Background: Shared decision-­ making aims to ensure that healthcare professionals and patients jointly make decisions regarding the patient's care. However, professionals often find it challenging to implement shared decision-­ making with older patients who have cognitive impairments or diminished decision-­making capacity. Research indicates a significant gap in the understanding of how decision-­ making processes unfold in prehospital settings.

Aim: The objective of this scoping review was to explore how decision-­making involving older patients in acute prehospital situations is characterized.

Design and Method: This scoping review is based on the Joanna Briggs Institute's guidelines for scoping reviews and is reportedusing the Preferred Reporting Items for Systematic Reviews and Meta-­Analyses extension for Scoping Review (PRISMA-­ScR).

Data Sources: CINAHL, PubMed, Scopus, PsychINFO and Web of Science were searched to identify relevant studies published between the years 2000 and 2024.

Results: The results are based on 26 studies and indicate that decision-­making among older patients is a conditional process,characterised by collaborative support involving the patient, significant others and healthcare professionals. Barriers to this process include hierarchical dynamics, fear of reprisals and uncertainty regarding the risk–benefit ratio. Factors that support decision-­making include situationally relevant competence, organisational resources and the presence of specific symptoms and signs.

Conclusion: Shared decision-­making with older patients in acute prehospital settings is conditional, often resulting in decisions being made primarily by healthcare professionals. There is considerable room for improvement in how this process is systematically approached. A structured approach is needed—one that assesses the older patient's decision-­ making capacity, considers the perspectives of family members, and incorporates input from individuals who know the patient well, all while minimizing hierarchical barriers.

Background: This study explored the dynamics of ethical encounters between frail older residents and assistant nurses during assisted bodily care at the end of life within nursing homes. While personalized palliative care is recognized as crucial for this demographic, little is known about the ethical dimensions of daily care practices in this setting. 

Design: Focused ethnography. 

Methods: Data consisted of 170 hours of fieldwork in an urban Swedish nursing home. This involved participant observation and interviews. Thematic analysis was used, with input from five public community stakeholders during a focus group. 

Results: Our findings uncover barriers to achieving ethical encounters in assisted bodily care within the nursing home, primarily linked to communication, relationships, and care quality. These obstacles stem from resource limitations, ineffective communication, and misaligned work values. However, ethical encounters can be facilitated through the promotion of moral sensitivity, genuine resident engagement, and collaborative practices, essential for person-centered care. Personnel, particularly assistant nurses, must recognize their responsibility in addressing resident vulnerability. 

Conclusion: We advocate for continuous moral reflection on communication, compassion, decision-making, and behavior, with a strong focus on the care relationship. To improve care quality, organizations should allocate resources for relationship-building and provide assistant nurses with adequate post-shift recovery time. Additionally, we recommend further research, including the implementation of ethically grounded palliative care, to continuously enhance care practices in nursing homes.

Ethical issues and approvals: The study followed ethical standards stated by the Declaration of Helsinki, approved by The Regional Ethics Board of Stockholm (Dnr 2017/8-31/1).

Background: Many older people in Swedish nursing homes have physical and/or mental conditions that may convey the violation of dignity. Dignity is a common caring science concept, however complex and multivalent. Thus, the aim was to explore aspects of dignity in older persons’ everyday lives. 

Design: Focused ethnography. 

Methods: Data consisted of 170 h of fieldwork, comprising observations (n=39) with residents (n=19), assistant nurses (n=22), and repeated interviews with residents (n=35). To study dignity-related concerns, the Chochinov model of dignity was used to direct a deductive analysis. 

Results: The residents suffered from illness-related concerns that inhibited a dignified life. Their failing bodies were the most significant threat to their dignity. This caused fear of extended dependency, agony, loneliness, and meaninglessness. The most dignity-conserving repertoire came from within themselves: their self-knowledge had provided them with self-esteem and tools to distinguish what was still possible from what had to be accepted. Socially, residents’ dignity depended on assistant nurses’ routines and behavior. Dignity-conserving interventions were observed, such as emphatic listening and care performed according to residents’ preferences. However, dignity was violated by long waiting times, lack of integrity, deteriorating routines, and harsh encounters with assistant nurses. 

Conclusions: Important dignity-conserving abilities came from within residents themselves. To protect residents’ dignity, all nursing home professions must provide holistic care that comprises attention to personal, bodily, social, spiritual, and psychological needs.

Ethical issues and approvals: The study followed ethical standards stated by the Declaration of Helsinki, approved by The Regional Ethics Board of Stockholm (Dnr 2017/8-31/1).

Background

It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians’ ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance service context. Thus, the aim of this study was to describe ambulance clinicians’ experiences of participating in ethics rounds.

Methods

This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteeninterviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis.

Results

Two themes describe the participants’ experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue.

Conclusion

Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service.

Background: Palliative care is expected to acknowledge physical, psychological, emotional, spiritual, and social needs, to which social workers can contribute with expertise on recognizing the importance of social relations and how social inequalities impact on individuals. The social work profession faces challenges in claiming their contributions in the hierarchies of medical professions. Polices play an important role in constructing and positioning responsibilities of professions.

Objectives: To analyze how social workers are positioned as contributors to palliative care within national-level policies in Sweden.

