Ethical challenges in the provision of end-of-life care in Norwegian nursing homes.

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. (c) 2010 Elsevier Ltd. All rights reserved.