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Ethical competence in DNR decisions: a qualitative study of Swedish physicians and nurses working in hematology and oncology care
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.ORCID iD: 0000-0001-6296-0160
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics.
2018 (English)In: BMC Medical Ethics, ISSN 1472-6939, E-ISSN 1472-6939, Vol. 19, article id 63Article in journal (Refereed) Published
Abstract [en]

Background

DNR decisions are frequently made in oncology and hematology care and physicians and nurses may face related ethical dilemmas. Ethics is considered a basic competence in health care and can be understood as a capacity to handle a task that involves an ethical dilemma in an adequate, ethically responsible manner. One model of ethical competence for healthcare staff includes three main aspects: being, doing and knowing, suggesting that ethical competence requires abilities of character, action and knowledge. Ethical competence can be developed through experience, communication and education, and a supportive environment is necessary for maintaining a high ethical competence. The aim of the present study was to investigate how nurses and physicians in oncology and hematology care understand the concept of ethical competence in order to make, or be involved in, DNR decisions and how such skills can be learned and developed. A further aim was to investigate the role of guidelines in relation to the development of ethical competence in DNR decisions.

Methods

Individual interviews were conducted with fifteen nurses and sixteen physicians. The interviews were analyzed using thematic content analysis.

Results

Physicians and nurses in the study reflected on their ethical competence in relation to DNR decisions, on what it should comprise and how it could be developed. The ethical competence described by the respondents related to the concepts being, doing and knowing.

Conclusions

In order to make ethically sound DNR decisions in oncology and hematology care, physicians and nurses need to develop appropriate virtues, improve their knowledge of ethical theories and relevant clinical guidelines. Ethical competence also includes the ability to act upon ethical judgements. Continued ethical education and discussions for further development of a common ethical language and a good ethical working climate can improve ethical competence and help nurses and physicians cooperate better with regard to patients in relation to DNR decisions, in their efforts to act in the best interest of the patient.

Place, publisher, year, edition, pages
2018. Vol. 19, article id 63
Keywords [en]
Ethical competence; DNR decisions; Oncology; Hematology; Nurses; Physicians
National Category
Medical Ethics
Identifiers
URN: urn:nbn:se:uu:diva-355087DOI: 10.1186/s12910-018-0300-7ISI: 000435613900002PubMedID: 29914440OAI: oai:DiVA.org:uu-355087DiVA, id: diva2:1223941
Funder
Swedish Cancer SocietyAvailable from: 2018-06-26 Created: 2018-06-26 Last updated: 2018-10-03Bibliographically approved
In thesis
1. COMPETENCE AND COMMUNICATION: Do Not Resuscitate Decisions in Cancer Care
Open this publication in new window or tab >>COMPETENCE AND COMMUNICATION: Do Not Resuscitate Decisions in Cancer Care
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Within cancer care, do not resuscitate (DNR) decisions are frequently made. DNR decisions can be ethically difficult and lead to conflicts of interest and disagreements within the medical team. This thesis brings together empirical knowledge of DNR decisions in cancer care and theoretical discussions on the ethical aspects and the competence needed to make such decisions.

The overall aim of this project was to investigate the clinical and ethical aspects of DNR decisions from the perspectives of nurses and physicians working in hematology and oncology care. The methods used were qualitative, with individual interviews, and quantitative, using a web survey. Ethical theories, principles and models were used   in the planning of the studies and to explain and discuss the results.

Fifteen nurses in Study I expressed a close relationship with their patients. They expressed how they needed clear and well-documented decisions on DNR to provide good care to patient and relatives. Sixteen physicians participated in Study II. They described how they made decisions on DNR mainly on medical grounds, but reflected on ethical aspects of the decision, weighing maleficence and beneficence.  In Study III, the interviews from Study I and II were analyzed from the perspective of ethical competence. The results showed that physicians and nurses were able to reflect on their ethical competence in relation to DNR decisions and described ethical competence as both being good and doing right. Also knowledge in ethics was emphasized.  In Study IV, 216 nurses and physicians participated. Most respondents thought it was important for patients and relatives to participate in, and be informed about, a DNR decision, but fewer thought that this was likely to happen. Nurses rated the importance higher than physicians did. The most important attributes in relation to DNR decisions for both nurses and physicians pertained more to medical viewpoints than to ethical values.

DNR decisions in cancer care can be associated with ethical conflicts of interest, and nurses and physicians have different perspective of DNR decisions which they need to share. Competence in ethics and inter-professional communication are crucial for nurses and physicians participating in such decisions.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 62
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1499
Keywords
DNR decisions, do not resuscitate, end-of-life, hematology, oncology, cancer care, medical ethics, nursing ethics, ethical conflicts of interest, communicative ethics, ethical values, ethical competence, palliative care, nurses, physicians, moral distress.
National Category
Medical Ethics
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-361788 (URN)978-91-513-0459-5 (ISBN)
Public defence
2018-11-23, A1:111a, Biomedicinskt centrum, Husargatan3, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2018-10-31 Created: 2018-10-03 Last updated: 2018-11-19

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Pettersson, MonaHedström, MariannHöglund, Anna T

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