Periodic Reporting for period 4 - CONT-END (Attempts to Control the End of Life in People with Dementia: Two-level Approach to Examine Controversies)
Berichtszeitraum: 2023-06-01 bis 2025-05-31
Dementia is a common cause of death. At the end of life, control is often lost because of cognitive and physical decline. CONT-END examined experiencing control through advance care planning (ACP), use of technology at the end of life and euthanasia. The interventions each contain an element of striving for control. In parallel, CONT-END examined researchers’ control in decisions in end-of-life research. This two-level approach was adopted to support navigating decisions that involve particular practical and ethical challenges in clinical and research practice.
Most people with dementia, their family caregivers and physicians in the Netherlands, Germany, Switzerland, the US, Israel and Japan found ACP acceptable. Fewer found use of technology to measure distress at the end of life acceptable, and euthanasia was the least acceptable, with widely divergent views between and within countries. People also differed in feeling in control through the interventions, related to factors such as life view and coping. For example, some people with dementia did not feel in control in life and did not pursue it, while others would rely on their family or physician to take over. Also, physicians with a ‘planning’ coping style or ‘religious coping’ found euthanasia less acceptable.
Regarding approaches to ACP, a less scripted psychosocial approach was slightly more acceptable than a medical approach. In research practice, we found that the level to which protocols are scripted matters for later decision making. Both over-defined and under-defined protocols necessitated decision making later on during the conduct of the research. Further, lack of awareness of decisions that adapt plans impedes transparency. At both levels, in dementia care practice and in research practice, to overcome limitations of protocols and checklists for future decision making, conversations that elicit relevant decisions and values at stake are key.
Most people with dementia, their family caregivers and physicians in the Netherlands, Germany, Switzerland, the US, Israel and Japan found ACP acceptable. Fewer found use of technology to measure distress at the end of life acceptable, and euthanasia was the least acceptable, with widely divergent views between and within countries. People also differed in feeling in control through the interventions, related to factors such as life view and coping. For example, some people with dementia did not feel in control in life and did not pursue it, while others would rely on their family or physician to take over. Also, physicians with a ‘planning’ coping style or ‘religious coping’ found euthanasia less acceptable.
Regarding approaches to ACP, a less scripted psychosocial approach was slightly more acceptable than a medical approach. In research practice, we found that the level to which protocols are scripted matters for later decision making. Both over-defined and under-defined protocols necessitated decision making later on during the conduct of the research. Further, lack of awareness of decisions that adapt plans impedes transparency. At both levels, in dementia care practice and in research practice, to overcome limitations of protocols and checklists for future decision making, conversations that elicit relevant decisions and values at stake are key.
The main work was organised in two Work Packages (WPs) on end of life with dementia, and a third WP on end-of-life research practice.
WP1. Acceptability of the four interventions was studied in a 6-country video vignette study. We developed and pilot-tested four animation videos (see image) to explain the interventions during interviews. Acceptability of euthanasia varied the most between individuals (e.g. 44% of 205 physicians) and countries (up to 66% in the Netherlands, where it is legal). Use of technology was more often acceptable (of the physicians, 66%; up to 74% in the US) and the large majority found ACP acceptable. Qualitative analyses showed that respecting the person’s autonomy was important for physicians, but it could create dilemmas as they also valued appropriate decisions that minimize suffering.
Participants with dementia (n=43) and family caregivers (n=46) showed similar patterns of acceptability. We continue to analyse the qualitative interview data to better understand their perspectives on how the four interventions could be helpful.
WP2. A cluster-randomised trial assessed effects of two approaches of ACP differing in level of control (the scripted medical approach based on shared decision making versus the more flexible coping-based psychosocial approach). General practitioners received two 3-hour training sessions and an e-learning with a conversation with a patient avatar. Participating practices enrolled 21 dyads of persons with dementia and their family caregivers for the medical ACP approach, and 7 for the psychosocial approach; an external control group comprised 54 dyads. Overall changes across groups during 3½ years of follow-up indicated worsening quality of life and improved decisional conflict over time, while families’ self-efficacy to interact, and communicate with physicians did not change. Outcomes did not differ, except for a significant worsening of perceived communication with the physician in the intervention group versus the control group. Possibly there were unmet expectations about continued conversations. Further longitudinal analyses are planned.
Qualitative interviews replaced subgroup analyses to compare approaches and helped refine the theory-based ACP approaches by assessing situations (for whom, when) in which either approach is preferred using data from both WP2 and WP1. Four attributes distinguished the situations: understanding, readiness, trust and momentum (image). For the medical approach, the first 3 were prerequisites for optimal momentum. In contrast, the psychosocial approach would help understand the person, create readiness and foster trust. Without a clear trigger, however, momentum needs to be created. A person-centred approach would entail skill in employing either approach as needed.
Regarding the acceptability of technology, Bispectral Index monitoring was examined in focus groups with 17 persons with dementia and 24 family caregivers. We demonstrated the device. People tried it and didn’t find it bothersome, yet acceptability varied between participants, groups and situations. For example, use in natural sleep was acceptable for most with dementia, not so for most family caregivers. Most would accept use at the end of life if the added value was clearer.
