The aim of the research was to describe, based on previous studies, what the nurses’ opinions and attitudes have been re
garding the implementation of the patient will in clinical practice and to find out the factors that have influenced the develop
ment of the nurses’ views and attitudes. The research material was 12 reports of previous research works, which dealt with
the opinions and attitudes of nurses regarding patient wills. The material under study reflected the unanimous opinion of
the nurses that a patient will is an important and useful measure in health care, which helps ensure the right of a person to
self-determination and allows patients to make informed and autonomous decisions regarding end-of-life treatment and care.
The predominantly positive and supportive attitude of nurses may be due to the overlapping of the idea of a patient will with
the most central core value of nurses - the well-being and protection of the patient. Nurses’ self-confident attitude was signifi
cantly related to their knowledge and practical experience in implementing patient testaments in clinical practice. Exposure
to cultural dogmas, socio-cultural beliefs and religious views affect the perceptions and attitudes of nurses.
Keywords: Nurse; Opinion; Attitude; Patient will; Palliative care; End-of-life discussion; Treatment and nursing care planning
In order to respect the principle of patient personal autonomy, several countries have created the possibility to prepare a patient's will to document their wishes, which is also called advanced care directives (ACD) [1,2]. It is a collection of the patient's decisions, which one has already expressed in matters concerning his care and treatment, what he/she wants or does not want at a time when he is no longer able to autonomously express his preferences [3].
Several studies have highlighted the positive aspects of the ACD: improvement of patients' quality of life (QoL); reductions in medical paternalism, healthcare costs, and hospital mortality; hospice service optimization; reduction of tensions between families and healthcare professionals and ensuring legal certainty for healthcare professionals [4-7]. At the same time, there are challenges in the implementation of ACD in clinical practice: ethical and legal issues; uncertainty and lack of knowledge among patients, relatives and healthcare workers; poor communication skills in endof-life (EoL) matters; poor relationships between the patient and the healthcare professional; unclear documentation; availability of documents; lack of national policy and people's subjective opinions and attitudes towards living wills [4,6-8].
In Estonia, as in other Baltic countries, there is currently no legal regulation of ACD [2,9]. The Obligations Act regulating the provision of health care services [10] provides a meaningful opportunity to draw up ACDs in the context of Estonian law. Significant developments are noticeable in social and political processes in relation to the issues of regulation of the expression of a person's will. Several expert assessments and opinion articles have appeared in the media [11]; the topic is discussed by the Chancellor of Justice and the Social Committee of the Parliament of Estonia [12,13]; the Ministry of Social Affairs, doctors and the patient's relatives [14], and the Estonian Doctors' Association has formed a national working group on ACDs. In order to help patients and their families in the ethical and legal issues of EoL treatment and care, it is important that Estonian nurses are aware of both death/ dying wishes and ethics.
During the last decade, most Western European countries have recognized the importance of ACDs in situations where the patient is incapacitated [11,15]. Research results and world practice show that nurses' opinions and attitudes towards ACDs affect both the administration and execution of ACDs, as well as nursing care planning and the quality of EoL care [15,16]. Although the Council of Europe has forwarded a recommendation that the possibility of a ACDs must be more actively introduced to the adult population in all member states [17], the topic of an ACDs ll is still under-researched in Estonia. The aim of the research is to describe what the nurses' opinions and attitudes have been regarding the implementation of the advanced care directives in clinical practice and to find out the factors that have influenced the development of the nurses' views and attitudes in other countries.
The research paper is a narrative review of the literature. Evidence-based literature sources were used to conduct the research, which dealt with studies of nurses' opinions and attitudes towards patient wills. The following electronic scientific databases were used to search for materials: PubMed, CINAHL, MEDLINE, ScienceDirect, UpToDate and Google Scholar.
The following search words were used in various combinations to identify suitable literature: advance directive, living will, advance care planning, palliative care, end-of-life, nurse, nursing, attitude, opinion. Boolean logic operators “AND” and “OR” were used to limit and expand searches.
