Forgoing artificial nutrition or hydration in patients nearing death in six European countries

Use of artificial hydration in patients diagnosed with senility as the cause of death by home care physicians: A cross₋sectional study

Background

The aim of this study was to investigate the frequency, effectiveness, and reasons for the use of artificial hydration (AH) in senile patients in the last week, and patient-related factors associated with its usage.

Methods

Between April and May 2023, I conducted a cross₋sectional study among medical institutions affiliated with the Japan Network of Home Care Supporting Clinics. Eligible cases included those in which senility was listed as the cause of death on the death certificate from January 1, 2022, to December 31, 2022. The questions asked use of AH, reasons for AH, and symptoms that improved or worsened with AH. Patient characteristics, including age, gender, place of death, length of treatment, and complication of dementia, were also asked. Descriptive statistics were performed. Univariate and multivariate analyses were conducted to examine the association between patient characteristics and the use of AH.

Results

Eighty-three medical institutions (12.5%) provided responses, contributing a total of 714 cases. AH was administered in 236 cases (33.1%). The most common reason was "due to family preference" in 110 cases (46.6%). One hundred thirty-five cases (57.2%) reported "no improved symptoms," while symptom worsening was reported as "no worsened symptoms" in 176 cases (74.6%). Multivariate analysis on 699 cases using complete-case analysis identified age (risk ratio [RR]:0.98, 95% confidence interval [CI]: 0.96-0.99) and female (RR:0.73, 95% CI:0.58-0.92) as factors associated with the use of AH.

Conclusion

This study revealed that AH was commonly used based on family preferences and to alleviate psychological burdens on the family.

Interventions that may increase control at the end of life in persons with dementia: the cross-cultural CONT-END acceptability study protocol and pilot-testing

BACKGROUND

Interventions such as advance care planning (ACP), technology, or access to euthanasia may increase the sense of control over the end of life. In people with advanced dementia, the loss of cognitive and physical function limits the ability to control care. To date, little is known about the acceptability of these interventions from the perspective of persons with dementia and others involved. This study will examine the cross-cultural acceptability, and factors associated with acceptability, of four end-of-life interventions in dementia which contain an element of striving for control. Also, we report on the development and pilot testing of animation video vignettes that explain the interventions in a standardized manner.

METHODS

Cross-sectional mixed-methods vignette study. We assess acceptability of two ACP approaches, technology use at the end of life and euthanasia in persons with dementia, their family caregivers and physicians in six countries (Netherlands, Japan, Israel, USA, Germany, Switzerland). We aim to include 80 participants per country, 50 physicians, 15 persons with dementia, and 15 family caregivers. After viewing each animation video, participants are interviewed about acceptability of the intervention. We will examine differences in acceptability between group and country and explore other potentially associated factors including variables indicating life view, personality, view on dementia and demographics. In the pilot study, participants commented on the understandability and clarity of the vignettes and instruments. Based on their feedback, the scripts of the animation videos were clarified, simplified and adapted to being less slanted in a specific direction.

DISCUSSION

In the pilot study, the persons with dementia, their family caregivers and other older adults found the adapted animation videos and instruments understandable, acceptable, feasible, and not burdensome. The CONT-END acceptability study will provide insight into cross-cultural acceptability of interventions in dementia care from the perspective of important stakeholders. This can help to better align interventions with preferences. The study will also result in a more fundamental understanding as to how and when having control at the end of life in dementia is perceived as beneficial or perhaps harmful.

TRIAL REGISTRATION

The CONT-END acceptability study was originally registered at the Netherlands Trial Register (NL7985) at 31 August, 2019, and can be found on the International Clinical Trials Registry Platform.

Older adults' medical preferences for the end of life: a cross-sectional population-based survey in Switzerland

OBJECTIVES

Medical decision-making at the end of life is common and should be as patient-centred as possible. Our study investigates older adults' preferences towards three medical treatments that are frequently included in advance directive forms and their association with social, regional and health characteristics.

SETTING

A cross-sectional study using population-based data of wave 8 (2019/2020) of the Swiss component of the Survey of Health, Ageing and Retirement in Europe.

PARTICIPANTS

1430 adults aged 58 years and older living in Switzerland.

PRIMARY AND SECONDARY OUTCOME MEASURES

Three questions on the preferences regarding cardiopulmonary resuscitation (CPR); life-prolonging treatment in case of high risk of permanent mental incapacity; reduced awareness (sedation) to relieve unbearable pain and symptoms. Their associations with individuals' social, regional and health characteristics.

RESULTS

Most older adults expressed a wish to receive CPR (58.6%) and to forgo life-prolonging treatment in case of permanent mental incapacity (92.2%). Most older adults also indicated that they would accept reduced awareness if necessary to receive effective treatment for pain and distressing symptoms (59.2%). Older adults' treatment preferences for CPR and life-prolonging treatment differed according to sex, age, partnership status, linguistic region and health status, while willingness to accept reduced awareness for effective symptom treatment was more similarly distributed across population groups.

CONCLUSIONS

Simultaneous preferences for CPR and refusal of life-prolonging treatment might appear to be conflicting treatment goals. Considering individuals' values and motivations can help clarify ambivalent treatment decisions. Structured advance care planning processes with trained professionals allows for exploring individuals' motivations and values and helps to identify congruent care and treatment goals.

