Attitudinal patterns determining decision-making in the treatment of the elderly: a comparison between physicians and nurses in Germany and Sweden.

OBJECTIVE: 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. DESIGN AND PARTICIPANTS: 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. RESULTS: 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'. CONCLUSIONS: 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.

The compliance of doctors and nurses with do-not-resuscitate orders in Germany and Sweden.

A questionnaire based on a case-scenario offering three levels of available information about the patients' wishes was circulated with the objective to evaluate compliance with do-not-resuscitate orders (DNR) and advance directives (AD) from a cross-cultural perspective. Replies from 191 doctors and 182 nurses from Germany and 104 doctors and 122 nurses from Sweden were studied. The frequency of cardiopulmonary resuscitation (CPR) performed against the patients wishes varied between 32.5% (German doctors for DNR-scenario) and 8.3% (Swedish nurses for AD-scenario). The variance regarding the CPR decision could be explained by the help obtained by increasing information regarding the patients wishes and preferred treatment options. Since compliance is related to detailed information given by the patient the use of DNRs and ADs should be encouraged to a larger extent.

Attitudinal patterns determining decision-making in severely ill elderly patients: a cross-cultural comparison between nurses from Sweden and Germany.

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.

Personality characteristics of physicians and end-of-life decisions in Russia.

OBJECTIVE: To explore the relationships between personality characteristics, underlying attitudes, and treatment decisions for severely ill elderly patients in a sample of Russian doctors. DESIGN: Survey. SETTING: Group sessions during meetings or individual presentations of questionnaire. SUBJECTS: A convenience sample of 231 physicians from the Archangelsk region in northern Russia who frequently encounter treatment situations with incompetent elderly patients. MEASUREMENTS: Temperament and Character Inventory (Cloninger et al, 1994) for assessing personality dimensions. The questionnaire on decision-making is based on the original developed by Molloy and coworkers from McMaster University in Canada. In a case-vignette, the condition of an 82-year-old man with acute gastrointestinal bleeding is described comprehensively in combination with 3 different levels of information about the patient wishes (no information, DNR order, advance directive). Questions about importance of legal concerns, patient and family wishes, hospital costs, patient's age and level of dementia, and physician's religion for the doctor's decision-making are added. MAIN RESULTS: No significant relationship was found between chosen treatment options and personality traits in any of the 3 situations. However, personality characteristics such as self-directedness, cooperativeness, and self-transcendence, in particular, show significant relationships with attitudes underlying these decisions. CONCLUSIONS: Physicians should be trained to improve their cooperative abilities in the treatment of severely ill elderly patients to be better prepared for their decision-making and coping concerning end-of-life decisions and the use of do-not-resuscitate orders and advance directives. Ethical values in clinical practice, especially patient autonomy, should be addressed during the early stage of the medical curriculum.

[Decisions and attitudes of nurses caring for severely ill elderly patients: a culture-comparing study]. / Entscheidungen und Einstellungen von Krankenschwestern bei der Behandlung schwerkranker alter Menschen: Eine kulturvergleichende Studie.

Results of a comparative investigation in Swedish and German nurses are presented. Based on a case-vignette with three levels of available information about patient wishes the subjects were asked about their decisions. Generally, the Swedish nurses showed a tendency towards less aggressive treatment-options and to perform less frequent cardio-pulmonary resuscitation (CPR) against the patient written will compared with the Germans. The compliance with patient wishes among nurses from both countries was related with the valuation of the patient directive as a useful tool in their decision-making process. Furthermore, the "level of dementia" emerged as a significant predictor of the treatment decision in both groups. The results point to the necessity of continuous education and training of nurses aiming at the issues of ethical attitudes and coping with ethically problematic situations in the treatment of the elderly in order to improve patient autonomy.