Impact Of Written Ethics Policy On Euthanasia From The Perspective Of Physicians And Nurses A Multiple Case Study In Hospitals

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Impact of Written Ethics Policy on Euthanasia From the Perspective of
Physicians and Nurses: A Multiple Case Study in Hospitals
Joke Lemiengrea
; Chris Gastmansa
; Paul Schotsmansa
; Bernadette Dierckx de Casterléb
a
Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, b
Centre for Health Services
and Nursing Research, Katholieke Universiteit Leuven,
Online publication date: 28 June 2010
To cite this Article Lemiengre, Joke , Gastmans, Chris , Schotsmans, Paul and Dierckx de Casterlé, Bernadette(2010)
'Impact of Written Ethics Policy on Euthanasia From the Perspective of Physicians and Nurses: A Multiple Case Study in
Hospitals', AJOB Primary Research, 1: 2, 49 — 60
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2. AJOB Primary Research, 1(2): 49–60, 2010
Copyright c
Taylor Francis Group, LLC
ISSN: 2150-7716 print / 2150-7724 online
DOI: 10.1080/21507716.2010.489347
Impact of Written Ethics Policy on
Euthanasia From the Perspective of
Physicians and Nurses: A Multiple Case
Study in Hospitals
Joke Lemiengre, Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven
Chris Gastmans, Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven
Paul Schotsmans, Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven
Bernadette Dierckx de Casterlé, Centre for Health Services and Nursing Research,
Katholieke Universiteit Leuven
Euthanasia decision making is a complex process for physicians and nurses that involves clinical, legal, ethical, and personal–emotional aspects. In this respect, attention
has been given to hospitals’ written ethics policies on euthanasia. The aim of our study was to explore the impact of a written ethics policy on euthanasia, as experienced
by physicians and nurses involved in euthanasia care processes. A qualitative multiple case study in three selected general hospitals was conducted. Grounded theory
methodology was used to guide data collection and analysis. The purposive sample resulted in 23 in-depth interviews with physicians (n = 11) and nurses (n = 12).
The euthanasia policy gave the care providers a sense of being supported throughout the euthanasia care process. While care providers mainly feel the influence of a
euthanasia policy on practical and professional levels of providing care, the influence of a policy on the providers’ ethical reflection and practice is less clear. The study
raises questions about the meaning of a written ethics policy for the ethical practice of physicians and nurses, when they have to deal with ethically sensitive issues such
as euthanasia.
Keywords: care practice, ethics policy, euthanasia, hospitals, impact, qualitative study
Medical end-of-life decisions are discussed in many coun-
tries. The countries’ cultural values, which are reflected in
their laws, clearly influence how care providers deal with
medical end-of-life decisions in clinical practice. Only the
Netherlands (de Haan 2002), Belgium (Belgian Ministry of
Justice 2002), and Luxembourg (Luxembourg Euthanasia
Law 2009) permit physician-performed euthanasia under
strict due care conditions. Of all deaths in the Netherlands
and Belgium, 1.7% (van der Heide et al. 2007) and 1.2%
(van der Heide et al. 2003), respectively, resulted from eu-
thanasia. Even in countries where euthanasia is legal, the
law provides no guaranteed solution for all issues that care
providers confront in their practice.
For care providers, euthanasia decision making is a
complex process that involves clinical, legal, ethical, and
personal–emotional aspects. First, the concrete application
of legal procedures in actual clinical practice is not evident.
A Dutch study showed that more than one out of four physi-
cians who had performed euthanasia encountered problems
Acknowledgment: The authors gratefully thank the hospitals and interviewees for participating in this study. This study was made
possible by a grant from the Fonds voor Wetenschappelijk Onderzoek Vlaanderen.
Address correspondence to Joke Lemiengre, PhD, RN, Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Kapucij-
nenvoer 35, Box 7001 3000, Leuven, Belgium. E-mail: Joke.Lemiengre@med.Kuleven.de
in decision making related to at least one of the legal due
care criteria, especially those related to the interpretation
of a patient’s request or the interpretation of a patient’s
suffering (Buiting et al. 2008). Second, being involved in eu-
thanasia care processes is an intense experience for care
providers, one that is associated with a mix of positive
and negative feelings (van Marwijk, Haverkate, van Royen,
and The 2007; Georges, The, Onwuteaka-Philipsen, and
van der Wal 2008; Denier, Dierckx de Casterlé, De Bal,
and Gastmans 2010). Third, decision making transcends
the purely clinical discourse and has an ethical dimension,
because it involves questions of human dignity, meaning-
fulness, and quality of life (Gastmans 2005). Although a
euthanasia decision can be legally acceptable, this does not
necessarily mean that the decision is ethically acceptable.
This may complicate the decision-making process for care
providers.
The complexity of euthanasia decision making goes
beyond the individual relationship between patients and
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3. AJOB Primary Research
care providers. It affects the broader responsibility of health
care institutions (Winkler 2005; Lemiengre et al. 2007a; Pas-
man et al. 2009). This responsibility is twofold: on the one
hand, guaranteeing qualitative care for patients requesting
euthanasia, and on the other hand, supporting care
providers so that they can provide qualitative care. In this
respect, great attention has been given to hospitals’ writ-
ten ethics policies on euthanasia. Surveys showed that 80%
of Dutch hospitals and 63% of Flemish hospitals (Flanders
is the Dutch-speaking region of Belgium) have a written
euthanasia policy (Lemiengre et al. 2007b; Pasman et al.
