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The standard of care in the United States favors stabilizing any adult who arrives in an emergency department after a failed suicide attempt, even if he appears decisionally capacitated and refuses life-sustaining treatment. I challenge this ubiquitous practice. Emergency clinicians generally have a moral obligation to err on the side of stabilizing even suicide attempters who refuse such interventions. This obligation reflects the fact that it is typically infeasible to determine these patients' level of decisional capacitation-among other relevant information-in this unique setting. Nevertheless, I argue, stabilizing suicide attempters over their objection sometimes violates a basic yet insufficiently appreciated right of theirs-the right against bodily invasion. In such cases, it is at least prima facie wrong to stabilize a patient who wants to die even if they lack a contrary advance directive or medical order and suffer from no terminal physical illness., (© 2024 The Hastings Center.)

WHAT IS KNOWN ON THE SUBJECT?: Australia is a commonwealth of federated states and territories with each having unique mental health legislation. Victoria implemented advance statements based on legislation from overseas jurisdictions such as Scotland. The aim of this Victorian legislation was to underpin an individual's autonomy and decision-making in relation to treatment, particularly compulsory treatment. Advance statements allow individuals within the healthcare setting to document preferences for care and treatment during times of decompensated mental health, including informing nominated persons and preferences for recovery-oriented care; however, advance statements continue to attract barriers in their implementation and use. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: This paper focuses on legislation within one jurisdiction, Victoria, highlighting that several barriers to uptake exist, including uncertainty around the legal status of advance statements, the ideal setting to implement advance statements and concern around perceived consumer capacity to contribute to developing advance statements. There are substantial differences of opinion regarding adherence to treatment and recovery preferences contained within the advance statement, especially when decisions are made in the context of decompensated mental health. The Theoretical Domains Framework (TDF) model has been used to formulate recommendations in several other health studies, but to date has not been used to provide recommendations for greater implementation of advance statements. Implementation science is a contemporary research translation movement that seeks to identify factors and strategies that influence the adoption and integration of interventions like advance statements in real world settings. For this study it has been useful to identify barriers, consider implementation strategies and link this with policy frameworks to support practice change. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our study revealed that real challenges exist for mental health clinicians in adopting advance statements despite them having a strong held intention to empower service users to play a greater role in their own treatment and care decisions. The facilitators identified in this study highlight the notion that advance statements, and the concept of supported decision-making are needed in contemporary mental health care. Implementation science can assist in identifying barriers and suggesting facilitators including enhanced training, incentivization of advance statement creation, and greater awareness of the overarching purpose and principle of advance statement creation. Continued support and training in implementing and maintaining advance statements is required if mental health clinicians are to drive the uptake of this important reform to mental health legislation. Training needs to be provided that will address attitudes, and strongly held beliefs that pose barriers to the use of advance statements., Abstract: INTRODUCTION: Advance statements, also known as advance directives or psychiatric wills, provide individuals the opportunity to document care and recovery preferences during a period of mental ill health. Although the use of advance statements has gained momentum, little research has explored the factors that promote or hinder further uptake., Aim: To determine the factors that promote or hinder the uptake of advance statements., Method: Cross-sectional online survey of healthcare workers (n = 190)., Results: Promoting factors include high perceived value of advance statements, particularly their role in recovery focussed care, while hindering factors include disagreement or responsibility for advance statement creation and legal status., Discussion: This study indicates that several hindering factors or barriers to advance statement uptake remain, and until these factors are addressed future implementation is arguably hindered. In this paper, we have used the Theoretical Domains Framework (TDF) model to outline suggestions to address hindering factors to implementation and guide future implementation strategies for advance statement uptake and practice change., Implications for Practice: The ongoing uptake of advance statements requires tailored implementation strategies address hindering factors. Strong promoting factors, such as the shared belief in the advance statement model and its role in recovery focused care, should be considered a strong foundation for implementation strategies., (© 2023 The Authors. Journal of Psychiatric and Mental Health Nursing published by John Wiley & Sons Ltd.)

Background: With modern intensive care medicine, even older patients and those with pre-existing conditions can survive critical illnesses and major operations; however, unreflected application of intensive care treatment might lead to a state called chronic critical illness. Today, withholding treatment and/or treatment withdrawal precede many deaths in the intensice care unit (ICU). We looked at changes in measures at the end of life and withholding or withdrawal of treatment in the ICU of a German tertiary hospital in 2017/2018 compared to 2011/2012., Methods: In this retrospective explorative study, we analyzed end of life practices in adult patients who died in an intermediate care unit (IMC)/ICU of Klinikum Hanau in 2017/2018. We compared these data with data from the same hospital in 2011/2012 RESULTS: Of the 1246 adult patients who died in Klinikum Hanau in 2017/2018, 433 (35%) died in an ICU or IMC unit. Deceased ICU patients were 74.0 ± 12.5 years and 86.6% were older than 60 years. At least one life-sustaining measure was withheld in 278 (76.2%) and withdrawn in 159 (46.3%) of patients. More than three quarters of patients (n = 276, 75.6%) had a do not resuscitate (DNR) order and in about half of the patients invasive ventilation (n = 175, 49.9%) or renal replacement therapy (n = 191, 52.3%) was limited. In 113 patients (31.0%) catecholamine treatment was withdrawn, in 72 (19.7%) patients invasive ventilation and in 49 (13.4%) patients renal replacement therapy. Compared to 2011/2012, we saw an increase by ~15% (absolute increase) in withholding and withdrawal of treatment and observed an effect of documents like advance directive or healthcare proxy., Conclusion: In 76.2% of deceased ICU patients withholding treatment and in 43.6% treatment withdrawal preceded death. Compared to 2011/2012 treatment was withheld or withdrawn more often. Compared to 2011/2012, we saw an increase (~15% absolute) in withholding and withdrawal of treatment. After withholding or withdrawal of treatment, most patients died within 3 and 2 days, respectively., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Despite the substantial personal and economic implications of end-of-life decisions, many individuals fail to document their wishes, which often leads to patient dissatisfaction and unnecessary medical spending. We conducted a randomized trial of 1,200 patients aged 55 years and older to facilitate advance directive (AD) completion and better understand why patients fail to engage in high-value planning. We found that including a physical AD form with paper letters as a nudge to decrease hassle costs increased AD completion by 9.0 percentage points (95% confidence interval [CI] = [4.2, 13.9] percentage points). The intervention was especially effective for individuals aged 70 years and older, as AD completion increased by 17.5 percentage points (95% CI = [5.7, 9.4] percentage points). When compared with the impact of costless electronic reminders, each additional AD completion from the letter interventions costs as little as US$37. Our findings suggest that simple, inexpensive interventions with paper communication as behavioral nudges can be effective, especially in older populations. [ABSTRACT FROM AUTHOR]

