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BMC Geriatr ; 19(1): 212, 2019 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-31382893


BACKGROUND: Despite the perceived ethical, personal and health service benefits of advance care planning (ACP), the extent to which older and seriously ill Australian inpatients have considered future health decisions remains uncertain. This study aimed to determine in a sample of older and seriously ill inpatients, the proportion who had: 1) engaged in four advance care planning (ACP) activities; 2) not engaged in ACP activities but wanted to; and 3) reasons why they had not engaged. METHODS: Cross-sectional face-to-face standardised interview survey with inpatients in a tertiary referral centre who were either: aged 80+ years; aged 55+ years with progressive chronic disease(s); or judged by treating clinicians as having a life expectancy of less than 12 months. Patients indicated whether they had engaged in four ACP activities: (1) appointed medical substitute-decision-maker(s), (2) recorded end-of-life wishes in an advance directive or care plan; and talked about their end-of-life wishes with their: (3) support persons and/or (4) doctors. Patients who had not engaged in activities were asked whether they wished this to occur and reasons why. RESULTS: One hundred eighty-six inpatients consented to the study (80% of approached). Of these, 9% (n = 16) had engaged in four ACP activities; 27% (n = 50) had not engaged in any. Half (n = 94, 52%) had appointed a medical substitute-decision-maker, 27% (n = 50) had recorded wishes in an advance directive or care plan, 51% (n = 90) had talked about their end-of-life wishes with support persons and 27% (n = 48) had talked with their doctor. Patients who wanted to, but had not, engaged in the four ACP activities were unaware they could record wishes or appoint decision-makers, or indicated providers had not initiated conversations. CONCLUSION: Relatively few inpatients had engaged in all four ACP activities. More inpatients had discussed end of life issues with family and appointed substitute decision makers, than completed written documents or talked with doctors. Community education and a more active role for community and hospital-based providers in supporting patients and families to collaboratively resolve end-of-life decisions may increase the probability wishes are known and followed.

Planejamento Antecipado de Cuidados/tendências , Tomada de Decisão Clínica/métodos , Índice de Gravidade de Doença , Assistência Terminal/métodos , Assistência Terminal/tendências , Diretivas Antecipadas/tendências , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Doença Crônica , Comunicação , Estudos Transversais , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade
Rev Bras Enferm ; 72(1): 256-264, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30916293


OBJECTIVE: to explain the approaches and discussions about the Advance Healthcare Directives spread among health professionals, lawyers and society. METHOD: bibliographic search in the databases SciELO, LILACS, BDENF, in Portuguese, carried out from December 2017 to January 2018. RESULTS: 22 articles were considered for analysis with interviews and testimonies of physicians, intensivists and geriatricians, nurses, technicians and Nursing auxiliaries, Medical students, lawyers and Law students. CONCLUSION: there is a small number of papers on the Advance Healthcare Directives in Brazil, and a wide range of approaches that have not yet been clarified. The theme is not widely spread and little clarified in its essence.

Diretivas Antecipadas/tendências , Direito a Morrer/ética , Tomada de Decisões , Humanos , Autonomia Pessoal
Soc Sci Med ; 215: 16-22, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30196148


Advance care directives situate persons as rational and self-determining actors who can make anticipatory plans about their futures. This paper critically examines how people interpret individual and future-oriented approaches to medical decision-making with limited access to information and knowledge, and reduced opportunities to prepare and document their care preferences. Based on ethnographic research with Asian migrant families living in Adelaide, South Australia (August 2015-July 2018), it reveals a discord between planning for a finite future and the contingencies and continuities of social life. It unsettles the detached reasoning that is privileged in end-of-life decision-making and reveals limitations to "do-it-yourself" approaches to advance care directives which, it will be argued, not only forecasts potential futures but also forecloses them. Taking Derrida's critique of death and decision-making as a point of departure, it develops the concept of temporal dissonance as a theoretical framework to articulate the tensions that are constituted in advance care directives. The paper suggests that attention to temporal incongruities may help to shed light on the many complex interpretations of advance care directives and the difficulties of promoting them in diverse contexts.

