BACKGROUND:There is increasing evidence that the individual physician is the main factor influencing variability in end-of-life decision-making in intensive care units. End-of-life decisions are complex and should be adapted to each patient. Physician-related variability is problematic as it may result in unequal assessments that affect patient outcomes. The primary aim of this study was to investigate factors contributing to physician-related variability in end-of-life decision-making.METHOD:This is a qualitative substudy of a previously conducted study. In-depth thematic analysis of semistructured interviews with 19 critical care specialists from five different Swedish intensive care units was performed. Interviews took place between 1 February 2017 and 31 May 2017.RESULTS:Factors influencing physician-related variability consisted of different assessment of patient preferences, as well as intensivists' personality and values. Personality was expressed mainly through pace and determination in the decision-making process. Personal prejudices appeared in decisions, but few respondents had personally witnessed this. Avoidance of criticism and conflicts as well as individual strategies for emotional coping were other factors that influenced physician-related variability. Many respondents feared criticism for making their assessments, and the challenging nature of end-of-life decision-making lead to avoidance as well as emotional stress.CONCLUSION:Variability in end-of-life decision-making is an important topic that needs further investigation. It is imperative that such variability be acknowledged and addressed in a more formal and transparent manner. The ethical issues faced by intensivists have recently been compounded by the devastating impact of the COVID-19 pandemic, demonstrating in profound terms the importance of the topic.

BACKGROUND:To make end-of-life (EOL) decisions is a complex and challenging task for intensive care physicians and a substantial variability in this process has been previously reported. However, a deeper understanding of intensivists' experiences and attitudes regarding the decision-making process is still, to a large extent, lacking. The primary aim of this study was to address Swedish intensivists' experiences, beliefs and attitudes regarding decision-making pertaining to EOL decisions. Second, we aimed to identify underlying factors that may contribute to variability in the decision-making process.METHOD:This is a descriptive, qualitative study. Semi-structured interviews with nineteen intensivists from five different Swedish hospitals, with different ICU levels, were performed from 1 February 2017 to 31 May 2017.RESULTS:Intensivists strive to make end-of-life decisions that are well-grounded, based on sufficient information. Consensus with the patient, family and other physicians is important. Concurrently, decisions that are made with scarce information or uncertain medical prognosis, decisions made during on-call hours and without support from senior consultants cause concern for many intensivists. Underlying factors that contribute to the variability in decision-making are lack of continuity among senior intensivists, lack of needed support during on-call hours and disagreements with physicians from other specialties. There is also an individual variability primarily depending on the intensivist's personality.CONCLUSION:Swedish intensivists' wish to make end-of-life decisions based on sufficient information, medically certain prognosis and consensus with the patient, family, staff and other physicians. Swedish intensivists' experience a variability in end-of-life decisions, which is generally accepted and not questioned.

The Delegation for Medical Ethics within the Swedish Society of Medicine has taken the initiative to create national ethical guidelines on cardiopulmonary resuscitation. The reasons behind this initiative were indications of differences in the way decisions about cardiopulmonary resuscitation were made and documented and requests expressed by health-care professionals for new national ethical guidelines. During the process of creating the guidelines, a number of workshops were held with representatives from the delegation and clinical experts from various branches of medicine. Several versions of the working document were sent to consultation bodies with requests for comments. We therefore believe that the final guidelines are well supported by the medical profession in Sweden. The purpose of this article is to present ethical issues on which it was difficult to reach consensus due to divergent opinions expressed by the people and organisations involved. The arguments for and against a particular point of view or wording in the text are presented. The main controversies were related to the following six issues; Determining whether or not cardiopulmonary resuscitation is beneficial for the patient – The presence of close loved ones during cardiopulmonary resuscitation – Performing cardiopulmonary resuscitation for the benefit of people other than the patient – Ambulance personnel’s mandate to decide not to initiate and to terminate cardiopulmonary resuscitation outside hospital – Limiting the length and content of cardiopulmonary resuscitation – Whether or not to specify a week of gestation before which cardiopulmonary resuscitation should not be started.

INTRODUCTION:Despite that heart rate (HR) control is one of the guideline-recommended treatment goals for heart failure (HF) patients, implementation has been painstakingly slow. Therefore, it would be important to identify patients who have not yet achieved their target heart rates and assess possible underlying reasons as to why the target rates are not met. MATERIALS AND METHODS:The survey of HR in patients with HF in Sweden (HR-HF survey) is an investigator-initiated, prospective, multicenter, observational longitudinal study designed to investigate the state of the art in the control of HR in HF and to explore potential underlying mechanisms for suboptimal HR control with focus on awareness of and adherence to guidelines for HR control among physicians who focus on the contributing role of beta-blockers (BBs). RESULTS:In 734 HF patients the mean HR was 68 ± 12 beats per minute (bpm) (37.2% of the patients had a HR >70 bpm). Patients with HF with reduced ejection fraction (HFrEF) (n = 425) had the highest HR (70 ± 13 bpm, with 42% >70 bpm), followed by HF with preserved ejection fraction and HF with mid-range ejection fraction. Atrial fibrillation, irrespective of HF type, had higher HR than sinus rhythm. A similar pattern was observed with BB treatment. Moreover, non-achievement of the recommended target HR (<70 bpm) in HFrEF and sinus rhythm was unrelated to age, sex, cardiovascular risk factors, cardiovascular diseases, and comorbidities, but was related to EF and the clinical decision of the physician. Approximately 50% of the physicians considered a HR of >70 bpm optimal and an equal number considered a HR of >70 bpm too high, but without recommending further action. Furthermore, suboptimal HR control cannot be attributed to the use of BBs because there was neither a difference in use of BBs nor an interaction with BBs for HR >70 bpm compared with HR <70 bpm. CONCLUSION:Suboptimal control of HR was noted in HFrEF with sinus rhythm, which appeared to be attributable to physician decision making rather than to the use of BBs. Therefore, our results underline the need for greater attention to HR control in patients with HFrEF and sinus rhythm and thus a potential for improved HF care.