2009). Our content analysis of policy documents showed
that hospitals with a euthanasia policy endeavored to deal
with euthanasia requests according to a broader clinical and
ethical framework, first by clarifying the hospital’s stance
on euthanasia, and second by providing a detailed step-by-
step plan to guide the euthanasia care process. The crux
of the analysis was that the policies of hospitals (and of
Catholic hospitals in particular) approached euthanasia de-
cision making more cautiously than legally required by
stressing the importance of palliative care and interdisci-
plinary cooperation (Lemiengre et al. 2008).
However, the mere presence of euthanasia policies does
not guarantee that care providers adhere to them, that
the policies support care providers through the euthanasia
care process, or that the policies improve the quality of
care for patients requesting euthanasia. Empirical studies
on the implementation of ethics policies on end-of-life care
are scarce; until now, the impact of institutional ethics poli-
cies on euthanasia has yet to be investigated (Lemiengre et
al. 2007a). Therefore, the aim of our study was to explore the
impact of a general hospital’s written ethics policy on eu-
thanasia, as experienced by physicians and nurses involved
in euthanasia care processes.
METHOD
Design
A qualitative multiple case study was conducted to inves-
tigate the impact of a euthanasia policy within a real-life
context—a general hospital—through the experiences of
physicians and nurses (Yin 2003). We used the grounded
theory methodology to guide data collection and analysis
by using the constant comparison technique (Corbin and
Strauss 2008). To ensure that our overall findings repre-
sent refined concepts, findings that reflect the general real-
ity rather than those stemming from a single case design,
we adopted the strategy of Yin (2003) for data collection
and analysis. In this strategy, findings obtained through the
analysis of the first data collected (i.e., first hospital inter-
views) are used to further refine subsequent data collection
and analyses.
Definitions
According to Article 2 of the Belgian Euthanasia Act, eu-
thanasia is the intentional termination of life by someone
81 Flemish hospitals
71 participating hospitals survey (Lemiengre et al. 2007b)
42 hospitals with a euthanasia policy (Lemiengre et al. 2008)
5 hospitals that met selection criteria
• Hospital with ethical infrastructure
• Development: euthanasia policy was developed in an interdisciplinary context,
was approved by board of directors, and was implemented for more than 2
years
• Format and content: contained clear and unequivocal content based on legal
procedures, scientific literature, and expertise of care providers, and included a
practical euthanasia procedure
• Communication and accessibility: was communicated to physicians and nurses
and was easily accessible
3 included hospitals
4 interviews with key persons
23 interviews with physicians (n = 11) and nurses (n = 12)
Figure 1. Procedure for data collection.
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4. Impact of Written Ethics Policy on Euthanasia
other than the person concerned, at the latter’s request.
“Someone other” is understood to be a physician, and “ter-
minating life” is interpreted to be the administration of a
lethal dose of medication (Belgian Ministry of Justice 2002).
A written institutional ethics policy is defined as written agree-
ments (statements, procedures, guidelines, protocols, etc.)
authorized at an institutional level to guide caregivers as
they approach a clinical–ethical problem that includes a
decision-making process and/or phased plan (Haverkate
1999).
Setting
Participants were from three selected hospitals. Hospitals
should provide the most rich and complete information con-
cerning the impact of euthanasia policies. To select hospitals
having a euthanasia policy implemented in most optimal
circumstances, we based our selection criteria on literature
related to effectiveness of ethical guidelines and codes (Fry
and Johnstone 2002; Biton and Tabak 2003; Verpeet, Dierckx
de Casterlé, Lemiengre, and Gastmans 2006). These criteria
dealt with the (1) availability of an ethical infrastructure, (2)
development of a policy, (3) format and content of the pol-
icy, and (4) communication and accessibility of the policy
(Figure 1).
In 2005, a database was set up that contained data about
the prevalence, development, content, and communication
of written ethics policies on euthanasia in Flemish hospi-
tals. Data were collected during a survey study in which
88% (71/81) of Flemish hospitals participated (Lemiengre
et al. 2007b), and during a content analysis of euthanasia
policy documents of these hospitals (Lemiengre et al. 2008).
We searched the database for hospitals that met the already
mentioned criteria. Of the 42 hospitals that had submitted
their written ethics policy on euthanasia (Lemiengre et al.
2008), only 5 hospitals met these criteria (four general hos-
pitals with a Roman-Catholic affiliation and one hospital
without a religious affiliation). Of these hospitals, we chose
one hospital (hospital A) for the first phase of our study. For
the second phase, we selected hospital B, and for the third
phase, we selected hospital C (Figure 1).
The included hospitals were located in three different
provinces of Flanders. Each hospital had an active ethics
committee that also was involved in the development of
ethics policies on end-of-life decisions other than euthana-
sia and that provided ad hoc ethical advice to physicians
and nurses. Furthermore, the euthanasia policy of the three
hospitals was available on the hospitals’ intranet. Hospi-
tals A and C had a Roman-Catholic affiliation and were
members of Caritas Flanders, the umbrella organization
of all Roman-Catholic hospitals in Flanders. Both hospi-
tals implement criteria that are stricter than the due care
criteria of the euthanasia law. They allow euthanasia for
terminally ill patients only when legal due care criteria are
met, and they follow additional criteria (the palliative filter
and the consideration of the request by an interdisciplinary
team). In addition, except for extenuating circumstances, eu-
thanasia is not permitted for non-terminally ill patients and
incompetent terminally ill patients. Hospital B was a public
hospital and was not Catholic affiliated. Hospital B’s eu-
thanasia policy paid special attention to the responsibilities
of physicians and nurses. Euthanasia is allowed in the hospi-
tal according to the legal due care criteria, but the palliative
filter and interdisciplinary consideration of the request are
recommended.
