Australian nurses' experiences and attitudes in the “do not resuscitate” decision

The effects of Australian nurses' (n = 285) awareness of a “Do Not Resuscitate” (DNR) policy and various practice settings on the DNR decision were examined. A questionnaire, developed by the investigator, was used to gauge nurses' experiences and attitudes in DNR practice. Decision making was not significantly affected by nurses' awareness of a DNR policy in hospitals where a policy was present. Although nurses believed that the patient, next-of-kin, and nurse should play a predominant role in the DNR decision, medical staff were usually responsible for the decision. Various strategies are suggested as to how nurses could make a greater impact on the DNR decision. © 1998 John Wiley & Sons, Inc. Res Nurs Health 21: 429–441, 1998     

Finnish nurses' views on end-of-life discussions and a comparison with physicians' views

This study investigated Finnish nurses' experiences and views on end-of-life decision making and compared them with physicians' views. For this purpose, a questionnaire was sent to 800 nurses, of which 51% responded. Most of the nurses had a positive attitude towards and respect for living wills, more often than physicians. Most also believed that a will had an effect on decision making. Almost all of the nurses considered it their responsibility to talk to physicians about respecting living wills. Do-not-resuscitate (DNR) orders were often interpreted to imply partial or complete palliative (symptom-orientated) care, which may cause confusion. Half of the nurses reported that a DNR decision was discussed always or often with a patient who was able to communicate; physicians were more positive in this respect. Surprisingly, many nurses (44%) stated that active treatment continued too long. Two-thirds thought that their opinions were taken into account sufficiently, even though only half believed that, in general, they had some impact.     

On the topic of do not resuscitate (DNR) orders on intensive care units: an evaluation of the present status on intensive care units of the Innsbruck University clinics

INTRODUCTION: Intensive care physicians are frequently called upon to decide whether intensive care treatment is justified. Critically ill patients with a poor prognosis receive "Do Not Resuscitate (DNR) Orders", which entitles the physician in charge to withhold cardiopulmonary resuscitation in case of cardiac arrest. Guidelines concerning the implementation of DNR orders do not exist for Austrian intensive care units. The aim of this study was to evaluate the different practices of issuing a DNR order in the departments of intensive care medicine at the University Hospital of Innsbruck. METHODS: Forty-nine physicians working in intensive care units were interviewed about the different procedures in the management of a DNR order. Furthermore, the various answers of senior physicians and assistant physicians were evaluated. RESULTS: Thirty-nine per cent of the interviewed physicians reported that DNR orders were always issued in writing. According to the answers of 63% of intensive care physicians, the decision to issue a DNR order is usually made by senior physicians. Twenty-nine per cent mentioned that nurses are never included in the decision making process and 6%, that the family is not included in the decision making process. According to 29%, the family is regularly informed about a written DNR order. Twenty per cent of the interviewed physicians reported that the quality of the administration of a written DNR order is very good, 6% that the quality is poor. CONCLUSION: We believe that the unsatisfactory situation in regard of DNR orders is not due to inactivity on the part of physicians, but is more likely a result of the inconclusive and, in part, contradictory legal situation. The physician is compelled to take a major decision within a poorly defined legal situation.     

Attitudes towards do-not-resuscitate decisions: differences among health professionals in a Portuguese hospital

