Do advance directive attitudes and perceived susceptibility and end-of-life life-sustaining treatment preferences between patients with heart failure and cancer differ?

There is limited evidence on the relationships of preference for end-of-life life-sustaining treatments [LSTs] and diagnostic contexts like heart failure [HF] or cancer, and patient attitudes toward and perceived susceptibility to use advance directives [ADs]. Thus, this study aimed to compare attitudes and perceived susceptibility between HF patients and community-dwelling patients with cancer, and examine the associations of these variables with their preference for each LST (cardiopulmonary resuscitation [CPR], ventilation support, hemodialysis, and hospice care). Secondary data were obtained from 36 outpatients with HF (mean age, 65.44 years; male, 69.4%) and 107 cancer patients (mean age, 67.39 years; male, 32.7%). More patients with HF preferred CPR than cancer patients (41.7% and 15.9%, χ2 = 8.88, P = 0.003). Attitudes and perceived susceptibility were similar between the two diagnostic cohorts. HF patients and those with more positive attitudes had greater odds of preferring CPR (odds ratio [OR] = 3.02, confidence interval [CI] = 1.19, 7.70) and hospice care (OR = 1.14, CI = 1.06, 1.23), respectively. HF diagnosis and AD attitudes increased the preference for CPR and hospice care, respectively. This suggests that it is important to gain positive attitudes toward ADs and consider diagnostic context to facilitate informed decision-making for LSTs.

Systematic Approach to Selecting and Preparing a Medical Power of Attorney in the Gynecologic Oncology Center.

PURPOSE: Advance care planning (ACP) supports national priorities of patient engagement, person-centered care, and safety. A systematic approach is uncommon in most care settings. Our institution offers all patients with cancer new to the institution an opportunity to select and prepare a medical decision maker (MDM) after social work counseling. The goals of this study were to determine the success of a systematic institutional process for selecting a prepared MDM. The primary objectives were that (1) 70% or more of new patients would have one or more documented social work ACP discussions by the third office visit within 4 months, and (2) there would be a two-fold increase in scanned medical power of attorney (MPOA) documents available in the electronic health record (EHR). The secondary objectives were (1) improved surrogate preparedness for medical decision making, and (2) to determine whether patients with metastatic disease demonstrated greater readiness for selection of an MDM than those with localized disease. MATERIALS AND METHODS: We conducted a retrospective chart review of consecutive gynecology oncology outpatients. RESULTS: Of 133 patients, 93 (70%) had metastatic disease. The median number of visits was two (one to three). Forty-seven patients (39.3%) met with social work by visit 3. Review of ACP notes suggested that most patients were in the early stages of selecting a prepared MDM. At visit 1, 39 (29.3%) reported having an advance directive document; 14 (10.5%) had an MPOA in the EHR. There was no increase by visit 3. Fewer patients with metastatic disease than those with localized cancer (32.3% v 67.5%; P = .001) had three visits; no other parameter, including presence of MPOA documents in the EHR, achieved statistical significance between groups. CONCLUSION: Current processes fail to engage patients in selecting and preparing an MDM.

Advance directives from haematology departments: the patient's freedom of choice and communication with families. A qualitative analysis of 35 written documents.

BACKGROUND: In France, advance directives are favourably perceived by most of the population, although the drafting rate is low. This ambivalence is challenging because advance directives are meant to promote the autonomy and freedom of choice of patients. The purpose of this study was to analyse the content of advance directives written by patients suffering from malignant haemopathies to better understand how patients put them into practice. These could be relevant as early as the initial diagnosis of haematological malignancies because of the uncertain course of the disease. METHODS: This was a multicentre, qualitative, descriptive study. The advance directives written by patients with malignant haemopathies treated in one of the six French hospital departments were included in the study from 01/06/2008 to 15/04/2016. A thematic analysis of the advance directives was performed by two researchers: a senior haematologist and a research assistant. RESULTS: The median age of the patients was 69. Most were women (sex ratio: 0.59), living as a couple (57%), with lymphoid pathologies (66%), who were still alive two years after the instructions were written (63%) and had nominated a health care proxy (88.6%). Free texts (62.9%) were richer in content than pre-defined forms. The advance directives were used in three ways: for a purely legal purpose, to focus on medical treatments or actions, or to communicate a message to the family. Three main themes emerged: (1) refusal of medical treatment (100%), in which patients express refusal of life-sustaining care (97.1%). The actual treatments or the moment when they should be limited or stopped were not always mentioned in detail. (2) A desire for effective pain relief to avoid suffering (57.1%) and (3) messages for their family (34.3%), such as funeral arrangements (17.1%) and messages of love or trust (14.3%). CONCLUSIONS: Patients who write advance directives are not necessarily at the end of their lives. Their content mainly conveys treatment wishes, although patients also use them to pass on personal messages to their close family. This emerging role of advance directives to communicate messages within the family should be valued, even if it is not their original purpose.