Data Collection Method
The core of the study comprised in-depth interviews of
physicians and nurses concerning their experiences with
their hospital’s euthanasia policy. We conducted the inter-
views over a period of one year (May 2008–April 2009).
The interviews were planned successively. All interviews
were tape-recorded with the participant’s permission. The
interview guide was constructed based on earlier findings
(Lemiengre et al. 2007a; 2007b; 2008), and on a systematic
review of supervisors. The interview guide was adapted
during the study. The interviews were all conducted and
transcribed by the same researcher (JL).
Additionally, for each hospital we conducted a
semistructured interview with one or two key persons who
were selected by the hospital’s ethics committee. The key
persons helped us to find physicians and nurses that met
our inclusion criteria. The key-person interviews also gave
us crucial information about the organizational and cultural
characteristics of the hospitals, enabling us to understand
the context of the hospital. Furthermore, to frame the inter-
views in the broader context of each hospital, we performed
document analysis (euthanasia policy documents, mission
statement).
Sample
A purposive sample of physicians and nurses was con-
structed, thus ensuring a wide range of perspectives on the
impact of euthanasia policies. We selected physicians and
nurses on the basis of two main criteria: (1) They were in-
volved in at least one euthanasia care process, and (2) they
used the euthanasia policy of the hospital.
Key persons were part of the hospital’s ethics commit-
tee, were familiar with the hospital culture, and were in-
volved in the development and/or implementation of the
policies.
Analysis
Data were analyzed according to the grounded theory ap-
proach of Corbin and Strauss (2008). Data collection and
analyses were performed systematically and simultane-
ously. Moreover, data collection and analyses were cyclical
in that constant comparisons were made according to earlier
results. Through systematic reading, examination, and reex-
amination of the interview transcripts, we identified themes
and patterns in the stories of the physicians. We then com-
pared and checked the themes for similarities, differences,
and connections. Only themes that were present in the data
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y
Practical manual
Guideline for
professional practice
Support for
ethical practice
Safety
Certainty
‘right’ care
SUPPORT for care providers during
euthanasia care process
Impact on CARE PROVIDER as PERSON
Peace of mind
‘good’ care
Impact on PRACTICE
Increasing willingness to
take on responsibility in
euthanasia care process
Increasing openness to
euthanasia request
Facilitating practical aspects
in euthanasia care process
Figure 2. Conceptual framework of the impact of euthansia policies as experienced by physicians and nurses during
the euthanasia care process.
of the three hospitals were deemed main themes in the con-
ceptual framework that we developed to gain insight into
the possible impact of a euthanasia policy as experienced
by physicians and nurses (Figure 2).
All analyses were carried out by using the software
program QSR NVivo 8 (QSR International, Southport,
UK).
Trustworthiness
We used seven techniques to bolster the trustworthiness
of our study. Triangulation underlies the methodologi-
cal strength of our case study. It was achieved in three
ways: (1) researcher triangulation; (2) triangulation of data
source (physicians, nurses, key persons); and (3) triangu-
lation of method (interviews and document analysis). For
researcher triangulation, in addition to the main researcher
(JL), two other researchers each coded two interviews in or-
der to compare possible differences in interpretation. Four
other techniques were used to increase the trustworthi-
ness of our findings: (1) self-reflection (personal and pro-
fessional position of the researcher, prior knowledge of
literature and earlier studies, possible expectations about
the study are described to cope with possible subjectiv-
ity and prejudices); (2) audit trail (all decisions, difficul-
ties, and changes of plans that occurred during the study
were accurately reported); (3) peer review; and (4) peer de-
briefing (experts familiar with qualitative research or with
the research topic were asked to read raw data together
with the preliminary interpretations). The peer debrief-
ings served as an extra check of the interpretations of the
findings.
Ethical Considerations
The ethics committee of the Faculty of Medicine of the
Katholieke Universiteit Leuven approved the study proto-
col. For each hospital, we obtained the approval of both the
hospital’s ethics committee and management. All potential
participants received written information about the study.
In addition, we obtained written and verbal informed con-
sent from each participant. Anonymity of the hospitals and
participants was guaranteed.
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6. Impact of Written Ethics Policy on Euthanasia
Table 1. Description of sample of physicians and nurses (n = 23)
Profession n Religious or philosophical orientation n
Nurse 12 Roman-Catholic 15
Educational degree: Bachelor’s 9 Addressed as very important 6
Educational degree: Master’s 3 Addressed as important 5
Physician 11 Addressed as not important 4
Humanist 6
Sex Addressed as very important 4
Male 13 Addressed as important 2
Female 10 Not religious 2
Age Involvement in hospital’s ethics policy
20–29 years 1 Not involved 13
30–39 years 5 Member ethics committee 7
40–49 years 6 Involved in development or implementation
of ethics policy on euthanasia
10
50–59 years 11
Position and specialty Experience with euthanasia (not necessary
Ward physician 8 limited to performance of euthanasia)
Geriatrics 2 Once 2
Gastroenterology 2 2 to 4 times 11
Oncology 1 5 to 10 times 7
Anesthesiology 1 More than 10 times 3
Neurology 1
Surgery 1 Physicians that actually performed 6
Physician palliative support team 3 euthanasia at least once
Senior nurse 5 Nurses that actually attended a performance 6
Palliative care 2 of euthanasia at least once
Oncology 2
Pneumology 1 Stance on euthanasia
Rather positive 11
Rather restrictive 9
Neutral 3
Nurse palliative support team 4
Bedside nurse (palliative care ward) 2
Nurse social service 1
RESULTS
Sample
The sample resulted in 23 interviews with physicians (n =
11) and nurses (n = 12), spread over three hospitals (hospital
A, n = 11; hospital B, n = 7; hospital C, n = 5). The majority
of nurses were palliative care specialists, while most of the
physicians were internal medicine specialists. Variations in
religious convictions, involvement in hospital’s ethics pol-
icy, experience with euthanasia, and stance on euthanasia
were present in the sample (Table 1).
