Scientific letter
Attitudes and beliefs towards advance directives and end-of-life care preferences among elderly population in a community health centre
Actitudes y opiniones sobre el documento de instrucciones previas y preferencias sobre los cuidados del final de la vida en población mayor de un centro de salud
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Verónica Gil Caravaca, Eduardo Osuna Carrillo de Albornoz" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Julia" "apellidos" => "Cuevas García" "email" => array:1 [ 0 => "juliacuevasliso@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Verónica" "apellidos" => "Gil Caravaca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Eduardo" "apellidos" => "Osuna Carrillo de Albornoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Medicina Familiar y Comunitaria, Centro de Salud Santa María de Gracia, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Medicina Legal y Forense, Universidad de Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actitudes y opiniones sobre el documento de instrucciones previas y preferencias sobre los cuidados del final de la vida en población mayor de un centro de salud" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 944 "Ancho" => 1675 "Tamanyo" => 82486 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Column chart: bivariate analysis between willingness to talk to the doctor about care and attitude towards the AHD document.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AHD: advance healthcare directive.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Today, increasing life expectancy and population ageing have led to an increase in chronic diseases. These diseases often lead to functional impairment, vulnerability and dependency in the population, raising major questions in medical practice.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The advance health care directive (AHD) guarantees the patient's prospective decision-making on his or her own health,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> however, its formalisation in the general population is rare.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In order to find out the opinions and preferences of older patients regarding knowledge, attitude and consent of the AHD document, an observational, descriptive and cross-sectional study was conducted. Patients ≥ 65 years of age in primary care who were administered a survey were included; those with terminal illness or cognitive impairment were excluded. The sample size was calculated by simple random sampling, estimating 168 subjects. The study complied with research standards and was approved by the Ethics Committee of the University of Murcia (ID: 2735/2020).</p><p id="par0020" class="elsevierStylePara elsevierViewall">We obtained a response rate of 93.45% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>156). The mean age was 76.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.6 years, 55.1% were women, 86.5% Catholics, 26.3% had no schooling, and 68.6% had previously acted as caregivers for people with serious illnesses.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Of those surveyed, 39.1% reported having thought about end-of-life care only sometimes and 34.6% often. We observed that the degree of consideration about caregiving increased in women (<span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10.576; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.005) and in former caregivers (<span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4.029; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.045). Of the patients, 63.5% had had end-of-life discussions, mostly with a family member (57.7%) and 0.6% with healthcare professionals.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Among the subjects, 52.6% were unaware of the AHD document and only 5% had registered it. Certain factors are related to a more favourable attitude towards the formalisation of an AHD.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In this sense, we found a greater predisposition to register the AHD document in women (<span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3. 662; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.050) and in subjects aged 65–74 (<span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6.431; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.040). In addition, the number of times care work had been carried out for others was also associated with a more favourable attitude towards completing the AHD document (Mann-Whitney U<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2071.5; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.005).</p><p id="par0035" class="elsevierStylePara elsevierViewall">In our study, 71.8% of the subjects stated that end-of-life decisions should be made by the patient, 28.2% by relatives and 19.2% exclusively by the physician.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Also, the majority of the sample (76.3%) was willing to discuss these issues with the family doctor, but it was striking that, less than 50% of these subjects would complete this process by actually registering the AHD document (<span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16.661; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.000) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). These results are in line with other recent research.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, the population analysed shows a willingness to express their preferences regarding end-of-life care, but the AHD document is not reported as the means of choice. This is due, on the one hand, to the public's lack of awareness of their existence and, on the other hand, to patients' preference for humane rather than bureaucratic treatment.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The experience of having provided care triggers reflections on the end of life and leads to the communication of these reflections, generating a greater willingness to formalise preferences through the AHD document. Women are more involved in this process because of the gender role they have traditionally played as caregivers.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally, there is evidence that patients want to take the lead in making decisions about their own care and want to discuss this with their doctor, even if these discussions take place very occasionally. From this arises the need for further research in order to implement communication tools in health clinics, based on accompaniment and active listening, which encourage and trigger a shared deliberative process between the patient, family members and health professionals.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">This research has not received specific support from public sector agencies, commercial or non-profit organisations.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 944 "Ancho" => 1675 "Tamanyo" => 82486 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Column chart: bivariate analysis between willingness to talk to the doctor about care and attitude towards the AHD document.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AHD: advance healthcare directive.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Medicina geriátrica. 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