Hausärztlicher Umgang mit Patientenverfügung und Vorsorgevollmacht bei Demenzpatienten – Eine Querschnittsstudie unter deutschen Hausärzten

Zusammenfassung

Ziel Aufgrund der abnehmenden Selbstständigkeit und Handlungsfähigkeit von Demenzpatienten ist es wichtig, rechtzeitig Zukunftsvorkehrungen in Form einer Patientenverfügung und Vorsorgevollmacht zu treffen. Diese Studie zeigt, ob Hausärzte ihre Patienten mit Demenz auf diese Dokumente ansprechen und ob es Zusammenhänge dieses Vorgehens mit dem weiteren Kommunikations- und Aufklärungsverhalten der Ärzte gibt.

Methodik Eine Querschnittsstudie unter einer Zufallsstichprobe von 982 Hausärzten in Nordrhein-Westfalen wurde von Oktober 2017 bis Januar 2018 durchgeführt. Ein selbstentwickelter, schriftlicher, standardisierter Fragebogen wurde eingesetzt. Deskriptive statistische Analysen und logistische Regressionsanalysen wurden mittels IBM SPSS Statistics, Version 24, durchgeführt.

Ergebnisse 339 Hausärzte nahmen an der Befragung teil (Rücklaufquote: 34,5%). 70,1% der Hausärzte stimmen eher bzw. völlig zu, ihre Patienten nach Diagnosestellung einer Demenz auf die Notwendigkeit einer Patientenverfügung und Vorsorgevollmacht anzusprechen. Ärzte, die sich sicher in der Mitteilung von Demenzdiagnosen fühlen, berichten auch häufiger, dass sie diese Vorsorgedokumente ansprechen (aOR: 1,97; 95%-KI: 1,17–3,33). Auch sprechen tendenziell Hausärzte mit höherem Alter und Kenntnissen von lokalen Hilfestellen eher diese Thematik an.

Schlussfolgerung Hausärzte leisten einen wesentlichen Beitrag, Demenzpatienten und ihre Angehörigen frühzeitig auf eine Patientenverfügung und Vorsorgevollmacht anzusprechen. Aus den dargelegten Zusammenhängen lässt sich schließen, dass sowohl die hausärztliche Aneignung von Wissen und Erfahrungen zu Demenz und dem lokalen Hilfesystem als auch der Umgang mit Betroffenen gestärkt werden sollte, um die Ansprache dieser Vorsorgedokumente zu optimieren.

Abstract

Objectives Issues of living will and power of attorney must be addressed as early as possible in dementia patients because of their decreasing independence and ability to act for themselves. The aim of this study was to investigate whether general practitioners (GPs), who usually have long-standing and regular contact with this group of patients, address these precautionary measures and if there is any association between this approach and further communication and educational behaviour of doctors.

Methods A cross-sectional survey, using standardized, written questionnaires, was conducted in a random sample of 982 GPs in North Rhine-Westphalia in western Germany between October 2017 and January 2018. Descriptive statistical as well as logistic regression analyses were carried out using IBM SPSS Statistics, version 24.

Results A total of 339 GPs responded to the survey questionnaire (response rate: 34.5%). A majority of GPs (70.1%) agreed totally or partially that it was necessary to address their dementia patients on living will and power of attorney; GPs who were more confident in communicating a dementia diagnosis reported addressing the issue of documents for the end of life more frequently (aOR: 1.97; 95%-CI: 1.17–3.33). Older GPs with greater knowledge of regional services for dementia patients also tended to address this topic more frequently.

Conclusions General practitioners make a major contribution to help dementia patients and their relatives to plan ahead at an early stage of the disease. It can be concluded from our results that GPs’ knowledge and experiences about dementia and local services, as well as how to deal with those affected should be improved in order to optimise communication on living will and power of attorney as precautionary measures.

