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Herreros B, Benito M, Gella P, Valenti E, Sánchez B, Velasco T. Why have Advance Directives failed in Spain? BMC Med Ethics 2020; 21:113. [PMID: 33198746 PMCID: PMC7667789 DOI: 10.1186/s12910-020-00557-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/29/2020] [Indexed: 11/25/2022] Open
Abstract
Background In Spain, there has been great effort by lawmakers to put Advance Directives (ADs) into practice since 2002. At the same time, the field of bioethics has been on the rise, a discipline that has spurred debate on the right of patients to exercise their autonomy. Despite all this, the implementation of ADs can be said to have failed in Spain, because its prevalence is very low, there is a great lack of knowledge about them and they have very little impact on clinical decisions. The purpose of this article is to analyze and discuss the main reasons for the failure of ADs in Spain. Main body The main reasons why ADs have no impact on clinical practice in Spain have been fundamentally four: (1) the training of health professionals about the end of life and AD is lacking; (2) there has been no public process to increase awareness about AD, and therefore people (with the exception of specific highly sensitized groups) know little about them; (3) the bureaucratic procedure to document and implement ADs is excessively complex and cumbersome, creating a significant barrier to their application; (4) in Spain, the remnants of a paternalistic medical culture continue to exist, which causes shared decision-making to be difficult. Conclusion Due to the four reasons mentioned above, AD have not been a useful tool to help honor patients’ autonomous decisions about their future care and, therefore, they have not achieved their objective. However, despite the difficulties and problems identified, it has also been observed that health care professionals and the Spanish public have a very positive view of AD. Having identified the problems which have kept AD from being successful, strategies must be developed to help improve their implementation into the future.
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Affiliation(s)
- Benjamín Herreros
- Instituto de Ética Clínica Francisco Vallés, Universidad Europea de Madrid, Madrid, Spain. .,Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain.
| | - María Benito
- Legal Medicine, Psychiatry and Pathology Department, Universidad Complutense , Plaza de Ramón y Cajal, s/n, 28040, Madrid, Spain
| | - Pablo Gella
- Instituto de Ética Clínica Francisco Vallés, Universidad Europea, Plaza de Francisco Morano, s/n, 28005, Madrid, Spain
| | - Emanuele Valenti
- Centre for Ethics in Medicine, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Beatriz Sánchez
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain
| | - Tayra Velasco
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense, Plaza de Ramón y Cajal, s/n, 28040, Madrid, Spain
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Sánchez B, Guijarro C, Velasco M, Vicente MJ, Galán M, Herreros B. Evaluating the efficacy of an Advanced Care Planning Program for Health Decisions in patients with advanced heart failure: protocol for a Randomized Clinical Trial. BMC Cardiovasc Disord 2020; 20:456. [PMID: 33087061 PMCID: PMC7579909 DOI: 10.1186/s12872-020-01738-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/11/2020] [Indexed: 11/13/2022] Open
Abstract
Background An Advanced Care Planning (ACP) program of health decisions is the result of a process of reflection and relationship-building between the patient, their relatives and health professionals. It is based on respect for patients’ autonomy, involving them in making decisions about their disease in a way that is shared between the medical team, the patient and their relatives. Up until now, the efficacy of an ACP has not been measured in the existing literature, and therefore it is unknown if these programs reach their goal. The main objective of our study is to evaluate the efficacy of an ACP program for decision-making in patients with advanced heart failure (HF) in comparison to usual follow up and care. This objective will be evaluated by the Patient Activation Measure test, which measures the participation and self-management of the patient in decision-making. Secondary objectives: to evaluate the effect of the program on quality of life, to know if the patients wishes expressed through the ACP program are fulfilled, to measure the impact of the program on patients’ caregivers, to determine the satisfaction of patients included in the program and to evaluate the effect on quality of death. Methods Randomized multicentre clinical trial at four hospitals in Madrid. Once they are included in the study, patients’ allocation to groups (control vs intervention) will be made by alternative sampling. ACP will be applied to the intervention group, whereas in the Control Group usual follow-up will be carried out in HF units. All patients will fulfil questionnaires and tests related to the objectives of the study again after a 12-month follow-up period in order to gauge the effect of ACP in patients with advanced HF. Discussion The characteristics of patients with advanced HF make them a model for designing ACP programs, given the high prevalence of this disease, the progressive increase in its incidence and it’s clinical characteristics. Until now, the efficacy of this type of program has not been measured, so this Clinical Trial can provide relevant data for future ACP projects. Trial registration ClinicalTrials.gov Identifier: NCT04424680. Registered 9 June 2020. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04424680?term=NCT04424680&draw=2&rank=1.
