[The availability of living wills in an interdisciplinary emergency department: results of a patient survey]

[Opportunities and risks of advance directives : An appraisal of the practice in Germany after legal regulation in 2009]

BACKGROUND

Living wills/advance directives (AD) are an important tool for specifying patient wishes regarding medical care in the case of future inability to consent. Since 2009, German legislation defines framework conditions for the creation and validity of such directives in § 1901a BGB.

METHODS

An extensive literature search in an international and a German-language database was conducted to identify, analyze, and evaluate scientific articles on opportunities, risks, and problems in the creation and implementation of living wills.

RESULTS

Between 10 and 40% of patients have an AD. Among the stipulations in the AD, the demand for sufficient pain therapy is very important. However, numerous problems in the preparation and implementation of ADs reduce their value in everyday clinical practice. In particular, unclear conditions of validity, unspecific instructions for action, and lack of availability of the directives prevent practitioners from determining the patient's will. Other fundamental problems include frequent patient ambivalence and clinical ethical dissent. In addition, the framework condition of unlimited coverage set by the law carries the risk that changes of opinion in the course of life or disease are not taken into account.

CONCLUSION

Preparing an AD requires a high level of information, consultation, and time, as well as regular review or adjustment of its content. These factors are often not considered, thus complicating implementation and reducing the value of living wills. Possible solutions to these problems or alternative concepts for different patient settings are discussed in this review.

[Survey on the presence of palliative care knowledge and palliative care structures in German emergency departments]

Patients with life-limiting or palliative illnesses represent a challenge for emergency departments because, despite the growing availability of specialized outpatient palliative care resources at home, patients often present during symptom exacerbations or when family caregivers become overwhelmed. Also, as life-limiting illnesses are frequently first diagnosed there and treatment goals are adjusted, it appears advantageous to establish early connections between emergency patients with palliative needs and palliative care resources. The objective of this study was to conduct a survey evaluating the availability of fundamental palliative care knowledge and palliative care structures in clinical acute and emergency medicine. For this purpose, an online survey was distributed via emergency medicine blogs, targeting physicians working in emergency departments. In total, 383 fully completed questionnaires were analyzed. It was found that the respondents often encounter patients with palliative needs. However, both outpatient and inpatient palliative resources are not universally accessible, and where, for instance, consultation services are available, there is a lack of consensus regarding the appropriate timing for their utilization. Structures for end of life care are largely in place, although time and personnel are often insufficiently available. There is an expressed interest in further education and training in palliative care. In conclusion, as emergency departments serve as the interface between outpatient and inpatient care, an interdisciplinary and holistic approach can be employed to lay the groundwork for ongoing palliative care, benefiting patients with palliative needs.

360-degree Delphi: addressing sociotechnical challenges of healthcare IT

BACKGROUND

IT systems in the healthcare field can have a marked sociotechnical impact: they modify communication habits, alter clinical processes and may have serious ethical implications. The introduction of such systems involves very different groups of stakeholders because of the inherent multi-professionalism in medicine and the role of patients and their relatives that are often underrepresented. Each group contributes distinct perspectives and particular needs, which create specific requirements for IT systems and may strongly influence their acceptance and success. In the past, needs analysis, challenges and requirements for medical IT systems have often been addressed using consensus techniques such as the Delphi technique. Facing the heterogeneous spectrum of stakeholders there is a need to develop these techniques further to control the (strong) influence of the composition of the expert panel on the outcome and to deal systematically with potentially incompatible needs of stakeholder groups. This approach uses the strong advantages a Delphi study has, identifies the disadvantages of traditional Delphi techniques and aims to introduce and evaluate a modified approach called 360-Degree Delphi. Key aspects of 360-Degree Delphi are tested by applying the approach to the needs and requirements analysis of a system for managing patients' advance directives and living wills.

