Family solidarity and informal care: the case of care for people with dementia

Dementia, identity and the role of friends

Ronald Dworkin (1993) introduced the example of Margo, who was so severely demented that she could not recognise any family or friends, and could not remember anything of her life. At the same time, however, she seemed full of childish delight. Dworkin also imagines that, before her dementia, Margo signed an advance refusal of life-saving treatment. Now severely demented, she develops pneumonia, easy to treat, but lethal if untreated. Dworkin argues that the advance refusal ought to be heeded and Margo be allowed to die of that pneumonia, on the basis that the prior refusal expresses her true wishes (her 'critical interests'). In this paper I want to challenge Dworkin's understanding of identity and his conclusion about advance refusals, and I develop my argument in two directions. First, I argue that the demented Margo is not some 'lesser' version of the 'true' Margo, but instead that the present Margo's wishes should take precedence over those of the past Margo, on the grounds that all of us are entitled to change our minds. Second, I argue for a stronger role for friends and family members in sustaining the demented Margo's identity through her years of decline. Based on this, I argue for a presumption against the advance refusal, but I allow that in extreme cases (which I describe), a friend might have the authority to demand that it be heeded.

Restraint Use in Older Adults Receiving Home Care

OBJECTIVES

To determine the prevalence, types, frequency, and duration of restraint use in older adults receiving home nursing care and to determine factors involved in the decision-making process for restraint use and application.

DESIGN

Cross-sectional survey of restraint use in older adults receiving home care completed by primary care nurses.

SETTING

Homes of older adults receiving care from a home nursing organization in Belgium.

PARTICIPANTS

Randomized sample of older adults receiving home care (N = 6,397; mean age 80.6; 66.8% female).

MEASUREMENTS

For each participant, nurses completed an investigator-constructed and -validated questionnaire collecting information demographic, clinical, and behavioral characteristics and aspects of restraint use. A broad definition of restraint was used that includes a range of restrictive actions.

RESULTS

Restraints were used in 24.7% of the participants, mostly on a daily basis (85%) and often for a long period (54.5%, 24 h/d). The most common reason for restraint use was safety (50.2%). Other reasons were that the individual wanted to remain at home longer, which necessitated the use of restraints (18.2%) and to provide respite for the informal caregiver (8.6%). The latter played an important role in the decision and application process. The physician was less involved in the process. In 64.5% of cases, there was no evaluation after restraint use was initiated.

CONCLUSION

Use of restraints is common in older adults receiving home care nursing in Belgium. These results contribute to a better understanding of the complexity of use of restraints in home care, a situation that may be even more complex than in nursing homes and acute hospital settings.

First Do No Harm: Euthanasia of Patients with Dementia in Belgium

In Memory of Ed Pellegrino. Euthanasia in Belgium is not limited to terminally ill patients. It may be applied to patients with chronic degenerative diseases. Currently, people in Belgium wish to make it possible to euthanize incompetent patients who suffer from dementia. This article explains the Belgian law and then explores arguments for and against euthanasia of patients with dementia. It probes the dementia paradox by elucidating Dworkin's distinction between critical and experiential interests, arguing that at the end-of-life this distinction is not clearcut. It argues against euthanasia for patients with dementia, for respecting patients' humanity and for providing them with more care, compassion, and good doctoring.

The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units

BACKGROUND

Services in specialized day-care units for individuals with dementia are set up to enable these persons to live in their own home. The purpose of this paper is to discern the experiences of families with these services while caring for a close relative with dementia.

METHOD

Longitudinal interviews with 8 family members were conducted. In total, 25 interviews were carried out over a period of 5 years.

RESULTS

The experience of these families of looking after a close person with dementia appeared to be influenced by (a) the multifaceted meaning of ties, (b) the perception of purposeful relief of the day-care services and (c) the progress of the disease.

CONCLUSION

All families found the services of specialized day-care units both useful and pleasant. This kind of resource was shown to make everyday life much more manageable for all persons involved, most importantly for the patient with dementia.

