Biomedical subjects

Tore Nilstun

Publications and source records attributed to Tore Nilstun.

At least 19 recordsLinked to original sources

PubMed2006

End-of-life decision making in Europe and Australia: a physician survey.

BACKGROUND: The frequencies with which physicians make different medical end-of-life decisions (ELDs) may differ between countries, but comparison between countries has been difficult owing to the use of dissimilar research methods. METHODS: A written questionnaire was sent to a random sample of physicians from 9 specialties in 6 European countries and Australia to investigate possible differences in the frequencies of physicians' willingness to perform ELDs and to identify predicting factors. Response rates ranged from 39% to 68% (N = 10 139). Using hypothetical cases, physicians were asked whether they would (probably) make each of 4 ELDs. RESULTS: In all the countries, 75% to 99% of physicians would withhold chemotherapy or intensify symptom treatment at the request of a patient with terminal cancer. In most cases, more than half of all physicians would also be willing to deeply sedate such a patient until death. However, there was generally less willingness to administer drugs with the explicit intention of hastening death at the request of the patient. The most important predictor of ELDs was a request from a patient with decisional capacity (odds ratio, 2.1-140.0). Shorter patient life expectancy and uncontrollable pain were weaker predictors but were more stable across countries and across the various ELDs (odds ratios, 1.1-2.4 and 0.9-2.4, respectively). CONCLUSION: Cultural and legal factors seem to influence the frequencies of different ELDs and the strength of their determinants across countries, but they do not change the essence of decision making.

Australia↗

PubMed2006

Responders and non-responders in a study on medical end-of-life decisions in Denmark, the Netherlands, Sweden and Switzerland.

OBJECTIVES: To determine the direction and magnitude of participation bias in end-of-life research. METHODS: Within the framework of a European survey on medical end-of-life decisions, a non-response study was conducted among physicians in Denmark, the Netherlands, Sweden and Switzerland. People were asked about their attitudes and experiences in the area of medial end-of-life decision. The response rates ranged from 12.8% (Netherlands) to 39.4% (Switzerland). The responders (n = 5403) and the non-responders (n = 866) were compared regarding socio-demographic characteristics, experiences with terminal patients and agreement with attitudes towards "end-of-life decisions". The reasons for non-participation to the study were analyzed. RESULTS: Non-response did not cause socio-demographic distortion, but non-responders had statistically significantly fewer terminal patients than responders. Agreement rates were statistically significantly higher among responders than among non-responders for euthanasia, non-treatment decision and life-preserving statements. Neutral answers were statistically significantly more frequent among non-responders than among responders for life-preserving and euthanasia statements. The most commonly mentioned reason for non-participation was "lack of time". CONCLUSION: Non-participation does cause an overestimation of proponents of life-shortening, as well as of life-preserving end-of-life decisions. Non-responders more often have ambiguous attitudes towards end-of-life decisions than responders.

Adult↗

PubMed2006

Principles help to analyse but often give no solution--secondary prevention after a cardiac event.

The aim of this paper is to investigate whether or not ethical conflicts can be identified, analysed and solved using ethical principles. The relation between the physician and the patient with ischemic heart disease (IHD) as life style changes are recommended in a secondary prevention program is used as an example. The principal persons affected (the patient and his or her spouse) and the ethical principles (respect for autonomy, non-maleficence, beneficence and justice) are combined in a two dimensional model. The most important person affected by the recommendations is the patient. His or her autonomy is challenged by the suggested life style changes, the purpose of which is to promote the future wellbeing and health of the patient. The spouse is indirectly involved in and affected by the process. He or she often feels neglected by caregivers. Ethical conflicts can both be identified and analysed using ethical principles, but often no solution is implied. Most (if not all) physicians would strongly encourage life style changes, but surprisingly there is no uncontroversial justification for this conclusion using principles.

Beneficence↗

PubMed2006

Principlism revisited: response to Simon Waltho.

We respond to the comments provided on our paper 'Principles help to analyse but often give no solution-secondary prevention after a cardiac event' by Simon Waltho, and highlight points of clarification.

Casuistry↗

PubMed2006

Human tissue samples and ethics--attitudes of the general public in Sweden to biobank research.

PURPOSE: To survey the attitudes of the general public in Sweden to biobank research and to discuss the findings in the light of some well-known ethical principles. METHODS: A questionnaire was used to survey the opinions of the general public in Sweden, and an ethical analysis (using the principles of autonomy, non-maleficence, beneficence and justice) was performed to discuss the possible conditions of such research. FINDINGS: Between 3 and 9% answered that they did not want their samples to be collected and stored in a biobank. Many respondents required information about the purpose of the research and wanted to be able to consent or refuse. About one third of the respondents said they would have answered differently if financial gain was involved and those who commented indicated a more negative attitude. The principle of autonomy maintains that the right to self-determination should be respected, and the principles of non-maleficence and beneficence that the probable harms and benefits resulting from a particular project by using samples from a biobank should be balanced. The general public disagree about how these principles are to be balanced. INTERPRETATION: In the light of the findings different interpretations of the situation as well as possible alternatives are discussed in this paper.

