The role of nurses in euthanasia: A scoping review

Nursing care in assisted dying: Plasticity and relational commitment

BackgroundSpain's Euthanasia Law came into force in 2021. Nurses are involved throughout the entire process and yet the law only recognizes their role in the final administration of the drug.ObjectiveTo understand the practice and experience of nurses involved in the euthanasia process.Research designQualitative study with a phenomenological approach. An interpretative phenomenological analysis was conducted using ATLAS-ti.Participants and research contextThis study is part of a larger project for which the study population comprised professionals who have participated in the euthanasia process in Catalonia since the law came into force. This study is based on data collected from nurses through 6 in-depth interviews and 3 focus groups.Ethical considerationsThis study was approved by the Ethics Committee (22/094-P). All participants granted their informed consent. Interviews and focus groups were anonymized.FindingsThe results revolve around two themes: (1) Plasticity of nursing care in the face of regulatory gaps and (2) managing emotions while providing assisted dying. Nurses respond to patients and families by adapting to the demands of the process and self-managing any emotions that arise from participating in this practice. Nurses use rationalization to manage the range of emotions they experience resulting from the tension between respecting a person's autonomous decision to request euthanasia and upholding their professional duty to prevent harm. The team stands out as a crucial element in managing these emotions.ConclusionsSpanish nurses are involved throughout the entire euthanasia process, demonstrating great plasticity of care. Euthanasia care is complex and the relational context between professionals and the patient/family and between team members is key. The law should define and envisage the role of nurses, as it does for other professions.

The Perspectives of General Practitioners on the Roles and Competences of Nurses During a Euthanasia Process: A Cross-Sectional Study

Background: The legalization of euthanasia in Belgium in 2002 positioned nurses as possible participants in the euthanasia process. However, ethical and legal dilemmas necessitate clear definitions of their roles and competencies in this context. Given that general practitioners (GPs) are the primary medical professionals performing euthanasia, understanding their perspectives on the roles of nurses is crucial. Aim: This study aims to describe GPs' perceptions of the roles and competencies of nurses during the euthanasia process. The research question addressed is as follows: "What are GPs' views on the roles and competencies of nurses in euthanasia?". Methods: A quantitative cross-sectional survey was conducted among licensed GPs in Flanders, Belgium. Data were collected via an online survey using Qualtrics and analyzed with SPSS Statistics. Ethical approval was obtained from the Medical Ethics Committee of the university. Results: The study included responses from 237 GPs. GPs value the roles and competencies of nurses, recognizing euthanasia as a multidisciplinary process. They acknowledge the critical support nurses provide to patients and their families. GPs assert that the administration of euthanasia medication should remain the exclusive responsibility of the GP. The analysis further indicated that demographic factors did not significantly influence the results. Discussion/Conclusions: GPs in Belgium generally rated the roles and competencies of nurses positively. Enhancing multidisciplinary collaboration, legislating the roles of nurses, and incorporating practical euthanasia training in nursing curricula, e.g., via simulations, are recommended.

Decision-making process regarding passive euthanasia: Theory of planned behavior framework

BACKGROUND

Nurses have an essential role in caring for end-of-life patients. Nevertheless, the nurse's involvement in the passive euthanasia decision-making process is insufficient and lower than expected.

OBJECTIVES

To explore factors associated with nurses' intention to be involved in non-treatment decisions (NTD) regarding passive euthanasia decision-making versus their involvement in the palliative care of patients requesting euthanasia, using the Theory of Planned Behavior (TPB) framework.

DESIGN

A cross-sectional study utilizing a random sample.

PARTICIPANTS AND RESEARCH CONTEXT

The study was conducted in one of the largest hospitals in Israel among 125 nurses employed in internal and surgical care wards. Data was collected through face-to-face interviews between March and April 2019.

METHOD

A closed structured questionnaire was developed according to TPB instructions. A paired sample t test and two multiple hierarchical regressions were conducted. Variance explained (R2) and the significance of F change were calculated for each regression. The study used the STROBE statement guideline.

ETHICAL CONSIDERATIONS

The study was approved by the hospital's Helsinki Committee (#20.11.2017).

FINDINGS

A paired sample t test revealed that nurses' involvement in the palliative care of patients requesting passive euthanasia was significantly higher than in NTD regarding euthanasia. Regression analyses revealed that nurses' position and attitudes explain their intention to be involved in decision-making; attitudes and perceived behavioral control explain nurses' intention to be involved in the care of patients requesting euthanasia.

CONCLUSIONS

According to the TPB, nurses' attitudes explained their intention to participate in decision-making regarding passive euthanasia. It is recommended to enhance open discussion of this complex issue to encourage nurses' willingness to participate in NTD decision-making regarding euthanasia.

