Iranian Journal of Medical Ethics and History of Medicine

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By the late 1960s, there seems to be a growing number of articles in medical journals on the subject of the distress that many terminally ill patients declared they had gone through due to repeated resuscitations that only prolonged their suffering. This demonstrates that standard protocols of resuscitating any patient who is undergoing a cardiopulmonary arrest may bring about new problems. A review of studies shows that dealing with patients who are in the last days or hours of their life has been a major challenge for healthcare professionals, and making decisions on therapeutic approach is one of the most fundamental skills for healthcare staff. The scientific, ethical, religious and legal dilemmas in this field make decision-making difficult in some cases. In this paper, we reviewed articles published during the past 30 years, through which the views of health care providers including physicians and nurses on the issue of do not resuscitate (DNR) orders in different societies had been studied. The Islamic perspectives have also been discussed in brief. Moreover, DNR guidelines prepared by various countries such as America, Britain and Saudi Arabia have been assessed. For searching the related studies, we used authentic electronic databases and many reliable websites. Some articles were obtained through hand searching of the references of searched articles.The results showed that despite substantial studies, caring teams are still facing the challenge of DNR in different societies. In Iran, considering the religious values and beliefs, the matter needs more deliberation to help the caring teams to deal with the clinical issues. The religious and cultural background call for a national guideline to be adopted based on Iranian-Islamic culture. Education and awareness rising of different groups including patients, general public, healthcare staff, and health policy makers is crucial in all countries all over the world, and particularly in Iran.

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Moral distress is considered as an important issue in nursing. Nurses participation in ethical decision making and taking deliberate action are facing them with many ethical challenges in their work environment. Confronting those challenges can lead to moral distress. This descriptive study was conducted to determine moral distress and its contributing factors from the perspective of oncology nurses in Tehran teaching hospitals in 2011. Data collection was done through a demographic questionnaire, the Moral Distress Scale – revised (MDS-R) and a questionnaire on moral distress related factors administered to all oncology nurses with inclusion criteria. Findings showed that nurses reported a high level of moral distress overall. The highest level of moral distress was associated with giving inadequate information to patients about informed consent and carrying out a physicians’ order for unnecessary tests and treatments. A significant correlation was found between oncology nurses’ age, their work experience and employment status with moral distress. Institutional factors such as managers’ support, nurses’ autonomy and having determined duties had the greatest effect on moral distress from oncology nurses’ view. Oncology nurses commonly encounter situations that are associated with high levels of moral distress, and therefore strategies need to be developed in order to mitigate moral distress.

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When medical treatment is futile, the physicians must refrain from treating patients, and this can lead to serious and stressful problems. In this paper, in order to facilitate ethical decision making relevant literatures have been reviewed. This review article aimed to explaining the different clinical forms of futile treatment, and exploring theoretical and practical dimensions of futility. The first problem in this field is ambiguity in the definition of futility. The next problem is determining the practical criteria and attributing the meaning of futility to particular treatments. This ambiguity is partly due to different perspectives about the goal of treatment, and variations in physicians' and patients’ values and also disagreements regarding the person who should have the right to make decisions ultimately. It may also be related to finances and immoral motives. The third problem is some practical conflicts the most notable are futile care, requested by the patient and the sanctity of life, especially in the concern of religious considerations. In this regard, several definitions have been proposed for the futile treatment. Studies indicate that requesting futile care is often due to emotional problems or lack of trust a case that requires the physician’s tact to resolve and rarely is resolved by rule. Another serious problem that is regarding to end of life cares, especially in the context of religious views, is the necessity of life saving, that is closely related to the inactive euthanasia. This can be solved by giving priority to more important issues such as health budget constraints.

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Medical futility refers to diagnostic, treatment, and rehabilitation interventions that are unlikely to produce any positive outcome for patients. Doctors should beware of such actions due to their professional commitments. There are ambiguities in the definition of futility that have been the subject of many studies. In this paper, relevant literature was reviewed to find a definition for futility from the perspective of the four bioethical principles.Determining the futility of an action, whether it is the request of the patient, their family or service providers, is a highly sensitive matter that can lead to unethical decisions in the medical profession.Autonomy is a concept that is related to the diverse views on treatment objectives. In this paper we investigated the issues of physician and patient autonomy, and the differences between the values of the people involved. We have also discussed the concept of palliative care with an attempt to clarify the difference between this type of care and futile care, and to determine the boundaries. Another focus of our study was situations where physicians and other health care providers deliver futile treatment for various purposes. Such cases involve factors that may influence the judgment of physicians, and some of them are unethical due to incentives such as financial gain.Finally, ethical decision-making in this area is only possible through clarification of the different aspects of the issue and prioritization by experts and professionals. In order to do so, all circumstances need to be taken into account, including allocation of scarce resources within the health care system and fairness. Moreover, medical staff should have access to the necessary information so that they can make ethical decisions in different situations.

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Futile medical care is considered as the care or treatment that does not benefit the patient. Thus, perception of the clinical team regarding futile care is of great importance and it has an important role in the quality of nursing care and health of clinical team. This study aimed to determine the relationship between perception of nurses regarding futile medical care and their caring behaviors toward patients in the final stages of life admitted to intensive care units. This correlational, analytical study was performed on 181 nursing staff of the intensive care units (ICUs) of health centers affiliated to Mazandaran University of Medical Sciences, Mazandaran, Iran. The data collection tool included a two-part questionnaire containing demographic characteristics form, perception of futile care questionnaire, and caring behaviors inventory. To analyze the data, statistical tests and central indices of tendency and dispersion were used. Pearson’s correlation coefficient, partial correlation, t-test, and ANOVA tests were performed to assess the relationship between the variables. Findings illustrated that the majority of nurses (65.7%) had a moderate perception of futile care. In addition, it was only the mean working hours per week among the demographic variables that had a statistically significant relationship with perception of futile care (P<0.05). Given the moderate perception of nurses concerning futile care, implementing suitable interventions for minimizing the frequency of futile care and its resulting tension seems to be mandatory. It is imperative to train nurses on adjustment mechanisms and raise their awareness as to situations resulting in futile care.