How physicians see nurses' role in decision-making about life-prolonging treatments in patients with a short life expectancy: An interview study

OBJECTIVE

Exploring physicians' views on hospital nurses' role in decision-making about potentially life-prolonging treatments in patients with a short life expectancy.

METHODS

A qualitative study using semi-structured interviews with hospital physicians. Data were collected from May to September 2019 and analyzed following principles of thematic analysis.

RESULTS

Fifteen physicians working in different hospitals and specialisms participated. Physicians stated that they are responsible for the final decision about potentially life-prolonging treatments. They considered nurses' role in decision-making to be complementary to the roles of both patients and the physicians themselves, especially when there are doubts or complex situations. Physicians varied in how important they found nurses' involvement in the decision-making process: some physicians saw the involvement of nurses as "situation-dependent", while others viewed nurses' involvement as standard practice. Furthermore, physicians mentioned practical obstacles to involving nurses, like the limited time available to both nurses and physicians themselves.

CONCLUSION

Physicians recognize a complementary role for nurses in decision-making about potentially life-prolonging treatment, especially in cases with doubts or complex situations.

PRACTICE IMPLICATIONS

Physicians and nurses should engage with each other to make nurses' involvement less situation-dependent. This inter-professional collaboration regarding decision-making about life-prolonging treatments should be stimulated, supported and maintained.

Moral distress among nurses involved in life-prolonging treatments in patients with a short life expectancy: A qualitative interview study

OBJECTIVE

To explore whether nurses in hospital settings experience moral distress when involved in potentially life-prolonging treatments in adults with a short life expectancy.

METHODS

A qualitative study using semi-structured interviews.

RESULTS

23 Registered nurses working in inpatient or outpatient hospital settings participated. The nurses stated they were often not involved in decisions regarding life-prolonging treatments. They reported signs of moral distress such as feeling powerless when they when they were not being listened to in the decision-making process and when confronted with negative treatment outcomes. Nurses felt frustrated when their own values were not reflected in the decision-making or when physicians created unrealistic expectations.

CONCLUSIONS

Hospital nurses experience moral distress when they are involved in life-prolonging treatment because of the patient's advanced condition and their own lack of involvement in the decision-making process about the treatment. In these situations, moral distress is characterised by feelings of powerlessness and frustration.

PRACTICE IMPLICATIONS

Nurses need to be empowered by training programmes that focus on an active role in the decision-making process. Further research is needed to evaluate effective tools and training programmes that help nurses in shared decision-making processes.

Barriers and facilitators of appropriate antibiotic use in primary care institutions after an antibiotic quality improvement program - a nested qualitative study

BACKGROUND

Antibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs.

METHODS

After implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke.

RESULTS

We identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents' next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound.

CONCLUSIONS

Our qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians.

Association between subjective economic status and refusal of life-prolonging treatment: a cross-sectional study using content analysis with stratified random sampling

Introduction:

Older adults tend to refuse life-prolonging treatment for various reasons, and it is important to respect their choice of treatment at the end-of-life stage. The present study examines the associations of subjective economic status and gender with reasons for refusal of life-prolonging treatment in older adults in general population.

Methods:

In this cross-sectional study, using stratified random sampling, 1,595 older adults living in Koriyama City, Japan, as of 2016, completed self-administered questionnaires on subjective economic status and preference for life-prolonging treatment, with free-description regarding reasons for refusal. We analyzed the associations between the combination of subjective economic status and gender with frequently mentioned terms and their clusters regarding such reasons, using χ² test, content analysis, text mining and hierarchical cluster analysis.

Results:

The combinations of subjective economic status and gender were significantly associated with clustered reasons for refusal of life-prolonging treatment (p < 0.01). The reasons frequently mentioned were: ‘avoidance of unnecessary medical care’ and ‘dignity’ in well-off females; and ‘financial burden on family’ in poor males.

Conclusions:

Our findings suggest that older adults who at first glance appear to be freely refusing life-prolonging treatment, may have their decision making restricted through economic constraints.

Quality of life in men with metastatic prostate cancer in their final years before death - a retrospective analysis of prospective data

Background

Quality of Life (QoL) is the most important outcome for patients in palliative care along with symptom alleviation. Metastatic prostate cancer (mPC) is a life-threatening illness, and hence, a palliative care approach may be beneficial to this group. Over time, new life-prolonging treatments have been developed for men with mPC, but the possibility to prolong life should also be balanced against the men’s QoL, particularly because there are side effects involved with these treatments. The aim of this study was to evaluate QoL, functioning and symptoms in men with mPC during their final years before death.

Methods

This is a retrospective analysis of data from a long-term prospective study of men (n = 3885) with prostate cancer from two regions in Sweden. Validated questionnaires asking about participants’ QoL, functioning and symptoms were used to collect data. From the overall study, 190 men with mPC were identified. They were stratified into three groups, depending on the amount of time that had passed between the last questionnaire and their death; < 6 months, 6–18 months and > 18 months before death.

Results

Men with mPC generally rated their QoL poorly compared to established clinically significant threshold values. The group of men that were < 6 months before death rated their QoL, functioning and several symptoms significantly worse than the two other groups. Men that died after the year 2006 reported lower QoL and functioning and more pain and fatigue than those who died before 2006.

Conclusion

The results in this study indicate that men with mPC have unmet needs with regards to QoL and symptoms. A palliative care approach, alongside possible life-prolonging treatments, that focuses on QoL and symptom relief, may serve as an important frame to give the best support to these men in their final years of life.

[Provision of palliative care for people with advanced dementia]

As a result of a literature-based expert process, this review provides an overview about the principles of palliative care for people with advanced dementia that are relevant for clinical practice. In particular, the indications, impact and aims of palliative care for advanced dementia are described. Life-prolonging measures and management of symptoms at the end of life are discussed. Furthermore, the overview focuses on the legal basis of decision making.