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Am J Bioeth ; 20(8): 54-64, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32757910


Dementia patients in the moderate-late stage of the disease can, and often do, express different preferences than they did at the onset of their condition. The received view in the philosophical literature argues that advance directives which prioritize the patient's preferences at onset ought to be given decisive moral weight in medical decision-making. Clinical practice, on the other hand, favors giving moral weight to the preferences expressed by dementia patients after onset. The purpose of this article is to show that the received view in the philosophical literature is inadequate and is out of touch with real clinical practice. I argue that having dementia is a cognitive transformative experience and that preference changes which result from this are legitimate and ought to be given moral weight in medical decision-making. This argument ought to encourage us to reduce our confidence in the moral weight of advance directives for dementia patients.

Diretivas Antecipadas/ética , Cognição , Demência , Ética Médica , Competência Mental , Preferência do Paciente , Tomada de Decisões/ética , Dissidências e Disputas , Humanos , Princípios Morais
Rev. bioét. derecho ; (49): 25-40, jul. 2020.
Artigo em Espanhol | IBECS | ID: ibc-192092


La relación médico-paciente se encuentra en un proceso de cambio y evolución hacia un tratamiento más humano, sustentado sobre el principio de autonomía, con el objetivo de respetar los derechos del paciente y no sólo imponer la voluntad del médico. Un instrumento que salvaguarda esta situación es el Documento de Voluntades Anticipadas, como extensión del consentimiento informado. A pesar de su regulación internacional y nacional, en ciertos contextos, como el de la salud mental, el modelo hegemónico-paternalista sigue imperando y nos preguntamos por qué

The doctor-patient relations are undergoing a process of change and evolution towards a more humane approach, based on the principle of autonomy , with the aim of respecting the rights of patients and not just imposing the will of the phyisician. Advance Directives, as an extension of Informed Consent documents, can further safeguard such rights. Despite its international and national regulation, in certain contexts, such as mental health, the hegemonic-paternalistic model persists, and the authors question the underlying motive

La relació metge-pacient es troba en un procés de canvi I evolució cap a un tractament més humà basat en el principi d'autonomia, amb l'objectiu de respectar els drets del pacient I no només imposar la voluntat de metge. Un instrument que salvaguarda aquesta situació és el Document de Voluntats Anticipades, com a extensió del consentiment informat. Malgrat la seva regulació internacional I nacional, en certs contextos, com el de la salut mental, el model hegemònic-paternalista segueix imperant I ens preguntem per què

Humanos , Diretivas Antecipadas/ética , Diretivas Antecipadas/legislação & jurisprudência , Legislação Médica , Saúde Mental/ética , Pessoas Mentalmente Doentes/legislação & jurisprudência , Planejamento/ética , Saúde Mental/legislação & jurisprudência , Planejamento/legislação & jurisprudência , Relações Médico-Paciente/ética , Autonomia Pessoal , Assistência Centrada no Paciente/ética
Rev. bioét. derecho ; (49): 125-139, jul. 2020.
Artigo em Inglês | IBECS | ID: ibc-192098


Promoting measures that aim to mitigate discrepancies in the decision-making process, ensuring adequate training of physicians in the ethical aspect of care, and incrementing the wellbeing of patients and their families are becoming the principal objectives for high-quality care, especially in the Intensive Medicine Unit (ICU). In this paper, we're going to deal with the implementation of a specific ethics support for the ICU health care professionals, and considering the advanced Spanish experience on this matter, it deals with the current potentialities and limits of CEC's role to improve the quality of health care assistance

Promover medidas que tengan como objetivo mitigar las discrepancias en el proceso de toma de decisiones, garantizar la capacitación adecuada de los médicos en el aspecto ético de la atención e incrementar el bienestar de los pacientes y sus familias se están convirtiendo en los objetivos principales para una atención de alta calidad, especialmente en Medicina Intensiva. En este artículo abordaremos la implementación de un apoyo ético específico para los profesionales de la salud de la UCI. Teniendo en cuenta la amplia experiencia española en este tema, nos centraremos en el potencial y los límites actuales del rol del CEA para mejorar la calidad de asistencia sanitaria

