Documento de voluntades anticipadas: opinión de los profesionales sanitarios de Atención Primaria

Análisis del grado de conocimiento e interés de los profesionales sanitarios de nefrología sobre la planificación anticipada de la asistencia sanitaria

a tener que tomar decisiones continuamente. En este proceso los profesionales sanitarios no suelen preguntarles cómo querrían planificar el final de sus días. En una sociedad donde la “no limitación al esfuerzo terapéutico” parece una constante en nuestra práctica, el reflexionar sobre nuestros propios límites podría ayudarnos en la atención a los pacientes.Objetivo: Conocer el grado de conocimiento e interés por la Planificación Anticipada de la Asistencia Sanitaria (PAAS) en profesionales que atienden a pacientes con Enfermedad Renal Crónica.Material y Método: Estudio observacional descriptivo transversal mediante cuestionario autoadministrado a sanitarios participantes voluntarios a nivel nacional. El cuestionario incluía 22 preguntas sobre conocimiento e interés sobre la planificación anticipada de la asistencia sanitaria.Resultados: Respondieron 422 profesionales: 53,3% médicos; 45,0% enfermeras y 1,4% técnicos en cuidados auxiliares de enfermería. El 79,9% no conocen cuantos pacientes tienen registrado el Documento de Voluntades Anticipadas. El 63,5% han oído hablar de la Planificación Anticipada de la Asistencia Sanitaria. Un 28,7% conoce la diferencia entre la Planificación Anticipada de la Asistencia Sanitaria y el Documento de Voluntades Anticipadas. Un 96,2% afirma que tener esta información ayudaría a los pacientes a que estuvieran mejor atendidos en sus últimos días. El 97,6% de los profesionales piensan que está en nuestra mano hacer algo más, a un 94,5% les gustaría recibir formación.Conclusión: Existe falta de conocimiento y un gran interés por los profesionales sanitarios sobre la Planificación Anticipada de la Asistencia Sanitaria.

Knowledge and attitudes towards living wills among healthcare professionals, residents and relatives in nursing homes: A qualitative study

Living wills are a tool to support the principle of autonomy in end-of-life situations, when the person does not have the capacity to make decisions. The aim was to explore the knowledge and attitudes of residents, relatives and healthcare professionals in nursing homes in Cantabria regarding living wills. A qualitative phenomenological design was conducted. Two focus groups were held with seven participants in each group. A sample of 14 people participated in this study: four residents, five relatives and five professionals. This study was approved by the Clinical Research Ethics Committee of Cantabria. Two main categories were found, with six subcategories each: death, with six subcategories-as a social taboo, as a natural process, facing death, accompanying uncertainties, unnecessary lengthening of life and guilt-and living wills, with six subcategories-knowledge, unknowingness or misconceptions, usefulness, strategies to promote dissemination, intention of granting a living will and the professional's role in restricting or promoting autonomy. Unknowingness or misconceptions and uncertainties in relation to death were the most represented subcategories of each category. Although the attitudes among the study participants were mostly positive, there is a lack of knowledge concerning living wills, which is enhanced by the social taboo related to death.

Why have Advance Directives failed in Spain?

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.

The Use of Advance Directives in Specialized Care Units: A Focus Group Study With Healthcare Professionals in Madrid

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.

What do Galicia's nurses know about living wills?

OBJECTIVE

To analyse the level of knowledge and attitudes concerning living wills of nurses working in 3 hospitals of Servizo Galego de Saúde (Spain).

METHOD

Descriptive, cross-sectional, multi-centre study. Stratified sampling was carried out with nurses from the University Hospital Complexes of Ourense, Ferrol and Vigo. A sample size of 239 individuals was calculated. The data was collected during the first semester of 2018 using a validated self-administered questionnaire («Cuestionario de conocimientos y actitudes de los profesionales sanitarios en el proceso de declaración de voluntades vitales»).

RESULTS

A total of 262 nurses participated. Fifty percent believe that health professionals are obliged to inform about living wills. Two percent consider that they have enough information on the subject, and this is demonstrated in the knowledge questions, where between 61%-93% fail in the questions related to the documentation, use, and their legal aspects. Eighty-four percent consider that they have the obligation to uphold the values and beliefs of patients, and 89% that patients have the right to receive and decide on the right care. Thirteen percent consider that patients are not well informed about living wills, and 83% would recommend to chronic patients that they complete a living will.

CONCLUSIONS

Nurses have a great lack of knowledge about the legal aspects and the use of living wills, which makes them feel unable to inform their patients about them. Despite of the lack of knowledge, their attitude is positive and most of them state that they would recommend them to their patients.

[Social-health characteristics of subjects who make a living will]

INTRODUCTION

The Living Will (LW) is well publicised, and still largely unknown to the general public and health professionals.

OBJECTIVE

To describe the characteristics of the subjects that formalize a LW related to socio-demographic situation, health status, degree of dependence, healthcare characteristics and psychosocial aspects.

METHOD

Descriptive observational study conducted in the Health Area of Albacete including 123 people who formalized the LW in a Will Register in 2011. Study variables included: self-perceived health, functional status, morbidity, socio-demographic characteristics, use of health services, attitudes towards the LW, and psychosocial aspects.

RESULTS

Those that made an LW, were mainly women (64.2%), had a mean age of 53.3 years (SD: 14.5), higher levels of education (61% with at least secondary education), and a lifestyle other than living with a partner, and with children (67.5%). The majority were self-sufficient for their daily living activities (98.4% to 94.3% for basic and instrumental), and suffered from chronic disease (73.2%). Despite lasting relationships with their physicians (9.4 years; SD: 7.9), there was very little talk about the end of life (18.3%). More than a half had a family member who had previously signed a document (54.5%). More than two-thirds (68.5%) considered this document useful in the death of a relative, and also a 56.7% had also served as a caregiver of a terminal patient.

CONCLUSIONS

Middle-aged people, predominantly women, formalized an LW most often. They are usually chronic, but self-sufficient for their daily living activities, and are convinced that they can influence their health situation.