Assisted Suicide in Austria: Nurses' Understanding of Patients' Requests and the Role of Patient Symptoms

This study explores Austrian palliative and hospice care nurses' experiences regarding assisted suicide (AS). Following its legalization in 2022, occupational groups affected by the legislation, such as nurses, have been left without clear guidance or instructions on how to navigate this new landscape. This study aimed to explore how nurses perceive their patients' desire to die and its connection to the symptoms experienced by the patients. A cross-sectional online questionnaire survey was disseminated to all palliative and hospice care facilities in Austria and was eventually completed by 145 nurses, focusing on their understanding of patients' requests for AS and the severity of patients' symptoms. Factor analysis was used to identify symptom clusters, and Spearman rank correlations were employed to explore associations between nurses' understanding of AS and factors such as patient symptoms, nurse demographics, and attitudes toward AS. The results indicate that psychosocial factors, particularly loss of dignity (63.6%) and autonomy (76.4%), were the most frequently reported severe symptoms. Understanding patients' decisions was significantly associated with nurses' general support for AS (r = 0.34, p < 0.001) but not with age, work experience, or religious beliefs. Factor analysis revealed four symptom clusters, with 'loss of dignity' showing a small but significant correlation with nurses' understanding of patients' requests (r = 0.17, p = 0.044). The present findings highlight the importance of integrating psychosocial support into palliative care and emphasize the need for clear guidelines and training to better support nurses in managing AS-related challenges.

Navigating end-of-life care dilemmas: a qualitative inquiry of nurses' and midwives' knowledge of euthanasia and circumstantial factors influencing euthanasia in a resource-constraint setting

BACKGROUND

Deaths can be caused by terminal illnesses, accidents, or natural disasters. However, medically, death can be hastened by healthcare providers, patients themselves, or their relatives. In advanced cancers where the patient's quality of life is compromised, Euthanasia can be used to hasten death. Inadequate medical resources and low socioeconomic status have been cited as factors influencing Euthanasia. This study sought to explore nurses' and midwives' knowledge and perspectives on Euthanasia in resource-constrained health facilities.

METHODS

A qualitative exploratory, descriptive design was used to recruit 24 nurses and midwives from three major referral hospitals, two regional hospitals, and one district hospital. Data was collected through individual in-depth face-to-face and telephone interviews. Braun and Clarke's (2006) thematic data analysis approach was used.

FINDINGS

Three main themes and eight subthemes were generated from the data: the main themes include Knowledge of Euthanasia, health system resource constraint-driven euthanasia and family resource constraint-motivated euthanasia. The findings indicate that nurses and midwives lack understanding of some terminologies related to the act. Strict policy decisions, inadequate resources, and misunderstanding of palliative care resulted in the practice of Euthanasia. Additionally, unbearable pains and financial constraints of families of critically ill patients made them request Euthanasia in the health facilities.

CONCLUSION

The study highlights the challenges of end-of-life care in resource-constrained settings, emphasizing the need for provider training, increased healthcare capacity, and clearer national guidelines for ethical decision-making.

Nurses' opinions on euthanasia in Spain: an evaluation using a new version of the EAS

BACKGROUND

Bioethical dilemmas at the end of life have led to regularization processes for the provision of medical assistance in dying patients in different countries. Since the regulation of euthanasia in Spain in 2021, the euthanasia act has been included as one of the benefits of the health system, which has undergone uneven development and implementation in different autonomous communities. The aim of this study was to review the Spanish version of the Euthanasia Attitude Scale following the partial modification of four items.

METHODS

A cross-sectional study was conducted with a non-probabilistic sample of Spanish health workers from Islas Baleares. A self-reported sociodemographic questionnaire and the Euthanasia Attitude Scale were used for data collection. The psychometric properties of the scale were assessed, including reliability and validity, using a confirmatory factor analysis and a parallel analysis.

RESULTS

The Cronbach's alpha of the EAS was α = 0.892, which implies good internal consistency. According to the confirmatory factor analysis, a Kaiser-Meyer-Olkin-value of 0.938 was obtained, and the result of Bartlett's test of sphericity was < 0.001. The questionnaire included four loading factors, which explained up to 56.99% of the variance. The parallel analysis revealed three significant factors and a fourth, less interpretative factor.

CONCLUSIONS

The EAS-ES-R is a valid instrument for assessing the attitudes toward euthanasia of both trainees and practicing health professionals. It may also be of vital importance in detecting training, support and implementation needs for laws regulating euthanasia in Spain.

