Human Relationships at the End of Life: An Ethical Ontology for Practice

"Teach for ethics in palliative care": a mixed-method evaluation of a medical ethics training programme

BACKGROUND

Training in medical ethics aims to educate health care professionals in dealing with daily care ethical issues. To guarantee quality of life and spiritual and emotional support, palliative care professionals have to develop ethical and relational skills. We propose the implementation and evaluation of a specialized training programme in medical ethics dedicated to a hospital-based Palliative Care Unit.

METHODS

This study is a mixed-method before-after evaluation with data triangulation.

RESULTS

The results highlight that participants developed their ethical knowledge, and a deeper ethical awareness. They also felt more confident and motivated to widely apply ethical reflections and reasonings in their daily practice.

CONCLUSION

The participants appreciated the innovative structure of the training, especially regarding the integration of the theoretical-interactive and practical parts. However, they recommended increasing the number of concrete occasions for ethical supervision and practical application of what they learned during the programme. The training programme also has some potential practical implications: the development of advanced ethical skills within a hospital-based PC team may improve the quality of life of the patients and their families. In addition, health care professionals with advanced ethical competencies are able to educate patients and their families towards more active participation in the decision-making process.

Nurses' Moral Experiences of Ethically Meaningful End-of-Life Care: Distress, Resilience, Responsibility, and Care

BACKGROUND

Moral distress, the phenomenon in which an agent is constrained in acting on their ethical choice, is a reoccurring theme in the literature on nurses' experiences of end-of-life care (EOLC). Understanding moral engagement solely through a lens of moral distress can be limiting-as such, we sought to explore the diverse experiences nurses consider ethically meaningful in their palliative and EOLC practice.

PURPOSE AND METHODS

This article presents an exploration and analysis of stories told to us, within an interpretive description study, by five nurses practicing in EOLC in diverse settings across Canada. Although these stories were told to us in a research context, the purpose of this theory article is to explore what these stories demonstrate about the moral engagement of nurses caring for dying patients.

FINDINGS

Our analysis suggests that while moral distress is a feature of nursing stories, so too are many other dimensions of moral experience, including resilience, responsibility, and care.

IMPLICATIONS FOR PRACTICE

Expanding how we understand nurses' moral engagement in the care of dying patients has implications for how we account for the many responsibilities that nurses shoulder in striving to provide "good" care to people at the end of life.

Thinking about strengths in end-of-life nursing practice: the case of intensive care unit nurses

BACKGROUND

The intensive care unit (ICU) is a care context that is sometimes described as being unconducive to the values and ideals of a good death in end-of-life care. Such assumptions render the ICU emblematic of a troubling discourse about end-of-life care in this clinical context.

AIM

To stimulate a reflective examination of intensive care nursing practice with respect to end-of-life care.

METHODS

The work of contemporary nursing scholar Laurie Gottlieb is used to perform a strengths-based relational ethical examination of previously published literature that describes critical care nurses' experiences of providing end-of-life care in the ICU.

FINDINGS

This literature suggests that the relational ethical value of authentic engagement, which is fundamental to the disciplinary ethos of expert palliative care nursing, is reflected in the everyday practice of intensive care nurses whose patients die while under their care.

CONCLUSION

A strengths-based approach can make visible the relational ethical practice of critical care nurses who care for dying patients and their families in the ICU.

Towards a Guiding Framework for Prison Palliative Care Nursing Ethics

The number of people aging and dying behind bars is growing, bringing greater attention to the need for prison palliative care. While this trend has rightly led to increased scholarship, a focus on understanding the most effective way to deliver prison palliative care has overshadowed thinking about why the need itself has arisen, as well as deeper ethical thinking about how the nursing profession should respond. This article interweaves 4 strands of analysis-contextual, relational, social, and political-to produce a framework to guide ethical action in prison palliative care nursing, relevant to practice, research, policy, and education.

