Rewiring practice: community mental health professionals’ attitudes towards and knowledge of electroconvulsive therapy in the context of advance decision-making

Purpose In England, electroconvulsive therapy (ECT) cannot be administered to service users who make an advance decision to refuse the treatment, unless in life-threatening circumstances. In a sector where person-centred practice is revered, no prior research has investigated whether community mental health practitioners (CMHPs) encourage service users to make advance decisions about ECT. This study aims to explore whether CMHPs have supported advance decision-making about ECT and whether their profession, attitudes towards and knowledge of the treatment affect this. Design/methodology/approach A quantitative online survey was completed by n = 120 CMHPs (nurses, social workers and occupational therapists). The validated Questionnaire on Attitudes and Knowledge of ECT was used. Findings In total, 93% of participants knew service users who had undergone ECT, yet only 12% had supported a service user to make an advance decision about ECT. Compared to those who had not supported advance decision-making, those who had shown significantly higher knowledge and a more positive attitude. Nurses and those who had worked in the mental health field for over 10 years had significantly higher knowledge of ECT. Originality/value CMHPs are well placed to support advance decision-making about ECT. Increased knowledge about advance decisions and ECT may bolster the uptake of advance decision-making, thus greater training is recommended.

Mental Capacity Act 2005

This chapter covers the Mental Health Act 2005 and includes topics on The Core Test for Mental Capacity, The Obligation to Assist a Person to Gain Capacity, The Best Interests Assessment when a Patient Lacks Capacity, Non-Discrimination in Best Interests Assessment, Derivation of Liberty: General Principles, Derivation of Liberty: Life-Saving Treatment, Protection for Those Wrongly Assessing Capacity Or Best Interests, Definition of a Lasting Power of Attorney, General provisions on advanced directives, Effect of an advance decision, The Effect of Advance Decisions, Things that the Mental Capacity Act cannot authorise, and Authorising of Deprivation of Liberty.

Awareness and Attitudes towards Advance Care Directives (ACDs): An Online Survey of Portuguese Adults

(1) Background: Evidence shows that facilitated advance decisions can increase the number of meaningful and valid Advance Care Directives (ACDs) and improve the quality of care when End-Of-Life (EOL) is near. Little is known about the awareness and attitudes of Portuguese adults towards ACDs. The present study aims to assess the knowledge, attitudes, and preferences of a sample of Portuguese adults regarding EOL care decisions and ACDs. (2) Methods: A total of 1024 adults were assessed with an online cross-sectional survey collecting information on sociodemographic factors, knowledge, attitudes and preferences regarding advance decisions and EOL care. (3) Results: Participants had a mean age of 40.28 ± 11.41 years. Most were female and had a professional background related to healthcare. While 76.37% of participants had heard of ACDs, only a small percentage (2.34%) had actually ever made an ACD. Knowledge levels were weakly correlated with attitudes regarding ACDs (r = −0.344; p < 0.01). (4) Conclusions: Participants lacked a comprehensive understanding about ACDs, but revealed positive attitudes towards their use and usefulness. Further research can inform efforts to improve ACD engagement in this population. The discussion about ACDs should be part of health promotion education with a focus on planning for a comfortable and peaceful death.

The Characteristics and Motivations of Taiwanese People toward Advance Care Planning in Outpatient Clinics at a Community Hospital

Advance care planning (ACP) provides access to complete advance decisions (ADs). Despite the legalization of ACP in Taiwan, it is underutilized in community settings. The objective of this study is to describe the service at a community hospital in Southern Taiwan. We retrospectively analyzed participants who were engaged in ACP consultations from January 2019 to January 2020. The characteristics, motivations, content, and satisfaction of participants are reported. Factors associated with refusing life-sustaining treatments (LST) or artificial nutrition/hydration (ANH) were analyzed using multivariate logistic regression. Of the 178 participants, 123 completed the ACP. The majority were female (64.2%), aged 61 on average and more than 80% had never signed a do-not-resuscitate order. In the ADs, most participants declined LST (97.2%) and ANH (96.6%). Family-related issues (48.9%) were the most prevalent motivations. Rural residence (OR 8.6, p = 0.005), increased age (OR 7.2, p = 0.025), and reluctance to consent to organ donation (OR 5.2, p = 0.042) correlated with refusing LST or ANH. Participants provided a positive feedback regarding overall satisfaction (good, 83%) compared to service charge (fair/poor, 53%). The study demonstrated high AD completion when refusing LST or ANH. These findings may facilitate the development of ACP as a community-based service.

