Dying Care

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Thai Nurses’ Attitudes, Knowledge, Ethical Dilemmas, and Clinical Judgment
Related to End-of-Life Care in Thailand
A dissertation submitted in partial fulfillment of the requirements for the degree of

Doctor of Philosophy in Nursing at George Mason University
by
Chanphen Manosilapakom
Bachelor of Science in Nursing
Rangsit University, Pathumthani, Thailand, 1994
Master of Science in Health Sciences
University of Northumbria at Newcastle, England, 1999
Director: Jeanne M. Sorrell, Ph.D., R.N., FAAN

Professor
College of Nursing and Health Science
Spring Semester 2003

George Mason University
Fairfax, Virginia
Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.
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THAI NURSES’ ATTITUDES. KNOWLEDGE. ETHICAL DILEMMAS. AND
CLINICAL JUDGMENT RELATED TO END-OF-LIFE CARE IN THAILAND
by
Chanphen Manosilapakom
A Dissertation Submitted to the
Graduate Faculty
of
in Partial Fulfillment of the
Requirements for the Degree
of
Doctor of Philosophy
Nursing
Committee:
Director
Reader
Reader
_ Coordinator, Doctoral Program
Dean, College of Nursing and

Health Science
Date: ^ _______ Spring Semester, 2003

Fairfax, Virginia
Copyright 2003 Chanphen Manosilapakom
All Rights Reserved
DEDICATION
To my grandmothers for their love and support. My inspiration to write this

dissertation on end-of-life care is that because I experienced caring for these two
loved ones at the end of their lives. I hope that they are resting in peace.
To my dear parents, Mr. Sujin and Mrs. Wanna Monosilapakom, who have
always encouraged and given me unconditional and unceasing love. I am glad that
they will always be there for me. I know that they are very proud of me.
ACKNOWLEDGEMENTS
I would like to express my appreciation to the following people who have supported
and encouraged me throughout my doctoral journey.
Dr. Jeanne Sorrell, chair of my dissertation committee and fist teacher at GMU - you
have been my mentor since I was accepted to study in the nursing program - your
expertise, advice, and support are invaluable - thank you very much my exemplar
mentor.
Dr. Mary Silva, my dissertation committee and academic advisor - your kindness,
encouragement, and insight were greatly important to my journey - you are a real
philosopher, whose expertise I have experienced personally.
Dr. Norman Stanhope, my other member of my committee - your knowledge and

guidance truly helped me throughout this dissertation process - your death and dying
course gave me inspiration to write this dissertation.
Dr. Elizabeth Chong & Dr. Jean Pilon -their support, kindness and help with editing
are extremely significant in this dissertation.
Thai Professors: Dr. Wanida Wanant, Dr. Ampapom Puawilai, and Dr. Wassana
Juethong - their expertise, advice, and willingness to help are invaluable.
Nursing Faculty of the College of Nursing and Health Science: Dr.Heibatollah Baghi,
Dr. Jennie Wu, Dr. Frieda Butler, Dr. Veronica Feeg, Dr. Kathleen Gaffney, Dr. Jean
Moore, and Lorraine Rudowski,
Staff: Vannary Khov, Nasim Khawaja, Terri Guingab, and Edna Hertsch
Classmates: Om-Anong Wichaikhum and Nazik Zakari (NOC group)
My host families: Ms. Susanne Fogleman and the Smith’s family
Friends: Peed, Pom, Noi, Chompu, Nook, Som, P’Nang, P’Meao, Melody, Meg, Dr.
Jones (Derek Jones), N’Tem, N’Bow, N’Bee, Rangsit friends, andTSCA-GMU.
And finally, to my family, mum & dad, my brothers, sister-in-law, nephew & niece,
relatives, and my significant other, Mr. Sirichai Suriyawong (P’Buk-Auud) for their
love and support throughout my doctoral journey.
TABLE OF CONTENTS
Page
Chapter 1: Introduction.....................................................................................................I
Significance of S tudy................................................................................................3
Assumptions.............................................................................................................. 7
Purposes.................................................................................................................... 7
Research Questions................................................................................................... 8
Theoretical Framework............................................................................................. 10
Benner’s Clinical Judgment..............................................................................11
Gadamer’s Hermeneutic Philosophy................................................................. 12
Conceptual M ap.......................................................................................................17
Conceptual and Operational Definitions..................................................................18
Summary................................................................................................................. 21
Chapter 2: Review of Literature..................................................................................23
Aging Population and Chronic Illnesses.................................................................24
Terminal III and Dying Patients............................................................................. 25
Attitudes toward Death and Dying..........................................................................27
End-of-Life/ Palliative C are....................................................................................31
Problems and Concerns about End-of-Life C are ............................................... 34
Knowledge About End-of-Life Care.......................................................................35
End-of-Life Care in Thailand................................................................................. 36
Ethical Dilemmas Related to End-of-Life C a re .....................................................38
Clinical Judgment....................................................................................................43
Summary................................................................................................................. 47
Chapter 3: Methodology...............................................................................................49
Overview of the S tudy............................................................................................49
Research Questions.................................................................................................51
Sam ple..................................................................................................................... 52
Instrumentation....................................................................................................... 55
Research Design...................................................................................................... 59
van Manen’s Method................................................................................................59
Pilot Study............................................................................................................... 64
Psychometrics of Study Instrument.........................................................................66
Procedures............................................................................................................... 70
Data Analysis P lan .................................................................................................. 72
Rigor of the Study................................................................................................... 78
Trustworthiness........................................................................................................ 78
Ethical Considerations............................................................................................80
Limitations of Study Design....................................................................................82
Summary................................................................................................................. 82
Chapter 4: Presentation of Findings..............................................................................84
Quantitative Study.................................................................................................. 86
Response Rate.................................................................................................... 87
Demographic Characteristics............................................................................88
Quantitative Findings.............................................................................................. 91
Attitudes toward Death and Dying S urvey......................................................91
Research Question 1 ....................................................................................91
Research Question 2.................................................................................... 98
Research Question 3 .................................................................................. 100
RN End-of-Life Knowledge Assessment....................................................... 102
Research Question 4 ..................................................................................102
Research Question 8 .................................................................................. 107
Research Question 1 0 ................................................................................107
Research Question 1 1 ................................................................................ 107
Qualitative Study....................................................................................................113
Qualitative Findings.............................................................................................. 113
Characteristics of Participants......................................................................... 113
Uncovering Knowledge Embedded in End-of-Life Care Experience........... 116
Research Questions 1 3 .............................................................................. 118
Holistic Approach..................................................................................... 118
End-of-Life Decision Making................................................................... 128
Nursing Roles in End-of-Life C are...........................................................130
Ethical Dilemmas Related End-of-Life C a re ...........................................133
Exemplary on Ethical Dilemmas.........................................................136
Clinical Judgment...................................................................................... 139
Research Question 15.................................................................................142
Concerns for Improvement End-of-Life C are ..........................................142
Summary................................................................................................................147
Chapter 5: Interpretation and Discussion................................................................... 150
Study Concepts.......................................................................................................155
Attitudes toward Death and Dying.................................................................. 155
Problems and Concerns in End-of-Life C a re .................................................159
Knowledge about End-of-Life C are.............................................................161
Interpretative Themes............................................................................................ 163
Thai Nurses’Lived Experience in End-of-Life C are ..................................... 163
Theme: Helping Dying Patients to Have a Peaceful D eath..................... 164
Theme: Placed in the Middle..................................................................... 167
Theme: Home versus Hospital..................................................................170
Ethical Dilemmas and Clinical Judgment Related to End-of-Life Care 170
Theme: Pain Relief versus Euthanasia..................................................... 171
Theme: DNR versus C P R ........................................................................ 172
Theme: Belief of Providing Best C are .....................................................174
Theme: Caring Practice in the Nursing Profession................................. 174
Theme: Using Colleagues to Guide Clinical Judgment Making............. 175
Quality End-of-Life Care..................................................................................175
Theme: Supporting Cultural and Religious Beliefs..................................176
Theme: Respecting Patient’s Rights......................................................... 176
Theme: Promoting Clinical and Service Innovations.............................. 177
Implications........................................................................................................... 178
Nursing Administration...................................................................................178
Nursing Education........................................................................................... 181
Nursing Practice.............................................................................................. 183
Nursing Research............................................................................................ 185
Limitations of Study.............................................................................................. 186
Summary of Study............................................................................................ 187
References.................................................................................................................. 189
Appendix A: Introductory L etter.............................................................................. 201
Appendix B: Attitudes toward Death and Dying Survey.......................................... 204
Appendix C: RN End-of-Life Knowledge Assessment............................................ 209
Appendix D: RN Demographics Form ...................................................................... 217
Appendix E: Permissions for Research Instruments................................................. 220
Appendix F: Interview G uide.................................................................................... 223
Appendix G: HSRB Approval....................................................................................225
Appendix H: Informed C onsent................................................................................. 227
Appendix I: Evaluation Form for Content V alidity.................................................. 229
LIST OF TABLES
Page
1. Spearman Brown Formula with Doubled Number of Research T ools................... 70

2. Presentation o f Research Questions, Variables/Measurement, Level of
Measurement, and Methods o f Data Analysis............................................................. 74
3. Return and Response Rate of the Study Survey.......................................................... 87
4. Descriptive Statistics of M ajor Demographic Characteristics o f the Sample
in Quantitative S tu d y ......................................................................................................90
5. Descriptive Statistics of M inor Demographic Characteristics o f the Sample
Quantitative Study...........................................................................................................90
6. Frequency Distribution of Attitude toward Death and Dying Score by
Thai Nurse R espondents................................................................................................93
7. Thai Nurse Respondents’ Responses on the Disagreement o f Each Negative
Statement in the Attitudes toward Death and Dying Survey..................................... 95
8. Thai Nurse Respondents’ Responses on the Agreement of Each Positive
Statement in the Attitudes toward Death and Dying S u rv e y ................................... 97
9. An Average o f Attitude Score in Different Regions of H o sp itals...........................98
10. Frequency Distribution of Knowledge Score in End-of-Life Care by
Thai Nurse R espondents.............................................................................................102
11. Frequencies o f Thai Nurse Respondents’ Responses with Correct Answers
in RN End-of-Life Knowledge A ssessm ent............................................................104
12. Thai Nurse Respondents’ Knowledge in End-of-Life Care Score in
Different Regions of H ospitals................................................................................. 106
13. Correlation Matrix of the Attitudes Score and the Knowledge Score,
and M ajor Demographic Variables among Thai Nurse Respondents.................. 108
14. Summary of Quantitative Findings in Response to Research
Questions 1 through 12.................................................................................................109
15. Summary of Qualitative Findings in Response to Research
Questions 13 through 1 5 ............................................................................................. 147
LIST OF FIGURES
Page
1. Attitudes, knowledge, and ethical dilem mas related to
Thai nurses lived experience in end-of-Iife care........................................................ 17
2. The projections of aging population in the United States.........................................24
3. Attitude toward death and dying scale distribution....................................................94
4. Participants’ perceived problems in end-of-life care by percent...............................99
5. Participants’ concerns on improving end-of-life care..............................................101
6._KnowIedge in end-of-life care scale distribution..................................................... 103
ABSTRACT
THAI NURSES’ ATTITUDES, KNOWLEDGE, ETHICAL DILEMMAS, AND

CLINICAL JUDGMENT RELATED TO END-OF-LIFE CARE IN THAILAND
Chanphen Manosilapakom, Ph.D., RN.
George Mason University, 2003
Dissertation Director Dr. Jeanne Sorrell
This triangulated study explored Thai nurses providing end-of-life care in Thailand.
The main question was how to improve quality of end-of-life/ palliative care in
Thailand. In the quantitative study, 538 (89.7%) RNs from six general hospitals in
upper north, lower north, northeast, east, central and south of Thailand responded to a
questionnaire on the demographic characteristics, attitudes toward death and dying,
problems and concerns on end-of-life care, knowledge in end-of-life care. A
descriptive, correlation analysis was used by using the SPSS program. Quantitative
findings indicated: (I) the overall attitudes toward death and dying scores ranges from
25-48, with an average of 34.38, a median of 34.00s, a mode of 34, and the standard
deviation of 3.632; (2) the most three important problems in end-of-life care
perceived by Thai nurses are the inability to meet spiritual needs, loneliness, and
control of pain respectively; (3) the most three major concerns in improving end-of-
life care are the greater emphasis on spiritual care, greater family involvement, and
education in ethical issues respectively; (4) the overall knowledge in end-of-life care
scores ranges from 7-20, with an average of 13.22, a median of 13.00, a mode of 14,
and the standard deviation of 2.159; (5) there are statistically significant relationships
between the attitudes toward death and dying and the level of education (r = .147; p <
.01), the knowledge of end-of-life care and the level of education (r = .092; p < .05),
and the knowledge of end-of-life care and annual income (r = .095; p < .05).
In the qualitative study, this interpretative study also inquired into the lived
experience of Thai nurses in providing end-of-life care, and ethical dilemmas and
clinical judgments related to end-of-life care. Twelve nurse participants gave their
narrative accounts on their lived experience in end-of-life care that reflects several
categories. Interpretative themes are helping patients to have a peaceful death, placed
in the middle, home versus hospital, pain relief versus euthanasia, DNR versus CPR,
belief of providing best care, caring practice in the nursing profession, using
colleagues to guide clinical judgment making, supporting cultural and religious
beliefs, respecting patient’s right, and promoting clinical and service innovations.
These findings are a basis of partial documentation in end-of-life/ palliative care in
Thailand as the improvement of the quality of end-of-life care is warranted.
Recommendations for nursing administration, education, practice and research are
presented in regards to the improvement of end-of-life care in the nursing profession
in Thailand.
CHAPTER I
INTRODUCTION
“The nurse, in all professional relationships, practices with compassion and respect
fo r the inherent dignity, worth and uniqueness o f every individual, unrestricted by
considerations o f social or economic status, personal attributes, or the nature o f
health problems. ”
“Nursing care is directed toward meeting the comprehensive needs o f patients and
their families across the continuum o f care, and it is particularly vital in the care o f
patients and families at the end-of-life to prevent and relieve the cascade o f symptoms
and suffering that are commonly associated with dying. ”
“The nurse should provide interventions to relieve pain and other symptoms in the
dying patient even when those interventions entail risks o f hastening death. However,
nurses may not act with the sole intent o f ending a patients ’ life even though such
action may be motivated by compassion, respect fo r patient autonomy, and quality o f
life considerations. ”
--Code of Ethics for Nurses,
(American Nurses Association [ANA], 2001. pp. 7-8)
This chapter introduces the study with the statements of Code of Ethics for
Nurses by ANA (2001). The chapter is composed of several sections including the
significance of study, assumptions, purposes, research questions, theoretical
framework, conceptual map, and conceptual and operational definitions. A summary
of the chapter is then discussed.
The number of aging persons with chronic illnesses is rising worldwide, as
well as the number of dying persons. There is a need to understand how to provide
quality end-of-life care to dying persons who have been suffering and dying from
2
incurable illnesses, and to give support to the families of the dying persons as they
experience grieving processes. Questions about advance directives, refusal of
treatment, and withdrawal or withholding of life-sustaining interventions can be
difficult to address in end-of-life decisions (Scanlon, 2003). By any measure, efforts
to improve care for incurably ill and dying patients are seen as significant problems
(Byock, 1998).
Different cultures have different approaches to the problem of end-of-life care.
This study focuses on end-of-life care in Thailand. The main purpose of the study is to
explore the phenomenon of end-of-life care in Thailand. It is evident that chronic
illnesses are problematic, especially for older adults. Such chronic illnesses as cancer,
heart disease, diabetes, chronic obstructive pulmonary disease, and renal failure may
contribute to the cause of death in older adults. Nurses continue to strive toward
improving the quality of care not only for older adults but also for dying persons and
their family. Yet, little is known about how the phenomenon of end-of-life care is
understood by Thai nurses.
The researcher of this study had previous experience in providing care for
dying persons; this pointed out to her the significance of ethical dilemmas that nurses
encounter in end-of-life care. In one instance, she cared for a patient with end stage
ovarian cancer. Physicians and the family of the dying patient discussed the option of
withdrawing life-sustaining treatments from the patient because they felt a
commitment to help the patient die peacefully at home. As a nurse, the researcher had
to assume the responsibility of withdrawing treatments—feeding tube and intravenous
fluid—from the patient; these actions made her feel very frustrated and worried about
the patient’s condition. She believes that all the knowledge she has learned in nursing
3
is to help save a patient’s life and comfort patients, not to withdraw any treatments
that would result in hastening death. An ethical dilemma occurred that made her feel
uncomfortable because she was not able to balance her personal beliefs/attitudes and
professional duties.
Regarding nursing education in Thailand, the course of caring for dying
persons has been incorporated within the adult care course, which is one of the
requirements of coursework for student nurses. However, currently only a few
universities in Thailand have a specific course for end-of-life nursing or palliative
care. In Thailand, the reality is that nurses and other caregivers have had to provide
the care to dying persons, but there is a paucity of Thai literature that is focused on
end-of-life or palliative care.
Significance of Study
End-of-life care or palliative care is an important phenomenon to understand
for nurses providing care to the dying patients and to informal caregivers, who may be
families and friends who are inevitably affected by their loved ones’ illnesses. In
order to provide end-of-life care, it is imperative that healthcare professionals are
concerned about both the dying patients and their grieving families. On the one hand,
healthcare professionals should provide end-of-life care for relieving physical and
emotional distresses, as well as responding to social and spiritual needs of the dying
patients. On the other hand, they also need to support the family through grief. Byock
(1998) noted that end-of-life decision-making, care plans and proposed interventions,
and treatments need to reflect the impact on the dying patients, as well as their family.
In addition, support for the family should continue into the period of bereavement.
4
In general, the concepts of end-of-life care and palliative care are used
interchangeably. Palliative care is primarily aimed at providing quality end-of-life
care to each individual dying patient. Experience of the dying with incurable and
progressive illnesses has impacted every dimension of a person’s life: physical,
psychological, social, and spiritual (Byock, 1998). Thus, it is significant for caregivers
to find ways to provide quality end-of-life care in response to personal experience,
needs, and beliefs at the last stage of life.
As healthcare professionals seek to provide quality end-of-life care, many
difficult questions have been discussed: What does quality end-of-life care mean, how
can it be measured, and how can it be improved? The quality end-of-life care includes
a multidimensional concern in response to physical, psychological, social, and
spiritual needs of individual patients. Randall and Downie (1996) noted that quality of
palliative care is derived from six factors: (1) professional knowledge, technical skill,
and competence; (2) professional standards; (3) attitudes and behavior; (4) managerial
functions; (5) team work; and (6) teaching, audit and research. All of these factors are
imperative for nurses in the provision o f end-of-life care. The researcher of this study,
however, using her own experience, as well as information from the literature,
focused on three significant factors that encompass quality end-of-life care: nurses’
knowledge in end-of-life care, their attitudes toward death and dying, and their
clinical judgments in dealing with ethical dilemmas related to end-of-life care. Nurses
are the majority of healthcare professionals who provide end-of-life care to dying
patients. Ethical uncertainties and dilemmas occur routinely in palliative care nursing
(Scanlon, 2003). The nurses sometimes struggle with end-of-life care because
conflicts between their personal values and attitudes/beliefs and their professional role
5
obligations lead to ethical dilemmas. Their attitudes toward death and dying and their
knowledge about end-of-life care have impacted on those dilemmas and the quality of
palliative care given. In order to provide quality palliative care, nurses are responsible
for addressing physical and psychological needs, as well as social and spiritual needs
of their patients. However, within the burgeoning field of end-of-life care, ethical care
is an important concern.
Byock (1998) stated that ethical concerns hold far-reaching implications for
the quality of care that dying persons will receive. For example, withdrawing and
withholding treatments from dying patients, the do-not-resuscitate (DNR) order, and
euthanasia are understood to be morally wrong in Thailand. Especially, there is a
growing consensus among the Thai public that euthanasia (passive or active) is
morally unjustifiable because, within the framework of Thai Buddhist values, acts of
killing are described to be acts of hatred or ill-will (Ratanakul, 1990). With the
controversies between ways o f conventional medical treatments and the values of
Thai Buddhist culture, it is evident that Thai nurses have confronted ethical dilemmas
related to caring for dying patients in Thailand.
In providing care for the dying, therefore, it is important that nurses use
appropriate clinical judgments to deal with and minimize ethical dilemmas that occur
while providing end-of-life care. The clinical judgments of nurses are related to their
understanding of dying patients’ and families’ concerns and the way in which they
respond to those concerns, as well as supporting families in their grieving processes
and working through decisions (Benner, Tanner, & Chesla, 1996). Therefore, nurses’
attitudes toward death and dying, and their knowledge about end-of-life care, have
impacted on those dilemmas and quality of palliative care. Pimple, Schmidt and
6
Tidwell (2003) support that nursing education must be accountable and initiate
curricular changes to ensure that students have the knowledge and appropriate
attitudes needed in end-of-life care. Thus, it is important to examine nurses’ attitudes
and knowledge in end-of-life care in order to improve caring for dying patients.
Several factors such as age, experience, education, and income may have an
impact on healthcare professionals’ attitudes and knowledge in end-of-life care.
Different age groups vary in their attitudes toward death, because of their differential
proximity and exposure to death (Kastenbaum, 1979). Older adults often have less
fear of death than younger persons (Wass & Myers, 1982). Vazirani, Slavin and
Feldman (2000) conducted a longitudinal study of pediatric house officers’ attitudes
toward death and dying. Major findings of their study indicated that three main factors
influencing changes in participants’ attitudes toward death and dying were: (a) more
professional experience dealing with death and dying; (b) more personal experience
dealing with death and dying; and (c) years of training in the area of death and dying.
These three factors imply that age, years of experience, and education are related to
attitudes toward death and dying; therefore, the researcher of this study focused on
these factors in relation to Thai nurses’ attitudes and knowledge in end-of-life care.
The salary of nurses in the United States and Thailand are not comparable;
Thai nurses working in public hospitals receive a much lower income. Although there
is no literature that indicates that there is a relationship between income and the nature
of care given to terminal patients, the researcher of this study believes that the income
of Thai nurses may influence the nature of the care provided to dying patients and that
there may be a correlation between Thai nurses’ salaries and their attitudes and
knowledge in provision of end-of-life care.
7
In addition, there is a paucity of literature that addresses the phenomenon of
end-of-life or palliative care in Thailand. There are also no studies that focus on the
clinical judgments that Thai nurses use in resolving ethical dilemmas regarding care
of dying persons. Thus, research is needed to better understand how ethical dilemmas
and clinical judgments are reflected in the phenomenon of end-of-life care. It is
anticipated that findings o f this study will provide beginning documentation that will
help healthcare providers to improve end-of-life care in Thailand and other countries.
Assumptions
1. The dying process and death are inevitable in each person’s life, but
discussion about death and dying is often an avoided topic in Thai culture.
2. Attitudes regarding end-of-life care are important to the quality of care
given by nurses.
3. Knowledge regarding end-of-life care is important to the quality o f care
given by nurses.
4. Nurses sometimes struggle with end-of-life decisions.
5. Ethical dilemmas may occur if nurses are unable to balance their personal
attitudes/beliefs with their professional roles.
6. Nurses use a clinical judgment process to resolve ethical dilemmas that
reflects both knowledge and attitudes related to end-of-life care.
7. Culture and religion play significant roles in end-of-life care in Thailand.
Purposes
The specific purposes of this study are threefold: (I) examine Thai nurses’
attitudes toward death and dying, problems and concerns about end-of-life care, and
knowledge about end-of-life care; (2) determine relationships between Thai nurses'
8
attitudes toward death and dying, and knowledge about end-of-life care and selected
demographic variables (age, level of education, years of experience, and annual
income); and (3) explore Thai nurses’ lived experience in end-of-life care, and ethical
dilemmas and clinical judgments nurses used in resolving ethical dilemmas in order to
provide quality end-of-life care in Thailand.
Research Questions
Research questions are presented in the interrogative form in relation to
purposes of the study. They are explicit and direct in order to guide data collection to
answer each question (Polit & Hungler, 1999). Thus, the following research questions
were formulated to guide this study reflecting on the three main purposes of the study.
This triangulated study consists of both the quantitative (Research Questions 1
through 12) and the qualitative (Research Questions 13 through 15) portions. A design
that incorporates both quantitative and qualitative methods may improve the ability to
determine nurses’ contribution to patient outcomes (Mason, 1996; Streubert &
Carpenter, 1999).
Research questions I through 4 were formulated in response to the first
purpose of the study: Examining Thai nurses’ attitudes toward death and dying,
problems and concerns about end-of-life care, and knowledge about end-of-life care.
Research Question 1: What are Thai nurses’ attitudes toward death and dying
issues?
Research Question 2: What are the most important problems in caring for
dying patients in Thailand as perceived by Thai nurses?
9
Research Question 3: What are the most important concerns in caring for
dying patients that Thai nurses perceive are needed to improve quality end-of-life care
in Thailand?
Research Question 4: Are Thai nurses knowledgeable about end-of-life care?
Research Questions 5 through 12 were formulated in response to the second
purpose of the study: Determining relationships between Thai nurses' attitudes toward
death and dying, and their knowledge of end-of-life care and demographic variables
(age, level of education, years of experience, and annual income).
Research Question 5: What is the relationship between Thai nurses’ attitudes
towards death and dying issues and the age of Thai nurses?
Research Question 6: What is the relationship between Thai nurses' attitudes
towards death and dying issues and the level of education of Thai nurses?
towards death and dying issues and the years of experience in the nursing profession
of Thai nurses?
towards death and dying issues and the annual income of Thai nurses?
Research Question 9: What is the relationship between Thai nurses’
knowledge about end-of-life care and the age of Thai nurses?
knowledge about end-of-life care and the level of education of Thai nurses?
knowledge about end-of-life care and the years of experience in the nursing
profession of Thai nurses?
10
knowledge about end-of-life care and the annual income of Thai nurses?
Research Questions 13 through 15 were formulated in response to the last
purpose of the study: Exploring Thai nurses’ lived experience in end-of-life care, and
ethical dilemmas and clinical judgments nurses used in resolving ethical dilemmas in
order to provide quality end-of-life care in Thailand.
Research Question 13: What is Thai nurses’ lived experience in providing
end-of-life care in Thailand?
Research Question 14: How do Thai nurses describe their own ethical
dilemmas related to end-of- life care and the clinical judgment they use in dealing
with the ethical dilemmas?
Research Question 15: How have Thai nurses provided quality end-of-life
care?
Theoretical Framework
Benner’s clinical judgment and Gadamer’s hermeneutic philosophy are
conceptualized as a theoretical framework for integrating the quantitative and
qualitative aspects of this study. The first perspective, clinical judgment, was
developed by Benner et al. (1996). Benner et al. (1996) described the care of dying
patients and clinical judgment in which nurses should appropriately take actions on
concerns of both dying patients and their families. In this study, clinical judgment is
seen as the process used to resolve ethical dilemmas related to end-of-life care and
encompasses Thai nurses’ knowledge and attitudes. The second perspective,
Gadamer’s hermeneutic philosophy (1976), is used as a philosophical underpinning
for understanding the phenomenon of end-of-life care through uncovering Thai
11
nurses’ understanding of the ethical dilemmas and clinical judgment processes that
comprise their experiences with end-of-life care.
Benner's Conceptual Framework of Clinical Judgment
In both quantitative and qualitative portions of this study, the concept of
clinical judgment is used as a theoretical framework for the processes which Thai
nurses use in attempting to provide end-of-life care. The nurses’ clinical judgments
are related to the understanding with dying patients’ and families’ concerns, the way
in which they respond to those concerns, supporting families in their grieving
processes, and working through decisions (Benner et al., 1996). Clinical judgment
reflects ways in which nurses come to understand the problems, issues, or concerns of
clients and patients, to attend to salient information, and to respond in concerned and
involved ways” (Benner et al., 1996, p. 2). The authors identify five interrelated
aspects of clinical judgment:
1) ethical concern or the moral dimension of everyday judgment; 2) extensive

practice knowledge that includes not only scientifically derived knowledge
and theory but also the tacit knowing, that of knowing the particular patient; 3)
the context of the particular situation and the nurse’s emotional response to it
as guided by interpretation of the particular situation; 4) intuition or judgment
without calculative rationality; and 5) the role of narratives in which the
patient becomes not only the biological world of disease but a human
world of meanings, values, and concerns, (pp. 5-11)
Benner et al. (1996) provided an exemplar of nurses’ clinical judgment in
caring for dying patients, both in nurses’ clinical grasp of the situation and in their
action as moral agents (pp. 3-4). In this exemplar, the nurse provided a perspective for
the family of the dying through her experience with similar patients, orienting the
family to the patient’s current status and possible outcomes while being sensitive to
the family’s ability to hear and understand her explanations. She immediately
12
understood how on edge the family was, and responded to their needs. Benner et al.
(1996) suggested that no theory can explain and grasp the nurse’s experience of
providing care and support to the dying patient and the family. She noted that, in the
exemplar, the clinical judgments involved getting a good clinical grasp, the skill of
seeing (p. 5). The nurse heard about this patient from other nurses in the unit and
assessed the patient’s condition based on her practical knowledge and experience with
other patients in similar circumstances. She then recognized the patient’s fragility and
provided holistic care in response to the rapidly changing situation of this patient.
The above exemplar contains all five interrelated aspects—ethical concern,
practical knowledge, emotional response, intuition, and role of narratives—as
mentioned earlier. In addition, Benner (1984) also noted that qualitative distinctions
related to practical knowledge might be elaborated and refined only as nurses
compare their clinical judgments in actual patient care situations. Expanding on
Benner’s framework, Perryman (1999) used factor analysis in developing the
Attitudes/Beliefs/Knowledge/Practice Instrument in end-of-life decisions. Her work in
developing the instrument was also framed by three aspects of clinical judgment as
outlined by Benner: A caring practice, ethical concerns, and knowing (Perryman,
1999, p. 7).
Gadamer’s Hermeneutic Phenomenology
In the qualitative portion of this study, the second perspective, Gadamer’s
hermeneutic philosophy, is used as an integrative approach for understanding the
phenomenon of end-of-life care as experienced by Thai nurses, including lived
experiences in providing end-of-life care, ethical dilemmas, and clinical judgment
processes that comprise their experiences. Unlike other hermeneutic philosophers
13
(Heidegger, 1962; Husserl, 1962), Gadamer has particularly addressed the aspect of
ethics. The philosophical framework of Gadamer’s hermeneutic philosophy provides
a useful lens for gaining insight into nurses’ care of dying patients and ethical
dilemmas related to end-of-life care.
The goal of phenomenology is to describe human experience with all types of
phenomena (Streubert & Carpenter, 1999). The “dailiness” of everyday experiences
provides the main focus of phenomenological inquiry. In a phenomenological study,
“the researcher seeks a deeper and fuller meaning of the experience of the participants
of a particular phenomenon” (Mores & Field, 1996, p. 124). Moreover, van Manen
(1997) asserted that phenomenology offers a descriptive, reflective, interpretative, and
engaged mode of inquiry. Hermeneutic phenomenology is a “special kind of
phenomenological interpretation, designed to unveil otherwise concealed meaning in
the phenomena” (Spiegelberg, 1975, p. 57).
The work of the German philosopher, Hans-Georg Gadamer, has been
recognized as central to the evolution of contemporary hermeneutic philosophy
(Pascoe, 1996). The emergence o f hermeneutic discourse in nursing research is a
natural consequence of nursing phenomena, as well as social processes. Hermeneutic
phenomenology has been determined as a valuable framework for enabling nurses to
explore nursing knowledge about their practice (Larkin, 1998). In this study,
hermeneutic phenomenology refers to processes of interpreting the meanings of Thai
nurses’ lived experience in end-of-life care through individual narrative accounts.
Several nurse researchers have used Gadamer’s hermeneutic philosophy as the
framework for the interpretation of their findings (Benner, 1984; Diekelmann, 1988;
Larkin, 1998; Ome, 1992; Walsh, 1999). Pascoe (1996) also notes that Gadamer’s
14
hermeneutic philosophy may prove to be a valuable approach in enabling nurses to
gain a deeper and fuller understanding of phenomena that are central to nursing
practice.
One of the most well-known research applications of hermeneutic philosophy
in nursing research has been in the work of Benner (1984), who used hermeneutic
inquiry in her investigations of the phenomenon of caring. In nursing education,
Diekelmann (1988) has also applied hermeneutic philosophy in her discussion of
curriculum reform. Orae (1992) used Gadamer’s hermeneutic perspective to examine
the initial aftermath of a near-death experience and to uncover the meaning embedded
in the experience of survival. Moreover, the study of lived experience of Irish
palliative care nurses by Larkin (1998) applied Gadamer’s hermeneutic philosophy as
a framework. Another phenomenological study of the nurse-patient encounter by
Walsh (1999) used Gadamer’s hermeneutic philosophy for exploring the experience
of being a psychiatric nurse. It is evident that Gadamer's approach to hermeneutic
philosophy has found recent applications in nursing research and education. Thus,
Gadamer’s four concepts of prejudice, the fusion of horizons, the hermeneutic circle,
and play provide a framework for this phenomenological study.
In this research study, the researcher used the process of hermeneutic inquiry
to understand Thai nurses' responses to ethical dilemmas while providing care to
dying patients. Gadamer (1999) noted that a philosophical ethics is not only aware of
its own possible questions that people would ask, but takes these questions as one of
its essential contents to the unconditional moral in the situation. As Gadamer (1999)
noted, practical philosophy can do nothing, but pursue the force toward knowledge
and self-understanding that is always manifesting itself in human actions and
15
decisions. The practical philosophy may be explained in relation to what Gadamer
called “praxis.” In “Gadamer in Conversation” (2001), Gadamer determines that the
word “praxis” points to the totality of practical life, human action, and behavior, the
self-adaptation of the human beings as whole in this world (p. 78). Praxis may be
described as the sense that a person makes practical applications of scientific theories
adapted to reality.
Moreover, Gadamer (2001, p. 79) addressed “what is rational in the sense of
the right thing to do.” In this situation, he did not specifically give general orientations
about good or evil in the same way as the instructions for users that come with a tool.
Thus, moral knowledge is needed for people to leam and understand how to apply it
in the situation where an ethical dilemma occurs. “Moral knowledge determines what
needs to be done, what a situation requires; and it determines what is doable on the
basis of a conviction that the concrete situation is related to what is considered right
and proper in general” (Gadamer, 1999). Another question that Gadamer addressed is
that “what should be done.” To answer this question, an action is not just right, but
also it is useful, purposeful in that sense of right. Gadamer (1999) noted that moral
action is not right by reason of the fact that what is brought into existence is right;
rather its rightness lies primarily in us. In this study, ethical dilemmas related to end-
of-life care could be minimized if nurses have moral action as described by Gadamer.
The four concepts of Gadamer mentioned earlier, prejudice, the hermeneutic
circle, the fusion of horizons, and play are addressed in this study. Prejudice is related
to the notion of pre-understanding. Gadamer believes that prejudgments or prejudices
have an impact on interpretation and he also believes that meaning and understanding
are interconnected elements (Pascoe, 1996). Gadamer suggests that we cannot
16
interpret what we observe without our own prejudice, and theoretical and conceptual
assumptions and implications. The researcher must have some pre-understanding of
the subject before he can enter himself into the horizon of meaning. The “hermeneutic
circle'’’ is what Gadamer describes as a process of moving dialectically between a
background of shared meaning (the whole) and a focal experience within it (the part).
In this process, the researcher will have to determine her own understandings in order
to collaborate with those of the participants. At this point, the researcher will begin to
understand participants' meanings of experiences. This process is called the ‘‘fusion o f
h o r iz o n s understanding takes place when the horizon of the other intersects or fuses
with our own horizon and changes and extends our range of vision (Walsh, 1999).
The last concept described by Gadamer is "play. ” Play is described as how to get into
the hermeneutic circle of understanding that comprises individuals’ lived experiences.
Nurses engaged in research from the perspective of play would focus more on how
they relate toward the participants and endeavor to enter into the circle of
interpretation as a game to be played (Walsh, 1996). In undertaking this process, the
researcher can begin to respond in an appropriate and individualized way to the dying
patients' needs. This response constitutes an ethical knowing related to how nurses use
clinical judgment, as described by Benner et al. (1996) and through ideas that have
evolved from Gadamer and other philosophers.
These two perspectives— Benner’s clinical judgment and Gadamer’s
hermeneutic philosophy—were used as an overarching framework for the fifteen
research questions of this study. From a review of literature, the researcher also
developed a conceptual map reflecting main areas to be studied that provided
guidance for addressing the research questions.
Conceptual Map
Nurses’ Attitudes toward

Death and Dying
- Problems and Concerns
about End-of-Life Care
- Demographics: Age,
Level o f Education, Years
of experience, and income
Nurses’ Knowledge about

