Decision-making in the treatment of elderly people: a cross-cultural comparison between Swedish and German physicians and nurses

OR IG INAL ART ICLE

Decision-making in the treatment of elderly people:a cross-cultural comparison between Swedish andGerman physicians and nurses

Jorg Richter1PhD (Professor), Martin R. Eisemann2

PhD (Professor), Barbara Bauer3MD PhD (Associate

Professor), Hannelore Kreibeck4Dipl.-KS and Sture Astrom5

PhD (Lecturer)1Psychiatric and Psychotherapeutic Clinic, Rostock University, Rostock, Germany, 2Unit of Medical Psychology, Umea University, Umea,

Sweden and Psychological Institute, University of Treomsoe, Treomsoe, Norway, 3Director of the Neurologic Clinic Neubrandenburg,

Neubrandenburg, Germany, 4Director of Advanced Nursing, Community Hospital, Neubrandenburg, Germany, and 5Department of

Advanced Nursing, Umea University, Umea, Sweden

Scand J Caring Sci; 2002; 16; 149–156

Decision-making in the treatment of elderly people:

a cross-cultural comparison between Swedish

and German physicians and nurses

The aim of the study was to evaluate the comparability of

decisions in the treatment of severely ill incompetent

elderly patients among physicians and nurses from a cross-

cultural perspective. Convenience samples of 192 doctors

and 182 nurses from Germany and 104 doctors and 122

nurses from Sweden have been investigated by a ques-

tionnaire in a cross-sectional study. Between 39 and 58%

of the subjects in the various groups have chosen treat-

ment options, which are not consistent with the patient’s

will. However, nurses showed a significantly higher com-

pliance than doctors. The probability of choosing

cardio-pulmonary resuscitation decreased with increasing

information about the patient’s wish. Ethical concerns and

the patient’s wishes appeared as the most important

determinants of treatment decisions, whereas the hospital

costs as well as the physicians’ religion were of minor

importance. The inconsistencies concerning decision-

making within and between the groups reflect differences

in underlying values and lack of societal consensus, which

represent a prerequisite for the improvement of patient

autonomy. To focus more frequently and to a larger extent

onto the problems related to the treatment of severely ill

elderly patients as well as onto the training of communi-

cation skills with an orientation towards informed consent

in the medical training seems to be warranted.

Keywords: incompetent elderly patients, decision-

making, advance directive, cross-cultural comparison.

Submitted 15 May 2001, Accepted 5 November 2001

Introduction

The care and treatment of severely ill patients is related to

some of the most complicated medical (1), care (2, 3),

ethical (4–8) and legal (4–11) problems. Problems arising

from recent developments in medical technology and its

common application, in many cases irrespective of the real

conditions of the patient and its probable outcome have

been discussed considering the consequences of these

practice from an ethical point of view (12, 13). Within this

process the role of doctors and nurses has been broadened

to include also healers, comforters, delayers of death and

givers of new life.

In order to reduce decision-making conflicts, do-not-

resuscitate (DNR) orders and advance directives (AD) have

been developed and implemented (14–17). Much research

has been performed during the last 10 years concerning

the use of advance directives and the attitudes of various

populations regarding these issues. In general, most of the

results on the one hand suggest, that a large majority of the

actual and potential patients would like to use an advance

directive (13, 15, 17, 18) and would prefer treatment

which focused on comfort (18, 19). On the other hand, the

treatment was frequently reported to be of the opposite

and of a more intensive nature. Furthermore, the prepar-

edness among physicians, to comply with advance direc-

tives still seems to be limited (20, 21). The postulated shift

among health care providers by Quill and Brody (22) from

paternalism to autonomy seems to be a more theoretical

Correspondence to:

Prof. Dr Jorg Richter, Rostock University, Clinic of Psychiatry and

Psychotherapy, Gehlsheimer Str. 20, D-18147 Rostock, Germany.

