Abstract
This research and development project aims to develop a community-based model of promoting an uptake of a living will among the elderly. It was implemented in Prapplachai Sub-district located in Uthong District in Suphanburi province. The project has 2 major phases. The first phase involved a survey of 880 samples including 360 senior population (60+), 360 family members of senior people, 120 healthcare providers, 20 village health volunteers and 20 community leaders. Besides the survey, the research team compiled qualitative data utilizing 20 in-depth interviews with senior people and focus group discussions with 26 participants consisting of the community leaders and village health volunteers. Compiled data include attitudes towards patients in a palliative care stage, knowledge and attitudes about the living will. An analysis of the quantitative data relies on descriptive statistics (mean and percentage), whereas a content analysis is applied to the compiled qualitative data. Both qualitative and quantitative data supported one another. Biases towards living wills were palpable. All groups of the sample had a limited knowledge about the meaning and benefits of living wills. They also have inadequate understanding and ability to write and to utilize the living wills. The survey results show 94 % of the samples comprising the elderly, their family members, healthcare providers, community leaders and village health volunteers have never written their living will. Almost half of the elderly (47.5%) had a thought about writing their living will. Supporting reasons persuading them to write the living will included recommending from healthcare personnel (40%), their increased age (30%), and their desire to tell their needs to the family members (30%). Nevertheless, the survey has revealed that more than a half of the ageing people (62%) expressed their need about having the doctors to choose proper medical treatments for them instead of choosing by themselves. Also, 62 % of them preferred choosing medical treatments together with their doctors. The project assessed the samples’ knowledge about living wills using 10 questions, and each question has 1 score. A comparison of knowledge scores shows that the mean scores among the elderly, family members, community leaders, healthcare staff, and village health volunteers were 7.4, 7.5, 7.6, 7.4 and 3.9 respectively. The qualitative data has unveiled that a certain number of samples confused or misunderstood that the living will is similar to a consent to treatment, a body and organ donation, and a last will. Despite having some knowledge, the studied samples barely understood a comprehensive meaning of the living will. Especially, the village health volunteers had a lowest mean score of the knowledge Items that showed their lack of knowledge were describing one’s needs, choosing a person who will make a decision for oneself, identifying a person who can make a decision in case that you cannot make it by yourself due to health conditions, do not know when the living should be used, do not know that the living will can help doctors and caregivers to communicate an issue about choices of medical treatments for patients, do not know that the living will can be revised or annulled by the owners at any time. Likewise, a majority of aging, their family members and health volunteers were unsure or did not know about a right time to compose their living will. The Community leaders as well as health volunteers did not understand that patients and their family members might refuse medical treatments recommended by the doctors if they did not want to. Also, the study illustrates that healthcare personnel has limited knowledge about the living will in some issues such as they did not know that the living will can be used to reaffirm the patient’s needs regarding the alternative treatments in case the patients could not communicate with other people, that the living will could be cancelled or be revised by the owners at any time, and that the patients have the right to refuse medical treatments. The percentages of healthcare providers who were short of knowledge mentioned above are 47%, 29% and 20 % respectively. The second phase tied up with a model development aiming at increasing an uptake of living wills among the elderly. The research team organized workshops to share research results with the community members and to facilitate drafting a plan for promoting and increasing an uptake of the living wills, especially among the elderly. The elderly peer leaders, family representatives, community leaders, health volunteers and healthcare stuff from the community hospital as well as from the sub-district health promotion hospitals were invited to participate in the workshops. The model comprises 3 key components as the followings. 1) Empowering of all stakeholders: the activities included using a participatory approach to establish a committee mechanism which is responsible for promoting the living will uptake, Providing the training of the trainers (TOT) workshop to equip participants with knowledge and skill in writing the living wills. Participants were the elderly leaders, community leaders, healthcare personnel, and health volunteers. 2) Participatory strategic planning: The committees determined strategic activities to promote an acceptance of living wills. Planned activities were identifying platforms to dissimilate knowledge and information. For example, the village health volunteers proposed setting up a group line to provide Q&A about living wills to community members, distributing information and a living will form on the sub-district official website, disseminating information via village broadcasting station as well as via the community radio program, holding training workshops to help the elderly and their family members to write living wills, and presenting cases that have had an experience writing and using the living wills. 3) Strengthening the hospital system: To work with the community hospital’s director and healthcare stuff in order to integrate tasks about living wills into the services. Moreover, to develop a guideline or instruction for patients and caregivers to ease the writing and utilizing of the living wills. The project recommends the government, local hospitals, and local administrative organizations to 1) promote comprehensive knowledge, understanding, and positive attitudes towards living wills at the community level; 2) create a clear manual and form to help people to become capable of writing their living wills, and disseminating them in a variety of available platforms, such as in hospitals, public service offices, and new social media; 3) train local change agents, such as elderly leaders, family leaders, community leaders, village health volunteers, and local healthcare personnel to have adequate knowledge and ability to transform people’s bias and misapprehension towards living wills, as well as to coach people how to write living wills; 4) developing and strengthening the healthcare staff’s skills about palliative care, care for patients with chronic diseases, advance care plan, and how to write and utilize a living will; 5) integrate promoting living wills among patients and caregivers to be a KPI (key performance index) of hospitals at all level; 6) demand that local administrative organizations build the database of people who have their living wills and share the database with hospitals; 7) encourage community leaders, health volunteers and healthcare providers work together to support a unified service with respect to the utilization of living wills.
