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OBJECTIVE: To explore doctor-patient interactions and decision-making processes before high-risk cardiac surgery or intervention with special attention to existential challenges. Design, SETTING AND PARTICIPANTS: We conducted a qualitative study with data drawn from doctor-patient dialogues preceding high-risk procedures. The study setting was the cardiac department of a university hospital with 24-hour emergency service. We recruited a purposive sample of 10 patients and eight doctors. The patients were categorised as high-risk patients in accordance with EuroSCORE and established angiographic procedural high-risk criteria. Transcripts from the dialogues were analysed with systematic text condensation, inspired by discourse analysis. MAIN OUTCOME MEASURE: Accounts of doctor-patient interaction reflecting existential aspects of the decision-making process. RESULTS: The main existential concerns identified in the doctor-patient interactions were surviving uncertainty, negotiating responsibility and trusting the doctor's proficiency. When handling uncertainty, doctors imparted complex information about risk, warnings and recommendations, while patients sought and trusted the doctors' advice. Though the decisions were made in asymmetrical power relations, they were based on a shared responsibility discussed and defined throughout the dialogues. The patients expressed a profound confidence in the doctor's ability to get them through the high-risk treatment and give the best help possible. CONCLUSIONS: Uncertainty, mortality, responsibility and trust are fundamental existential issues concerning both patients and doctors before high-risk procedures, with an impact on decision-making processes. Increasing focus on underlying existential conditions, ethical reasoning and power relations in medical education may improve the quality of shared decision-making and informed consent related to high-risk treatment. [ABSTRACT FROM AUTHOR]

Objectives: Due to prognostic uncertainty and limited decision-making capacity, the choice to perform transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS) and comorbid dementia is challenging. This study explores older adults' perspectives on complex decision-making preceding TAVI in the hypothetical setting of comorbid dementia., Design: Qualitative study entailing semistructured interviews. Analysis was by systematic text condensation. The interview guide addressed their attitudes regarding treatment dilemmas before TAVI in patients living with dementia., Setting: Patients were recruited from the TAVI outpatient clinic at a university hospital performing TAVI., Participants: A purposive sample of 10 older adults (5 women) with AS and without dementia (range 77-94 years), where 8/10 had undergone TAVI were included., Results: Three main challenges were identified: (1) Risk assessment. Participants found it hard to compare the burden of aortic stenosis vs dementia. They acknowledged the dilemma of implanting a new heart valve to achieve symptom relief while risking severe dementia in the future due to prolonged life span. (2) Autonomous capacity. A profound uncertainty was described regarding who should participate in decision-making if the person was incapacitated due to dementia. (3) Customised information. Participants advocated for thorough information describing facts and uncertainty, aiming to protect and support the person living with dementia., Conclusion: Older adults with severe aortic stenosis find it hard relating to dilemmas arising from providing TAVI in patients living with dementia. There is a need for tailor-made information to support autonomy and decision-making under uncertainty., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Competence in palliative medicine is required in clinical practice. Based on a literature review, we developed a two-week elective course in palliative medicine for 5th and 6th year medical students. We wanted to study learning outcomes from the course, especially related to knowledge, confidence, and reflections on the doctor's role in palliative care., Methods: A multiple-choice questionnaire (MCQ) assessed knowledge in palliative care pre and post course. The Thanatophobia Scale (TS) and the Self-efficacy in Palliative Care Scale (SEPC) measured confidence in communication with patients close to death and in providing palliative care, respectively. Reflection notes were analysed using Systematic Text Condensation, a cross-case thematic analysis. Lave & Wenger's theory about situated learning was used to support interpretations., Results: From 2018 to 2022 we ran four courses for a total of 48 students. Test results improved over the course in all four groups. On average, MCQ scores increased by 22% (range 13-33), TS scores were reduced by 28% (24-32), and SEPC scores increased by 50% (42-64), reflecting increased confidence in dealing with seriously ill and dying patients and their relatives. The participants prepared reflection notes describing their main impressions and take-home messages from the course, focusing specifically on the role of the doctor. They described the doctor's role linked to an overarching task of creating a sense of security for patients and relatives. Through the course, and especially through talking to patients and relatives and being part of the interprofessional team, the participants learned how this sense of security was built by gaining competence in the following domains: 1) Patient-centred communication about the disease, expected trajectory, and needs, establishing common ground and support; 2) Being the medical expert in symptom relief and decision-making, providing guidance and reassurance in difficult situations; 3) Professionalism rooted in a holistic and relational approach; and 4) Being a good team player, aware of their function and limitations., Conclusions: A two-week student-selected course in palliative medicine improved knowledge and skills and increased confidence in providing palliative care. The comprehensive understanding of the doctor's role obtained in this course may also be relevant to other clinical specialties., Trial Registration: Not applicable (no clinical trial)., (© 2024. The Author(s).)

