In this essay, the occasion of a medically induced death is examined to illustrate how circumstances surrounding a medically induced death are interpreted through a theory of how social agents, on occasion, respond inappropriately. The essay illustrates and assesses an occasion when a health professional, faced with a medical crisis that was laden with professional, ethical, and even legal considerations, responded in a manner that overlooked all those standards when she injected potassium chloride into her patient, Paul Mills. In the essay, the case is chronicled and the character of the social and communicative mechanism that led to the disaster is given and used to interpret the events.
The induction of sedation at the end of life is a much debated practice and not very documented. The goal of this study was to explore the practice from both a clinical and ethical point of view.
Data were collected through semistructured interviews with 19 Quebec physicians working in palliative care.
Doctors' first priority was their patients, not patients' families. Clinically, the therapeutic aim of sedation was strictly to relieve suffering on the part of the patient. Ethically, getting the patient's consent was imperative. The family's consent was only required in cases of incapacity. Generally, sedation and euthanasia were seen as two distinct practices.
There are still very few guidelines regarding end-of-life sedation in Québec, and its normative framework is more implicit than explicit. It should be noted that most of the respondents regarded sedation and euthanasia as two distinct practices.
We carried out a postal survey of a sample of Finnish doctors ( n=1182) concerning their attitudes and ethical decisions in end-of-life care. A scenario was presented in which a patient with terminal cancer wished to obtain unorthodox treatment. Factors possibly influencing decision making such as general attitudes, life values and demographics were investigated. The response rate was 62%. The patient's plan to use unorthodox treatment was accepted by 54% of doctors. Gender or speciality did not influence the decision, but doctor's age was a significant factor ( P=0.0005). Doctors aged 35-49 years were more accepting; younger and older ones less accepting. Doctors who had clinical experience in terminal care were more compliant to the patient's plan ( P=0.034). A stepwise logistic regression analysis was used to create a model for explaining not accepting versus accepting the treatment with the background variables. Altogether eight independent significant variables were included in the final model of explaining a doctor's choice in the presented scenario. According to the model the patient's wish was more frequently accepted if the doctor was middle-aged, had clinical experience in terminal care, valued a high standard of living, considered terminal care satisfying, was less critical of health economics, considered advance directives helpful, had a high fear-of-death index score, and valued professional status less.
Although attention to healthcare ethics in rural areas has increased, specific focus on rural palliative care is still largely under-studied and under-theorized. The purpose of this study was to gain a deeper understanding of the values informing good palliative care from rural individuals' perspectives.
We conducted a qualitative ethnographic study in four rural communities in Western Canada. Each community had a population of 10, 000 or less and was located at least a three hour travelling distance by car from a specialist palliative care treatment centre. Data were collected over a 2-year period and included 95 interviews, 51 days of field work and 74 hours of direct participant observation where the researchers accompanied rural healthcare providers. Data were analyzed inductively to identify the most prevalent thematic values, and then coded using NVivo.
This study illuminated the core values of knowing and being known, being present and available, and community and mutuality that provide the foundation for ethically good rural palliative care. These values were congruent across the study communities and across the stakeholders involved in rural palliative care. Although these were highly prized values, each came with a corresponding ethical tension. Being known often resulted in a loss of privacy. Being available and present created a high degree of expectation and potential caregiver strain. The values of community and mutuality created entitlement issues, presenting daunting challenges for coordinated change.
The values identified in this study offer the opportunity to better understand common ethical tensions that arise in rural healthcare and key differences between rural and urban palliative care. In particular, these values shed light on problematic health system and health policy changes. When initiatives violate deeply held values and hard won rural capacity to address the needs of their dying members is undermined, there are long lasting negative consequences. The social fabric of rural life is frayed. These findings offer one way to re-conceptualize healthcare decision making through consideration of critical values to support ethically good palliative care in rural settings.
Often the type of information collected in surveys of physicians' opinions about active euthanasia has not revealed their experiences and the rationale(s) they use in arriving at their opinions. This paper presents a qualitative analysis of comments made in a large survey of Alberta physicians' opinions about active euthanasia to identify issues physicians commented upon, and to explore the rationale(s) behind their opinions. This information adds an important qualitative perspective to the current debate about euthanasia and assisted suicide.
