The Association of Surrogate Decision Makers' Religious and Spiritual Beliefs With End-of-Life Decisions

Exploration of decision aids to support advance care planning: A scoping review

BACKGROUND

Advance care planning is a process through which people communicate their goals and preferences for future medical care. Due to the complexity of the decision-making process, decision aids can assist individuals in balancing potential benefits and risks of treatment options.

OBJECTIVE

While decision aids have the potential to better promote advance care planning, their characteristics, content and application effectiveness are unclear and lack systematic review. Therefore, we aimed to explore these three aspects and establish a foundation for future research.

DESIGN

Scoping review.

METHODS

This scoping review adheres to the framework proposed by Arksey and O'Malley and the PRISMA-ScR list. Six English-language databases were systematically searched from the time of construction until 1 December 2023. Two researchers conducted the article screening and data extraction, and the extracted data was presented in written tables and narrative summaries.

RESULTS

Of the 1479 titles and abstracts, 20 studies fulfilled the inclusion criteria. Types of decision aids were employed, mainly websites and videos. Decision aid's primary components center around 11 areas, such as furnishing information, exploring treatment and care preferences. The main manifestations were a significant increase in knowledge and improved recognition of patients' target value preferences. Among the aids, websites and videos for advance care planning have relatively high content acceptability and decision-making process satisfaction, but their feasibility has yet to be tested.

CONCLUSIONS

Decision aids were varied, with content focused on describing key information and exploring treatment and care preferences. Regarding application effects, the aids successfully facilitated the advance care planning process and improved the quality of participants' decisions. Overall, decision aids are efficient in improving the decision-making process for implementing advance care planning in cancer and geriatric populations. In the future, personalised decision aids should be developed based on continuous optimization of tools' quality and promoted for clinical application.

REPORTING METHOD

The paper has adhered to the EQUATOR guidelines and referenced the PRISMAg-ScR checklist.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a review without patient and public contribution.

REGISTRATION

https://doi.org/10.17605/OSF.IO/YPHKF, Open Science DOI: 10.17605/OSF.IO/YPHKF.

Mystery and Miracle in Nursing: A Preliminary Unitary Appreciative Inquiry

This study of mystery and miracles in nursing offers a unique perspective in examning and understanding these phenomena grounded in a unitary science framework and guided by unitary appreciative inquiry. It examined 6 years of postings from an online course that gave nurses globally the opportunity to describe and elaborate upon experiences of mystery and miracles in their professional and personal lives. The analysis and synopsis processes used revealed the diversity and uniqueness of mystery and miracle phenomena and acceptance by nurses of their reality without need for scientific explanation despite the tendency to dismiss them by colleagues.

The experience of patients with hematological malignancy in their terminal stage: a phenomenological study from Jordan's perspective

BACKGROUND

Patients diagnosed with hematological malignancies residing in low-middle-income countries undergo significant physical and psychological stressors. Despite this, only 16% of them receive proper care during the terminal stages. It is therefore crucial to gain insight into the unique experiences of this population.

AIM

To have a better understanding of the needs and experiences of adult patients with advanced hematological malignancy by exploring their perspectives.

METHODS

A qualitative interpretive design was employed to collect and analyze data using a phenomenological approach. The study involved in-depth interviews with ten participants aged between 49 and 65 years, utilizing a semi-structured approach.

RESULTS

Two primary themes emerged from the participants' experiences of reaching the terminal stage of illness: "Pain, Suffering, and Distress" and "Spiritual Coping." The first theme encompassed physical and emotional pain, suffering, and distress, while the second theme was centered on the participants' spiritual coping mechanisms. These coping mechanisms included seeking comfort in religious practices, relying on spiritual support from family and friends, and finding solace in their beliefs and faith.

CONCLUSION

Patients with hematological malignancies in the terminal stages of their disease experience severe pain, considerable physical and psychosocial suffering, and spiritual distress. While they require support to cope with their daily struggles, their experiences often go unnoticed, leading to disappointment and loss of dignity. Patients mainly rely on their spirituality to cope with their situations. Healthcare providers must acknowledge these patients' needs and provide more holistic and effective care.