Bakgrunn: Legeforeningen har utarbeidd retningslinjer for lindrande sedering i livets sluttfase, sist revidert i 2014. Vi ville undersøke lungelegar sin kjennskap til retningslinjene og bruk av lindrande sedering ved lungesjukdomar., Materiale Og Metode: Eit elektronisk spørjeskjema blei sendt til alle medlemmer av Norsk forening for lungemedisin (529 legar) i oktober 2022. Svara blei analysert med deskriptiv statistikk, og fritekstkommentarane blei analysert ved systematisk tekstkondensering., Resultat: Totalt 50 legar svarte (9,5 %). 22 hadde kjennskap til retningslinjene, og eit mindretal meinte desse var tydelege og gav god støtte. 37 oppgav at lindrande sedering blei gjennomført der dei jobba, men det var stor variasjon i kor ofte. 25 av deltakarane hadde vore med på å gjennomføre lindrande sedering ein eller fleire gonger, og 19 hadde opplevd etiske utfordringar relatert til dette. Sederinga vart oftast utført hjå pasientar med lungekreft ved intraktabel dyspné og smerter, men også hjå andre sjukdomsgrupper. Avgjerda vart stort sett tatt i tverrfagleg fellesskap, og fritekstkommentarane utdjupa at dette gav støtte og tryggleik. Det vart påpeikt ein krevjande grenseoppgang mot dødshjelp, og ønskje om at gråsonene kunne utdjupast meir i retningslinjene., Tolking: Definisjonen av lindrande sedering blir framleis oppfatta ulikt og kan framstå uklar. Det kan moglegvis vere til hjelp å legge til diagnosespesifikke råd ved revisjon av gjeldande retningslinjer.

Background: To operationalize the palliative care approach and improve care across services, a palliative care pathway (PCP) was developed in Western Norway. The PCP is an evidence-based framework for palliative care assessment and interventions in the form of a web-based flowchart. Measures: An electronic questionnaire aimed at health care professionals (HCPs) examined perceived usability and content. We registered PCP webpage activity and conducted an evaluation seminar and group interviews. Intervention: The pathway was developed (2015) and piloted in two cities (2017-2018/2020). Outcomes: HCPs perceived that the PCP contributed to increased palliative care knowledge and skills and worked as a reference and educational tool. They found the PCP easily accessible but asked for a search option and easier webpage navigation. Conclusions/Lessons Learned: An available PCP can support a common language for palliative care in different settings and enhance patient-centered care. HCPs need time to familiarize themselves with its content and use.

Background: Coercion is rare in cancer treatment. We present a case where a young woman received gamma knife radiosurgery and immunochemotherapy under compulsory institutional care., Case Presentation: A previously healthy patient in her thirties was admitted to hospital due to confusion, apathy, weight loss and sleep disturbance. She had difficulties expressing herself and spoke with considerable latency. A brain MRI revealed a tumour of 23 mm in the left-side centrum semiovale and perifocal oedema, while a CT scan showed a 5.6 cm tumour in the right upper lobe and enlarged mediastinal lymph nodes. She was diagnosed with non-small cell lung cancer, no actionable mutations, PD-L1 <75 %. When she did not wish to return to the hospital to undergo gamma knife radiosurgery, she was readmitted under a formal decision to use coercion, and remained under institutional care for over six months. Today she is fully recovered and has no cancer progression almost five years after diagnosis., Interpretation: This case report illustrates the challenges of brain metastases and use of coercion during cancer treatment, both for the patient and healthcare personnel. There is a need for thorough interdisciplinary discussions and to establish as early as possible a shared understanding of the intention and scope of the forced treatment.

