52% of all deaths in Norway occur in nursing homes. Still advance care planning (ACP) is scarce and heterogeneous. To improve the implementation and practice of ACP in nursing homes, knowledge about health care professionals' views on ACP is vital. The objective of this study is to explore nurses and physicians' aims and experiences with carrying out ACP in nursing homes.
Semi-structured group interviews were conducted with 20 health care professionals, recruited from nursing homes where ACP was performed regularly. Qualitative content analysis was used to analyse the data.
The primary aim of the nursing home professionals when doing ACP in nursing homes were to build alliances with next of kin to avoid misunderstandings and future conflicts. Two main experiences with ACP were described: i) due to the sensitivity of ACP issues, it was important to balance directness with being sensitive, and ii) when the physicians raised questions concerning future medical treatment, the answers from residents as well as next of kin were often hesitant and unclear.
Our study add insights into how ACP is practiced in nursing homes and the professionals' agenda. A focus on medical issues and achieving consensus with next of kin may result in lack of involvement of the residents and limited awareness of the residents' needs. Interdisciplinary approaches, ACP-training and tailored guidelines may improve the implementation and practice of ACP.
Clinical ethics committees have recently been established in nearly all Norwegian hospital trusts. One important task for these committees is clinical ethics consultations. This qualitative study explores significant barriers confronting the ethics committees in providing such consultation services. The interviews with the committees indicate that there is a substantial need for clinical ethics support services and, in general, the committee members expressed a great deal of enthusiasm for the committee work. They also reported, however, that tendencies to evade moral disagreement, conflict, and 'outsiders' are common in the hospitals. Sometimes even the committees comply with some of these tendencies. The committees agree that there is a need to improve their routines and procedures, clarify the committees' profile and field of responsibility, to make the committees well-known, to secure adequate operating conditions, and to develop organizational integration and support. Various strategies to meet these challenges on a local, regional or national level are also explored in this paper.
More knowledge is needed on how to reduce the prevalence of formal and informal coercion in Norwegian mental health care. To explore possible reasons for the widespread differences in coercive practice in psychiatry and drug addiction treatment in Norway, and the poor compliance to change initiatives, we performed a nationwide survey. Six vignettes from concrete and realistic clinical situations where coercive measures were among the alternative courses of action, and where the difference between authoritarian (paternalistic) and dialogical (user participation) practices was explicitly delineated, were presented in an electronic questionnaire distributed to five groups of professionals: psychiatrists, psychologists, nurses, other professionals and auxiliary treatment staff. Non-coercive dialogical resolutions were more likely than coercive authoritative. However, there is a clear professional hierarchy with regard to authoritarian approaches, with the psychiatrists on top, followed by nurses and other professionals, and with psychologists as the least authoritarian. The majority of the respondents sometimes prefer actions that are illegal, which suggests that individual opinions about coercion often overrule legislation. The variation between and within professional groups in attitudes and opinions on coercion is extensive, and may account for some of the hitherto meagre results of two ministerial action plans for coercion reduction.
The first clinical ethics committees (CEC) in Norway were established in 1996. This started as an initiative from hospital clinicians, the Norwegian Medical Association, and health authorities and politicians. Norwegian hospitals are, by and large, publicly funded through taxation, and all inpatient treatment is free of charge. Today, all the 23 hospital trusts (providing specialized and hospital-based healthcare services to the Norwegian population of 4.9 million people) have established at least one committee. Center for Medical Ethics (SME), University of Oslo, receives an annual amount of US$335,000 from the Ministry of Health and Care Services to coordinate the committees and to facilitate competency building for committee members.
With disagreement, doubts, or ambiguous grounds in end-of-life decisions, doctors are advised to involve a clinical ethics committee (CEC). However, little has been published on doctors' experiences with discussing an end-of-life decision in a CEC. As part of the quality assurance of this work, we wanted to find out if clinicians have benefited from discussing end-of-life decisions in CECs and why. We will disseminate some Norwegian doctors' experiences when discussing end-of-life decisions in CECs, based on semi-structured interviews with fifteen Norwegian physicians who had brought an end-of-life decision case to a CEC. Almost half of the cases involved conflicts with the patients' relatives. In a majority of the cases, there was uncertainty about what would be the ethically preferable solution. Reasons for referring the case to the CEC were to get broader illumination of the case, to get perspective from people outside the team, to get advice, or to get moral backing on a decision already made. A great majority of the clinicians reported an overall positive experience with the CECs' discussions. In cases where there was conflict, the clinicians reported less satisfaction with the CECs' discussions. The study shows that most doctors who have used a CEC in an end-of-life decision find it useful to have ethical and/or legal aspects illuminated, and to have the dilemma scrutinized from a new perspective. A systematic discussion seems to be significant to the clinicians.
