Surrogate consent for dementia research: a national survey of older Americans

BACKGROUND

Research in novel therapies for Alzheimer disease (AD) relies on persons with AD as research subjects. Because AD impairs decisional capacity, informed consent often must come from surrogates, usually close family members. But policies for surrogate consent for research remain unsettled after decades of debate.

METHODS

We designed a survey module for a random subsample (n = 1,515) of the 2006 wave of the Health and Retirement Study, a biennial survey of a nationally representative sample of Americans aged 51 and older. The participants answered questions regarding one of four randomly assigned surrogate-based research (SBR) scenarios: lumbar puncture study, drug randomized control study, vaccine study, and gene transfer study. Each participant answered three questions: whether our society should allow family surrogate consent, whether one would want to participate in the research, and whether one would allow one's surrogate some or complete leeway to override stated personal preferences.

RESULTS

Most respondents stated that our society should allow family surrogate consent for SBR (67.5% to 82.5%, depending on the scenario) and would themselves want to participate in SBR (57.4% to 79.7%). Most would also grant some or complete leeway to their surrogates (54.8% to 66.8%), but this was true mainly of those willing to participate. There was a trend toward lower willingness to participate in SBR among those from ethnic or racial minority groups.

CONCLUSIONS

Family surrogate consent-based dementia research is broadly supported by older Americans. Willingness to allow leeway to future surrogates needs to be studied further for its ethical significance for surrogate-based research policy.

Partnership in health care: views of family caregivers on sharing care responsibility with government, clients and health insurers

In this study, we asked family caregivers about their opinion on division of care responsibility between the government, family caregivers, clients, and health insurers. We investigated whether different clusters of respondents could be distinguished, using Latent Cluster Analysis, and what is the relation is with perceived stress and joy and with several background characteristics. Three clusters of respondents could be distinguished: a 'caring together', a 'caring individually', and a 'government-responsible caring' cluster. Family caregivers in cluster 1 attach great importance to both governmental responsibility and individual responsibility. Family caregivers who belong to cluster 2 want themselves to take full responsibility for caregiving, and caregivers in cluster 3 want the government to take most of the responsibility for caregiving. Unemployed caregivers and caregivers with lower educational attainment have a higher chance to belong to the 'caring individually' cluster and this group has relatively more self-reported stress. Policymakers and professionals should bear these three clusters in mind when developing care policy and care guiding practice.

The use of legal guardians and financial powers of attorney among home-dwellers with Alzheimer's disease living with their spousal caregivers

We conducted a cross-sectional survey of a random sample of 1943 spouses of home-dwellers with Alzheimer's disease (AD) to examine the prevalence of court-appointed guardians or financial powers of attorney for persons with AD, related factors and the need for information about these issues among caregiving families. The questionnaire consisted questions on variables of demographic characteristics, disability, symptoms and care needs of the person with dementia, the strain of caregiving, the use of court-appointed legal guardians or powers of attorney, as well as discussions about these issues -- and the need for them -- with a doctor. The response rate was 77% and the mean ages of those with AD and caregivers were 80.2 and 78.2 years, respectively. The use of legal guardians was rare (4.3%), while the use of financial powers of attorney was more common (37.8%). Only 9.9% of the couples had discussed these issues with their doctor, whereas 47.9% expressed a need for it. The factors associated with the use of these legal arrangements were related to the severity of dementia, including experiencing dementia symptoms for more than 3 years, poor functioning, incontinence and behavioural symptoms. There is a clear need for information on medico-legal issues related to dementia among caregivers of AD patients. If held soon after the diagnosis, such discussions could support the autonomy of these persons in spite of AD and enable them to plan for the future as they wish.

Taking the hit: focusing on caregiver "error" masks organizational-level risk factors for nursing aide assault

Beliefs about the causes of events have implications for emotional reactions, distress, expectations for the future, and behavioral responses. In this article we report on two issues: the organizational context that contributes to nursing aide (NA) assault and reporting, and serendipitous findings that arose from investigating unexpected response rates to a survey. Data were collected in 11 rural nursing homes using a structured prospective event-reporting diary to collect detailed information about incidents of physical aggression, followed by focus groups to further explore NAs' perceptions of these events. Here we report on analysis of 19 focus groups conducted with 138 NAs. Participants described organizational-level factors that constrained their practice, affected their interactions with residents, and created a context that put them at risk for physical assault. These factors also affected their willingness to provide written documentation about aggressive incidents. The key issues were frustration at being blamed for causing aggression, lack of action to address the problem, and a desire for respect and involvement in decision making. Organizational changes are needed to modify the contextual factors contributing to assault risk. Researchers must be willing to modify study designs to more fully understand the nature of the problem studied.

