An international perspective of active euthanasia: attitudes of nurses in seven countries

Is Every Life Worth Saving: Does Religion and Religious Beliefs Influence Paramedic's End-of-Life Decision-making? A Prospective Questionnaire-based Investigation

Background:

Paramedics, arriving on emergency cases first, have to make end-of-life decisions almost on a daily basis. Faith shapes attitudes toward the meaning and worth of life itself and therefore influences decision-making.

Objective:

The objective of this study was to detect whether or not religious and spiritual beliefs influence paramedics in their workday life concerning end-of-life decisions, and whether it is legally possible for them to act according to their conscience.

Methods and Design:

This is a literature review of prior surveys on the topic using five key words and questionnaire-based investigation using a self-administered online survey instrument.

Settings/Participants:

Paramedics all over Germany were given the opportunity to participate in this online questionnaire-based study.

Measurements:

Two databases were searched for prior studies for literature review. Participants were asked about their religiosity, how it affects their work, especially in end-of-life situations, how experienced they are, and whether or not they have any legal latitude to withhold resuscitation.

Results:

A total of 429 paramedics answered the questionnaire. Religious paramedics would rather hospitalize a patient holding an advance directive than leave him/her at home (P = 0.036) and think death is less a part of life than the nonreligious (P = 0.001). Otherwise, the Spearman's rho correlation was statistically insignificant for all tests regarding resuscitation.

Conclusions:

The paramedic's religiosity is not the prime factor in his/her decision-making regarding resuscitation.

Indian Nurses’ Attitudes Toward Euthanasia

The debate about euthanasia continues worldwide, with nurses’ attitudes becoming increasingly more important. The aim of this study is to investigate gender differences among nurses’ perceptions of attitudes toward euthanasia. A nonprobability quantitative, cross-sectional design was carried out among nurses working at a tertiary care center. Data were collected through self-reported questionnaires at their work place. Significant differences were found between men and women to the items such as “Fear of death shows differences due to religious beliefs” (χ2 = 10.550, p < 0.05), “If patient wants euthanasia, nutrition support should be stopped” (χ2 = 12.209, p < 0.05), “CPR should not be applied in case of sudden respiration and heart stop” (χ2 = 9.591, p < 0.05), and “burden for relatives to take care of a patient who is in terminal period and who will die” (χ2 = 9.069, p < 0.05). The present study depicts that gender plays an important role in euthanasia; hence, the researchers strongly suggest that there is an urgent need to draft uniform guidelines after wide consultation with all the stake holders regarding nurses’ role in taking care of patients who request euthanasia, to face these situations effectively and competently within professional boundaries.

The Attitudes of Greek Physicians and Lay People on Euthanasia and Physician-Assisted Suicide in Terminally Ill Cancer Patients

The purpose of this article is to explore the attitudes of lay people and physicians regarding euthanasia and physician-assisted suicide in terminally ill cancer patients in Greece. The sample consisted of 141 physicians and 173 lay people. A survey questionnaire was used concerning issues such as euthanasia, physician-assisted suicide, and so forth. Many physicians (42.6%) and lay people (25.4%, P = .002) reported that in the case of a cardiac and/or respiratory arrest, there would not be an effort to revive a terminally ill cancer patient. Only 8.1% of lay people and 2.1% of physicians agreed on physician-assisted suicide ( P = .023). Many of the respondents, especially physicians, supported sedation but not euthanasia or physician-assisted suicide. However, many of the respondents would prefer the legalization of a terminally ill patient's hastened death.