Promoure mesures que tinguin com a objectiu mitigar els discrepàncies en el procés de presa de decisions, garantir la capacitació adequada dels metges respecte a l'aspecte ètic de l'atenció I incrementar el benestar dels pacients I els seves families s'estan convertint en els objectius principals per a una atenció de qualitat, especialment a Medicina Intensiva. En aquest article abordarem la implementació d'un soport ètic específic per a professionals de la salut de l'UCI. Tenint en compte l'àmplia experiència espanyola en aquest tema, ens centrarem en el potencial I els límits actuals del rol del CEA per a millorar la qualitat de l'assistència sanitària

Humanos , Pessoal de Saúde/ética , Cuidados Críticos/ética , Comitê de Profissionais/ética , Tomada de Decisões/ética , Diretivas Antecipadas/ética , Unidades de Terapia Intensiva/ética , Diretivas Antecipadas/legislação & jurisprudência
J Clin Ethics ; 31(2): 126-135, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32585656


Dementia is a growing issue at the end of life that presents unique challenges for advance care planning. Advance directives are a useful and important component of end-of-life planning, but standard advance directives have less utility in cases of loss of capacity due to dementia. An advance directive designed to specifically address end-of-life issues in the setting of dementia can provide patients with increased autonomy and caregivers with improved information about the desires of the individual in question. The Dartmouth Dementia Directive is a dementia-specific advance directive, available online, that seeks to address common concerns of individuals who are planning for dementia-related end-of-life care. This directive was piloted in a community-based workshop, which provided important details and perspective on the best use of dementia-specific advance directives in the greater population.

Diretivas Antecipadas , Demência , Assistência Terminal , Planejamento Antecipado de Cuidados , Diretivas Antecipadas/ética , Cuidadores , Humanos
Rev Esp Salud Publica ; 942020 May 05.
Artigo em Espanhol | MEDLINE | ID: mdl-32382000


OBJECTIVE: Terminal patients and their relatives must know their real situation, and be treated according to the principle of autonomy, to establish therapeutic objectives adapted each one, according to their needs and decisions. The objective of this study is to identify the sufficient existence of records in the Medical Histories of terminal patients, which indicate their situation, such as the information given to the patients, or the LET, No-RCP or Z.51.5 codes, and the statistical relation they have with the sociodemographic and clinical variables. METHODS: Cross-sectional study in a third-level hospital, with patients admitted between January and December 2017, who died with terminal illness criteria. Data were collected from the medical records, and, fundamentally, from the nursing clinical notes. The statistical analysis was performed with the SPSS program, version 22. RESULTS: Participants were 140 people, 54.3% men, of 78.51 (SD=13.5) of middle age. People up to 70 years of age received less information (Odds ratio (OR): 0.077, 95% Confidence interval (CI): 0.015-0.390) and lower sedation (OR: 0.366, 95% CI: 0.149-0.899). Proceeding from city reduced the probability of receiving information (OR: 0.202; IC95%: 0.058-0.705). Presenting dyspnea reduced LTE (OR: 0.44, 95% CI: 0.20-093), No CPR (0.29, 95% CI: 0.12-0.68) and sedation (OR: 0.27; 95% CI: 0.12-060). Fatigue increased the probability of being Non-CPR (OR: 2.77, 95% CI: 1.166-6.627) and of receiving sedation (OR: 2.6, 95% CI: 1.065-6.331). CONCLUSIONS: Efforts to empower the patient in the decision of their process and the management of the information of their diagnosis and prognosis are still lacking. A greater and better clinical records facilitates knowing how actions are developed, allowing to identify and implement ethical and responsible interventions.

Diretivas Antecipadas/ética , Registros Médicos , Participação do Paciente , Autonomia Pessoal , Melhoria de Qualidade/ética , Assistência Terminal/ética , Centros de Atenção Terciária/ética , Adulto , Diretivas Antecipadas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Tomada de Decisões/ética , Feminino , Hospitalização , Humanos , Consentimento Livre e Esclarecido/ética , Consentimento Livre e Esclarecido/normas , Consentimento Livre e Esclarecido/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Participação do Paciente/métodos , Participação do Paciente/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Estudos Retrospectivos , Espanha , Assistência Terminal/normas , Assistência Terminal/estatística & dados numéricos , Centros de Atenção Terciária/normas , Centros de Atenção Terciária/estatística & dados numéricos
Monash Bioeth Rev ; 38(1): 49-67, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32335862


