Turkish critical care nurses' views on end-of-life decision making and practices.

BACKGROUND: Life-sustaining treatments are increasingly used in intensive care units (ICUs) for EOL care, but the decision to use these may cause ethical issues. AIMS AND OBJECTIVES: The aim of this study was to investigate the views and practices of critical care nurses in Turkey on the end-of-life (EOL) care. DESIGN: This was a cross-sectional study. METHODS: The research was conducted in 32 second- and third-level ICUs of 19 Ministry of Health research hospitals in Turkey. The Views of European Nurses in Intensive Care on EOL Care tool was used for data collection. RESULTS: The total sample size was 602. While half of the nurses stated that the withholding and withdrawal of life support were ethically different decisions, 40% felt both decisions were unethical. The expected quality of life as viewed by the patient, the medical team, the family and the nursing team (90·4%, 85·4%, and 83·4%, respectively) was an important factor in EOL decision making. The majority of the nurses (75·7%) were not directly involved in the EOL decision making and 78·4% of nurses were committed to family involvement in EOL decisions. When withdrawing treatment, 87·2% of ICU nurses agreed that the patient and family members should perform their final religious and spiritual duties. Further results showed that after withdrawing treatment, a majority of nurses (86%) agreed to continue pressure sore prevention, effective pain relief (85·5%), nutritional support (77·6%) and hydration (64·8%). Almost half (48·2%) indicated that keeping the patients in the ICU was unnecessary. CONCLUSION: ICU nurses expressed a range of experiences and practices regarding EOL care. ICU nurses should be more involved in the decision-making process about EOL care. RELEVANCE TO CLINICAL PRACTICE: Due to their unique relationship with patients, nurses should be involved in EOL care decision making; however, patients, families or nurses are not often involved in the decision-making process in Turkey.

Attitudes of physicians and patients towards disclosure of genetic information to spouse and first-degree relatives: a case study from Turkey.

BACKGROUND: When considering the principle of medical confidentiality, disclosure of genetic information constitutes a special case because of the impact that this information can have on the health and the lives of relatives. The aim of this study is to explore the attitudes of Turkish physicians and patients about sharing information obtained from genetic tests. METHODS: The study was carried out in Kocaeli, Turkey. Participants were either paediatricians and gynaecologists registered in Kocaeli, or patients coming to the genetic diagnosis centre for karyotype analysis in 2008. A self-administered paper questionnaire was given to the physicians, and face-to-face structured interviews were conducted with patients. We used a case study involving a man who was found to be a balanced chromosome carrier as a result of a test conducted after his first baby was born with Down's syndrome. However, he refused to share this information with his wife or his siblings. Percentages of characteristics and preferences of the participants were calculated, and the results were analysed using Kruskal-Wallis test. RESULTS: A total of 155 physicians (68% response rate) and 104 patients (46% response rate) were participated in the study. Twenty-six percent of physicians and 49% of patients believed that genetic information belongs to the whole family. When participants were asked with whom genetic information should be shared for the case study, most of the physicians and patients thought the physician should inform the spouse (79%, 85%, respectively). They were less likely to support a physician informing a sibling (41%, 53%, respectively); whereas, many thought the testee has an obligation to inform siblings (70%, 94%, respectively). CONCLUSIONS: Although Turkey's national regulations certainly protect the right of privacy of the testee, the participants in our study appear to believe that informing the spouse, who is not personally at risk of serious damage, is the physician's responsibility, while informing siblings, is the testee's responsibility. Therefore we believe that opening ethical discussions with clinicians about the sharing of genetic information, establishing guidelines for practice and sharing these guidelines and the reasons behind them with the wider population, will help to pre-empt ethical dilemmas.

Determination of national midwifery ethical values and ethical codes: in Turkey.

It is important to define and practice ethical rules and codes for professionalisation. Several national and international associations have determined midwifery ethical codes. In Turkey, ethical rules and codes that would facilitate midwifery becoming professionalised have not yet been determined. This study was planned to contribute to the professionalisation of midwifery by determining national ethical values and codes. A total of 1067 Turkish midwives completed the survey. The most prevalent values of Turkish midwives were care for mother-child health, responsibility and professional adequacy. The preferred professional codes chosen by Turkish midwives were absence of conflicts of interest, respect for privacy, avoidance of deception, reporting of faulty practices, consideration of mothers and newborns as separate beings and prevention of harm. In conclusion, cultural values, beliefs and expectations of society cannot be underestimated, although the international professional values and codes of ethics contribute significantly to professionalisation of the midwifery profession.

