While certain substantial moral dilemmas in health care have been given much attention, like abortion, euthanasia or gene testing, doctors rarely reflect on the moral implications of their daily clinical work. Yet, with its aim to help patients and relieve suffering, medicine is replete with moral decisions. In this qualitative study we analyse how doctors handle the moral aspects of everyday clinical practice. About one hundred consultations were observed, and interviews conducted with fifteen clinical doctors from different practices. It turned (...) out that the doctors’ approach to clinical cases followed a rather strict pattern across specialities, which implied transforming patients’ diverse concerns into specific medical questions through a process of ‘essentialising’: Doctors broke the patient’s story down, concretised the patient’s complaints and categorised the symptoms into a medical sense. Patients’ existential meanings were removed, and the focus placed on the patients’ functioning. By essentialising, doctors were able to handle a complex and ambiguous reality, and establish a medically relevant problem. However, the process involved a moral as well as a practical simplification. Overlooking existential meanings and focusing on purely functional aspects of patients was an integral part of clinical practice and not an individual flaw. The study thus questions the value of addressing doctors’ conscious moral evaluations. Yet doctors should be aware that their daily clinical work systematically emphasises beneficence at the expense of others—that might be more important to the patient. (shrink)

Objectives: This study investigated Finnish physicians’ experiences of decisions concerning living wills and do not resuscitate orders and also their views on the role of patients and family members in these decisions.Design: A questionnaire was sent to 800 physicians representing the following specialties: general practice ; internal medicine ; neurology , and oncology .Results: The response rate was 56%. Most of the respondents had a positive attitude toward , and respect for living wills, and 72% reported situations in which such (...) a will would have been helpful, although experience with their use was limited. The physicians reported both benefits and problems with living wills. Thirteen per cent had completed a living will of their own. Half did not consider living wills to be reliable if they were several years old. Do not resuscitate orders were interpreted in two ways: resuscitation forbidden or only palliative care required . The respondents also documented DNR orders differently. Seventy two per cent discussed DNR decisions always or often with patients able to communicate, and even 76% discussed DNR orders with the family members of patients unable to communicate. Most respondents were able to approach a dying patient without difficulty. They also felt that education in general was needed.Conclusions: In general Finnish physicians accept living wills, but find they are accompanied by several problems. Many problems could be avoided if physicians and patients conducted progressive discussions about living wills. The differing interpretations of DNR orders are a matter of concern in that they may affect patient treatment. The promotion of patient autonomy with respect to treatment seems rather good, but the limitations of the study need to be kept in mind. (shrink)

Objectives: This study investigated Finnish physicians’ experiences of decisions concerning living wills and do not resuscitate orders and also their views on the role of patients and family members in these decisions.Design: A questionnaire was sent to 800 physicians representing the following specialties: general practice ; internal medicine ; neurology , and oncology .Results: The response rate was 56%. Most of the respondents had a positive attitude toward , and respect for living wills, and 72% reported situations in which such (...) a will would have been helpful, although experience with their use was limited. The physicians reported both benefits and problems with living wills. Thirteen per cent had completed a living will of their own. Half did not consider living wills to be reliable if they were several years old. Do not resuscitate orders were interpreted in two ways: resuscitation forbidden or only palliative care required . The respondents also documented DNR orders differently. Seventy two per cent discussed DNR decisions always or often with patients able to communicate, and even 76% discussed DNR orders with the family members of patients unable to communicate. Most respondents were able to approach a dying patient without difficulty. They also felt that education in general was needed.Conclusions: In general Finnish physicians accept living wills, but find they are accompanied by several problems. Many problems could be avoided if physicians and patients conducted progressive discussions about living wills. The differing interpretations of DNR orders are a matter of concern in that they may affect patient treatment. The promotion of patient autonomy with respect to treatment seems rather good, but the limitations of the study need to be kept in mind. (shrink)

The aim of this study was to examine physicians' and nurses' preferences regarding the use of life-sustaining treatments for severely ill elderly patients, and the patient- and social-centered factors that influence them. Physicians and nurses working in Israeli general hospitals completed structured questionnaires referring to their preferences for using LST in three severe health conditions. The participants were also asked about factors influencing these preferences, including patients' wishes, quality of life, religiosity and the current law. Both physicians and nurses indicated (...) that they would use less LST for patients with metastatic cancer than with those suffering from the other two health conditions. Our findings indicate that the attitudes of professionals involved in these processes are influenced not only by the patient's condition but also by their professional orientations and personal values. Open communication among professionals for clarifying the various beliefs, as well as the antecedents of these beliefs, is important for the benefit of professional teams, patients and families. (shrink)

Physicians and families need to interact more meaningfully to clarify the values and preferences at stake in advance care planning. The current use of advance directives fails to respect patient autonomy. This paper proposes using the family covenant as a preventive ethics process designed to improve end-of-life planning by incorporating other family members—as agreed to by the patient and those family members—into the medical care dialogue. The family covenant formulates advance directives in conversation with family members and with the assistance (...) of a physician, thereby making advance directives more acceptable to the family, and more intelligible to other physicians. It adds the moral force of a promise to the obligation of respecting a patient’s preferences about end-of-life care. These negotiations between patient, family, and physician, from early planning phases through implementation, should greatly reduce the incidence of family disagreements on what the patient would have wanted. The family covenant ensures advance directive discussions within the family, promotes and respects the autonomy of other family members, and might even spur others in the family to complete advance directives through additional covenants. The family covenant holds the potential to transform moral quagmires into meaningful moral conversation. J Am Geriatr Soc 51:1155–1158, 2003. (shrink)