Advance care planning (ACP) is a nuanced process where patients identify their goals and consider their preferences for medical care over time. Recent systematic reviews have shown mixed findings about the association of ACP with the provision of goal-concordant care, completion of advance directives, and health care utilization. Despite a lack of consistent benefit, patients and clinicians value ACP and policy makers at the state and federal level have been moving ACP policies forward. All fifty states have policies regarding advance directives, and federal policy has had important implications on promoting awareness of ACP and its corresponding legal documents such as advance directives. However, challenges to effectively incentivize and facilitate the delivery of high-quality ACP exist. This paper provides an overview of key federal policy aspects and barriers that affect ACP use including: limitations of Medicare ACP billing codes, disparities in telemedicine access, difficulties with interoperability of advance directives, and underutilization of ACP as a mandatory measure in federal programs. This paper highlights key opportunities to improve federal ACP policy. Because ACP is an essential part of high-quality care and is deeply embedded in state and federal policies, it is imperative that clinicians are knowledgeable about these issues so they may more effectively engage in ACP policy. [ABSTRACT FROM AUTHOR]

Over the past decades, literature in dementia ethics has extensively looked at moral questions revolving around the care of older people living with dementia. Particularly prevalent are autonomy-related concerns regarding topics such as advance directives. In this paper, we argue that these discussions are crucially premised on how dementia is understood and represented. Despite the multiplicity of dementia presentations in people, the dominant discourse predominantly frames dementia as 'monstrous,' an 'enemy,' a destructive experience in need of eradication. We contend that such a monolithic approach, from a moral standpoint, is problematic in several respects. Indeed, framing heavily influences the way dementia is understood and experienced, leading to stigmatization, bias, and distress. Not only does it influence decisions and discussions on advance directives, but we argue that this flawed understanding of dementia is rooted in and contributes to epistemic harm. In the first section, we introduce the ethics of advance directives. More specifically, we introduce the view developed by Dworkin who has largely influenced the debate by making the case for advance directives by grounding them in the principles of autonomy and beneficence. In the second section, we show how dementia is still mostly framed monolithically as a 'destructive experience.' We then show that this framing is problematic because it oversteps the different pathologies dementia implies, which leads to an inaccurate representation of the condition. In the third section, we present possible alternative framings: dementia as normal aging, a person-centered care framework, and an embodied view. In the fourth section, drawing on recent developments in the epistemic injustice literature, we explore how maintaining and utilizing flawed understandings of dementia may lead to distinct moral-epistemic harms for those living with dementia and inform ongoing discussions on advance directives. Finally, in the concluding section, we return to the case of advance directives and what the implications of rethinking dementia are. [ABSTRACT FROM AUTHOR]

Introduction: Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. Methods: A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. Results: Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics". Conclusion: The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged. [ABSTRACT FROM AUTHOR]

Advance directives (ADs) have for some time been championed by ethicists and patient associations alike as a tool that people newly diagnosed with dementia, or prior to onset, may use to ensure that their future care and treatment are organized in accordance with their interests. The idea is that autonomous people, not yet neurologically affected by dementia, can design directives for their future care that caregivers are morally obligated to respect because they have been designed by autonomous individuals. In this paper, we first criticize the idea that ADs can retain moral authority in severe dementia by arguing that it is paradoxical. Second, we consider two arguments that initially seem to refute this critique of ADs, but we eventually dismiss them. The first argument states that ADs retain moral authority in severe dementia because autonomously formed interests, for example, ADs, can only be appropriately discarded by autonomous persons. This we term the historical autonomy argument. We dismiss it by demonstrating how we, in analog cases, are not obligated to continue to respect autonomously formed interests even though they have been discarded under nonappropriate conditions. The second argument is that ADs can be justified by what we term external interests. While we agree that people with severe dementia plausible can be said to have external interests, we show that ADs cannot express such interests and hence cannot be justified by them. We conclude that none of the discussed arguments support the use of ADs and because of this, the idea of ADs should be reassigned. [ABSTRACT FROM AUTHOR]

To effectively identify the key material parameters of different zones of concrete face rockfill dams and improve the efficiency of parameter optimization, a global sensitivity analysis method of parameters based on sparse polynomial chaotic expansion (sPCE) is proposed in this paper. The latin hypercube sampling method is used to select multiple groups of material parameters, and then finite element method is used to calculate the displacement of dam characteristic nodes in dam body. On this basis, the displacement is expanded by sPCE, and the polynomial basis function is reconstructed by orthogonal matching pursuit to improve the construction and analysis efficiency of the proxy model. According to the chaos coefficients, Sobol' indices are calculated to evaluate the influence of the material parameters and their interaction on different displacements of the dam. The results show that the sPCE model can accurately simulate dam displacement and its statistical characteristics with a relatively small sample size. The sensitivity of the same parameter has spatial variability, and under the influence of parameter levels and spatial distribution of different materials, the parameter sensitivity ranking of different zones has certain differences. The proposed method provides a new reference to sensitivity analysis and uncertainty analysis for practical engineering., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Ran et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Professor Latham has written a thought-provoking commentary 1 on my paper about advance directives. 2 I am grateful for this opportunity to integrate the debate on the moral binding nature of these manifestations of will.

