Canadian outpatients and advance directives: poor knowledge and little experience but positive attitudes.

OBJECTIVE: To examine the knowledge of, previous experience with, attitudes toward and perceived barriers to completing advance directives among outpatients at two general medicine clinics. DESIGN: Cross-sectional questionnaire administered in face-to-face structured interviews. SETTING: General internal-medicine outpatient clinics at a university teaching hospital. PATIENTS: One hundred and five adult outpatients who could communicate in spoken English and who consented to be interviewed. RESULTS: Of 167 patients approached, 58 were excluded because they could not communicate in spoken English, and 4 refused to participate. Of the remaining 105 patients, 17 (16%) knew about living wills, 12 (11%) about durable powers of attorney for health care and 4 (4%) about advance directives. Twenty-three (22%) had thought about their preferences for life-sustaining treatment, 20 (19%) had discussed them, none had written them down, and 45 (43%) had thought about choosing a proxy. Sixty-one (58%) wanted to think about their preferences for treatment, 65 (62%) wanted to discuss them, 32 (30%) wanted to write them down, and 80 (76%) wanted to choose a proxy. The perceived barriers to completing an advance directive were inability to write, the belief that an advance directive was unnecessary, a fatalistic attitude, previous discussion of preferences, a desire to leave the decision to doctors, uncertainty about preferences, a desire to discuss preferences rather than document them, a desire to wait until the situation arose, a desire to write down preferences in the future and a desire to avoid thinking about preferences or advance directives. Respondents with more knowledge of life-sustaining treatments were more likely to want to complete an advance directive. CONCLUSIONS: Outpatients have positive attitudes toward advance directives, but their knowledge and experience are limited. These data underscore the need for patient education and for policies to eliminate the barriers to completing advance directives that patients face.     

Advance directives: the views of health care professionals.

OBJECTIVES: This study examined the views and experiences of 20 physicians and 20 nurses at a major Canadian teaching hospital regarding the use of advance directives in clinical care. DESIGN: The participants were purposively drawn from four clinical specialties: family and community medicine, oncology, intensive care and geriatrics. Detailed interviews were conducted in person. Content analysis was used to code the data, which were further analysed with both quantitative and qualitative techniques. MAIN RESULTS: Thirty-nine of the 40 participants favoured the use of advance directives in clinical care; physicians had somewhat less positive attitudes than nurses toward such directives. Advance directives were thought by participants to be helpful in resolving disagreements between patients and their families about treatment options; in making patients more comfortable, both physically and psychologically, during the process of dying; and in opening up communication and trust among patients, their families and health care professionals. Concerns about the use of advance directives focused on the lack of clarity in some patients' instructions, the absence of legal status for directives, the possible interference with a practitioner's clinical judgement, the adequacy and appropriateness of patients' information about their circumstances, and the type of intervention (passive or active) requested by patients. CONCLUSIONS: New regulations and legislation are making the use of advance directives more widespread. Health care professionals should participate in the development and implementation of these directives. Continuing professional education is essential in this regard.     

Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.     

香港市民和护士对预前指示及末期病患者采用维持生命治疗看法的调查研究

本研究目的是分析香港市民和注册护士对预前指示的态度和使用时所考虑的因素，及他们对垂死病患者采用维持生命治疗的看法。结果显示年龄和学历高的受访者普遍接受预前指示．市民和护士的看法不同。预前指示普及已是社会的趋势，但现时社会预前指示的理解如维持生命治疗的决策过程仍模糊不清，唯医护人员的理解较深。因此，医护人员对预前指示这一概念的推广和教育上应兼付什么责任的问题值得思考。     

Comparison of patients' and health care professionals' attitudes towards advance directives.