Schlüsselwörter

Demenz - Patientenverfügung - Vorsorgevollmacht - Lebensende - Hausarzt

Keywords

Dementia - living will - precautionary power - end of life - general practitioner

Publication History

Article published online:
20 December 2019

• Literatur

• 1 Ferri CP, Prince M, Brayne C. et al. Global prevalence of dementia: a Delphi consensus study. Lancet (London, England) 2005; 366: 2112-2117
• 2 Doblhammer G. Demografie der Demenz. 1. Aufl Bern: Huber; 2012
• 3 Statistisches Bundesamt (Destatis). Bevölkerung mit Migrationshintergrund. Ergebnisse des Mikrozensus. Fachserie 1 Reihe 2.2.
• 4 Agüero-Torres H, Fratiglioni L, Guo Z. et al. Mortality from dementia in advanced age: a 5-year follow-up study of incident dementia cases. Journal of clinical epidemiology 1999; 52: 737-743
• 5 Rait G, Walters K, Bottomley C. et al. Survival of people with clinical diagnosis of dementia in primary care: cohort study. BMJ (Clinical research ed.) 2010; 341: c3584
• 6 Todd S, Barr S, Roberts M. et al. Survival in dementia and predictors of mortality: a review. International journal of geriatric psychiatry 2013; 28: 1109-1124
• 7 deLima Thomas J, Sanchez-Reilly S, Bernacki R. et al. Advance Care Planning in Cognitively Impaired Older Adults. Journal of the American Geriatrics Society 2018; 66: 1469-1474
• 8 Rietjens JAC, Sudore RL, Connolly M. et al. Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care. The Lancet Oncology 2017; 18: e543-e551
• 9 van der Steen JT, Radbruch L. Hertogh CMPM et al. White paper defining optimal palliative care in older people with dementia: a Delphi study and recommendations from the European Association for Palliative Care. Palliative medicine 2014; 28: 197-209
• 10 Bundesministerium der Justiz und für Verbraucherschutz Patientenverfügung. Leiden- Krankheit- Sterben. Wie bestimme ich, was medizinisch unternommen werden soll, wenn ich entscheidungsunfähig bin?. Paderborn: Bonifatius GmbH; 2018
• 11 Schers H, van den Hoogen H, Bor H. et al. Familiarity with a GP and patientsʼ evaluations of care. A cross-sectional study. Family practice 2005; 22: 15-19
• 12 Tilburgs B, Vernooij-Dassen M, Koopmans R. et al. The importance of trust-based relations and a holistic approach in advance care planning with people with dementia in primary care: a qualitative study. BMC geriatrics 2018; 18: 184
• 13 Sachs GA, Shega JW, Cox-Hayley D. Barriers to excellent end-of-life care for patients with dementia. Journal of general internal medicine 2004; 19: 1057-1063
• 14 Mitchell SL, Kiely DK, Hamel MB. Dying with advanced dementia in the nursing home. Archives of internal medicine 2004; 164: 321-326
• 15 Cavalieri TA, Latif W, Ciesielski J. et al. How physicians approach advance care planning in patients with mild to moderate Alzheimerʼs disease. The Journal of the American Osteopathic Association 2002; 102: 541-544
• 16 Nakash RA, Hutton JL, Jørstad-Stein EC. et al. Maximising response to postal questionnaires – a systematic review of randomised trials in health research. BMC medical research methodology 2006; 6: 5
• 17 Muñoz-Leiva F, Sánchez-Fernández J, Montoro-Ríos F. et al. Improving the response rate and quality in Web-based surveys through the personalization and frequency of reminder mailings. Qual Quant 2010; 44: 1037-1052
• 18 van Mol C. Improving web survey efficiency: the impact of an extra reminder and reminder content on web survey response. International Journal of Social Research Methodology 2017; 20: 317-327
• 19 Christensen AI, Ekholm O, Kristensen PL. et al. The effect of multiple reminders on response patterns in a Danish health survey. European journal of public health 2015; 25: 156-161
• 20 Mason RL, Annear MJ, Lo A. et al. Development and preliminary psychometric properties of the General Practitioner Attitudes and Confidence Scale (GPACS-D) for dementia. BMC family practice 2016; 17: 105