Development of the Perceptions of Conscience Questionnaire

Health care often involves ethically difficult situations that may disquiet the conscience. The purpose of this study was to develop a questionnaire for identifying various perceptions of conscience within a framework based on the literature and on explorative interviews about perceptions of conscience (Perceptions of Conscience Questionnaire). The questionnaire was tested on a sample of 444 registered nurses, enrolled nurses, nurses’ assistants and physicians. The data were analysed using principal component analysis to explore possible dimensions of perceptions of conscience. The results showed six dimensions, found also in theory and empirical health care studies. Conscience was perceived as authority, a warning signal, demanding sensitivity, an asset, a burden and depending on culture. We conclude that the Perceptions of Conscience Questionnaire is valid for assessing some perceptions of conscience relevant to health care providers.

Assisted dying in dementia: a systematic review of the international literature on the attitudes of health professionals, patients, carers and the public, and the factors associated with these

BACKGROUND

Assisted death and dementia is a controversial topic that, in recent years, has been subject to considerable clinical, ethical and political debate.

OBJECTIVE

This paper reviews the international literature on attitudes towards assisted dying in dementia and considers the factors associated with these.

DESIGN

A systematic literature search was conducted in Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, PsychINFO and Web of Science between 1992 and August 2013. Electronic and hand searches identified 118 potential relevant studies. Eighteen studies met the full inclusion criteria and were screened using a quality assessment tool.

RESULTS

Health professionals hold more restrictive views towards assisted dying, which appear less affected by their cultural background, than the public, patients and carers. However, opinions within each population vary according to dementia severity and issues of capacity, as well as differing according to factors such as age, ethnicity, gender and religion of those surveyed. There also appears to be a trend towards more accepting attitudes over time.

CONCLUSIONS

Sociodemographic factors can influence attitudes towards assisted dying. The impact of these, however, may also differ according to the population surveyed. The findings from this review can contribute to current debates and inform clinical practice and future research in this area.

Attitudes toward Euthanasia and Related Issues among Physicians and Patients in a Multi-cultural Society of Malaysia

INTRODUCTION

Due to globalization and changes in the health care delivery system, there has been a gradual change in the attitude of the medical community as well as the lay public toward greater acceptance of euthanasia as an option for terminally ill and dying patients. Physicians in developing countries come across situations where such issues are raised with increasing frequency. As euthanasia has gained world-wide prominence, the objectives of our study therefore were to explore the attitude of physicians and chronically ill patients toward euthanasia and related issues. Concomitantly, we wanted to ascertain the frequency of requests for assistance in active euthanasia.

MATERIALS AND METHODS

Questionnaire based survey among consenting patients and physicians.

RESULTS

The majority of our physicians and patients did not support active euthanasia or physician-assisted suicide (EAS), no matter what the circumstances may be P < 0.001. Both opposed to its legalization P < 0.001. Just 15% of physicians reported that they were asked by patients for assistance in dying. Both physicians 29.2% and patients 61.5% were in favor of withdrawing or withholding life-sustaining treatment to a patient with no chances of survival. Among patients no significant differences were observed for age, marital status, or underlying health status.

CONCLUSIONS

A significant percentage of surveyed respondents were against EAS or its legalization. Patient views were primarily determined by religious beliefs rather than the disease severity. More debates on the matter are crucial in the ever-evolving world of clinical medicine.

Motivations of physicians and nurses to practice voluntary euthanasia: a systematic review

BACKGROUND

While a number of reviews have explored the attitude of health professionals toward euthanasia, none of them documented their motivations to practice euthanasia. The objective of the present systematic review was to identify physicians' and nurses' motives for having the intention or for performing an act of voluntary euthanasia and compare findings from countries where the practice is legalized to those where it is not.

METHODS

The following databases were investigated: MEDLINE/PubMed (1950+), PsycINFO (1806+), CINAHL (1982+), EMBASE (1974+) and FRANCIS (1984+). Proquest Dissertations and Theses (1861+) was also investigated for gray literature. Additional studies were included by checking the references of the articles included in the systematic review as well as by looking at our personal collection of articles on euthanasia.

