Acute Care Decision-Making for Patients with Advanced Dementia: An Exploratory Study Using Cognitive Task Analysis

Abstract

Decision-making by medical and health care staff forms the core of professional practice. Thought processes, including non-clinical considerations, significantly impact how clinical decisions are made. Such considerations become more relevant when addressing end-of-life care decisions for patients with advanced dementia (PAD). Though palliative care is recommended for this population, its implementation tends to vary. Given the medical staff’s significant influence in guiding clinical decisions, we examined thought processes that accompany staff decisions. We used Cognitive Task Analysis (CTA) to analyze interviews conducted with 15 physicians and 11 nurses working in acute care wards in Central Israel. Participants were interviewed regarding their clinical decision-making in a hypothetical scenario of a PAD who presents with an acute, potentially life-threatening medical problem. Moral judgment orientation was the primary factor affecting clinical decision-making for advanced dementia, with a pronounced dichotomous split between deontological and utilitarian approaches. This polarization was highly associated with the medical specialty. Practitioners in surgical wards tended to focus on the patient’s current medical condition, as an isolated or disease-centered illness perspective, supported by deontological moral lines of thinking. This perspective was contrary to that of staff in medical wards who mostly treated the patient from a holistic perspective with a patient-focus approach, supported by utilitarian moral lines of thinking. Although all respondents presented the patient or family as primary decision partners, the practitioners were motivated to make decisions based on unit hierarchies or positions of authority figures. Therefore, clinical end-of-life decisions are influenced by different thinking processes of the health staff and several non-clinical factors. The moral thinking paradigm was found to be associated with a professional orientation. Understanding the subjective, non-clinical aspects of decision-making for PAD might improve end-of-life care in this population.

Practice of end-of-life care for patients with advanced dementia by hospital physicians and nurses: Comparison between medical and surgical wards

“… Nabozny et al (2016) found that internists were more than twice as likely to base treatment decisions on quality of life than surgeons. This finding is reinforced by the findings from the qualitative part of this study ( Erel et al, 2021a ). The majority of medical ward staffs perceived quality of life and the palliative care approach as the most appropriate care, while the surgical ward staffs perceived aggressive care (surgical intervention) to be best.…”

“…Many surgical cases may be perceived as potentially treatable and reversible with a better prognosis, such as the removal of a benign tumor. Two studies comparing medical to surgical staff found an association between medical education and goals of care ( Erel et al, 2021a ; Nabozny et al, 2016 ). Nabozny et al (2016) found that internists were more than twice as likely to base treatment decisions on quality of life than surgeons.…”

“…This questionnaire was part of a larger study that used a mixed methods methodology aimed at investigating the decision-making process and cognitive biases related to care of patients with advanced dementia among healthcare workers in acute care hospitals. The qualitative part of the research was published previously (Erel et al, 2021a(Erel et al, , 2021b.…”

Do Perceptions about Palliative Care Affect Emergency Decisions of Health Personnel for Patients with Advanced Dementia?

“…This is a cross sectional survey, part of a mixed-methods (qualitative/quantitative) research study that evaluates preferences of physicians and nurses regarding treatment choices, including PC, for patients with AD under acute care settings. The qualitative part of the study included an interview assessing the thought processes involved in decision-making regarding a hypothetical case scenario of a patient with AD who presents with bowel obstruction related to a space-occupying lesion [ 18 ].…”

“…Health personnel who consider care options that do not follow this approach may receive negative responses from their peers, which can lead to suppressing their initial intentions [ 16 , 17 ]. Factors associated with this approach are related to legal concerns, hierarchical and organizational authority, and responses of patient’s relatives [ 12 , 13 , 18 ].…”