The structure of ethics work in a hospital is complex. Professional ethics, research ethics and clinical ethics committees (CECs) are important parts of this structure, in addition to laws and national and institutional codes of ethics. In Norway all hospital trusts have a CEC, most of these discuss cases by means of a method which seeks to include relevant guidelines and laws into the discussion. In recent years many committees have received more cases which have concerned questions of principle. According to Ellen Fox and co-authors the traditional CEC model suffers from a number of weaknesses. Therefore, in their organization a separate body deals with organizational matters. In this paper, we discuss what is gained and what is lost by creating two separate bodies doing ethics consultation. We do this through an analysis of detailed minutes of CEC discussions in one CEC during a 6-year period. 30 % of all referrals concerned matters of principle. Some of these discussions originated in a dilemma related to a particular patient. Most of the discussions had some consequences within the hospital organization, for clinical practice, for adjustment of guidelines, or may have influenced national policy. We conclude that a multiprofessional CEC with law and ethics competency and patient representation may be well suited also for discussion of general ethical principles. A CEC is a forum which can help bridge the gap between clinicians and management by increasing understanding for each others' perspectives.
As in other Western countries, most Norwegian nursing home patients are suffering from multi-pathological conditions and a large majority of them will die in the nursing home. End-of-life care represents many challenges, and it is a widespread concern that several nursing homes lack both resources and competence to ensure good quality care. This article examines the types and prevalence of ethical challenges in end-of-life care as nursing home staff consider them, as well as what they believe can help them to better cope with the ethical challenges. It is based on a national survey probing Norwegian nursing homes' end-of-life care at the ward level conducted in 2007. 664 respondents from 364 nursing homes answered the questionnaire, representing 68% of the patients and 76% of the nursing home sample. Inadequate care due to lack of resources and breaches of the patient's autonomy and integrity were the ethical challenges reported most often. Conflicts with the next of kin regarding nursing care and termination of life-prolonging treatment were reported more seldom. However, when asking the respondents to outline one of the most recent ethical dilemmas they had encountered, the majority of the respondents described ethical dilemmas concerning limitation of life-prolonging treatment, often mixed with disagreements between the wish of the family and that of the patient, or between the wish of the next of kin and what the staff consider to be right. Ethical dilemmas associated with breaches of the patient's autonomy and integrity were also thoroughly described. According to the staff, better ethical knowledge along with more time to reflect on ethical dilemmas were the initiatives most desired to improve the staff's way of handling ethical challenges. Furthermore, to have an opportunity to consult with a person holding ethical competence was emphasised by more than half of the respondents.
In this article we report findings from a qualitative study that explored how doctors and nurses in nursing homes describe professional collaboration around dying patients. The study also examined the consequences this can have for the life-prolonging treatment of patients and the care of them and their relatives. Nine doctors and 10 nurses from 10 Norwegian nursing homes were interviewed about their experience of decision-making processes on life-prolonging treatment and care. The findings reveal that the frameworks for the professional collaboration and organization of physicians and nurses prevent patient treatment and care complying with ethical considerations and the law. These conditions have a challenging impact on the care of dying patients and their relatives.
To study the attitudes of Norwegian physicians to resuscitation of hypothetical patients all at risk of neurological sequelae.
A cohort of Norwegian physicians who are representative of the national physician corps.
A total of 1650 Norwegian physicians (7% of practicing physicians in Norway) received a written questionnaire describing six scenarios of patients all in need of emergency life-saving intervention. Respondents were asked whether they would resuscitate; whether such resuscitation was in the patient's best interest; whether a surrogate's refusal of intervention would be accepted; and whether they would have wanted resuscitation if the patient were their own child, their spouse, or themselves. Positive or negative responses on a four-point Likert scale were recorded.
A total of 1,069 respondents (response rate, 65%). Physicians responding to these scenarios were a) more inclined to resuscitate an anonymous patient than if the patient were themselves or their kin; b) willing to resuscitate although they do not consider this intervention to be in the patient's best interest; c) willing to refrain from resuscitation on surrogate request in spite of a reasonably good prognosis; d) willing to accept surrogate's refusal of resuscitation in spite of a stated opinion that such intervention would be in the patient's best interest; and e) less willing to resuscitate newborn infants compared with older children and adults (except the aged) with similar prognoses.
There appear to be differences in medical thinking about best interest, surrogate decision making, and the relative value of lives as far as these are applied to acute, life-saving treatment.