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Vid existensens gräns: Etiskt vårdande och professionellt ansvar vid hjärtstopp utanför sjukhus
Högskolan i Borås, Institutionen för vårdvetenskap.ORCID iD: 0000-0001-7865-3480
2012 (Swedish)Doctoral thesis, comprehensive summary (Other academic)Alternative title
At the border of existence : Ethical caring and professional responsibility in the context of out-of-hospital cardiac arrests (Swedish)
Abstract [en]

Aim: To describe and interpret patients’, family members’ and ambulance personnel’s experiences with regard to survival, attendance, and caring at cardiac arrests and deaths, and to analyze ethical conflicts that arise in relation to families and how the personnel’s ethical competence can affect caring and the ability to handle ethical problems.

Method: The three interview studies were guided by a reflective lifeworld approach grounded in phenomenology and analyzed by searching for the essence of the phenomenon in two studies and by attaining a main interpretation in one study. In the fourth study, the general approach was supplemented by “reflective equilibrium” that guided the ethical analysis.

Results: The survivors are striving towards a good life by means of efforts to reach meaning and coherence, facing existential fear and insecurity as well as gratitude and the joy of life. Family members lose everyday control through feelings of unreality, inadequacy and overwhelming responsibility. Ambulance personnel’s care mediates hope and despair until the announcement of survival or death. After the event, family members risk involuntary loneliness and anxiety about the future. For the ambulance personnel, caring for families involves a need for mobility in decision making, forcing the personnel to balance their own perceptions, feelings and reactions against interpretative reasoning. To base decision making on emotional reactions creates the risk of erroneous conclusions and a care relationship with elements of dishonesty, misdirected benevolence and false hopes. Identification with family members can promote recognition of and response to their existential needs, but also frustrate meeting family members emotions’ and handling one’s own vulnerability and inadequacy. It was found that futile cardiopulmonary resuscitation, administered to patients for the benefit of family members, is not an acceptable moral practice, due both to norms of not deliberately treating persons as mere means and to norms of taking care of families.

Conclusions: Ethical conflicts exist when it comes to conveying realistic hope, relief from guilt, participation, responsibility for decision making, and fairness in the professional role. Ambulance personnel need support to enhance ethical caring competence and to deal with personal discomfort, as well as clear guidelines on family support.

Place, publisher, year, edition, pages
Växjö: Linnaeus University Press , 2012. , 200 p.
Series
Linnaeus University Dissertations, 75/2012
Keyword [en]
emergency medical services, ethical competence, ethics, out-of hospital cardiac arrest, lifeworld, phenomenology, professional responsibility, sudden cardiac death
National Category
Nursing
Research subject
Health and Caring Sciences, Caring Science
Identifiers
URN: urn:nbn:se:lnu:diva-16285ISBN: 9789186983253 (print)OAI: oai:DiVA.org:lnu-16285DiVA: diva2:468848
Public defence
2012-01-27, Myrdal, Georg Lückligs väg 8, Växjö, 15:54 (Swedish)
Opponent
Supervisors
Available from: 2011-12-22 Created: 2011-12-21 Last updated: 2017-05-03Bibliographically approved
List of papers
1. To Survive Out-of-Hospital Cardiac Arrest: A Search for Meaning and Coherence
Open this publication in new window or tab >>To Survive Out-of-Hospital Cardiac Arrest: A Search for Meaning and Coherence
2009 (English)In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 19, no 3, 323-338 p.Article in journal (Refereed) Published
Abstract [en]

The primary responsibility of prehospital emergency personnel at out-of-hospital cardiac arrests (OHCA) is to provide lifesaving care. Ethical considerations, decisions, and actions should be based in the patient’s beliefs about health and well-being. In this article, we describe patients’ experiences of surviving OHCA. By using a phenomenological approach, we focus on how OHCA influences patients’ well-being over time. Nine survivors were interviewed. Out-of-hospital cardiac arrest is described as a sudden and elusive threat, an awakening in perplexity, and the memory gap as a loss of coherence. Survival means a search for coherence with distressing and joyful understanding, as well as existential insecurity exposed by feelings of vulnerability. Well-being is found through a sense of coherence and meaning in life. The study findings show survivors’ emotional needs and a potential for prehospital emergency personnel to support them as they try to make sense of what has happened to them.

 

Place, publisher, year, edition, pages
Thousand Oaks, CA: Sage Publications, 2009
Keyword
emergency medical services, heart health, illness and disease, acute, quality of life, phenomenology
National Category
Nursing
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:vxu:diva-5092 (URN)10.1177/1049732309348369 (DOI)
Projects
Vårdetiska prioriteringar inom ambulanssjukvård
Available from: 2009-04-20 Created: 2009-04-20 Last updated: 2017-05-03Bibliographically approved
2. Experiencing Out-of-Hospital Cardiac Arrest: Significant Others’ Lifeworld Perspective
Open this publication in new window or tab >>Experiencing Out-of-Hospital Cardiac Arrest: Significant Others’ Lifeworld Perspective
2009 (English)In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 19, no 10, 1407-1420 p.Article in journal (Refereed) Published
Abstract [en]

When patients suffer out-of-hospital cardiac arrests (OHCA), significant others find themselves with no choice about being there. Afterwards they are often left with unanswered questions about the life-threatening circumstances, or the patient’s death, the emergency treatment and future needs. When it is unclear how the care, and the event itself will affect significant others’ well being, prehospital emergency personnel face ethical decisions. This study describes the experiences of significant others present at OHCA, focusing on ethical aspects and values. Using a lifeworld phenomenological approach, seven significant others were interviewed. The essence of the phenomenon of OHCA can be stated as: Unreality in the reality; Overwhelming responsibility; Inadequacy and limitation; Hope and hopelessness; Ethical considerations; Insecurity about the future; Trembling of life. These study findings show how significant others’ sense of unreality, inadequacy, and overwhelming responsibility at OHCA can threaten values deemed important for a good life.