Under the Victorian 2014 Mental Health Act (MHA14), Victorians have a right to advance statements. While there have been initiatives to support uptake, under 3% of consumers have done so. In March 2021, the Royal Commission into Victoria's Mental Health System (the Commission) released its report, including a call to repeal MHA14 and enact a new Act no later than mid-2022. In this paper, we discuss the role of advance planning documentation and instruments used in Australian legislation. Drawing on the Commission's recommendations, models of advance planning in Australia and the Victorian legislative context, this paper proposes a model of both binding and non-binding advance directives. This model would bring the rights of Victorian consumers into alignment with rights provided under the Medical Treatment, Planning and Decisions Act 2016 (Vic) and assist in bringing the new Act into compatibility with the Charter of Human Rights and Responsibilities Act 2006 (Vic). [ABSTRACT FROM AUTHOR]

The authors aimed to analyze the Italian law of 10 February 2020, n. 10, which governs the post mortem donation of one's body and tissues for training, educational and scientific research purposes. The different models of consent set forth in this set of norms are discussed, reaching the conclusion that the most suitable option for balancing the interests at stake is the one that authorizes all uses of the body for the sole purposes expressly permitted by the donor. After briefly laying out the current legislation on the subject, particularly regarding the ways of expressing consent, the authors highlight how the legislation enacted by Italian lawmakers is meant to codify the absolute preeminence to the donor's right to self-determination., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Advance directives are intended to extend patient autonomy by enabling patients to prospectively direct the care of their future incapacitated selves. There has been much discussion about issues such as whether the future incompetent self is identical to the agent who issues the advance directive or whether advance directives can legitimately secure patient autonomy. However, there is another important question to ask: to what extent and in what conditions is it ethically appropriate for one to limit the liberty or agency of one's future incompetent self by issuing an advance directive? In this paper, I use a virtue‐ethical approach to explore this question, focusing on the case of an advance directive for the future self with moderate dementia. First, I examine virtuous attitudes with regard to autonomy and argue that one can manifest vices or ethically undesirable character traits in trying to intervene in the future self's life. In particular, I argue that this case can manifest vices such as disdainfulness, intellectual arrogance, and self‐dictatorship, which is the vice of trying to control one's life to an excessive degree, and that a self‐dictator fails to give due moral consideration to the future self's liberty or agency. I then introduce the Daoist idea of wu‐wei, which recommends embracement of what happens in one's life, as one of the possible remedies for the overemphasis on the value of autonomy and control. [ABSTRACT FROM AUTHOR]

Systemic risk refers to the uncertainty that arises due to the breakdown of a financial system. The concept of "too connected to fail" suggests that network connectedness plays an important role in measuring systemic risk. In this paper, we first recover a time series of Bayesian networks for stock returns, which allow the direction of links among stock returns to be formed with Markov properties in directed graphs. We rank the stocks in the time series of Bayesian networks based on the topological orders of the stocks in the learned Bayesian networks and develop an order distance, a new measure with which to assess the changes in the topological orders of the stocks. In an empirical study using stock data from the Hang Seng Index in Hong Kong and the Dow Jones Industrial Average, we use the order distance to predict the extreme absolute return, which is a proxy of extreme market risks, or a signal of systemic risks, using the LASSO regression model. Our results indicate that the network statistics of the time series of Bayesian networks and the order distance substantially improve the predictability of extreme absolute returns and provide insights into the assessment of systemic risk., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Chan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Informed consent is an essential requirement for the ethical conduct of research. It is also a necessary requirement for the lawful conduct of research. Informed consent provides a legal basis to enrol human subjects in clinical research. In paediatric research, where children do not generally enjoy a presumption of competence, a legal representative must authorise a child's enrolment. Determining who should act on behalf of the child is a matter of law, rather than ethical principle. But, if national laws are lacking or do not reflect socio-cultural realities, legal uncertainty can arise, which can have implications for children's enrolment in clinical research. Using Thailand as its case study, this paper contemplates how international legal frameworks, such as the UN Convention on the Rights of the Child, could be leveraged to navigate legal uncertainty in the informed consent process, enabling more children to access and participate in paediatric clinical research., (© 2022 The Authors. Developing World Bioethics published by John Wiley & Sons Ltd.)

Dengue fever is an acute mosquito-borne disease that mostly spreads within urban or semi-urban areas in warm climate zones. The dengue-related risk map is one of the most practical tools for executing effective control policies, breaking the transmission chain, and preventing disease outbreaks. Mapping risk at a small scale, such as at an urban level, can demonstrate the spatial heterogeneities in complicated built environments. This review aims to summarize state-of-the-art modeling methods and influential factors in mapping dengue fever risk in urban settings. Data were manually extracted from five major academic search databases following a set of querying and selection criteria, and a total of 28 studies were analyzed. Twenty of the selected papers investigated the spatial pattern of dengue risk by epidemic data, whereas the remaining eight papers developed an entomological risk map as a proxy for potential dengue burden in cities or agglomerated urban regions. The key findings included: (1) Big data sources and emerging data-mining techniques are innovatively employed for detecting hot spots of dengue-related burden in the urban context; (2) Bayesian approaches and machine learning algorithms have become more popular as spatial modeling tools for predicting the distribution of dengue incidence and mosquito presence; (3) Climatic and built environmental variables are the most common factors in making predictions, though the effects of these factors vary with the mosquito species; (4) Socio-economic data may be a better representation of the huge heterogeneity of risk or vulnerability spatial distribution on an urban scale. In conclusion, for spatially assessing dengue-related risk in an urban context, data availability and the purpose for mapping determine the analytical approaches and modeling methods used. To enhance the reliabilities of predictive models, sufficient data about dengue serotyping, socio-economic status, and spatial connectivity may be more important for mapping dengue-related risk in urban settings for future studies.