Introduction: Excessive and insufficient physical exercise have both been associated with accelerated muscle function decline in boys with Duchenne Muscular Dystrophy (DMD), and optimal exercise remains unclear., Objective: This study explored participants' experiences with a one-year training program., Methods: Five semi-structured qualitative individual interviews and one focus group interview were conducted and analyzed using systematic text condensation., Results: Participants included boys with DMD who participated in the intervention study ( n  = 10), their relatives and/or assistants ( n  = 7). Four main themes emerged: 1) the crucial role of motivation to maintain training routines, 2) benefiting from exercise, but with a need for balancing it, 3) time management challenges, and 4) the training as a social arena and meeting place. The participants emphasized the importance of experiencing progress, basic skills and enjoyable training. Parents were reassured knowing the appropriate exercise intensity and technique. The boys needed flexibility and support to find a balance between exercise and other activities and described benefits from sharing experiences with each other., Conclusion: Clinical guidelines for physical exercise in DMD should encompass customization of exercise interventions supporting motivational factors, balance and social interaction, and identify competing commitments. Successful training programs may enhance quality of life and functionality for these boys.

Introduction: The value of shared decision-making and decision aids (DA) has been well documented yet remain difficult to integrate into clinical practice. We wanted to investigate needs and challenges regarding decision-making about advanced lung cancer treatment after first-line therapy, focusing on DA applicability., Methods: Qualitative data from separate, semi-structured focus groups with patients/relatives and healthcare professionals were analysed using systematic text condensation. 12 patients with incurable lung cancer, seven relatives, 12 nurses and 18 doctors were recruited from four different hospitals in Norway., Results: The participants described the following needs and challenges affecting treatment decisions: 1) Continuity of clinician-patient-relationships as a basic framework for decision-making; 2) barriers to information exchange; 3) negotiation of autonomy; and 4) assessment of uncertainty and how to deal with it. Some clinicians feared DA would steal valuable time and disrupt consultations, arguing that such tools could not incorporate the complexity and uncertainty of decision-making. Patients and relatives reported a need for more information and the possibility both to decline or continue burdensome therapy. Participants welcomed interventions supporting information exchange, like communicative techniques and organizational changes ensuring continuity and more time for dialogue. Doctors called for tools decreasing uncertainty about treatment tolerance and futile therapy., Conclusion: Our study suggests it is difficult to develop an applicable DA for advanced lung cancer after first-line therapy that meets the composite requirements of stakeholders. Comprehensive decision support interventions are needed to address organizational structures, communication training including scientific and existential uncertainty, and assessment of frailty and treatment toxicity., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Nursing home residents were particularly vulnerable to a serious clinical course of COVID-19. It was therefore decided early in the pandemic that nursing homes needed to be protected through measures such as testing and isolation regimens and restrictions on visiting. This entailed new procedures and guidelines for nursing home doctors. Norwegian and international studies show that the pandemic presented new ethical dilemmas for healthcare staff. The aim of this study was to provide a better understanding of the ethical issues faced by nursing home doctors during the pandemic., Material and Method: Nine semi-structured in-depth interviews with doctors at five nursing homes in Bergen were analysed using Attride-Stirling's thematic network analysis., Results: The doctors told of challenges related to deciding the level of treatment, setting limits for palliative care, adapting visiting restrictions, and assessing the use of coercion with regard to testing and isolation. This entailed difficult ethical considerations whereby doctors were faced with conflicts of interest and value judgements, central to which was consideration for the individual resident versus society., Interpretation: The nursing home doctors in our study found it difficult to find a balance between protecting the residents' autonomy and preventing the spread of infection.

Aims: The objective of this study was to examine baseline frailty status (including cognitive deficits) and important clinical outcomes, to inform shared decision-making in older adults receiving transcatheter aortic valve implantation (TAVI)., Methods and Results: We conducted a prospective, observational study of 82 TAVI patients, recruited 2013 to 2015, with 2-year follow-up. Mean age was 83 years (standard deviation (SD) 4.7). Eighteen percent of the patients were frail, as assessed with an 8-item frailty scale. Fifteen patients (18%) had a Mini-Mental Status Examination (MMSE) score below 24 points at baseline, indicating cognitive impairment or dementia and five patients had an MMSE below 20 points. Mean New York Heart Association (NYHA) class at baseline and 6 months was 2.5 (SD 0.6) and 1.4 (SD 0.6), (p < 0.001). There was no change in mean Nottingham Extended Activities of Daily Living (NEADL) scale between baseline and 6 months, 54.2 (SD 11.5) and 54.5 (SD 10.3) points, respectively, mean difference 0.3 (p = 0.7). At 2 years, six patients (7%) had died, four (5%, n = 79) lived in a nursing home, four (5%) suffered from disabling stroke, and six (7%) contracted infective endocarditis., Conclusions: TAVI patients had improvement in symptoms and maintenance of activity of daily living at 6 months. They had low mortality and most patients lived in their own home 2 years after TAVI. Complications like death, stroke, and endocarditis occurred. Some patients had cognitive impairment before the procedure which might influence decision-making. Our findings may be used to develop pre-TAVI decision aids.

