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Variability in nurses' decisions about the care of chronically ill elderly patients: An international study
... Nevertheless, patient's wishes and ethical concerns were identified by all participants as the most important factors for decision making. Lever et al. (2008) utilized the same questionnaire as Richter et al. (2002) to determine nurses' decisions regarding intensity of treatment for an older man with dementia with a potentially life-threatening gastrointestinal haemorrhage. The sample included registered nurses, nursing assistants, and nurse specialists from Canada (n = 343), Sweden (n = 87), Wales (n = 36) and Scotland (n = 65). ...
... Based on prior research, it is apparent that nurses' EOL treatment preferences vary across countries. Two studies by Richter et al. (2002) and Lever et al. (2008) used a questionnaire by Molloy (2011) and Molloy et al. (1991a,b) to explore nurses' treatment preferences and found that nurses do not always follow patient's wishes for EOL treatment. Using a researcherdeveloped questionnaire, Latour et al. (2009) found that assessment of the patient's outcome was considered to be the most ...
... EOL treatment preferences of nurses varied from country to country. This is similar to Lever et al. (2008) and Richter et al. (2002); however, participants in our study were unaware of the patient's wishes. Nurses in Ireland chose the palliative care option in each case scenario more often than all other participants. ...
Previous research has focused on physician's perspectives of end-of-life (EOL) decision making as well as patient and family EOL decision making. There is a lack of research pertaining to the EOL treatment preferences of nurses and especially nurses working in a variety of care settings.
The aim of this study was to compare nurses' EOL treatment preferences in Hong Kong, Ireland, Israel, Italy and the USA.
A comparative descriptive design was used with a convenience sample of nurses (n = 1089). A survey questionnaire using EOL hypothetical clinical case scenarios was used to collect data between June 2011 and July 2012.
Nurses in every country consistently chose a more aggressive option for patients than for themselves or for a parent. The treatment preferences of nurses varied from country to country. Lack of knowledge of patients' wishes and duty of care were the main influencing factors on treatment preferences.
The study was limited to the hypothetical nature of the scenarios; however, the study highlights numerous future research questions.
This study is the first to examine and compare nurses' preferred EOL treatment choices in five countries from three different continents. The findings of this study raise several important questions for healthcare researchers, for policy development, and highlight the need for further international collaboration.
... For example, the code of the Canadian Nurses Association states that 'ethical nursing practice' requires, among other things, that 'nurses respect and promote the autonomy of clients and help them to express their health needs and values, and to obtain the appropriate information and services' (pp. 3,6). 2 Advance directives represent the wishes of an individual and are, in some way, the extension of that person's autonomy. Given the eventuality that the use of advance directives becomes more and more widespread, 3 it is essential to verify the attitude of nurses towards such documents, as well as their intention of complying with them. ...
... 3,6). 2 Advance directives represent the wishes of an individual and are, in some way, the extension of that person's autonomy. Given the eventuality that the use of advance directives becomes more and more widespread, 3 it is essential to verify the attitude of nurses towards such documents, as well as their intention of complying with them. This article will shed light on the beliefs that influence nurses' intentions when it comes to respecting or not respecting the written wishes of a patient that are expressed in an advance directive document. ...
... This result is in keeping with those of other studies carried out previously among nurses. 3,6,[9][10][11] However, little research has focused on shedding light on the determinants of nurses' intentions in order to understand this positive attitude. Among the determinants of the proposed theoretical framework we note respect for autonomy, justice, and the dimension concerned with relationships and emotions. ...
This article seeks to shed light on the beliefs that influence nurses’ intention of respecting or not respecting an advance directive document, namely a living will or a durable power of attorney. Nurses’ beliefs were measured using a 44-statement questionnaire. The sample was made up of 306 nurses working either in a long-term care centre or in a hospital centre offering general and specialized care in the province of Québec. The results indicate that nurses have a strong intention of complying with advance directives written by patients. The analysis also shows that four variables determine the strength of this intention: respect for autonomy; the location of the workplace; justice; and the dimension of relationships and emotions. Although these documents favour the expression of patients’ wishes, nurses should be aware that they do not systematically guarantee respect of a patient’s autonomy, nor do they replace a relationship based on trust between patients and health care professionals.