The selection criteria of literature sources are presented in Table 1.
The inclusion and exclusion criteria were applied as follows: reading the titles; removal of articles that were not in English (n=81); duplicate articles that appeared in all databases (n=271). Research papers that were opinion articles by physicians (n=133) were excluded from the selection; discussion documents (n=71); intervention studies (n=49); articles that did not meet the research objectives (n=291), did not reflect nurses' opinions (n=196) or their attitudes (n=137), and did not meet the requirements of scientific articles (n=12). Articles that described nurses' opinions and attitudes regarding the patient will and met the requirements of the research (n=37) remained in the sample. In the following process, articles were excluded where the opinions and attitudes of nurses Opinions and attitudes regarding advanced directives
Time limit Study published: 2010-2020 Target group Nurses A phenomenon The field of nursing All fields Type of research Qualitative, quantitative, mixed method Language Estonian, English Country All countries did not differ in the results (n=4). Additionally those research results that did not provide new information (n=3) (Figure 1).
As a final result, 12 studies from 14 countries and four continents were included in this research. Altogether, the thoughts of 4,231 nurses were represented through surveys of previous studies. The Critical Appraisal Skills programme (CASP) Checklists were used for assessing quality of quantitative and qualitative studies. All together 9 quantitative and 2 qualitative studies and 1 mixed method (both quantitative and qualitative) were involved in this study (Table 2).
Benefits of a patient will: The research material reflected the general opinion of nurses that the patient will is an important and useful measure in ensuring the right of self-determination and allowing patients to make informed and autonomous decisions regarding EoL treatment and care [7,8,18]. Nurses believe that every person has the right to choose how to live and die and to be legally protected from treatment preferred by others [19]. The researchers noted that for the patients, the preparation of the ACD had a psychologically liberating effect, their mental health became more positive, and their lifestyle became more active, as they could control what was happening in their life and care [4,20].
The nurses emphasized that the usefulness of the ACD is also important for healthcare professionals. It was valued as a resource supporting the nurse in daily practice and helps in complex cases where legal, moral and ethical issues arise [19]. It also reduces Exclusion criteria Study published: … < January 2010 Physicians, psychologists, pharmacists, physiotherapists, carers Training and education related to the advanced directives - Literature reviews All other languages - errors in EoL care, provides certainty in treatment choices and symptom management, and removes stress about the legal implications of treatment restrictions [4,7,9,19]. Korean nurses brought up the idea that the impact of the ACD extends even further - it does not only concern the patients, but the nation as a whole. It helps people think about dying and death, giving them more time to prepare their death with their loved ones [16].
Ethical issues: The implementation of ACDs in the clinical setting involves the issue of freedom of conscience for healthcare professionals. A Portuguese study revealed that the right to refuse to execute an ACD if it conflicts with her personal beliefs created uncertainty and ambivalence for nurses: 52.5% of the respondents felt that a healthcare professional should have such a right, while 41.7% of the nurses either agreed or ruled it out [18]. In a study conducted in Germany, 4.0% of palliative care nurses confirmed that they have been in situations where the implementation of a ACD has caused an internal value conflict in them [8]. At the same time, US nurses were convinced that they must stand up for patients' wishes even if they conflict with the nurse's own views [21]. Australian nurses added a clause - "unless there is a clear and important reason not to do it" [4].