Using simulation to teach nursing students how to deal with a euthanasia request

Nursing students are confronted with euthanasia during their internship and certainly during their later career but they feel inadequately prepared in dealing with a euthanasia request. This study presents a simulation module focused on euthanasia and evaluates nursing students' perceptions after they have completed the simulation practice. The 'euthanasia module' consisted of a preparatory online learning module, a good-practice video, an in-vivo simulation scenario, and a debriefing session. The module's content was validated by four experts in end-of-life care. The module was completed by three groups of students from two different University Colleges (n = 17 in total). The students were divided into three groups: one with no previous simulation education experience, one with all students having previous experience, and another with a mix of experiences. After completing the entire module, each group had a discussion regarding their perceptions and expectations concerning this simulation module. Thematic content analysis was conducted on audio-recorded group interviews using NVIVO® software, involving initial open coding, transformation into specific themes and subthemes through axial coding, and defining core themes through selective coding, with data analysis continuing until data saturation was reached. Students generally found the online learning module valuable for background information, had mixed perceptions of the good-practice video, and appreciated the well-crafted scenarios with the taboo of euthanasia emerging during simulations, while the debriefing process was seen as enhancing clinical reasoning abilities. Students considered the simulation module a valuable addition to their education and nursing careers, expressing their satisfaction with the comprehensive coverage of the sensitive topic presented without sensationalism or taboos. This subject holds significance for nations with established euthanasia laws and those lacking such legal frameworks. The findings of this study can aid teachers in developing and accessing euthanasia simulation training programs, contributing to broader education's emphasis on integrating euthanasia-related knowledge and skills.

Definition and validation of the nursing diagnosis label "wish to die": a research protocol

BACKGROUND

Euthanasia has been incorporated into the health services of seven countries. The legalisation of these practices has important repercussions for the competences of nurses, and it raises questions about their role. When a patient with advanced disease expresses a wish to die, what is expected of nurses? What are the needs of these patients, and what kind of care plan do they require? What level of autonomy might nurses have when caring for these patients? The degree of autonomy that nurses might or should have when it comes to addressing such a wish and caring for these patients has yet to be defined. Recognising the wish to die as a nursing diagnosis would be an important step towards ensuring that these patients receive adequate nursing care. This study-protocol aims to define and validate the nursing diagnosis wish to die in patients with advanced disease, establishing its defining characteristics and related factors; to define nursing-specific interventions for this new diagnosis.

METHODS

A prospective three-phase study will be carried out. Phase-A) Foundational knowledge: an umbrella review of systematic reviews will be conducted; Phase-B) Definition and validation of the diagnostic nomenclature, defining characteristics and related factors by means of an expert panel, a Delphi study and application of Fehring's diagnostic content validation model; Phase-C) Definition of nursing-specific interventions for the new diagnosis. At least 200 academic and clinical nurses with expertise in the field of palliative care or primary health care will be recruited as participants across the three phases.

DISCUSSION

The definition of the wish to die as a nursing diagnosis would promote greater recognition and autonomy for nurses in the care of patients who express such a wish, providing an opportunity to alleviate underlying suffering through nursing-specific interventions and drawing attention to the needs of patients with advanced disease. The new diagnosis would be an addition to nursing science and would provide a framework for providing care to people with advanced disease who express such a wish. Nurses would gain professional autonomy about identifying, exploring and responding clinically to such a wish.

The paradoxical position of nurses regarding euthanasia and its legalisation: A descriptive quantitative study

AIMS AND OBJECTIVES

To learn about the attitudes of nurses working in the Andalusian Public Health System regarding euthanasia and its legalisation.

BACKGROUND

Euthanasia often finds itself in the crosshairs of ethical and political debate on an international scale. Currently, the Spanish Organic Law 3/2021 of 24 March, 2021, recognises euthanasia as a fundamental right in Spain. It is of particular interest to know about the views, attitudes and stances that Andalusian nurses have of euthanasia as they are key players within the framework of euthanasia and administration of life-ending drugs. They play a central role in guiding patients through the euthanasia application process.

DESIGN

Observational descriptive study.

METHODS

A study of Andalusian Public Health System nurses was carried out using non-probability convenience sampling. 518 nurses with an average age of 44.75 years answered in a questionnaire that was distributed on an online platform. Socio-demographic and occupational variables were assessed, together with the Death Anxiety Scale and the Euthanasia Attitude Scale. A bivariate analysis and a multivariate linear regression model were performed. The STROBE checklist was used.

RESULTS

The mean score obtained on the Euthanasia Attitude Scale was 75.95 (SD = 16.53). The mean score obtained on the Death Anxiety Scale was 7.56 (SD = 3.05). The variables age and work experience were negatively correlated with the total scores of the Euthanasia Attitude Scale and the categories 'Ethical considerations', 'Practical considerations' and 'Treasuring life'. On the other hand, there was a significant positive correlation between age and work experience and 'Spiritual beliefs' category.

CONCLUSIONS

The current situation shows a worrying paradox. There is a stark difference between positive professional attitudes towards euthanasia and the desire to participate in its application.