OBJECTIVES: Implementation of an in-hospital cardiopulmonary resuscitation (CPR) program stresses the need to discuss do-not-resuscitate (DNR) orders, as CPR may not be desirable in some terminally ill patients. Ethical, social, educational, and professional issues may influence these decisions. This study was designed to evaluate attitudes among four categories of healthcare professionals. DESIGN AND SETTING: Survey in a tertiary hospital in Portugal. METHODS: An anonymous self-completed questionnaire was distributed to 825 staff members, 527 of whom responded (20% physicians, 44% nurses, 20% health technicians, 16% healthcare domestic staff). Responses were compared between the various health professional groups. RESULTS: The level of medical/health training was positively related to the frequency of DNR decisions (physicians and nurses could foresee more circumstances warranting DNR decisions than technical/administrator or domestic staff) and negatively related to the willingness to include the patient's family in the DNR decision (physicians and nurses saw less need for the family's participation than technical/administrator or domestic staff). Significant differences were also found between professional groups regarding the physician's responsibility and the nurses' participation in DNR decisions. There was no difference between the professional groups regarding the need to note the DNR decision in clinical charts. CONCLUSION: Health professionals differ in their attitudes concerning DNR decisions. In particular, the level of medical/health training and/or degree of involvement with the patient's daily care may play an important role in DNR decisions.     

Withdrawal of life support – who should decide?

Objective: To examine the attitudes of the general public regarding who should decide about the withdrawal of life support and to compare these attitudes with those of intensive care personnel. Design: Nationwide postal questionnaire survey. Setting: Sweden. Participants: One thousand one hundred ninety-six randomly selected persons from the Swedish population register, 339 nurses and 121 physicians from 29 randomly selected intensive care units (ICUs). Measurements and results: Respondents' answers to questions related to two clinical scenarios: one with a conscious and competent patient and one with an unconscious patient. The response rates were 64 % for the general public, 86 % for the nurses and 88 % for the physicians. Concerning the competent patient, 48 % of the public, 31 % of the nurses and 8 % of the physicians were of the opinion that a decision about continued ventilator treatment should be made by the patient alone or together with the family, but without the physician. The vast majority of physicians (87 %) wanted to make the decision themselves, either alone or together with the patient or family. Concerning the incompetent patient, 73 % of the general public and 70 % of the nurses advocated a joint decision made by the family and the physician together. The majority of the physicians (61 %) regarded themselves as the sole decision-maker, a view supported by only 5 % of the public and 20 % of the nurses. Conclusions: While existing Swedish guidelines recommend that the physician should be the sole decision-maker, the general public favour more patient and family influence on the decision to withdraw life support as compared with intensive care physicians. Received: 7 October 1998 Final revision received: 28 April 1999 Accepted: 3 May 1999     

Referrals from home care to emergency hospital care: basis for decisions

The Swedish government implemented a reform, the Adel reform, in the care of older citizens in 1992, so that the communities where older people live became responsible for their care and housing. Nurses were appointed to make sure that older people were given accurate care and to act as supervisors for nurses' aides. In this study, 10 Registered Nurses from community home care services and four consultant head physicians in primary care were interviewed in order to illuminate what they thought influenced nurses' decisions to refer patients for emergency treatment and what support they requested to facilitate the decision. Content analysis showed the necessity of feeling secure in one's role as a community nurse. The categories that developed were: own competence, knowledge about the patient and a supportive working environment. The main theme was To feel safe in one's role - a basis for decision-making. High demands were put on the nurses' competence and their burden of responsibility became too great. This influenced decision-making negatively, if nurses felt that they were lacking in their own personal competence. Training in documentation for the nurses was required, as well as the need for organizations to provide staff with sufficient time for accurate documentation. A greater input of nursing and medical care was required to make it possible for patients to be cared for at home if they so wished. Respondents described considerable deficiencies in their working environment and in co-workers' competence, and nurses' professional roles within the community were not made clear. If these problems were remedied, this would improve working conditions, increase understanding, and reduce feelings of uncertainty among decision-makers.     

Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it

This study investigated the perceptions and attitudes of ICU nurses towards the 'do not resuscitate' (DNR) decision and changes in their nursing activities after implementation of the DNR decision in South Korea. A data survey was conducted in South Korea between August and October 2008, with a convenience sample of 252 ICU nurses who had more than one year of clinical experience. The data were collected via a self-administered questionnaire. Most of the nurses perceived the necessity of the DNR decision in cases where there would be no chance of patient recovery despite massive efforts. Very few of the nurses' activities changed, either passively or actively, after implementation of the DNR decision. Moreover, the findings of this research provide suggestions for the future direction of the DNR decision and ethical nursing guidelines in South Korea. Further investigations are needed for the development of decision-making skills and intervention guidelines for end-of-life nursing.     

