End-of-life Decision-making Process Research Articles

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

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. 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. 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. 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.

Do nurses participate in end-of-life decision making?

To explore how Jordanian nurses participate in the end-of-life (EoL) decision-making process. Interviews with 10 patients and family caregivers, and focus group discussions with seven healthcare professionals (HCPs), were conducted. Interviews were audio-recorded, transcribed and analysed following inductive thematic analysis. The participants agreed that nurses are not fully engaged and did not have a direct role in the EoL decision-making process. However, the participants highlighted that 'nurses bridge the gaps in the decision-making process', where nurses act as mediators to facilitate the decision-making process. Lastly, nurses were viewed as 'nurturers and supporters during the journey of the patient's illness'; they were always available to answer their questions, offer help and advise when necessary during palliative referral and throughout the illness. Although nurses did not directly participate in EoL decisions, they have several vital contributions that need to be rearranged into structured decisional coaching.

Exploring physician approaches to conflict resolution in end-of-life decisions in the adult intensive care unit: protocol for a systematic review of qualitative research

IntroductionConflict is unfortunately well-documented in the adult intensive care unit (AICU). In the context of end-of-life (EOL) decision-making (ie, the withdrawal or withholding of life-sustaining treatment), conflict commonly occurs when...

Factors Influencing the Initiative Behavior of Intensive Care Unit Nurses toward End-of-Life Decision Making: A Cross-Sectional Study.

Background: Although the importance of intensive care unit (ICU) nurse initiative in end-of-life (EOL) decision making has been confirmed, there are few studies on the nurses' initiative in EOL situations. Objectives: To explore the role and mechanism of facilitators/barriers and perceived stress on the behavior of ICU nurses that initiate EOL decision making (i.e., initiative behavior). Design: This research adopted a cross-sectional descriptive design. Setting/Participants: A questionnaire composed of demographics, facilitators/barriers scale, perceived stress scale, and initiative behavior for EOL decision-making scale was used for registered ICU nurses in five tertiary general hospitals in Zhejiang Province, China. Results: The average score of the EOL decision initiative behavior was 5.54 on a range of 2-10. The results of correlation analysis indicated that the facilitators promote the initiative behavior, whereas the barriers interfere with initiative behavior. Facilitators/barriers in the EOL decision-making process significantly predicted the initiative behavior of ICU nurses in decision making (β = 0.698, p < 0.001). Facilitators/barriers had a significant indirect effect on the initiative behavior of ICU nurses through perceived stress. The 95% confidence interval was (-0.327 to -0.031), and the mediating effect of perceived stress accounted for 6.31% of the total effect. Conclusion: In the EOL context, the decision initiative of ICU nurses was at a medium level. Medical managers should implement intervention strategies based on the path that affects the initiative behavior of ICU nurses to reduce barriers and stress level in the decision-making process. That is, they should improve inter-team collaboration, nurse-patient communication, clarity of role responsibilities, and emotional support in dying situations to increase initiative and participation of ICU nurses in decision making.

Physician Approaches to Addressing Conflict Arising in End-of-Life Decision-Making in the Adult Intensive Care Unit: A Systematic Review

"Background: Conflict is unfortunately well-documented in the adult intensive care unit (AICU). In the context of end-of-life (EOL) decision-making (i.e. the withdrawal or withholding of life-sustaining treatment), conflict commonly occurs when a consensus cannot be reached between the healthcare team and the patient’s family on the “best interests” of the critically ill, incapacitated patient, as per England’s Mental Capacity Act 2005. Whilst existing literature has identified potential routes for conflict resolution, it is less clear how these approaches are perceived and utilised by stakeholders in the EOL decision-making process. Aim: We aim to explore this by systematically reviewing and synthesising the published evidence, which addresses the following research question: what does existing qualitative research reveal about physician approaches to addressing conflict arising in EOL decisions in the AICU? Methods: Peer-reviewed qualitative studies (retrieved from MEDLINE, Project Muse, EMBASE, Web of Science, PsycINFO, CINAHL and LILACS) examining conflict and dispute resolution in the context of EOL decisions in the AICU setting will be included. Two reviewers will independently screen for eligibility and extract data from either all or 10% of the included studies, with a third reviewer independently screening studies of uncertain eligibility. The ‘thematic synthesis’ approach will be utilised to analyse the resulting data (Thomas &amp; Harden, 2008). The systematic review is currently underway, laying the foundations for a larger empirical study, undertaken for a PhD, funded by the Wellcome Trust BABEL (Balancing Best Interests in Healthcare, Ethics, and Law) Collaborative Award. The results will be presented at the conference. "