Background: For the benefits of advance care planning to be realised during a hospital admission, the treating team must have accurate knowledge of the law pertaining to implementation of advance care directives (ACDs) and substitute decision making., Aims: To determine in a sample of Junior Medical Officers (JMOs): (1) knowledge of the correct order to approach people as substitute decision makers if a patient does not have capacity to consent to treatment; (2) knowledge of the legal validity of ACDs when making healthcare decisions for persons without capacity to consent to treatment, including the characteristics associated with higher knowledge; and (3) barriers to enacting ACDs., Methods: A cross-sectional survey was conducted at five public hospitals in New South Wales, Australia. Interns, residents, registrars, and trainees on clinical rotation during the recruitment period were eligible to participate. Consenting participants completed an anonymous pen-and-paper survey., Results: A total of 118 JMOs completed a survey (36% return rate). Fifty-five percent of participants were female and 56.8% were aged 20-29 years. Seventy-five percent of JMOs correctly identified a Guardian as the first person to approach if a patient did not have decision-making capacity, and 74% correctly identified a person's spouse or partner as the next person to approach. Only 16.5% identified all four persons in the correct order, and 13.5% did not identify any in the correct order. The mean number of correct responses to the questions assessing knowledge of the legal validity of ACDs was 2.6 (SD = 1.1) out of a possible score of 6. Only 28 participants (23.7%) correctly answered four or more knowledge statements correctly. None of the explored variables were significantly associated with higher knowledge of the legal validity of ACDs. Uncertainty about the currency of ACDs and uncertainty about the legal implications of relying on an ACD when a patient's family or substitute decision maker disagree with it were the main barriers to enacting ACDs., Conclusion: JMOs knowledge of the legal validity of ACDs for persons without decision making capacity and the substitute decision making hierarchy is limited. There is a clear need for targeted education and training to improve knowledge in this area for this cohort., (© 2022. The Author(s).)

Abstract Introduction Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person’s future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. Methods A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. Results Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients’ age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: “Lack of knowledge of the ADs concept” and “Previous experience of the disease”, the subjective norm category includes three subcategories: “Social support and interaction with family”, “Respecting the patient’s wishes” and “EOL care choices”. Also, the category of perceived control behavior was categorized into two sub-categories: “Decision-making” and “Access to the healthcare system”, as well as external factors affecting the model, including “socio-demographic characteristics”. Conclusion The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.

Discussions between health professionals and nursing home (NH) residents or their families about the current or future goals of health care may be associated with better outcomes at the end of life (EOL), such as avoidance of unwanted interventions or death in hospital. The timing of these discussions varies, and it is possible that their influence on EOL outcomes depends on their timing. This study synthesized current evidence concerning the timing of goals of care (GOC) discussions in NHs and its impact on EOL outcomes. Systematic review. Adult populations in NH settings. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Embase, and Cumulative Index of Nursing and Allied Health from January 2000 to September 2022. We included studies that examined timing of GOC discussions in NHs, were peer-reviewed, and published in English. Quality of the studies was assessed using the Newcastle-Ottawa Scale. Screening of 1930 abstracts yielded 149 papers that were evaluated for eligibility. Of the 18 articles, representing 16 distinct studies that met review criteria, 12 evaluated the timing of advance directives. There was variation in the timing of GOC discussions and compared with discussions that occurred within a month of death, earlier discussions (eg, at the time of facility admission) were associated with lower rates of hospitalization at the EOL and lower health care costs. The timing of GOC discussions in NHs varies and evidence suggests that late discussions are associated with poorer EOL outcomes. The benefits of goal-concordant care may be enhanced by earlier and more frequent discussions. Future studies should examine the optimal timing for GOC discussions in the NH population. [ABSTRACT FROM AUTHOR]

Background: General Practitioners (GPs) are central in the care of Dutch older people and in a good position to have Advance Care Planning (ACP) conversations. Interview studies reveal that the doctor-patient relationship is important when initiating ACP conversations and can also be influenced by ACP conversations. We aimed to examine the association between having an ACP conversation and the patient feeling the GP knows him or her and the patient trusting the GP and vice versa.Methods: Implementation of ACP in primary care was evaluated in a pre-and post design. Questionnaires before implementation of ACP and 14 months later were sent to patients aged 75 years or older within 10 GP-practices and 2 care homes. Multivariable logistic regression was used to model the relationship between ACP conversations during implementation and the patient-GP relationship before implementation. Odds ratios were adjusted for potential confounders. Generalized ordered logistic regression was used to model the relationship between the changes in patient-GP relationship before and after implementation and ACP conversations during implementation.Results: Four hundred fifty-eight patients filled out the pre- and post-test questionnaire. There was no association between the GP knowing the patient and trust in the pre-test and having an ACP conversation during the implementation. For people who had had an ACP conversation at the end of the implementation period their trust remained more often the same or was higher after implementation (trust to provide good care OR 2.93; trust to follow their wishes OR 2.59), compared to patients who did not have an ACP conversation. A reduction in trust was less likely to happen to patients who had an ACP conversation compared to patients who did not have an ACP conversation.Conclusions: Although we have not found evidence for trust as a prerequisite for ACP conversations, this paper shows that ACP conversations can be beneficial for the doctor-patient relationship. [ABSTRACT FROM AUTHOR]

Background: In 2016, the Act on Decisions on Life‐Sustaining Treatment for Patients in Hospice and Palliative Care was implemented in Korea, providing a broad framework for end‐of‐life decision‐making for the first time and making advance directives legally recognized documents. This Act can correct long‐standing under‐recognition of patients as valid decision makers for their own treatment choices. However, limited recognition of patient self‐determination, rigid legal forms for documenting patient wishes, and the roles of family under the Act may pose challenges both to patients and nurses. Aim: This paper critiques whether this newly introduced system of advance directives can truly guarantee protection of the patient's interests and respect for patient autonomy in real life​, and discusses ethical and legal issues regarding the Act. Source of evidence: We reviewed the current system of advance directives by raising three questions: (1) Do advance directives reflect a competent person's voluntary and informed choice?, (2) Are advance directives applicable in diverse clinical situations?, and (3) Does the Korean advance directive system ensure that such directives are honored in reality? Conclusion: Although the Act is an important first step in respecting patient autonomy in end‐of‐life decision‐making, it remains inadequate as it fails to provide thorough guidance in terms of the quality of writing process, applicability, and the guaranteed effects of advance directives. Implications for nursing and health policy: As nurses are best situated for addressing these limitations due to their roles and competencies in clinical practice, expanding the roles of nurses in every stage of advance directive practice could help achieve the original purpose of advance directives. This calls for a policy that promotes an expanded role of nurses to improve the quality of advance directive practice. [ABSTRACT FROM AUTHOR]

