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Herreros B, Benito M, Gella P, Valenti E, Sánchez B, Velasco T. Why have Advance Directives failed in Spain? BMC Med Ethics 2020; 21:113. [PMID: 33198746 PMCID: PMC7667789 DOI: 10.1186/s12910-020-00557-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/29/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Benjamín Herreros
- Instituto de Ética Clínica Francisco Vallés, Universidad Europea de Madrid, Madrid, Spain. .,Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain.
| | - María Benito
- Legal Medicine, Psychiatry and Pathology Department, Universidad Complutense , Plaza de Ramón y Cajal, s/n, 28040, Madrid, Spain
| | - Pablo Gella
- Instituto de Ética Clínica Francisco Vallés, Universidad Europea, Plaza de Francisco Morano, s/n, 28005, Madrid, Spain
| | - Emanuele Valenti
- Centre for Ethics in Medicine, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Beatriz Sánchez
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922, Alcorcón, Madrid, Spain
| | - Tayra Velasco
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense, Plaza de Ramón y Cajal, s/n, 28040, Madrid, Spain
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O'Halloran P, Noble H, Norwood K, Maxwell P, Shields J, Fogarty D, Murtagh F, Morton R, Brazil K. Advance Care Planning With Patients Who Have End-Stage Kidney Disease: A Systematic Realist Review. J Pain Symptom Manage 2018; 56:795-807.e18. [PMID: 30025939 PMCID: PMC6203056 DOI: 10.1016/j.jpainsymman.2018.07.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 01/02/2023]
Abstract
CONTEXT Patients with end-stage kidney disease have a high mortality rate and disease burden. Despite this, many do not speak with health care professionals about end-of-life issues. Advance care planning is recommended in this context but is complex and challenging. We carried out a realist review to identify factors affecting its implementation. OBJECTIVES The objectives of this study are 1) to identify implementation theories; 2) to identify factors that help or hinder implementation; and 3) to develop theory on how the intervention may work. METHODS We carried out a systematic realist review, searching seven electronic databases: Medline, Embase, CINAHL, PsycINFO, Cochrane Library, Google Scholar, and ScienceDirect. RESULTS Sixty-two papers were included in the review. CONCLUSION We identified two intervention stages-1) training for health care professionals that addresses concerns, optimizes skills, and clarifies processes and 2) use of documentation and processes that are simple, individually tailored, culturally appropriate, and involve surrogates. These processes work as patients develop trust in professionals, participate in discussions, and clarify values and beliefs about their condition. This leads to greater congruence between patients and surrogates; increased quality of communication between patients and professionals; and increased completion of advance directives. Advance care planning is hindered by lack of training; administrative complexities; pressures of routine care; patients overestimating life expectancy; and when patients, family, and/or clinical staff are reluctant to initiate discussions. It is more likely to succeed where organizations treat it as core business; when the process is culturally appropriate and takes account of patient perceptions; and when patients are willing to consider death and dying with suitably trained staff.
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Affiliation(s)
- Peter O'Halloran
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, Belfast, United Kingdom.
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, Belfast, United Kingdom
| | - Kelly Norwood
- School of Psychology, Ulster University, Coleraine Campus, Coleraine, United Kingdom
| | - Peter Maxwell
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Health Sciences Building, Belfast, United Kingdom; Regional Nephrology Unit, Belfast City Hospital, Belfast, United Kingdom
| | - Joanne Shields
- Regional Nephrology Unit, Belfast City Hospital, Belfast, United Kingdom
| | - Damian Fogarty
- Regional Nephrology Unit, Belfast City Hospital, Belfast, United Kingdom
| | - Fliss Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull, United Kingdom
| | - Rachael Morton
- Sydney Medical School, University of Sydney, NSW, Australia
| | - Kevin Brazil
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, Belfast, United Kingdom
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Vukusich A, Catoni MI, Salas SP, Valdivieso A, Browne F, Roessler E. [Ethical issues perceived by health care professionals working in chronic hemodialysis centers]. Rev Med Chil 2016; 144:14-21. [PMID: 26998978 DOI: 10.4067/s0034-98872016000100003] [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: 04/22/2015] [Accepted: 10/29/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical teams working at chronic hemodialysis centers (CHC) frequently have to face ethical problems, but there is no systematic approach to deal with them. AIM To study the ethical problems perceived by health professionals at CHC. MATERIAL AND METHODS Eighty randomly selected physicians and 139 nurses from 23 CHC, answered a structured questionnaire, devised by the research team. RESULTS Twenty-six percent of respondents had postgraduate studies in clinical ethics. The ethical problems mentioned by respondents were therapeutic disproportion in 66.7%, lack of communication between patients, their families and the clinical team in 25.9%, personal conflicts of interests related with hemodialysis prescription in 14.6% and conflicts of interests of other members of the clinical team in 30.6%. The percentage of respondents that experienced not starting or discontinuing hemodialysis treatment due to decision of patients relatives was 86.8%. Only 45.2% of health professionals had the opportunity to take part in decision-making meetings. Eighty seven percent of respondents supported the use of advanced directives in the event of a cardio respiratory arrest during treatment. CONCLUSIONS To improve the approach to ethical problems in CHC, it is necessary to improve training in clinical ethics, promote an effective dialogue between the patients, their families and health professionals, and follow their advance directives in case of cardiac arrest during treatment.
