scholarly journals 64Initial Programme Theories of Mechanisms that Support the Implementation of Assisted Decision-Making with Older People in the Acute Setting

2018 ◽  
Vol 47 (suppl_5) ◽  
pp. v13-v60
Author(s):  
Deirdre O Donnell ◽  
Éidín Ní Shé ◽  
Carmel Davies ◽  
Francesco Fattori ◽  
Sarah Donnelly ◽  
...  
Keyword(s):  
Decision Making ◽  
Older People ◽  
Acute Setting

scholarly journals “What Bothers Me Most Is the Disparity between the Choices that People Have or Don’t Have”: A Qualitative Study on the Health Systems Responsiveness to Implementing the Assisted Decision-Making (Capacity) Act in Ireland

2020 ◽  
Vol 17 (9) ◽  
pp. 3294 ◽  
Author(s):  
Éidín Ní Shé ◽  
Deirdre O’Donnell ◽  
Sarah Donnelly ◽  
Carmel Davies ◽  
Francesco Fattori ◽  
...  
Keyword(s):  
Decision Making ◽  
Older People ◽  
Healthcare System ◽  
Health Systems ◽  
Critical Incident ◽  
Family Carers ◽  
Acute Setting ◽  
Face To Face ◽  
Health And Social Care ◽  
Diagnosis Of Dementia

Objective: The Assisted Decision-Making (ADM) (Capacity) Act was enacted in 2015 in Ireland and will be commenced in 2021. This paper is focused on this pre-implementation stage within the acute setting and uses a health systems responsiveness framework. Methods: We conducted face-to-face interviews using a critical incident technique. We interviewed older people including those with a diagnosis of dementia (n = 8), family carers (n = 5) and health and social care professionals (HSCPs) working in the acute setting (n = 26). Results: The interviewees reflected upon a healthcare system that is currently under significant pressures. HSCPs are doing their best, but they are often halted from delivering on the will and preference of their patients. Many older people and family carers feel that they must be very assertive to have their preferences considered. All expressed concern about the strain on the healthcare system. There are significant environmental barriers that are hindering ADM practice. Conclusions: The commencement of ADM provides an opportunity to redefine the provision, practices, and priorities of healthcare in Ireland to enable improved patient-centred care. To facilitate implementation of ADM, it is therefore critical to identify and provide adequate resources and work towards solutions to ensure a seamless commencement of the legislation.

scholarly journals Factors associated with the decision to prescribe and administer antipsychotics for older people with delirium: a qualitative descriptive study

BMJ Open ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. e047247
Author(s):  
Emily J Tomlinson ◽  
Helen Rawson ◽  
Elizabeth Manias ◽  
Nicole (Nikki) M Phillips ◽  
Peteris Darzins ◽  
...  
Keyword(s):  
Decision Making ◽  
Older People ◽  
Health Professionals ◽  
Acute Care Hospital ◽  
Nursing Workload ◽  
Care Hospital ◽  
Antipsychotic Medications ◽  
Factors Associated ◽  
Multiple Factors ◽  
Qualitative Descriptive

ObjectivesTo explore factors associated with decision-making of nurses and doctors in prescribing and administering as required antipsychotic medications to older people with delirium.DesignQualitative descriptive.SettingTwo acute care hospital organisations in Melbourne, Australia.ParticipantsNurses and doctors were invited to participate. Semi-structured focus groups and individual interviews were conducted between May 2019 and March 2020. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis.ResultsParticipants were 42 health professionals; n=25 nurses and n=17 doctors. Themes relating to decisions to use antipsychotic medication were: safety; a last resort; nursing workload; a dilemma to medicate; and anticipating worsening behaviours. Nurses and doctors described experiencing pressures when trying to manage hyperactive behaviours. Safety was a major concern leading to the decision to use antipsychotics. Antipsychotics were often used as chemical restraints to ‘sedate’ a patient with delirium because nurses ‘can’t do their job’. Results also indicated that nurses had influence over doctors’ decisions despite nurses being unaware of this influence. Health professionals’ descriptions are illustrated in a decision-making flowchart that identifies how nurses and doctors navigated decisions regarding prescription and administration of antipsychotic medications.ConclusionsThe decision to prescribe and administer antipsychotic medications for people with delirium is complex as nurses and doctors must navigate multiple factors before making the decision. Collaborative support and multidisciplinary teamwork are required by both nurses and doctors to optimally care for people with delirium. Decision-making support for nurses and doctors may also help to navigate the multiple factors that influence the decision to prescribe antipsychotics.

scholarly journals Healthcare professionals’ practice and interactions in older peoples’ cross-sectoral clinical care trajectories when acutely hospitalized - a qualitative observation study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Maiken Hjuler Persson ◽  
Christian Backer Mogensen ◽  
Jens Søndergaard ◽  
Helene Skjøt-Arkil ◽  
Pernille Tanggaard Andersen
Keyword(s):  
Decision Making ◽  
Older People ◽  
New Public Management ◽  
Healthcare Professionals ◽  
Clinical Care ◽  
Research Integrity ◽  
Care Practice ◽  
Observation Study ◽  
Person Centered Care ◽  
Centered Care

