Nurses' involvement in end-of-life decisions

In Dutch healthcare, patients and physicians are responsible for medical end-of-life decisions. These include nontreatment decisions, withholding or withdrawing parenteral hydration and nutrition where the patient can no longer drink or eat, relieving pain and other symptoms with drugs that might shorten life, euthanasia, and physician-assisted suicide. The objective of this study is to investigate the views of nurses on their role with regard to discussing these kinds of decisions, as well as their actual role in the decision-making process. Nurses (n = 489) involved in palliative terminal care answered questions about their preferred and actual role in end-of-life decision-making processes. Nurses want to be involved in making end-of-life decisions, but this depends partly on the kind of decision that has to be taken. When caring for terminal patients, 62% of the nurses usually talk about such decisions with patients or their families. Three-quarters of the nurses had been involved in an end-of-life decision-making process in the previous 2 years, mostly by talking with the physician and the patient's family. It is concluded that physicians should discuss these decisions with nurses more often. The finding that characteristics of the nurses influence their role in end-of-life decision-making processes emphasizes the importance of developing mechanisms to ensure that end-of-life decisions are made in a consistent manner and do not depend on the demographic characteristics of nurses.     

Dutch nurses' attitudes towards euthanasia and physician-assisted suicide

This article presents the attitudes of nurses towards three issues concerning their role in euthanasia and physician-assisted suicide. A questionnaire survey was conducted with 1509 nurses who were employed in hospitals, home care organizations and nursing homes. The study was conducted in the Netherlands between January 2001 and August 2004. The results show that less than half (45%) of nurses would be willing to serve on committees reviewing cases of euthanasia and physician-assisted suicide. More than half of the nurses (58.2%) found it too far-reaching to oblige physicians to consult a nurse in the decision-making process. The majority of the nurses stated that preparing euthanatics (62.9%) and inserting an infusion needle to administer the euthanatics (54.1%) should not be accepted as nursing tasks. The findings are discussed in the context of common practices and policies in the Netherlands, and a recommendation is made not to include these three issues in new regulations on the role of nurses in euthanasia and physician-assisted suicide.     

Euthanasia and assisted suicide in Dutch hospitals: the role of nurses

Aim. To report a study on the role of nurses in euthanasia and physician‐assisted suicide in hospitals, conducted as part of a wider study on the role of nurses in medical end‐of‐life decisions. Background. Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician‐assisted suicide gave the Dutch Minister for Health reason to commission a study on the role of nurses in medical end‐of‐life decisions in hospitals, homecare and nursing homes. Method. A questionnaire was sent in 2003 to 692 nurses employed in 73 hospital locations. The response suitable for analysis was from 532 (76·9%) nurses. Data were quantitatively analysed using spss version 11.5 for Windows. Results. In almost half of the cases (45·1%), the nurse was the first with whom patients discussed their request for euthanasia or physician‐assisted suicide. Consultations between physicians and nurses quite often took place (78·8%). In several cases (15·4%), nurses themselves administered the euthanatics with or without a physician. It is not self‐evident that hospitals have guidelines concerning euthanasia/physician‐assisted suicide. Conclusions. In the decision‐making process, the consultation between the physician and the nurse needs improvement. In administering the euthanatics, physicians should take responsibility and should not leave these actions to nurses. Guidelines may play an important role to improve the collaboration between physicians and nurses and to prevent procedural, ethical and legal misunderstandings. Relevance to clinical practice. Nurses in clinical practice are often closely involved in the last stage of a person's life. Consequently, they are often confronted with caring for patients requesting euthanasia or physician‐assisted suicide. The results provide relevant information and may help nurses in defining their role in euthanasia and physician‐assisted suicide, especially in case these practices should become legalised.     

