Abstract Background When fever causes concerns for parents, they can contact Swedish Healthcare Direct (SHD), i.e. the telephone nursing (TN) service. However, ensuring satisfaction, consensus and trust is crucial for parental reassurance and adherence to the advice. There is limited research investigating parents’ views of TN, especially as regards children with fevers. The study aimed to explore and describe parents’ experiences of telephone nursing when their child has a fever. Method The study uses a convergent mixed-method design. Parents who contacted the TN service regarding their child’s fever were invited to participate. Quantitative data were collected in 113 questionnaires and analysed with descriptive statistic (n, %, median and interquartile range). Qualitative data were collected in 12 semi-structured interviews and analysed with manifest content analysis. Quantitative and qualitative data were analysed separately and then integrated and presented in a way that compares similarities and differences. Finally, an overall interpretation took place. Results Descriptive statistics showed that the majority of parents had both high expectations of the telenurses and also high parental satisfaction with the TN service. The qualitive analysis identified three themes; seeking answers, getting a caring conversation, and getting an assessment and guidance. The integrated results show that the qualitative findings both confirmed and extended the questionnaire responses. The interaction with the telenurse plays an important role and sometimes seems to play an even larger role in parents’ satisfaction with a call than the actual advice they received. The parents describe being cared for by someone with an empathetic response including a reassuring tone of voice. Although the waiting times can be perceived as too long, the lengths of the calls are generally described as appropriate, not because of the duration itself, but because the telenurses seem calm and do not end conversations prematurely. Conclusion The findings show that telephone nursing encompasses both advice and the telenurse-parent interaction surrounding its provision. Each of these aspects are important in creating satisfied and reassured parents. The advice must be clear, consistent and preferably include safety netting. At the same time, the telenurse must listen, validate and take the parent’s concerns seriously. Clinical trial number Not applicable.

The purpose of both precision medicine and precision nursing is to improve patient outcomes. This theoretical article is designed as a conceptual and position paper situated within caring science, with a specific focus on understanding precision nursing across diverse clinical contexts. Rather than presenting empirical findings, the paper synthesizes theoretical perspectives, caring science foundations, and selected scholarly literature. In this position paper, we seek to expand the concept of precision nursing from a caring science perspective with clinical examples, vignettes, from an emergency care context. Precision medicine can be viewed as an effort to truly individualize a treatment and make it as accurate and effective as possible. While the focus on measurable outcomes saves lives, it also carries the risk of narrowing attention to what can be observed and quantified. These visible clinical markers represent only part of what matters in care. To get the full picture of a patient and their treatment, caring must serve as the foundation for precision nursing, as it is caring that ensures that technological advancements remain aligned with individual patient needs. Precision medicine and precision nursing may offer direction, but to provide meaning to the concepts, a grounding in caring science is provided in this study.

Background: Persons living with dementia (PLWD) are at an increased risk of going missing, with an elevated risk of harm. In Sweden, thousands of PLWD go missing annually, and the police are responsible for locating them. However, there is limited knowledge about the key factors that contribute to effective search efforts. Therefore, this study aimed to identify these key factors as expressed by police experts. Method: Using the Delphi technique, this exploratory study sought consensus among 43 Swedish police search experts over three rounds. The consensus was set at ≥70%. Results: Of the initial 73 items described by individual police experts, 53 reached consensus among the expert group. Five categories were identified: Information, Search Management, Search Tactics, Knowledge, and Collaboration. Discussion/conclusion: Limited situational awareness and lack of structure can hamper police search efforts when PLWD go missing. Knowing the person, critical partners, and the terrain all enhance search effectiveness.

