Dying with dignity according to Swedish medical students

Dignity at the end of life in traditional Chinese culture: Perspectives of advanced cancer patients and family members

PURPOSE

This study aimed to explore the meaning of patient dignity at the end of life in traditional Chinese culture from perspectives of advanced cancer patients and their family members.

METHOD

A descriptive qualitative study was conducted with 15 advanced cancer patients and 10 family members in a tertiary hospital in Beijing, China between March and July 2019. Data were collected through face-to-face semi-structured interviews and were analyzed using thematic analysis.

RESULTS

Dignity at the end of life in traditional Chinese culture were classified into four categories: (1) cultural-specific dignity, including themes of stigma-free, moral traits and "face"; (2) self-related dignity, including themes of staying healthy and alive, living a normal life as a normal person, spiritual peace, personal value and privacy; (3) family-related dignity, including themes of concerns to the family, not being a burden to the family, and family support; and (4) care- and treatment-related dignity, including themes of being respected, high quality service and disclosure of information and consent-based decision making.

CONCLUSIONS

Patient dignity at the end of life in traditional Chinese culture was relevant to the culture, the individuals, their family, and the care and treatment they received. Patient dignity is supposed to be supported by collaborative efforts from the family and healthcare professionals, and meanwhile taking patient's cultural background and personal wishes and values into account.

Defining a Good Death (Successful Dying): Literature Review and a Call for Research and Public Dialogue

There is little agreement about what constitutes good death or successful dying. The authors conducted a literature search for published, English-language, peer-reviewed reports of qualitative and quantitative studies that provided a definition of a good death. Stakeholders in these articles included patients, prebereaved and bereaved family members, and healthcare providers (HCPs). Definitions found were categorized into core themes and subthemes, and the frequency of each theme was determined by stakeholder (patients, family, HCPs) perspectives. Thirty-six studies met eligibility criteria, with 50% of patient perspective articles including individuals over age 60 years. We identified 11 core themes of good death: preferences for a specific dying process, pain-free status, religiosity/spirituality, emotional well-being, life completion, treatment preferences, dignity, family, quality of life, relationship with HCP, and other. The top three themes across all stakeholder groups were preferences for dying process (94% of reports), pain-free status (81%), and emotional well-being (64%). However, some discrepancies among the respondent groups were noted in the core themes: Family perspectives included life completion (80%), quality of life (70%), dignity (70%), and presence of family (70%) more frequently than did patient perspectives regarding those items (35%-55% each). In contrast, religiosity/spirituality was reported somewhat more often in patient perspectives (65%) than in family perspectives (50%). Taking into account the limitations of the literature, further research is needed on the impact of divergent perspectives on end-of-life care. Dialogues among the stakeholders for each individual must occur to ensure a good death from the most critical viewpoint-the patient's.

An integrative review of dignity in end-of-life care

BACKGROUND

Dying with dignity is regarded as a goal of quality end-of-life care. However, the meaning of dying with dignity is ambiguous, and no comprehensive synthesis of the existing literature has been published.

AIM

To synthesize the meaning of dying with dignity and to identify common aspects of dignity in end-of-life care.

DESIGN

This is an integrative review article. Methodological strategies specific to the integrative review method proposed by Whittemore and Knafl were followed to conduct data analysis. The matrix method was used to summarize characteristics of included articles.

DATA SOURCES

Five electronic databases were searched in October 2012, with no date restriction: PubMed, CINAHL, PsycINFO, Academic Search Premier, and Social Sciences Abstracts. Theoretical reports, and both qualitative and quantitative empirical reports, focused on dignity in end-of-life care were included.

RESULTS

Themes of dying with dignity are as follows: a human right, autonomy and independence, relieved symptom distress, respect, being human and being self, meaningful relationships, dignified treatment and care, existential satisfaction, privacy, and calm environment. Factors influencing dignity include demographic, illness-related, and treatment-/care-related factors, as well as communication. Models of dignity in end-of-life care and instruments to measure dignity were reported. Interventions to support dignity stressed physical, psychological, and spiritual supports not only to dying patients but also to family members.

