Advance Directives and End-of-Life Decision Making

Oncology nurses' knowledge, attitudes, and practice behaviours towards advance care planning: A nationwide cross-sectional study

BACKGROUND

With the increasing cancer prevalence in China, discussions surrounding end-of-life care have become more frequent within the purview of oncology nursing. Nonetheless, limited research has explored the current state of Advance Care Planning (ACP) among oncology nurses in China. Hence, it is essential to comprehensively assesses oncology nurses' ACP knowledge, attitudes, and practice behaviours, addressing existing literature gaps and revealing China's oncology nursing ACP status.

OBJECTIVES

To explore oncology nurses' knowledge, attitudes, and practice behaviours regarding ACP and identify factors impacting ACP practice behaviours.

DESIGN

A multi-centre, observational, cross-sectional study.

SETTINGS

The research is conducted in oncology hospitals across 22 provinces, 4 municipalities, and 5 autonomous regions across China.

PARTICIPANTS

Convenience sampling was used to recruit 1800 registered oncology nurses.

METHODS

Data were collected via an electronic questionnaire between December 2021 and January 2022. Univariate and hierarchical multiple regression analyses were used for data prediction (P < 0.05).

RESULTS

In the knowledge section, respondents achieved an average accuracy rate of 51.94 % and demonstrated moderate positive attitudes towards ACP. Their practice behaviour scores were moderately graded. Sociodemographic characteristics and attitude were included as predictors of practice behaviour in the hierarchical multiple regression analysis, explaining 12.2 % and 31.1 % of the variance, respectively. The final model accounted for 43.3 % of the variance. The results indicated that attitudes had a significant and positive impact on practice behaviours, indicating that nurses with more positive attitudes were more likely to engage in ACP practice.

CONCLUSIONS

Chinese oncology nurses seem to have more positive attitudes towards ACP, but they do not prepare adequately in practice. By enhancing workplace values, beliefs, and policies, it is feasible to enhance the attitudes of oncology nurses towards ACP and, consequently, promote practice behaviours. Furthermore, this study underscores the need for targeted interventions to bridge the gap between positive attitudes and actual ACP implementation among oncology nurses in China.

Intention to sign an advance directive among nephrology medical staff and its related factors

BACKGROUND

Advance care planning enables people to record their future health and care wishes and appoint someone as an advocate. An advance directive can be made in the event that a person is incapacitated, so that their wishes are still upheld. The beliefs of the nephrology team might affect patients' choices and willingness to sign an advance directive. To increase the number of dialysis patients who have signed an advance directive, it is necessary to educate the nephrology medical staff.

AIM

To explore the intention to sign an advance directive and its related factors among nephrology medical staff.

METHODS

A cross-sectional and correlational design was used. This study recruited 160 nephrology medical staff. Data were analysed by using the Statistical Package for Social Science 21.0 for Windows.

FINDINGS

The results found that the longer someone has worked as part of the nephology medical staff, the more knowledgeable they were about an advance directive. This led to them being more likely to want to sign an advance directive for themselves.

CONCLUSION

In order to improve the knowledge and awareness of advance directives among nephrology medical staff, hospital managers should provide continuing education on this topic.

Advance care planning in chronic kidney disease: A national Danish survey of knowledge and attitudes among clinicians

INTRODUCTION

Patients with chronic kidney disease and their families strongly request advance care planning. They want it to start early-before treatment decisions are made-and to be an ongoing process during their illness trajectory. Previous international studies show that health care professionals find there to be significant barriers that impact the extent of involvement in advance care planning.

AIM

To identify Danish nephrology health care professionals' knowledge and attitudes to advance care planning and the status of current advance care planning practice in Denmark.

METHOD

An anonymous, cross-sectional survey was administrated online. The questionnaire was developed in Australia and translated and culturally adapted into Danish. Health care professionals were recruited via email lists. In descriptive statistics and multiple ordinal regression, the influence of the respondents' attributes on the extent of involvement in advance care planning was explored, along with the involvement of family, and skills, comfort, barriers and facilitators in relation to advance care planning.

RESULTS

The 207 respondents comprised nephrologists (23%), other physicians (8%), nurses (62%) and other HCPs (7%), of whom 27% had participated in advance care planning training. In total, 66% indicated that they lacked access to material about advance care planning for patients with chronic kidney disease and 46% indicated that the conversations were performed ad hoc. A total of 47% reported that advance care planning was performed well at their workplace. Reported barriers were time, lack of experience and procedure. Training in advance care planning could facilitate the involvement. Nurses were less likely to feel skilled and comfortable in engaging advance care planning, while those with more than 10 years of experience were more likely to feel skilled and comfortable.

CONCLUSION

Training in advance care planning with patients with chronic kidney disease and their families on both a theoretical and clinical level is important to ensure comfort among health care professionals and to facilitate the extent of involvement. A systematic chronic kidney disease-specific approach is significant, in order to guide the conversations and ensure that advance care planning is conducted to a set standard.

