BACKGROUND: The aim of this study was to describe the kinds of ethical dilemmas surgeons face during practice. METHODS: Five male and five female surgeons at a University hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of physicians and nurses about ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. RESULTS: No gender differences were found in the kinds of ethical dilemmas identified among male and female surgeons. The main finding was that surgeons experienced ethical dilemmas in deciding the right treatment in different situations. The dilemmas included starting or withholding treatment, continuing or withdrawing treatment, overtreatment, respecting the patients and meeting patients' expectations. The main focus in the narratives was on ethical dilemmas concerning the patients' well-being, treatment and care. The surgeons narrated about whether they should act according to their own convictions or according to the opinions of principal colleagues or colleagues from other departments. Handling incompetent colleagues was also seen as an ethical dilemma. Prioritization of limited resources and following social laws and regulations represented ethical dilemmas when they contradicted what the surgeons considered was in the patients' best interests. CONCLUSION: The surgeons seemed confident in their professional role although the many ethical dilemmas they experienced in trying to meet the expectations of patients, colleagues and society also made them professionally and personally vulnerable.
To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders.
Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (n = 1989), nursing homes (n = 3310), and assisted living (n = 335) in 67 LTC facilities in 19 municipalities were assessed.
Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (R(2) = 0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (R(2) = 0.11), impaired cognition (R(2) = 0.07), level of LTC (R(2) = 0.05), and diagnoses (R(2) = 0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders.
We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.
The do-not-resuscitate (DNR) order is a mechanism of withholding cardiopulmonary resuscitation (CPR). The lack of DNR guidelines specific for acute stroke may result in many stroke patients receiving unnecessary and futile resuscitation and ventilator-assisted breathing.
A prospective multicenter evaluation of disease-specific criteria for DNR orders in acute stroke was initiated using a modified Delphi process. The participants were the Canadian and Western New York Stroke Consortium members who are closely involved in caring for acute stroke patients and conducting clinical trials at the academic centers. Previously published provisional criteria were reviewed by the participants. Modifications were made to the criteria until statistically significant agreement (P
There is great debate regarding the extent of intensive care interventions for extremely premature newborns. In this report, we describe Canadian neonatologists' attitudes towards delivery room resuscitation decisions in neonates at the threshold of viability.
We interviewed neonatologists (N = 121) practising in Canadian tertiary care neonatal units between June 2004 and April 2005, and asked whether they would support a parental request not to initiate resuscitation for newborns of 23 to 26 weeks' gestation. Bivariate analyses were performed to identify sociodemographic or cultural factors that might affect resuscitation decisions.
Most Canadian neonatologists would support a parental request not to initiate resuscitation of an infant at 23 and 24 weeks' gestation (98% and 80%, respectively). However, we observed heterogeneity across the country in attitudes primarily at 25 weeks, but also at 24 weeks' gestation. At 24 weeks' gestation, decisions also appear to be significantly related to personal experience with a disabled close friend or relative. For newborns of 25 weeks' gestation, neonatologists are divided: a majority (76%) would strongly advocate resuscitation and/or resuscitate a "viable" fetus against parental wishes, and a minority (24%) would agree not to initiate treatment. At 26 weeks' gestation, more than 97% would not support a request not to initiate resuscitation.
Attitudes of Canadian neonatologists towards resuscitation of newborns at the threshold of viability primarily differ at 25 weeks and to a lesser extent at 24 weeks of gestation. Our findings highlight important nuances in relation to existing national guidelines.
To explain determinants in the decision-making of nurses in the treatment of severely ill incompetent patients and to describe underlying attitudes, consecutive samples of nurses from Germany and Sweden have been investigated by means of a case scenario and a questionnaire. Whereas the level of dementia emerged as the only factor being significantly related with the treatment option within the Swedish group, patient's age, patient's wishes and ethical concerns were correlated among German nurses. The more the nurses have been able to participate in the provision of the available do-not-resuscitate order or of an advance directive, the less frequent they would perform CPR against the patient's wishes.
BACKGROUND: In Norway, few studies have been done to map the extent of do-not-resuscitate (DNR) orders and the consequence for patients (treatment and outcome). MATERIAL AND METHODS: All patients with DNR orders, referred to the stroke unit of Akershus University Hospital during the year 2005, were identified and data on treatment and outcome were recorded. RESULTS: A DNR order was found for 79 of 855 (9 %) patients (mean age 80 years [SD 9]). Reasons for referral to hospital were: cerebral infarction (49 [62 %] patients), intracerebral haemorrhage (28 [35 %] patients), and other diseases (2 [3 %] patients). Mean NIH Stroke Scale was 19 (SD 6) (scale 0 - 42; 0 in score meaning no stroke related symptoms). Hospital mortality was 39/79 (49 %). Apart from once, all decisions regarding withholding and/or withdrawing life-sustaining treatment were taken in the aftermath of a DNR order. For 43 patients (54 %), treatment was limited in some way and hospital mortality for this group was 27/43 (63 %). Mortality was 12/36 (33 %) for those who had full treatment. 45 patients (57 %) with a DNR order had a bacterial infection and 32 of them were treated with antibiotics (71 %). INTERPRETATION: Patients with DNR orders were old and had had severe stroke. Treatment was rarely withheld despite high morbidity and mortality among the patients.
Comment In: Tidsskr Nor Laegeforen. 2009 Feb 12;129(4):31019219101