Adult↗

PubMed2006

Continuous deep sedation: physicians' experiences in six European countries.

Continuous deep sedation (CDS) is sometimes used to treat refractory symptoms in terminally ill patients. The aim of this paper was to estimate the frequency and characteristics of CDS in six European countries: Belgium, Denmark, Italy, The Netherlands, Sweden, and Switzerland. Deaths reported to death registries were sampled and the reporting doctors received a mailed questionnaire about the medical decision making that preceded the death of the patient. The total number of deaths studied was 20,480. The response rate ranged between 44% (Italy) and 75% (The Netherlands). Of all deaths, CDS was applied in 2.5% in Denmark and up to 8.5% in Italy. Of all patients receiving CDS, 35% (Italy) and up to 64% (Denmark and The Netherlands) did not receive artificial nutrition or hydration. Patients who received CDS were more often male, younger than 80 years old, more likely to have had cancer, and died more often in a hospital compared to nonsudden deaths without CDS. The high variability of frequency and characteristics of CDS in the studied European countries points out the importance of medical education and scientific debate on this issue.

Adult↗

PubMed2006

Patient refusal of emergency cesarean delivery: a study of obstetricians' attitudes in Europe.

OBJECTIVE: To compare the attitudes of a large sample of obstetricians from eight European countries toward a competent woman's refusal to consent to an emergency cesarean delivery for acute fetal distress. METHODS: Obstetricians' attitudes in response to a hypothetical clinical case were surveyed through an anonymous, self-administered questionnaire. The sample included 1,530 obstetricians (response rate 77%) from 105 maternity units (response rate 70%) in eight countries: France, Germany, Italy, Luxembourg, Netherlands, Spain, Sweden and the United Kingdom. RESULTS: In every country, the majority of obstetricians would keep trying to persuade the woman, telling her that failure to perform cesarean delivery might result in the fetus surviving with disability, or even that her own life might be endangered. In Spain, France, Italy, and, to a lesser extent, Germany and Luxembourg, a consistent proportion of physicians would seek a court order to protect fetal welfare or avoid possible legal liability or both. In the United Kingdom, Sweden, and Netherlands, several respondents (59%, 41%, and 37%, respectively) would accept the woman's decision and assist vaginal delivery. Only a small minority (from 0 in the United Kingdom to 10% in France) would proceed with cesarean delivery without a court order. CONCLUSION: Case law arising from a few countries (United States, Canada, and the United Kingdom) and professional guidelines favoring women's autonomy have not solved the underlying ethical conflict, and in Europe acceptance of a woman's right to refuse cesarean delivery, at least in emergency situations, is not uniform. Differing attitudes between obstetricians from the eight countries may reflect diverse legal and ethical environments. LEVEL OF EVIDENCE: III.

Adult↗

PubMed2005

Narratives about resuscitation--family members differ about presence.

BACKGROUND: Healthcare professionals disagree about admitting family members into the resuscitation room. AIM: The aim of this study was to illuminate family members' experiences and views about being present in the resuscitation room with a relative requiring resuscitation. RESULTS: Seventeen family members were interviewed. Their narratives were analysed using content analysis. The main theme was interpreted as family members being "afraid of disturbing the resuscitation efforts, meaning that the most important person for them was the patient". Three groups of persons were in focus: patients, family members, and healthcare professionals. The theme related to the patient was "to be caring for the good of oneself and others" describing what family members believed the patient would want and what they themselves would have wanted if in the same situation. The themes related to family members were "to be dependent on the interplay between trusting oneself and advocating the patient and to be sensitive to one's own emotions and to be reasonable". The theme related to healthcare professionals was "to submit to or ignore the guidance of the healthcare professionals". CONCLUSION: Family members differ about their presence in the resuscitation room. Omnipresent in the narratives was being afraid of disturbing the resuscitation efforts.

Adult↗

PubMed2005

Access to death certificates: what should research ethics committees require for approval?

PURPOSE: To present and discuss the reactions of research ethics committees (RECs) in a number of countries when asked for approval of a study requiring access to death certificates to identify the physicians signing the certificates and to send them a four-page questionnaire about medical decisions made at the patient's end-of-life that could possibly have hastened death. METHODS: A simple questionnaire were sent to the responsible national investigator in an international study (Australia, Belgium, Denmark, Italy, the Netherlands, Sweden, Switzerland) asking about the interactions between the national research group and the national/regional REC(s). RESULTS: Different laws or guidelines were used by the RECs. Denmark, the Netherlands, and Switzerland did not require an application to a REC. In Australia and Sweden, the RECs wanted changes in the research protocol, and one national research group had to refrain from publishing its results because the attrition rate became too high, probably due to the required changes in the protocol. RECOMMENDATIONS: Generally, similar demands from all RECs in relation to one project are strongly desirable. In epidemiological research, in which voluntary completion of an anonymous questionnaire demonstrates consent, additional prior informed consent about being approached should not be required.