One of the most complex ethical challenges was the area of relationships with the patient and loved ones [4,16,19]. For Saudi Arabian and Brazilian nurses, ACD conversations created an ethical problem in that they took away the patient's hope [3,7]. The morally hardest thing for nurses was for the patient to accept the condition before death, when they had to be told that the patient would no longer recover and the family lacked understanding [3]. Repeated articles (n=271) Not published in English (n=81) Excluded: opinion articles (n=133); duplicates (n=129); discussion papers (=71); intervention studies (n=49) Excluded: does not meet the requirements of a scientific article (n=291); does not reflect nurses' attitudes (n=137); does not reflect nurses' opinions (n=196) Manually excluded: does not meet the requirements of the Articles reflecting nurses' attitudes and opinions, compliance with research requirements (n=37) Articles describing nurses' opinions and attitudes (n=15) Excluded: the results do not distinguish nurses' opinions and attitudes (n=4); does not provide new information Literature search in six databases: PubMed, UpToDate, Google Scholar (n=22100) Search words in English: „advance care planning „nurse“, „nursing“, „attitude Titles of found articles (n=22,100) Article titles before reading abstracts (n=883) Full texts of articles (n=244) (n=3) Articles included in the research material (n=12)
CINAHL, MEDLINE, ScienceDirect, „advance directive“, „living will“, “, „palliative care“, „end-of-life“, “, „opinion“, „narrative review“ scientific article (n=12) tive-cross-sective-cross-sec-
- Predominantly positive attitude towards Semi-struc- legalization of patient will.
tured inter- - Declaration of will protects patients views legally from futile treatment and wishes of relatives; Nurses n=16 - Wills provide individuals with the ability to establish treatment preferences according (palliative care) to their beliefs.
- Difficulties in implementation.
-Nurses are ready for conversations about the patient's will, but the initiative is low.
(intensive care, surgery, - Minimal exposure to the declaration of will. resuscitation, pulmonology, -Uncertainty in attitudes.
infectious diseases department) -Nurses have a higher level of knowledge and a more positive attitude towards advanced Questionnaire directives than physicians.
Nurses n=170 -Nurses value the declaration of advanced directives because it helps to make informed (oncology, decisions about treatment and care.
neurology, intensive care) -An ethical problem arises if advanced directives conversations take away hope from the patient.
-The palliative care system is under developed, researchers have rarely approached EoL issues.
-For nurses, EoL discussions are ethical and Nurses n= 244 acceptable.
(palliative care, -ACDs are the tool to help resolve clinical, ethical and legal issues.
oncology) -Beliefs, attitudes, and values of nurses influence the realization of the patient's wishes at the EoL.
Rietze, et al. Identifying the To examine the extent to A cross-sec[20] Factors Associated which Canadian nurses tional study With Canadian participate in the endCanada Registered Nurses of-life care and nursing Engagement in care planning process and Advance Care how they view decisions Planning related to this practice.
Coffey, et al. Nurses’ knowlTo examine nurses' [15] edge of advance knowledge of patient directives and wills and their perceived Hong Kong, perceived confi- A cross-secconfidence in working in Ireland, dence in end-of-life tional study end-of-life care in Hong Israel, Italy, care: a cross-secKong, Ireland, Israel, Italy USA tional study in five and the USA.
countries To explore the views and experiences of Australian palliative care profesJohnson, et Palliative care sionals al. [4] health professionals’ experiences of regarding the patient will Australia nationwide caring for patients and treatment and nursstudy with advance care ing care planning.
directives Zenz J and Survey on German Zenz, M. Palliative Care To investigate the views of [8] Specialists’ Experi- palliative care specialists ences with Advance regarding patient wills.
Germany Directives - EoL decisions are important part of nurses`- daily work.
-Most of the nurses did not participate in the Nurses n=125 planning of treatment and nursing care.
(executive -The effects of paternalism.
nurses) Obstacles to EoL care planning: lack of educational preparation, patient/family readiness, organizational barriers, etc.
-Nurses have a positive attitude towards EoL discussions.
-US nurses have higher knowledge, greater experience in implementing the declaration of ACD.
-Older nurses (>35 years) and with more Nurses n=1089 professional experience were more confident in relieving patients' symptoms, discontinuing (general nurses, medication, dealing with the dying patient's acute care) grieving family.
-Nurses do not have enough time for ACDs discussions.
-Positive attitude of nurses in both areas.
-With ACD, organizing EoL care is easier and more efficient, and communication is easier.
-The processes surrounding the declaration (palliative care) of intent, especially incomplete and faulty documentation, reduce its acceptance and implementation.
-ACD must be a clear, comprehensive, medically relevant and accessible document.
-ACD is well-functioning in palliative care.
