Strategies used by respiratory nurses to stimulate self-management in patients with COPD.

AIMS AND OBJECTIVES: To gain an insight into strategies, adopted by Dutch respiratory nurses during clinic sessions, to improve self-management of patients with chronic obstructive pulmonary disease. BACKGROUND: Chronic obstructive pulmonary disease is highly prevalent and a significant cause of morbidity and mortality, impacting on quality of life and healthcare expenditure. Health promotion is therefore an important consideration. By applying specific strategies, respiratory nurses can play a major role in the promotion of self-management. Research has shown that respiratory nurses, who run clinics, have insufficient knowledge of evidence-based strategies that can be adopted to promote self-management among chronic obstructive pulmonary disease patients. It appears that respiratory nurses adopt their own strategies during clinic sessions. DESIGN: A qualitative research study was carried out using Grounded Theory method. METHODS: Data were collected during open interviews conducted by an external researcher with a nursing background. The interviews were analysed through coding after which categories were developed. RESULTS: Fourteen respiratory nurses were interviewed. The results show that respiratory nurses emphasise quitting smoking during the consult. Attention is also paid to inhalation medication and techniques. Other self-management strategies that respiratory nurses use are: application of specific interviewing techniques, referring to other healthcare professionals and providing tools for coping with the illness in everyday life. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: The main emphasis during the clinic session is directed at quitting smoking. Other self-management strategies such as providing information regarding nutrition and exercise, instilling confidence and becoming an equal discussion partner, gain less attention. During the clinic session, respiratory nurses should also focus on these self-management strategies in addition to quitting smoking. Further research should be directed at self-management strategies used by respiratory nurses in relation to different characteristics of patients. In this way, a more patient-oriented form of consultation could be developed for chronic obstructive pulmonary disease patients.

Relatives' perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands.

This study used retrospective interviews with 87 relatives to describe the experiences of patients who died by euthanasia or physician-assisted suicide (EAS) in the Netherlands. Most of the patients suffered from cancer (85%). The relatives were most often a partner (63%) or a child (28%) of the patient. Before explicitly requesting EAS most patients (79%) had spoken about their wishes concerning medical end-of-life decisions to be made at a later date. Hopeless suffering, loss of dignity, and no prospect of recovery were the most prevalent reasons for explicitly requesting EAS. According to the relative, in 92% of patients EAS had contributed favourably to the quality of the end of life, mainly by preventing or ending suffering.

Physicians' opinions on palliative care and euthanasia in the Netherlands.

BACKGROUND: In recent decades significant developments in end-of-life care have taken place in The Netherlands. There has been more attention for palliative care and alongside the practice of euthanasia has been regulated. OBJECTIVE: The aim of this paper is to describe the opinions of physicians with regard to the relationship between palliative care and euthanasia, and determinants of these opinions. DESIGN: Cross-sectional. SETTING/SUBJECTS: Representative samples of physicians (n = 410), relatives of patients who died after euthanasia and physician-assisted suicide (EAS; n = 87), and members of the Euthanasia Review Committees (ERCs; n = 35). MEASUREMENTS: Structured interviews with physicians and relatives of patients, and a written questionnaire for the members of the ERCs. RESULTS: Approximately half of the physicians disagreed and one third agreed with statements describing the quality of palliative care in The Netherlands as suboptimal and describing the expertise of physicians with regard to palliative care as insufficient. Almost two thirds of the physicians disagreed with the suggestion that adequate treatment of pain and terminal care make euthanasia redundant. Having a religious belief, being a nursing home physician or a clinical specialist, never having performed euthanasia, and not wanting to perform euthanasia were related to the belief that adequate treatment of pain and terminal care could make euthanasia redundant. CONCLUSION: The study results indicate that most physicians in The Netherlands are not convinced that palliative care can always alleviate all suffering at the end of life and believe that euthanasia could be appropriate in some cases.

Requests to forgo potentially life-prolonging treatment and to hasten death in terminally ill cancer patients: a prospective study.

This study investigates the background and evolution of requests to forgo treatment and hasten death in terminally ill cancer patients. Physicians participating in a nationwide study on end-of-life decision making were asked whether they were treating a terminally ill cancer patient whose life expectancy was longer than 1 week but no longer than 3 months and who they would continue to treat until the patient's death. Of the 120 physicians who had a patient who met the inclusion criteria, 85 (70.8%) completed a questionnaire each month until the patient's death. The questionnaire provided information on the patient's symptoms, concerns, and requests involving end-of-life decisions. Most patients suffered from cancer of the gastrointestinal tract or the respiratory system, and 66% died within 2 months of the initial interview. The prevalence of requests involving end-of-life decisions increased during the last 3 months of a patient's life. The evolution of a request was especially related to an increase in the number of severe symptoms and concerns. Requests to forgo treatment were related to general weakness, whereas loss of dignity was a major reason for requests to hasten death. Physical suffering alone appeared to lead to less drastic requests than suffering blended by concerns and psychological problems leading to requests for hastened death. The results emphasize the importance of gaining insight into the patients' suffering to provide meaningful assistance.