All key persons were members of the hospital’s ethics
committee, and of those selected, two were chairpersons,
one was an ethicist, and one was a lawyer.
The one-on-one interviews lasted an average of 40 min-
utes (variation: 20 minutes to 1.45 h).
Impact of Euthanasia Policy as a Gradual Process
Euthanasia policies do have an impact on physicians and
nurses, namely, the policies gives them a sense of being sup-
ported throughout the euthanasia care process. This support
is experienced in two ways: (1) an impact on their actual care
practice, affecting their actions and reasoning, and (2) an im-
pact on themselves as persons, affecting their feelings and
experiences. We illustrate how euthanasia policies have an
impact on care providers in terms of pyramids, which show
that the impact has no univocal storyline (Figure 2). The
way in which care providers experience an impact on their
actual care practice and on themselves as persons varies
and occurs at three levels (Figure 2). These levels reflect a
gradual evolution in line with a growing process that care
providers may experience.
During the euthanasia care process, the majority of in-
terviewees experienced the impact of the euthanasia policy
mainly on a practical level (level 1 or base of the pyramid;
Figure 2). To a lesser extent, interviewees also experienced
an impact on a professional level (level 2 of the pyramid). A
minority of interviewees experienced an impact not only on
a practical professional level but also on a personal–ethical
level (level 3 or top of the pyramid). One should keep in
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7. AJOB Primary Research
mind that although we will describe the levels separately, in
reality they are interwoven and may partially overlap. Fur-
thermore, the euthanasia policy gave all the care providers
a sense of being supported throughout the euthanasia care
process, both in their care practice and personally.
Lastly, these results strongly suggest that the gradual
evolution characterizing the way care providers experience
an impact of a policy is related to contextual factors, of which
the hospital presence of a “guiding person” in euthanasia
care seems to be a determining factor. A guiding person
is a person who mediates the euthanasia policy. He or she
has mastered the policy and law, and guides care providers
through the euthanasia care process.
Impact of Euthanasia Policy on Care Providers’ Care
Practice
Interviewees experienced an impact of a euthanasia pol-
icy on their actual care practice: The policy “gives them
something to hold on to.” As we described earlier, the ex-
tent to which care providers view the euthanasia policy
as a concrete support for their care practice shows grad-
ual variations. Interviewees unanimously reported that the
policy supported the practical and organizational aspects
of their practice, as does a practical manual. Many of them
also viewed the policy as a guideline that supported their
care practice on a professional level, and some of them also
viewed it as a support for their ethical practice (Figure 2).
Euthanasia Policy as a Practical Manual
Almost all interviewed care providers considered a eu-
thanasia policy as a practical manual that guides them
systematically through the complex euthanasia care pro-
cess. This manual gives them an overview and describes
the concrete structure of the organization and course of the
euthanasia care process. However, we observed variations
between physicians’ and nurses’ experiences. Physicians
in particular stressed that euthanasia policies create trans-
parency regarding a hospital’s position on euthanasia, more
specifically, under which conditions euthanasia is allowed
or disallowed within the hospital walls. This transparency
helps them to communicate in a clear, honest, and concrete
way when a patient requests euthanasia. In this respect,
physicians referred to a euthanasia policy that includes a
clearly formulated stance on euthanasia.
Nurses in particular expressed that euthanasia policies
are practical manuals that support them to plan and orga-
nize the practical aspects of the euthanasia care process. The
euthanasia policy provides insight into the different tasks
that should be performed by supplying care providers with
a concrete instrument that shows them how to handle the
euthanasia care process. The euthanasia policy allows them
to check whether steps of the process have been forgotten.
Also, for instance, when preparing the medication, what do we
need? What should be in the room for the drip? What kind of
material do we need? Where do we prepare the medication? To
make sure that all medication is ready on time, that everything
is there, so that it [the policy] is really concrete. Just like from
formerly, for nursing techniques, now you have to do this, and
then you have to do that, hum . . .. When it [the instructions
dealing with the euthanasia care process] is prescribed in detail
. . . just like when you buy a machine, which has instructions
for use, and you follow them all from now [on]: You have to
do this, and then you have to do that. (nurse 2)
Additionally, care providers expressed that euthanasia
policies clarify their specific responsibilities (e.g., who is re-
sponsible for picking up the medication, who should we
contact in case of conscientious objections, who will care for
the family after the patient dies, etc.). Consequently, the eu-
thanasia policy supports the streamlined and smooth course
of the euthanasia care process by facilitating its practical as-
pects.
Physicians and nurses who play an important role
in guiding and coordinating the euthanasia care process
(mainly members of the palliative support team) described
the policy as a useful instrument for teaching and support-
ing care providers with no or little experience and expertise
in euthanasia and other medical end-of-life decisions.
Euthanasia Policy as Guideline for Professional
Practice
According to the majority of interviewed nurses and physi-
cians, the euthanasia policy represented more than only a
practical manual. The euthanasia policy broadens and deep-
ens one’s ability to optimize the quality of the euthanasia
care process. Besides, nurses and physicians felt supported
by the euthanasia policy, which helped them to act as profes-
sionals during the euthanasia care process. The interviews
showed that the euthanasia policy stimulates and supports
professional attitudes such as competence and carefulness.