Death Certificates↗

PubMed2005

Forgoing treatment at the end of life in 6 European countries.

BACKGROUND: Modern medicine provides unprecedented opportunities in diagnostics and treatment. However, in some situations at the end of a patient's life, many physicians refrain from using all possible measures to prolong life. We studied the incidence of different types of treatment withheld or withdrawn in 6 European countries and analyzed the main background characteristics. METHODS: Between June 2001 and February 2002, samples were obtained from deaths reported to registries in Belgium, Denmark, Italy, the Netherlands, Sweden, and Switzerland. The reporting physician was then sent a questionnaire about the medical decision-making process that preceded the patient's death. RESULTS: The incidence of nontreatment decisions, whether or not combined with other end-of-life decisions, varied widely from 6% of all deaths studied in Italy to 41% in Switzerland. Most frequently forgone in every country were hydration or nutrition and medication, together representing between 62% (Belgium) and 71% (Italy) of all treatments withheld or withdrawn. Forgoing treatment estimated to prolong life for more than 1 month was more common in the Netherlands (10%), Belgium (9%), and Switzerland (8%) than in Denmark (5%), Italy (3%), and Sweden (2%). Relevant determinants of treatment being withheld rather than withdrawn were older age (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.31-1.79), death outside the hospital (death in hospital: OR, 0.80; 95% CI, 0.68-0.93), and greater life-shortening effect (OR, 1.75; 95% CI, 1.27-2.39). CONCLUSIONS: In all of the participating countries, life-prolonging treatment is withheld or withdrawn at the end of life. Frequencies vary greatly among countries. Low-technology interventions, such as medication or hydration or nutrition, are most frequently forgone. In older patients and outside the hospital, physicians prefer not to initiate life-prolonging treatment at all rather than stop it later.

Adolescent↗

PubMed2005

Justifications of physicians' choice of action.

OBJECTIVE: To compare choice of actions and justifying reasons among the general public, GPs and oncologists. DESIGN: A postal questionnaire using four vignettes: a healthy patient reluctant to quit smoking and one demanding an X-ray, a pulmonary cancer patient reluctant to quit smoking and one demanding immunotherapy. Subjects A random sample of the general public (n = 1000), GPs (n = 200), and oncologists (n = 200). MAIN OUTCOME MEASURES: The respondents' choice of how the physician should act (general public)/would act (physicians), and, with reference to their choice of action, their justifying reasons. RESULTS: A majority answered that the physician should/would bring up the question about smoking cessation with the reluctant patient, justified by promotion of medical benefit and protection from harm. With reference to the reluctant cancer patient every second oncologist and every third GP would not mention smoking cessation, justified by respect for self-determination and enhancement of the relationship. Facing the patient demanding a new X-ray the general public was more in favour while the physicians rejected it. One-third of the general public answered that the seriously ill patient's demand for immunotherapy should be granted and referred to respect for self-determination and enhanced relationship. A majority of the physicians rejected such a demand, justified by promotion of a fair distribution of resources. CONCLUSION: The fear of infringing the patient's right to self-determination and harming the relationship is exaggerated by physicians. They are mostly expected to bring up smoking cessation with a reluctant patient. How to manage demanding patients is more controversial.

Adult↗

PubMed2005

From cure to palliation: staff communication, documentation, and transfer of patient.

In the transition from curative treatment to palliative care of a general end-of-life patient population, the internal communication of the acute care staff seems to be less than optimal. The communication had reference to the dialogue within the staff both before and after the decision to concentrate on palliative care, and possible transfer of the patient. This survey of Swedish nurses and physicians showed that most of 780 respondents wanted more internal communication, and a more individualized procedure of decision-making. All staff should be informed about the decision made but full agreement was not seen as realistic. The largest difference of opinion between nurses and physicians concerned the involvement of nurses in the decision-making about the transition. A uniform documentation of the decision to transfer care focus was the ideal. Approximately every fourth patient in acute care is transferred to receive palliative care. Only approximately half of the respondents had any training in palliative care and the majority wanted more training. There seems to be a need for more palliative care training, perhaps somewhat different for each specialty. Furthermore, a common language to enable nurses and physicians to communicate more easily may improve the transition process.

Communication↗

PubMed2004

Physicians' attitudes towards end-of-life decisions: a comparison between seven countries.

In the context of an European collaborative research project (EURELD), a study on attitudes towards medical end-of-life decisions was conducted among physicians in Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland. Australia also joined the consortium. A written questionnaire with structured questions was sent to practising physicians from specialties frequently involved in the care of dying patients. 10,139 questionnaires were studied. Response rate was equal to or larger than 50% in all countries except Italy (39%). Apart from general agreement with respect to the alleviation of pain and symptoms with possible life-shortening effect, there was large variation in support--between and within countries--for medical decision that may result in the hastening of death. A principal component factor analysis found that 58% of the variance of the responses is explained by four factors. 'Country' explained the largest part of the variation of the standardized factor scores.

Adult↗

PubMed2004