OBJECTIVES: This study was designed to identify and compare the attitudes of patients and health care professionals towards advance directives. Advance directives promote recognition of the patient's autonomy, letting the individual exercise a certain measure of control over life-sustaining care and treatment in the eventuality of becoming incompetent. DESIGN: Attitudes to advance directives were evaluated using a 44-item self-reported questionnaire. It yields an overall score as well as five factor scores: autonomy, beneficence, justice, external norms, and the affective dimension. SETTING: Health care institutions in the province of Québec, Canada. Survey sample: The sampling consisted of 921 subjects: 123 patients, 167 physicians, 340 nurses and 291 administrators of health care institutions. RESULTS: Although the general attitude of each population was favourable to the expression of autonomy, multivariate analysis of variance (MANOVA) indicated that physicians attached less importance to this subscale than did other populations (p < .001). Above all, they favoured legal external norms and beneficence. Physicians and administrators also attached less importance to the affective dimension than did patients and nurses. Specifically, physicians' attitudes towards advance directives were shown to be less positive than patients' attitudes. CONCLUSION: More attention should be given to the importance of adequately informing patients about advance directives because they may not represent an adequate means for patients to assert their autonomy.     

Relationships between various attitudes towards self-determination in health care with special reference to an advance directive

OBJECTIVES: The subject of patient self-determination in health care has gained broad interest because of the increasing number of incompetent patients. In an attempt to solve the problems related to doctors' decision making in such circumstances, advance directives have been developed. The purpose of this study was to examine relationships between public attitudes towards patient autonomy and advance directives. SUBJECTS AND MAIN OUTCOME MEASURES: A stratified random sample of 600 adults in northern Sweden was surveyed by a questionnaire with a response rate of 78.2%. The subjects were asked about their wish for control of their health care, their concerns about health care, their treatment preferences in a life-threatening situation (both reversible and irreversible), and their attitudes towards the application of advance directives. RESULTS: Numerous relationships between various aspects of self-determination in health care (desire for control, fears of over-treatment, and choice of treatment level) in general and advance directives, in particular, were found. Those who wanted to have a say in their health care (about 94%) also mainly supported the use of an advance directive. CONCLUSIONS: The fact that almost 30% of the respondents were undecided concerning their personal use of advance directives points to a lack of knowledge and to the necessity of education of the public on these issues.     

French district nurses' opinions towards euthanasia, involvement in end-of-life care and nurse patient relationship: a national phone survey

OBJECTIVES: To assess French district nurses' opinions towards euthanasia and to study factors associated with these opinions, with emphasis on attitudes towards terminal patients. DESIGN AND SETTING: An anonymous telephone survey carried out in 2005 among a national random sample of French district nurses. PARTICIPANTS: District nurses currently delivering home care who have at least 1 year of professional experience. Of 803 district nurses contacted, 602 agreed to participate (response rate 75%). MAIN OUTCOME MEASURES: Opinion towards the legalisation of euthanasia (on a five-point Likert scale from "strongly agree" to "strongly disagree"), attitudes towards terminal patients (discussing end-of-life issues with them, considering they should be told their prognosis, valuing the role of advance directives and surrogates). RESULTS: Overall, 65% of the 602 nurses favoured legalising euthanasia. Regarding associated factors, this proportion was higher among those who discuss end-of-life issues with terminal patients (70%), who consider competent patients should always be told their prognosis (81%) and who value the role of advance directives and surrogates in end-of-life decision-making for incompetent patients (68% and 77% respectively). Women and older nurses were less likely to favour legalising euthanasia, as were those who believed in a god who masters their destiny. CONCLUSIONS: French nurses are more in favour of legalising euthanasia than French physicians; these two populations contrast greatly in the factors associated with this support. Further research is needed to investigate how and to what extent such attitudes may affect nursing practice and emotional well-being in the specific context of end-of-life home care.     