Diretivas Antecipadas/tendências , Atitude Frente a Morte , Tomada de Decisões , Previsões/métodos , Diretivas Antecipadas/etnologia , Diretivas Antecipadas/estatística & dados numéricos , Grupo com Ancestrais do Continente Asiático/etnologia , Grupo com Ancestrais do Continente Asiático/psicologia , Grupo com Ancestrais do Continente Asiático/estatística & dados numéricos , Barreiras de Comunicação , Emigrantes e Imigrantes/estatística & dados numéricos , Humanos , Austrália do Sul/etnologia
Gac. sanit. (Barc., Ed. impr.) ; 32(4): 333-338, jul.-ago. 2018. tab
Artigo em Espanhol | IBECS | ID: ibc-174156


Objetivo: Examinar los conocimientos y actitudes, en la etapa final de la vida, sobre los cuidados paliativos, el documento de instrucciones previas, los cuidados psicofísicos, el suicidio médicamente asistido y el acompañamiento espiritual. Método: Estudio transversal efectuado en la población usuaria de un centro de salud de atención primaria de la Comunidad Autónoma de Madrid. Participaron 425 personas seleccionadas mediante un muestreo sistemático aplicado a las hojas de consulta de los/las profesionales sanitarios/as. Se analizaron 42 variables del cuestionario autoadministrado. Resultados: La población madrileña encuestada presentó las siguientes características: estudios superiores 58%, 51-70 años 47%, casados/as 60%, y mujeres 61%. Al 91% les gustaría decidir sobre sus cuidados al final de la vida. El 58% de los/las encuestadas conoce los cuidados paliativos y el 53% solicitaría acompañamiento espiritual. Conocen las instrucciones previas (50%), pero no tienen efectuado el documento. El 54% están a favor de legalizar la eutanasia y el 42% el suicidio asistido. Conclusiones: La población madrileña estudiada decidirá los cuidados al final de la vida y solicitará acompañamiento espiritual. Sobresalen los partidarios de la eutanasia frente al suicidio asistido. Desearían recibir cuidados paliativos y efectuarían las instrucciones previas. Para contrastar la opinión de la población y dar a conocer los recursos sociosanitarios de la Comunidad Autónoma de Madrid deberían realizarse encuestas en diferentes áreas sanitarias de atención primaria

Objective: To assess the attitudes and knowledge in the life's end about palliative care, advance directives, psychological-physical care, medically assisted suicide and spiritual accompaniment. Method: A cross-sectional study performed in the population at primary health care center of the Autonomous Region of Madrid (Spain). It participated 425 selected people that a simple random was applied in the consultation sheets of health professionals. They analyzed 42 variables of self-administered questionnaire. Results: The surveyed population of Madrid displayed the following characteristics: university studies 58%, 51-70 years 47%, married 60%, and women 61%. 91% would like to decide about their care at life's end. 58% of respondents are aware of palliative care and 53% would request spiritual accompaniment. They know advance directives (50%) but have not made the document. 54% are in favor of legalizing the euthanasia and 42% the assisted suicide. Conclusion: Madrid's people state they would like to decide what care they will receive at life's end and request spiritual accompaniment. Outstanding advocates of euthanasia against assisted suicide. They would like to receive palliative care and complete advance directives documents. To draw comparisons within the population, thereby increasing awareness about social health care resources in Autonomous Region of Madrid, surveys should be conducted in different primary health care centers areas of Madrid

Humanos , Cuidados Paliativos na Terminalidade da Vida/tendências , Diretivas Antecipadas/tendências , Direito a Morrer , Cuidados para Prolongar a Vida/tendências , Adesão a Diretivas Antecipadas/tendências , Tomada de Decisão Clínica/ética , Conhecimentos, Atitudes e Prática em Saúde , Suicídio Assistido/tendências , Eutanásia Ativa Voluntária/tendências , Terapias Espirituais/tendências , Estudos Transversais , Inquéritos e Questionários
Gac. sanit. (Barc., Ed. impr.) ; 32(4): 346-351, jul.-ago. 2018. tab
Artigo em Espanhol | IBECS | ID: ibc-174158


