The heart of palliative care is relational: a scoping review of the ethics of care in palliative medicine

BACKGROUND

Palliative care, perhaps more than any subspecialty in healthcare, is deeply relational and engages patients and families at times of great vulnerability. Ethics of care, or relational ethics, developed through contributions from feminist ethics, offers conceptual tools and ways of thinking that seem especially suited to palliative care practice.

AIM

To identify and describe studies and theoretical analyses applying the ethics of care to palliative care (both adult and paediatric), specifically, its use to guide and improve practice and education for palliative care practitioners.

DESIGN

We conducted a scoping review of six databases covering clinical, social science and normative ethics scholarship and conducted a thematic analysis of the findings and ethical discussions or arguments.

DATA SOURCES

Databases searched included PubMed, CINAHL, PsychINFO, EMBASE, Web of Science and Philosopher's Index from 1982 to November 2024.

RESULTS

30 publications meeting our inclusion criteria were identified. Major themes reflected the relational obligations, attributes and character traits ideally developed in palliative care providers in their work and relationships with patients and families, including responsiveness, connectedness and hope, as well as in caring for ourselves and each other on palliative care teams. An emerging literature recognises the special guidance for palliative care for children.

CONCLUSIONS

Clinical and ethical scholarship in palliative care reveals a valuable but still underexplored connection between the ethical commitments within the ethics of care tradition and palliative care training and practice. Ethics of care addresses important gaps in training, particularly having to do with practitioners' relationships and ways of being with patients, families, colleagues and themselves.

The movement of virtue from ethos to action

In this paper, we explore the concept of virtue in nursing care. We particularly examine the description of 'virtue' offered by Aristotle, who considers it the mental constitution that forms the basis for laudable social behaviour. We then turn to Katie Eriksson's work on caritative caring ethics and draw parallels between the Aristotelian concept of virtue and being a good nurse. Eriksson suggests that embracing an ethos, a set of basic values, affects nurses' attitudes as well as the way they speak and take on their responsibility for the patient. We discuss these ideas in relation to a tentative ideal model of the movement from ethos to action to understand and address nurses' ethical thinking and acting. Here, we focus on the catalytic role of virtue as a means for realizing a deliberate, intentional acting with the best of the patient in mind. As an outcome of our analysis, we suggest that the movement of virtue from ethos to action is most usefully conceptualized as knowledge about facts, habits of the heart, deeds of the hand and the power of words. Implications for nursing leadership are suggested, including incorporating organizational values through the means of ethical conversations.

Self-competence in death work among health and social care workers: a region-wide survey in Hong Kong

BACKGROUND

According to the Quality of Death Index, Hong Kong is lagging behind many other Western and Asian countries in the category of palliative and healthcare. To ensure the provision of high-quality palliative care, it is important to explore the self-competence of health and social care workers in coping with death work including palliative care. This region-wide study aims to assess the level of self-competence with a validated Self-Competence in Death Work Scale (SC-DWS) and examine its correlates.

METHODS

The SC-DWS was administered to a cross-sectional convenience sample of health and social care workers across eight healthcare institutions between January and October 2016. Total scores for the 16-item SC-DWS and its Existential and Emotional subscales were calculated. We then examined sociodemographic variables (e.g., age, profession, place of employment) in relation to the total and subscale scores using multiple linear regression. Coding was conducted on responses to a final open-ended question asking about the personal views of the workers towards their self-competence in death work.

RESULT

We collected data from 885 health and social care workers. Mean score of the SC-DWS was 60.16 (range: 16 - 80), while its Existential and Emotional subscales scored 37.90 (range: 10 - 50) and 14.46 (range: 4 - 20) respectively. Four categories of personal view towards self-competence in death work including (1) personal resources; (2) existential challenges and coping; (3) emotional challenges and coping; and (4) personal recommendations on improving self-competence were identified. In multivariate analyses, workers aged 50 or above, divorced, working in Hospice A, Rehabilitation Hospital B (where a quality improvement initiative in end-of-life care was implemented) and Acute Hospital B (a Christian institution with strong caring culture) and with personal bereavement experience had significantly higher scores, whereas nurses scored significantly lower than less-educated personal care assistants.

CONCLUSION

There is still room for improvement in self-competence in death work among health and social care workers, particularly the young, nurses and those working in acute hospitals. Future initiatives should involve identifying barriers in individual healthcare institutions. Training of the provision of palliative care is necessary.

The Caring Relationship in Hospice Care: An analysis based on the ethics of the caring conversation

Good nursing is more than exercising a specific set of skills. It involves the personal identity of the nurse. The aim of this article is to answer two questions: (1) what kind of person should the hospice nurse be? and (2) how should the hospice nurse engage in caring conversations? To answer these questions we analyse a nurse’s story that is intended to be a profile of an exemplary hospice nurse. This story was constructed from an analysis of five semistructured interviews with hospice nurses, based on the ‘ethics of the caring conversation’, which is inspired by the ethical perspective of Paul Ricoeur. The research questions concentrate on the norms of respect, responsibility and reciprocity, which are integral parts of the ‘ethics of the caring conversation’.

Coping With Existential and Emotional Challenges: Development and Validation of the Self-Competence in Death Work Scale

CONTEXT

Palliative care professionals often are confronted by death in their work. They may experience challenges to self, such as aroused emotions and queries about life's meaningfulness. Assessing their level of "self-competence" in coping with these challenges is crucial in understanding their needs in death work.

OBJECTIVES

This study aims to develop and validate the Self-Competence in Death Work Scale (SC-DWS).

METHODS

Development of this scale involved three steps: 1) items generated from a qualitative study with palliative care professionals, (2) expert panel review, and (3) pilot test. Analysis was conducted to explore the factor structure and examine the reliability and validity of the scale. Helping professionals involved in death work were recruited to complete questionnaires comprising the SC-DWS and other scales.

RESULTS

A total of 151 participants were recruited. Both one-factor and two-factor structures were found. Emotional and existential coping were identified as subscales in the two-factor structure. Correlations of the whole scale and subscales with measures of death attitudes, meaning in life, burnout and depression provided evidence for the construct validity. Discriminative validity was supported by showing participants with bereavement experience and longer experience in the profession and death work possessed a significantly higher level of self-competence. Reliability analyses showed that the entire scale and subscales were internally consistent.

CONCLUSION

The SC-DWS was found to be valid and reliable. This scale may facilitate helping professionals' understanding of their self-competence in death work, so appropriate professional support and training may be obtained.

Ethical competence

Background:

Exploring the concept of ethical competence in the context of healthcare is essential as it pertains to better quality of care. The concept still lacks a comprehensive definition covering the aspects of ethical expertise, ethical knowledge and action of a health professional.

Objective:

This article aims to report an analysis of the concept of ethical competence.

Method:

A modified strategy suggested by Walker and Avant was used to analyse the concept.

Results:

As a result, the concept of ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. Virtuous professional, experience of a professional, human communication, ethical knowledge and supporting surroundings in the organisation can be seen as prerequisites for ethical competence. Ethical competence results in the best possible solutions for the patient, reduced moral distress at work and development and democratisation of society.

Conclusion:

The results of the analysis establish a basis for an instrument to evaluate health professionals’ ethical competence. It will guide educators, as well as managers in healthcare, to support the development of ethical conduct in healthcare.