Factors Which Influence Hospital Doctors' Advance Care Plan Adherence

Craig, Denise; Ray, Robin; Harvey, Desley; Shircore, Mandy

doi:10.1016/j.jpainsymman.2019.12.008

Cited by 6 publications

(7 citation statements)

References 27 publications

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“…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]. Notably, the majority of the sample was comprised of junior doctors (interns and residents), a group that have received less training and perhaps less exposure to these types of situations.…”

Section: Discussionmentioning

confidence: 99%

“…In New South Wales (NSW), an instructional ACD is recognised by common law, and the legal appointment of a SDM both by the person in advance of them losing capacity and by a tribunal is recognised [29,31]. 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].…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

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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“…Patients and family members both referred to the beliefs that they are powerless in facing death and that ACP discussion was unethical and uncertain on health (Cheung et al 2020;Greutmann et al 2013;Knauft et al 2005;Li and Li 2016) and that concentrating on staying alive was a preferable response (Cheung et al 2020;Greutmann et al 2013;Knauft et al 2005;Steiner et al 2019;Van den Heuvel et al 2016). Physicians' beliefs impeding their involvement in ACP included affording it lower priority and considering it to be time-consuming (Hutchison et al 2017;Van den Heuvel et al 2016), the role of a physician is to treat the illness (Curtis and Patrick 1997;Ladin et al 2021) and that end-of-life care discussion was best done by other experts (Cai et al 2023;Craig et al 2020;Greutmann et al 2013;Hutchison et al 2017;Steiner et al 2020;Van den Heuvel et al 2016).…”

Section: Personal Beliefmentioning

confidence: 99%

What makes advance care planning discussion so difficult? A systematic review of the factors of advance care planning in healthcare settings

Suen,

Chow,

Woo

et al. 2024

Pall Supp Care

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Objectives Existing systematic reviews related to advance care planning (ACP) largely focus on specific groups and intervention efficacy or are limited to contextual factors. This research aims to identify the modifiable factors perceived by different users of ACP in healthcare settings and inform healthcare professionals about the factors affecting ACP practice. Methods Five English-language databases (ProQuest, PubMed, CINAHL Plus, Scopus, and Medline) and two Chinese-language databases (CNKI and NCL) were searched up to November 2022. Empirical research identifying factors related to ACP in healthcare settings was included. ACP is defined as a discussion process on future end-of-life care. Thematic synthesis was performed on all included studies. Results A total of 1871 unique articles were screened; the full texts of 193 were assessed by 4 reviewers, and 45 articles were included for analysis. Twenty-two (54%) studies were qualitative, 15 (33%) were quantitative, and 6 (13%) used mixed methods. Foci varied from 28 (62%) studies on a single subject group (either patient, family, or physician), 11 (25%) on 2 subject groups (either patient and family or patient and healthcare professional), and 6 (13%) covered 3 subject groups (patient, family, and healthcare professional). Among the 17 studies involving more than 1 subject group, only 2 adopted a dyadic lens in analysis. Complex interwoven factors were categorized into (1) intrapersonal factors, (2) interpersonal factors, and (3) socio-environmental factors, with a total of 11 themes: personal belief, emotions, the burden on others, timing, responsiveness, relationship, family dynamics, experience, person taking the lead, culture, and support. Significance of results Patients, families, and healthcare professionals are the essential stakeholders of ACP in healthcare settings. Factors are interweaved among the intrapersonal, interpersonal, and socio-environmental dimensions. Research is warranted to examine the dynamic interactions of the 3 essential stakeholders from a multidimensional perspective, and the mechanism of the interweaving of factors.

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“…16 In so doing, the focus of the inpatients’ hospitalisation may transcend the question of what is wrong with the patient, to what matters most to the patient. However, a recent scoping review of hospital doctors’ application of ACP 17 to medical decision-making indicated that although doctors held largely positive attitudes towards ACPs, they prefer temporal decision-making and often do not read patients’ ACPs.…”

Section: Introductionmentioning

confidence: 99%

Advance Care Plans and the Potentially Conflicting Interests of Bedside Patient Agents: A Thematic Analysis

Craig¹,

Ray²,

Harvey³

et al. 2021

JMDH

Self Cite

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Aim People diagnosed with a neurodegenerative disorder often contend with a threat to independence and control, leading some to complete an advance care plan. Advance care plans are commonly associated with treatment limitations; however, key patient agents (such as doctors, allied health, nurses and family) may instead make temporal, best interests or good medical practice decisions on behalf of the patient. Accordingly, there is a need to better understand ancillary decision-maker’s perspectives, particularly of doctors. Purpose To explain how the potentially conflicting interests of bedside patient agents operates as a factor which influences doctors’ application of advance care plans of people with a neurodegenerative disorder. Participants and Methods Using a constructivist grounded theory informed thematic analysis, 38 semi-structured interviews were conducted with hospital-based doctors, allied health, nurses and family of people with a neurodegenerative disorder who had an advance care plan. Data were inductively analysed using open and focused coding. Results Analysis revealed two main themes: dynamics of discerning best interests; and avoiding conflict. Rather than applying advance care plans, doctors largely involved families to attempt best interests decision-making partnerships on patients’ behalf. Bedside agents demonstrated significant intra and interpersonal challenges associated with their roles as patient agents. Doctors appeared protective of families and patients with neurodegenerative disorder. Conclusion Although bedside agents value advance care plans, doctors often favour temporal healthcare decisions in consultation with family. We suggest there are limitations to the effectiveness of advance care plans in practice, with application typically only occurring close to death. Despite the intentions of advance care planning, bedside agents may still experience considerable dissonance.

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Factors Which Influence Hospital Doctors' Advance Care Plan Adherence

Cited by 6 publications

References 27 publications

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

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

What makes advance care planning discussion so difficult? A systematic review of the factors of advance care planning in healthcare settings

Advance Care Plans and the Potentially Conflicting Interests of Bedside Patient Agents: A Thematic Analysis

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