Objetivo: Establecer tipologías de la población general madrileña ante el final de la vida, mediante un análisis de clusters. Método: A la muestra (N = 425), perteneciente a un centro de salud de la Comunidad Autónoma de Madrid, se le aplicó el programa SPAD 8. Se efectuó una técnica de análisis de correspondencias múltiples, seguida de un análisis de conglomerados para lograr un dendograma jerárquico ascendente. Previamente se realizó un estudio transversal con los resultados de un cuestionario. Resultados: Se identificaron cinco clusters. Cluster 1: grupo que no respondió a numerosas preguntas del cuestionario (5%). Cluster 2: partidarios de recibir cuidados paliativos y de la eutanasia (40%). Cluster 3: se oponen al suicidio asistido y no solicitarían ayuda espiritual (15%). Cluster 4: partidarios de recibir cuidados paliativos y del suicidio asistido (16%). Cluster 5: contrarios al suicidio asistido y solicitarían ayuda espiritual (24%). Conclusiones: Sobresalieron estos cuatro clusters. Los clusters 2 y 4 eran partidarios de recibir cuidados paliativos, la eutanasia (2) y el suicidio asistido (4). Los clusters 4 y 5 practicaban mucho sus creencias y sus familiares no habían recibido cuidados paliativos. Por el contrario, los clusters 3 y 5 se oponían a la eutanasia y mayormente al suicidio asistido. Apenas practicaban sus creencias los clusters 2 y 3. Los clusters 2, 4 y 5 no efectuaron el documento de instrucciones previas. Este estudio se podría tener en cuenta para elegir los cuidados que mejoren la calidad del final de la vida

Objective: To establish typologies within Madrid's citizens (Spain) with regard to end-of-life by cluster analysis. Method: The SPAD 8 programme was implemented in a sample from a health care centre in the autonomous region of Madrid (Spain). A multiple correspondence analysis technique was used, followed by a cluster analysis to create a dendrogram. A cross-sectional study was made beforehand with the results of the questionnaire. Results: Five clusters stand out. Cluster 1: a group who preferred not to answer numerous questions (5%). Cluster 2: in favour of receiving palliative care and euthanasia (40%). Cluster 3: would oppose assisted suicide and would not ask for spiritual assistance (15%). Cluster 4: would like to receive palliative care and assisted suicide (16%). Cluster 5: would oppose assisted suicide and would ask for spiritual assistance (24%). Conclusions: The following four clusters stood out. Clusters 2 and 4 would like to receive palliative care, euthanasia (2) and assisted suicide (4). Clusters 4 and 5 regularly practiced their faith and their family members did not receive palliative care. Clusters 3 and 5 would be opposed to euthanasia and assisted suicide in particular. Clusters 2, 4 and 5 had not completed an advance directive document (2, 4 and 5). Clusters 2 and 3 seldom practiced their faith. This study could be taken into consideration to improve the quality of end-of-life care choices

Humanos , Cuidados Paliativos na Terminalidade da Vida , Direito a Morrer/ética , Cuidados para Prolongar a Vida , Diretivas Antecipadas/tendências , Planejamento Antecipado de Cuidados , Atitude do Pessoal de Saúde , Direitos do Paciente/ética , Estudos Transversais , Análise por Conglomerados , Espiritualidade , Preferência do Paciente/estatística & dados numéricos
Ther Umsch ; 75(2): 105-111, 2018 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-30022725


Dementia from a palliative care perspective: why a disease-specific advance care planning is necessary Abstract. Palliative Care has to transform profoundly in the context of population aging in many countries around the globe. It has to collaborate increasingly with geriatric medicine and incorporate geriatric expertise. One of the pivotal challenges of geriatric palliative care is ethically appropriate decision making for patients who have lost decision-making capacity. While the traditional approach to advance directives (living wills) has demonstrably proven ineffective, the new approach that is currently being embraced, including in German-speaking countries, is the systemic process of advance care planning (ACP). In this article, ACP is first presented with its general aims, elements and effects. Second, it is shown why we need an adapted ACP program for people with dementia and what such a dementia-specific ACP must entail.

Planejamento Antecipado de Cuidados , Diretivas Antecipadas , Demência/terapia , Cuidados Paliativos/métodos , Planejamento Antecipado de Cuidados/ética , Planejamento Antecipado de Cuidados/tendências , Diretivas Antecipadas/ética , Diretivas Antecipadas/tendências , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisões , Demência/diagnóstico , Demência/epidemiologia , Previsões , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Cuidados Paliativos/ética , Cuidados Paliativos/tendências , Suíça
BMC Palliat Care ; 17(1): 78, 2018 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-29793469