Israeli nurses and genetic information disclosure

The debate continues about whether people have a duty to pass on the positive results of their genetic tests to relatives who are at risk from the same disease, and, should they refuse, whether physicians and genetic counselors then have the duty to do so. To date, the role and views of nurses in this debate have not been investigated. In our study, a sample of Israeli nurses, untrained in genetics, were asked for their theoretical opinions and what practical steps they would take in the case of patients' refusal to disclose. The nurses were very sure that patients should inform their families but were equally sure that nurses must respect their decision to disclose or not. Few said they would take practical steps to disclose information if the patient objected. The authors believe that the most useful and appropriate role for nurses in this field is in working to bring about co-operation between patients and family members.     

Physician's role in home care for children with cancer

We interviewed 29 physicians who had participated to varying degrees in a home care program for children dying of cancer. All physicians stated that they would use home care again and saw such care as an integral part of their practice. Most physicians felt that home care provides psychological advantages to the family; they viewed assessment of the family's needs by the home care nurses an important factor of home care treatment. Some physicians expressed concern of the nurse's assuming too much responsibility or failing to report significant changes observed in the patient, particularly observations of the side effects of medication. Divergent philosophies of physicians and nurses regarding side effects were seen by some physicians as a potential source of confusion and anxiety for families. The legal ramifications of home care were discussed by only a few physicians; the consensus of opinion among the physicians was that close contact among physician, family, and nurse would assure the absence of legal problems     

Physician's role in home care for children with cancer.

We interviewed 29 physicians who had participated to varying degrees in a home care program for children dying of cancer. All physicians stated that they would use home care again and saw such care as an integral part of their practice. Most physicians felt that home care provides psychological advantages to the family; they viewed assessment of the family's needs by the home care nurses an important factor of home care treatment. Some physicians expressed concern of the nurse's assuming too much responsibility or failing to report significant changes observed in the patient, particularly observations of the side effects of medication. Divergent philosophies of physicians and nurses regarding side effects were seen by some physicians as a potential source of confusion and anxiety for families. The legal ramifications of home care were discussed by only a few physicians; the consensus of opinion among the physicians was that close contact among physician, family, and nurse would assure the absence of legal problems.     

老年冠心病患者个性特征及其与应对方式相关性的研究

目的 探讨老年冠心病患者的个性特征及其与应对方式的关系。方法 应用艾森克个性问卷（EPQ）及医学应对方式问卷（MCMQ）对246例社区居家及住院治疗的老年冠心病患者进行测试研究。结果（1）老年冠心病患者的个性倾向以中间型为主占46．3％；其次为外向型占22．4％，倾向外向型占13．8％。情绪稳定性亦以中间型为主占44．3％，其次为倾向稳定型占20．7％，情绪不稳定型占15．9％，倾向不稳定型占10．2％。（2）与全国常模相比较，老年冠心病患者EPQ的E因子分显著高于常模，P因子分显著低于常模（P〈0．05）；（3）E因子与面对及回避应对方式得分呈正相关；N、P因子与屈服应对方式得分呈正相关，E、L因子与屈服应对方式得分呈负相关（P〈0．05）。结论 老年冠心病患者个性偏外向，情绪稳定性各异；应对方式与个性密切相关，社区与临床护理人员可针对患者的个性特征，采取有效的干预措施，促进患者应用积极的应对方式。     

