Advance care planning by proxy in German nursing homes: Descriptive analysis and policy implications.

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State: Public
Version: Final published version
License: CC BY-NC-ND 4.0
Serval ID
serval:BIB_06A6F3EBBE43
Type
Article: article from journal or magazin.
Collection
Publications
Institution
Title
Advance care planning by proxy in German nursing homes: Descriptive analysis and policy implications.
Journal
Journal of the American Geriatrics Society
Author(s)
In der Schmitten J., Jox R.J., Pentzek M., Marckmann G.
ISSN
1532-5415 (Electronic)
ISSN-L
0002-8614
Publication state
Published
Issued date
05/05/2021
Peer-reviewed
Oui
Language
english
Notes
Publication types: Journal Article
Publication Status: aheadofprint
Abstract
Legally recognized advance directives (ADs) have to be signed by the person to whom the decisions apply. In practice, however, there are also ADs written and signed by legal proxies (surrogates) on behalf of patients who lack decision-making capacity. Given their practical relevance and substantial ethical and legal implications, ADs by proxy (AD-Ps) have received surprisingly little scientific attention so far.
To study the form, content, validity, and applicability of AD-Ps among German nursing home residents and develop policy implications.
Secondary analysis of two independent cross-sectional studies in three German cities, comprising 21 nursing homes and 1528 residents. The identified AD-Ps were analyzed in parallel by three independent raters. Inter-rater agreement was measured using free-marginal multi-rater kappa statistics.
Altogether, 46 AD-Ps were identified and pooled for analysis. On average (range), AD-Ps were 1 (1-7) year(s) old, 0.5 (0.25-4) pages long, signed by 1 (0-5) person, with evidence of legal proxy involvement in 35%, and signed by a physician in 20% of cases. Almost all the AD-Ps reviewed aimed to limit life-sustaining treatment (LST), but had widely varying content and ethical justifications, including references to earlier statements (30%) or actual behavior (11%). The most frequent explicit directives were: do-not-hospitalize (67%), do-not-tube-feed (37%), do-not-attempt-resuscitation (20%), and the general exclusion of any LST (28%). Inter-rater agreement was mostly moderate (kappa ≥0.6) or strong (kappa ≥0.8).
Although AD-Ps are an empirical reality in German nursing homes, formal standards for such directives are lacking and their ethical justification based on substituted judgment or best interest standard often remains unclear. A qualified advance care planning process and corresponding documentation are required in order to safeguard the appropriate use of this important instrument and ensure adherence to ethico-legal standards.
Keywords
advance care planning, advance directives, healthcare proxy, nursing homes, surrogate decision-making
Pubmed
Web of science
Open Access
Yes
Create date
11/05/2021 12:49
Last modification date
26/06/2021 7:13
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