E-mail: [email protected]

ª 2002 Nordic College of Caring Sciences, Scand J Caring Sci 149

one in terms of attitudes, which is not always reflected by

the physicians in clinical practice. Nevertheless, respecting

someone should include the respect of his or her choice

based on the individual’s own values, even if the person

cannot explain his or her choice at large and is not based

on totally comprehensive knowledge or if his or her

decision is contrary to doctors’ or nurses’ advice. However,

nurses predominantly seem to perceive patients as

individuals and not as someone with diseases. They are

emotionally closer to patients compared with physicians

which make them inclined to act according to the patients’

wishes (2, 3).

Physicians and nurses are involved in the decis-

ion-making process both with specific and with shared

roles. The doctor has to decide at the very end, which kind

of treatment corresponds best to the conditions of a

patient, and has to treat the patient accordingly. The nurse

however, who has to execute the doctor’s decision, has to

develop care plans in line with the doctor’s treatment

orders. Thereby the nurse is in closer contact with the

patient which in turn implies more possibilities and

demands for communications as well as for the development

of closer relations. Therefore, the nurses perceive more

easily when patients cannot take in any more and they focus

rather on the quality of life of the patients under treatment

compared with the physicians (2, 3). Finally, the nurse has

the opportunity to be more frequently in contact with the

patient’s family than doctors.

Doctors and nurses agreement on the further treatment

of the patient is a prerequisite for effective collaboration

aiming at an optimal treatment. Against this background

we have investigated doctors and nurses to estimate the

comparability of their decisions and attitudes in the care of

severely ill incompetent elderly patients.

The juridical regulation of DNR orders is still vague in

most European countries. Nevertheless, a major part of the

public in these countries would like to use and to rely on

such documents (6, 23).

The aims of the study were to evaluate (a) the com-

parability of decisions in the care of severely ill incom-

petent elderly patients among physicians and nurses and

(b) from a cross-cultural perspective the similarities and

differences regarding how these health care professionals

would deal with written treatment wishes by patients.

Methods

Participants

Consecutive samples of physicians and nurses from teach-

ing and university hospitals who frequently encountered

treatment situations with incompetent elderly patients

were surveyed in the eastern part of Germany (Rostock and

Neubrandenburg) and in Sweden (Umea) (Table 1). The

samples were selected according to the availability and

are not regarded as representative. The participation was

Swedish

physicians

Swedish

nurses

German

physicians

German

nurses

Total number 104 122 192 182

Sex

Male 70 5 60 2

Female 30 95 40 98

Age category

20–29 42 16 20 47

30–39 50 45 48 39

40–49 6 34 15 10

50–59 2 5 13 4

60–69 0 0 4 0

Level of training

Resident 9 14

Intern 26 35

Specialist 65 50

Nurse 43 64

Specialist nurse 57 36

Number of years in practice

0–9 68 57 19 52

10–19 24 26 60 34

20–29 6 14 13 11

30–39 2 3 9 3

Table 1 Characteristics of participants

(in percentage)

ª 2002 Nordic College of Caring Sciences, Scand J Caring Sci

150 J. Richter et al.

voluntary and a questionnaire had to be completed

anonymously. It was administered either during regular

grand rounds or individually. The response rate for the

physicians and nurses was 100% and overall 95%,

respectively. In general, the experience among the

health-care professionals in Germany and Sweden with

DNR orders or AD is limited and these documents are not

regulated by laws yet.

Measurement

The questionnaire is based on the original developed by

Molloy et al. (24–26) and was translated, retranslated

according to the established guidelines and adapted to the

various countries considering the prevailing terminology

(27). It contains three case vignettes based on the same

patient providing different levels of information about his

treatment wishes, followed by various questions about

factors generally determining the doctor’s decision-making

process in elderly patients (legal and ethical concerns,

patient’s and family wishes, hospital costs, patient’s age

and level of dementia and physician’s religious beliefs) on

a five-point scale. Finally, some demographic aspects of the

participants were collected (see Table 1).