Ibtisam Lale Atahan (1946-2007): The first female Turkish physician in the discipline of radiation oncology.

Female physicians started to earn up their deserved places as late 1970's in the historically male predominant Radiation Oncology community. The first female physician emerging as a leading scientist in the Discipline of Radiation Oncology was Professor Ibtisam Lale Atahan, who untimely passed away in 2007. This eulogy attempts to shine the light on her life, achivements and legacy.

Attributes of a good physician: what are the opinions of first-year medical students?

BACKGROUND: Undergraduate medical education is beginning to concern itself with educating students about professional attributes as well as about clinical knowledge and skills. Defining these characteristics, and in particular seeking the help of the students themselves to define them, can be a useful starting point when considering how to incorporate aspects of professional behaviour into the medical curricula. METHOD: This study explores the views of first-year medical students at Kocaeli University Faculty of Medicine in the 2007-8 academic year. The students were asked the open-ended question: 'What, in your opinion, are the attributes a good physician should have?' Four topics were defined by researchers based on the undergraduate and graduate education projects. The attributes expressed by the students were evaluated by the researchers according to these topics and compared with the topics covered in the undergraduate and graduate education projects. RESULTS: A total of 127 students responded, and between them suggested 756 attributes. The majority of these attributes (54.6%) were concerned with interpersonal relations and communication, whereas the category representing the fewest attributes (12.3%) was that involving scientific knowledge and medical practice. In general, students' perception corresponded to the concept of the 'competent physician' as described in the professionalism projects, but attributes reflecting their world-view were also expressed. CONCLUSION: Experience suggests that the active participation of students in determining which attributes are necessary for a good physician is a positive way of ensuring they embrace the importance of such qualities and attributes in themselves.

Turkish nurses' decision making in the distribution of intensive care beds.

The aim of this study was to assess the opinions and role of intensive care unit (ICU) nurses regarding the distribution of ICU beds. We conducted this research among 30% of the attendees at two ICU congresses in Turkey. A self-administered questionnaire was used, which included 13 cases and allocation criteria. Of the total (136 nurses), 53.7% participated in admission/discharge decisions. The most important criterion was quality of life as viewed by the physician; the least important was the patient's social status. According to the findings, the nurses thought that medical benefit and avoiding discrimination were important. On the other hand their ignorance of patients' autonomous preferences arouses suspicions about these nurses' role in advocating for patients' rights. For this reason, nurses' role in allocation decisions should be clearly described and should also be the basis on which intensive care nurses' duties in allocation decisions should be determined.

Triage decisions of emergency physicians in Kocaeli and the principle of justice.

BACKGROUND: We aimed to examine the accuracy of triage decision-making among emergency physicians, using a multiple casualty scenario. This will assist in determining the necessity of triage training, which is the foundation of emergency medical ethics. METHODS: A self-administered questionnaire including a multiple casualty scenario requiring each casualty to be prioritized for treatments by Simple Triage and Rapid Treatment (START) was given to 110 emergency physicians working at pre-hospital and hospital emergency services in Kocaeli. The differences between personal/professional characteristics and triage decisions were analyzed using chi-square test. RESULTS: Accurate triage decision rates of the emergency physicians ranged from 83.6% to 90.0% for four immediate casualties, 26.4% to 78.2% for seven urgent casualties, 70.9% to 91.8% for four delayed casualties, and 82.7% to 97.3% for two dead cases. Personal and professional characteristics were found to be statistically significant in five cases (p<0.05). CONCLUSION: This study showed that emergency physicians tended to under-triage patients. This result and the discrepancy of the accuracy rates in urgent casualties revealed the necessity for improvement in medical-ethical decision-making in the training programs. This improvement will help in reducing violation of the important duties of justice and of do no harm by the emergency physicians.

[Informed consent in emergency medicine]. / Acil tip'ta aydinlatilmis onam.

Informed consent is a prerequisite for the ethical and legal validity of the emergency intervention in emergency medicine, since it protects the fiduciary relationship between the physician and patient; the principle of honesty that grounds this relationship; the principle of autonomy that necessitates right of self-determination; and the principle of respect for persons. Informed consent in emergency medicine, which is supposed to include the nature, benefits and risks of emergency medical intervention, differentiates with respect to definite groups of patients: (1) conscious patients, (2) unconscious patients, and (3) children and mature minors. In addition, informed consent differentiates between medical, psychological and even social circumstances of the patients, referred to as valid consent, expressed-explicit consent, blanket consent, presumed consent, tacit consent, proxy consent, and parental consent. There are a few exceptions in which emergency medical intervention is administered without informed consent. In addition to the exceptions of life-saving interventions, when a patient can not decide for herself/himself, intervention of the physician in the best interest of the patient or children is based on the "therapeutic privilege" of the physician. As an ethically defensible right, since therapeutic privilege may open a door to hard paternalistic approaches, in those situations, emergency physicians should be cautious not to violate a patient's autonomy.