Perceptions and Knowledge Regarding Medical Situations at the End of Life among Older Adults in Switzerland

Background: Perceptions and knowledge regarding end-of-life health and health care can influence individuals' advance care planning, such as the completion and content of advance directives. Objectives: To assess older adults' perceptions of medical end-of-life situations in Switzerland along with their accuracy and corresponding associations with sociodemographic characteristics. Design: This is an observational study. Setting/study subjects: A nationally representative sample of adults aged 58 years and older who participated in wave 8 (2019/2020) of the Swiss part of the Survey of Health, Ageing, and Retirement in Europe (cooperation rate: 94.3%). Measurements: Subjective likelihood of 11 end-of-life situations on a 4-point scale: very unlikely (0-25%), rather unlikely (26%-50%), rather likely (51%-75%), and very likely (76%-100%). Results: Older adults' perceptions of end-of-life medical situations in Switzerland were rather heterogeneous and often inaccurate. Study subjects overestimated the success of cardiopulmonary resuscitation, the utility of a fourth-line chemotherapy, of hospital admission for pneumonia for patients with advanced dementia, and for artificial nutrition and hydration in the dying phase, while underestimating the effectiveness of pain management in this situation. Less than 28% of older adults correctly assessed the likelihood of dying in a nursing home, hospital, or at home, respectively. Inaccurate views were more frequent in men (p < 0.01) and individuals with financial difficulties (p < 0.05), whereas adults aged 75+ years (p < 0.01) and respondents from the German-speaking part of Switzerland (p < 0.01) had more accurate perceptions. Conclusions: The wide variation and low accuracy of end-of-life perceptions suggest considerable scope for communication interventions about the reality of end-of-life health and health care in Switzerland.

Decision Making of Artificial Nutrition and Hydration for Cancer Patients at Terminal Stage-A Systematic Review of the Views From Patients, Families, and Healthcare Professionals

BACKGROUND

Decision making on nutrition and hydration for cancer patients during terminal stage cause critical impacts toward patient's comfort and living quality. The management of nutrition is the main dilemma that arises in these final situations and has been the subject of intense debate over the last few decades.

AIM

To find the views of patients, families, and healthcare professionals related to how decisions are made when cancer patients are at terminal stage.

DESIGN

This systematic review used PRISMA strategy to search and used Critical Appraisal Skills Programme checklist to evaluate the papers.

DATA SOURCES

All English papers through August 2020 that contained the view of the decision making at artificial nutrition and hydration with cancer patients, families, and healthcare professionals at terminal stage were included. Selected studies were independently reviewed, and data collaboratively synthesized into core themes.

RESULTS

Most of the terminal stage cancer patients and their families initially started the decision-making process when facing the reduction of oral intake. There are two primary considerations of patients and families, one is for prolonging patients life, and the other is to maintain their life quality. The voices of patients were influential, but not determinative; families usually had influence, but seldom make the final recommendation by themselves; healthcare professionals frequently face the dilemma about their decision.

CONCLUSION

The decision of nutritional support was dynamic; the interaction between patients and families frequently be hesitated to protect the rights of life, unnecessarily prolonging lifetime. Therefore, a better understanding of the views on nutritional support and processing the clinical guideline of decision making for healthcare professional is necessary.

How do people living with dementia perceive eating and drinking difficulties? A qualitative study

Background

Eating and drinking problems are common among people living with later-stage dementia, yet few studies have explored their perspectives.

Objective

This study aimed to explore how people living with mild dementia understand possible future eating and drinking problems and their perspectives on assistance.

Design

Qualitative study using semi-structured interviews.

Setting

Community.

Methods

We conducted semi-structured interviews with 19 people living with mild dementia. Interviews were transcribed verbatim and analysed thematically.

Results

Five themes were identified: (i) awareness of eating and drinking problems; (ii) food and drink representing an individual’s identity and agency; (iii) delegating later decisions about eating and drinking to family carers; (iv) acceptability of eating and drinking options; and (v) eating and drinking towards the end of life. For people living with mild dementia, possible later eating and drinking problems could feel irrelevant and action may be postponed until they occur. Fears of being a burden to family and of being treated like a child may explain reluctance to discuss such future problems. People living with mild dementia might wish to preserve their agency and maintain good quality of life, rather than be kept alive at later stages by artificial nutrition and hydration.

Conclusion

For people with mild dementia, eating and drinking problems may seem unrelated to them and so get left undiscussed. Negative connotations regarding eating and drinking problems may hinder the discussion. The optimal time to discuss possible future problems with eating and drinking with people with mild dementia may need an individual approach.

Beliefs and Perceptions About Parenteral Nutrition and Hydration by Family Members of Patients With Advanced Cancer Admitted to Palliative Care Units: A Nationwide Survey of Bereaved Family Members in Japan

CONTEXT

There has been a growing consensus that parenteral nutrition and hydration is to be forgone in terminally ill patients with cancer. However, it remains unclear what the beliefs and perceptions of parenteral nutrition and hydration by the family members are.

OBJECTIVES

To clarify their beliefs and perceptions and examine the relationships between the factors of family members, their beliefs and perceptions, and their overall satisfaction with the care the patient received at the place of death.

METHODS

This study was performed as a part of the cross-sectional anonymous nationwide survey of the bereaved family members of patients with cancer in Japan.