WP3. Ethnographic fieldwork in two end-of-life research groups entailed 12 months of observing how researchers navigate decisions. The ethnographer witnessed researchers’ influence in particular when the research protocol was either under-defined or over-defined, leading to either operationalise or adapt the plans. Research practice involved continued decision making. At times, researchers were unaware of making a decision to adapt plans, potentially limiting transparency. Further, decisions were often rooted in uncertainty due to incomplete information or moral ambiguity.
Greater protocolization cannot solve this. As with ACP, a ‘checkbox approach’ in making decisions in advance fails in educating people on what might happen, and falls short in increasing awareness of their values relevant to future decisions. Rather, researchers should be taught how to navigate decisions. As a team, we put this into practice, regularly discussing research dilemmas.
A proposed Delphi study to synthesize findings was infeasible due to divergent timelines of the WPs, with pandemic-related delays in WP1 and WP2 data collections. We then conducted a literature review and found that, except for Bispectral Index monitoring, technologies to monitor distress had not been tested for use at the end of life. Also, we could conduct an online Delphi study on ACP in dementia with exceptional rigour (image).
We presented findings at conferences and in scientific journals on dementia, palliative, and primary care and research integrity.
WP1. Acceptability of the four interventions was studied in a 6-country video vignette study. We developed and pilot-tested four animation videos (see image) to explain the interventions during interviews. Acceptability of euthanasia varied the most between individuals (e.g. 44% of 205 physicians) and countries (up to 66% in the Netherlands, where it is legal). Use of technology was more often acceptable (of the physicians, 66%; up to 74% in the US) and the large majority found ACP acceptable. Qualitative analyses showed that respecting the person’s autonomy was important for physicians, but it could create dilemmas as they also valued appropriate decisions that minimize suffering.
Participants with dementia (n=43) and family caregivers (n=46) showed similar patterns of acceptability. We continue to analyse the qualitative interview data to better understand their perspectives on how the four interventions could be helpful.
WP2. A cluster-randomised trial assessed effects of two approaches of ACP differing in level of control (the scripted medical approach based on shared decision making versus the more flexible coping-based psychosocial approach). General practitioners received two 3-hour training sessions and an e-learning with a conversation with a patient avatar. Participating practices enrolled 21 dyads of persons with dementia and their family caregivers for the medical ACP approach, and 7 for the psychosocial approach; an external control group comprised 54 dyads. Overall changes across groups during 3½ years of follow-up indicated worsening quality of life and improved decisional conflict over time, while families’ self-efficacy to interact, and communicate with physicians did not change. Outcomes did not differ, except for a significant worsening of perceived communication with the physician in the intervention group versus the control group. Possibly there were unmet expectations about continued conversations. Further longitudinal analyses are planned.
Qualitative interviews replaced subgroup analyses to compare approaches and helped refine the theory-based ACP approaches by assessing situations (for whom, when) in which either approach is preferred using data from both WP2 and WP1. Four attributes distinguished the situations: understanding, readiness, trust and momentum (image). For the medical approach, the first 3 were prerequisites for optimal momentum. In contrast, the psychosocial approach would help understand the person, create readiness and foster trust. Without a clear trigger, however, momentum needs to be created. A person-centred approach would entail skill in employing either approach as needed.
Regarding the acceptability of technology, Bispectral Index monitoring was examined in focus groups with 17 persons with dementia and 24 family caregivers. We demonstrated the device. People tried it and didn’t find it bothersome, yet acceptability varied between participants, groups and situations. For example, use in natural sleep was acceptable for most with dementia, not so for most family caregivers. Most would accept use at the end of life if the added value was clearer.
WP3. Ethnographic fieldwork in two end-of-life research groups entailed 12 months of observing how researchers navigate decisions. The ethnographer witnessed researchers’ influence in particular when the research protocol was either under-defined or over-defined, leading to either operationalise or adapt the plans. Research practice involved continued decision making. At times, researchers were unaware of making a decision to adapt plans, potentially limiting transparency. Further, decisions were often rooted in uncertainty due to incomplete information or moral ambiguity.
Greater protocolization cannot solve this. As with ACP, a ‘checkbox approach’ in making decisions in advance fails in educating people on what might happen, and falls short in increasing awareness of their values relevant to future decisions. Rather, researchers should be taught how to navigate decisions. As a team, we put this into practice, regularly discussing research dilemmas.
A proposed Delphi study to synthesize findings was infeasible due to divergent timelines of the WPs, with pandemic-related delays in WP1 and WP2 data collections. We then conducted a literature review and found that, except for Bispectral Index monitoring, technologies to monitor distress had not been tested for use at the end of life. Also, we could conduct an online Delphi study on ACP in dementia with exceptional rigour (image).
We presented findings at conferences and in scientific journals on dementia, palliative, and primary care and research integrity.
The Delphi study and the interviews in WP1 and WP2 resulted in important conceptualizations of ACP, more clearly distinguishing typical approaches. We propose a role for persons with dementia themselves and family throughout, and using a care goals model that adds psychosocial goals of protection of identity and coping with grief and loss. We also developed digital conversation exercises with a patient avatar.
The findings can improve clinical practice and improve the quality and transparency of research. Similar as in ACP, when considering decisions during research, checklists listing potential decisions are of limited value while dialogue with multiple team members reflecting on pros and cons is key.
The findings can improve clinical practice and improve the quality and transparency of research. Similar as in ACP, when considering decisions during research, checklists listing potential decisions are of limited value while dialogue with multiple team members reflecting on pros and cons is key.