Background: The ERANet-LAC CODE (Care Of the Dying Evaluation) international survey assessed quality of care for dying cancer patients in seven countries, by use of the i-CODE questionnaire completed by bereaved relatives. The aim of this sub study was to explore which factors improve or reduce quality of end-of-life (EOL) care from Norwegian relatives' point of view, as expressed in free text comments., Methods: 194 relatives of cancer patients dying in seven Norwegian hospitals completed the i-CODE questionnaire 6-8 weeks after bereavement; recruitment period 14 months; response rate 58%. Responders were similar to non-responders in terms of demographic details.104 participants (58% spouse/partner) added free text comments, which were analyzed by systematic text condensation., Results: Of the 104 comments, 45% contained negative descriptions, 27% positive and 23% mixed. 78% described previous experiences, whereas 22% alluded to the last 2 days of life. 64% of the comments represented medical/surgical/oncological wards and 36% palliative care units. Four main categories were developed from the free text comments: 1) Participants described how attentive care towards the practical needs of patients and relatives promoted dignity at the end of life, which could easily be lost when this awareness was missing. 2) They experienced that lack of staff, care continuity, professional competence or healthcare service coordination caused uncertainty and poor symptom alleviation. 3) Inadequate information to patient and family members generated unpredictable and distressing final illness trajectories. 4) Availability and professional support from healthcare providers created safety and enhanced coping in a difficult situation., Conclusions: Our findings suggest that hospitals caring for cancer patients at the end of life and their relatives, should systematically identify and attend to practical needs, as well as address important organizational issues. Education of staff members ought to emphasize how professional conduct and communication fundamentally affect patient care and relatives' coping.

To investigate which factors individuals with a psychotic depression experience as preventive of suicide while beeing hospitalized. Semi-structured qualitative interviews with nine inpatients, all hospitalized for a unipolar or bipolar depressive episode with psychosis, were conducted at time of discharge. For analysis we used systematic text condensation. Main outcomes were accounts of participants' experiences of suicide prevention measures and treatment, and how these affected suicidal ideation, plans, and attempts. Participants experienced (1) suicide attempts being physically interrupted or prevented; (2) receiving medical treatment to alleviate unbearable suffering; (3) finding refuge behind locked doors; (4) receiving guidance to redefine their identity and situation. They reported being protected from suicidal impulses and imagined persecutors in a secure environment with staff present. They described their autonomy as compromised by intense suffering and chaos. They retrospectively appreciated staff interventions, if these were performed compassionately and with empathy. Participants described that suicidal thoughts and actions were triggered by terrifying psychotic experiences, anxiety and sleeplessness, and felt that medication - and in one instance electroconvulsive therapy- alleviated suffering. At time of discharge, participants reported no psychotically motivated suicidal thoughts. They described a new, insightful self-view and acknowledged having been severely mentally ill. To prevent impulsive suicidal behavior, findings highlight the need for both security measures and a treatment approach focusing on modifying psychotic experiences and intense anxiety. Gaining anxious and paranoid patients' trust is essential to build motivation for medical treatment. Patients emphasize that having time to talk is crucial to this process.