BACKGROUND: ACP involving a facilitated conversation with a health or care professional is more effective than document completion alone. In policy, there is an expectation that health and care professionals will provide ACP support, commonly within their existing roles. However, the potential contributions of different professionals are outlined only broadly in policy and guidance. Research on opportunities and barriers for involving different professionals in providing ACP support, and feasible models for doing so, is currently lacking. METHODS: We identified twelve healthcare organizations aiming to offer system-wide ACP support in the United States, Canada, Australia and New Zealand. In each, we conducted an average 13 in-depth interviews with senior managers, ACP leads, dedicated ACP facilitators, physicians, nurses, social workers and other clinical and non-clinical staff. Interviews were analyzed thematically using NVivo software. RESULTS: Organizations emphasized leadership for ACP support, including strategic support from senior managers and intensive day-to-day support from ACP leads, to support staff to deliver ACP support within their existing roles. Over-reliance on dedicated facilitators was not considered sustainable or scalable. We found many professionals, from all backgrounds, providing ACP support. However, there remained barriers, particularly for facilitating ACP conversations. A significant barrier for all professionals was lack of time. Physicians sometimes had poor communication skills, misunderstood medico-legal aspects and tended to have conversations of limited scope late in the disease trajectory. However, they could also have concerns about the appropriateness of ACP conversations conducted by others. Social workers had good facilitation skills and understood legal aspects but needed more clinical support than nurses. While ACP support provided alongside and as part of other care was common, ACP conversations in this context could easily get squeezed out or become fragmented. Referrals to other professionals could be insecure. Team-based models involving a physician and a nurse or social worker were considered cost-effective and supportive of good quality care but could require some additional resource. CONCLUSIONS: Effective staffing of ACP support is likely to require intensive local leadership, attention to physician concerns while avoiding an entirely physician-led approach, some additional resource and team-based frameworks, including in evolving models of care for chronic illness and end of life.

Diretivas Antecipadas/tendências , Internacionalidade , Admissão e Escalonamento de Pessoal/normas , Planejamento Antecipado de Cuidados/organização & administração , Planejamento Antecipado de Cuidados/estatística & dados numéricos , Assistência à Saúde/organização & administração , Pessoal de Saúde/estatística & dados numéricos , Política de Saúde/tendências , Humanos , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Pesquisa Qualitativa , Recursos Humanos
Swiss Med Wkly ; 148: w14628, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29767827


This article describes the Swiss law on advance directives that was passed at the beginning of 2013 and led to more certainty about the legally binding character of such directives. However, for various reasons the drafting of advance directives is not yet widespread in Switzerland, and many resources might be put to better use if this became a common practice. A recent proposal by members of a political party to make the discussion, although not the actual drafting, of advance directives mandatory was rejected by the Swiss Federal Parliament, and the proposal was written off after having been pending for 2 years. We consider that the rejection of this proposal was not justified and that discussion of advance directives should become mandatory, so that individuals can fully assume their role as responsible citizens taking proactive decisions. The decision not to draft advance directives should be a deliberate one, marking a shift from the current "opt-in" approach to an "opt-out" scenario.

Diretivas Antecipadas/legislação & jurisprudência , Comportamento de Escolha , Tomada de Decisões , Diretivas Antecipadas/tendências , Humanos , Suíça
J Emerg Med ; 55(1): 141-142, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29776701


BACKGROUND: Critically ill or injured emergency department or prehospital patients who lack decision-making capacity sometimes present with a non-standard advance directive, such as a "Do Not Resuscitate" tattoo or medallion. Emergency clinicians must immediately address the question of whether to withhold treatment based on what may or may not be a valid patient directive. DISCUSSION: Advance directives have been standardized for a good reason. Emergency department or prehospital healthcare providers must be able to immediately interpret and act on them without needing a legal interpretation. When faced with non-standard directives, physicians can follow them, ignore them, or simply use them as an additional piece of information about the individual's wishes for some situations at one point in his or her life. Absent the patient's input or that of aknowledgeable surrogate, both the patient's initial reasons for their non-standard directive and his or her present wishes concerning resuscitation cannot be independently known. Therefore, healthcare providers must initiate treatment while they buy time, attempt to return the patient to lucidity, and search for probative information regarding their current wishes concerning medical treatment. Without such additional information, the moral weight will always favor initiating treatment, since withholding treatment is often irreversible and any treatment instituted can later be withdrawn.

