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Berkowitz E, Trevick S. Non-Psychiatric Treatment Refusal in Patients with Depression: How Should Surrogate Decision-Makers Represent the Patient's Authentic Wishes? HEC Forum 2024:10.1007/s10730-024-09522-9. [PMID: 38280180 DOI: 10.1007/s10730-024-09522-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2024] [Indexed: 01/29/2024]
Abstract
Patients with mental illness, and depression in particular, present clinicians and surrogate decision-makers with complex ethical dilemmas when they refuse life-sustaining non-psychiatric treatment. When treatment rejection is at variance with the beliefs and preferences that could be expected based on their premorbid or "authentic" self, their capacity to make these decisions may be called into question. If capacity cannot be demonstrated, medical decisions fall to surrogates who are usually advised to decide based on a substituted judgment standard or, when that is not possible, best interest. We propose that in cases where the patient meets the widely accepted cognitive criteria for capacity but is making decisions that appear inauthentic, the surrogate may best uphold patient autonomy by following a "restorative representation" model. We see restorative representation as a subset of substituted judgement in which the decision-maker retains responsibility for deciding as the patient would have, but discerns the decision their "truest self" would make, rather than inferring their current wishes, which are directly influenced by illness. Here we present a case in which the patient's treatment refusal and previously undiagnosed depression led to difficulty determining the patient's authentic wishes and placed a distressing burden on the surrogate decision-maker. We use this case to examine how clinicians and ethicists might better advise surrogates who find themselves making these clinically and emotionally challenging decisions.
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Affiliation(s)
- Esther Berkowitz
- Ascension Holy Family, 100 North River Rd, Des Plaines, IL, 60016, USA.
| | - Stephen Trevick
- Northwest Neurology, Ltd., 22285 North Pepper Rd #401, Barrington, IL, 60010, USA
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Hendrickson KW, Hopkins RO, Groat DL, Stokes SC, Schroeder FM, Butler JM, Hirshberg EL. Patient experiences with SARS-CoV-2: Associations between patient experience of disease and coping profiles. PLoS One 2023; 18:e0294201. [PMID: 37983278 PMCID: PMC10659202 DOI: 10.1371/journal.pone.0294201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/27/2023] [Indexed: 11/22/2023] Open
Abstract
INTRODUCTION Severe acute respiratory syndrome coronavirus 2, (SARS-CoV-2,) caused an influx of patients with acute disease characterized by a variety of symptoms termed COVID-19 disease, with some patients going on to develop post-acute COVID-19 syndrome. Individual factors like sex or coping styles are associated with a person's disease experience and quality of life. Individual differences in coping styles used to manage COVID-19 related stress correlate with physical and mental health outcomes. Our study sought to understand the relationship between COVID-19 symptoms, severity of acute disease, and coping profiles. METHODS An online survey to assess symptoms, functional status, and recovery in a large group of patients was nationally distributed online. The survey asked about symptoms, course of illness, and included the Brief-COPE and the adapted Social Relationship Inventory. We used descriptive and cluster analyses to characterize patterns of survey responses. RESULTS 976 patients were included in the analysis. The most common symptoms reported by the patients were fatigue (72%), cough (71%), body aches/joint pain (66%), headache (62%), and fever/chills (62%). 284 participants reported PACS. We described three different coping profiles: outward, inward, and dynamic copers. DISCUSSION Fatigue, cough, and body aches/joint pains were the most frequently reported symptoms. PACS patients were sicker, more likely to have been hospitalized. Of the three coping profiles, outward copers were more likely to be admitted to the hospital and had the healthiest coping strategies. Dynamic copers activated several coping strategies both positive and negative; they were also younger and more likely to report PACS. CONCLUSION Cough, fatigue, and body aches/joint pain are common and most important to patients with acute COVID-19, while shortness of breath defined the experience for patients with PACS. Of the three coping profiles, dynamic copers were more likely to report PACS. Additional investigations into coping profiles in general, and the experience of COVID-19 and PACS is needed.