Abstract Background Healthcare services have become more complex, globally and nationally. Denmark is renowned for an advanced and robust healthcare system, aiming at a less fragmented structure. However, challenges within the coordination of care remain. Comprehensive restructures based on marketization and efficiency, e.g. New Public Management (NPM) strategies has gained momentum in Denmark including. Simultaneously, changes to healthcare professionals’ identities have affected the relationship between patients and healthcare professionals, and patient involvement in decision-making was acknowledged as a quality- and safety measure. An understanding of a less linear patient pathway can give rise to conflict in the care practice. Social scientists, including Jürgen Habermas, have highlighted the importance of communication, particularly when shared decision-making models were introduced. Healthcare professionals must simultaneously deliver highly effective services and practice person-centered care. Co-morbidities of older people further complicate healthcare professionals’ practice. Aim This study aimed to explore and analyse how healthcare professionals’ interactions and practice influence older peoples’ clinical care trajectory when admitted to an emergency department (ED) and the challenges that emerged. Methods This qualitative study arises from a hermeneutical stand within the interpretative paradigm. Focusing on the healthcare professionals’ interactions and practice we followed the clinical care trajectories of seven older people (aged > 65, receiving daily homecare) acutely hospitalized to the ED. Participant observations were combined with interviews with healthcare professionals involved in the clinical care trajectory. We followed-up with the older person by phone call until four weeks after discharge. The study followed the code of conduct for research integrity and is reported in accordance with the Standards for Reporting Qualitative Research (SRQR) guidelines. Results The analysis revealed four themes: 1)“The end justifies the means – ‘I know what is best for you’”, 2)“Basic needs of care overruled by system effectiveness”, 3)“Treatment as a bargain”, and 4)“Healthcare professionals as solo detectives”. Conclusion Dissonance between system logics and the goal of person-centered care disturb the healthcare practice and service culture negatively affecting the clinical care trajectory. A practice culture embracing better communication and more person-centered care should be enhanced to improve the quality of care in cross-sectoral trajectories.

scholarly journals 023 PP: INVOLVING PATIENTS AND CARERS IN RESEARCH: THE EXPERIENCE OF OLDER PEOPLE IN THE SHARED DECISION-MAKING PROCESS IN ADVANCED KIDNEY CARE a

BMJ Open ◽  
2017 ◽  
Vol 7 (Suppl 2) ◽  
pp. bmjopen-2017-016492.41
Author(s):  
N Thomas ◽  
K Jenkins ◽  
S Datta ◽  
R Endacott ◽  
J Kent ◽  
...  
Keyword(s):  
Decision Making ◽  
Older People ◽  
Shared Decision Making ◽  
Decision Making Process ◽  
Shared Decision

Critical Illness and the Emergency Room

2011 ◽  
pp. 63-74
Author(s):  
R. K. Goyal ◽  
M. O’Neill ◽  
N. Agostinelli ◽  
P. Wyer
Keyword(s):  
Decision Making ◽  
Critical Illness ◽  
Emergency Room ◽  
Medical Futility ◽  
Critically Ill Patient ◽  
Industrial Complex ◽  
Acute Setting ◽  
Construction Of Knowledge ◽  
Military Industrial Complex ◽  
The Military

The care of the critically-ill patient in the acute setting, an ‘everyday’ occurrence in most urban emergency departments, often proceeds through the dictates of Parsonian paternalism: the Physician knows best. But through a discussion of three such ‘everyday’ encounters, we hope to complicate this notion and find a place for healthcare users in the decision making process while developing a language and analytic basis for thinking seriously about the clinical dyad and the construction of knowledge in relationship economies. Finally, we discuss the escalation and de-escalation (terms derived from the military industrial complex) of care as it relates to medical futility.

scholarly journals 171 Programme Theory to Guide the Adoption of Assisted Decision Making with Older People in Acute Healthcare: Realist Evaluation

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii1-iii16
Author(s):  
Carmel Davies ◽  
Deirdre O'Donnell ◽  
Éidín Ní Shé ◽  
Sarah Donnelly ◽  
Francesco Fattori ◽  
...  
Keyword(s):  
Decision Making ◽  
Older People ◽  
Acute Care ◽  
Professional Training ◽  
Legal Framework ◽  
Realist Evaluation ◽  
Shared Responsibility ◽  
Programme Theory ◽  
Key Informants ◽  
People With Dementia

