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Postpone death?: Nurse-physician perspectives on life-sustaining treatment and ethics rounds
Örebro University, School of Health and Medical Sciences.ORCID iD: 0000-0003-0679-5695
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The starting point of the present thesis is nurses’ reported experiences of disagreements with physicians for pushing life sustaining treatment too far. The overall aim was to describe and compare nurses’ and physicians’ perspectives on the boundaries for life-sustaining treatment and to evaluate whether ethics rounds could promote mutual understanding and stimulate ethical reflection. A mixed methods design with qualitative and quantitative data was used, including interviews and questionnaires. The health professionals’ experiences/perceptions were based on known patients foremost from general wards, but also intensive care units, at four Swedish hospitals. The first two studies treated the perspective on boundaries for life-sustaining treatment and the last two evaluated philosopher- ethicist led ethics rounds. Analysis of data was performed using a phenomenological approach and content analysis as well as comparative and descriptive non-parametric statistics.

In the first study, the essence of the physicians’ decision-making process to limit life-sustaining treatment for ICU patients, was a process of principally medical considerations in discussions with other physicians. In the second study, there were more similarities than differences between nurses’ and physicians’ opinions regarding the 714 patients studied. The physicians considered limited treatment as often as the nurses did. The ethics rounds studies generated mixed experiences/perceptions. It seemed that more progress was made toward the goal of promoting mutual understanding than toward the goal of stimulating ethical reflection. Above all, the rounds seemed to meet the need for a forum for crossing over professional boundaries. The most salient finding was the insight to enhance team collaboration, that the interprofessional dialogue was sure to continue. Predominating new insights after rounds were interpreted as corresponding to a hermeneutic approach. One of nurses’ negative experiences of the ethics rounds was associated with the lack of solutions. Based on the present findings, one suggestion for improvement of the model of ethics rounds is made with regard to achieving a balance between ethical analyses, conflict resolution and problem solving. In conclusion, the present thesis provides strong evidence that differences in opinions regarding boundaries for life-sustaining treatment are not associated with professional status. The findings support the notion of a collaborative team approach to end-of-life decision-making for patients with diminished decisionmaking capacity. There is an indication that stimulation of ethical reflection in relation to known patients may foremost yield psychosocial insights. This could imply that social conflicts may overshadow ethical analysis or that ethical conflicts and social conflicts are impossible to distinguish.

Place, publisher, year, edition, pages
Örebro: Örebro universitet , 2008. , p. 73
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 16
Keywords [en]
Clinical ethics, Life-sustaining treatment, End-of-life decisions, Attitudes, Nurses, Physicians, Inter-professional relations, Ethics consultation, Ethics rounds
National Category
Clinical Science
Research subject
Surgery
Identifiers
URN: urn:nbn:se:oru:diva-2093ISBN: 978-91-7668-596-9 (print)OAI: oai:DiVA.org:oru-2093DiVA, id: diva2:135876
Public defence
2008-05-16, Wilandersalen, M-huset, Universitetssjukhuset, Örebro, 13:00 (English)
Opponent
Supervisors
Available from: 2008-04-22 Created: 2008-04-22 Last updated: 2017-10-18Bibliographically approved
List of papers
1. End-of-life decisions in Swedish ICUs: how do physicians from the admitting department reason?
Open this publication in new window or tab >>End-of-life decisions in Swedish ICUs: how do physicians from the admitting department reason?
2003 (English)In: Intensive & Critical Care Nursing, ISSN 0964-3397, E-ISSN 1532-4036, Vol. 19, no 4, p. 241-251Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

To study how physicians from the admitting department reason during the decision-making process to forego life-sustaining treatment of patients in intensive care units (ICUs).

DESIGN:

Qualitative interview that applies a phenomenological approach.

SETTING:

Two ICUs at one secondary and one tertiary referral hospital in Sweden.

PARTICIPANTS:

Seventeen admitting-department physicians who have participated in decisions to forego life-sustaining treatment.

RESULTS:

The decision-making process as it appeared from the physicians' experiences was complex, and different approaches to the process were observed. A pattern of five phases in the process emerged in the interviews. The physicians described the process principally as a medical one, with few ethical reflections. Decision-making was mostly done in collaboration with other physicians. Patients, family and nurses did not seem to play a significant role in the process.

CONCLUSION:

This study describes how physicians reasoned when confronted with real patient situations in which decisions to forego life-sustaining treatment were mainly based on medical--not ethical--considerations.

