Oncology nurses' perceptions of advance directives for patients with cancer

Abstract

This study examined oncology nurses' perceptions of the impact of advance directives on oncology patients' end‐of‐life care. Nurses (n = 104), who were members of an oncology nursing society or worked in a large metropolitan cancer center, completed a cross‐sectional survey assessing perceptions of advance directives. There was high agreement that advance directives (i) make decisions easier for family (87%) and providers (82%); (ii) are doctors' responsibility to implement (80%); (iii) reduce unwanted aggressive treatment in the last weeks of life (80%); (iv) protect patient autonomy (77%); and (v) increase the likelihood of dying in a preferred location (76%). There was moderate or low agreement that advance directives (i) are accessible when needed (60%); (ii) are oncology nurses' responsibility to implement (46%); (iii) are always followed (41%); (iv) reduce the likelihood of pain in the last weeks of life (31%); (v) contain difficult to follow statements (30%); and (vi) have no impact on comfort in the last weeks of life (15%). Most nurses perceive benefits for advance directives, however, there remains uncertainty around accessibility and implementation. Guidelines and education about advance directive processes in oncology could improve person‐centered end‐of‐life care.

A quantitative study of nurses perception to advance directive in selected private and public secondary healthcare facilities in Ibadan, Nigeria

“…Making known and reporting violation of patients’ directives were found to be nurses’ responsibilities in the present study. This was in consistent with Hobden et al [ 27 ] that found nurses play a key role in ensuring that patients’ preferences are honored throughout end-of-life care.…”

“…Nurses at private facilities saw it as the doctors’ obligation to begin and record the decision while they made the document readily available when needed, in contrast to nurses at public hospitals who saw it as their role. These was similar to findings in South Africa, Korea and Australia by Bull and Mash, Son et al, and Hobden et al [ 24 , 27 , 28 ], where nurses saw themselves as the custodians of AD document rather than its initiators and/or implementers. The findings demonstrated that nurses in the private sector are more likely to refer patients whose orders they find objectionable to another nurse or facility.…”

“…The findings demonstrated that nurses in the private sector are more likely to refer patients whose orders they find objectionable to another nurse or facility. These both supports Siamak’s [ 23 ] findings that nurses have the autonomy to decline participation in the withdrawing or withholding of treatment if such a decision contradicts their personal and/or professional convictions and Hobden’s [ 27 ] findings where 60% of their study participants showed neutrality or disagreement that ADs will still be adhered to even if the medical team does not agree with them. Fear of litigation and the fact that nurses at the public sector enjoyed more autonomy, employment security, and public reputation than those in the private sector are some contributing factors to this [ 26 ].…”

“…Over 50% of the study participants in the two sectors agreed and are neutral on the statement that many ambiguous terms are frequently used in AD without enough context or justification thereby making it difficult to interpret. Previous researchers have also noted that unclear instructions and the use of ambiguous language could lead to misreading of patients’ preferences [ 20 , 21 , 27 , 29 ]. The fact that patients’ mostly give their directives verbally when they are critically ill and sometime by their relatives in Nigeria can also contribute to the misapprehension of the directives [ 7 , 30 ].…”

“…These contributed to the controversy in its implementation. Thus, decisional conflict that results from translating a written order into practice has previously been identified as an obstacle to the application of AD [26][27][28]. Ernestina et al [3] showed that AD can fail in practice if changes in patient personal value fail to reflect in the directive.…”