社区老年居民及家属预先指示知识和态度及其影响因素研究

背景　社区老年居民是预先指示的重点应用人群之一，了解社区老年居民及家属的预先指示知识和态度有助于预先指示的推广应用。目的　了解社区老年居民及家属对预先指示的知识和态度，并探讨预先指示接受度的影响因素。方法　采用一般资料调查表、预先指示知识量表和预先指示态度问卷，于2019年11-12月对天津市滨海新区塘沽街10个社区的200例社区老年居民和200例家属进行调查。结果　社区老年居民回收问卷170份，家属回收问卷180份。社区老年居民及家属预先指示知识量表中位得分分别为0（0，0）、0（0，0）分。社区老年居民对预先指示的知晓率和接受度分别为6.5%（11/170）和41.2%（70/170），家属为10.6%（19/180）和58.9%（106/180）。Logistic逐步回归分析结果显示，影响社区老年居民预先指示接受度的因素包括：文化程度、病情难以逆转或疾病晚期是否放弃治疗、病情难以逆转或在疾病晚期生存质量还是生存时间重要、是否听说过预先指示（P<0.05）；影响家属预先指示接受度的因素包括：文化程度、与老人居住方式、预先指示知识水平、病情难以逆转或疾病晚期是否应采取对症治疗、是否听说过生前预嘱（P<0.05）。结论　社区老年居民及家属对预先指示的了解甚少，接受度有待提高，社区居民预先指示知识教育需加强。社区医护人员应对社区居民及家属开展预先指示宣传，让更多社区居民及家属了解预先指示。     

Physicians's reports on the impact of living wills at the end of life in Japan

CONTEXT: A growing number of Japanese people have completed advance directives, especially living wills, even though there is no legislation recognising such documents and little empirical research on their impact on clinical care at the end of life in Japan. OBJECTIVES: To investigate physicians' attitudes about living wills and their experiences with patients who had completed a living will and later died. DESIGN: Self administered survey and qualitative study using open question and content analysis. SETTING: Japan. PARTICIPANTS: Physicians known to have cared for a patient who had presented a living will prior to death. MEASUREMENTS: The physician's response to receiving a living will, communication about the living will, the impact of the living will on clinical care, demographics, and their opinion on advance directives, especially living wills. MAIN RESULTS: Fifty five per cent of respondents approved of advance directives in general, and 34% had more opportunities to communicate with a patient and his/her family after receiving the living will. Sixty nine per cent of the physicians who received a living will did not, however, change their course of therapy as a consequence of receiving the living wills. Based on the analysis, we identified three areas of concern in the comments on living wills: (1) concerns relative to patients, physicians, and families; (2) social context, and (3) clinical and administrative concerns. The physicians raised various topics for discussion; they tended to describe the issues from a clinical perspective. CONCLUSIONS: Our identified areas of concern should prove helpful in better understanding the clinical and ethical implications of living wills in Japan.     

How strictly do dialysis patients want their advance directives followed?

OBJECTIVE--The Cruzan case and the Patient Self-Determination Act will encourage patients to specify in advance which life-sustaining treatments they would want if they become mentally incompetent. However, strictly following such advance directives may not always be in a patient's best interests. We sought to determine whether patients differ in how strictly they want advance directives followed. DESIGN--Interview study. SETTING--Seven outpatient chronic dialysis centers. PARTICIPANTS--One hundred fifty mentally competent dialysis patients. INTERVENTION--Using a structured questionnaire, we asked the subjects whether they would want dialysis continued or stopped if they developed advanced Alzheimer's disease. We then asked how much leeway their physician and surrogate should have to override that advance directive if overriding were in their best interests. Subjects granting leeway were also asked what factors should be considered in making decisions for them. RESULTS--Subjects varied greatly in how much leeway they would give surrogates to override their advance directives: "no leeway" (39%), "a little leeway" (19%), "a lot of leeway" (11%), and "complete leeway" (31%). Subjects also varied in how much they wanted various factors considered in making decisions, such as pain or suffering, quality of life, possibility of a new treatment, indignity caused by continued treatment, financial impact of treatment on family members, and religious beliefs. CONCLUSIONS--Strictly following all advance directives may not truly reflect patients' preferences. To improve advance directives, we recommend that physicians explicitly ask patients how strictly they want their advance directives followed and what factors they want considered in making decisions.     

