Lalit Kumar Radha Krishna

Should Patients and Family be Involved in "Do Not Resuscitate" Decisions? Views of Oncology and Palliative Care Doctors and Nurses.

Background: “Do not resuscitate” (DNR) orders are put in place where cardiopulmonary resuscitation is inappropriate. However, it is unclear who should be involved in discussions and decisions around DNR orders. Aim: The aim was to determine the views of oncology and palliative care doctors and nurses on DNR orders. Materials and Methods: A questionnaire survey was conducted on 146 doctors and nurses in oncology and palliative care working within a tertiary specialist cancer center in Singapore. Results: Perceived care differences as a result of DNR determinations led to 50.7% of respondents reporting concerns that a DNR order would mean that the patient received a substandard level of care. On the matter of DNR discussions, majority thought that patients (78.8%) and the next of kin (78.1%) should be involved though with whom the ultimate decision lay differed. There was also a wide range of views on the most appropriate time to have a DNR discussion. Conclusions: From the viewpoint of oncology and palliative care healthcare professionals, patients should be involved at least in discussing if not in the determination of DNR orders, challenging the norm of familial determination in the Asian context. The varied responses highlight the complexity of decision making on issues relating to the end of life. Thus, it is important to take into account the innumerable bio-psychosocial, practical, and ethical factors that are involved within such deliberations.

The English and Chinese versions of the five-level EuroQoL Group's five-dimension questionnaire (EQ-5D) were valid and reliable and provided comparable scores in Asian breast cancer patients

ObjectiveTo examine the measurement properties of and comparability between the English and Chinese versions of the five-level EuroQoL Group’s five-dimension questionnaire (EQ-5D) in breast cancer patients in Singapore.MethodsThis is an observational study of 269 patients. Known-group validity and responsiveness of the EQ-5D utility index and visual analog scale (VAS) were assessed in relation to various clinical characteristics and longitudinal change in performance status, respectively. Convergent and divergent validity was examined by correlation coefficients between the EQ-5D and a breast cancer-specific instrument. Test–retest reliability was evaluated. The two language versions were compared by multiple regression analyses.ResultsFor both English and Chinese versions, the EQ-5D utility index and VAS demonstrated known-group validity and convergent and divergent validity, and presented sufficient test–retest reliability (intraclass correlation = 0.72 to 0.83). The English version was responsive to changes in performance status. The Chinese version was responsive to decline in performance status, but there was no conclusive evidence about its responsiveness to improvement in performance status. In the comparison analyses of the utility index and VAS between the two language versions, borderline results were obtained, and equivalence cannot be definitely confirmed.ConclusionThe five-level EQ-5D is valid, responsive, and reliable in assessing health outcome of breast cancer patients. The English and Chinese versions provide comparable measurement results.

Nasogastric feeding at the end of life: A virtue ethics approach

The use of Nasogastric (NG) feeding in the provision of artificial nutrition and hydration at the end of life has, for the most part, been regarded as futile by the medical community. This position has been led chiefly by prevailing medical data. In Singapore, however, there has been an increase in its utilization supported primarily by social, religious and cultural factors expressly to prolong life of the terminally ill patient. Here this article will seek to review the ethical and clinical impact of this treatment and provide some understanding for such decisions in the light of the Duty of Palliative Care [DoPC]. Complemented by virtue ethics theory, the DoPC highlights and seeks to realize the individual case specific goals of care that maximize comfort and quality of life of the patient in the face of rapid attenuation of treatment options and the eminence of the final outcome by considering each of these factors individually in order to provide the best outcome for the patient and the family.

