In this study, over 90% of participants chose to decline both LST and ANH, revealing consistent trends in willingness expression across five hypothetical clinical conditions. The highest refusal rates were observed in persistent vegetative states, indicating a marked propensity for intervention in scenarios characterized by severe cognitive impairment. This reluctance to accept LST and ANH persisted, especially in persistent vegetative states, severe dementia, and irreversible coma. In cases with persistent vegetative state, severe dementia, and irreversible coma, more participants expressed a desire to refuse treatment compared to terminal illness scenarios. Of note, a higher proportion of participants supported limited-time treatment for both LST and ANH in case of terminal illness.
Primarily in the context of terminal illness, consideration of refusing LST treatment does not extend to conditions such as a persistent vegetative state, severe dementia, or irreversible coma. [4]. Unlike patients facing terminal illness who typically retain intellectual capacity, patients in a persistent vegetative state, severe dementia, or irreversible coma have the ability to make independent decisions. They don’t have the autonomy to do so. As a result, some countries have adopted proactive approaches to proactive medical decision-making with the aim of increasing the prevalence of autonomous decisions. [4]. Particularly in Taiwan, neurological conditions that were not initially considered terminal illnesses, such as persistent vegetative states, severe dementia, and irreversible coma, are on the rise among Asians. [10], is gradually being added to the list of terminal illnesses. These diseases, newly included in Taiwan’s PRAA, are associated with neurological disorders that are highly likely to cause cognitive impairment, dependence on others for care, reduced quality of life, and incapacitation and dependence. I am. [11].
A national population-based study conducted in Taiwan highlighted the healthcare burden associated with dementia, revealing higher rates of hospitalization, intensive care unit admission, and long-term hospitalization than cancer patients. Ta [10]. With the exception of blood transfusions, the utilization of LST and ANH was significantly higher in patients with dementia than in patients with cancer. Additionally, ANH utilization rates are significantly lower than additional requirements such as enteral tube insertion (72.6%), nutritional support (67.4%), mechanical ventilation (61.5%), endotracheal intubation (59.6%), and cardiopulmonary resuscitation (33.9%). The utilization rate exceeded that of LST. ), hemodialysis (17.6%) [10]. Furthermore, the prevalence of enteral feeding or enteral tube insertion among patients with dementia in Taiwan is significantly higher than in Europe (20.5% in Italy), North America (25% in America, 11% in Canada), and other Asian regions. (66% in Hong Kong) [10].
Compared to LST, participants indicated a higher acceptance of ANH as a time-limited treatment as well as a preference to approve HCA for subsequent decisions. In cases of irreversible coma, more participants preferred to refer decisions regarding ANH to their licensed HCA. In conditions of severe dementia or terminal illness, more participants were willing to accept ANH treatment for a limited time. Regarding declared intolerable/incurable disease, more participants approved her HCA to determine her ANH.
Priorities for LST and ANH can be influenced by a variety of factors, including culture, religion, tradition, values and beliefs, administrative guidelines, and relationship dynamics between physicians, families, and patients. [1, 12,13,14]. Several studies have highlighted the challenges in providing her ANH to terminally ill patients. [15, 16]. Patients may require artificial nutrition for a variety of reasons, including survival, improving mood, and maintaining appearance for their families. [3, 17]. For example, artificial nutrition can serve as essential support for patients in a coma or persistent vegetative state, filling the gap until recovery is imminent or unlikely. [16].Late-stage dementia is characterized by loss of the ability to eat and appetite, causing emotional distress in relatives when patients reduce their oral intake. [16, 17]. Conflicting views exist regarding ANH, either as a fundamental aspect of basic nursing care or as a medical therapy that still lacks clear indications. [3, 18].
This study revealed that participants’ sociodemographic characteristics significantly influenced their preferences for LST and ANH. In general, women tended to refuse both LST and ANH outright without expressing indecision, opting for time-limited treatment, permission for HCA, or no treatment. In contrast, men were more likely to receive full or time-limited treatment. The gender differences in LST and ANH preferences observed in our study are consistent with previous studies on gender differences in palliative care preferences and treatments. [19,20,21,22].Societal perceptions that diseases are wars, treatments represent battles, and aspirations for treatments are framed as battles may motivate people to confront and fight these diseases. [19, 23]. On the other hand, social values give women more room to be sentimental, express symptoms, and seek social support. [19, 24].
Additionally, the results of this study indicate that participants currently signing AD typically do not have a serious illness, as more than 73% did not self-report any illness or non-life-threatening chronic illness. is shown. The decision to engage AD was based on consideration of five hypothetical clinical scenarios. There was a significant correlation between the decision to sign an AD and participants’ age, suggesting that age influences participants’ deliberations, attitudes, and decisions. Participants under 40 years of age were more likely to choose full treatment or limited-time treatment and authorize the HCA for subsequent decisions, rather than refusing outright. Participants between 40 and 65 years of age were more likely to remain undecided, and participants over 65 years of age were more likely to decline full or time-limited treatment. This age-related trend is consistent with research showing a positive association between age and AD signs in nursing homes and cancer patients. [25]older patients are more commonly ordered DNAR. [26].
Additionally, two important family-related factors contributing to refusal of LST and ANH treatment are family reluctance to assume responsibility and refusal to appoint an HCA. This reflects her ACP issues prevalent in Asian cultures, which primarily revolve around family-related concerns. [6, 15]. Sun et al. We reported a case in which a surrogate mother in the ICU faced emotional interference from family members with conflicting views regarding medical care, thereby influencing decision-making. [27]. With the introduction of PRAA, it is expected that patient autonomy will be better understood and valued, allowing doctors to provide more accurate diagnoses and have more direct communication with patients.
Research limitations
This study only investigated immediate preferences regarding AD during ACP consultations. The scope of the study did not extend to subsequent changes in selection or post-consultation discussions. Additionally, participants were selected from Taipei Municipal Hospital, which is designated as the main testing and demonstration facility for his ACP in Taipei City. The focus on patients from only one hospital limits the external validity of the findings.
implication
The findings of this study provide insights for tailoring ACP consultation methods to ANH, taking into account social and cultural nuances. Adaptable and sensitive approaches can address the needs of diverse populations, including those who are resistant to ACP consultation. Future research may investigate how health care choices evolve in response to changes in health status and identify determinants that influence the duration of time-limited treatment. Further investigation of the perspectives and attitudes of Taiwanese medical professionals regarding the removal of LST and ANH for patients with neurological diseases may improve our understanding.