Involvement of nurses in physician-assisted dying

BACKGROUND: Death in modern societies is often preceded by medical end-of-life decisions. Empirical research on these end-of-life decisions focuses predominantly on the physicians' role. Little is known about the role of other health care workers, especially that of nurses. AIM: This paper reports the findings of a study that investigated how often nurses are consulted by physicians in the decision-making process preceding end-of-life decisions and how often nurses participate in administering lethal drugs in end-of-life decisions. METHOD: Data were collected within a nationwide cross-sectional retrospective death certificate study in Flanders, the Dutch-speaking part of Belgium. We selected 3999 deaths, a 20% random sample of all those occurring during the first 4 months of 1998. Anonymous questionnaires were mailed to the physicians who signed the death certificates. Several questions concerned the involvement of nurses in end-of-life decisions. RESULTS: We received 1925 valid questionnaires. For all reported end-of-life decisions (39.3% of all deaths in Flanders), physicians provided information about the involvement of nurses. Physicians consulted at least one nurse in 52% of end-of-life decisions cases occurring in institutions, compared with 21.4% of such cases at home. Nurses administered lethal drugs in 58.8% of euthanasia cases occurring in institutions and in 17.2% at home. For cases in which life was ended without the patient's explicit request because, predominantly, they were too ill to do so, these percentages were respectively 82.7% and 25.2%. In institutions, nurses mostly administered drugs without the attendance of a physician who had prescribed the drugs. CONCLUSIONS: Nurses in Belgium are largely involved in administering lethal drugs in end-of-life decisions, while their participation in the decision-making process is rather limited. To guarantee prudent practice in end-of-life decisions, we need clear guidelines, professionally supported and legally controlled, for the assignment of duties between physicians and nurses regarding the administration of lethal drugs to reflect current working practice. In addition, we need appropriate binding standards governing mutual communication about all end-of-life decisions.     

End-of-life care in the intensive care unit: a challenge for nurses.

Results from several research studies combined with increasing public tensions surrounding physician-assisted suicide have fueled a growing awareness of the inadequacies of end-of-life care. Investigators also suggest that intensive care unit nurses have a limited role in end-of-life decision making and care planning. This article explores cultural issues influencing end-of-life care in intensive care units, explores factors surrounding the limited involvement of critical care nurses in end-of-life decision making and care planning, and offers recommendations for changing nursing practice. Because improving end-of-life care will require cultural changes, an understanding of the cultural issues involved is needed. Recommendations for changing nursing practice include a model of end-of-life care that incorporates the goals of both cure and comfort care, as well as a shared decision-making process. Nurses are essential to improving end-of-life care in today's intensive care units.     

Relatives' perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands

This study used retrospective interviews with 87 relatives to describe the experiences of patients who died by euthanasia or physician-assisted suicide (EAS) in the Netherlands. Most of the patients suffered from cancer (85%). The relatives were most often a partner (63%) or a child (28%) of the patient. Before explicitly requesting EAS most patients (79%) had spoken about their wishes concerning medical end-of-life decisions to be made at a later date. Hopeless suffering, loss of dignity, and no prospect of recovery were the most prevalent reasons for explicitly requesting EAS. According to the relative, in 92% of patients EAS had contributed favourably to the quality of the end of life, mainly by preventing or ending suffering.     

Euthanasia and physician-assisted suicide in Scandinavia--with a conceptual suggestion regarding international research in relation to the phenomena

This article analyses and compares recent research on Scandinavian physicians' attitudes towards, as well as their practice of, euthanasia and physician-assisted suicide. The studies discussed are quite dissimilar in their design, resulting in considerable difficulties as far as comparability is concerned. Such difficulties are common in these fields of research. As an intended contribution to the amendment of future research, we suggest what we take to be detailed and precise definitions of the terms euthanasia and physician-assisted suicide for use internationally. Our definitions, or interpretations, basically draw on the Dutch experience and understanding of these terms. The Dutch approach implies that acts of abstention from life-prolonging treatment, i.e., withholding and withdrawing treatment, and pain and symptom treatment that theoretically could shorten life (including terminal sedation) are to be considered 'normal medical practice'. Furthermore, death is seen as having natural causes in all of these acts. That, however, is not the case with euthanasia and physician-assisted suicide. When a physician performs either of these acts, he or she is required to state 'unnatural death' in the patient's death certificate. Our conceptual suggestions do not address the ethical status of the various medical decisions that are made with regard to the death of patients; our aim is conceptual clarity only. As far as euthanasia and physician-assisted suicide in Scandinavia is concerned, even though comparisons prove difficult, we do think some observations may be made: physicians from Norway, Denmark and Sweden display differences in both attitude and practice concerning these phenomena. Norwegian physicians are most restrictive with regard to attitude. Danish and Swedish physicians display a more liberal attitude, the latter being the most liberal. These findings did not fit the physicians' practice. Danish physicians have performed euthanasia and physician-assisted suicide more often than Norwegian physicians. Swedish physicians, even though they are the most liberal when it comes to attitude, appear never to have performed euthanasia and very seldom physician-assisted suicide.     