Patient and family involvement in decision making for management of cancer patients at a centre in Singapore

Background The practice of patient autonomy within the prevailing bioethical framework in the West appears increasingly at odds with the prominent influence of the family in medical decision making in the Asian culture. The actual extent of involvement of patient versus the family in the decision making process for cancer management in clinical practice is largely unknown in Asia. Aims (1) To describe patient and family involvement in healthcare decision making in actual practice, and to determine whether those practices are consistent with Singapore law; and (2) to act as a pilot for a larger prospective study examining the preferences of cancer patients on the decision making process, and the reasons for excluding patients from that process. Methods A retrospective review of patients who died in an oncology ward in Singapore General Hospital from February to April 2011. Patient and family involvement in discussions on (1) disclosure of diagnosis, (2) initial treatment decisions and (3) initiation of a ‘maximum ward management’ order was evaluated by reviewing case notes completed by healthcare professionals. Results Data were collected for 55 patients. Involvement of patients and families at first disclosure of diagnosis was noted in 61% and 64% of cases, respectively. In 12% of cases, the family requested withholding of the diagnosis from the patient. 86% of patients were involved in the initial treatment decisions, and their family was involved in 65% of cases. Only 9% of the 32 alert patients were consulted in end of life decisions. Factors associated with lower patient involvement were advanced age and inability to speak English. Conclusions While most cancer patients are involved in the healthcare decision making process during the early phase, familial involvement gains prominence as the disease progresses.

Factors considered in end-of-life care decision making by health care professionals

Aim: To explore the importance of factors influencing the end-of-life care decision making of health care professionals (HCPs) in Singapore. Methods: This cross-sectional survey encompassed facets of patient, family, and HCP-related care considerations. In total, 187 questionnaires were distributed to physicians and nurses and had a response rate of 78.6%. Results: The respondents rated patients’ wishes (96.6%), their clinical symptoms (93.9%), and patients’ beliefs (91.1%) very high. In all, 94.6% of the HCPs would respect a competent patient’s wishes over the family’s wishes when goals conflict. However, 59.9% of HCPs would abide by the family’s wishes when the patient loses capacity even if the patient’s previously expressed wishes are known. Conclusion: End-of-life care decision making by HCPs appears largely patient centered, although familial determination still wields significant influence with implications for advance care planning.

Limits to relational autonomy—The Singaporean experience:

Recognition that the Principle of Respect for Autonomy fails to work in family-centric societies such as Singapore has recently led to the promotion of relational autonomy as a suitable framework within which to place healthcare decision making. However, empirical data, relating to patient and family opinions and the practices of healthcare professionals in Confucian-inspired Singapore, demonstrate clear limitations on the ability of a relational autonomy framework to provide the anticipated compromise between prevailing family decision-making norms and adopted Western led atomistic concepts of autonomy. Evidence suggests that despite a growing infusion of Western influence, there is still little to indicate any major shift to individual decision making, particularly in light of the way society and healthcare are structured. Similarly, the lack of employing a shared decision-making model and data that discredit the notion that the complex psychosocial and cultural factors that affect the decision making may be considered “content neutral” not only prevents the application of relational autonomy but questions the viability of the values behind the Principle of Respect for Autonomy. Taking into account local data and drawing upon a wider concept of personhood that extends beyond prevailing family-centric ideals along with the complex interests that are focused upon the preservation of the unique nature of personhood that arises from the Ring Theory of Personhood, we propose and “operationalize” the employing of an authoritative welfare-based approach, within the confines of best interest decision making, to better meet the current care needs within Singapore.

Mentoring relationships between senior physicians and junior doctors and/or medical students: A thematic review

Abstract Introduction: Mentoring relationships are pivotal to the outcome of the mentoring process. This thematic review seeks to study the key aspects of mentoring relationships between senior physicians and junior doctors and/or medical students to inform efforts to improve mentoring programs. Methods: Literature search was performed on publications across PubMed, ERIC, Cochrane Database of Systematic Reviews, OVID and ScienceDirect databases between 1 January 2000 and 31 December 2015 by three independent reviewers. The BEME guide and STORIES statement were used to develop a narrative from the articles selected. Results: Thematic analysis of 49 articles reveals five semantic themes of initiation process, developmental process, evaluation process, sustaining mentoring relationship, and obstacles to effective mentoring. The evolving and relational-dependent nature of mentoring pivots upon the compatibility of mentors and mentees and the quality of their interactions, which in turn depend on mentoring environments and awareness of mentor-, mentee-, organizational-related factors and changes in context and goals. Conclusions: Embrace of a consistent mentoring approach to ensure effective oversight of the mentoring process must be balanced with sufficient flexibility to ensure a mentee-centered approach. Efforts must be made to optimize the key aspects of mentoring relationships in order to ensure successful mentoring processes and outcomes.

