Realizing autonomy in responsive relationships

The goal of this article is to augment the ethical discussion among nurses with the findings from empirical research on autonomy of older adults with type 2 diabetes mellitus. There are many factors influencing autonomy. These include: health conditions, treatment, knowledge, experience and skills, personal approach as well as familial patterns, type of relationship, life history and social context. Fifteen older adults with type 2 diabetes mellitus were interviewed in a nurse-led diabetes clinic. These participants perceive three processes which support autonomy in responsive relationships: preserving patterns of concern and interaction, nurturing collaborative responsibilities and being closely engaged in trustful and helpful family relations. People with diabetes realize autonomy in various responsive relationships in their unique life context. Next, we performed a literature review of care ethics and caring in nursing with regard to relational autonomy. We classified the literature in five strands of care: attitude-oriented, dialogue-oriented, activity-oriented, relationship-oriented and life-oriented. According to our respondents, autonomy in responsive relationships is fostered when patient, nurses, professionals of the health team and family members carry out care activities supported by a relational attitude of care. They can best realize autonomy in relationships with others when several essential aspects of care and caring are present in their lives. Therefore, we advocate a comprehensive approach to care and caring

Patient autonomy in nurse-led shared care: A review of theoretical and empirical literature

Title. Patient autonomy in nurse-led shared care: a review of theoretical and empirical literature. Aim. This paper presents a review of the theoretical and empirical literature addressing patient autonomy and how nurses can support patient autonomy. Background. Nurse-led, shared care settings provide needs-based care to patients who are encouraged to participate actively in their care. Patient autonomy is a complex ethical concept with many different meanings. As a result, nurses must solve various problems to foster patient autonomy successfully. Method. Two methods were used to identify literature for the review: (a) a search of the MEDLINE, Embase, CINAHL and Online Contents databases and the keywords 'patient autonomy' in combination with 'nursing', and the Dutch Central Catalogue for material published from 1966 to 2005; (b) ethical and nursing literature was selected on the basis of its identification of positive and negative freedom. We reviewed qualitative empirical research to explore the patients' views of autonomy. Findings. Negative freedom emphasizes freedom of action and freedom from interference by others. Positive freedom stresses the idea that people should direct their lives according to their personal convictions and individual reasons and goals. The most prominent theories fitting negative freedom are those defining autonomy as self-governance and self-care. Theories fitting positive freedom are those focusing on autonomy in caring, autonomy as identification, autonomy as communication and autonomy as goal achievement. In the empirical literature, two studies centred on patient autonomy in home care, one in nursing home care and three in hospital settings. To achieve autonomy, patients prefer a mixed approach that combines features of negative and positive freedom. Conclusion. Nurses cannot rely exclusively on one model of autonomy to foster patient autonomy. Rather, it requires in-depth knowledge of, and interaction with, patients in the context of each particular nursing encounter because people express their autonomy through particular courses of action

Health care ethics and health law in the Dutch discussion on end of life decisions: a historical analysis of the dynamics and development of both disciplines

Over the past three or four decades, the concept of medical ethics has changed from a limited set of standards to a broad field of debate and research. We define medical ethics as an arena of moral issues in medicine, rather than a specific discipline. This paper examines how the disciplines of health care ethics and health care law have developed and operated within this arena. Our framework highlights the aspects of jurisdiction (Abbott) and the assignment of responsibilities (Gusfield). This theoretical framework prompted us to study definitions and changing responsibilities in order to describe the development and interaction of health care ethics and health law. We have opted for the context of the Dutch debate about end-of-life decisions as a relevant case study. We argue that the specific Dutch definition of euthanasia as ‘intentionally taking the life of another person by a physician, upon that person’s request’ can be seen as the result of the complex jurisdictional process. This illustrates the more general conclusion that the Dutch debate on end-of-life decisions and the development of the two disciplines must be understood in terms of mutual interaction

Trust in medical decision-making concerning older people: The views of key professionals in the Dutch health care practice

This article deals with the issue of public trust in decisions made by individual physicians, concerning older people, as perceived by various key professionals. While trust is a basic element in our health care service, it is at the same time a difficult phenomenon to conceptualize. This article tries to contribute to a better understanding of what trust in medical practice entails and what are the necessary conditions for a society to put trust in the medical profession. The focus is on care for older people under the condition of scarcity in health care resources. Our study has a qualitative design consisting of semi-structured in-depth interviews with 24 key professionals focusing on decision-makers and those in line of professionally organizing or influencing the decision-making process. We found roughly three categories of trust: distrust; trust; and qualified trust. In each category we found different reasons to give or withhold trust and different views on how far the discretionary power of doctors should go. We recommend promoting trust by addressing the criteria or limits brought forward in the qualified trust category. The preconditions as identified in the qualified trust section provide the boundaries and marking points between which physicians have to move regarding the care for older people. The qualifications provide us insight in where and how to invest in trust under these and under different circumstances. An important conclusion is that trust is never finished: trust needs to be gained and negotiated in a continuous process of action and interaction

What is a good death? Terminally ill patients dealing with normative expectations around death and dying

Objective: Developing good care for dying people is important nowadays. Normative expectations about what could be considered as a good death are inextricably bound up with this issue. This article aims to offer an insight in the way terminally ill patients talk about death and dying and how they refer to current western normative expectations about a 'good' death. Method: Thirteen patients with a life expectancy of less than 3 months living at home were interviewed about how they experienced the last phase of their lives. The analysis focused on the way patients tell their personal stories by using normative expectations that are part of a broader cultural western framework. Results: Five categories of normative expectations were discriminated in the stories of patients: awareness and acceptance, open communication, living one's life till the end, taking care of one's final responsibilities and dealing adequately with emotions. Conclusions: The results of this study show that in the search of a good death people show a clear diversity in their way of referring to as well as in dealing with normative expectations that are part of the current cultural paradigm. Practice implications: Professional caregivers should be responsive to how a patient deals with and relates to normative expectations about a good death and should support patients in their individual process of dying an 'appropriate death'

A case study of sea and shorebird breeding recovery following goat and cat eradication on Klein Curaçao, southern Caribbean

Here, we document major seabird breeding recovery on a satellite island of Curaçao in the southern Caribbean following the removal of goats in 1997, significant reforestation from 2000–2005, and the extermination of cats in 2001. The only seabird to have been confirmed to breed on the island since the 1960s and until recently has been the Least Tern ( Sternula antillarum ). However, we now confirm nesting for an additional eight sea- and shorebird species on the island for the first time based on field observations in 2021 and 2022. The total number of documented nesting pairs annually has increased from a maximum of 140 pairs (of a single species in 2002), to > 430 pairs (of all species combined) in 2021 and 650 pairs in 2022. The dominant species are the Cayenne Tern ( Thalassaeus sandviscensis ), Laughing Gull ( Larus atricilla ), Sooty Tern ( Onychoprion fuscatus ), and Least Tern, in that order. Breeding by the Sooty Tern and Bridled Tern ( Onychoprion anatheus ) are new national records for Curaçao. Klein Curaçao is now the island group’s most diverse and active seabird breeding location. Major threats to the nascent recovery of seabird breeding in this Ramsar-designated wetland area are the growing and uncontrolled human recreation, the repeated threat of reintroduction of feral cats, and predation by rats. Recommendations are made on measures needed to address these threats. The case study of Klein Curaçao demonstrates the potential for seabird recovery when deleterious invasive mammals are eradicated from islands