Development and Validation of a Questionnaire investigating the Knowledge, Attitudes and Practices of Healthcare Workers in the Field of Anesthesiology concerning the Italian Law on Advance Healthcare Directives: a Pilot Study

Main Article Content

Alessandro Bonsignore
Nicola Luigi Bragazzi
Chiara Basile
Paolo Pelosi
Angelo Gratarola
Giulia Bonatti
Nicolò Patroniti
Rosagemma Ciliberti

Keywords

advance healthcare directives; knowledge, attitudes and practices questionnaire; survey; development and validation of questionnaire; exploratory factor analysis; bioethics

Abstract

Advance healthcare directives are legal documents, in which the patient, foreseeing a potential loss of capacity and autonomy, makes in advance decisions regarding future care and, in particular, end-of-life arrangements. In Italy, advance healthcare directives  are regulated by the Law 219 of 22 December 2017. Objectives of the study were: i) to develop and validate a questionnaire dedicated to evaluate the knowledge of the Law in a sample of 98 anesthesiologists, and ii) to shed light on the process of health-related decision-making and its determinants (age, gender, doctor/training resident, religious beliefs). A second part of the survey  not analyzed  in the present study, aimed to assess, through two simulated clinical scenarios, how patient’ directives, relatives and the medical staff could influence physicians’ clinical decision. Overall Cronbach’s alpha coefficient of the questionnaire resulted 0.83. Three factors explaining up to 38.4% of total variance (communication and relationship with the patient; critical life-threatening situations and binding nature of the advance directive for the physician; and involvement of patients). Most of the doctors (58.7%) did not fully know the recent legislative provision. The lack of knowledge is critical in view of the specificity of the clinical area investigated (anesthesiology and intensive care), which has to cope with ethical issues. An adequate revision and implementation of the traditional curricula could help medical students and trainees develop the aptitudes and skills needed in their future profession.

Abstract 458 | PDF Downloads 296

References

1. Gristina RG, Busatta GR, Piccinni LM. The Italian law on informed consent and advance directives: its impact on intensive care units and the European legal framework. Minerva Anestesiologica 2019;85(4):401-11.
2. Ciliberti R, Gorini I, Gazzaniga V, De Stefano F, Gulino M. The Italian law on informed consent and advance directives: New rules of conduct for the autonomy of doctors and patients in end-of-life care. J Crit Care. 2018 Dec;48:178-182.
3. Di Paolo M, Gori F, Papi L, Turillazzi E. A review and analysis of new Italian law 219/2017: ‘provisions for informed consent and advance directives treatment’. BMC Med Ethics. 2019; 20: 17.
4. Giannini A, Miccinesi G. Mechanical ventilation withdrawal at end of life: terminal extubation and terminal weaning. Minerva Anestesiologica 2017;83:350-2.
5. Cortegiani A, Russotto V, Raineri SM, Gregoretti C, Giarratano A, Mercadante S. Attitudes towards end-of-life issues in intensive care unit among Italian anesthesiologists: a nation-wide survey. Support Care Cancer 2018;26:1773-80.
6. Chin M, Lagasse RS. Assessment of competence: developing trends and ethical considerations. Curr Opin Anaesthesiol 2017;30:236-41.
7. Rasoal D, Skovdahl K, Gifford M, Kihlgren A. Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review. HEC Forum 2017; 29: 313346.
8. Ciliberti R, Baldelli I, Gallo F, Patuzzo S, De Stefano F, Bonsignore A. Physicians' perception of the importance of ethical and deontological issues in a major Italian Province: pilot questionnaire and its validation. Acta Biomed 2019;90:56-67.
9. SIAARTI Le cure di fine vita e l’anestesista rianimatore: raccomandazioni per l’approccio alla persona morente update 2018 http://www.siaarti.it/SiteAssets/Ricerca/documento-siaarti-fine-vita/Documento%20SIAARTI%20Fine%20vita.pdf
10. Caruso R, Rocco G, Dellafiore F, Brognoli G, Magon A, Conte G, et al. 'Nosce te ipsum': An Italian national survey to explore choice's differences in End of Life (EoL) care between healthcare professionals and general public. Appl Nurs Res 2019;46:8-15.
11. National Bioethics Committee. Advanced treatment statements 18 December 2003. Available from: http://bioetica.governo.it/media/1869/p58_2003_dichiarazioni_anticipate_trattamento_it.pdf
12. Federazione Nazionale degli Ordini dei Medici Chirurghi e Odontoiatri (FNOMCeO) Italia. Codice di deontologia medica. 2014. Available from: https://portale.fnomceo.it/fnomceo/showArticolo.2puntOT?id=115184 .
13. Wiesing U, Jox RJ, Hessler HJ, Borasio GD. A new law on advance directives in Germany. J Med Ethics 2010;36:779-83. 14. Brauer S, Biller-Andorno N, Andorno R. Country reports on advance directives. Available from: https://www.ethik.uzh.ch/dam/jcr:00000000-14d5-886d-ffff-fffff1488f30/Country_Reports_AD.pdf
14. Andorno R, Brauer S. Advance Health Care Directives: Towards a Coordinated European Policy? Eur J Health Law 2009;16(3):207-27.
15. Geppert CM, Andrews MR, Druyan ME. Ethical issues in artificial nutrition and hydration: a review. JPEN J Parenter Enteral Nutr 2010;34:79-88.
16. Brody H, Hermer LD, Scott LD, Grumbles LL, Kutac JE, McCammon SD. Artificial Nutrition and Hydration: The Evolution of Ethics, Evidence, and Policy. J Gen Intern Med. 2011;26: 1053-8.
17. Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, et al. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clinical Nutrition (2016), http://dx.doi.org/10.1016/j.clnu.2016.02.006.
18. Moreschi C, Da Broi U, Rodriguez D, Froldi R, Porzionato A, Macchi V, et al. The Eluana Englaro Case: cause of death after the withdrawal of artificial nutrition and hydration in a subject in a permanent vegetative state and with quadriplegia. Forensic Sci Int 2013;231(1-3):e24-9.
19. Solarino B, Bruno F, Frati G, Dell'Erba A, Frati P. A national survey of Italian physicians' attitudes towards end-of-life decisions following the death of Eluana Englaro: reply to M.Y. Rady. Intensive Care Med 2011;37:1394-5.
20. Mallia P. Are clarifications on feeding and hydration in PVS needed by Catholic authorities?J Int Bioethique 2012;23(3-4):179-88.
21. Latronico N, Manenti O, Baini L, Rasulo FA. Quality of reporting on the vegetative state in Italian newspapers. The case of Eluana Englaro. PLoS One 2011;6:e18706.
22. Sulmasky D.P. Italy’s New Advance Directive Law When in Rome. JAMA Intern Med 2018;178:607-8
23. Comitato Nazionale di Bioetica. Sedazione palliativa profonda continua nell’imminenza della morte. 29 gennaio 2016. http://www.fedcp.org/images/news/CNB_sedazione_profonda.pdf
24. Ranjan P, Kumari A, Chakrawarty A. How can Doctors Improve their Communication Skills? J Clin Diagn Res 2015; 9(3): JE01–JE04.
25. Chiapponi C, Dimitriadis K, Özgül G, Siebeck RG, Siebeck M. Awareness of ethical issues in medical education: an interactive teach-the-teacher course. GMS J Med Educ 2016;33(3): Doc45.