Diretivas antecipadas de vontade: desafios legais e educacionais na visão de enfermeiros / Advanced directives of will: legal and educational challenges in the nurse's view

As Diretivas Antecipadas de Vontade (DAV) são um registro documental no qual o indivíduo descreve os procedimentos que gostaria ou não de ser submetido. Objetivou-se neste artigo discutir os desafios emergentes com o uso das DAV em termos éticos-legais e educacionais na visão de enfermeiros. Estudo qualitativo exploratório realizado mediante entrevistas semiestruturadas com 19 enfermeiros de Terapia Intensiva e Clínica Médica de um Hospital Universitário. A análise dos dados conduziu-se segundo a técnica de Análise Textual Discursiva. Emergiram duas grandes categorias de desafios associados às DAV: Desafios legais à sua adoção no Brasil e Desafios educacionais e de conhecimento relacionados à adoção das DAV; além de outros resultados aqui também explicitados. O tabu referente à morte, a carência de respaldo legal e de capacitações profissionais acerca da terminalidade e autonomia do enfermo surgem como desafios à divulgação e utilização das DAV na realidade estudada.

The Advanced directives of will (ADW) are documental registries which the individual describes the procedures that he or she would like to be submitted or not. The objective of this article is to discuss the emerging challenges to use the ADW in ethical-legal and educational terms from the nurse's view. An exploratory qualitative study composed of semi-structured interviews with 19 nurses from the Intensive Care and Medical Clinic of a University Hospital. We conducted the data analysis folling the Discursive Textual Analyisis technique. Two main categories of challenges associated to ADW emerged: Legal challenges related to ADW adoption in Brazil and Educational and knowledge challenges related to ADW adoption; besides other results also reported here. The taboo related to death, the lack of legal backing and professional training related to terminality and autonomy of the patient, arise as challenges to promote and to use ADW in the studied reality.

Opinions about the new law on end-of-life issues in a sample of french patients receiving palliative care.

BACKGROUND: In February 2nd 2016, the French government enacted the Claeys-Leonetti law that forbade euthanasia and established the right to deep and continuous sedation for end-of-life patients. Moreover, the law also obliges clinicians to abide by any advance directives regarding treatment and investigation, except in cases where they are "obviously inappropriate" in a given medical situation, or in cases of emergency, in order to allow medical staff to take time to assess the patient's situation. Artificial feeding and hydration are considered as treatment. The aim of this report is to investigate individuals receiving palliative care about their opinion about euthanasia, about advance directives, about the right to deep and continuous sedation, and the right to stopping artificial feeding and hydration. METHODS: The study was an opinion survey conducted among patients treated in two different palliative care institutions: a palliative care unit at the University Hospital (Timone, Marseille, France) and a non-profit association palliative care home ("La Maison", Gardanne, France). Face-to-face interviews were performed by two investigators. The survey included sociodemographics, clinical data, and opinions about euthanasia, deep and continuous sedation, stopping artificial feeding and hydration, and advance directives. RESULTS: Forty patients were interviewed. The mean age was 59.8 years (standard deviation 12). Fifty three percent reported opposition to legalized euthanasia. Eighty three percent were in favour of the right to deep and continuous sedation in patients with refractory pain, 75% when it concerns a patient unable to express their wishes, and 68% when the patient decides to stop vital treatment. Fifty eight percent reported that artificial nutrition and hydration should be considered as care. Fifty eight percent of the patients interviewed would like to see doctors follow the express wishes contained in advance care directives and 53% that advance directives should be subject to a validity period. CONCLUSIONS: This work demonstrates the feasibility of discussing sensitive issues such as euthanasia, continuous and deep sedation and cessation of care with patients receiving palliative care. These preliminary results point to the need to perform a larger study in order to find determinant factors in this specific situation and to incorporate them into thinking about end-of-life laws.