In the case vignette the condition of an 82-year-old man

living in a nursing home who is brought to the Emergency

Room with a gastrointestinal bleeding is described. He

vomited copious amounts of blood and passed a large

melena stool earlier that night. He is now pale, stuporous,

diaphoretic, understands simple commands, but cannot

answer simple questions coherently. His heart rate is

120 beats/min and his blood pressure is 70/40 mmHg. The

note from the nursing home states that he was investigated

3 years ago by a neurologist, who diagnosed Alzheimer’s

disease following a complete work-up. The accompanying

nurse describes him as an active 82-year old, who occa-

sionally displays agitated behaviour with the staff. He needs

assistance in washing and dressing and wanders about

during the day. He has difficulty remembering names and

occasionally does not recognize his daughter. He is incon-

tinent of urine all the time and of stool occasionally.

Three different paragraphs were added at the end of the

case vignette indicating the level of information about his

treatment wishes. The first scenario is characterized by the

absence of information. In the second scenario a DNR

request is available, written by the family physician on a

doctor’s order sheet in the nursing home, which is

co-signed by the patient’s daughter. In the third scenario a

detailed therapeutic and resuscitative effort chart (DTREC)

is provided including a DNR order.

The participants were asked to choose one of the four

treatment options (described in more detail in Table 2) and

to indicate whether they would attempt cardio-pulmonary

resuscitation (CPR) in the event of cardiac arrest.

Statistical analysis

Because of the small number of males in both groups of

nurses (Sweden: six; Germany: three), the data analysis

has been performed irrespective of gender differences. We

Table 2 Descriptions of treatment options given in the questionnaire and chosen options by physicians and nurses (in percentage)

Option Description

Scenario Swedish physicians Swedish nurses German physicians German nurses

Supportive measures only (SUPP) [measures that enhance comfort or minimize pain (e.g. use of morphine); no intravenous lines; do not group and

cross-match; do not investigate cause of bleeding]

First scenario 9 7 2 11

Second scenario 7 14 3 14

Third scenario 8 6 2 14

Limited therapeutic effort (LIM) [start intravenous line, cross-match and transfuse; N/G tube, blood tests and X-ray examination; Cimetidine or

Ranitidine intravenous; do not transfer to intensive care unit (ICU); do not operate even if the patient continues to bleed]




Maximum effort (MAX) [LIM plus the following: emergency gastroscopy if necessary, emergency surgery if necessary, do not ventilate (except for

surgery)]




Maximum effort with ICU (MICU) [MAX plus the following: transfer to ICU, ventilate if necessary, may insert central lines, Swan Ganz, etc. if

necessary]




Decision-making in treatment of elderly 151


calculated Mann–Whitney U–Wilcoxon rank tests (z-score)

and K-tests for comparisons of probabilities between two

groups for the comparisons of the data between the groups

under study. Multiple regression analyses (method: enter –

all dependent variables are included in the regression

equation in one step) and Spearman correlations have

been applied for testing the relationships between deter-

mining attitude-factors (patient and family wishes, ethical

and legal concerns, patient’s age and level of dementia,

hospital costs, and religious beliefs of the nurses or physi-

cians) in the treatment of the elderly and chosen treat-

ment-option concerning the three different scenarios as

well as chi-square tests for relationships between treat-

ment options and the answers for questions about the

decisions. Statistical data analysis has been performed by

the Statistical Package for Social Sciences (SPSS; 28).

In general, we exclusively present results, which

are significant at a p-level of 0.01, except for some

which indicate important trends in our opinion. This pro-

cedure seems to be necessary because of the limitations of

sampling in order to reduce the probability of over-inter-

pretations.

Results

Confounding variables (those influencing the relationship

between attitudes and decision, i.e. socio-demographic

background data)

The level of training, age and the number of years in

practice affected some of the recorded variables. However,

we could not find systematic effects in all samples. The

older the nurses, the more important they have evaluated

their religious beliefs in the decision making (v2 ¼ 30.88;

d.f. ¼ 12; p ¼ 0.002). Specialist nurses perceived a lower

level of help by the patient’s DNR order in the second

scenario (v2 ¼ 14.19; d.f. ¼ 4; p ¼ 0.007) and they scored

higher on the importance of ethical factors compared with

nonspecialist nurses (v2 ¼ 13.52; d.f. ¼ 4; p ¼ 0.009).

