Palliative care nursing involvement in end-of-life decision-making: Qualitative secondary analysis

Methodological and ethical challenges in designing and conducting research at the end of life: A systematic review of qualitative and textual evidence

AIM

This systematic review aims to identify methodological and ethical challenges in designing and conducting research at the end of life from the perspective of researchers and provide a set of recommendations.

BACKGROUND

Conducting research with patients and family carers facing end-of-life issues is ethically and methodologically complex.

DESIGN

A systematic review was conducted.

DATA SOURCES

Four databases (MEDLINE, EMBASE, CINAHL, PsycInfo) were searched from inception until the end of 2021 in February 2022.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews was followed, and the JBI Approach to qualitative synthesis was used for analysis.

RESULTS

Seventeen of 1983 studies met inclusion criteria. Data were distilled to six main themes. These included (1) the need for flexibility at all stages of the research process; (2) careful attention to timing; (3) sensitivity in approach; (4) the importance of stakeholder collaboration; (5) the need for unique researcher skills; and (6) the need to deal with the issue of missing data.

CONCLUSION

The findings illuminate several considerations that can inform training programmes, ethical review processes and research designs when embarking on research in this field.

Nurses' experiences of ethical challenges concerning thirst in dying patients in specialist palliative care: a qualitative study

AIM

To describe nurses' experiences of ethical challenges in relation to thirst in terminally ill patients in specialist palliative care units.

RESEARCH DESIGN

A qualitative, reflexive thematic design with an inductive analysis was used.

PARTICIPANTS AND RESEARCH CONTEXT

Eighteen qualitative interviews with nurses working in six different specialist palliative care units in different hospitals in Sweden were conducted. The interviews were transcribed verbatim and analysed with a reflexive thematic analysis.

RESULTS

This study identified four themes that reflect ethical challenges experienced by nurses in the palliative care regarding thirst: Harmful infusions interfere with peaceful dying; conflict between tradition and personal experience; What is the right intervention to quench thirst? and; Lack of standard procedures, competence and interest among team members.

CONCLUSION

Palliative care nurses experience a number ethical challenges in relation to thirst in dying patients. The main challenge is the provision of fluids to dying patients via artificial infusions, which nurses struggle with, as they do not want to interfere with a peaceful dying process.

Navigating end-of-life decision-making in nursing: a systematic review of ethical challenges and palliative care practices

OBJECTIVES

This systematic review aimed to synthesize evidence on the ethical dilemma's nurses encounter in end-of-life care and effective palliative care practices. The objectives were to understand key ethical issues, evaluate communication and decision-making strategies, and identify approaches to support nurses and patients.

METHODS

A comprehensive search of major databases was conducted according to the PRISMA guidelines. Studies directly relating to nursing ethics, challenges in end-of-life decision-making, and palliative care practices were included. The risk of bias was assessed using ROBVIS-II. Data on ethical issues, palliative interventions, and outcomes was extracted and analyzed thematically.

RESULTS

22 studies met the inclusion criteria. Key themes that emerged were: (1) Effective communication and involving patients in decision-making are essential but complex. (2) Nurses face dilemmas around balancing autonomy, beneficence and relational issues. (3) Integrating palliative care principles enhances symptom management and aligns care with patient values. (4) Education and organizational support are needed to equip nurses with skills and coping strategies.

CONCLUSION

Navigating end-of-life care requires addressing interconnected ethical, communication and support needs. While studies provided insights, further research is required on cultural competence training, standardized education programs and longitudinal evaluations.

Nurses' perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents- a qualitative study

BACKGROUND

Over the years, caring has been explained in various ways, thus presenting various meanings to different people. Caring is central to nursing discipline and care ethics have always had an important place in nursing ethics discussions. In the literature, Joan Tronto's theory of ethics of care is mostly discussed at the personal level, but there are still a few studies that address its influence on caring within the nursing context, especially during the provision of end-of-life care. This study aims to explore nurses' perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

METHODS

This study has a qualitative descriptive design. Data were collected by conducting five individual interviews and one focus group during a seven-month period between April 2022 and September 2022. Nine nurses employed at four Norwegian nursing homes were the participants in this study. Data were analysed by employing a qualitative deductive content analysis method.

