Role of nurses in institutional ethics policies on euthanasia

Involvement of Nurses in the Euthanasia Care Process in Flanders (Belgium): An exploration of Two Perspectives

This study explored nurses’ involvement in the care process for mentally competent, terminally ill patients requesting euthanasia in general hospitals in Flanders, Belgium. In-depth interviews with 18 nurses who had experience in caring for patients requesting euthanasia since May 2002 were analyzed using grounded theory qualitative methods. We found that the involvement of nurses in the care process is influenced by their predominant perspective on it: the procedural, action-focused perspective, from which good practical organization of the care process is essential; or the existential-interpretative perspective, from which it is important to understand the patient's request within a dialogue-focused and communicational atmosphere. Findings show that the two perspectives are not mutually exclusive, but rather complementary dimensions of the euthanasia care process. Hence, sufficient support for nurses to reach a well-balanced integration of both perspectives is essential.

Social-cultural factors in end-of-life care in Belgium: a scoping of the research literature

BACKGROUND

As end-of-life (EoL) care expands across Europe and the world, service developments are increasingly studied. The sociocultural context in which such changes take place, however, is often neglected in research.

AIM

To explore sociocultural factors in EoL care in Belgium as represented by the literature.

DESIGN

A scoping of the empirical research literature following a systematic search procedure with a focus on thematic analysis based on the literature findings.

DATA SOURCES

Searches were carried out in eight electronic databases, five journals, reference lists, and grey literature (through September 2010). Articles informing about sociocultural issues in EoL care were included.

RESULTS

One hundred and fifteen original studies met the inclusion criteria, the majority (107) published between 2000 and 2010. Four major themes were: Setting; Caregivers; Communication; and Medical EoL Decisions (the largest category). Minority Ethnic Groups was an emerging theme. Gaps included: research in Wallonia and Brussels; the role and experiences of informal caregivers; issues of access to palliative care; and experiences of minority ethnic groups. There was a paucity of in-depth qualitative studies.

CONCLUSIONS

Various sociocultural factors influence the provision of EoL care in Belgium. This country provides a unique opportunity to witness how euthanasia is put into practice when legalized, in a context where palliative care is also highly developed and where many health care institutions have Catholic affiliation, providing an important example to others. Attention to how the sociocultural context affects EoL care adds to the current evidence base of service provision, which is essential in the further development of EoL care.

Culture and end of life care: a scoping exercise in seven European countries

AIM

Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries.

METHODS

We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes.

RESULTS

A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities.

CONCLUSION

This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.

Euthanasia in Greece: Greek nurses' involvement and beliefs

Euthanasia has become a prominent social and ethical issue in which nurses play an important role. This study evaluated, for the first time in Greece, the acceptance and enactment of passive euthanasia among Greek nursing staff, measured in relation to the type of patients cared for. Passive euthanasia, illegal in Greece, is defined as either withdrawing or withholding life-sustaining treatment. Fifty-one per cent responded that they would not be willing to withhold life-sustaining treatment if legalized, while almost 30% responded that they had withheld life-sustaining treatment from a patient at least once in the past; specifically 47.7% of intensive care unit nurses (OR 8.2; 95% CI: 1.6-41.3), 20% of cancer ward nurses (OR 2.7; 95% CI: 0.5-15.6) and 8.3% of other nurses from other wards (P = 0.001). Age, gender and self-reported levels of religiosity among Greek nurses were not found to affect statistically any variable regarding euthanasia and its enactment.

Nursing and Euthanasia: a Review of Argument-Based Ethics Literature

This article gives an overview of the nursing ethics arguments on euthanasia in general, and on nurses' involvement in euthanasia in particular, through an argument-based literature review. An in-depth study of these arguments in this literature will enable nurses to engage in the euthanasia debate. We critically appraised 41 publications published between January 1987 and June 2007. Nursing ethics arguments on (nurses' involvement in) euthanasia are guided primarily by the principles of respect for autonomy, nonmaleficence, beneficence and justice. Ethical arguments related to the nursing profession are described. From a care perspective, we discuss arguments that evaluate to what degree euthanasia can be considered positively or negatively as a form of good nursing care. Most arguments in the principle-, profession- and care-orientated approaches to nursing ethics are used both pro and contra euthanasia in general, and nurses' involvement in euthanasia in particular.

Practices of responsibility and nurses during the euthanasia programs of Nazi Germany: A discussion paper

In this paper, we focus on the contexts of moral decision-making by nurses in the euthanasia programs of Nazi Germany between 1939 and 1945 using Urban Walker's philosophical model. We use the second hypothesis of this model, that morality consists of practices of responsibility, to give an analysis of the understandings nurses had of their responsibilities in the euthanasia programs. The article starts with a brief introduction to the euthanasia programs of Nazi Germany from 1939 to 1945 and nurse participation, to illustrate how the responsibilities of nurses were manipulated. Secondly, nursing as moral practices are analysed in the context of the euthanasia programs that implement commonly shared understandings and practices of responsibility. Thirdly, the reasons that nurses gave for avoiding any responsibilities are examined. Fourthly, it is examined if nurses took any responsibility in the euthanasia programs. In conclusion, this paper discusses three points of relevance such a reflection on moral responsibility in the context of Nazi Germany has for nurses today who may be confronted with euthanasia.

Institutional ethics policies on medical end-of-life decisions: a literature review

OBJECTIVES

The responsibility of healthcare administrators for handling ethically sensitive medical practices, such as medical end-of-life decisions (MELDs), within an institutional setting has been receiving more attention. The overall aim of this paper is to thoroughly examine the prevalence, content, communication, and implementation of written institutional ethics policies on MELDs by means of a literature review.

METHODS

Major databases (Pubmed, Cinahl, PsycINFO, Cochrane Library, FRANCIS, and Philosopher's Index) and reference lists were systematically searched for all relevant papers. Inclusion criteria for relevance were that the study was empirically based and that it focused on the prevalence, content, communication, or implementation of written institutional ethics policies concerning MELDs.

RESULTS

Our search yielded 19 studies of American, Canadian, Dutch and Belgian origin. The majority of studies dealt with do-not-resuscitate (DNR) policies (prevalence: 10-89%). Only Dutch and Belgian studies dealt with policies on pain and symptom control (prevalence: 15-19%) and policies on euthanasia (prevalence: 30-79%). Procedural and technical aspects were a prime focus, while the defining of the specific roles of involved parties was unclear. Little attention was given to exploring ethical principles that question the ethical function of policies. In ethics policies on euthanasia, significant consideration was given to procedures that dealt with conscientious objections of physicians and nurses. Empirical studies about the implementation of ethics policies are scarce.

CONCLUSIONS

With regard to providing support for physicians and nurses, DNR and euthanasia policies expressed support by primarily providing technical and procedural guidelines. Further research is needed whether and in which way written institutional ethics policies on MELDs could contribute to better end-of-life care.