RELEVANCE TO CLINICAL PRACTICE

It is vital that educational and healthcare institutions make the necessary efforts to ensure that nurses develop sound moral judgement, displaying the moral conscience and ethical commitment required of this established profession.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Nursing students' view on their future role and skills regarding euthanasia due to unbearable mental suffering: A mixed-method Study

AIM

To explore final-year bachelor nursing students' view on their future role and skills regarding euthanasia due to unbearable mental suffering (UMS-euthanasia) and to discover possible education needs.

BACKGROUND

Since UMS-euthanasia is legal in Belgium, nursing students will be confronted with this issue during their future internship, or professional career. Graduated nurses believe to have an important role in the process of euthanasia where good communication skills and sufficient legal knowledge are essential.

DESIGN

Mixed-methods sequential explanatory design.

METHODS

First, a questionnaire was administered to all final-year bachelor nursing students at eight university colleges in Flanders (October 2020 and March 2021). Second, qualitative information was collected by organising focus groups with these students to gain more insights into the quantitative results (October 2021).

RESULTS

The final-year nursing students from the survey (n = 249) and from the three focus groups (n = 21) see a clear future role for themselves in the decision-making process, as well as in supporting the patient and family before, during and after UMS-euthanasia, but not in assisting in administering UMS-euthanasia. However, they also indicate they lack knowledge and skills in dealing adequately with UMS-euthanasia. Psychiatric internship alumni perceive a diminished role for themselves in the preparatory acts (p < 0.05). Ever involved in euthanasia shows a statistically significant difference in the demand for simulation.

CONCLUSIONS

Nursing students see an important role for nurses in UMS-euthanasia but feel inadequately prepared to take on this role. A combination of theoretical knowledge, clinical experience, open discussions, reflection and simulation is an opportunity to prepare nurses for their future role.

First-Hand Recommendations for Nursing Management to Support Nurses Involved in the Process of Hastened Death: A Systematic Review of the Qualitative Evidence

Aim

The aim of this review was to support nursing management in creating frameworks for the care of people requesting hastened death, based on the best available evidence on the experiences of nurses.

Background

The legalisation of hastened death presents nurses with a complex set of ethical and moral risks. The largely unregulated role of nurses in the politics of hastened death can lead to moral distress and burnout. Evaluation. A systematic database search was conducted in CINAHL, LIVIVO, Medline, OVID, and Web of Science. The meta-aggregative approach was used to synthesise the findings. Quality appraisal was done using criteria of the Joanna Briggs Institute. Key Issues. Sixteen studies from four different countries were included. Interview data were from 200 nurses. Meta-aggregation resulted in ten synthesised findings including the need for guidelines; time resources; a supporting team; and professional, social, and personal skills.

Conclusions

A working environment with clear guidelines, sufficient resources, structured professional adjustment programmes, and educational measures is supportive for nurses. Implications for Nursing Management. Nursing management should create a professional strategy, guidelines, promote good team culture, implement education, and training activities.

Nursing students' attitudes regarding euthanasia due to unbearable mental suffering: Cross-sectional study using the adapted and validated Euthanasia Attitude Scale

AIM

To explore final year nursing students' attitudes towards euthanasia due to unbearable mental suffering by using the adapted and validated Euthanasia Attitude Scale.

DESIGN

Cross-sectional survey.

METHODS

Explorative, descriptive cross-sectional study conducted using an e-mail survey between October 2020 and March 2021 by a sample of final-year baccalaureate nursing students (n = 273) from eight of the eleven Flemish university colleges. The actual questionnaire contains 21 questions and was developed based on a consensus reached following independent translations. The psychometric properties of the Euthanasia Attitude Scale were assessed, including reliability and validity. Independent-sample Mann-Whitney U-test was used to investigate relation between demographic and education-related data, and domain and total score of the UMS-EAS-NL. This study received ethical approval from the Ethical Committee of the University Hospital Brussels, Belgium.

RESULTS

McDonald's omega was 0.838 for the total Euthanasia Attitude Scale scores, supporting the validity of the questionnaire. A statistically significant difference in 'Naturalistic beliefs' score was found relating to the year of birth. There are clinically important results between those students who have been involved in euthanasia and those who have not.

CONCLUSIONS

Most of the final-year nursing students supported the probability of patients' access to euthanasia due to unbearable mental suffering. To monitor adequate care, it is necessary to prepare nursing students adequately for this complex matter.

IMPACT

To date, no large-scale study has examined nursing students' attitudes towards euthanasia because of unbearable mental suffering. It is expected that nursing students may be confronted with such a euthanasia request during an internship, or later in their professional career, in countries where euthanasia is legal. Students showed a high acceptability towards UMS-euthanasia. Clinically significant differences were found for students who had ever been involved in euthanasia.