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Affiliation(s)
- Beatriz Sánchez
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain
| | - Carlos Guijarro
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain
| | - María Velasco
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain
| | - María Jesús Vicente
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain
| | - Miguel Galán
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain
| | - Benjamín Herreros
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain. .,Instituto de Ética Clínica Francisco Vallés, Universidad Europea de Madrid, Madrid, Spain.
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Herreros B, Monforte MJ, Molina J, Velasco M, Olaciregui Dague K, Valenti E. The Use of Advance Directives in Specialized Care Units: A Focus Group Study With Healthcare Professionals in Madrid. JOURNAL OF BIOETHICAL INQUIRY 2020; 17:395-405. [PMID: 32725402 DOI: 10.1007/s11673-020-09991-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 07/10/2020] [Indexed: 06/11/2023]
Abstract
Eight focus groups were conducted in four public hospitals in Madrid to explore healthcare professionals' perceptions of advance directives (ADs) in order to improve the understanding of their lack of success among physicians and patients. A purposive sample of sixty healthcare professionals discussed ADs and reasons for their infrequent use. Three main themes were identified: perceptions about their meaning, appraisals of their use in clinical practice, and decision-making about them. Healthcare professionals perceived a lack of clarity about their definition and implementation. There is insufficient awareness of their efficacy in improving the quality of clinical relationships and decision-making, and they are often perceived only as a bureaucratic procedure. Advance directives are not integrated in the clinical practice of Madrid's healthcare specialist services because their application is exceedingly complex, because of insufficient education about them (for both professionals and citizens), and because of lack of procedural clarity. Consequently, healthcare professionals are not aware of how ADs could improve clinical decision-making, of when and for whom their use is appropriate, and of who has responsibility for providing ADs-related information to patients. These circumstances contribute to patients' lack of interest in completing these documents and to physicians' sceptical views about their usefulness.
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Affiliation(s)
- Benjamín Herreros
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Instituto de Ética Clínica Francisco Vallés, Universidad Europea, Calle Budapest 1, Alcorcón, Madrid, Spain.
| | - María José Monforte
- Servicio de Medicina Interna, Hospital Quirónsalud San José, Calle de Cartagena, 111, 28002, Madrid, Spain
| | - Julia Molina
- Unidad de Investigación, Hospital Universitario Fundación Alcorcón, HUFA, Unidad de Investigación, Calle Budapest 1, Alcorcón, Madrid, Spain
| | - María Velasco
- Unidad de Investigación, Hospital Universitario Fundación Alcorcón, HUFA, Unidad de Investigación, Calle Budapest 1, Alcorcón, Madrid, Spain
| | - Karmele Olaciregui Dague
- Epileptology Department, University Hospital Bonn, Germany, Building 83, Venusberg-Campus 1, 53113, Bonn, Germany
| | - Emanuele Valenti
- Instituto de Ética Clínica Francisco Vallés, Universidad Europea, Centre for Ethics in Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Population Health Sciences, Bristol, BS2 8BH, UK
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What do older patients and their families think about the limitation of therapeutic effort? Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2018.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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¿Qué opinan los pacientes mayores y sus familiares sobre la limitación del esfuerzo terapéutico? Rev Clin Esp 2018; 218:449-451. [DOI: 10.1016/j.rce.2018.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 11/19/2022]
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Ortiz-Gonçalves B, Albarrán Juan E, Labajo González E, Santiago-Sáez A, Perea-Pérez B. Decisiones al final de la vida: resultados del cuestionario validado por expertos. GACETA SANITARIA 2018; 32:333-338. [DOI: 10.1016/j.gaceta.2017.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/12/2017] [Accepted: 09/17/2017] [Indexed: 11/27/2022]
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Toro-Flores R, López-González R, López-Muñoz J. Conocimientos y actitudes de los pacientes críticos y sus familiares respecto a las directivas anticipadas y la toma de decisiones al final de la vida. ENFERMERIA INTENSIVA 2017. [DOI: 10.1016/j.enfi.2016.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Pérez M, Herreros B, Martín MD, Molina J, Kanouzi J, Velasco M. Do Spanish Hospital Professionals Educate Their Patients About Advance Directives? : A Descriptive Study in a University Hospital in Madrid, Spain. JOURNAL OF BIOETHICAL INQUIRY 2016; 13:295-303. [PMID: 26797513 DOI: 10.1007/s11673-016-9703-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/09/2015] [Indexed: 06/05/2023]
Abstract
It is unknown whether hospital-based medical professionals in Spain educate patients about advance directives (ADs). The objective of this research was to determine the frequency of hospital-based physicians' and nurses' engagement in AD discussions in the hospital and which patient populations merit such efforts. A short question-and-answer-based survey of physicians and nurses taking care of inpatients was conducted at a university hospital in Madrid, Spain. In total, 283 surveys were collected from medical professionals, of whom 71 per cent were female, with an average age of thirty-four years. Eighty-four per cent had never educated patients about ADs because of lack of perceived responsibility, time, or general knowledge of ADs. Patient populations that warranted AD discussions included those with terminal illnesses (77 per cent), chronic diseases (61 per cent), and elderly patients (43 per cent). Regarding degree of AD understanding in medical professionals: 57 per cent of medical professionals claimed sufficient general knowledge of ADs, 19 per cent understood particulars regarding AD document creation, and 16 per cent were aware of AD regulatory policies. Engagement in AD discussions was considered important by 83 per cent of medical professionals, with 79 per cent interested in participating in such discussions themselves. The majority of hospital physicians and nurses do not educate their patients about ADs, despite acknowledging their importance. Patient populations of highest priority included those with terminal diseases or chronic illness or who are of advanced age.
