The challenges of ethical deliberation in palliative care settings: A descriptive study.

OBJECTIVE: Inadequate deliberation processes about ethical problems occurring in palliative care settings may negatively impact both patients and healthcare professionals. Better knowledge of the palliative care professionals' practices regarding such processes could help identify specific education needs to improve the quality of palliative care in the context of complex ethical situations. Therefore, this descriptive study aimed to (1) examine ethical deliberation processes in interprofessional teams in five palliative care settings; (2) identify organizational factors that constrain such processes; and (3) based on this knowledge, identify priority education needs for future and current palliative care professionals. METHOD: The study involved three data collection activities: (1) direct observation of simulated interprofessional ethical deliberations in various palliative care settings; (2) individual semi-structured interviews; and (3) deliberative dialogues. RESULTS: Thirty-six healthcare professionals took part in the simulated ethical deliberations and in the deliberative dialogue activities, and 13 were met in an individual interview. The study results revealed suboptimal interprofessional collaboration and ethical deliberation competencies, particularly regarding awareness of the ethical issue under consideration, clarification of conflicting values, reasonable decision making, and implementation planning. Participants also reported facing serious organizational constraints that challenged ethical deliberation processes. SIGNIFICANCE OF RESULTS: This study confirmed the need for professional education in interprofessional collaboration and ethical deliberation so that palliative care professionals can adequately face current and future ethical challenges. It also enabled the identification of educational priorities in this regard. Future research should focus on identifying promising educational activities, assessing their effectiveness, and measuring their impact on patient and family experience and the quality of palliative care.

The Humanbecoming theory as a reinterpretation of the symbolic interactionism: a critique of its specific nature and scientific underpinnings.

Discussions about real knowledge contained in grand theories and models seem to remain an active quest in the academic sphere. The most fervent of these defendants is Rosemarie Parse with her Humanbecoming School of Thought (1981, 1998). This article first highlights the similarities between Parse's theory and Blumer's symbolic interactionism (1969). This comparison will act as a counterargument to Parse's assertions that her theory is original 'nursing' material. Standing on the contemporary philosophy of science, the very possibility for discovering specific nursing knowledge will be questioned. Second, Parse's scientific assumptions will be thoroughly addressed and contrasted with Blumer's more moderate view of knowledge. It will lead to recognize that the valorization of the social nature of existence and reality does not necessarily induce requirements and methods such as those proposed by Parse. According to Blumer's point of view, her perspective may not even be desirable. Recommendations will be raised about the necessity for a distanced relationship to knowledge, being the key to the pursuit of its improvement, not its circular contemplation.

Psychosocial determinants of nurses' intention to practise euthanasia in palliative care.

BACKGROUND: Most studies on euthanasia fail to explain the intentions of health professionals when faced with performing euthanasia and are atheoretical. RESEARCH OBJECTIVE: The purpose of this study was to identify the psychosocial determinants of nurses' intention to practise euthanasia in palliative care if it were legalised. RESEARCH DESIGN: A cross-sectional study using a validated anonymous questionnaire based on an extended version of the Theory of Planned Behaviour. PARTICIPANTS AND RESEARCH CONTEXT: A random sample of 445 nurses from the province of Quebec, Canada, was selected for participation in the study. ETHICAL CONSIDERATIONS: The study was reviewed and approved by the Ethics Committee of the Centre hospitalier universitaire de Québec. FINDINGS: The response rate was 44.2% and the mean score for intention was 4.61 ± 1.90 (range: 1-7). The determinants of intention were the subjective (odds ratio = 3.08; 95% confidence interval: 1.50-6.35) and moral (odds ratio = 2.95; 95% confidence interval: 1.58-5.49) norms. Specific beliefs which could discriminate nurses according to their level of intention were identified. DISCUSSION: Overall, nurses have a slightly positive intention to practise euthanasia. Their family approval seems particularly important and also the approval of their medical colleagues. Nurses' moral norm was related to beneficence, an ethical principle. CONCLUSION: To our knowledge, this is the first study to identify nurses' motivations to practise euthanasia in palliative care using a validated psychosocial theory. It also has the distinction of identifying the ethical principles underlying nurses' moral norm and intention.

[From humanism to nihilism: dialectics on Jean Watson's caring theory]. / De l'humanisme au nihilisme: une dialectique sur la théorie du caring de Jean Watson.