... Three recent parallel studies (Alemayehu et al., 1991;Lever et al., 1992;Molloy, Guyatt, et al., 1991) addressed decision making in a population of nurses and physicians when selecting a level of care. The scale used, however, focused exclusively on the choice of medical treatment. ...
... As noted by Lever et al. (1992), any action designed to give the patient the best possible care requires obtaining more information on health-care professionals' attitudes and practices. In this regard, it is of considerable interest to ask nurses to use a level-of-care scale that describes nursing care corresponding to various levels. ...
... The study also shows that the expression of wishes by the patient results in a level of care being selected that complies with the patient's wishes. These findings support the conclusions of Alemayehu et al. (1 99 1) and Lever et al. (1992) regarding the fact that most health-care professionals (nurses and physicians) clearly intend to act in such a way as to respect the wishes expressed by the patient. ...
The aim of this study is to evaluate the level of care nurses intended to select in a potential situation of overly aggressive therapy, whether the patient had or did not have a living will. MANOVA revealed that the presence of a living will had a significant impact on nurses’ decision making when selecting a level of care (p < .0001); this impact was noted for each construct in the theoretical framework (p < .005). Multiple regression analysis indicated the 86% of the variance in nurses’ intention was determined by the cognitive component of their attitude and perceived professional norm (p < .0001). In summary, most of the nurses intended to respect the wishes expressed by the patient in a living will.
Advances in medical technology are changing the lives of older adults in both positive and negative ways. Health care professionals are now able to sustain life through aggressive measures, sometimes resulting in poorer quality of life. Advance directives allow individuals to maintain control of their own health care should a time come when they are critically ill and unable to communicate their health care wishes. The use of technology can be appreciated by older adults and their families for its role in preserving life. However, by completing an advance directive, an individual can eliminate the fear of prolonging the dying process. To receive the full benefit of advance directives and understand their purpose and use, older adults need to be educated about advanced medical technology and its use. This article discusses the necessity and importance of educating seniors about advance directives.
Objective: To develop an instrument that reliably measures barriers to advance directive implementation in
different health care settings.
• Design: Items identified based on literature review and interviews with health care professionals were compiled in an item-reduction instrument. Those identified most frequently as barriers to advance directive use and/or rated most important were included in the final Barriers to Implementing Advance Directives (BIAD) instrument.
• Setting and participants: Data were collected from health care professionals (eg, nurses, physicians, social workers, health care aides) working in community agencies, hospitals, nursing homes, and homes for the aged in a large metropolitan area in Ontario, Canada. All participants had experience with implementing advance directives.
• Measurements: The instrument was tested for reliability using the intraclass correlation coefficieint (ICC).
• Results: The BIAD identifies 30 items as potential barriers to advance directive completion. The total score had an ICC of 0.85. Among the occupational categories of Physician, Nurse, and Other, BIAD scores were statistically significantly different between nurses and other occupational categories.
• Conclusion: The BIAD reliably measures barriers to advance directive implementation in different health care settings. Documenting these barriers will allow clinicians and investigators to apply targeted strategies to circumvent barriers and increase directive use, which will give more individuals the opportunity to maintain control of their health and personal care despite incapacity.
Decision‐making in the treatment of elderly people: a cross‐cultural comparison between Swedish and German physicians and nurses
The aim of the study was to evaluate the comparability of decisions in the treatment of severely ill incompetent elderly patients among physicians and nurses from a cross‐cultural perspective. Convenience samples of 192 doctors and 182 nurses from Germany and 104 doctors and 122 nurses from Sweden have been investigated by a questionnaire in a cross‐sectional study. Between 39 and 58% of the subjects in the various groups have chosen treatment options, which are not consistent with the patient's will. However, nurses showed a significantly higher compliance than doctors. The probability of choosing cardio‐pulmonary resuscitation decreased with increasing information about the patient's wish. Ethical concerns and the patient's wishes appeared as the most important determinants of treatment decisions, whereas the hospital costs as well as the physicians' religion were of minor importance. The inconsistencies concerning decision‐ making within and between the groups reflect differences in underlying values and lack of societal consensus, which represent a prerequisite for the improvement of patient autonomy. To focus more frequently and to a larger extent onto the problems related to the treatment of severely ill elderly patients as well as onto the training of communication skills with an orientation towards informed consent in the medical training seems to be warranted.