RESULTS

In total, 1001 questionnaires were sent, and 610 questionnaires were returned. Among these, 499 were analyzed. Regarding the prevalence of beliefs and perceptions about parenteral nutrition and hydration, when a patient cannot eat enough, parenteral hydration is needed was the highest (87.7%), followed by the opinions of medical staff are important in the issue of parenteral nutrition and hydration, parenteral hydration serves as a substitute for oral hydration, and if I were a patient and could not eat enough, parenteral hydration would be needed (85.1%, 81.0%, and 80.0%, respectively). We extracted two concepts as follows: belief that parenteral nutrition and hydration are beneficial and perceived need for parenteral nutrition and hydration. They were not identified as independent determinants of overall care satisfaction.

CONCLUSION

This study showed that beliefs and perceptions about parenteral nutrition and hydration were important in the family members in palliative care.

How to manage terminal dehydration

Although dehydration is a serious condition associated with significant morbidity and mortality in palliative care patients, as in any other patient group, treatment remains controversial. A narrative review of the causes of dehydration during end of life was conducted paying special attention to the nature of terminal dehydration. A comprehensive search of the literature was performed to identify relevant articles published in English and German languages between 1960 and 2018. Currently available options for bed-side evaluation and therapeutic approaches were critically appraised and areas of future research are emphasized. The following inferences can be derived: 1) the available evidence does not support a clear decision in favor or against fluid therapy during the dying phase. 2) There is inadequate precision of the term end of life care (ELC) and insufficient differentiation between modes of dehydration of palliative care patients. 3) Evaluation of dehydration based on its clinical appearance is considered the method of choice compared to invasive procedures. 4) Detailed clinical assessment of symptom reversibility in terminal dehydration by an appropriate fluid challenge is mandatory in the decision-making process. 5) If despite adequate rehydration measures, complete reversibility of the clinical picture of dehydration can no longer be achieved since organ systems are gradually deteriorating, the cessation of clinically assisted hydration (CAH) can be considered. 6) If symptoms of dehydration are reversible after fluid challenge and no other patient wishes to the contrary are known, fluid management should be continued in the context of symptom control. 7) Hyperhydration represents a considerable threat during fluid management that needs to be prevented by noninvasive monitoring procedures. In conclusion, if CAH is applied as a part of ELC the hydration status needs to be individually appraised and all therapeutic measures constantly need to be adapted to the findings of diligent monitoring procedures.

Enteral versus oral feeding in advanced dementia

The global population is aging, and with this demographic shift, the incidence and prevalence of dementia are expected to increase. According to the World Health Organization, an estimated 50 million people are living with dementia worldwide, and this number is expected to triple to 150 million by 2050. Dementia initially affects the brain, eventually affecting the entire body culminating in death, commonly from the complications and comorbidities. People with dementia often experience eating difficulties in addition to a severe decline in cognitive, verbal, and functional abilities secondary to gradual neurodegenerative process, leading to weight loss, malnutrition, and dehydration. When eating difficulties and weight loss occur, health care providers and families often feel obligated to decide to either continue the oral feeding or opt for feeding tube placement. Primary care clinicians, both nurse practitioners and physicians, are presented with challenges when facilitating the decision regarding the feeding options in patients with advanced dementia. This narrative review aims at evaluating the impact of enteral nutrition versus oral feeding by comparing the rates of survival and adverse events in older adults with advanced dementia. It also highlights the best approaches to optimizing nutrition for this frail population.

Is parenteral hydration beneficial in terminally ill cancer patients?

INTRODUCTION

It is common for terminally ill patients to have a reduced fluid intake, which often results in a need for more medical support. However, it is not clear if this measure has a real clinical impact.

METHODS

To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data from primary studies and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified four systematic reviews including 51 studies overall, from which three were randomized trials. We concluded the administration of parenteral hydration might make little or no difference in terms of survival and quality of life in terminally ill cancer patients, and that it is not clear whether it has any other benefit because the certainty of the evidence is very low.

Pneumonia in Nursing Home Patients With Advanced Dementia: Decisions, Intravenous Rehydration Therapy, and Discomfort

BACKGROUND

Comfort may be an appropriate goal in advanced dementia. Longitudinal studies on physician decision-making and discomfort assessed by direct observation are rare, and intravenous rehydration therapy is controversial.

METHODS

To assess treatment decisions and discomfort in patients with advanced dementia and pneumonia and to compare by intravenous rehydration therapy, we used data from the observational multicenter Italian End of Life Observatory-Prospective Study On DEmentia patients Care. We analyzed 109 episodes of pneumonia, which involved decisions in 77 nursing home patients with Functional Assessment Staging Tool stage 7. We assessed decisions, decision-making, and treatments every fortnight. Trained observers assessed discomfort with the Discomfort Scale-Dementia Alzheimer Type (DS-DAT).

RESULTS

Most decisions referred to treatment with antibiotics (90%; 98 of 109) and intravenous rehydration therapy (53%; 58 of 109), but hospitalization was rare (1%). Selecting decisions with antibiotics, with rehydration therapy, the prognosis was more frequently <15 days (34% vs 5% without rehydration therapy; P = .001), and a goal to reduce symptoms/suffering was more common (96% vs 74%; P = .005) while there was no difference in striving for life prolongation (a minority). With rehydration therapy, the decision was more often discussed with family rather than communicated only. Mean DS-DAT scores over time proximate to the first decision ranged between 9.2 and 10.5.

CONCLUSIONS

Italian nursing home patients with advanced dementia and pneumonia frequently received invasive rehydration therapy in addition to antibiotics, however, mostly with a palliative intent. Discomfort was high overall and symptom relief may be improved. Relations between invasive rehydration therapy and discomfort need further study.