• 21 Tillmann J, Schnakenberg R, Puth M-T. et al. Barriers in general practitionersʼ dementia diagnostics among people with a migration background in Germany (BaDeMi) – study protocol for a cross-sectional survey. BMC medical research methodology 2018; 18: 124
• 22 Meeussen K, van den Block L, Echteld M. et al. Advance care planning in Belgium and The Netherlands: a nationwide retrospective study via sentinel networks of general practitioners. Journal of pain and symptom management 2011; 42: 565-577
• 23 Evans N, Pasman HRW, Donker GA. et al. End-of-life care in general practice: A cross-sectional, retrospective survey of ̒cancerʼ, ̒organ failureʼ and ̒old-age/dementiaʼ patients. Palliative medicine 2014; 28: 965-975
• 24 Brazil K, Carter G, Galway K. et al. General practitioners perceptions on advance care planning for patients living with dementia. BMC palliative care 2015; 14: 14
• 25 Piers R, Albers G, Gilissen J. et al. Advance care planning in dementia: recommendations for healthcare professionals. BMC palliative care 2018; 17: 88
• 26 Poppe M, Burleigh S, Banerjee S. Qualitative evaluation of advanced care planning in early dementia (ACP-ED). PloS one 2013; 8: e60412
• 27 Dening KH, Jones L, Sampson EL. Preferences for end-of-life care: a nominal group study of people with dementia and their family carers. Palliative medicine 2013; 27: 409-417
• 28 Robinson L, Dickinson C, Bamford C. et al. A qualitative study: professionals’ experiences of advance care planning in dementia and palliative care, ‘a good idea in theory but …’. Palliative medicine 2013; 27: 401-408
• 29 Sellars M, Chung O, Nolte L et al. Perspectives of people with dementia and carers on advance care planning and end-of-life care: A systematic review and thematic synthesis of qualitative studies. Palliative medicine 2018; 269216318809571
• 30 Tilburgs B, Vernooij-Dassen M, Koopmans R. et al. Barriers and facilitators for GPs in dementia advance care planning: A systematic integrative review. PloS one 2018; 13: e0198535
• 31 Kim SYH, Caine ED. Utility and limits of the mini mental state examination in evaluating consent capacity in Alzheimerʼs disease. Psychiatric services (Washington, D.C.) 2002; 53: 1322-1324
• 32 Sturman ED. The capacity to consent to treatment and research: a review of standardized assessment tools. Clinical psychology review 2005; 25: 954-974
• 33 Pruchno RA, Smyer MA, Rose MS. et al. Competence of Long-Term Care Residents to Participate in Decisions About Their Medical Care: A Brief, Objective Assessment. The Gerontologist 1995; 35: 622-629
• 34 Lee L, Hillier LM, Locklin J. et al. Advanced Care Planning for Persons With Dementia in Primary Care: Attitudes and Barriers Among Health-Care Professionals. Journal of palliative care 2018; 825859718812463
• 35 Glaudemans JJ, van Moll Charante EP, Willems DL. Advance care planning in primary care, only for severely ill patients? A structured review. Family practice 2015; 32: 16-26
• 36 Robinson L, Tang EYH. caring for people with dementia towards, and at the end of life. Mental Health and Older People.
• 37 GKV-Spitzenverband. Vereinbarung nach § 132g Abs. 3 SGB V über Inhalte und Anforderungen der gesundheitlichen Versorgungsplanung für die letzte Lebensphase vom 13.12.2017
• 38 Bundesärztekammer. Ärztestatistik zum 31. Dezember 2017. Bundesgebiet gesamt 2017
• 39 Kopetsch T. Dem deutschen Gesundheitswesen gehen die Ärzte aus! Studie zur Altersstruktur- und Arztzahlenentwicklung. 3. Aufl Berlin: Bundesärztekammer u. Kassenärtzl. Bundesvereinigung; 2005
• 40 German Institute of Medical Documentation and Information. German Clinical Trials Register (DRKS) (2017). Online: https://www.drks.de/drks_web/setLocale_EN.do; 2017
• 41 Universitätsklinikum Bonn. Studienzentrum. UKB-Studienregister. Online: https://www.studienzentrum-bonn.de/index.php?id=280; 2017