End-of-life decision-making in patients with dementia is a complex topic. Belgium and the Netherlands have been at the forefront of legislative advancement and progressive societal changes concerning the perspectives toward physician-assisted death (PAD). Careful consideration of clinical and social aspects is essential during the end-of-life decision-making process in patients with dementia. Geriatric assent provides the physician, the patient and his family the opportunity to end life with dignity. Unbearable suffering, decisional competence, and awareness of memory deficits are among the clinical considerations that physicians should incorporate during the end-of-life decision-making process. However, as other societies introduce legislature granting the right of PAD, new social determinants should be considered; Mexico City is an example. Current perspectives regarding advance euthanasia directives (AED) and PAD in patients with dementia are evolving. A new perspective that hinges on the role of the family and geriatric assent should help culturally heterogeneous societies in the transition of their public health care policies regarding end-of-life choices.

Diretivas Antecipadas/ética , Tomada de Decisões/ética , Demência , Ética Médica , Eutanásia/ética , Legislação Médica , Suicídio Assistido/ética , Diretivas Antecipadas/legislação & jurisprudência , Idoso , Bélgica , Bioética , Cultura , Eutanásia/legislação & jurisprudência , Família , Humanos , Consentimento Livre e Esclarecido , México , Países Baixos , Pessoalidade , Médicos , Políticas , Mudança Social , Fatores Sociológicos , Suicídio Assistido/legislação & jurisprudência , Assistência Terminal/ética , Assistência Terminal/legislação & jurisprudência
Rev. bioét. derecho ; (48): 41-59, mar. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-192077


Desde su origen, la Medicina Intensiva y la Bioética han compartido un desarrollo común, reforzándose entre ambas. Los límites de la tecnología, el cambio en la relación clínica, el respeto a las preferencias de los pacientes, han generado distintos conflictos éticos entre profesionales, pacientes y familiares. El objetivo del presente artículo es analizar como los pacientes que ingresan en las unidades de cuidados intensivos pueden participar en la toma de decisiones sobre actuaciones presentes (consentimiento informado) o futuras (voluntades anticipadas) e identificar el papel tanto del profesional sanitario como de la familia durante todo el proceso

Since its origin, Intensive Medicine and Bioethics have shared a common development, reinforcing each other. The limits of technology, the change in the clinical relationship, and respect for patients' preferences have generated different ethical conflicts between professionals, patients and family members. The objective of this article is to analyze how patients admitted to intensive care units can participate in decision-making about present (informed consent) or future (advance directives) actions and to identify the role of both the health professional and the family during the whole process

Des del seu origen, la Medicina Intensiva i la Bioètica han compartit un desenvolupament comú, reforçant-se mútuament. Els límits de la tecnologia, el canvi en la relació clínica, el respecte a les preferències dels pacients, han generat diferents conflictes ètics entre professionals, pacients i familiars. L'objectiu del present article és analitzar com els pacients que ingressen en les unitats de vigilància intensiva poden participar en la presa de decisions sobre actuacions presents (consentiment informat) o futures (voluntats anticipades) i identificar el paper tant del professional sanitari com de la família durant tot el procés

Humanos , Consentimento Livre e Esclarecido/ética , Unidades de Terapia Intensiva , Diretivas Antecipadas/ética , Tomada de Decisões/ética , Consentimento Livre e Esclarecido/legislação & jurisprudência , Diretivas Antecipadas/legislação & jurisprudência , Relações Profissional-Família/ética , Bioética
Theor Med Bioeth ; 41(1): 23-37, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32034586


This paper revisits Ronald Dworkin's influential position that a person's advance directive for future health care and medical treatment retains its moral authority beyond the onset of dementia, even when respecting this authority involves foreshortening the life of someone who is happy and content and who no longer remembers or identifies with instructions included within the advance directive. The analysis distils a eudaimonist perspective from Dworkin's argument and traces variations of this perspective in further arguments for the moral authority of advance directives by other authors. It then critiques a feature of the eudaimonist perspectives within these arguments-namely, the position that dementia has a retroactive negative impact on what a person has previously valued-and challenges the commonly held assumption underlying them that a person's life and well-being have relatively low value beyond the onset of dementia. Although advance directives have moral authority as a means of guiding one's future health care, accounts that dismiss the value of the lives and well-being of people living with dementia should be questioned to the extent that such accounts are used to support the moral authority of advance directives stipulating measures to foreshorten individuals' lives.