Interventions and decision-making at the end of life: the effect of establishing the terminal illness situation

Background

Many ‘routine’ interventions performed in hospital rooms have repercussions for the comfort of the patient, and the decision to perform them should depend on whether the patient is identified as in a terminal phase. The aim of this study is to analyse the health interventions performed and decisions made in the last days of life in patients with advanced oncological and non-oncological illness to ascertain whether identifying the patient’s terminal illness situation has any effect on these decisions.

Methods

Retrospective study of the clinical histories of deceased patients in four hospitals in Granada (Spain) in 2010. Clinical histories corresponding to the last three months of the patient’s life were reviewed.

Results

A total of 202 clinical histories were reviewed, 60 % of which were those of non-oncology patients. Opioid prescriptions (58.4 %), palliative sedation (35.1 %) and Do Not Resuscitate (DNR) orders (34.7 %) were the decisions most often reflected in the histories, and differences in these decisions were found between patients registered as terminal and those who were not registered as terminal. The most frequent interventions in the final 14 days and 48 h were parenteral hydration (96–83 %), peripheral venous catheter (90.1–82 %) and oxygen therapy (81.2–70.5 %). There were statistically significant differences between the patients who were registered as terminal and those not registered as terminal in the number of interventions applied in the final 14 days and 48 h (p = 0.01–p = 0.00) and in many of the described treatments.

Conclusion

The recognition of a patient’s terminal status in the clinical history conditions the decisions that are made and is generally associated with a lower number of interventions.

Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study

BACKGROUND

Evidence indicates that hypodermoclysis is as safe and effective as intravenous rehydration in the treatment of the symptomatology produced by mild to moderate dehydration in patients for whom oral route administration is not possible. However, the knowledge about the use of the subcutaneous hydration and its correlates is still limited.

AIM

To explore the perceptions, attitudes and opinions of health professionals in palliative care on the administration of subcutaneous hydration.

DESIGN

This is a qualitative focus group study with health professionals of palliative care. Four focus groups were carried out until data saturation. A qualitative content analysis was performed.

SETTING/PARTICIPANTS

A total of 37 participants, physicians and nurses, were recruited from different services of palliative care in Spain.

RESULTS

In all, 856 meaning units were identified, from which 56 categories were extracted and grouped into 22 sub-themes, which were distributed among four themes: 'factors which influence the hydration decision', 'factors related to the choice of the subcutaneous route for hydration', 'the subcutaneous hydration procedure' and 'performance guidelines and/or protocols'.

CONCLUSIONS

Variables which most often influence the use of subcutaneous route to hydration are those that are linked to the characteristics of the patient, the team and the family, and other like the context and professionals' subjective perceptions about this medical practice.

Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies

AIM

The aim of the present study was to investigate the proportion of physicians and nurses who agree with the administration of antibiotic therapy (AT), artificial hydration (AH), and artificial nutrition (AN) in patients with advanced dementia and different life expectancies. Furthermore, we aimed at analyzing the correlates of the opinion according to which medical treatments should no longer be given to advanced dementia patients once their life expectancy falls.

METHODS

End-of-life decisions and opinions were measured with a questionnaire that was sent to geriatric units, hospices and nursing homes in three different regions of Italy. Multivariate logistic regressions were carried out to ascertain the correlates of the agreement with the administration of AH, AT or AN.

RESULTS

When the patient's life expectancy was 1-6 months, 83% of respondents agreed with AH, 79% with AT and 71% with AN. When the life expectancy was less than 1 month, a large proportion of respondents still agreed with AH and AT (73% and 61%), whereas less than one in two respondents (48%) agreed with AN.

CONCLUSIONS

The findings of the present study showed that AN creates more ethical dilemmas in the clinical management of end of life than other treatments, such as AH or AT. Opinions on whether or not these practices are appropriate at the end of life were related with feelings, thoughts and ethical issues that played a different part for physicians and nurses. Geriatr Gerontol Int 2017; 17: 487-493.

Old age and forgoing treatment: a nationwide mortality follow-back study in the Netherlands

BACKGROUND

The ageing of the population raises the need to study forgoing treatment decisions among older people.

AIM

To describe the incidence and decision-making of forgoing treatment and identify age-related differences.

METHODS

A nationwide study of a stratified sample from the Statistics Netherlands death registry to which all deaths were reported in 2010. All attending physicians of those deaths received a questionnaire about end-of-life decisions. 6600 cases were studied. We examined three age groups: 17-64, 65-79, and 80 and above. Logistic regression analyses were performed to identify age-related differences controlling for other patient characteristics.

RESULTS

Forgoing treatment occurred in 37% of the total population, with a significant increase in the incidence across age. The most common treatments withheld/withdrawn were artificial hydration/nutrition, medication and antibiotics. Age-related differences were found, especially for withholding artificial hydration/nutrition among patients aged 65-79 (OR 2.04), and for withdrawing medication (OR 2.51) and antibiotics (OR 2.10) among the oldest when compared to the youngest patients. The most common reason for making the decision was 'no chance of improvement'. The likelihood of forgoing treatment due to 'loss of dignity' was higher for the oldest (OR 2.32), as well as due to the request/wish of the patient (OR 1.97), when compared to the youngest patients.

CONCLUSIONS

Forgoing treatment occurred in a substantial proportion of older people, and more often than in younger age groups. The avoidance of burdensome treatment solely to prolong life suggests a better acceptance that these patients are nearing death.