Advance Care Planning and palliative care for patients with advanced cancer in Uganda

The study sought to identify the extent to which Advance Care Planning (ACP) is practised by palliative care health professionals providing care to patients with advanced cancer and their families in Uganda. A mixed methods study design using qualitative and quantitative methods was used for the assessment. In-depth interviews with a group of nine highly experienced health professionals were conducted using a semi-structured interview guide. Quantitative data were retrieved and analysed from a survey administered to 124 health professionals of whom only 57 (45.9%) responded. The qualitative data were analysed using inductive thematic analysis and descriptive analysis was used for the quantitative data. Of the 57 health professionals who participated in the survey, 87% were aware of ACP and 55% reported regular practice. Fifty-five (55%) percent reported regular provision of ACP for their patients and 46% reported engaging in informal ACP practices. However, 58.5% resp. 37.5% reported that they routinely provide ACP to more than 50% resp. 75% of their patients. A group of nine highly experienced palliative care professionals had a pooled ACP prevalence of only 1.2%. There was a generally good attitude towards ACP with 98.2% acknowledging that patients should be able to determine their future care. However, 32% reported being uncomfortable withholding or withdrawing life sustaining treatment. There are a number of socio-cultural beliefs and barriers, for instance that discussing death and dying is a "taboo", as well as witchcraft, family influence in decision-making, religious beliefs that do not agree with palliative care practices and a preference to use aggressive treatment like chemotherapy for terminally ill, etc. Institutional barriers like lack of a legal framework for ACP, limited time for health professionals to engage in ACP and other patient factors such as denial of diagnosis and collusion to withhold information from patients were reported by 78.2% resp. 84% of the respondents. Despite the good awareness and attitude to ACP, there is a range of barriers that are affecting the implementation of ACP in Uganda. There is need for development of a legal framework for ACP, more research to understand the contextual barriers and develop appropriate education and public sensitisation programs.

Psychometric properties of the end-of-life care decision inventory (EOL-CDI): a mixed-methods study

Background

End-of-life care decision-making has become important to support dignity and quality of life for patients who are facing death in Korea, along with the enactment of the Life-Sustaining Treatment Act in 2018. However, it seems that the concepts and policies related to the law are not yet familiar to health care providers or the general public. This unfamiliarity can hinder efficient end-of-life care discussions. Therefore, the purpose of this study was to propose a valid and reliable tool to explore the level of understanding of concepts and attributes related to end-of-life care decisions.

Methods

This is a mixed-methods study design. A relevant law and literature analysis, expert consultation, cognitive interviews of 10 adults, and cross-sectional survey for psychometric tests using data from 238 clinical nurses were performed to update a tool developed before the life-sustaining treatment Act was enacted in Korea.

Results

29 items of the draft version were polished in terms of literacy, total length, and scoring method via cognitive interviews and finalized into 21 items through psychometric tests and expert consultations. The 21 items conformed to the Rasch unidimensional paramenters.

Conclusion

A tool to identify the level of understanding of concepts related to end-of-life care decisions was proposed through a rather rigorous process to ensure feasibility and validity/reliability. We recommend the proposed tool to apply to the adult population and nurses for evaluation and educational purposes.

Trends in Nursing Research on Life-Sustaining Treatment in South Korea after the Enforcement of the Act on Decisions on Life-Sustaining Treatment

Purpose

This study investigated trends of nursing research on life-sustaining treatment in South Korea.

Methods

The period for data search was set from January 2018 to December 2020. The major search terms used were advance directives and life-sustaining treatment. Of the 492 records identified in the initial search, 461 articles were excluded for various reasons. A total of 31 records were included in the final qualitative analysis.

Results

Sixteen studies had nursing students as study subjects, while nine studies had nurses as study subjects. The majority of the studies employed cross-sectional descriptive surveys as their research design. The major themes that emerged from the studies were as follows attitudes toward withdrawal of life-sustaining treatment, knowledge of and attitudes toward advance directives, perceptions of a good death, and nurses' attitude toward life support care. Most of the studies reviewed concluded that attitudes toward withdrawal of life-sustaining treatment significantly impacted both knowledge of and attitudes toward advance directives and perceptions of a good death.

Conclusion

To date, Korea still lacks extensive nursing research concerning life support care. Further research is needed to provide systematic education for nursing ethics and life support care, as well as the introduction of a specialist course. Furthermore, a multidisciplinary approach is necessary to provide diverse support systems and policy measures. In particular, since nurses are directly responsible for providing life support care, nurses' roles should be expanded in accordance with the Act on Decisions on Life-Sustaining Treatment.