Factors affecting the attitudes and opinions of ICU physicians regarding end-of-life decisions for their patients and themselves: A survey study from Turkey.

INTRODUCTION: Turkey is constitutionally secular with a Muslim majority. There is no legal basis for limiting life-support at the end-of-life (EOL) in Turkey. We aimed to investigate the opinions and attitudes of intensive care unit (ICU) physicians regarding EOL decisions, for both their patients and themselves, and to evaluate if the physicians' demographic and professional variables predicted the attitudes of physicians toward EOL decisions. METHODS: An online survey was distributed to national critical care societies' members. Physicians' opinions were sought concerning legalization of EOL decisions for terminally ill patients or by patient-request regardless of prognosis. Participants physicians' views on who should make EOL decisions and when they should occur were determined. Participants were also asked if they would prefer cardiopulmonary resuscitation (CPR) and/or intubation/mechanical ventilation (MV) personally if they had terminal cancer. RESULTS: A total of 613 physicians responded. Religious beliefs had no effect on the physicians' acceptance of do-not-resuscitate (DNR) / do-not-intubate (DNI) orders for terminally ill patients, but atheism, was found to be an independent predictor of approval of DNR/DNI in cases of patient request (p<0.05). While medical experience (≥6 years in the ICU) was the independent predictor for the physicians' approval of DNI decisions on patient demand, the volume of terminal patients in ICUs (between 10-50% per year) where they worked was an independent predictor of physicians' approval of DNI for terminal patients. When asked to choose personal options in an EOL scenario (including full code, only DNR, only DNI, both DNR and DNI, and undecided), younger physicians (30-39 years) were more likely to prefer the "only DNR" option compared with physicians aged 40-49 years (p<0.05) for themselves and age 30-39 was an independent predictor of individual preference for "only DNR" at the hypothetical EOL. Physicians from an ICU with <10% terminally ill patients were less likely to prefer "DNR" or "DNR and DNI" options for themselves at EOL compared with physicians who worked in ICUs with a higher (>50%) terminally ill patient ratio (p<0.05). CONCLUSION: Most ICU physicians did not want legalization of DNR and DNI orders, based solely on patient request. Even if EOL decision-making were legal in Turkey, this attitude may conflict with patient autonomy. The proportion of terminally ill patients in the ICU appears to affect physicians' attitudes to EOL decisions, both for their patients and by personal preference, an association which has not been previously reported.

The Nursing Students' Views About the Patient's Rights at the West Black Sea Universities in Turkey.

BACKGROUND: The members of healthcare team have an important role in implementation and protection of patient's rights. Contemporary nursing entails an ethical responsibility to advocate and protect the patients' rights. OBJECTIVES: This study was designed to evaluate how ready nursing students, at the end of their education, were to play the role of patient's rights advocates and to discuss ethics education in nursing. MATERIALS AND METHODS: This descriptive study was performed on nursing students at Black Sea Universities in the academic year 2010-2011. Data were collected using a structured questionnaire about students' attitudes regarding patients' rights including patient's rights regulations. The association between gender and students' attitudes was analyzed using Chi-square test. RESULTS: The mean age of the 238 participants was 22.11 ± 1.21 years and 82.8% of them were female. The majority of the nursing students held desirable attitudes toward patient information, truth telling, and protection of patients' privacy and medical records. However, the students' views about the rights of patients to refuse treatment, children's active participation in treatment, prioritization of the quality of life in treatment, and respect for the rights of dying patients were less satisfactory. CONCLUSIONS: The results of this study was concerning with regard to nursing students' readiness for duties such as patient's rights advocacy. Therefore, it proposes ethics education that covers both patient's rights and the obligations of nurses to defend these rights.

Definition of the ethical values and ethics codes for Turkish midwifery: a focused group study in kocaeli.