Critical decisions for older people with advanced dementia: a prospective study in long-term institutions and district home care

OBJECTIVE

To describe and compare the decisions critical for survival or quality of life [critical decisions (CDs)] made for patients with advanced dementia in nursing homes (NHs) and home care (HC) services.

DESIGN

Prospective cohort study with a follow-up of 6 months.

SETTING

Lombardy Region (NHs) and Reggio-Emilia and Modena Districts (HC), Italy.

PARTICIPANTS

Patients (496 total; 315 in NHs and 181 in HC) with advanced dementia (Functional Assessment Staging Tool score ≥ 7) and expected survival ≥ 2 weeks.

MEASUREMENTS

At baseline, the patients' demographic data, date of admission and of dementia diagnosis, type of dementia, main comorbidities, presence of pressure sores, ongoing treatments, and current prescriptions were abstracted from clinical records. At baseline and every 15 days thereafter, information regarding the patients' general condition and CDs (deemed critical by the doctor or team) was collected by an interview with the doctor. For each CD, the physician reported the problem that led to the decision, that was eventually made, the purpose of the decision, whether the decision had been discussed with and/or communicated to the family, who made the final decision, whether the decision was maintained after 1 week, whether it corresponded to what the doctor would have judged appropriate, and the expected survival of the patient (≤ 15 days).

RESULTS

For 267 of the 496 patients (53.8%; 60.3% in NHs and 42.5% at home), 644 CDs were made; for 95 patients, more than 1 CD was made. The problems that led to a CD were mainly infections (respiratory tract and other infections; 46.6%, 300/644 CDs); nutritional/hydration problems (20.6%; 133 CDs); and the worsening of a pre-existing disease (9.3%; 60 CDs). The most frequent type of decision concerned the prescription of antibiotics (overall 41.1%, 265/644; among NH patients 44.6%, 218/488; among HC patients, 30.2%, 47/156). The decision to hospitalize the patient was more frequently reported for HC than NH patients (25.5% vs 3.1%). The most frequent purposes of the CDs in both settings were reducing symptoms or suffering (more so in NHs; 81.1% vs 57.0% in HC) and prolonging survival (NH 27.5%; HC 23.1%; multiple purposes were possible). For 26 decisions (3.8%), the purpose was to ease death or not to prolong life.

CONCLUSIONS

Decisions critical for the survival or quality of life of patients with advanced dementia were made for approximately one-half of the patients during a 6-month time frame, and such decisions were made more frequently in NHs than in HC. HC patients were more frequently hospitalized, and a sizeable minority of these patients were treated with the goal of prolonging survival. Italian patients with advanced dementia may benefit from the implementation of palliative care principles, and HC patients may benefit from the implementation of measures to avoid hospitalizing patients near the end of life.

Forgoing artificial nutrition or hydration at the end of life: a large cross-sectional survey in Belgium

OBJECTIVES

To examine the frequency and characteristics of decisions to forgo artificial nutrition and/or hydration (ANH) at the end of life.

DESIGN

Postal questionnaire survey regarding end-of-life decisions (including ANH) to physicians certifying a large representative sample (n=6927) of Belgian death certificates in 2007.

SETTING

Flanders, Belgium, 2007.

PARTICIPANTS

Treating physicians of deceased patients.

RESULTS

Response rate was 58.4%. A decision to forgoANH occurred in 6.6% of all deaths (4.2% withheld,3.0% withdrawn). Being female, dying in a care home or hospital and suffering from nervous system diseases(including dementia) or malignancies were the most important patient-related factors positively associated with a decision to forgo ANH. Physicians indicated that the decision to forgo ANH had had some life-shortening effects in 77% of cases. There had been no consultation with the patient in 81%, mostly due to incapacity (coma or dementia). The family, colleague physicians and nurses were involved in decision making in 76%,41% and 62%, respectively.

CONCLUSIONS

A substantial number of deaths are preceded by a decision to forgo ANH in Belgium. These decisions, ethically laden and involving a considerable chance of life shortening, are mostly not preceded by discussion with the patient despite existing patient rights legislation. It is recommended that physicians and patients and their families alike dedicate ample time to the discussion of treatment options and communication about the possibility of forgoing ANH and that this discussion takes place earlier as part of overall end-of life care planning rather than at the very end of life.

Artificial nutrition at the end of life: ethical issues

Artificial nutrition is a medical treatment that first of all needs a sound scientific base before prescribing it. This base is absent for dying patients and patients in the end stage of dementia. Because feeding is a very emotional and symbolical issue, patient and family may request this treatment despite the lack of evidence. These issues should be addressed in good communication with patient and relatives. For comatose patients and patients in a persistent vegetative state artificial nutrition is a necessary support to bridge the time until either recovery is imminent or improbable. At that moment artificial nutrition no longer contributes to the life of the patient and should be ceased. Artificial nutrition has no place in patients that voluntary decide to stop eating and drinking in order to die.

Religion and United States physicians' opinions and self-predicted practices concerning artificial nutrition and hydration

This study surveyed 1,156 practicing US physicians to examine the relationship between physicians' religious characteristics and their approaches to artificial nutrition and hydration (ANH). Forty percent of physicians believed that unless a patient is imminently dying, the patient should always receive nutrition and fluids; 75 % believed that it is ethically permissible for doctors to withdraw ANH. The least religious physicians were less likely to oppose withholding or withdrawing ANH. Compared to non-evangelical Protestant physicians, Jews and Muslims were significantly more likely to oppose withholding ANH, and Muslims were significantly more likely to oppose withdrawing ANH.

