Ethical challenges in primary care: a focus group study with general practitioners, nurses and informal caregivers.

BACKGROUND: General practitioners (GPs), nurses and informal caregivers are often jointly involved in healthcare situations in which ethical issues play an important role. OBJECTIVES: To describe ethical problems from the perspective of these three groups and to investigate whether there is a common experience of ethical issues in primary care. METHODS: We conducted six focus groups with general practitioners, nurses and informal caregivers in Germany. We asked the participants to describe at least one experience of ethical problem in detail and documented the findings by an illustration software that visualized and structured the discussion. We used thematic analysis to identify ethical problems and to develop categories of ethical issues. RESULTS: Problems reported barely overlapped. GPs had to do mainly with uncertainty about the scope and limits of their responsibility for patients. Nurses were concerned about bureaucratic and other barriers to professional care and about dual loyalty if they had to consider the conflicting interests of patients and family members. They often felt powerless and unable to act according to their professional standards. Informal caregivers reported problems that resulted from role strain and being both a family member and a caregiver. GPs, nurses and informal caregivers sometimes perceived the other parties as a source of ethical problems. CONCLUSIONS: All parties may benefit from ethics support services, a rarity in German primary care so far. Furthermore, nurses' self-confidence towards GPs, demanding patients and family members has to be strengthened. Informal caregivers, the most vulnerable group, need more attendance and tailored support.

[The Frequency of Ethical Conflicts in Primary Care and the Need for Ethical Consultations - The Perspective of General Practitioners]. / Häufigkeit ethischer Konflikte in der ambulanten Versorgung und Bedarf an Ethikberatung ­ aus Sicht von Hausärzten.

BACKGROUND: Our knowledge about ethical conflicts in primary care is limited. The aim of this study was to ascertain the frequency of ethical conflicts and the need of professional consultation services - seen from the perspective of general practitioners (GPs). METHODS: A random sample of GPs from Lower Saxony, a federal state of Germany, received a standardized questionnaire about their experiences with ethical conflicts and their need for an ethical consultation. RESULTS: A total of 456 GPs took part in the survey (response rate = 45.6 %). Eighty percent experienced the conflict of a "withdrawal of medicines due to questionable benefit for the patient" once in 3 months, at least (95 % confidence interval: 76.0 to 83.6 %). Further frequent conflicts were "the continuation of a therapy of questionable benefit" (68 %; 63.3 to 72.0 %) and the "usefulness of diagnostic procedures for early detection of diseases and risk factors in seriously ill patients" (62 %; 57.7 to 66.8 %). About one-third (138/451) of the participants requested an ethical consultation. GPs frequently wished an ethical consultation by phone. CONCLUSIONS: Although GPs experienced several of the ethical conflicts frequently, only one-third requested an ethical consultation. Low threshold offers may be a way to make ethical consultations more attractive for GPs.