Methods and materials: A policy analysis was conducted through a constructivist lens. Data were collected from 10 Swedish national-level policy documents on palliative care.

Results: Three themes emerged: “A natural presence conveying special expertise”; “Emotional conversational support before and after death”; and “Practical support.” Overall, social workers’ contribution was vaguely described and in similar ways as registered nurses.

Conclusion: In Swedish policies analyzed, social workers’ contributions were difficult to differentiate from that of registered nurses, which may complicate their mutual collaborations and cause confusion for individuals at the end of life and their next of kin. Future research on how different professions are positioned within palliative care is needed to reduce risks of role blurring between professions with similar aims. Moreover, given social workers long history of psychosocial knowledge, meanings of this concept need to be further acknowledged.

Aim: To describe ambulance clinicians' experiences of self-determination in older patients.

Design: The study had an inductive and explorative design, guided from a life-world perspective.

Methods: Thirty-two Swedish ambulance clinicians were interviewed in six focus groups in November 2019. The data were analysed with content analysis, developing manifest categories and latent themes.

Findings: The ambulance clinicians assessed the older patients' exercise of self-determination by engaging in conversation and by being visually alert, to eventually gain an overall picture of their decision-making capacity. This assessment was used as a platform when informing older patients of their rights, thus promoting their participation in care. Having limited time and narrow guidelines counteracted ambulance clinicians' ambitions to support older patients' general desire to avoid hospitalization, which resulted in an urge to displace their responsibility to external decision-makers.

Conclusion: Expectations that older patients with impaired decision-making ability will give homogeneous responses mean an increased risk of ageist attitudes with a simplified view of patient autonomy. Such attitudes risk the withholding of information about options that healthcare professionals do not wish older patients to choose. When decision-making is difficult, requests for expanded guidelines may paradoxically risk alienation from the professional nursing role.

Implications and Impact: The findings show ambulance clinicians' unwillingness to shoulder their professional responsibility when encountering older patients with impaired decision-making ability. In assuming that all older patients reason in the same way, ambulance clinicians tend to adopt a simplistic and somewhat ageist approach when it comes to patient autonomy. This points to deficiencies in ethical competence, which is why increased ethics support is deemed suitable to promote and develop ethical competence. Such support can increase the ability to act as autonomous professionals in accordance with professional ethical codes.

Reporting Method: This study adhered to COREQ guidelines.

Patient and Public Contribution: None.

Background: As more people are living longer, they become frail and are affected by multi-morbidity, resulting in increased demands from the ambulance service. Being vulnerable, older patients may have reduced decision-making capacity, despite still wanting to be involved in decision-making about their care. Their needs may be complexand difficult to assess, and do not always correspond with ambulance assessment protocols. When needing an ambulance, older patients encounter ambulance clinicians who are under high workloads and primarily consider themselves as emergency medical care providers. This situates them in the struggle between differing expectations, and ethical conflicts may arise. To resolve these, providing ethical care, focussing on interpersonal relationships and using ethical competence is needed. However, it is not known whether ambulance clinicians possess the ethical competence required to provide ethical care. Thus, the aim of this study was to deductively explore their ethical competence when caring for older patients with reduced decision-making ability.

Methods: A qualitative deductive and exploratory design was used to analyse dyadic interviews with ambulance clinicians. A literature review, defining ethical competence as comprising ethical sensitivity, ethical knowledge, ethical reflection, ethical decision-making, ethical action and ethical behaviour, was used as a structured categorization matrix for the analysis.

Results: Ambulance clinicians possess ethical competence in terms of their ethical knowledge, highlighting the need for establishing an interpersonal relationship with the older patients. To establish this, they use ethical sensitivity to interpret the patients’ needs. Doing this, they are aware of their ethical behaviour, signifying how they must act respectfully and provide the necessary time for listening and interacting.

Conclusions: Ambulance clinicians fail to see their gut feeling as a professional ethical competence, which might hinder them from reacting to unethical ways of working. Further, they lack ethical reflection regarding the benefits and disadvantages of paternalism, which reduces their ability to perform ethical decision-making. Moreover, their ethical knowledge is hampered by an ageist approach to older patients, which also has consequences for their ethical action. Finally, ambulance clinicians show deficiencies regarding their ethical reflections, as they reflect merely on their own actions, rather than on their values

This study explores how papers published in internationaljournals in palliative and end-of-life care report ethical approval andinformed consent. A literature search following PRISMA guidelines wasconducted in PubMed, the Web of Science Core Collection, Scopus, theProQuest Social Science Premium Collection, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). A total of169 empirical studies from 101 journals were deductively coded andanalysed. The results showed that 5% of publications provided no information on ethical approval, 12% reported minimal information, 56%reported rudimentary information, and 27% reported comprehensivedetails. We also found that 13% did not report any information oninformed consent, 17% reported minimal information, 50% reported rudimentary information, and 19% reported comprehensive details. The prevalence of missing and incomplete ethical statements and inadequatereporting of informed consent processes in recent publications raises concerns and highlights the need for improvement. We suggest that journalsadvocate high reporting standards and potentially reject papers that donot meet ethical requirements, as this is the quickest path toimprovement.