Medical end-of-life decisions in Norway

A Qualitative Analysis of Ethical Problems Experienced by Physicians and Nurses in Intensive Care Units in Turkey

In this qualitative study, we aimed to identify and compare the ethical problems perceived by physicians and nurses in intensive care units at Baskent University hospitals in Turkey. A total of 21 physicians and 22 nurses were asked to describe ethical problems that they frequently encounter in their practice. The data were analyzed using an interactive model. The core problem for both physicians and nurses was end-of-life decisions (first level). In this category, physicians were most frequently concerned with euthanasia while nurses were more concerned with do-not-resuscitate orders (second level). At the third level, we saw that almost all of the participants’ responses related to negative perceptions about euthanasia. Communication and hierarchical problems were the second most reported main category. Nurses were more likely to cite problems with hierarchy than physicians. At the third level, a large percentage of nurses described communication problems with authority and hierarchical problems with physicians. In the same category, physicians were most often concerned with communication problems with patients’ relatives. The ethical problems were reported at different frequencies by physicians and nurses. We asked the participants about ethical decision-making styles. The results show that nurses and physicians do not follow a systematic pattern of ethical decision making.

Are end-of-life practices in Norway in line with ethics and law?

BACKGROUND

End-of-life decisions, including limitation of life prolonging treatment, may be emotionally, ethically and legally challenging. Euthanasia and physician-assisted suicide (PAS) are illegal in Norway. A study from 2000 indicated that these practices occur infrequently in Norway.

METHODS

In 2012, a postal questionnaire addressing experience with limitation of life-prolonging treatment for non-medical reasons was sent to a representative sample of 1792 members of the Norwegian Medical Association (7.7% of the total active doctor population of 22,500). The recipients were also asked whether they, during the last 12 months, had participated in euthanasia, PAS or the hastening of death of non-competent patients.

RESULTS

Seventy-one per cent of the doctors responded. Forty-four per cent of the respondents reported that they had terminated treatment at the family's request not knowing the patient's own wish, doctors below 50 and anaesthesiologists more often. Anaesthesiologists more often reported to have terminated life-prolonging treatment because of resource considerations. Six doctors reported having hastened the death of a patient the last 12 months, one by euthanasia, one by PAS and four had hastened death without patient request. Male doctors and doctors below 50 more frequently reported having hastened the death of a patient.

CONCLUSION

Forgoing life-prolonging treatment at the request of the family may be more frequent in Norway that the law permits. A very small minority of doctors has hastened the death of a patient, and most cases involved non-competent patients. Male doctors below 50 seem to have a more liberal end-of-life practice.

Culture and end of life care: a scoping exercise in seven European countries

AIM

Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries.

METHODS

We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes.

RESULTS

A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities.

CONCLUSION

This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.

Ethical problems in end-of-life decisions for elderly Norwegians

Norwegian health professionals, elderly people and family members experience ethical problems involving end-of-life decision making for elders in the context of the values of Norwegian society. This study used ethical inquiry and qualitative methodology to conduct and analyze interviews carried out with 25 health professionals, six elderly people and five family members about the ethical problems they encountered in end-of-life decision making in Norway. All three participant groups experienced ethical problems involving the adequacy of health care for elderly Norwegians. Older people were concerned about being a burden to their families at the end of their life. However, health professionals wished to protect families from the burden of difficult decisions regarding health care for elderly parents at the end of life. Strategies are suggested for dialogue about end-of-life decisions and the integration of palliative care approaches into health care services for frail elderly people.

Being an intensive care nurse related to questions of withholding or withdrawing curative treatment

AIMS AND OBJECTIVES

The aim of the study was to acquire a deeper understanding of what it is to be an intensive care nurse in situations related to questions of withholding or withdrawing curative treatment.

BACKGROUND

Nurses in intensive care units regularly face critically ill patients. Some patients do not benefit from the treatment and die after days or months of apparent pain and suffering. A general trend is that withdrawal of treatment in intensive care units is increasing. Physicians are responsible for decisions concerning medical treatment, but as nurses must carry out physicians' decisions, they are involved in the consequences.