Older people (those aged 65 years and over) are the major users of health care services, especially acute hospital beds. Since the creation of the NHS there has been concern that older people inappropriately occupy acute hospital beds when their needs would be best served by other forms of care. Many factors have been associated with delayed discharge (age, sex, multiple pathology, dependency and administrative inefficiencies). However, many of these factors are interrelated (or confounded) and few studies have taken this into account. Using data from a large study of assessment of older patients upon discharge from hospital in England, this paper examines the extent of delayed discharge, and analyses the factors associated with such delays using a conceptual model of individual and organisational factors. Specifically, this paper evaluates the relative contribution of the following factors to the delayed discharge of older people from hospital: predisposing factors (such as age), enabling factors (availability of a family carer), vulnerability factors (dependency and multiple pathology), and organisational/administrative factors (referral for services, type of team undertaking assessments). The study was a retrospective patient case note review in three hospitals in England and included four hundred and fifty-six patients aged 75 years and over admitted from their own homes, and discharged from specialist elderly care wards. Of the 456 patients in the sample, 27% had a recorded delay in their discharge from hospital of three plus days. Multivariate statistical analysis revealed that three factors independently predicted delay in discharge: absence of a family carer, entry to a nursing/residential home, and discharge assessment team staffing. Delayed discharge was not related to the hypothesised vulnerability factors (multiple dependency and multiple pathology) nor to predisposing factors (such as age or whether the older person lived alone). The delayed discharge of older people from hospital is a topic of considerable policy relevance. Our study indicated that delay was independently related to two organisational issues. First, entry into long-term care entailed lengthy assessment procedures, uncertainty over who pays for this care, and waiting lists. Second, the nature of the team assessing people for discharge was associated with delay (the nurse-coordinated team made the fewest referrals for multidisciplinary assessments and had the longest delays). Additionally, the absence of a family carer was implicated in delay, which underlines the importance of family and friends in providing posthospital care and in maintaining older people in the community. Our study suggests that considerable delay in discharging older people from hospital originates from administrative/organisational issues; these were compounded by social services resource constraints. There is still much to be done therefore to improve coordination of care in order to provide a truly ‘seamless service’.
Health care decision making in incompetent severely ill patients presents many difficult medical, ethical, and legal problems for the physician. At the same time nurses represent the group of medical professionals who have the closest contact with the patient and who have to carry out most of the decisions and instructions.
Treatment decisions and their determinants have been assessed by means of a questionnaire based on three case scenarios offering three different levels of available information of the patient's wishes (no information, DNR-order, advance directive). Responses of 191 doctors and 182 nurses have been analyzed. In both groups ethical factors and patient wishes were regarded as the most important. With an increasing level of information about the patient's will the compliance increased in both groups, being more pronounced among the nurses. The more important the will of the patient was estimated, the less difficult were the decisions, the less aggressive was the treatment level chosen, the less frequent rescuscitation was made, and the more helpful the information on patient's will were experienced. These important relationships occured mainly in the nurses.
Furthermore, age and level of dementia were related with the decisions though with less importance. The more legal aspects were regarded the more aggressive treatment options were chosen. Hospital cost were less important and did not influence the decision making. The results indicate that a more frequent use of advance directives would foster patient autonomy and at the same time lessen the burden on the medical staff. A comprehensive education of both the medical professions and the general public seems warranted.
