- Email: [email protected]
Attitudes towards euthanasia among Greek intensive care unit physicians and nurses
Heart & Lung xxx (2015) 1e4
Contents lists available at ScienceDirect
Heart & Lung journal homepage: www.heartandlung.org
Attitudes towards euthanasia among Greek intensive care unit physicians and nurses Georgios Kranidiotis, MD a, *, Julia Ropa, RN a, John Mprianas, RN b, Theodoros Kyprianou, MD c, Serafim Nanas, MD a a
First Critical Care Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 45-47 Ypsilantou Str, Athens 10675, Greece Sixth Respiratory Medicine Department, “Sotiria” Hospital for Diseases of the Chest, 152 Mesogeion Ave, Athens 11527, Greece c Critical Care Department, Nicosia General Hospital, 215 Old Road Nikosia-Limassol, Nikosia 2029, Cyprus b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 September 2014 Received in revised form 27 February 2015 Accepted 7 March 2015 Available online xxx
Objectives: To investigate the attitudes of Greek intensive care unit (ICU) medical and nursing staff towards euthanasia. Background: ICU physicians and nurses deal with end-of-life dilemmas on a daily basis. Therefore, the exploration of their stances on euthanasia is worthwhile. Methods: This was a descriptive quantitative study conducted in three ICUs in Athens. The convenience sample included 39 physicians and 107 nurses. Results: Of respondents, 52% defined euthanasia inaccurately, as withholding or withdrawal of treatment, while 15% ranked limitation of life-support among the several forms of euthanasia, together with active shortening of the dying process and physician e assisted suicide. Only one third of participants defined euthanasia correctly. While 59% of doctors and 64% of nurses support the legalization of active euthanasia, just 28% and 26% of them, respectively, agree with it ethically. Conclusions: Confusion prevails among Greek ICU physicians and nurses regarding the definition of euthanasia. The majority of staff disagrees with active euthanasia, but upholds its legalization. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Euthanasia Limitation of life-sustaining treatment End-of-life decisions Quality of life Shared decision-making
Introduction Euthanasia is defined as administering medication or performing other interventions with the intention of causing a patient’s death.1 Unlike the practice of withholding or withdrawing life-sustaining treatments, which is widely accepted,2 euthanasia is prohibited by professional medical and nursing codes3,4 and remains illegal in Greece and in most other countries of the world. Intensive care unit (ICU) physicians and nurses constitute a group of health care professionals who deal with end-of-life dilemmas on a daily basis. Therefore, the exploration of their attitudes towards euthanasia could valuably contribute to the relevant debate. Specifically, nurses’ opinions are of great importance. Nurses are closer to patients and their suffering, and more deeply involved in end-of-life care than physicians. However, the debate about
Abbreviations: ICU, intensive care unit; SD, standard deviation; CPR, cardiopulmonary resuscitation. * Corresponding author. Tel.: þ30 6974071547. E-mail address: [email protected] (G. Kranidiotis). 0147-9563/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2015.03.001
euthanasia is usually focused on the physicians’ perspective. The voices of nurses are scarcely heard.5,6 The objective of this study was to investigate the attitudes of Greek ICU medical and nursing staff towards euthanasia, and to evaluate the possible association of these attitudes with sociodemographic and professional variables. Methods This was a descriptive quantitative study conducted in three multidisciplinary ICUs, affiliated with two general hospitals in Athens, from March to December 2010. Of these ICUs, the first one was medical/surgical and comprised of 12 beds, while the other two were medical/respiratory and consisted of 8 and 12 beds, respectively. The convenience sample included 39 physicians and 107 nurses who volunteered to participate in the survey. Data were collected by means of a structured self-administered questionnaire, which was created by the researchers for the purposes of this study on the basis of relevant literature, and consisted of two parts. The first part recorded sociodemographic characteristics of participants, such as age, gender, educational level, years of experience, and religious beliefs. The second part comprised eleven
2
G. Kranidiotis et al. / Heart & Lung xxx (2015) 1e4
Table 1 Sociodemographic characteristics of participants. Characteristic
Age (years) 20e29 30e39 40e59 Gender Male Female Marital status Single Married Divorced Widowed Experience (years) 1e5 6e10 10e15 16 Religious affiliation Greek orthodox Non-religious
Doctors (n ¼ 39) No. (%)
Table 3 Definitions of euthanasia.