Instrument Development: Knowledge, Attitudes, and Confidence in Palliative Care Concepts Held by Trauma and Neuroscience Intensive Care Nurses

BACKGROUND AND PURPOSE

Unique pressures impact trauma intensive care unit (TICU) nurses in their provision of care for severely injured patients. When it becomes clinically obvious that these patients may not survive, TICU nurses must continue life-saving measures while at the same time consider a palliative care consultation. In order to facilitate this referral, TICU nurses need to have the appropriate knowledge, attitude, and confidence in doing so. The purpose of this study is to refine an instrument that aims to support this process.

METHODS

A convenience sample of 42 respondents completed the Knowledge, Attitudinal, and Experiential Survey on Advance Directive (KAESAD).

RESULTS

Domains with the highest Cronbach's alpha value were "professional attitudes" (α = .995) and "clinical experiences" (α = .999).

CONCLUSIONS

Reliability assessments suggest that most domains of the instrument have strong internal consistency, and with a larger sample size, future studies may elucidate how nurse educators can use this instrument to target areas for continuing education.

Discrepancies among knowledge, practice, and attitudes towards advance care planning among Chinese clinical nurses: A national cross-sectional study

AIMS AND OBJECTIVES

To explore the Chinese nurses' knowledge and attitudes concerning advance care planning (ACP) and their engagement in ACP practice.

BACKGROUND

Nurses' knowledge, attitude, and practice of ACP are important in promoting ACP in patients, but little is known about knowledge, attitudes, and practice of ACP among nurses in countries where there are no national policies or regulations on ACP.

DESIGN

A descriptive study with a cross-sectional design.

METHODS

An online questionnaire survey was distributed to Chinese nurses who attended a national conference.

RESULTS

A total of 531 nurses completed the survey and were included in the final analysis. No nurses answered all questions correctly, while 31 (5.8%) answered all the survey questions wrong. The participants were most knowledgeable about the item "Once ACP is made, the content of advance directives cannot be revoked" and were least knowledgeable about the item "ACP is valid only when the patients are well informed of the medical condition". The implementation of ACP was favored by 92.5% of participants, but only 3.4% of them had actually engaged in all 5 ACP practices listed in the survey. Experience of dealing with death was positively associated with nurses' knowledge concerning ACP. The number of dying patients cared for in the past 6 months, school education of palliative care, knowledge of ACP, and age were related to engagement in the practice of ACP.

CONCLUSION

Chinese nurses have supportive attitudes towards ACP, but they have limited knowledge and little practice in ACP.

A Network Analysis of Research Topics and Trends in End-of-Life Care and Nursing

This study identified the trends in end-of-life care and nursing through text network analysis. About 18,935 articles published until September 2019 were selected through searches on PubMed, Embase, Cochrane, Web of Science, and Cumulative Index to Nursing and Allied Health Literature. For topic modeling, Latent Dirichlet Allocation (K = 8) was applied. Most of the top ranked topic words for the degree and betweenness centralities were consistent with the top 1% through the semantic network diagram. Among the important keywords examined every five years, "care" was unrivaled. When analyzing the two- and three-word combinations, there were many themes representing places, roles, and actions. As a result of performing topic modeling, eight topics were derived as ethical issues of decision-making for treatment withdrawal, symptom management to improve the quality of life, development of end-of-life knowledge education programs, life-sustaining care plan for elderly patients, home-based hospice, communication experience, patient symptom investigation, and an analysis of considering patient preferences. This study is meaningful as it analyzed a large amount of existing literature and considered the main trends of end-of-life care and nursing research based on the core subject control and semantic structure.

Self-Perceived Knowledge and Comfort Discussing Palliative Care and End-of-Life Issues among Professionals Managing Neuroinflammatory Diseases

Background: The growing trend in providing palliative care and end-of-life services has dictated that healthcare providers be adequately trained to care for people with serious illnesses, such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). These progressive inflammatory diseases lead to physical, cognitive and emotional deficits and have exceptionally high care demands leading to high levels of distress. Because the impact on the delivery of patient care is influenced by the specialists' knowledge and comfort discussing end-of-life issues, it is concerning that interventions to address unmet palliative care needs in MS and NMOSD rarely include clinician-patient dyads. Objectives: To evaluate the neurology clinicians' knowledge and level of comfort discussing palliative care and end-of-life issues. Design: A cross sectional survey was conducted. The statistical analyses included frequencies, chi square statistics and logistic regression. Setting/Subjects: 414 MS specialists answered an online anonymous survey. The survey was conducted using email distributions to MS professionals through the Consortium of MS Centers (CMSC), the International Organization of MS Nurses (IOMSN) and the UK Nurses' MS Organization. Measurement: The "End of Life Professional Caregiver Survey" (EPCS) was used to collect data. Results: The majority of the multidisciplinary professionals were female, white, nurses, and older than 40 years of age. 41% had their own advance directives and 57.6% had end-of-life basic training. There was a statistically significant association between end-of-life training or having advance directives and comfort discussing palliative care and end of life issues. Professionals that had basic end-of-life training and their own advance directives had higher comfort discussing code status, specific end-of-life issues, and advance directive planning. Conclusions: Basic end-of-life training and having advance directives among MS professionals were associated with better communication of palliative care and end-of-life domains with patients and their care partners.