Cancer physicians frequently interact with dying patients, but little is known about these physicians' practices. The purpose of this study was to evaluate the frequency and nature of bereavement practices among medical oncologists (MOs), radiation oncologists (ROs), and palliative care specialists (PCs); and to identify factors associated with bereavement follow-up.
Survey of all Canadian MOs, ROs, and PCs via their respective national organizations using an anonymous electronic and postal mail survey.
A total of 535 of 756 eligible physicians completed the survey (71%). Overall, 33.3% (95% confidence interval [CI], 29.3%-37.4%) of respondents indicated that they usually or always make a telephone call, send a condolence card, or attend a funeral following a patient's death; 30.5% (95% CI, 26.5%-34.4%) reported performing at least 1 of these practices sometimes; and 36.2% (95% CI, 32.1%-40.3%) reported performing at least 1 of these practices rarely or never. Among the specific practices, respondents were more likely to call a family at least sometimes than to send a condolence card or attend funeral services. Palliative care specialists reported the highest rates of bereavement follow-up. In multivariate regression analysis, female sex, working in an academic setting, palliative care specialty, lack of formal palliative care program, endorsement of the statement that physicians had a responsibility to send a condolence card, and high number of patient deaths were associated with more frequent bereavement follow-up.
Few cancer physicians provide bereavement follow-up routinely. This suggests that consensus is lacking among cancer physicians regarding their role in bereavement care.
William Osler Health System, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, University Health Network, University of Toronto. Paula.email@example.com
To increase our understanding of the notion of "best interests" in end of life disagreements through an updated review of decisions made by the Consent and Capacity Board of Ontario. There was a significant increase (235%) in decisions from this tribunal between 2009 and 2011. "Best interests" test is used when no prior expressed wishes are known to the surrogate decision-makers.
Purposively sampled written decisions of the Consent and Capacity Board of Ontario between 2003 and 2011 that focused on the "best interests" of patients at the end of life. Interpretive content analysis was performed independently by 3 reviewers, and themes were identified by consensus.
We found substitute decision makers (SDMs) rely on an appeal to their own values or religion in their interpretation of best interests; physicians rely on clinical conditions; board emphasizes alignment with Health Care Consent Act. In the more recent cases, we found that SDMs report that patients value suffering; that SDMs have unrealistic hope for recovery and can communicate and get direction from the incapable patient; that SDMs need education on their role and responsibility as SDM; and that SDMs need time to provide consent, and that most proposed treatment plans that were sources of conflict included "palliative care."
Several lessons are drawn for the benefit of health care teams engaged in disagreements at end of life with SDMs over the best interests of patients.
The aim of this study was to highlight community nurses' experiences of ethical dilemmas in palliative care.
There are many studies on palliative care but research on how community nurses experience ethical dilemmas in palliative home care is lacking. The ethical dilemmas to which these nurses are exposed seriously challenge their ethical competence.
Seven community nurses described their experiences of ethical dilemmas in palliative home care. The data was analysed by means of qualitative content analysis.
The core themes that emerged were: powerlessness, frustration, and concern in relation to ethical dilemmas in palliative care. The nurses were motivated and felt responsibility for their patients' end of life, and their relatives, and took their duties seriously. They wanted to satisfy all parties; the patient, the relatives and other palliative care professionals.
The study confirms the need for knowledge about how community nurses experience dilemmas in ethical decision-making. They have the freedom to act and the willingness to make decisions, but they lack competence and knowledge about how their colleagues' experience and deal with such issues.
It is well known that close relatives of terminally ill patients endure great emotional stress. Many factors, such as existential concerns, contribute to the distress of these relatives. In this study, interviews were conducted to explore experiences concerning life restrictions, emotional distress, and limited support, in a group of close relatives of patients with amyotrophic lateral sclerosis (ALS). The purpose was to identify, illuminate and clarify ethical problems related to these experiences. The results indicate that close relatives of patients with ALS need someone to talk to, as well as more information about the disease and its process. Furthermore, the study illustrates how ethical problems are related to choices and conflicts, and that a process including shared decision making is often an ideal when trying to find a solution to ethical problems.