-Nurses have many contacts.
-Nurses are closer to the wishes and needs of Nurses n= 276 patients at the end of life.
(palliative care) -Nurses actively interviewed patients/relatives about the declaration of ACD.
-Nurses have experiences of internal conflict of values when implementing a declaration of ACD.
-Discussions about EoL decisions often take place late in the patient's illness, for some it is too late to make difficult decisions. Qualitative and Son, et al. Nurses' perspec[16] tives on advance To explore Korean nurses' directives before attitudes, experiences, Korea the establishment and opinions regarding of the new well-dy- patient wills prior to the quantitative ing law in Korea: introduction of the Well A mixed methods Dying Law.
study Chris- Advance Care To investigate the knowltensen, et Planning in Rural edge, attitudes and experial. [21] Montana: exploring ences of nurses regarding the nurse’s role patient wills USA Hamano, et Attitudes and Other To explore the attitudes al. [23] Factors Influencing of physicians, nurses and End-of-Life Discus- care workers towards endJapan sion by Physicians, of-life discussions with nationwide Nurses, and Care terminally ill patients and survey Staff: A Nationwide to explore the factors that Survey in Japan influence their attitudes.
Cogo, et al. Challenges to To explore problems and [3] implementation of limitations related to advance directives the implementation of a Qualitative Brazil of will in hospital patient will in a hospital practice context.
-Implementation of ACD and making EoL decisions is important due to patient autonomy, the right to self-determination and Questionnaire, ensuring a dignified death.
semi-structured interviews.
-Attitude: The nurse must help patients get information about the condition and treatment alternatives. Nurses themselves need to gain knowledge about laws and communication (surgery, intenskills.
sive care, -The legalization of the ACD is important. hospital inpaNurses' fear that relatives may abuse the ACD. tient) -The nurse's most important role is to help the patient become aware of the ACD. -Nurses' belief: The patient's wishes must be supported even if they conflict with the nurse's own views.
-Nurses training and updating their knowledge of patient wills is an ongoing need to enhance their work and meet the needs of patients/families.
(hospice, home nursing) -Discussions of the patient's will and finding out the patient's wishes and preferences require more time than the nurses have been able to give so far.
-Nurses have long professional experience.
-EoL discussions are not sufficient for terminal patients.
-Nurse training and educational programs are (hospitals, necessary for effective discussions. clinics, home nursing, care -Lack of communication skills is problemfacilities) atic-Nurses' experience dying patients their behavior to place greater value on sharing information from EoL care conversations with the care team.
-A patient will requires respect for the patient's autonomy and proper communication.
Semi-struc- -The EoL lead to various dilemmas and tured inter- conflicts.
views -The limitations and difficulties related to the Nurses n=8 implementation of ACD are largely influenced by the fact that the experience of approaching (hospitals) death makes it difficult for patients to express their wishes.
- EoL issues require an open dialogue between all parties to discuss the patient's true needs and preferences.
Death, a dying patient and solving complex situations resulting from people's fear of death caused for nurses an inner feeling of helplessness and sadness [16]. Nonetheless, healthcare professionals still felt obliged not to ignore the ethical obligation to talk to patients about difficult topics [3,21].
Nursing role: The nurse's role as the patient's advocate and emotional supporter was highlighted the most where nurses described their role as counsellors who support both the patient as an individual and his family in making EoL decisions [16,21]. Nurses agreed that their role is to help inform patients about their situation and treatment alternatives [19,21]. Nurses commented on situations where they had problems with the team not respecting the ACD, continuing active treatment that contradicted the patient's previously expressed wishes. They also pointed out that when a patient was admitted to the hospital, informed consent was not always actively sought [4,8]. Nurses believed that they had a responsibility to consult with the doctor about treatment if the patient's rights were not taken into account [21]. Most nurses also agreed that conversations regarding EoL options should be done as early as possible. According to palliative care nurses, discussions about EoL decisions often took place at a late stage of the patient's illness, which for some was already too late to make such complex decisions [6].