Barriers to Counseling on Advance Directives Based on Counselors' Experiences: Focus Group Interviews

Purpose

In Korea, since the Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End of Life was implemented in February 2018, advance directives (ADs) have become legally effective and should be documented after sufficient explanation by a registered counselor. However, little is known regarding the adequacy of current AD counseling. This qualitative study aimed to explore the barriers to AD counseling based on counselors' experiences.

Methods

We conducted focus group interviews using purposive sampling. Seven counselors working at hospitals, community health institutions, and non-profit organizations participated in this study. They were asked about the challenges and problems they encountered during AD counseling.

Results

Three themes emerged from this study; 1) issues regarding consistency in AD counseling, 2) issues regarding AD counselors' competency and work environment, and 3) issues regarding the adequacy of the service system. The interviewees stated that the lack of a manual for standardized service made AD counseling inconsistent. The limited competency and poor work environment of counselors were pointed out as major barriers. The interviewees also stated that a proper service system considering individual circumstances is absent.

Conclusion

The goals of AD counseling should be clarified and guidance should be implemented for providing standardized services. Further efforts to enhance the competency of AD counselors and to improve their working conditions are needed. Establishing an integrated framework for an adequate service system is also essential to overcome systematic barriers to AD counseling.

Knowledge of, and participation in, advance care planning: A cross-sectional study of acute and critical care nurses' perceptions

BACKGROUND

Nurses have a core role in facilitating discussions and enacting decisions about end-of-life issues for patients in hospitals. Nurses' own knowledge and attitudes may influence whether they engage in meaningful end-of-life conversations with patients.

AIMS

To determine in a sample of nurses working in acute and critical care hospital wards: 1) their knowledge of advance care planning, including the authority of substitute decision-makers and legal validity of advance directives; 2) their own participation in advance care planning decision-making practices; and 3) associations between nurses' socio-demographic characteristics; clinical expertise; and knowledge and behaviour in relation to advance care planning practices.

DESIGN

Questionnaire-based, cross-sectional study.

SETTING AND PARTICIPANTS

The study was conducted with 181 registered and enrolled nurses employed in acute and critical care wards of three metropolitan hospitals in Australia.

RESULTS

Nurses were least knowledgeable about items relating to the authority of medical (56%) and financial (42%) substitute decision-makers. Few nurses had prepared advance directives (10%) or appointed medical (23%) or financial (27%) decision-makers, when compared to discussing end-of-life wishes (53%) or organ donation (75%). Overall, 15% of nurses had not engaged in any advance care planning practices. Nurses who had cared for 11-30 dying patients in the last six months were more likely to have an increased knowledge score. Older nurses were more likely to participate in a greater number of advance care planning practices and an increase in shifts worked per week led to a significant decrease in nurses' participation.

CONCLUSION

Nurses have a key role in providing advice and engaging dying patients and their families in advance care planning practices. Nurses' own knowledge and rates of participation are low. Further education and support is needed to ensure that nurses have an accurate knowledge of advance care planning practices, including how, when and with whom wishes should be discussed and can be enacted.

Knowledge, Attitudes, and Experience With Advance Directives Among Prelicensure Nursing Students

BACKGROUND

End-of-life decision making can be distressing for nursing students, and the purpose of this investigation was to assess undergraduate nursing students' knowledge, attitudes, and experiences with advance directives.

METHOD

One hundred sixty-six Bachelor of Science in Nursing students at four different program levels were surveyed about their knowledge, personal and professional experience, and personal and professional attitudes regarding advance directives.

RESULTS

There was a statistically significant progression of knowledge from the junior 1 to the senior 2 semesters. In addition, there was a statistically significant difference in personal attitudes about advance directives by progressive semesters, in personal and professional attitudes between White/Caucasian and Black/African American students, and in knowledge of advance directives and professional attitudes between students 18 to 25 years old and those 26 years and older.

CONCLUSION

It is important that nursing students are exposed to advance directives in the prelicensure curriculum to prepare them for their role as professional nurses. [J Nurs Educ. 2018;57(1):35-39.].

Advance Directives in Hospice Healthcare Providers: A Clinical Challenge

BACKGROUND

On a daily basis, healthcare providers, especially those dealing with terminally ill patients, such as hospice workers, witness how advance directives help ensure the wishes of patients. They also witness the deleterious consequences when patients fail to document the care they desire at their end of life. To the best of our knowledge there are no data concerning the prevalence of advance directives among hospice healthcare providers. We therefore explored the prevalence and factors influencing completion rates in a survey of hospice healthcare providers.

METHODS

Surveys that included 32 items to explore completion rates, as well as barriers, knowledge, and demographics, were e-mailed to 2097 healthcare providers, including employees and volunteers, at a nonprofit hospice.