Background and Aims: Advance care planning (ACP) is communication about wishes and preferences for end-of-life care. ACP is not routinely used in any Norwegian hospitals. We performed a pilot study (2014-2017) introducing ACP on a thoracic medicine ward in Norway. The aims of this study were to explore which topics patients discussed during ACP conversations and to assess how patients, relatives and clinicians experienced the acceptability and feasibility of performing ACP., Methods: Conversations were led by a study nurse or physician using a semistructured guide, encouraging patients to talk freely. Each conversation was summarised in a report in the patient's medical record. At the end of the pilot period, clinicians discussed their experiences in focus group interviews. Reports and transcribed interviews were analysed using systematic text condensation., Results: Fifty-one patients participated in ACP conversations (41-86 years; 9 COPD, 41 lung cancer, 1 lung fibrosis; 11 women); 18 were accompanied by a relative. Four themes emerged: (1) disturbing symptoms, (2) existential topics, (3) care planning and (4) important relationships. All participants appreciated the conversations. Clinicians (1 physician and 7 nurses) participated in two focus group interviews. Reports from ACP conversations revealed patient values previously unknown to clinicians; important information was passed on to primary care. Fearing they would deprive patients of hope, clinicians acted as gatekeepers for recruitment. Although they reported barriers during recruitment, many clinicians saw ACP as pertinent and called for time and skills to integrate it into their daily clinical practice., Conclusions: Patients, relatives and clinicians showed a positive attitude towards ACP. Focusing on present and future symptom control may be an acceptable way to introduce ACP. Important aspects for implementing ACP in this patient group are management support, education, training, feasible routines and allocated time to perform the conversations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The doctors' strike in 2016 highlighted an ongoing debate on the tightening of working conditions for doctors. With this strike as a backdrop, we wanted to investigate the attitudes and expectations for future working conditions among medical students., Material and Method: Four focus-group interviews with a total of 21 medical students (48 % women, age 21-38 years) in their third to sixth year of study were conducted and analysed with the aid of systematic text condensation., Results: The students described how the doctors' efforts to help each other had a positive effect on the working environment, but might also paradoxically worsen the working conditions of the collegial community. They highlighted the importance of consensus around public health services, a good professional community and idealism, but perceived that these aspects could be threatened by competition for positions and distrust in political governance processes. The need to be competent and succeed in competing for temporary jobs, as well as a strong motivation to become a doctor, made the students vulnerable to accepting tough working conditions. The students' attitudes and expectations had mainly been formed through work placement experience and by family members, but the strike had impacted particularly the older cohorts' assessment of their future working situation., Interpretation: Medical students express concerns about accepting entry into a system that they are not immediately able to change, and where safeguarding their own needs and a favourable work-life balance might be difficult. This has implications for raising awareness of these issues during the medical studies and developing an organisational culture that ensures justifiable and sustainable working conditions for doctors.

Aims: Established surgical scores have limitations in delineating risk among candidates for transcatheter aortic valve implantation (TAVI). Assessment of frailty might help to estimate the mortality risk and identify patients likely to benefit from treatment. The aim of the study was to develop a frailty score to guide the decision for TAVI., Methods and Results: We conducted a prospective observational study in patients ≥70 years referred for TAVI during 2011-15. A Heart Team had declined the patients for open heart surgery due to high risk but accepted them for TAVI. Prior to the procedure, a geriatric assessment (GA) was performed. Based on this, an 8-element frailty score with a 0-9 (least frail-most frail) scale was developed. A total of 142 patients, 54% women, mean age 83 (standard deviation 4) years, with severe and symptomatic aortic stenosis were assessed. All-cause 2 year mortality was 11%. The novel GA frailty score predicted 2-year mortality in Cox analyses, also when adjusted for age, gender, and logistic EuroSCORE [hazard ratio (HR) 1.75, 95% confidence interval (CI): 1.28-2.42, P < 0.001]. A receiver operating characteristic (ROC) curve analysis indicated that a GA frailty score cut-off at ≥4 predicted 2-year mortality with a specificity of 80% (95% CI: 73-86%) and a sensitivity of 60% (95% CI: 36-80%). The area under the curve was 0.81 (95% CI 0.71-0.90)., Conclusion: A novel 8-element GA frailty score identified gradations in survival in patients declined for open heart surgery. Patients with higher GA frailty scores had significantly higher 2-year mortality after TAVI., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Advance care planning (ACP) is a communication process for mapping a patient's wishes and priorities for end-of-life care. In preparation for the introduction of ACP in Norway, we wanted to explore the views of Norwegian pulmonary patients on ACP. We conducted four focus group interviews in a Norwegian teaching hospital, with a sample of 13 patients suffering from chronic obstructive pulmonary disease, lung cancer or lung fibrosis. Analysis was by systematic text condensation. Participants' primary need facing end-of-life communication was "the comforting safety", implying support, information and transparency, with four underlying themes: 1) provide good team players; 2) offer conversations with basic information; 3) seize the turning point; and 4) balance transparency. Good team players were skilled communicators knowledgeable about treatment and the last phase of life. Patients preferred dialogues at the time of diagnosis and at different "turning points" in the disease trajectory and being asked carefully about their needs for communication and planning. Transparency was important, but difficult to balance. ACP for patients with life-threatening pulmonary disease should rest upon an established patient-doctor/nurse relationship and awareness of turning points in the patient's disease progression. Individually requested and tailored information can support and empower patients and their relatives., Competing Interests: Conflict of interest: None declared.