RESULTS

This paper reviews a total of 27 empirical quantitative studies out of the 1 703 articles identified at the beginning. Five studies were in countries where euthanasia is legal and 22 in countries where it is not. Seventeen studies were targeting physicians, 9 targeted nurses and 1 both health professionals. Six studies identified the motivations underlying the intention to practice euthanasia, 16 the behavior itself and 5 both intention and behavior. The category of variables most consistently associated with euthanasia is psychological variables. All categories collapsed, the four variables most frequently associated with euthanasia are past behavior, medical specialty, whether the patient is depressed and the patient's life expectancy.

CONCLUSIONS

The present review suggests that physicians and nurses are motivated to practice voluntary euthanasia especially when they are familiar with the act of euthanasia, when the patient does not have depressive symptoms and has a short life expectancy and their motivation varies according to their medical specialty. Additional studies among nurses and in countries where euthanasia is legal are needed.

Euthanasia: the perceptions of nurses in India

Euthanasia provokes controversies in various domains, such as the moral, ethical, legal, religious, scientific, and economic. India legalised passive euthanasia (withdrawal of life support) for patients with brain death or who are in a permanent vegetative state in 2011, but research on perceptions of euthanasia among people in India is limited. This study aimed to examine nurses' perceptions of the practice of euthanasia as well as factors influencing those perceptions. A non-probability quantitative, cross-sectional design was adopted for a sample of 214 nurses working at a tertiary care centre. Data was collected through self-reported questionnaires at the nurses workplace.The findings revealed mixed opinions on euthanasia among the nurses. However, the majority of the participants did not agree with the practice of euthanasia. Nonetheless, further research is needed on this issue across the country among various health professionals in the context of current legislation.

'We are (not) the master of our body': elderly Jewish women's attitudes towards euthanasia and assisted suicide

OBJECTIVES

In Belgium, dominant ideological traditions--Christianity and non-religious humanism--have the floor in debates on euthanasia and hardly any attention is paid to the practices and attitudes of ethnic and religious minorities, for instance, Jews. This article aims to meet this lacuna.

DESIGN

Qualitative empirical research was performed in the Orthodox Jewish community of Antwerp (Belgium) with a purposive sample of elderly Jewish (non-)Hasidic and secularised Orthodox women. In-depth interviews were conducted to elicit their attitudes towards (non-)voluntary euthanasia and assisted suicide.

RESULTS

The research reveals diverse views among women in the community on intentionally terminating a patient's life. Absolute rejection of every act which deliberately terminates life is found among the overwhelming majority of (religiously observant) Orthodox (Hasidic and non-Hasidic) women, as they have an unconditional faith and trust in God's sovereign power over the domain of life and death. On the other hand, the views of secularised Orthodox women--mostly irreligious women, who do not consider themselves Orthodox, thus not following Jewish law, yet say they belong to the Orthodox Jewish community--show an acceptance of voluntary euthanasia and assisted suicide but non-voluntary euthanasia is approached more negatively. As they perceive illness and death as merely profane facts, they stress a patient's absolute right towards self-determination, in particular with regard to one's end of life. Among non-Hasidic Orthodox respondents, more openness is found for cultivating a personal opinion which deviates from Jewish law and for the right of self-determination with regard to questions concerning life and death. In this study, these participants occupy an intermediate position.

CONCLUSION

Our study reveals an interplay between ethical attitudes on euthanasia and religious convictions. The image one has of a transcendental reality, or of God, has a stronger effect on one's (dis)approval of euthanasia than being (ir)religious.