Diretivas Antecipadas/tendências , Tomada de Decisões , Ressuscitação/ética , Diretivas Antecipadas/ética , Medicina de Emergência/métodos , Medicina de Emergência/tendências , Serviço Hospitalar de Emergência/organização & administração , Humanos , Ressuscitação/tendências , Tatuagem/efeitos adversos , Tatuagem/tendências
BMC Palliat Care ; 17(1): 54, 2018 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-29587711


BACKGROUND: Advance care planning (ACP) aids can help prepare patients, family members, and physicians for in-the-moment medical decision-making. We wished to describe the content and approach of paper-based ACP aids in order to characterize existing aids and inform the development of a new ACP aid. METHODS: Paper-based ACP aids were identified through an environmental scan and screened for eligibility. ACP conceptual frameworks and data were gathered via stakeholder engagement and used to inform the coding framework that two investigators used to independently code each aid. A directed content analysis was conducted on these eligible aids. Aids were categorized through a deliberative process with an investigator abstracting general information for each aid. RESULTS: Fifteen aids met the eligibility criteria. They ranged in length from 6 to 78 pages with the average aid written at an eighth-grade reading level. The content analysis revealed that many aids encouraged choosing a surrogate decision maker and informed users about legal medical documents. Fewer than half of the aids facilitated patient clarification of values regarding quality of life issues. The authors identified and termed the following three categories of aids: informative; semi-action oriented; and action-oriented. It was often unclear whether patients contributed to the development or testing of the ACP aids reviewed. CONCLUSIONS: Most existing paper-based ACP aids address legal matters such as completing an advance directive. Only a minority elicited patient values and it was unclear whether any were developed in partnership with patients. Future development of ACP aids should account for patient preferences with a goal of supporting in-the-moment medical decision-making.

Planejamento Antecipado de Cuidados/normas , Tomada de Decisões , Folhetos , Assistência Centrada no Paciente/normas , Diretivas Antecipadas/tendências , Humanos , Preferência do Paciente/psicologia , Assistência Centrada no Paciente/métodos , Assistência Terminal/métodos , Assistência Terminal/normas
BMC Palliat Care ; 17(1): 10, 2018 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-29291716


BACKGROUND: In France, advance directives are favourably perceived by most of the population, although the drafting rate is low. This ambivalence is challenging because advance directives are meant to promote the autonomy and freedom of choice of patients. The purpose of this study was to analyse the content of advance directives written by patients suffering from malignant haemopathies to better understand how patients put them into practice. These could be relevant as early as the initial diagnosis of haematological malignancies because of the uncertain course of the disease. METHODS: This was a multicentre, qualitative, descriptive study. The advance directives written by patients with malignant haemopathies treated in one of the six French hospital departments were included in the study from 01/06/2008 to 15/04/2016. A thematic analysis of the advance directives was performed by two researchers: a senior haematologist and a research assistant. RESULTS: The median age of the patients was 69. Most were women (sex ratio: 0.59), living as a couple (57%), with lymphoid pathologies (66%), who were still alive two years after the instructions were written (63%) and had nominated a health care proxy (88.6%). Free texts (62.9%) were richer in content than pre-defined forms. The advance directives were used in three ways: for a purely legal purpose, to focus on medical treatments or actions, or to communicate a message to the family. Three main themes emerged: (1) refusal of medical treatment (100%), in which patients express refusal of life-sustaining care (97.1%). The actual treatments or the moment when they should be limited or stopped were not always mentioned in detail. (2) A desire for effective pain relief to avoid suffering (57.1%) and (3) messages for their family (34.3%), such as funeral arrangements (17.1%) and messages of love or trust (14.3%). CONCLUSIONS: Patients who write advance directives are not necessarily at the end of their lives. Their content mainly conveys treatment wishes, although patients also use them to pass on personal messages to their close family. This emerging role of advance directives to communicate messages within the family should be valued, even if it is not their original purpose.

Diretivas Antecipadas/psicologia , Comportamento de Escolha , Família/psicologia , Adolescente , Adulto , Diretivas Antecipadas/legislação & jurisprudência , Diretivas Antecipadas/tendências , Idoso , Idoso de 80 Anos ou mais , Comunicação , Feminino , França , Hematologia/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Estudos Retrospectivos
BMC Palliat Care ; 16(1): 43, 2017 Aug 29.
Artigo em Inglês | MEDLINE | ID: mdl-28851337