Ethical and moral considerations of (patient) centredness in nursing and healthcare: Navigating uncharted waters

This discussion paper aims to explore potential ethical and moral implications of (patient) centredness in nursing and healthcare. Healthcare is experiencing a philosophical shift from a perspective where the health professional is positioned as the expert to one that re-centres care and service provision central to the needs and desires of the persons served. This centred approach to healthcare delivery has gained a moral authority as the right thing to do. However, little attention has been given to its moral and ethical theoretical grounding and potential implications for nurses, persons served and the healthcare system. Based upon a review of academic and grey literature, centredness is proposed as a value-laden concept in nursing inquiry. Potential moral and ethical implications of centredness on nurses/healthcare providers, persons served and the healthcare system are discussed. These challenges are then considered within the context of normative and relational ethical theories. These perspectives may offer guidance relative to how one should act in those circumstances as well as an understanding as to how interdependency and engagement with the other person(s) can help navigate the challenges of a centred care approach. Viewing centredness through an ethical theoretical lens provides a valuable discourse to nursing in efforts to expand the knowledge base and integrate centred approaches into practice and policy.

"Who would want to die like that?" Perspectives on dying alone in a long-term care setting

The discourse of dying alone is negatively weighted and models of a good death identify not dying alone as a key outcome. Understanding why dying alone is viewed negatively and its effects on care is a priority. In separate focus groups with long-term care residents, family caregivers, and staff, we identified evidence for four different perspectives on the importance of presence at the time of death. However, while each individual had their own unique perspective on dying alone, the predominant view expressed across respondent groups was that having human connection near the end of one's life was important.

Relational ethics of delirium care: Findings from a hospice ethnography

Delirium, a common syndrome in terminally ill people, presents specific challenges to a good death in end-of-life care. This paper examines the relational engagement between hospice nurses and their patients in a context of end-of-life delirium. Ethnographic fieldwork spanning 15 months was conducted at a freestanding residential hospice in eastern Canada. A shared value system was apparent within the nursing community of hospice; patients' comfort and dignity were deemed most at stake and therefore commanded nurses' primary attention. This overarching commitment to comfort and dignity shaped all of nursing practice in this hospice, including practices related to end-of-life delirium. The findings of this study elaborate the ways in which hospice nurses interpreted and responded to the discomfort of their patients in delirium, as well as the efforts they made to understand their patients' subjective experiences and to connect with them in supportive ways. In addition to what is already known about clinical assessment and treatment of delirium in palliative care settings, the findings of this study offer points of reflection for nurses anywhere who are contending with the relational challenges that delirium presents in end-of-life care.

Nurses’ moral experiences of assisted death: A meta-synthesis of qualitative research

Background:

Legislative changes are resulting in assisted death as an option for people at the end of life. Although nurses’ experiences and perspectives are underrepresented within broader ethical discourses about assisted death, there is a small but significant body of literature examining nurses’ experiences of caring for people who request this option.

Aim:

To synthesize what has been learned about nurses’ experiences of caring for patients who request assisted death and to highlight what is morally at stake for nurses who undertake this type of care.

Design:

Qualitative meta-synthesis.

Methods:

Six databases were searched: CINAHL, Medline, EMBASE, Joanna Briggs Institute, PsycINFO, and Web of Science. The search was completed on 22 October 2014 and updated in February 2016. Of 879 articles identified from the database searches, 16 articles were deemed relevant based on inclusion criteria. Following quality appraisal, 14 studies were retained for analysis and synthesis.

Results:

The moral experience of the nurse is (1) defined by a profound sense of responsibility, (2) shaped by contextual forces that nurses navigate in everyday end-of-life care practice, and (3) sustained by intra-team moral and emotional support.

Discussion:

The findings of this synthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The findings further demonstrate that to fully appreciate the ethics of assisted death from a nursing standpoint, it is necessary to understand the broader constraints on nurses’ moral agency that operate in everyday end-of-life care.

Ethical considerations:

Research ethics board approval was not required for this synthesis of previously published literature.

Conclusion:

In order to understand how to enact ethical practice in the area of assisted death, the moral experiences of nurses should be investigated and foregrounded.

Relational and embodied knowing: Nursing ethics within the interprofessional team

In this article we attempt to situate nursing within the interprofessional care team with respect to processes of ethical practice and ethical decision making. After briefly reviewing the concept of interprofessionalism, the idea of a nursing ethic as ‘unique’ within the context of an interprofessional team will be explored. We suggest that nursing’s distinct perspective on the moral matters of health care stem not from any privileged vantage point but rather from knowledge developed through the daily activities of nursing practice. Because of their position vis-à-vis patients and families in everyday clinical care, nurses cultivate ethical knowledge of at least two forms: (1) relational knowledge; and (2) embodied knowledge. Through the integration of these forms of knowledge, nurses develop a unique moral perspective and can make a meaningful contribution to the realm of ethics in interprofessional care.