Background: Advance research directives (ARD) have been suggested as a means by which to facilitate research with incapacitated subjects, in particular in the context of dementia research. However, established disclosure requirements for study participation raise an ethical problem for the application of ARDs: While regular consent procedures call for detailed information on a specific study ("token disclosure"), ARDs can typically only include generic information ("type disclosure"). The introduction of ARDs could thus establish a double standard in the sense that within the context of ARDs, type disclosure would be considered sufficient, while beyond this context, token disclosure would remain necessary., Main Body: This paper provides an ethical analysis of ARDs, taking into account the results of numerous empirical studies that have been performed so far. It will be argued that a revised understanding of informed consent can allow for context-sensitive disclosure standards. As a consequence, ARDs that include type disclosure can be acceptable under suitable circumstances. Such an approach raises a number of objections. A thorough examination shows, however, that they are not sufficient to justify a rejection of the approach., Conclusion: The approach presented in this paper avoids introducing a double standard. It is, therefore, more suitable for the implementation of ARDs than established approaches., (© 2021. The Author(s).)

Advance statements, advance directives, or psychiatric wills are a key component of a shift to mental healthcare that promotes autonomy and choice and aims to reduce restrictive and coercive care practices in mental health treatment settings. The use of advance statements has gained momentum to provide a means for individuals to detail clear preferences for mental health treatment. This paper uses a qualitative descriptive design to explore the experiences of clinicians (n = 15) implementing advance statements in the state of Victoria, Australia, a region that introduced advance statements as part of an overhaul of mental health legislation in 2014. The study, reported using the COREQ framework, found two key themes after analysis: experiences of advance statement training, with the availability and quality of training and training as a driver of change emerging as sub‐themes, and experiences of advance statements in practice, with participants providing narratives of the barriers and facilitators to successful advance statement implementation. We recommend that clinician and service user experiences of advance statement implementation are further explored to identify existing and emerging barriers to implementation of these tools, which are crucial to achieve autonomy and choice for individuals receiving mental healthcare. [ABSTRACT FROM AUTHOR]

Background: In palliative care, caregivers frequently act as surrogate decision-makers, but their knowledge of patients' preferences for end-of-life care is sometimes scarce and incorrect. Advance Directives might be a powerful communication tool to promote the dialogue between patients and caregivers. Aims: This work aims to find evidence supporting the use of the Advance Directives documents by health practitioners as a communication tool to improve caregivers' capacity as health surrogates in palliative care. Methods: A literature review was conducted in four databases—Medline, Web of Science, Scopus, and Cochrane to identify studies published until February 27th, 2021, analysing advance directive's use as a communication tool between palliative patients and their caregivers. Findings: Of the 1251 papers screened, only one article met the defined criteria, presenting results statistically favourable to advance directive's use, although with the risk of significant bias. Conclusions: Although the results seem promising, more studies are needed to validate this strategy scientifically. [ABSTRACT FROM AUTHOR]

Background: Although advance care planning (ACP) for persons with dementia (PWD) can promote patient‐centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians. Methods: Qualitative study using semi‐structured interviews (August 2018–December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision‐making was approached, and how decision‐making capacity was assessed. Results: Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision‐making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision‐making assessments that allow PWD and carepartner involvement regardless of the patients' capacity. Conclusions: Clinicians found early ACP for PWD valuable in promoting patient‐centered care among an at‐risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models. [ABSTRACT FROM AUTHOR]

The scholarly debate on advance directives (ADs) in the context of dementia is mainly built around ethical arguments. Empirical studies that shed light into the realities of ADs of persons living with dementia are few and far between and too little is known about the effect of national AD legislation on such realities. This paper offers insight into the preparation phase of ADs according to German legislation in the context of dementia. It presents results from a document analysis of 100 ADs and from 25 episodic interviews with family members. Findings show that drafting an AD involves family members and different professionals in addition to the signatory, whose cognitive impairment differed considerably at the time of preparing the AD. The involvement of family members and professionals is at times problematic, which prompts the question of how much and what kind of involvement of others turns an AD of a person living with dementia into an AD about a person living with dementia. The results invite policy makers to critically review legislation on ADs from the perspective of cognitively impaired persons, who might find it difficult to protect themselves from inappropriate involvement when completing an AD. [ABSTRACT FROM AUTHOR]

Advance directives are intended to extend patient autonomy by enabling patients to prospectively direct the care of their future incapacitated selves. There has been much discussion about issues such as whether the future incompetent self is identical to the agent who issues the advance directive or whether advance directives can legitimately secure patient autonomy. However, there is another important question to ask: to what extent and in what conditions is it ethically appropriate for one to limit the liberty or agency of one's future incompetent self by issuing an advance directive? In this paper, I use a virtue‐ethical approach to explore this question, focusing on the case of an advance directive for the future self with moderate dementia. First, I examine virtuous attitudes with regard to autonomy and argue that one can manifest vices or ethically undesirable character traits in trying to intervene in the future self's life. In particular, I argue that this case can manifest vices such as disdainfulness, intellectual arrogance, and self‐dictatorship, which is the vice of trying to control one's life to an excessive degree, and that a self‐dictator fails to give due moral consideration to the future self's liberty or agency. I then introduce the Daoist idea of wu‐wei, which recommends embracement of what happens in one's life, as one of the possible remedies for the overemphasis on the value of autonomy and control. [ABSTRACT FROM AUTHOR]