INTRODUCTION: nursing today is heir to values that have developed over many years. In addition to the values of human care, present-day nursing embraces values that shape our modern world. This dialectical study first traces the evolution of a number of the traditional values associated with human care that nursing has retained. It goes on to show how some of the values of human care have been cast aside in favour of modern--neoliberal, technocratic and bureaucratic--values which have in turn given rise to disturbing problems of instrumentalization. Watson's theory of caring proposes two ways to remedy such instrumentalization: espousing a transcendental, metaphysical mode of thought and adopting an altruistic humanism. However, many critics have questioned the theoretical consistency and very legitimacy of the theory as a means of dealing with instrumentalization. AIM AND METHODOLOGY: this study analyses Watson's proposals, using a Nietzschean dialectic approach to test them and to suggest possible solutions. Significant problems in terms of both consistency and relevance are brought to light, tending to refute Watson's notions. RESULTS AND DISCUSSION: the study findings suggest that the application of Watson's theory may paradoxically perpetuate dualism and nihilism and, rather than curb their invasive impact, lead inevitably to a conversion to instrumental values. CONCLUSION: it's suggested an alternative, ethics-of-life approach based on the synthesis of our dialectics that would foster a return to, and respect for, humanity's essential nature.

Psychosocial determinants of physicians' intention to practice euthanasia in palliative care.

BACKGROUND: Euthanasia remains controversial in Canada and an issue of debate among physicians. Most studies have explored the opinion of health professionals regarding its legalization, but have not investigated their intentions when faced with performing euthanasia. These studies are also considered atheoretical. The purposes of the present study were to fill this gap in the literature by identifying the psychosocial determinants of physicians' intention to practice euthanasia in palliative care and verifying whether respecting the patient's autonomy is important for physicians. METHODS: A validated anonymous questionnaire based on an extended version of the Theory of Planned Behavior was mailed to a random sample of 445 physicians from the province of Quebec, Canada. RESULTS: The response rate was 38.3% and the mean score for intention was 3.94 ± 2.17 (range: 1 to 7). The determinants of intention among physicians were: knowing patients' wishes (OR = 10.77; 95%CI: 1.33-86.88), perceived behavioral control-physicians' evaluation of their ability to adopt a given behavior-(OR = 4.35; 95%CI: 1.44-13.15), moral norm-the appropriateness of adopting a given behavior according to one's personal and moral values-(OR = 3.22; 95%CI: 1.29-8.00) and cognitive attitude-factual consequences of the adoption of a given behavior-(OR = 3.16; 95%CI: 1.20-8.35). This model correctly classified 98.8% of physicians. Specific beliefs that might discriminate physicians according to their level of intention were also identified. For instance, physicians' moral norm was related to the ethical principle of beneficence. CONCLUSIONS: Overall, physicians have weak intentions to practice euthanasia in palliative care. Nevertheless, respecting patients' final wishes concerning euthanasia seems to be of particular importance to them and greatly affects their motivation to perform euthanasia.

Motivations of physicians and nurses to practice voluntary euthanasia: a systematic review.

BACKGROUND: While a number of reviews have explored the attitude of health professionals toward euthanasia, none of them documented their motivations to practice euthanasia. The objective of the present systematic review was to identify physicians' and nurses' motives for having the intention or for performing an act of voluntary euthanasia and compare findings from countries where the practice is legalized to those where it is not. METHODS: The following databases were investigated: MEDLINE/PubMed (1950+), PsycINFO (1806+), CINAHL (1982+), EMBASE (1974+) and FRANCIS (1984+). Proquest Dissertations and Theses (1861+) was also investigated for gray literature. Additional studies were included by checking the references of the articles included in the systematic review as well as by looking at our personal collection of articles on euthanasia. RESULTS: This paper reviews a total of 27 empirical quantitative studies out of the 1 703 articles identified at the beginning. Five studies were in countries where euthanasia is legal and 22 in countries where it is not. Seventeen studies were targeting physicians, 9 targeted nurses and 1 both health professionals. Six studies identified the motivations underlying the intention to practice euthanasia, 16 the behavior itself and 5 both intention and behavior. The category of variables most consistently associated with euthanasia is psychological variables. All categories collapsed, the four variables most frequently associated with euthanasia are past behavior, medical specialty, whether the patient is depressed and the patient's life expectancy. CONCLUSIONS: The present review suggests that physicians and nurses are motivated to practice voluntary euthanasia especially when they are familiar with the act of euthanasia, when the patient does not have depressive symptoms and has a short life expectancy and their motivation varies according to their medical specialty. Additional studies among nurses and in countries where euthanasia is legal are needed.

Beyond nursing nihilism, a Nietzschean transvaluation of neoliberal values.