Polarization in public attitudes toward end-of-life decisions in Israel - A cross-sectional study

OBJECTIVES

End-of-life (EoL) processes are a complex socio-normative and ethical phenomenon. This study aimed to generate a database of public opinion in Israel concerning EoL processes and decisions and to identify differences in attitudes across subgroups in the population, particularly based on experience as a family caregiver of a dying patient.

METHODS

This cross-sectional study was performed in late March 2022. The study utilized an online sample of 605 adults over the age of 50 including those who accompanied a loved one to their death in the last 3 years. Participants were requested to provide their opinions and attitudes on several aspects of EoL decisions, including truth-telling, medically assisted dying, EoL procedures, pre-death actions, and family caregivers' engagement.

RESULTS

While only 27% and ∼30% of participants support artificial respiration or feeding (respectively) of terminally ill patients, 66% support analgesic treatment, even at the risk of shortening life. The data show an association between religiosity and agreement with life-extending procedures. For example, while 83% of seculars support medically assisted dying, only 59% and 26% of traditional and religious respondents support it. However, no statistically significant differences were observed in support of family involvement in EoL process in any sociodemographic variable.

SIGNIFICANCE OF RESULTS

The results of this study suggest that the Israeli public is relatively polarized on several issues about EoL processes, specifically patient autonomy and medically assisted dying. Yet, at the same time, there is a consensus among the Israeli public about certain EoL elements, particularly the importance of family caregivers in the EoL decision-making process.

Characteristics Associated With Mexican-American Hospice Use: Retrospective Cohort Study Using the Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE)

BACKGROUND

Hospice use is lower among ethnic/racial minorities in the United States, though little is known about trends, associated factors and duration of hospice use by Mexican-Americans.

AIM

The purpose of this study is to examine Mexican-American characteristics associated with hospice stay, both ≤ and > 7 days.

DESIGN

This retrospective cohort study used data from the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE) and the Centers for Medicare and Medicaid Services. Multivariate logistic regression models were used to estimate the ORs and 95% CIs for hospice stay among Mexican-Americans, both ≤ and > 7 days.

SETTING AND PARTICIPANTS

The first cohort (N = 970) includes H-EPESE participants who died between 2004 and 2016 who had Medicare parts A and B. The second cohort (N = 403) includes participants who completed the H-EPESE survey within the last 2 years of life.

RESULTS

Although hospice use increased among Mexican-Americans between 2004 and 2016 (OR 1.88, 95% CI 1.19-2.97), 38% of participants died within the first week of hospice care. Mexican-Americans in New Mexico and Arizona were 2-4 times more likely to use hospice than those in Texas and Colorado. Dementia was associated with hospice use (OR 1.47, 95% CI 1.11-1.94). Characteristics, like church attendance and living alone, were not associated with hospice use.

CONCLUSIONS

The substantial proportion of Mexican-Americans with 7 days or less of hospice use underscores the need for early palliative/hospice intervention to mitigate variation in use.

South African speech-language therapists' practices regarding feeding tube placement in people with advanced dementia

BACKGROUND

 Studies related to tube feeding in people with dementia (PWD) remain a contested topic, neglecting the importance of speech-language therapists' (SLTs) role in dysphagia management. Furthermore, SLT practices and beliefs regarding tube feeding in people with advanced dementia in an upper-middle-income country, such as South Africa, are unexplored.

OBJECTIVE

 This study aimed to determine the practices and beliefs of SLTs in South Africa regarding tube feeding placement in PWD.

METHOD

 A self-compiled online survey was distributed using social media platforms and was completed by 83 South African SLTs with experience in swallowing and feeding management of PWD.

RESULTS

 Most SLTs (78.8%) strongly believed they play a vital role in the decision-making regarding feeding tube insertion in PWD. This role is often met with several challenges, such as limited support from other healthcare professionals. Speech-language therapists with more experience and increased involvement in palliative care appeared to be more confident in supporting and counselling families of PWD on tube feeding. Many SLTs still recommend tube feeding despite its known negative consequences for PWD.

CONCLUSION

 The findings indicate a need for continued professional development for South African SLTs on feeding decisions in advanced dementia to increase knowledge and confidence in clinical practice. Speech-language therapists require guidelines by professional bodies and further dialogue amongst healthcare professionals to guide difficult feeding decisions in people with advanced dementia.

