September 01, 2002
Georgia nurses report on end-of-life care practices in Center for Ethics survey
Nurses have long been primary care providers for patients who are dying, providing comfort and caring for patients, supporting grieving families as they struggle through this difficult time, and coordinating aspects of care provided by other healthcare providers. As a part of an interdisciplinary study, Georgia nurses were mailed a survey inquiring about current institutional and individual practices, attitudes, beliefs and experiences in caring for patients at the end of life. The Whitehead Foundation funded this survey as a part of the broader commitment to improve end-of-life care by the Health Care Ethics Consortium of Georgia at the Center for Ethics, in conjunction with the Georgia Collaborative to Improve End-of-Life Care.
With a focus on nurses who most frequently care for patients who are dying, surveys were sent to over 1300 nurses in the state of Georgia and 337 completed surveys were returned. The majority of the respondents reported that they provided direct clinical care in intensive care units, had six or more year’s experience, and cared for dying patients monthly, weekly or daily. In addition to critical care nurses, other respondents included nurses working in areas of adult and pediatric oncology, gerontology, HIV/AIDS, and neonatology.
Although these nurses reported that Advance Directives (Durable Power of Attorney for Health Care and Living Wills) were helpful tools in providing end-of-life (EOL) care, they reported that “Do Not Resuscitate” orders were more effective, more frequently followed and more frequently seen in patient care. Somewhat concerning were responses indicating that Advance Directives and DNR orders are less frequently followed when there is disagreement on the part of the family and/or the physician.
Despite reporting that there was a multitude of ways in which EOL pain is assessed, slightly more than half of respondents reported that institutional pain assessment practices are effective. When asked about their personal skill, three quarters of respondents reported they were confident in their own skills in assessing EOL pain. Most nurses felt they personally were knowledgeable and were adequately prepared to provide appropriate pain management but fewer reported that pain management within their institution was adequately treated. For them personally, the majority of nurses did not find fear of hastening death to be a barrier to providing appropriate pain management. However, they did report that this is sometimes a problem with physicians prescribing effective doses of pain medications.
Most respondents reported that institutions allow physicians to withhold and to withdraw life-sustaining measures. Individually, they supported withholding CPR and withdrawal of mechanical ventilation and dialysis. They were less in favor of withdrawal of artificial nutrition, hydration or antibiotics.
As has been found in several other studies, a small number of Georgia nurses stated that on some occasions “medication is given to a patient with the intent to allow the patient to end his or her life.” Some respondents reported that professional ethics, legal repercussions, and religious beliefs may act to deter institutional practices and respondents individually from advocating for or facilitating the hastening of a patient’s death.
In addition, as reported in numerous other studies, Georgia nurses reported a lack of EOL care and EOL pain assessment and management courses in their basic professional education. However, about twice as many nurses stated that they had received some education on these topics as part of continuing education and/or as part of on the job training programs.
In many areas this survey supported the findings of other national surveys of end-of-life care by nurses. Its findings reinforced the need to improve EOL education with our nursing education programs and the need to improve nursing assessment of EOL pain and its management. It raised some questions about Advance Directives and compliance with them in the face of disagreement on the part of patient’s families and physicians. It also demonstrated that nurses have mixed feelings about practices that may hasten a patient’s death. The Center for Ethics continues to address these areas of identified need and to study the role of nurses and other healthcare providers in improving the care of patients at end-of-life.
For additional information about this study and about the work of Center for Ethics in the area of end-of-life care, please contact Kathy Kinlaw, Associate Director, at (404) 727-2201 or Karen Trotochaud, Senior Program Associate, at (404) 727-2796.
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