Researcher studies nurses' end-of-life care choices for patients

May 15 2013

Nurses will use extreme measures to save their patients and parents; but if they were dying, they prefer less aggressive ones for themselves, according to results from an international survey on nurses' end-of-life preferences.

The April issue of the International Nursing Review reported the findings about the end-of-life preferences of 1,089 nurses in the first multinational and cross-cultural view of nurses' end-of-life care choices.

Two factors influenced the care of people dying: lack of knowledge about the patient's wishes and the call of duty, according to Joyce Fitzpatrick, PhD, RN, FAAN, from the Frances Payne Bolton School of Nursing at Case Western Reserve University and a lead investigator on the study.

"Globally nurses chose different EOL treatments for themselves than they do for their patients," Fitzpatrick said. "The question is if they chose this as best personal choice, why isn't it the one for the patients?"

Fitzpatrick was part of a group of researchers that sought more information about end-of-life preferences among nurses. While doctors and families have been widely studied, the nurses' perspective is missing.

To find answers, nurses in Hong Kong, Ireland, Israel, Italy and the United States responded to a survey using three hypothetical scenarios of dying patients to find out what nurses in the different countries would do for the patient, their parents and themselves.

The foremost voice in the end-of-life decision is the patient. "Making these decisions is complicated when the patient is unable to speak due to cognitive or medical problems," said Fitzpatrick, Elizabeth Brooks Ford Professor of Nursing at the Frances Payne Bolton School of Nursing. Then the hard and emotional decision is left to the family and healthcare professionals.

For many years, the decision was left to the doctor. But, efforts are underway globally to give the patient a choice in the decision through advance directives of what to do if incapacitated or health proxies to speak and decide when the patient is unable. The United Kingdom, Australia, Canada, Israel, U.S. and several other European countries have adopted the advance directives.

But Hong Kong, Ireland and Italy do not have them in place.

The researchers report that end-of-life issues are in the midst of a global social debate on type of treatment, who makes the decisions (family or doctor) and when differences arise between the family and doctor, who has the power to decide.

Fitzpatrick said this study contributes some answers to this complicated issue and the nurses' perspective.

Nurses for the study were recruited through leaflets distributed in clinical settings, with the goal to recruit 200 nurses from each country. Surveying took place between June 2011 and July 2012.

The respondents provided demographic information and then read a scenario about an 84-year-old male Alzheimer's patient in a nursing home who had gastrointestinal bleeding, was in shock and likely to die without an intervention. Participants had to chose from one of four treatment options: palliative, limited, surgical or intensive care.

The scenario was repeated with the old man as the survey-taker's father and in the third scenario they were to imagine themselves in the role of the older man.

They also were asked about their preference for using CPR or feeding tubes. Nurses from all countries would use CPR with the data ranging from 55 percent from Hong Kong to 85 percent in the U.S. These numbers also reflected the choice for the parent and participant.

Divergent responses came for the tube feeding intervention. Again a majority of the nurses would give the patient and the parent tube-feeding support. Those numbers dropped for the nurses from only 25 percent in Italy (48 percent for their parents) to 34 percent of nurses in Hong Kong (65 percent for their parents).

Then the participants responded to 18 factors that might influence their care decisions using a scale of never to always.

Comparing the nurses' influencing factors for the end-of-life decisions, they globally reported the influences of their duty of care, uncertainty of the acute outcome, lack of knowledge of the patient's wishes, personal experiences with a family member, the patient's age, and lack of contact with the family.

Fitzpatrick said this study contributes important information in developing global policies that provide patients with end-of-life choices.

Source: Case Western Reserve University