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Challenges faced by patients, relatives and clinicians in end-stage dementia decision-making: A qualitative study of swallowing problems

Lookup NU author(s): Professor Julian Hughes

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Abstract

© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.Background: Decision-making in end-stage dementia (ESD) is a complex process involving medical, social, legal and ethical issues. In ESD, the person suffers from severe cognitive problems leading to a loss of capacity to decide matters regarding health and end-of-life issues. The decisional responsibility is usually passed to clinicians and relatives who can face significant difficulty in making moral decisions, particularly in the presence of life-threatening swallowing problems. Aim: This study aimed to understand the decision-making processes of clinical teams and relatives in addressing life-threatening swallowing difficulties in ESD in long-term care in Malta. Method: The study followed a qualitative approach where six case studies, involving six different teams and relatives of six different patients, were interviewed retrospectively to understand their decision-making in connection with the management of swallowing difficulties in ESD. Data were collected through semistructured interviews with each stakeholder. All data were transcribed and subjected to thematic analysis. Results: Four themes were identified: the vulnerability of patients in dementia decision-making; the difficult role of relatives in decision-making; the decisional conflict between aggressive care through tube feeding versus oral comfort feeding; a consensus-building decision-making process as ideal to facilitate agreement and respect for patient's dignity. Conclusion: Decision-making to manage swallowing difficulties in ESD is a challenging process, which involves an interpretation of personal values, beliefs, patient preferences, care needs and clinical practice. Better communication between clinicians and relatives in dementia helps promote agreement between stakeholders leading to a care plan that respects the dignity of patients at their end of life.

Publication metadata

Author(s): Dimech J, Agius E, Hughes JC, Bartolo P

Publication type: Article

Publication status: Published

Journal: Journal of Medical Ethics

Year: 2020

Volume: 47

Issue: 12

Online publication date: 03/08/2020

Acceptance date: 13/05/2020

ISSN (print): 0306-6800

ISSN (electronic): 1473-4257

Publisher: BMJ Publishing Group

URL: https://doi.org/10.1136/medethics-2020-106222

DOI: 10.1136/medethics-2020-106222

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