Objectives: Working conditions in nursing homes (NHs) may hamper teamwork in providing quality end-of-life (EOL) care, especially the participation of NH physicians. Dutch NH physicians are specialists or trainees in elderly care medicine with NHs as the main workplace, whereas in Norway, family physicians usually work part time in NHs. Thus, we aimed at assessing and comparing NH physicians' perspectives on barriers and strategies for providing EOL care in NHs in Norway and in The Netherlands., Design: A cross-sectional study using an electronic questionnaire was conducted in 2015., Setting and Participants: All NH physicians in Norway (approximately 1200-1300) were invited to participate; 435 participated (response rate approximately 35%). Of the total 1664 members of the Dutch association of elderly care physicians approached, 244 participated (response rate 15%)., Measurements: We explored NH physicians' perceptions of organizational, educational, financial, legal, and personal prerequisites for quality EOL care. Differences between the countries were compared using χ 2 test and t-test., Results: Most respondents in both countries reported inadequate staffing, lack of skills among nursing personnel, and heavy time commitment for physicians as important barriers; this was more pronounced among Dutch respondents. Approximately 30% of the respondents in both countries reported their own lack of interest in EOL care as an important barrier. Suggested improvement strategies were routines for involvement of patients' family, pain- and symptom assessment protocols, EOL care guidelines, routines for advance care planning, and education in EOL care for physicians and nursing staff., Conclusions: Inadequate staffing levels, as well as lack of competence, time, and interest emerge as important barriers to quality EOL care according to Dutch and Norwegian NH physicians. Their perspectives were mostly similar, despite large educational and organizational differences. Key strategies for improving EOL care in their facilities comprise education and incorporating available palliative care tools and systems., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: This study investigated how severely depressed individuals experienced the relationship between psychotic symptoms and suicidal ideation and behavior., Method: Semi-structured qualitative interviews were conducted with a purposive sample of nine inpatients from a psychiatric university hospital between September 2012 and May 2013 fulfilling diagnostic criteria for a psychotic depressive episode as part of a unipolar or bipolar disorder. Analysis was conducted using systematic text condensation., Results: Participants experienced (1) being directed to perform impulsive potentially fatal actions, (2) feeling hounded to death, (3) becoming trapped in an inescapable darkness, and (4) being left bereft of mental control. They described how impulsivity directed by delusions and hallucinations resulted in unpredictable actions with only moments from decision to conduct. Suicide was seen as an escape not only from life problems but also from psychotic experiences and intense anxiety. Participants reported being in a chaotic state, unable to think rationally or anticipate the consequences of their actions. Their ability to identify and communicate psychotic symptoms and suicidal ideation and behavior was compromised, leaving them to struggle alone with these terrifying experiences., Conclusions: Suicide risk assessments based on verbal reports from individuals with psychotic depression may not always be valid due to potential impulsivity and underreporting of suicidal ideation. It may be important for clinicians to explore the delusional content of such patients' experiences to assess the possibility of suicide as a result of shame, guilt, remorse, or altruistic intentions to save others from harm.

