Knowledge, Opinion, and Attitude About the Italian Law on Advance Directives: A Population-Based Survey

User appraisal of a booklet for advance care planning in multiple sclerosis: a multicenter, qualitative Italian study

OBJECTIVES

Implementation of advance care planning (ACP) in people with progressive multiple sclerosis (PwPMS) is limited. We aimed to involve users (PwPMS, significant others, and healthcare professionals involved in PwPMS care) in the evaluation and refinement of a booklet to be used during the ACP conversations.

METHODS

This qualitative study consisted of cognitive interviews with PwPMS and significant others and a focus group with healthcare professionals from three Italian centers. We analyzed the interviews using the framework method and the focus group using thematic analysis.

RESULTS

We interviewed 10 PwPMS (3 women; median age 54 years; median Expanded Disability Status Scale score 6.0) and three significant others (2 women; 2 spouses and one daughter). The analysis yielded three themes: booklet comprehensibility and clarity, content acceptability and emotional impact, and suggestions for improvement. Twelve healthcare professionals (7 neurologists, 3 psychologists, one nurse, and one physiotherapist) participated in the focus group, whose analysis identified two themes: booklet's content importance and clarity and challenges to ACP implementation. Based on analysis results, we revised the booklet (text, layout, and pictures) and held a second-round interviews with two PwPMS and one significant other. The interviewees agreed on the revisions but reaffirmed their difficulty in dealing with the topic and the need for a physician when using the booklet.

CONCLUSIONS

Appraisal of the booklet was instrumental in improving its acceptability and understandability before using it in the ConCure-SM feasibility trial. Furthermore, our data reveal a lack of familiarity with ACP practice in the Italian context.

Towards the implementation of law n. 219/2017 on informed consent and advance directives for patients with psychiatric disorders and dementia. Physicians' knowledge, attitudes and practices in four northern Italian health care facilities

BACKGROUND

On December 2017 the Italian Parliament approved law n. 219/2017 "Provisions for informed consent and advance directives" regarding challenging legal and bioethical issues related to healthcare decisions and end-of life choices. The law promotes the person's autonomy as a right and provides for the centrality of the individual in every scenario of health care by mean of three tools: informed consent, shared care planning and advance directives. Few years after the approval of the law, we conducted a survey among physicians working in four health care facilities specific for the care of people suffering from psychiatric disorders, cognitive disorders and dementia located in the North of Italy aiming to investigate their perceived knowledge and training need, attitudes regarding law n. 219/2017 provisions, and practices of implementation of the law.

METHODS

A semi-structured questionnaire was developed on an online platform. The invitation to participate in the survey was sent by email to the potential participants. Information was collected by means of the online platform (Google Forms) which allows to export data in a spreadsheet (Windows Excel) to perform basic statistical analysis (frequency distributions, bar chart representation).

RESULTS

Twenty-five out of sixty physicians participated in the survey. None of the respondents value their knowledge of the law as very good, 10 good, 13 neither poor nor good, 1 poor and 1 very poor. All the respondents want to learn more about the law (21 yes and 4 absolutely yes). The majority of respondents agrees with the content of the law as a whole (3 absolutely agree, 13 agree), and on each provision. The question on the clarity of the concept of capacity in the law received mixed answers and this impacted on the physicians' opinion regarding the legitimacy in principle for our groups of patients to realize shared care planning and write advance directives. Thirteen physicians neither introduced the theme of shared care planning nor arranged for shared care planning and the main reason for this was that no patient was in a clinical situation to require it. When shared care planning is realized, a variability in terms of type and number of meetings, mode of tracking and communication is registered.

CONCLUSIONS

Our survey results indicate a need for more clarity regarding the interpretation and implementation of the law in the patient groups under study. There are in particular two related areas that deserve further discussion: (1) the question of whether these patient groups are in principle legitimized by the law to realize shared care planning or write advance directives; (2) the notion of capacity required by the law and how this notion can be declined in real-life situations.

Public awareness of advance care planning and hospice palliative care: a nationwide cross-sectional study in Korea

CONTEXT

Advance care planning (ACP) and hospice palliative care (HPC) have potential benefits for individuals and health systems. Public awareness of them might increase their acceptance.

OBJECTIVES

To examine public awareness of ACP and HPC and related factors including individuals' experience of health care among Korean population.

METHODS

A cross-sectional study based on a nationally representative sample was conducted. Data from participants aged 15 years or older were examined. Socio-demographic characteristics, health-related factors, health care experience in the past year, and awareness of ACP and HPC were analyzed. Subgroup analysis was conducted to determine associations between specific experiences during outpatient visit and awareness of ACP and HPC.

