Annette Street

Seven deaths in Darwin : case studies under the Rights of the Terminally III Act, Northern Territory, Australia

BACKGROUND During the 9 months between July, 1996, and March, 1997, the provision of euthanasia for the terminally ill was legal in the Northern Territory of Australia. Seven patients made formal use of the Rights of the Terminally Ill (ROTI) Act; four died under the Act. We report their clinical details and the decision-making process required by the Act. METHODS We taped in-depth interviews with the general practitioner who provided euthanasia. Further information was available from public texts created by patients, the media, and the coroner. FINDINGS All seven patients had cancer, most at advanced stages. Three were socially isolated. Symptoms of depression were common. Having met criteria of the Act, some patients deferred their decision for a time before proceeding with euthanasia. Medical opinions about the terminal nature of illness differed. INTERPRETATION Provision of opinions about the terminal nature of illness and the mental health of the patient, as required by the ROTI Act, created problematic gatekeeping roles for the doctors involved.

Desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines: a systematic review

Purpose: Patients’ desire for hastened death within the context of advanced disease and palliative care is a controversial topic, frequently discussed in the international literature. Much of the discussion has focused on opinion and debate about ethical matters related to hastened death. Not many research studies seem to have specifically targeted why palliative care patients may desire hastened death, and few have focused on clinical guidelines for responding to such requests. Methods: Using a systematic literature review process, we evaluated the research evidence related to the reasons patients express a desire for a hastened death, and the quality of clinical guidelines in this area. Results: Thirty-five research studies met the inclusion criteria related to reasons associated with a desire for hastened death. The factors associated with a desire to die were often complex and multifactorial; however, psychological, existential and social reasons seem to be more prominent than those directly related to physical symptoms, such as pain. Much of the evidence supporting the reasons for these statements is based on: (a) patients’ perceptions of how they may feel in the future, and (b) health professionals’ and families’ interpretations of why desire to die statements may have been made. Several publications provided expert opinion for responding to requests for physician-assisted suicide and euthanasia. In keeping with this limited research base, there is a lack of evidence-based guidelines for clinical care that addresses the desire to die among terminally ill patients. Most literature has focused on discipline specific responses, with minimal exploration of how clinicians might respond initially to a statement from a patient regarding a desire to die. Conclusions: In order to advance understanding of the complex issue of desire for hastened death in the context of palliative care, research should focus on studies with patients who have actually made a desire to die statement and the development of guidelines to help health professionals respond. Direction for research in this area is described.

Relationships between stressors, work supports, and burnout among cancer nurses.

This pilot study investigated the relationships between stressors, work supports, and burnout among cancer nurses. One hundred and one registered nurses, employed at a major specialist oncology, metropolitan Australian hospital, completed self-report questionnaires measuring these constructs and provided responses to open-ended questions. The 50 listed stressors were experienced as sources of stress by more than 50% of the sample; most work support came from peers, rather than supervisor and organizational supports; and the overall level of burnout for the sample was moderate to low. Significant positive correlations were found between Stressors and the Emotional Exhaustion and Depersonalization subscales of the Maslach Burnout Inventory and a significant weak positive correlation between Peer Support and Personal Accomplishment (intensity). Findings are discussed in relation to developing strategies for reducing stress and burnout among cancer nurses, and directions for further study are suggested.

Responding to desire to die statements from patients with advanced disease: recommendations for health professionals

It is not uncommon for patients with advanced incurable disease to express a desire to hasten their death. Health professionals often have difficulty responding to such statements, and find it challenging to ascertain why these statements are made. Health professionals may struggle to determine whether a ‘desire to die’ statement (DTDS) is about a request for hastened death, a sign of psychosocial distress, or merely a passing comment that is not intended to be heard literally as a death wish. Given the lack of guidelines to assist health professionals with this issue, we have prepared multidisciplinary recommendations for responding to a DTDS, underpinned by key principles of therapeutic communication and a systematic review of empirical literature. Where the relevant literature was lacking, the recommendations were drafted by the authors (clinicians and/ or academics from the following disciplines: nursing, medicine, psychiatry, psychology, sociology, aged care and theology), based on their expert opinion. Multiple drafts of the recommendations were circulated to the authors for refinement until consensus was reached. Strategies for advancing the evidence base for the maturation of guidelines in this area are offered.

Let's talk about sex: risky business for cancer and palliative care clinicians.