The operationalisation of religion and world view in surveys of nurses' attitudes toward euthanasia and assisted suicide

Most quantitative studies that survey nurses' attitudes toward euthanasia and/or assisted suicide, also attempt to assess the influence of religion on these attitudes. We wanted to evaluate the operationalisation of religion and world view in these surveys. In the Pubmed database we searched for relevant articles published before August 2008 using combinations of search terms. Twenty-eight relevant articles were found. In five surveys nurses were directly asked whether religious beliefs, religious practices and/or ideological convictions influenced their attitudes, or the respondents were requested to mention the decisional basis for their answers on questions concerning end-of-life issues. In other surveys the influence of religion and world view was assessed indirectly through a comparison of the attitudes of different types of believers and/or non-believers toward euthanasia or assisted suicide. In these surveys we find subjective religious or ideological questions (questions inquiring about the perceived importance of religion or world view in life, influence of religion or world view on life in general, or how religious the respondents consider themselves) and objective questions (questions inquiring about religious practice, acceptance of religious dogmas, and religious or ideological affiliation). Religious or ideological affiliation is the most frequently used operationalisation of religion and world view. In 16 surveys only one religious or ideological question was asked. In most articles the operationalisation of religion and world view is very limited and does not reflect the diversity and complexity of religion and world view in contemporary society. Future research should pay more attention to the different dimensions of religion and world view, the religious plurality of Western society and the particularities of religion in non-Western contexts.

Religion and Nurses' Attitudes To Euthanasia and Physician Assisted Suicide

In this review of empirical studies we aimed to assess the influence of religion and world view on nurses' attitudes towards euthanasia and physician assisted suicide. We searched PubMed for articles published before August 2008 using combinations of search terms. Most identified studies showed a clear relationship between religion or world view and nurses' attitudes towards euthanasia or physician assisted suicide. Differences in attitude were found to be influenced by religious or ideological affiliation, observance of religious practices, religious doctrines, and personal importance attributed to religion or world view. Nevertheless, a coherent comparative interpretation of the results of the identified studies was difficult. We concluded that no study has so far exhaustively investigated the relationship between religion or world view and nurses' attitudes towards euthanasia or physician assisted suicide and that further research is required.

Perception of Palliative Care and Euthanasia Among Recently Graduated and Experienced Nurses

Palliative care and euthanasia have become the subject of ethical and political debate in Poland. However, the voice of nurses is rarely heard. The aim of this study is to explore the perception of palliative care and euthanasia among recent university bachelor degree graduates and experienced nurses in Poland. Specific objectives include: self-assessment of the understanding of these terms, recognition of clinical cases, potential acceptability of euthanasia, and an evaluation of attitudes towards palliative care and euthanasia. This is an exploratory study. A convenience sample of 206 recent graduates and 252 experienced nurse practitioners were interviewed. A structured questionnaire was used for collecting and interpreting data. Subjective perception of the terms `palliative care' and `euthanasia' was high and consistent with the recognition of clinical cases. The majority of the nurses excluded euthanasia from palliative care. They recognized personal philosophy of life as the most influential factor affecting attitudes towards euthanasia. The importance of the law was valued more highly by the experienced nurses.

Israeli critical care nurses' attitudes toward physician-assisted dying

BACKGROUND

Within critical care, end-of life decisions are common, including hastening of the dying process. One type of hastening the dying process is physician-assisted dying (PAD).

OBJECTIVES

The purpose of this study was to determine Israeli critical care nurses' attitudes and practices toward PAD.

METHODS

A convenience sample of 71 intensive care unit nurses were asked to fill out a modified critical care, Hebrew version of the Nurse's Attitudes Regarding Physician-Assisted Dying Questionnaire. Subjects were also asked whether they were requested or whether they performed actions to hasten the dying process.

RESULTS

The majority of nurses supported PAD. However, only 10% of the respondents agreed to participate when PAD was to be administered by the nurse. Some nurses were asked by patients (12.7%) and/or by families (7.0%) to hasten the dying process. No nurse reported administering any lethal treatment. No significant differences in responses to the vignettes were found based on gender, marital status, place of birth or parents' place of birth, religion, age, type of education, having taken a post-basic course, years of general or intensive care unit nursing experience, or type of intensive care unit. However, significant differences were found in four vignettes based on level of self-perceived religiosity.