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Li W, Ng HL, Li W, Piano AN, Karim SA, Tay KY, Au WL, Tan LC. Treatment Preferences at the End-of-Life in Parkinson's Disease Patients. Mov Disord Clin Pract 2016; 3:483-489. [PMID: 30363514 DOI: 10.1002/mdc3.12313] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/13/2015] [Accepted: 11/19/2015] [Indexed: 11/08/2022] Open
Abstract
Background Few studies have been performed on palliative care in Parkinson's disease (PD). This study was undertaken to understand treatment preferences of PD patients toward end-of-life care. Methods A questionnaire modified from the Willingness to Accept Life-Sustaining Treatment instrument was administered to participants. Four different scenarios based on the burden of care and outcome of the treatment were presented in detail to obtain decisions for end-of-life care. The responses in each scenario were compared between PD patients and controls. Further analyses were performed to identify factors that influenced treatment preferences among PD patients. Results In total, 136 PD patients and 60 controls were recruited. Parkinson's disease patients and controls were demographically similar, except that PD patients had more previous hospital admissions (P = 0.0195). Parkinson's disease patients were more likely to opt for high-burden care with poor outcome than controls (odds ratio [OR] = 2.11, P = 0.04).In the subgroup analysis for PD patients, the factors that influenced treatment preference toward end-of-life care were belief in religion (OR: 7.43, 95% confidence interval:1.97-28.07), higher Unified Parkinson's Disease Rating Scale (UPDRS) motor score (2.51, 1.14-5.50) in scenario B; belief in religion (6.93, 2.23-21.43), married patients (6.93, 2.23-21.43) in scenario C; and Chinese patients (0.29, 0.10-0.79), better PD knowledge (0.37, 0.17-0.80), and higher UPDRS motor scores (3.05, 1.35-6.9) in scenario D. Conclusion Parkinson's disease patients were more likely to agree to high-burden care with a poor outcome compared to controls. Among PD patients, race, marital status, religious status, knowledge about PD, and severity of motor impairment significantly influenced their end-of-life treatment preferences.
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Affiliation(s)
- Wei Li
- Department of Neurology National Neuroscience Institute Singapore.,Parkinson's Disease and Movement Disorders Centre National Neuroscience Institute Singapore
| | - Hwee Lan Ng
- Department of Neurology National Neuroscience Institute Singapore.,Parkinson's Disease and Movement Disorders Centre National Neuroscience Institute Singapore
| | - Wenyun Li
- Centre for Quantitative Medicine Duke-NUS Graduate Medical School Singapore
| | - Anthony N Piano
- Department of Neurology National Neuroscience Institute Singapore.,Parkinson's Disease and Movement Disorders Centre National Neuroscience Institute Singapore
| | - Shireen Abdul Karim
- Department of Neurology National Neuroscience Institute Singapore.,Parkinson's Disease and Movement Disorders Centre National Neuroscience Institute Singapore
| | - Kay Yaw Tay
- Department of Neurology National Neuroscience Institute Singapore.,Parkinson's Disease and Movement Disorders Centre National Neuroscience Institute Singapore.,Duke-NUS Graduate Medical School Singapore
| | - Wing Lok Au
- Department of Neurology National Neuroscience Institute Singapore.,Parkinson's Disease and Movement Disorders Centre National Neuroscience Institute Singapore.,Duke-NUS Graduate Medical School Singapore
| | - Louis Cs Tan
- Department of Neurology National Neuroscience Institute Singapore.,Parkinson's Disease and Movement Disorders Centre National Neuroscience Institute Singapore.,Duke-NUS Graduate Medical School Singapore
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Hing Wong A, Chin LE, Ping TL, Peng NK, Kun LS. Clinical Impact of Education Provision on Determining Advance Care Planning Decisions among End Stage Renal Disease Patients Receiving Regular Hemodialysis in University Malaya Medical Centre. Indian J Palliat Care 2016; 22:437-445. [PMID: 27803566 PMCID: PMC5072236 DOI: 10.4103/0973-1075.191788] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Advance care planning (ACP) is a process of shared decision-making about future health-care plans between patients, health care providers, and family members, should patients becomes incapable of participating in medical treatment decisions. ACP discussions enhance patient's autonomy, focus on patient's values and treatment preferences, and promote patient-centered care. ACP is integrated as part of clinical practice in Singapore and the United States. AIM To assess the clinical impact of education provision on determining ACP decisions among end-stage renal disease patients on regular hemodialysis at University Malaya Medical Centre (UMMC). To study the knowledge and attitude of patients toward ACP and end-of-life issues. MATERIALS AND METHODS Fifty-six patients were recruited from UMMC. About 43 questions pretest survey adapted from Lyon's ACP survey and Moss's cardiopulmonary resuscitation (CPR) attitude survey was given to patients to answer. An educational brochure is then introduced to these patients, and a posttest survey carried out after that. The results were analyzed using SPSS version 22.0. RESULTS Opinion on ACP, including CPR decisions, showed an upward trend on the importance percentage after the educational brochure exposure, but this was statistically not significant. Seventy-five percent of participants had never heard of ACP before, and only 3.6% had actually prepared a written advanced directive. CONCLUSION The ACP educational brochure clinically impacts patients' preferences and decisions toward end-of-life care; however, this is statistically not significant. Majority of patients have poor knowledge on ACP. This study lays the foundation for execution of future larger scale clinical trials, and ultimately, the incorporation of ACP into clinical practice in Malaysia.
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Affiliation(s)
| | - Loh Ee Chin
- University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Tan Li Ping
- University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Ng Kok Peng
- Department of Internal Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Lim Soo Kun
- University Malaya Medical Centre, Kuala Lumpur, Malaysia
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