A major shift in the care of terminally ill people, due to advances in technology, and the development of legislation regarding patient self-determination and autonomy, has occurred over recent years. Critical care nurses (CCNs) are involved daily in issues of death and dying and are very aware of the needs, fears and psychosocial issues of patients and their families. Professional associations see a legitimate role for nurses in assisting the dying to achieve a dignified death 1.For legislation, policies and guidelines surrrounding end-of-life issues to be effective, and to assist nursing staff with these sensitive, often difficult concerns, it is important that data on the opinions and perspectives of CCNs be objectively obtained.In a study by the Department of Social and Preventive Medicine at the University of Queensland, questionnaires were sent to 1100 randomly sampled community members and almost 1200 health professionals (nurses, general practitioners and specialists), including 299 CCNs. The response rate of CCNs to a 30-page postal questionnaire was 79 per cent (n = 231), indicating those nurses’ high levels of interest in and/or concern regarding this area.CCNs supported the use of advance directives, the appointment of proxies and the need for doctors and nurses to give sufficient medication to relieve pain, even if this hastened the death of the patient. In addition, CCNs, more than any other professional group, supported the right of the terminally ill patient to physician-assisted suicide or euthanasia, their responses being very similar to those of community members.CCNs clearly face issues which, from legal, medical and ethical viewpoints, cause them concern. In sharing their personal experiences, CCNs stressed the need for more communication between doctors and patients, as well as between doctors and nurses. In addition, CCNs saw a clear role for themselves as advocates for patients/families in the decision-making process.
To the Editor: Do physicians, nurses, allied health professionals, and members of the general public systematically choose more aggressive treatment for patients they do not know and family members than they would want for themselves? To answer this question, we prepared a questionnaire, which was completed by 90 doctors, 251 nurses and other health professionals, and 193 high-school students and members of the general public. Using a standard clinical scenario tested in other studies,1–3 we asked respondents to choose a treatment for an 82-year-old man with dementia who was described as having arrived in the emergency department with life-threatening . . .
Do-not-resuscitate orders (DNR orders) and advance directives (AD) have been developed and their use by patients is increasing. The objective of the study was to evaluate the compliance with patient's wishes and doctors' and nurses' agreement on decision-making in the treatment of elderly patients from a cross-cultural perspective.
One hundred and four Swedish physicians and 122 nurses as well as 192 German physicians and 182 nurses from teaching and university hospitals were surveyed by a questionnaire based on a case-vignette with three scenarios of available information about patient's wishes for treatment.
A relationship between the perceived level of help and the chosen treatment option was established for all four samples, especially for the scenario in which an AD was available. Two patterns of closely related determinants appeared: (a) 'patient's wishes', 'ethical concerns', and 'family wishes'; and (b) 'patient's age', 'level of dementia', and 'hospital costs'.
An intensive and continuous education of physicians and nurses in medical ethics is required to promote patient autonomy in clinical practice. The ethical implications of patient's age and level of dementia in relation to hospital costs should constitute important topics of these educational programs.
To explain determinants in the decision-making of nurses in the treatment of severely ill incompetent patients and to describe underlying attitudes, consecutive samples of nurses from Germany and Sweden have been investigated by means of a case scenario and a questionnaire. Whereas the level of dementia emerged as the only factor being significantly related with the treatment option within the Swedish group, patient's age, patient's wishes and ethical concerns were correlated among German nurses. The more the nurses have been able to participate in the provision of the available do-not-resuscitate order or of an advance directive, the less frequent they would perform CPR against the patient's wishes.
Older people (those aged 65 years and over) are the major users of health care services, especially acute hospital beds. Since the creation of the NHS there has been concern that older people inappropriately occupy acute hospital beds when their needs would be best served by other forms of care. Many factors have been associated with delayed discharge (age, sex, multiple pathology, dependency and administrative inefficiencies). However, many of these factors are interrelated (or confounded) and few studies have taken this into account. Using data from a large study of assessment of older patients upon discharge from hospital in England, this paper examines the extent of delayed discharge, and analyses the factors associated with such delays using a conceptual model of individual and organisational factors. Specifically, this paper evaluates the relative contribution of the following factors to the delayed discharge of older people from hospital: predisposing factors (such as age), enabling factors (availability of a family carer), vulnerability factors (dependency and multiple pathology), and organisational/administrative factors (referral for services, type of team undertaking assessments). The study was a retrospective patient case note review in three hospitals in England and included four hundred and fifty-six patients aged 75 years and over admitted from their own homes, and discharged from specialist elderly care wards. Of the 456 patients in the sample, 27% had a recorded delay in their discharge from hospital of three plus days. Multivariate statistical analysis revealed that three factors independently predicted delay in discharge: absence of a family carer, entry to a nursing/residential home, and discharge assessment team staffing. Delayed discharge was not related to the hypothesised vulnerability factors (multiple dependency and multiple pathology) nor to predisposing factors (such as age or whether the older person lived alone). The delayed discharge of older people from hospital is a topic of considerable policy relevance. Our study indicated that delay was independently related to two organisational issues. First, entry into long-term care entailed lengthy assessment procedures, uncertainty over who pays for this care, and waiting lists. Second, the nature of the team assessing people for discharge was associated with delay (the nurse-coordinated team made the fewest referrals for multidisciplinary assessments and had the longest delays). Additionally, the absence of a family carer was implicated in delay, which underlines the importance of family and friends in providing posthospital care and in maintaining older people in the community. Our study suggests that considerable delay in discharging older people from hospital originates from administrative/organisational issues; these were compounded by social services resource constraints. There is still much to be done therefore to improve coordination of care in order to provide a truly 'seamless service'.