RESULTS

The content analysis generated five categories that were labelled similar to Tronto's five phases of the care process: (i) caring about, (ii) caring for, (iii) care giving, (iv) care receiving and (v) caring with. The findings revealed that nurses' autonomy more or less influences the decision-making care process at all five phases, demonstrating that the Tronto's theory contributes to greater reflectiveness around what may constitute 'good' end-of-life care.

CONCLUSIONS

Tronto's care ethics is useful for understanding end-of-life care practice in nursing homes. Tronto's care ethics provides a framework for an in-depth analysis of the asymmetric relationships that may or may not exist between nurses and nursing home residents and their next-of-kin. This can help nurses see and understand the moral dimension of end-of-life care provided to nursing home residents during their final days. Moreover, it helps handle moral responsibility around end-of-life care issues, providing a more complex picture of what 'good' end-of-life care should be.

What are the triggers for palliative care referral in burn intensive care units? Results from a qualitative study based on healthcare professionals' views, clinical experiences and practices

BACKGROUND

Burns are a global public health problem, accounting for around 300,000 deaths annually. Burns have significant consequences for patients, families, healthcare teams and systems. Evidence suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making processes and family care. Research is needed on how to optimise palliative care referrals.

AIM

To identify triggers for palliative care referral in critically burned patients based on professionals' views, experiences and practices.

DESIGN

Qualitative study using in-depth interviews.

SETTING/PARTICIPANTS

All five Burn Intensive Care Units reference centres across Portugal were invited; three participated. Inclusion criteria: Professionals with experience/working in these settings. A total of 15 professionals (12 nurses and 3 physicians) participated. Reflexive thematic analysis was performed.

RESULTS

Three main triggers for palliative care referral were identified: (i) Burn severity and extension, (ii) Co-morbidities and (iii) Multiorgan failure. Other triggers were also generated: (i) Rehabilitative palliative care related to patients' suffering and changes in body image, (ii) Family suffering and/or dysfunctional and complex family processes, (iii) Long stay in the burn intensive care unit and (iv) Uncontrolled pain.

CONCLUSIONS

This study identifies triggers for palliative care in burn intensive care units based on professionals' views, clinical experiences and practices. The systematisation and use of triggers could help streamline referral pathways and strengthen the integration of palliative care in burn intensive care units. Research is needed on the use of these triggers in clinical practice to enhance decision-making processes, early and high-quality integrated palliative care and proportionate patient and family centred care.

A bioethical perspective on the meanings behind a wish to hasten death: a meta-ethnographic review

BACKGROUND

The expressions of a "wish to hasten death" or "wish to die" raise ethical concerns and challenges. These expressions are related to ethical principles intertwined within the field of medical ethics, particularly in end-of-life care. Although some reviews were conducted about this topic, none of them provides an in-depth analysis of the meanings behind the "wish to hasten death/die" based specifically on the ethical principles of autonomy, dignity, and vulnerability. The aim of this review is to understand if and how the meanings behind the "wish to hasten death/die" relate to and are interpreted in light of ethical principles in palliative care.

METHODS

We conducted a meta-ethnographic review according to the PRISMA guidelines and aligned with Noblit and Hare's framework. Searches were performed in three databases, Web of Science, PubMed, CINAHL, with no time restrictions. Original qualitative studies exploring the meanings given by patients, family caregivers and healthcare professionals in any context of palliative and end-of-life care were included. A narrative synthesis was undertaken. PROSPERO registration CRD42023360330.

RESULTS

Out of 893 retrieved articles, 26 were included in the analysis, accounting for the meanings of a total of 2,398 participants. Several factors and meanings associated with the "wish to hasten death" and/or "wish to die" were identified and are mainly of a psychosocial and spiritual nature. The ethical principles of autonomy and dignity were the ones mostly associated with the "wish to hasten death". Ethical principles were essentially inferred from the content of included articles, although not explicitly stated as bioethical principles.