Competence. According to many interviewees, the eu-
thanasia policy supports care providers in providing pro-
fessional care during the euthanasia care process by help-
ing them to develop knowledge and skills, such as how to
communicate effectively with patients. The euthanasia pol-
icy provides them with the necessary information, enabling
them to inform patients in a more professional and open
way about the euthanasia procedure and about the possible
alternatives. Nurses who were involved in several euthana-
sia cases, or those who were involved in the development or
implementation of a hospital euthanasia policy, expressed
a desire to have the euthanasia policy integrated into their
practice, stating that doing so increases one’s expertise on
euthanasia issues.
It gives you a grip, uh, safety, and support, so that you can go to
the patient without being clumsy, so that you know what you
are doing, and so that you can provide quality care, between
brackets. Yes, [a euthanasia policy is] like any other protocol for
something else, I would say, just like [when] you have to place
a catheter, that first, how you do it, you have to make it familiar.
It is a technique, between brackets, that you have to work out,
with all the frills, because otherwise, you are not professional.
The euthanasia policy helps you in that way. (nurse 3)
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8. Impact of Written Ethics Policy on Euthanasia
Carefulness. Carefulness is about much more than
only checking whether all prescribed care is given, but it is
about the way the care is provided and organized, as stimu-
lated by the euthanasia policy. First, carefulness is generally
realized through more qualitative communication with all
involved parties. The euthanasia policy supports intra- and
interdisciplinary cooperation: It stimulates the euthanasia
care process as a team experience, with great attention be-
ing paid to communication within the nursing team about
the euthanasia request and about the planning of when eu-
thanasia will take place.
In addition, interviewed physicians and nurses reported
that the euthanasia policy encourages physicians to cooper-
ate with other parties such as the nursing team, palliative ex-
perts, and the ethics committee. Both physicians and nurses
merit interdisciplinary cooperation as important and nec-
essary for promoting a careful and thorough interpretation
of the euthanasia request (careful decision making), on the
one hand, and for providing good care for the patient and
family (with the needed expertise and competence), on the
other hand. For instance, some physicians articulated that
interdisciplinary cooperation really supported their deci-
sions regarding euthanasia.
The fundamental option [of the euthanasia policy] is that it
[euthanasia] should be possible, and it should happen in a
good way without extra obstacles. And what is extra, is to
clear the request in a better way. For instance, it gives you a
completely different feeling when you know that the GP, who
knows the patient for more than 30 years, can understand the
euthanasia request. That gives you more confidence. One of
the first things we do is call the GP and ask him, “what do you
think?” . . . It gives you more confidence, more ground under
your feet to gain a certain attitude. (physician 6)
Second, carefulness is realized through an objective and
systematic way of providing care for a patient requesting
euthanasia. The euthanasia policy helps nurses to follow
the same care path, which facilitates the continual course
of the care process wherein all phases follow successively,
even when other nurses take over the care. The objective
and systematic way of providing care was experienced as
support, especially when nurses experienced the euthanasia
care process as emotional.
We expressed that regularly to her [colleague involved as fam-
ily of a patient requesting euthanasia], that she can be family,
and also to us, that we should stay professional. We should not
do it [euthanasia care process] differently, because a colleague
is involved. We just should follow the euthanasia policy. . . .
Well, we should use the euthanasia policy for everyone, be-
cause otherwise, we will loosen the ground under our feet,
and we will not be working in a good way. (nurse 3)
Lastly, carefulness is promoted by encouraging care for
the involved care providers. This care is implicitly realized
by drawing attention to or by being attentive to the role of all
involved parties, as outlined within the euthanasia policy.
For instance, nurses expressed that they felt acknowledged
as professionals and partners when they have specific in-
put on the euthanasia care process, such as in the decision-
making process. Care for care providers is also in a more
explicit way encouraged by the euthanasia policy through
the organization of peer debriefings after euthanasia takes
place—which is important for dealing with emotions—and
through the support of the palliative support team during
the euthanasia care process.
Euthanasia Policy: A Support for Ethical Practice
In an implicit or explicit way, the minority of care providers
described the euthanasia policy as a support for their ethi-
cal practice. Implicitly, some care providers expressed that
the euthanasia policy supports their personal stance on eu-
thanasia: for instance, during the decision-making process.
Very few care providers experienced the euthanasia policy
as an incentive that enables them to reflect explicitly about
euthanasia or about their ethical responsibility as physician
or nurse in the euthanasia care process. Care providers who
attained this ethical level shared two characteristics: They
were involved in the development or implementation of
the euthanasia policy, and they were involved in several
euthanasia cases.
I can say, maybe I deal with it [euthanasia] even more cau-
tiously because of the policy. Maybe also because I am dealing
more with illness, suffering, and death than before as a nurse
. . . but the policy makes me think and helps me to support
people by means of it, to apply it through [to the end]. [The
ethics policy] supports me. (nurse 10)
Impact of Euthanasia Policy on the Care Provider as a
Person
Next to having an impact on the care practice, the euthanasia
policy also had an impact on the care provider as a per-
son, or, more specifically, on his or her feelings and experi-
ences. “The euthanasia policy gives me the feeling of having
ground under my feet” was a common remark made dur-
ing the interviews. As with the impact of euthanasia poli-
cies on the care providers’ practice, their impact on the care
provider as a person also shows three levels that similarly
evolve gradually. The majority of interviewees described
feelings of being safe (practical level). To a lesser extent,
they experienced feelings of being certain of providing the
“right” care (professional level). Few interviewees experi-
enced the feeling of having peace of mind in providing
“good” care (personal–ethical level) (Figure 2).