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Affiliation(s)
- Kathryn W. Hendrickson
- The Oregon Clinic, Department of Pulmonary, Critical Care, and Sleep Medicine East, Portland, Oregon, United States of America
| | - Ramona O. Hopkins
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah, United States of America
- Intermountain Health, Center for Humanizing Critical Care, Murray, Utah, United States of America
| | - Danielle L. Groat
- Intermountain Health, Center for Humanizing Critical Care, Murray, Utah, United States of America
- Intermountain Health, Division of Pulmonary and Critical Care, Murray, Utah, United States of America
| | - Stephanie C. Stokes
- Intermountain Health, Strategic Research, Salt Lake City, Utah, United States of America
| | - Fiona M. Schroeder
- Intermountain Health, Strategic Research, Salt Lake City, Utah, United States of America
| | - Jorie M. Butler
- Intermountain Health, Center for Humanizing Critical Care, Murray, Utah, United States of America
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States of America
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Informatics Decision-Enhancement and Analytic Sciences (IDEAS), Center for Innovation & Geriatrics Research, Education, and Clinical Center (GRECC), VA Salt Lake City Health Care System, Salt Lake City, UT, United States of America
| | - Eliotte L. Hirshberg
- Intermountain Health, Center for Humanizing Critical Care, Murray, Utah, United States of America
- Intermountain Health, Division of Pulmonary and Critical Care, Murray, Utah, United States of America
- Division of Pulmonology, School of Medicine, University of Utah, Salt Lake City, Utah, United States of America
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Butler JM, Wang X, Riddoch M, Thorpe A, Stevens V, Scherer LD, Drews FA, Shoemaker H, Fagerlin A. Veterans and Nonveterans Coping With Stress During 4 Months of COVID-19. Ann Fam Med 2023; 21:508-516. [PMID: 38012035 PMCID: PMC10681693 DOI: 10.1370/afm.3046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 11/29/2023] Open
Abstract
PURPOSE Identifying how people have been coping with stress during the COVID-19 pandemic allows us to anticipate how the population may react to similar stressors over time. In this study, we assessed patterns of coping styles among veterans and nonveterans, and stability and change in these strategies at 3 time points during the pandemic. METHODS Using an online survey platform, we circulated a questionnaire at 3 time points during the period when COVID-19 vaccines became widely available (December 2-27, 2020; January 21-February 6, 2021; and March 8-23, 2021). The questionnaire asked participants about their extent of use of 11 coping strategies, and symptoms of anxiety and depression. RESULTS A total of 2,085 participants (50.8% veterans) completed the questionnaire at 1 or more time points and 930 participants (62.8% veterans) completed it at all 3 time points. Cluster analysis identified 3 distinct coping styles: adaptive, distressed, and disengaged. Compared with nonveterans, veterans more commonly had adaptive and disengaged coping styles, and less commonly had a distressed coping style. The majority of the cohort (71.3%) changed coping style at least once during the study period. Participants who used the same coping style across all 3 time points reported lower levels of anxiety and depression. CONCLUSIONS Our data demonstrate a need to better understand the dynamic nature of coping with pandemic-level stressors across time. We did not find patterns of change in coping styles, but our findings point to potential advantages of stability in coping style. It is possible that less adaptive styles that are more stable may be advantageous for mental health. This research has implications for supporting patients dealing with stress in family medicine.
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Affiliation(s)
- Jorie M Butler
- Department of Biomedical Informatics, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Geriatrics Research, Education, and Clinical Center (GRECC), VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Xuechen Wang
- Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Marian Riddoch
- Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Alistair Thorpe
- Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Vanessa Stevens
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Laura D Scherer
- University of Colorado School of Medicine, Aurora, Colorado
- VA Denver Center for Innovation, Denver, Colorado
| | - Frank A Drews
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- University of Utah College of Social and Behavioral Science, Salt Lake City, Utah
| | - Holly Shoemaker
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Angela Fagerlin
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
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Kavčič T, Avsec A, Zager Kocjan G. Coping profiles and their association with psychological functioning: A latent profile analysis of coping strategies during the COVID-19 pandemic. PERSONALITY AND INDIVIDUAL DIFFERENCES 2021; 185:111287. [PMID: 34584300 PMCID: PMC8461263 DOI: 10.1016/j.paid.2021.111287] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/15/2021] [Accepted: 09/21/2021] [Indexed: 11/24/2022]
Abstract
While many adversities affect limited groups of people, the COVID-19 pandemic brought a range of stressors to entire populations. Using a person-centered approach, this study analyzed the most frequent combinations of coping strategies used by general population during the first wave of the pandemic in a sample of 1347 Slovenian adults. Latent profile analysis identified three coping profiles similar to those found in previous studies in specific samples and stressful circumstances: the engaged profile (active coping, planning, acceptance, positive reframing), the disengaged profile (low problem-focused coping, social support, acceptance, positive reframing), and the avoidant profile (substance use, self-blame, humor). Individuals with the engaged profile reported the highest levels of well-being and the lowest levels of ill-being. While individuals with the avoidant profile had the highest levels of anxiety and stress, those with the disengaged profile had the lowest levels of well-being, especially engagement and positive relationships. The results imply the need to distinguish between the two less adaptive coping profiles, as one is characterized by the active use of dysfunctional strategies, and the other by the low use of all strategies, suggesting that psychological interventions should be tailored to these specificities.
