Joris Gielen

The Attitudes of Indian Palliative-care Nurses and Physicians to Pain Control and Palliative Sedation

Aim: We wanted to assess Indian palliative-care nurses and physicians’ attitudes toward pain control and palliative sedation. Materials and Methods: From May to September 2008, we interviewed 14 physicians and 13 nurses working in different palliative-care programs in New Delhi, using a semi-structured questionnaire, and following grounded-theory methodology (Glaser and Strauss). Results: The interviewees did not consider administration of painkillers in large doses an ethical problem, provided the pain killers are properly titrated. Mild palliative sedation was considered acceptable. The interviewees disagreed whether palliative sedation can also be deep and continuous. Arguments mentioned against deep continuous palliative sedation were the conviction that it may cause unacceptable side effects, and impedes basic daily activities and social contacts. A few interviewees said that palliative sedation may hasten death. Conclusion: Due to fears and doubts regarding deep continuous palliative sedation, it may sometimes be too easily discarded as a treatment option for refractory symptoms.

Palliative care physicians' religious / world view and attitude towards euthanasia: A quantitative study among flemish palliative care physicians

Aims: To Study the religious and ideological views and practice of Palliative Care physician towards Euthanasia. Materials and Methods: An anonymous self administered questionnaire approved by Flemish Palliative Care Federation and its ethics steering group was sent to all physicians(n-147) working in Flemish Palliative Care. Questionnaire consisted of three parts. In first part responded were requested to provide demographic information. In second part the respondents were asked to provide information concerning their religion or world view through several questions enquiring after religious or ideological affiliation, religious or ideological self-definition, view on life after death, image of God, spirituality, importance of rituals in their life, religious practice, and importance of religion in life. The third part consisted of a list of attitudinal statements regarding different treatment decisions in advanced disease on which the respondents had to give their opinion using a five-point Likert scale.99 physician responded. Results: We were able to distinguish four clusters: Church-going physicians, infrequently church-going physicians, atheists and doubters. We found that like the Belgian general public, many Flemish palliative care physicians concoct their own religious or ideological identity and feel free to drift away from traditional religious and ideological authorities. Conclusions: In our research we noted that physicians who have a strong belief in God and express their faith through participation in prayer and rituals, tend to be more critical toward euthanasia. Physicians who deny the existence of a transcendent power and hardly attend religious services are more likely to approve of euthanasia even in the case of minors or demented patients. In this way this study confirms the influence of religion and world view on attitudes toward euthanasia.

Flemish palliative-care nurses’ attitudes to palliative sedation A quantitative study

Palliative sedation is an option of last resort to control refractory suffering. In order to better understand palliative-care nurses’ attitudes to palliative sedation, an anonymous questionnaire was sent to all nurses (589) employed in palliative care in Flanders (Belgium). In all, 70.5% of the nurses (n = 415) responded. A large majority did not agree that euthanasia is preferable to palliative sedation, were against non-voluntary euthanasia in the case of a deeply and continuously sedated patient and considered it generally better not to administer artificial floods or fluids to such a patient. Two clusters were found: 58.5% belonged to the cluster of advocates of deep and continuous sedation and 41.5% belonged to the cluster of nurses restricting the application of deep and continuous sedation. These differences notwithstanding, overall the attitudes of the nurses are in accordance with the practice and policy of palliative sedation in Flemish palliative-care units.

Can curative or life-sustaining treatment be withheld or withdrawn? The opinions and views of Indian palliative-care nurses and physicians

Introduction: Decisions to withdraw or withhold curative or life-sustaining treatment can have a huge impact on the symptoms which the palliative-care team has to control. Palliative-care patients and their relatives may also turn to palliative-care physicians and nurses for advice regarding these treatments. We wanted to assess Indian palliative-care nurses and physicians’ attitudes towards withholding and withdrawal of curative or life-sustaining treatment. Method: From May to September 2008, we interviewed 14 physicians and 13 nurses working in different palliative-care programmes in New Delhi, using a semi-structured questionnaire. For the interviews and analysis of the data we followed Grounded-Theory methodology. Results: Withholding a curative or life-sustaining treatment which may prolong a terminal cancer patient’s life with a few weeks but also has severe side-effects was generally considered acceptable by the interviewees. The majority of the interviewees agreed that life-sustaining treatments can be withdrawn in a patient who is in an irreversible coma. The palliative-care physicians and nurses were of the opinion that a patient has the right to refuse life-saving curative treatment. While reflecting upon the ethical acceptability of withholding or withdrawal of curative or life-sustaining treatment, the physicians and nurses were concerned about the whole patient and other people who may be affected by the decision. They were convinced they can play an important advisory role in the decision-making process. Conclusion: While deciding about the ethical issues, the physicians and nurses do not restrict their considerations to the physical aspects of the disease, but also reflect upon the complex wider consequences of the treatment decisions.

The operationalisation of religion and world view in surveys of nurses’ attitudes toward euthanasia and assisted suicide

Most quantitative studies that survey nurses’ attitudes toward euthanasia and/or assisted suicide, also attempt to assess the influence of religion on these attitudes. We wanted to evaluate the operationalisation of religion and world view in these surveys. In the Pubmed database we searched for relevant articles published before August 2008 using combinations of search terms. Twenty-eight relevant articles were found. In five surveys nurses were directly asked whether religious beliefs, religious practices and/or ideological convictions influenced their attitudes, or the respondents were requested to mention the decisional basis for their answers on questions concerning end-of-life issues. In other surveys the influence of religion and world view was assessed indirectly through a comparison of the attitudes of different types of believers and/or non-believers toward euthanasia or assisted suicide. In these surveys we find subjective religious or ideological questions (questions inquiring about the perceived importance of religion or world view in life, influence of religion or world view on life in general, or how religious the respondents consider themselves) and objective questions (questions inquiring about religious practice, acceptance of religious dogmas, and religious or ideological affiliation). Religious or ideological affiliation is the most frequently used operationalisation of religion and world view. In 16 surveys only one religious or ideological question was asked. In most articles the operationalisation of religion and world view is very limited and does not reflect the diversity and complexity of religion and world view in contemporary society. Future research should pay more attention to the different dimensions of religion and world view, the religious plurality of Western society and the particularities of religion in non-Western contexts.