Integration of BIM and advanced digital technologies to the end of life decision-making process: a paradigm of future opportunities

PurposeAt the end of a building’s lifecycle, there are several limitations to the decision-making process (DMP). There is a lack of data available from the building’s history, the difficulty in assessing the condition of a building and the variety of stakeholders’ needs that have to be satisfied. The purpose of this paper is to answer the question: how would end-of-life (EOL) DMP change when buildings will have been digitally built? The answer will be illustrated through a conceptual framework.Design/methodology/approachA qualitative analysis of the existing literature has been performed to identify the elements within building information modelling (BIM) and advanced digital technologies that could be of support to the DMP. The findings have been collected and summarised in a conceptual framework that has been validated and enhanced through online interviews with industry experts.FindingsThe enhanced framework has identified that BIM technology would bring the benefit of providing the initial digital data source, from which machine learning and data analytics would then extract the relevant data needed to measure accurately the criteria during the analysis of the EOL options put on the table.Originality/valueThe findings of this research could contribute to developing the software modules making the bridge between BIM and machine learning technologies, to implement them in the EOL DMP.

Perceived quality of palliative care in intensive care units among doctors and nurses in Taiwan.

To compare perceptions of various aspects of palliative care for doctors and nurses; and examine factors contributing to perceived quality palliative care in intensive care units (ICUs). A cross-sectional survey study conducted from November to December 2013. Questionnaires used were Knowledge, Attitudinal and Experiential Survey on Advance Directives (ADs), Clarke's Quality of Palliative Care and Nurses' Participation in the end-of-life (EOL) decision-making process. Seven adult medical and surgical ICUs at a medical center in Northern Taiwan. In total, 172 doctors and nurses who worked in adult ICU for more than 3 months. Nurses' and doctors' perception of quality palliative care. Nurses provided better care than doctors in symptom management, comfort care and spiritual care; their participation in EOL decision-making was the sole modifiable contributor to perceived quality palliative care in ICUs (β = 0.24, P < 0.01). Both doctors and nurses had positive attitudes towards ADs (mean = 4.05/10; standard deviation [SD] = 1.38) while their knowledge of ADs was poor (mean = 29.72/40; SD = 3.00). More than half of nurses currently participated in EOL decision-making and over 80% of doctors and nurses agreed both parties should engage in EOL decision-making process. Majority of doctors (83.9%) reckoned nurses agreed with their EOL decisions while a significant percentage (40%) of nurses were uncertain about doctors' decisions (χ2 = 12.07, P < 0.01). Nurses' participation in EOL decision-making and strengthening spiritual care are imperative to rendering quality palliative care in ICUs. Potential disagreements arose during EOL decision-making between doctors and nurses; and insufficient knowledge of ADs should be addressed.

Family Communication about End-of-Life Decisions and the Enactment of the Decision-Maker Role.

End-of-life (EOL) decisions in families are complex and emotional sites of family interaction necessitating family members coordinate roles in the EOL decision-making process. How family members in the United States enact the decision-maker role in EOL decision situations was examined through in-depth interviews with 22 individuals who participated in EOL decision-making for a family member. A number of themes emerged from the data with regard to the enactment of the decision-maker role. Families varied in how decision makers enacted the role in relation to collective family input, with consulting, informing and collaborating as different patterns of behavior. Formal family roles along with gender- and age-based roles shaped who took on the decision-maker role. Additionally, both family members and medical professionals facilitated or undermined the decision-maker’s role enactment. Understanding the structure and enactment of the decision-maker role in family interaction provides insight into how individuals and/or family members perform the decision-making role within a cultural context that values autonomy and self-determination in combination with collective family action in EOL decision-making.