Abstract Background In Ireland, the Assisted Decision-Making (ADM) (Capacity) Act and emerging Codes of Practice provide a legal framework for Healthcare Professionals (HCPs) to enable ADM for patients with impaired capacity. ADM ensures that a person’s will and preference is at the centre of all decisions related to their care. This study conducted a realist evaluation and developed a Programme Theory (PT) to highlight how ADM for older people can be operationalised within an Acute Care (AC) context. Methods Key informants with interest in ADM informed this evaluation. Interviews were conducted in two Acute Care (AC) sites with multidisciplinary HCPs working within older person services (n=20). Interviews with informants that recently received care within an AC setting involved older people (n=3) people with dementia (n=4) and family carers (n=5). Ethnographic observations from AC multidisciplinary team meetings also informed the review. The framework that guided the qualitative analysis was from a PT informed by literature on ADM implementation in healthcare (O'Donnell, Ní Shé, Davies et al.2018). Results The refined PT is supported by credible evidence that is informed by authentic experiences of decision making support in the AC setting. Validation groups (n=4) with the key informants verified the PT. Three mechanisms were identified as a positive climate and receptive environment for the adoption of formal ADM. These are: AC settings that adopt inter-professional accountability and shared responsibility for patient care that is guided by a clear policy process. Acute care and practice that is informed by a shared commitment to person-centred care and shared decision making. HCPs that operate within an AC setting where organisational learning informs practice through inter-professional training, mentorship and peer support. Conclusion Involving stakeholders in PT development enhances the utility, feasibility and applicability of the results. This PT provides a framework for those planning ADM implementation within the AC settings.

scholarly journals 233 Potential Deprivation of Patient Liberty: A Qualitative Study of Current Practice Amongst Geriatricians in a Tertiary Setting

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Michelle O'Brien ◽  
Deirdre O'Donnell ◽  
Barbara Clyne
Keyword(s):  
Decision Making ◽  
Perceived Risk ◽  
Current Practice ◽  
Structured Interview ◽  
Structured Interviews ◽  
Healthcare Ethics ◽  
Patient Decision Making ◽  
Acute Setting ◽  
Difficult Decision ◽  
Patient Decision

Abstract Background The Assisted Decision Making (ADM) Act 2015 was introduced to support decision making and maximise a person’s capacity to make decisions but has not yet commenced. Within this context, medical professionals such as geriatricians must adjust from a best interest’s outlook to that of patient autonomy in response to the changing legislation. The aim of this study is to explore current geriatrician’s practice. In scrutinizing current practice, it will be evident as to what, if any, adaptations are required in order to practice in accordance with the new legislation. Methods Ten semi-structured interviews with individual consultant geriatricians were conducted, each lasting approximately 20 minutes on average in one hospital. Each interview was recorded and transcribed verbatim. The interview involved the geriatrician reading a vignette and answering questions as to how they would manage this situation. Following the vignette, the semi-structured interview proceeded covering topics including; patient decision making in the acute setting, deprivation of patient liberty in the acute setting, thoughts on the ADM (Capacity) Act 2015, and elements learned from experiences in other countries. A thematic analysis was conducted. Results Preliminary themes identified from the interviews include; (a) identification, accessibility and availability of medical and legal colleagues in assisting with difficult decision making, (b) need for clear frameworks, guidance and education in relation to laws applying to medical practice, (c) influence of environment, family, perceived risk and delirium on capacity assessment, (d) paternalism versus autonomy. This work is being conducted as part of a master’s in healthcare ethics and law. Conclusion Preliminary results highlight the need for collaborative communication between medics and the legal profession in order to achieve a structured and supportive framework to inform practice considering the new legislation.

scholarly journals Hypertension management: experiences, wishes and concerns among older people—a qualitative study

BMJ Open ◽  
2019 ◽  
Vol 9 (8) ◽  
pp. e030742 ◽  
Author(s):  
Emma van Bussel ◽  
Leony Reurich ◽  
Jeannette Pols ◽  
Edo Richard ◽  
Eric Moll van Charante ◽  
...  
Keyword(s):  
Decision Making ◽  
Older People ◽  
Community Dwelling ◽  
Hypertension Management ◽  
Anticipated Regret ◽  
Qualitative Interview Study ◽  
Data Saturation ◽  
Explicit Consideration ◽  
Perceived Involvement ◽  
The Right

ObjectivesSixty-five per cent of older people have hypertension, but little is known about their preferences and concerns regarding hypertension management. Guidelines on hypertension lack consensus on how to treat older people without previous cardiovascular disease (CVD). This asks for explicit consideration of patient preferences in decision making. Therefore, the aim of this study was to explore older peoples’ experiences, preferences, concerns and perceived involvement regarding hypertension management.DesignQualitative interview study.SettingParticipants were selected from 11 general practitioner (GP) practices in the Netherlands and purposively sampled until data saturation was achieved. Semistructured interviews were conducted, audio recorded and analysed by two researchers using thematic analysis.ParticipantsFifteen community dwelling older people aged 74–93 years with hypertension and without previous CVD participated.ResultsInterviewees rarely started the conversation about hypertension management with their GP, although they did have concerns. Reasons for not discussing the subject included low priority of hypertension concerns, reliance on GPs or trust in GPs to make the right decision on their behalf. Also, interviewees anticipated regret of reducing medication, fearing vascular incidents. Interviewees would like to discuss tailoring treatment to their needs, deprescription of medication and ways to reduce side effects. They expected GPs to be more transparent on treatment effects.ConclusionOlder people describe having little involvement in hypertension management, although they have several concerns. Since GPs are also known to be hesitant to bring up this subject, we signal a conspiracy of silence about antihypertensive medication. Through breaking this silence, GPs can facilitate shared decision-making on hypertension management and better tailored care.

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