RESULTS

Of 890 respondents, 44% reported having completed an advance directive. Ethnicity, age, relationship status, and perceived knowledge were all significant factors influencing the completion rates, whereas years of experience or working directly with patients had no effect. Procrastination, fear of the subject, and costs were common reasons reported as barriers. Upon completion of the survey, 43% said they will now complete an advance directive, and 45% will talk to patients and families about their wishes.

CONCLUSION

The majority of hospice healthcare providers have not completed an advance directive. These results are very similar to those for other healthcare providers treating patients with terminal diseases, specifically oncologists. Because, at completion, 43% said that they would now complete an advance directive, such a survey of healthcare providers may help increase completion rates.

Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions: A systematic review

BACKGROUND

Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient's wishes or delayed physician-family communications on preference.

AIM

To determine whether advance care documentation encourages healthcare professional's timely engagement in end-of-life discussions.

DESIGN

Systematic review of the English language articles published from January 2000 to April 2015.

DATA SOURCES

EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists.

RESULTS

A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available.

CONCLUSION

Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff to perceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians' confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review.

Engaging Patients With Advance Directives Using an Information Visualization Approach

Despite the benefits of advance directives (AD) to patients and care providers, they are often not completed due to lack of patient awareness. The purpose of the current article is to advocate for creation and use of an innovative information visualization (infovisual) as a health communication tool aimed at improving AD dissemination and engagement. The infovisual would promote AD awareness by encouraging patients to learn about their options and inspire contemplation and conversation regarding their end-of-life (EOL) journey. An infovisual may be able to communicate insights that are often communicated in words, but are much more powerfully communicated by example. Furthermore, an infovisual could facilitate vivid understanding of options and inspire the beginning of often difficult conversations among care providers, patients, and loved ones. It may also save clinicians time, as care providers may be able to spend less time explaining details of EOL care options. Use of an infovisual could assist in ensuring a well-planned EOL journey.

[Nurses' perception, experience and knowledge of palliative care in intensive care units]

BACKGROUND

Adequate provision of palliative care by nursing in intensive care units is essential to facilitate a "good death" to critically ill patients.

OBJECTIVE

To determine the perceptions, experiences and knowledge of intensive care nurses in caring for terminal patients.

METHODOLOGY

A literature review was conducted on the bases of Pubmed, Cinahl and PsicINFO data using as search terms: cuidados paliativos, UCI, percepciones, experiencias, conocimientos y enfermería and their alternatives in English (palliative care, ICU, perceptions, experiences, knowledge and nursing), and combined with AND and OR Boolean. Also, 3 journals in intensive care were reviewed.

RESULTS

Twenty seven articles for review were selected, most of them qualitative studies (n=16). After analysis of the literature it has been identified that even though nurses perceive the need to respect the dignity of the patient, to provide care aimed to comfort and to encourage the inclusion of the family in patient care, there is a lack of knowledge of the end of life care in intensive care units' nurses.

CONCLUSION

This review reveals that to achieve quality care at the end of life, is necessary to encourage the training of nurses in palliative care and foster their emotional support, to conduct an effective multidisciplinary work and the inclusion of nurses in decision making.

Opening end-of-life discussions: how to introduce Voicing My CHOiCES™, an advance care planning guide for adolescents and young adults

OBJECTIVE

Each year, more than 11,000 adolescents and young adults (AYAs), aged 15-34, die from cancer and other life-threatening conditions. In order to facilitate the transition from curative to end-of-life (EoL) care, it is recommended that EoL discussions be routine, begin close to the time of diagnosis, and continue throughout the illness trajectory. However, due largely to discomfort with the topic of EoL and how to approach the conversation, healthcare providers have largely avoided these discussions.

METHOD

We conducted a two-phase study through the National Cancer Institute with AYAs living with cancer or pediatric HIV to assess AYA interest in EoL planning and to determine in which aspects of EoL planning AYAs wanted to participate. These results provided insight regarding what EoL concepts were important to AYAs, as well as preferences in terms of content, design, format, and style. The findings from this research led to the development of an age-appropriate advance care planning guide, Voicing My CHOiCES™.

RESULTS

Voicing My CHOiCES™: An Advanced Care Planning Guide for AYA became available in November 2012. This manuscript provides guidelines on how to introduce and utilize an advance care planning guide for AYAs and discusses potential barriers.

SIGNIFICANCE OF RESULTS

Successful use of Voicing My CHOiCES™ will depend on the comfort and skills of the healthcare provider. The present paper is intended to introduce the guide to providers who may utilize it as a resource in their practice, including physicians, nurses, social workers, chaplains, psychiatrists, and psychologists. We suggest guidelines on how to: incorporate EoL planning into the practice setting, identify timepoints at which a patient's goals of care are discussed, and address how to empower the patient and incorporate the family in EoL planning. Recommendations for introducing Voicing My CHOiCES™ and on how to work through each section alongside the patient are provided.