Bereaved relatives' perspectives of the patient's oral intake towards the end of life: a qualitative study

BACKGROUND

Patients approaching death often have a decreasing oral intake, which can be distressing for relatives. Little is known about the relatives' experiences with and perceptions of oral intake at the end of life.

AIM

This study aims to contribute to a more thorough understanding of relatives' concerns regarding decreased oral intake of the patient at the end of life.

DESIGN

Qualitative interview study: semi-structured interviews were transcribed verbatim and analysed using qualitative content analysis.

SETTING/PARTICIPANTS

Twenty-three bereaved relatives of patients who had been referred to a New Zealand palliative care service were interviewed.

RESULTS

All relatives experienced significant changes in patients' oral intake at the end of life. Oral intake towards the end of life was considered important and is perceived as meaningful by relatives in different ways, such as nutritional value, enjoyment, social time, daily routine and a way of caring. Relatives responded differently to decreasing oral intake; some accepted it as inherent to the dying process, others continued efforts to support the patient's oral intake. Some relatives perceived decreasing oral intake as the patient's choice, and some viewed maintaining oral intake as part of the battle against the disease. Relatives recalled limited communication with health-care professionals concerning oral intake at the end of life.

CONCLUSIONS

This study revealed the complexity of meaning relatives' experiences with dying patients' decreasing oral intake. Their perceptions and concerns were related to their awareness of the imminent death. These findings can guide staff involved in care delivery to better support relatives.

Ethics, choices, and decisions in acute medicine: a national survey of Norwegian physicians' attitudes

OBJECTIVE

To study the attitudes of Norwegian physicians to resuscitation of hypothetical patients all at risk of neurological sequelae.

DESIGN

Mail-based survey.

SETTING

A cohort of Norwegian physicians who are representative of the national physician corps.

INTERVENTIONS

A total of 1650 Norwegian physicians (7% of practicing physicians in Norway) received a written questionnaire describing six scenarios of patients all in need of emergency life-saving intervention. Respondents were asked whether they would resuscitate; whether such resuscitation was in the patient's best interest; whether a surrogate's refusal of intervention would be accepted; and whether they would have wanted resuscitation if the patient were their own child, their spouse, or themselves. Positive or negative responses on a four-point Likert scale were recorded.

MEASUREMENTS AND MAIN RESULTS

A total of 1,069 respondents (response rate, 65%). Physicians responding to these scenarios were a) more inclined to resuscitate an anonymous patient than if the patient were themselves or their kin; b) willing to resuscitate although they do not consider this intervention to be in the patient's best interest; c) willing to refrain from resuscitation on surrogate request in spite of a reasonably good prognosis; d) willing to accept surrogate's refusal of resuscitation in spite of a stated opinion that such intervention would be in the patient's best interest; and e) less willing to resuscitate newborn infants compared with older children and adults (except the aged) with similar prognoses.

CONCLUSION

There appear to be differences in medical thinking about best interest, surrogate decision making, and the relative value of lives as far as these are applied to acute, life-saving treatment.

Issues and needs in end-of-life decision making: an international modified Delphi study

BACKGROUND

end-of-life decision making is an important aspect of end-of-life care that can have a significant impact on the process of dying and patients' comfort in the last days of life.

AIM

the aim of our study was to identify issues and considerations in end-of-life decision making, and needs for more evidence among palliative care experts, across countries and professions.

PARTICIPANTS

90 palliative care experts from nine countries participated in a modified Delphi study. Participants were asked to identify important issues and considerations in end-of-life decision making and to rate the need for more evidence.

RESULTS

experts mentioned 219 issues in end-of-life decision making related to the medical domain, 122 issues related to the patient wishes and 92 related to relatives' wishes, regardless of profession or country (p > 0.05). In accordance, more than 90% of the experts rated the comfort and wishes of the patient and the potential futility of treatment as important considerations in end-of-life decision making, although some variation was present. When asked about issues that are in need of more evidence, 87% mentioned appropriate indications for using sedatives and effects of artificial hydration at the end of life. A total of 83% mentioned adequate communication approaches.

CONCLUSIONS

palliative care experts from different professions in different countries encounter similar issues in end-of-life decision making. Adequate communication about these issues is universally experienced as a challenge, which might benefit from increased knowledge. This shared experience enables and emphasizes the need for more international research.

Practice patterns and perceptions about parenteral hydration in the last weeks of life: a survey of palliative care physicians in Latin America

CONTEXT

Parenteral hydration at the end of life is controversial and has generated considerable debate for decades.

OBJECTIVES

To identify palliative care physician parenteral hydration prescribing patterns and factors that influence prescribing levels (PLs) for patients during their last weeks of life.

METHODS

A cross-sectional, representative online survey of Latin American palliative care physicians was conducted in 2010. Physicians were asked to report the percentage of their terminally ill patients for whom they prescribed parenteral hydration. Predictors of parenteral hydration PLs were identified using logistic regression analysis.

