title: Being a legal guardian - the nursing perspective.
abstract: BACKGROUND
  Surrogate decision making is common in public healthcare worldwide. In Israel any incompetent adult patient requires a Legal Guardian (LG), appointed by the court, for approval of invasive none-life saving procedures. Usually, the LG is a close family member of the patient. Nurses are the most available healthcare providers to the families and the LG during the process of appointment and afterwards. The patient's family is often anxious or even depressed, and thus the perceptions and behavior of nurses charged with providing support are crucial. In a previous study based on interviews of LGs we found that the most difficult issues for the LGs were decision related issues, family related issues and appointment bureaucracy issues.
  
  
  OBJECTIVE
  To qualitatively assess nurses attitudes regarding the difficulties that families and LGs face during and after appointments and to compare the findings to previously accessed LG attitudes.
  
  
  METHODS
  After IRB approval, demographic and semi-structured questionnaires were used to assess the attitudes of a convenience sample of 34 nurses who were participating in a critical care training course (41 % of the respondents were from the ICU, 47 % from medical or surgical wards, and 12 % from other departments at secondary and tertiary hospitals in Israel.) regarding LGs difficulties. After reading and analyzing the responses provided by the nurses, the authors categorized the pertinent topics raised using content analysis. Nurses' perceptions were also compared to those of LGs reported in previous research by the authors.
  
  
  RESULTS
  Three main themes emerged: 1. Decision related issues; namely coping with the complexity of end of life decision issues; 2. Family related issues; namely, family dynamics related to the various decisions regarding LG identity and patient care; and 3. Bureaucracy issues; namely, the formal process related to LG appointment and decisions. Regarding the first two themes, the feelings of the nurse respondents were quite similar to those of LG respondents from our earlier research. The third theme - bureaucracy issues - was never mentioned by the nurses, as opposed to LGs who mentioned it frequently. This suggests that the nurses did not consider it to be an important issue.
  
  
  CONCLUSIONS
  The difficulties of decision making as well as family support and responsibility of LGs are well known by nurses. The appointment and bureaucracy issues were neglected by nurses, although they are very important to the LGs. Improvement of this parameter of care is needed. Possible directions for improvement include raising awareness of nurses regarding the appointment process and alleviation of bureaucracy. Further research is required to identify appropriate strategies for improving these aspects of care.
authors.affiliation: General ICU, Assaf Harofeh Medical Center, Beer Jaacov, 70300 Israel ; The Hebrew University School of Public Health and Community Medicine, Faculty of Medicine, Jerusalem, Israel.
authors.forename: Michael
authors.initials: M
authors.lastname: Kuniavsky
authors.affiliation: Hadassah-Hebrew University School of Nursing, Faculty of Medicine, Jerusalem, Israel.
authors.forename: Ilana
authors.initials: I
authors.lastname: Kadmon
authors.affiliation: The Hebrew University School of Public Health and Community Medicine, Faculty of Medicine, Jerusalem, Israel.
authors.forename: David
authors.initials: D
authors.lastname: Chinitz
keywords: Legal guardian; Nurses; Qualitative research; Surrogate decision making