Voluntary refusal of food and fluids: attitudes of Oregon hospice nurses and social workers

As the ethical debate about euthanasia and physician-assisted suicide (PAS) continues, one alternative that has been suggested is for the patient to voluntarily refuse all food and fluids (VRFF). The article describes the results of a study of hospice nurses' and social workers' attitudes towards VRFF and compares them with their attitudes towards PAS. In 2001, a questionnaire was posted to nurses and social workers who care for Oregon residents enrolled in hospice programmes to determine their attitudes towards PAS and VRFF. In general, hospice workers expressed support for patients who choose to hasten their death by VRFF; they were less supportive of PAS. The results from this study suggest that perceptions regarding VRFF are significantly different from those regarding PAS. These results may have important clinical implications for nurses and social workers involved in end-of-life care who encounter patients who wish to hasten their deaths.     

The role of nurses in AIDS care regarding voluntary euthanasia and assisted suicide: a call for further dialogue

The role of nurses in AIDS care regarding voluntary euthanasia and assisted suicide: a call for further dialogue Because of the nature of their work, nurses are directly involved with terminally ill patients and the problems associated with the decision to hasten death through voluntary euthanasia or assisted suicide (VE/AS). An anonymous survey delivered to nurses working in HIV/AIDS settings in Canada was used to analyse nurses' experiences and attitudes regarding VE/AS. An emergent analysis of 22 nurses' responses to an open-ended prompt appearing at the end of the survey reveals that nurses: support death-hastening practices; believe that legislation for these practices needs to be established; are wary of the potential abuse of VE/AS; and believe that further discussion on end-of-life issues is imperative. Their caring role in the health care setting places nurses in key positions to stimulate discussion in this area.     

How nurses and physicians face ethical dilemmas--the Croatian experience

The aim of this study was to assess nurses' and physicians' ethical dilemmas in clinical practice. Nurses and physicians of the Clinical Hospital Centre Rijeka were surveyed (N=364). A questionnaire was used to identify recent ethical dilemma, primary ethical issue in the situation, satisfaction with the resolution, perceived usefulness of help, and usage of clinical ethics consultations in practice. Recent ethical dilemmas include professional conduct for nurses (8%), and near-the-end-of-life decisions for physicians (27%). The main ethical issue is limiting life-sustaining therapy (nurses 15%, physicians 24%) and euthanasia and physician-assisted suicide (nurses 16%, physicians 9%). The types of help available are similar for nurses and physicians: obtaining complete information about the patient (37% vs. 50%) and clarifying ethical issues (31% vs. 39%). Nurses and physicians experience similar ethical dilemmas in clinical practice. The usage of clinical ethics consultations is low. It is recommended that the individual and team consultations should be introduced in Croatian clinical ethics consultations services.     

End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs.

OBJECTIVE: To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units. METHODS: A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia. RESULTS: Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent. CONCLUSIONS: Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.     

End-of-life decisions in the Intensive Care Unit (ICU) – Exploring the experiences of ICU nurses and doctors – A critical literature review

BackgroundEnd-of-life decision making in the Intensive Care Unit (ICU), can be emotionally challenging and multifaceted. Doctors and nurses are sometimes placed in a precarious position where they are required to make decisions for patients who may be unable to participate in the decision-making process. There is an increasing frequency of the need for such decisions to be made in ICU, with studies reporting that most ICU deaths are heralded by a decision to withdraw or withhold life-sustaining treatment.ObjectivesThe purpose of this paper is to critically review the literature related to end-of-life decision making among ICU doctors and nurses and focuses on three areas: (1) Who is involved in end-of-life decisions in the ICU?; (2) What challenges are encountered by ICU doctors and nurses when making decisions?; and (3) Are these decisions a source of moral distress for ICU doctors and nurses?Review methodThis review considered both qualitative and quantitative research conducted from January 2006 to March 2014 that report on the experiences of ICU doctors and nurses in end-of-life decision making. Studies with a focus on paediatrics, family/relatives perspectives, advance care directives and euthanasia were excluded. A total of 12 papers were identified for review.ResultsThere were differences reported in the decision making process and collaboration between doctors and nurses (which depended on physician preference or seniority of nurses), with overall accountability assigned to the physician. Role ambiguity, communication issues, indecision on futility of treatment, and the initiation of end-of-life discussions were some of the greatest challenges. The impact of these decisions included decreased job satisfaction, emotional and psychological ‘burnout’.ConclusionsFurther research is warranted to address the need for a more comprehensive, standardised approach to support clinicians (medical and nursing) in end-of-life decision making in the ICU.     