BACKGROUND: Completion of Advance Directives (ADs), being financial and healthcare proxy or instructional documents, is relatively uncommon in Australia. Efforts to increase completion rates include online education and prompting which past literature suggests may be effective. The aim of this randomized controlled trial was to assess computer-based online AD information and email prompting for facilitating completion of ADs by Australian Baby Boomers (b.1946-1965) as well as factors which may impede or assist completion of these documents by this generation when using the online environment. METHODS: Two hundred eighty-two men and women aged 49-68 years at the time of the trial were randomly assigned to one of 3 intervention groups: education module only; email prompt only; email prompt and education module; and a control group with no education module and no email prompt. The randomized controlled trial was undertaken in participants' location of choice. Randomization and allocation to trial group were carried out by a central computer system. The primary analysis was based on a final total of 189 participants who completed the trial (n = 52 education module only; n = 44 email prompt only; n = 46 email prompt and education module; and n = 47 control). The primary outcome was the number of individuals in any group completing any of the 4 legal ADs in South Australia within 12 months or less from entry into the trial. Frequency analysis was conducted on secondary outcomes such as reasons for non-completion. RESULTS: Mean follow-up post-intervention at 12 months showed that 7% of overall participants completed one or more of the 4 legal ADs but without significant difference between groups (delta = 1%, p = .48 Prompt/Non-Prompt groups, delta = 5%, p = .44 education/non-education groups). Reasons offered for non-completion were too busy (26%) and/or it wasn't the right time (21%). CONCLUSION: Our results suggest that neither email prompting nor provision of additional educational material online were sufficient to significantly impact AD completion rates for this generational cohort. Research with this cohort over longer periods of time exploring online preferences for engagement with ADs as they age may provide better insight into using this environment for ADs with this group. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616000425493 .

Diretivas Antecipadas/tendências , Educação a Distância/normas , Correio Eletrônico/normas , Interface Usuário-Computador , Idoso , Austrália , Estudos de Coortes , Educação a Distância/métodos , Educação a Distância/tendências , Correio Eletrônico/tendências , Feminino , Humanos , Internet/tendências , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
Holist Nurs Pract ; 31(4): 234-242, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28609408


A newly developed Korean-Advance Directive (K-AD) consists of a value statement, treatment directives, and proxy appointment. It remains undetermined whether K-AD is applicable to community-dwelling persons (≥ aged 60 years). Using a descriptive study design, 275 elderly persons completed the K-AD (mean age = 77.28 ± 8.24 years). The most frequent value at the end of life was comfort dying, followed by no burden to family (23.6%). Among 4 K-AD treatment options, more than half had a preference for hospice care and had reluctance with aggressive treatment choices of cardiopulmonary resuscitation (76.4%), artificial ventilation (75.6%), and tube feeding (76.4%), with one-fifth having a desire for such options. All persons provided proxies, who were predominantly descendants (77.1%), followed by spouses (17.5%). For treatment preferences, men and those with no religion were more likely to receive life-sustaining treatments. These data support the K-AD as being applicable and acceptable among community-dwelling elderly persons; awareness of the K-AD in the community setting may facilitate future application when the need occurs.

Diretivas Antecipadas/legislação & jurisprudência , Diretivas Antecipadas/tendências , Vida Independente/tendências , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Política de Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , República da Coreia
Inf. psiquiátr ; (228): 33-39, abr.-jun. 2017.
Artigo em Espanhol | IBECS | ID: ibc-164419


En las últimas décadas, los profundos y transformadores cambios acaecidos en las sociedades occidentales también han afectado la práctica de la medicina. La tradicional estructura piramidal en la relación médico-paciente considerada benefactora durante el siglo pasado, ha dado un giro espectacular centrándose actualmente en la autonomía del paciente, nuevo y necesario concepto para entender la relación clínica establecida hoy en día. El principio de autonomía en el ámbito sanitario se apoyó en el desarrollo del consentimiento informado, que nació como defensa ante los abusos de poder de algunos médicos que llevaban el paternalismo y el principio de beneficencia hasta extremos inaceptables. Hoy es un derecho reconocido por las legislaciones de todos los países desarrollados. El consentimiento informado y la autonomía del paciente se han ido afianzando ante la progresiva e intensa tecnificación de la medicina. Su aplicación cobra una importancia clave en el final de la vida, donde el entorno es especialmente sensible debido la presencia de un mayor sufrimiento y vulnerabilidad. Las voluntades anticipadas (VA) emergen así de la autonomía y de la información, buscan planificar la asistencia que se quiere recibir ante una situación avanzada o terminal, cuando el enfermo no puede expresarla por él mismo. Puesto que la muerte en nuestra sociedad se produce la mayoría de las veces en un entorno hospitalario, las VA deberían ayudar a los profesionales de estos centros en la toma de decisiones en esos momentos. De la medicina se espera que ‘haga lo que debe hacer’ y que no haga ‘todo lo que puede hacer’, adecuando la intensidad diagnóstica y terapéutica a la fragilidad que aparece cuando se acerca el fallecimiento. Las VA surgieron como freno y como guía de actuación establecida por uno mismo frente a la intervención médica1 . Las VA o mejor aún, una planificación anticipada de la asistencia con actualizaciones periódicas, deberían dominar la relación asistencial en el futuro