National Category
Nursing
Research subject
Caring sciences
Identifiers
urn:nbn:se:oru:diva-2974 (URN)10.1016/S0964-3397(03)00055-7 (DOI)
Available from: 2008-04-22 Created: 2008-04-22 Last updated: 2017-12-14Bibliographically approved
2. Nurses’ and physicians’ opinions on aggressiveness of treatment for general ward patients
Open this publication in new window or tab >>Nurses’ and physicians’ opinions on aggressiveness of treatment for general ward patients
2006 (English)In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 13, no 2, p. 147-162Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to evaluate agreement between nurses’ and physicians’ opinions regarding aggressiveness of treatment and to investigate and compare the rationales on which their opinions were based. Structured interviews regarding 714 patients were performed on seven general wards of a university hospital. The data gathered were then subjected to qualitative and quantitative analyses. There was 86% agreement between nurses’ and physicians’ opinions regarding full or limited treatment when the answers given as ‘uncertain’ were excluded. Agreement was less (77%) for patients with a life expectancy of less than one year. Disagreements were not associated with professional status because the physicians considered limiting life-sustaining treatment as often as the nurses. A broad spectrum of rationales was given but the results focus mostly on those for full treatment. The nurses and the physicians had similar bases for their opinions. For the majority of the patients, medical rationales were used, but age and quality of life were also expressed as important determinants. When considering full treatment, nurses used quality-of-life rationales for significantly more patients than the physicians. Respect for patients’ wishes had a minor influence.

National Category
Social Sciences Interdisciplinary Nursing Humanities and the Arts Religious Studies
Research subject
Nursing Science
Identifiers
urn:nbn:se:oru:diva-2975 (URN)10.1191/0969733006ne861oa (DOI)
Available from: 2008-04-22 Created: 2008-04-22 Last updated: 2018-01-13Bibliographically approved
3. Learning a way through ethical problems: Swedish nurses’ and doctors’ experiences from one model of ethics rounds
Open this publication in new window or tab >>Learning a way through ethical problems: Swedish nurses’ and doctors’ experiences from one model of ethics rounds
Show others...
2008 (English)In: Journal of Medical Ethics, ISSN 0306-6800, E-ISSN 1473-4257, Vol. 34, no 5, p. 399-406Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To evaluate one ethics rounds model by describing nurses' and doctors' experiences of the rounds.

METHODS: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to promote mutual understanding and stimulate ethical reflection, without giving any recommendations or solutions. Interviews with seven doctors and 11 nurses were conducted regarding their experiences from the rounds, which were then analysed using content analysis. Findings: The goal of the rounds was partly fulfilled. Participants described both positive and negative experiences. Good rounds included stimulation to broadened thinking, a sense of connecting, strengthened confidence to act, insight into moral responsibility and emotional relief. Negative experiences were associated with a sense of unconcern and alienation, as well as frustration with the lack of solutions and a sense of resignation that change is not possible. The findings suggest that the ethics rounds above all met the need of a forum for crossing over professional boundaries. The philosophers seemed to play an important role in structuring and stimulating reasoned arguments. The nurses' expectation that solutions to the ethical problems would be sought despite explicit instructions to the contrary was conspicuous.

CONCLUSION: When assisting healthcare professionals to learn a way through ethical problems in patient care, a balance should be found between ethical analyses, conflict resolution and problem solving. A model based on the findings is presented.

National Category
Humanities and the Arts Religious Studies Social Sciences Interdisciplinary Nursing
Research subject
Nursing Science
Identifiers
urn:nbn:se:oru:diva-2976 (URN)10.1136/jme.2006.019810 (DOI)
Available from: 2008-04-22 Created: 2008-04-22 Last updated: 2018-01-13Bibliographically approved
4. Interprofessional ethics rounds concerning dialysis patients: staff's ethical reflections before and after rounds
Open this publication in new window or tab >>Interprofessional ethics rounds concerning dialysis patients: staff's ethical reflections before and after rounds
Show others...
2008 (English)In: Journal of Medical Ethics, ISSN 0306-6800, E-ISSN 1473-4257, Vol. 34, no 5, p. 407-413Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To evaluate whether ethics rounds stimulated ethical reflection. METHODS: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to stimulate ethical reflection and promote mutual understanding between professions but not to offer solutions. Questionnaires directly before and after rounds were answered by 194 respondents. The analyses were primarily content analysis with Boyd's framework but were also statistical in nature. FINDINGS: Seventy-six per cent of the respondents reported a moderate to high rating regarding new insights on ethical problem identification, but the ethics rounds did not seem to stimulate the ethical reflection that the respondents had expected (p < 0.001). Dominant new insights did not seem to fit into traditional normative ethics but were instead interpreted as hermeneutic ethics. This was illustrated in the extended perspective on the patient and increased awareness of relations to other professions. Regarding insights into how to solve ethical problems, the request for further interprofessional dialogue dominated both before and after rounds. CONCLUSION: The findings show the need for interprofessional reflective ethical practice but a balance between ethical reflection and problem solving is suggested if known patients are discussed. Further research is needed to explore the most effective leadership for reflective ethical practice.

Place, publisher, year, edition, pages
London: BMJ Publ. Group, 2008
National Category
Nursing Social Sciences Interdisciplinary Humanities and the Arts
Research subject
vårdvetenskap
Identifiers
urn:nbn:se:oru:diva-5376 (URN)10.1136/jme.2007.023572 (DOI)
Available from: 2009-02-06 Created: 2009-02-06 Last updated: 2018-01-13Bibliographically approved

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