The role of the nurse in active euthanasia and physician-assisted suicide

The researchers wanted to obtain insight into the cooperation between physicians and nurses with regard to active euthanasia and physician-assisted suicide (EAS). In study I a stratified random sample of 203 clinical specialists, 152 general practitioners (GPs) and 50 nursing home physicians (NHPs) participated. In study II a random sample of 521 GPs was drawn from the province of North Holland and a random sample of 521 GPs was drawn from the rest of the Netherlands. For study III all NHPs were approached. Data were collected by means of an interview in study I. In studies II and III an anonymous, postal questionnaire was used. Approximately half of the GPs did not consult with nurses about a patient's request for EAS, the intention to administer EAS, and the actual administration. In 5% of cases, the NHPs and the specialists did not consult with nurses concerning these aspects. The GPs and NHPs indicated in 4% and 3% of the cases, respectively, that nurses administered the lethal drug(s) to the patients; the corresponding figure for the specialists was 21%. Almost all GPs and NHPs and about three-quarters of the specialists thought that nurses should never be allowed to administer EAS.     

Assisted Dying and Nursing Practice

Nurses' views are often solicited about physician-assisted dying, a concept that incorporates both assisted suicide and active euthanasia. Yet nurses are rarely asked about their own clinical experience of assisted dying. The literature indicates that many nurses experience difficulty distinguishing professionally sanctioned end-of-life interventions from those that are not. In this article the investigator explores the social, legal, and political roots of assistance in dying, and critically examines the profession's position on nurse participation in assisted dying and the research regarding nurse-assisted dying.

Scope:

The bioethics and nursing literature was reviewed from 1990 to 1999. The databases used were the Cumulative Index to Nursing and Allied Health Literature and Medline.

Conclusions:

The complex nature of caring for highly symptomatic dying patients, and the difficulty some nurses experience in distinguishing a moral difference between hastening and assisting death, strongly indicate a need for additional nursing research that does not use a forced answer.     

Alleviation of pain and symptoms with a life-shortening intention

This article reports the findings of a study into the role of Dutch nurses in the alleviation of pain and symptoms with a life-shortening intention, conducted as part of a study into the role of nurses in medical end-of-life decisions. A questionnaire survey was carried out using a population of 1509 nurses who were employed in hospitals, home care organizations and nursing homes. The response rate was 82.0%; 78.1% (1179) were suitable for analysis. The results show that in about half of the cases (55.8%) nurses were involved in the decision making by the physician and that nurses were frequently (81.5%) involved in administering the medication. The authors' conclusion is that alleviation of pain and symptoms with a life-shortening intention represents a ;grey' area, in which physicians and nurses act on the basis of personal ethical norms rather than legal rules, professional guidelines or shared moral values.     

Nurses' involvement in 'do not resuscitate' decisions on acute elder care wards

AIM: This paper reports the involvement of nurses in 'do not resuscitate' decision-making on acute elder care wards and their adherence to such decisions in the case of an actual cardiopulmonary arrest. BACKGROUND: Previous literature showed that nurses are involved in half or less than half of 'do not resuscitate' decisions in hospitals, but their involvement in this decision-making on acute elder care wards in particular has not been investigated. METHOD: A questionnaire was sent in 2002 to the head nurses of all acute elder care wards in Flanders, Belgium (n = 94). They were asked whether nurses had been involved in the last 'do not resuscitate' decision-making process on their ward and whether nurses 'never', 'rarely', 'sometimes', 'often' or 'always' started resuscitation in case of cardiopulmonary arrest of patients with 'do not resuscitate' status and of those without. RESULTS: The response rate was 86.2% (n = 81). In 74.7% of the last 'do not resuscitate' decisions on acute elder care wards in Flanders, a nurse was involved in the decision-making process. For patients with 'do not resuscitate' status, 54.3% of respondents reported that cardiopulmonary resuscitation was 'never' started on their ward, 'rarely' on 39.5% and 'sometimes' on 6.2%. For patients without 'do not resuscitate' status, nurses started cardiopulmonary resuscitation 'rarely' or 'sometimes' on 22.2% of all wards, and 'often' or 'always' on 77.8%. CONCLUSION: To make appropriate 'do not resuscitate' decisions and to avoid rash decision-making in cases of actual cardiopulmonary arrest, nurses should be involved early in 'do not resuscitate' decision-making. If institutional 'do not resuscitate' guidelines were to stress more clearly the important role of nurses in all kinds of end-of-life decisions, this might improve the 'do not resuscitate' decision-making process.     