2005-2010年不同层次护理管理者应具备的管理技能调查分析

目的调查2005-2010年不同层次护理管理者应具备的管理技能,为制订管理者的培训课程提供依据。方法采用自行设计的护理管理人员管理技能问卷,调查全国77家医院的1004名护士、护士长及护理部主任。结果2005-2010年,护士长最应具备的能力为平衡家庭与工作之间的关系的能力,其次为急救能力、人才的培养;具备决策能力、工作有计划、合理使用人才对2005-2010年的护理部主任最为重要。结论不同层次的护理管理人员的管理技能要求是不同的;应对不同层次的护理管理者分层次进行培训。     

Physician's role in home care for children with cancer

Abstract

We interviewed 29 physicians who had participated to varying degrees in a home care program for children dying of cancer. All physicians stated that they would use home care again and saw such care as an integral part of their practice. Most physicians felt that home care provides psychological advantages to the family; they viewed assessment of the family's needs by the home care nurses an important factor of home care treatment. Some physicians expressed concern of the nurse's assuming too much responsibility or failing to report significant changes observed in the patient, particularly observations of the side effects of medication. Divergent philosophies of physicians and nurses regarding side effects were seen by some physicians as a potential source of confusion and anxiety for families. The legal ramifications of home care were discussed by only a few physicians; the consensus of opinion among the physicians was that close contact among physician, family, and nurse would assure the absence of legal problems     

Should Parents Be Present during Emergency Department Procedures on Children,and Who Should Make That Decision? A Survey of Emergency Physician and Nurse Attitudes

OBJECTIVE: To survey physician and nurse attitudes regarding parental presence during painful procedures on children performed in the emergency department (ED) and who should make that decision. METHODS: The design was an anonymous written survey consisting of six clinical scenarios distributed to all staff and resident physicians and nurses in ten EDs at institutions in the United States routinely caring for children. Participants were asked whether parents should remain with children undergoing intravenous (IV) placement, laceration repair, lumbar puncture, conscious sedation, major resuscitation, and major resuscitation with death. They also were asked who should make the decision. RESULTS: The percentage of physicians who responded that parents should be present was 91.3% for peripheral IV start, 93.3% for laceration repair, 65.7% for lumbar puncture, 83.1% for conscious sedation, 31.9% for major resuscitation, and 35.6% for major resuscitation where death was likely. The percentage of nurses who responded that parents should be present was 86.8% for peripheral IV start, 89.6% for laceration repair, 55.0% for lumbar puncture, 74.9% for conscious sedation, 41.4% for major resuscitation, and 54.3% for major resuscitation where death was likely. In 64.8% of the completed surveys, the physicians indicated that they alone or in conjunction with a parent should make the decision. In 61.5% of the completed surveys, the nurses indicated that they should be involved in the decision. CONCLUSIONS: A majority of emergency physicians and nurses indicated parents should be present for some invasive pediatric procedures. However, as the invasiveness of the pediatric procedures increased, fewer physicians and nurses believed that parents should be present.     

Perianesthesia Nursing Advocacy: An Influential Voice for Patient Safety

Perianesthesia nurses are called to advocate for their patients, promote a safe work environment, and contribute to the continued advancement of the nursing profession. Nurses must demonstrate vigilance in their nursing care to protect patients from harm. It is an ethical and legal responsibility to request physicians to review with patients their informed consents when they report they do not understand or have questions about the surgical procedure. Likewise, nurses need to alert managers and administrators when they experience unsafe work environments, such as actual or potential nurse staffing issues, unsafe nurse-to-patient ratios, medication errors, and nurse fatigue. This article focuses on the valuable role perianesthesia nurses play in patient advocacy by: (1) speaking out on behalf of the patient, (2) assuring a safe work environment, (3) assessing for nurse fatigue, and (4) advocating patient safety for the global nursing profession.     

