Decision‐making for older patients by Australian and New Zealand doctors with Advance Care Directives: a vignette‐based study

Mitropoulos, Joanna; Austin, Nicole; Hunter, Peter; Cairney, H; Parikh, Seema

doi:10.1111/imj.14263

Cited by 5 publications

(5 citation statements)

References 17 publications

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“…The technical training of health professionals in the area of end-of-life care , [ 15 , 21 , 28 , 39 , 45 , 46 , 53 , 60 , 62 , 63 ] which includes experience in this area of expertise, technical knowledge of symptom control and the knowledge of the ethical-legal aspect of the proposed conduct, [ 39 , 62 ] appears as a negative influence on decision-making due to a deficit in this learning, which shows a fragility in the formation and dissemination of this theme, especially in the practical aspect. The communication skill [ 26 , 30 , 42 , 46 , 48 , 56 , 62 ] mainly mentioned in relation to the training in this type of scenario is a strong influencing factor in decision-making.…”

Section: Discussionmentioning

confidence: 99%

The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review

Silva

Corradi-Perini

2023

IJPC

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Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword ‘clinical decision-making’ AND ‘terminal care’ OR ‘end-of-life care’ and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.

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Section: Discussionmentioning

confidence: 99%

The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review

Silva

Corradi-Perini

2023

IJPC

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“…Limited knowledge about what constitutes a legally binding ACD and the circumstances in which ACDs should be followed has been previously reported in studies involving doctors, medical students and allied health professionals [37,47,48]. In a previous vignette study of decisions involving the use of ACDs by Australian and New Zealand doctors, agreement on treatment decisions varied according to the vignette complexity, ACD content, speciality and seniority of the doctor [35]. Doctors have identified subjective terminology, prognostic uncertainty, questionable validity and currency, family opposition, as well as time pressures as key barriers to ACD implementation [32,38].…”

Section: Discussionmentioning

confidence: 99%

“…Variation in adherence to ACDs is attributed to an array of factors including doctors' specialty and experience, their attitudes towards ACDs, and their knowledge of the law [30,32]. While knowledge of the law related to ACDs can vary according to specialty, significant gaps remain [33][34][35][36]. Doctors often prioritise patient-related clinical and ethical considerations over the law when making medical decisions at the end of life [37].…”

Section: Introductionmentioning

confidence: 99%

Junior medical doctors’ decision making when using advance care directives to guide treatment for people with dementia: a cross-sectional vignette study

et al. 2022

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Background Junior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors’ decision-making processes when treating people with dementia who have advance care directives (ACDs), or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: (1) their legal compliance and decision-making process related to treatment decisions; (2) the factors influencing their clinical decision-making; and (3) the factors associated with accurate responses to one hypothetical vignette. Method A cross-sectional survey of junior doctors, including trainees, interns, registrars and residents, on clinical rotation in five public hospitals located in one Australian state. The anonymous, investigator-developed survey was conducted between August 2018 and June 2019. Two hypothetical vignettes describing patients with dementia presenting to hospital with an ACD and either: (1) bacterial pneumonia; or (2) suspected stroke were presented in the survey. Participants were asked to indicate whether they would commence treatment, given the ACD instructions described in each vignette. Results Overall, 116 junior doctors responded (35% consent rate). In Vignette 1, 58% of respondents (n = 67/116) selected the legally compliant option (i.e. not commence treatment). Participants who chose the legally compliant option perceived ‘following patient wishes’ (n = 32/67; 48%) and ‘legal requirements to follow ACDs’ (n = 32/67; 48%) as equally important reasons for complying with the ACD. The most common reason for not selecting the legally compliant option in Vignette 1 was the ‘ACD is relevant in my decision-making process, but other factors are more relevant’ (n = 14/37; 38%). In Vignette 2, 72% of respondents (n = 83/116) indicated they would commence treatment (i.e. not follow the ACD) and 18% (n = 21/116) selected they would not commence treatment. (i.e. follow the ACD). Similar reasons influenced participant decision-making in Vignette 2, a less legally certain scenario. Conclusions There are critical gaps in junior doctors’ compliance with the law as it relates to the implementation of ACDs. Despite there being differences in relation to the legal answer and its certainty, clinical and ethical factors guided decision-making over and above the law in both vignettes. More education and training to guide junior doctors’ clinical decision-making and ensure compliance with the law is required.

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“…A cross-sectional survey vignette study (14)(15)(16)(17) was conducted between March 2020 and March 2021. To determine variation in pre-pregnancy counselling between medical specialists in the Netherlands, five clinical vignettes were constructed.…”

Section: Methodsmentioning

confidence: 99%

Counselling on Conceiving: Attitudes and Factors Influencing Advice of Professionals in Transplantation

Buren

Gosselink²,

Massey

et al. 2023

Transpl Int

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Pregnancy after kidney transplantation (KT) conveys risks of adverse pregnancy outcomes (APO). Little is known about performance of pre-pregnancy counselling after KT. This study investigated perceptions of risk, attitudes towards pregnancy and factors influencing advice given at pre-pregnancy counselling after KT. A web-based vignette survey was conducted among nephrologists and gynaecologists between March 2020 and March 2021, consisting of five vignettes containing known risk factors for APO and general questions on pre-pregnancy counselling after KT. Per vignette, attitudes towards pregnancy and estimation of outcomes were examined. In total 52 nephrologists and 25 gynaecologists participated, 56% from university hospitals. One third had no experience with pregnancy after KT. All gave positive pregnancy advice in the vignette with ideal circumstances (V1), versus 83% in V2 (proteinuria), 81% in V3 (hypertension), 71% in V4 (eGFR 40 ml/min/1.73 m2). Only 2% was positive in V5 (worst-case scenario). Chance of preeclampsia was underestimated by 89% in V1. 63% and 98% overestimated risk for graft loss in V4 and V5. Professionals often incorrectly estimated risk of APO after KT. As experience with pregnancy after KT was limited among professionals, patients should be referred to specialised centres for multidisciplinary pre-pregnancy counselling to build experience and increase consistency in given advice.

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Decision‐making for older patients by Australian and New Zealand doctors with Advance Care Directives: a vignette‐based study

Cited by 5 publications

References 17 publications

The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review

The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review

Junior medical doctors’ decision making when using advance care directives to guide treatment for people with dementia: a cross-sectional vignette study

Counselling on Conceiving: Attitudes and Factors Influencing Advice of Professionals in Transplantation

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