CONCLUSIONS

This meta-ethnographic review shows a reduced number of qualitative studies on the "wish to hasten death" and/or "wish to die" explicitly stating ethical principles. This suggests a lack of bioethical reflection and reasoning in the empirical end-of-life literature and a lack of embedded ethics in clinical practice. There is a need for healthcare professionals to address these topics compassionately and ethically, taking into account the unique perspectives of patients and family members. More qualitative studies on the meanings behind a wish to hasten death, their ethical contours, ethical reasoning, and implications for clinical practice are needed.

Compromised end-of-life syndrome in cancer patients: A clinical validation study

PURPOSE

To identify the prevalence of the nursing diagnosis of compromised end-of-life syndrome in patients in end-of-life care.

METHODS

This is a clinical validation based on a cross-sectional epidemiological clinical study conducted at the National Cancer Institute in Rio de Janeiro, Brazil. The defining characteristics of a syndrome diagnosis were identified, defined as a "subset of nursing diagnoses," using sensitivity and specificity measures through the application of latent class statistical methods.

FINDINGS

The statistical results revealed seven nursing diagnoses characterizing the syndrome: imbalanced nutrition: less than body requirements, nausea, anxiety, ineffective breathing pattern, disturbed sleep pattern, ineffective thermoregulation, and fatigue. Compromised end-of-life syndrome was present in 76% of the sample.

CONCLUSION

The study demonstrated the presence of compromised end-of-life syndrome in most end-of-life patients from the sample.

IMPLICATIONS FOR NURSING PRACTICE

Recognizing the presence of the syndrome diagnosis enables nurses to have efficient and effective clinical reasoning for implementing the nursing process in palliative care. CAAE Number: 85415618.0.3001.5274.

Using the Kipling method to explore the contextual factors of decision-making during advance care planning for older cancer patients, their family, and health-care professionals: A qualitative secondary analysis

OBJECTIVES

Advance care planning (ACP) interventions are supposed to affect patients' autonomy and family health-care outcomes positively. However, the clinical benefits of ACP actualization and associated contextual factors merit questioning. Therefore, this study explores the critical contextual and procedural factors related to ACP decision-making based on the actual situation of older patients with cancer encountering end-of-life care in Taiwan.

METHODS

This retrospective qualitative secondary analysis used the Kipling method (5W1H) to explore further the critical contextual and procedural factors related to ACP decision-making processes. We applied thematic analysis and dual coding for 35 narratives, including 10 patients with cancer, 10 family caregivers, and 15 health-care staff, derived from a preliminary qualitative study regarding palliative care decision-making among patients with advanced cancer, their families, and health-care staff.

RESULTS

We identified 6 domains detailing the contextual factors for ACP decision-making: (1) WHO (decision makers); (2) WHAT (discussion content); (3) WHEN (care plan for which disease stage); (4) WHERE (patient's situational location); (5) WHY (reasons underpinning the decisions); and (6) HOW (the way to form the decisions).

SIGNIFICANCE OF RESULTS

Using the Kipling method to elaborate the contextual factors for ACP decision-making among older patients with cancer strengthens the understanding of complicated end-of-life care decision-making procedure. This study also demonstrates the dynamic and cultural complexity and the various factors considered during end-of-life care and future ACP discussion.

NICU nurses' moral distress surrounding the deaths of infants

BACKGROUND

As Korean neonatal nurses frequently experience the deaths of infants, moral distress occurs when they provide end-of-life care to the infants and their families. Although they need to care for the patients' deaths and consequently experience burnout and turnover due to moral distress from the situation, there is a lack of a support for nurses. Moreover, not much information is available on the moral distress of neonatal nurses. There is a need to better understand Korean neonatal nurses' moral distress to develop and implement appropriate supports.

OBJECTIVE

This study aimed to describe nurses' experience of moral distress when they provide end-of-life care to infants and their families in neonatal intensive care units.

RESEARCH DESIGN

This is a secondary analysis qualitative study. Content analysis was performed based on Corley's theory of moral distress to develop a codebook and identify themes regarding moral distress among the nurses.

PARTICIPANTS AND RESEARCH CONTEXT

Qualitative data were collected from 20 nurses working in two NICUs in Seoul, South Korea.

ETHICAL CONSIDERATIONS

The original study obtained permission from a university's institutional review board (IRB). This secondary analysis study obtained the exemption from another university's IRB. Nurses' participation was voluntary and confidential.