End-of-Life Care
- Demographics: Age,
Level o f Education, Years
of experience, and income
Figure 1. Attitudes, knowledge, ethical dilemmas, and clinical judgment related to
Thai nurses lived experience in end-of-life care in Thailand
18
Figure 1 illustrates how attitudes, knowledge, and ethical dilemmas are
conceptualized within the study in relation to Thai nurses’ lived experience in end-of-
life care and, ultimately, quality end-of-life care
Conceptual and Operational Definitions
From the conceptual map, the researcher of this study identified conceptual
and operational definitions appropriate for the research study. These are listed here as
they relate to both quantitative and qualitative aspects of the study.
1. Nurse
Conceptual Definition: A person skilled in caring for and waiting on the
infirm, the injured, or the sick and trained to carry out such duties under the
supervision of physicians.
Operational Definition: A nurse who meets the study criteria: (a) Thai
nursing licensure as registered nurse (GN or RN); (b) employed in a general hospital
in Thailand (500 or more patient beds); and (c) experienced in providing end-of-life
care in hospital settings in Thailand.
2. Dying Patient
Conceptual Definition: A terminally ill patient with incurable illnesses who
is close to the stage of death.
Operational Definition: A hospitalized patient who has been in the end-of-
life stage, regardless of ethnicity, religious belief, age, and types of illnesses.
3. Attitudes toward Death and Dying
Conceptual Definition: An individual or personal belief in the issues of death
and dying.
19
Operational Definition: Nurses’ beliefs or feelings about issues of death,
dying, and caring for dying patients. Attitudes were measured by the Attitudes toward
Death and Dying Survey.
4. Perceived Problems in End-of-Life Care
Conceptual Definition: Problems that Thai nurses perceive while providing
care for dying patients who hospitalized in general hospitals in Thailand.
Operational Definition: Questions related to the perceived problems
addressed by Thai nurses were embedded in the Attitudes toward Death and Dying
Survey.
5. Concerns on the Improvement of End-of-Life Care
Conceptual Definition: Important issues or concerns that Thai nurses believe
need to be improved in order to have a better quality of end-of-life care in Thailand.
Operational Definition: Questions related to important issues on the
improvement of end-of-life care were embedded in the Attitudes toward Death and
Dying Survey.
6. Knowledge of End-of-Life Care
Conceptual Definition: Particular knowledge on caring for dying patients
Operational Definition: Nurses’ knowledge on caring for hospitalized dying
patients in terms of general knowledge and ethical issues, pain and symptom
management, communication, death and dying issues related to end-of-life care.
Knowledge of end-of-life care was measured by the RN End-of-Life Knowledge
Assessment.
20
7. Selected Demographic Variables
Conceptual Definition: Primary demographic factors were assumed to have
relationships with nurses’ attitudes toward death and dying, and the knowledge on
end-of-life care. The factors included (a) age of participants, (b) the highest nursing
education that participants attained, (c) years of experience of participants in nursing
profession, and (d) annual income o f participants.
Operational Definition: Questions related to the age, level of nursing
education, years of experience in nursing profession, and annual income were
embedded in the RN Demographics Form.
8. Lived Experience
Conceptual Definition: The experiences in daily lives o f Thai nurses in
providing end-of-life care to dying patients.
Operational Definition: No operational definition was appropriate because
the definition came from participants of the study.
9. End-of-life Care
Conceptual Definition: The provision of care to dying patients during the end
stage of life in hospital settings.
10. Ethical Dilemmas Related to End-of-Life Care
Conceptual Definition: “Circumstances in which moral obligations demand
or appear to demand that a person adopt each of two (or more) alternative actions, yet
the person cannot perform all the required alternatives” (Beauchamp & Childress,
2001, p. 10).
21
11. Clinical Judgment
Conceptual Definition: Clinical judgment is “ways in which nurses come to
understand the problems, issues, or concerns of clients and patients, to attend to
salient information, and to respond in concerned and involved ways” (Benner et al.,
1996, p. 2).
12. Quality End-of-life Care
Conceptual Definition: The provision of care to dying patients during the end
stage of life in response to physical, psychological, social, and spiritual needs of the
patients in order to help the patients to have a peaceful death.
Summary
Chapter I introduced the problem of discovering how Thai nurses’ attitudes,
knowledge, ethical dilemmas, and clinical judgments become significant concerns for
quality end-of-life care. The statement of problem and significance of the study were
presented in relation to the increasing number of older persons with chronic illnesses
and those terminally ill, as well as the limited research on end-of-life care in Thailand.
The assumptions and research questions of the study were then addressed. The
theoretical framework was described in terms of the concept of clinical judgment by
Benner et al. (1996) and Gadamer’s hermeneutic philosophy (1976). This framework
22
is used to guide the study in terms of attitudes, knowledge, ethical dilemmas, and
clinical judgment processes relative to end-of-life care in Thailand. The next chapter
presents a review of the literature pertinent to the framework of the study and what is
known about the aging population with chronic illnesses, terminally ill and dying
patients, attitudes of nurses toward death and dying, nurses' knowledge of end-of-life
issues, ethical dilemmas, and clinical judgments related to end-of-life care.
CHAPTER II
REVIEW OF LITERATURE
“Being ready to die does not mean we will not have sadness in leaving this world.
It means we will know it is okay to leave. We can have a calm assurance that
our future and the future o f those we love are secure. ”
—Dunn, 1999, p. 28
This chapter contains a review of the literature on attitudes toward death and
dying, knowledge of end-of-life care, and the experiences of nurses working with
dying patients as they face ethical dilemmas that are related to end-of-life care. The
first section of this literature review provides a description of aging populations with
chronic illness, as well as terminally ill and dying patients. The second section
provides a description of the attitudes of nurses toward death and dying, including
problems and concerns about end-of-life care, and knowledge about end-of-life care.
The third section presents an overview of end-of-life care and the end-of-life care in
Thailand. The last section presents ethical dilemmas and clinical judgments related to
end-of-life care in Thailand.
The following databases were searched for pertinent literature: CINAHL,
MED-LINE, Health Reference Center, Books in Prints, Dissertation Abstracts
International, and PsychlNFO. In searching the literature, key words that were used
included (1) attitudes toward death and dying, (2) knowledge about end-of-life care,
23
24
(3) end-of-life/palliative care, (4) ethical dilemma, (5) clinical judgment, and the
combination of all these key words.
Aging Population and Chronic Illnesses
The size of the aging population is continually and dramatically increasing,
not only in the United States but also in other countries worldwide. In 2000, in the
U.S., the number of persons 65 years old and over was about 40 million; in the next
10 years, the projection for these persons will be approximately 45.5 million (U.S.
Census Bureau, March, 2001, see Figure 2).
501
45 (
40 (
35000
30000
25000
20000
15000
10000
5000
1998 2000 2002 2004 2006 2008 2010
F em a les M a les " ■ Total
Source: U.S. Census bureau National Population Projections,