When the private sphere goes public: exploring the issues facing family caregiver organizations in the development of long-term care policies

Though family caregiving forms the backbone of the long-term care system in the United States, long-term care policies have traditionally focused on paid services that frail older people and people with disabilities utilize for their day-to-day functioning. Part of the exclusion of family caregiving from the long-term care discourse stems from the traditional separation of the private sphere, where family caregiving occurs, from the public sphere of policy making. However, the passage of the Family and Medical Leave Act (FMLA), the National Family Caregiver Support Program (NFCSP) and Medicaid waiver legislation may reflect recent changes in the government's position on their role in addressing issues related to the "private spheres." In this article, we explore the nature of family caregiving in the United States, the divide between the public and private spheres and provide an overview of family caregiving-related policies and programs in the U.S. In our review, we examine the provisions in the FMLA, NFCSP, and Medicaid waiver legislation that support family caregiving efforts. We also examine the roles of family caregiver organizations in making family caregiving an important element of long-term care policy and influencing policy-making.

Child care providers who commit sexual offences: a description of offender, offence, and victim characteristics

The aim of this investigation was to undertake an exploratory analysis of child care providers who sexually offend against children and adolescents and the circumstances related to these offences. Archival Violent Crime Linkage Analysis System (ViCLAS) reports were obtained from the Royal Canadian Mounted Police (RCMP), and demographic and criminal characteristics for the offender, as well as information about the victim and offence, were selected for analyses. A descriptive approach was used to analyze the qualitative reports for a group of 305 Canadian sexual offenders between 1995 and 2002. Adult male (N = 163) and female ( N = 14), along with juvenile male (N = 100) and female (N = 28) child care providers who were involved in a sexual offence against a child or adolescent are described. This article provides unique information about the crimes committed by child care providers in that it is focused on crime characteristics, rather than on personality or treatment variables. Furthermore, it represents a comprehensive examination of this type of offender by including understudied groups, namely juvenile and female offenders.

What criteria do child protective services investigators use to substantiate exposure to domestic violence?

The primary purpose of this study is to determine whether child protective services investigators apply a recognizable set of criteria to substantiate batterers and victims of battering for exposing their children to domestic violence. Although domestic violence occurred in 35% of the 1,248 substantiated incidents of child maltreatment, only 31 (7.1%) couples were investigated for exposing a child to domestic violence or failing to protect a child from domestic violence. All of the batterers investigated and in the caregiver role when their children were exposed to domestic violence were substantiated. The unsubstantiated victims of battering tended to use more protective behaviors (M=3.82) than the substantiated victims (M=2.00); yet, at the case level, using more than one protective behavior did not seem to be a criterion used to substantiate the victims. Instead, it appears that investigators were discriminating between those protective behaviors by the victims that ended contact between the batterers and the children--for a substantial amount of time--and those that did not in both the substantiation and removal decision. Key issues related to applying criteria in incidents involving domestic violence are discussed along with recommendations to further refine and document them.

Barring 'inappropriate people'? The operation of a barring list of social care workers: an analysis of the first referrals to the Protection of Vulnerable Adults list

Since July 2004, employers of social care staff working with vulnerable adults in England and Wales have been required to refer workers dismissed for misconduct that harmed vulnerable adults or placed them at risk of harm, to the Protection of Vulnerable Adults (POVA) list. Employers are also required to check the list before employing people to work with vulnerable adults. The Department of Health commissioned the authors to analyse the first 100 referrals to the POVA list. Key findings include the over-representation of males and care home staff in the sample of referrals, compared with national figures on care figures and the tendency for male staff to be involved in more physical types of misconduct. These findings are discussed in the light of the literature on workforce regulation and suggestions are made for the implementation of the Bichard Inquiry recommendations. While it is argued that the list is a positive development, it is also stressed that more general measures to improve the quality of services may be at least as important a means of protecting vulnerable adults. Furthermore, the article argues for public debate on the proper balance between the rights of staff and the protection of vulnerable people.