Practices of end-of-life decisions in 66 southern French ICUs 4 years after an official legal framework: A 1-day audit

ObjectiveSince the implementation of two French laws in 2002 and 2005 and the implementation of guidelines about End-of-Life (EoL) decisions, few studies concerning EoL practices in French intensive care units (ICUs) have been reported. This study was aimed at assessing compliance with recommendations and current legislation concerning EoL decisions. MethodProspective observational study based on 1-day audit conducted from January to May 2009 in 66 southern French ICUs. ResultsSix hundred and twenty-five patients were included (median age: 63 [52–76] years, median SAPS II: 46 [34–58]). The written designation of a surrogate decision-maker was reported for 87 (15%) patients. Advance directives were completed for only 4% of patients. The EoL decision-making process consisted in a multidisciplinary approach for 99 (47%) patients and was recorded in the medical chart for 63 (64%) cases. Families were informed about medical decisions in 58% of cases. This proportion was higher (87%) if a decision to forego life-sustaining therapy was made. EoL decisions consisted of withholding treatments for 72 (94%) patients and withdrawal of treatments for 5 (6%) patients. In the multivariate stepwise logistic regression, four variables were independently associated with a decision to forego life support: preexisting dependence on others (P<0.0001), advance directives (P=0.01), age (P=0.008) and the SAPS 2 score (P=0.009). ConclusionThe major finding of the present study is the existence of a gap between the widely approved EoL recommendations made by scientific societies and the daily practice of southern French ICUs. Even if EoL decisions are mostly shared with relatives, their written documentation in medical charts remains insufficient. Concerning EoL practices, the withdrawal of treatment remains an uncommon decision.

ABSTRACT 21

Background and aims: Treatment of an individual critically ill patient during intensive care treatment may at some point become hopeless. Aims: To determine characteristics of end-of-life decision making (EOLDM) in the Slovene Pediatric and Adult Intensive Care Units (ICUs). Methods: Prospective clinical study in the three-month period in 2013 was performed in all 34 Slovene ICUs. The study was approved by the Slovene National Medical Ethics Committee. IBM® SPSS® Statistics 20 (IBM Corp., Somers, NY, USA) was used for statistical analysis; p value significance level was determined at p≤0.001. Results: Completed forms were obtained from 33 out of 34 ICUs. 4226 patients were included in the study. Overall mortality rate in patients admitted was 10.8%. In 112 patients (2.7% of all admitted patients and 24.6% of those who died in the ICU) an EOLDM process have been made. No differences were found in EOLDMs between adult (medical or surgical) and paediatric ICUs. The advance directive in adult ICUs was used in 2.2%. Initiative for EOLDMs was taken by the physicians in 96.2% and relatives were actively involved in 61.8%. Two and a half days passed from the EOLDMs to the death in ICU. Do-not-resuscitate order was most commonly used during withholding of treatment, and inotropes/vasopresors were most commonly withdrawn. In 72.3% of the cases palliative care was included. Conclusions: EOLDM was regularly applied in the Slovene ICUs, but not as frequently as in some other European countries. Among adult medical or surgical and pediatric ICUs we haven’t found any significant difference in EOLDMs.

Perceived role in end-of-life decision making in the NICU affects long-term parental grief response

BackgroundShared decision making (DM) is increasingly advocated as the most appropriate model to support parents confronted with end-of-life (EoL) decisions for a child in the neonatal intensive care unit (NICU)....

A new method for evaluating the best product end-of-life strategy during the early design phase

The choice of an appropriate end-of-life (EOL) destination for discarded products is becoming an important issue for most manufactured products, given the current problems of environmental waste impact and landfill saturation. To address these issues, the design of a product must be optimised with a view to incorporating in that product an environmentally sustainable EOL scenario that respects economic and legislative constraints. The new EOL scenario evaluation method (ELSEM) that we propose in this paper takes these fundamental aspects into account, and provides a method for evaluating the various options for the EOL scenario of a product during early design phase. The ELSEM provides a simple and intuitive tool for designers to help them construct arguments for the EOL decision-making process. It is built using the fuzzy technique for order preference by similarity to ideal solution method, a multi-criteria decision process that is highly appropriate in the uncertain and subjective environment in which the designer works during the early stages of product development. Our method is illustrated with a case study involving a vehicle engine.