Family caregivers' assessments of caring for a relative with dementia: a comparison of urban and rural areas

AIM

This study aimed to describe and compare urban and rural family caregivers' reactions to caring for a relative with dementia and to examine the associations between caregiving and socio-demographic factors.

BACKGROUND

Most studies on family caregivers' experiences caring for older people with dementia have been conducted in urban areas, and little is known about the experiences of family caregivers living in rural areas.

DESIGN

A cross-sectional study design was used.

METHODS

A total of 102 caregivers (response rate 85%) from urban (n=57) and rural (n=46) areas completed the Caregiver Reaction Assessment (CRA) Scale and demographic information. Data were analysed using descriptive and inferential statistics and linear regression models.

RESULTS

Overall, family caregivers reported high satisfaction even if they also reported high impact on finances and daily living. Rural caregivers experienced a higher negative impact on finances but reported more support from family members than urban caregivers. Age, gender and relationship were significantly associated with four of the five CRA subscales. Educational level and geographical setting were not associated with any of the CRA subscales.

CONCLUSIONS

The results of the study raise questions about the financial situation of older female caregivers and on the expectations of built-in family structures in urban and rural areas. Further studies focusing on the meaning and constitution of a family would help us to understand how these factors influence family caregiving both in rural and urban areas.

IMPLICATIONS FOR PRACTICE

To provide person-centred care and to avoid stereotyped caregiving, a better picture of traditions in family caregiving can improve a more differentiated and appropriate professional caregiving pliable with the cultural context in which it is carried out.

Exploring the collective hospice caregiving experience

BACKGROUND

Collective caregiving, performed by caregivers working in pairs (informal primary and secondary caregivers working together), is common in the hospice setting. Research suggests that caregiving pairs may experience different caregiver outcomes. However, little is known about how caregiving pairs differ from solo caregivers (informal primary caregivers) on outcome measures.

OBJECTIVE

The goal of this study was to determine whether being in a caregiver pair affected caregiver anxiety and depression and how outcomes changed over time.

DESIGN

A mixed model analysis was used.

SETTING/SUBJECTS

Hospice caregivers (260 solo caregivers and 44 caregivers in 22 pairs) who participated in a larger, randomized controlled trial completed caregiver measures upon hospice admission and periodically until the death of the patient or hospice decertification.

MEASUREMENTS

Measured were caregiver quality of life, social support, anxiety, and depression.

RESULTS

Caregiver pairs had higher anxiety and depression scores than solo caregivers. Emotional, financial, and physical quality of life were associated with decreased depression, whereas only emotional and financial quality of life were correlated with lower levels of anxiety. Social support was associated with lower levels of depression and anxiety.

CONCLUSIONS

Despite assumptions that social support is positively facilitated vis-a-vis collective caregiving, caregiving pairs may be at higher risk for anxiety and depression. Future research is needed to address why individuals become anxious and/or depressed when working as part of a caregiving pair.

Philosophical issues in dementia

PURPOSE OF REVIEW

This review aims to consider the philosophical literature from the last 18 months relevant to dementia. Philosophical thought should underpin and strengthen developments in clinical practice. For instance, deepening our thoughts about personhood should support the development of person-centred care.

RECENT FINDINGS

There is relatively little work written by philosophers about dementia. But much of the writing by health and social care researchers and much empirical work in this field throws up philosophical issues. These do not solely concern personal identity, personhood and selfhood, even if the literature frequently refers to these topics. Instead we see, first, that there are other issues (around citizenship, rights, the nature of mind, of normality and of ageing) which deserve further philosophical attention and, secondly, that the discussions about personhood have moved beyond the concern that our persistence over time as individuals depends on memory to encompass a broader view which emphasizes instead the ability of people to continue to construct their life-worlds through their persisting meaningful relationships.

SUMMARY

Real interaction with people with dementia creates an increasingly nuanced account of the life-worlds of people with dementia, which should stimulate both philosophical work and clinical practice.