Att utrona medicinska behov, fatta beslut och se dem genomforda ar lakarens ansvar.For att fa veta den enskilde patientens varderingar och onskemal kravs en fortroendefull relation med vardgivaren. ...

Att utrona medicinska behov, fatta beslut och se dem genomforda ar lakarens ansvar.For att fa veta den enskilde patientens varderingar och onskemal kravs en fortroendefull relation med vardgivaren. ...

The aim of this article is to elucidate the traditional ward round from an historical, ethical and legal perspective. On the traditional ward round in hospitals, a senior clinician leads a group of other clinicians and health professionals on a walking tour through the ward to visit the patients for whom they are responsible at bedside. It is a long-lived tradition or routine, which has been substantially resistant to change. We recommend that work designed to improve the ward round should begin from values or ethical principles, such as respecting the patient's integrity and right to participate in decision-making. Moreover, the focal point should be creating opportunities for »the good meeting« and patient narratives. A team-based, person-centred ward round has been implemented in some hospitals in Sweden. The patient meets the ward team in a separate room to discuss the plan of care together. We argue that it is no longer possible to defend the traditional way of walking rounds, either ethically or legally.

The primary aim of this qualitative study, which was based on interviews with 24 patients with diabetes mellitus, was to identify factors that influence patients' willingness and ability to adhere to prescribed medicines, to recommend lifestyle choices and to acquire a deeper understanding of the way these factors influence adherence. The starting point for the study was our belief that it may be of pivotal importance for health professionals to address patients' life experiences, present life situations and cultural background, as well as their conceptions and attitudes, in order to understand why some patients have or may encounter difficulty in following treatment recommendations and realising treatment goals.Four main themes related to the primary research questions were identified. Patients with diabetes may regard diabetes as a lifelong follower but not a real problem: a trifle in relation to the daily struggle with difficulties; something out of one's control; something not worth giving up the good things in life for. In our opinion, the main result of this study is that patients may view diabetes as a marginal problem in relation to other burdens and troubles in life, such as other somatic diseases and symptoms, mental illnesses due to previous traumatic experiences, concerns for loved ones and economy.We argue that the desired goals in terms of adherence and outcomes for patients with diabetes in general need to be adapted to what is desirable and realistic for the individual patient. Copyright (C) 2016 John Wiley & Sons.

Etiken och juridiken tydlig kring livsuppehallande behandling [Ethics and jurisprudence concerning life-sustaining treatment is clear]

Ethical guidelines on out-of-hospital cardio-pulmonary resuscitation (CPR) are designed to provide substantial guidance for the people who have to make decisions and deal with situations in the real world. The crucial question is whether it is possible to formulate practical guidelines that will make things somewhat easier for ambulance personnel. The aims of this article are to address the ethical aspects related to out-of-hospital CPR, primarily to decisions on not starting or terminating resuscitation attempts, using the views and experience of ambulance personnel as a starting point, and to summarise the key points in a practice guideline on the subject.

Background: There is a shortage of reports on what potential recipients of implantable cardioverter–defibrillators (ICDs) need to be informed about and what role they can and want to play in the decision-making process when it comes to whether or not to implant an ICD. Aims: To explore how patients with heart failure and previous episodes of malignant arrhythmia experience and view their role in the decision to initiate ICD treatment. Patients and methods: A qualitative content analysis of semistructured interviews was used. The study population consisted of 31 outpatients with moderate heart failure at the time of their first ICD implantation. Setting: The study was performed at Sahlgrenska University Hospital, Göteborg, Sweden. Results: None of the respondents had discussed the alternative option of receiving treatment with anti-arrhythmic drugs, the estimated risk of a fatal arrhythmia, or the expected time of survival from heart failure in itself. Even so, very little criticism was directed at the lack of information or the lack of participation in the decision-making process. The respondents felt that they had to rely on the doctors’ recommendation when it comes to such a complex and important decision. None of them regretted implantation of the ICD. Conclusions: The respondents were confronted by a matter of fact. They needed an ICD and were given an offer they could not refuse, simply because life was precious to them. Being able to give well-informed consent seemed to be a matter of less importance for them.