Symptoms, treatment and "dying peacefully" in terminally ill cancer patients: a prospective study.

GOALS: The aims of this study were to describe the symptoms, their treatment during the final months of life of terminally ill cancer patients and to assess characteristics of the dying process. PATIENTS AND METHODS: We used a prospective study design. From a representative sample of physicians who participated in a study of end-of-life decision making, we asked whether they were treating a patient with cancer whose treatment was no longer aimed at cure, whose life expectancy was probably longer than 1 week but no longer than 3 months and who would probably continue to be treated by the same physician until their death; 85 physicians completed a monthly questionnaire until patients' deaths. RESULTS: Patients were confronted with an increasing amount of symptoms during the final months of their life. Fatigue, loss of appetite, dependency and feeling unwell were the most prevalent symptoms. Physical symptoms were more often treated than psychosocial symptoms. The number of medical disciplines involved in the patient's care decreased in the period before death, but the number of informal caregivers increased; 73% of patients died peacefully. A peaceful death was impeded by feelings of anxiety and loneliness but promoted by the involvement of children in their patients' care. CONCLUSION: The results give insight into the nature of suffering and factors related to the dying process of terminally ill cancer patients. Attention to psychosocial well-being and to the need to be with loved ones appears to be essential for patients' quality of life.

Differences between terminally ill cancer patients who died after euthanasia had been performed and terminally ill cancer patients who did not request euthanasia.

Palliative care, directed at improving the quality of life of terminally ill patients, is generally not aimed at any form of postponing or hastening death. It is possible that high quality palliative care could prevent requests for euthanasia. However, empirical evidence on this issue is scarce. In a national survey of end-of-life medical decisions in The Netherlands the subject of care at the end of life has been addressed. Data on terminally ill cancer patients who died after their request was granted and euthanasia had been performed were compared with those of terminally ill cancer patients who did not request euthanasia. The results show that the prevalence and severity of symptoms e.g., pain, feeling unwell, nausea, was higher in patients who died after their request was granted and euthanasia had been performed. No differences concerning the treatment of symptoms or the care provided were found between the two groups. The results suggest that the practice of euthanasia is mainly related to the patient's suffering.

Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001.

Empirical data on the rate of euthanasia, physician-assisted suicide, and other end-of-life decisions have greatly contributed to the debate about the role of such practices in modern health care. In the Netherlands, the continuing debate about whether and when physician-assisted dying is acceptable seems to be resulting in a gradual stabilisation of end-of-life practices. We replicated interview and death-certificate studies done in 1990 and 1995 to investigate whether end-of-life practices had altered between 1995 and 2001. Since 1995, the demand for physician-assisted death has not risen among patients and physicians, who seem to have become somewhat more reluctant in their attitude towards this practice.

Being a palliative care nurse in an academic hospital: a qualitative study about nurses' perceptions of palliative care nursing.

The original philosophy of palliative care emphasizes the importance of the integration of compassion and medical science. The meaning palliative care nurses assign to their relationships with patients has been described in several studies. This qualitative research was undertaken in order to elicit the way nurses working on a palliative care ward in an academic hospital perceive their role and gain insight into the problems they encounter. The findings present two different perceptions held by nurses about the nature of their work. The first, the more prominent, is 'striving to adopt a well-organized and purposeful approach as a nurse on an academic ward'; the second is 'striving to enhance the well-being of the patient'. Nurses should be supported in the development of their palliative care approach and be assisted in reflecting on their practice in terms of a model of 'reflective practice' and in the development of 'moral imagination'.

Moral problems experienced by nurses when caring for terminally ill people: a literature review.

This article is a review of the literature on the subject of how nurses who provide palliative care are affected by ethical issues. Few publications focus directly on the moral experience of palliative care nurses, so the review was expanded to include the moral problems experienced by nurses in the care of the terminally ill patients. The concepts are first defined, and then the moral attitudes of nurses, the threats to their moral integrity, the moral problems that are perceived by nurses, and the emotional consequences of these moral problems are considered in turn. The results show that the moral behaviour of nurses, which is theoretically grounded in commitment to care and to the patient, appears to be shaped by specific processes that lead to engagement or to mental and behavioural disengagement in morally difficult situations. Nurses often appear to fail to recognize the moral dimensions of the problems they experience and also to lack the skills they need to resolve moral problems adequately. Although the findings show that several elements that are beyond the control of nurses, owing to their lack of autonomy and authority, influence their moral experience, intrinsic factors such as feelings of insecurity and powerlessness have a profound effect on nurses' perceptions and attitudes in the face of moral problems. The moral problems perceived by these nurses are related to end-of-life issues, communication with patients, the suffering of patients, and the appropriateness of the medical treatment.