[Knowledge, attitude and opinion of patients regarding the new German legislation on advance care planning : Results of a survey in a department of general internal medicine]. / Wissen, Haltung und Meinung von Patienten zum neuen Patientenverfügungsgesetz : Ergebnisse einer Umfrage in einer allgemeininternistischen Abteilung.

BACKGROUND: In September 2009 a new legislation for advance care planning was introduced in Germany with the important characteristics of bindingness and unlimited validity for individual directives. Knowledge regarding this act and the attitude towards its characteristics among patients is unclear. AIM OF THIS STUDY: Analysis of knowledge, attitude and opinion of patients in a general internal medical department regarding advance care planning in general and the recent German legislation. METHODS: A total of 200 consecutive patients in an internal medicine ward were interviewed with the help of a questionnaire regarding their attitude to and knowledge on advance care planning in general and the current legislation. RESULTS: Approximately 40 % of the patients had issued some form of directive (either advance care directive or health care proxy) and only 7.5 % were advised by their physicians to make an advance directive. Patients with no directive were not willing to deal with dying and death, were not well-informed about directives or assumed that relatives or physicians would make an appropriate decision. Characteristics of the new legislation were controversially assessed; only 21 % of the patients wished to have a literal implementation of their directive. Regarding the content of an advance directive, more than 80 % of the patients voted for pain control in the palliative setting. CONCLUSION: The proportion of patients with a directive regarding advance care planning is only slowly increasing. Many patients are not well-informed, do not want to deal with dying or would like to delegate decisions to relatives and physicians. The present characteristics of the German legislation are controversially assessed and often do not represent the wishes of the patients.

Desafios da implementação das diretivas antecipadas de vontade à prática hospitalar / Desafíos para la implementación de las directivas anticipadas de voluntad en la práctica hospitalaria / Challenges to implementation of advance directives of will in hospital practice

RESUMO Objetivo: conhecer as dificuldades e limitações relacionadas à implementação das Diretivas Antecipadas de Vontade no contexto hospitalar. Método: estudo qualitativo, do tipo descritivo e exploratório, mediante entrevista semiestruturada com enfermeiros, médicos residentes e cuidadores familiares. Os dados foram analisados por meio da técnica de análise textual discursiva e ancorados no referencial dos princípios da bioética. Resultados: emergiram as categorias: A terminalidade como expressão de derrota e a cura como opção para o cuidado? Receios das implicações legais; Diretivas Antecipadas de Vontade requerem autonomia do paciente e adequada comunicação. Conclusão: as limitações e dificuldades atribuídas à prática das diretivas antecipadas de vontade, na perspectiva dos participantes, indicam, além dos inúmeros conflitos e dilemas relacionados às questões de final de vida, que vivências da iminência da morte não têm possibilitado que os desejos dos pacientes sejam respeitados.

RESUMEN Objetivo: conocer dificultades y limitaciones relacionadas a la implementación de las Directivas Anticipadas de Voluntad en el contexto hospitalario. Método: estudio cualitativo, de tipo descriptivo y exploratorio, mediante entrevista semiestructurada con enfermeros, médicos residentes y cuidadores familiares. Los datos fueron analizados por técnica de análisis textual discursivo, y fundamentados en referencial de principios de la bioética. Resultados: surgieron las categorías: ¿La terminalidad como expresión de derrota y la cura como opción para el cuidado? Temores a las implicaciones legales; Las Directivas Anticipadas de Voluntad requieren de autonomía del paciente y de adecuada comunicación. Conclusión: las limitaciones y dificultades atribuidas a la práctica de las directivas anticipadas de voluntad, en la perspectiva de los participantes, indicaron, además de los numerosos conflictos y dilemas relacionados al final de la vida, que las vivencias de la muerte inminente no han permitido que los deseos de los pacientes sean respetados.

ABSTRACT Objective: to understand the difficulties and limitations in the implementation of advance directives of will in the hospital context. Method: qualitative, exploratory and descriptive study conducted by means of semi-structured interviews with nurses, resident physicians and family caregivers. The data were analyzed by using discursive textual analysis based on the framework of bioethics principles. Results: the following categories emerged: Terminality as an expression of loss and cure as an option for care; concerns about legal implications; advance directives of will demand patient autonomy and proper communication. Conclusion: limitations and difficulties in practice of advance directives of will from the perspective of the participants show, apart from countless conflicts and dilemmas regarding end-of life matters, that impending death experiences obstruct patients' wishes.