Being Safe
Most physicians, and to a lesser extent nurses, expressed
that the euthanasia policy gives them the feeling of being
safe, as it gives them the opportunity to check whether they
fulfilled all legal due care criteria. Consequently, they feel
that they are protected against possible prosecution. The
feeling of being safe is not limited to being legally safe. It
is also about feeling safe within their own hospital, in the
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9. AJOB Primary Research
context of acting according to the hospital norms. Know-
ing the hospital boundaries regarding euthanasia (i.e., the
hospital’s stance on euthanasia) and knowing one’s respon-
sibilities gives care providers the feeling of being covered
for making mistakes.
Being Certain
The euthanasia policy also bolstered the confidence of some
care providers in that the policy enabled them to gain in-
sight into how to act professionally during the euthanasia
care process. The policy both clarified and solidified their
professional role during the care process: They felt sup-
ported to provide competent, careful, and correct patient
care, resulting in less stress and chaos.
You have all these little steps, so you cannot forget things. So
you are going to be more calm. You come across to the patient
as being more calm. . . .. So it [the policy] helps you to talk about
it [euthanasia] without forcing yourself on him. But then, you
experience . . . that because of the policy how it [euthanasia
care process] happens systematically, even [if] you experience
stress. And it isn’t easy to follow everything, but when you
view it [the euthanasia policy] in that way, then you think, “oh
yeah, I should ask this,” and “perhaps I forgot that,” and “I
should order the medication on time,” and . . . It [the policy]
just helps. (nurse 3)
For physicians, being certain related to the decision
of performing euthanasia. Because the policy outlines for
physicians a careful process of consulting several parties,
physicians felt more confident about the correctness of their
euthanasia decision.
Having Peace of Mind
The minority of physicians and nurses experienced a deeper
feeling of peace of mind: They believed that the euthanasia
policy guides them to what is in the best interest of the
patient, which goes further than providing patient care in
the correct professional way. The feeling of peace of mind
manifests itself on a personal–ethical level. Having peace of
mind also seemed to be important for the coping process of
physicians and nurses at a personal level.
You can fill in everything in a concrete way, and if you can
put yourself behind it, then you experience fewer difficulties
in coping with these crucial issues as a human being. . . . After-
ward you have peace of mind. Also as a Christian, you cannot
stand to see unbearable suffering. And when palliative care
does not work, now we have another way to deal with that
unbearable suffering. That gives me a good feeling. (physician
1)
Support for Care Providers During the Euthanasia
Care Process
The euthanasia policy gave the care providers something to
hold on to through the euthanasia care process (impact on
care practice) and gave them the feeling of “having ground
under their feet” (impact on the care provider as a person).
This impact on their care practice and on themselves as per-
sons resulted in a common experience of being supported
during the euthanasia care process.
Many interviewed care providers reported that they ex-
perienced the euthanasia request of a patient as difficult to
extremely difficult. The euthanasia policy did not necessar-
ily make it easier for care providers to be involved in the
euthanasia care process, but the euthanasia policy helped
them to deal with this difficult situation. It did so by facilitat-
ing the practical aspects of the euthanasia process (practical
level), by increasing the open communication surrounding
the euthanasia request (professional level), and by increas-
ing the care providers’ willingness to take on their responsi-
bility in the euthanasia care process (personal/ethical level)
(Figure 2).
Facilitating Practical Aspects of the Euthanasia Care
Process
For many interviewees, the euthanasia policy paved the
way for practical and organizational issues dealing with
the euthanasia care process. The euthanasia policy gives
them concrete information about euthanasia (it makes the
legal euthanasia procedure more accessible and readable),
about the conditions wherein euthanasia is or is not allowed
within the hospital, and about who they can contact for help,
etc. In this manner, the euthanasia policy provides comfort
for the practical and organizational issues of the euthana-
sia care process. The majority of interviewees valued this
provision as the most important impact of the euthanasia
policy.
Yes, at that moment, it [the euthanasia policy] was really an
added value. I am very happy that we have a well-delineated
policy in our hospital, but I also think that it is important that
the policy is clear and unambiguous to everyone. It is easier
to walk on a street that is already paved. Then you don’t have
to pave the way yourself. The way is prepared and is well
prepared, which makes it easier. Otherwise, you have to figure
out the law . . . it makes it much easier. (physician 9)
Increasing Openness Toward a Euthanasia Request
Some physicians and nurses experienced that their hospital
atmosphere was more open toward euthanasia as a result
of the euthanasia policy. This openness made it easier for
care providers to listen to the patient’s euthanasia request
and to communicate more clearly and professionally with
the patient about his or her request.
Without the hospital’s policy, I would indeed have less courage
to respond to it [euthanasia request], to dare to announce it, and
to say that it is possible within the hospital; and if the treating
physician cannot do it, then we can talk to another physician.
(nurse 6)
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10. Impact of Written Ethics Policy on Euthanasia
For some nurses with a rather restrictive attitude to-
ward euthanasia, the euthanasia policy helped them be
more open-minded to the patient’s wish. The policy mo-
tivates care providers to focus squarely on performing
competently and carefully the euthanasia care process. This,
together with the approval of the policy at the institutional
level, helps these care providers to put aside their initial
reservations and to listen as a professional to the patient.