Summary Files, ‘Total Resident Population by 5-Year Age Groups”
http://www.census.gov/population/www/proiections/natsum-T3.html
Figure 2. The projections of aging population in the United States.
Similarly as in the U.S. and other countries worldwide, one of the most
significant phenomena observed in Thailand has been the dramatic increase in the
number and proportions of persons aged 60 and over. In 1985, throughout Thailand,
25
there were 3,352,700 persons aged 60 and over, which is 6.5% of the total population.
By the year 2015, these figures are projected to rise to 9, i 18,032, which will then
represent 13.2% of the total population (Thailand National Statistical Office, 1985).
In addition, when people get older, chronic illnesses often accompany the
aging process. In Thailand, the most common chronic illnesses causing death in older
adults are heart disease, cancer, and chronic renal failure. With the projected rise of
the aging population in Thailand, it is imperative for nurses to be concerned about the
elderly with chronic illnesses and to be prepared to provide care for those who suffer
from those illnesses. The issues of death and dying are inevitable when there is no
way to cure people with incurable diseases and the number of terminally ill and dying
patients that must be looked after. Thus, the need to care for terminal and dying
persons becomes essential.
Terminally 111 and Dying Patients
A number of terminally ill patients who are dying from chronic illnesses, as
well as the increasing numbers of the aging population, challenge healthcare
professionals to pay more attention to end-of-life or palliative care. Dying patients
with incurable diseases are suffering from the aggravation of their illnesses that
cannot effectively be cured and cared for by conventional medicines. Examples of
such incurable diseases are cancer, chronic renal failure, heart disease, and AIDS.
Hathirat (2001) discussed several reasons that bring about an increasing number of
terminally ill patients. These reasons include newly developed terminal diseases,
limited resources, high expectations and needs in relation to incurable diseases, a
rapidly increasing elderly population, a lack of understanding of the fact that death is
a natural stage of human life that should be related to a positive attitude toward death
26
and dying, and the availability of the high technologies of life-prolonging/sustaining
treatments. He also stated that it is evident that the number o f terminally ill patients is
rapidly increasing and may become problematic in Thailand (Hathirat, 2001).
The Spanish Association for Palliative Care (1993) described five conditions
that are required for a disease to be considered terminal and appropriate for palliative
care in order to see a broader picture of the characteristics of dying patients with
terminal illnesses. These conditions are: (1) progressive, incurable, advanced disease,
(2) lack of a reasonable possibility of response to active specific treatment, (3)
multiple problems or symptoms that tend to be intense, multifactorial and changeable,
(4) high emotional impact on the patient, family, and team that is related explicitly or
not to the proximity of death, and (5) expected survival of less than 6 months.
Similarly, Hathirat (2001) described a patient who is in the terminal stage of his/her
life and hopeless as: (1) intentionally wishing to have care and treatments in a
hospital, (2) having physical and psychological illness. (3) having no chance of
survival or cure by medical interventions, (4) experiencing suffering from illnesses or
interventions, and (5) having an inability to take care of himself/herself and help
others.
The need for quality end-of-life or palliative care is o f concern with the
increasing number of terminally ill patients and incurable diseases. By providing end-
of-life care to dying persons, the attitudes toward death and dying of the healthcare
providers are related to the given care. All nurses inevitably face the dying and death
of some of their patients, and need to provide empathetic care especially to the
grieving and bereaved families (Payne, Dean, & Kalus, 1998). Thus, their attitudes
27
toward death and dying are important to the quality of end-of-life care as described in
the next section.
Attitudes toward Death and Dying
Anxiety about death is a normal phenomenon when persons with serious
illnesses are facing the dying stage. Death has always been the most significant
question of the human experience, although it is a phenomenon that people try to
avoid (DeSpelder & Strickland, 1999), even though it is obvious that no one can
escape death. The definition of death is determined differently in different regions and
countries around the globe. There is a uniformly accepted criterion to determine death
in Western countries, such as the Harvard criterion of brain-oriented death that
stipulates that the end of brain activity is the death of a person. In Thailand many
neurosurgeons in Bangkok have adopted the Western brain-oriented death criterion
rather than determining death by the traditional heart-lung activity criterion
(Ratanakul, 1990). However, Thailand as a land of Buddhism, adheres to the
traditional cultural understanding which upholds a holistic view of death as a total
cessation of mental and physical functions in terms of the death of a whole person and
not in terms of the death of cells, tissues, or organs (Ratanakul, 1990), as postulated
by the Buddhist belief that has shaped Thai perceptions and values for centuries.
Discussions about dying have become more acceptable, and patients and
families have increasingly played a greater role in making end-of-life decisions and
treatment plans (Foley & Gelband, 2001). The cultural traditions and the possession
of a religious faith with a promise of life after death influence these attitudes because
28
they postulate the continuum of individual life in some forms (Robbins, 1983). Death
and dying are understood and experienced within a complex web of cultural and
social meanings. Societal attitudes have evolved in caring for dying persons and
concerns in end-of-life care (Foley & Gelband, 2001). Thus, in end-of-life care, the
respect for individual and cultural differences in attitudes toward death and dying is
considered an essential aspect of the appropriate care for dying patients (Olarte &
Guillen, 2001).
A dying person may have a variety of reactions as death approaches. Kubler-
Ross (1986) identified five basic stages of response as common to those facing death:
denial, anger or the “Why me?”, bargaining, depression, and acceptance of death. The
first stage is denial: when a dying person first learns about his/her diagnosis and
senses shock. This stage also is described as adaptive; the dying person requires it
after the initial unexpected shock (Kubler-Ross, 1986). Anger is the second stage of
response to death. The dying person does not accept that he/she will not be able to do
activities that were planned. This stage is very crucial because the angry reaction may
be directed to anyone in the dying person’s environment. The third stage is bargaining
in which the dying person believes that he/she can succeed in entering into some sort
of an agreement, which may postpone an inevitable death (Kubler-Ross, 1986). The
dying person attempts to gain more time by offering good behaviors and actions.
Depression is the next stage following the bargaining stage. The dying person then
becomes less active as well as weaker in fighting with the postponement of death.
Finally, the fifth stage is the acceptance of his or her fate. Kubler-Ross (1986) stated:
“if a dying person has had enough time... and has been given some help in working
29
through the previously described stages, he will reach a stage during which he is
neither depressed nor angry about fate” (pp. 112-113).
Similarly, Neimeyer (1994) studied personal attitudes toward death including
the fear of death, death avoidance, neutral acceptance (a stage where death is neither
feared nor welcomed), and an escape acceptance, which describes death as a welcome
alternative to a life full of pain and suffering. He noted that personal attitudes toward
death strongly influence how people live their lives. He also concluded that
individuals who exhibit a high neutral acceptance can live happy, fulfilled lives,
whereas those with a strong fear of death may be unable to live their lives fully,
particularly finding it difficult to have close relationships because they may fear the
death of their loved ones. It is necessarily important for those providing care for dying
persons to be concerned about these five stages of responses in order to help the dying
get through the dying processes, and to have experiences of peacefulness and a good
death.
In end-of-life situations, nurses are involved with patients from the beginning
of a diagnosed illness to the end stage of the illness. Thus, their perspectives on death
and dying issues are essential to dying persons’ quality of life and to the provision of
end-of-life care. Since attitudes are associated with behavior, it is important that
nurses, who care for dying patients and their families, recognize the effect of their
personal thoughts and feelings about death (Robbins, 1983).
There are many questions related to the attitudes of nurses toward dying
patients. For instance, nurses may have different attitudes toward such questions as:
Should terminally ill patients be informed about their prognosis?, who is going to tell
30
patients and their families if these patients are dying?, and can patients accept
themselves in such situations? Nurses must recognize how their attitudes may
influence their responses to these questions because they work hand-in-hand with
physicians to prolong life and cure the dying patients. Real change in standard end-of-
life care will only occur when professional attitudes toward dying and public
expectations of end-of-life care change (Byock, 1997).
In addition, communication with terminally ill patients and their families is not
always emphasized in nursing and medical schools. It is difficult to inform patients
and their families about bad news of terminal illnesses and that there is no hope that
the patient will get better. Morgan and Winter (1996) stated that one of the most
difficult aspects of death and dying issues for physician residents is in communicating
the bad news. Attitudes toward information and diagnosis disclosure are significant
for those caring for dying patients. In addition, DeSpelder and Strickland (1999)
stated that experiences with terminally ill patients and death have changed over the
last hundred years, including the place of death, the life-extending technologies, and
the funeral. Professionals, rather than the family and the friends of the deceased, carry
out the preparation for the dead and the surrounding rituals in the modem funeral
(DeSpelder & Strickland, 1999).
It is necessary for nurses to examine the traditions of other cultures as well as
the personal experiences and the natural coping mechanisms regarding death and
dying. Before nurses can help dying patients to overcome the fear of death and
optimize their lives, they must understand the patient’s fears and beliefs. However,
many of the most profound transformations in the attitudes of nurses toward end-of-
31
life care have come about as a result of activities in the legal arena (Zuckerman,
1999).
End-of-Life/ Palliative Care
End-of-life care may be defined as palliative care given to a dying person
during the end stage of life so that the terms end-of-life care and palliative care are
used interchangeably. Its goal is to offer an alternative way or better way to die
(McNamara, Waddell, & Colvin, 1995). Obviously, terminally ill patients, regardless
of the types of illnesses, are suffering from physical, psychological, social, and
spiritual distresses. In addition, in Thailand currently there is an increasing number of
patients needing end-of-life or palliative care.
The World Health Organization (WHO, 1990) defines palliative care as: “The
active total care of patients at a time when their disease is no longer responsive to
curative measures and when control of pain and other symptoms and psychological,
social and spiritual problems are paramount.” Physicians, nurses and other palliative
caregivers have been significantly involved in providing end-of-life care. As defined
by the WHO, palliative caregivers propose to (a) affirm life and regard dying as a
normal process; (b) neither hasten nor postpone death; (c) provide relief from pain
and other distressing symptoms; (d) integrate the psychological and spiritual aspects
of patient care; (e) offer a support system to help patients live as actively as possible
until death; and (f) offer a support system to help families cope during patients’ illness
and their own bereavement (Rousseau, 1998).
32
In addition, the National Hospice Organization (1993) noted that palliative
care refers to the therapy that enhances comfort, and improves the quality of a patient
at the end stage of his/her life. No specific therapy is excluded from consideration.
The test of palliative care treatment lies in the agreement by the patient, the physician,
the primary caregiver, and the hospice team that expected outcome is relief from
distressing symptoms, easing of pain, and enhancement o f quality of life.
According to the Robert Wood Johnson Foundation’s Last Acts Campaign in
1997, palliative care refers to “the comprehensive management of the physical,
psychological, social, spiritual and existential needs of patients, in particular those
with incurable, progressive illnesses. Palliative care affirms life and regards dying as a
natural process that is a profoundly personal experience for the individual and family.
The goal of palliative care is to achieve the best possible quality of life through relief
of suffering, control of symptoms and restoration of functional capacity while
remaining sensitive to personal, cultural, and religious values, beliefs and practices
(pp. 2-4).” In addition, there are six major skills sets that comprise end-of-life/
palliative care: communication, decision-making, management of complications of
treatment and the disease, symptom control, psychosocial care of patient and family,
and care of the dying (Foley & Gelband, 2001). The quality of end-of-life / palliative
care can be achieved with these goals and major skills, thus dying patients could
finally have a peaceful death.
There is a need for the perception and the recognition of the quality of end-of-
life or palliative care given, especially the care for dying patients. The Institute of
Medicine (IOM) defines quality of care as “degree to which health services for
33
individuals and populations increased the likelihood of desired health outcomes and
are consistent with professional knowledge” (IOM, 1990). With this concept of
quality of care, the conceptual model of the quality of care is based on both the
knowledge of health professional and the needs of the patient. The American
Geriatrics Society (1997) noted that the domains of quality of end-of-life care that are
important to the care of dying patients and their family: physical and emotional
symptoms, support of function and autonomy, advance care planning, aggressive care
near death (place to die, CPR and hospitalization), patient and family satisfaction,
global quality of life, family burden, survival time, provision of continuity and skill,
and bereavement.
Nurses provide more care to dying patients and their families than any other
healthcare professional so that quality end-of-life care depends on the availability of
well-prepared nursing professionals (Pimple et al., 2003). There is evidence that
nurses participate in end-of-life care including pain management (Ferrell &
McCaffery, 1997; Field & Cassel, 1997), management of other physical,
psychosocial, emotional, and spiritual dimensions (Vainio & Auvinen, 1996;
Weissman & Griffie, 1994), facilitation of communication with patients and families
(Ferrell, Virani, & Grant, 1999), and preparation of the staff and family for death
(Ferrell, 1998). A qualitative study by Singer, Martin, and Kelner (1999) indicated
that patients reflected their anticipation at the end-of-life stage in five domains of
quality end-of-life care: (1) receiving adequate pain-relieving medication and
symptom management, (2) avoiding inappropriate prolongation of dying, (3)
34
achieving a sense of control, (4) relieving burdens, and (5) strengthening relationships
with loved ones.
Recently, many healthcare professionals have realized that they need to find
appropriate ways to respond to substantial needs for end-of-life or palliative care
because they increasingly have a large number of patients afflicted with terminal
incurable diseases close to death. In order to promote quality end-of-life care, nurses
in practice have verified the need for nursing education curricula to include contents
related to caring for dying patients (Pimple et al., 2003). However, Field and Cassel
(1997) noted that the IOM reported that there are major deficiencies in end-of-life
care, including the absence of a death curriculum in medical schools, of the
availability of educational materials on end-of-life care, and of clinical experiences in
end-of-life care. They also pointed out that there is a compelling need to prepare
clinicians better to assess and manage symptoms, to communicate with patients and
families, and to participate in interdisciplinary care that meets the varied needs of
dying patients and those close to them. AH these deficiencies should be verified
because they may bring about problems and concerns about end-of-life care.
Problems and Concerns about End-of-Life Care
There are several major problems and concerns regarding the quality of end-
of-life care. The IOM and the National Research Council (NRC) reported that there
are barriers to quality of end-of-life care. These barriers include the lack of
professional education in palliative and end-of-life care for physicians and nurses, the
inadequate standard of end-of-life care and quality indicators for end-of-life care, the
inadequate training for health care personnel in symptom management in caring for
35
dying patients, the lack of reliable data at the end-of-life stage on quality of care, and
the low level of public investment in palliative care and end-of-life care research
(Foley & Gelband, 2001).
Like physicians, most nurses in the U.S. do not receive the training and
practical experience they need to provide care to dying patients (Foley & Gelband,
2001). Ferrell, et al (2000) noted that nursing curricula have been studied less in end-
of-life issues than medical curricula, but this has been changing, particularly in
response to the debates about assisted suicide and euthanasia. Education in end-of-
life/palliative care is essentially required for those who will be taking care of dying
patients. Palliative care nurses aim to provide holistic care for the dying patient,
focusing not only on the patients’ physical needs but also on their psychological,
social, and spiritual needs (Payne et al., 1998).
Knowledge about End-of-Life Care
One of the most critical challenges in end-of-life or palliative care is the lack
of education in palliative care among health care professionals (Raudonis et al.,
2002). This deficiency of knowledge in end-of-life care may have an impact on the
ability of caregivers to provide care to the dying patients and their families. Especially
in clinical settings, nurses have verified the need for nursing education curricula to
incorporate the content related to caring for dying patients (Pimple et al., 2003). The
Association of American Colleges of Nursing (AACN) and the City of Hope National
Medical Center (2000) developed the End-of-Life Nursing Education Consortium
(ELNEC). The main purpose of this collaboration was to coordinate national
education efforts in end-of-life care. The ELNEC curriculum contains 9 areas: (a)
36
nursing care at the end-of-life; (b) pain management; (c) symptom management; (d)
ethical/legal issues; (e) cultural considerations; (f) communication; (g) grief, loss,
bereavement; (h) preparation and care for the time of death; and (i) achieving quality
care at the end-of-life (AACN & City of Hope National Medical Center, 2000). The
curriculum is an exemplary innovation for nursing education not only in the United
States, but also in any other country.
End-of-Life Care in Thailand
The term, end-oflife or palliative care, is not a new concept in Thailand. It has
been used in health care services in Thailand for years. Nurses have taken a
significant role in the provision o f end-of-life care. Cultural and religious issues also
have played significant roles in providing care for the dying in Thailand. At the end-
of-life stage, nurses need to provide holistic care to dying patients in response to
physical and psychological needs, as well as social and spiritual needs.
Physical and Psychological Needs
There are similarities in any country in the provision of care in response to
physical and psychological needs. At the end-of-life stage, nurses are responsible for
the provision of care for patients in such activities as bathing, feeding, dressing,
transferring, and giving medical treatment as required. However, in Thailand, at the
end stage of life, when there is no way to help the dying patients to maintain their
daily living, alternative therapies are often used. Even though those alternatives are
not verified scientifically, patients and their families often prefer alternative care such
as the use of herbal medicines, acupuncture, and ointment therapies to support their
physical and psychological needs.
37
Social and Spiritual Needs
In the Eastern cultures, the response toward social and spiritual needs in end-
of-life care is often different than that is found in Western cultures. In Thailand,
people live together as an extended family, including grandparents, parents, and
children. This family structure has an impact on end-of-life care in regards to the
social needs of dying patients. In general, conscious terminal patients at the end stage
of life often wish to return home and to have a gende death in a familiar environment
while surrounded by their loved ones.
Moreover, to respond to the spiritual needs of dying patients in end-of-life
care, it is important for nurses to respect the faith and beliefs of their patients.
However, respecting the faith and religious beliefs of patients and their families
sometimes causes conflict for nurses. For example, the Buddhist belief on the subject
of organ donation sometimes creates a conflict. Some Buddhists believe that a dying
person should keep all the organs with which he or she was bom and they should be
buried with every part of his or her body. Moreover, Nakasone (2000) notes that in
Buddhism, organ transplantations are possible only at the expense o f another person’s
life, which is a violation of the precept that stipulates that one must refrain from
taking life. Thus in Thailand, organ donations have not been fully promoted. It is
important to understand these religious beliefs and not attribute this attitude toward
organ transplants to ignorance.
In Thailand, more than 90% of the total population believes in Buddhism and
Buddhists believe that end-of-life care should emphasize a peaceful and gentle death.
For a Buddhist, request for euthanasia represents a conflict between the respect for
38
life and the compassion to end continued suffering (Nakasone, 2000). The practice of
euthanasia is, however, acceptable in Buddhism when the continuation of life might
not be the best alternative and causes needless suffering for dying patients. Thus, for
nurses working with dying persons, decision-making regarding euthanasia and
assisted suicide clearly raise an ethical dilemma. Accordingly, nurses should strive
among individuals for a balance between dignity, needs, duties, and responsibilities.
However, it is evident that Thai nurses working with dying patients are
experiencing ethical dilemmas related to end-of-life care. These ethical dilemmas
have a direct impact on the services provided to the dying patients. The dilemmas can
develop into moral questions on the subject of what is right or wrong in the making
end-of-life decisions for a dying person suffering from terminal illnesses. The moral
response to suffering generates a heavy moral burden in nurses (Oberle & Hughes,
2001). Nurses are concerned about providing quality end-of-life care to dying
persons, but in doing so, they sometimes struggle to balance their personal beliefs and
their professional role obligations. This results in an ethical dilemma for them. The
next section will discuss the ethical dilemmas related to end-of-life care in Thailand.
Ethical Dilemmas Related to End-of-life Care in Thailand
Ethical dilemmas are “circumstances in which moral obligations demand or
appear to demand that a person adopt each of two (or more) alternative actions, yet
the person cannot perform all the required alternatives” (Beauchamp & Childress,
2001, p. 10). For example, nurses strive to improve the quality of end-of-life care, as
well as to maintain the human dignity and the quality of life of dying persons, thus
moral conflict may still occur while they are providing care services.
39
Possible objectives of end-of-life care are both (a) to cure disease and halt the
progress of a life-threatening disease or the aging process and (b) to relieve suffering
from disease and provide a good death (Poor & Poirrier, 2001). However, during the
end stage of life, these two objectives can cause ambiguity for health care providers in
their ethical decision-making. The conflict may occur when a practitioner is forced to
choose between pursuing advanced medical treatments for patients dying from
terminal illnesses, or withdrawing life-prolonging treatments to stop the suffering
caused by these terminal illnesses, thus supporting a gentle death. Knowing the
purpose of end-of-life care may not always help nurses decide between what they
believe is unethical versus what they believe is their role obligation. Oberle and
Hughes (2001) noted that the nurses experience moral distress when they believe that
the wrong course of action is being followed and that they are contributing to the
patient’s misery. This situation raises an inevitably ethical dilemma related to end-of-
life care among those nurses.
Each day nurses have to deal with the orders of physicians, the needs of the
dying patients, the demands of families, the rules of the law, the bureaucracy of the
hospital, and their own physical and emotional limits. Thus the conflict between some
of these preceding points may be expressed as an ethical problem in nursing
(Chambliss, 1996). These ethical problems cause ethical dilemmas in nurses. Oberle
and Hughes (2001) conducted a research study regarding the perceptions of doctors
and nurses on ethical problems in end-of-life decisions. Results of the study indicate
that the perspectives on ethical problems appeared different, because the doctors bore
the burden of having to make the decision and write the orders, whereas the nurses
40
bore the burden of living with the application of the decision made by someone else
(Oberle & Hughes, 2001). The moral obligation of nurses is to minimize suffering,
and the moral burden for them associated with making and responding to end-of-life
decisions. Conflicts between the perceived moral obligation and the associated burden
bring about dilemmas in the provision of end-of-life care.
Beauchamp and Childress (2001) address several types of moral conflicts that
raise ethical dilemmas: (1) a conflict between moral principles and rules, (2) a conflict
between moral requirements and self-interest, (3) a conflict between role obligations
and personal ethics, and (4) a conflict between ethics and law. In order to make a
broader picture of the ethical dilemmas related to end-of-life care that Thai nurses
confront, the following examples of ethical dilemmas are explored within a
framework of ethical principles:
Disclosure of Diagnosis (Giving Information)
Moral conflict related to disclosure and the provision of information to dying
patients often involves the ethical principle of respect for autonomy. To respect an
autonomous agent is, at a minimum, to acknowledge that person’s right to hold views,
to make choices, and to take actions based on his or her personal values and beliefs
(Beauchamp & Childress, 2001). In end-of-life care, respect for autonomy is
associated with the right of dying persons to know about the progress of their illnesses
and their right to make choices for themselves. However, this principle is probably the
most difficult to meet in Thailand because families require from practitioners that they
do not inform their patients about their diagnoses or prognoses. Families believe that
telling the truth about a terminal diagnosis will cause a worsening of the health of a
patient. This situation results in a moral conflict for a nurse between the respect for
41
the autonomy of a patient and beneficence (doing good). In addition, it is prevalent in
the Asian cultures that paternalism, rather than autonomy, dominates the decision
making. Paternalism is based on the claim that beneficence may override autonomy
(Silva, 1990). Specifically, end-of-life decisions are made not only on behalf of the
patients’ desires but also on the family needs and the physician’s recommendations.
Braun, Pietsch and Blanchette (2000) also argue that end-of-life decisions usually are
made by family deliberation and by consensus. Adequate supportive care of patients
with terminal illnesses includes the decision of whether or not to disclose the
diagnosis to the patient (Olarte & Guillen, 2001).
Withholding versus Withdrawing
A legal and ethical consensus exists that there is no difference between “not
starting” (withholding) and “stopping” (withdrawing) care (Campbell, 1998). This
aspect involves the ethical principles of beneficence and nonmaleficence. A clinical
judgment of withholding versus withdrawing may raise dilemmas for the health care
providers and for the family of the dying person. There ought to be a consensus
between the caregiver and the family on both the subjects of withholding and
withdrawing treatment for dying persons.
DNR versus CPR Orders
The do-not-resuscitate (DNR) order applies to almost all cases of medical
intervention and care, except for the intervention specifically intending to obtain the
resuscitation of the patient. This DNR order raises an ethical dilemma among nurses
even though the order comes from either the wish of a patient or the wish of his
family. The dilemma results from the imbalance between the ethical principles of
autonomy (the patient wish) and nonmaleficence (do no harm). However, the best
42
way to deal with the dilemma caused by the DNR orders is for nurses to concern
themselves with what is in the best interest of the patient and his family.
Euthanasia
Euthanasia is the assistance of death by physicians through the use of their
medical expertise to help ensure a painless death in circumstances of terminal illness
(Tschudin, 1994). Euthanasia (mercy-killing) is morally unacceptable in Thailand and
many other countries. Ratanakul (1990) postulated that, when a physician performs
what he believes to be a mercy-killing for his patient’s benefit, euthanasia actually is
the result of hatred and is unwholesome both for himself and for the patient. The
ethical principles of beneficence (doing good) and nonmaleficence (do no harm) may
be involved. Conflicts and ethical dilemmas occur when practitioners are unable to
balance their personal beliefs with their professional role obligations. For example, in
the case of a terminally ill cancer patient, where a nurse provides an analgesic in
response to a physician’s order for euthanasia, he or she could have an ethical
dilemma between helping the patient relieve his pain and ending his life. Thus, the
concept of euthanasia leads to a conflict between the ethical principles of beneficence
and nonmaleficence.
Limited Resources
The ethical principle of justice requires equity in the provision of services and
the distribution of resources to patients. Beauchamp and Childress (2001) stated that
the principle of justice identifies no particular aspects in which equals ought to be
treated equally, and that whatever aspects are relevant, persons equal in those respects
should be treated equally. Nurses face dilemmas when they are made responsible for
resource allocation because they believe that their decisions about resource allocation
43
to one patient may impact on another. For example, because of the shortage of beds, a
decision to continue the treatment of one patient might mean that another patient is
denied care because a bed is not available (Oberle & Hughes, 2001). In Thailand,
such a situation causes the nurses considerable distress. Organ transplants are another
example of distributive injustice in Thailand because elderly patients normally have
less opportunity to receive transplants than younger patients. With the application of a
criterion for transplants based on the age of a patient, justice is hard to maintain
because it is felt that the transplantation will sometimes provide better benefit and
effectiveness to younger patients than to older patients. Thus, distributive justice is
overridden by the principle of beneficence, which creates an ethical dilemma for
nurses.
Conflicts between the above principles create a significant concern for nurses.
These conflicts indicate that there is a vital need for both the specification and the
balancing of ethical principles (Beauchamp & Childress, 2001). The next section will
discuss factors that influence the clinical judgments of nurses that are used to deal
with ethical dilemmas.
Clinical Judgment
In making a clinical judgment, a person forms an opinion using critical
thinking to identify problems, solve problems, and make decisions (Harkreader,
2000). Clinical judgment refers to the ways in which nurses come to understand the
problems, issues, or concerns of clients/patients, to attend to salient information, and
to respond in concerned and involved ways (Benner et al., 1996, p. 2). It is clear that
clinical thinking is basically related to clinical judgment, thus nurses have to think
44
critically in order to make a clinical judgment that deals with problems and dilemmas
in end-of-life care.
Kataoka-Yahiro and Saylor (1994) have established a model of critical
thinking that assists nurses to make the clinical judgments needed for effective
nursing practice. The model is composed of four components: (1) a specific
knowledge base, (2) experience, (3) competencies, and (4) attitudes and standards of
critical thinking.
In applying the model of critical thinking in end-of-life care, it is necessary for
nurses to make clinical judgments that are based on the four components proposed by
Kataoka-Yahiro and Saylor (1994). A specific knowledge base is the first component
that is required in critical thinking to result in an effective clinical judgment in nursing
care. The thinking processes depend on the knowledge base of each individual nurse
in regards to science, liberal art, and nursing knowledge (Kataoka-Yahiro & Saylor,
1994). Nurses should have particular knowledge in end-of-life/ palliative care to care
for dying patients. Palliative care is the holistic approach that responds to the
individual needs of a patient in terms of physical, psychological, social, and spiritual
knowledge bases needed. The second component is the experience that the individual
nurse brings to nursing education. Different nurses may have different experiences in
clinical settings, thus the exchange of their experience can facilitate the making of
clinical judgments in end-of-life care. The third component is competencies, or the
cognitive processes used to make clinical judgments. Competencies related to quality
end-of-life care that nurses need in caring for dying patients include: the ability to
identify problems and dilemmas they confront while providing end-of-life care, the
ability to assess a dying patient’s needs, the ability to make decision on ways to
45
improve a patient’s health, and the ability to evaluate if the nursing care given has
improved a patient’s condition, which is an indication of quality end-of-life care.
In Thailand, clinical judgment related end-of-life care is fraught with
individual, ethical, cultural, religious, social, legal, economic, and medical
difficulties. Although racial, religious, and cultural differences influence the way the
physician views end-of-life decisions, such characteristics also will influence the way
dying patients and their families wish to be treated (Vincent, 2001). The following are
factors that influence the clinical judgment of Thai nurses in relation to end-of-life
care.
Wishes of Patients
A respect for the wishes of patients in terms of advanced directives or living
wills is a concern for nurses. The concept of advance directives has not yet been fully
applied in Thailand. In the United States, a well-prepared advance directive that
includes statements in relation to the values of a patient, goals, life plans, healthcare
choices, and relevant scenarios for those choices minimizes the dilemmas confronting
nurses (Campbell, 1998). Aging with Dignity (2001) states the "‘'five wishes" that
comprise a document helping dying persons express how they want to be treated if
they are seriously ill and unable to speak for themselves. The “Five Wishes” lets your
family and doctors know:
1. Which person you want to make health care decisions for you when
you can’t make them.
2. The kind of medical treatment youwant or don’t want.
3. How comfortable you want to be.
4. How you want people to treat you.
46
5. What you want your loved ones to know.
There are 33 states, including the District of Columbia, that apply the Five
Wishes under state law. Clearly, end-of-life decisions should be made in accordance
with what is believed to be in the best interests of the dying persons and their families
if the five wishes are inapplicable.
Medical Conditions
Dying persons at the end stage of life suffer from their existing illnesses. The
medical conditions of the dying patients are important to end-of-life decision making
in Thailand. Physicians and nurses will discuss the conditions o f the patients, as well
as the prognoses of terminal illnesses, between themselves and the family. In making
a decision, the nutrition and hydration, the use of life-sustaining technology, and the
withdrawing/withholding of treatment may all be considered under a mutual
agreement between the family and the health care practitioner and increasingly also
the wishes of the patient.
Economics
In Thailand, because there is a fee for services of the health care system,
another significant issue related to end-of-life decision making is related to money.
Thai people without health insurance and government support struggle with the cost
of health care services. The decisions for prolonging life or hastening death are
sometimes concerned with financial issues, especially at the end stage of life.
Economic analyses of costs for various end-of-life therapies are used to help make
decisions in health care services when resources are constrained (Pronovost & Angus,
2001). Physicians are responsible for the allocation of scarce resources in end-of-life
decisions, and of the cost-effectiveness of end-of-life therapies.
47
Moreover, the financial status of dying persons and their families is considered
as a significant factor in end-of-life decisions and its therapies. Families of poorer
terminally ill patients experience adverse economic effects on end-of-life care. In the
U.S., the authors of the Study to Understand Prognoses and Preferences for Outcomes
and Risks of Treatment (SUPPORT) report that families o f seriously ill patients
experienced substantial economic losses, in 20% of the families a person had to stop
working to become a caregiver and 31% of the families lost most of their savings
(Covinsky et al., 1994).
Cultures and Beliefs
Cultural factors and belief systems play an important role in the making of
end-of-life decision in Thailand. One factor that makes an important difference in the
provision of end-of-life care is the cultural variation found in the population (Ekblad,
Marttila, & Emilsson, 2000). The response to the needs of dying persons regarding
cultural issues requires a better understanding of the beliefs of the individuals and
their families. Thus, ultimately for the patient, end-of-life decisions should be based
on considerations dealing with the promotion of human dignity and the improvement
of the quality of life.
The above factors often cause ethical dilemmas in end-of-life decision for
nurses and physicians. These dilemmas are related to moral conflicts caused in those
providing care by decisions that are meant to be the best interest of the dying person.
Sum m ary
Chapter II presented a review of the literature indicating that caring for the
dying is difficult. The literature review is related to several main concepts in this
study: (1) the attitudes of nurses toward death and dying, (2) knowledge about end-of-
48
life care, and (3) ethical dilemmas and clinical judgments related to end-of-life care.
Decision-making in end-of-life care raises conflicts and ethical dilemmas for nurses
by creating difficulty in balancing their personal and professional beliefs. Culture,
religious belief, and the role of family members have an impact on the end-of-life care
in Thailand.
Thus, nurses should be concerned about providing holistic care in relation not
only to the physical and psychological needs, but also to the social and spiritual needs
of the dying patients in respect of their faith. Nurses, more than other health care
professionals, are the frontline caregivers for dying patients. Thus, they should be
adequately educated and prepared for the provision of quality end-of-life care. They
essentially provide support not only to the dying patients but also to the grieving
families. In order to minimize conflicts, the strict application of appropriate clinical
judgment processes is necessary when ethical dilemmas occur. There is a need to
support nurses in their roles as advocates for the dying persons and their families, and
for continuous education on end-of-life care in the provision of terminal care. The
researcher for this study examined the relationships between factors influencing
attitudes toward death and dying, and knowledge about end-of-life care. The next
section will discuss the methodology used in this research study.
CHAPTER III
METHODOLOGY
“The interpretive study o f nursing practice provides new insights into how
skilled clinicians make judgments in their everyday practice."
-Benner et al., 1996, p. I
The preceding chapter reviewed the literature that has been done in the area of
end-of-life or palliative care. This chapter describes how the study was designed and
conducted. The chapter is organized into several different sections: (1) overview of
the study; (2) research questions; (3) study sample; (4) instrumentation; (5) research
design; (6) van Manen’s method; (7) pilot study; (8) psychometrics of study
instruments; (9) procedure; (10) data analysis plan; and (11) rigor of the study and
trustworthiness. Ethical considerations of the study are then addressed, followed by
the limitations of the study design and a summary of the chapter.
Overview of the Study
The purposes of this study are threefold: (1) examine Thai nurses’ attitudes
toward death and dying, problems and concerns about end-of-life care, and
knowledge about end-of-life care; (2) determine relationships between Thai nurses'
attitudes toward death and dying, and knowledge of end-of-life care and selected
demographic variables (age, level of education, years of experience, and annual
income); and (3) explore Thai nurses’ lived experience in end-of-life care, and ethical
dilemmas and clinical judgments nurses used in resolving ethical dilemmas in order to
49
50
provide quality end-of-life care in Thailand. This study applied a triangulation
approach of both quantitative and qualitative methods to achieve all purposes of the
study.
In the quantitative study, with convenience sampling, self-administered
questionnaires were distributed to 600 Thai registered nurses working in six general
hospitals in the upper-north, lower-north, northeast, east, central and south of
Thailand. The researcher of this study used the Statistical Package for the Social
Sciences (SPSS) program version 11.0 for the data analysis in terms of central
tendency, frequency distribution, and percent. With the SPSS program, a descriptive,
correlation analysis also was conducted to determine the relationship between
attitudes of nurses toward death and dying and significant factors, including age, level
of education, years of experience and annual income that may influence the attitudes.
The relationship between knowledge of end-of-life care and these significant factors
also was conducted.
In the qualitative study, the researcher used a hermeneutic phenomenological
method to explore the perceived lived experience of individual nurses providing care
for the dying patients in a situation where an ethical dilemma occurred, and where
nurses’ clinical judgments were used in dealing with such a dilemma. An open-ended,
semi-structured interview was conducted with a purposive sample of twelve Thai
nurse participants to describe their lived experiences, the ethical dilemmas related to
end-of-life care and the clinical judgment processes that they use to deal with these
ethical dilemmas, and the quality end-of-life care that they provided.
51
Research Questions
The following 15 research questions were formulated to guide this study.
Research Question 1: What are Thai nurses’ attitudes toward death and dying
issues?
in Thailand?
towards death and dying issues and the level of education of Thai nurses?
of Thai nurses?
knowledge of end-of-life care and the age of Thai nurses?
knowledge of end-of-life care and the level of education of Thai nurses?
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knowledge of end-of-life care and the years of experience in the nursing profession of
Thai nurses?
knowledge of end-of-life care and the annual income of Thai nurses?
care?
Sample
A study sample refers to a subset o f a population from which participants in
the study were drawn. A sampling technique is a process of selecting a portion of the
population in order to represent the entire population (Polit & Hugler, 1999). The
sample in both quantitative and qualitative portions of this study was drawn from the
entire nursing population working in general hospitals in Thailand. In identifying a
study sample, there were three criteria that defined participants of the study. In both
quantitative and qualitative portions, these criteria for selecting a participant were: (a)
Thai nursing licensure as registered nurse (GN or RN); (b) employed in a general
hospital in Thailand (500 or more patient beds); and (c) experienced with providing
end-of-life care in hospital settings in Thailand. For the last criteria, the researcher
asked this question: “Have you ever had experience in providing care for dying
53
patients?” This question is in the RN Demographics Form. However, the researcher of
the study expected that all nursing participants had experience in providing end-of-life
care.
Quantitative Study
In the quantitative study, stratified random sampling was used to select
hospitals from which participants would be recruited. According to Polit and Hungler
(1999), “stratified random sampling is a variant of simple random sampling in which
the population is first divided into two or more strata or subgroups” (p. 286). In
Thailand, there are 22 general hospitals with 500 or more patient beds, under the
authority of the Ministry of Public Health. Geographically, there are six main
regions—upper-north, lower-north, northeast, east, central, and south— in Thailand.
The reason for stratifying the sample of the study in six main regions is that in
different parts of Thailand, people have different cultures that may have an impact on
end-of-life issues and the provision of end-of-life care. To enhance generalization of
the study, the researcher used the convenience sampling technique in selecting one
hospital in each of the six regions.
For developing sample size estimates for quantitative studies, a power analysis
was used. The power analysis procedure used in this study was based on the book.
Statistical Power Analysis, by Murphy and Myors (1998). In determining sample size
with four independent variables (age, level o f education, years of experience, and
annual income), to achieve power of .80, an effect size of .05, with a level of
significance of .05 (a = .05), a minimum sample size of 409 participants was
estimated (i.e., N = 405 + 3 + 1) (Murphy & Myors, 1998, p. 59).
54
In 2002, the total number of registered nurses employed in the 22 general
hospitals (n = 22) in Thailand was approximately 9, 558. Based on the total number of
general hospitals and the registered nurses employed in these 22 hospitals across six
main regions (upper-north, lower-north, northeast, east, central, and south) of the
country, the researcher of this study asked nurse administrators of each of the targeted
hospitals to select 100 RNs working in different practice areas (i.e. Med-Surg, I.C.U.,
Pediatrics, emergency) in these hospitals as the convenience sample to complete the
survey. Thus, the proposed sample size of the quantitative study was 600 participants
from the combined six regions, which met the calculated power analysis (N = 409).
Qualitative Study
Individuals are selected to participate in qualitative research based on their
firsthand experience with a culture, social interaction, or phenomenon of interest
(Streubert & Carpenter, 1999). In the qualitative study, a purposive sample was
selected through the following criteria: (a) Thai nursing licensure as registered nurse
(GN or RN); (b) employed in a general hospital in Thailand (500 or more patient
beds); and (c) experienced with providing end-of-life care in hospital settings in
Thailand. To participate in the qualitative study, a participant needed to sign the
informed consent before the interview was conducted. As Benner (1984) stated that
the problem solving of proficient or expert nurses differs from that of novice or
competent nurses, the researcher of this study asked nurse administrators of the six
targeted hospitals (upper-north, lower-north, northeast, east, central, and south) to
purposively select two participants who had varied ages, years of experience in
nursing, and different practice areas. Interviews were conducted before the
distribution of questionnaires so that some participants in the qualitative study may
55
have also completed a survey. Streubert and Carpenter (1999) noted that the actual
sample size for qualitative studies depends on data saturation indicating that there is
no new information, and that redundancy is achieved. The data saturation for this
study was achieved in the sixth hospital; thus, a total of twelve participants were
included; two participants from each region were interviewed.
Instrumentation
In the quantitative study, including an introduction letter (Appendix A), three
research instruments were used to obtain data: (a) Attitudes toward Death and Dying
Survey adapted from Tuch & Genesis ElderCare (1998) (Appendix B); (b) RN End-
of-Life Knowledge Assessment adapted from City of Hope (1999) (Appendix C); and
(c) RN Demographics Form, including demographic information developed by the
researcher of this study (Appendix D). The permissions for using and modifying the
Attitudes toward Death and Dying Survey and the RN End-of-Life Knowledge
Assessment were obtained from the authors of the instruments (Appendix E). The
authors of these instruments did not report validity and reliability. However, the
researcher of this study believes that contents of these tools are appropriate and
relevant for the assessment of Thai nurses' attitudes toward death and dying issues
and their knowledge of end-of-life care. Therefore, the researcher evaluated and
examined the quality and adequacy of these measuring instruments in terms of content
validity that is aimed to measure knowledge in the areas of attitudes toward death and
dying and knowledge of end-of-life care o f Thai nurse participants. She also
examined reliability of the two instruments for the degree of consistency of
measurement. The measurement of the validity and reliability of the instruments will
be discussed in detail in the section of psychometrics. In addition, all of the
56
instruments were translated into Thai language to enhance participants’ understanding
of the instruments because Thai people use English as a second language. The
translated instruments were approved by a Thai nursing professor with a doctoral
degree in nursing from the United States.
Attitudes toward Death and Dying Survey
The Attitudes toward Death and Dying Survey is composed of two main parts:
Part A, ten statements on attitudes toward death and dying issues; and Part B, two
questions about perceived problems in end-of-life care and important issues on the
improvement of the quality end-of-life care. In Part A, the ten statements contain both
positive and negative attitudes/beliefs toward issues of death and dying. Statements I,
3,4, 6 and 8 are negative statements on death and dying issues and statements 2, 5, 7,
9 and 10 are positive ones. The researcher of this study applied a five-level Likert
scale that ranged from strongly disagree, disagree, uncertain, agree, to strongly agree
level. Responses to the 10 statements were coded from “ 1-strongly disagree” to “5-
strongly agree.” Scores in each statement ranged from 1-5 so that with these ten
statements, total scores could range from 10-50, and a higher attitude score indicates a
positive attitude.
In Part B of the Attitudes Survey, the two questions were asked: (1) the most
important problems nurses perceived while providing care of the dying hospitalized;
and (2) the most important concerns related to the improvement of quality end-of-life
care. The participants responded through ranking the three most important problems
and concerns in response to those questions. The first question is: What do you think
are the most important problems in caring for the dying in your hospital? Nine
problems in caring for dying patients were addressed: (a) control of pain, (b)
57
depression, (c) loneliness, (d) legal and hospital regulatory concerns, (e)
communication with physicians and other professional caregivers, (f) communication
with family, (g) inability to meet spiritual needs, (h) uncertainty about what is best
care, and (i) other please specify.
The second question is: What are the most important concerns that would help
improve the end-of-life care in your hospital? Nine concerns were addressed: (a)
education and training in pain control, (b) greater access to hospice services, (c)
greater physician and nursing staff involvement, (d) greater family involvement, (e)
education in legal and regulatory concerns, (f) education in ethical issues, (g) use of
palliative care team, (h) greater emphasis on spiritual care, and (i) other please
specify.
RN End-of-Life Knowledge Assessment
Twenty questions with multiple choices about end-of-life issues and palliative
care are embedded in the RN End-of-Life Knowledge Assessment. There was only
one correct answer to each question. The knowledge assessment tool consisted of five
main areas in end-of-life care: (1) general knowledge and ethics related to end-of-life
care (questions 1 through 5); (2) pain management (questions 6 through 10); (3) other
symptoms management (questions 11 through 15); (4) communication in end-of-life
care (questions 16 and 17); and (5) conclusion of death, dying, grieving and end-of-
life care (questions 18 through 20). Knowledge scores were calculated as the number
of correct responses; total scores could range from 0-20.
RN Demographics Form
The RN Demographics Form consisted of several demographic questions
about the status of the individual registered nurse. Major areas of demographic
58
interest that the researcher assumed to have relationships with nurses’ attitudes toward
death and dying issues and nurses’ end-of-life knowledge included the age of
participants, level of nursing education, years of experience in nursing profession, and
annual income of participants. Other demographic variables with less interest, but
possible influencing end-of-life care experience, included gender, marital status,
religion, practice area, region of clinical practice, and experience in providing end-of-
life care.
In the qualitative study, the interview guide (Appendix F) was used to guide
procedural interviews. Each individual interview took approximately 45-60 minutes.
Interview Guide
The interview guide was translated into the Thai language and consisted of the
criteria for selecting a participant, location for conducting the interview, and questions
to be asked. Participants were asked the following questions:
1. What kinds of end-of-life issues have you experienced in providing
care for dying patients?
2. What does an ethical dilemma mean to you? Can you tell me about an
incident when you experienced an ethical dilemma that is related to end-of-life
care?
3. In the situation you described, how did you make clinical judgments
about the ethical dilemma?
4. What are your concerns on the improvement of quality end-of-life
care?
59
Research Design
As mentioned earlier, the study applied the triangulation approach including
quantitative and qualitative methods. The study had two phases: In Phase One, the
quantitative portion, a self-administered questionnaire was used to examine attitudes
of Thai nurses toward death and dying. Another tool was used to measure Thai nurses'
knowledge of end-of-life issues. Demographic data were also collected from all
participants. Benner’s clinical judgment was used as the framework in which nurses
provide end-of-life care regarding the dying patients’ conditions and needs, and they
also provide perspective for the family through the grieving process.
In Phase Two, the qualitative portion, Thai nurses with varying years of
experience in working with dying patients were purposively selected to be
participants in the qualitative interviews. A qualitative descriptive approach based on
hermeneutic phenomenology was used to describe the types of ethical dilemmas
experienced by Thai nurses and the clinical judgment processes they use to deal with
these dilemmas. Based on the two philosophical frameworks: Benner’s conceptual
framework of clinical judgment and Gadamer’s hermeneutic philosophy, the
qualitative study was also guided by van Manen’s methodology.
Van Manen’s Method as a Procedure for Data Collection and Theme
Analysis
Gadamer’s hermeneutic phenomenology and Benner’s clinical judgment
provide a philosophical underpinning for this research study. However, van Manen
(1997) has discussed the distinguishing feature of the German and Dutch
phenomenology that “there was a marked unconcern with methods and epistemology”
(p. 2). In Truth and Method, Gadamer (1989) explored the possibility of interpretation
60
but he did not provide a method for interpretation (Koch, 1996) and did not describe
specific ways to analyze phenomenological data. Thus, van Manen’s method was
used as a procedure for data collection and analysis in this study.
In his book, Researching Lived Experience: Human Science fo r an Action
Sensitive Pedagogy, van Manen (1997) stated that his book is an attempt to explicate
a hermeneutic phenomenological approach to human science research.
Phenomenological research finds its point of departure in the situation, which for
purpose of analysis, description, and interpretation functions as an exemplary nodal
point of meanings that are embedded in this situation (van Manen, 1997, p. 18). Van
Manen (1997) described, “lived experience” as the starting point and end point of
phenomenological study. The aim of phenomenology is to transform lived experience
into a textual expression of its meaningful essence (van Manen, 1997). He did not
specify a particular philosophy underpinning his methodological dimensions, but
instead he cited several philosophers—Heidegger, Gadamer, Husserl, and Dilthey—in
this book. The researcher of this study has adopted van Manen’s method because it is
compatible with Gadamer’s hermeneutic-based philosophy. Van Manen’s method
includes four research activities related to hermeneutic phenomenology. These four
activities are composed of:
Step one: Turning to the nature of lived experience. Lived experience is a
focal point of phenomenological research. Gadamer (1989) stated that the word
“experience” has a condensing and intensifying meaning: “If something is called or
considered an experience, its meaning rounds it into the unity of a significant whole”
(p. 60). In phenomenology, a phenomenon can be better understood by studying lived
61
experience. There are three main processes in this step to get started in conducting
phenomenological research:
1) Orienting to the phenomenon. This starting point of phenomenological
research is largely a matter of identifying what it is that deeply interests the researcher
and of identifying this interest as a true phenomenon (van Manen, 1997). In this
study, the researcher identified her interests regarding end-of-life care, ethical
dilemmas confronting Thai nurses while providing end-of-life care, and how the
nurses use clinical judgment to deal with this situation.
2) Formulating the phenomenological question. To do phenomenological
research is not only to question something phenomenologically but also to address the
question of what something is really like (van Manen, 1997). Researchers are
concerned with the essence of the question that reflects their interests. Gadamer
(1989) addressed the essence of the question as the opening up, and keeping open, of
possibilities. He also stated that the real power of hermeneutical consciousness “is our
ability to see what is questionable” (p. 13). In this process, research questions have
been formulated: (a) What is Thai nurses’ lived experience in providing end-of-life
care in Thailand? (b) how do Thai nurses describe their own ethical dilemmas related
to end-of- life care and the clinical judgment they use in dealing with the ethical
dilemmas?, and (c) how have Thai nurses provided quality end-of-life care?
3) Explicating assumptions and pre-understandings. Researchers often have
their own assumptions, pre-understandings, and existing knowledge related to the
phenomenon. Gadamer (1989) also mentioned about the concept of prejudice or pre-
understanding that we cannot interpret what we observe without our own prejudice,
and theoretical and conceptual assumptions and implications because prejudice can
62
influence the meaning and understanding of the text. Researchers should explicate
these assumptions before conducting the qualitative study. For this study, the
researcher acknowledged her personal assumptions before conducting qualitative
interviews and attempted to keep them outside the process of exploring the
phenomenon, so as to maintain openness to possibilities about the phenomenon that
might enfold.
Step two: Investigating experience as we live i t This step involves
exploring the phenomenon of interest by using personal experience as a starting point
and then gathering or collecting lived experiences from participants of the study. It is
also associated with the process of transformations of interesting experiences. Van
Manen (1997) stated that all recollection of experiences, reflections on experiences,
descriptions of experiences, taped interviews about the experiences, or transcribed
conversations about experiences are already transformations of those experiences.
Gadamer (1989) described the concept of “hermeneutic circle" as a process of moving
dialectically between a background of shared meaning (the whole) and a focal
experience within it (the part). This hermeneutic circle is compatible with the process
of investigating experience as van Manen described. As stated in the significance of
the study, the researcher experienced an ethical dilemma in which she could not
balance her personal beliefs and professional roles in caring for a dying person. In
clarification of the term “ethical dilemma,” the researcher translated this term into
Thai language, “nnwvinittnnnfllnBi'jjj” in a manner that maintains the accuracy of the
original meaning of this term.
Step three: Reflecting on the essential themes. Phenomenological reflection
helps the researcher to grasp the essence or meaning of a phenomenon. This step
63
includes conducting thematic analysis, composing linguistic transformations of
experiences, and interpreting through conversation. “In determining the universal or
essential quality of a theme our concern is to discover aspects or qualities that make a
phenomenon what it is and without which the phenomenon could not be what it is”
(van Manen, 1997, p. 107). This step of van Manen is similar to the process that
Gadamer described as the “fusion o f horizons;” understanding takes place when the
horizon of the other intersects or fuses with our own horizon and changes and extends
our range of vision. In this study, the researcher conceptualized the experience of
providing end-of-life care, having an ethical dilemma related to end-of-life care, and
the clinical judgments that nurses used in dealing with the dilemma in relation to the
provision of quality end-of-life care. She began to understand participants' meanings
of lived experiences, and then described themes through reading the transcripts in
order to find sentences that reveal meanings of the phenomenon.
Step four: Describing the phenomenon through the a rt of writing and
rewriting. This step is aimed at presenting findings or outcomes of a research study
in a manner that helps to enhance understanding of the phenomenon. It includes
attending to the speaking of language, varying the examples, writing, and rewriting.
Gadamer (1976) addressed the exploration of understanding by providing a strong
emphasis on language and he also noted that with the concept of “play,” the
researcher could play with the interpretations of experience in the art of language. The
researcher of this study applied this step o f hermeneutic writing to present
interpretative findings.
64
Pilot Study
The purposes of the pilot study were to: (a) establish reliability of the
Attitudes toward Death and Dying Survey and the RN End-of-Life Knowledge
Assessment; (b) determine practicality of the RN Demographics Form and Interview
Guide; (c) assess researcher’s skills: organizational, analytical and interview skills;
(d) assess appropriateness of the interview tool; and (e) determine feasibility of the
research design.
After obtaining approval from the Human Subjects Review Board (HSRB) of
the Office of Sponsored Programs at George Mason University (Appendix G), as well
as the authorization of the Ministry of Public Health in Thailand, the researcher
conducted a pilot study at a public community hospital in her hometown. This
community hospital has 30 patient beds located in a small town in the lower-north
region of Thailand.
Procedures in Pilot Study
The pilot study was organized in two parts: Quantitative and qualitative. In the
quantitative study, the pilot study was conducted with a convenience sample of 20
nurses selected by a nurse administrator of the hospital. The researcher informed the
nurse administrator of the study criteria: (a) Thai nursing licensure as registered nurse
(GN or RN); (b) employed in a general hospital (500 or more patient beds) in
# Thailand; and (c) experienced with providing end-of-life care in hospital settings in
Thailand. However, the 20 nurse participants in the pilot study did not meet the
second criteria because they worked in the community hospital (30 patient beds). An
introductory letter and each of the instruments were translated into Thai language. A
packet of the questionnaire included the introductory letter, the RN Demographics
65
Form, the Attitudes toward Death and Dying Survey, and the RN End-of-Life
Knowledge Assessment. The researcher did not use a specific informed consent for
the quantitative study because study purposes, design, data collection process,
confidentiality and risks were addressed in the introductory letter and the participant’s
completion of the questionnaire was assumed as the informed consent. Twenty
questionnaires were put in one envelope and given to the nurse administrator, who
was responsible for distributing and collecting the questionnaires. After two weeks,
the researcher received 15 completed questionnaires collected by the nurse
administrator. The nurse administrator could not collect 5 questionnaires because
nurse respondents did not return questionnaires in the period of time given.
In the qualitative study, the researcher asked the nurse administrator to select
two voluntary participants who met the study criteria for conducting the interview. A
packet of information for the qualitative interview contained an informed consent
form (Appendix H) and the translated Interview Guide, including the interview
process and questions to be interviewed. All participants read and signed the informed
consent form before conducting the interviews. The researcher conducted the
interview individually with two participants by using a tape-recorder in a quiet room
at the hospital. The interview procedure flowed smoothly with rich qualitative data in
response to all of the questions in the Interview Guide.
Benefits from Pilot Study
The pilot study helped the researcher in using the tape-recorder. By using the
SPSS program, the pilot study also provided reliability for the Attitudes toward Death
and Dying Survey and the RN End-of-Life Knowledge Assessment distributed and
practicality of the Interview Guide, as well as procedural clarity and feasibility.
66
Adaptations and modifications such as rewording and changes in the order of
questions of the RN Demographics Form, the Attitudes survey, the RN End-of-Life
Knowledge Assessment, the Interview Guide, and data collection procedure were
carried out as appropriate after the pilot study.
Psychometrics of the Study Instrument
The instruments (the Attitudes toward Death and Dying Survey and the RN
End-of-Life Knowledge Assessment) used in this study had not been reported with
validity and reliability. The researcher of the study had requested the authors of the
instruments to provide the psychometrics of the instruments, but they did not examine
the psychometrics. However, the authors of these instruments have used the
instruments in several current research and in the education projects related to end-of-
life care. Content areas of the instruments were relevant, since the researcher of this
study was interested in examining both the attitudes toward death and dying and the
knowledge in end-of-life care. Thus, the researcher identified the psychometrics of
these instruments used in this study in terms of validity and reliability.
Validity
The validity of the instruments is of essential concern in this research study.
Polit and Hungler (1999) stated that “validity refers to the degree to which an
instrument measures what it is supposed to be measuring” (p. 418). There are several
approaches in measuring validity of an instrument, such as face validity, content
validity, criterion-related validity, and construct validity. However, the researcher of
this study focused on the content validity of the instruments. The rationale of
examining content validity is that the researcher would like to measure knowledge in
a specific content area of end-of-life care that refers to the RN end-of-Life Knowledge
67
Assessment In addition, Polit and Hungler (1999) also noted that the issue o f content
validity arises in conjunction with measures of attributes other than knowledge, such
as in attitudinal measures. Thus, the researcher believes that the examination of
content validity of the measurement is appropriate to the Attitudes toward Death and
Dying Survey.
Polit, Beck and Hungler (2001) addressed that “content validity is concerned
with adequacy of coverage of the content area being measured and necessarily based
on judgment” (p. 309). Content validity of the study instruments was examined by an
expert team of five people who had varied experience in the nursing profession and
end-of-life issues. The expert team consisted of three doctoral students—two Thais
and one Saudi Arabian—and two American professors. An evaluation form for testing
content validity of the instruments established by Zakari, 1991 (Appendix I) was used.
The form consisted of ten criteria: (1) Clear and simple wording of questions, and
easy to understand; (2) Relevant to purpose of the study; (3) Comprehensive
questions; (4) Appropriate for Thai culture; (5) Appropriate length of each question;
(6) Appropriate length of entire questionnaire; (7) No bias responses in certain
direction; (8) Appropriate ordering of the questions; (9) Appropriate number of
questions; and (10) Appropriate to the scope of end-of-life issues. With these criteria,
two responses of “yes” and “no” with comments and additional comments were
focused. All of the expert team of five people agreed on criteria 1, 2, 5, 6, 7, 8, 9 and
10. Those who were not Thai did not answer the fourth criterion, which is “the
instrument is appropriate to Thai culture”, but the two Thai respondents said the two
instruments were appropriate to Thai culture. According to the third criterion, which
is “comprehensive questions,” one American professor disagreed with the Attitudes
68
toward Death and Dying Survey as consisting of comprehensive questions, but the
rest of the team responded that both instruments were composed of comprehensive
questions. One American professor gave extensive suggestions on the content and
grammatical areas. Suggested areas, comments, rephrasing sentences, and ordering
questions for improvement on the instruments’ content were taken as advice and the
instruments were revised accordingly.
Reliability
“Reliability of an instrument is the degree of consistency with which it
measures the attribute it is supposed to be measuring” (Polit & Hugler, 1999, p. 411).
Aspects that help the researcher measure reliability of the instrument include factors
such as stability, internal consistency, and equivalence. The internal consistency/
homogeneity approach to estimating the reliability of the instruments is probably the
most widely used method today. Polit and Hugler (1999) noted that the internal
consistency approach is not only that it is economical but also it is the best means of
assessing one o f the most important sources of measurement error in psychosocial
instruments. Thus, the researcher of this study focused on the internal consistency
procedures for examining the instruments being used in this study.
After testing the study instruments in a pilot study of 15 respondents, the
reliability of each instrument was examined by using the analysis of Scale (Reliability
Analysis) in the SPSS program. The coefficient alpha (Cronbach’s alpha) analysis
with the C.I. of 95% was calculated as a measure of the internal consistency for the
two instruments. The Attitudes toward Death and Dying Survey (10 items) exhibited
an alpha coefficient of .6100 with the statistical significance of .0028 (p < .01). The
RN End-of-Life Knowledge Assessment (20 items) indicated alpha coefficient of
69
.4912 with the statistical significance of .0206 (p < .05). The analysis confirmed the
reliability of each of the instruments used in this study. To make the instruments more
readable and understandable, rewording and rephrasing of statements and reordering
of questions were slightly adjusted. After revision of the instruments was completed,
the procedure of data collection began in July 2002.
However, in conducting the quantitative study with a total of 600 (response
rate 538) respondents in six general hospitals of Thailand the reliability of these tools
dropped: the attitude survey (a = .2924) and the knowledge assessment tool (a =
.3143). The explanation for decreasing reliability of the two tools is that alpha is the
average correlation of all pair-wise correlations across items, and the correlation
coefficient is related to the population being studied as the more homogenous the
population from which the sample is taken, the lower the correlation between items.
According to this study, the sample is very homogenous in terms of background
education, and religion so that the coefficient alpha of the tools is not high. Moreover,
the alpha is also associated with the number of items included in the instrument.
Using Spearman Brown formula (Pedharzur, & Schmelkin, 1991, p. 91) in explaining
what would happen to alpha when number of items is doubled as described in the
following table (see Table I) that the more number of items, the higher the alpha of
each instrument.
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Table 1
Spearman Brown Formula with Doubled Number o f Research Tools
Instruments Number of Items Alpha Doubled Alpha
Coefficient Number of Items Coefficient
(before) (after)
Attitudes toward 10 .2924 20 .45
Death and Dying
Survey
RN End-of-Life 20 .3143 40 .48
Knowledge
Assessment
Procedure
After the pilot study, the analysis o f content validity and reliability, and the
revision of the instruments, the researcher started the data collection process in six
general hospitals of the lower-north, upper-north, northeast, east, central and south
regions respectively. In the quantitative study, during July through September 2002,
the researcher contacted nurse administrators of each hospital to coordinate the
process of data collection, and then went to the targeted six hospitals. The nurse
administrators of the each hospital were informed about sample criteria in distributing
the survey. A convenience sample was used in which the nurse administrators
personally delivered survey packets to head nurses of each unit of the hospitals and
clarified the sample criteria to them. Head nurses of each unit then personally
distributed the survey to registered nurses who were available on the units. The survey
71
packet included the introductory letter, the Attitudes toward Death and Dying Survey,
the RN End-of-Life Knowledge Assessment, and the RN Demographics Form. The
researcher provided a postal box and stamp for nurse administrators to mail complete
questionnaires to the researcher’s home address. The questionnaires were returned to
the researcher during August through October 2002.
In the qualitative study, the researcher used open-ended, semi-structured
interviews for obtaining insight into the individual participants’ perspectives on the
ethical dilemmas and the clinical judgment processes related to the care of the dying,
and the quality end-of-life care. The Interview Guide developed by the researcher was
used as a tool in conducting the qualitative interview. The interviews took place in the
six hospitals during July through September 2002. In the six targeted hospitals located
in upper-north, lower-north, northeast, east, central and south, the participants who
met sample criteria, with varied ages, experience, and practice areas were purposively
selected by nurse administrators of each hospital. It is possible that these same nurses
completed the survey. However, they did not see the survey packet before interviews
were conducted since the researcher asked nurse administrators to distribute the
survey after all interviews were completed. Individual interviews of approximately
one hour were audiotaped in a private and quiet room in each hospital. The researcher
and a research assistant transcribed the interview verbatim in Thai. A copy of each
transcription was then returned to each participant to verify the accuracy of the
transcribed contents. All participants returned the transcriptions with some additional
contents and suggestions to the researcher. The researcher redrafted the transcriptions
and then translated them into English. Translated transcripts were sent to three Thai
nursing professors who validated the accuracy of the translations. All of these
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professors possessed a doctoral degree in nursing from the United States. In addition,
the researcher and the chair o f the dissertation committee independently read all
transcripts, and then summarized and compared essential themes of the transcripts.
D ata Analysis Plan
An analysis of the data of the study was planned in response to each research
question. In the quantitative study, Research Questions 1 through 12 were analyzed by
using the Correlate (Bivariate) in the SPSS program to perform descriptive and
correlation analyses. In the qualitative study, Research Questions 13 through 15 were
analyzed by using van Manen’s approach to qualitative data analysis.
Quantitative Analysis
Quantitative data analyses were conducted for computation and analyses of the
quantitative portion of the study. Coding proceeded by checking every item on each
questionnaire for response errors. Missing data were applied into the range of 11-99 in
unanswered items of questionnaires. After the coding process, the researcher then
entered the data into the SPSS program of a computer database.
For Research Questions 1, 2, 3, and 4, data from surveys were analyzed with
descriptive statistics and presented in terms of frequency and percentage. In the
Attitudes toward Death and Dying Survey, for the first ten questions, scores ranged
from 1 to 5, with 5 indicating that the participant "strongly disagreed" with the
statement. For question 11 and 12 of the Attitudes toward Death and Dying Survey,
the researcher used the descriptive statistics in the SPSS program to describe
participants' perceptions of the most common problems encountered by dying patients
in the hospital and the measures to improve end-of-life care most frequently
mentioned by participants. In the RN End-of Life Knowledge Assessment, the
73
researcher scored the surveys and calculated a total score of correct answers for each
participant; each question counts one score. A total score for each of the two
instruments was computed in terms of frequency and percentage through the SPSS
program.
For Research Questions 5, 6, 7, 8, 9, 10, 11 and 12, the SPSS program was
used to analyze data through correlation analysis that indicates the relationships
between dependent variables (attitudes and knowledge), and independent variables
(age, level of education, years of experience, and annual income).
Qualitative Analysis
For Research Questions 13, 14 and 15, the researcher focused on the third step
of van Manen’s approach to data analysis as described earlier as hermeneutic
phenomenological reflection. After qualitative data were transcribed verbatim, the
researcher read each transcript while listening to the audiotape. Any inaccuracies in
the transcription were corrected. The researcher then reread each transcript carefully
to identify categories that frequently emerged from the texts. The researcher then
identified and extracted significant statements from all transcripts. These statements
were then interpreted into a coding system developed by which the researcher
managed and organized subcategories. The codes and categories of qualitative data
were noted and reviewed across all transcripts to form final categories that were
reflected in most of the conversations.
The researcher carried out the procedural analysis in collaboration with her
dissertation chair. Finally, the researcher wrote interpretive summaries for transcripts
that identify tentative themes that emerged from the data. After discussion and
validation of themes from all of the interviews (12 transcripts) with her dissertation
74
chair, the researcher wrote interpretive summaries of all other transcripts. In writing
the summaries, the researcher made connections between statements and themes
obtained from the interview process. Streubert and Carpenter (1999) support that it is
critical to identify how statements and central themes emerged and are connected to
one another if the final description is to be comprehensive and exhaustive. After
finishing the written summaries, the researcher and her dissertation chair discussed
themes reflected across the summaries and then finalized the summaries and themes.
Table 2
Presentation o f Research Questions, Variables/Measurement, Level o f Measurement,
and Methods o f Data Analysis
Research Questions Variables/ Measures Level of Tool Analysis
M easurement
1. What are Thai nurses’ - Attitudes toward - Ratio - Attitudes - Descriptive
attitudes toward death and death and dying Toward Death analysis
dying issues? and Dying (Central
Survey tendency.
Frequency
distribution and
Percents) by
SPSS
2. What are the most - Most important - Ordinal - Attitudes - Descriptive
important problems in caring problems in caring for Toward Death analysis
for dying patients in the dying and and Dying (Frequency
Thailand as perceived by Survey distribution and
Thai nurses? Percents) by
SPSS
75
Research Questions V ariables/ Measures Level of Tool Analysis
M easurement
3. What are the most - Most important -Ordinal - Attitudes - Descriptive
important concerns in caring concerns in improving Toward Death analysis
for dying patients that Thai end-of-life care and Dying (Frequency
nurses perceive are needed to Survey distribution and
improve quality end-of-life Percents) by
care in Thailand? SPSS
4. Are Thai nurses - Knowledge about - Ratio - RN End-of- - Descriptive
knowledgeable about end-of- end-of-life care Life Care analysis
life care? Knowledge (Central
Assessment tendency.
Frequency
distribution and
Percents) by
SPSS
5. What is the relationship - Attitudes toward - Ratio -R N - Correlation
between Thai nurses’ death and dying Demographics Analysis
attitudes toward death and - Age (year) - Ratio Form (Bivariate) by
dying issues and the age of SPSS
Thai nurses?
between Thai nurses' death and dying Demographics Analysis
attitudes toward death and - Level of education -Ordinal Form (Bivariate) by
dying issues and the level of SPSS
education of Thai nurses?
76
Research Questions Variables/ Measures Level of Tool Analysis
Measurement
attitudes toward death and - Years o f experience - Ratio Form (Bivariate) by
dying issues and the years of SPSS
experience in the nursing
attitudes toward death and - Annual income - Rado Form (Bivariate) by
dying and the annual income SPSS
of Thai nurses?
9. What is the relationship - Knowledge about - Rado -R N - Correlation
between Thai nurses’ end-of-life care Demographics Analysis
knowledge about end-of-life - Age - Ratio Form (Bivariate) by
care and the age of Thai SPSS
nurses?
10. What is the relationship - Knowledge about - Rado -R N - Correlation
knowledge about end-of-life - Level of education - Ordinal Form (Bivariate) by
care and the level of SPSS
77
Research Questions V ariables/ Measures Level of Tool Analysis
M easurem ent
11. What is the relationship - Knowledge about - Ratio -R N - Correlation
knowledge about end-of-life - Years of experience - Ratio Form (Bivariate) by
care and the years of SPSS
12. What is the relationship - Knowledge about - Ratio -R N - Correlation
knowledge about end-of-life - Annual income - Ratio Form (Bivariate) by
care and the annual income SPSS
of Thai nurses?
13. What is Thai nurses’ - Lived experience in - Narrative - Interview - van Manen’s
lived experience in providing end-of-life care account Guide method
14. How do Thai nurses - Ethical dilemmas - Narrative - Interview - van Manen’s
describe their own ethical - Clinical judgment account Guide method
dilemmas related to end-of-
life care and the clinical
judgment they use in dealing
15. How have Thai nurses - Quality end-of-life - Narrative - Interview - van Manen’s
provided quality end-of-life care account Guide method
care?
78
Table 2 summarizes all variables, measurement, level of measurement, and
methods of data analysis in response to the 15 research questions of this study.
Rigor of the Study
The researcher implemented specific procedures to maintain the rigor of both
quantitative and qualitative aspects of the study. Rigor in quantitative research is
related to the prevention of error in the study. In interpreting findings of the
quantitative study, the credibility of quantitative results is associated with assessing
the accuracy of results. Polit et al. (2001) noted that the credibility of quantitative
findings should be based on an analysis of evidence, which is both external and
internal evidence (p. 407). They described that the external evidence comes from the
body of prior research if the results are consistent. If so, the credibility of the findings
is enhanced. However, if the results are inconsistent with prior research, possible
reasons for discrepancy should be sought. Polit et al. (2001) also noted that the
internal evidence for the accuracy of the findings comes from an evaluation of major
methodological decisions made in planning and executing the study to determine
whether alternative decisions might have given different results (p. 407).
Trustworthiness
In order to conduct valid qualitative research, it is essential that the researcher
is aware of personal cultural perspective, bias, or agenda (Morse & Field, 1996).
Morse and Field (1996) noted that qualitative research studies have been criticized
because empirical researchers believed there was a lack of control over the validity
and reliability of the findings. Throughout a qualitative study, a researcher must
demonstrate its rigor through establishing trustworthiness.
79
One of the earliest attempts to describe the issue of trustworthiness was made
by Lincoln and Guba (1985). The term “trustworthy” in the qualitative paradigm
means that the processes of the research are carried out fairly and that the products
represent as closely as possible the experiences of the participants (Lincoln & Guba,
1985). Guba (1981) has identified four foundation components of trustworthiness that
strengthen the rigor of the work: credibility, dependability, confirmability, and
transferability.
Credibility or T ruth Value. Lincoln and Guba (1985) used the term
credibility as it related to internal validity in quantitative research. Credibility is
established when the participants’ perspectives have been reported as clearly and
accurately as possible (Morse & Field, 1996). However, Leininger (1994) has pointed
out that one limitation to the credibility of qualitative research may be too little time
in the field to understand participants’ lived experiences. In this study, all
interviewees were given the opportunity to validate, confirm, add, or change the
transcripts in order to ensure that the findings were represented according to their
experiences in providing end-of-life care.
Dependability. Dependability is a criterion met once researchers have
established the credibility of the findings (Streubert & Carpenter, 1999). The
dependability of qualitative data refers to data stability over time and over conditions
(Polit et al., 2001). In order to ensure the dependability of the data, interview
transcripts were read independently by the researcher of the study and the chair of the
dissertation committee and summaries and themes of the transcripts were compared.
Confirmability. Confirmability refers to the objectivity or neutrality of the
data, such that two or more independent people would agree about the data’s
80
relevance or meaning (Polit et al., 2001, p. 315). The way researchers have
determined the confirmability of the findings is to leave an audit trail, which is a
recording of activities over time that another individual can follow (Streubert &
Carpenter, 1999). In order to ensure confirmability, Leininger (1994) suggests that the
researcher must obtain evidence on the researcher’s interpretations, returning to the
participants to check the emerging interpretations. The researcher of this study sent
the summaries of transcripts to all participants and then gave all translations to three
Thai nursing professors to confirm the accuracy of the translations.
Transferability. ‘Transferability refers to the extent to which the findings
from the data can be transferred to other settings or groups and is thus similar to the
concept of generalizability” (Polit et al., 2001, p. 316). Streubert and Carpenter (1999)
also support that transferability is concerned with the probability that the findings
have meaning to others in similar situations. Transferability depends upon the degree
of similarity between two contexts. In this study, summaries o f transcripts suggested
that participants working in different practice areas gave similar narrative accounts
regarding the provision of end-of-life care.
In summary, rigor of quantitative research can ensure the validity and
accuracy of the study findings. In order to establish trustworthiness in the qualitative
research, it is imperative that the researcher must understand the findings in a holistic
context including actions, events, communication and other relevant contextual and
environment factors (Leininger, 1994).
Ethical Considerations
Based on ethical principles of autonomy, beneficence, nonmaleficence, and
justice, the researcher of this study promoted individual participant’s rights in the
81
study. The protection of study participants is important regardless of whether the
research paradigm incorporates a quantitative or qualitative approach. Thus, the
approval of the study was obtained from the George Mason University Human
Subjects Review Broad (GMU HSRB), the Ministry of Public Health, and the six
general hospitals in Thailand. In the quantitative study, the introductory letter was
addressed that anonymity and confidentiality would be maintained. In the content of
the letter, the researcher informed the participants not to write their names on the
survey, and findings from this study were confidential. However, in the qualitative
study, anonymity was not possible, since the researcher needed participants’
identification in order to send transcripts to all participants to review the data given by
them and to request the final report. In the presentation of qualitative findings,
pseudonyms were applied to all participants to maintain anonymity.
In the quantitative study, the introductory letter consisting of purposes of the
study, research procedures, and confidentiality of the data was provided to all
respondents. There was no consent form for the respondents in the quantitative study
because the introductory letter indicated all information about the study’s procedures,
anonymity, and confidentiality of findings from the study. If a respondent completed
and returned the survey to a nurse administrator, it served as his/her consent for
participating in the study.
However, in the qualitative study, an informed consent form was distributed to
all participants before participating in the processes of interviews. The statements in
the informed consent are composed of: (a) the purpose of the study; (b) research
procedures; (c) risks and benefits; (d) confidentiality of the data; (e) rights of
participants to participate in or withdraw from the study; and (f) persons to contact if
t
82
the participants have any questions, comments or concerns of the study. Participants
had no questions about consent forms and they signed the informed consent before
starting the interview process.
Limitations of Study Design
The research design of this study had some limitations. The first limitation
was associated with sample characteristics. As mentioned, the pilot study, with 20
nurse participants in the quantitative and 2 participants in the qualitative study, was
conducted in the community hospital in a rural area of Thailand, while the study
sample was recruited from general hospitals in urban areas. It would be better if the
researcher could have conducted the pilot study in a general hospital in order to have
a greater generalization of sampling.
A second limitation of the study design was a language issue. Even though
translations of the research instruments were approved by a Thai professor who
received a doctoral degree in nursing in the U.S., the researcher of this study is
concerned about accurate meaning of original instruments in the English version.
However, the instruments were translated and adapted in regards to Thai
understandings and interpretations of contents.
The last limitation was associated with the small amount of literature on end-
of-life care in Thailand. This limitation may have an impact on the credibility of
findings. However, this study will begin documentation in end-of-life/ palliative care
that has not been fully promoted in Thailand.
Summary
This chapter presented the research methodology including design,
instruments, study sample, pilot study, data collection, data analysis plan,
83
rigor/trustworthiness, ethical considerations, and limitations. The use of a
triangulation approach in this study helps the researcher expand the scope of findings
and significance of the study. Understanding and valuing the importance of both
qualitative and quantitative research methods in the development of nursing
knowledge can enhance nurses’ comprehension of the entire research process and
facilitate reading and using research in clinical practice settings (Beyea, 1997).
CHAPTER IV
PRESENTATION OF FINDINGS
“I will always prefer not to know, or to know as little as possible.

