International Journal of Nursing Studies 38 (2001) 381–388 Attitudinal patterns determining decision-making in severely ill elderly patients: a cross-cultural comparison between nurses from Sweden and Germany Jo¨rg Richter a, *, Martin R. Eisemann b a Department and University Hospital of Psychiatry and Psychotherapy, Rostock University, Gehlsheimer Str. 20, 18147 Rostock, Germany b Department of Psychiatry, Unit of Medical Psychology, Umea ˚ University, Sweden Received 11 May 1999; received in revised form 14 July 2000; accepted 16 August 2000 Abstract To explain determinants in the decision-making of nurses in the treatment of severely ill incompetent patients and to describe underlying attitudes, consecutive samples of nurses from Germany and Sweden have been investigated by means of a case scenario and a questionnaire. Whereas the level of dementia emerged as the only factor being significantly related with the treatment option within the Swedish group, patient’s age, patient’s wishes and ethical concerns were correlated among German nurses. The more the nurses have been able to participate in the provision of the available do-not-resuscitate order or of an advance directive, the less frequent they would perform CPR against the patient’s wishes. # 2001 Elsevier Science Ltd. All rights reserved. Keywords: Decision-making; Incompetent patients; Elderly; Advance directive; Cross-cultural comparison 1. Introduction The achievements of modern medicine in terms of technology and treatment make it possible to prolong life and postpone death even in the presence of severely debilitating conditions. Obviously, the widespread use of medical technology may become problematic, in parti- cular when it is used for life-sustaining measures in terminally ill patients (Noyes et al., 1977; Smedira et al., 1990; Sprung, 1990; Tomlinson and Brody, 1988). This problem applies especially to patients in the final stage of AIDS and to the elderly. Since both patient populations are increasing in our western societies with a simultaneous rise in health-care costs, this issue becomes more important (Arcangelo, 1994; Levinsky, 1990; Scitovsky, 1984). Some elderly people fear that an overzealous applica- tion of high-tech life-saving procedures will just prolong their suffering and compromise their dignity in case of a life-threatening condition. The above-mentioned con- cerns have, in some countries led to the development and implementation of living wills and other forms of advance directives. Such health-care-related documents inform health-care providers about what level of treatment the individual would wish in the event of cardiac arrest or of another acute life-threatening condition (Bruce-Jones et al., 1996; Emanuel et al., 1994; Ghusn et al., 1997; Molloy and Mepham, 1992). Care-planning and treatment of severely ill incompetent patients is a complex process which contains a number of difficult medical, ethical (American Geriatric Society, 1990; American Medical Association. Council of Ethical and Juridical Affairs, 1991; Keffer and Keffer, 1994; Kuuppelomaki, 1993; Murphy and Sweeney, 1995) and *Corresponding author. Tel.: +49-381-494-9564; fax: +49- 381-494-9502. E-mail address: joerg.richter@med.uni-rostock.de (J. Richter). 0020-7489/01/$-see front matter # 2001 Elsevier Science Ltd. All rights reserved. PII:S0020-7489(00)00093-6