Do-not-resuscitate orders Ethical aspects on decision making and communication among physicians, nurses, patients and relatives

The purpose was to describe ethical aspects on how do-not-resuscitate (DNR) deci-sions are made, established, and communicated between physicians, nurses, patients and relatives. A random sample of 220 physicians and nurses answered a questionnaire about their attitudes to and experiences of the making and communication of a DNR decision. The re-sponse rate was 73%. Twenty seriously ill patients, and 21 relatives of patients who died with a DNR order, were interviewed. The literature on medical futility was searched for conditions for futility and moral consequences. The results showed that many physicians and nurses are uncertain about the rules and ethics of DNR orders. There are discrepancies between guidelines and attitudes regarding DNR orders, as well as between attitudes and behaviour. Seriously ill patients estimate open and straightforward conversations about treatments in the end of life. Relatives seem to get acceptable information and counselling. Conditions and consequences of medical futility may be approached in a new clinical way. There are numerous possible ethical conflicts within and between the principles of autonomy, non-maleficence, beneficence, and the virtues and ideals of the profession. Start a dialogue about end-of-life support with chronically ill and elderly patients, and their relatives, while they still are capable of understanding and authorisation. The clinical conversation model may make it easier. All involved should understand why certain deci-sions are made. Conditions and consequences of futility should be ascertained together with the patients, the relatives and the staff, after which a joint decision can be reached

Proximity morality in medical school – medical students forming physician morality "on the job": Grounded theory analysis of a student survey

<p>Abstract</p> <p>Background</p> <p>The value of ethics education have been questioned. Therefore we did a student survey on attitudes about the teaching of ethics in Swedish medical schools.</p> <p>Methods</p> <p>Questionnaire survey on attitudes to ethics education with 409 Swedish medical students participating. We analyzed > 8000 words of open-ended responses and multiple-choice questions using classic grounded theory procedures.</p> <p>Results</p> <p>In this paper we suggest that medical students take a proximity morality stance towards their ethics education meaning that they want to form physician morality "on the job". This involves comprehensive ethics courses in which quality lectures provide "ethics grammar" and together with attitude exercises and vignette reflections nurture tutored group discussions. Goals of forming physician morality are to develop a professional identity, handling diversity of religious and existential worldviews, training students described as ethically naive, processing difficult clinical experiences, and desisting negative role modeling from physicians in clinical or teaching situations, some engaging in "ethics suppression" by controlling sensitive topic discussions and serving students politically correct attitudes.</p> <p>Conclusion</p> <p>We found that medical students have a proximity morality attitude towards ethics education. Rather than being taught ethics they want to form their own physician morality through tutored group discussions in comprehensive ethics courses.</p

Physicians' experiences with end-of-life decision-making: Survey in 6 European countries and Australia

Background: In this study we investigated (a) to what extent physicians have experience with performing a range of end-of-life decisions (ELDs), (b) if they have no experience with performing an ELD, would they be willing to do so under certain conditions and (c) which background characteristics are associated with having experience with/or being willing to make such ELDs. Methods: An anonymous questionnaire was sent to 16,486 physicians from specialities in which death is common: Australia, Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland. Results: The response rate differed between countries (39–68%). The experience of foregoing life-sustaining treatment ranged between 37% and 86%: intensifying the alleviation of pain or other symptoms while taking into account possible hastening of death between 57% and 95%, and experience with deep sedation until death between 12% and 46%. Receiving a request for hastening death differed between 34% and 71%, and intentionally hastening death on the explicit request of a patient between 1% and 56%. Conclusion: There are differences between countries in experiences with ELDs, in willingness to perform ELDs and in receiving requests for euthanasia or physician-assisted suicide. Foregoing treatment and intensifying alleviation of pain and symptoms are practiced and accepted by most physicians in all countries. Physicians with training in palliative care are more inclined to perform ELDs, as are those who attend to higher numbers of terminal patients. Thus, this seems not to be only a matter of opportunity, but also a matter of attitude

Sjukvårdens metoder bör analyseras ur ett etiskt perspektiv.

Many methods exist for ethical analysis guiding decision-making. This essay presents only one method. Both facts and values are employed with this method and, as an example we use a Swedish preventative measure for individuals who abuse narcotics. The ethical analysis presupposes good knowledge of the case at hand and the approach recommended is a combination of stakeholder analysis and decision matrix analysis. In applying the model, stakeholders are identified and the ethical principles are formulated to identify the ethical costs and benefits. To balance the costs and benefits good medical judgement is needed. But now and again this approach is not enough. The method may be in need of some form of supplementary analysis, which, for instance, could be the use of similar cases, situation ethics and virtue ethics

Vetenskapsteori i medicin och klinik

Vad är vetenskapsteori? Vad är skillnaden mellan bra och dålig forskning? Hur skeptisk bör man förhålla sig till vetenskapen? Behövs kunskapsutbyte över disciplingränserna? Det är en del av de frågor som tas upp i denna bok. I boken redovisas även de skilda angreppssätt som vanligen används i samband med klinisk forskning, epidemiologi och fallstudier. Den etiska prövningen av projekt presenteras och övergången från forskningsresultat till praxis inom sjukvårdens område diskuteras. Slutligen tas några av vetenskapsteorins mer kontroversiella ämnen upp: Finns en eller flera typer av verklighet, och vad är i så fall relationen mellan dessa olika typer av verklighet? Vad menas med uttryck som "induktion", "kausalitet", "determinism" och "fri vilja"? Hur ska teorin om paradigm förstås? Boken avslutas med ett vetenskapsteoretiskt lexikon

Scientific dishonesty--questionnaire to doctoral students in Sweden.