No human being knows when he is going to arrive in this world;
therefore I believe that his natural state is also not to know when he will depart. ”
—Anonymous
This research study applied a triangulation approach including quantitative
and qualitative methods. The study was undertaken to examine Thai nurses’ attitudes
toward death and dying, problems and concerns on end-of-life care, and knowledge
related to end-of-life care. In addition, the study was also undertaken to determine
factors that influence the attitudes and the knowledge, and to explore nurses’ ethical
dilemmas and their clinical judgment process used in resolving these dilemmas, as
well as the provision of quality end-of-life care in Thailand.
Chapter III described the methodology of this study including research design,
the study sample, pilot study, data collection, data analysis plan, ethical
considerations, and limitations of the study. In Chapter IV, the study findings are
organized into two main sections: (a) the quantitative study and (b) the qualitative
study, presented in response to the research questions. Presentation of findings from
the quantitative study consists of three main parts: the return and response rate;
demographic characteristics; and the presentation of quantitative findings related to
the research questions 1 through 12. Presentation of findings from the qualitative
84
85
study consists of two main parts: the descriptions of participants’ attributes and the
presentation of qualitative findings regarding themes related to end-of-life care,
ethical dilemmas and clinical judgments related to end-of-life care, and participants’
perceptions about what needed to be improved for quality end-of-life care. A
summary of quantitative and qualitative findings concludes the chapter. Research
questions that guided the data analysis of the study were as follows:
Research Question I: What are Thai nurses’ attitudes toward death and dying
issues?
in Thailand?
towards death and dying issues and the level of education o f Thai nurses?
of Thai nurses?
86
knowledge about end-of-life care and the age of Thai nurses?
knowledge about end-of-life care and the level of education of Thai nurses?
knowledge about end-of-life care and the years of experience in the nursing
knowledge about end-of-life care and the annual income of Thai nurses?
care?
Quantitative Study
The purpose of the quantitative study was to examine Thai nurses’ attitudes
toward death and dying, problems and concerns on end-of-life care, and knowledge
related to end-of-life care, and to determine variables that influence the attitudes and
knowledge. Presentation of quantitative findings is divided into three sections. The
first section presents response and return rate of the surveys. The second section
describes major and minor demographic characteristics—age, gender, marital status,
religion, levels of education, practice area, years of experiences, annual income,
87
region, and experience in providing end-of-life care—of the study sample. The last
section describes quantitative findings in response to each research question.
Return and Response Rate
A total of 600 questionnaires were distributed to nurses of the targeted six
general hospitals in six main regions of Thailand (upper-north, lower-north, northeast,
east, central, and south) in August and September 2002. With the collaboration of the
Ministry of Public Health in Thailand and the six general hospitals, all questionnaires
were distributed and collected by nurse administrators of each hospital. The
researcher asked the nurse administrators to select a convenience sample of nurses
who met the study criteria. With reminder calls made by the researcher to nurse
administrators of the hospitals in the upper-north and the south regions, a total of 540
questionnaires (90%) were returned in September 2002. Blank questionnaires (n = 2)
reduced the usable sample. An 89.7% response rate indicated 538 usable
questionnaires (see Table 3). The 538 respondents indicate the sufficiency of sample
size based on the power analysis (n = 409) calculated before distributing the surveys.
Table 3
Return and Response Rate o f the Study Survey
Questionnaires N %
Distributed 600 100
Returned 540 90
-Incomplete 2 0.3
Not Returned 60 10
Usable Questionnaire 538 89.7
88
Demographic Characteristics
From the RN Demographics Form, descriptive statistics regarding central
tendency and percentage of the sample on basic demographic characteristics were
computed by using the SPSS program. All demographic findings in the quantitative
study are reported in Table 4 and 5.
The ages of participants ranged from 21-53 years with an average age of 31.58
years, a median of 30.00 and a mode o f 25 with the standard deviation of 6.796.
Females represented 97.8% (n = 526) of the study sample, while 2.2% (n = 12) were
male. Single (n = 314, 58.4%) was identified as the most frequent marital status.
Single was followed by married status (n = 210, 39.0%) as the next most frequently
identified marital status. The 1.7% of respondents (n = 9) identified themselves
separated or divorce, and widowhood (n = 5, 0.9%) was identified as the least
frequent marital status. About ninety-seven percent (n = 523) of the sample were
Buddhist, 2.0% (n = 11) were Christian and less than 1% (n = 2) were Muslim. None
of them identified themselves as Hindu and 0.4 percent (n = 2) of the sample did not
reply to the question.
All respondents (N = 538) in the quantitative study had at least a Bachelor of
Science in Nursing (BSN). About ninety-seven percent (n = 524) reported the
Bachelor Degree as the highest level of education and less than 3% (n = 14) reported
the Master Degree. None of the respondents reported the Doctoral and Post-Doctoral
Degree in Nursing. The medical-surgical practice area (n= 335, 62.3%) was noted to
be the most frequent specialty, followed by the Intensive Care Unit (n = 125, 23.2%).
The Pediatric practice area represented 2.8% (n = 15), while the rest of the sample (n
89
= 63, 11.7%) represented Obstetric/Gynecology, Orthopedics, Emergency, and
Operating units as their practice areas.
The years of experience in nursing ranged from 1-30 with a mean of 8.95
years, a median of 7.00 years and a mode of 2 years with the standard deviation of
6.786. Levels of annual incomes ranged from 70,000-400,000 baht with a mean of
145,089.2 baht, a median of 120,000.00 baht and a mode of 100,000 baht, with the
standard deviation of 58,790.2 (/ U.S. dollar = 40 baht).
The respondents in the upper north region represented 14.9% (n = 80), the
lower north represented 17.3% (n = 93), the northeast represented 15.4% (n = 83), the
east represented 17.5% (n = 94), the central represented 18.0% (n = 97), and the south
represented 16.9% (n = 91). All respondents (n = 538, 100%) reported that they had
experience in providing end-of-life care.
The following tables present central tendency and percentage of demographic
characteristics in response to the questions in the RN Demographics Form. Table 4
presents major demographic characteristics (age, levels of education, years of
experience, and annual income). Based on the review of literature of this study and
the researcher’s experience, these major variables that were selected may have an
impact on Thai nurses’ attitudes toward death and dying, and their knowledge in end-
of-life care. It is, however, interesting to see other demographic characteristics of 538
nurse respondents working in different regions of Thailand.
90
Table 4
Descriptive Statistics o f Major Demographic Characteristics o f the Sample in
Quantitative Study
Variable N Mean Range SD %
Age 538 31.58 21-53 6.796 100.0
Level of Education 538 100.0

Bachelor 524 97.4
Master 14 2.6
Doctorate - -
Post-Doctorate - -
Years of Experience 538 8.95 1-30 6.786 100.0
Annual Income 538 145,089.2 70,000- 58,790.2 100.0

(baht)* 400,000
* 1 U.S. dollar is approximately equivalent 40 baht.
Table 5
Descriptive Statistics o f Minor Demographic Characteristics o f the Sample in
Quantitative Study
Variable N %
Gender
Female 526 97.8
Male 12 2.2
Total 538 100.0
Marital Status
Single 314 58.4
Married 210 39.0
Separated/Divorced 9 1.7
Widowed 5 0.9
Total 538 100.0
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Variable N %
Religion
Buddhist 525 97.2
Christian 11 2.0
Muslim 2 0.4
Hindu - 0.0
Unknown 2 0.4
Total 538 100.0
Practice Area
Medical-Surgical 335 62.3
I.C.U. 125 23.2
Pediatrics 15 2.8
Others 63 11.7
Total 538 100.0
Region
Upper North 80 14.9
Lower North 93 17.3
North-East 83 15.4
East 94 17.5
Central 97 18.0
South 91 16.9
Total 538 100.0
Experience in End-of-Life care
Yes 538 100.0
No - 0.0
Total 538 100.0
Quantitative Findings
Findings of the surveys were divided into three areas. The first area represents
findings from the Attitudes toward Death and Dying Survey. The second area
represents findings from the RN End-of-Life Knowledge Assessment. Last,
correlations among dependent and independent variables were represented. These
findings are presented here with each research question.
Research Question I: What are nurses ’ attitudes toward death and dying?
92
The Attitudes toward Death and Dying Survey was composed of two parts:
Part A, ten statements on issues of death and dying; and Part B, two questions on
problems found by nurses while providing end-of-life care and important concerns
about the improvement of care for dying persons. Findings of Part A helped the
researcher to answer Research Question 1. In part A, the ten statements consisted of
both positive and negative attitudes/beliefs toward issues of death and dying.
Questions I, 3, 4, 6 and 8 were negative attitude statements, and questions 2, 5, 7, 9
and 10 were positive attitude statements. The researcher applied the 5-Likert scale to
measure the degrees to which participants agreed or disagreed with those statements.
Five levels of the scale ranged from strongly disagree, disagree, uncertain, agree, to
strongly agree. Responses to the ten questions were coded from “ I-strongly disagree”
to “5-strongly agree” and in the data analysis the coding of negative statement scales
was reversed. Possible total scores could range from 10-50 with a higher score
representing a higher positive attitude toward death and dying. The following table
presents different levels of attitude scores in relation to frequency distribution. The
frequency distribution makes it convenient to see at a glance the highest and lowest
scores, the most common score, where the scores clustered, and how many
respondents were in the sample (Polit et al., 2001, p. 332)
Table 6 presents a frequency distribution of the Thai nurse respondents’
attitudes scores; all respondents (N = 538) completed the Attitudes Survey and there
were no missing data in this section. Overall scores ranged from 25-48 with an
average score of 34.38, a median score of 34, a mode of 34, and a standard deviation
of 3.632. About 52% of respondents (n = 280) scored lower than the average scores,
indicating that majority of Thai nurse respondents were more likely to have slightly
93
negative attitudes toward death and dying issues. However, Figure 3 below represents
a normal distribution of frequencies (bell-shaped curve) on the Attitudes toward
Death and Dying Survey. The normal distribution is symmetric, unimodal, and not
very peaked as many attributes of humans (e.g., height, intelligence) have been found
to approximately a normal distribution (Polit et al., 2001, p. 334).
Table 6
Frequency Distribution o f Attitude toward Death and Dying Score by Thai Nurse
Respondents
Attitude Score N % Cum. %
25 2 .4 .4
26 4 .7 1.1
27 5 .9 2.0
28 11 2.0 4.1
29 19 3.5 7.6
30 46 8.6 16.2
31 38 7.1 23.2
32 41 7.6 30.9
33 54 10.0 40.9
34 61 11.3 52.2
35 55 10.2 62.5
36 56 10.4 72.9
37 43 8.0 80.9
38 32 5.9 86.8
39 24 4.5 91.3
40 16 3.0 94.2
41 15 2.8 97.0
42 11 2.0 99.1
43 3 .6 99.6
44 1 .2 99.8
48 I .2 100.0
Total 538 100.0
94
200
100
Std. Dev = 3.63

Mean = 34.4
0 N = 538.00
25.0 27J 30.0 32.5 35.0 37.5 40.0 42.5 45.0 47.5
Attitudes Score
Figure 3. Normal distribution of the Attitude toward Death and Dying Scale
For each question of Part A in the Attitude toward Death and Dying Survey,
the table below indicated the percent of agreement and disagreement. The degrees of
agreement included both agree and strongly agree answers, and the degrees of
disagreement included both disagree and strongly disagree answers given by
participants on ten statements in the survey.
From Table 7, approximately 13% of respondents (n = 72) disagreed on the
first negative statements indicating that the majority of the Thai nurse respondents
agreed that the end of life is a time of great suffering. This result can be assumed that
the respondents had negative attitudes toward death and dying. O n the third statement,
the result indicates that majority of Thai nurse respondents (n = 436, 81.1%) agreed
with the fact that the use of morphine can cause the dying patient to stop breathing.
This means the respondents had unfavorable attitudes toward the use of pain
95
management in end-of-life care, and they might feel uncomfortable administering
morphine to patients for the purpose of pain relief. On the fourth statement, the result
indicates that almost 50% of respondents felt uncomfortable providing end-of-life
care. Because end-of-life care is a sensitive area for the family and healthcare
professionals, the respondents might not feel comfortable caring for dying patients.
However, this finding cannot be assumed that the respondents had negative attitudes
toward the provision of end-of-life care.
Table 7
Thai Nurse Respondents' Responses on the Disagreement o f Each Negative Statement
in the Attitudes toward Death and Dying Survey
Negative Statement N %
(Disagreement)
S#l. The end of life is a time of great 72 13.4

suffering
S#3. The use of strong pain medication 102 18.9

such as morphine can cause the patient to
stop breathing
S#4.1 am not comfortable caring for the 249 46.3

dying patient
S#6. When a patient dies I feel that 179 33.3

something went wrong
S#8.1 am not comfortable talking to 156 29.0

families about death
96
On the sixth statement, approximately 67% of the Thai nurse respondents felt
something went wrong when a patient dies. This result indicates that the majority of
respondents could not accept the death o f the patient as a normal process of human
life, and they might have negative attitudes toward death and dying processes. On the
eighth statement, the majority of Thai nurse respondents (71%) felt uncomfortable to
talk to the families of the dying patients about death. This result indicates that it
would be hard for the respondents to disclose information or communicate about the
death or the loss of their loved ones. However, as healthcare professionals, nurses
should be confident, and have an ability to communicate with the families and the
patients regarding death and dying issues.
On the other hand, table 8 reveals the degree of participants’ agreement on
each positive statement. On the second statement, most respondents (n = 527, 98.0%)
believed that they could help dying patients to have a peaceful death. This means that
Thai nurse respondents might realize that it was necessary to provide something to
fulfill needs of the patients at the end of life stage. The agreement on this statement
was favorable and anticipated by the researcher of this study. According to the
financial consideration in end-of-life care, almost 60% of respondents agreed with the
fifth statement that end-of-life decisions should be made regardless of financial issues.
However, the financial issues sometimes are of concern because Thai people in rural
areas are very poor and sometimes unable to afford costs of expensive treatments and
transportation to the city where a general hospital is located. The result from this
question was expected. On the seventh and tenth statements, the researcher expected
to have a high number of responses indicating agreement. The results from these two
statements indicate that the majority of Thai nurse respondents believed that they
97
could provide a peaceful death to dying patient, and encourage the patients to fight
with their illnesses and to not give up. On the ninth statement, almost 90% of
respondents believed that the dying patients have the rights to make decisions for any
treatment and intervention for themselves. Thus, nurses and other healthcare
professionals must respect decisions and preferences made by the dying patients.
Table 8
Thai Nurse Respondents ’ Responses on the Agreement o f Each Positive Statement in
the Attitudes toward Death and Dying Survey
Positive Statement N %
(Agreement)
S#2. Even though a patient is terminally 527 98.0

dying, something should be done to help
the dying to achieve a sense of peace at
the end of life
S#5. Family decisions about end-of-life 316 58.8

treatment should be made independent of
financial considerations
S#7.1 feel satisfied when my patients 455 84.5

experience what they believe to be a good
death
S#9. Patients have the right to refuse 474 88.1

medical treatment, even if that treatment
prolongs life
S#10. Never take away hope from 482 89.6

patients/families; even though it is
hopeless
98
Moreover, the following table (see Table 9) describes the scores on the
Attitudes toward Death and Dying Survey regarding participants from six general
hospitals in each region. Overall scores ranged from 34.1-34.8. The hospital in the
east region had the highest average of the attitude scores, and the hospitals in the
northeast and the central regions had the lowest average o f the attitude scores.
However, the findings indicated that there is no significant difference on the attitude
scores among different regions of the country.
Table 9
An Average o f Attitude Score in Different Regions o f Hospitals
Region N Mean Range SD
Upper North 80 34.7 25-42 3.7
Lower North 93 34.3 27-48 3.8
Northeast 83 34.1 25-42 3.7
East 94 34.8 27-42 3.5
Central 97 34.1 26-43 3.5
South 91 34.3 26-44 3.7
dying patients in Thailand as perceived by Thai nurses ?
The first question of Part B of the Attitudes toward Death and Dying Survey
asked: What do you think are the most important problems in caring for the dying
99
patients in your hospital? Nine problems were addressed; respondents were asked to
rank what they perceived to be the three most important issues: (a) control of pain, (b)
depression, (c) loneliness, (d) legal and hospital regulatory concerns, (e)
communication with physicians and other professional caregivers, (f) communication
with family, (g) inability to meet spiritual needs, (h) uncertainty about what is best
care and (i) other please specify.
Inability to meet Loneliness Control of pain

spiritual needs________________________
Figure 4. Thai nurse respondents’ perceived most important problems in end-of-life
care by percent
From Figure 4, it can be seen that findings of the survey indicated that the
“inability to meet spiritual needs” (n = 155, 28.8%) was noted to be the most
important problem in end-of-life care. This means that respondents considered the
necessity of the provision of spirituality to dying patients, but they were less likely to
meet the spiritual needs of dying patients. The second important problem was the
100
issue of “loneliness” (n = 98, 18.2%). Respondents may assume that dying patients
would feel lonely; thus psychological support from caregivers and the family
involvement are needed in order to minimize the issue of loneliness among dying
patients. Last, respondents considered the “control of pain” (n = 87, 16.2%) to be the
third important problem in end-of-life care. Pain is one of the most significant
symptoms obviously seen in dying patients, especially in the end stage cancer
patients. Thus, the education of pain management or pain relief is necessary in end-of-
life nursing care.
Research Question 3: What are the most important concerns in caring fo r
dying patients that Thai nurses perceive are needed to improve end-of-life care in
Thailand?
The second question of Part B of the Attitudes toward Death and Dying
Survey asked: What are concerns that you think would help improve end-of-life care
in your facility? Nine concerns were addressed; respondents were asked to rank what
they perceived to be the three most important concerns in the improvement of end-of-
life care: (a) education and training in pain control, (b)greater access to hospice
services, (c) greater physician and nursing staff involvement, (d) greater family
involvement, (e) education in legal and regulatory concerns, (f) education in ethical
issues, (g) use of palliative care team, (h) greater emphasis on spiritual care and (i)
other please specify.
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30
25
20
15
10
0 Greater emphasis Greater family involvement Education in

_________ on spiritual care______________________ ethical issues________
Figure 5. Thai nurse respondents’ most important concerns on the improvement of
end-of-life care
From Figure 5, it can be seen that the findings indicate that the “greater
emphasis on spiritual care” (n = 135, 25.1%) was noted to be the most important
concern on improving the end-of-life care. The majority of Thai nurse respondents
had particularly focused on the provision of spirituality on the care o f dying patients.
Spirituality is very important because this finding is congruent with the previous
research question that respondents perceived the important problem as they had the
inability to meet spiritual needs of dying patients. Respondents considered the
“greater family involvement” to be the second important concern on the improvement
of end-of-life care. Families of dying patients should be involved in parts of care
given to the patients because they have an ability to assess the patients’ needs and
preferences, better than healthcare professionals. Thus, family involvement should be
promoted. The last important concern was the “education in ethical issues.” As
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Scanlon (2003) noted, ethical dilemmas arise routinely in palliative care nursing; the
researcher of this study expected to have the important concern on ethical issues. It is
evident that nurses faced ethical dilemmas while providing end-of-life care. Thus, the
education in ethical issues related to end-of-life care is needed in nursing curricula.
In response to Research Question 4, the RN End-of-Life Knowledge
Assessment was analyzed. A total score could range from 0-20, with a higher score
indicating a higher knowledge in end-of-life care.
Table 10
Frequency Distribution o f Knowledge Score in End-of-Life Care by Thai Nurse
Respondents
Knowledge Score N % Cum. %
7 5 .9 .9
8 7 1.3 2.2
9 14 2.6 4.8
10 35 6.5 11.3
11 48 8.9 20.3
12 81 15.1 35.3
13 91 16.9 52.2
14 106 19.7 71.9
15 73 13.6 85.5
16 53 9.9 95.4
17 18 3.3 98.7
18 6 1.1 99.8
20 1 .2 100.0
Total 538 100.0
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All respondents (N = 538) answered the questions and there were no missing
data. With a maximum score of twenty and a minimum score of zero, the descriptive
statistics by the SPSS program indicates that the overall scores ranged from 7-20
scores with an average score of 13.22, a median score of 13.00, a mode score of 14,
and a standard deviation of 2.159. As demonstrated by Table 10, approximately 52%
of respondents had lower scores than the average of 13.2. However, the figure below
also represents a normal distribution of frequencies (bell-shaped curve) on the
knowledge score.
300 ---------------------------------------------------------------------------------------------------
Knowledge Score
Figure 6._Normal distribution of knowledge scores in the RN End-of-Life Care
Assessment
In addition, the knowledge assessment tool was divided into five main areas of
end-of-life care: (a) general knowledge and ethics related to end-of-life care
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(questions 1-5); (b) pain management (questions 6-10); (c) other symptoms
management (questions 11-15); (d) communication in end-of-life care (questions 16-
17); and (e) conclusion of death, dying, grieving, and end-of-life care (questions 18-
20). Table 11 indicates the number of respondents who gave correct answers in
response to each part of the assessment tool.
Table 11
Frequencies o f Thai Nurse Respondents’ Responses with Correct Answers in RN End-
of-Life Knowledge Assessment
End-of-Life Care N (Correct) %

Knowledge
Knowledge and ethics in

end-of-life care
- Qi 473 87.9
- Q2 304 56.5
- Q3 316 58.7
- Q4 455 84.6
- Q5 514 95.5
Pain management
- Q6 438 81.4
- Q7 172 32.0
- Q8 281 52.2
- Q9 176 32.7
- Q10 329 61.2
Other symptoms’
management
- Q ll 524 97.4
- Q12 78 14.5
- Q13 139 25.8
- Q14 290 53.9
- Q15 418 77.7
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End-of-Life Care N (Correct) %

Knowledge
Communication
- Q16 477 88.7
- Q17 457 84.9
Conclusion
- Q18 434 80.7
- Q19 315 58.6
- Q20 521 96.8
Findings from Table 11 indicate that the majority of Thai nurse respondents
had the highest score in the general area of knowledge regarding end-of-life care,
death and dying issues, as well as communication in end-of-life care. However,
findings also indicate that the weakest area of the respondents is the pain and
symptom management in end-of-life care. More attention is needed in this weakest
area.
The following table (see Table 12) describes the scores on the RN End-of-Life
Knowledge Assessment by participants from six general hospitals in each region. The
average scores ranged from 12.4-13.7. The hospitals in the east and the south regions
had the highest average of the knowledge scores, and the hospitals in the upper-north
region had the lowest average of the knowledge scores. However, the findings
indicated that there is no significant difference on the knowledge scores among
different regions of the country.
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Table 12
Thai Nurse Respondents' Knowledge in End-of-Life Care Score in Different Regions
o f Hospitals
Region N Mean Range SD
Upper-North 80 12.4 7-18 2.4
Lower-North 93 13.0 7-18 2.2
Northeast 83 13.0 7-17 2.0
East 94 13.7 7-20 2.3
Central 97 13.4 7-17 1.9
South 91 13.7 9-18 2.0
Correlation analysis (Bivariate) in the SPSS program was used for examining
relationships among variables. Table 13 demonstrates a correlation matrix that was
constructed to verify the associations among selected major variables in response to
Research Questions 5 through 12. To review, these research questions were:
towards death and dying issues and the age o f Thai nurses?
towards death and dying issues and the level o f education o f Thai nurses?
towards death and dying issues and the years o f experience in the nursing profession
o f Thai nurses?
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towards death and dying issues and the annual income o f Thai nurses?
Research Question 9: What is the relationship between Thai nurses ’
knowledge about end-of-life care and the age o f Thai nurses?
Research Question 10: What is the relationship between Thai nurses'
knowledge about end-of-life care and the level o f education o f Thai nurses?
Research Question II: What is the relationship between Thai nurses'
knowledge about end-of-life care and the years o f experience in the nursing
profession o f Thai nurses?
knowledge about end-of-life care and the annual income o f Thai nurses?
From these eight research questions, dependent variables were the Attitudes
Score and the Knowledge Score, and independent variables were age, level of
education, years of experience and annual income of participants. Pearson correlation
was analyzed with the level of significance at .05 (2-tailed). Table 13 presents the
correlation matrix of attitude and knowledge scores, and the major demographic
variables.
From the correlation matrix in response to research questions 5 through 12,
there are few relationships that are statistically significant: (1) a slightly positive
correlation (r = .147; p < .01) between the attitudes score and the level of education of
respondents; (2) a slightly positive correlation (r = .092; p < .05) between the
knowledge score and the level of education; and (3) a slightly positive correlation (r =
.095; p < .05) between the knowledge and the annual income of respondents. These
findings interpret: (I) the higher the level of nursing education, the higher the
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attitudes toward death and dying; (2) the higher the level of nursing education, the
higher the knowledge about end-of-life care; and (3) the higher the annual income of
nurses, the higher the knowledge about end-of-life care.
Table 13
Correlation Matrix o f the Attitudes Score and the Knowledge Score, and Major
Demographic Variables among Thai Nurse Respondents
Attitudes Knowledge
Score Score AGE EDUCATIO YEAREXPE INCOME
Attitudes Score Pearson Correlation
Sig. (2-taiied)
N 538
Knowledge Score Pearson Correlation .060
Sig. (2-tailed) .166
N 538 538
AGE Pearson Correlation
-.038 .060 -
Sig. (2-tailed) .379 .167
N 538 538 538
EDUCATIO Pearson Correlation .147 " .092 * .091 • -
Sig. (2-tailed) .001 .033 .035

N 538 538 538 538
YEAREXPE Pearson Correlation -.019 .063 .938 " .120 " -
Sig. (2-tailed) .652 .142 .000 .005
N 538 538 538 538 538
INCOME Pearson Correlation .001 .095 ’ .827 " .086 * .809 "
Sig. (2-tailed) .983 .028 .000 .046 .000
N 538 538 538 538 538 538
Correlation is significant at the 0.01 level (2-tailed).
’. Correlation is significant at the 0.05 level (2-tailed).
However, these relationships have low correlation coefficients that may be
interpreted with little practical value in the large sample size (N = 538), although
observed relationships are statistically significant. Polit et al. (2001) supported that
the absence of statistically significant results does not mean that the results are
unimportant—although, because of problems in interpreting the non-significant
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results, the case is more complex (p. 411). They also noted that if a very large sample
was used, the non-significant results would come from a low probability of a Type II
error (p. 411).
In addition, there are high relationships with statistical significance that were
found related to the independent variables themselves. For example, there are
statistically significant relationships between age and annual income (r = .827; p <
.01), and age and years of experience (r = .938; p < .01), and age and levels of
education (r = .091; p < .05). Because this quantitative study contains several
variables, Table 14 presents a summary of quantitative findings in response to each
research question.
Table 14
Summary o f Quantitative Findings in Response to Research Questions I through 12
Research Questions Variables/ Measures Analysis Findings
1. What are Thai nurses’ - Attitudes toward death - Descriptive analysis - Overall scores ranged from
attitudes toward death and and dying/ Attitude Score (Central tendency, 25-48 with an average score
dying issues? Frequency distribution of 34.38, a median score of
and Percents) by 34, a mode of 34, and a
SPSS standard deviation of 3.632.
- Sum: The majority of Thai
nurse respondents are more
likely to have negative
attitudes toward death and
dying issues.
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2. What are the most - Important problems in - Descriptive analysis - The 1“ important problem:
important problems in caring for the dying/ (Frequency Inability to meet spiritual
caring for dying patients in Ordering of the most distribution and needs (n = 155,28.8%)
Thailand as perceived by three important problems Percents) by SPSS - The 2nd: Loneliness (n =
Thai nurses? 98, 18.2%)
- The 3rd: Control of pain (n
= 87, 16.2%)
3. What are the most - Important concerns in - Descriptive analysis - The 1st important concern:
important concerns in improving quality end- (Frequency greater emphasis on
caring for dying patients of-life care/ Ordering the distribution and spiritual care (n = 135,
that Thai nurses perceive most three important Percents) by SPSS 25.1%)
are needed to improve concerns - The 2nd: greater family
quality end-of-life care in involvement (n = 124, 23%)
Thailand? - The 3rd: education in
ethical issues (n = 67,
12.5%)
4. Are Thai nurses - Knowledge about end- - Descriptive analysis - Overall scores ranged from
knowledgeable about end- of-life care/ Knowledge (Central tendency, 7-20 scores with an average
of-life care? Score Frequency distribution score of 13.22, and standard
and Percents) by deviation of 2.159.
SPSS - Sum: The majority of Thai
nurse respondents lack in
some areas such as pain and
symptom management
Ill
Research Questions Variables/Measures Analysis Findings
5. What is the relationship - Attitudes toward death - Correlation Analysis - No statistically significant
between Thai nurses’ and dying, and Age/ by SPSS relationship (r = -.038: p =
attitudes toward death and Pearson Correlation .379)
dying and the age o f Thai
nurses?
6. What is the relationship - Attitudes toward death - Correlation Analysis - There is a statistically
between Thai nurses' and dying, and Level of by SPSS significant positive
attitudes toward death and education/ Pearson relationship (r = . 147; p =
dying and the level of Correlation .001 ) * *
between Thai nurses' and dying, and Years of by SPSS relationship (r = -.019; p =
attitudes toward death and experience/ Pearson .652)
dying and the years of Correlation
between Thai nurses' and dying, and Annual by SPSS relationship (r = .001; p =
attitudes toward death and income/ Pearson .983)
the annual income o f Thai Correlation
nurses?
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9. What is the relationship - Knowledge about end- - Correlation Analysis - No statistically significant
between Thai nurses’ of-Iife care and Age/ by SPSS relationship (r = .060; p =
knowledge about end-of- Pearson Correlation .167)
life care and the age o f
Thai nurses?
10. What is the relationship - Knowledge about end- - Correlation Analysis - There is a statistically
between Thai nurses’ of-Iife care and Level of by SPSS significant positive
knowledge about end-of- education relationship (r = .092; p =
life care and the level of .033)*
11. What is the relationship - Knowledge about end- - Correlation Analysis - No statistically significant
between Thai nurses’ of-life care and Years of by SPSS relationship (r = .063; p =
knowledge about end-of- experience/ Pearson .142)
life care and the years of Correlation
12. What is the relationship - Knowledge about end- - Correlation Analysis - There is a statistically
between Thai nurses’ of-life care and Annual by SPSS significant positive
knowledge about end-of- income/ Pearson relationship (r = .095; p =
life care and the annual Correlation .028)*
income of Thai nurses?
** Correlation is significant at the 0.01 level (2-tailed).