Currently, in the United States, there is no legal obligation for medical professionals or civil courts to uphold patients’ Advance Directives (ADs) regarding end-of-life care. The applicability and standing of ADs prepared by Alzheimer’s patients is a persistent issue in bioethics. Those who argue against giving ADs full status take two main approaches: (1) appealing to beneficence on behalf of the Alzheimer’s patient and (2) claiming that there is no longer any personal equivalence between the AD’s creator and the subject of the AD. In this paper, I present profound arguments against both approaches. Firstly, I argue that the principle of beneficence cannot apply in the case of Alzheimer’s patients, and, secondly, that the moral and legal authority of the AD need not depend on strict equivalence of personal identity. I conclude by arguing that valid ADs protect the dignity and autonomy of Alzheimer’s patients and that, therefore, there are moral obligations to uphold ADs which should be reflected in public policy and legislation. [ABSTRACT FROM AUTHOR]

People with impaired decision-making capacity enjoy the same rights to access technology as people with full capacity. Our paper looks at realising this right in the specific contexts of artificial intelligence (AI) and mental capacity legislation. Ireland's Assisted Decision-Making (Capacity) Act, 2015 commenced in April 2023 and refers to 'assistive technology' within its 'communication' criterion for capacity. We explore the potential benefits and risks of AI in assisting communication under this legislation and seek to identify principles or lessons which might be applicable in other jurisdictions. We focus especially on Ireland's provisions for advance healthcare directives because previous research demonstrates that common barriers to advance care planning include (i) lack of knowledge and skills, (ii) fear of starting conversations about advance care planning, and (iii) lack of time. We hypothesise that these barriers might be overcome, at least in part, by using generative AI which is already freely available worldwide. Bodies such as the United Nations have produced guidance about ethical use of AI and these guide our analysis. One of the ethical risks in the current context is that AI would reach beyond communication and start to influence the content of decisions, especially among people with impaired decision-making capacity. For example, when we asked one AI model to 'Make me an advance healthcare directive', its initial response did not explicitly suggest content for the directive, but it did suggest topics that might be included, which could be seen as setting an agenda. One possibility for circumventing this and other shortcomings, such as concerns around accuracy of information, is to look to foundational models of AI. With their capabilities to be trained and fine-tuned to downstream tasks, purpose-designed AI models could be adapted to provide education about capacity legislation, facilitate patient and staff interaction, and allow interactive updates by healthcare professionals. These measures could optimise the benefits of AI and minimise risks. Similar efforts have been made to use AI more responsibly in healthcare by training large language models to answer healthcare questions more safely and accurately. We highlight the need for open discussion about optimising the potential of AI while minimising risks in this population. [ABSTRACT FROM AUTHOR]

Context: Advance Care Planning (ACP), as a process for expressing and recording patients' preferences about end-of-life care, has received increasing attention in recent years. However, implementing ACP has been challenging in Iran. Objectives: To assess the readiness for advance care planning and related factors in the general population of Iran. Methods: This cross-sectional study was conducted on the general population of Iran in 2022. The data was collected using demographic information questionnaire and The RACP Scale. The purpose and methodology of the research was explained to all participants, and upon their agreement an informed consent was obtained. Participants were invited to fill out the questionnaires wherever is more convenient for them, either alone or if needed, with the help of the researcher to protect their privacy. Chi-square, fisher exact test and multiple logistic Regression model were used to assess the effective factors on the RACP. The data were analyzed by SPSS software version 26. Results: A total of 641 people with an average age of 36.85 ± 12.05 years participated in this study. Of those, 377 (58.8%) had high RACP. The logistics model showed an association between the chance of readiness for receiving ACP with participants' education level, such that the chance of readiness in those with Master's or Ph.D. degrees was three times higher than those with a diploma (p = 0.00, OR:3.178(1.672, 6.043)). However, the chances of readiness in those with bachelor's degrees was not significantly different from those with a diploma (p = 0.936, OR: 0.984 (0.654, 1.479)). Moreover, the chance of readiness was 1.5 higher in participants over 40 years of age compared with participants under the age of 40 (P = 0.01, OR: 1.571(1.10, 2.23)). Conclusion: According to the findings of this study, it can be concluded that there is a relatively RACP among people in Iranian society. The readiness of individuals for ACP increases by their age and education level. Therefore, by holding appropriate training intervention, we can increase the readiness of the public for ACP to improve their end-of-life outcome. [ABSTRACT FROM AUTHOR]

Respect for patient autonomy is a bioethical principle that has become increasingly imperative, particularly in the 21st century. However, in many Asian countries, medical paternalism to a larger degree remains prevalent in the healthcare setting. While a doctor is ethically and legally bound to respect a patient's values and wishes in administering treatment, the duty to do so is more complex in end-of-life care, where the patient is unable to partake in the decision-making process. Accordingly, it has been argued that advanced medical directives (AMDs) could ensure that the patient's right to make autonomous decisions is preserved and will not be defeated by any future incapacity. It also serves to extenuate the ethical dilemma faced by doctors in determining the course of treatment according to the incompetent patient's wishes. In turn, this facilitates healthcare providers to manage the distribution of scarce medical resources effectively. The need for AMDs is seen to be increasingly pressing in ageing countries such as Malaysia and Indonesia, where end-of-life care has yet to be integrated into mainstream healthcare services. This paper seeks to discuss the viability of integrating AMDs into the Malaysian and Indonesian regulatory frameworks on health care, by employing the qualitative method of content analysis of both primary and secondary sources of the two countries. Findings show that statutory reform is both recommended and necessary to ensure better management of medical resources, as well as to promote the delivery of a more inclusive and compassionate healthcare system.