RESULTS

Two hundred thirty-eight of 320 physicians completed the survey (74% response rate). Sixty percent of physicians reported prescribing parenteral hydration to 40%-100% of their patients during the last weeks of life. Factors influencing moderate/high PLs were the following: agreeing that parenteral hydration is clinically and psychologically efficacious (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.5-8.3), disagreeing that withholding parenteral hydration alleviates symptoms (OR 3.3, 95% CI 1.3-8.1), agreeing that parenteral hydration is essential for meeting the minimum standards of care (OR 3.2, 95% CI 1.4-7.5), preferring the subcutaneous route of parenteral hydration for patient comfort and home use (OR 2.9, 95% CI 1.3-6.5), and being younger than 45 years of age (OR 2.6, 95% CI 1.3-5.2).

CONCLUSION

The strongest determinant of prescribing patterns was agreement with the clinical/psychological efficaciousness of parenteral hydration. Our results reflect parenteral hydration prescribing patterns and perceptions that substantially differ from the conventional/traditional hospice philosophy. These findings suggest that the decision to prescribe or withhold parenteral hydration is largely based on clinical perceptions and that most palliative care physicians from this region of the world individualize treatment decisions.

The ethical and legal aspects of palliative sedation in severely brain-injured patients: a French perspective

To fulfill their crucial duty of relieving suffering in their patients, physicians may have to administer palliative sedation when they implement treatment-limitation decisions such as the withdrawal of life-supporting interventions in patients with poor prognosis chronic severe brain injury. The issue of palliative sedation deserves particular attention in adults with serious brain injuries and in neonates with severe and irreversible brain lesions, who are unable to express pain or to state their wishes. In France, treatment limitation decisions for these patients are left to the physicians. Treatment-limitation decisions are made collegially, based on the presence of irreversible brain lesions responsible for chronic severe disorders of consciousness. Before these decisions are implemented, they are communicated to the relatives. Because the presence and severity of pain cannot be assessed in these patients, palliative analgesia and/or sedation should be administered. However, palliative sedation is a complex strategy that requires safeguards to prevent a drift toward hastening death or performing covert euthanasia. In addition to the law on patients' rights at the end of life passed in France on April 22, 2005, a recent revision of Article 37 of the French code of medical ethics both acknowledges that treatment-limitation decisions and palliative sedation may be required in patients with severe brain injuries and provides legal and ethical safeguards against a shift towards euthanasia. This legislation may hold value as a model for other countries where euthanasia is illegal and for countries such as Belgium and Netherlands where euthanasia is legal but not allowed in patients incapable of asking for euthanasia but in whom a treatment limitation decision has been made.

A national survey of Italian physicians' attitudes towards end-of-life decisions following the death of Eluana Englaro

BACKGROUND

Ethical issues regarding patient care have recently been raised in Italy by the case of Eluana Englaro, a 36-year-old woman who remained in a persistent vegetative state (PVS) for 17 years. There are no specific laws on the books in Italy regarding euthanasia and physician-assisted suicide. In November 2008, a controversial decision by the Italian Supreme Court granted the woman's father his wish to discontinue nutrition and hydration provided to her. Because of this historic decision, the authors carried out a survey of Italian physicians' beliefs regarding end-of-life practices.

METHODS

A questionnaire was e-mailed to 70,000 physicians working for the Italian Public Health System and University Medical Hospitals.

RESULTS

A total of 22,219 doctors responded to the questionnaire (32.3%), of whom 17,252 (77.6%) had some experience in treating PVS patients. Nearly 70% of responding doctors were aware of PVS diagnostic criteria; most of them (61%) considered tube feeding to be a medical therapy, and 66% of respondents believed that withdrawal of assisted nutrition and hydration (ANH) might be appropriate depending on the patient's wishes. Moreover, even though 50% of doctors surveyed were not in favor of euthanasia, a significant percentage (42%) did approve of it, while 8% of this sample was uncertain.

CONCLUSIONS

Italian doctors probably have the least experience in end-of-life decisions in Europe, therefore this national survey is a great chance to understand their authentic opinions regarding such remarkable issues. There is broad consensus that a clear legislative position regarding euthanasia and ANH is needed.

Artificial nutrition and hydration for patients with advanced dementia: perspectives from medical practitioners in the Netherlands and Australia

The appropriate use of artificial nutrition or hydration (ANH) for patients with advanced dementia continues to be a subject of debate. We investigated opinions of Dutch and Australian doctors about the use of ANH in patients with advanced dementia. We interviewed 15 Dutch doctors and 16 Australian doctors who care for patients with advanced dementia. We transcribed and analysed the interviews and held consensus meetings about the interpretation. We found that Dutch and Australian doctors use similar medical considerations when they decide about the use of ANH. In general, they are reluctant to start ANH. Disparities between the Dutch and Australian doctors are related to the process of decision-making: Dutch doctors seem to put more emphasis on a comprehensive assessment of the patient's actual situation, whereas Australian doctors are more inclined to use scientific evidence and advance directives. Furthermore, Dutch doctors take the primary responsibility themselves whereas Australian general practitioners seem to be more inclined to leave the decision to the family. It seems that Dutch and Australian doctors use somewhat different care approaches for patients with advanced dementia. Combining the Dutch comprehensive approach and the Australian analytic approach may serve the interest of patients and their families best.

Ethical decision making with end-of-life care: palliative sedation and withholding or withdrawing life-sustaining treatments

Palliative sedation (PS) is the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. Although uncommon, some patients undergoing aggressive symptom control measures still have severe suffering from underlying disease or therapy-related adverse effects. In these circumstances, use of PS is considered. Although the goal is to provide relief in an ethically acceptable way to the patient, family, and health care team, health care professionals often voice concerns whether such treatment is necessary or whether such treatment equates to physician-assisted suicide or euthanasia. In this review, we frame clinical scenarios in which PS may be considered, summarize the ethical underpinnings of the practice, and further differentiate PS from other forms of end-of-life care, including withholding and/or withdrawing life-sustaining therapy and physician-assisted suicide and euthanasia.