CONCLUSION

This review clarified the meaning of dying with dignity and synthesized common aspects of dignity in end-of-life care. Further research is needed to evaluate the meaning of dying with dignity across cultures and to explore individualized dignity-based care.

Death with dignity from the perspective of the surviving family: a survey study among family caregivers of deceased older adults

BACKGROUND

Death with dignity has been identified as important both to patients and their surviving family. While research results have been published on what patients themselves believe may affect the dignity of their deaths, little is known about what family caregivers consider to be a dignified death.

AIM

(1) To assess the prevalence of death with dignity in older adults from the perspective of family caregivers, (2) to determine factors that diminish dignity during the dying phase according to family caregivers, and (3) to identify physical, psychosocial, and care factors associated with death with dignity.

DESIGN

A survey study with a self-administered questionnaire.

PARTICIPANTS

Family caregivers of 163 deceased older (>55 years of age) adults ("patients") who had participated in the Longitudinal Aging Study Amsterdam.

RESULTS

Of the family caregivers, 69% reported that their relative had died with dignity. Factors associated with a dignified death in a multivariate regression model were patients feeling peaceful and ready to die, absence of anxiety and depressive mood, presence of fatigue, and a clear explanation by the physician of treatment options during the final months of life.

CONCLUSIONS

The physical and psychosocial condition of the patient in combination with care factors contributed to death with dignity from the perspective of the family caregiver. The patient's state of mind during the last phase of life and clear communication on the part of the physician both seem to be of particular importance.

Death and dignity through fresh eyes

BACKGROUND

Trinity College Dublin remains one of the Medical Schools that uses traditional dissection to teach anatomy, exposing students from the first week of entry to cadavers. This early exposure makes it imperative that issues surrounding death and donor remains are explored early on within the main structure of the curriculum.

CONTEXT

The School of Medicine began a programme of Medical Humanities student-selected modules (SSMs) in 2010, and the opportunity to offer a module on medical ethics regarding death and dignity was taken.

INNOVATION

A course was devised that touched only lightly on subjects such as palliative care and the concept of a good death. The course focused much more strongly on the reality of death as part of cultural and societal identity and placement. This was facilitated by field trips to settings where discussions regarding death, dying and dignity were commonplace and authentic experiences, rather than classroom discussions based on theoretical circumstances that may not yet have been experienced by the student.

IMPLICATIONS

The module ran very well, with students feeling that they had had a chance to think critically about the role of death as an event with significance within society and culture, rather than purely in a medico-legal framework. Options to extend the module to the compulsory element of the course, to be built upon in later years looking at more technical aspects surrounding death, are being explored.

Patient rights and medical education: clinical principles

The rights of patients may be considered within three broad categories: (i) health as a fundamental human right, (ii) equitable healthcare provision by governments and institutions, and (iii) professional relationships with individual health practitioners. Doctors should be well prepared in medical schools to understand and uphold patient rights. A simplified framework for learning and for teaching medical students about patient rights is proposed with the acronym DROIT--dignity, respect, obligation, information and trust.

Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation

BACKGROUND

Today, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest.

METHODS

During a period of 2 years, we retrolectively analysed emergency medical calls with regard to palliative care emergency situations dealing with cardiac arrest. We evaluated the numbers of patients who were resuscitated, the prevalence of an advance directive or other end-of-life protocol, the first responder on cardiac arrest, the return of spontaneous circulation (ROSC) and the survival rate.

RESULTS

Eighty-eight palliative care patients in cardiac arrest were analysed. In 19 patients (22%), no resuscitation was started. Paramedics and prehospital emergency physicians began resuscitation in 61 cases (69%) and in 8 cases (9%), respectively. A total of 10 patients (11%) showed a ROSC; none survived after 48 h. Advance directives were available in 43% of cases. The start of resuscitation was independent of the presence of an advance directive or other end-of-life protocol.

