title: Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty.
abstract: In most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of 'good death' to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis.
  
  
  
  To capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature.
  
  
  
  Initial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as 'natural' and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies.
  
  
  
  Together these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury.
authors.affiliation: Centre for Ethics in Medicine, University of Bristol, Bristol, UK. giles.birchley@bristol.ac.uk.
authors.forename: Giles
authors.identifier: 0000-0002-2973-2163
authors.initials: G
authors.lastname: Birchley
authors.affiliation: Faculty of Health and Social Care, The Open University, Milton Keynes, UK.
authors.forename: Kerry
authors.initials: K
authors.lastname: Jones
authors.affiliation: Centre for Ethics in Medicine, University of Bristol, Bristol, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Huxtable
authors.affiliation: Department of Social and Policy Sciences, University of Bath, Bath, UK.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Dixon
authors.affiliation: Coma and Disorders of Consciousness Research Centre, Cardiff University, Cardiff, UK.
authors.forename: Jenny
authors.initials: J
authors.lastname: Kitzinger
authors.affiliation: REACH: The Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK.
authors.forename: Linda
authors.initials: L
authors.lastname: Clare
mesh_terms: D016223:Advance Directives; D000368:Aged; D001293:Attitude to Death; D000070642:Brain Injuries, Traumatic; D003657:Decision Making; D003704:Dementia; D005190:Family; D016330:Frail Elderly; D006801:Humans; D007258:Informed Consent; D062528:Medicalization; D016743:Mental Competency; D010358:Patient Participation; D010820:Physicians; D013727:Terminal Care; D035501:Uncertainty
keywords: Decision-making; Dementia; End-of-life; Frailty; Good Death; Mental capacity; Scoping review; Thematic synthesis; Traumatic brain injury