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Affiliation(s)
- Tina Kavčič
- Faculty of Health Sciences, University of Ljubljana, Zdravstvena pot 5, 1000 Ljubljana, Slovenia
| | - Andreja Avsec
- Department of Psychology, Faculty of Arts, University of Ljubljana, Aškerčeva 2, 1000 Ljubljana, Slovenia
| | - Gaja Zager Kocjan
- Department of Psychology, Faculty of Arts, University of Ljubljana, Aškerčeva 2, 1000 Ljubljana, Slovenia
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Safitri D, Kurnia A, Al Jihad M. Family Experience during Patient Assistance Process in General Intensive Care Unit: A Phenomenology Study. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.5804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Intensive care unit (ICU) treatment can lead to fear, anxiety, depression, panic, and tension in the family. Place of the family as active presence, guardian, facilitator, historian, and coaching of the family cannot be separated from the recovery process. During the assistance of ICU patients, the family is faced with a strange environment, strict rules, emotional stress, and everyday life changes that have caused them to encounter psychological and physiological concerns.
AIM: This study aims to describe and interpret of the family’s experience during assistance patient in the ICU.
METHODS: A phenomenological methodology is used to explore experience of family. In-depth interviews were conducted on nine participants who were selected using purposive sampling. Data were analyzed by Colaizzi techniques, began with read transcripts, look for phenomenon, formulated data, organized, and verified to the participants.
RESULTS: The result is presented in three themes; physically and psychologically tired; good language is a medicine, strengthens each other’s companion.
CONCLUSION: The support of the patient in the ICU helps the family face a number of stressful circumstances. Adaptive coping and psychosocial help from health care workers and friends build a supportive family to cope with the difficulties when supporting patients in the ICU.
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Wu F, Zhuang Y, Chen X, Wen H, Tao W, Lao Y, Zhou H. Decision-making among the substitute decision makers in intensive care units: An investigation of decision control preferences and decisional conflicts. J Adv Nurs 2020; 76:2323-2335. [PMID: 32538477 DOI: 10.1111/jan.14451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 04/10/2020] [Accepted: 05/22/2020] [Indexed: 01/22/2023]
Abstract
AIMS To explore decision control preferences and decisional conflicts and to analyse their association among the surrogate decision makers in the intensive care unit. DESIGN The study carried out a cross-sectional survey among the surrogates. METHODS The participants were 115 surrogate decision makers of critical patients, from August to September 2019. A Chi-squared test and logistic regression were used to assess decision control preferences and decisional conflicts, and Spearman's rank correlation coefficient was employed to examine their association. RESULTS Of the 115 surrogate decision makers, 51.3% preferred a collaborative role, and 63.48% were somewhat unsure about making decisions. Logistic regression analysis identified decision control preferences was associated with surrogates' age, education level, and personality traits, while decisional conflicts was associated with surrogates' age, education level, character, medical expense burden, and Acute Physiology and Chronic Health Evaluation-II score. Cohen's kappa statistics showed a bad concordance of decision-making expectations and actuality, with kappa values of 0.158 (p < .05). Wherein surrogates who experienced discordance between their preferred and actual roles, have relatively higher decisional conflicts. CONCLUSION This study identified individual differences of surrogate decision makers in decision control preferences and decisional conflicts. These results imply that incorporation of the individual decision preferences and communication styles into care plans is an important first step to develop high quality decision support. IMPACT This research is a contribution to the limited study on decision control preferences and decisional conflicts among surrogate decision makers of critically ill patients. Moreover based on the investigation of understanding the status and related factors of decision preferences and decisional conflicts set the stage for developing effective decision support interventions.
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Affiliation(s)
- Feixia Wu
- School of Nursing, Huzhou University, Huzhou, China
| | - Yiyu Zhuang
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiangping Chen
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huan Wen
- School of Nursing, Huzhou University, Huzhou, China
| | - Wenwen Tao
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuewen Lao
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongchang Zhou
- School of Medicine and Nursing Sciences, Huzhou University, Huzhou Central Hospital, Huzhou, China
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Alexis Ruiz A, Wyszyńska PK, Laudanski K. Narrative Review of Decision-Making Processes in Critical Care. Anesth Analg 2019; 128:962-970. [DOI: 10.1213/ane.0000000000003683] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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