[Advance directives in dermato-oncology: The current situation and future prospects]. / Directives anticipées en dermato-oncologie : situation actuelle et perspectives.

INTRODUCTION: Patient information and advance directives (AD) are described in the French laws of 4 March 2002 and 22 April 2005, which concern the decisions of subjects regarding end-of-life treatment. At present, practitioners rarely seek the opinion of patients on this matter. The Claeys-Leonetti law requires doctors to identify any advance directives by patients, which are binding upon medical staff. The present study sought to analyse the extent of application of the laws of 2002 and 2005 and to collect the observations of clinicians in dermato-oncology regarding the new legislation. METHODS: We contacted members of the French dermato-oncology group by email and asked them to assess their practices with regard to information provision, patient surrogates and advance directives. RESULTS: To 111 requests we received 34 replies from hospital dermatologists, i.e. a response rate of 31 %. In all, 85 % of clinicians informed patients with metastasis that their disease was incurable, and 94 % stated that they have procedures in place concerning the appointment of a patient surrogate. One third of respondents reported having a procedure in place for provision of information or collection of advance directives. According to 91 % of clinicians, the binding nature of advance directives did not constitute any loss of chance for the patient in question; 59 % felt that the new law would affect their practices, but of these, paradoxically, 60 % felt that this would have no impact on their therapeutic decision-making. In all, 26 clinicians (76.5 %) did not intend to modify their decision-making process. CONCLUSION: The law of 2002 is generally better known than that of 2005. Dermato-oncologists are not aware of the practical consequences of the new binding nature of advance directives with regard to the doctor-patient relationship and the actual decision-making process.

[Can the vascular specialist improve patient awareness about advanced directives?]. / Le médecin vasculaire peut-il sensibiliser ses patients aux directives anticipées sur la fin de vie ?

INTRODUCTION: In France, the Leonetti law, adopted on April 22, 2005, stipulates the regulations concerning advanced directives. This is a patient's right that is not well known and rarely applied. In 2015, a new law project was thus presented in which the French National Authority for Health recommended that doctors, including all specialists, bring up the subject, especially during consultation. OBJECTIVES: To evaluate the vascular specialist's possibility to mention the topic of advanced directives during consultations. METHOD: A single and non-interventional prospective study conducted with the help of patients who consulted a private practitioner vascular specialist: recurrent patients regularly consulting a private practitioner vascular specialist were included. First-time consultants, minors and patients to whom it was not adapted to speak about the subject were not included. RESULTS: Between July 27 and September 23, 2015, 159 consecutive patients were examined. Fifty-five first-time consultants and four patients for whom the interview was unsuitable were excluded. In all, 100 patients were questioned. None of them refused to talk about the subject. Women made up a majority of the population (63 %) with an average age of 67 years (23-97). The principal diagnostics were common to vascular medicine consultations: deep vein thrombosis (20 %), peripheral arterial disease (15 %), varicose veins (11 %), lymphedema (11 %) and leg ulcers (9 %). Thirteen percent of the people had a history of cancer. Half of the patients had had follow-ups for over 10 years. The average time devoted to discussing the topic was 12minutes (5-40). Only 22 % of the patients declared having been familiar with advance directives. Once informed however, 78 % chose to write up an adapted form: 36 % with the help of their doctor and 42 % with a doctor and a relative. Seventy-three percent of the consultants thought that talking about the advance directives would reinforce the confidence link between the doctor and the patient. CONCLUSION: In private practice vascular medicine, it seems possible to mention the subject of advance directives, as recommended by the French authorities. The procedure is well perceived by the patients. It nevertheless implies allotting a non-negligible amount of additional consultation time. The reinforcement of the doctor-patient relationship suggested by these results should be confirmed by a qualitative study made up of meetings.

[The suitability of therapeutic effort: An end-of-life strategy]. / Adecuación del esfuerzo terapéutico, una estrategia al final de la vida.

End-of-life treatment and attention to the needs of relatives are not adequate for several reasons: Society denies or hides the death; it is very difficult to predict it accurately; treatment is frequently fragmented between different specialists, and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts with decisions made at the end of life, particularly the suitability of therapeutic effort. The attitude of professionals on the adequacy of therapeutic effort is not homogenous, and varies depending on the specialty, experience, and beliefs. Many doctors are still afraid of inconveniencing patients. Primary care is in a privileged position to approach the life and values of our patients and their families, and not just the disease, which makes it the right place to guide and advise the patient on the preparation and registration of living wills.