 

Keyword
crisis management, emergency medical services, ethics, families, quality of life, phenomenology
National Category
Nursing
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:vxu:diva-5094 (URN)10.1177/1049732309348369 (DOI)
Available from: 2009-04-20 Created: 2009-04-20 Last updated: 2017-05-03Bibliographically approved
3. Balancing Between Closeness and Distance: Emergency medical services personnel’s experiences of caring for families at out-of-hospital cardiac arrests and deaths
Open this publication in new window or tab >>Balancing Between Closeness and Distance: Emergency medical services personnel’s experiences of caring for families at out-of-hospital cardiac arrests and deaths
2012 (English)In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 27, no 1, 42-52 p.Article in journal (Refereed) Published
Abstract [en]

Introduction: Out-of-hospital cardiac arrest (OHCA) is a lethal health problem thataffects between 236,000 and 325,000 people in the United States each year. As resuscitationattempts are unsuccessful in 70-98% of OHCA cases, Emergency Medical Services(EMS) personnel often face the needs of bereaved family members.Problem: Decisions to continue or terminate resuscitation at OHCA are influenced byfactors other than patient clinical characteristics, such as EMS personnel’s knowledge,attitudes, and beliefs regarding family emotional preparedness. However, there is littleresearch exploring how EMS personnel care for bereaved family members, or how theyare affected by family dynamics and the emotional contexts. The aim of this study is toanalyze EMS personnel’s experiences of caring for families when patients suffer cardiacarrest and sudden death.Methods: The study is based on a hermeneutic lifeworld approach. Qualitative interviewswere conducted with 10 EMS personnel from an EMS agency in southern Sweden.Results: The EMS personnel interviewed felt responsible for both patient care and familycare, and sometimes failed to prioritize these responsibilities as a result of their ownperceptions, feelings and reactions. Moving from patient care to family care implied amovement from well-structured guidance to a situational response, where the personnelwere forced to balance between interpretive reasoning and a more direct emotionalresponse, at their own discretion. With such affective responses in decision-making, thepersonnel risked erroneous conclusions and care relationships with elements of dishonesty,misguided benevolence and false hopes. The ability to recognize and respond to people’sexistential questions and needs was essential. It was dependent on the EMS personnel’sbalance between closeness and distance, and on their courage in facing the emotionalexpressions of the families, as well as the personnel’s own vulnerability. The presence offamily members placed great demands on mobility (moving from patient care to familycare) in the decision-making process, invoking a need for ethical competence.Conclusion: Ethical caring competence is needed in the care of bereaved family membersto avoid additional suffering. Opportunities to reflect on these situations within a frameworkof care ethics, continuous moral education, and clinical ethics training are needed.Support in dealing with personal discomfort and clear guidelines on family support couldbenefit EMS personnel.Bremer A, Dahlberg K, Sandman

Place, publisher, year, edition, pages
Cambridge: Cambridge University Press, 2012
Keyword
out-of-hospital cardiac arrest, resuscitation, sudden death, ethics, emergency medical services, experiences, lifeworld hermeneutic
National Category
Nursing
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:lnu:diva-16284 (URN)10.1017/S1049023X12000167 (DOI)2-s2.0-84862087812 (Scopus ID)
Note

free article

Available from: 2011-12-21 Created: 2011-12-21 Last updated: 2017-05-03Bibliographically approved
4. Futile cardiopulmonary resuscitation for the benefit of others: An ethical analysis
Open this publication in new window or tab >>Futile cardiopulmonary resuscitation for the benefit of others: An ethical analysis
2011 (English)In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 18, no 4, 495-504 p.Article in journal (Refereed) Published
Abstract [en]

It has been reported as an ethical problem within prehospital emergency care that ambulance professionals administer physiologically futile cardiopulmonary resuscitation (CPR) to patients having suffered cardiac arrest to benefit significant others. At the same time it is argued that, under certain circumstances, this is an acceptable moral practice by signalling that everything possible has been done, and enabling the grief of significant others to be properly addressed. Even more general moral reasons have been used to morally legitimize the use of futile CPR: That significant others are a type of patient with medical or care needs that should be addressed, that the interest of significant others should be weighed into what to do and given an equal standing together with patient interests, and that significant others could be benefited by care professionals unless it goes against the explicit wants of the patient. In this article we explore these arguments and argue that the support for providing physiologically futile CPR in the prehospital context fails. Instead, the strategy of ambulance professionals in the case of a sudden death should be to focus on the relevant care needs of the significant others and provide support, arrange for a peaceful environment and administer acute grief counselling at the scene, which might call for a developed competency within this field.

Place, publisher, year, edition, pages
Sage Publications, 2011
Keyword
cardiopulmonary resuscitation, emergency medical services, end of life, ethics, futility, rituals
National Category
Nursing Ethics
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:lnu:diva-16282 (URN)10.1177/0969733011404339 (DOI)
Available from: 2011-12-21 Created: 2011-12-21 Last updated: 2017-05-03Bibliographically approved

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