Nurses' tasks were seen as a guidance role to help patients and families plan treatment and nursing care and prepare ACDs [16,18] as they are in closer contact with them than physicians [4]. 92.4% of nurses surveyed in Canada were convinced that finding out patients' EoL values and treatment wishes is an important part of a nurse's work. In certain healthcare systems, particularly Saudi Arabia, there is still a noticeable adherence to the historical hierarchy in the working relationships between nurses and physicians where doctors have taken a leading role in patient care, despite nurses’ high knowledge and positive attitude towards ACDs. [8,20]. The position of doctors on the same question remained at a somewhat lower level [22]. For ethically sensitive topics, nurses proposed the idea of shared co-responsibility about ACD among healthcare professionals as one solution [4,9].
Thirdly, it was emphasized that the nurse's role is to resolve conflicts where disagreements have arisen. It was considered important to understand the principles of both parties and to do everything possible to help reduce these differences and maintain a neutral attitude [19]. Research results showed that involving relatives in EoL discussions is extremely important. It must also be acknowledged however, that relatives have the greatest potential for conflict in clinical work [8,16].
Role clarity with regards to living wills was not always clear for all nurses. What made it complicated was the so-called "switching" between roles [19]. Adoption of their role was also hampered by organizational policies that did not support or encourage the initiation and conduct of EoL conversations and did not clearly define the roles and responsibilities of nurses [15,20].
Difficulties in implementation: The nurses described several factors that prevented the successful implementation of the patient's EoL wishes in clinical practice. The most frequently mentioned problems were documentation. An ACD lost its value to health care professionals if it was not clearly related and consistent with the patient's medical circumstances. Medical issues were not sufficiently explained to patients and families, so people lacked full awareness. Australian palliative care nurses noticed that there was more confusion when the preparation of ACDs was left to junior healthcare professionals who lacked the necessary legal knowledge and skills to prepare the documents [3,4].
In Italy, where nurses had recent experience with the law regulating the ACD, the subjects expressed their assessment that the texts of the law were difficult for people and could be interpreted in many ways [19]. Brazilian nurses expressed the view that if the ACD legislation remains vague, it leaves room for multiple interpretations and becomes a limiting factor in the implementation of the ACD in clinical practice [3]. However, the opposite positive result emerged from a study in Germany, where legislation regulating ACDs was interpreted by the authors of the study as a positive sign of the clear nature of German legislation [8]. Nurses noted that despite the legal regulation, there were still problems with the registration and availability of ACD documents [19].
The nurses also found that the ACD is not an end in itself. There must be ongoing discussions between healthcare professionals, patients and their families about EoL care [4,19]. Unfortunately, research results showed that ACDs were not always respected in clinical practice [23].
Finally, nurses mentioned people's fear of talking about death as one of the possible difficulties in implementing the patient's EoL wishes. The difficulties of ACDs are related to the real situation of dying [3], and if healthcare professionals are unable or unwilling to address and reduce these fears, this is a serious barrier to patients' willingness to make an EoL statement [19].
Positive attitude: From the included studies, it was revealed that a predominantly positive attitude towards the ACD prevailed among nurses [6,16,20]. An Italian study pointed out that some nurses had a neutral attitude towards legalized ACDS, and in their opinion, EoL wishes did not lead to any changes in daily work [19]. However, the majority of nurses found that the existence of a ACD simplifies the process of decisions related to the EoL and thus affects their daily work [7,9,19].
An interesting fact emerged from the study in Saudi Arabia, that the nurses had a significantly more positive attitude towards the ACD than the physicians, which has been correlated with their better knowledge of the content and nature of the declaration of intent [7]. The positive attitude was expressed primarily in the nurses' readiness and active participation in the process of implementing the ACD. Rietze et al. [20] have pointed out that it is a strong motivator for nurses when they see that the implementation of EoL guidelines and treatment and nursing care planning improve the QoL of their patients.
