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Evaluating the Level of Ethical Decision Making of Nurses and Its Relationship with the Attitudes of End-Of-Life Care of Patients with COVID-19
Mohammad Torabi, Mahsa Eslamipanah,
Volume 14, Issue 0 (3-2021)
Abstract
Nurses are among the members of the treatment team who have the most contact with Corona Virus Disease- 2019 (COVID-19) patients and their ethical decision-making is inevitable during patient care. On the other hand, nurses' motivation to implement end-of-life care is influenced by their attitude, awareness, and moral reasoning. The aim of this study was to investigate the level of ethical decision making of nurses and its relationship with the attitudes of end-of-life care of patients with COVID-19 in hospitals affiliated to Hamadan University of Medical Sciences in 2021. In this study, 180 nurses working in hospitals affiliated to Hamadan University of Medical Sciences were selected by convenience sampling method. Data collection tools included: demographic Information questionnaire, Nursing Dilemma Test (NDT) questionnaire, and Frommelt Attitudes towards End-of-Life Care questionnaire. According to the results, there is a direct relationship between nurses' ethical decisions and the attitude of end-of-life care (<0.05, r=0.819). The mean score of nurses' ethical decision-making indicates the low level of ethical decision-making (39.19 (5.3)) and the mean score of nurses' practical considerations (20.62(4.2)) showed that the process of nurses' ethical decision-making is relatively influenced by environmental factors. Also, the average score of nurses' exposure to moral challenges indicates that nurses are familiar with similar situations. The mean score of nurses' attitudes toward end-of-life care was reported at an undesirable level (81.58(7.8)). According to the results, by identifying the factors affecting nurses' ethical decision-making and educational planning to improve their decision-making level, it is possible to improve the quality of patients care while improving nurses' attitudes toward end-of-life care.

Nurses’ Attitudes About Euthanasia: A Systematic Review
Shabnam Rasoulpoor, Reza Nematollahi Maleki, Neda Tagizadeh,
Volume 17, Issue 0 (12-2024)
Abstract
Euthanasia, defined as the intentional ending of a patient's life to relieve intractable suffering, presents complex ethical, legal, and emotional challenges for healthcare professionals, particularly nurses. Nurses play a pivotal role in end-of-life care, making their attitudes toward euthanasia crucial for understanding its implications in clinical practice. This review aims to synthesize existing literature on nurses' attitudes about euthanasia to identify key influencing factors and areas requiring further exploration. This study was conducted using the PRISMA 2020 guideline with no time limitation (by December 2024). Eligible articles were selected following a search in various databases (Scopus, Web of Science, PubMed, ScienceDirect, Embase, and Google Scholar) using keywords and operators of “AND” & “OR.” The search strategy included “Perceptions” OR “Attitudes” OR “Nurse” AND “Euthanasia.” Data extraction and risk-of-bias assessment were performed independently by two reviewers (SR and NT). Studies were evaluated with the Appraisal Tool for Cross-Sectional Studies (AXIS Tool). A total of 21 studies were included in the review. The review revealed that nurses’ attitudes toward euthanasia vary widely depending on legal frameworks, cultural norms, religious beliefs, and personal values. In countries where euthanasia is legalized, such as Belgium and the Netherlands, nurses often report greater acceptance and willingness to participate in the process, emphasizing their role in ensuring patient autonomy and dignity. Conversely, in regions where euthanasia is illegal, nurses frequently express ethical concerns, moral distress, and reluctance to support the practice. Common themes include the need for clear guidelines, ethical training, and emotional support systems for nurses dealing with euthanasia-related situations. Nurses’ attitudes about euthanasia are influenced by a complex interplay of cultural, legal, and personal factors. While some nurses view euthanasia as an extension of compassionate care, others experience ethical dilemmas and professional conflict. This highlights the need for robust ethical frameworks, specialized training, and supportive resources to help nurses navigate the challenges associated with euthanasia in their practice.