RESULTS

Of a total of 13,546 subjects, 39.3% and 35.7% reported awareness of ACP and HPC, respectively. About half (48.6%) of participants reported that they were completely unaware of ACP or HPC. Recent outpatient visit was positively associated with HPC awareness. Participants were more likely to recognize ACP or HPC if they had experience in hospitalization and health checkup over the past year and had trust in the medical system. Conversely, participants who had inadequate health care access due to cost burden showed low awareness of ACP and HPC.

CONCLUSION

There was a lack of public awareness of ACP and HPC. There were significant differences depending on various factors, especially individual health care experiences. Appropriate interventions are needed to facilitate discussion of ACP and HPC, thereby increasing public awareness.

Italian cross-cultural adaptation of the Quality of Communication questionnaire and the 4-item advance care planning engagement questionnaire

BACKGROUND

Advance care planning (ACP) is influenced by several factors (e.g., patient's readiness to engage, clinician's skills, and the cultural environment). Availability of reliable and valid self-reported measures of the ACP domains is crucial, including cross-cultural equivalence.

AIM

To culturally adapt into Italian the 19-item Quality of Communication (QOC) and the 4-item ACP Engagement (4-item ACP-E) questionnaires.

METHODS

We translated and culturally adapted the two questionnaires and produced a significant other (SO) version of the QOC (QOC-SO). Each questionnaire was field tested via cognitive interviews with users: nine patients (QOC, 4-item ACP-E) and three SOs (QOC-SO) enrolled at three palliative care services.

RESULTS

We made minor changes to 5/19 QOC items, to improve clarity and internal consistency; we changed the response option 'didn't do' into 'not applicable'. Finally, we slightly revised the QOC to adapt it to the paper/electronic format. QOC debriefing revealed that the section on end of life was emotionally challenging for both patients and SOs. We simplified the 4-item ACP-E layout, added a sentence in the introduction, and revised the wording of one item, to improve coherence with the Italian ACP legislation. ACP-E debriefing did not reveal any major issue.

CONCLUSIONS

Results were satisfactory in terms of semantic, conceptual and normative equivalence of both questionnaires. Acceptability was satisfactory for the 4-item ACP-E, while findings of the QOC cognitive debriefing informed a major amendment of a pilot trial protocol on ACP in multiple sclerosis (ConCure-SM): use of the interviewer version only, in an adaptive form. Psychometric testing of both questionnaires on a large, independent sample will follow.

Italian law n. 219/2017 on consent and advance directives: survey among Ethics Committees on their involvement and possible role

Background

On December 2017 the Italian Parliament approved law n. 219/2017 “Provisions for informed consent and advance directives” regarding challenging legal and bioethical issues related to healthcare decisions and end-of-life choices. The law does not contain an explicit reference to Ethics Committees (ECs), but they could still play a role in implementing the law.

Methods

A questionnaire-based survey was performed among the ECs of the Italian Institute for Research and Care belonging to the Network of neuroscience and neurorehabilitation, with the aim of (1) knowing whether the ECs participated and, if so, how in the process of implementation of law n. 219/2017 in the referring institutes; (2) investigating the point of view of the ECs regarding their possible involvement in the process; (3) exploring the contribution ECs can provide to give effective implementation to the law principles and provisions.

Results

Seventeen ECs out of thirty took part in the survey; the characteristics of the responding and non-responding committees are similar, so the responding ECs can be regarded as representative of all ECs in the Network. Nine ECs did not discuss the law in anyway: the main reason for this is that the referring institutions (6) and the health care professionals (3) did not ask for an EC intervention. Nevertheless, the large majority of the ECs believe that their involvement in the implementation of the law as a whole is appropriate (8) or absolutely appropriate (6), while 3 of them are neutral. No EC believes that the involvement is inappropriate. The aspect of the law on which the 14 ECs converge in considering the EC involvement appropriate/absolutely appropriate is the one related to the health facilities obligation to guarantee the full and proper implementation of the principles of the law.

Conclusions

Our survey confirms that ECs believe they can play a role in the implementation of law n. 219/2017, although this does not entirely correspond to what the committees have actually done in reality. This role could be better exercised by ECs specifically established for clinical practice, which would have a composition, functioning and a mandate better suited to the purpose. This supports the call for a national regulation of ECs for clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00858-w.

Patient Safety and Legal Regulations: A Total-Scale Analysis of the Scientific Literature

OBJECTIVE

The aim of the study was to quantitatively analyze the scientific literature landscape covering legal regulations of patient safety.

