Professionals' perspectives on trusted persons in French nursing homes

France faces growing challenges with an aging population and neurodegenerative disorders. French health law allows patients to appoint a trusted person ("personne de confiance") to communicate their medical preferences if incapacitated. Introduced by the Kouchner Law in 2002, this reflects a shift from paternalistic to autonomist care, emphasizing patient autonomy. Despite their importance in conveying patient wishes in nursing homes, research remains limited, with most studies focusing on hospitals.

We conducted semi-structured interviews with 14 healthcare professionals (directors, psychologists, coordinating physicians, nurse managers, psychometricians) working in or with French nursing homes from February 2021 to September 2022. Interviews lasted 26-80 min and we analyzed them using grounded theory methodology. Theoretical saturation was achieved after 9 interviews and confirmed through 5 additional interviews.

Through grounded theory analysis, we identified that professionals continuously balance three competing needs when collaborating with trusted persons: patient-oriented needs (ensuring care quality, safety, dignified end-of-life), relatives-oriented needs (supporting families, protecting mental health), and self-oriented needs (legal protection, professional well-being, administrative efficiency). This core balancing process is shaped by three contextual factors: (1) evolving nursing home environments with cognitively impaired residents and regulatory complexity; (2) insufficient knowledge of the trusted person system among families and professionals; and (3) family burden during end-of-life phases, including guilt and death-related taboos. Under the influence of these contextual factors, professionals' balancing efforts manifest through heterogeneous practices in informing families about designation and varied approaches to involving trusted persons in decision-making and care.

From the perspective of healthcare professionals, effective trusted person involvement would be facilitated by early education before admission. Our findings suggest organizational and educational interventions may improve trusted person collaboration, though research engaging trusted persons and patients directly is needed to validate these professional perspectives and develop appropriate interventions.