Nurses (n ¼ 107) No. (%)
Total (n ¼ 146) No. (%)
p-Value
Definition
1. Active shortening of the dying process 2. Physician-assisted suicide 3. Withholding or withdrawal of treatment 4. 1 and 2 5. 1, 2, and 3
0 (0.0) 22 (56.4) 17 (43.6)
25 (23.4) 48 (44.9) 34 (31.8)
25 (17.1) 70 (47.9) 51 (34.9)
0.004
21 (53.8) 18 (46.2)
36 (33.6) 71 (66.4)
57 (39.0) 89 (61.0)
0.027
11 27 1 0
(28.2) (69.2) (2.6) (0.0)
27 64 11 5
(25.2) (59.8) (10.3) (9.1)
38 91 12 5
(26.0) (62.3) (8.2) (3.4)
0.278
10 16 6 7
(25.6) (41.0) (15.4) (17.9)
26 27 25 29
(24.3) (25.2) (23.4) (27.1)
36 43 31 36
(24.7) (29.5) (21.2) (24.7)
0.259
136 (93.2) 10 (6.8)
0.085
34 (87.2) 5 (12.8)
102 (95.3) 5 (4.7)
Table 2 Definitions of quality of life.
1. Absence of pain and distressing symptoms 2. Mental well-being 3. Social well-being 4. Life with dignity 5. Autonomy 6. All of the above
Nurses (n ¼ 107) No. (%)
3 (7.7)
8 (7.5)
0 0 9 1 26
(0.0) (0.0) (23.1) (2.6) (66.7)
7 0 16 4 72
(6.5) (0.0) (15.0) (3.7) (67.3)
Total (n ¼ 146) No. (%)
0 (0.0)
10 (9.3)
10 (6.8)
0 (0.0) 23 (59.0)
3 (2.8) 53 (49.5)
3 (2.1) 76 (52.1)
8 (20.5) 8 (20.5)
27 (25.2) 14 (13.1)
35 (24.0) 22 (15.1)
The sociodemographic characteristics of participants are shown in Table 1. Their mean age was 37 7 (SD) years. Doctors were older than nurses (mean age 41 9 vs. 36 7 years, p ¼ 0.001). Women represented a higher proportion of the responding nurses than of the doctors. Doctors and nurses were asked to give the definitions of quality of life and euthanasia, choosing them from among a list of prespecified meanings (Tables 2 and 3). No statistically significant differences were determined between doctors and nurses, in regards to the definitions given. Concerning the acceptability of active euthanasia, 28% of doctors and 26% of nurses (p ¼ 0.755) approve of it, whereas 16% of all staff is undecided. On the contrary, withholding or withdrawal of treatment, when the patient’s illness is irreversible, and life e sustaining therapy just prolongs the dying process, is endorsed by 82% of doctors and 73% of nurses (p ¼ 0.429) (Table 4). Among ICU team members, women were more likely to oppose active euthanasia than men (p ¼ 0.023). Also, Greek e orthodox nurses rejected active euthanasia more often than non-religious ones (p ¼ 0.019). No other associations of euthanasia support with sociodemographic and professional variables were found. When asked whether a patient had ever asked them to hasten his or her death with active euthanasia, 38% of doctors and 18% of nurses (p ¼ 0.009) answered affirmatively. Of them, 70% had received more than one request. Participants were invited to record on a Likert five points scale their agreement or disagreement with four statements expressing attitudes towards euthanasia. Physicians’ and nurses’ responses, as presented in Table 5, did not differ significantly from each other. When asked whether they would consider practicing active euthanasia if it was legal, 20% of doctors and 10% of nurses (p ¼ 0.183) stated that they would do so. Forty nine per cent of doctors and 47% of nurses responded negatively. The remainder of the staff was undecided. Regarding the question who must decide on the performance of active euthanasia, the majority of physicians and nurses (82% and Table 4 Agreement with active euthanasia, and withholding/withdrawal of treatment. Agreement with
Doctors (n ¼ 39) No. (%)
Nurses (n ¼ 107) No. (%)
Results
closed questions (seven of them with a Likert response scale) about their opinions and views on specific items concerning euthanasia. To ensure content validity and readability (i.e. adequate understanding of the meaning of the questions, and sufficiently short time to be required for answering them), the questionnaire was tested and discussed by a small number of participants (n ¼ 10) in a pilot study. The questionnaires were distributed by the researchers to participants hand to hand at their workplace. Personal contact with the respondents allowed us to inform them about the study’s aim, and assure them of the confidentiality and anonymity of the process. We suggested that the questionnaire be completed at home, to ensure, as much as possible, honest and reliable answers, not affected by external factors (e.g. workload, presence of seniors or other colleagues). We were available for clarifications whenever needed. After 2e3 days, the questionnaires were returned, enclosed in sealed envelopes. Of the 200 questionnaires handed out, 146 were returned completed; this represents a response rate of 73%. Statistical procedures included descriptive statistics, chi-square (c2) and Fisher’s exact tests for analysis of categorical variables, and t-test for analysis of continuous variables. Differences were accepted as statistically significant when p < 0.05. Data analyses were performed using the Statistical Package for Social Sciences (SPSS) version 14.0. The study protocol was approved by the Scientific Council and the Ethics Committee of Evangelismos Hospital, Athens, Greece. Since the respondents volunteered to partake in the survey, filling out the questionnaire automatically implied consent for participating in the research.
Definition
Doctors (n ¼ 39) No. (%)
Total (n ¼ 146) No. (%) 11 (7.5) 7 0 25 5 98
(4.8) (0.0) (17.1) (3.4) (67.1)
Active euthanasia Yes No Undecided Withholding or withdrawal of treatment Yes No Undecided
Total (n ¼ 146) No. (%)
Doctors (n ¼ 39) No. (%)
Nurses (n ¼ 107) No. (%)
11 (28.2) 23 (59.0) 5 (12.8)
28 (26.2) 60 (56.1) 19 (17.8)
39 (26.7) 83 (56.8) 24 (16.4)
32 (82.1) 6 (15.4) 1 (2.6)
78 (72.9) 22 (20.6) 7 (6.5)
110 (75.3) 28 (19.2) 8 (5.5)
G. Kranidiotis et al. / Heart & Lung xxx (2015) 1e4 Table 5 Physicians’ and nurses’ responses to four statements expressing attitudes towards euthanasia. Response
Doctors (n ¼ 39) No. (%)
Nurses (n ¼ 107) No. (%)
Total (n ¼ 146) No. (%)
“A person has the right to decide on the time and manner of his/her death” Strongly agree 23 (59.0) 49 (45.8) 72 (49.3) Agree 6 (15.4) 12 (11.2) 18 (12.3) Undecided 3 (7.7) 12 (11.2) 22 (15.1) Disagree 1 (2.6) 7 (6.5) 8 (5.5) Strongly disagree 6 (15.4) 20 (18.7) 26 (17.8) “Greek legislation should be changed to permit active euthanasia under certain conditions” Strongly agree 16 (41.0) 43 (40.2) 59 (40.4) Agree 7 (17.9) 28 (26.2) 35 (24.0) Undecided 2 (5.1) 14 (13.1) 16 (11.0) Disagree 3 (7.7) 2 (1.9) 5 (3.4) Strongly disagree 11 (28.2) 20 (18.7) 31 (21.2) “If active euthanasia is legalized, patients will lose confidence in the medical profession” Strongly agree 12 (30.8) 21 (19.6) 33 (22.6) Agree 8 (20.5) 20 (18.7) 28 (19.2) Undecided 6 (15.4) 32 (29.9) 38 (26.0) Disagree 3 (7.7) 10 (9.3) 13 (8.9) Strongly disagree 10 (25.6) 24 (22.4) 34 (23.3) “My view on active euthanasia is affected by my religious beliefs” Strongly agree 10 (25.6) 19 (17.8) 29 (19.9) Agree 4 (10.3) 18 (16.8) 22 (15.1) Undecided 3 (7.7) 17 (15.9) 20 (13.7) Disagree 3 (7.7) 8 (7.5) 11 (7.5) Strongly disagree 19 (48.7) 45 (42.1) 64 (43.8)
77%, respectively) prefer a model in which the responsibility for the decision is shared among the patient, his/her relatives, and the health-care professionals. Nevertheless, significantly more nurses than doctors (19% vs. 3%, p ¼ 0.004) believe that the patient is the only one who has the right to take the decision.
Discussion Two thirds of surveyed doctors and nurses gave a comprehensive definition of quality of life, which includes a cluster of factors: not only the absence of pain and distressing symptoms, but also mental and social well-being, dignity, and autonomy. Half of ICU health care professionals defined euthanasia inaccurately, as withholding or withdrawal of treatment. In addition, another significant percentage of respondents ranked withholding/ withdrawal of treatment among the several forms of euthanasia, together with active shortening of the dying process and physicianassisted suicide. Only one third of participants defined euthanasia correctly, as active shortening of the dying process or physicianassisted suicide. The misconception of euthanasia by Greek ICU physicians and nurses is impressive, and demonstrates the need for more systematic education on bioethical issues. Apparently, the moral distinction between killing and allowing a patient to die is not clear enough to them. Probably, their confusion is further compounded by their perception of withdrawal of treatment as an “action”. Current consensus statements2,7 accept that intensive care may protract suffering of patients who have been unresponsive to the treatment already provided, and declare that limitation of lifesustaining therapy is an ethically grounded practice, which must not be confused with euthanasia. Additionally, although critical care providers are psychologically more comfortable withholding treatments than withdrawing them,8e10 societal recommendations emphasize that there is no morally relevant difference between the two practices.
3
Only one fourth of respondents agree with active euthanasia; this is a low but still significant acceptance rate, consistent with the results of studies conducted in other European countries.11e13 Much fewer would consider performing active euthanasia, if it was legal. Nevertheless, most doctors and nurses recognize a person’s right to decide on the time and manner of his/her death, and support the legalization of active euthanasia. The above findings, which confirm the results of a previous Greek survey,14 imply that Greek health care professionals, theoretically, share a liberal, individualistic view on euthanasia, even though, personally, they disapprove of it, probably on the basis of their private moral or religious beliefs. The great majority of ICU staff approve withholding/withdrawal of life support in futile cases, i.e. in patients for whom the possibility of surviving or regaining an acceptable quality of life is nil, and in whom intensive care only prolongs the dying process. However, this attitude seems not to be reflected in daily clinical practice. As has been shown by a multicenter cohort study,15 in Greek ICUs, limitation of life-sustaining treatment is almost equivalent to the withholding of cardiopulmonary resuscitation (CPR) alone. Withholding of other therapies besides CPR is not routine, while withdrawal of any form of support, ranging from artificial nutrition to mechanical ventilation, is quite infrequent. End-of-life practices in Greek ICUs appear very similar to those implemented in the ICUs of other southern European countries, whereas they diverge substantially from the standard prevailing in northern European countries, as well as in North America; in the latter areas of the world, the incidence of withholding and withdrawal of life-sustaining treatment reaches 90% of patients who die in the ICU.16,17 Concerning the decision-making procedure that should be followed before committing active euthanasia, most participants are in favor of shared decision-making. This is a remarkable finding, since the aforementioned study15 revealed that, actually, medical paternalism predominates in end-of-life decision-making; patients’ and relatives’ involvement in it is uncommon. Our study has several limitations. First, the sample examined was a convenience sample, not representative of the entire Greek population of ICU physicians and nurses. Larger and randomly selected samples are needed to make more inferences about attitudes of Greek health care professionals towards euthanasia. Second, the fixed-response format of the questionnaire may have limited the amount of information obtained and the level of detail in the responses. By not imposing a definition for euthanasia from the beginning of the questionnaire, our aim was not to maintain the existing confusion between euthanasia and withholding/withdrawal of treatment, but rather to highlight it. To avoid further perplexity, the term “active euthanasia” was used in the remainder of the questionnaire, whose objective was to explore attitudes towards euthanasia.
Conclusions Confusion prevails among Greek ICU physicians and nurses regarding the definition of euthanasia. The majority of staff disagrees with active euthanasia, as a clinical practice. Nonetheless, they uphold its legalization, and respect the patient’s right to decide on the time and manner of his/her death. Shared decisionmaking is preferred as a model to handle end-of-life dilemmas. Future research is needed to investigate the factors that shape critical care providers’ attitudes towards euthanasia, and the impact of working conditions and organization on such attitudes. Improving ICU professionals’ knowledge of bioethics is necessary in order to clarify euthanasia issues, and ameliorate understanding and management of end-of-life situations.
4
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References 1. Emanuel EJ. Euthanasia: historical, ethical, and empiric perspectives. Arch Intern Med. 1994;154:1890e1901. 2. Truog RD, Campbell ML, Curtis JR, et al. American Academy of Critical Care Medicine recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med. 2008;36:953e963. 3. American Medical Association, Council on Ethical and Judicial Affairs. Decisions near the end of life. JAMA. 1992;267:2229e2233. 4. American Nurses Association. Position Statement on Active Euthanasia. Washington, DC: American Nurses Association; 1994. 5. DeKeyser Ganz F, Musgrave CF. Israeli critical care nurses’ attitudes toward physician-assisted dying. Heart Lung. 2006;35(6):412e422. 6. Berghs M, Dierckx de Casterlé B, Gastmans C. The complexity of nurses’ attitudes toward euthanasia: a review of the literature. J Med Ethics. 2005;31: 441e446. 7. Carlet J, Thijs LG, Antonelli M, et al. Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med. 2004;30:770e784. 8. Vincent JL. Forgoing life support in Western European intensive care units: the results of an ethical questionnaire. Crit Care Med. 1999;27:1626e1633.
9. Solomon MZ, O’Donnell L, Jennings B, et al. Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health. 1993;83: 14e23. 10. Giannini A, Pessina A, Tacchi EM. End-of-life decisions in intensive care units: attitudes of physicians in an Italian urban setting. Intensive Care Med. 2003;29: 1902e1910. 11. Kumas¸ G, Oztunç G, Nazan Alparslan Z. Intensive care unit nurses’ opinions about euthanasia. Nurs Ethics. 2007;14:637e650. 12. Grassi L, Magnani K, Ercolani M. Attitudes toward euthanasia and physicianassisted suicide among Italian primary care physicians. J Pain Symptom Manage. 1999;17:188e196. 13. Brzostek T, Dekkers W, Zalewski Z, et al. Perception of palliative care and euthanasia among recently graduated and experienced nurses. Nurs Ethics. 2008;15:761e776. 14. Parpa E, Mystakidou K, Tsilika E, et al. Attitudes of health care professionals, relatives of advanced cancer patients and public towards euthanasia and physician assisted suicide. Health Policy. 2010;97:160e165. 15. Kranidiotis G, Gerovasili V, Tasoulis A, et al. End-of-life decisions in Greek intensive care units: a multicenter cohort study. Crit Care. 2010;14:R228. 16. Sprung CL, Cohen SL, Sjokvist P, et al. End-of-life practices in European intensive care units: the Ethicus study. JAMA. 2003;290:790e797. 17. Prendergast TJ, Luce JM. Increasing incidence of withholding and withdrawing life support from critically ill. Am J Respir Crit Care Med. 1997;155:15e20.
Contents lists available at ScienceDirect
Heart & Lung journal homepage: www.heartandlung.org
Attitudes towards euthanasia among Greek intensive care unit physicians and nurses Georgios Kranidiotis, MD a, *, Julia Ropa, RN a, John Mprianas, RN b, Theodoros Kyprianou, MD c, Serafim Nanas, MD a a
First Critical Care Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 45-47 Ypsilantou Str, Athens 10675, Greece Sixth Respiratory Medicine Department, “Sotiria” Hospital for Diseases of the Chest, 152 Mesogeion Ave, Athens 11527, Greece c Critical Care Department, Nicosia General Hospital, 215 Old Road Nikosia-Limassol, Nikosia 2029, Cyprus b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 September 2014 Received in revised form 27 February 2015 Accepted 7 March 2015 Available online xxx
Objectives: To investigate the attitudes of Greek intensive care unit (ICU) medical and nursing staff towards euthanasia. Background: ICU physicians and nurses deal with end-of-life dilemmas on a daily basis. Therefore, the exploration of their stances on euthanasia is worthwhile. Methods: This was a descriptive quantitative study conducted in three ICUs in Athens. The convenience sample included 39 physicians and 107 nurses. Results: Of respondents, 52% defined euthanasia inaccurately, as withholding or withdrawal of treatment, while 15% ranked limitation of life-support among the several forms of euthanasia, together with active shortening of the dying process and physician e assisted suicide. Only one third of participants defined euthanasia correctly. While 59% of doctors and 64% of nurses support the legalization of active euthanasia, just 28% and 26% of them, respectively, agree with it ethically. Conclusions: Confusion prevails among Greek ICU physicians and nurses regarding the definition of euthanasia. The majority of staff disagrees with active euthanasia, but upholds its legalization. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Euthanasia Limitation of life-sustaining treatment End-of-life decisions Quality of life Shared decision-making
Introduction Euthanasia is defined as administering medication or performing other interventions with the intention of causing a patient’s death.1 Unlike the practice of withholding or withdrawing life-sustaining treatments, which is widely accepted,2 euthanasia is prohibited by professional medical and nursing codes3,4 and remains illegal in Greece and in most other countries of the world. Intensive care unit (ICU) physicians and nurses constitute a group of health care professionals who deal with end-of-life dilemmas on a daily basis. Therefore, the exploration of their attitudes towards euthanasia could valuably contribute to the relevant debate. Specifically, nurses’ opinions are of great importance. Nurses are closer to patients and their suffering, and more deeply involved in end-of-life care than physicians. However, the debate about
Abbreviations: ICU, intensive care unit; SD, standard deviation; CPR, cardiopulmonary resuscitation. * Corresponding author. Tel.: þ30 6974071547. E-mail address: [email protected] (G. Kranidiotis). 0147-9563/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2015.03.001
euthanasia is usually focused on the physicians’ perspective. The voices of nurses are scarcely heard.5,6 The objective of this study was to investigate the attitudes of Greek ICU medical and nursing staff towards euthanasia, and to evaluate the possible association of these attitudes with sociodemographic and professional variables. Methods This was a descriptive quantitative study conducted in three multidisciplinary ICUs, affiliated with two general hospitals in Athens, from March to December 2010. Of these ICUs, the first one was medical/surgical and comprised of 12 beds, while the other two were medical/respiratory and consisted of 8 and 12 beds, respectively. The convenience sample included 39 physicians and 107 nurses who volunteered to participate in the survey. Data were collected by means of a structured self-administered questionnaire, which was created by the researchers for the purposes of this study on the basis of relevant literature, and consisted of two parts. The first part recorded sociodemographic characteristics of participants, such as age, gender, educational level, years of experience, and religious beliefs. The second part comprised eleven
2
G. Kranidiotis et al. / Heart & Lung xxx (2015) 1e4
Table 1 Sociodemographic characteristics of participants. Characteristic
Age (years) 20e29 30e39 40e59 Gender Male Female Marital status Single Married Divorced Widowed Experience (years) 1e5 6e10 10e15 16 Religious affiliation Greek orthodox Non-religious
Doctors (n ¼ 39) No. (%)
Table 3 Definitions of euthanasia.
Nurses (n ¼ 107) No. (%)
Total (n ¼ 146) No. (%)
p-Value
Definition
1. Active shortening of the dying process 2. Physician-assisted suicide 3. Withholding or withdrawal of treatment 4. 1 and 2 5. 1, 2, and 3
0 (0.0) 22 (56.4) 17 (43.6)
25 (23.4) 48 (44.9) 34 (31.8)
25 (17.1) 70 (47.9) 51 (34.9)
0.004
21 (53.8) 18 (46.2)
36 (33.6) 71 (66.4)
57 (39.0) 89 (61.0)
0.027
11 27 1 0
(28.2) (69.2) (2.6) (0.0)
27 64 11 5
(25.2) (59.8) (10.3) (9.1)
38 91 12 5
(26.0) (62.3) (8.2) (3.4)
0.278
10 16 6 7
(25.6) (41.0) (15.4) (17.9)
26 27 25 29
(24.3) (25.2) (23.4) (27.1)
36 43 31 36
(24.7) (29.5) (21.2) (24.7)
0.259
136 (93.2) 10 (6.8)
0.085
34 (87.2) 5 (12.8)
102 (95.3) 5 (4.7)
Table 2 Definitions of quality of life.
1. Absence of pain and distressing symptoms 2. Mental well-being 3. Social well-being 4. Life with dignity 5. Autonomy 6. All of the above
Nurses (n ¼ 107) No. (%)
3 (7.7)
8 (7.5)
0 0 9 1 26
(0.0) (0.0) (23.1) (2.6) (66.7)
7 0 16 4 72
(6.5) (0.0) (15.0) (3.7) (67.3)
Total (n ¼ 146) No. (%)
0 (0.0)
10 (9.3)
10 (6.8)
0 (0.0) 23 (59.0)
3 (2.8) 53 (49.5)
3 (2.1) 76 (52.1)
8 (20.5) 8 (20.5)
27 (25.2) 14 (13.1)
35 (24.0) 22 (15.1)
The sociodemographic characteristics of participants are shown in Table 1. Their mean age was 37 7 (SD) years. Doctors were older than nurses (mean age 41 9 vs. 36 7 years, p ¼ 0.001). Women represented a higher proportion of the responding nurses than of the doctors. Doctors and nurses were asked to give the definitions of quality of life and euthanasia, choosing them from among a list of prespecified meanings (Tables 2 and 3). No statistically significant differences were determined between doctors and nurses, in regards to the definitions given. Concerning the acceptability of active euthanasia, 28% of doctors and 26% of nurses (p ¼ 0.755) approve of it, whereas 16% of all staff is undecided. On the contrary, withholding or withdrawal of treatment, when the patient’s illness is irreversible, and life e sustaining therapy just prolongs the dying process, is endorsed by 82% of doctors and 73% of nurses (p ¼ 0.429) (Table 4). Among ICU team members, women were more likely to oppose active euthanasia than men (p ¼ 0.023). Also, Greek e orthodox nurses rejected active euthanasia more often than non-religious ones (p ¼ 0.019). No other associations of euthanasia support with sociodemographic and professional variables were found. When asked whether a patient had ever asked them to hasten his or her death with active euthanasia, 38% of doctors and 18% of nurses (p ¼ 0.009) answered affirmatively. Of them, 70% had received more than one request. Participants were invited to record on a Likert five points scale their agreement or disagreement with four statements expressing attitudes towards euthanasia. Physicians’ and nurses’ responses, as presented in Table 5, did not differ significantly from each other. When asked whether they would consider practicing active euthanasia if it was legal, 20% of doctors and 10% of nurses (p ¼ 0.183) stated that they would do so. Forty nine per cent of doctors and 47% of nurses responded negatively. The remainder of the staff was undecided. Regarding the question who must decide on the performance of active euthanasia, the majority of physicians and nurses (82% and Table 4 Agreement with active euthanasia, and withholding/withdrawal of treatment. Agreement with
Doctors (n ¼ 39) No. (%)
Nurses (n ¼ 107) No. (%)
Results
closed questions (seven of them with a Likert response scale) about their opinions and views on specific items concerning euthanasia. To ensure content validity and readability (i.e. adequate understanding of the meaning of the questions, and sufficiently short time to be required for answering them), the questionnaire was tested and discussed by a small number of participants (n ¼ 10) in a pilot study. The questionnaires were distributed by the researchers to participants hand to hand at their workplace. Personal contact with the respondents allowed us to inform them about the study’s aim, and assure them of the confidentiality and anonymity of the process. We suggested that the questionnaire be completed at home, to ensure, as much as possible, honest and reliable answers, not affected by external factors (e.g. workload, presence of seniors or other colleagues). We were available for clarifications whenever needed. After 2e3 days, the questionnaires were returned, enclosed in sealed envelopes. Of the 200 questionnaires handed out, 146 were returned completed; this represents a response rate of 73%. Statistical procedures included descriptive statistics, chi-square (c2) and Fisher’s exact tests for analysis of categorical variables, and t-test for analysis of continuous variables. Differences were accepted as statistically significant when p < 0.05. Data analyses were performed using the Statistical Package for Social Sciences (SPSS) version 14.0. The study protocol was approved by the Scientific Council and the Ethics Committee of Evangelismos Hospital, Athens, Greece. Since the respondents volunteered to partake in the survey, filling out the questionnaire automatically implied consent for participating in the research.
Definition
Doctors (n ¼ 39) No. (%)
Total (n ¼ 146) No. (%) 11 (7.5) 7 0 25 5 98
(4.8) (0.0) (17.1) (3.4) (67.1)
Active euthanasia Yes No Undecided Withholding or withdrawal of treatment Yes No Undecided
Total (n ¼ 146) No. (%)
Doctors (n ¼ 39) No. (%)
Nurses (n ¼ 107) No. (%)
11 (28.2) 23 (59.0) 5 (12.8)
28 (26.2) 60 (56.1) 19 (17.8)
39 (26.7) 83 (56.8) 24 (16.4)
32 (82.1) 6 (15.4) 1 (2.6)
78 (72.9) 22 (20.6) 7 (6.5)
110 (75.3) 28 (19.2) 8 (5.5)
G. Kranidiotis et al. / Heart & Lung xxx (2015) 1e4 Table 5 Physicians’ and nurses’ responses to four statements expressing attitudes towards euthanasia. Response
Doctors (n ¼ 39) No. (%)
Nurses (n ¼ 107) No. (%)
Total (n ¼ 146) No. (%)
“A person has the right to decide on the time and manner of his/her death” Strongly agree 23 (59.0) 49 (45.8) 72 (49.3) Agree 6 (15.4) 12 (11.2) 18 (12.3) Undecided 3 (7.7) 12 (11.2) 22 (15.1) Disagree 1 (2.6) 7 (6.5) 8 (5.5) Strongly disagree 6 (15.4) 20 (18.7) 26 (17.8) “Greek legislation should be changed to permit active euthanasia under certain conditions” Strongly agree 16 (41.0) 43 (40.2) 59 (40.4) Agree 7 (17.9) 28 (26.2) 35 (24.0) Undecided 2 (5.1) 14 (13.1) 16 (11.0) Disagree 3 (7.7) 2 (1.9) 5 (3.4) Strongly disagree 11 (28.2) 20 (18.7) 31 (21.2) “If active euthanasia is legalized, patients will lose confidence in the medical profession” Strongly agree 12 (30.8) 21 (19.6) 33 (22.6) Agree 8 (20.5) 20 (18.7) 28 (19.2) Undecided 6 (15.4) 32 (29.9) 38 (26.0) Disagree 3 (7.7) 10 (9.3) 13 (8.9) Strongly disagree 10 (25.6) 24 (22.4) 34 (23.3) “My view on active euthanasia is affected by my religious beliefs” Strongly agree 10 (25.6) 19 (17.8) 29 (19.9) Agree 4 (10.3) 18 (16.8) 22 (15.1) Undecided 3 (7.7) 17 (15.9) 20 (13.7) Disagree 3 (7.7) 8 (7.5) 11 (7.5) Strongly disagree 19 (48.7) 45 (42.1) 64 (43.8)
77%, respectively) prefer a model in which the responsibility for the decision is shared among the patient, his/her relatives, and the health-care professionals. Nevertheless, significantly more nurses than doctors (19% vs. 3%, p ¼ 0.004) believe that the patient is the only one who has the right to take the decision.
Discussion Two thirds of surveyed doctors and nurses gave a comprehensive definition of quality of life, which includes a cluster of factors: not only the absence of pain and distressing symptoms, but also mental and social well-being, dignity, and autonomy. Half of ICU health care professionals defined euthanasia inaccurately, as withholding or withdrawal of treatment. In addition, another significant percentage of respondents ranked withholding/ withdrawal of treatment among the several forms of euthanasia, together with active shortening of the dying process and physicianassisted suicide. Only one third of participants defined euthanasia correctly, as active shortening of the dying process or physicianassisted suicide. The misconception of euthanasia by Greek ICU physicians and nurses is impressive, and demonstrates the need for more systematic education on bioethical issues. Apparently, the moral distinction between killing and allowing a patient to die is not clear enough to them. Probably, their confusion is further compounded by their perception of withdrawal of treatment as an “action”. Current consensus statements2,7 accept that intensive care may protract suffering of patients who have been unresponsive to the treatment already provided, and declare that limitation of lifesustaining therapy is an ethically grounded practice, which must not be confused with euthanasia. Additionally, although critical care providers are psychologically more comfortable withholding treatments than withdrawing them,8e10 societal recommendations emphasize that there is no morally relevant difference between the two practices.
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Only one fourth of respondents agree with active euthanasia; this is a low but still significant acceptance rate, consistent with the results of studies conducted in other European countries.11e13 Much fewer would consider performing active euthanasia, if it was legal. Nevertheless, most doctors and nurses recognize a person’s right to decide on the time and manner of his/her death, and support the legalization of active euthanasia. The above findings, which confirm the results of a previous Greek survey,14 imply that Greek health care professionals, theoretically, share a liberal, individualistic view on euthanasia, even though, personally, they disapprove of it, probably on the basis of their private moral or religious beliefs. The great majority of ICU staff approve withholding/withdrawal of life support in futile cases, i.e. in patients for whom the possibility of surviving or regaining an acceptable quality of life is nil, and in whom intensive care only prolongs the dying process. However, this attitude seems not to be reflected in daily clinical practice. As has been shown by a multicenter cohort study,15 in Greek ICUs, limitation of life-sustaining treatment is almost equivalent to the withholding of cardiopulmonary resuscitation (CPR) alone. Withholding of other therapies besides CPR is not routine, while withdrawal of any form of support, ranging from artificial nutrition to mechanical ventilation, is quite infrequent. End-of-life practices in Greek ICUs appear very similar to those implemented in the ICUs of other southern European countries, whereas they diverge substantially from the standard prevailing in northern European countries, as well as in North America; in the latter areas of the world, the incidence of withholding and withdrawal of life-sustaining treatment reaches 90% of patients who die in the ICU.16,17 Concerning the decision-making procedure that should be followed before committing active euthanasia, most participants are in favor of shared decision-making. This is a remarkable finding, since the aforementioned study15 revealed that, actually, medical paternalism predominates in end-of-life decision-making; patients’ and relatives’ involvement in it is uncommon. Our study has several limitations. First, the sample examined was a convenience sample, not representative of the entire Greek population of ICU physicians and nurses. Larger and randomly selected samples are needed to make more inferences about attitudes of Greek health care professionals towards euthanasia. Second, the fixed-response format of the questionnaire may have limited the amount of information obtained and the level of detail in the responses. By not imposing a definition for euthanasia from the beginning of the questionnaire, our aim was not to maintain the existing confusion between euthanasia and withholding/withdrawal of treatment, but rather to highlight it. To avoid further perplexity, the term “active euthanasia” was used in the remainder of the questionnaire, whose objective was to explore attitudes towards euthanasia.
Conclusions Confusion prevails among Greek ICU physicians and nurses regarding the definition of euthanasia. The majority of staff disagrees with active euthanasia, as a clinical practice. Nonetheless, they uphold its legalization, and respect the patient’s right to decide on the time and manner of his/her death. Shared decisionmaking is preferred as a model to handle end-of-life dilemmas. Future research is needed to investigate the factors that shape critical care providers’ attitudes towards euthanasia, and the impact of working conditions and organization on such attitudes. Improving ICU professionals’ knowledge of bioethics is necessary in order to clarify euthanasia issues, and ameliorate understanding and management of end-of-life situations.
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