BACKGROUND: The independent roles of midwives have not been properly defined, and midwifery ethical values and moral codes proper to Turkish culture have not been developed. The absence of legal regulations concerning midwifery has negatively affected midwifery in the process of professionalization. OBJECTIVES: The purpose of this study was to identify the professional values of midwifery in Turkey. MATERIALS AND METHODS: A focus group was created with the participation of nine midwives working at two state hospitals and a university hospital that provide birth service for women in Kocaeli, which is the most important industrial city in Turkey. The opinions of the midwives on the characteristics that a good midwife should possess and the professional values that a good midwife should observe were collected via in-depth interviews. The interviews were recorded. A total of three meetings were held with the participants. Finally, the notes taken by the reporter during these interviews were rearranged, and the recordings were transcribed by the researchers. RESULTS: THE CHARACTERISTICS SUGGESTED BY THE PARTICIPANTS WERE CLASSIFIED INTO THREE CATEGORIES: professional, personal, and interpersonal. Professional competence, capacity to properly inform interested parties, trustworthiness, respect for individuals and human dignity, and empathy were the most commonly named characteristics. As for the professional values of midwifery, professional competence, trustworthiness, responsibility, maximum benefit, and protection of privacy were the most often identified. Midwives also reported that most of the difficulties they faced in the exercise of daily tasks concerned protecting the privacy of their patients as well as the integrity and prestige of the profession, achieving the maximum benefit and least harm for patients, and providing a just and equal service. CONCLUSIONS: The professional values were mentioned by participant midwives were similar to the values proposed by international professional organizations. But there were some differences perhaps due to cultural differences.

Attitudes about prenatal HIV testing in Turkey.

The aim of this study was to assess the attitudes of Turkish pregnant women and antenatal health care providers towards prenatal HIV testing. A self-administered questionnaire was used. The relationships between the different groups' knowledge and attitudes were analysed by using the chi-squared statistic. A total of 494 pregnant women and 181 care providers participated. Forty-four per cent of the pregnant women thought that prenatal HIV testing should be mandatory, and 84% of the health care providers thought it should be performed routinely or be mandatory. The majority of the pregnant women (74%) and half of the care providers agreed that the test results should be disclosed first to the pregnant woman. The study results also revealed that most of the prenatal care providers would not protect pregnant women's autonomy and privacy, contrary to the pregnant women's own preferences. It is essential to establish national prenatal HIV testing policies in order to prevent unethical practices and ensure satisfaction for pregnant women and health care providers.

Undertaking the role of patient advocate: a longitudinal study of nursing students.

Patient advocacy has been claimed as a new role for professional nurses and many codes of ethics for nurses state that they act as patient advocates. Nursing education is faced with the challenge of preparing nurses for this role. In this article we describe the results of a study that considered the tendencies of a cohort of nursing students at the Kocaeli University School of Nursing to act as advocates and to respect patients' rights, and how their capacities to do so changed (or not) as a result of their nursing education. This longitudinal study used a questionnaire consisting of 10 statements relating to patient care. It was performed both at the start (1998) and at the end (2002) of the nursing training. At the beginning of their course 77 students participated; in the study. After four years, only 55 students participated, the reason for this drop in number being unknown. The questions asked nurses if patients should have: the right to receive health care; the right to participate in the decision-making process about their treatment; the right always to be told the truth; and the right to have access to their own medical records. They were also asked: if quality of life should be a criterion for discontinuing treatment; if patients have the right to die and the right to refuse treatment; if patients should be assisted to die or helped to undergo active euthanasia; and if severely disabled newborn babies should be allowed to die. The student nurses demonstrated considerable insight into contemporary nursing issues and were ready to act as patient advocates. Professional responsibility demands that good nurses advocate strongly for patients' choices.

A study of the ethical sensitivity of physicians in Turkey.

In order to prepare bioethics and clinical ethics courses for clinicians in Turkey, we needed to know the attitudes of physicians when placed in ethically difficult care situations. We presented four cases to 207 physicians who are members of the Physicians' Association in Kocaeli, Turkey. Depending on the decisions they made in each case, we determined whether they were aware of the ethical aspects of the cases and the principles they chose as a basis for their decisions. We aimed to gain information about their ethical tendencies and moral sensitivity. A small number of physicians stated that they would 'show respect for a patient's living will' in the first case, but more stated that they would 'let the patient refuse the treatment' in the second. In the third case, where medical confidentiality was the significant ethical issue, most of the physicians said that they would act in order to maintain confidentiality. For the last case, more than half the physicians chose to 'tell the truth' to the patient. The paternalism shown in the doctors' decisions on the first two cases was no longer observed in those made for the last two cases. We concluded that the physicians who participated in our study have low sensitivity to living wills (or advance directives) and patients refusing treatment. However, when issues of medical confidentiality and truth-telling are concerned, they take care to protect the autonomy of the individual an are relatively more aware of the ethical aspects of these cases.