DESIGN AND METHODS

The research design was qualitative, based on interpretative phenomenology. The study was carried out at an adult intensive care unit in Norway. Data were collected by group interviews inspired by focus group methodology. Fourteen female intensive care nurses participated, divided into two groups. Colaizzi's model was used in the process of analysis.

RESULTS

The analysis revealed four main themes which captured the nurses' experiences: loneliness in responsibility, alternation between optimism and pessimism, uncertainty--a constant shadow and professional pride despite little formal influence. The essence of being an intensive care nurse in the care of patients when questions were raised concerning curative treatment or not, was understood as 'being a critical interpreter and a dedicated helper.'

CONCLUSIONS

The findings underpin the important role of intensive care nurses in providing care and treatment to patients related to questions of withholding or withdrawing curative treatment.

RELEVANCE TO CLINICAL PRACTICE

The findings also show the need for physicians, managers and intensive care nurses themselves to recognize the burdens intensive care nurses carry and to appreciate their knowledge as an important contribution in decision making.

Ethical issues in intensive care--a survey among Scandinavian intensivists

BACKGROUND

The general principles of medical ethics are universally accepted. In practice, however, there is variation on how these principles are interpreted by people with different cultural backgrounds. The aim of this study was to document the views of Scandinavian intensive care physicians on intensive care unit (ICU) admission, triage, withholding and withdrawal of intensive care, and communication between the patient, the family and the ICU team.

METHODS

A questionnaire was developed and sent to 84 intensive care physicians working in Denmark, Finland, Sweden and Norway.

RESULTS

The response rate was 61%. In general, the responses were in agreement with published guidelines. Nevertheless, there was considerable variation on what factors are taken into account when priority decisions are made. In addition, the views on the content of information provided to the family varied. A majority of 80% reported priority decisions being made on a regular basis. Less than one-half of the respondents had correct knowledge regarding the existence or lack of national guidelines on intensive care ethics. Only 8% of the respondents were aware of guidelines published by the Society of Critical Care Medicine.

CONCLUSION

Variation in priority determinants between individual physicians may compromise justice in health care. An effort should be made to discuss and adopt mutual principles. In addition, the quality of information available to the patients' representatives deserves our attention. The results of this study could be used as a basis for discussion when guidelines on the ethical aspects of intensive care are developed and reviewed.

Action ethical dilemmas in surgery: an interview study of practicing surgeons

Background

The aim of this study was to describe the kinds of ethical dilemmas surgeons face during practice.

Methods

Five male and five female surgeons at a University hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of physicians and nurses about ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation.

Results

No gender differences were found in the kinds of ethical dilemmas identified among male and female surgeons. The main finding was that surgeons experienced ethical dilemmas in deciding the right treatment in different situations. The dilemmas included starting or withholding treatment, continuing or withdrawing treatment, overtreatment, respecting the patients and meeting patients' expectations. The main focus in the narratives was on ethical dilemmas concerning the patients' well-being, treatment and care. The surgeons narrated about whether they should act according to their own convictions or according to the opinions of principal colleagues or colleagues from other departments. Handling incompetent colleagues was also seen as an ethical dilemma. Prioritization of limited resources and following social laws and regulations represented ethical dilemmas when they contradicted what the surgeons considered was in the patients' best interests.

Conclusion

The surgeons seemed confident in their professional role although the many ethical dilemmas they experienced in trying to meet the expectations of patients, colleagues and society also made them professionally and personally vulnerable.

Unhappy doctors? A longitudinal study of life and job satisfaction among Norwegian doctors 1994-2002

Background

General opinion is that doctors are increasingly dissatisfied with their job, but few longitudinal studies exist. This study has been conducted to investigate a possible decline in professional and personal satisfaction among doctors by the turn of the century.