Background: Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW), e.g. as advance directives, can guide clinicians in making end-of-life decisions that respect the patient’s wishes and autonomy. However, patient centered decisions are hindered by limited availability of DPWs in emergency settings. Objective: This systematic review aims to congregate present data on recorded rates for DPW existence and availability in the emergency department (ED) as well as contributing factors for these rates. Methods: We searched MEDLINE, Google Scholar, Embase and Web of Science databases in September 2023. Publications providing primary quantitative data on DPW in the ED were assessed. Publications referring only to a subset of ED patients (other than geriatric) and investigating DPW issued after admission were excluded. Results: A total of 22 studies from 1996 to 2021 were included in the analysis. Most were from the US (n = 12), followed by Australia (n = 4), Canada (n = 2), South Korea, Germany, the United Kingdom and Switzerland (n = 1 each). In the general adult population presenting to the ED, 19.9–27.8% of patients reported having some form of DPW, but only in 6.8% or less it was available on presentation. In the geriatric population, DPW rates (2.6–79%) as well as their availability (1.1–48.8%) varied widely. The following variables were identified as positive predictors of having DPW, among others: higher age, poorer overall health, as well as sociodemographic factors, such as female gender, having children, being in a relationship, higher level of education or a recent previous presentation to hospital. Conclusions: Existence and availability of a recorded DPW among ED patients was low in general and even in geriatric populations mostly well below 50%. While we were able to gather data on prevalence and predictors, this was limited by heterogeneous data. We believe further research is needed to explore the quality of DPW and measures to increase both rates of existence and availability of DPW in the ED. [ABSTRACT FROM AUTHOR]

As the family usually plays a central role at the end of life, the quality of family relationships may influence how individuals approach advance care planning (ACP). Our study investigates the associations of trust in relatives with regard to end-of-life (EOL) issues—used as a proxy measure of family relationship quality—with individuals' engagement in EOL discussions, advance directive (AD) awareness, approval and completion, and designation of a healthcare proxy. Using nationally representative data of adults aged 55 years and over from wave 6 (2015) of the Survey of Health, Ageing, and Retirement in Europe (SHARE) in Switzerland (n = 1911), we show that complete trust in relatives is related to higher engagement in ACP. Subject to patient consent, the family should, therefore, be included in the ACP process, as such practice could enhance patient-centered EOL care and quality of life at the end of life. [ABSTRACT FROM AUTHOR]

Aims and Objectives: This study aimed to describe the knowledge, attitudes and practices (KAP) of nurses in implementing advance directives (ADs) for older patients and analyze the influencing factors before the establishment of the first advance directives act in China. Design: Multicenter cross‐sectional survey. The standards for reporting the STROBE checklist are used. Methods: This cross‐sectional study developed a self‐designed structured questionnaire to assess nurses' knowledge, attitudes and practices about ADs. Nurses were recruited by stratified random sampling through the Nursing Departments of 12 hospitals in southwest China and were asked to fill out the questionnaire face to face about knowledge, attitudes and practices. Data were analyzed following descriptive statistics, rank‐sum test and multiple linear regression. Results: This study included 950 nurses. The study found that nurses were extremely supportive of ADs. Unmarried nurses had better knowledge of ADs than married ones. Nevertheless, there was a discrepancy between the participants' knowledge, attitude and practice. The participants' practice was lower (4.3%) compared with their attitude (81.9%) and knowledge (42.2%). Knowledge on, attitudes towards and standardized procedures for ADs in the workplace affected nursing practice. Conclusions: The study recommends that courses on ADs and appropriate support from medical institutions should be provided to nurses to increase their knowledge and confidence in implementing ADs. Healthcare professionals should be sufficiently equipped to implement ADs and handle their execution appropriately to provide adequate end‐of‐life care corresponding to patients' wishes. Relevance to Clinical Practice: The study results inform rich insights as it discusses the numerous interrelating factors influencing these three fundamental aspects that affect the success of any AD policy by surveying the knowledge, attitudes and practices of clinical nurses. Furthermore, our results hint at distinct areas of improvement in the nursing practice to facilitate the wider implementation and acceptance of ADs in China. Patient or Public Contribution: This study involved no patient. [ABSTRACT FROM AUTHOR]

Background: Many widely used advance directives templates include direct questions on individuals' preferences for cardiopulmonary resuscitation (CPR) in case of decision-making incapacity during medical emergencies. However, as knowledge of the survival rates of CPR is often limited, individuals' advance decisions on CPR may be poorly aligned with their preferences if false beliefs about the survival rates of CPR shape stated preferences for CPR. Methods: We analyzed nationally representative data from 1,469 adults aged 58+ y who responded to wave 8 (2019/2020) of the Swiss version of the Survey on Health, Ageing, and Retirement in Europe (SHARE) to assess the partial association between knowledge of CPR survival rates and stated preferences for CPR using multivariable probit regression models that adjust for social, health, and regional characteristics. Knowledge of CPR survival rates was assessed by asking how likely it is in general in Switzerland for a 70-y-old to survive until hospital discharge from a CPR performed outside of a hospital. Preferences for CPR were measured by asking respondents if they would wish to be resuscitated in case of cardiac arrest. Results: Only 9.3% of respondents correctly assessed the chances for a 70-y-old to survive until hospital discharge from a CPR performed outside of a hospital, while 65.2% indicated a preference to be resuscitated in case of a cardiac arrest. Respondents who correctly assessed CPR survival were significantly more likely to wish not to be resuscitated (average marginal effect: 0.18, P < 0.001). Conclusions: Reducing misconceptions concerning the survival rates of CPR could change older adults' preferences for CPR and make them more likely to forgo such treatments. Highlights: Many older adults in Switzerland overestimate the survival rates of cardiopulmonary resuscitation (CPR). The study reveals that individuals with accurate knowledge of CPR survival rates are more likely to refuse resuscitation in case of cardiac arrest. Overestimation of CPR survival rates may lead to a mismatch between individuals' preferences for CPR and their actual end-of-life care decisions. Improving the general population's knowledge of CPR survival rates is crucial to ensure informed decision making and effective advance care planning. [ABSTRACT FROM AUTHOR]

Psychiatric Advance Directives (PADs) have been adopted in many jurisdictions around the world and in most Australian states and territories. They are seen as a less restrictive and patient-centered approach to the provision of mental health care. Electroconvulsive therapy (ECT) is a restricted treatment in most jurisdictions in Australia and across the world. This paper explores the history, regulation and use of ECT and PADs and the intersections between them. It provides an overview of the legislative framework in each Australian state and territory and explores some of the issues which have arisen such as complexity of the regulatory framework, making PADs binding for refusing and consenting to ECT, involving treating teams in how PADs are made, using restrictive interventions to implement PADs, and the role of the Tribunal. While PADs are often framed as an important legal tool for allowing patients to refuse psychiatric treatment (especially ECT), the paper emphasizes that they can also be an innovative way for people to consent to psychiatric treatment in advance and an empowering option to access mental health care. It then makes some suggestions for future reform. [ABSTRACT FROM AUTHOR]