Toward an Interprofessional Mentoring Program in Palliative Care - A Review ofUndergraduate and Postgraduate Mentoring in Medicine, Nursing, Surgery andSocial Work

Objective: Key to effective Palliative Care is interdisciplinary collaboration and holistic support of members of the multidisciplinary team. Mentoring is increasingly seen as being a critical facet of this process however; there is a dearth of guidance on establishing such a program within the Palliative Care setting. To fill this gap, this review analyzes mentoring programs in medicine, surgery, nursing and social work in order to identify key elements and common facets of successful mentoring programs that can be used to create a multi-professional mentoring program in Palliative Care. Methods: A review of systematic review of undergraduate and postgraduate mentoring programs in medicine, surgery, nursing and social work involving senior clinicians and junior doctors and/or medical students. Results: A total of 20 reviews were included. One review was on mentoring in medicine and nursing, 10 in medicine, 4 in surgery and 5 in nursing. There were no reviews of mentoring in social work. Thematic analysis revealed 3 themes, which were definition of mentoring, components of a mentoring approach and elements of the mentoring process Conclusion: Despite its context sensitive, goal specific and mentee- and mentor- dependent features, common features in mentoring in medicine, surgery and nursing lay the foundation for a learning theory of interprofessional mentoring that can guide construct effective mentorship programs.

Creating Effective Interprofessional Mentoring Relationships in Palliative Care-Lessons from Medicine, Nursing, Surgery and Social Work

Palliative Care requires multidisciplinary teamwork to achieve its patient specific objectives. Success of this approach pivots on nurturing effective interprofessional relationships through the provision of holistic support and multidimensional training of multiprofessional Palliative Care team members. Mentoring is seen as an effective means of facilitating multiprofessional collaborations however little data exists on operationalizing an interprofessional mentoring program in Palliative Care. To address this gap and circumnavigate the context-specific nature of mentoring, we scrutinized mentoring approaches in medicine, surgery, nursing and medical social work to identify common elements of mentoring within their respective practices that will provide the basis of an interprofessional mentoring in Palliative Care. Thematic analysis of 20 reviews of undergraduate and postgraduate mentoring programs in medicine, surgery and nursing suggest that successful mentoring programs are underscored by effective nurturing and support of mentoring relationships. Successful mentoring relationships are built on strong relational ties between mentees and mentors. Delineating the key elements to effective mentoring relationships allow for the forwarding of a basic framework to enhance relational ties within interdisciplinary mentoring in Palliative Care and the proffering of an evidence-based platform for the adoption of a cognitive apprenticeship model that can guide the operationalization of a multiprofessional mentoring program in Palliative Care.

Towards a Practice Guided Evidence Based Theory of Mentoring in PalliativeCare

Provision of end of life care and coping with the emotional and existential distress engendered by palliative care demands the provision of holistic support and training for palliativists. Mentoring is an effective means of meeting this need; however little is known of mentoring in palliative care and a universally accepted learning theory of mentoring remains lacking in this setting. To advance mentoring practice in palliative care, we review the only two evidenced based mentoring theories based upon narrative reviews of mentoring practice in the key specialties within palliative care teams. Building upon mentoring’s mentee, mentor and organizational dependent, goal specific, context sensitive features highlighted in both recent reviews of mentoring this paper proffers a working theory of mentoring. Constructed Krishna’s Mentoring Pyramid that underlines the 5 core elements of successful mentoring programs, we propose melding elements of the cognitive apprenticeship model with the adult learning theory using the multi-theories model of adult learning offers an effective starting point for a mentoring theory. More context-specific studies are needed to provide better insight into the validity of this framework in the ongoing pursuit of an interprofessional mentoring theory in Palliative Medicine.