* Correlation is significant at the 0.05 level (2-tailed).
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Qualitative Study
The purpose of the qualitative study was to explore the lived experience of
Thai nurses in providing end-of-Iife care. Qualitative findings of the study were
obtained from 45-60 minutes, tape-recorded, semi-structured interviews with 12 Thai
nurses working in general hospitals in six main regions of Thailand; there were two
participants from each region (upper-north, lower-north, northeast, east, central, and
south) of Thailand.
Qualitative Findings
From collecting and analyzing the qualitative data, the findings are presented
here in three main parts: descriptions of characteristics of participants, a description of
narrative accounts in relation to end-of-life care experience, ethical dilemmas and
clinical judgments, and themes. Participants" statements and phrases are incorporated
with the description of the data and themes.
This section was guided by Research Question 13: What is Thai nurses’ lived
experience in providing end-of-life care in Thailand?. Research Question 14: How do
Thai nurses describe their own ethical dilemmas related to end-of- life care and the
clinical judgment they use in dealing with the ethical dilemmas?, and Research
Question 15: How have Thai nurses provided quality end-of-life care?
Characteristics of Participants
Twelve participants were purposively selected from different parts of
Thailand. The participants were Thai registered nurses with a range of experience
from 1 year to 30 years. As Benner (1984) stated that the problem solving ability of
nurses differs with different levels of experience, the researcher requested nurse
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administrators of six targeted hospitals to select a variety of participants of varied
years of experience in nursing and of different practice areas and workplaces.
This section presents the characteristics of participants in order to have a better
understanding of stories related to each individual participant. To maintain
anonymity, pseudonyms were given to all of the following participants:
Nittaya has been working as a registered nurse in one of the general hospitals
in the lower-north region of Thailand for over 30 years. She has had much experience
in caring for dying patients. She serves on the ethics committee of the hospital and has
written some articles about ethical issues and Buddhism for the hospital. She is now
working in the administration department of the hospital.
Natalee is a young nurse with four years of experience in nursing practice. She
is now working in the hemodialysis unit of a general hospital in the lower-north
region of part of Thailand. She has had experience in providing end-of-life care to
patients with end stage chronic renal failure.
Lanta is also working in a general hospital in the upper-north region of
Thailand. She has approximately 10 years of experience in nursing. She is now
practicing in the AIDS unit of the hospital and she has provided end-of-life care for
dying HTV patients.
After graduation with her nursing degree, in the same hospital as Lanta,
Lalana has been working in the Intensive Care Unit (ICU) for over 10 years. She has
worked with dying patients with acute or chronic conditions. She has attended
conferences and seminars on the topic of end-of-life care.
Kanokwan has been working over 20 years in a general hospital in the
northeast of Thailand. She graduated with her Master’s degree in nursing a few years
115
ago. She has served as the director of a medical-surgical unit and developed several
innovative programs for the unit.
Kanda is also from a general hospital in the northeast area and is now in her
retirement year. She has worked as a nurse for over 30 years and has much experience
in providing end-of-life care in different units. However, she will plan to serve as a
consultant in med-surg area for the hospital after her retiremenL
With 10 years experience in the intensive care neuro-surgical unit, Ramita has
worked in a general hospital in the eastern region of Thailand so that she has had
experience with caring for dying patients and their families on her unit
Rapeepom is now working in a general hospital in the east of Thailand. She
graduated from a nursing diploma program and worked as a LPN for 10 years. She
continued her education and became a registered nurse 5 years ago. She has had
experience in providing care to dying patients.
Rungthip is in her 30th year in the nursing profession. She has worked in
different areas of a hospital in the central region of Thailand. She stated that “she has
much experience in providing care to dying patients.” Her idea on visiting book is
excellent. The visiting book is organized for families and relatives, as well as friends
of dying patients writing some notes for each other.
Rattana is working in the ICU of a hospital in the central region of Thailand.
She has had experience in providing care for dying and unconscious patients in her
unit. She is now in her 10th year of experience in the ICU.
Suratchanee is a novice nurse with four years of experience in nursing
practice. She is now working in the medical-surgical unit of a general hospital in the
southern area of Thailand and has had experience in providing care for end stage
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cancer patients. Because her own chronic illness, she is extremely interested in end-
of-life issues.
Sorada has also worked in the same hospital as Suratchanee. With the
geographic area, her experience in providing care for dying Muslim patients is of
concern. She is now in her 17th year in the nursing profession.
Uncovering Knowledge Embedded in End-of-Life Care Experiences
Findings from quantitative aspects o f the study described nurses’ attitudes
toward death and dying and knowledge of end-of-life care. The researcher believed
that quantitative findings would not be sufficient to understand nurses’ attitudes and
knowledge related to end-of-life care. Thus, the qualitative study was done to explore
the lived experience of nurses as caregivers in providing care o f dying patients.
Narrative accounts given from participants’ experience in providing end-of-life care
helped the researcher uncover knowledge embedded in nursing practice. As Benner
(1984) stated that “experience is a requisite for expertise” (p. 3), experience in
providing end-of-life care is related to the way nurses perceive the situations, use past
concrete situations as paradigms to deal with the actual end-of-life situation, and
provide appropriate resources in end-of-life decision-making. Expertise in complex
human decision making makes the interpretation of clinical situations possible, and
the knowledge embedded in this clinical expertise is significantly important to the
advancement of nursing practice and the development of the nursing profession
(Benner, 1984). However, because the study participants consisted of Thai nurses
with varied levels of experience in the nursing profession, the experience of nurses
who just graduated or had few years of experience was also explored in this study.
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Death and dying is an unavoidable topic when talking about life threatening
diseases and unbeatable illnesses. In end-of-life care, nurses are the major
professional caregivers who provide care to dying patients and their families. End-of-
life nursing care has an impact on the well-being and the death o f end stage patients.
Thus it is important to uncover knowledge embedded in end-of-life care through
analyzing and interpreting nurses’ lived experience.
After the introduction of the interview process, the researcher started the
interview by asking questions about participants’ years of experience in the nursing
profession and their practice areas. This helped to develop rapport with the
participants. As described in Chapter HE, methodology, qualitative analysis of data
particularly involved the third step of van Manen’s method—reflecting on the
essential themes—that includes conducting thematic analysis, composing linguistic
transformations of experiences, and interpreting through conversation.
In the interview processes, the researcher asked the participants questions by
using the Interview Guide: Could you please tell me about your experience in caring
for dying patients? This inquiry served to answer Research Question 13. Some
narrative accounts of the participants may not reflect the depth of lived experience
narratives as van Manen described because of the ways that Thai nurses express
themselves. Most participants used the word “we” instead of “I” in defining
themselves because individuals are more likely to use the term “we/ us” in Asian
cultures. Thus, the narratives may seem more descriptive, rather than reflecting the
direct experience of participants. The researcher of this study translated and used the
transcriptions exactly as the participants spoke.
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Research Question 13: What is Thai nurses' lived experience in providing
end-of-life care?
The qualitative analysis of participants’ answers to this question led to
identification of three categories of experiences reflected across interviews: Holistic
approach to end-of-life care, end-of life decision making, and nursing role in end-of-
life care.
Holistic Approach to End-of-Life Care
Participants described poignant experiences of providing holistic end-of-life
care that included attention to physical, psychological/emotional, social, and spiritual
needs. In end-of-life care, nurses, physicians, and other health caregivers pursue
providing quality of end-of-life care to dying patients. Most of participants in this
study gave rich narrative accounts of a connection between holistic care and end-of-
life care. This is illustrated by Rapeepom’s narrative account:
When discussing the care of dying patients, I think about a holistic

care concept encompassing the physical, psychological, social and
spiritual care of the patients. In practice, this means that in general
nurses would assess the problems of the patients and then set the
priority for their treatments. When assessing dying patients, I would
observe the following: the respiratory system, the blood circulation,
the digestive system, the vital sign, the neuro-sign, the coma scores,
and the intake and output of the terminal patient. I also realize that
nurses must provide psychological and emotional support to the
dying patients and their families.
Kanda gave a rich narrative account of holistic care that points a broader
picture of the care she had been providing to her patients. She stated that:
In terminal care, the nurses should be concerned about holistic care

in response to the physical, the psychological, the social and the
spiritual needs of dying patient. I provide hygienic care, a clean
environment, comfort care, and an appropriate diet in response to the
physical needs of the patients. I always ask the patients whether they
like or not the food provided by the hospital. If the patients are not
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satisfied with the food, the nurses should adjust the dietary plan for
them. For example in the cases of some terminal patients suffering
from the terminal stage of chronic renal failure, the patients would be
restricted on their sodium intake. However, they would always
request to have salt in their diet because they are used to it. I told
them then that it is going to make them worse, but that you may
sometimes have a little bit of salt with your food. Nurses also provide
psychological support to both the dying patients and their families.
For dying patients, it is important to note that this psychological
support may encourage them to fight their illnesses. For their
families, this psychological support may help them get through their
grief and to be ready to prepare a funeral. I would allow the families,
friends and relatives to spend more time with the dying patients when
they also can provide support to the dying in response to their social
needs. I would also encourage the families to provide spiritual
care/practice to the dying patients. Some families wish the dying
patients to listen Buddhist tapes in order to make the patient
peaceful. I would allow the families to play the tapes when it does
not disturb the other patients.
Holistic care seems to connect with caring for a dying patient. The nurse
provides support not only for the dying but also for the family of the dying because
the family primarily suffers from losing o f their loved one. It is similar to what Lalana
said:
I think that nurses should provide holistic care respecting the

principles of nursing practice. I mean by this that nurses should
provide holistic care in response to physical, psychological, social,
and spiritual needs of the dying patients while incorporating the
principles of nursing practice. To respond to the physical needs of
the dying patients, I perform a physical assessment, which includes a
review of signs and symptoms, vital signs, pain in cancer patients,
diet, and intake and output of the patients. I also provide them with
hygienic care and a clean environment such as clean bed sheets and
an optimum room temperature. In addition, I provide psychological
and social supports to both the dying patients and their families.
Moreover, as I mention earlier, I also promote cultural and spiritual
activities.
Ramita also supported that holistic care is extremely important to care at the
end of life. She also gave an example of providing care in relation to spirituality and
cultural tradition. Her narrative account was:
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I give total care in relation to the needs of the patients. I think holistic
care is extremely important for care at the end-of-life stage. With the
principle of nursing care, I provide end-of-life care in response to
physical, psychological, social and spiritual needs of the patients. For
example, I allowed a family and their relatives to practice spiritual
activities for the patients because they believe that these activities
would help them to have a peaceful death and to go to the heaven.
Ratana has been working in the Intensive Care Unit so she sees a large number
of dying patients. She mentioned about “total care,” which is more likely related to
holistic care as previously described by other participants. She said that:
I worked in the I.C.U and I took care of dying patients. Most of the
patients there were acutely ill and unconscious. I always try to
provide total care to these patients, thus preventing the complications
resulting from unconsciousness. I would assess the patient needs. For
instance, I evaluated patients with brain hemorrhage by observing
their ‘coma scores’ combined with a neurological check and other
signs and symptoms checks that would help set the priorities for the
patients in these serious conditions.
Malignancies are sometimes identified only when large or in a critical
location, and many cancer patients have no available treatments that substantially alter
the course (Foley & Gelband, 2001). It is evident that at the end stage, cancer patients
are suffering from many physical discomforts depending on where the locations of
malignancies are. Thus, cancer is one of the major incurable diseases that lead to
impending death in patients. Regardless of types and locations of cancer, a patient
who has been diagnosed with cancer is definitely sad when he or she first is informed
about the diagnosis. It is extremely hard for physicians and nurses to disclose the
diagnosis of cancer. Kanokwan described the three stages of cancer patient’s
condition since the beginning of being informed until the stage of hopelessness. She
explained that:
In this unit, there were a number of cancer patients who were

terminal for whom nurses could provide holistic care: physical,
psychological, social, and spiritual care. We know cancer as an
121
incurable disease. I am concerned about three stages for these

patients: (a) diagnosis, (b) cancer therapy, and (c) their mental
hopelessness.
The first stage is wHen patients initially find out about their
cancer diagnosis; at this point they are very weak and feel hopeless.
It is then crucial to give information to the patients. I discussed with
the physicians and the relatives of the patients how to inform the
patient of his diagnosis. At this stage therapeutic communication
skills are important. An ethical dilemma can occur here because the
families of the cancer patients sometimes do not want to tell them
about the diagnosis of cancer. There is a conflict between patients
right to know and the actual telling the truth that could make patients
worse.
Second Stage: Physicians and nurses need to inform the
patients about the types of cancer therapies they will be given. The
possible treatments are surgery, radiation, chemotherapy or a
combination of these. Patients need to know the side effects o f their
treatments. I explain to them that the side effects of these therapies are
hair loss, nausea and vomiting, and fatigue. These therapies can also
make patients weak and lower their self-esteem. After informing them
of these side effects, I provided them with psychological support to
counteract the subsequent depression.
Third Stage: At this stage, the patients often express their fear
of death and their hopelessness. When there is no cure, the families
of the dying patients always ask for alternative therapies such as the
use of herbs or Chinese medicine and of religious rituals. I personally
know that herbs will not change the prognosis of the patients.
However, I allow the families to provide the dying patients with
herbal medicine so that may make their families feel better. It is not
only necessary to give psychological support to the patients but also
to their families.
To disclose a patient’s diagnosis of cancer is to be a good communicator. As
Kanokwan described in the first stage, it is true in the Asian culture that the families
do not want the cancer patients to know the diagnosis, because they believe that the
disclosure would discourage the patients and make their conditions worse. Thus, the
families always ask the physicians and nurses not to disclose the truth to the patients.
Hu, Chiu, Chuang and Chen (2002) reported that in the Eastern culture it is common
for health professionals not to disclose the true diagnosis of diseases, especially to a
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patient with terminal cancer. The decision of whether or not to disclose the cancer
diagnosis and prognosis is usually left to the families.
As described by the American Geriatrics Society (1997), end-of-life/palliative
care refers to the comprehensive management of the physical, psychological, social,
spiritual and existential needs of patients; the researcher of this study organized the
sub-sections on individual patient’s needs that are given by the participants.
Physical needs. Care of the dying patient is concerned with total physical care
that results in fulfilling the physical needs of the dying. In order to respond to the
physical needs of the dying, nursing care includes hygiene and environmental care,
vital signs (body temperature, blood pressure, pulse rate and respiratory rate), neuro
sign, medications, pain management, nutrition, intake/output, and other medical
treatments regarding patient’s prognosis. Lanta’s narrative account presented physical
care given to the dying patient was:
I provide comfort to terminal care patients by providing them with

physical and hygienic care. I pay particularly attention to the vital
signs and symptoms of the dying patients to determine if I can do
anything to make them feel more physically comfortable. I monitor
the pain of the patients and give them pain medication as necessary.
If they have respiratory problems, I would report these to the
physicians to obtain proper respiratory care for the patients. I think
that the dying patients that are kept comfortable can rest and are not
agitated.
Like Lanta, Rungthip also mentioned how she would assess physical needs of
patients. She stated that in providing nursing care at the end stage of life, in order to
provide physical care, “first I check on patients’ physical assessment: signs and
symptoms, vital signs and neuro-sign, respiratory system, blood circulation, nutrition,
physical movement, and results of blood tests.”
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Psychological/ emotional needs. Most participants specifically mentioned how
important psychological support is for care of dying patients. They even said that at
the end of life, psychological support is more important than physical support. Nurses
provide psychological support not only for dying patients facing death and dying
situation but also for their families in losing their loved ones. Lanta has been working
in the HIV unit and said that psychological support is greatly needed on her unit. She
stated that:
I find that HIV patients are particularly in need of psychological

support from their families, relatives and healthcare professionals. It
is particularly hard for the HTV patients to accept the diagnosis that
the ADDS virus infects them. The physicians once they receive the
HTV positive results will discuss these with the family of the patients
and explain them the prognosis and the pathology of the disease.
Whether the physicians also inform the patients directly depend on
the mutual agreement between the family and the relatives. However,
most of the terminal HIV patients and I mean near death, know that
they are suffering from the AIDS virus. Psychological support can
help the dying patients and their families to cope with this incurable
disease. At the terminal stage, I provide HTV patients with safety and
comfort and I do not mind caring for them. I have also seen the
families take very good care of the dying patients. I provide health
education to the patients and their families on the required preventive
care for the HTV patients such as avoiding contact with the secretions
and the blood of the patients. I provide the families of HTV patients
with the disposable gloves and masks required to give proper
hygienic care.
With over thirty years of experience in clinical nursing, Kanda gave an
interesting point on providing psychological support to her dying patients. She
illustrated how alternative therapies promoted psychological care:
The provision of psychological and emotional support is very

important in end-of-life care. The dying patients are in extreme need
of psychological support from their families, friends, and nurses.
This support is related to encouragement and it may help the patients
keep their hope. I believe that alternative therapies are in some ways
related to the psychological support. The families of the terminal
cancer patients almost always ask if they can take the patients home
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to follow a traditional herbal therapy. I am aware that some kinds of

herbs have not been scientifically proven to cure diseases. In this
case, I always ask the families what kinds of herbs that they will be
using and if those herbs have side effects that can affect the patients
and their treatments. I tell the families that they can integrate the
herbal remedies with the medications that patients are receiving
while hospitalized after I obtain the agreement of the physician to use
the herbal medicines. I think that the physician give this permission
because there is no way to cure the disease and also because the
families of the terminal patients can provide care and support in the
home environment.
Social needs. Social needs are included in Maslow’s theory of needs. Social
support is also necessary for dying patients. Generally, in society people live in the
family and have relatives and friends doing activities. At the end stage of life, those
with life-threatening illnesses become dying persons and face the stage of death. They
sometimes need socialization and visiting from family, relatives and friends.
Rapeepom’s narrative account illustrated the type of social support provided by
nurses:
In response to the social needs of patients, I understand that the dying

patients wish to have their family and relatives with them while they
are hospitalized. When the patients are in private rooms, there is no
problem for the families and relatives to stay with them. However,
when the patients are in non-private rooms, there is no space for the
families and relatives to stay with the patients. Thus, in terminal
cases, I am more flexible about the visiting time for the families and
relatives.
Spiritual needs. Spirituality has a greater influence on end-of-life care in
Thailand than in many countries. To support spiritual needs of dying patients is to
realize cultural and religious beliefs and to provide care regarding such beliefs. Most
participants described how cultural traditions and religions related to spiritual support
for end-of-life care in Thailand.
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1. Buddhism. In Thailand, more that 90 percent of the Thai population
believes in Buddhism. Buddhism plays a significant role in the daily lives of Thai
people from birth to death. Most of the study participants mentioned the significance
of Buddhist belief in end-of-life care. Based on her own experience of losing her
father, Nittaya gave her narrative account on Buddhism and its influence on the issue
of death and dying. She stated that:
The dying also will be asked to pray two words: “Bhud” and
“Tho.”Yes. In this fashion, the dying patients can obtain a peaceful
mind and think about good things. In Buddhism, for example, the
dying person will be asked to pray and respect the Buddha.
Buddhists believe that if the dying pray, the Buddha will take him to
a peaceful place (heaven) and let him have a peaceful death.” When
talking about a peaceful death, I can give you the example of my
father who passed away years ago. My father was watching his
favorite programs while I was in my bedroom. Later on, he seemed
to be very quiet in the armchair. I called him to go to bed but he did
not respond. I was very sad and thought that it might be his time to
die. I prayed that if it were his time to die, to please let him go
peacefully. Then my brother told us that our father had already
passed away.
In Buddhism, some activities given to dying patients are meditation, prayer,
burning scents and candles, and giving donation to Buddhist temples. Most
participants mentioned about these activities. Lalana also described such religious
activities given in caring for dying patients. She said that:
In terminal care, the nurses need to support the cultural and spiritual
beliefs of the families of the dying patients. When the request is
acceptable and agreeable among physicians and nurses, we try to do
our best. However, I believe that the request of the families for
cultural and spiritual activities should only be accepted when it
respects the privacy of the other patients. Such activities are (a) the
families of the dying patients inviting a Buddhist monk to come and
pray for the dying and (b) the families bringing the holy or magic
water to be aspersed on the dying patients by a Buddhist monk
(Buddhist belief). Before I give the permission to perform these
religious activities, I always consider whether these activities may be
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disturbing to the other residents and making a noisy environment in

the hospital.
It is imperative for nurses to be concerned about promoting spiritual care in
response to the wishes of the patients and their families. However, it is crucial that
nurses should also support spiritual care unless such care does not bother other
residents who hospitalizes in the same unit.
Buddhists strongly believe that practicing the religious activities helps a dying
person have a peaceful death. Ratana and Sorada mentioned about the attaining of a
peaceful death through supporting spirituality. Ratana’s narrative account was:
In Buddhist cultures, the families will ask me if the dying person can
have a candle, incense or a white string held by Buddhist monks in
his or her hands as a form of respect for the Buddha that results in a
peaceful death. To respond to these spiritual needs of the patients, I
believe that there is a requirement for healthcare professionals to
accept these requests.
Sorada also supported that in the hopeless cases, families of patients primarily
request religious activities because they believe that such activities would help the
dying have a peaceful death in response to the spiritual need of the dying. For
instance, Buddhist families always ask nurses or physicians if they could invite a
monk to pray for the dying at the bedside.
2. Islam. Islamic belief also plays a significant role in caring fcr dying patients
in Thailand, especially the south of Thailand where a number of Muslims has lived.
Kanda, Ramita and Suratchanee mentioned about the Islamic belief on peaceful death.
Kanda stated that:
When Islamic patients are near death, their families and relatives
prefer to remove any advance technologies so that the patients can
have a peaceful death.
Ramita also supported that:
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Religion and cultures are also important for decision-making. For

example, in Islamic patients, I have difficulty when the families do
not want the dying patients to undergo a tracheotomy even though
such a treatment helps the patients with his respiration.
Suratchanee’s narrative account was illustrated that:
Most Muslims believe that to have a peaceful death, a dying patient

should not be intubated nor given any treatment requiring the
insertion of needles in the body. Thus, when a Muslim patient is
dying, the family does not want physicians and nurses to help him
with resuscitation. According to the Islamic faith, the body must be
buried within 24 hours after his legal death.
3. Chinese traditions. There are a number of Thai people with a Chinese
background in Thailand. In every culture, people have specific beliefs that they
believe to be good for a dying person. Chinese people in Thailand believe that the
traditional cultures support the spirituality of the dying, and they also believe in the
next life. Several participants mentioned about how significant Chinese traditions are
toward the end-of-life care. Rungthip said:
In our unit, we also support cultural beliefs. For instance, most

Chinese families are concerned about the time of death. I used to
help the families of dying patients dress up the dead body with
artificial jewelry and several layers of new clothing because they
believe that the dying person will carry these precious things in his
after life and thus have a peaceful death. In order to prepare the dead
body, my colleagues and I had to keep the deceased in the unit until
two hours before his departure for the funeral at home.
Rattana also pointed out the time of death. She stated that:
When physicians announce the time of death, the nurses always have
to ask what the families’ wishes are for the disposal of the corpse. In
Chinese cultures, the families prepare several clothing outfits for the
dying persons that will be put on them after death to respond to their
spiritual beliefs.
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End-of-Life Decision Making
Participants told stories o f their experiences with end-of-life decision-making
in caring for their patients. A dying patient at the end stage of life is known not to be
cured by medications or treatments. Based on the experience in providing end-of-life
care gained from participants o f the study, an end-of-life decision will be made by the
family of a dying patient, incorporated with physicians’ advice on patient’s prognosis
of illness. The participants also mentioned that most of end stage patients are
unconscious and unable to make the decision by themselves. Thus, the family would
be a decision-maker on behalf o f the dying. Rungthip’s narrative account illustrated
that:
The end-of-life decisions are made on the basis of the information

given by the physicians and nurses. When the dying patients are in a
critical condition, the family members know about this prognosis
thus they can prepare themselves for the unwanted news and the
funeral. I give psychological support to the family throughout the
grieving process. Based on my experience, the family members are
the decision makers, especially the oldest son.
The order of “Do-Not-Resuscitate” (DNS) is primarily related to end-of-life
decision making. Even though this order is rarely made in end-of-life care, it is
sometimes involved in the family’s agreement. Natalee stated that:
In the case of an unconscious patient, the end-of-life decisions are

made on the basis of the advice of the physicians and the wishes of
the families. The families of the dying patients will reach a mutual
agreement. At this stage, the physicians take a significant role in
decision making for any life-sustaining treatment. For example, the
giving of the order for the Circulatory Pulmonary Resuscitation
(CPR) or the Do-Not-Resuscitate (DNR) order would be decided on
the basis of the illness progression in relation to death. The
physician, nursing staff and I discussed the prognosis of illnesses
with the families of dying patients. The physicians will give either a
“CPR” or “DNR” order after the families have discussed the
prognosis. Generally CPR is the dominant treatment plan. However,
a DNR order is issued in approximately only 5% of the cases.
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A wish to die at home is one of the decisions that have been made in response
to the dying patient’s wish. In many cases at the end stage of life, dying persons
would like to go home and die at home surrounded by their family. Lalana addressed
that:
When the patients are dying, I allow the families and relatives to stay
with them as much as possible. The families are thus able to be with
the terminal patients and give them support. The physicians explain
the patient conditions to the families and provide some suggestions
on end-of-life decisions after discussing the pros and cons of further
treatments, and the possible complications after these treatments.
When patients are unconscious, the families and relatives will make a
decision on the basis of the information provided by the physicians
and the wishes of the patients to die at home.
As described by a couple o f the participants, in general the nurse has
participated in the discussion on end-of-life decision-making. Based on information
and effective communication, end-of-life decisions are made. Rattana gave their
narrative accounts on this issue. Her narrative account illustrated that:
Unconscious patients are unable to make the decision so the family of

these patients has to make a decision for them. However, cancer
patients are sometimes conscious and are capable to make the decision
by themselves. I think the most important issue here is the open
communication with the patient and his family. In particular, we
provide the patients’ families with up-to-date information on the
condition of the patient so that they are kept aware of any changes in
their condition.
Financial consideration may be an influencing factor in end-of-life decision.
Because of high costs of life-sustaining treatment, patients sometimes cannot afford
such costs. However, in general hospitals in Thailand with the national insurance
coverage, patients pay a little amount of money for health care services. Like the
narrative account of Ramita, the financial issue is not a concern for making end-of-life
decisions. Ramita added:
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Patients in public hospitals pay much less than those receiving

services in private hospitals. Thus I believe that end-of-life treatment
decision in our hospital has no financial consideration.
Nittaya also agreed that financial consideration is not a big concern in end-of-
life decision-making. She stated that:
Patients in public general hospitals pay a smaller amount for services

than those in private hospitals because of the national health
insurance. Thus, in the provision of end-of-life care, the financial
issue is not a concern for the end-of-life decision.
Moreover, cultural and religious beliefs have an impact on end-of-life
decisions. As mentioned earlier, the Islamic belief on spirituality prohibits inserting
any advance treatments such as tracheotomy tube in the body of dying person. The
decision on planning for the advancement of treatments such as tracheotomy will not
be granted in Islamic patients. Ramita addressed that religion and cultures are also
important for the decision-making. She gave an example of Islamic belief in end-of-
life care that families do not want the dying to have a tracheotomy tube even though
such treatment helps the patients with respiration.
Nursing Roles in End-of-Life Care
Nurses comprise the majority of caregivers in hospitals. The participants
addressed how important the nurse is in providing end-of-life care and how the
nursing roles relate to satisfaction among dying patients and their families. There are
several roles given by participants— nurse as patient’s relative, nurse as supporter,
nurse as informant, nurse as coordinator, and nurse as advocate.
Nurse as patient’s relative. Kanokwan addressed the nursing role in end-of-
life care in relation to the thought of being patients’ relatives. Her narrative account
follows:
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Actually, as a nurse, I have to work within the scope of the nursing

principles. I always recognize patients as my own relatives when I
am giving them care because this helps me attain a satisfactory level
of peace of mind and in practice to provide the best possible care to
the patients. Especially in terminal care, the dying patients need a lot
of psychological support from the caregivers because of their
hopelessness.
Nurse as supporter. The nurse has another significant role as a supporter for
dying patients and their families. Kanda stated that:
I always ask the patients and their families how they feel about the
care and the services that are given, what else could be done to help
them feel better, and if anything how could we help the patient feel
comfortable while being hospitalized. I have to be a support for the
patients and their families. I will not know whether the care fulfills
their needs if I do not ask or communicate with them. Moreover,
most of patients from rural areas sometimes hesitate to let us know
what their concerns and needs are because they do not want to give
work to the nurses. Nurses should therefore use their communicative
skills in order to assess the problems and needs of the patients.
Sorada addressed her support through the religious activities in providing end-
of-life care. Her narrative account was stated that:
I support the families of the terminal patients because it is really hard

for the families who are losing their loved ones. I always understand
how their feelings of loss, thus I encourage them to have religious
activities that will make them felt better. Small things can be done to
help support the families get through their grief and sadness.
Nurse as informant. As he informant in the hospital, the nurse should be
concerned with all information about patients’ prognosis and progression before
giving the information to patients and their family. Telling bad news is hard for nurses
and other caregivers. Therefore, communication skill is needed in end-of-life care.
Several participants mentioned the nursing role as informant and how important this
role is toward the care given. Rungthip pointed out that nurses should give
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information about patients’ conditions to the family and what kinds of treatment and
care that patients receive.
Lalana also described her experience in telling the bad news for the family of a
dying patient. She felt anxious and uncomfortable while giving unwanted news to the
family. She stated that:
Providing information to the families is crucial for their decision

making processes. The nurses are in contact with the dying patients
24 hours a day. They are a particularly good contact between the
families and the physicians. They take a significant role in the care of
the dying patients. Nurses often have to tell the bad news to the
families and relatives. Previously I felt uncomfortable to give this
bad news to the families. However, since I believe that what I have
done is the best interest for the patients, I feel more confident
recendy when I provide this information to the families.
Similarly, Sorada explained how she tried to help the family get thorough grief
by periodically giving information about the dying patient’s prognosis, signs and
symptoms, and treatments given. She also stated “I think giving information about the
patients can help the families get through grieving process because the families may
gradually accept the reality that the patients are nearly dead.”
Nurse as coordinator. As working among other healthcare professionals, the
nurse should be concerned about being a coordinator occurred among caregivers.
Kanokwan described how nursing role as coordinator in the provision of end-of-life
care in her unit. She stated that:
I always respect other healthcare professionals including physicians,

medical technologists, physical therapists, as well as my co-workers.
As being very close to the dying patients 24 hours a day, I have a
role of coordinator among other healthcare professionals.
Ramita also supported Kanokwan’s statement. She stated that she has taken a
role of coordinator among other caregivers and family of the dying. She not only
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provided care, but also provided convenience for the family such as claiming
insurance, helping with death certificate, and supporting cultural beliefs.
Nurse as Patient Advocate. A role of advocate for patients was also
mentioned by participants. This role is fairly limited to nursing practice. However,
one participant had pointed out the advocating role in end-of-life care. Kanokwan
believed that the nurses give the best care in relation to the patients’ interest. Even
though she could not make any decision on the treatment, she considers herself as an
advocate for dying patients and their families. Nurses should realize that giving
information is very important for patients and families to make end-of-life decisions.
The qualitative analysis of participants’ answers to this question led to
identification of three categories of emphasis: Their experiences with ethical
dilemmas related to end-of-life care, clinical judgments, and concerns and innovations
in improving end-of-life care.
Ethical Dilemmas Related to End-of-Life Care
Kanokwan’s narrative account illustrates the dilemma that exists between the
promotion of the wished of the patients and preventing the harm that may arise from
agreeing to those wishes in terminal cancer patients. She stated that:
In this unit, the majority of the patients are suffering from cancer. In
the provision of end-of-life care, many of the patients and their
families request the use of alternative remedies such as herbal
medicine or Chinese medicine integrated with their conventional
therapy. Some natural herbs that have not been scientifically tested
can have untoward side effects on both the disease and the treatment.
For example, the family of a dying patient requested that they
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integrate alternative medicines with the conventional therapies. I told

the family that I had to ask the physician for the permission to use
the alternative medicines. Thus, this request to use alternative
remedies caused an ethical dilemma among healthcare professionals.
I believe that I provide holistic care to my patients in general;
however sometimes there can be a conflict between honoring the
wishes of the patients and the possible side effects arising from those
wishes. This creates an ethical dilemma that needs to be balanced.
Several participants—Rapeepom and Nittaya,—described the ethical
dilemmas resulting from the wish to die at home. Rapeepom mentioned about how
she felt when a patient’s wish to die at home was dominant. She stated that:
There can be situations when the wish of a patient to die at home can
become an issue. For example, a dying cancer patient in my unit
wished to go back home to be around his family and relatives, rather
than remain in the hospital. The patient was anxious and restless
while hospitalized and seemed to believe that he was going to die
soon. Thus, he desired to die at home in a familiar environment. This
situation raised an ethical dilemma for the physicians and the nurses.
I felt that if the patient went home, he would die from his life-
threatening illness. He was having several problems such as severe
pain, intake and output deficits, anemia, and dyspnea while
hospitalized. Thus, he was on oxygen therapy, received intravenous
fluid and pain medications, and had a urinary catheter, and so on. I
thought that it would be better if he stayed in the hospital, but this
patient and his family really wanted to go back home. I persuaded the
patient to remain in the hospital for a few more days, but in the end it
did not work out.
Similarly, Nittaya described an ethical dilemma when the wish to die at home
was granted. She felt frustrated about that situation and stated that:
The fact is that the dying patients have a right to be with their family
and relatives. However, the hospital rules and restrictions do not
allow the family and relatives to visit as frequently as they would
like. They should have an opportunity to provide palliative care to
their loved ones and to say goodbye before their death occurs. Often
the relatives of the patients believe that their loved ones should have
a peaceful death at home in their familiar environment and be with
their family, relatives and friends. Thus, they always ask the
physicians to let them take the dying home where there is no
possibility for a cure to save the patient lives. An ethical dilemma
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occurs when the caregivers cannot balance their duties to provide

care and the wishes o f their patients to die at home.
The order of Do-Not-Resuscitate (DNR) raised an ethical dilemma among
caregivers. One of the participants pointed out the dilemma related to the DNR order.
Kanda was a novice nurse and had only four years experience in the nursing
profession. She was uncomfortable in response to the DNR order. She stated:
An ethical dilemma may occur with terminal patients, when their

families and their physicians have a mutual agreement on an order of
“do-not-resuscitate” (DNR). There is a conflict between the DNR
order and the desire of the other healthcare providers for a CPR
(Central Pulmonary Resuscitation) order. I gave nursing care to the
patients even though the physicians placed a DNR order. I assess
signs and symptoms, observe changes, and then report to the
physicians. I sometimes ask them if the dying patients should be
given further treatments and medications. I really believe that I
provide the best possible care to respond to the interest of the dying
patients.
Hospital regulation o f visiting time sometimes raised an ethical dilemma
related to end-of-life care. Nittaya mentioned a conflict between the restricted visiting
time and her personal empathy for patients and their family. She described that:
I think that the hospital regulations are a major cause of ethical

dilemmas. Often the hospital regulations are too restrictive on the
visiting hours for dying patients. For example, the hospital rules for
visiting hours do not allow the family and relatives adequate time to
be with the dying patients at his end of life stage. In addition, both
the hospitals and the staff do not always allow the provision of
appropriate cultural activities and religious rituals for the dying
patients. These rules create internal conflicts for me because I do not
believe that they should be applied to end-of-life care.
Sometimes cultural and religious beliefs cause ethical dilemmas related to
end-of-life care. Rungthip described the dilemma that occurred when the family of the
dying asks for the religious rituals to be performed at the hospital. Or because of the
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cultural norms the family wishes to take the patient home to die. Her narrative
account is as follows:
For instance, a physician ordered “Nothing per Oral” (NPO) to a

dying patient, but the patient’s family asked me to feed the magic
water made by a Buddhist monk as the family believed the water
would help the patient get well. I did not allow the family to give a
drink to the patient. With the NPO order, I thought that the patient
would be harmed from consuming the water. Therefore, I suggested
to the family to use the magic water to wash the patient’s face instead
of having him drink it. In many terminal cases, the families wish to
have the patients die at home raises an ethical dilemma. I think that
such a dilemma occurs when there has been more than one choice of
action. However, I really think that decision should be based on the
best interest of the dying person. I ask the families if it would be
sufficient for them to be present at the end and not to provide the
patients with “extraordinary care.” The dying could suffer from a
dyspnea and be gasping for air without the administration of oxygen.
The families always ask me if I were them, on what basis I would
make an end-of-life decision. I tell them that I would let the
physicians and nurses take care of them until there is no hope for
recovery, and then I would recommend palliative care for a peaceful
death.
Suratchanee provided another example that supports the dilemma arising from
cultural and religious beliefs. She gave an example of an Islamic patient that
frustrated her by not allowing the provision of life-sustaining treatments. She stated
that:
I feel very frustrated because in some cases when Islamic patients

were not yet really terminal and still had an opportunity to get better
from life-sustaining treatments, these therapies were not allowed
because of the Islamic faiths. Muslim families do not want the
patients to suffer from such therapies. This causes an ethical dilemma
that results in frustration for the healthcare professionals because
they have to abide by the decisions made by the patient and his
family.
Exemplar cases on ethical dilemmas. In the book, From Novice to Expert,
Benner (1984, p. 41) described that exemplars can illustrate nursing performance that
represents a complex of enabling skills. She also noted that not all the exemplars
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reflect a proficient or expert level of practice, but all reflect clinical knowledge.
Congruently, van Manen (1997, p. 18) also addressed that phenomenological research
finds its point of departure in the situation, which for purpose of analysis, description,
and interpretation functions as an exemplary nodal point of meanings that are
embedded in this situation. In this study, there were several exemplars where nurse
participants gave examples about how ethical dilemmas occurred while they provided
care for dying patients. All participants had been in the situations where the dilemmas
and conflicts occurred. They expressed their feelings and how frustrated they were.
Any nurse can compare these exemplars with similar and dissimilar situations from
his/her own practice; when disagreement, agreement, questions, refinement, or
extension of the exemplars is encountered, it will be an indication a new area of
clinical knowledge that is being uncovered (Benner, 1984, p. 42).
From the experiences of the participants, several ethical issues are involved
with terminating or withholding therapies. These often involve pain management in
cancer patients, the wish to die at home, and the provision of heart stimulating
medications. Natalee provides examples of ethical dilemma that occurs in Medical-
Surgical and Renal-dialysis units. Her account on ethical dilemmas resulting from the
termination of life-sustaining therapies illustrates the following:
A physician had intubated a patient suffering from dyspnea and