The importance of family wishes (v2 ¼ 31.88; d.f. ¼ 12;

p ¼ 0.001) and of the level of dementia (v2 ¼ 27.75;

d.f. ¼ 12; p ¼ 0.006) as determinants of the decisions were

found as decreasing with an increasing practical experi-

ence in the total group of doctors from Germany and

Sweden. The total Swedish group has regarded the family

wishes as more important, the older the participants have

been (v2 ¼ 34.37; d.f. ¼ 16; p ¼ 0.005). In addition, they

have chosen less aggressive treatment for the first

(v2 ¼ 28.13; d.f. ¼ 12; p ¼ 0.005) and for the third scen-

ario (v2 ¼ 31.49; d.f. ¼ 12; p ¼ 0.002).

Treatment decisions

Most of the doctors as well most of the nurses have, on

average, chosen the limited therapeutic effort-option or

the maximum effort-option for each scenario (see Table 2).

Whereas the Swedish groups do not differ from each other

in any of the scenarios, the German doctors have chosen,

on average a significantly more aggressive treatment-

option for the first and for the third scenario compared

with German nurses (first scenario: z ¼ –4.94/p < 0.001;

third scenario: z ¼ –6.05/p < 0.001) and their Swedish

colleagues (first scenario: z ¼ –6.12/p < 0.001; third scen-

ario: z ¼ –5.90/p < 0.001). It is important to note that

between 39 and 58% of the various groups have chosen

treatment options which are not consistent with the

patient’s will. Nevertheless, nurses showed a significantly

higher compliance than doctors in the second and third

scenario, i.e. when information about the wishes of the

patient is given.

In all groups of subjects the probability for a decision in

favour of CPR decreased with increasing information about

the patient’s wish (Table 4). In most of the variants of the

scenario the German professionals of both groups (nurses –

first scenario: K ¼ 1.57; n.s.; second: K ¼ 1.80; p ¼ 0.050;

third K ¼ 2.58; p ¼ 0.001 and physicians – first scenario:

K ¼ 4.35; p ¼ 0.001.; second: K ¼ 2.31; p ¼ 0.010; third

K ¼ 3.47; p ¼ 0.001) have chosen more often a CPR pro-

cedure than their Swedish counterparts and the nurses

have generally chosen CPR less frequently than the phy-

sicians except for the scenario without any information

about the patient’s wish (Swedish – first scenario:

K ¼ 5.20; p ¼ 0.001; second: K ¼ 0.12; n.s.; third

K ¼ 13.23; p < 0.001 and Germans – first scenario:

K ¼ 0.12; n.s.; second: K ¼ 1.87; p ¼ 0.050; third K ¼ 2.14;

p ¼ 0.010). Nevertheless, the frequency of CPR decisions

against the patient’s wish varied between 32.5% (German

doctors for DNR scenario) and 8.3% (Swedish nurses for

AD scenario). That means, the majority of the health-care

professionals have made decisions concerning treatment

options and CPR, which reflect compliance with the

patient’s wish.

Difficulty in decision-making and help by patients’ directive

On average, most of the doctors and nurses have perceived

very little or little difficulties in the decision processes for

each scenario (Table 3). Interestingly, both German sam-

ples reported less difficulties in deciding for the first scen-

ario (nurses: z ¼ –3.10; p ¼ 0.002; physicians: z ¼ –2.76;

p ¼ 0.006) and the German doctors have reported less

difficulties in deciding in the second and third scenario

compared with the German nurses (second scenario:

z ¼ –3.54; p ¼ 0.001; third scenario: z ¼ –2.61; p ¼ 0.009).

The Swedish nurses answered that they would perceive,

on average, ‘a little’ to ‘some’ help and scored significantly

higher than the Swedish doctors (second scenario:

z ¼ –2.67; p ¼ 0.008; third scenario: z ¼ –3.93; p < 0.001)

and their German counterparts (second scenario: z ¼ –2.52;

p ¼ 0.012; third scenario: z ¼ –4.37; p < 0.001).



