UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland.
Graduate School of Healthcare Management, Royal College of Surgeons in Ireland, Dublin, Ireland.
Health Expect. 2023 Jun;26(3):1339-1348. doi: 10.1111/hex.13750. Epub 2023 Mar 14.
Supported (assisted) healthcare decision-making (ADM) focuses attention on how people with disabilities, including cognitive impairments, can be best supported to make decisions about their health and social care on an equitable basis with others. Meaningful implementation of legal frameworks for ADM challenges long-held presumptions about who has access to valued decision-making resources, influence and power within a particular socio-cultural setting. This study aims to explore the relational power dynamics around ADM with older people in acute care settings.
This study adopts a critical hermeneutic approach to qualitatively explore the lived experience of ADM from the perspectives of Health and Social Care Professionals (N = 26). This is supported by an exploration of the experiences of older people (N = 4), older people with a diagnosis of dementia (N = 4) and family carers (N = 5).
We present three themes of data analysis that represent three spaces where the relational aspects of power in ADM are manifested. The first space, centralising decision-making power within multidisciplinary teams identified the privileging of physicians in traditional hierarchical leadership models that may lead to the implicit exclusion of family carers and some Health and Social Care Professionals in the ADM process. Privileging cognitive and communication competence identified a tendency to attribute decision-making autonomy to those with cognitive and communication competency. The final space, balancing the duty of care and individual autonomy, recognises acute care settings as typically risk-averse cultures that limit autonomy for decisions that carry risk, especially for those with cognitive impairment.
Findings indicate the need to address cultural sources of power operating through social norms premised on ageist and ableist ideologies. It is necessary to challenge institutional barriers to meaningful ADM including positional power that is associated with hierarchies of influence and protectionism. Finally, meaningful ADM requires resistance to the disempowerment created by structural, economic and social circumstances which limit choices for decision-making.
A public and patient involvement panel of older people were consulted in the development of the grant application (HRB: APA-2016-1878). Representatives from Alzheimer's Society Ireland and Family Carers Ireland were steering committee members guiding design and strategy.
支持（辅助）医疗决策（ADM）侧重于关注如何最好地支持残疾人士（包括认知障碍者）在与其他人平等的基础上就其健康和社会护理做出决策。在特定社会文化背景下，对 ADM 的法律框架进行有意义的实施，这对长期以来关于谁有权获得有价值的决策资源、影响和权力的假设提出了挑战。本研究旨在探讨在急性护理环境中与老年人有关 ADM 的关系权力动态。
本研究采用批判解释学方法，从卫生和社会保健专业人员（N=26）的角度定性探讨 ADM 的生活体验。这一方法得到了对老年人（N=4）、被诊断患有痴呆症的老年人（N=4）和家庭照顾者（N=5）的体验探索的支持。
我们提出了三个数据分析主题，代表了 ADM 中权力关系方面表现出来的三个空间。第一个空间，将决策权力集中在多学科团队中，确定了在传统的等级领导模式中赋予医生的特权，这可能导致家庭照顾者和一些卫生和社会保健专业人员在 ADM 过程中被隐性排除在外。赋予认知和沟通能力的特权确定了一种倾向，即将决策自主权赋予具有认知和沟通能力的人。最后一个空间，平衡护理责任和个人自主权，认识到急性护理环境通常是一种规避风险的文化，限制了对带有风险的决策的自主权，尤其是对那些认知受损的人。
研究结果表明，有必要解决通过基于年龄歧视和能力歧视思想的社会规范运作的文化权力来源。必须挑战对有意义的 ADM 的制度障碍，包括与影响力和保护主义有关的等级制度相关的职位权力。最后，有意义的 ADM 需要抵制由限制决策选择的结构性、经济和社会环境造成的权力丧失。
在制定资助申请时，咨询了一个由老年人组成的公众和患者参与小组（HRB：APA-2016-1878）。来自爱尔兰阿尔茨海默病协会和爱尔兰家庭护理协会的代表是指导设计和战略的指导委员会成员。