The nurses' positive attitude towards the necessity of making EoL decisions reflected their overall advocacy for patients [21]. It is noteworthy that across countries, the positive attitude did not depend on whether the ACD was legalized or not. While Lithuania, Ireland and Saudi Arabia lacked regulatory legislation and nurses' practical experience with ACD, they had high levels of trust and willingness to participate in the creation of a will and the EoL care process [9,15].
Confidence and moral satisfaction: An international study of nurses in five countries found that nurses' self-confident attitudes were significantly related to their practical experiences of implementing ACD in clinical practice. Self-confidence was the highest among nurses in the United States, who already had knowledge of the ACD before starting the study [15]. The same is confirmed by Christensen's [21] study among US nurses and also in a study from Saudi Arabia [7].
Recognizing who the patient is as an autonomous person helped increase nurse confidence. Knowing the ACD motivated the nurse to stand up for the patient's preferences when treatment choices were made or when the wishes of the patient's relatives conflicted with what was expressed in the ACD [4,21].
For nurses, moral satisfaction was primarily related to those clinical situations where they had been able to provide their patient with EoL care and treatment they wanted and to ensure that the person dies with dignity. This emotional state was compared by nurses to the experience of being rewarded, which reflected that everything went right in EoL care [4].
Uncertainty: Beside positive thoughts and attitudes, there were opinions that expressed insecurity by the nurses. In two countries where ACD had recently been legalized, the new reality and the accompanying changes created uncertainty and conflicting feelings for nurses. Italian palliative care nurses pointed out that national legislation on ACD may not always make the situation clearer and simpler and nurses experience that both patients and healthcare professionals had not been given correct information. The nurses wanted to work effectively, but in reality they encountered bureaucratic barriers and errors. Also, the content of the law was not explained to the nurses [19]. In Portugal, nurses had difficulties in deciphering the nature of EoL instructions, and the fact that they did not have a clear understanding of whether patient-specified EoL instructions are a special form of euthanasia or not proved challenging [18].
The uncertain attitude of nurses was also reflected in surveys conducted in other countries. The most expressed concern was their lack of knowledge, that they could not give adequate explanations about the ACD [16,20]. Nurses did not know how to communicate and help patients and families and needed either mentoring or training in this regard [4,16,23]. An uncertain attitude was manifested in the initiation and conduct of EoL discussions, from which nurses sometimes refrained from for personal comfort, fear or other reasons [3,7,9,20].
Factors arising from education and experience: For nurses, educational background was one of the main factors influencing their opinions and judgments about ACDS. In 12 research reports examined, it was consistent that nurses want more ethical and legal knowledge, as well as communication and counselling skills in matters related to the EoL [4,15,21]. Based on Portuguese research, Silva, et al. [18] questioned the effectiveness of introducing ACD legislation without prior training of health professionals and public consultation. The nurses did express their readiness to initiate patient will discussions, but the statistical numbers did not reflect their initiative in clinical activities: 96.4% of the nurses had not told their patients about the possibility of making a ACD in one year, and 95% of them had never heard that a patient would have initiate EoL discussions However, the study noted that awareness and confidence in implementing an ACD was higher in the group with longer seniority, EoL care experience, and more academic and professional training. Similar results were confirmed by Coffey, et al. [15] study in five countries. Based on this, it was concluded that after a palliative care educational intervention, nurses' practice, confidence and knowledge about EoL care improves.
It was noticeable that where nurses' values had been formed through personal experiences - for example, neglect of patient autonomy or deterioration of the patient's QoL as a result of aggressive medical intervention - their attitudes towards the necessity of an ACD were stronger [4,16,19,20,23].
Patient and relatives factors: The preparation and implementation of ACD document is more than a two-person relationship between a patient and a healthcare professional. EoL discussions require the patient's and family's willingness to talk openly about death [19,20]. Nurses' experiences showed that people may be afraid of documenting an ACD due to fear of death or prejudices, and nurses as specialists need to start dealing with this [3,16]. Patients' wishes and EoL care priorities were sometimes volatile, especially when the condition stabilized [4]. The patients' and family's perceptions of illness, the symptoms of the disease, the necessity of treatment or alternative treatment options were sometimes contradictory and required additional time and emotional resources from the nurses [3,7]. The language barrier with the patient also had its effect, which led to mutual tensions in the relationship and assessments of the quality of the service [20].