Importance of factors determining decision-making

in the elderly

Ethical concerns and the patient’s wishes appeared in each

sample as the most important factors whereas the hospital

costs as well as the physicians religion have been found to

be the factors of lowest importance (Table 4). Family

wishes seemed to be significantly more important for the

Swedish participants (nurses: z ¼ –8.53; p < 0.001/doctors:

z ¼ –7.57; p < 0.001) as well as for each group of nurses

compared with the physicians (Swedish: z ¼ – 5.82;

p < 0.001/German: z ¼ –3.53; p < 0.001). The factor ‘level

of dementia’ appeared in the third place among the group

of Swedish doctors with significantly higher scores

compared with Swedish nurses (z ¼ –4.71; p < 0.001) and

German physicians (z ¼ –7.50; p < 0.001).

Determinants of treatment decisions

The assessed factors could explain between 13 and 42%

of the variance in the chosen treatment options. There

were consistent factors within each group regardless the

situation: Swedish nurses – the importance of family

wishes; German nurses – the importance of patient

wishes and level of dementia; both samples of physicians

– the importance of the level of the patient’s dementia;

Swedish physicians – the importance of patient wishes

(Table 5).

Table 3 Questions about the decision

(in percentage)Swedish

physicians

Swedish

nurses

German

physicians

German

nurses

1st Scenario: No information situation

Difficulty of the decision

No difficulty 12 21 29 29

Very little difficulty 32 16 23 21

Little difficulty 17 21 25 26

Some difficulty 38 34 18 20

Very difficult 1 8 5 4

Resuscitation yes 23 58 48 48

2nd Scenario: DNR order situation








Help by patient’s order

Not at all 23 21 35 33

Very little 18 15 14 10

A little 28 11 14 13

Some 19 18 19 24

Much 12 35 18 20

3rd Scenario: Advance directive situation








Help by patient’s directive

Not at all 23 11 28 28

Very little 12 13 13 13

A little 21 12 18 15

Some 28 22 23 24

Much 16 42 18 20



The level of dementia seems to be a crucial predictor for

the treatment decision even if it was scored to be only of

moderate importance (median of 3 or 4; Table 4). Inter-

estingly, both factors, which have occurred as the most

important – ethical concerns and patient wishes – appeared

not as predictors of the decisions, except of the groups of

Swedish doctors and German nurses.

Discussion

Our study was designed to evaluate cross-cultural simi-

larities and differences concerning the choice of treatment

between doctors and nurses of two European countries,

both of them are involved in the decision making and care

of patients. The interpretation of the results is partly lim-

ited by the hypothetical character of the situations and by

the nonrepresentative character of the investigated sam-

ples. When interpreting the results we have to keep in

mind that the use of DNR orders and AD is not very

common in either country (20, 29, 30). However, some

important trends could be found. For all subsamples, with

increasing amounts of information about the patient’s

wishes, there is a tendency towards compliance with the

patients’ wishes. Nevertheless, the high number of health-

care professionals who would act against the patient’s

written will point to the importance to improve the atti-

tudes of the health-care professionals in both countries

with regard to patient autonomy. Nurses in general

however, are more likely to act according to the patients’

wishes than physicians which confirms the results of Uden

and coworkers (2, 3) from Norway.

In general, the Swedish health-care professionals have

chosen less aggressive treatment options compared with

their German colleagues implying, that the former could

be characterized by more pragmatic attitudes towards

dying and death. Interestingly, the German doctors have

perceived fewer difficulties in their decision making when

no information is available about the patient wishes, even

if they have chosen the most aggressive treatment-option,

which might be an expression of paternalistic attitudes

among German doctors (31).

Generally, nurses have shown a stronger tendency to

comply with the patient wishes than doctors (25). One

explanation of this finding could be that because of their

closer relationships with patients, and greater involvement

in the care of the patients in terms of bedside contact and

time, the nurses have a deeper understanding of the

patients’ well-being and needs (2, 3).