Bedside nurse involvement in end-of-life decision making: a brief review of the literature

Bedside nurses in the critical care setting deal with death on a regular basis. Historically, end-of-life decision making has been addressed by physicians with the family and patient, yet nurses may be a better resource for families during the decision-making process. The purpose of this article was to provide a brief review of literature surrounding end-of-life decision making. As patient advocates, nurses should be more actively involved with facilitating the end-of-life decision-making process for critically ill patients and their families.

Factors that affect decisions to receive (or not receive) life-sustaining treatment in advance care planning

This study identifies factors that affect decisions people make regarding whether they want to receive life-sustaining treatment. It is an interpretive-descriptive study based on qualitative data from three focus groups (N = 23), representing a diverse population in central Pennsylvania. Study sites included a suburban senior center serving a primarily White, middle-class population; an urban senior center serving a frail, underserved, African American population; and a breast cancer support group. The most important factors affecting whether participants wished to receive life-sustaining medical treatment were prognosis, expected quality of life, burden to others, burden to oneself in terms of the medical condition and treatment, and effect on mental functioning and independence. Our findings contribute to the knowledge of the complex factors that influence how people make decisions about advance care planning and life-sustaining treatments. This understanding is critical if nurses are to translate the patient's goals, values, and preferences into an actionable medical plan.

Experiences with advance care planning: nurses' perspective

AIMS AND OBJECTIVES

The aim of this paper is to report the findings of a case study that explored the phenomenon of advanced care planning and advance care directives in residential care settings in Australia. In particular, this paper focuses on the experiences of Registered Nurses with advanced care planning and advance care directives.

BACKGROUND

Nurses need to know how to engage with residents and families when they invest time and effort on advanced care planning and documentation of advance care directives.

METHODS

A case-study design involving participant observation, field note recording, semi structured interviews and document analysis was used. Data were collected over 7 months. Data analysis involved thematic content analysis.

FINDINGS

The factors that enhanced and inhibited the experiences of the Registered Nurses with advanced care planning were identified. The enhancing factors include; 'it is their essence of who they are', and 'back-up from family members and other nursing staff’. The inhibiting factors are 'lack of time', 'a culture of do everything and don't go there', and 'lack of family involvement'.

CONCLUSION

The findings of the current study provided nurses with evidence of the positive nature of experiences of older people, family members, and nurses themselves with advanced care planning in an attempt to better implement and practise advanced care planning.

Knowledge about patients' rights among professionals in public health care in Finland

BACKGROUND

The legal rights of patients include civil rights for patients and the duties of healthcare professionals. Knowledge of legislation and the ability to put juridical norms into practice are among the main aspects of professionals.

AIM

The aim of the study was to describe the level of healthcare professionals' knowledge about patients' legal rights and to describe background variables associated with the knowledge. The legal rights are based on the Finnish Act on the Status and Rights of Patients.

METHOD

The data were collected from healthcare professionals (nurses and physicians) in public health care in Finland (recruited N = 290, responded n = 191) with a questionnaire designed for the study. The response rate was 66%. The data were analysed statistically.

RESULTS

Healthcare professionals were partially familiar with patients' legal rights. The right to good health care, treatment and access to care and right to self-determination were the best-known areas. The respondents lacked knowledge on the right to information and the right to use the services of patient ombudsman. Based on self-evaluation, half of the respondents thought that they had weak knowledge of the legislation on patients' rights. However, they perceived knowledge about patients' rights as being important. There was no correlation between respondents' self-evaluated knowledge and actual scoring on the knowledge test.

CONCLUSION

These results implicate a need for further education aimed at healthcare professionals and development of professional training about patients' legal rights.

Nursing Roles and Strategies in End-of-Life Decision Making in Acute Care: A Systematic Review of the Literature

The objective of this paper is to analyze the literature concerning nurses' roles and strategies in EOL decision making in acute care environments, synthesize the findings, and identify implications for future research. We conducted searches in CINAHL and PubMed, using a broad range of terms. The 44 articles retained for review had quantitative and qualitative designs and represented ten countries. These articles were entered into a matrix to facilitate examining patterns, themes, and relationships across studies. Three nursing roles emerged from the synthesis of the literature: information broker, supporter, and advocate, each with a set of strategies nurses use to enact the roles. Empirical evidence linking these nursing roles and strategies to patients and family members outcomes is lacking. Understanding how these strategies and activities are effective in helping patients and families make EOL decisions is an area for future research.

Ethics at the End of Life in Transplant Recipients

The field of transplantation is intended to try to save or improve people's lives. In some situations though, the length of a person's life is not as vital as the quality of that life. As a member of a transplant team, one must recognize the differences between quality and quantity and apply the ethical principles of autonomy, justice, nonmaleficence, and beneficence. When a lung transplant recipient became ill with posttransplant lymphoproliferative disease 10 months after her surgery, these ethical principles came to the foreground. This dynamic, vibrant woman, recently engaged, faced her own mortality with grace. There is a time for everything. When death is a long time coming, many people are referred to hospice care and the death is viewed as a blessing. This situation rarely occurs in the transplant field. Many people, whether professionals or laypersons, have a difficult time letting go. Our team and this very special woman all knew when it was time. Creating a warm and open environment in the intensive care unit helped her through the rhythms of transition in dying.