Exploring Advance Directives and End-of-Life Preferences in Heart Failure Patients: A Systematic Review and Meta-Analysis
Aydin Feyzi, Amirali Soheili, Samira Chaibakhsh, Fidan Shabani, Shiva Khaleghparast,
Volume 17, Issue 0 (12-2024)
Abstract
Advance directives (ADs) are legal instruments that enable individuals to express their healthcare preferences in anticipation of a future loss of decision-making capacity. These directives are particularly important in the context of chronic conditions such as heart failure (HF), a disease marked by progressive functional decline and unpredictable medical crises. ADs help safeguard patient autonomy by ensuring that care aligns with personal values and preferences, especially at the end of life. This systematic review and meta-analysis was conducted in accordance with PRISMA guidelines to examine the preferences of patients with heart failure regarding life-sustaining treatments and end-of-life decision-making. A comprehensive literature search was performed across PubMed, Scopus, and Web of Science databases, covering publications up to March 2024. Search terms included "advance directive," "advance care planning," "heart failure," and "end-of-life decision-making." Studies were included if they were original, peer-reviewed, full-text articles focusing on HF patients aged 18 and older. Non-peer-reviewed works and inaccessible full texts were excluded. A total of 25 eligible studies were identified and appraised using the NIH quality assessment tool. Extracted data included demographic characteristics, preferences for treatment, surrogate decision-making, and educational interventions. Findings from the reviewed literature reveal consistently low levels of awareness and completion of ADs among HF patients. Completion rates varied significantly across studies, reflecting potential cultural and systemic influences. Preferences for surrogate decision-makers overwhelmingly favored family members over healthcare professionals. A notable finding from Jawahri et al. (2016) indicated that patients who received video-based education were significantly less inclined to choose cardiopulmonary resuscitation (CPR) or mechanical ventilation compared to those receiving only verbal information. Additional qualitative insights, such as those from Formiga et al. (2004), showed that patients prioritized maintaining dignity, independence, and meaningful relationships over merely extending life. These patterns highlight the necessity of aligning care with patients’ broader goals and values. Across the 25 studies included, a total of 4,091 heart failure patients were analyzed, with a mean age of 68.22 years. Meta-analytic findings demonstrated diverse preferences regarding life-sustaining interventions: approximately 53.73% of patients favored such treatments, while 45.37% declined CPR. These statistics underscore a substantial variability in end-of-life preferences, further reinforcing the need for individualized care planning. In conclusion, patients with heart failure display heterogeneous preferences concerning end-of-life care, shaped by cultural context, personal values, and the type of information provided. Despite the established importance of ADs, significant deficits in awareness, understanding, and documentation persist. These findings point to a critical need for tailored educational interventions, improved provider-patient communication, and culturally sensitive approaches to advance care planning. Future research should focus on designing and integrating standardized AD facilitation tools into routine clinical practice to support truly patient-centered care.

Avoidable Suffering at the End of Life
Mamak Tahmasebi,
Volume 17, Issue 0 (12-2024)
Abstract
Avoidable suffering at the end of life refers to the unnecessary pain and distress experienced by individuals with terminal illnesses—pain that can often be alleviated through effective palliative care practices. Addressing this issue is critical for improving the quality of life for both patients and their families during this challenging period. The recognition of holistic care, which considers physical, emotional, spiritual, and social needs, has fueled efforts to enhance end-of-life care to reduce suffering and uphold patients' autonomy. Numerous studies indicate that many terminally ill patients endure avoidable physical and emotional pain as they approach death, highlighting gaps in healthcare delivery. For instance, research from the National Center for Health Statistics reveals that a significant number of hospice patients report unmanaged pain despite the availability of effective interventions. Psychological distress, including anxiety and depression, is also prevalent among terminally ill patients, underscoring the need for comprehensive care that integrates mental health support. Furthermore, neglecting spiritual and social needs can leave patients feeling isolated and despairing, exacerbating their suffering. Ethical considerations in pain management at the end of life remain a subject of debate, particularly concerning the principles of beneficence and non-maleficence. The principle of double effect, which permits actions to relieve suffering even if they may unintentionally hasten death, continues to spark controversy among healthcare providers, patients, and families. Additionally, ethical dilemmas arise in advanced care planning, particularly in respecting patient autonomy while navigating complex end-of-life decisions. Addressing avoidable suffering at the end of life requires a multidisciplinary approach that honors patients' values and preferences while striving to minimize unnecessary distress. As research and clinical practices advance, healthcare systems must prioritize strategies to reduce avoidable suffering and ensure patients' dignity during their final days.
 