Increasing Willingness to Take on Responsibility in the
Euthanasia Care Process
Some nurses reported that, by means of the euthanasia pol-
icy, they experienced an evolution in their personal and
ethical attitude toward euthanasia. Euthanasia remains a
difficult issue, but because of the nature of the euthana-
sia care process, which focuses attention on performing the
process carefully and on sharing responsibility throughout
the process; some nurses were more willing to take on their
responsibility in the euthanasia care process.
When you feel very uncomfortable [with a euthanasia request],
there is the risk that you act just as if you did not hear it [the
request]. Or that you, yeah, you hush up. . . . Thanks to the
euthanasia policy, I feel more confident . . . I know that when I
hear something like that [euthanasia request], there is a way to
deal with it. And I can let it come. I can pass it to someone else.
There is a way to deal with it. What I do with the request is no
longer purely my responsibility. . . . It does not matter anymore
whether or not I have objections against euthanasia. . . . As
a care provider—as a nurse, a physician, a psychologist—it
does not matter. It [euthanasia] is possible because there is a
law, and we have the euthanasia policy for that. I experience a
euthanasia request as a call [appèl], and by means of the policy,
I can answer it. (nurse 7)
“Guiding Person” as a Mediator of the Euthanasia
Policy
Through all the interviews, it is clear that the presence of
a “guiding person” plays an important role in how a eu-
thanasia policy will affect care providers. A guiding person
is one who knows the euthanasia policy and the euthana-
sia law and one who serves as a mediator to guide care
providers through the different phases of the euthanasia
care process. Care providers who are part of the pallia-
tive support team or who have been involved in the de-
velopment or implementation of the euthanasia policy are
more likely to adopt this guiding role. The guiding persons
serve as a bridge between the theory (the euthanasia pol-
icy) and the practice (the euthanasia care process). In other
words, they can be considered to be catalysts or mediators
of the euthanasia policy. As care providers experience the
euthanasia care process as a complex and intensive event,
they look for more guidance and support as they deal with
this process. The guiding persons are selected on the basis of
their competence (e.g., palliative care). They coordinate the
care process and support the team involved. Guiding per-
sons seem to have incorporated the euthanasia policy into
the three levels of their practice—practical, professional,
personal–ethical—it has become a part of themselves as in-
dividuals. Nonetheless, they do not always implement the
policy consciously.
Let’s say that maybe I don’t really use it [policy], but I know
the position of the hospital. And I try, actually, to make it clear
to people where the hospital stands and how we treat euthana-
sia requests in general. . . . It happens that you don’t have to
talk about the position, because a euthanasia request is a rare
occurrence. So in an actual euthanasia request . . . it is more like
trying to fit the question within the team, within team consid-
erations. But I cannot say that I really consult the euthanasia
policy. In fact, I am completely persuaded by it, so it is in me
[laughs]. I take it with me. (nurse 10)
Care providers who are unfamiliar with euthanasia or
end-of-life care stressed that the written euthanasia policy
does not offer them enough guidance through the euthana-
sia care process. Rather, they viewed the policy as an ex-
ternal tool that they had not integrated into their practice.
They addressed the importance of a person who supports
and reassures them in a familiar way.
You have people in the house that you can consult, with whom
you can talk, and that, in particular, was very important. That
you have someone who can help you with it [the policy], [a
person] who can guide you . . . With X [the guiding person], it
makes it easier . . . It gives you a little, I would say, a feeling of
less stress. At the moment that it’s all over, [I would ask myself]
“did I do it in the right way?” I have then, something like, “ok,
we performed it well.” And you have someone who you can
ask for help. That was very important for me. . . . Yeah, someone
you can trust, who has the knowledge, I mean, about the law,
the practical stuff, the emotional, the organization on the ward.
It is all pretty on paper, but as a matter of fact, I remember, when
we did the euthanasia, I thought that we were well prepared,
but actually, afterward you experience the importance of that
[guiding person]. (physician 9)
DISCUSSION
Since the Belgian Act on euthanasia came into force in 2002,
an increase in ethics policies on euthanasia was observed
in Flemish hospitals (Lemiengre et al. 2007b). Our study is
the first to contribute to an in-depth understanding of the
impact of a written ethics policy on euthanasia, from the per-
spective of physicians and nurses (Lemiengre et al. 2007a).
The current study is part of a broader nationwide study
about written institutional ethics policies on euthanasia in
Flanders, Belgium. The findings of our survey (Lemiengre
et al. 2007b) and content analysis (Lemiengre et al. 2008)
guided the careful and purposive selection of hospitals and
participants and helped us to put the findings back into
the context of institutional ethics policies on euthanasia in
Flanders.
Our qualitative approach, by means of a multiple case
study, enabled us to explore the impact of a written ethics
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11. AJOB Primary Research
policy on euthanasia in an in-depth manner. We purpo-
sively selected three hospitals that made great efforts to de-
velop and implement a euthanasia policy. This purposive
sampling, together with several strategies to increase the
trustworthiness of the findings, contributed to maximizing
the picture of the possible impact of a euthanasia policy.
Our study provides a baseline for future studies that aim
to further refine our findings and to determine the under-
lying causes of our findings. We are aware of a possible
selection bias of hospitals and care providers, which is in-
evitable for case study methods. However, it is not our aim
to generalize our findings to all Flemish hospitals with a
euthanasia policy. Another possible source of bias is that
this study was carried out by a research team having a
particular view on euthanasia (Gastmans 2005). Further re-
search is needed in more and other settings, and from other
perspectives.
