Ethically relevant decisions are often characterised by nurses adjusting their aspiration levels to the practical conditions with which they are confronted.
This article considers the role and the practices of spiritual care in hospices. While spiritual care was firmly established as one of the four pillars of practical hospice care alongside medical, psychological and social care by Cicely Saunders, the importance and functions of spiritual care in daily practice remain arguable. When speaking about spirituality, what are we actually speaking about? What form do the spiritual relations take between full-time staff and volunteers on the one hand, and the patients and their family members on the other? These were central questions of a qualitative study that we carried out in four hospices in North Rhine-Westphalia, Germany, to explore how spiritual care is provided in hospices and what significance spirituality has in hospices. The study shows that the advantages of a broader definition of spirituality lie in “spiritual care” no longer being bound to one single profession, namely that of the chaplain. It also opens the way for nurses and volunteers—irrespective of their own religious beliefs—to provide spiritual end-of-life care to patients in hospices. If the hospice nurses and volunteers were able to mitigate the patients’ fear not only by using medications but also in a psychosocial or spiritual respect, then they saw this as a successful psychological and spiritual guidance. The spiritual guidance is to some degree independent of religious belief because it refers to a “spirit” or “inner core” of human beings. But this guidance needs assistance from professional knowledge considering religious rituals if the patients are deeply rooted in a (non-Christian) religion. Here, the lack of knowledge could be eliminated by further education as an essential but not sufficient condition.
The present article considers conflicts and conflict regulation in hospices. The authors carried out a qualitative study in three hospices in North Rhine-Westphalia, Germany, to explore how conflicts arise and how conflict regulation proceeds. Hospice nurses should act according to a set of ethical codes, to mission statements of the institution and to professional standards of care. In practice the subjective interpretations of codes and/or models concerning questions of care are causes of conflicts among nurses, with doctors, patients and family members. The management has two choices to react to these conflicts. It can either tolerate the conflicts, as long as they do not disturb the daily routine. Or it can increase the degree of organisation by integrating the different viewpoints into its own program and/or by restructuring its organisational units.
3O r i g i n a l a r b e i t Zusammenfassung in der vorliegenden arbeit geht es um entscheidungsspielräume und entscheidungsprozesse von hauptamtlichen Hospizmitarbeiterinnen und -mitarbeitern in ethisch relevanten Situationen. Wie sich diese Prozesse und Spielräume konkret in der Praxis gestalten, erforschten wir mittels einer qualitativen Studie, die wir in drei A. Walker, C. Breitsameter by means of a qualitative study that we performed in three hospices in north rhineWestphalia how these processes and discretions in practice are specifically constructed. Arguments The medication during the prefinal phase, the use of terminal sedation, and the hydration and nutrition at the end of life resulted as the ethically relevant main areas of activity of the surveyed caregivers. Decisions within these fields are usually collectively taken. the individual discretion of caregivers concerns primarily the style of care and the time management related to the patient. Conclusion the arrangement of the discretions depends often less on a theoretical framework, as models or codes of ethics might suggest, but instead on an adjustment of claims of caregivers in practice, as models of bounded rationality suggest. therefore, the team in a hospice has a self advisory and corrective function on ethical matters, which in the light of the individual dying of a patient are negotiated again and again.Keywords Hospice · end-of-life decision making · Palliative care · bounded rationality Einleitung
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