Organizational factors: This research also identified organisational factors that nurses deem intervening the process of implementing ACDs. The most typical inconsistencies between people and work were pointed out: increased workload, limited time, unclear division of roles and lack of a unified organizational policy. The nurses' work had become broader, legally more complicated and requiring greater competence. However, in the midst of rapidly changing clinical tasks, it was difficult for nurses to find time and privacy to talk with patients about important topics and build trusting relationships. Some nurses perceived that the institution lacked interest or an action plan to support the planning of treatment and nursing care for patients suffering from incurable diseases. [3,20]. Negative situations were experienced where medical paternalism prevailing in the organization's culture limited autonomous choices [3,4].
Cultural and religious factors: Different cultural dogmas, socio-cultural views and religious beliefs have their influence on how individuals approach EoL [7]. The social context of each individual and nation is unique, which is why it is difficult and even inappropriate to draw parallels between countries in these matters [19].
In Saudi Arabia, respecting the sanctity of life is one of the most important values. The question of what could a person's dying and a dignified death be like, making decisions about treatment restrictions at the EoL and using the patient's will in the service of all this. However, the internal attitude of the Saudi nurses motivated them to research, investigate and familiarize themselves with the topic of the ACD [7]. In Israel, the patient will is regulated by national legislation, but the introduction and implementation of the will in hospital practice has remained complicated due to people's religious beliefs. In the Judaic tradition, similar to Islam, a central value is respect for the sanctity of human life. The strong religious heritage prevailing in the society may have influenced the nurses' attitudes, so that their interest and willingness to participate in the process of implementing a patient will remain modest [15].
In Korea, being influenced by Confucianism, it is rare to document an ACD. The filial piety principle (the virtue of respecting parents) makes it difficult for people to understand personal autonomy in their world of thought. Compared to Western cultures, the Korean family is more influenced by blood kinship and shared values. Korean nurses revealed a positive attitude towards ACDs and the understanding that patients must have the right to choose between life extension and dignified death where expressed. Nurses` most important role is to inform and support their patients so that they can make their own autonomous EoL decisions freely and independently [16].
Although the public debate on the regulation of ACDs has become more active in Estonia in recent years, there is still lacking evidence-based literature, which deals with the opinions of nurses who care for patients at the end of their lives.
There is a clear indication in the international literature that nurses have an equally important role in implementing the goals of an ACD as physicians, their task is to help patients understand and prepare the will documents. The nurses' point of view and attitudes become a weighting factor in how the process of managing the ACD proceeds. The experience of other countries shows that the success of the implementation of ACD can be questionable if there is no prior preparation of healthcare professionals and public discussion. As a result of the analysis of the research, four main topics were distinguished in the nurses' opinions: the benefits of the ACD, ethical issues, the nurse's role and difficulties in implementation. For the majority of nurses, it became important in determining the usefulness of an ACD and that helped ensure the patient's desired treatment and care at the EoL. The predominance of such thoughts shows that the specifics of a nurse's work - to be by the patient's side until the end of their life span - strongly influence their world of thoughts and feelings and behavioural choices. It is possible that this also explains the fact why the practice of drawing up an ACD has so far been best rooted in the context of palliative care, where the mindset of the health care staff is not to prolong the patient's life, but to ensure their well-being. However, well-being is always related to the reasons why a person wants to be alive.
Basic questions of the ACD are what does the patient consider important and what worries him. When evaluating the benefits of an ACD, the views of the nurses were not limited to the individual. The effect was extended to the interconnected and mutually supporting whole - the patient, his relatives, health care professionals and eventually the whole nation, who all get the opportunity to think about dying and death and talk about it openly with each other [16]. Such a view of nurses is in line with the views of scientific and legal literature, where in the argumentation of the strength of the ACD, the multifaceted benefits of the declaration of will for various interest groups are emphasized.