CONCLUSION

The findings demonstrated that the Israeli critical care nurses sampled tended to agree with the concept of PAD but were unlikely to agree to having a more active role in hastening the dying process. This particular finding was true especially among those nurses who considered themselves more religious.

Palliative care nurses' views on euthanasia

BACKGROUND

In debates on euthanasia legalization in Belgium, the voices of nurses were scarcely heard. Yet studies have shown that nurses are involved in the caring process surrounding euthanasia. Consequently, they are in a position to offer valuable ideas about this problem. For this reason, the views of these nurses are important because of their palliative expertise and their daily confrontation with dying patients.

AIM

The aim of this paper is to report a study of the views of palliative care nurses about euthanasia.

METHODS

A grounded theory approach was chosen, and interviews were carried out with a convenience sample of 12 palliative care nurses in Flanders (Belgium). The data were collected between December 2001 and April 2002.

FINDINGS

The majority of the nurses were not a priori for or against euthanasia, and their views were largely dependent on the situation. What counted was the degree of suffering and available palliative options. Depending on the situation, we noted both resistance and acceptance towards euthanasia. The underlying arguments for resistance included respect for life and belief in the capabilities of palliative care; arguments underlying acceptance included the quality of life and respect for patient autonomy. The nurses commented that working in palliative care had a considerable influence on one's opinion about euthanasia.

CONCLUSION

In light of the worldwide debate on euthanasia, it is essential to know how nurses, who are confronted with terminally ill patients every day, think about it. Knowledge of these views can also contribute to a realistic and qualified view on euthanasia itself. This can be enlightening to the personal views of caregivers working in a diverse range of care settings.

AIDS, nursing, and physician-assisted suicide: Part 2

Nurses who work in HIV/AIDS care often hold conflicting views from each other about appropriate nursing roles in relation to physician-assisted suicide. Regardless of whether the individual nurse supports or opposes physician-assisted suicide, nurses in HIV/AIDS care need to have a broad knowledge base of the legal and ethical issues related to physician-assisted suicide. This article has as its major purpose to provide nurses with the knowledge base they need to assist them in their work in clinical practice, education, policy development, and research.

Attitudes of cancer patients, their family members and health professionals toward active euthanasia

This qualitative study describes the attitudes of four groups of people in cancer care toward active euthanasia. Patients (32) with incurable cancer, their family members (13), nurses (13) and physicians (13) participated in the study which was carried out in two central hospitals and in four health centres in Finland. The data was collected by means of focused interviews which were taped, transcribed and then analysed by content analysis. More than half of the participants said that they could ethically justify active euthanasia. Most of these were family members and nurses. The main reasons for their ethical justification were the terminal illness of the patient, the presence of suffering and pain and the patient's own request. Those who could not justify active euthanasia said that one human being has no right to decide death of another. Potential abuse, uncertainty about the finality of the situation, the possibility of effective alleviation of symptoms and the effects which the practice might have on medical staff were also mentioned by this group. The results of this study support the assumption given in the earlier literature that attitudes toward active euthanasia are most positive where terminally ill cancer patients are concerned.

Meanings and attitudes toward end-of-life preferences in Israel

Thirty-six elderly people in Israel were interviewed concerning their meanings and attitudes toward end-of-life preferences. The phenomenological analysis method resulted in the identification of six meaning themes and a continuum of favorable to unfavorable attitude positions for each meaning theme. The combination of meaning themes and attitude positions produced 4 patterns of perspectives toward euthanasia, as well as a more holistic and integrative cultural dimension that was labeled Israel ego integrity. The 6 meaning themes were (a) moral perspectives, (b) religious beliefs, (c) mental and physical suffering, (d) family and community implications, (e) gaining control by willingness to trust others, and (f) previous experiences with death. The 4 patterns of perspectives toward euthanasia emphasized consequences for others, religious perspectives, concerns for personal suffering, and concerns for moral choice. The extensive diversity in the meaning-attitude perspectives from a small sample of elderly people suggested challenges for Israeli policy in regard to legalizing the living will to respect patients' rights to make end-of-life decisions.