In many Western countries, there are debates about the
acceptability of euthanasia and the regulation of euthana-
sia (Cohen, Marcoux, Bilsen, Deboosere, van der Wal, and
Deliens 2006). In the Netherlands, Belgium, and Luxem-
bourg, these debates have led to laws that permit euthana-
sia under strict conditions. Consequently, in these countries,
care providers must respond to patients with euthanasia re-
quests within a legal context. However, the actual involve-
ment of care providers in euthanasia practice in these coun-
tries is far from evident (van Marwijket al. 2007; Georges
et al. 2008; Denier et al. in press). By developing euthana-
sia policies, hospitals attempted to support care providers
under their responsibility to deal with euthanasia in prac-
tice. Possible aims of written institutional ethics policies are
stimulation of ethical reflection within an institution, delin-
eation of care provider responsibilities, prevention of illegal
practices, and creation of more transparency in conducted
policy (Lemiengre et al. 2007a).
Our study shows that care providers feel positively sup-
ported by the euthanasia policy during euthanasia care
processes. They feel supported by the policy as persons
and as professionals to provide well-organized and pro-
fessional care for patients requesting euthanasia. Although
they feel mainly the influence of the euthanasia policy
on the practical and professional level of providing care,
its impact on their ethical reflection and practice is less
clear and seems to be more difficult to achieve. This may
raise questions about the meaning of a written ethics pol-
icy for the ethical practice of physicians and nurses, when
they have to deal with ethically sensitive issues such as
euthanasia.
The limited impact of euthanasia policies on a
personal–ethical level may be related to the fact that both
euthanasia and euthanasia policies are recent phenomena
in contemporary clinical practice in Flanders; thus, care
providers have limited experience in this area. The num-
ber of actual euthanasia cases is small in Flanders: 234
cases in hospitals in 2007, which translates to two to three
cases for each hospital in 2007 (Federal Control and Eval-
uation Commission Euthanasia 2007). Consequently, care
providers generally have limited experience in euthanasia,
which we also observed in our sample composition. Fur-
thermore, Flemish euthanasia policies have only been de-
veloped since 2002, the year the Belgium Euthanasia Act
was enacted (Lemiengre et al. 2007b).
Our interviews showed that, in particular, care
providers with little experience stressed the practical sup-
port of the policy, while care providers with more experi-
ence also described an impact on a personal–ethical level
in their practice. Patricia Benner (1984) described the influ-
ence of care providers’ experience in how they deal with
guidelines (e.g., euthanasia policies) as a gradual growing
process, comprising five stages, “from novice to expert.”
Benner’s model can help us to understand the gradual evo-
lution of the impact of euthanasia policies.
Physicians and nurses with little experience in euthana-
sia, i.e., ones who are equivalent to Benner’s “novice”
nurses, may especially value the practical guidance pro-
vided by a euthanasia policy. Clear and practical guidelines
provide them with the information needed to promote skill
and knowledge development. The unfamiliarity of many
care providers with euthanasia may explain their need for
clarity and for a safety net, which they find in the euthana-
sia policy, and for guidance, which they gain from more
experienced persons.
We found that as care providers build up more experi-
ence, knowledge, and competence (as in the case of guid-
ing persons), they no longer rely exclusively on guidelines.
They have already integrated the euthanasia policy into
their practice, as would Benner’s “expert” nurses. These
expert nurses are flexible and readily adapt the process ac-
cording to each patient in order to ensure a “good” euthana-
sia process, even when not all the rules are strictly followed.
They no longer have to struggle with the practical and pro-
fessional aspects of the euthanasia care process; thus, they
have created in this way more time for reflection about their
behavior on a personal–ethical level.
Next to the importance of time and experience, some
contextual factors may function as levers that increase the
impact of a euthanasia policy on the personal–ethical level
of care providers’ practice. In this respect, the impact of
an ethics infrastructure in the classic, static, and conserva-
tive way (i.e., ethics committees that develop written ethics
policies) is probably insufficient to actually influence the
ethical practice of care providers. One of the main tasks of
ethics committees in Flemish hospitals is the development
and implementation of ethics policies that focus on ethi-
cal issues in patient care, such as euthanasia (Meulenbergs,
Vermylen, and Schotsmans 2005). Our survey showed that
ethics committees were largely involved in the development
of euthanasia policies of Flemish hospitals (Lemiengre et al.
2007b). Consequently, we questioned whether the develop-
ment of a written ethics policy as such by an ethics com-
mittee allows the policy to have a real impact on the ethical
practice of care providers.
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12. Impact of Written Ethics Policy on Euthanasia
In contrast to the situation in Belgium, in many Euro-
pean countries, ethics committees are transforming their
roles as distant experts and their focus on written poli-
cies into a role focused on providing a dynamic service,
a service involving them as ethics consultants. Ethics con-
sultants with moral skills and knowledge can help care
providers deal with ethical issues “on the floor” (Molenwijk,
Verkerk, Milius, and Widdershoven 2008; Chen and Chen
2008). Given the facilitating role of the “guiding person”
in increasing the impact of ethics policies, as became clear
in our study, ethics consultants may function as mentors
to guide and support “novices” in their ethically sensitive
practices. Nonetheless, further research must demonstrate
whether the development and use of ethics consultants in
hospitals will indeed support care providers in dealing with
ethical issues of euthanasia practices. If this is the case,
the combination of a written ethics policy developed by
an ethics committee and the availability of an ethics con-
sultant who can facilitate the translation of the theoretical
ethics policy into real practice could be a successful for-
mat in order to increase the impact of these policies on care
providers, even on an ethical level.
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