respiratory problems. The patient was still conscious, but restless,
and he was very worried about his death. His condition deteriorated
and the physician discussed end-of-Iife care with the family of the
patient. Their decision was to remove the tracheotomy tube in order
to provide the patient with a peaceful death. This caused me an
ethical dilemma because I did not want to end the life of the patient
even though this decision had been mutually reached by the family
and the physician.
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The issues of passive and active euthanasia are problematic in end-of-life care.
They often result in ethical dilemmas among the caregivers. In giving pain
medication, several participants have faced ethical dilemmas. On this subject,
Suratchanee states:
There was a case in which I had to take care of a patient who was
diagnosed with terminal liver cancer. He suffered from severe
abdominal pain. His case was hopeless and his family realized that
he was in extreme pain. The family asked me to administer a stronger
pain medication to relieve the pain. However, I knew that the side-
effect of stronger doses of pain medication would slow down the
patient’s respiration rates so that he would eventually die. This
situation made me feel very uncomfortable.
Natalee presents her experience with the dilemma caused when a patient
wishes to die at home. She had to show the family how to remove the respiratory
ventilator and the tube when arriving home from the hospital. She expressed her
feeling of frustration in this situation and said that I really did not want to be the
person who asked the family to take off the tube. Her narrative account is as follows:
When the disease reached incurable stage, the families would ask
physician if they could provide psychological support by taking the
patients home. This creates an ethical dilemma because the
caregivers and nurses do not have the intention of removing the tube
from the patients when they are still alive. The families of the dying
insisted in taking the patients home and were requested to sign a
release form against the medical advice. In this instance, the
caregivers would not remove the tube because they knew that the
patients would die from it. Thus, nurses have to teach the families to
remove the tube when they got home.
Lalana described her experience with a Chinese family who requested that the
life of the patient be extended by the administration of stimulating medication until a
auspicious death time arrived. She stated that:
When a dying patient was at the end of life (BP and HR dropped),
but still on heart controlling medication such as Dopamine, the
Chinese family would ask the nurses to administer more medication
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to extend the life of the patient. They did this because they were
waiting for a family member to arrive before the patient death. In
addition, some families of patients at the end-of-life stage asked the
nurses to extend the life of the patient until an auspicious time
arrived for their death. They believe that if the dying person died
before this auspicious time, it might affect the well-being of the
entire family.
In summary, these narrative accounts revealed that several factors could raise
ethical dilemmas among the nurses providing end-of-life care. Such factors are the
use o f alternative therapies, the wish of the patients to die at home, the DNR order,
and cultural beliefs and religious rituals. The nurses shared their examples of how
they resolved their ethical dilemmas by the use of clinical judgments in providing
end-of-life care.
Clinical Judgments
Clinical judgments stem from knowledge, clinical experience, and a holistic
approach in response to patient’s needs (Harkreader, 2000). Clinical judgment
processes are related to a way of clinical thinking in which nurses describe a
perceived problem, find ways to solve the problem, and make decisions in response to
the problem. When the participants were asked about how they used clinical judgment
in dealing with ethical dilemmas related to care of dying patients, different
experiences were described in their narratives. As Benner et al. (1996) noted, clinical
judgment consists of five interrelated aspects: (a) ethical concern; (b) extensive
practice knowledge that includes not only scientifically derived knowledge and theory
but also the tacit knowing, that of knowing the particular patient; (c) the context of the
particular situation and the nurse’s emotional response to it as guided by interpretation
of the particular situation; (d) intuition or judgment without calculative rationality;
and (e) the role of narratives in providing care. Some of the narrative accounts given
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by nurse participants reflect the five aspects and indicate how the participants made
judgments in dealing with ethical dilemmas.
Discontinuity of life-prolonging treatments is one of the significant issues that
raise ethical dilemmas. As the physician sometimes stopped giving more life-
sustaining medications in response to life-shortening complications, the nurse
sometimes became frustrated from the situation. Patients’ wish to die at home was
another issue that created a dilemma for Lalana. She described her experience and
told how she was dealing with the dilemma through sharing and discussing the
situation while providing care. Her narrative account was:
I discussed the termination of treatments by the physicians with my

colleagues. If I did not have a clear understanding of the orders of the
physicians, I would be incapable of providing information to the
families of the terminal patients on the quality of the care given to
them. Not only did I discuss the treatment plan with the physicians
but I also asked the about the issues that made me feel uncomfortable
and could become an ethical dilemma. Thus, it made me and my
colleagues (nurses) feel better because we were actually providing
the best possible care for the dying patients within the scope of our
nursing practice. I was then confident to tell the families that the
patients had been given the best end-of-life care. The families always
ask the healthcare professionals if they can take the patients home in
response to their wishes. This results in another potential ethical
dilemma. To resolve the ethical dilemmas associated with the end-of-
life care at home, I think that it is important for nurses to provide
health education to the patients and their families on the subjects of
good patient nutrition, and the comfort measure required to assure a
peaceful death at home.
Sorada also mentioned about her discussion of the ethical dilemma that
resulted from the patient’s wish to die at home. She addressed the essence of effective
communication as a strategy used in the clinical judgment toward resolving the
dilemma. She stated that:
As an experienced nurse in end-of-life care, after discussion of the

case with the other health care providers, I was able to persuade the
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dying patient and his family to stay for a few more days in the
hospital. If the patients did not improve, we could revisit the issue of
home dying again. I believe that the condition of the patients will
deteriorate if he goes home at this stage. However, if the families
really desire to take the patient home, I will provide them with the
appropriate health education. I think effective communication is
extremely important in the provision of end-of-life care. I think the
nurses should listen attentively and assess the needs of the patient,
and evaluate the problems of the patient while hospitalized. I always
establish a rapport with the patients and their families in order for
them to be comfortable and let the nurses know about their problems
and needs. In this fashion, I am capable of responding to their needs
and preferences in the end-of-life care. I am particularly concerned
with the needs of the family because I empathize with the families in
their forthcoming loss.
An issue of pain relief sometimes raises the ethical dilemma. Suratchanee
mentioned about the dilemma associated with pain medications. However, she
balanced her responsibility and personal feelings. She stated that:
I think that the purpose of providing pain medications is to relieve

the pain of the patient, and not to end the patient’s life. In this
circumstance, I am doing my duties within the treatment plan and the
scope of my responsibility. I respect the decision made by the family
of the dying patient because he is not only suffering from the pain,
but his family is suffering as well.
Most participants faced ethical dilemmas while proving care of dying patients.
They definitely were frustrated from having such dilemmas and used their clinical
judgment in dealing with these dilemmas. However, some participants believed that
they had provided “best practice” for the dying; therefore the belief of providing best
care made them felt better and less frustrated about the dilemmas. As Natalee
illustrated that:
I discuss the situation with my colleagues when an ethical dilemma

occurs. In this fashion, we agree that we are providing the best
possible care to the dying patients. We did this within the order of
the physicians to keep the patients comfortable. All of my colleagues
feel the same ways about having ethical dilemmas. As caregivers, we
believe that we provide the best care for the dying persons and this
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helps us deal with ethical dilemmas related to the end-of-life

decisions.
Rapeepom expressed the feelings of frustration when the wish to die at home
was granted. She supported the idea of providing best practice in dealing with the
dilemma. Her narrative account illustrated that:
I am sometimes frustrated by the decision made by the dying patient

and his family. I give them all the pertinent information on the
prognosis, the progress of the disease and how the treatments are to
be implemented. Ultimately when the patient decides to go home, I
have to respect his wishes and decisions. This helps me reconcile
myself with the ethical dilemma. Once at home, the patient can be
around with his family, his relatives and friends who can provide him
with psychological support. He can also practice his religious rituals
for his spiritual support I discussed this dilemma with my
colleagues and they felt that I had supported the wishes and the rights
of the patient.
At the end of the interview process, the researcher asked the question about
what would be important concerns for the improvement of the end-of-life care in
Thailand. This question is raised in response to the following research question 15.
care ?
Concerns for the Improvement of End-of-Life Care
The nurses identified significant concerns to improve the quality of end-of-life
care in Thailand. They believed that these issues would help the dying patients receive
the best possible care in the contexts of their illnesses. Concerns included: (1)
legislation and laws for the protection of health caregivers in ethical dilemmas; (2)
ethical concerns; (3) cultural and religious concerns; (4) the right of the patients; and
(5) clinical and service innovations.
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Legislation and laws. Suratchanee mentioned that there should be legislation
that supports the healthcare professionals who provide end-of-life care. She also
stated that:
The legislation should provide relief for the individual from the
fhistration of having ethical dilemmas and it should address the
ethical concerns related to end-of-life issues. Thus, the healthcare
providers should devote their energy on the provision of holistic care
to the dying patients in response to their physical, psychological,
social, and spiritual needs.
Ethical concerns. Nittaya mentioned ethical concerns that can help improve
quality end-of-life care. She stated that:
To improve end-of-life care, we should incorporate ethics in the care

given to the dying patients. However, hospital administrators while
providing care and services to all patients must also realize that there
are ethical concerns involved. Even though the nurses have an
increasing workload because they have to care for a higher number
of patients, they should be allowed to organize their care plans in
order to provide ethical care, which encompasses the psychological
and spiritual needs of the patients.
Cultural and religious concerns. Rattana discussed the importance of
cultural and traditional beliefs in relation to end-of-life care. Her narrative account
was:
Another important issue concerns the cultural and traditional beliefs

of patients and their families. Nurses should promote and support the
patients and their families to maintain these beliefs. They should
never take away hope from the dying patients and their families even
though the situation is sometimes hopeless.
Nittaya also supported the significance of cultural and religious beliefs in the
provision of spiritual care. She states that:
The administrators are less concerned about the provision of spiritual

care to the dying patients. Thailand is the land of Buddhism and the
practice of Buddhism is integrated with all aspects of life. Therefore,
it is imperative to allow the practice of religious rituals and the
provision of spiritual care. All caregivers should understand the
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importance of the need for spiritual practice and support it. When
they are practicing Buddhist, they understand the requirement for and
can provide spiritual care to the dying patients. Yes, I give them the
opportunity to satisfy their spiritual needs in accordance to their faith
not only for Buddhists, but also for other religions such as
Christianity, Islamic, or Hindu.
The rights of patients. A concern for the rights of patients was mentioned by
the nurses. They realize that the rights of the patients to receive ethical care should be
promoted.
Lanta states that:
I am concerned about the rights of patients which have been

addressed in the Ministry of Public Health plan to promote health.
All patients have the right to receive equally healthcare services.
When dying patients are conscious, they should have the right to
decide for their end-of-life care.
Rattana also says that:
Moreover, recently the issue of the rights of the patient has been
discussed among healthcare providers. The rights of the patient have
not been fully promoted in the healthcare arena. Thus, it is important
to address the rights of the patients in the provision of the end-of-life
care.
Suratchanee supports that:
Recently, the hospitals have been paying attention to the rights of the
patients because the Ministry of Public Health has been promoting a
patient bill of rights. This includes ten components, one of which is
dying with dignity.
Clinical and service innovations. Some nurses described clinical and service
innovations established in their units in order to support the dying patients and their
family. Some also proposed innovations that might be fully developed in the hospital.
These programs should be appropriately promoted in the care for dying patients.
I. Isolated room for near death experience cases: Lanta provided an idea of
having the isolated room for near death HIV patients. She stated that:
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It would be better if the end stage of HTV patients have an isolated

room where they can be with their families and relatives. The reason
of having the isolated room is of concern for other residents where
they can have the feelings of discouragement when experiencing the
grieving processes from the dying patients. In addition, the families
can give spiritual care and religious activities that will not disturb the
other patients.
2. Comfort with Shampooing: Kanokwan described a program “comfort with
shampooing” that she has developed and was successfully appreciated by dying
patients and their family. Her narrative account was:
In this unit, we have an innovative program that can physically and

psychologically support patients. The program is called “Comfort with
Shampooing.” The program is about shampooing hospitalized patients who
are admitted in our unit. Most people are happy about the program, especially
the cancer patients with severe pain. It is one of the most effective ways to
relieve pain and anxiety in cancer patients with which shampooing helps the
patients relax and turn their attentions out of the pain. Not only do we provide
shampooing for patients, but we also provide them touch. All patients have
experienced in receiving the shampooing services from us feel that nurses and
other staffs really care about them. It is independently nursing roles that we
can provide to patients. When patients are happy and satisfied with services
given, nurses are happy too. Some families of patients have brought us a half
dozen of shampoo bottles. They truly appreciate the program.
3. Five principles in care: Kanda had addressed the holistic approach in caring
for dying patients. She also mentioned about five principles on proving such care. Her
narrative account was illustrated that:
There are five principles that the nurses should be concerned with
proving end-of-life care: good diet, good air, good digestion, good
emotion and good exercise. I have been practicing care for dying
patients based on these five principles.
4. Meeting and Training: Sorada mentioned about how effective the meetings
among nurses in the unit were and more training is needed in the area of end-of-life
care. Sorada stated that:
Experience in end-of-life care of caregivers is also important. The

more experience, quality of care you provide. In addition, education
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and training in nursing end-of-life care need to be promoted in order

to have standardized palliative care throughout the country. In our
unit, we have a morning meeting everyday. The meeting helps us
discuss what the problems or treatment plans for patients. When we
have any problem, we would discuss in the unit and find appropriate
ways to solve the problem and help patients to receive quality of
care.
5. Visiting Book: An idea of having the visiting book for each individual
patient in I.C.U. is very interesting. Rungthip described that:
We use a “visiting book” for every patient Families and relatives of

the dying patients who come to visit the patients will write messages
in the visiting book. The book is for communicating among families
and relatives. The families and relatives are impressive with the idea
of having the visiting book for the communication among families,
relatives and friends. This idea came from our experience and it
could be a memory while patients stay in the hospital. If patients
were discharged from the hospital, we would give the visiting book
to them.
6. Tele-visiting: Tele-visiting was very innovative. Rattana stated that:
In the I.C.U., families and relatives are not allowed to be with

patients all day and night. They can come and stay with the patients
during the visiting time provided by the unit. Other than the visiting
time, my colleagues and I always use the telephone to contact the
families of the dying patients. Our unit provides card phones for
nurses to contact families of the dying and giving them information
about the patient.
7. Home Visit: Lalana gave an interesting idea of home visit for dying patients
who wished to die at home. She stated that:
Having home visit is another concern. In the cases, patients’ wish to

die at home is granted. It would be better if dying persons would
receive the visit from the hospital. Nursing visitors can follow up the
cases and give advices to them.
Table 15 presents a summary of themes in qualitative findings of this study in
response to the Research Questions 13, 14 and 15.
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Table 15
Summary o f Qualitative Findings in Response to Research Questions 13 through 15
Research Questions Variables/ Analysis Findings/ Themes
Measures
13. What is Thai nurses’ lived - Lived experience - van Manen’s method - Experiences with a holistic
experience in providing end-of- in end-of-life care/ - Benner’s Clinical approach to end-of life care
life care in Thailand? Narrative account Judgment - End-of life decision making
- Nursing role in end-of -life
care
14. How do Thai nurses - Ethical dilemmas - van Manen’s method - Experiences with ethical
describe the ethical dilemmas and Clinical - Benner’s Clinical dilemmas related to end-of-life
related to end-of-life care and judgment/ Narrative judgment care
clinical judgment they use in account - Clinical judgments
dealing with the ethical
dilemmas in providing quality
end-of-life care?
15. How have Thai nurses - Quality end-of-life - van Manen’s method - Concerns about the
provided quality end-of-life care/ Narrative - Benner’s Clinical improvement of quality end-
care? account Judgment of-life care in Thailand
Summary
Chapter IV presented both quantitative and qualitative findings of the study.
Quantitative findings were obtained from surveys in six different hospitals regarding
the Thai nurses’ attitudes toward death and dying, the knowledge about end-of-life
care, as well as the important problems and concerns about end-of-life care.
Qualitative findings were obtained from interviewing twelve Thai nurses working in
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different regions of Thailand about their lived experience in providing end-of-life
care, ethical dilemmas related to end-of-life care, clinical judgments in dealing with
the dilemmas, and concerns for improving the quality end-of-life care.
Quantitative findings indicated that response rate was 89.7%, with 538 usable
questionnaires. According to the demographic characteristics, the ages of participants
ranged from 21-53 years with an average age of 31.58 years. Females represented
97.8% (n = 526) of the study sample. Single (n = 314, 58.4%) was identified as the
most frequent marital status. About ninety-seven percent (n = 523) of the sample was
Buddhist. All respondents (n = 538) had at least a Bachelor of Science in Nursing
(BSN). About ninety-seven percent (n = 524) reported the Bachelor Degree as the
highest level of education. Medical-Surgical area (n= 335, 62.3%) was noted to be the
most frequent specialty, followed by the Intensive Care Unit (I.C.U.) with the number
of 125 respondents (23.2%). The years of experience in nursing ranged from 1-30
years with a mean of 8.95 years. Levels of annual incomes ranged from 70,000-
400,000 baths with a mean of 145,089.18 baths. The respondents in the upper north
region represented 14.9% (n = 80), the lower north represented 17.3% (n = 93), the
northeast represented 15.4% (n = 83), the central represented 18.0% (n = 97), the east
represented 17.5% (n = 94) and the south represented 16.9% (n = 91). All respondents
(n = 538, 100%) reported that they had experience in providing end-of-life care.
All respondents (N = 538) scored on the Attitudes toward Death and Dying
Survey and there were no missing data in this section. With the maximum score of
fifty and the minimum score of ten, the overall scores ranged from 25-48, with an
average of 34.38, a median of 34.00s, a mode of 34, and the standard deviation of
3.632. Findings regarding the problems in end-of-life care perceived by Thai nurses
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indicated that “inability to meet spiritual needs” (n = 155, 28.8%) was noted to be the
most important problem, followed by “loneliness” (n = 98, 18.2%), and “control of
pain” (n = 87, 16.2%) respectively. Findings regarding concerns in improving end-of-
life care indicated that “greater emphasis on spiritual care” (n = 135, 25.1%) was
noted to be the most important issue on improving the end-of-life care, followed by
“greater family involvement” (n = 124, 23%), and “education in ethical issues” (n =
67, 12.5%). Findings of the RN End-of-Life Care Knowledge Assessment tool
indicated that all respondents (N = 538) answered the questions and there were no
missing data. With the maximum score of twenty and the minimum score of zero, the
overall scores ranged from 7-20, with an average o f 13.22, a median of 13.00, a mode
of 14, and the standard deviation of 2.159.
In the correlation analysis, correlations with statistically significant
relationships were: correlations between attitudes toward death and dying and level of
education (r = .147; p < .01); knowledge of end-of-life care and level of education (r =
.092; p < .05); and the knowledge and annual income (r = .095; p < .05). Moreover,
statistically significant differences were found related to the independent variables
themselves.
In the qualitative study, twelve nurse participants gave their narrative accounts
on end-of-life care that reflect several themes. In the overview of end-of-life care,
significant themes were holistic approach in response to physical, psychological/
emotional, social and spiritual needs of dying patients, cultural traditions and religious
beliefs, nursing roles in end-of-life care, end-of-life decision making, ethical
dilemmas related to end-of-life care, clinical judgment, and concerns of the
improvement of quality end-of-life care.
CHAPTER V
INTERPRETATION AND DISCUSSION
“We experience an addressive moment when a text suddenly speaks to us in a manner

that validates our experience, when it conveys a life understanding that stirs our
sensibilities, when it pulls the strings o f unity o f our being. ”
—van Manen, 2002, p. 237
This chapter presents the interpretation and discussion of the overall findings
of this research study. Starting with the discussion of the overall study, the chapter is
composed of three main sections: (a) study concepts; (b) implications for nursing
administration, education, practice, and research; and (c) limitations followed by a
conclusion of the study. The triangulated study of both quantitative and qualitative
methods examined Thai nurses’ attitudes toward death and dying, problems and
concerns in end-of-life care, and knowledge about end-of-life care. It also explored
Thai nurses’ lived experience of confronting ethical dilemmas regarding the provision
of end-of-life care and the clinical judgments used in dealing with the ethical
dilemmas. The study also examined the attitudes and knowledge in relation to age,
level of education, years of experience, and annual income. A descriptive and
correlational design was used to explore the attitude and knowledge scores, and
variables and their relationships, and a phenomenological study was used to explore
the lived experience of Thai nurses providing end-of-life care.
150
151
Benner’s clinical judgment was used as a framework for the processes which
nurses use in attempting to resolve ethical dilemmas related to end-of-life care. The
clinical judgment framework reflected in the study (Benner et al., 1996), included five
areas: (a) ethical concern or the moral dimension of everyday judgment; (b) extensive
practice knowledge that includes not only scientifically derived knowledge and theory
but also the tacit knowing, that of knowing the particular patient; (c) the context of the
particular situation and the nurse’s emotional response to it as guided by interpretation
of the particular situation; (d) intuition or judgment without calculative rationality;
and (e) the role of narratives in which the patient becomes not only the biological
world of disease but of a human world of meanings, values, and concerns (pp. 5-
11). Findings of this research study reflected and supported what Benner et al. (1996)
addressed that the nurses’ clinical judgments are related to understanding of dying
patients’ and families’ concerns, which guide the way in which they respond to those
concerns, support families in their grieving processes, and work through decisions.
Sorada, who was one of the participants, gave her narrative account that could be an
exemplar in making clinical judgment. She stated:
As an experienced nurse in end-of-life care, after discussion of the

case with the other health care providers, I was able to persuade the
dying patient and his family to stay for a few more days in the
hospital. If the patients did not improve, we could revisit the issue of
home dying again. I believe that the condition of the patients will
deteriorate if he goes home at this stage. However, if the families
really desire to take the patient home, I will provide them with the
appropriate health education. I think effective communication is
extremely important in the provision of end-of-life care. I think the
nurses should listen attentively and assess the needs of the patient,
and evaluate the problems of the patient while hospitalized. I always
establish a rapport with the patients and their families in order for
them to be comfortable and let the nurses know about their problems
and needs. In this fashion, I am capable of responding to their needs
and preferences in the end-of-life care. I am particularly concerned
152
with the needs of the family because I empathize with the families in
their forthcoming loss.
Sorada’s experience reflects the five aspects given by Benner’s clinical
judgment framework. First, her ethical concern is associated with her persuasion of
the patient and family to stay at the hospital for a little longer, rather than stay at
home. Second, based on her practice knowledge and experience, she discussed the
patient’s condition with the physicians and her colleagues. Third, she was concerned
about the family and felt empathy for the loss of their loved one. Fourth, her first
intuitive response is that she thought the patient’s condition would worsen at home,
not thinking about pros and cons of being in the home environment. Last, she
effectively communicated with the family, reflecting the role of narratives in
Benner’s framework.
The second philosophical underpinnings for this study included Gadamer’s
hermeneutic philosophy (1976)). Gadamer’s hermeneutic philosophy with his four
concepts of prejudice, fusion of horizons, hermeneutic circle, and play provided a
valuable approach for studying this previously unexplored area of end-of-life nursing
care in Thailand. Walsh (1996) noted that these concepts of Gadamer help to
illuminate what she believes to be a way for nurse researchers to comport or orient
themselves in their research world. In order to describe how the qualitative phase of
this study was framed by Gadamer’s philosophy; the four concepts of Gadamer’s
hermeneutic philosophy are discussed here.
The four concepts of Gadamer—prejudice, the hermeneutic circle, the fusion
of horizons, and play—provide an underpinning for this study. In the qualitative
phase, the researcher acknowledged her own "pre-understanding" and "prejudices"
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about the nurses’ lived experience in end-of-life care, and ethical dilemmas and
clinical judgments related to end-of-life care. In acknowledgment of the prejudice
concept, she did not make her own judgments based on her own experience in caring
for dying patients. Because pre-understanding is essential to interpretation of
qualitative findings, it may lead to false interpretation. Once the prejudice concept
was achieved, the researcher then sought to clarify whether her understanding
matched those of the nurses. To achieve this process, the researcher entered herself
into the “hermeneutic circle.” In this process, the researcher determined her own
understanding in order to collaborate with those of the participants. At this point, the
researcher began understanding participants' meanings of experiences in providing
end-of-life care. This process is called the "fusion o f horizons'," understanding takes
place when the horizon of the other intersects or fuses with our own horizon and
changes and extends our range of vision (Walsh, 1999). Then, a new horizon is open
to allow an expansion of what is possible to see, leam, and understand (Gadamer,
1989) about participants’ lived experience in end-of-life care and ethical situations.
The last concept described by Gadamer is "play." Play is described as a dynamic
process where the researcher circles back and forth in the data, rereading and
reflecting until she feels comfortable in the interpretative process. In undertaking this
process, the researcher engaged herself through reading and rereading in a dialogue
with narrative accounts given by participants.
Findings of the study suggest that attitudes toward death and dying,
knowledge in end-of-life care, ethical concerns related to caring for dying persons,
and clinical judgments are contributing factors for improving the quality of end-of-life
care in Thailand. The literature review covered concepts of attitudes toward death and
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dying, end-of-life/ palliative care, ethical dilemmas related to end-of-life care, and
clinical judgments, and reflected the initial literature review that was undertaken
before data collection, as well as an updated review written after data were analyzed.
Instruments used in this study were (a) Attitudes toward Death and Dying
Survey, (b) RN End-of-Life Knowledge Assessment, (c) RN Demographics Form,
and (d) Interview Guide. Content validity of the Attitudes Survey and the Knowledge
Assessment tools was examined by an expert team of five nurses. The revision of the
instruments was done after the evaluation given by the expert team. For a
psychometric measurement of reliability, the researcher focused on the Attitude
Survey and the Knowledge Assessment tools, since the authors did not report the
reliability. The reliability of these two instruments was examined in terms of alpha
coefficient.
In the quantitative study, data were collected by means of a questionnaire
packet, which consisted of the introduction letter, the RN Demographics Form, the
Attitudes towards Death and Dying Survey (Tuch & Genesis ElderCare, 1998), and
the RN End-of-Life Knowledge Assessment (City of Hope, 1999). The questionnaires
were distributed to 600 Thai registered nurses, with 540 returned surveys; 538 had
complete data and were used for the quantitative data analysis by using the SPSS
program version 11.0. Descriptive statistics, measures of central tendency, frequency
distribution, and Pearson’s correlation were computed.
In the qualitative study, semi-structured interviews were conducted with a
total of twelve Thai registered nurses. Interviews were conducted in the Thai language
and audio taped. The interview style was primarily unstructured, as Gadamer (1976)
noted that the hermeneutic experience is characterized by the openness of the
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exchange. The researcher listened to participants’ stories and exemplary situations.
These interviews were audiotaped and participants’ narrative accounts were
transcribed by a research assistant. All transcripts were returned to participants for
validation of accuracy and opportunity to add comments. The researcher then
translated Thai transcripts into English, with the approval of three Thai nursing
professors attesting to accuracy of the translation. Van Manen’s method was used to
guide qualitative data analysis.
Study Concepts
Overall findings in the quantitative and qualitative research of this study
covered four main concepts: (a) attitudes toward death and dying with problems and
concerns about end-of-life care; (b) knowledge in end-of-life care; (c) nurses’
experience in end-of-life care; (d) ethical dilemmas and clinical judgment related to
end-of-life care; and (e) quality end-of-life care in Thailand.
Attitudes toward Death and Dying
The findings in the attitudes toward death and dying indicated that with the
maximum score of fifty and minimum score of ten, the overall scores (N = 538)
ranged from 25-48, with an average of 34.38, a median of 34.00, a mode of 34, and
the standard deviation of 3.632. A higher score indicates a positive attitude. About
52% of respondents (n = 280) had an attitude score lower than the average score.
Even though the average of attitudes scores (34.38) was higher than 50% (25) of the
maximum of fifty, the overall scores were slightly lower than what the researcher
expected from the sample. These results suggest that the majority of respondents were
more likely to have slightly negative attitudes toward the death and dying issues. The
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majority of Thai nurses (86.6%, n = 466) agreed with the first statement, the end o f
life is a time o f great suffering.
Moreover, in response to the fourth statement: la m not comfortable caring fo r
the dying patient, the sixth statement: When a patient dies I feel that something went
wrong, and the eighth statement: I am not comfortable talking to families about death,
less than 50% of respondents disagreed on these statements: 46.3%, 33.3%, and
29.0% respectively. This means that more than half of respondents agreed with these
negative statements, suggesting that the majority of respondents had negative attitudes
toward the nature of death and dying processes as they supposed a dying person
would be suffering at the end stage of his/ her life, and they felt uncomfortable caring
for the dying. However, if nurses had positive attitudes toward death as a natural
process of human being, they would be able to help dying patients and grieving
family feel more comfortable and relaxed getting through the end o f life time.
On the third statement, the use o f strong pain medications such as morphine
can cause the patient to stop breathing, only 18.9% (n = 102) of participants
disagreed on this statement. This result means that the majority of participants
(81.1%, n = 436) agreed that the use of morphine might suppress respiratory system
and stop patients’ breathing. Similarly, narrative accounts given by a couple of
participants in the qualitative study illustrated: the use of morphine aimed to relieve
severe pain in end stage cancer patients may result in a patient’s death (passive
euthanasia). There is an ongoing controversy on the issues of pain relief or pain
management versus euthanasia in Thailand and other countries. This controversy
should be recognized and appropriate ways identified to deal with its impact.
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Scientific tests on using these pain medications may be the best way to answer and
help nurses feel secure over the controversy.
According to attitude scores on positive statements, the results showed that
more than 80% of respondents strongly agreed or agreed on positive statements of 2,
7, 9 and 10: Even though a patient is terminally dying, something should be done to
help the patient to achieve a sense o f peace at the end o f life', I feel satisfied when my
patients experience what they believe to be a good death; Patients have the right to
refuse medical treatment, even i f that treatment prolongs life; and Never take away
hope from patients/families even though it is hopeless respectively. These results
suggest that the majority of nurse respondents had more positive attitudes on their
ability to help dying patients experiencing a peaceful death, promoting patients’ rights
in end-of-life decisions, and thus supporting hope for patients and family. However,
these positive statements contrast with negative statements indicating that nurse
respondents seemed to feel uncomfortable caring for dying patients. Responses
suggest that nurse respondents were concerned about respecting patients’ rights of
determination, helping the dying to have a peaceful death, and supporting the
families, while talking about death with the dying and families and understanding the
nature of inevitable event such as death still created discomfort among the
respondents. In Buddhism, to meet death, not only as an event at the end of life, but as
an ever-present ingredient in the life-process itself, is the final goal to be sought in the
individual life (Kubler-Ross, 1986). Kubler-Ross (1993) also suggested that one of
the most important things in dealing with terminal illnesses in healthcare services is
health professionals’ attitudes and ability to face death and dying issues.
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According to the fifth statement, about 59% of respondents agreed with this
statement, fam ily decisions about end-of-life treatment should be made independent o f
financial considerations. Forty-one percent of respondents believed that the decisions
on end-of-life treatments seemed to have an association with financial issues.
Conversely, a couple of participants in the qualitative study of this study indicated
that financial issues should not be an influencing factor for end-of-life decision
making because of the new implementation of coverage o f the nadonal health
insurance. With these contrasting results, based on the researcher’s own experience,
high costs o f interventions such as dialysis and transplantation are sometimes limited
to dying patients with regards to their conditions and prognoses. In addition, some
families of the dying in Thailand are extremely poor and live in rural areas. In order to
visit and stay with the dying in general hospitals, which are mainly located in urban
cities, family members cannot afford costs of transportation to the cities and they have
to be absent from their jobs, which creates more financial difficulties. These financial
considerations could be somewhat barriers in end-of-life care.
Analysis of the Attitude Survey revealed the following findings: the
participants (n = 80) from the upper north had an average of attitude scores of 34.7,
with the range between 25-42 and the standard deviation of 3.7; those (n = 93 from
the lower north had an average of attitude score of 34.3, with the range between 27-48
and the standard deviation of 3.8; those (n = 83) from the northeast had an average of
attitude score of 34.1, with the range between 25-42 and the standard deviation of 3.7;
those (n = 93) from the east had an average of attitude score of 34.8, with the range
between 27-42 and the standard deviation of 3.7; those (n = 97) from the central had
an average of attitude score of 34.1, with the range between 26-43 and the standard
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deviation of 3.5; and those (n = 91) from the south had an average of attitude score of
34.3, with the range between 26-44 and the standard deviation of 3.7 respectively.
Because there was no significant correlation (r = .044; p = .312) between attitude
score and region of respondents, it is clear from this analysis that there is no
significant difference on the attitude scores among different regions of the country,
thus strongly supporting the homogeneity of variance and generalization of the study
sample.
Relationships between attitude scores and demographic variables (age, level of
education, years of experience and annual income) were examined through statistical
correlations. Major findings indicated that there were no significant correlations
between attitude scores and these demographic variables, but the attitude and level of
education had a slightly positive relationship (r = . 147; p < .01), which was significant
at the 0.01 level (2-tailed). Results can be interpreted that the higher the level of
education of Thai nurses, the higher the positive attitudes toward death and dying.
However, a non-significant result means that any observed relationship could have
been the result of a chance of fluctuation (Polit et al., 2001).
Problems and concerns about end-of-life care. Problems about end-of-life
care were examined in the Attitude toward Death and Dying Survey. Thai nurse
respondents identified the three most important problems that they perceived in
providing end-of-life care: the “inability to meet spiritual needs” (n = 155, 28.8%),
the “loneliness” (n = 98, 18.2%), and the “control of pain” (n = 87, 16.2%)
respectively. According to the concerns on improving the quality end-of-life care, the
respondent ranked the three most important concerns that needed to be improved in
end-of-life care: the “greater emphasis on spiritual care” (n = 135, 25.1%), the
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“greater family involvement” (n = 124, 23%), and the “education in ethical issues” (n
= 67, 12.5%) respectively.
Findings in these sections of problems and concerns have important practical
significance. Especially, the inability to meet spiritual needs was perceived to be the
most important problem. This is congruent with the most important concern, which is
the greater emphasis on spiritual care. The results are similar to those findings in the
qualitative aspect of this study, in that nurse participants believed that spirituality is
essential to care of dying patients. Participants in the qualitative study also described
that they were supporting spiritual care in terms of cultural and religious beliefs as
requested by families of the dying.
Loneliness was ranked to be the second important problem for Thai nurses in
providing end-of-life care. This suggests that Thai nurses felt dying patients would
primarily have lonely feelings when they faced to the final stage of their lives. With
this problem, nurses should emotionally support and encourage hospitalized patients
to be involved in care and decisions related to their treatments. Incredibly, the second
important concern in improving end-of-life care was the greater family involvement
that was also significantly related to the problem of loneliness. With this congruence
of the problem of loneliness and the concern of greater family involvement, these
findings suggest that nurses should promote families of the dying participating as
caregivers in end-of-life care in order to minimize the problem o f loneliness.
One of the most important physical symptoms found in dying patients is
“pain.” Yet major barriers to effective pain management exist worldwide
(Stjemsward, Colleau, & Ventafridda, 1996). Findings of this study showed that pain
control was another significant problem that Thai nurses confronted in providing end-
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of-Iife care. This problem may relate to the management of pain in end stage cancer
patients who are the majority of recipients in end-of-Iife care. One of the reasons that
Thai nurses perceived the pain control as important is that it is evidence of the
controversy of pain relief versus euthanasia that raises an ethical dilemma among
nurses. Qualitative findings in this study also support that nurses felt frustrated while
giving pain medication such as morphine because they thought the medication could
have a side effect of suppressing a patient’s respiration. This dilemma may result in a
reluctance to provide such medication. Initially, the third concern in improving the
quality end-of-life care was the education in ethical issues. This concern suggests a
need for education to increase nursing knowledge on ethical issues related to end-of-
life care and help nurses protect and deal with ethical dilemmas confronting them.
Knowledge about End-of-Life Care
Findings from the RN End-of-Life Knowledge Assessment tool indicated that
with the maximum of twenty and the minimum of zero scores, the overall scores
ranged from 7-20, with an average score of 13.22, a median of 13.00, a mode of 14,
and the standard deviation of 2.159. More than 50% of respondents (52.2 %, n = 280)
had the knowledge scores lower than the average score. Findings showed that
questions 7, 9, 12 and 13 had a small number of respondents who answered correctly
(32.0%, 32.7%, 14.9% and 25.8% respectively). Questions 7 and 9 were about the
issue of pain management, and questions 12 and 13 were about the issue of other
physical symptom management regarding dyspnea and nausea/ vomiting. The results
of lower scores on these questions suggest that there is a lack of nursing knowledge
on pain and symptom management. These results are congruent with the American
long-term care study by Ersek, Kraybill and Hansberry (1999), indicating that
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education in the content areas of pain and symptom management is required in long
term care services. Surprisingly, these findings also support the results from
participants’ perceived problems, in which pain control was perceived as one o f the
most important problems that Thai nurses considered in caring for dying patients.
Therefore, nurses should be educated and find appropriate ways to address physical
symptoms of distress that affect dying patients.
Findings also indicated that the participants (n = 80) from the upper north had
an average of knowledge scores of 12.4, with the range between 7-18 and the standard
deviation of 2.4; those (n = 93) from the lower north had an average of knowledge
scores of 13.0, with the range between 7-18 and the standard deviation of 2.2; those (n
= 83) from the northeast had an average of knowledge scores of 13.0, with the range
between 7-17 and the standard deviation of 2.0; those (n = 94) from the east had an
average of knowledge scores of 13.7, with the range between 7-20 and the standard
deviation of 2.3; those (n = 97) from the central had an average of knowledge scores
of 13.4, with the range between 7-17 and the standard deviation of 1.9; and those (n =
91) from the south had an average of knowledge scores of 13.7, with the range
between 9-18 and the standard deviation of 2.0 respectively. Average of knowledge
scores of respondents from different regions of Thailand did not differ significantly
because there was no significant correlation between knowledge score and region (r =
-.004; p = .918). This interpretation supports the generalization and homogeneity of
the study sample.
According to the correlation analysis on the relationships between knowledge
scores and demographic variables (age, level of education, years of experience, and
annual income), findings also indicated that there were no significant relationships
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between knowledge scores, age, and years of experience. However, there were
significant positive relationships between knowledge scores and level of education (r
= .092; p < .05), and knowledge scores and income (r = .095; p < .05), which are
significant at the 0.05 level (2-tailed). The significant relationships suggest that
higher levels of nursing education and much knowledge in end-of-life care may
enhance nurse competence in caring for dying patients and their families, thus
resulting in enhanced quality of end-of-life care. Moreover, there is a slightly positive
relationship between knowledge scores and income (r = .095; p <.05) that seems to
suggest that Thai nurses with higher income are more likely to continue individual
education and obtain more nursing knowledge. This interpretation was not
anticipated, but it is interesting to consider how income might be related to higher
education and knowledge. However, Polit et al. (2001) noted that with large samples,
even modest relationships are statistically significant, but not necessary important.
These authors gave an example that with a sample of 500 subjects, a correlation
coefficient o f . 10 is significant at the .05 level, but a relationship of this magnitude
might have little practical value (p. 410). With these low correlations in a large
sample size (N = 538), therefore, findings of these relationships may not be
practically significant
Interpretative Themes
Thai Nurses’ Lived Experience in End-of*Life Care
The third step, reflecting essential themes (hermeneutic phenomenological
reflection), of van Manen was focused in the analysis of qualitative data. This process
is to grasp the meaning of focal experience or phenomenon reflected by participants
in the study. Van Manen (1997) noted that the insight into the essence of a
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phenomenon involves a process of reflectively appropriating, clarifying, and making
explicit the structure of meaning of the lived experience (p. 77). As noted in Chapter
IV, the analysis of nurses’ experience in end-of-life care related to Research Question
13: What is Thai nurses' lived experience in providing end-of-life care?, elicited
three categories: Holistic approach to end-of-life care, end-of-life decision making,
and nursing roles in end-of-life care. After reading through all the categories, an
analysis of themes for the qualitative data was done. Generally, theme in qualitative
data refers to an element that occurs frequently in the narrative accounts. It also gives
control and order to the research study. Van Manen (1997) stated that “theme
analysis” refers to the process of recovering the theme or themes that are embodied
and dramatized in the evolving meanings and imagery of the data (p. 78). When data
were examined across these categories, three interpretive themes were identified:
Helping dying patients to have a peaceful death, Placed in the middle, and Home
versus hospital.
Theme: Helping dying patients to have a peaceful death. The concept of
“helping dying patients to have a peaceful death” is considered to be one of the most
significant themes in this study. Most participants in the qualitative phase of this study
addressed this theme. One participant addressed that “the dying would have a
peaceful mind and think about all good things. In Buddhism, for example, the dying
person will be asked to pray for the Buddha. Buddhists believe that if the dying
person prays, the Buddha will take him to a peaceful place (heaven) and have a
peaceful death.” From interviews in this study, it is evident that Buddhism plays a
significant role in care of the dying for nurses in Thailand. Kubler-Ross (1986)
supported the account that Buddhist teachings concerning death to be lucid and calm
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is where the Buddha has come to receive the soul o f the deceased into a Buddha-
realm or Paradise (Happy Land). Findings from the quantitative phase of this study
substantially strengthen this theme, helping the dying to have a peaceful death,
because the majority of respondents (n = 527, 98.0%) also agreed with the second
statement, Even though a patient is critically dying, something should be done to help
the dying to achieve a sense o f peace at the end o f life, and also (n = 455, 84.5%)
agreed with the seventh statement, I feel satisfied when my patients experience what
they believe to be a peaceful death, in the Attitude toward Death and Dying Survey.
The “holistic approach” in end-of-life care is an essential component of
helping the dying to have a peaceful death. It is also considered to be the single best
quality in the ethics o f care in terms of which moral phenomena can be approached
from a multidimensional and multifactorial basis (Gilligan, Ward, & Taylor, 1994).
When asked about end-of-life care or caring for dying patients, most participants in
the qualitative study mentioned the importance of the holistic care or total care in
relation to the provision of physical, psychological/emotional, social, and spiritual
comfort to dying patients. They believed that supporting patients’ needs can help
patients to have a peaceful death. Congruently, Payne et al. (1998) noted that
palliative care nurses aim to provide holistic care for terminally ill patients, focusing
not only on the patients’ physical needs, but with a greater emphasis on their social,
psychological, and spiritual needs. Because the experience of living with progressive
illnesses impacts every dimension of a person’s life: physical, social, emotional and
spiritual (Byock, 1998), the holistic care is necessary in end-of-life care.
In addition, the notion of holistic approach in end-of-life care was evident in
the quantitative phase of this study. Findings from the RN End-of-Life Knowledge
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Assessment substantially support the narrative accounts given by the participants in
the qualitative portion of this study. More than 95% of respondents chose correct
answers for questions 5, focus o f end-of-life care includes control ofphysical
symptoms, psychological support o f patient and family, attention to spiritual needs
and question 20, the most important aspect in end-of-life care is that the provision o f
the quality o f end-of-life care in response to patient’s physical, psychological, social
and spiritual needs, regarding the essence of end-of-life care. The results suggest that
the majority of Thai nurse participants reflected their understanding of the necessity
of holistic approach in providing end-of-life care. Having this understanding of focal
point in end-of-life care is simply not enough; nurses should practice and provide care
based on this understanding so that dying patients would have better care, resulting in
comfort and peace at the last stage of their lives.
The essence of helping dying patients to have a peaceful death stems from the
notion of “cultural and religious influence” on end-of-life care. Support for cultural
and religious beliefs is essential to the provision of spiritual care needed to help
patients to have a peaceful death. Qualitative findings in this study significantly
indicated the influence of cultural traditions and Buddhist teachings on end-of-life
care in Thailand. Most participants stated that nurses had been requested by the family
of the dying to support their cultural traditions and religious activities in terms of their
beliefs to have a good or peaceful death. The following narrative account illustrates
this:
To respond to the spiritual need of patients is to provide them a