Abstract Few health professionals feel confident and comfortable when communicating with patients about the sexual and intimate changes that might occur after a diagnosis of cancer. Little research has focused on why health professionals find this type of patient communication so challenging. Drawing on data from a larger study examining issues of intimacy and sexuality from the perspectives of patients and health professionals in cancer and palliative care, this paper will present the health professional perspective. In the larger study a reflexive inquiry methodology enabled data to be collected through semi-structured participant interviews (n=82), a textual analysis of national and international clinical practice guidelines (n=33) and documented feedback from patients and health professionals attending educational forums where preliminary findings of the study were presented (n=15). In the part of the study reported here, a total of 32 health professionals recognised as members of a multidisciplinary team and working in cancer and or palliative care for a minimum of 12 months were interviewed. Results revealed that patient sexuality and intimacy was largely medicalised so that health professional discussions remained at the level of patient fertility, contraception, erectile or menopausal status. Many unchecked assumptions about patient sexuality were made by health professionals, based on the patient’s age, diagnosis, culture, partnership and disease status. It was personally confronting and a ‘risky’ business to communicate about issues of patient intimacy and sexuality after cancer, particularly when the clinical setting emphasised medicalised, health professional driven and problem-based communication. Implications for practice will be discussed.

Psychosocial adaptation in female partners of men with prostate cancer

The objective was to explore the psychosocial adaptation of female partners living with men with a diagnosis of either localized or metastatic prostate cancer. Semi-structured qualitative interviews were conducted with 50 women at two time points (baseline and 6 months later). The interviews examined emotions, experiences, attitudes to sexual and continence issues and treatment decision making. As part of a larger prospective observational study, demographic data and scores for depression and anxiety were collected. Initial analysis demonstrated that the group of 11 women assessed as distressed on the anxiety and depression measures described reduced coping skills and poorer adaptation after 6 months. In contrast, the 39 women in the non-distressed group reported emotional adaptation that fitted the Lazarus and Folkman pattern of coping through appraisal of the impact of the diagnosis on their partner and themselves, appraisal of coping strategies and reappraisal of the situation. A surprise finding was the high level of resilience displayed by majority of these women. Results suggest that a psychosocial intervention could strengthen healthy adaptation and provide better coping skills for distressed couples.

Managing Shame and Stigma: Case Studies of Female Carers of People With AIDS in Southern Thailand

The authors of this article discuss the effects of shame and stigma on female caregivers of people living with AIDS in southern Thailand. They conducted a longitudinal ethnographic case study over 8 months and collected data using interviews, observations, field notes, and journaling. The authors performed qualitative content analysis and narrative analysis. Public judgment was created in a moral climate, framed by Buddhist precepts of correct and honorable behavior, with different levels of tolerance and stigmatization between men and women. Women caregivers engaged in concealing practices, deception, and withdrawal from social relationships to manage the effects of shame and stigma.

Nurses and doctors communicating through medication order charts in critical care

The structure and content of written forms of communication dynamically interact with the social and historical conditions underlying critical care nursing activities. One important form of documentation regularly used in the critical care area is the medication order chart. This paper considers the ways in which medication order charts are used to structure interactions among nurses and between nurses and doctors. The critical ethnographic study upon which this paper is based involved a research group of six nurses who worked in one critical care unit. Data collection methods involved professional journalling, participant observation and individual and focus group interviews. Data analysis identified four major issues for consideration: imbalance between medical knowledge and legal authority; the nurse as go-between and medication expert; coaching the doctor; and the self policing nurse. The critical care nurses role extends beyond the traditional passive activity of medication administration. By exploring the power relations underlying this role, there is greater opportunity for improved nursing relationships and patient care.

Dispensing Death, Desiring Death: An Exploration of Medical Roles and Patient Motivation During the Period of Legalized Euthanasia in Australia

A qualitative case study was conducted to explore the clinical decision making processes that underpinned the practice of euthanasia under the Rights of the Terminally Ill (ROTI) Act. The key informant for this research was Philip Nitschke, the general practitioner responsible for the legal cases of euthanasia. His information was supported by extensive document analysis based on the public texts created by patients in the form of letters and documentaries. Further collaborating sources were those texts generated by the media, rights groups, politicians, the coroners court, and the literature on euthanasia and assisted suicide. A key study finding was that the ROTI legislation did not adequately provide for the specific medical situation in the Northern Territory, Australia. The medical roles, as proscribed by the legislation, carried many inherent assumptions about the health care context and the availability of appropriately qualified medical staff committed to providing euthanasia. These assumptions translated into difficulties in establishing clinical practices for the provision of euthanasia. A further finding concerned the motivations of those who requested euthanasia. This article addresses the medical roles and the motivations of those seeking euthanasia.

Cognitive Existential Couple Therapy for newly diagnosed prostate cancer patients and their partners: A descriptive pilot study

This paper aims to describe ‘Cognitive Existential Couple Therapy’ (CECT), a novel couples‐based intervention for men with early stage prostate cancer (PCa) and their partners, and to report preliminary findings from a pilot study that investigated the acceptability and feasibility of the intervention and the measures to be used in a subsequent randomised controlled trial.