Like most goods-producing sectors in the West, modern health-care systems have been profoundly changed by globalization and the neoliberal policies that attend it. Since the 1970s, the role of the welfare state has been considerably reduced; funding and management of health systems have been subjected to wave upon wave of reorganization and assimilated to the private sector. At the same time, neoliberal policy has imposed the notion of patient empowerment, thus turning patients into consumers of health. The literature on nursing has accordingly reported on the significant repercussions on all aspects of the profession, from delivery of care and treatment, through training for new nurses, to legislated policy reforms regarding the role and responsibilities of modern nurses. In light of these developments, this paper analyses and theorizes about the way the injection of neoliberal policy is linked to and affects the practice of nursing. Drawing on a number of Nietzschean arguments, we begin with an exploration of the complex effects of neoliberalism, bureaucratization, and technocratization on the health system and the practice of nursing. Our main theoretical point here is that neoliberal policy engenders and promotes a neoliberal tide, which results in the conversion of the values that drive modern nursing practice. We then examine this tide in the light of Nietzsche's concepts. Starting with an analysis based on the ontology of the will to power, we show that nurses are dominated by neoliberal values embedded in technocratic and bureaucratic ideologies. Finally, we argue that the application of neoliberal policy constitutes a form of domestication from which one might potentially be freed through the Nietzschean concept of transvaluation of values. This transvaluation, as its freeing from some of the neoliberal tide, may be accomplished in accordance with a hierarchy of specific life-affirming values for nursing culture and practice.

The integration of a person-centered approach in palliative care.

OBJECTIVE: The philosophy underlying palliative care places the respect of patients and their autonomy at the heart of clinical practice. A study was conducted at a palliative care facility to document changes that occurred after the integration of a person-centered approach focusing on human freedom (which is linked to autonomy): the humanbecoming school of thought. It aimed to describe changes observed in the beliefs and practices of healthcare providers, the concept and respect of autonomy by healthcare providers, care and respect of autonomy experienced by patients' relatives, and consideration of patients' wishes through their documentation. METHOD: The method adopted consisted of a pre-project - process - post-project descriptive qualitative design and was inspired by teaching-learning and mentoring models. Data were collected from 51 healthcare providers and 10 relatives through semistructured interviews and from the medical records of 30 patients during the pre- and post-project phases. They were analyzed and compared at the end of the study. The process phase consisted of offering training sessions and mentoring, encouraging the involvement of healthcare providers, and cocreating integration and care tools. RESULTS: While the analysis exposed some discrepancies with the language of the approach and differences between nurses and other healthcare providers, it revealed, above all, similarities in the changes observed between the different sources of data. The focus moved from being task-centered to being person-centered; the affirmation of the priority of respecting patients' choices, desires, and needs; a presence shifting from being available to true listening; the affirmation of following the ever-changing rhythm of the patient; and a notion of respect of autonomy now including the other. SIGNIFICANCE OF RESULTS: In line with the philosophy of palliative care, the project demonstrated that the integration of the humanbecoming approach can result in changes that contribute to the development of a more person-centered practice.

Developing palliative care competencies for the education of entry level baccalaureate prepared Canadian nurses.

Educational preparation of health professionals for Palliative and End of Life Care (PEOLC) is inadequate, and nurses are no exception. In 2004, the Canadian Association of Schools of Nursing struck a Task Force to develop PEOLC competencies to address this issue. The development of national PEOLC nursing competencies involved a multi-step, emergent, interactive, and iterative process. An overarching principle guiding this process was building national consensus about the essential PEOLC specific competencies for nurses among experts in this field while simultaneously generating, revising, and refining them. There have been three stages in this iterative, multi-step process: 1) Generating a preliminary set of competencies, 2) Building a national consensus among educators and experts in the field on PEOLC specific competencies for nurses, and 3) Refining the consensus based competencies for curriculum development. Ongoing follow up work for this project is focusing on the integration of these competencies into nursing curricula.

The dying person: an existential being until the end of life.

This article explores the experience of death from the perspective of existential philosophy, for the purpose of finding ways to humanize end-of-life nursing care. A person in his or her final days is seen by the caregiver as a being seeking the continual creation of his human becoming, from the experience of sickness to death. From the moment the torment of suffering begins, a person needs a presence of humanistic professionalism that embraces the values of the nursing profession.

Nursing, healthcare, and culture: views from Canada and Taiwan for the year 2050. Interview by Jacqueline Fawcett.

This column presents a dialogue with Canadian nurse scholar Mireille Lavoie and Taiwanese nurse scholar Yea-Ing Lotus Shyu, who share their own vision and their understanding of their country's vision of nursing, health-care, and quality of life in the year 2050.

The nature of care in light of Emmanuel Levinas.

The discipline of nursing is still struggling with the differences that need to be clearly defined between the notions of care and nursing care. To be able to clarify this distinction, agreement must first be reached on the meaning of care itself. The present article proposes a conception of care in light of the philosophy of Emmanuel Levinas (1906-1995). This philosopher's thought throws considerable light on the ontology of care, thanks especially to his focus on the deeper implications of human encounter. A profound sense of responsibility towards the other enables Levinas to bring out such dimensions of the concept of care as the relation involved, the feeling of affection, and the interventions. We examine here what these entail regarding nursing care.