FINDINGS

The nurses' moral distress was derived when they faced moral constraints and/or moral conflicts. Two distinct categories of moral constraints and four distinct categories of moral conflicts were identified among the neonatal nurses. In addition, impacts of moral distress on patients and nurses were identified.

CONCLUSIONS

This study identified occasions neonatal nurses experience moral distress, and thus can guide in developing and implementing effective interventions to decrease their moral distress and improve their resilience in end-of-life care by providing insight into neonatal nurses' needs for support in end-of-life care.

Nursing education on palliative care across Europe: Results and recommendations from the EAPC Taskforce on preparation for practice in palliative care nursing across the EU based on an online-survey and country reports

BACKGROUND

Nurses are the largest regulated group of healthcare professionals involved in palliative care. In 2004, a taskforce of the European Association for Palliative Care (EAPC) launched the 'Guide for development of palliative nurse education in Europe' (hereinafter, the EAPC 2004 Guide). No systematic evaluation of its impact in the development of palliative care education was undertaken.

AIMS

To describe current undergraduate and postgraduate nursing education across Europe; to identify the roles that nurses with different palliative care educational levels have in palliative care; and to assess the uptake of the EAPC 2004 Guide in the development of palliative care nursing in Europe.

DESIGN

Descriptive research involving an online survey among nursing experts, and the consultation of national representatives.

SETTING/PARTICIPANTS

A total of 135 nurses (52% response rate) from 25 countries completed the online survey; representatives from 16 countries were consulted.

RESULTS

In 14 (56%) countries, palliative care was not identified as a mandatory subject within undergraduate nursing education. The EAPC 2004 Guide is widely known and was/is being used in many countries to promote palliative care nursing education. Large variations were found across and within country responses.

CONCLUSIONS

Palliative care nursing education varies largely in Europe. The wide awareness and use of the EAPC 2004 Guide show how policy measures can influence the development of palliative care education. Recommendations are built and focus on both fostering the use of this guide and implementing policy measures to ensure that palliative care nursing is recognised and certified as a specialty in all European countries.

The practices and attitudes of nurses regarding palliative sedation: A scoping review

BACKGROUND

Palliative sedation is used as a last-resort option to treat refractory symptoms of dying patients. Nurses are important participants in the process of sedation. However, little is known about palliative sedation from a nursing perspective.

OBJECTIVES

To analyze the practices and attitudes of nurses concerning palliative sedation.

DATA SOURCES AND REVIEW METHODS

A scoping review guided by Arksey and O`Malley`s methodological framework was used to analyze existing peer-reviewed empirical research on the topic of the practices and attitudes of nurses related to the palliative sedation of patients aged 18 years and older. Of the 316 publications identified from the PubMed, CINAHL and Cochrane Library, 17 full-text articles were included in this review. The data of the included articles were charted (author(s), year of publication, country, objectives, study design, data collection, setting, respondents, definition of palliative sedation, focus of the study and key findings), and the results were summarized with inductive content analysis. The PRISMA-ScR checklist was used as a guideline for the reporting in this review.

RESULTS

During the decision-making concerning the start of palliative sedation, nurses usually have an advocatory and supportive role, although the role varies between different countries. This role then changes to a relatively independent performance of sedation; including administration of the medication, monitoring the effectiveness of sedation, and in some cases taking decisions concerning the medication and dosage policy. Further, nurses provide information and compassionate care to both the patient and the family during the process of palliative sedation. Most nurses view palliative sedation as a positive and sometimes necessary last resort therapy to relieve refractory suffering of dying patients. However, sedation poses ethical problems for many nurses. These problems especially concern the essential elements of deciding to use palliative sedation, the depth of sedation, the potential for shortening life, and the loss of social interaction.

CONCLUSIONS

Nurses play a key role in palliative sedation, as they often perform sedation independently and have important information about the needs and wishes of both patients and their families due to their unique position at the bedside of the patient. Although nurses generally see palliative sedation as a positive practice for selected patients, many of them feel it is ethically controversial. This scoping review reveals a great need for further research and discussion on the practices and attitudes of nurses regarding palliative sedation.