METHODS

360-Degree Delphi (short 360°D), as a modified Delphi process, is specified as a structured workflow with the optional use of stakeholder groups. The approach redefines the composition of the expert panel by setting up groups of different stakeholders. Consensus is created within individual stakeholder groups, but is also communicated between groups, while the iterative structure of the Delphi process remains unchanged. We hypothesize that (1) 360-Degree Delphi yields complementary statements from different stakeholders, which would be lost in classical Delphi; while (2) the variation of statements within individual stakeholder groups is lower than within the total collective. A user study is performed that addresses five stakeholder groups (patients, relatives, medical doctors, nurses and software developers) on the topic of living will communication in an emergency context. Qualitative open questions are used in a Delphi round 0. Answer texts are coded by independent raters who carry out systematic bottom-up qualitative text analysis. Inter-rater reliability is calculated and the resulting codes are used to test the hypotheses. Qualitative results are transferred into quantitative questions and then surveyed in round 1. The study took place in Germany.

RESULTS

About 25% of the invited experts (stakeholders) agreed to take part in the Delphi round 0 (three patients, two relatives, three medical doctors, two qualified nurses and three developers), forming a structured panel of the five stakeholder groups. Two raters created a bottom-up coding, and 238 thematic codes were identified by the qualitative text analysis. The inter-rater reliability showed that 44.95% of the codes were semantically similar and coded for the same parts of the raw textual replies. Based on a consented coding list, a quantitative online-questionnaire was developed and send to different stakeholder groups. With respect to the hypotheses, Delphi round 0 had the following results: (1) doctors had a completely different focus from all the other stakeholder groups on possible channels of communications with the patient; (2) the dispersion of codes within individual stakeholder groups and within the total collective - visualized by box plots - was approximately 28% higher in the total collective than in the sub-collectives, but without a marked effect size. With respect to the hypotheses, Delphi round 1 had the following results: different stakeholder groups had highly diverging opinions with respect to central questions on IT-development. For example, when asked to rate the importance of access control against high availability of data (likert scale, 1 meaning restrictive data access, 6 easy access to all data), patients (mean 4.862, Stdev +/- 1.866) and caregivers (mean 5.667, Stdev: +/- 0.816) highly favored data availability, while relatives would restrict data access (mean 2.778, stdev +/- 1.093). In comparison, the total group would not be representative of either of these individual stakeholder needs (mean 4.344, stdev +/- 1.870).

CONCLUSION

360-Degree Delphi is feasible and allows different stakeholder groups within an expert panel to reach agreement individually. Thus, it generates a more detailed consensus which pays more tribute to individual stakeholders needs. This has the potential to improve the time to consensus as well as to produce a more representative and precise needs and requirements analysis. However, the method may create new challenges for the IT development process, which will have to deal with complementary or even contradictory statements from different stakeholder groups.

Advance Directives and Powers of Attorney in Intensive Care Patients

BACKGROUND

Advance directives and powers of attorney are increasingly common, yet data on their use in clinical situations remain sparse.

METHODS

In this single center cross-sectional study, we collected data by questionnaire from 1004 intensive care patients in a university hospital. The frequencies of advance directives and powers of attorney were determined, and the factors affecting them were studied with multivariate logistic regression analysis.

RESULTS

Usable data were obtained from 998 patients. 51.3% stated that they had prepared a document of at least one of these two kinds. Among them, 39.6% stated that they had given the relevant document(s) to the hospital, yet such documents were present in the patient's hospital record for only 23%. 508 patients stated their reasons for preparing an advance directive or a power of attorney: the most common reason (48%) was the fear of being at other people's mercy, of the lack of self-determination, or of medical overtreatment. The most important factors associated with a patient's statement that he/she had prepared such a document were advanced age (advance directive: 1.022 [1.009; 1.036], p = 0.001; power of attorney: 1.027 [1.014; 1.040], p<0.001) and elective admission to the hospital (advance directive: 1.622 [1.138; 2.311], p<0.007; power of attorney: 1.459 [1.049; 2.030], p = 0.025). 39.8% of the advance directives and 44.1% of the powers of attorney that were present in the hospital records were poorly interpretable because of the incomplete filling-out of preprinted forms. Half of the patients who did not have such a document had already thought of preparing one, but had not yet done so.

CONCLUSION

For patients hospitalized in intensive care units, there should be early discussion about the presence or absence of documents of these kinds and early evaluation of the patient's concrete wishes in critical situations. Future studies are needed to determine how best to assure that these documents will be correctly prepared and then given over to hospital staff so that they can take their place in the patient's record.