METHODS

This retrospective bibliometric analysis queried Web of Science database to identify relevant publications. The identified scientific literature was quantitatively evaluated to reveal prevailing study themes, contributing journals, countries, institutions, and authors, as well as citation patterns.

RESULTS

The identified 1295 publications had a mean of 13.8 citations per publication and an h-index of 57. Approximately 78.8% of them were published since 2010, with the United States being the top contributor and having the greatest publication growth. A total of 79.2% (n = 1025) of the publications were original articles, and 12.5% (n = 162) were reviews. The top authors (by number of publications published on the topic) were based in the United States and Spain and formed 3 collaboration clusters. The top institutions by number of published articles were mainly based in the United States and United Kingdom, with Harvard University being on top. Internal medicine, surgery, and nursing were the most recurring clinical disciplines. Among 4 distinct approaches to improve patient safety, reforms of the liability system (n = 91) were most frequently covered, followed by new forms of regulation (n = 73), increasing transparency (n = 67), and financial incentives (n = 38).

CONCLUSIONS

Approximately 78.8% of the publications on patient safety and its legal implications were published since 2010, and the United States was the top contributor. Approximately 79.2% of the publications were original articles, whereas 12.5% were reviews. Healthcare sciences services was the most recurring journal category, with internal medicine, surgery, and nursing being the most recurring clinical disciplines. Key relevant laws around the globe were identified from the literature set, with some examples highlighted from the United States, Germany, Italy, France, Sweden, Poland, and Indonesia. Our findings highlight the evolving nature and the diversity of legislative regulations at international scale and underline the importance of healthcare workers to be aware of the development and latest advancement in this field and to understand that different requirements are established in different jurisdictions so as to safeguard the necessary standards of patient safety.

Study protocol on advance care planning in multiple sclerosis (ConCure-SM): intervention construction and multicentre feasibility trial

INTRODUCTION

Multiple sclerosis (MS) is the most common cause of progressive neurological disability in young adults. The use of advance care planning (ACP) for people with progressive MS (pwPMS) remains limited. The ConCure-SM project aims to assess the effectiveness of a structured ACP intervention for pwPMS. The intervention consists of a training programme on ACP for healthcare professionals caring for pwPMS, and a booklet to be used during the ACP conversation. Herein, we describe the first two project phases.

METHODS

In phase 1 we translated and adapted, to the Italian legislation and MS context, the ACP booklet of the National ACP Programme for New Zealand. Acceptability, comprehensibility and usefulness of the booklet were assessed via 13 personal cognitive interviews with pwPMS and significant others (SOs), and one health professional focus group. Based on these findings, we will revise the booklet. In phase 2 we will conduct a single-arm pilot/feasibility trial with nested qualitative study. Participants will be 40 pwPMS, their SOs, health professionals from six MS and rehabilitation centres in Italy. In the 6 months following the ACP conversation, we will assess completion of an advance care plan document (primary outcome), as well as safety of the intervention. Secondary outcomes will be a range of measures to capture the full process of ACP; patient-carer congruence in treatment preferences; quality of patient-clinician communication and caregiver burden. A qualitative process evaluation will help understand the factors likely to influence future implementation and scalability of the intervention.

ETHICS AND DISSEMINATION

The project is coleaded by a neurologist and a bioethicist. Phase 1 has received ethical approvals from each participating centre, while phase 2 will be submitted to the centres in May 2021. Findings from both phases will be disseminated widely through peer-reviewed publications, conferences and workshops.

TRIAL REGISTRATION NUMBER

ISRCTN48527663; Pre-results.

Development and psychometric properties of the general public's attitudes toward advance care directives scale in Portugal

Background: To date, no instrument in Portugal has evaluated the attitudes of the population about advance care directives. This paper describes the development and testing of the General Public's Attitudes Toward Advance Care Directives (GPATACD) Scale. Design and Methods: Methodological study. The development of the instrument was based on a literature review, updated in 2018. Face and content validity were verified by an expert panel and piloted among six participants. Data were collected in an online survey of 1024 Portuguese adults. The obtained data were analyzed using Varimax rotation, while the reliability was evaluated by calculating Cronbach's alpha. Results: The scale achieves good Item-Content Validity Index (I-CVI) values, between 0.89 and 1.00, and scale-CVI values of 0.91. A principal component analysis generated four dimensions with 26 items as a final scale, with overall Cronbach's alpha of 0.848. Conclusions: The findings demonstrate that the scale is valid and reliable as a vehicle for assessment of the general public's attitudes toward advance care directives.