Diretivas Antecipadas/ética , Demência , Obrigações Morais , Humanos , Filosofia Médica
HEC Forum ; 32(1): 47-62, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31691879


In the United States, there is no consensus about who should make decisions in acute but non-emergent situations for incapacitated patients who lack surrogates. For more than a decade, our academic medical center has utilized community volunteers from the hospital ethics committee to engage in shared decision-making with the medical providers for these patients. In order to add a different point of view and minimize conflict of interest, the volunteers are non-clinicians who are not employed by the hospital. Using case examples and interviews with the community members, this paper describes how the protocol has translated into practice over the years since its inception. Members reported comfort with the role as well as satisfaction with the thoroughness of their discussions with the medical team. They acknowledged feelings of moral uncertainty, but expressed confidence in the process. Questions raised by the experience are discussed. Overall, the protocol has provided oversight, transparency, and protection from conflict of interest to the decision-making process for this vulnerable patient population.

Diretivas Antecipadas/ética , Tomada de Decisões/ética , Ética Clínica , Procurador/estatística & dados numéricos , Adulto , Diretivas Antecipadas/psicologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
HEC Forum ; 32(1): 33-45, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31686275


To date no one has identified or described the population of incapacitated patients being treated in an inpatient setting who lack proxy decision-makers. Nor, despite repeated calls for protocols to be developed for decision-making, has any institution reported on the utilization of such a protocol. In 2005, our urban tertiary care hospital instituted a protocol utilizing community members of the ethics committee to meet with the medical providers and engage in shared decision-making for patients without proxies (PWPs). We conducted a retrospective chart review and in this paper describe nearly 200 patients who were identified and treated according to the protocol over a 12 year period. After an aggressive search, family members were located for a surprising number of patients, leaving 80 patients who needed decisions to be made utilizing the PWP committee. We review the decisions required, the results of the shared decision-making meetings, and the patient outcomes. Our experience has shown that a protocol involving community volunteers to make decisions for PWPs in a timely manner is feasible and ethically defensible. The protocol has been accepted by physicians and utilized with increasing frequency. Because it was possible to gather at least minimal information on most patients, a standard of "informed best interest" was used to make decisions. PWP committee recommendations varied, but in all cases agreement was reached with the attending physicians.

Diretivas Antecipadas/ética , Tomada de Decisões/ética , Ética Clínica , Adulto , Diretivas Antecipadas/legislação & jurisprudência , Diretivas Antecipadas/psicologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
J Med Ethics ; 45(11): 693-699, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31484783


This paper presents four arguments in favour of respecting Ulysses Contracts in the case of individuals who suffer with severe chronic episodic mental illnesses, and who have experienced spiralling and relapse before. First, competence comes in degrees. As such, even if a person meets the usual standard for competence at the point when they wish to refuse treatment (time 2), they may still be less competent than they were when they signed the Ulysses Contract (time 1). As such, even if competent at time 1 and time 2, there can still be a disparity between the levels of competence at each time. Second, Ulysses Contracts are important to protect people's most meaningful concerns. Third, on the approach defended, the restrictions to people's liberty would be temporary, and would be consistent with soft paternalism, rather than hard paternalism: the contracts would be designed in such a way that individuals would be free to change their minds, and to change or cancel their Ulysses Contracts later. Finally, even if one rejects the equivalence thesis (the claim that allowing harm is as bad as doing harm), this is still consistent with the claim that, in particular cases, it can be as wrong to allow a harm as to do a harm. Nevertheless, controversies remain. This paper also highlights several safeguards to minimise risks. Ultimately, we argue that people who are vulnerable to spiralling deserve a way to protect their autonomy as far as possible, using Ulysses Contracts when necessary.