Development and Psychometric Assessment of a Spirituality Questionnaire for Indian Palliative Care Patients.

Introduction: There are only a few studies on spirituality among palliative care patients in India. This gap in research may be caused by the absence of relevant questionnaires and scales specifically designed for Indian palliative care populations. In this study, we describe the development of such a questionnaire and explain its psychometric characteristics. Methods: We designed a questionnaire on the basis of a systematic review of the literature. After a review of the questionnaire by specialists and a subsequent pilot study, the questionnaire was amended. The final questionnaire consisted of a list of 36 spirituality items. It was administered to a sample of 300 cancer patients attending the pain clinic of a tertiary hospital in New Delhi. Results: A factor analysis led to four factors explaining 54.6% of variance: Shifting moral and religious values (Factor 1), support from religious relationship (Factor 2), existential blame (Factor 3), and spiritual trust (Factor 4). The skewness and kurtosis for Factors 1, 3, and 4 were within a tolerable range for assuming a normal distribution, but Factor 2 was skewed. The alphas showed that the four factors have an acceptable internal consistency. Statistically significant associations were observed for age and Factor 3 (P = 0.004), gender and Factor 4 (P = 0.014), marital status and Factors 3 (P = 0.002) and 4 (P = 0.001), educational level and Factors 3 (P < 0.001) and 4 (P < 0.001), and pain scores and Factors 1 (P < 0.001), 2 (P < 0.001), and 3 (P = 0.001). Conclusion: The questionnaire offers promising prospects for the study of spirituality among palliative care patients in India.

The Diverse Influence of Religion and World View on Palliative-Care Nurses’ Attitudes towards Euthanasia

Studies assessing the influence of religion and world view on palliative-care nurses’ attitudes towards euthanasia, have reached diverging conclusions. We decided to use data from a qualitative study undertaken among palliative-care nurses in Flanders (Belgium) in 2006 to reassess the influence of religion and world view on palliative-care nurses’ attitudes towards euthanasia. A highly significant association was observed between religious or ideological clusters and euthanasia clusters (p < 0.001). Nurses belonging to religious or ideological clusters, characterised by a more frequent attendance of religious services, seem to be less likely to support euthanasia. Yet, religious beliefs such as belief in a God who actively intervenes in human lives were also more typical of these clusters. Such beliefs could influence attitudes towards euthanasia. The comparison of euthanasia clusters with religious and ideological factors showed that the ideological dimension, among palliative-care nurses in Flanders, most strongly determines euthanasia attitudes.

Euthanasia and Palliative Care in Belgium: The Attitudes of Flemish Palliative Care Nurses and Physicians Toward Euthanasia

Little research has been carried out to determine the attitudes of palliative care professionals to euthanasia. This research aimed to find out how Flemish palliative care nurses and physicians think about euthanasia. An anonymous questionnaire was sent to all physicians (147) and nurses (589) employed in palliative care teams and institutions in Flanders (Belgium). The questionnaire contained a demographic part, and an attitudinal part, consisting of a long series of ethical statements using a 5-point Likert-scale. Four hundred fifteen nurses (response rate 70.5%) and 99 physicians (67.3%) responded. A cluster analysis of the euthanasia questions resulted in three clusters: (moderate) opponents of euthanasia (n = 105, 23%), moderate advocates of euthanasia (n = 161, 35.2%), and staunch advocates of euthanasia (n = 191, 41.8%). A majority in all clusters believe that as soon as a patient experiences the benefits of good palliative care, most requests for euthanasia disappear and that all palliative care alternatives must be tried before a euthanasia request can be considered. Being a member of the cluster of the (moderate) opponents of euthanasia is associated with being male (p = .01), being older (p = .05), increasing years of experience in palliative care (p = .02), and being a physician (p = .02). Since most Flemish palliative care nurses and physicians are not absolutely against voluntary euthanasia, their attitudes seem to differ from the attitudes of their palliative care colleagues elsewhere. However, the attitudes of the Flemish palliative care nurses and physicians are largely contextual. For a very large majority, euthanasia is an option of last resort only.

Mahātmā Gandhi's view on euthanasia and assisted suicide

To many in India and elsewhere, the life and thoughts of Mohandas Karamchand Gandhi are a source of inspiration. The idea of non-violence was pivotal in his thinking. In this context, Gandhi reflected upon the possibility of what is now called ‘euthanasia’ and ‘assisted suicide’. So far, his views on these practices have not been properly studied. In his reflections on euthanasia and assisted suicide, Gandhi shows himself to be a contextually flexible thinker. In spite of being a staunch defender of non-violence, Gandhi was aware that violence may sometimes be unavoidable. Under certain conditions, killing a living being could even be an expression of non-violence. He argued that in a few rare cases it may be better to kill people who are suffering unbearably at the end of life. In this way, he seems to support euthanasia and assisted suicide. Yet, Gandhi also thought that as long as care can be extended to a dying patient, his or her suffering could be relieved. Since in most cases relief was thus possible, euthanasia and assisted suicide were in fact redundant. By stressing the importance of care and nursing as an alternative to euthanasia and assisted suicide, Gandhi unconsciously made himself an early advocate of palliative care in India. This observation could be used to strengthen and promote the further development of palliative care in India.