Ethical frameworks for complex medical decision making in older patients: A narrative review

Background: With an ageing population physicians are more and more faced with complex medical and moral situations. Medical professional guidelines are often of limited use in these cases. To assist the decision making process, several ethical frameworks have been proposed. Ethical frameworks are analytical tools that are designed to assist physicians and other involved healthcare workers in complex moral decision-making situations. Most frameworks are step-by-step plans that can be followed chronologically during moral case deliberations. Some of these step-by-step plans provide specific moral guidance as to what would constitute a morally acceptable conclusion, while others do not. Objective: In this narrative review we will present and discuss the ethical frameworks used for medically complex situations in older people that have been proposed in literature. Methods: Three electronic databases (embase.com. Medline Ovid and PsychINFO Ovid) were searched from inception to January 24, 2020, with the help of expert librarians. Results: Twenty-three studies were included in the review, containing seventeen different frameworks. Twenty studies described step-by-step-frameworks, with the number of steps varying from three to twelve. In four studies suggestions were made as how to balance conflicting moral values. Conclusions and implications of key findings: Ethical frameworks are meant to assist healthcare professionals who are faced with morally complex decisions in older patients. In our view, these frameworks should contain a stepby-step plan, moral values and an approach to balancing moral values

Consultation Recording: What Is the Added Value for Patients Aged 50 Years and Over? A Systematic Review

This systematic review aimed to provide medical professionals with insight into beneficial and harmful effects of consultation recording for patients aged 50 years and over. This insight could enable medical professi

What to do when patients and physicians disagree? Qualitative research among physicians with different working experiences

Purpose: Impasses between patients, relatives and physicians occur frequently. With the growing attention for shared decision making, it is valuable to know how impasses arise. To understand the challenges experienced by physicians when their opinion on medical decisions differ from those of patients or relatives. Methods: Fifteen physicians with different working experiences, from five medical specialties were interviewed using a narrative approach. Interviews were based on two patient stories provided by the physician. First of a patient (or relative) who did not want to adhere to a treatment the physician deemed necessary, and the second of a patient (or relative) who requested a treatment the physician felt was unnecessary. Data were analyzed using a bottom-up approach, with identification of five themes (autonomy of the patient, communication, emotions, circumstances and metaphors). Twenty subthemes were formed. Results: 693 references were made. Six major nodes were identified: frustration experienced by the physician, role of the relatives, agreement, cultural/religious aspects, comprehension by the patient of the situation and the existence of an established relationship between patient and physician. Conclusions: Physicians felt uncomfortable when there was disagreement between themselves and patients or relatives. Frustration was felt when relatives spoke on behalf of the patient, while there was no evidence the desired decision was ever expressed by the patient. A disagreement with a patient was described as being less frustrating, when the patient was able to explain the reasons for making a decision. Differences in background, especially religious, were often mentioned as complicatin

The incidence and impact of implantable cardioverter defibrillator shocks in the last phase of life: An integrated review

Background: Although the implantable cardioverter defibrillator is successful in terminating life

Trends in time in the management of the implantable cardioverter defibrillator in the last phase of life: a retrospective study of medical records

Background: The implantable cardioverter defibrillator (ICD) might give unwanted shocks in the last month of life. Guidelines recommend deactivation of the ICD prior to death. Aims: The aims of this study were to examine trends in time (2007–2016) in how and when decisions are made about ICD deactivation, and to examine patient- and disease-related factors which may have influenced these decisions. In addition, care and ICD shock frequency in the last month of life of ICD patients are described. Methods: Medical records of a sample of deceased patients who had their ICD implanted in 1999–2015 in a Dutch university (n = 308) or general (n = 72) hospital were examined. Results: Median age at death was 71 years, and 88% were male. ICD deactivation discussions increased from 6% for patients who had died between 2007 and 2009 to 35% for patients who had died between 2013 and 2016. ICD deactivation rates increased in these periods from 16% to 42%. Presence of do-not-resuscitate (DNR) orders increased from 9% to 46%. Palliative care consultations increased from 0% to 9%. When the ICD remained active, shocks were reported for 7% of patients in the last month of life. Predictors of ICD deactivation were the occurrence of ICD deactivation discussions after implantation (OR 69.30, CI 26.45–181.59), DNR order (OR 6.83, CI 4.19–11.12), do-notintubate order (OR 6.41, CI 3.75–10.96), and palliative care consultations (OR 8.67, CI 2.76–27.21) Conclusion: ICD deactivation discussions and deactivation rates have increased since 2007. Nevertheless, ICDs remain active in the majority of patients at the end of life, some of whom experience shocks