Honoring Black Hopes: How to respond when the family is hoping for a miracle

Background: Racial and ethnic disparities in end-of-life healthcare can be reduced by showing physicians how to best respond to a documented underlying cause: African American families’ hopes for a miracle via divine intervention influence their end-of-life medical decisions, like, for example, making them not want to withdraw ventilatory support in cases of poor neurologic prognosis because they are still hoping for God to intervene. 

Methods: Autoethnographic research probing the author’s Spiritual Care experience in this context yields a nuanced, 90-second point-of-care spiritual intervention physicians can use to address the religious aspect of African American families who base end-of-life medical decisions on their hopes for a miracle via divine intervention. Autoethnographic analysis is framed by physician-author, Dr. Jessica Zitter’s documented journey of grappling with this context. The evolution of Dr. Zitter’s responses to miracle-hoping African American families provides a framework for applying autoethnographic analysis to a critical appropriation of the Johns Hopkins “AMEN” communication protocol for families hoping for a miracle. 

Results: The common instinct of white physicians to remain neutral, holding miracle-hoping African American families at arm’s length, rather than supportively engaging their hopes, is shown to be an intellectual ruse for emotional avoidance. A novel, counterintuitive spiritual intervention for the religious aspect of miracle-hoping African American families is integrated into an existing physician communication protocol for responding to families hoping for a miracle with recommendations for utilization of existing communication technology when necessary. 

Conclusion: Properly addressing the religious dimension of African American families hoping for a miracle may help physicians to increase their therapeutic connection with families, decrease their own stress/burnout levels, and eliminate racial and ethnic disparities in end-of-life healthcare. 

Top Ten Tips Palliative Care Clinicians Should Know About Spirituality in Serious Illness

Assessment of spiritual suffering and provision of spiritual care are a central component of palliative care (PC). Unfortunately, many PC clinicians, like most medical providers, have received limited or superficial training in spirituality and spiritual distress. This article, written by a group of spiritual care providers, and other PC and hospice clinicians, offers a more in-depth look at religion and spirituality to help to enhance readers' current skills while offering a practical roadmap for screening for spiritual distress and an overview of partnering with colleagues to ensure patients receive values-aligned spiritual care provision.

When is it considered reasonable to start a risky and uncomfortable treatment in critically ill patients? A random sample online questionnaire study

Background

Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment.

Methods

We performed an anonymous online survey in a random sample of 1,052 participants recruited via email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0–100%.

Results

Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival (0–33% survival) when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients.

Conclusion

No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the “inappropriateness” of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00705-4.

Improving End of Life Cancer Outcomes Through Development and Implementation of a Spiritual Care Advocate Program

BACKGROUND

Explored whether increased support for spiritual concerns between the healthcare team and patients through the provision of a Spiritual Care Advocate (SCA) would improve end of life outcomes in a metastatic cancer population.

DESIGN

Newly diagnosed metastatic cancer patients were recruited at the University of Chicago Medical Center and received spiritual support from a Spiritual Care Advocate during chemotherapy treatments. The final sample consisted of 42 patients (58% of those approached) who completed the baseline survey and had known survival status.

MEASUREMENT

Patients completed pre/post surveys measuring spiritual support and palliative quality of life. Baseline measurements of religious practice and externalizing religious health beliefs were also obtained. Receipt of aggressive EOL care was derived from the electronic medical record.

RESULT

Median age was 61 years, with 48% Black, and predominantly male (62%). Of the 42 patients, 30 (70%) had died by the time of this analysis. Perceived spiritual support from the medical team increased in 47% of those who received non-aggressive EOL care and by 40% in those who received aggressive EOL care (p=0.012). Patient perceptions of spiritual support from the medical community increased from 27% at baseline to 63% (p=0.005) after the SCA intervention. Only 20% of recipients received aggressive treatments at end of life.

CONCLUSION

The SCA model improved the perceived spiritual support between the healthcare team and patients. Although limited by a small sample size, the model was also associated with an improvement in EOL patients' quality of life, spiritual wellbeing, and decreased aggressive EOL care.