spiritual care. The dying patients usually may not have a full
consciousness so that families of the dying always ask the permission
from nurses if they could provide spiritual care. In most of the time if
families asked me for favors to help and support the dying, I always
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support the spiritual and religious activities that make patients and
families feel good and relaxed. Families sometimes read about
Buddhism or pray for the dying. Some of them may invite a Buddhist
monk to pray for the dying at their bed site. As a Buddhist, I also
provide comfort dying patients to be peaceful, and ask them to think
about the Buddha and good things.
Moreover, the advance directives such as living will and power o f attorney
have not yet been fully promoted in Thailand. Patients have not expressed their
decisions for preferences of care at the last stage of their lives. Thus, families of the
dying usually make end-of-life decisions on behalf of the patients with the notion of
what would be best for their loved ones to have a peaceful death. Findings from the
narrative accounts in this study indicated that family members, especially the eldest
son of the dying, made end-of-life decisions based on physicians’ advice and
information. Congruently, findings of the American study by the National Hospice
Foundation (1993) indicated that 50% of American adults rely on their family or
friends to make end-of-life decisions, although many of them have not discussed these
plans with their loved ones. In America, nurses believe that a dying patient should
have a right to make his or her own end-of-life decision if he or she has the ability to
do so. The question is raised whether advance directives such as a living will and
power of attorney should be promoted in Thailand in order to support patient
autonomy, rather than the paternalism, which is dominant in Eastern culture. Thus, an
individual nurse should respect the explicit or implicit delegation of decision making
by the patient
Theme: Placed in the middle. Qualitative findings of this study indicate that
several participants found themselves in the middle between the wishes of
patients/families and physicians. The nurses’ stories reflected a balancing act between
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their professional roles and their personal empathy for dying patients and the families.
Some experiences that left nurses feeling in the middle include issues of giving
information, use of alternative therapies, and request for spiritual and religious
practices.
Several participants suggested that their role as an informant placed them in
between physicians and families. Giving information is imperative and requires good
communication skills. In the hospital, nurses, rather than other caregivers, have
always been with dying patients and have provided necessary information to patients
in terms of treatments, medications, prognosis, and progressiveness of disease. For the
nursing profession, an informant role is essential in end-of-life care. Especially for the
family of the dying patient who sometimes cannot be with patients because of the
limitations of visiting time, nurses are the persons who tell the family about patients’
symptoms and changes. Congruently, a study in Taiwan by Hu et al. (2002)
conclusively suggested that health professionals: (I) communicate with families for
the acceptance of patients’ outcomes, (2) discuss with the families regarding possible
emotional reactions and the coping mechanisms, (3) give patients enough time to
reflect on their sickness, and (4) give more information based on patients’
expectations and support them compassionately.
Quantitative findings of this study also supported that nurses saw their
information-providing role as very important. In the RN End-of-Life Knowledge
Assessment, question 17 is: “What is a key component of improving care at the time
of death?” The result of this question indicated that about 85% (n = 457) of
respondents selected the correct answer: informing and educating family members
about signs and symptoms. Qualitative data suggest that nurses who found themselves
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taking on the informant role between physicians and families sometimes felt in the
middle.
The use of alternative therapies was another area where several nurse
participants in this study found themselves in the middle between patients/families
and physicians. The participants stated that the uses of herbal medicines, ointment
therapies, and meditation were requested by patients and families when medical or
conventional treatments did not effectively support dying patients. Families of the
dying asked nurses for a permission to use these alternatives. Nurses were unable to
make a decision unless physicians gave permission for these alternatives, even though
families would have used these treatments at home. Placing themselves in the middle,
nurses went to physicians as patient advocates for the request of these alternative
treatments.
In addition, the families of the dying patients always wish to practice spiritual
and religious rituals, as they believed that the dying patients would have a peaceful
death. In a study of spirituality and health in older Thai persons, Pincharoen and
Congdon (2003) support that Thai people focus on spirituality based on religious
beliefs, and it is a part of their daily lives. They also assert that maintaining religious
beliefs, practicing religious activities and accumulating religious merit are ways to
help Thai people experience comfort and peace, and to gain patience and harmony in
their lives. This request for the spiritual and religious practices may also put nurses in
the middle because some types of these practices (burning candles and prayer by
monks) may result in the disturbance or inconvenience for the other patients. Nurses
have to be concerned when they allow the families to give spiritual practices.
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Theme: Home versus hospital. A notion of home versus hospital is the last
theme recognized in Thai nurses’ lived experience in end-of-life care. Several nurse
participants in the qualitative study expressed their feelings about which hospitalized
patients would be given good practice and care. They mentioned how they felt
uncomfortable if the patient’s wish to die at home was granted. However, life-
sustaining interventions may not be as important as psychosocial and spiritual
supports from families of the dying in the home environment. At home, families,
relatives, and friends can always stay with the dying, and the dying would feel more
comfortable in the familiar atmosphere. Culturally important spiritual care and
religious practices can be provided more readily in the home. Byock (1998) also noted
that as a patient’s disease progresses and there is proportionately less that medicine
can offer in terms of life-prolongation, it is rational and inevitable for the focus of
care to progressively shift toward the goals of comfort and quality of life. For patients
and families in Thailand, this usually means the home.
Ethical Dilemmas and Clinical Judgments Related to End-of-Life Care
The majority of respondents (58.7%, n = 315) in the quantitative phase of this
study indicated an understanding of what is meant by ethical dilemmas related to end-
of-life care. From the correct answer in the RN End-of-Life Knowledge Assessment
tool, the ethical dilemma was described as the nurse cannot balance her or his
personal belief and role obligations while providing end-of-life care. Botes (2000)
noted that ethical dilemmas would remain unresolved if there was no complementary
application of the ethics of justice and the ethics of care. The ethics of justice consists
of an ethical perspective in terms of which ethical decisions are made on the basis of
universal principles and rules, with a view to ensuring fair and equitable treatments of
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all people. The ethics of care, on the other hand, consists of an ethical approach of
involvement, in which harmonious relations and needs play a significant part in
decision-making (Botes, 1998). In analysis of the qualitative findings on caring for
dying patients, ethical dilemmas related to end-of-life care would seem to be better
resolved on the basis of the ethics of care, rather than the ethics of justice (bioethics).
The researcher of this study believes that nurses providing end-of-life care focus more
on the essence of caring in terms of involvement, empathy, and holistic nature, than
the essence of fairness and equality based on universal principles and rules. Allmark
(1998) supported that the ethics of care is appealing to nurses partly because it is more
likely to offer a different way of doing things from mainstream ethics, reflecting the
belief that care is central to nursing.
As noted in Chapter IV, analysis of nurses’ experience in end-of-life care
related to Research Question 14: How do Thai nurses describe the ethical dilemmas
related to end-of- life care and clinical judgment they use in dealing with the ethical
dilemmas in providing quality end-of-life care?, resulted in identification of Ethical
Dilemmas Related to End-of-Life Care and Clinical Judgments related to end-of-life
care. When data were examined across categories related to ethical dilemmas, two
interpretive themes were identified: Pain relief versus euthanasia, and DNR versus
CPR.
Theme: Pain relief versus euthanasia. Narrative accounts given by
participants in the qualitative study illustrated ethical dilemmas related to pain relief
or pain management. Several participants described situations where they gave pain
medication such as morphine to relieve severe pain in cancer patients. Most of them
believed that morphine may have a serious side effect on patients’ respiratory system,
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but with their duties, they had to give morphine to patients. These situations raised
ethical dilemmas for them. It can be interpreted that the dilemmas of giving pain
medications occurred when nurse participants could not balance their beliefs and
duties to give pain medications. It is implied that there is a conflict between the
ethical principles of beneficence (pain relief) and nonmaleficence (do no harm). As
Gadamer (1989) noted, knowledge of a general ethical principle and moral action is in
itself knowledge of how to act only in the particular ethical situations it governs, not
in all situations. Ethical knowledge is not epistemic knowledge like that of
mathematics, but it evolves from the history of one’s experience in specific situations
(Gadamer, 1989). Thus, participants’ reactions to the pain control were varied in
regards to their own ethical knowledge and previous experience in similar situations.
However, the issue of pain management in end stage patients is problematic.
Quantitative Endings of this study also supported that pain control was considered to
be a significant problem perceived by Thai nurse respondents.
Theme: DNR versus CPR. Some participants in this qualitative study
validated a controversy over the orders of Do-Not-Resuscitate (DNR) and Cardio
pulmonary Resuscitation (CPR) that made them feel uncomfortable in regards to the
DNR orders. In many cases, families of the dying who request a DNR order may wish
to avoid artificial respiration in which they believe the dying would suffer from the
artificial life support The orders of DNR and CPR raise a controversy among nurses.
According to Buddhism, Buddhist teachings about death and dying are that people
who face death calmly, courageously, and confidently will see death as an ever
present ingredient in the life-process (Kubler-Ross, 1986). In this controversy on the
DNR orders, Karetzky, Karetzky and Brandstetter (1996) noted that we should take a
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lesson from Buddha that the acceptance of death and the limitations of CPR allow for
the acceptance of DNR with all comforts and compassion. If the DNR order is
requested by the patient or the family, nurses should be able to support this preference
on the basis of the ethics of care.
However, the DNR orders only preclude resuscitative efforts and should not
influence other therapeutic treatments that may be appropriate (Council on Ethical
and Judicial Affairs American Medical Association, 1991). When making a decision
about CPR, physicians should particularly ask about the patient’s preferences for
incubation in the event of pulmonary arrest and the patient’s goals should be
communicated to all involved in the patient’s care (Beach & Morrison, 2002). Thus,
in order to reduce the dilemma of DNR orders, patients’ goals and treatment
preference should be clarified before the DNR decision is made so that nurses would
be more comfortable on the position of DNR orders.
Gadamer (1989) noted that judgment can be learned—but not in the abstract
because it is not an abstract rule: it can be learned only in the concrete by being
practiced from case to case (p. 31). In making a clinical judgment in end-of-life care,
based on their own experience and practices, all participants in the qualitative study
identified problems in terms of ethical dilemmas they confronted and found
appropriate ways to help them feel less frustrated with these dilemmas. Their
narrative accounts illustrated how they made clinical judgments in dealing with
frustration and anxiety from ethical dilemmas related to end. Three main interpretive
themes of participants’ clinical judgment processes were identified: Belief of
providing best care, Caring practice in the nursing profession, and Using colleagues to
guide ethical decision making.
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Theme: Belief of providing best care. Narrative accounts of the participants
illustrated the practical reasoning and clinical judgment of the belief of providing best
care. When ethical dilemmas occurred to be problematic, the participants realized
what they were practicing in the care of dying patients. Most participants believed that
when they provide the best practice to the dying, it made them less frustrated with the
dilemmas. Congruently, Benner et al. (1996) described clinical judgment in nursing
practice and addressed the notions of the good as “the nurse’s disposition toward what
is good and right is not a matter of individual ethics, but it is rather socially structured
and embedded within the discipline as well as within the norms and mores of the
particular unit on which she practices” (p. 15). The essence of these notions of good
described by Benner et al. (1996) could be explained in relation to nurse respondents’
beliefs in providing end-of-life care. In addition, Gadamer (1989) noted that based on
judgment, the grasp and moral control of the concrete situation require subsuming
what is given under the universal that is the goal he or she can pursue to do the right
thing (pp. 21-22).
Theme: Caring practice in the nursing profession. Caring is one of the
most significant concepts in the nursing profession that participants in this study
addressed. The concept of caring in nursing is very important for nurses in providing
end-of-life care. When an ethical dilemma occurs, Thai nurse participants tried to
balance what they believed to be good for dying patients and what their
responsibilities were under the scope of nursing practice. Caring practice is more
likely to be the answer for them to make clinical judgments on situations where the
dilemmas occurred. Moreover, caring practices bring about the possibility for the
nurses to know the patient as a person, opening new horizons for identifying and
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understanding what is most important to the patient and family (Bennner, et al.,
1996). The concept of caring is so broadly open in the nursing profession, but in end-
of-life care, it is very important for nurses to identify needs of patients and the
families, understand their cultural background and beliefs, and fulfill such needs that
are central to nursing.
Theme: Using colleagues to guide clinical judgment making. Several
participants also mentioned that discussions of ethical dilemmas with colleagues
could help decrease their frustration. Sharing problems and experiences of providing
end-of-life care could be one of the best ways to make clinical judgments and deal
with dilemmas. Benner et al. (1996) noted that nursing practice cannot be done in
isolation: therefore, the part of nursing expertise is associated with strengthening and
working with others so that no one is overburdened and all possible resources can be
brought to bear in difficult situations. However, making judgments about right or
wrong, proper and improper is primarily based on common sense (Gadamer, 1989, p.
32). Gadamer (1989) asserted that whoever has a sound judgment is not thereby
enabled to judge particularly under universal viewpoints, but with the common
sense—German term, “sensus communis”—he/she see thinks right by his/her points
of view (p. 32). Nurses can incorporate their common sense, nursing knowledge, and
shared experience in making clinical judgments in order to help them deal with ethical
uncertainties and dilemmas related to end-of-life care.
Quality End-of-Life Care
The last question of this study is how Thai nurse participants have provided
quality end-of-life care. The concept of quality end-of-life care is hard to determine,
although it is very important in the care of dying patients. From several categories on
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the concerns about the improvement of quality end-of-life care in Chapter IV, there
are three main interpretative themes that are related to the concerns about the
improvement of quality end-of-life care in Thailand. The three themes include:
Supporting cultural and religious beliefs, respecting patient’s rights, and promoting
clinical and service innovations
Theme: Supporting cultural and religious beliefs. Several Thai nurse
participants described the importance of supporting and providing patients’ spiritual
needs regarding the cultural and religious activities. Gadamer (1989) noted that
culture (German word “Bildung”) does not result from achieving the manner of
technical construction, but it grows out of an inner process of formation and
cultivation. Culture can refer to the traditional manner and activities that people have
set aside and practiced for years. According to religious belief, the majority of
patients in hospitals believe in Buddhism. The Buddhist belief has primarily
influenced the ways that Thai people live from the birth to the death of a person.
Thus, it is imperative for nurses to assess cultural and religious experiences in end-of-
life care that can be determinants in achieving better quality end-of-life care.
Theme: Respecting patient’s rights. In the United States, the patient’s rights
have been a significant issue in healthcare services. In Thailand, however, the
patient’s rights have not fully promoted. However, during the past few years, the
Ministry of Public Health in Thailand focused on the promotion of patient’s rights
while hospitalized. In this qualitative study, several Thai nurse participants addressed
the issue of patients’ rights in end-of-life care. They mentioned that dying patients
have their rights to make decisions, to be equally treated, to stop the life-sustaining
interventions, and to die at home. It seems that nurses respect patient’s rights, but the
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end-of-life decisions are still based on the family agreement, as well as physicians’
recommendations.
Theme: Promoting clinical and service innovations. It is surprising that
most of Thai nurse participants told the researcher of this study about clinical and
service innovations on their units when they were asked about quality improvement.
All innovations described are very interesting. They included an isolated room for
near-death patients, comfort with shampooing, principles of care, meeting and
training for end-of-life care, tele-visiting, and home visit. These innovations need to
be promoted in other hospitals to focus on end-of-life issues.
In summary, five key concepts that guided the analysis and discussion of this
study are: (a) attitudes toward death and dying, and problems and concerns about end-
of-life care; (b) knowledge in end-of-life care; (c) lived experience in end-of-life care;
and (d) ethical dilemmas and clinical judgments related to end-of-life care; (e) quality
end-of-life care. Essential themes in narrative accounts regarding nurses’ lived
experience in end-of-life care include helping patients to have a peaceful death,
placed in middle, and home versus hospital. Regarding the nurses’ ethical dilemmas,
essential themes consist of pain relief versus euthanasia and DNR versus
CPR.Themes that are related to nurses’ clinical judgments include belief of providing
best care, caring practice in the nursing profession, and using colleagues to guide
clinical judgment making. Themes that are related to quality end-of-life care include
supporting cultural and religious beliefs, respect for patient’s rights, and promoting
clinical and service innovations. The overall findings from quantitative and qualitative
portions suggest implications for nurses in order to improve the care for dying
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patients. These implications relate to nursing administration, education, practice, and
research.
Implications for Nursing
The variables examined in this study—attitudes toward death and dying,
perceived problems in end-of-life care, concerns for improving end-of-life care,
knowledge in end-of-life care, ethical dilemmas related to end-of-life care, and
clinical judgment in dealing with the ethical dilemmas are essential to the quality of
end-of-life care.
Nursing Administration
Twenty-two general hospitals, which have 500 and more patient beds, are
governed and financed by the Ministry of Public Health with a goal of serving and
giving health care services to all residents in Thailand. With the greater number of
recipients of care, most of the general hospitals have admitted a substantial number of
dying patients who are suffering from incurable disease and dying. However, the
qualitative findings in this study indicate that there are not adequate palliative care
units in general hospitals in Thailand because none of the participants mentioned
specific palliative care units for care of dying patients.
Thus, there is a need for developing palliative care units in hospitals in
Thailand where end stage patients can receive care in response to the preferences of
dying patients and their families in terms of physical, psychological, social, and
spiritual needs as well as cultural and religious beliefs. As major health care
professionals in hospitals, nurses primarily have a greater involvement in caring for
dying patients. Nursing administrators should be pioneers for developing programs of
palliative care units in hospitals. Quality outcomes of the implementation can be
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measured in terms of the satisfaction of dying patients, family, and staff with an
improvement of care and services provided in palliative care units. With several
ethical issues related to end-of-life care as described by participants of the study, the
palliative care units will provide a standard of palliative care for dying patients and
their families. With this standardization of practice, nurses and other palliative care
team members will receive guidance with conflicts and dilemmas related to end-of-
life care. Likewise, Olarte and Guillen (2001) addressed two main reasons that
palliative care has been well promoted in Spain: (a) on the one hand, since palliative
care links with existing cultural traditions, politicians and administrators are
convinced that introducing palliative care programs is the best way of interpreting the
actual wishes of dying patients and family, thus improving the quality of end-of-life
care through better management of pain and suffering; and (b) these politicians are
probably convinced that developing palliative care is also the best way to avoid the
politically difficult and disturbing debate about euthanasia.
None of the participants in this study mentioned hospital ethics committees.
Based on the ethical principles of autonomy, beneficence, nonmaleficence, and
justice, an ethics committee consisting of team members of health care professionals
(physician, pharmacist, medical technologist, physical therapist, social worker, and
nurse) should be established. Aims of the ethics committee are to promote a patient’s
right and preference in end-of-life care, and to help resolve ethical dilemmas
confronting health care professionals while providing end-of-life care. Nursing
administrators and other hospital administrators should collaborate in establishing the
hospital ethics committee.
180
Enhancing the nursing role in end-of-life care is of extreme importance to
nurse administrators. The nurse has assumed several roles in caring for dying patients.
Patient advocacy is one of the most essential nursing roles in caring for the dying and
their family. Because of progressiveness of incurable diseases and grieving
environment, the dying patient and family may not fully express their wishes and
rights in end-of-life care and decision-making. Nurse managers and nurses could take
the advocate role in order to help the patient and family in response to beliefs and
wishes for care at the end stage. The question of support for patient autonomy rather
than paternalism should be addressed. In end-of-life decision-making, advance
directives regarding living wills should be promoted to all dying patients who are
conscious and have an ability to make the decision by themselves.
Furthermore, findings in this study also indicate a slightly positive relationship
between knowledge in end-of-life care and annual income (r = .095; p < .05). It seems
that income or financial issues may have an impact on nurses’ knowledge. Helping a
patient and family through the process of dying can be an intensely rewarding
experience (Vazirani et al., 2000). Thus, nurse administrators should recognize good
performance and practice and give rewards for those exemplary nurses providing care
for dying patients. A measure of good practice is more likely to elicit the patient’s and
family’s appreciation and satisfaction. For example, a couple o f participants in the
qualitative study mentioned how patients and families appreciated services so the
families brought fruits, snacks, and flowers to units after the patients were discharged
from hospitals. Nurse administrators and managers should also support creativity and
flexibility in caring for dying patients in order to enhance satisfaction of dying
patients and their families.
181
Nursing Education
Findings from the RN End-of-Life Knowledge Assessment indicate that
approximately 52% of respondents had lower scores than the average of 13.2. It may
be assumed that the majority of Thai nurse respondents in the study lack specific
knowledge in end-of-life/palliative care. Ln addition, whereas few universities in
Thailand have currendy developed specific palliative care courses in the nursing
curriculum, palliative care concepts are integrated into courses related to adult care or
elderly care. Findings also indicate that “education in ethical issues” (n = 67, 12.5%)
is the third most important concern in improving the quality of end-of-life care. Thus,
it may be beneficial to develop a specific course in end-of-life care or palliative care
incorporating nursing ethics and ethics of care in end-of-life care for nursing
education curricula throughout the country. The course should encompass the
management of physical, psychological, social, and spiritual needs of dying patients
and family. In the American study of long-term care nurses’ knowledge in end-of-life
care, Raudonis et al.,(2002) concluded that integration of end-of-life content into the
curricula at all levels of nursing education is needed in order to improve nurse
competence in end-of-life care for future long-term care residents. Pimple et al.
(2003) also assert that within a palliative care course, three major components—
education, collaboration, and accountability—should be identified to enhance the
ability of student nurses to delivery quality end-of-life care. They noted that education
provides students the knowledge and skills in providing end-of-life care and
empowers them to educate others; collaboration refers to the necessity of utilizing an
interdisciplinary approach in delivering care in response to patients’ and families’
182
needs; and accountability provides students with the understanding of the
responsibility to advocate for dying patients and their families.
Results in the attitude toward death and dying survey for this study also
indicated the majority of participants had more negative attitudes toward the death
and dying processes, as they felt uncomfortable talking about these issues. If nurses
had more positive attitudes toward death as a natural human process, they would be
able to help dying patients and grieving families feel more comfortable at the end-of-
life. Therefore, nursing instructors should encourage student nurses to identify their
own attitudes toward death and dying, and to be able to identify and respect differing
attitudes toward death and dying among people from different social, cultural, and
religious backgrounds.
Some elective courses on death, dying and grieving, death education, and
cultural studies should be recommended to students in order to enhance their positive
attitudes toward death and dying, and prepare them for care of dying persons from
different cultural backgrounds. Durand, Dickinson, Sumner and Lancaster (1990)
substantiate this recommendation as they found more positive attitudes toward end-of-
life issues in physicians who had received some specific death education. Moreover, a
preceptor development program is a specific strategy for teaching students who first
experience caring for a dying patient Nursing instructors should collaborate with
nurse managers and chief nurses to provide a mentoring role in discussion of and
participation in caring for dying patients.
Organizing the nursing seminars and conferences on the issues of end-of-life
or palliative care should be promoted in community, national, and international levels
in order to share new information about the body of knowledge in end-of-life care.
183
Nursing Practice
Practicing nurses primarily are involved in care of dying patients where the
focal care for this specific type of patient is associated with a holistic approach in
terms of physical, psychological, social, and spiritual care. Based on the
complementary application of the universal ethical principles (autonomy, beneficence,
nonmaleficence, and justice) and the ethics of care, the provision o f holistic care at the
end of life is especially important for nurses and those caring for dying patients.
However, an ethical dilemma sometimes occurs when nurses cannot balance their
personal beliefs and their professional role obligations. Training is needed in ethical
roles and communication skills that can minimize the barriers and enhance healthcare
professionals’ abilities in providing patients and their families with adequate
information (Parle et al., 1997).
As stated in findings of this study, pain and other physical symptom
management and other physical symptoms such as fatigue, dyspnea, and anemia
should be a concern of practicing nurses. Moreover, findings of this study suggest that
at the end stage of life, the nurse should be well prepared for the provision of end-of-
life care, not only to patients in the dying process but also to family through grief and
bereavement. An essence of nursing roles in end-of-life care was also described in the
findings of the qualitative study. Such nursing roles are informant, patient advocate,
supporter, coordinator, and patient’s relative.
The findings also indicated that ethical dilemmas related to end-of-life care led
to frustration, discomfort, and dissatisfaction among practicing nurses. Clinical
thinking and clinical judgment are necessary in situations in which any ethical
dilemma occurs. Discussions among colleagues can help nurses through sharing
184
information and experience, encouraging individuals in providing care and supporting
the belief of providing best practice in end-of-life care. In order to minimize conflicts
confronting nurses in end-of-life decisions, nurses should encourage greater family
involvement associated with a patient’s preference for care.
Seminars and conferences on end-of-life nursing care and spiritual care for
dying patients are needed because nurses would have an opportunity to participate and
get credits for attending, thus improving knowledge in end-of-life care. As Benner
(1984) suggested, clinical judgment seminars for nurses can provide a significant
opportunity for nurses with different experiential background related to end-of-life
care to meet and discuss their clinical practice, ethical dilemmas, and problems and
ways to deal with these problems while providing care to dying patients. Uncovering
knowledge in nurses’ experience would be stimulants for the development o f nursing
practice.
As results of this study demonstrate, the level of education in nursing is a
contributing factor in nurses’ attitudes and knowledge related to end-of-life care.
Mentoring and nursing staff education are important in health care organizations.
Educational needs in the content areas of philosophy and principles of palliative care,
pain and symptom management, and psychological aspects of end-of-life care need to
be addressed (Ersek et al., 1999; Raudonis et al., 2002). Novice nurses should be
provided an orientation program for care o f dying patients with specific needs before
they actually enter practice. Scholarships in nursing programs could also be an
incentive for staff nurses in continuing of nursing education at the Master and
Doctoral levels. Moreover, a certification program in palliative care should be
developed because nurses would be certified in caring for dying patients, resulting in
185
a greater understanding of patients’ needs and a betterment of quality end-of-life care.
Clinical and service innovations are needed in this area.
Nursing Research
Research is warranted to extend the presently limited knowledge of end-of-life
care in Thailand. Because this study was conducted in general hospitals located in
urban areas, a replication of the study is needed in rural areas such as community
hospitals and villages, as well as in private hospitals in order to provide a means of
comparing and contrasting the findings with this study. The results o f this study also
indicate concerns of cultural traditions and religious beliefs in relation to issues of
death and dying, as well as end-of-life care. Thus, caring for dying persons in
community or rural areas may expand more cultural and traditional beliefs in terms of
attitudes toward death, dying, grief, and bereavement.
According to the uniqueness of care at the end stage, needs o f dying patients
with specific types of illnesses may be varied. The research should be specifically
conducted in particular diseases and types of illnesses that cause dying and death such
as the end-of-life care issues in cancer, HTV, chronic renal failure (CRF), diabetes
mellitus, chronic obstructive pulmonary disease (COPD), as well as the dying in
children, youth, and old age patients.
In addition, the issue of death or end-of-life is a sensitive area. In order to
obtain in-depth data, qualitative research is needed. Further qualitative research is
needed to focus on lived experience of nurses in providing end-of-life care and
patients’ near death experience, as well as families with grief. Further quantitative
research is also essential for the nursing profession to improve quality of end-of-life
186
care. However, with the small number of instruments regarding end-of-life issues,
instrument development is extremely needed in this area.
Limitations of the Study
Ethics is a concept that may be difficult for nurses to interpret in concrete
terms. Qualitative interviews were conducted in the Thai language. Thus, one of the
limitations of the study is the translation of transcripts from Thai into English.
Misinterpreting of meanings might occur during the translation and transformation of
data. It was difficult to translate the Thai transcripts into English because sentence
structures were ordered differently. Skilled translation is required in the processes of
data analysis and interpretation of findings. However, in order to minimize this
limitation, the researcher transcribed and translated qualitative data herself. The
researcher also had an expert team of three Thai nursing professors to verify and
approve the translations. These professors have doctoral degrees in nursing from the
United States and expertise in gerontology, qualitative research, and end-of-life care.
Moreover, qualitative research has not been gready promoted in Thai or Asian
cultures because people generally do not express their feelings or explicit thoughts of
their lived experience. Other methods should be considered to incorporate with
phenomenology including ethnography, historical research, or observation methods.
Another limitation of the study is that there is little Thai literature relevant to
end-of-life issues. Litde research has been done in the area of end-of-life care in
Thailand, so there are few studies that can support findings of this study. The
researcher anticipates that findings from this study will add to understanding of the
significant problem of ethical dilemmas encountered by Thai nurses in providing end-
of-life care. Furthermore, there are a small number of available research instruments
187
with high reliability and validity used in the area of end-of-life or palliative care. The
development of appropriate tools regarding Thai culture in end-of-life care should be
strongly promoted.
Summary of Study
The five concepts—(a) attitudes toward death and dying including problems
and concerns on end-of-life care, (b) knowledge in end-of-life care, (c) lived
experience in end-of-life care, (d) ethical dilemmas and clinical judgments related to
end-of-life care, and (e) quality end-of-life care—are primarily important in response
to aims of end-of-life or palliative care given for both dying patients and grieving
families. Findings from the quantitative study indicated that about 52% of respondents
(n = 280) were more likely to have unfavorable attitudes toward death and dying
issues, the three most important problems in providing end-of-life care perceived by
Thai nurses were the inability to meet spiritual needs, loneliness and control of pain,
and the three most important concerns about improving quality end-of-life care were
the greater emphasis on spiritual care, greater family involvement and education in
ethical issues. The strongest area of Thai nurses’ knowledge in end-of-life care was in
the general knowledge and communication in end-of-life care, and the weakest area
was in pain and symptom management. The correlation analysis indicated three
statistically significant relationships between variables, but these relationships may
not be practically significant with the large sample size (N = 538).
Findings from the qualitative study indicated that interpretative themes of Thai
nurses’ lived experience included helping patients to have a peaceful death, placed in
the middle, and home vs. hospital. The themes on ethical dilemmas and clinical
judgments related to end-of-life care included pain relief vs. euthanasia, DNR vs.
188
CPR orders, belief of providing best care, caring practice in the nursing profession,
and using colleagues to guide clinical judgm ent Themes on quality end-of-life care
included supporting cultural and religious beliefs, respecting patient’s rights, and
promoting clinical and service innovations.
End-of-life care is not focused on aggressively advanced interventions with
the goal of curing, but it is more likely to focus on the provision of psychosocial and
spiritual comfort to the dying and their families. As a patient’s disease progressively
advances and there is proportionately less that medicine can provide in terms of life-
prolongation, it is both rational and inevitable for the focus of care to shift toward the
goals of comfort and quality of life (Byock, 1998). In end-of-life care, administration,
education, practice, and research of the nursing profession should be unceasingly
developed. It is evident that nurses confront ethical situations indicating ethical
dilemmas related to end-of-life care that make them felt frustrated and uncomfortable
while providing care. These situations should be resolved so that the nurses would
feel comfortable to provide the quality of care based on the ethics of care.
As nurses provide more care to dying patients and their families than any other
healthcare professional, the quality end-of-life care depends on the availability of
well-prepared nursing professionals (Pimple et al., 2003). Benner (1984) also noted
that “expertise in complex human decision making, such as nursing requires, makes
the interpretation of clinical situations possible, and the knowledge embedded in this
clinical expertise is central to the advancement of nursing practice and the
development of nursing science” (p. 3).”
189
References
190
References
Aging with Dignity. (2001). Five wishes. Retrieved February 14, 2002, from
http://www.agingwithdignity.org/5wishes.html
Allmark, P. (1998). Is caring a virtue? Journal o f Advanced Nursing, 28(3), 466-472.
American Association of Colleges of Nursing (AACN), & City of Hope National
Medical Center. (2000). End-of-Life Nursing Education Consortium (ELNEC)
Project. Retrieved January 12, 2002, from http://www.aacn.nche.edu/elnec/
American Nurses Association. (2001). Code o f ethics fo r nurses with interpretive
statements. Washington, DC: American Nurses Publishing.
American Geriatrics Society. (1997). Measuring quality of care at the end of life: A
statement of principles. Journal o f American Geriatrics Society, 45, 526-527.
Beach, M. C., & Morrison, R. S. (2002). The effect of do-not-resuscitate orders on
physician decision-making. Journal o f American Geriatrics Society, 50(12),
2057- 2061.
Beauchamp, T. L., & Childress, J. F. (2001). Principles o f biomedical ethics (5th ed.).
New York: Oxford University Press.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing
practice. Menlo Park, CA: Addison-Wesley.
Benner, P., Chesla, C., & Tanner, C. (1996). Expertise in nursing practice: Care,
clinical judgment, and ethics. New York: Springer.
191
Beyea, S. C. (1997). Qualitative and quantitative approaches to nursing research.
AORN, 66(2), 323-325.
Botes, A. C. (1998). Ethics o f justice and ethics o f care. Johannesburg, South Africa:
Rand Afrikaans University Press.
Botes, A. C. (2000). A comparison between the ethics o f justice and the ethics of care.
Journal o f Advanced Nursing, 32(5), 1071-1075.
Braun, K. L., Pietsch, J. H., & Blanchette, P. L. (Eds.). (2000). Cultural issues in end-
of-life decision making. Thousand Oaks, CA: Sage.
Byock, I. R. (1997). Death and dying. In C. Jaffe, & C. H. Ehriich (Eds.), All kinds o f
love: Experiencing hospice. New York: Baywood.
Byock, I. R. (1998). Hospice and palliative care: A parting of the ways or a path to the
future? Journal o f Palliative Medicine, 1(2), 165-176.
Campbell, M. L. (1998). Forgoing life-sustaining therapy: How to care fo r the patient
who is near death. Aliso Viejo, CA: AACN Critical Care Publication.
Chambliss, D. F. (1996). Beyond caring: Hospitals, nurses, and the social
organization o f ethics. Chicago: The University o f Chicago Press.
City of Hope National Medical Center. (1999). Instruments used in end o f life care
(EOL) education. Duarte, CA: City of Hope Resource Center.
Covinsky, K. E., Goldman, L., Cook, E. F., Oye, R., Desbiens, N., Reding, D.,
Fulkerson, W., Connors, A. F., Lynn, J., & Phillips, R. S. (1994). The impact
of serious illness on patients’ families. Support Investigators. Study to
understand prognoses and preferences for outcomes and risks of treatment.
JAMA, 272, 1839-1844.
192
Council on Ethical and Judicial Affairs of the American Medical Association. (1991).
Guidelines for the appropriate use of do-not-resuscitate orders. JAMA, 265,
1868-1871.
DeSpelder, L. A., & Strickland, A. L. (1999). The last dance: Encountering death and
dying (5th ed). Mountain View, CA: Mayfield
Diekelmann, N. (1988). Curriculum revolution: A theoretical and philosophical
mandate fo r change. New York: National League for Nursing.
Dunn, H. (1999). Light in the shadows: Meditations while living with a life-
threatening illness. Herndon, VA: A & A Publishers, Inc.
Durand, R. P., Dickinson, G. E., Sumner. E. D., & Lancaster, C. J. (1990). Family
physicians’ attitudes toward death and terminally ill patient. Family Practice
Research Journal, 9(2), 123-129.
Ekblad, S., Marttila, A., & Emilsson, M. (2000). Cultural challenges in end-of-life
care: Reflections from focus groups’ interview with hospice staff in
Stockholm. Journal o f Advanced Nursing, 31(3), 623-630.
Ersek, M., Kraybill, B. M., & Hansberry, J. (1999). Investigating the educational
needs of licensed nursing staff and certified nursing assistants in nursing
homes regarding end-of-life care. American Journal o f Hospice and Palliative
Care, 16, 573-582.
Ferrell, B.(1998). End-of-life care: How well do we serve our patients? Nursing, 98,
58-60.
Ferrell, B., & McCaffey, M. (1997). Nurses’ knowledge about equianalgesia and
opioid dosing. Nursing, 20, 201-212.
193
Ferrell, B., Virani, R., & Grant, M. (1999). Review of communication and family
caregiver content in nursing texts. Journal o f Hospice and Palliative Nursing,
1 0 ), 97-107.
Ferrell, B., Virani, R., Grant, M., Coyne, P., & Uman, G. (2000). Beyond the
Supreme Court decision: Nursing perspectives on end-of-life care. Oncology
Nursing Forum, 27(3), 445-455.
Field, M. J., & Cassel, C. K. (Eds.). (1997). Approaching death: Improving care at
the end-of-life. Washington. DC: National Academic Press.
Foley, K. M., & Gelband, H. (Eds.). (2001). Improving palliative care fo r cancer.
Washington, DC: National Academy Press.
Gadamer, H. G. (1976). Philosophical hermeneutics (D. Linghe, Trans.). Berkeley,
CA: University CA Press.
Gadamer, H. G. (1989). Truth and method (2nd Rev. ed.). (J. Weinsheimer & D. G.
Marshall, Trans). London: Sheed and Ward.
Gadamer, H. G. (1999). Hermeneutics, religion, and ethics (J. Weinsheimer, Trans.).
New Haven, CT: Yale University Press.
Gadamer, H. G. (2001). Gadamer in conversation (R. E. Palmer, Trans.). New Haven,
CT: Yale University Press.
Gilligan, C., Ward, J. V., & Taylor, J. M. (1994). Mapping the moral domain.
Cambridge, England: Harvard University Press.
Guba, E. G. (1981). Criteria for assessing the trustworthiness of naturalistic inquiries.
Educational Communication and Technology Journal, 29, 75-92.
194
Harkreader, H. (2000). Fundamentals o f nursing: Caring and clinical judgment.
Philadelphia: W.B. Saunders.
Hathirat, S. (2001). Rights to live or die: Caring fo r hopeless patients (C.
Manosilapakom, Trans.). Bangkok, Thailand: Mor-Choa-Ban Press.
Heidegger, M. (1962). Being and time (J. Macquarrie & E. Robinson, Trans.). New
York: Harper and Row.
Hu, W. Y, Chiu, T. Y., Chuang, R. B., & Chen, C. Y. (2002). Solving family related
barriers to truthfulness in cases of terminal cancer in Taiwan: A professional
perspective. Cancer Nursing, 25(6), 486-492.
Institute of Medicine. (1990). Medicare: A strategy fo r quality assurance.
Washington, DC: National Academy Press.
Husserl, E. (1962). Ideas: General introduction to pure phenomenology. New York:
Colloer.
Karetzky, P. E., Karetzky, M., & Brandstetter, R. D. (1996). CPR or DNR: Lessons
from Buddha. Chest, 109(6), 1415-1422
Kastenbaum, R. (1979). Human developing: A lifespan perspective. Boston: Allyn &
Bacon.
Kataoka-Yahiro, M., & Saylor, C. (1994). A critical thinking model for nursing
judgment. Journal o f Nursing Education, 33, 351-355.
Koch, T. (1996). Implementation of a hermeneutic inquiry in nursing: Philosophy,
rigour and representation. Journal o f Advanced Nursing, 24(1), 174-184.
Kubler-Ross, E. (1986). Death: The final stage o f growth. New York: Simon &
Schuster Inc.
195
Kubler-Ross, E. (1993). On death and dying: What the dying have to teach doctors,
nurses, clergy, and their own families. New York: Colllier Books &
Macmillan.
Larkin, P. J. (1998). The lived experience of Irish palliative care nurses. International
Journal o f Palliative Nursing, 4(3), 120-126.
Last Acts Task Force. (1997). Precepts o f palliative care. Princeton, NJ: Robert
Wood Johnson Foundation.
Leininger, M. (1994). Evaluation criteria and critique of qualitative research studies.
In J. M. Morse (Ed.), Critical issues in qualitative health research methods
(pp. 95-115). Thousand Oaks, CA: Sage.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage.
Mason, J. (1996). Qualitative researching. London: Sage.
McNamara, B., Waddell, C., & Colvin, M. (1995). Threats to the good death: The
cultural context of stress and coping among hospice nurses. Sociology o f
Health and Illness, 17(2), 222-244.
Ministry of Public Health Thailand. (2001). Retrieved December 5, 2001, from
http://www.moph.gov.th
Morgan, E. R., & Winter, R. J. (1996). Teaching communication skills: An essential
part of residency training. Archives o f Pediatrics and Adolescence Medicine,
150,638-642.
Morse, J. M., & Field, P. A. (1996). Nursing Research: The application o f qualitative
approaches (2nd ed.). New York: Chapman & Hall.
196
Murphy, K. R., & Myors, B. (1998). Statistical power analysis: A simple and general
model fo r traditional and modem hypothesis tests. Mahwah, NJ: Lawrence
Erlbaum Associates.
Nakasone, R. Y. (2000). Buddhist issues in end-of-life decision making. In K. L.
Braun, J. H. Pietsch, & P. L. Blanchette (Eds.), Cultural issues in end-of-life
decision making. Thousand Oaks, CA: Sage.
National Hospice Organization. (1993). Standards o f a hospice program o f care.
Arlington, VA: National Hospice Organization.
Neimeyer, R. A. (Ed.). (1994). Death anxiety book: Research, instrumentation, and
application. Washington, DC: Taylor & Francis.
Oberle, K., & Hughes, D. (2001). Doctors’ and nurses’ perceptions of ethical
problems in end-of-life decision. Journal o f Advanced Nursing, 33(6), 707-
715.
Olarte, J. M. N., & Guillen, D. G. (2001). Cultural issues and ethical dilemmas in
palliative and end-of-life care in Spain. Cancer Control, 5(1), 46-54.
Ome, R. M. (1992). The meaning o f survival: A hermeneutic study o f the initial
aftermath o f a near-death experience. Unpublished doctoral dissertation,
Adelphi University.
Parle, M., Maguire, P., & Heaven, C. (1997). The development of a training model to
improve health professionals’ skills, self-efficacy and outcome expectancies
when communicating with cancer patients. Social Science Medicine, 44(2),
231-240.
Pascoe, E. (1996). The value to nursing research of Gadamer’s hermeneutic
philosophy. Journal o f Advanced Nursing, 24(6), 1309-1314.
197
Payne, S. A., Dean, S. J., & Kalus, C. (1998). A comparative study of death anxiety in
hospice and emergency nurses. Journal o f Advanced Nursing, 25(4), 700-706.
Pedhazur, E. J., & Schmelkin, L. P. (1991). Measurement, design, and analysis: An
integrated approach. Hillsdale, NJ: Lawrence Erlbaum Associates.
Perryman, J. P. (1999). Factors in end-of-life decision-making: Caring practice,
ethical concern, and personal knowing. Unpublished doctoral dissertation,
Georgia State University.
Pimple, C., Schmidt, L., & Tidwell, S. (2003). Achieving excellence in end-of-life
care. Nurse Educator, 25(1), 40-43.
Pincharoen, S., & Congdon, J. G. (2003). Spirituality and health in older Thai persons
in the United States. Western Journal o f Nursing Research, 25(1), 93-108.
Polit, D. F., & Hungler, B. P. (1999). Nursing research: Principles and methods (6th
ed.). Philadelphia: Lippincott.
Polit, D.F., Beck, C.T., & Hungler, B.P. (2001). Essentials o f nursing research:
Methods, appraisal, and utilization (5th ed.). Philadelphia: Lippincott.
Poor, B., & Poirrier, G. P. (2001). End-of-life nursing care. Boston: Jones and
Bartlett.
Pronovost, P., & Angus, D. C. (2001). Economics of end-of-life care in the intensive
care unit. Critical Care Medicine, 29(2), 46-51.
Randall, F., & Downie, R. S. (1996). Palliative care ethics: A good companion.
Oxford, England: Oxford University Press.
Ratanakul, P. (1990). Thailand: Refining cultural values. The Hastings Center Report,
20(2), 25-33.
198
Raudonis, B. M., Kyba, F., & Kinsey, T. (2002). Long-term care nurses’ knowledge
of end-of-life care. Geriatric Nursing, 23 (6), 296-301.
Robbins, J. (Ed.). (1983). Caring fo r the dying patient and the family. London: Harper
& Row.
Rousseau, P. (1998). Palliative care in managed Medicare: Reasons for hope-and for
concern. Geriatrics, 11, 59-65.
Sanz Ortiz, J., Gomez-Batiste, X., & Gomez Sancho, M. et al. (1993). Cuida-dos
paliativos: Recomendaciones de la Sociedad Espanola de Cuidados Paliativos
(SECPAL). Serie guias y manuals. Madrid, Spain: Ministerio de Sanidad y
Consumo (Spanish Association for Palliative Care).
Scanlon, C. (2003). Ethical concerns in end-of-life care: When questions about
advance directives and the withdrawal of life-sustaining interventions arise,
how should decisions be made? American Journal o f Nursing. 103(1), 48-55.
Silva, M. C. (1990). Ethical decision making in nursing administration. Norwalk, CT:
Appleton & Lange.
Singer, P. A., Martin, D. K., & Kelner, M. (1999). Quality end of life care: Patients’
perspectives. JAMA, 281(1), 163-168.
Spiegelberg, H. (1975). Doing phenomenology. Dordrecht, The Netherlands: Martinus
Nijhoff.
Stjemsward, J., Colleau, S. M., & Ventafridda, V. (1996). The World Health
Organization cancer pain and palliative care program: Past, present, and
future. Journal o f Pain and Symptom Management, 12, 65-72.
Streubert, H. J., & Carpenter, D. R. (1999). Qualitative research in nursing:
Advancing the humanistic imperative (2nd ed.). Philadelphia: Lippincott.
199
Thailand National Statistic Office. (1985). Populations. Retrieved December 5, 2001,
from http://www.aging.co.th
Tschudin, V. (1994). Ethics: Nursing people with special needs. London: Scutari
Press.
Tuch, H., & Genesis ElderCare (1998). Attitudes toward death survey. Retrieved
March 4, 2002, from http://www.nursing.upenn.edu
U.S. Census bureau National Population Projections. (2001). Summary Files: Total
Resident Population by 5-Year Age Groups. Retrieved October 31, 2001, from
http://www.census.gov/population/www/projections/natsum-T3.html
Vainio, A., & Auvinen, A. (1996). Prevalence of symptoms among patients with
advanced cancer: An international collaborative study. Journal of Pain and
Symptom Management, /2(1). 3-10.
van Manen, M. (1997). Researching lived experience: Human science for an action
sensitive pedagogy (2nd ed.). New York: State University of New York Press,
van Manen, M. (Ed.). (2002). Writing in the dark: Phenomenological studies in
interpretative inquiry. London, Ontario, Canada: The Althouse Press.
Vazirani, R. M., Slavin, S. J., & Feldman, J. D. (2000). Longitudinal study of
pediatric house officers’ attitudes toward death and dying. Critical Care
Medicine, 28(11), 3740-3745.
Vincent, J. L. (2001). Cultural differences in end-of-life care. Critical Care Medicine,
29(2), 52-55.
Walsh, K. (1996). Philosophical hermeneutics and the project of Hans Geroge
Gadamer. Implications for nursing research. Nursing Inquiry, 3 ,231-237.
200
Walsh. K. (1999). Shared humanity and the psychiatric nurse-patient encounter. The
Australian and New Zealand Journal o f Mental Health Nursing, 8(1), 2-8.
Wass, H.. & Myers, J. E. (1982). Psychosocial aspects of death among the elderly: A
review of the literature. Personnel and Guidance Journal, 61, 131-137.
Weissman, D., & Griffie, J. (1994). The palliative care consultation service of the
Medical College of Wisconsin. Journal o f Pain and Symptom Management,
9(7), 474-479.
World Health Organization. (1990). Cancer pain relief and palliative care. Geneva,
Switzerland: WHO
Zakari, M. N. (1991). Identifying factors that affect the pattern o f attendance o f
pregnant Saudi women at antenatal care facilities. Unpublished Master’s
thesis, King Saud University, Riyadh, Saudi Arabia.
Zuckerman, C. (1999). End-of-life care and hospital legal counsel: Current
involvement and opportunities fo r the future. New York: United Hospital
Fund.
APPENDIX A: Introductory Letter
202
Introductory Letter
666-668 Moo 2, Thabkhlo,