The physician's professional role in end-of-life decision-making: Voices of racially and ethnically diverse physicians

Objective Previous studies have shown racial/ethnic differences in preferences for end-of-life (EOL) care. We aimed to describe values and beliefs guiding physicians’ EOL decision-making and explore the relationship between physicians’ race/ethnicity and their decision-making. Methods Seven focus groups (3 Caucasian, 2 African American, 2 Hispanic) with internists and subspecialists ( n = 26) were conducted. Investigators independently analyzed transcripts, assigned codes, compared findings, reconciled differences, and developed themes. Results Four themes appeared to transcend physicians’ race/ethnicity: (1) strong support for the physician's role; (2) responding to “unreasonable” requests; (3) organizational factors; and (4) physician training and comfort with discussing EOL care. Five themes physicians seemed to manage differently based on race/ethnicity: (1) preventing and reducing the burden of surrogate decision-making; (2) responding to requests for “doing everything;” (3) influence of physician–patient racial/ethnic concordance/discordance; (4) cultural differences concerning truth-telling; and (5) spirituality and religious beliefs. Conclusions Physicians in our multi-racial/ethnic sample emphasized their commitment to their professional role in EOL decision-making. Implicitly invoking the professional virtue of self-effacement, they were able to identify racially/ethnically common and diverse ethical challenges of EOL decision-making. Practice implications Physicians should use professional virtues to tailor the EOL decision-making process in response to patients’ race/ethnicity, based on patients’ preferences.

An interactive educational workshop to improve end of life communication skills

An understanding of legal, ethical, and cultural concerns and an ability to communicate when faced with clinical dilemmas are integral to the end of life decision-making process. Yet teaching practicing clinicians these important skills in addressing conflict situations is not strongly emphasized. A one-day interactive continuing education workshop was designed to improve interactions among multiprofessional intensive care unit (ICU) clinicians, their colleagues, and families in a range of end of life situations using standardized families and colleagues (SF/SCs). Workshop participants completed preworkshop and postworkshop evaluations. Data were analyzed using the McNemar test for paired categorical data to evaluate changes in comfort, knowledge, and skill. The majority of evaluation respondents were nursing professionals, while only one physician (of two in attendance) responded. Statistically significant improvement was seen in all comfort levels, except when approaching cultural differences. Expectations were exceeded according to 76.2% of responses, while 82.4% rated SF/SCs "excellent" for improving communication skills and comfort levels with ethical and legal dilemmas. Peer discussions were highly valued in meeting educational objectives (95.2% good or excellent), and 95.2% rated achievement of personal learning objectives good or excellent. Qualitative data supported a high overall perception of success and achievement of educational objectives. An interactive workshop can be a valuable educational intervention for building capacity and confidence in end of life communication skills and ethical and legal knowledge for health care providers; further physician involvement is required to extrapolate results to this population.

Residents?? End-of-Life Decision Making with Adult Hospitalized Patients: A Review of the Literature

The authors performed a structured literature review to understand residents' experiences with end-of-life (EOL) decision making with adult hospitalized patients, specifically regarding decisions to withhold or withdraw advanced life-support measures. An Ovid-based strategy was used to search Medline, ERIC, PsychINFO, and CINHAL databases for articles published between 1966 and February 2005, combining the domains of "resuscitation orders," "decision making," and "internship and residency." All quantitative and qualitative studies examining residents' EOL decision making with adult hospitalized patients were included. The authors developed and applied a scoring system for relevance and quality, performed data abstraction and quality assessment independently and in duplicate, then met to collate findings and identify factors in residents' EOL decision making. The searches yielded 884 articles, of which 26 were included. Variable methodologies precluded meta-analysis. In these studies, residents felt unprepared to handle patient EOL decision making, although exposure to EOL discussions helped them gain confidence. Residents' attitudes, skills, and knowledge were key determinants of whether EOL decisions were addressed. Many misinterpreted the terms "DNR" and "futility." Residents' understanding of the patient EOL decision-making process could be extremely variable, and their do-not-resuscitate discussions suboptimal. Residents' lived practice experience of the patient EOL decision-making process was often at odds with what they were taught in formal curricula. Educational strategies aimed at changing residents' knowledge, skills and attitude should address the hidden curriculum for the patient EOL decision-making process that is part of the experienced culture of every day practice. Future studies of this experienced culture would inform specific educational interventions.