Background: Doctors often find dialogues about death difficult. In Norway, 45% of deaths take place in nursing homes. Newly qualified medical doctors serve as house officers in nursing homes during internship. Little is known about how nursing homes can become useful sites for learning about end-of-life care. The aim of this study was to explore newly qualified doctors' learning experiences with end-of-life care in nursing homes, especially focusing on dialogues about death., Methods: House officers in nursing homes (n = 16) participated in three focus group interviews. Interviews were audiotaped and transcribed verbatim. Data were analysed with systematic text condensation. Lave & Wenger's theory about situated learning was used to support interpretations, focusing on how the newly qualified doctors gained knowledge of end-of-life care through participation in the nursing home's community of practice., Results: Newly qualified doctors explained how nursing home staff's attitudes taught them how calmness and acceptance could be more appropriate than heroic action when death was imminent. Shifting focus from disease treatment to symptom relief was demanding, yet participants comprehended situations where death could even be welcomed. Through challenging dialogues dealing with family members' hope and trust, they learnt how to adjust words and decisions according to family and patient's life story. Interdisciplinary role models helped them balance uncertainty and competence in the intermediate position of being in charge while also needing surveillance., Conclusions: There is a considerable potential for training doctors in EOL care in nursing homes, which can be developed and integrated in medical education. This practice based learning arena offers newly qualified doctors close interaction with patients, relatives and nurses, teaching them to perform difficult dialogues, individualize medical decisions and balance their professional role in an interdisciplinary setting.

Background: Patient autonomy is a leading principle in bioethics and a basis for shared decision making. This study explores conditions for an autonomous choice experienced by older adults who recently underwent trans-catheter aortic valve replacement (TAVR)., Methods: Qualitative study entailing semi-structured interviews of a purposive sample of ten older (range 73-89, median 83.5 years) adults after TAVR (median 23 days). The study setting was a cardiac department at a university hospital performing TAVR since 2010. Analysis was by systematic text condensation., Results: Even when choice seemed hard or absent, TAVR-patients deliberately took the chance offered them by processing risk assessment, ambivalence and fate. They regarded declining the treatment to be worse than accepting the risk related to the procedure. The experience of being thoroughly advised by their physician formed the basis of an autonomous trust. The trust they felt for the physicians' recommendations mitigated ambivalence about the procedure and risks. TAVR patients expressed feelings consistent with self-empowerment and claimed that it had to be their decision. Even so, choosing the intervention as an obligation to their family or passively accepting it was also reported., Conclusions: Older TAVR patients' experience of an autonomous decision may encompass frank tradeoff; deliberate physician dependency as well as a resilient self-view. Physicians should be especially aware of how older adults' subtle cognitive declines and inclinations to preserve their identities which can influence their medical decision making when obtaining informed consent. Cardiologists and other providers may also use these insights to develop new strategies that better respond to such inherent complexities.

Background: Myocardial infarction (MI) patients may find it challenging to adhere to lifestyle advice and medications. Understanding motivational factors and barriers to change is crucial. However, empirical evidence on patients' ability to effect lifestyle changes at the time of discharge is limited., Aim: The aim of this study was to identify at the time of hospital discharge the goals, resources, and barriers to future change in MI patients., Methods: We conducted a qualitative interview study with a purposive sample of 20 MI patients (eight women) in a cardiac department at a university hospital in Norway. All interviews were conducted before hospital discharge, transcribed verbatim, and analysed using qualitative content analysis., Findings: Three themes suggested that, at the time of discharge, patients' views of their MI were complex and diverse. Patients were motivated to change their lifestyle and contemplated taking their life in new directions, adopting a change of life perspective. Frequently, patients struggled to understand the context of living with an MI, manage symptoms, and understand the precipitating causes of MI. There were also patients who wanted to maintain their present lifestyle and live as normal as possible. They just wanted to keep going., Conclusions and Implications: There is a need for a different approach to communicating with MI patients at the time of discharge. Person-centred care that allows personal narratives to emerge may enable health-care professionals to offer more individualised guidance to MI patients that will help them cope with the everyday challenges they experience after discharge., (© The European Society of Cardiology 2015.)

Objective: Explore the impact of existential vulnerability for nursing home doctors' experiences with dying patients and their families., Methods: We conducted a qualitative study based on three focus group interviews with purposive samples of 17 nursing home doctors. The interviews were audio-recorded, transcribed, and analyzed with systematic text condensation., Results: Nursing home doctors experienced having to balance treatment compromises in order to assist patients' and families' preparation for death, with their sense of professional conduct. This was an arduous process demanding patience and consideration. Existential vulnerability also manifested as powerlessness mastering issues of life and death and families' expectations. Standard phrases could help convey complex messages of uncertainty and graveness. Personal commitment was balanced with protective disengagement on the patient's deathbed, triggering both feelings of wonder and guilt., Conclusion: Existential vulnerability is experienced as a burden of powerlessness and guilt in difficult treatment compromises and in the need for protective disengagement, but also as a resource in communication and professional coping., Practice Implications: End-of-life care training for nursing home doctors should include self-reflective practice, in particular addressing treatment compromises and professional conduct in the dialogue with patient and next-of-kin., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