[Advance directives in Italy: a goal not yet reached but already passed?]. / Direttive anticipate in Italia: un obiettivo non ancora raggiunto ma già superato?

The advance directives (ADs) have been adopted in many countries to defend patients' autonomy. In Italy, in the past, this topic gave rise to a heated debate involving philosophers, theologians, and politicians. In 2009, the government presented a bill of law on ADs firmly criticized from a scientific, moral and juridical point of view because the bill's content is against the principles of Italian Constitution, Italian Code of Medical Ethics, Oviedo Convention, and official statements of many scientific societies. Although the bill has passed the Low Chamber it lies, even since, in the Senate, lacking in regard any agreement among the political parties. The purpose of this article is to highlight that, in our country, patients, relatives and doctors deserve a law not only related to the specific topic of ADs, but - as in other European countries (Germany, Spain, France, UK) - aimed to deal with the complex issue of end of life care as a whole. This law should take into account the sound evidence existing in regard to the four fundamental principles supporting the best scientific and ethical approaches to the end of life issues: shared decision making process between doctors and patients/relatives; rejection of dying process marked by the suffering; withholding/withdrawing futile treatments together with palliative sedation as two crucial contributions to suppress the patient suffering and pain; clear-cut difference between these clinical/ethical options and euthanasia. At the same time, this law should be able to provide physicians with a legal coverage to make all the clinical and ethical decisions more and more complex because of the continuous evolution of medical science on one hand, and the impressive development of biotechnology on the other hand.

Understanding the Code: acting in a patient's best interests.

The revised Code of the Nursing and Midwifery Council (NMC), the statutory professional regulator for registered district nurses, makes clear that while district nurses can interpret the values and principles for use in community settings, the standards are not negotiable or discretionary. They must be applied or the district nurse's fitness to practice will be called into question. In this article in the continuing series analysing the legal implications of the Code on district nurse practice, the author considers the fourth standard that requires district nurses to act in the best interests of people at all times.

[Health care power of attorney project at the University Hospital Frankfurt]. / Patientenautomonie und Aufklärung - Implementierung einer "Gesundheitsvollmacht" am Universitätsklinikum Frankfurt.

Under German law it is the patient alone who has the right to decide whether or not to undergo a particular medical procedure. Treating a patient without his or her consent always constitutes a serious infringement of the patient's constitutional right of self-determination as well as the right to physical integrity. By issuing a power of attorney in health care matters to a person he or she trusts, a patient can safeguard his or her rights in the event of incapacitation. At the University Hospital Frankfurt patients who are scheduled for major elective surgery are informed about the advantages of a health care power of attorney during premedication. The University Hospital has developed its own health care power of attorney form for patient use. In addition, patients have the option of receiving additional information about other types of health care advance directives, such as a living will.

Advance Directives-The Israeli Experience.

CONTEXT: A major step in end-of-life care was achieved in December 2005 when the Israeli parliament passed the "Dying Patient Law." The law (§31-§36) allows a competent person, even if he/she is healthy, to leave written instructions known as advance medical directives (AD), in which they explain their wishes in detail with respect to future medical treatment should it be determined that they are an incompetent terminally ill patient, as defined by the provisions of that law. OBJECTIVES: The aims were to characterize the group of individuals that completes ADs, characterize the content of recorded ADs, and analyze trends associated with them. METHODS: We performed a cross-sectional study of the entire population that signed ADs in Israel from 2007 to September 2010. All computerized AD forms were retrieved from the Ministry of Health's database. A descriptive analysis of trends, characteristics, and authorized procedures relating to the population of AD signatories was done. RESULTS: There was an increase in the number of ADs signed during the study period (1167 signatories). About 90% of the AD signatories were 65 years of age or older and 95% were healthy at the time they completed the AD. In an end-stage condition, the mean number of procedures declined was 16.6 ± 4.7 of 19. In a non-end-stage condition, the corresponding mean number was 12.7 ± 3.7 of 15. CONCLUSION: There is a need to increase awareness in the general population of the option to prepare ADs. Family physicians, oncologists, and geriatricians should be more involved in this process.

Code status discussions in psychiatric and medical inpatients.

