Communication in nursing care for patients requesting euthanasia: a qualitative study.

AIM: To describe the communication during the euthanasia care process for mentally competent, terminally ill patients in general hospitals in Flanders, as seen from the perspective of the nurse. BACKGROUND: International literature shows that nurses are involved in the care process surrounding euthanasia, regardless of the legal status of euthanasia in the country being studied. In particular, research shows that communication is an important part of good euthanasia care. However, the actual way nurses' communication contributes to the quality of the euthanasia care process remains unclear. DESIGN: A Grounded Theory Design was used. METHODOLOGY: Analysis of 18 in-depth, semi-structured interviews with nurses from nine different hospitals in Flanders (Belgium). The interviews took place during a 20-month period in 2005-2006. RESULTS: The euthanasia care process for mentally competent, terminally ill patients in general hospitals in Flanders is a complex and dynamic process, the connecting thread of which is nurses' communication. During this process, nurses perceive that they communicate often and a lot, with various people, in different contexts, in different ways and with various purposes. This communicative process is intensified by the moral and psychological weight of the theme, and its impact on everyone involved, as well as by the relatively short period of time, during which it all takes place. CONCLUSION: This article adds to the growing body of literature on nursing care for patients requesting euthanasia. The findings suggest that for nurses, communication is a key instrument for realising good-quality euthanasia care. RELEVANCE TO CLINICAL PRACTICE: Being the essence of nursing care for patients requesting euthanasia, nurses' communication requires support and guidance on the level of nursing education, professional guidelines and hospital context.

Nursing care for patients requesting euthanasia in general hospitals in Flanders, Belgium.

AIM: This paper is a report of a study exploring nurses' involvement in the care process for mentally competent, terminally ill patients requesting euthanasia in general hospitals in Flanders, Belgium. BACKGROUND: International literature shows that nurses are involved in the care process surrounding euthanasia, regardless of the legal status of euthanasia in the country being studied. However, their actual involvement remains unclear. METHODS: A grounded theory approach was used. Data were collected over a 20-month period in 2005 and 2006, using individual in-depth interviews. The sample included 18 Registered Nurses employed in nine general hospitals geographically spread over the five provinces of Flanders, Belgium. RESULTS: The care process for patients requesting euthanasia is complex and dynamic, consisting of several stages. Major themes characterized nurses' involvement: being on the alert for a euthanasia request; open and active listening; multidisciplinary team cooperation and analysis of the group dynamics; continuously providing maximum palliative care; multi-tasking; organizing and directing the euthanasia; and finally, providing support for the family, colleagues and oneself. CONCLUSION: Nurses make a unique and indispensable contribution to making the euthanasia care process a good care process. This has to do with their specific form of knowledge, expertise and responsibilities, and their willingness to personally, continually and fully care for the patients requesting euthanasia and for their relatives.

"It's intense, you know." Nurses' experiences in caring for patients requesting euthanasia.

The Belgian Act on Euthanasia came into force on 23 September 2002, making Belgium the second country--after the Netherlands--to decriminalize euthanasia under certain due-care conditions. Since then, Belgian nurses have been increasingly involved in euthanasia care. In this paper, we report a qualitative study based on in-depth interviews with 18 nurses from Flanders (the Dutch-speaking part of Belgium) who have had experience in caring for patients requesting euthanasia since May 2002 (the approval of the Act). We found that the care process for patients requesting euthanasia is a complex and dynamic process, consisting of several stages, starting from the period preceding the euthanasia request and ending with the aftercare stage. When asked after the way in which they experience their involvement in the euthanasia care process, all nurses described it as a grave and difficult process, not only on an organizational and practical level, but also on an emotional level. "Intense" is the dominant feeling experienced by nurses. This is compounded by the presence of other feelings such as great concern and responsibility on the one hand, being content in truly helping the patient to die serenely, and doing everything in one's power to contribute to this; but also feeling unreal and ambivalent on the other hand, because death is arranged. Nurses feel a discrepancy, because although it is a nice death, which happens in dignity and with respect, it is also an unnatural death. The clinical ethical implications of these findings are discussed.