Methods

We have done a survey among a representative sample of 1 174 Norwegian doctors in 2002 (response rate 73 %) and compared the findings with answers to the same questions by (most of) the same doctors in 1994 and 2000. The main outcome measures were self reported levels of life satisfaction and job satisfaction according to the Job Satisfaction Scale (JSS).

Results

Most Norwegian doctors are happy. They reported an average life satisfaction of 5.21 in 1994 and 5.32 in 2002 on a scale from 1 (extremely dissatisfied) to 7 (extremely satisfied). Half of the respondents reported a very high level of general life satisfaction (a score of 6 or 7) while only one third said they would have reported this high level of satisfaction five years ago. The doctors thought that they had a higher level of job satisfaction than other comparable professional groups. The job satisfaction scale among the same doctors showed a significant increase from 1994 to 2002. Anaesthesiologists and internists reported a lower and psychiatrists and primary care doctors reported a higher level of job satisfaction than the average.

Conclusion

Norwegian doctors seem to have enjoyed an increasing level of life and job satisfaction rather than a decline over the last decade. This challenges the general impression of unhappy doctors as a general and worldwide phenomenon.

Impact of feeling responsible for adverse events on doctors' personal and professional lives: the importance of being open to criticism from colleagues

OBJECTIVE

To investigate the impact of adverse events that had caused patient injury and for which the doctor felt responsible, and the experience of acceptance of criticism among colleagues.

DESIGN

Self-reports based on postal questionnaires to 1616 doctors.

SETTING

Norway.

PARTICIPANTS

A representative sample of 1318 active doctors.

RESULTS

368/1294 (28%) reported that they had experienced at least one adverse event with serious patient injury. Being male and working within a surgical discipline (including anaesthesiology, obstetrics and gynaecology) significantly increased the probability of such reports. 38% of the events had been reported to official authorities and, for 17% of doctors, the incident had a negative impact on their private life; 6% had needed professional help. 50% and 54%, respectively, found it difficult to criticise colleagues for their ethically or professionally unacceptable conduct. Doctors who found it easy to criticise colleagues also reported having received more support from their colleagues after a serious patient injury.

CONCLUSION

Male surgeons report the highest prevalence of adverse events. Criticism for professionally and ethically unacceptable conduct is difficult to express among doctors. More acceptance of criticism of professional conduct may not only prevent patient harm, but may also give more support to colleagues who have experienced serious patient injury.

Long term survival and costs per life year gained after out-of-hospital cardiac arrest

PURPOSE

To study long-term survival and estimate the costs per year of survival after out-of-hospital cardiac arrest of cardiac origin.

MATERIALS AND METHODS

Cardiac arrest patients treated by the physician-manned ambulance in Oslo from January 1971 to June 1992. The condition of the patient when discharged from hospital was noted and survival followed until June 2002. Costs of the Emergency Medical Service (EMS), hospital treatment, rehabilitation and nursing homes and psychiatric institutions after discharge from hospital were included in a cost-effectiveness analysis.

RESULTS

1300 (42%) of 3065 patients receiving ALS were admitted to hospital after return of spontaneous circulation (ROSC). 1066 of these patients had a cardiac cause of the arrest, full hospital report and were found in the National Registry. Median age was 68 years (60-74) and 802 (75%) were men. 269 of the 1066 patients were discharged from hospital alive, 239 to their homes and 30 patients to rehabilitation/nursing homes or psychiatric institutions. The mean survival of the 1066 patients was 532 days. They spent mean 3.4 days in a CCU, 6.8 days in a general ward and 11.2 days in nursing/rehabilitation homes or psychiatric institutions. 30 patients were discharged to rehabilitation/nursing homes or psychiatric institutions. The mean survival time for the 269 patients discharged from hospital alive was 6.13 years. 110 patients were alive after five and 61 after 10 years. The cost per patient discharged alive was 40,642 or 6,632 per life year gained.

CONCLUSIONS

Cardiac arrest patients do not occupy intensive care beds too long, and few end up in a vegetative state. Methodological differences in different studies makes meaningful comparisons of costs difficult, but the costs per life year saved are not high compared to other publications.