'Scientific dishonesty' implies the fabrication, falsification or plagiarism in proposing, performing or reviewing research or in reporting research results. A questionnaire was given to postgraduate students at the medical faculties in Sweden who attended a course in research ethics during the academic year 2008/2009 and 58% answered (range 29%-100%). Less than one-third of the respondents wrote that they had heard about scientific dishonesty in the previous 12 months. Pressure, concerning in what order the author should be mentioned, was reported by about 1 in 10 students. We suggest that all departments conducting research should have a written policy about acceptable research behaviour and that all doctoral students should be informed of the content of this policy. Participants in the research groups concerned should also be required to analyse published articles about scientific dishonesty and critically discuss what could be done about unethical conduct

Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-making

Background: In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, problems exist in areas where the evidence base is weak, e.g. elderly patients with heart disease and multiple co-morbidities. Objective: Our aim is to evaluate the views of Swedish cardiologists on decision-making for elderly people with multiple co-morbidities and acute coronary syndrome without ST-elevation (NSTE ACS), and to generate some hypotheses for testing. Methods: A confidential questionnaire study was conducted to assess the views of cardiologists/internists (n = 370). The response rate was 69%. Responses were analyzed with frequencies and descriptive statistics. When appropriate, differences in proportions were assessed by a chi-square test. A content analysis was used to process the answers to the open-ended questions. Results: 81% of the respondents reported extensive use of national quidelines for care of heart disease in their clinical decision-making. However, when making decisions for multiple-diseased elderly patients, the individual physician's own clinical experience and the patient's views of treatment choice were used to an evidently greater extent than national guidelines. Approximately 50% estimated that they treated multiple-diseased elderly patients with NSTE ACS every day. Preferred measures for improving decision-making were: (a) carrying out treatment studies including elderly patients with multiple co-morbidities, and (b) preparing specific national guidelines for multiple-diseased elderly patients. Conclusions: In the future, national guidelines for heart disease should be adapted in order to be applicable for elderly patients with multiple co-morbidities.The final, definitive version of this paper has been published in:Scandinavian Journal of Public Health, (38), 3, 325-331, 2010.Niklas Ekerstad, Rurik Löfmark and Per Carlsson, Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-makinghttp://dx.doi.org/10.1177/1403494809354359by SAGE Publications Ltd, All rights reserved.http://www.uk.sagepub.com

Views of patients with heart failure about their role in the decision to start implantable cardioverter–defibrillator treatment: prescription rather than participation

Background: There is a shortage of reports on what potential recipients of implantable cardioverter-defibrillators ( ICDs) need to be informed about and what role they can and want to play in the decision-making process when it comes to whether or not to implant an ICD. Aims: To explore how patients with heart failure and previous episodes of malignant arrhythmia experience and view their role in the decision to initiate ICD treatment. Patients and methods: A qualitative content analysis of semistructured interviews was used. The study population consisted of 31 outpatients with moderate heart failure at the time of their first ICD implantation. Setting: The study was performed at Sahlgrenska University Hospital, Goteborg, Sweden. Results: None of the respondents had discussed the alternative option of receiving treatment with antiarrhythmic drugs, the estimated risk of a fatal arrhythmia, or the expected time of survival from heart failure in itself. Even so, very little criticism was directed at the lack of information or the lack of participation in the decision-making process. The respondents felt that they had to rely on the doctors' recommendation when it comes to such a complex and important decision. None of them regretted implantation of the ICD. Conclusions: The respondents were confronted by a matter of fact. They needed an ICD and were given an offer they could not refuse, simply because life was precious to them. Being able to give well-informed consent seemed to be a matter of less importance for them

http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-73752 Coronary Heart Disease Frailty Is Independently Associated With Short-Term Outcomes for Elderly Patients With Non–ST-Segment

Background—For the large and growing population of elderly patients with cardiovascular disease, it is important to identify clinically relevant measures of biological age and their contribution to risk. Frailty is an emerging concept in medicine denoting increased vulnerability and decreased physiological reserves. We analyzed the manner in which the variable frailty predicts short-term outcomes for elderly non–ST-segment elevation myocardial infarction patients. Methods and Results—Patients aged �75 years, with diagnosed non–ST-segment elevation myocardial infarction were included at 3 centers, and clinical data including judgment of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale. The impact of the comorbid conditions on risk was quantified by the coronary artery disease–specific index. Of 307 patients, 149 (48.5%) were considered frail. By multiple logistic regression, frailty was found to be strongly and independently associated with risk for the primary composite outcome (death from any cause, myocardial reinfarction, revascularization due to ischemia, hospitalizatio