Involvement of hospital nurses in care decisions related to administration of artificial nutrition or hydration (ANH) in patients with dementia: a qualitative study

BACKGROUND

Nurses that care for patients with advanced dementia are increasingly faced with consequences of disease progression, often requiring them to decide whether to artificially feed these patients. Clarifying how nurses can be better supported in complex care processes involving ethically sensitive decision-making requires that their practice be mapped out.

OBJECTIVES

The aims of this study were to explore and describe how nurses are involved in the care that surrounds decisions concerning artificial nutrition or hydration in hospitalized patients with dementia.

DESIGN

We used a qualitative interview design. Data collection and analysis were informed by the grounded theory approach.

SETTING

Nine hospitals geographically spread throughout the five provinces of Flanders, Belgium.

PARTICIPANTS

Twenty-one nurses were purposively selected for interview, with the aim of including nurses that reflected diverse personal characteristics and experiences with the subject matter.

METHODS

Between April 2008 and June 2009, we conducted 21 interviews that were audiotaped and later transcribed. Data processing involved (1) simultaneous and systematic data collection and analysis, (2) constant forwards-backwards wave, (3) continuous dialogue with the data, and (4) interactive team processes.

RESULTS

Nurses' involvement was characterized by a desire to provide 'good care', which was the basis for their motivation and aspiration during the care process. Early in the process, nurses developed a holistic picture of their patients, laying the foundation of their 'good care' view. During the actual decision-making, nurses fulfilled the roles of messengers and guiding communicators, as they attempted to realize their 'good care' view. Nurses judged the physicians' decisions in light of their care view. If a decision matched their view, they supported the decision. If not, they resisted it openly or covertly. Some nurses remained passively in the background, while others took action to override the decision. Nurses' involvement ended with the intensive aftercare of the patients and their family.

CONCLUSIONS

Nurses are closely and continuously involved in the care that surrounds decisions concerning artificial nutrition or hydration in hospitalized patients with advanced dementia. During the care process, nurses play several and specific roles, giving their contribution a unique and variable character.

Dying with advanced dementia in long-term care geriatric institutions: a retrospective study

OBJECTIVE

The aim of this study is to describe the last month of life of severely demented elders in long-term care institutions, and the clinical decisions in the management of their end-of-life events.

DESIGN

Retrospective exploratory study.

SETTING

Seven Italian long-term care institutions with more than 200 beds.

PARTICIPANTS

One hundred forty-one patients with advanced (FAST stage = 7c) dementia (Alzheimer disease, vascular, other kinds of dementia, severe cognitive impairment).

MEASUREMENT

Diagnosis, Mini-Mental State Examination, cause of death. Data were collected from clinical and nursing records referring to the last 30 days of life: symptoms and signs, intensity and incidence, treatments (antibiotics, analgesics, anxiolytics, antidepressants, artificial nutrition/hydration, and use of restraints); the last 48 hours: cardiopulmonary resuscitation attempts and life-sustaining drugs.

RESULTS

Patients were given antibiotics (71.6%), anxiolytics (37.1%), and antidepressants (7.8%). Twenty-nine patients (20.5%) were tube- or percutaneous endoscopic gastrostomy (PEG)-fed. Most patients (66.6%) were also parenterally hydrated (72 intravenously, 15 by hypodermoclysis). Some form of physical restraint was used for 58.2% (bed-rails and other immobilizers). Almost half of the patients had pressure sores. In general, attention to physical suffering was fairly good, but during the last 48 hours a number of interventions could be considered inappropriate for these patients: tube feeding (20.5%), intravenous hydration (66.6%), antibiotics (71.6%), and life-sustaining drugs (34.0%).

CONCLUSIONS

Some indicators imply a less than optimal quality of care (restraints, pressure sores, psychoactive drugs, and the lack of documentation of shared decision-making) and suggest that far advanced demented patients are not fully perceived as "terminal."

Physicians' experiences with end-of-life decision-making: survey in 6 European countries and Australia

BACKGROUND

In this study we investigated (a) to what extent physicians have experience with performing a range of end-of-life decisions (ELDs), (b) if they have no experience with performing an ELD, would they be willing to do so under certain conditions and (c) which background characteristics are associated with having experience with/or being willing to make such ELDs.

METHODS

An anonymous questionnaire was sent to 16,486 physicians from specialities in which death is common: Australia, Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland.

RESULTS

The response rate differed between countries (39-68%). The experience of foregoing life-sustaining treatment ranged between 37% and 86%: intensifying the alleviation of pain or other symptoms while taking into account possible hastening of death between 57% and 95%, and experience with deep sedation until death between 12% and 46%. Receiving a request for hastening death differed between 34% and 71%, and intentionally hastening death on the explicit request of a patient between 1% and 56%.

CONCLUSION

There are differences between countries in experiences with ELDs, in willingness to perform ELDs and in receiving requests for euthanasia or physician-assisted suicide. Foregoing treatment and intensifying alleviation of pain and symptoms are practiced and accepted by most physicians in all countries. Physicians with training in palliative care are more inclined to perform ELDs, as are those who attend to higher numbers of terminal patients. Thus, this seems not to be only a matter of opportunity, but also a matter of attitude.