医学类专业学生统计学态度现状调查及相关影响因素分析

目的 调查高校医学类专业学生的统计学态度现状,探讨其影响因素,并分析统计学态度与统计学课程成绩的相关性,为探索教学改革方向和提升教学效果提供科学依据。 方法 以教育部直属某综合性大学医学院2018~2019学年开设医学统计学的学生为研究对象,使用汉化版的统计学态度调查量表(SATS-36)作为测量工具,量表各条目均以Likert 7分法计分,得分越高代表态度越积极。通过问卷星平台进行在线调查,调查结果采用SPSS软件进行统计分析。 结果 共有776名学生完成调查,总量表条目均分为4.84±0.64;分维度统计,努力程度得分最高(6.41±0.85),其次是价值判断(5.93±0.88),得分最低的维度为难度评价(2.73±0.77);性别、学历层次、专业和数学背景是影响统计学态度的主要因素,量表得分男生高于女生,研究生高于本科生,临床专业和公共卫生/卫生管理专业高于其他专业;数学成绩自评等级越高者统计学态度越积极;课程成绩与统计学态度呈正相关,但相关程度属弱相关(Spearman相关系数为0.227,P<0.001)。 结论 医学生的统计学态度属中等偏上积极性,尤其在努力程度和价值判断方面,积极性最高,但存在明显的畏难情绪;态度积极性与统计学课程成绩呈正相关。进行医学统计学教学时,应针对不同性别、不同专业和不同层次医学生的学习障碍,采取不同的应对措施,改革教学方法,以达到帮助学生提高积极性进而提高学业成绩的目的。     

Survey of Japanese physicians'' attitudes towards the care of adult patients in persistent vegetative state.

OBJECTIVES: Ethical issues have recently been raised regarding the appropriate care of patients in persistent vegetative state (PVS) in Japan. The purpose of our study is to study the attitudes and beliefs of Japanese physicians who have experience caring for patients in PVS. DESIGN AND SETTING: A postal questionnaire was sent to all 317 representative members of the Japan Society of Apoplexy working at university hospitals or designated teaching hospitals by the Ministry of Health and Welfare. The questionnaire asked subjects what they would recommend for three hypothetical vignettes that varied with respect to a PVS patient's previous wishes and the wishes of the family. RESULTS: The response rate was 65%. In the case of a PVS patient who had no previous expressed wishes and no family, 3% of the respondents would withdraw artificial nutrition and hydration (ANH) when the patient did not require any other life-sustaining treatments, 4% would discontinue ANH, and 30% would withhold antibiotics when the patient developed pneumonia. Significantly more respondents (17%) would withdraw ANH in the case of a PVS patient whose previous wishes and family agreed that all life support be discontinued. Most respondents thought that a patient's written advance directives would influence their decisions. Forty per cent of the respondents would want to have ANH stopped and 31% would not want antibiotics administered if they were in PVS. CONCLUSIONS: Japanese physicians tend not to withdraw ANH from PVS patients. Patients' written advance directives, however, would affect their decisions.     

Advance directives and older people: ethical challenges in the promotion of advance directives in New Zealand

In New Zealand an advance directive can be either an oral statement or a written document. Such directives give individuals the opportunity to make choices about future medical treatment in the event they are cognitively impaired or otherwise unable to make their preferences known. All consumers of health care have the right to make an advance directive in accordance with the common law. When we consider New Zealand's rapidly ageing population, the fact that more people now live with and die of chronic rather than acute conditions, the importance given to respecting autonomous decision-making, increasing numbers of individuals who require long-term residential care, and financial pressures in the allocation of medical resources, there would seem to be a number of compelling reasons to encourage individuals to write or verbalize an advance directive. Indeed the promotion of advance directives is encouraged. However, caution should be exercised in promoting advance directives to older people, especially in light of several factors: ageist attitudes and stereotypes towards them, challenges in the primary healthcare setting, and the way in which advance directives are currently focused and formulated. This paper considers some of the specific challenges that need to be addressed if the promotion of advance directives are to improve outcomes of patient treatment and care near the end of life.     

