The National Cancer Institute describes end-of-life care as “care given to people who are near the end of life and have stopped treatment to cure or control their disease. End-of-life (EOL) care includes physical, emotional, social, and spiritual support for patients and their families." End-of-life care is a portion of palliative care that is directed toward the care of persons who are nearing end of life (1). Palliative care is fundamental to health and human dignity and is a basic human right. Palliative care staff have specialist expertise in symptom management; and emotional, spiritual, practical, and cultural care. They might be involved in managing more complex care problems (2).
Nurses, physicians, and allied health professionals agree that EOL care should be provided to patients in palliative care units or hospitals where staff has sufficient knowledge of EOL care (2). However, EOL care is provided in a variety of healthcare settings, not just palliative care hospitals, which makes it very important to assess all the barriers to EOL care and to provide safe and quality services to patients. Therefore, providing EOL care in any setting can be challenging (3). Nurses play a key role in EOL care, and their approach to patient EOL care and preparedness is an important factor in ensuring quality patient and family-centered care (4,5). End-of-life and palliative care provide practical help with daily tasks as well. The goal is to improve quality of life for patients, family, friends, and caregivers. End-of-life and palliative care are based on what the patient needs (6).
The attitudes of nurses towards death and nurses' readiness to provide EOL care might influence the care they provide to terminal or dying patients (7). Factors that determine attitudes towards death and dying depend not only on culture, society, values orientation, and religion but also on an individual’s perception and personal attitudes of death and dying (8). Patients' deaths often lead to anxiety and undesirable attitudes among nurses, which can influence the quality of patient care. Communication with palliative and terminally ill patients might be reflected by a nurse's attitude. Therefore, the quality of care is highly dependent on the professional readiness of both nurses and physicians to provide EOL care. Many nurses will not have experiences of meeting or caring for someone who is dying. As death can occur in any setting at any time, it is vital that all registered nurses regardless of the setting in which they work, have EOL care training (9).
Sasahara et al. revealed that 92 percent of the nurses expressed concerns about providing EOL care, and it was particularly difficult for them to help patients express their anger and concern regarding death. And 91 percent of the nurses did not know how to react when a patient start talking about death and dying (10). In general, nurses felt discomfort when talking about EOL issues with patients and their loved ones. Based on the scientific literature, this trend is similar in many cultures (8,12,13). Researchers revealed that nurses did not feel ready to discuss EOL issues with patients because EOL care was emotionally distressing and required a lot of specific knowledge (8). Therefore, communication with patients was hard work, and nurses expressed a desire to do something else instead (14).
Researchers emphasized that positive nurses' attitudes in caring for dying patients could be influenced by nurses’ demographic characteristics, experience, and previous education. Nurses with greater experience in dealing with dying patients felt more confident and had a more positive attitude in providing EOL care (15,16). In addition, nurses' clinical experience and time spent with dying patients increased positive attitudes toward EOL care (17,18). It is important to explore nurses’ attitudes toward caring for dying patients and to develop strategies to alleviate these communication difficulties between nurses and patients to improve care in the terminal phase. Therefore, the importance of EOL nursing care underscores the necessity to investigate nurses' attitudes and their readiness to provide EOL care in multi-profile hospitals.
Research context
In Lithuania, palliative care is provided in an institution, a day centre, or at the patient’s home. Palliative care is the comprehensive care of patients with incurable, progressive diseases. Depending on the needs of the patient and his or her family members, necessary assistance is provided to the patient by a doctor, nurse, social worker, psychologist, and other staff. Palliative care was introduced as a concept in 2006 under the National Cancer Control and Prevention Programme. Legal regulation of EOL issues in Lithuania started in 2007; the procedure for providing palliative care was approved. Regulatory arrangements for palliative care provision under contracts with the National Health Insurance Fund (NHIF) were introduced in 2007. The contract terms included a description of indications for referral, relevant procedures and provision standards (e.g., a team of at least three professionals, including a physician, nurse, and social worker; a list of equipment for health-care facilities; minimum duration of consultations at a patient’s home) (19).
Subsequently, in 2012 a description of the requirements for the provision of supportive treatment and nursing services was approved. Following these descriptions, EOL care was provided. However, writing a last will and testament of the future is still not standard practice, and discussion with the patient and his or her relatives about EOL care priorities remains a forbidden topic. In most cases, health care professionals must take moral responsibility for decisions related to EOL care. Also, the reality is that intersectoral collaboration for health still remains a delicate issue in Lithuania (20,21). Regardless of the general acceptance that other sectors of society are important for the health of the population, no effective mechanisms to implement this intersectoral collaboration have been in place until recently (20,21,22). And cross-sectoral and multidisciplinary collaboration in the provision of not only life care services but also all other health care services is essential to ensure quality and safe services for the patient. The aim of this study was to describe nurses' attitudes in providing EOL care and exploring barriers and facilitating behaviors of nurses in multi-profile hospitals in Eastern Europe.