A telling example here is the ethical questions accompanying the EoL declaration, on the basis of which human behaviour and choices are evaluated. Nurses caused vague and contradictory thoughts. The issue of freedom of conscience of the healthcare professional is an aspect that cannot be ignored when it comes to the patient's expression of ACD. When drawing boundaries, each nurse has their own subjective value system and criteria for ethical decisions. When it comes to the topic of dying and death, it is inevitable that it has a strong psychological impact on people, which is also aptly expressed by the name given to EoL conversations - difficult conversations.
Cogo, et al. [3] pointed out the opinion of nurses that learning to know a patient requires time as well as knowing when and how to talk about difficult topics. People don't need facts as much as the meanings behind the information. Understanding that the healthcare professional is on their side and acting in their best interest was of outmost importance. This is where the background of the practice visible from previous studies emerges, why the role and involvement of nurses in the process of preparing and managing an ACD is so high in the countries that have legalized ACD.
For nurses working in clinical practice, time is always a critical resource. Even if there is the idea, the ACD and the readiness of nurses, it can all shrink and disappear due to overload, multiplicity of tasks or lack of knowledge. Analysing the factors complicating the implementation of ACDs, we felt how societal and official expectations posed on nurses were not in proportion to cope with such tasks. Thinking about Estonia's perspective, the challenge here is how to use the available time sensibly in practice and prudently and to prepare all important specialists, agencies and society for the arrival of the ACD.
By mapping the nurses' attitudes, there emerged four topics: positive attitude, self-confidence and moral satisfaction, and insecurity. Based on the results of the included studies, it can be said that nurses have played a definite role in implementing ACD. According to the research, the positive and supportive attitude of the nurses may be due to the overlapping of the idea and nature of the ACD with one of the most central core values of the nurses, which is the well-being and protection of the patient. Based on the research results of Rietze, et al. [20], it can be seen how nurses' motivation to work for the implementation of the ACD increased when they were convinced that the will improved the QoL of their patients and reduced the chances of futile treatment. A similar principle is supported by other findings from the included studies, where nurses' perceived self-confidence and moral satisfaction were related to their better knowledge and experience with patients requiring EoL care.
Similarly, it is possible to change nurses' uncertain attitude towards ACDs. In this study, the factors that influenced nurses' opinions and attitudes were classified into four areas: factors arising from education and experience, factors arising from patients, factors arising from the organization, and factors arising from culture and religion. The results of the research emphasize that educational preparation was a stronger influence on the development of nurses' assessments and attitudes. Despite the different parts of the world, cultures and the possibilities of the health care system, nurses had an internal will and effort to develop and apply their abilities.
Seen from the Estonian context, there is a rich land of opportunities to shape the opinions and attitudes of nurses through the provision of various learning opportunities. Reflecting on Estonia and the tasks facing nursing - there is a big difference, whether our nurses start learning the information accompanying the declaration of ACD and EoL care out of a sense of duty or because it is worth thinking, contributing and self-development for them. In this regard, the key issue in the planned trainings is motivating nurses and creating practical content for education that supports them: how to convey difficult messages, train communication skills, be prepared to cope in crisis situations, etc.
Nurses have predominantly positive attitude towards the patient will. Nurses' self-confident attitudes were significantly related to their practical experiences of implementing patient will in clinical practice. Beside positive thoughts and attitudes, there were opinions and assessments that expressed the insecure attitude perceived by the nurses. For nurses, educational background was one of the main factors influencing their opinions.
EoL discussions require the patient's and family's willingness to talk openly about death. The most typical between people and work were pointed out: increase in workload, limited time, unclear division of roles and lack of a unified organizational policy. Different cultural dogmas, socio-cultural views and religious beliefs also have their influence on how individuals approach EoL and the preparation of a patient's will.
Nurses cannot be left out of process of planning, designing and following care. In this context, it is important that they know and feel the nature of the patient's will, and nurses' task is to inform, respect and care for the patient, taking into account his true wishes and well-being in the last stage of life.