Knowledge, attitudes, and practice behaviors of oncology advanced practice nurses regarding advanced care planning for patients with cancer

PURPOSE/OBJECTIVES

To establish initial reliability and validity of a Web-based survey focused on oncology advanced practice nurses' (APNs') knowledge, attitudes, and practice behaviors regarding advanced care planning, and to obtain preliminary understanding of APNs' knowledge, attitudes, and practice behaviors and perceived barriers to advanced care planning.

DESIGN

Descriptive, cross-sectional, pilot survey study.

SETTING

The eastern United States.

SAMPLE

300 oncology APNs.

METHODS

Guided by the Theory of Planned Behavior, a knowledge, attitudes, and practice behaviors survey was developed and reviewed for content validity. The survey was distributed to 300 APNs via e-mail and sent again to the 89 APNs who responded to the initial survey. Exploratory factor analysis was used to examine the construct validity and test-retest reliability of the survey's attitudinal and practice behavior portions.

MAIN RESEARCH VARIABLES

Respondents' demographics, knowledge, attitudes, practice behaviors, and perceived barriers to advanced care planning practice.

FINDINGS

Exploratory factor analysis yielded a five-factor solution from the survey's attitudes and practice behavior portions with internal consistency using Cronbach alpha. Respondents achieved an average of 67% correct answers in the 12-item knowledge section and scored positively in attitudes toward advanced care planning. Their practice behavior scores were marginally positive. The most common reported barriers were from patients' and families' as well as physicians' reluctance to discuss advanced care planning.

CONCLUSIONS

The attitudinal and practice behaviors portions of the survey demonstrated preliminary construct validity and test-retest reliability. Regarding advanced care planning, respondents were moderately knowledgeable, but their advanced care planning practice was not routine.

IMPLICATIONS FOR NURSING

Validly assessing oncology APNs' knowledge, attitudes, and practice behaviors regarding advanced care planning will enable more tailored approaches to improve end-of-life care outcomes.

A social work perspective: attitudes toward end-of-life planning

This research examined social workers' attitudes toward end-of-life planning and related factors in a cross-sectional study (N = 844). Data were gathered on completion of a health care proxy, personal comfort, training experiences of social workers, and demographics. Attitudes toward end-of-life planning were related to personal completion of the health care proxy, personal comfort, and years of social work experience. These measures remained significant in all steps of the regression, regardless of practice grouping (health and aging or other than health and aging), suggesting the relative importance of personal rather than professional aspects. Respondents in the health and aging fields are older than those in other than health and aging, underscoring concerns about workforce issues in the field of aging.

Nebraska veterans' preferences for end-of-life care

More than 1,800 veterans die in a variety of healthcare settings each day, illustrating a need to improve their end-of-life (EOL) care. In 2006, the Nebraska End-of-Life Survey was mailed to 2,713 urban and rural Nebraskan adults' homes; 44 of 324 first-time respondents (14%) were veterans. This article compares survey responses from veterans and nonveterans and discusses four issues: personal desires during the dying process, fear of dying, completion of advance directives, and communication preferences. Compared to nonveterans, veterans were significantly less likely to want friends or family visiting at EOL, less likely to place importance on being at peace spiritually, less afraid of dying alone, more likely to turn to a spouse to initiate EOL conversations, and less trusting of primary physicians on EOL issues. In addition, veterans had higher rates of completion of advance directives. Examining the survey responses can help guide clinical oncology nurses in delivering EOL care to veterans.

[Perception of ethical attitudes of intensive care nurses on treatment limitation]

OBJECTIVE

Analyze the perception of intensive care nurses regarding the limitation of therapeutic efforts (LET).

METHOD

A 2-month cross-sectional, descriptive study carried out among Intensive Care nursing staff of our Hospital. An anonymous survey was used to assess the attitudes of intensive care nurses on LET.

RESULTS

Fifty-two nurses (86.6%), 57.7% women, with a working experience of 8.8±4.8 years and 17.7%, had some additional training in ethics. The decision not to hospitalize a patient whose short term quality of life is very poor changes when the patient's opinion is considered (36.5% vs 61.5%, p=0.008), a difference that is greater in male nurses without prior training in ethics. A total of 23.1% were not aware of the existence of agreed on guidelines on LET in the Service. A total of 17.3% consider that limiting treatment, either by not providing it or by withdrawing it, is a form of passive euthanasia, which would be an acceptable practice as opposed to euthanasia and 84.6% consider that administering a treatment is not the same as withdrawing it. Of those surveyed, 36.5% felt that the neither the nursing staff should not participate in the decision to limit treatment nor the patients (34.6%) nor family (23.1%).