Phichit 66150 Thailand
August 5, 2002
Dear Registered Nurse,
My name is Chanphen Manosilapakom, a doctoral candidate of the College of

Nursing and Health Science, George Mason University, Fairfax, Virginia. My dissertation
topic is ““Thai Nurses' Attitudes, Knowledge, and Ethical Dilemmas Related to End-of-
life Care in Thailand.” The purposes of the study are threefold: (1) examine Thai nurses’
attitudes toward death and dying, problems and concerns on end-of-life care, and
knowledge about end-of-life care; (2) determine factors that influence Thai nurses'
attitudes toward death and dying and their knowledge of end-of-life care; and (3) explore
Thai nurses’ ethical dilemmas and the clinical judgments used in resolving ethical
dilemmas.
You are invited to participate in the study. There are three instruments in the
study: RN Demographics Form, Attitudes toward Death and Dying Survey and RN End-
of-Life Knowledge Assessment. The approximate time used to answer the questionnaires
is about 20-25 minutes.
Any information that is obtained in this study will be confidential. You do not
have to put your name and address in the questionnaires. Thank you very much for your
participation in the study.
Yours sincerely,
Chanphen Manosilapakom,
Doctoral Candidate
Fairfax, Virginia
203
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204
APPENDIX B: Attitudes toward Death and Dying Survey
205
Below are statements about attitudes/ beliefs about death & dying, and end-of-life issues.
After each statement there are five responses: strongly disagree, disagree, not sure, agree,
or strongly agree. Please indicate how much you agree or disagree with each of the
following statements, by circling number beside the statement that best described your
feelings.
Strongly Disagree Not Sure Agree Strongly
Disagree Agree
1. The end of life is a time of 1 2 3 4 5

great suffering
2. Even though a patients is 1 2 3 4 5

terminally dying, something
should be done to help the
patient achieve a sense of peace
at the end of life
3. The use of strong pain

medication such as morphine
can cause the patient to stop
breathing
4. I am not comfortable caring

for the dying patient
5. Family decisions about

end-of-life treatment should
be made independent of
financial considerations
6. When a patient dies I feel that

something went wrong.
7. I feel satisfied when my

patients experience what they
believe to be a good death
8. I am not comfortable talking

to the families about death
9. Patients have the right to 1 2 3 4 5

refuse a medical treatment,
even if that treatment prolongs life
10. Never take away hope from 1 2 3 4 5

patients/ families; even though
it is hopeless.
206
11. What do you think are the most important problems in caring for the dying
resident in the hospital? (circle all that you believe to be appropriate)
a. Control of pain
b. Depression
c. Loneliness
d. Legal concerns/ Hospital regulatory concerns
e. Communication with doctor and other healthcare professionals
f. Communication with family
g- Inability to meet spiritual needs
h. Uncertainty about what is best care
i. Other fplease specify)
Please name the top three from the above list (1st is the most important problem)
1. _________________________________
2 . _____________________________________________
3. _________________________________
12. What are concerns that you think would help improve end of life care in your
facility? (circle all that you believe to be appropriate)
a. Education and training in pain control
b. Greater access to Hospice services
c. Greater physician involvement and nursing staff involvement
d. Greater family involvement
e. Education in legal and regulatory concerns
f. Education in ethical issues in end-of-life care
g. Use of a palliative care team
h. Greater emphasis on spiritual care
i. Other (please specify)___________
Please name the top three from the above list (1st is the most important issue)
1. _________________________________
2.
3.
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APPENDIX C: RN End-of-Life Care Knowledge Assessment
210
Please circle only one answer that is the most appropriate for each question regarding
your knowledge about end-of-life issues.
1. The goals of end of life care include all except

a. halting the progress of the disease
b. controlling the pain
c. relieving emotional and spiritual distress
d. enhancing patient/family choices regarding the final stage of life
2. Which approach to addressing cultural beliefs in end of life care is not appropriate?
a. treat all patients in exactly the same way
b. be attentive to individual patient needs
c. assess patients' values and beliefs about end of life care
d. assess who makes the important health care decisions in the patient's family
3. What is best described an “ethical dilemma” related to end-of-life care confronting the
nurse?
a. conflicts among family of a dying patient about financial issues
b. the nurse cannot balance her personal beliefs and role obligations while providing
end-of-life care
c. a wish to go home of the dying patient
d. none of above is appropriate
4. The roles of nurses in end-of-life ethical decision making include

a. gathering information about the patient's diagnosis and physical condition as
much as possible
b. determining the patient’s and family’s wishes about providing end-of-life care
c. collaborating and giving information of patient preferences, fears, and concerns to
other healthcare professionals
d. all of the above
5. The focus of end-of-life care includes

a. control of physical symptoms
b. psychosocial support of the patient and family
c. attention to spiritual needs
d. all of the above
6. The most accurate judge of the intensity of the patient's pain at the end stage of life is
a. the treating physician
b. the primary nurse
c. the patient
d. the patient’s spouse or family
211
7. Mr. C has terminal pancreatic cancer but he is concerned that he is becoming addicted
to his pain medication. You explain to him that
a. he ought not to worry about addiction because it happens to everyone on narcotics
b. he is right to worry and you will speak to his physician about changing his
medication
c. he is not addicted to his medication, please do not worry about that
d. he is terminally ill
8. Analgesia for chronic pain should be given

a. around the clock on a fixed schedule
b. only when the patient asks for the medication
c. only when the nurse determines that the patient has moderate or severe discomfort
d. only when the patient’s family requests pain medication to be given
9. The recommended route of administration of opioid analgesics to patients with

continuous cancer-related pain is
a. intravenous
b. intramuscular
c. oral
d. rectal
10. The most likely explanation for why a patient with pain would request increased
doses of pain medication is
a. the patient is experiencing increasing pain
b. the patient is experiencing increased anxiety or depression
c. the patient is trying to become more sedated
d. the patient’s request are related to addiction
11. All of the following are interventions to relieve dyspnea at the end of life
a. administering oxygen
b. discontinue oxygen to hasten death
c. reduce anxiety
d. administering morphine
12. Fatigue at the end of life can be a result of

a. anemia, medication, dehydration
b. constipation, diarrhea, nausea and vomiting
c. cardiac failure, pneumonia, dyspnea
d. none of the above
13. All of the following interventions help to relieve nausea EXCEPT

a. medicating with an anti-emetic only when vomiting is experienced
b. avoiding fatty or spicy foods
c. medicating with anti-emetic on a round-the clock basis until nausea subsides
d. using relaxation or visual imagery techniques
212
14. Which statement about medically provided hydration and nutrition (such as tube
feedings or IV hydration) is untrue?
a. it is always appropriate for terminally ill patients
b. it may be refused by a competent adult
c. it may increase a patient’s suffering (i.e., accumulation of fluid in the patient’s
lungs)
d. family members may resist discontinuing food and fluids because of the nurturing
or comfort associated with these treatments
15. Signs and symptoms of impending death include all EXCEPT

a. bowel incontinence
b. pupils reactive to light
c. unresponsive to stimulus
d. decreased pulse and respiration
16. All of the followings are barriers to family communication patterns including
a. fear of dying
b. isolation from family members
c. pre-existing family conflicts
d. all of the above
17. A key component of improving care at the time of death is

a. informing and educating family members about signs and symptoms
b. since each case is different, treat symptoms only as the symptoms appear
c. avoidance of bothering the family with information about what might happen at
the end of life
d. minimizing family involvement when the patient is dying
18. It is important to remember

a. death is a great time of suffering
b. each death is not different, and must be concerned in the same way.
c. to allow the family time with the body after death to say goodbye
d. to support Buddhist spirituality to all deaths
19. Grief
a. is an individual process whereby one progresses at his/her own rate
b. can be complicated by unresolved family issues related to the dying individual
c. is a cumulative experience of multiple losses that have occurred during the illness
experience
d. all of the above
20. What is the most important aspect for nurses in providing end-of-life care person?
a. provision the quality of care in response to patient’s physical, psychological,
social, and spiritual needs
b. decision-making in end-of-life care depends only on physician and family desires
c. patient’s wish to go back and dye at home will not be effective if physician does
not allow the patient to do so
d. none of above is important
213
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217
APPENDIX D: RN Demographics Form
218
ID #
R N Demographics Form
Please make a selection of what is appropriate to yourself *
1- A ge________
2. Gender
1Q Female 2Q
3. Marital
rital Status
St
Single 3( Separated/ Divorce
22 (8 ) Married 4f Widow
4. Religion.
5. Highest Level of Nursing Education
Bachelor Doctorate
Master Post-Doctorate
6. Practice Area
1Q Med-S-Surg Pediatrics
2O I-C.U. Other (please specify).
7. Years of Experience in Nursing.

8. Annual Income________
9. Region of Practice
Upper North East
‘O
2 0 Lower North sO Central
3 0 Northeast 6 0 South
10. Have you ever had experience in providing end-of-life care?

iO Yes 2O No
219
ID #
imuaouoiu A: KBjjariujTuriVli]
(RN Demographics Form)
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8. molftitasimofl_______
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3O m ntm iu 6O
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220
APPENDIX E: Permissions for Instruments
221
From "Howard Tuch” <hstuch@msn.com>

Date Friday, April 19, 2002 7:38 am
To <cmanosil@gmu.edu>
Subject Re: Permission for Attitudes Toward Death Survey
Dear Champhen,
• You have my permission to use the attitudes toward death survey in your work . You also
have my permission to translate it into the Thai language.
Howard Tuch, M.D.
Director Palliative Care Resources
3324 Westmoreland Drive, Tampa FI 33618
ph/fax :813-963-6280
— Original Message —
From: cmanosfl@gmu.edu
S e n t Tuesday. April 16, 2002 5:39 PM
To: hstuch
Subject: Permission for Attitudes Toward Death Survey
Dear.. Dr. Howard,
According to the Review Board a t George Mason University, I would like

you to write me a formal permission to use the Attitudes toward death
survey. I have to modify and translate the tool into Thai language. Is
it ok for that? Thank you so much.
Best regards,
Chanphen Manosilapakorn
Doctoral Candidate
Fairfax, VA
Original M essage-----
From: “hstuch" < hstuch@msn.com>
Date: Wednesday, April 3, 2002 2:27 pm
Subject: Re: RE: The Attitudes Toward Death Survey
> Hi,
>
> It is fine to use the tool . Please acknowledge in any publication
> th a t the
> tool was developed by Dr Howard Tuch and Genesis ElderCare.
>
> HT
ittp://mserver2.gmu.ed u/frame.html 03/10/2003
223
APPENDIX F: Interview Guide
224
Interview Guide
Who will be participants o f the study ?

Twelve to fifteen Thai nurses experiencing in end-of-life care will be interviewed.
The participants will be drawn from the original group of the study, and have varying
years of experience in providing end-of-life care.
Where will the interview take place?

The interview will take place in a private and quiet room at general hospitals in
Thailand where participants have been working.
When will the interview occur?

The interview will occur during a three-month period (July-September 2002). This
period includes the follow-up interviews, verbatim transcription and translation.
How long will the interview take?

The interview will take approximately 45-60 minutes.
What is the interview process?

Informed consent will be distributed to all participants at the beginning of the
interview process. The semi-structured interview will be given to all participants of the
study. The researcher of the study will use tape-recorder in collecting information.
Interview Questions
1. What kinds of end-of-life issues have you experienced in providing care for
dying patients?
2. What does an ethical dilemma mean to you? Can you tell me about an incident
when you experienced an ethical dilemma that is related to end-of-life care?
3. In the situation you described, how did you make clinical judgments about the
ethical dilemma?
4. What are your concerns on the improvement of quality end-of-life care?
225
APPENDIX G: HSRB Approval
226

Fairfax, Virginia 22030-4444
Office of Sponsored Programs

Compliance Department
TO: ^ D rJ^ a n ^ S o tr^ ^ ^ H S
FRbM: Rostyn'Steon, M.S.. Assistant Director for Research Compliance
PROTOCOL NO.: 3458
TITLE: Attitudes, Knowledge and Ethical Concerns Related to End of Life Care in Thailand
DATE: May 30. 2002
Cc: Chanphen Manosilapakorn, CNHS
At its convened meeting on May 22, 2002, the George Mason University Human Subjects Review
Board (GMU HSRB) reviewed and approved the above-cited protocol.
You may proceed with data collection. Please note that all modifications to your protocol must be
submitted to the Office of Sponsored Programs for review and approval prior to implementation.
Any adverse events or unanticipated problems involving risks to subjects including problems
involving confidentiality of the data identifying the participants must be reported to me in the
GMU Office of Sponsored Programs and reviewed by the GMU HSRB.
Theânniversary date of this study is_May 21, 2003. You may not collect data beyond that date
without GMU HSRB approval. Prior to that date, the GMU Office of Sponsored Programs will
send a letter to you regarding continuing review procedures.
If you have any questions, please do not hesitate to contact me at 703/993-4015.
227
APPENDIX H: Informed Consent
228
Consent Form
Attitudes. Knowledge. and Ethical Concerns Related to End o f Life Care in Thailand
(Qualitative Study: Interview)
Chanphen Manosilapakom, RN. PhD C andidate

College o f Nursing and Health Science
George M ason U niversity
Fairfax. Virginia
This research is being conducted to explore nurses' ethical dilem m as related to end-of-life
care. I f you agree to participate, you will be interview ed by the researcher. The questions will
be about your lived experience in ethical dilem m as w hile providing care for dying patients.
T he interview will take approxim ately 60-90 m inutes in a private and quiet room. The
researcher will use the audio-tape recorder during the interview process. All tapes w ill be
kept secure in a locked metal box. and will be destroyed when all procedures o f the research
have been done. The researcher is the only person w ho will have access to the tapes. Y our
identity will be known only to the researcher.
There are no foreseeable risks involved in the participation, but discom fort and emotional
reaction due to the nature o f questions that will be asked may occur. There are no benefits to
you as a participant other than further o f research in im proving palliative care program in
nursing curriculum . The study outcomes may bring a broader picture o f nurses' attitudes and
know ledge related to care near the end-of-life. and m ay help health care professionals in
developing the quality o f end-of-life care in Thailand. T he data in this study will be
confidential. The collection and submission o f the inform ation from this research will be
accom plished with adherence to professional standards o f confidentiality. T he data will be
sum m arized and reported only in group form. N am es and other identifiers will not be
required on surveys or other research data.
Y our participation is voluntary, and you may w ithdraw from the study at any time and for
any reason. If you decide not to participate or if you withdraw form the study, there is no
penalty or loss o f benefits. T here are no costs to you o r any other party.
This research is being conducted by Chanphen M anosilapakom , the C ollege o f N ursing and
Health Science at G eorge M ason University. The researcher can be reached at 056-641-194.
T he research advisor is Dr. Jeanne Sorrell" the college o f Frealth Science at George Mason
University. She may be reached at 703-993-1944 o r jso rrelk ag m u .ed u for questions or to
report a research related problem . You may contact the G eorge M ason U niversity Office o f
Sponsored Program s at 703-993-2295 or pbetor@ gm u.edu i f you have any questions or
com m ents regarding your rights as a participant in the research. This research has been
reviewed according to G eorge Mason University procedures governing your participation in
this research.
I hat e read this form and hereby consent to participate in this research study.
Signature Date o f Signature

expires
MAY 2 ] 2003
GeorgeMason University
229
APPENDIX I: Evaluation Form for Content Validity
230
Evaluation Form for Testing the Content Validity of Instruments
"Attitudes toward Death and Dying Survey”
Name:__
Degree: _
Job Title:
No Criteria for Validity Yes No Comments
1. Clear and simple wording

of questions, and easy to
understand
2. Relevant to purpose of the
study
3. Comprehensive questions
4. Appropriate to Thai
Culture
5. Appropriate length of each
question
6. Appropriate length of
entire questionnaire
7 No bias responses in
certain direction
8. Appropriate ordering of
the questions
9. Appropriate number of
questions
10. Appropriate to the scope
of end-of-life issues
Additional Comments:
231
Evaluation Form for Testing the Content Validity of Instruments
"RN End-of-Life Knowledge Assessment”
Name:_
Degree: _
Job Title:
No Criteria for Validity Yes No Comments
1. Clear and simple wording

of questions, and easy to
understand
2. Relevant to purpose of the
study
3. Comprehensive questions
4. Appropriate to Thai
Culture
5. Appropriate length of each
question
6. Appropriate length of
entire questionnaire
7 No bias responses in
certain direction
8. Appropriate ordering of
the questions
9. Appropriate number of
questions
10. Appropriate to the scope
of end-of-life issues
Additional Comments:
CURRICULUM VITAE
Chanphen Manosilapakom was bom on March 19, 1973, in Phichit, Thailand and is a
citizen of Thailand. She graduated from Taphanhin High School, Phichit, Thailand, in
1990. She received her baccalaureate degree in nursing from Rangsit University,
Pathumthani, Thailand, in 1994. She is a registered nurse. Following two years of
employment with the Phya Thai II Hospital, Bangkok, Thailand, she was awarded a
scholarship from the Royal Thai Government to study for masters and doctorate
degrees in nursing programs abroad. She received a Master of Science in Health
Sciences from the University of Northumbria at Newcastle, Newcastle upon Tyne, the
United Kingdom, in 1998.
Ms. Manosilapakom' professional experience is in gerontology. She was an intern

student at the National Council on the Aging, Washington D.C., in 2001. She
published an article titled “Ethical Dilemmas Related to End of Life Care of Elderly
Persons in Thailand” in the Ethics Forum, the Office of Health Care Ethics, George
Mason University, Virginia. She was a member o f the “Home Care” research project,
created in response to the request of the Department of Family and Health Services,
Fairfax County, Virginia, in 2001. Ms. Manosilapakom presented this project at
various nursing conferences. She also pursued a gerontology certification from the
College of Nursing and Health Science, George Mason University, in 2003.
Ms. Manosilapakom is a member of the Thai Nursing Council, Thailand. She is also a
member of the Epsilon Delta Chapter of Phi Beta Delta and Sigma Theta Tau
International. She serves as a nursing instructor of the Praboromarajchanok Institute
of Nursing College, Bangkok, Thailand.

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INFORMATION TO U SER S

The quality of this reproduction is dependent upon the quality o f th e

Oversize materials (e.g., maps, drawings, charts) are reproduced by

ProQuest Information and Learning

A dissertation submitted in partial fulfillment of the requirements for the degree of

Director: Jeanne M. Sorrell, Ph.D., R.N., FAAN

Spring Semester 2003

ProQuest Information and Learning Company

_ Coordinator, Doctoral Program

Dean, College of Nursing and

Date: ^ _______ Spring Semester, 2003

To my grandmothers for their love and support. My inspiration to write this

Dr. Norman Stanhope, my other member of my committee - your knowledge and

Classmates: Om-Anong Wichaikhum and Nazik Zakari (NOC group)

My host families: Ms. Susanne Fogleman and the Smith’s family

1. Spearman Brown Formula with Doubled Number of Research T ools................... 70

THAI NURSES’ ATTITUDES, KNOWLEDGE, ETHICAL DILEMMAS, AND

Chanphen Manosilapakom, Ph.D., RN.

George Mason University, 2003

Dissertation Director Dr. Jeanne Sorrell

questionnaire on the demographic characteristics, attitudes toward death and dying,

problems and concerns on end-of-life care, knowledge in end-of-life care. A

colleagues to guide clinical judgment making, supporting cultural and religious

These findings are a basis of partial documentation in end-of-life/ palliative care in

Thailand as the improvement of the quality of end-of-life care is warranted.

Recommendations for nursing administration, education, practice and research are

presented in regards to the improvement of end-of-life care in the nursing profession

significance of study, assumptions, purposes, research questions, theoretical

framework, conceptual map, and conceptual and operational definitions. A summary

of the chapter is then discussed.

The number of aging persons with chronic illnesses is rising worldwide, as

experience grieving processes. Questions about advance directives, refusal of

treatment, and withdrawal or withholding of life-sustaining interventions can be

difficult to address in end-of-life decisions (Scanlon, 2003). By any measure, efforts

Different cultures have different approaches to the problem of end-of-life care.

explore the phenomenon of end-of-life care in Thailand. It is evident that chronic

understood by Thai nurses.

withdrawing life-sustaining treatments from the patient because they felt a

to assume the responsibility of withdrawing treatments—feeding tube and intravenous

Regarding nursing education in Thailand, the course of caring for dying

requirements of coursework for student nurses. However, currently only a few

universities in Thailand have a specific course for end-of-life nursing or palliative

end-of-life or palliative care.

End-of-life care or palliative care is an important phenomenon to understand

order to provide end-of-life care, it is imperative that healthcare professionals are

interchangeably. Palliative care is primarily aimed at providing quality end-of-life

progressive illnesses has impacted every dimension of a person’s life: physical,

to find ways to provide quality end-of-life care in response to personal experience,

needs, and beliefs at the last stage of life.

As healthcare professionals seek to provide quality end-of-life care, many

a multidimensional concern in response to physical, psychological, social, and

euthanasia are understood to be morally wrong in Thailand. Especially, there is a

controversies between ways o f conventional medical treatments and the values of

related to caring for dying patients in Thailand.

respond to those concerns, as well as supporting families in their grieving processes

attitudes needed in end-of-life care. Thus, it is important to examine nurses’ attitudes

impact on healthcare professionals’ attitudes and knowledge in end-of-life care.

Feldman (2000) conducted a longitudinal study of pediatric house officers’ attitudes

knowledge in provision of end-of-life care.

In addition, there is a paucity of literature that addresses the phenomenon of

and clinical judgments are reflected in the phenomenon of end-of-life care. It is

2. Attitudes regarding end-of-life care are important to the quality of care

3. Knowledge regarding end-of-life care is important to the quality o f care

4. Nurses sometimes struggle with end-of-life decisions.