Research Article: Perceptions of Japanese patients and their family about medical treatment decisions

Internationally, nurses and physicians are increasingly expected to undertake roles in communication and patient advocacy, including in Japan, where the reigning principle underlying medical ethics is in transition from paternalism to respect for patient autonomy. The study reports the results of a survey in two Japanese teaching hospitals that clarified the perspectives of 128 patients and 41 family members regarding their current and desired involvement in health decision‐making. The commonest process that was desired by patients and their family was for patients to make decisions after consultation with both the physician and their family. The decision‐making preferences for competent patients varied among the participants, who believed that families have a crucial role to play in health‐care decision‐making, even when patients are competent to make their own decisions. The findings will inform health professionals about contemporary Japanese health‐care decision‐making and the ethical issues involved in this process, as well as assist the future development of a culturally relevant model to support patients' preferences for ethical decision‐making.     

Changes in intensive care unit nurse involvement in end of life decision making between 1999 and 2016: Descriptive comparative study

ObjectiveComparison of nurse involvement in end of life decision making in European countries participating in ETHICUS I- 1999 and ETHICUS II- 2015.MethodologyThis was a prospective observational study of 22 European ICUs included in the ETHICUS-II and I. Data were collected as per the ETHICUS-I and ETHICUS-II protocols. Four questions within the ETHICUS protocols related to nurse involvement in end of life decision making were analyzed. This is a comparison of changes in nurse involvement in end of life decisions from 1999 to 2015.SettingInternational e-based questionnaire completed by an intensive care clinician when an end of life decision was performed on any patient.SubjectsIntensive care physicians and nurses, no interventions were performed.MeasurementsA 20 question survey was used to describe the decision making process, on what basis was the decision made, who was involved in the decision making process, and what precise decisions were made.ResultsA total of 4592 cases from 22 centres are included. While there was more agreement between nurses and physicians in ETHICUS-I compared to ETHICUS-I, fewer discussions with nurses occurred in ETHICUS-II. The frequency of end of life decisions that were discussed with nurses decreased in all three regions between ETHICUS-I and ETHICUS-II.ConclusionBased on the results of the current study, nurses should be further encouraged to increase their involvement in end of life decision-making, especially those in southern Europe.     

Marketing the home healthcare agency. Do nurses and physicians agree?

Increasingly, hospital nurse administrators are being called upon to organize and implement home care services and to market these services to physicians, patients, and family members. A survey of hospital personnel revealed that both nurses and physicians perceived themselves as the persons primarily responsible for determining the patient's need for postdischarge home care. In listing criteria for selecting a home care agency for patient referral, nurses and physicians rated service dependability and nursing care quality as the most important criteria.     

Perceptions of physicians, nurses, and respiratory therapists about the role of acute care nurse practitioners.

BACKGROUND: Information about the contributions of acute care nurse practitioners to medical management teams in critical care settings is limited. OBJECTIVE: To examine contributions of acute care nurse practitioners to medical management of critically ill patients from the perspectives of 3 disciplines: medicine, respiratory care, and nursing. METHODS: Attending physicians, respiratory therapists, and nurses in 2 intensive care units were asked to list 3 advantages and 3 disadvantages of collaborative care provided by acute care nurse practitioners. Qualitative methods (coding/constant comparative analysis) were used to identify common themes and subthemes. Overall response rate was 35% (from 69% for attending physicians to 26% for nurses). RESULTS: Responses were grouped into 4 main themes: accessibility, competence/knowledge, care coordination/communication, and system issues. Acute care nurse practitioners were valued for their accessibility, expertise in routine daily management of patients, and ability to meet patient/family needs, especially for "long-stay" patients. Also, they were respected for their commitment to providing quality care and for their communication skills, exemplified through teaching of nursing staff, patient/family involvement, and fluency in weaning protocols. Physicians valued acute care nurse practitioners' continuity of care, patient/family focus, and commitment. Nurses valued their accessibility, commitment, and patient/family focus. Respiratory therapists valued their accessibility, commitment, and consistency in implementing weaning protocols. CONCLUSION: Responses reflected unique advantages of acute care nurse practitioners as members of medical management teams in critical care settings. Despite perceptions of the acute care nurse practitioner's role as medically oriented, the themes reflect a clear nursing focus.