CONCLUSIONS

Nursing is not aware of the importance it can have, along with the family and patient, in decision making in relationship to the limitation of the treatment of the critical patient, providing a humanizing and ethical view of the care.

A literature review: Advance directives and patients with implantable cardioverter defibrillators

PURPOSE

The purpose of this literature review is to describe the severity of and susceptibility for negative outcomes in patients with implantable cardioverter defibrillators (ICDs) who lack advanced directives.

DATA SOURCES

A comprehensive review of literature was conducted with articles selected from CINAHL, Pubmed, Ovid, Medline, evidence-based medicine, evidence-based nursing, and the Web of Science from 1990 to the present. Key words such as ICD, randomized controlled trials, case studies, advanced directives, end-of-life, living will, health care proxy, and durable power of attorney were used to identify specific studies.

CONCLUSIONS

Advanced directives are becoming an essential part of care for the ICD population. The recommendations in the literature suggest that clinicians should initiate end-of-life discussions with their patients when they are healthy. The patients' preferences should be discussed often in patient care in case they would like changes made to their advance directive as their condition changes.

IMPLICATIONS FOR PRACTICE

Implementation of advanced directives in patients' medical care will need to be encouraged in the event of illness. Advanced practice nurses can provide clear explanations of patients' treatment choices in outpatient and inpatient settings.

The cardiovascular intensive care unit nurse's experience with end-of-life care: a qualitative descriptive study

PURPOSE

Nurses in the cardiovascular intensive care unit (CVICU) informally expressed moral angst when caring for patients who are approaching the end of life. The purpose of this study was to better understand CVICU nurses' perceptions about their roles and responsibilities in the decision-making process about change in intensity of care and end-of-life care for patients within the CVICU setting.

PARTICIPANTS AND METHODS

Nineteen nurses from one CVICU consented to being interviewed individually regarding their experiences caring for patients approaching the end of life, and specifically regarding the initiation of a change in code status. Investigators used a qualitative descriptive approach to collect and analyse the data. Transcript data were analysed and as concepts emerged they were compared with those from earlier interviews to establish similarities and differences. Investigators reached consensus about the major themes.

FINDINGS

Analysis revealed four major themes: (a) exhausting patient treatments; (b) promoting family presence; (c) acknowledging physician authority; and (d) walking a fine line.

CONCLUSIONS

This research adds to the limited body of knowledge concerning CVICU nurses' experiences with end-of-life care. Results of this study provide a basis for putting in place support systems for CVICU nurses.

Contradictions in end-of-life decisions for self and other, expressed by relatives of chronically ventilated patients

OBJECTIVES

In certain populations, social, legal, and religious factors may influence end-of-life decisions in ventilator-dependent patients. This study aims to evaluate attitudes of first-degree relatives of chronically ventilated patients in Israel, toward end-of-life decisions regarding their loved ones, themselves, and unrelated others.

MATERIALS AND METHODS

The study was conducted in a chronic ventilation unit. First-degree family members of chronically ventilated patients were interviewed about their end-of-life attitudes for patients with end-stage diseases. Distinctions were made between attitudes in the case of their ventilated relatives, themselves, and unrelated others; between conscious and unconscious patients; and between a variety of interventions.

RESULTS

Thirty-one family members of 25 patients were interviewed. Median length of ventilation at the time of the interview was 13.4 months. Most interviewees wanted further interventions for their ventilated relatives, yet, for themselves, only 21% and 18% supported chronic ventilation and resuscitation, respectively, and 48% would want to be disconnected from the ventilator. Interventions were more likely to be endorsed for others (vs self), for the conscious self (vs unconscious self), and for artificial feeding (vs chronic ventilation and resuscitation). Interviewees were reluctant to disconnect patients from a ventilator.

CONCLUSIONS

Family members often want escalation of treatment for their ventilated relatives; however, most would not wish to be chronically ventilated or resuscitated under similar circumstances. Advance directives may reconcile people's wishes at the end of their own lives with their reticence to make decisions regarding others.

Nursing Roles in End-of-Life Decision Making in Critical Care Settings

This study used a grounded theory approach to formulate a conceptual framework of the nursing role in end-of-life decision making in a critical care setting. Fourteen nurses from an intensive care unit and cardio-respiratory care unit were interviewed. The core concept, Supporting the Journey, became evident in four major themes: Being There, A Voice to Speak Up, Enable Coming to Terms, and Helping to Let Go. Nurses described being present with patients and families to validate feelings and give emotional support. Nursing work, while bridging the journey between life and death, imparted strength and resilience and helped overcome barriers to ensure that patients received holistic care. The conceptual framework challenges nurses to be present with patients and families at the end of life, clarify and interpret information, and help families come to terms with end-of-life decisions and release their loved ones.