RÉSUMÉ
Un grand nombre de personnes ont besoin d'une sonde au cours de la dernière étape de leur vie. Par ailleurs, la décision du maintien des fonctions vitales revient souvent à une autre partie. Lorsque les membres d'une famille sont tenus de prendre cette décision pour un patient incompétent, quels facteurs influenceront leur choix? Une étude de cas et un sondage ethnométhodologique ont révélé clairement et en détail les facteurs ayant influencé une femme devant décider si les fonctions vitales de sa mére en état d'incapacité totale et de grave débilité devaient être maintenues au moyen d'une sonde pour gavage. La décision était difficile à prendre et survenait à un moment critique. Malheureusement, les facteurs ayant eu la plus forte influence furent les suivants: a) le besoin pressant d'une décision en raison d'un décès imminent; b) une lacune quant à la connaissance des valeurs et des préférences de la mère au sujet du maintien de ses fonctions vitales au moyen d'une sonde pour gavage; c) un manque de connaissance quant à la réalité de l'alimentation par sonde; et d) la croyance que cette mesure ne prolongerait pas la vie ni la souffrance de la mère. De plus, neuf autres facteurs, moins importants, ont été déterminés. Cette étude est principalement axée sur l'amélioration de la sensibilité des professionnels de la santé vis-à-vis de l'angoisse qu'éprouvent les gens à décider de maintenir les fonctions vitales d'un proche et du mode de décision en tant que tel.
Hospital elderly care teams in England assess whether patients need assistance, such as community or residential care, upon discharge from hospital. Does the type of multidisciplinary team influence post-hospital care decisions? The aim of this study was to identify which factors predict the services that older people receive upon discharge from hospital. Three multidisciplinary teams were compared where different professionals took the lead in co-ordinating the care assessment process. Data were collected in a case note review of patients (n = 456) aged 75 years and over: patient characteristics, referral patterns, and the types of service received in the month after leaving hospital. Multivariate statistical analysis (controlling for patient characteristics) showed different predictors for different post-hospital services. The nurse-led team was least likely to refer patients for care assessment and these patients received the least post-hospital services. The occupational therapy-led team arranged the most occupational therapy services and equipment and their patients received the most home care. The social work-led team referred the most patients for care assessment and their patients received the greatest range but not the greatest amount of services. These results suggest that multidisciplinary team configurations influence post-hospital services for older patients, reflecting professional preoccupations as much as patient care needs.
The study was performed in order to determine cross-culturally to what extent various attitudes (legal and ethical concerns, hospital costs, level of dementia, patient's age, patient's wishes, family wishes, doctor's religion) influence the treatment decisions of doctors in face of a critically ill incompetent elderly patient. Convenience samples of doctors in Sweden (n=104), Germany (n=191) and Russia (n=232) were surveyed by means of a self-administered questionnaire comprising a case-vignette of an incompetent elderly patient. The importance of various attitudes attributed to the treatment decision varied between countries. The differences were mostly pronounced for the importance of hospital costs (highest in Russia), patient and family wishes (both highest in Sweden) and level of dementia (highest in Sweden). They reflect diverging clinical practice and underlying societal values. They point to the necessity of the development of uniform standards and training of doctors in ethical issues.
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