs increased the knowledge, attitudes towards shared decision-making, perceived communication skills, confidence, comfort and experiences concerned with discussing end-of-life (EOL) issues. Patient advocacy, job satisfaction and perceived level of adequate training for EOL care were improved. The use of 'decision aids' was rated as acceptable and clinically useful. CONCLUSIONS: Training for healthcare professionals in ACP has positive effects on their knowledge, attitude and skills. The use of decision aids and advanced technology, instructional sessions with role play, training content focused on ACP communication skills and the needs and experience of patient in the ACP process, and a values-based ACP process are all those factors that made the ACP training programs effective.


Assuntos
Planejamento Antecipado de Cuidados/normas , Diretivas Antecipadas , Pessoal de Saúde/educação , Tomada de Decisões , Prática Clínica Baseada em Evidências , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
17.
A A Pract ; 13(5): 188-189, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31180907

RESUMO

We report the case of a 55-year-old woman who required extracorporeal membrane oxygenation for extreme respiratory distress after a liver transplant and eventually died. As is so often the case, this patient's values and wishes were not documented before she had a risky surgical procedure. Anesthesiologists, in partnership with surgeons, can participate in preoperative discussions exploring wishes and values and document them in advance directives which will help clinicians respect patients' preferences.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Relações Médico-Paciente/ética , Insuficiência Respiratória/terapia , Diretivas Antecipadas , Evolução Fatal , Feminino , Humanos , Transplante de Fígado/efeitos adversos , Pessoa de Meia-Idade , Insuficiência Respiratória/etiologia
18.
J Clin Ethics ; 30(2): 89-95, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31188784

RESUMO

In the United States, patients who lose the ability to make their own medical decisions are subject to the laws of their respective states. Laws governing advance directives and physician orders for life-sustaining therapies (POLST), and establishing a surrogate in the absence of an advance directive, vary substantially by jurisdiction. This article traces those laws from their origins, describes current practices and challenges with their application to patient care, and considers future avenues for ethics research and legislative reform.


Assuntos
Médicos , Ordens quanto à Conduta (Ética Médica) , Diretivas Antecipadas , Tomada de Decisões , Humanos , Estados Unidos
20.
Am J Nurs ; 119(7): 72, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31232785

RESUMO

To help health care proxies with end-of-life decisions, ask about patients' former selves.


Assuntos
Diretivas Antecipadas , Tomada de Decisões , Assistência Terminal , Adulto , Feminino , Humanos
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