BACKGROUND: The Patient Self-Determination Act along with regulatory standards and institutional standards of care highlight the need for collaboration between care providers and patients with respect to goals of care and, in emergency situations, code status and measures to be taken in keeping with patients' wishes. Addressing code status may be lacking in patients who require psychiatric hospitalization due to the nature of psychiatric illness, relative medical stability, and a general expectation of survival. We sought to compare code status documentation and discussion between psychiatric and medical inpatients, as this knowledge will help shape future interventions for process improvement. METHOD: We conducted a retrospective chart review of hospitalized patients in psychiatric and medical units during a 12-month period in 2008. For those with multiple admissions, we reviewed only the index (or first) hospitalization. Data collected included demographic information, clinical information regarding cancer as a primary diagnosis or a diagnosis that met National Hospice and Palliative Care Organization (NHPCO) guidelines, code status order and discussion documentation, the presence of an advance directive, length of stay, and 1-year mortality. Data were summarized using mean values, percentages, and frequencies. The 2 groups (psychiatric and medical groups) were compared. RESULTS: The charts of 276 psychiatric patients and 317 general medical patients were reviewed. More psychiatric patients had dementia (P < .001). Medical inpatients had a higher rate of code status order documented on admission (96% vs 65%, P < .001) and "full-code, discussed" order (67% vs 33%, P < .001). Psychiatric inpatients had more "do not resuscitate/do not intubate" orders (20% vs 13%, P = .037), more frequent changes in code status order (18% vs 7%, P < .001), and a higher percentage of advance directives (46% vs 25%, P < .001). CONCLUSIONS: A code status discussion with hospitalized patients needs to occur at admission regardless of reason for admission. Strategies are needed to improve this process for psychiatric inpatients.

Evaluation of occupational exposure to ELF magnetic fields at power plants in Greece in the context of European directives.

The scope of this paper is to comparatively present the extremely low-frequency (ELF) measurements performed at four power plants in Greece, focusing on: (a) the worst-case exposure conditions, (b) the existence of magnetic field harmonic components, (c) the technical similarities among the power plants and (d) comparison of the measured percentages of reference levels at typical working areas in the power plants. A detailed measurement methodology is proposed, including broadband on-site inspection of the working areas, weighted averaged root-mean-square and peak values of magnetic flux density, percentage of reference levels, according to 1998 ICNIRP guidelines and harmonic analysis of the multi-frequency magnetic fields. During the analysis of the occupational exposure in all power plants, the new Directive 2013/35/EU has been taken into account. The study concludes by proposing a mapping procedure of working areas into certain zones, in order to take measures for workers safety.

[Advance Directives - Not a Lot of Margin for Error - The Surgeon's View of a Complex Medical-Legal Topic]. / Patientenverfügungen - welchen Spielraum erlauben sie? - Chirurgische Sicht auf ein komplexes medizinjuristisches Thema.

Since September 1st, 2009, the most recent version of the German "Betreuungsrechtsänderungsgesetz" has been validated by the legislators. It precisely sets out how physicians and nursing staff have to deal with a written declaration of a patient's will. This new law focuses in a special way on advance directives, describes the precise rules for the authors of an advance directive and shows both its sphere of action and its limitations. This article aims to give an overview on the legal scope of advance directives, and to illustrate potential limitations and conflicts. Furthermore, it shows the commitments and rights of the medical team against the background of an existing advance directive.

[Experiences of Austrian nursing staff in dealing with advance directives]. / Umgang von österreichischen Pflegepersonen mit der Patientenverfügung.

BACKGROUND: Advance directive is a contemporary issue because of accentuation of patients' autonomy and the increasing medical progress. But problems arise in drafting an advance directive as well as in realisation of advance directives in institutions. The duties and the influence of nursing in this context are hardly an object of scientific investigations. This article first describes empirically the role of nurses in connection with advance directives. AIM: AIM of this study is the description of nurses' experiences in connection with advance directives. METHOD: A descriptive-explorative cross-section design was used for this study. Data were recorded by means of a semi-structured questionnaire. This questionnaire was handed out to 266 nurses working at an Austrian university hospital. RESULTS: On the part of nurses there is a great insecurity with concurrent existence of sufficient theoretical professional knowledge and missing structures of the part of organisation. Because of these situations some interdisciplinary conflicts arise in connection with realisation of advanced directives. CONCLUSION: To avoid conflicts and to improve the handling and realisation of advance directives in practice it is recommendable to establish clinical ethical consultation. The tasks of the clinical ethical consultation are the creation and implementation of ethical directives in the institution, the realisation of individual case discussions and the ethical education of the affected health care professionals.