Involvement of nurses in the euthanasia care process in Flanders (Belgium): an exploration of two perspectives.

This study explored nurses' involvement in the care process for mentally competent, terminally ill patients requesting euthanasia in general hospitals in Flanders, Belgium. In-depth interviews with 18 nurses who had experience in caring for patients requesting euthanasia since May 2002 were analyzed using grounded theory qualitative methods. We found that the involvement of nurses in the care process is influenced by their predominant perspective on it: the procedural, action-focused perspective, from which good practical organization of the care process is essential; or the existential-interpretative perspective, from which it is important to understand the patient's request within a dialogue-focused and communicational atmosphere. Findings show that the two perspectives are not mutually exclusive, but rather complementary dimensions of the euthanasia care process. Hence, sufficient support for nurses to reach a well-balanced integration of both perspectives is essential.

Nurses' involvement in the care of patients requesting euthanasia: a review of the literature.

OBJECTIVES: The aim of this paper is to thoroughly examine the involvement and experiences of nurses in the care of mentally competent, adult patients requesting euthanasia (i.e. administration of lethal drugs by someone other than the person concerned with the explicit intention of ending a patient's life, at the latter's explicit request) by means of a literature review. DESIGN: A keyword search was used to identify relevant journal articles and books published between 1990 and 2007. Manual searches of review article bibliographies were also conducted as well as searches of archives and collections of key journals. DATA SOURCES: The electronic databases Medline, Cinahl, PsycINFO, The Cochrane Library, Social Sciences Citation Index, and Invert were searched using a combination of keywords and carefully constructed inclusion criteria. REVIEW METHODS: Forty-two publications of empirical research were identified and included in the present study after critical appraisal. The included publications represented 35 separated studies (20 quantitative, 11 qualitative and 4 mixed-method publications) and 28 different research samples. RESULTS: Analysis of these studies revealed that nurses across diverse geographic and clinical settings play a major role in caring for and showing a personal interest in patients requesting euthanasia. The nurses' feelings about euthanasia and their involvement are extremely complex. Descriptions of personal conflict, moral uncertainty, frustration, fear, secrecy,and guilt appear to reflect a complex array of personal and professional values as well as social, religious, and legal rules. CONCLUSIONS: Nurses can make a significant contribution to the quality of care by assisting and counseling patients and their families, physicians, and their nursing colleagues in a professional manner, even in countries where euthanasia is not legal. However, research on nurses' involvement in euthanasia has methodological and terminological problems,leading to our recommendation for more carefully designed qualitative studies that explore in-depth the experiences of nurses in caring for patients requesting euthanasia.

Living with dementia from the perspective of older people: is it a positive story?

Dementia, even at an early stage, may pose problems and challenge one's quality of life. Having accurate knowledge of what one experiences when living with dementia is important for developing proactive care for individuals with dementia and their families. The aim of our Grounded Theory study was to explore what it means for elderly people to live with early-stage dementia. We interviewed 20 elderly people with probable mild dementia and their family members. Living with dementia was often presented as a positive narrative, one that told of only minor problems and which stressed abilities and contentment with life. Being valued, rather than losing one's cognition or identity was central in their experience. More in-depth analyses of participants' narratives revealed, however, that they were constantly balancing their feelings of value and worthlessness, struggling to remain someone of value. This struggle was prompted by threats posed by dementia and by the persons' interactions with others. Superficially, a positive narrative may be understood as a lack of awareness or as denial due to cognitive loss. Our findings suggest, however, that we should look beyond this superficial view and seek to understand the narrative as an expression of one's attempt to counterbalance devaluation.

Implementation of discharge management for geriatric patients at risk of readmission or institutionalization.