The Swedish nurses as well as doctors placed more

importance on family wishes in their decision making

Table 4 Important factors for decision-making in the elderly by sample and regression on the treatment option by scenario (first line: median/% with

answers of extremely and very important; second line: Spearman correlation coefficient first/second/third scenario–significant R in bold)

Swedish physicians Swedish nurses German physicians German nurses

Patient wishes 2/88.5 1/95.9 2/71.2 2/80.2

0.03/0.06/0.06 0.02/)0.03/0.22 0.04/0.05/0.01 0.22*/0.31*/0.31*

Ethical concerns 2/94.2 1/95.1 2/89.0 2/87.4

0.06/0.09/0.09 0.01/0.07/0.01 0.07/0.04/)0.01 0.20*/0.21*/0.23*

Family wishes 3/31.1 2/69.4 4/6.3 4/22.0

0.07/0.04/0.04 0.07/0.14/0.25 0.11/0.17/0.07 )0.12/)0.06/)0.10

Legal concerns 3/39.4 2/68.6 3/39.8 2/53.3

0.15/0.17/0.17 )0.09/)0.05/)0.01 )0.09/)0.02/)0.08 )0.07/0.10/)0.01

Level of dementia 3/42.3 3/21.5 4/13.1 4/25.8

0.51*/0.49*/0.49* 0.36*/0.31*/0.11 0.34*/0.35*/0.33* 0.45*/0.39*/0.37*

Patient’s age 3/56.7 4/6.6 4/13.6 4/20.3

0.17/0.19/0.19 0.19/0.08/0.24 0.18/0.19*/0.16 0.44*/0.40*/0.38*

Religious beliefs 5/11.5 5/15.6 5/17.4 5/7.1

0.07/0.02/0.02 0.16/0.16/0.01 0.02/0.09/0.09 0.07/)0.05/0.03

Hospital costs 5/7.7 5/9.9 5/2.6 5/3.8

0.24/0.19/0.19 0.12/0.04/0.01 0.07/0.09/0.17 0.03/0.10/)0.01

Median: 1 ¼ extremely; 2 ¼ very; 3 ¼ moderately; 4 ¼ somewhat important; 5 ¼ unimportant; *p < 0.01 for R.

Swedish

physicians

Swedish

nurses

German

physicians

German

nurses

First scenario 0.33/<0.001 0.16/0.012 0.16/<0.001 0.42/<0.001

Second scenario 0.30/<0.001 0.13/0.038 0.16/<0.001 0.35/<0.001

Third scenario 0.30/<0.001 0.13/0.038 0.14/0.002 0.35/<0.001

Table 5 Multiple regression (r2/p) with

important determining factors for decision-

making in the elderly as independent variables

and treatment options as dependent variables

by sample



compared with their German colleagues. One reason might

be that in Sweden, families become more involved when a

member is suffering from a severe illness. Furthermore, it

points to a more pragmatic approach among Swedish

doctors in the treatment of the elderly reflected by the

finding that they rated the level of dementia of a patient

and his/her age as more important compared with their

German counterparts.

Our results show that the treatment of incompetent

elderly patients with a life-threatening illness seems to

vary widely within and between doctors and nurses in

both Germany and Sweden. This corresponds to the find-

ings from Norway (2, 3) that nurses are rather focused on

the patient as a person whereas physicians are focused on

their responsibility to make treatment decisions. These

inconsistencies assumingly reflect differences in underly-

ing values and lack of societal consensus. Such a consensus

is a prerequisite for the improvement of patient autonomy

as the core principle of medical ethics.

To focus more frequently and to a larger extent onto the

problems related to the treatment of severely ill elderly

patients as well as onto the training of communication

skills with an orientation towards informed consent in the

medical training seems to be warranted (32–34). This

could, in the long run, result in a different role of the

doctor which in turn would facilitate a more up-to-date

doctor–patient relationship characterized by a more pro-

nounced view of patients as subjects with individual needs

and wishes. Finally, the divergent opinions of health-care

professionals from both countries point to the necessity of

an adaptation of treatment standards and ethical education

programmes (35). This should coincide with the education

of the public about their rights and about the problems and

conflicts regarding the implementation of their autonomy

in daily clinical practice (36), as well as an legalization of

DNR orders and AD.

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Documents

Decision-making in the treatment of elderly people: a cross-cultural comparison between Swedish and German physicians and nurses