In the last decades, the profound and transformer changes occurred in the western societies have also affected the medical practice. The traditional pyramidal structure of the medical-patient relation considered benefactress during the last century, has turned in a spectacular way into patient autonomy, new and necessary concept to understand the clinical relationships nowadays. The principle of autonomy in the sanitary scene was sustain by the development of informed consent, that was born as a defense against the abuse of power of some professionals that carried the paternalism and the principle of benefit to unacceptable extremes. Today is well recognized right by the legislations of all developed countries. The informed consent and the autonomy of the patient have become entrenched in the progressive and intense technification of medicine. The application of these concepts turns vital in the end of life, where the environment is especially sensitive because of the presence of a bigger suffering and vulnerability. The advanced directives (AD) come from the autonomy and the information to find a planned assistance at the end of life or in advanced situations, when the patient cannot express their own wills by their own. As death, in our society, takes place in a hospital environment, the AD should help hospital professionals in the decision process at that moment. Medicine ‘has to do what it has to do’ not ‘do anything that can be done’, fitting diagnose and therapeutic intensity to frailty that shows up as the end of life approaches. The AD were born as a break and as a self-established guide of practice for medical intervention1 . The DA or even better, an anticipated planning of medical assistance with periodical updates, should dominate the medical practice in the future

Humanos , Diretivas Antecipadas/tendências , Tomada de Decisões , Cuidados Paliativos na Terminalidade da Vida/tendências , Autonomia Pessoal , Consentimento Livre e Esclarecido , Relações Médico-Paciente , Planejamento de Assistência ao Paciente/tendências
Inf. psiquiátr ; (228): 41-53, abr.-jun. 2017. tab
Artigo em Espanhol | IBECS | ID: ibc-164420


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

Humanos , Adesão a Diretivas Antecipadas/organização & administração , Planejamento de Assistência ao Paciente/organização & administração , Demência/epidemiologia , Técnicas de Apoio para a Decisão , Modelos Organizacionais , Relações Hospital-Paciente , Cuidados Paliativos na Terminalidade da Vida/organização & administração , Diretivas Antecipadas/tendências
Intern Med J ; 47(7): 798-806, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28401688


BACKGROUND: Advance cardiopulmonary resuscitation (CPR) discussions and decision-making are not routine clinical practice in the hospital setting. Frail older patients may be at risk of non-beneficial CPR. AIM: To assess the utility and safety of two interventions to increase CPR decision-making, documentation and communication for hospitalised older patients. METHODS: A pre-post study tested two interventions: (i) standard ward-based education forums with CPR content; and (ii) a combined, two-pronged strategy with 'Goals of Patient Care' (GoPC) system change and a structured video-based workshop; against usual practice (i.e. no formal training). Participants were a random sample of patients in a hospital rehabilitation unit. The outcomes were the proportion of patients documented as: (i) not for resuscitation (NFR); and (ii) eligible for rapid response team (RRT) calls, and rates of documented discussions with the patient, family and carer. RESULTS: When compared with usual practice, patients were more likely to be documented as NFR following the two-pronged intervention (adjusted odds ratio (aOR): 6.4, 95% confidence interval (CI): 3.0; 13.6). Documentation of discussions with patients was also more likely (aOR: 3.3, 95% CI:1.8; 6.2). Characteristics of patients documented NFR were similar between the phases, but were more likely for RRT calls following Phase 3 (P 0.03). CONCLUSION: An increase in advance CPR decisions occurred following GoPC system change with education. This appears safe as NFR patients had the same level of frailty between phases but were more likely to be eligible for RRT review. Increased documentation of discussions suggests routine use of the GoPC form may improve communication with patients about their care.