Over the past decades, literature in dementia ethics has extensively looked at moral questions revolving around the care of older people living with dementia. Particularly prevalent are autonomy-related concerns regarding topics such as advance directives. In this paper, we argue that these discussions are crucially premised on how dementia is understood and represented. Despite the multiplicity of dementia presentations in people, the dominant discourse predominantly frames dementia as ‘monstrous,’ an ‘enemy,’ a destructive experience in need of eradication. We contend that such a monolithic approach, from a moral standpoint, is problematic in several respects. Indeed, framing heavily influences the way dementia is understood and experienced, leading to stigmatization, bias, and distress. Not only does it influence decisions and discussions on advance directives, but we argue that this flawed understanding of dementia is rooted in and contributes to epistemic harm. In the first section, we introduce the ethics of advance directives. More specifically, we introduce the view developed by Dworkin who has largely influenced the debate by making the case for advance directives by grounding them in the principles of autonomy and beneficence. In the second section, we show how dementia is still mostly framed monolithically as a ‘destructive experience.’ We then show that this framing is problematic because it oversteps the different pathologies dementia implies, which leads to an inaccurate representation of the condition. In the third section, we present possible alternative framings: dementia as normal aging, a person-centered care framework, and an embodied view. In the fourth section, drawing on recent developments in the epistemic injustice literature, we explore how maintaining and utilizing flawed understandings of dementia may lead to distinct moral-epistemic harms for those living with dementia and inform ongoing discussions on advance directives. Finally, in the concluding section, we return to the case of advance directives and what the implications of rethinking dementia are.

Assisted dying is a divisive topic and draws both lamenting and approving commentary from political, medical, legal, and philosophical domains. This systematic review and qualitative evidence synthesis aims to identify the factors that healthcare professionals experience when working within assisted dying frameworks. PRISMA guidelines for systematic reviews were followed. Search results yielded 15,426 papers with 39 papers meeting inclusion criteria for this review. Remaining papers were subjected to critical appraisal and a thematic synthesis. Eight themes fell under the domain of ‘barrier’ and represented different personal and professional factors that hinder professionals from delivering assisted dying healthcare. Five themes came under the domain of ‘facilitators’ and represent factors that contribute to the smooth implementation and delivery of assisted dying services. Health professionals experience a range of factors that both impede and propel delivery of assisted dying frameworks. [ABSTRACT FROM AUTHOR]

Background: On December 2017 the Italian Parliament approved law n. 219/2017 "Provisions for informed consent and advance directives" regarding challenging legal and bioethical issues related to healthcare decisions and end-of life choices. The law promotes the person's autonomy as a right and provides for the centrality of the individual in every scenario of health care by mean of three tools: informed consent, shared care planning and advance directives. Few years after the approval of the law, we conducted a survey among physicians working in four health care facilities specific for the care of people suffering from psychiatric disorders, cognitive disorders and dementia located in the North of Italy aiming to investigate their perceived knowledge and training need, attitudes regarding law n. 219/2017 provisions, and practices of implementation of the law. Methods: A semi-structured questionnaire was developed on an online platform. The invitation to participate in the survey was sent by email to the potential participants. Information was collected by means of the online platform (Google Forms) which allows to export data in a spreadsheet (Windows Excel) to perform basic statistical analysis (frequency distributions, bar chart representation). Results: Twenty-five out of sixty physicians participated in the survey. None of the respondents value their knowledge of the law as very good, 10 good, 13 neither poor nor good, 1 poor and 1 very poor. All the respondents want to learn more about the law (21 yes and 4 absolutely yes). The majority of respondents agrees with the content of the law as a whole (3 absolutely agree, 13 agree), and on each provision. The question on the clarity of the concept of capacity in the law received mixed answers and this impacted on the physicians' opinion regarding the legitimacy in principle for our groups of patients to realize shared care planning and write advance directives. Thirteen physicians neither introduced the theme of shared care planning nor arranged for shared care planning and the main reason for this was that no patient was in a clinical situation to require it. When shared care planning is realized, a variability in terms of type and number of meetings, mode of tracking and communication is registered. Conclusions: Our survey results indicate a need for more clarity regarding the interpretation and implementation of the law in the patient groups under study. There are in particular two related areas that deserve further discussion: (1) the question of whether these patient groups are in principle legitimized by the law to realize shared care planning or write advance directives; (2) the notion of capacity required by the law and how this notion can be declined in real-life situations. [ABSTRACT FROM AUTHOR]

Introduction and objective: Advance care planning (ACP) communication and documentation are often inadequate, leading to care that is inconsistent with patients' preferences and moral dilemmas for family members. Nurses are patient advocates optimally positioned to initiate ACP but many feel that they lack the training and skills to navigate these conversations. The objective of this project was to increase nurses' capacity to engage in ACP. Methods: This project used the JBI audit and feedback method to implement evidence into practice. The JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit tools were used to incorporate ACP into nursing workflow. Eight audit criteria were created based on a JBI evidence summary. Compliance was measured by reviewing ACP notes from electronic health records and online survey responses. A baseline audit was followed by educational presentations and development of posted materials. Three follow-up audits examined sustainability. Results: Compliance with the best practice recommendation for nurses to engage in ACP discussions increased from 55% to 80%. There was improvement from zero ACP notes at baseline (0% compliance) to 12 ACP notes in the final audit. Of these notes, 42% included all best practice elements and 92% included patients' treatment preferences. Conclusions: Development of an integrative nursing education plan for ACP empowers nurses to engage in vital conversations. Informing nurses of their scope of practice, defining terms and expectations, and encouraging them to attempt and document conversations will benefit patients. Future initiatives would benefit from incorporating practical opportunities without real-life implications and providing continued support to cohorts. [ABSTRACT FROM AUTHOR]

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