CONCLUSIONS

Strategic and therapeutic approaches in outpatient palliative care patients with cardiac arrest differ depending on medical qualification. Although many of these patients do not wish to be resuscitated, resuscitation was started independent of the presence of advance directive. To reduce legal insecurity and to avoid resuscitation and a possible lengthening of the dying process, advance directives and/or "Do not attempt resuscitation" orders should be more readily available and should be adhered to more closely.

Quality of out-of-hospital palliative emergency care depends on the expertise of the emergency medical team--a prospective multi-centre analysis

BACKGROUND

The number of palliative care patients who live at home and have non-curable life-threatening diseases is increasing. This is largely a result of modern palliative care techniques (e.g. specialised out-of-hospital palliative medical care services), changes in healthcare policy and the availability of home care services. Accordingly, pre-hospital emergency physicians today are more likely to be involved in out-of-hospital emergency treatment of palliative care patients with advanced disease.

METHODS

In a prospective multi-centre study, we analysed all palliative emergency care calls during a 24-month period across four emergency services in Germany. Participating pre-hospital emergency physicians were rated according to their expertise in emergency and palliative care as follows--group 1: pre-hospital emergency physicians with high experience in emergency and palliative medical care, group 2: pre-hospital emergency physicians with high experience in emergency medical care but less experience in palliative medical care and group 3: pre-hospital emergency physicians with low experience in palliative and emergency medical care.

RESULTS

During the period of interest, the centres received 361 emergency calls requiring a response to palliative care patients (2.8% of all 12,996 emergency calls). Ten percent of all patients were treated by group 1; 42% were treated by group 2 and 47% were treated by group 3. There was a statistically significant difference in the treatment of palliative care patients (e.g. transfer to hospital, symptom control, end-of-life decision) as a result of the level of expertise of the investigated pre-hospital emergency physicians (p< 0.01).

CONCLUSIONS

In Germany, out-of-hospital emergency medical treatment of palliative care patients depends on the expertise in palliative medical care of the pre-hospital emergency physicians who respond to the call. In our investigation, best out-of-hospital palliative medical care was given by pre-hospital emergency physicians who had significant expertise in palliative and emergency medical care. Our results suggest that it may be necessary to take the core principles of palliative care into consideration when conducting out-of-hospital emergency medical treatment of palliative care patients.

Treatment of palliative care emergencies by prehospital emergency physicians in Germany: an interview based investigation

Palliative care medical emergencies as a consequence of advanced cancer account for approximately 3% of all prehospital emergency cases. Therefore, prehospital emergency physicians (EP) are confronted with 'end of life decisions'. No educational content exists concerning palliative medicine in emergency medicine curricula. Over the course of 6 months, we interviewed 150 EPs about their experiences in 'end of life decisions' using a specific questionnaire. The total response rate was 69% (n = 104). Most of the interviewed EPs (89%, n = 93) had been confronted with palliative care medical emergencies and expressed uncertainties in dealing with these difficult situations, especially in the area of psychosocial care of the patients (50%). The emergency treatment of palliative care patients can become a particular challenge for any EP. A large percentage of interviewed EPs felt uncertain about aspects of social care and in the assessment of decisions at the end of life. Further information and training are necessary to amenable EPs to provide adequate patient-oriented care to palliative care patients and their relatives in emergency situations.

Attitudes toward euthanasia among Swedish medical students

Attitudes toward euthanasia differ between individuals and populations, and in many studies the medical profession is more reluctant than the general public. Our goal was to explore medical students' attitude toward euthanasia. A questionnaire containing open-ended questions was answered anonymously by 165 first- and fifth-year medical students. Data were analysed using qualitative content analysis with no predetermined categories. The students' arguments opposing euthanasia were based on opinions of 1. euthanasia being morally wrong, 2. fear of possible negative effects on society, 3. euthanasia causing strain on physicians and 4. doubts about the true meaning of requests of euthanasia from patients. Arguments supporting euthanasia were based on 1. patients' autonomy and 2. the relief of suffering, which could be caused by severe illnesses, reduced integrity, hopelessness, social factors and old age. There are several contradictions in the students' arguments and the results indicate a possible need for education focusing on the possibility of symptom control in palliative care and patients' perceived quality of life.