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Affiliation(s)
- María Pérez
- Internal Medicine Unit, University Hospital Alcorcon Foundation (UHAF), Madrid, Spain
| | - Benjamín Herreros
- Internal Medicine Unit, University Hospital Alcorcon Foundation, Budapest St, 28.922, Alcorcon, Madrid, Spain.
- Francisco Vallés Clinical Ethics Institute, European University of Madrid, Madrid, Spain.
| | - M Dolores Martín
- Francisco Vallés Clinical Ethics Institute, European University of Madrid, Madrid, Spain
- Preventive Medicine Unit, Rey Juan Carlos Hospital, Madrid, Spain
| | - Julia Molina
- Francisco Vallés Clinical Ethics Institute, European University of Madrid, Madrid, Spain
- Research Unit, UHAF, Madrid, Spain
| | - Jack Kanouzi
- Francisco Vallés Clinical Ethics Institute, European University of Madrid, Madrid, Spain
| | - María Velasco
- Internal Medicine Unit, University Hospital Alcorcon Foundation (UHAF), Madrid, Spain
- Research Unit, UHAF, Madrid, Spain
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Busquets I Font JM, Hernando Robles P, Font I Canals R, Diestre Ortin G, Quintana S. [Advance directives. Representatives' opinions]. ACTA ACUST UNITED AC 2016; 31:373-379. [PMID: 27174650 DOI: 10.1016/j.cali.2016.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/15/2016] [Accepted: 02/16/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The use and usefulness of Advance Directives has led to a lot of controversy about their validity and effectiveness. Those areas are unexplored in our country from the perspective of representatives. OBJECTIVE To determine the opinion of the representatives appointed in a registered Statement of Advance Directives (SAD) on the use of this document. METHODS Telephone survey of representatives of 146 already dead people and who, since February 2012, had registered a SAD document. RESULTS More the two-thirds (98) of respondents recalled that the SAD was consulted, with 86 (58.9%) saying that their opinion as representative was consulted, and 120 (82.1%) believe that the patient's will was respected. Of those interviewed, 102 (69.9%) believe that patients who had previously planned their care using a SAD had a good death, with 33 (22.4%) saying it could have been better, and 10 (6.9%) believe they suffered greatly. CONCLUSION The SAD were mostly respected and consulted, and possibly this is related to the fact that most of the representatives declare that the death of those they represented was perceived as comfortable. It would be desirable to conduct further studies addressed at health personnel in order to know their perceptions regarding the use of Advance Directives in the process of dying.
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Affiliation(s)
- J M Busquets I Font
- Direcció General de Regulació, Planificació i Recursos Sanitaris, Barcelona, España
| | | | - R Font I Canals
- Comitè d'Ètica Assistencial, Hospital Universitari Mútua Terrassa, Terrassa, Barcelona, España
| | - G Diestre Ortin
- Consorci Hospitalari Parc Taulí, Sabadell, Barcelona, España
| | - S Quintana
- Comitè d'Ètica Assistencial, Hospital Universitari Mútua Terrassa, Terrassa, Barcelona, España.
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Leal Hernández M, Rivas Baez J, Martínez Monje F, Lozano Espinosa M. Papel del médico de familia en la cumplimentación y registro del documento de instrucciones previas. Semergen 2015; 41:164-7. [DOI: 10.1016/j.semerg.2014.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/07/2014] [Accepted: 05/09/2014] [Indexed: 10/24/2022]
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