Effect of a course in cancer prevention on students' attitudes and clinical behavior

The long-term effects of a first-year medical school course in disease prevention focusing on cancer were studied. The authors hypothesized that students' increased knowledge of disease prevention principles would result in more positive attitudes toward aggressive treatment and prevention of cancer and a more frequent use of disease prevention techniques in clinical settings. On two occasions one to three years after the course, groups of students who took the course and groups that did not take the course responded to a test of knowledge of cancer, a cancer attitude survey, a clinical practice survey, and an evaluation of the course's relevance. Also, their clinical behavior was observed and coded during videotaped interviews of patients. While the students who took the course were more knowledgeable about cancer than their peers who did not, they did not have significantly more positive attitudes; nor were they significantly more likely to use prevention techniques in clinical settings. However, the more knowledgeable students--both those who took the course and the control students--had more positive attitudes than the less knowledgeable students. Those students who considered the course relevant to their training were more knowledgeable and had more positive attitudes toward cancer prevention than those who did not consider it relevant.     

Medical researchers and the media. Attitudes toward public dissemination of research.

OBJECTIVE--To study the experience of recently published authors with the news media. DESIGN--A self-administered questionnaire. PARTICIPANTS--All first authors of scientific articles published in JAMA and The New England Journal of Medicine during a 6-month period. Of 397 surveyed, 92% responded. MAIN OUTCOME MEASURES--Researchers were asked about (1) their experience with the news media, (2) their attitudes toward the dissemination of health-related research to the general public, and (3) their attitudes toward the lay press. RESULTS--Of respondents, 65% stated that their research was discussed in the lay press, and 60% reported that they were directly contacted by the press. Researchers had positive attitudes toward the press; 86% reported that news reports based on their research were accurate and 44% felt that media coverage would help them achieve their overall professional goals. Positive aspects of media coverage most frequently endorsed were that (1) it improves the image of the profession, (2) it informs the professional community of their research, and (3) it allows the public to understand the topic better. Negative aspects of media coverage were (1) it gives the impression that the researcher is seeking publicity, (2) it creates jealousy among colleagues, and (3) it takes too much time. Researchers were not eager to change the existing dissemination process, yet they endorsed the need for uniform standards concerning relations with the press. CONCLUSIONS--The majority of first authors in two leading medical journals reported substantial media coverage of their research, expressed generally positive sentiments about the press coverage of their work, and expressed a need for consensus on interactions involving the press.     

肿瘤医院医护人员对预立医疗照护计划态度与行为意向的调查分析

  目的  本研究以调查浙江省某肿瘤专科医院医护人员对预立医疗照护计划(advance care planning,ACP)的态度及其行为意向,为姑息照护领域开展相关工作提供参考。  方法  采用随机抽样法,在2019年8—11月以浙江省某肿瘤专科医院的520名医护人员为调查对象,采用一般资料调查表、医务人员预立医疗照护计划态度与行为意向调查问卷进行调查研究。  结果  有99.8%的医护人员认为了解患者的生命意愿非常重要,有98.5%的医护人员认为医疗决策应是患者、家属及医生共同讨论后制定,且96.3%的医护人员赞同家属应该参与其中。肿瘤医院医护人员对ACP行为参与率为26.6%,在协助患者预先设立生命意愿意向方面,78.5%愿意、6.0%不清楚、15.6%不愿意。肿瘤医院医护人员实施ACP态度和行为意向影响单因素分析显示,不同工作年限、婚姻、文化程度、丧亲经历、对预先设立医疗照护计划认知的医护人员对ACP的态度及行为得分差异有统计学意义(均P < 0.05)。多因素分析调查发现已婚、高学历、有丧亲经历、认知预先设立医疗照护计划影响肿瘤医院医护人员实施ACP的态度和行为意向。  结论  医护人员对晚期癌症患者实施ACP的态度及行为意向总体呈现较为积极的接纳态度,医护人员推行ACP的态度会受学历及婚姻状况等影响。在患者治疗上医护人员存在一些分歧, 更倾向于ACP的实施,也更愿意帮助患者签署生命意愿。      

大学生心理求助态度与领悟社会支持的关系

目的:了解大学生专业心理求助态度的特点及与领悟社会支持的关系,为大学生心理求助能力的培养及高校心理健康教育机制的完善提供参考。方法:用自编一般情况量表、寻求专业性心理帮助的态度问卷(ATSPPH)和领悟社会支持量表(PSSS)分别对898名在校大学生进行测验和比较。结果:1不同性别大学生在心理求助态度总分及对耻辱的忍受性维度上的差异有统计学意义,总体而言女生比男生求助态度更积极。2有求助经历的大学生心理求助态度比没有求助经历的积极。3大学生专业心理求助态度与领悟社会支持呈正相关(r=0.148,P<0.01)。结论:大学生心理求助态度有待改善;领悟社会支持水平对大学生心理求助态度有一定的影响,大学生领悟到社会支持越多,其求助态度越积极。     

Effect of a course on students' attitudes toward substance abuse and its treatment

From 1978 through 1982, pretests and posttests of second-year medical students' attitudes toward substance abuse and its treatment showed that positive attitude change could be achieved during a substance abuse course. When the course was scheduled in competition with demanding basic science courses, however, the students' attitudes did not become as positive as or became more negative than when the course was part of a less demanding schedule. The course used lectures and reading assignments to provide information on substance abuse and used patient contact to change attitudes toward substance abusers and treatment. Emphasis was placed on patient management problems and small-group discussions. The changes in the students' attitudes are assumed by the authors to be positive, but the link between these attitudes and good clinical practice has not been demonstrated.     

护理人员对艾滋病的相关知识，态度及行为趋向的初步研究

目的 研究具有大专学历的在职护士有关艾滋病的相关知识、态度和行为趋向的现状。方法 用问卷法调查北京市12家医院421名具有大专学历的护士。结果 在知识方面,421名护士对各个问题回答的准确 率达80.00%-98.56%,但均未达100％。在态度和行为方面,45.33%的护士对AIDS患者采取正向态度,而有52.16%的护士则采取疏远或完全拒绝态度,仅有28.67%的护士愿意为患者做全部护理。研究结果还显示 与AIDS患者有过接触的护士,其态度和行为多趋于正向。结论 大多数护士对AIDS的病原、受侵害器官及主要传播途径有充分了解,但仍存有一定误区。在有关对AIDS 患者的态度和行为方面,护士各 持正、负向的态度和行为,而既往护理过AIDS患者的经历对护士的态度和行为趋向的选择有影响。     

医护人员对重性精神病患者参与治疗的态度和实施现状

目的探讨精神科医护人员对重性精神病患者参与治疗的态度和实施现状。方法将宝鸡市康复医院内的120名医护人员作为调查对象,应用自制的调查问卷对医护人员关于重性精神病患者参与治疗的态度和实施进行调查。应用统计学方法分析医院医护人员对重性精神病患者参与治疗的态度和实施现状。结果 69.3%的调查对象对"患者参与治疗"的概念熟悉,有7.0%的调查对象对"充权"概念熟悉。对患者参与诊断报告、药物使用决策、治疗过程的支持态度分别占调查对象的56.1%、69.3%、41.2%;在具体实施上支持的分别占调查对象的43.9%、24.6%、24.6%。医护人员对重性精神病患者参与治疗的实施明显低于态度(P<0.01)。医护人员对患者参与治疗的知识、态度和实施与其受教育程度、年龄及工作年限呈负相关(P<0.05)。结论精神科医护人员对重性精神病患者参与治疗支持的态度较高,但在实施上力度不足。医护人员对患者参与治疗的重视程度与其受教育程度、年龄及工作年限有关。