An Islamic Bioethics Framework for Decision-Making on the Life Support of Periviable Newborns
Forouzan Akrami,
Volume 17, Issue 0 (12-2024)
Abstract
For many years, the question of whether or not to resuscitate periviable newborns has been a topic of debate among perinatologists, neonatologists, and ethicists. Unlike other studies that focus on the value and sanctity of human life during intrauterine development, the present study seeks to address the ethical question of what constitutes the right decision regarding life-support measures for newborns born at peri-viability ages, within the ethical norms of the Islamic tradition. This study assumes the inherent value of every moment of human life and acknowledges the human dignity of individuals from the time of conception. This multi-method study was conducted in three parts: (1) a review of the ethical frameworks presented for supporting the lives of periviable newborns, (2) an explanation of the principles of Islamic bioethics based on common Sunni and Shiite sources, and (3) the development of an Islamic bioethics framework. According to the ethical principles of the Islamic tradition—contrary to secular biomedical ethics—first and foremost, efforts should be made to preserve and prolong the life of periviable newborns regardless of their anticipated quality of life. Second, in decisions involving life and death, the priority is not the preferences of the infant's parents but rather the saving of the infant's life and its preservation by the physician and medical team. Nonetheless, parental participation in the decision-making process is essential. Preserving life, however, is not an absolute obligation; the aim of life-support measures is not merely to extend the infant's life for a short period but to do so in proportion to the prognosis and expected benefits. Specifically, these measures should be considered when there is a significant probability of the newborn’s survival. This requires a case-by-case assessment of risks, taking into account the newborn’s clinical condition, as well as regional resources and conditions. It is recommended to use the proposed Islamic bioethical framework to develop a clinical guideline that includes criteria for classifying infants born at the edge of viability based on their clinical condition. Ethical decisions to intervene should then be based on the infant's clinical state, probability of survival, and the resources available in the region.

Investigating the Ethical Challenges of Nurses in End-of-Life Care at Home for Elderly Patients: A Review Study
Nayereh Baghcheghi, Zahra Maddah,
Volume 17, Issue 0 (12-2024)
Abstract
With the increasing elderly population and the growing demand for home healthcare and end-of-life care services, nurses are facing expanded duties and responsibilities. This intensification of responsibilities can expose them to significant ethical challenges. This study aimed to investigate the ethical issues nurses encounter in providing end-of-life care at home for elderly patients. This review study involved a comprehensive search of databases including PubMed (Medline), Google Scholar, ISI Scopus, ProQuest, Science Direct, SID, IranDoc, IranMedex, and Magiran. The keywords used were: nursing ethics, ethical challenges, end-of-life care, and home care, along with their Persian equivalents. The search covered literature published between 2000 and 2024. The review identified several prominent ethical challenges faced by nurses in home-based end-of-life care, including: lack of attention to patients’ rights and independence, disrespect for the dignity of elderly patients, inadequate empathetic care, poor communication, and unsafe home environments for nurses. These challenges may lead to moral distress, as well as psychological and emotional consequences for both the care providers and the elderly patients. Given the serious ethical challenges nurses face in end-of-life home care for the elderly, it is essential for them to be well-versed in ethical principles relevant to this context. Enhancing awareness and competence in ethical practices can help nurses uphold patient rights, promote autonomy, and provide high-quality, compassionate care through effective communication and support.

A Critique of the Jurisprudential-Ethical Foundations of Applying the Term “Death” to the Vegetative State
Sayyed Mohammad Taghi Hosseini Vardaniani, Dr Ahmad Salami, Sayyed Morteza Hosseini, Jannat Mashayekhi,
Volume 18, Issue 1 (3-2025)
Abstract
The vegetative state is a condition in contemporary medicine that raises numerous ethical, jurisprudential, and legal challenges. The most fundamental question when confronting this condition concerns whether individuals in such a state are considered alive or deceased, as subsequent rulings and implications are typically contingent upon the answer to this question. Some contemporary Islamic jurists, drawing upon the jurisprudential division of life into “stable life” and “unstable life”, have deemed individuals in a vegetative state to be deceased, given their lack of volition and consciousness. This study argues that the concept of “unstable life” does not apply to these individuals, particularly in cases of persistent and chronic vegetative states where the possibility of regaining consciousness, however remote, exists. Furthermore, the continued function of the brainstem and the non-fulfillment of the medical and legal criteria for brain death in many systems affirm that the designation of “deceased” is incorrect. From an Islamic perspective, the definitive separation of the soul from the body, which is the condition for the occurrence of death, cannot be ascertained in the vegetative state. Ultimately, in circumstances of doubt regarding the life or death of a person in a vegetative state, this uncertainty constitutes a “case-specific doubt”, and by applying the legal principle of “presumption of continued life”, the individual must be deemed alive and all the corresponding legal and religious consequences of life must be accorded to them.

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