COVID-19 Management in a UK NHS Foundation Trust with a High Consequence Infectious Diseases Centre: A Retrospective Analysis

Recent large national and international cohorts describe the baseline characteristics and outcome of hospitalised patients with COVID-19, however there is limited granularity to these reports. We aimed to provide a detailed description of a UK COVID-19 cohort, focusing on management and outcome. We performed a retrospective single-centre analysis of clinical management and 28-day outcomes of consecutive adult inpatients with SARS-CoV-2 PCR-confirmed COVID-19 from 31 January to 16 April 2020 inclusive. In total, 316 cases were identified. Most patients were elderly (median age 75) with multiple comorbidities. One quarter were admitted from residential or nursing care. Mortality was 84 out of 316 (26.6%). Most deaths occurred in patients in whom a ceiling of inpatient treatment had been determined and for whom end of life care and specialist palliative care input was provided where appropriate. No deaths occurred in patients aged under 56 years. Decisions to initiate respiratory support were individualised after consideration of patient wishes, premorbid frailty and comorbidities. In total, 59 (18%) patients were admitted to intensive care, of which 31 (10% overall cohort) required intubation. Multiple logistic regression identified associations between death and age, frailty, and disease severity, with age as the most significant factor (odds ratio 1.07 [95% CI 1.03–1.10] per year increase, p < 0.001). These findings provide important clinical context to outcome data. Mortality was associated with increasing age. Most deaths were anticipated and occurred in patients with advance decisions on ceilings of treatment.

Legal issues in end-of-life care 2: consent and decision-making

Paramedics are legally and professionally obliged to uphold their patients' right to dignity, respect and autonomy—and this includes the general requirement to obtain their consent before proceeding with any intervention. The first instalment of this two-part article considered the challenges that this might present to the paramedic. This second article develops this theme and further explores the legal framework underpinning the decision-making process when caring for a patient approaching the end of life. It also examines issues around consent and mental capacity in more depth and addresses matters such as such as advance decisions to refuse treatment (ADRT) and do not attempt cardio-pulmonary resuscitation (DNACPR) decisions.

From ovid to COVID: the metamorphosis of advanced decisions to refuse treatment into a safeguarding issue

Purpose This paper aims to examine advance decisions to refuse treatment (ADRTs) in the context of the COVID-19 (Coronavirus 2019) pandemic. This study considers the development of ADRTs, the lack of take up and confusion among the general public, clinicians and health and social care staff. Design/methodology/approach The paper is a conceptual piece that reflects on ADRTs in the particular context of COVID-19. It considers professional concerns and pronouncements on ADRTs. Findings ADRTs have a low take up currently. There is misunderstanding among public and professionals. There is a need for raising awareness, developing practice and a need to allay fears of misuse and abuse of ADRTs in clinical, health and social care settings. Practical implications The authors make recommendations that reflexive training and awareness become the norm in health and social care, that reform of ADRTs is undertaken to prevent misunderstandings and that the person becomes central in all decision-making processes. Originality/value This paper is original in considering ADRTs as a safeguarding issue from two perspectives: that of the person making the ADRT and being confident in respect for the decisions made; and that of clinicians and other professionals being reflexively aware of the need to accept advance decisions and not acting according to unconscious biases in times of crisis.

Dementia, Sexuality, and the Law: The Case for Advance Decisions on Intimacy

Some individuals develop dementia and the invariable consequence of dementia is a decline in cognition and level of functioning. Despite the effects of this illness, people with dementia still seek intimacy and companionship as part of their expression of basic human instincts and have the right to equal enjoyment of relationships and privacy for such. At the same time, they have the right to be safeguarded against abuse. The law in England and Wales, in common with the majority, if not all, jurisdictions around the world is clear on the requirement for contemporaneous consent to sexual activity, thereby creating unmet needs for people with dementia who no longer have the capacity to consent to intimacy/sexuality. This creates an impetus to find ways to empower individuals with dementia to enjoy intimacy in a safe and lawful way and enable them to live well despite dementia. This article proposes an instrument known as the Advance Decision on Intimacy, in pursuit of the concept of precedent autonomy, to empower individuals to make decisions about how they would wish to express their sexuality at a material time in future when they would have lost the capacity to consent to such acts. While the article is framed by reference to English law, the principles are of wider relevance.

End-of-life care part 1: implications for paramedic practice

Caring for patients who are approaching the end of life is an important part of the paramedic's role. Patients' circumstances are individual; for some, death is expected and may even a welcome (albeit sad) relief from a long period of pain and distress, while for others it is a tragic, unexpected outcome after every effort to prevent it has been exhausted. Regardless of circumstances, paramedics have to make wide-ranging clinical decisions, underpinned by a complex legal and regulatory framework. Paramedics generally have to obtain a patient's informed consent before proceeding with any intervention. They may be challenged if a dying patient refuses life-sustaining treatment or no longer has the mental capacity to consent and need to know the law on decision-making in these cases. This article discusses issues around capacity and consent at the end of life. The next article in this series considers issues such as advance decisions to refuse treatment and do not attempt CPR decisions.

Refusing and Demanding Medical Treatment in Intensive Care

This chapter examines the interactions in England and Wales between adult patients with capacity and the clinical team as regards the refusal of, or requests for, specific treatments. It sets out how to best determine what might constitute harm for that individual patient, and how to appropriately communicate the risks of having (or not having) the treatment. It provides an overview of both the professional guidance and ethical framework in which decisions are made, and the law and how it might constrain (or allow) them to act in certain ways, noting that professional guidance, ethical argument, and the law sometimes pull in different directions, and sometimes inform each other. It also addresses the position of such a patient seeking to project forward their decisions by way of advance decisions to refuse treatment. Co-written by a clinician and a lawyer, and placing the law within the setting of the intensive care unit, the chapter explores the dilemmas that arise when abstract principles meet clinical realities.