OBJECTIVE: To evaluate whether implementation of discharge management by trained social workers or nurses reduces hospital readmissions and institutionalizations of geriatric patients in a real-world setting. DESIGN: Quasi-experimental design. SETTING: Six general hospitals in Belgium. PARTICIPANTS: A representative sample of 824 patients, 355 of whom were assigned to the experimental group receiving comprehensive discharge management and 469 to the control group receiving usual care. Inclusion criteria were patients admitted to a geriatric, rehabilitation, or internal medicine ward, not residing in a nursing home, and showing risk of readmission or institutionalization on admission in the hospital. INTERVENTION: In-hospital discharge planning according to a case management protocol allowing for adjustment to participating hospitals' case mix and patients' and families' specific needs. MAIN OUTCOME MEASURES: Hospital readmission within 15 and 90 days post discharge; institutionalization at discharge and within 15 and 90 days post discharge. RESULTS: Discharge management resulted in fewer institutionalizations (n = 53; 14.9%) compared with usual care (n = 130; 23.7%) (adjusted odds ratio = 0.47; CI 95% = 0.31-0.70). Readmission rates between the intervention and usual care group were not significantly different. CONCLUSIONS: This implementation project showed that a discharge planning intervention can reduce institutionalization rates of elderly patients in real-life settings.

Involvement of nurses in caring for patients requesting euthanasia in Flanders (Belgium): a qualitative study.

BACKGROUND: Although nurses worldwide are confronted with euthanasia requests, how nurses experience their involvement in euthanasia remains unclear. OBJECTIVES: To explore nurses' involvement in the care for patients requesting euthanasia. DESIGN: A qualitative grounded theory strategy. SETTING: Two general hospitals (A, B) and a palliative care setting in Flanders (Belgium). PARTICIPANTS: Nurses who fulfilled the following inclusion criteria: (a) Dutch-speaking; (b) working for at least one year in hospital A or B; (c) working at least part-time (50%); and (d) ever received a euthanasia request. We collected data using purposeful sampling, superseded by theoretical sampling in a palliative care setting. The sample included one intensive care nurse, one oncology nurse, eight palliative care nurses, and five internal medicine nurses. All but five were women. Their age ranged from 24 to 49 years. METHODS: We conducted one-on-one semi-structured interviews between November 2001 and September 2002. Grounded theory was applied for guiding data collection and analysis. The trustworthiness of data was ensured by several strategies. RESULTS: Although euthanasia was still illegal, the nurses unanimously stated that they had an important role in caring for patients requesting euthanasia. Their personal and intense involvement caused them to experience a spectrum of emotions, chief among them being a sense of powerlessness. Several elements contributed to the nurses' conflicted involvement. Nurses became frustrated if the context (e.g., lack of time) hindered their efforts to provide compassionate care. The palliative care setting and its associated culture (group mentality, care philosophy) created the opportunity for nurses to take time to holistically support patients and their relatives. CONCLUSIONS: Hospital nurses are confronted with patients' euthanasia requests. Each stage of this process requires that the nurses possess specific competencies. Their willingness to personally care for these patients, in addition to their specific care expertise, allows them to be skilled companions.

Nurses' attitudes to euthanasia: a review of the literature.

This article provides an overview of the scarce international literature concerning nurses' attitudes to euthanasia. Studies show large differences with respect to the percentage of nurses who are (not) in favour of euthanasia. Characteristics such as age, religion and nursing specialty have a significant influence on a nurse's opinion. The arguments for euthanasia have to do with quality of life, respect for autonomy and dissatisfaction with the current situation. Arguments against euthanasia are the right to a good death, belief in the possibilities offered by palliative care, religious objections and the fear of abuse. Nurses mention the need for more palliative care training, their difficulties in taking a specific position, and their desire to express their ideas about euthanasia. There is a need to include nurses' voices in the end-of-life discourse because they offer a contextual understanding of euthanasia and requests to die, which is borne out of real experience with people facing death.