Factors related to the involvement of nurses in medical end-of-life decisions in Belgium: A death certificate study

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Abstract

Background

Although nurses play an important role in end-of-life care for patients, they are not systematically involved in end-of-life decisions with a possible or certain life-shortening effect (ELDs). Until now we know little about factors relating to the involvement of nurses in these decisions.

Objective

To explore which patient- and decision-characteristics are related to the consultation of nurses and to the administering of life-ending drugs by nurses in actual ELDs in institutions and home care, as reported by physicians.

Method

We sampled at random 5005 of all registered deaths in the second half of 2001 – before euthanasia was legalized – in Flanders, Belgium. We mailed anonymous questionnaires to physicians who signed the death certificates and asked them to report on ELDs, including nurses’ involvement.

Results

Response rate was 59% (n=2950). Physicians reported nurses involved in decision making more often in institutions than at home, and more often in care homes for the elderly than in hospitals (OR 1.70, 95% CI 1.15, 2.52). This involvement was more frequently when physicians intended to hasten the patient's death than when they had no such intention (institutions: OR 2.05, 95% CI 1.41, 2.99; home: OR 2.04, 95% CI 1.19, 3.49). In institutions, this involvement was also more likely where patients were of lower rather than higher education (OR 2.95, 95% CI 1.49, 5.84). The administering of life-ending drugs by nurses, as reported by physicians was also found more frequently in institutions than at home, and in institutions more frequently with lower rather than higher educated patients (p=.037).

Conclusions

These findings raise questions about physicians’ perception of the nurse's role in ELDs, but also about physicians’ skills in interacting with all patients. Education and guidelines for physicians and nurses are needed to optimize good communication and to promote a clearer assignment of responsibilities concerning the execution of those decisions.

Section snippets

What is already known about the topic?

  • Nurses play a key role in good end-of-life care and are frequently confronted with the question of euthanasia and other end-of-life decisions with a possible or certain life-shortening effect (ELDs).

  • Physicians do not systematically involve nurses in ELDs.

  • Studies about factors related to the involvement of nurses are limited to healthcare professionals’ characteristics and are only studied in a particular care unit or nursing specialization.

What this paper adds

  • Physicians consult nurses in ELDs more often when they intend to hasten the patient's death than without such intention, more often in care homes for the elderly than in hospitals and in institutions, more often with lower than higher educated patients.

  • As reported by physicians, nurses administer life-ending drugs more often in institutions than at home, and in institutions more often in case of lower than higher educated patients.

  • Physician's perceptions of the role of nurses, as well as their

Aim

The aim of this study is to explore which patient- and decision-characteristics are related to the consultation of nurses and the administering of life-ending drugs by nurses in actual ELDs in institutions as well as at home, as reported by physicians.

Design

A cross-sectional retrospective death certificate study was conducted in 2001 in Flanders, the northern Dutch-speaking region of Belgium where approximately 60% of the Belgian population lives and where about 56 000 deaths occur each year (54% in

Results

The response rate was 59% (n=2950). In 38.5% of all deaths (n=1354), death was preceded by at least one ELD: withholding or withdrawing a probably life-prolonging medical treatment were reported in 14.6%, alleviation of pain and/or symptoms with a possible life-shortening effect in 22.1%, the use of drugs with the explicit intention of hastening the patient's death at the patient's explicit request (euthanasia) occurred in 0.3%, and without the patient's explicit request in 1.5% of all deaths

Discussion

As in previous studies (Muller et al., 1997; Bilsen et al., 2004b), in this study nurses are consulted more frequently in an institution than they are at home. Additionally, we find that within institutions, nurses are consulted more frequently in care homes for the elderly than in hospitals. In care homes for the elderly, nurses provide supervision of and assistance in the daily activities of the residents and have great responsibility in the administering of treatments. They work autonomously

Acknowledgment

The authors thank J. Vanoverloop for his statistical advice, J. Mayes for her useful comments on the article, the Federal and Flemish Ministry of Public Health for their cooperation in the data collection, all participating physicians, and all members of the EURELD consortium.

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