Euthanasia: the way we do it, the way they do it

Although the Netherlands, Germany, and the United States are alike in having aging populations who die primarily of deteriorative diseases, they face end-of-life dilemmas quite differently. In the United States, withholding and withdrawing of treatment are the only legally recognized means for easing dying. In Holland, voluntary active euthanasia is also practiced; in (West) Germany, assisted suicide is a legal option, usually outside the medical setting. This paper examines objections to these three practices, and observes the differences in the background cultures. Rather than reliance on any of the three, it argues that physician-assisted suicide in terminal illness is the practice most compatible with the United States' special characteristics.     

National survey of end-of-life decisions made by UK medical practitioners

BACKGROUND: This study estimates the frequency of different end-of-life decisions (ELDs) in medical practice in the UK, compares these with other countries and assesses doctors' views on the adequacy of current UK law. METHOD: Postal survey of 857 UK medical practitioners using a questionnaire used in other countries. FINDINGS: The proportion of UK deaths involving an ELD were: 1) voluntary euthanasia 0.16% (0-0.36), 2) physician-assisted suicide 0.00%, 3) ending of life without an explicit request from patient 0.33% (0-0.76), 4) alleviation of symptoms with possibly life shortening effect 32.8% (28.1-37.6), 5) non-treatment decisions 30.3% (26.0-34.6). ELDs 1 and 2 were significantly less frequent than in the Netherlands and Australia; ELD 2 was also less frequent than Switzerland. ELD 3 was less frequent than in Belgium and Australia. Comparison of UK and New Zealand general practitioners showed lower rates of ELDs 4 and 5 in the UK. ELD 5 was more common than in most other European countries. A few doctors attending deaths felt UK law had inhibited or interfered with their preferred management of patients (4.6% (3.1-6.1%) of doctors) or that a new law would have facilitated better management (2.6% (1.4-3.8%) of doctors). INTERPRETATION: The lower relative rate of ELDs involving doctor-assisted dying in the UK, and the relatively high rate of non-treatment decisions, suggests a culture of medical decision making informed by a palliative care philosophy.     

Attitudes of nurses towards euthanasia and towards their role in euthanasia: A nationwide study in Flanders,Belgium

BackgroundNurses have an important role in caring for terminally ill patients. They are also often involved in euthanasia. However, little is known about their attitudes towards it.ObjectivesTo investigate on a nationwide level nurses’ attitudes towards euthanasia and towards their role in euthanasia, and the possible relation with their socio-demographic and work-related characteristics.Design and participantsA cross-sectional design was used. In 2007, a questionnaire was mailed to a random sample of 6000 of the registered nurses in Flanders, Belgium. Response rate was 62.5% and after exclusion of nurses who had no experiences in patient care, a sample of 3321 nurses remained.MethodsAttitudes were attained by means of statements. Logistic regression models were fitted for each statement to determine the relation between socio-demographic and work-related characteristics and nurses’ attitudes.ResultsNinety-two percent of nurses accepted euthanasia for terminally ill patients with extreme uncontrollable pain or other distress, 57% accepted using lethal drugs for patients who suffer unbearably and are not capable of making decisions. Seventy percent believed that euthanasia requests would be avoided by the use of optimal palliative care. Ninety percent of nurses thought nurses should be involved in euthanasia decision-making. Although 61% did not agree that administering lethal drugs could be a task nurses are allowed to perform, 43% would be prepared to do so. Religious nurses were less accepting of euthanasia than non-religious nurses. Older nurses believed more in palliative care preventing euthanasia requests and in putting the patient into a coma until death as an alternative to euthanasia. Female and home care nurses were less inclined than male and hospital and nursing home nurses to administer lethal drugs.ConclusionsThere is broad support among nurses for euthanasia for terminally ill patients and for their involvement in consultancy in case of euthanasia requests. There is, however, uncertainty about their role in the performance of euthanasia. Guidelines could help to make their role more transparent, taking into account the differences between health care settings.