Diretivas Antecipadas/ética , Transtornos Mentais/psicologia , Transtornos Mentais/terapia , Liberdade , Humanos , Competência Mental/psicologia , Paternalismo , Autonomia Pessoal , Recidiva , Índice de Gravidade de Doença
J Healthc Risk Manag ; 39(2): 11-18, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31433120


Health professionals have been known to override patients' advance directives. The most ethically problematic instances involve a directive's explicitly forbidding the administration of some life-prolonging treatment like resuscitation or intubation with artificial ventilation. Sometimes the code team is unaware of the directive, but in other instances, the override is done knowingly and intentionally with clinicians later pleading that it was done "in the patient's best interests." This article surveys a twenty-year period extending back to 1997 when ethicists began to question the legitimacy of overriding advance directives despite clinicians believing they had compelling reasons to do so. A legal and ethical analysis of advance directive overrides is provided as no court to date has awarded damages to plaintiffs who alleged their loved one suffered "wrongful life" following a successful life-prolonging intervention. A hypothetical scenario is especially discussed wherein a patient's DNR status is overridden because her cardiac arrest was caused by error whose effects might be reversible. The authors conclude with a strategy for mitigating certain vagaries associated with overriding advance directives, but suggest that until courts provide clinicians with clear guidelines and protections, violations of patients' advance directives are likely to continue.

Adesão a Diretivas Antecipadas/psicologia , Adesão a Diretivas Antecipadas/tendências , Diretivas Antecipadas/ética , Diretivas Antecipadas/legislação & jurisprudência , Tomada de Decisões/ética , Pessoal de Saúde/psicologia , Preferência do Paciente/estatística & dados numéricos , Adulto , Adesão a Diretivas Antecipadas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Estados Unidos
Narrat Inq Bioeth ; 9(2): 173-177, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31447455


A living will is a document in which an individual can communicate his or her health care choices to loved ones in the event that he or she is unable to do so directly. Many surrogate decision-makers use living wills as guides; however, the existence of such documents does not entirely relieve them of their burden. Surrogate decision-makers often need to consider the impact of the personal and family burdens entailed by their decisions, and the stress accompanying these burdens regularly creates high levels of anxiety and depression. This stress can be exacerbated when two surrogate decision-makers are at loggerheads as to the best way forward. This case study illustrates the effects of stress accompanying disagreement among surrogate decision-makers-here, the patient's adult sons-and demonstrates that a process of listening can help the bioethicist identify the values that are important to the patient and, consequently, to the surrogate as well, and use these values to help address the issue.

Diretivas Antecipadas/ética , Cuidados Críticos/ética , Pai , Consentimento do Representante Legal/ética , Idoso , Dissidências e Disputas , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Testamentos Quanto à Vida/ética , Masculino , Carcinoma de Células Escamosas de Cabeça e Pescoço/terapia
Bioethics ; 33(7): 842-848, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31264246


The present article reviews the state of public debate and legal provisions concerning end-of-life decision-making in Italy and offers an evaluation of the moral and legal issues involved. The article further examines the content of a recent law concerning informed consent and advance treatment directives, the main court pronouncements that formed the basis for the law, and developments in the public debate and important jurisprudential acts subsequent to its approval. The moral and legal grounds for a positive evaluation of this law, which attests that the patient may withhold or withdraw from life-prolonging treatment, will be offered with reference to liberal approaches and particularly to the frameworks of care and virtue ethics; but reasons will also be offered in order to consider not only the latter but also broader range of end-of-life treatment decisions as morally apt options. In this light, we argue in favour of a further development of the Italian legislation to encompass forms of assisted suicide and active euthanasia.

Diretivas Antecipadas/ética , Diretivas Antecipadas/legislação & jurisprudência , Consentimento Livre e Esclarecido/ética , Consentimento Livre e Esclarecido/legislação & jurisprudência , Assistência Terminal/ética , Assistência Terminal/legislação & jurisprudência , Suspensão de Tratamento/ética , Suspensão de Tratamento/legislação & jurisprudência , Tomada de Decisões , Humanos , Itália , Princípios Morais
J Alzheimers Dis ; 69(4): 989-1001, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31127774


