BackgroundJunior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors’ decision-making processes when treating people with dementia who have advance care directives, or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: their legal compliance and decision-making process related to treatment decisions; the factors influencing their clinical decision-making; and the factors (...) associated with accurate responses to one hypothetical vignette. MethodA cross-sectional survey of junior doctors, including trainees, interns, registrars and residents, on clinical rotation in five public hospitals located in one Australian state. The anonymous, investigator-developed survey was conducted between August 2018 and June 2019. Two hypothetical vignettes describing patients with dementia presenting to hospital with an ACD and either: bacterial pneumonia; or suspected stroke were presented in the survey. Participants were asked to indicate whether they would commence treatment, given the ACD instructions described in each vignette.ResultsOverall, 116 junior doctors responded. In Vignette 1, 58% of respondents selected the legally compliant option. Participants who chose the legally compliant option perceived ‘following patient wishes’ and ‘legal requirements to follow ACDs’ as equally important reasons for complying with the ACD. The most common reason for not selecting the legally compliant option in Vignette 1 was the ‘ACD is relevant in my decision-making process, but other factors are more relevant’. In Vignette 2, 72% of respondents indicated they would commence treatment and 18% selected they would not commence treatment.. Similar reasons influenced participant decision-making in Vignette 2, a less legally certain scenario.ConclusionsThere are critical gaps in junior doctors’ compliance with the law as it relates to the implementation of ACDs. Despite there being differences in relation to the legal answer and its certainty, clinical and ethical factors guided decision-making over and above the law in both vignettes. More education and training to guide junior doctors’ clinical decision-making and ensure compliance with the law is required. (shrink)

BackgroundHealthcare professionals use the ethics of justice and care to construct moral reasoning. These ethics are conflicting in nature; different value systems and orders of justice and care are applied to the cause of actual moral conflict. We aim to clarify the structure and factors of healthcare professionals’ moral conflicts through the lens of justice and care to obtain suggestions for conflict resolutions.MethodSemi-structured interviews about experiences of moral conflict were conducted with Japanese nurses recruited using the snowball sampling method. Interviews (...) were conducted based on the real-life moral conflict and choice interview. Interviews were recorded and transcribed verbatim, then analyzed based on the interpretive method of data analysis. Verbatim transcripts were read four times, first to get an overall sense of the conflict, then to understand the person’s thoughts and actions that explain the conflict, and third and fourth to identify perspectives of justice and care, respectively. Each moral perspective was classified into categories according to Chally’s taxonomy.ResultsAmong 31 responses, 2 that did not mention moral conflict were excluded, leaving 29 responses that were analyzed. These responses were classified into six cases with conflict between both justice and care perspectives or within one perspective, and into two cases without conflict between perspectives. The “rules” category of justice and the “welfare of others” category of care were included in many cases of conflict between two perspectives, and they frequently occurred in each perspective.ConclusionsThe nurses in this study suggest that they make moral judgments based on moral values that are intertwined with justice and care perspectives complex manner.Organizational, professional, and patient-related factors influenced conflicts between justice and care. Additionally, multiple overlapping loyalties created conflicts within justice perspectives, and multifaceted aspects of care-provider’s responsibility and patient need created conflicts within care. Decision-making biased towards one perspective can be distorted. It is important to consider ethical issues from both perspectives to resolve conflicts, especially the effective use of the ethics of care is recommended. (shrink)

The doctor-patient relationship has evolved to respect “the autonomy and patients’ rights”. One of the cornerstones in such autonomy is the opportunity for patients to draw living wills, also known as advance directives. However, information about AD available to patients remains scarce largely due to the lack of involvement of General practitioners for several reasons. The aim of our study was to evaluate current general practitioner residents’ behavior concerning their role in informing their patients about AD. We built a French (...) nationwide survey from GPR class of 2012 to 2014. Two thousand three hundred ten residents completed our survey. 89.8% declared their willingness to offer patients the opportunity of writing AD. When asked about the usefulness of AD, 73.6% of residents responded that these are a suitable help for patients, but 19.7% considered that AD are essentially geared towards frail patients. Among residents who want to inform patients about AD, 14.7% wanted to involve all patients. Only 20.5% thought that elderly people should be systematically informed about AD. When the question involves other frail people in various disease areas, information seems relevant for 60.1% of GPR considering patient with cancer or malignant hematologic disease and for 56.2% about patients affected by neurodegenerative disease. When considering the routine use of AD, 20.5% of GPR would take them into account only if they are in agreement with the patient’s decision. The results of the survey indicate that GPR would rather choose to decide who should be informed about AD, and when to take AD into account for ethical concerns. (shrink)