Reanimação Cardiopulmonar/tendências , Tomada de Decisão Clínica , Hospitalização/tendências , Planejamento de Assistência ao Paciente/tendências , Educação de Pacientes como Assunto/tendências , Gravação em Vídeo/tendências , Diretivas Antecipadas/tendências , Idoso , Idoso de 80 Anos ou mais , Reanimação Cardiopulmonar/métodos , Tomada de Decisão Clínica/métodos , Feminino , Humanos , Masculino , Assistência ao Paciente/métodos , Assistência ao Paciente/tendências , Educação de Pacientes como Assunto/métodos , Distribuição Aleatória , Reabilitação/métodos , Reabilitação/tendências , Gravação em Vídeo/métodos
Support Care Cancer ; 25(2): 523-531, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27718068


PURPOSE: The purposes of the study were to assess awareness and prevalence of advance directives (ADs) among patients with advanced cancer undergoing active outpatient care and to determine factors associated with AD completion before and after the diagnosis of cancer. METHODS: Patients with advanced solid tumor malignancy receiving treatment at the Chemotherapy Day Unit were approached for recruitment. They completed an onsite questionnaire about completion and timing of ADs, demographic information, and perceived health; a review of their medical records was conducted to document their cancer care and co-morbidities. Multinomial logistic regression analysis identified factors associated with the timing of AD completion (pre-cancer, post-cancer, or not at all). RESULTS: Two hundred patients were enrolled, with 193 surveys available for analysis. ADs were completed in 55 % (106/193) of patients, including a living will in 33 % (63/193), a power of attorney in 49 % (95/193), and a do-not-resuscitate (DNR) designation in 18 % (35/193). Most patients (53 %) had completed an AD before being diagnosed with cancer. Higher income (p = 0.02) and age (p = 0.004) were associated with AD completion pre-cancer diagnosis; discussion of end-of-life care (p = 0.02) and palliative care referral (p < 0.0001) were associated with AD completion post-cancer diagnosis. CONCLUSIONS: This study demonstrates that different factors may influence the completion of ADs before and after a diagnosis of cancer and highlights the potential for early palliative care to impact the completion of ADs in patients with advanced cancer who are undergoing active cancer treatment.

Diretivas Antecipadas/tendências , Conhecimentos, Atitudes e Prática em Saúde , Neoplasias/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Inquéritos e Questionários , Assistência Terminal
SEMERGEN, Soc. Esp. Med. Rural Gen. (Ed. Impr.) ; 42(8): 566-574, nov.-dic. 2016.
Artigo em Espanhol | IBECS | ID: ibc-157889


El tratamiento al final de la vida y la atención a las necesidades de sus familiares no son adecuados por diversos motivos: la sociedad niega u oculta la muerte, es muy difícil predecirla con exactitud, con frecuencia el tratamiento está fragmentado entre diferentes especialistas y hay una insuficiente formación en medicina paliativa, incluyendo habilidades de comunicación. Se producen frecuentes conflictos relacionados con las decisiones que se toman al final de su vida, especialmente en la adecuación del esfuerzo terapéutico. La actitud de los profesionales sobre la adecuación del esfuerzo terapéutico no es homogénea y cambia según la especialidad, la experiencia y las propias creencias. La atención primaria constituye una situación privilegiada para acercarse a la vida y a los valores de nuestros pacientes y sus familiares, y no solo a la enfermedad, lo que hace que sea el lugar adecuado para orientar y asesorar al paciente sobre la preparación y registro del documento de últimas voluntades (AU)

End-of-life treatment and attention to the needs of relatives are not adequate for several reasons: Society denies or hides the death; it is very difficult to predict it accurately; treatment is frequently fragmented between different specialists, and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts with decisions made at the end of life, particularly the suitability of therapeutic effort. The attitude of professionals on the adequacy of therapeutic effort is not homogenous, and varies depending on the specialty, experience, and beliefs. Many doctors are still afraid of inconveniencing patients. Primary care is in a privileged position to approach the life and values of our patients and their families, and not just the disease, which makes it the right place to guide and advise the patient on the preparation and registration of living wills (AU)

Humanos , Masculino , Feminino , Cuidados Paliativos na Terminalidade da Vida/métodos , Medicina de Família e Comunidade/métodos , Medicina de Família e Comunidade/tendências , Assistência Terminal/métodos , Assistência Terminal/organização & administração , Assistência Terminal , Atenção Primária à Saúde/métodos , Estratégia Saúde da Família , Diretivas Antecipadas/tendências , Bioética/tendências , Planejamento Antecipado de Cuidados/tendências , Volição/fisiologia , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/estatística & dados numéricos , Atenção Primária à Saúde/normas , Atenção Primária à Saúde/tendências , Atenção Primária à Saúde