Decisions and attitudes toward treatment of incompetent, chronically ill, elderly people: A comparison between nurses and physicians - or: Why does nobody ask the nurses?

Health care decision making in incompetent severely ill patients presents m any difficult medical, ethical, and legal problems for the physician. At th e same time nurses represent the group of medical professionals who have th e closest contact with the patient and who have to carry out most of the de cisions and instructions. Treatment decisions and their determinants have been assessed by means of a questionnaire based on three case scenarios offering three different level s of available information of the patient's wishes (no information, DNR-ord er, advance directive). Responses of 191 doctors and 182 nurses have been a nalyzed. In both groups ethical factors and patient wishes were regarded as the most important. With an increasing level of information about the pati ent's will the compliance increased in both groups, being more pronounced a mong the nurses. The more important the will of the patient was estimated, the less difficult were the decisions, the less aggressive was the treatmen t level chosen, the less frequent rescuscitation was made, and the more hel pful the information on patient's will were experienced. These important re lationships occured mainly in the nurses. Furthermore, age-and level of dementia were related with the decisions thou gh with less importance. The more legal aspects were regarded the more aggr essive treatment options were chosen. Hospital cost were less important and did not influence the decision making. The results indicate that a more fr equent use of advance directives would foster patient autonomy and at the s ame time lessen the burden on the medical staff. A comprehensive education of both the medical professions and the general public seems warranted.