BACKGROUND: Palliative care and Advance Care Planning (ACP) are increasingly recommended for an optimal management of late-stage dementia. In Belgium, euthanasia has been decriminalized in 2002 for patients who are "mentally competent" (interpreted as non-demented). It has been suggested that advance directives for euthanasia (ADE) should be made possible for dementia patients. OBJECTIVE: This study presents the results of an internet survey among Belgian dementia specialists. METHODS: In 2013, the Belgian Dementia Council (BeDeCo) organized a debate on end of life decisions in dementia. Participants were medical doctors who are specialists in the dementia field. After the debate, an anonymous internet survey was organized. The participation rate was 55%. The sample was representative of the BeDeCo members. RESULTS: The results showed consensus in favor of palliative care and ACP, although ACP is not systematically addressed in practice. Few patients with dementia have requested euthanasia, but for those who did the participants had agreed to implement it for some patients. A majority of participants (94%) believe that most patients and their families are poorly informed about euthanasia. Although most participants (77%) said they approved the Law on euthanasia, 65% said they were against an extension of the Law to allow ADE for dementia. CONCLUSION: Palliative care and ACP are clearly accepted by professionals, although a gap between recommendation and practice remain. Euthanasia is a much more debated issue, even if a majority of professionals are, in principle, in favor of the current Law and seem to disapprove with a Law change allowing ADE for dementia. A better education for both health professionals and the lay public will be a key element in the future.

Demência/terapia , Eutanásia Ativa Voluntária , Diretivas Antecipadas/ética , Diretivas Antecipadas/psicologia , Atitude do Pessoal de Saúde , Bélgica , Demência/psicologia , Eutanásia Ativa Voluntária/ética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sociedades Médicas , Inquéritos e Questionários , Assistência Terminal/ética
Fam Syst Health ; 37(3): 260-262, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31058526


Was this a silver-lining playbook-my mother's death? We had planned for this moment, talked together about her wishes, filled out the paperwork: We were that kind of family-the one that talked and debated about life and death. And my mother, in her true tenacious fashion, rehearsed with us her dying wishes. The papers were filed with her primary care physician, scanned into the Electronic Medical Record (EMR), and a copy placed in their freezer-a clever way to find it in a crisis. The playbook was in place. The rest of the story is on replay in my mind. I remember asking to speak to the physician in a demanding tone and wanting to know why my mom was intubated . . . "Didn't any one look at the paper work?" The Emergency Department (ED) physician explained, "Your mom's blood pressure is dropping. She doesn't have a complicated medical condition so we want to give her pressors so that we can keep her alive." I replied that neither my mom nor the family wanted any intervention. This experience pulled us into the power of the protocols that make it possible to keep hearts beating and lungs breathing. In my mother's case, her uncomplicated medical history in the EMR triggered those standing lifesaving orders. But no one assessed her personhood. No one asked about her level of functioning, her pain, her memory loss, her desires. No one took a minute to ask about this mother of five children who sang her way through life. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Diretivas Antecipadas/psicologia , Suspensão de Tratamento/ética , Diretivas Antecipadas/ética , Atitude Frente a Morte , Humanos
J Am Geriatr Soc ; 67(8): 1724-1729, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31059129


The decision-making process on behalf of unrepresented adults (ie, those who lack capacity to make medical decisions and have no identifiable surrogate) is at risk for not incorporating their interests, raising ethical concerns. We performed semistructured interviews with key stakeholders across multiple sectors in an urban county who participate in the care of or decision-making process for unrepresented adults. This included a safety net healthcare system, social services, and legal services. Participants were healthcare, social service, and legal professionals who worked with unrepresented adults (n = 25). Our interview questions explored the current process for proxy decision making in cases of unrepresented adults and potential alternatives. We recorded, transcribed, and analyzed interviews using the constant comparative method to identify major themes related to ethical challenges if they were raised. Participants grappled with multiple ethical challenges around the care of unrepresented adults. Themes described by participants were: (1) prioritizing autonomy; (2) varying safety thresholds; (3) distributing resources fairly; and (4) taking a moral toll on stakeholders. In conclusion, all stakeholders identified ethical challenges in caring for unrepresented adults. An applied ethical framework that takes these dilemmas into account could improve ethical practice for unrepresented adults and lessen the emotional toll on stakeholders. J Am Geriatr Soc 67:1724-1729, 2019.

Diretivas Antecipadas/ética , Tomada de Decisões/ética , Defesa do Paciente/ética , Procurador , Participação dos Interessados/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa