Red Cross College of Nursing, Chung-Ang University, Seoul, Republic of Korea.
Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA.
J Am Med Dir Assoc. 2022 Mar;23(3):488-492. doi: 10.1016/j.jamda.2021.07.001. Epub 2021 Jul 21.
Unrepresented adults are individuals who lack decision-making capacity and have neither an available surrogate decision maker nor an applicable advance directive. Currently, the prevalence of unrepresented nursing home (NH) residents and how medical decisions are made is unknown. We examined (1) the prevalence of unrepresented NH residents, (2) NH policies and procedures to address medical decision making for those residents, and (3) NH staff's perceptions of medical decision making for unrepresented residents.
We reviewed resident medical records and NH policy and procedure documents. We also conducted a survey of NH staff using an investigator-developed questionnaire.
Sixty-six staff members recruited from 3 NHs (433 residents total) in 1 metropolitan area of Georgia, USA.
Medical records and policy and procedure documents were reviewed using preset criteria. The survey included 31 structured and open-ended questions regarding medical decision-making practices for unrepresented residents (eg, awareness of medical decision-making processes, experiences in medical decision making, and suggestions to improve practice). We used descriptive statistics and conventional content analysis.
Four residents (1%) met the criteria of being unrepresented. We found no written statements that specifically addressed medical decision making for unrepresented residents in the participating NHs. Of 66 survey participants, 11 had been involved in medical decision making for unrepresented residents. The most common decisions involved do-not-resuscitate orders, major medical and surgical treatments, and life-sustaining treatments. These decisions were made primarily by relying on the resident's physician or through discussions within the facility's interdisciplinary team. Suggestions included adopting explicit mechanisms or protocols related to decision making for unrepresented residents, education/training, and resources for group-based decision making.
Although prevalence in the 3 NHs was low, NH care providers, ethical and legal professionals, and other key stakeholders should discuss practical approaches and policies to systematically identify unrepresented residents and to improve NHs' medical decision-making practices for them.
无代表成年人是指缺乏决策能力，既没有可用的替代决策人，也没有适用的预先指示的个人。目前，无代表的养老院（NH）居民的患病率以及医疗决策的制定情况尚不清楚。我们研究了（1）无代表的 NH 居民的患病率，（2）NH 为这些居民制定医疗决策的政策和程序，以及（3）NH 工作人员对无代表居民医疗决策的看法。
我们查阅了居民的医疗记录和 NH 政策和程序文件。我们还使用研究者开发的问卷对 NH 工作人员进行了调查。
在美国佐治亚州一个大都市区的 3 家 NH（共 433 名居民）招募了 66 名工作人员。
使用预设标准审查医疗记录和政策及程序文件。该调查包括 31 个关于无代表居民医疗决策实践的结构化和开放式问题（例如，对医疗决策过程的认识、医疗决策经验以及改进实践的建议）。我们使用描述性统计和常规内容分析。
有 4 名居民（1%）符合无代表的标准。我们在参与的 NH 中没有发现专门针对无代表居民医疗决策的书面声明。在 66 名调查参与者中，有 11 人参与了无代表居民的医疗决策。最常见的决策涉及不复苏医嘱、重大医疗和外科治疗以及维持生命的治疗。这些决策主要是依靠居民的医生或通过医疗机构的跨学科团队内部的讨论做出的。建议包括采用与无代表居民决策相关的明确机制或协议、教育/培训以及团体决策资源。
尽管在 3 家 NH 中的患病率较低，但 NH 护理提供者、伦理和法律专业人员以及其他利益相关者应讨论实际方法和政策，以系统地识别无代表居民，并改善 NH 为他们制定医疗决策的实践。
