The Changes of Ethical Dilemmas in Palliative Care A Lesson Learned from Comparison Between 1998 and 2013 in Taiwan

Abstract

The current ethical dilemmas met by healthcare professionals were never compared with those 15 years ago when the palliative care system was newly developing in Taiwan.The aim of the study was to investigate the ethical dilemmas met by palliative care physicians and nurses in 2013 and compare the results with the survey in 1998.This cross-sectional study surveyed 213 physicians and nurses recruited from 9 representative palliative care units across Taiwan in 2013. The compared survey in 1998 studied 102 physicians and nurses from the same palliative care units. All participants took a questionnaire to survey the “frequency” and “difficulty” of 20 frequently encountered ethical dilemmas, which were grouped into 4 domains by factor analysis. The “ethical dilemma” scores were calculated and then compared across 15 years by Student's t tests. A general linear model analysis was used to identify significant factors relating to a high average “ethical dilemma” score in each domain.All of the highest-ranking ethical dilemmas in 2013 were related to insufficient resources. Physicians with less clinical experience had a higher average “ethical dilemma” score in clinical management. Physicians with dissatisfaction in providing palliative care were associated a higher average “ethical dilemma” score in communication. Nurses reported higher “ethical dilemma” scores in all items of resource allocation in 2013. Further analysis confirmed that, in 2013, nurses had a higher average “ethical dilemma” score in resource allocation after adjustment for other relating factors.Palliative care nursing staff in Taiwan are more troubled by ethical dilemmas related to insufficient resources than they were 15 years ago. Training of decision making in nurses under the framework of ethical principles and community palliative care programs may improve the problems. To promote the dignity of terminal cancer patients, long-term fundraising plans are recommended for countries in which the palliative care system is in its early stages of development.

The views of nurses working at palliative care centers about palliative care and the influence of education on their knowledge level

“…Due to a study performed by Chih et al [24], some of the events occurred by the dilemma among health care staff about PC are: hiding the facts from the patient by some families, not giving information about the progress of the disease, overuse of medication and the decision for informing the patient about the bad news.…”

“…Within years, it is determined that ethical dilemmas may change and that resource shortage may increase ethical dilemmas [24].…”

Conflitos bioéticos nos cuidados de fim de vida

“…Alternatively, some studies [8][9][10]15 suggest educational work and clarification about patients' autonomy to support decision making. However, one must avoid shifting the focus of individual decision making to a supposed collectivity, sharing responsibilities or merely playing the role of "executor" of the will of patients with terminal illness 9,15 . It is a permanent education process in which healthcare staff also take on the role of guiding patients and their family to achieve humanized clinical practice 10 , considering the principles of principialist ethics.…”

Ethical Problems in Palliative Care: A Systematic Review

“…tarafından yürütülen çalışmada; kaynak yetersizliği, iletişim yetersizliği, kaynakların dağıtımı ile ilişkili olarak etik sorunların ortaya çıktığı saptanmıştır. 35 Bollig ve ark.nın gerçekleştirdiği çalışmada, palyatif bakımda özerkliğin kısıtlanması, hasta yakınları ile ilişkiler, kaynak eksikliği ile ilişki olarak etik sorunlar yaşandığı ve bu etik sorunların temelinde de etik sorunların önemsenmemesi olduğu bulunmuştur. 36 Vries de ve Plaskota'nın çalışmasında, sedasyon uygulanıp uygulanmaması konusunda etik ikilem yaşandığı sonucuna varılmıştır.…”