Valuing the invaluable: a new look at the economic value of family caregiving

The contributions of America's family caregivers, along with many friends and neighbors, often go unrecognized in public policy discussions about the financing and costs of health care and long-term services and supports (LTSS). Yet these unpaid caregivers provide by far the majority of long-term services and supports received by persons with disabilities of all ages. Many of these "informal" caregivers also provide health-related services. In fact, their contributions to loved ones and friends are not only the foundation of the nation's long-term care system but an important component of the U.S. economy, with an estimated economic value of about $350 billion in 2006. This issue brief discusses the financial impact of caregiving on the caregivers themselves as well as the economic value of their contributions to society. It compares the economic value of informal caregiving to other benchmarks in order to underscore the magnitude of these unpaid contributions, presents estimates of productivity losses to U.S. businesses from caregiving, and highlights the critical role that family caregivers play in the nation's long-term care system. Finally, it recommends ways to support informal caregivers through public policies and in the private sector.

Families, work, and an aging population: developing a formula that works for the workers

This article examines the intersection of family caregiving, work, and long-term care. Supporting families who provide care in order to minimize negative work effects while enhancing the acceptability of care options is of common concern to employers, state and federal policymakers, and the homecare professionals in the community-based care system. The contribution of families to the long-term care system, how employer policies have developed, how the public policy agenda has addressed family caregiving, and the importance of a more effective partnership on the state level are discussed.

Safeguarding adults at end of life: audit and case analysis in a palliative care setting

This paper reports an audit of safeguarding adults' cases arising over two years from the introduction of an adult protection policy in a UK palliative care service serving a diverse area with 48 beds, over 600 home care and 100 day care patients. Twenty cases were identified, involving institutional, physical, verbal, and financial abuse and neglect. Most patients wanted protective work, but some did not want to disturb personal care and relationships in spite of abuse. Protection from abuse increased support for patients and carers. An analysis of cases where neglect was associated with physical abuse identified a large proportion of cases where difficulties in existing family relationships, sometimes associated with alcohol and drug misuse and histories of mental illness, exacerbated the stresses of caring at end of life, leading to abuse allegations or concerns. Assessment of family relationships and interventions to clarify and organize family caring responsibilities, and deliver services that can support carers and monitor potential abuse are useful social work contributions.

Commentary: what role for the family and Medical Leave Act in long-term care policy?

The Family and Medical Leave Act provides unpaid leave but a key component is its intergenerational structure, permitting employees to take time off from work to care for an infant as well as an ill elderly parent. However, in an effort to provide paid leave, 23 of 28 states dropped the elder care provision in new initiatives introduced between 2000 and 2003. This article argues that in reforming leave policy in the future, the leave should be paid, remain intergenerational, cover more workers, and be adaptable to changing family patterns in an aging society. Also discussed is California's paid leave law, which meets these criteria.

HIPAA and talking with family caregivers: what does the law really say?

The Health Insurance Portability and Accountability Act of 1996 (PL 104-191), known as HIPAA, has confused and unnecessarily alarmed many conscientious health care providers. Nurses in particular are likely to be on the front line of family caregivers' inquiries, because physicians are often difficult to reach and because family caregivers look to nurses as sources of reliable information. A major retraining of health care providers at all levels is needed to dampen the "HIPAA scare" and clarify what HIPAA does and does not say about communication with family caregivers.

The impact of state TANF policy decisions on kinship care providers

Based on a survey of public assistance and child welfare agency staff, this article examines how state Temporary Assistance for Needy Families (TANF) policy decisions have affected kinship care providers. Findings indicate that most states have continued using TANF to provide income support to kinship caregivers, and some have used TANF to find related support services. These payments, however, are much lower than rates for licensed providers, and many kinship caregivers are subject to work, training requirements, and time limits.

The caregiver balancing act: giving too much or not enough

Although there are many reasons why an individual becomes a caregiver, there are even more ways for a caregiver to suffer "burnout," which can endanger his or her well-being and limit the ability to provide adequate care to another. This article provides a summary of the manner in which an individual may approach caregiving, the reasons for becoming a caregiver, the causes of caregiver fatigue and burnout, and the liability that a caregiver may face if he or she does not provide adequate care. Additionally, this article will discuss federal and state programs to assist caregivers, as well as recommendations for public policies and programs to help caregivers and protect the individuals in need of care.