In the end stages of life, drug treatment goals shift to symptom control and quality of life and as such changes in drug utilization are expected. The aim of this paper is to review the extent to which costs are considered in drug utilization research at the end of life, with a particular focus on the outcome measures being used. This systematic review identified seven studies across varied settings studies reporting both drug utilization and medication cost outcome measures. The main factors identified that impacted medication use and cost were the time period considered and the provision of specialist palliative care services. Combining drug utilization and medication cost outcomes is critical for the allocation of healthcare resources and the development of a sound health policy.

Objective: To examine drug treatment in nursing home patients at the end of life, and identify predictors of palliative drug therapy., Design: A historical cohort study., Setting: Three urban nursing homes in Norway., Subjects: All patients admitted from January 2008 and deceased before February 2013., Main Outcome Measures: Drug prescriptions, diagnoses, and demographic data were collected from electronic patient records. Palliative end-of-life drug treatment was defined on the basis of indication, drug, and formulation., Results: 524 patients were included, median (range) age at death 86 (19-104) years, 59% women. On the day of death, 99.4% of the study population had active prescriptions; 74.2% had palliative drugs either alone (26.9%) or concomitantly with curative/preventive drugs (47.3%). Palliative drugs were associated with nursing home, length of stay > 16 months (AOR 2.10, 95% CI 1.12-3.94), age (1.03, 1.005-1.05), and a diagnosis of cancer (2.12, 1.19-3.76). Most initiations of palliative drugs and withdrawals of curative/preventive drugs took place on the day of death., Conclusion: Palliative drug therapy and drug therapy changes are common for nursing home patients on the last day of life. Improvements in end-of-life care in nursing homes imply addressing prognostication and earlier response to palliative needs.

Objective: Synthesize research about patients' and relatives' expectations and experiences on how doctors can improve end-of-life care in nursing homes., Methods: We systematically searched qualitative studies in English in seven databases (Medline, Embase, PsycINFO, CINAHL, Ageline, Cochrane Systematic Reviews and Cochrane Trials). We included 14 publications in the analysis with meta-ethnography., Results: Patients and families emphasized the importance of health personnel anticipating illness trajectories and recognizing the information and palliation needed. Family members who became proxy decision-makers reported uncertainty and distress when guidance from health personnel was lacking. They worried about staff shortage and emphasized doctor availability. Relatives and health personnel seldom recognized patients' ability to consent, and patients' preferences were not always recognized., Conclusion: Nursing home patients and their relatives wanted doctors more involved in end-of-life care. They expected doctors to acknowledge their preferences and provide guidance and symptom relief., Practice Implications: High-quality end-of-life care in nursing homes relies on organization, funding and skilled staff, including available doctors who are able to recognize illness trajectories and perform individualized Advance Care Planning., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Coping with existential challenges is important when struck by serious disease, but apart from cancer and palliative care little is known about how patients deal with such issues and maintain hope. To explore how patients with life-threatening heart disease experience hope when coping with mortality and other existential challenges, we conducted a qualitative study with semi-structured interviews. We made a purposive sample of 11 participants (26-88 years) who had experienced life-threatening disease: eight participants with serious heart disease, two with cancer, and one with severe chronic obstructive pulmonary disease. Analysis was by systematic text condensation. The findings showed that hope could enhance coping and diminish existential distress when patients were confronted with mortality and other existential challenges. Hope was observed as three types of dynamic work: to shift perception of mortality from overwhelming horror toward suppression or peaceful acceptance, to foster reconciliation instead of uncertainty when adapting to the new phase of life, and to establish go-ahead spirit instead of resignation as their identity. Meaning of life could, hence, be sustained in spite of serious threats to the persons' future, everyday life, and self-conception. The work of hoping could be supported or disturbed by relationships with family, friends, and health care professionals. Hope can be regarded as an active, dynamic state of existential coping among patients with life-threatening disease. Physicians may support this coping and thereby provide personal growth and alleviation of existential distress by skillfully identifying, acknowledging, and participating in the work of hoping performed by the patient.