Implantable cardioverter defibrillator deactivation and advance care planning: A focus group study

Objective: Implantable cardioverter defibrillators can treat life-threatening arrhythmias, but may negatively influence the last phase of life if not deactivated. Advance care planning conversations can prepare patients for future decision-making about implantable cardioverter defibrillator deactivation. This study aimed at gaining insight in the experiences of patients with advance care planning conversations about implantable cardioverter defibrillator deactivation. Methods: In this qualitative study, we held five focus groups with 41 patients in total. Focus groups were audio-recorded and transcribed. Transcripts were analysed thematically, using the constant comparative method, whereby themes emerging from the data are compared with previously emerged themes. Results: Most patients could imagine deciding to have their implantable cardioverter def

Delirium: A Frequent Manifestation in COVID-19 Older Patients

The authors report a high prevalence of delirium in COVID-19 old patients admitted in an academic hospital. During the recent COVID-19 period, delirium was present in 38% of old patients admitted with delirium at the COVID ward of the Erasmus MC University Medical Center of Rotterdam. We do not know in which patients COVID-19 can cause delirium; however, considering the high prevalence of delirium in COVID-19 old patients and the potential serious consequences, attention is needed in order to reduce disability and mortality in this vulnerable category of patients

Assessment of Visual Association Memory in Low-Educated, Non-Western Immigrants with the Modified Visual Association Test

Background: Neuropsychological tests are influenced by culture, language, level of education, and literacy, but there are few cognitive tests of which the applicability in ethnic minority populations has been studied. Objectives: The aim of this study was to assess the reliability and validity of the Visual Association Test (VAT), a test of visual association memory, in a non-Western, low-educated memory clinic population. Additionally, a modified version of the VAT using colored photographs instead of line drawings was studied (mVAT). Method: Both the original VAT and the mVAT were administered to non-Western immigrants (n = 73) from 2 multicultural memory clinics in Rotterdam, The Netherlands, and a control sample of non-demented Turkish elderly (n = 14) with low education levels (32 and 29% illiterate, respectively). Results: Both the VAT and the mVAT were able to discriminate persons with and without dementia (area under the curve: VAT, 0.77-0.88; mVAT, 0.85-0.95). The mVAT had more homogeneous item difficulty levels than the VAT. Administration of parallel versions of the VAT and the mVAT within the same person revealed higher scores on the mVAT (Z = -3.35, p = 0.001). Conclusions: The mVAT is a reliable and valid measure of memory in non-Western immigrants. Clinicians and researchers should be aware that the memory performance of immigrants may be systematically underestimated when using tests with black-and-white line drawings, such as the original VAT

Early recognition and treatment of neuropsychiatric symptoms to improve quality of life in early Alzheimer's disease

__Background:__ Neuropsychiatric symptoms (NPS) are very common in patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD) dementia and are associated with various disadvantageous clinical outcomes including a negative impact on quality of life, caregiver burden, and accelerated disease progression. Despite growing evidence of the efficacy of (non)pharmacological interventions to reduce these symptoms, NPS remain underrecognized and undertreated in memory clinics. The BEhavioural symptoms in Alzheimer's disease Towards early Identification and Treatment (BEAT-IT) study is developed to (1) investigate the neurobiological etiology of NPS in AD and (2) study the effectiveness of the Describe, Investigate, Create, Evaluate (DICE) approach to structure and standardize the current care of NPS in AD. By means of the DICE method, we aim to improve the quality of life of AD patients with NPS and their caregivers who visit the memory clinic. This paper describes the protocol for the intervention study that incorporates the latter aim. __Methods:__ We aim to enroll a total of 150 community-dwelling patients with MCI or AD and their caregivers in two waves. First, we will recruit a control group who will receive care as usual. Next, the second wave of participants will undergo the DICE method. This approach consists of the following steps: (1) describe the context in which NPS occur, (2) investigate the possible causes, (3) create and implement a treatment pl

Ethics, End-of-Life and VulnerabilityRozemarijn

In this thesis several, clinically relevant medical-ethical dilemma's in vulnerable adults are discussed, such as scientific research in vulnerable adults, interventions in vulnerable adults and treatment decisions in vulnerable adults. Considerations and recommendations are provided