Information disclosure: the moral experience of nurses in China

While the movement to ensure patient's rights to information and informed consent spreads throughout the world, patient rights of this kind have yet to be introduced in mainland China. Nonetheless, China is no different from other parts of the world in that nurses are expected to shoulder the responsibility of safeguarding patients' best interests and at the same time to uphold their right to information. This paper expounds on the principle of protectiveness grounded in traditional Chinese medical ethics concerning the practice of informed consent. Nurses in China have a moral obligation to treat patients with sincerity. This notion carries a strong sense of parental protectiveness. As far as information-giving is concerned, nurses in China are ambivalent about the notion of truthfulness. The findings of an empirical study undertaken in seven Chinese cities reveal that nurses in China experience similar difficulties related to the disclosure of information as their counterparts in other parts of the world. A nurse's narrative, the Chan case, is used to illustrate the typical difficult situation that nurses in China often encounter in looking after vulnerable patients who would like to learn more about their therapeutic regimens. The moral tension embedded in nursing practice is analysed. It is found that most nurses would prefer to tell the truth to patients, but their primary ethical justification is not that of respect for patients' autonomy or safeguarding patients' right to self-determination. Rather, it is basically beneficent in nature; that is, they base their decision to reveal the truth on whether or not patients will receive more relevant treatment and better nursing care.

Descriptions of suffering in connection with life values. Healthy individuals' reflections in interviews

Nine semistructured interviews with attendant questions were conducted with the purpose of elucidating how healthy individuals describe suffering and life values in their reflections upon active euthanasia. In order to find the intended meaning in utterances, the interviews were interpreted step by step. The point of departure was the following question: What expressions of suffering and what expressions of life values can be found in the text? A connection was found between the interviewees' descriptions of suffering and life values in their reflections upon active euthanasia. The interviewees who considered close relations to be a value of life expressed suffering as dependence, compassion, violation, abandonment and feelings of guilt, while those to whom health was a value of life expressed suffering as torment, dependence, physical pain, feebleness, hopelessness and dying. Those who saw autonomy as a value of life expressed suffering as dependence and violation and those to whom doing good was a value of life expressed suffering as compassion. When organizing health care and deciding about the response to suffering, it seems important to strive for a response built upon the individual patient's description of suffering and life values.

Retired registered nurses' stories about being in ethically difficult care situations

Twelve retired nurses were asked to narrate a care situation in which it had been difficult for them as nurses to know what was the right and good thing to do. The transcribed interviews were examined by content analyses. Physicians were the central coactors in the nurses' stories. Colleagues were seldom mentioned. Other ward staff were mainly called "the girls". The patient was central and referred to with respect. All the nurses focused on experiential learning. Guiding ethical principles are listed.

Cross-cultural research on euthanasia and abortion

Based on cross-cultural studies of euthanasia and abortion, we hypothesized that attitudes toward euthanasia and abortion were socioculturally determined. Using a 2 x 2 factorial design, we examined the effects of culture (America and China) and type of death (infanticide and geronticide). We found that students from the American culture were less likely to favor infanticide than those from the Chinese culture, and that students from the People's Republic of China believed infanticide to be more common and more prevalent than geronticide in Chinese society. Finally, we found that education, judgment of population density, and traditional family values were related to attitudes toward euthanasia, abortion, and female infanticide in the Chinese, but not in the American, culture.