Chaplaincy Care in the MICU: Examining the Association Between Spiritual Care and End-of-Life Outcomes

BACKGROUND

Seriously ill patients admitted to the Intensive Care Unit (ICU) experience severe spiritual and existential distress. Patients' surrogate decision makers face the burden of making complex decisions about their loved ones' care. Experienced chaplains may play a role in assisting with decision-making, possibly by aligning patients' values and wishes with treatment plans and avoiding non-beneficial aggressive measures.

OBJECTIVES

To identify associations between chaplaincy care and length of stay (LOS) in the medical ICU (MICU).

METHODS

This was a retrospective observational study of usual spiritual care in the adult MICUs of 4 medical centers in the United States over a 3-month period. Inclusion criteria were death in the MICU or discharge to palliative care or hospice. Measures included medical, treatment, and spiritual care information. Through bivariate and multivariable analyses associations between spiritual care and LOS were examined.

RESULTS

In multivariable analysis of the 254 patients, receiving spiritual care was associated with an increased likelihood of being in a higher LOS tertile (adjusted odds ratio = 2.94, p < .001). In post hoc bivariate analysis, cases receiving spiritual care within the first 48 hours of MICU admission revealed a trend toward lower LOS (p = .181).

CONCLUSION

Spiritual care in the MICU was associated with longer LOS. Early intervention by chaplains who are well-integrated in the ICU may assist patients and their loved ones in coming to terms with grave illness and making difficult treatment decisions. Further well-designed studies of spiritual care interventions that may affect outcomes are needed.

Proposing religiously informed, relationally skillful chaplaincy theory

Research on the multiple uses of religion/spirituality (R/S) in healthcare and on the practices of healthcare chaplaincy support creation of a middle-range, prescriptive theory for chaplaincy for patients who use R/S in their healthcare experiences. Religiously Informed, Relationally Skillful Chaplaincy Theory (RIRSCT) seeks to integrate research into practice in order to improve spiritual care and allow for testing RIRSCT. The components of RIRSCT are: patients whose religion is a significant part of their worldview often use R/S in healthcare to make meaning, to cope, and to make medical decisions; chaplains should be the members of the healthcare team to assess and address R/S; healthcare teams could provide more personalized treatment by integrating patients' R/S into the treatment plan, which could improve patient experience. This article describes the components of RIRSCT and provides examples of chaplaincy guided by RIRSCT. Selected research articles supporting theory components are reviewed.

Assisted life termination and truth telling to terminally ill patients - a cross-sectional study of public opinions in Israel

BACKGROUND

End-of-life decisions are highly complex socio-normative and ethical phenomena. The goal of this study was to provide an assessment of public opinions in Israel concerning aspects of end-of-life decisions.

METHODS

An online cross sectional study was performed in February 2020. The primary tool including items pertaining to death assistance and truth telling to patients. A sample of 515 participants representative of the adult Israeli population was obtained.

RESULTS

The majority of participants (71%) supports telling the entire truth to patients even in harsh conditions. Support for truth telling decreases with affiliation to religion, with as little as 40% support among ultra-orthodox. People with vocational education are the least supportive of truth telling. Concerning doctor assisted death, almost half (49%) of the sample were supportive. Opposition is positively associated with religiosity, with 90% of ultra-orthodox and 58% of religious participants opposing doctor-assisted death, compared to only 18% among seculars. Non-Jews were 3.35 times (95%CI: 1.90, 5.91) more likely to oppose doctor assisted death than Jews (p < .0001). An Interrelationship analysis crossing between attitudes revealed that the largest group (39%) was comprised of participants who support both ("autonomists").

CONCLUSIONS

Israelis are overwhelmingly supportive of truth telling to patients. In contrast, Israeli public opinions on doctor assisted death are divided. For both attitudes, religiousness plays a crucial role as a catalyst for conservatism and opposition to change. Almost a half of the public is also supportive of an autonomist approach that would allow patients to decide on ending their own lives.

Psychological Attachment Orientations of Surrogate Decision-Makers and Goals-of-Care Decisions for Brain Injury Patients in ICUs

Supplemental Digital Content is available in the text.

To determine whether ICU surrogates with “insecure” psychologic attachment orientations are more prone to requesting tracheostomy and gastrostomy (i.e., life-sustaining therapy) for severe acute brain injury patients with poor prognosis compared to surrogates with “secure” orientations.