Neonatal euthanasia: attributions of students and nurses

An attributional analysis of neonatal euthanasia was undertaken in two studies to compare the responsibility attributions of nursing and non-nursing students (Study 1) and nurses (Study 2) toward a physician for a critically ill neonate's death. In both studies, vignettes about a newborn's death differed with respect to the physician's treatment of the critically ill newborn. In the student study, the physician was attributed the least responsibility for the newborn's death when cardiopulmonary resuscitation was attempted but failed, followed by the physician's issuance of either a "Do Not Resuscitate" order or an order to turn off the infant's respirator. Greatest responsibility was attributed to the physician when he ordered the infant's nutritional and hydration support to be terminated. In addition, the student's major (nursing vs. non-nursing) and the nursing student's educational cohort impacted the level of physician responsibility attributed. In contrast, the nurses' study found that the termination of nutritional and hydrational support was viewed as different from the physician's other three actions.

The stories of physicians, registered nurses and enrolled nurses about ethically difficult care episodes in surgical care

Twenty physicians, 19 registered nurses (RN), and 20 enrolled nurses (EN) working in surgical care in Sweden narrated their experiences of being in ethically difficult care situations. All three professional groups disclosed a strong wish to help patients. The narrations of the physicians and the ENs indicated that they were very much involved in their patients, while most of the RNs' stories were narrated from a distanced onlooker's perspective and disclosed a lot of moral outrage, mainly directed towards physicians. The physicians were the only group that emphasized the importance of acting in accordance with science and proven experience. Like RNs they emphasized the importance and difficulty of telling the truth to the patients and their families and being open to one's own and others' harsh experiences. RNs and ENs emphasized the patient's right to a death with dignity and the difficulties connected with being with dying patients, and they also described feelings of powerlessness and neglect of patients related to a heavy work load. ENs narrated difficulties related to providing patients with individualized but fair care.

Nursing students' attitudes towards assisted suicide and euthanasia--a study from four different schools of nursing

In 1991/92, 289 students from four different schools of nursing in Norway participated in a case-related attitudes test. The nursing students answered questions concerning their personal views on the moral and legal implications of either assisting suicide or performing euthanasia. They also indicated whether they themselves were willing to perform these acts. The results were compared with responses from a study on students from other faculties in 1988. The findings suggested that nursing students were significantly (p < 0.0005) more restrictive than the other students in their attitudes towards voluntary active euthanasia (VAE). Factors that influenced the nursing students' attitudes towards VAE were measured by the index of VAE. Religious belief (p < 0.0001), conservative political view (p < 0.01), and the perception of life as meaningful (p < 0.02) were the best predictors of the dependent variable.

When the severely ill elderly patient refuses food. Ethical reasoning among nurses

Forty registered nurses (RNs) regarded as "good and experienced" in either cancer or dementia care, were asked about their decision to feed or not feed a severely ill elderly woman (a hypothetical case). In order to compare ethical reasoning in the two groups of nurses and to illuminate what it means to RNs to face a situation where the patients can/cannot decide for themselves, a phenomenological hermeneutic approach was used for the analysis. Both groups saw themselves as the advocate for their patients but in different ways. The RNs who talked about a mentally alert patient emphasized that they encouraged their patient to speak up for herself, while the RNs who talked about a severely demented patient emphasized that they tried very hard to interpret their patient's vague and unclear communicative cues and to act as her advocate, especially in relation to physicians. Transcending experiences of dying relatives and patients as well as role models helped them to achieve their ambition of putting themselves in the patient's shoes in order to respect and understand her or his wish and/or what was best for them. The majority of RNs strongly rejected active euthanasia.

Ethical reasoning concerning the feeding of severely demented patients: an international perspective

Structured interviews were held with 149 registered nurses in seven countries in America, Asia, Australia and Europe concerning the feeding of severely demented patients who do not accept food. The most common reasons for nurses being willing to change their decision to feed or not to feed were an order from the medical head, a request from the patient's husband and/or the staff meeting. There was a connection between the willingness to feed and the ranking of ethical principles. Nurses who were most prone to feed the patient most often gave a high rank to the ethical principle of sanctity of life, while those who primarily chose not to feed the patient gave a high rank to the ethical principle of autonomy. All nurses stressed the ethical principle of beneficence.