Responding to people in suicidal crisis is a significant part of the work of Swedish police patrol officers (PPOs). PPOs can prevent suicide and provide the person in crisis with support, but their presence can also have unintended effects, like escalation of the situation and stigma. The aim of this study was to describe PPOs’ experiences and actions when they encounter people in suicidal crisis. The study was performed with an inductive and descriptive qualitative design using the critical incident technique (CIT). A total of 26 PPOs were interviewed. Their experiences could be grouped under the main areas Navigating on the edge of chaos, The stakes are high and A split objective, and their actions under the main categories Striving for control, Pursuing adaptation and Engaging in collaboration. The results give us insights in the balancing acts PPOs perform when confronting people in suicidal crisis, as they must weigh providing safety and control against being present, adapting to suffering, and the specific needs of the situation and the individual.

Abstract Background Ambulance clinicians increasingly refer patients to self-care, positioning ambulance service within a wider gatekeeping role and necessitating the assessment of whether self-care is a safe option or if further support is needed. Contrary to primary healthcare centre (PHC) referrals, self-care referrals often lack structured follow-ups, with the decision consequences remaining underexplored. This study investigates the outcomes and predictors of subsequent healthcare contact (SHC) and mortality among patients referred to self-care by ambulance services in three Swedish regions. Methods This retrospective cohort study included 6,452 (954 children and 5,498 adults) ambulance assignments between 1 January 2023 and 31 December 31 2023 that resulted in self-care referrals. The primary outcome was SHC (PHC visits, ambulance service recontact, emergency department visits, and hospitalisations) and all-cause mortality within 72 h and 30 days. Bayesian multilevel logistic regression models were used to estimate the probability of recontact and mortality. Results Approximately 30% and 25% of the adults and children sought SHC, respectively, with the majority being PHC visits. Mortality was < 2% within 30 days, and no deaths were observed among the children. Respiratory, infectious, and medical symptoms predominated among the children, compared with medical, surgical, and neurological symptoms among adults. Predictors of SHC included increased age, longer on-scene time, advisory decision support system (ADSS) use, and distance to hospital. Conclusion Approximately one-third (30%) of patients sought SHC within 72 h of a self-care referral decision. Whilst this does not necessarily indicate adverse events, the lack follow-up and patient-reported data limits interpretation. Although the ADSS have the potential to reduce ED conveyance, they cannot replace nuanced clinical judgment, risking inequitable care for patients in rural areas, those with low health literacy, and frail older adults. Non‑conveyance decisions for patients aged 80 years or older should therefore be approached with heightened caution. Future research should explore patient perspectives to better understand re-engagement and improve the safety of self-care referrals.

Suicide is a leading cause of death globally and represents a common, resource-intensive duty for police patrol officers (PPOs). Responding to suicidal crises is often traumatic, and PPOs rarely receive comprehensive training, leaving them inadequately prepared. Police authorities frequently assume operational responsibility in such situations, encompassing emotional, legal, tactical and safety considerations. This study aimed to explore and describe the competencies required of PPOs when encountering individuals in suicidal crisis. An exploratory, descriptive design was employed using a modified Delphi technique. Descriptions provided by PPOs of encounters with individuals in suicidal crisis were used to inform the development of items for a two-round questionnaire distributed to an expert panel. Experts were defined as individuals employed by the Swedish Police Authority or a university college, with additional training and/or teaching experience related to managing suicidal crises. Of the 50 experts invited, 43 completed both rounds, yielding a response rate of 86

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 reported using 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:The number of persons living with dementia is increasing globally, including in Sweden, and these persons are at heightened risk of going missing and coming to harm. When they do go missing, the police get involved. There is a dearth of knowledge surrounding the prevalence and outcomes of harm in these instances in many countries, including Sweden, which affects our understanding of the associated risks and necessary interventions. Therefore, the aim of this study was to describe incidents of missing people and explore factors associated with harm in persons living with dementia as reported to the Swedish Police. METHODS:Data on background characteristics, the missing incidents, and police response was collected from a nationwide police registry. The missing incidents were analysed using descriptive statistics and logistic regression was used to explore factors associated with harm. RESULTS:A total of 1,041 missing person case reports concerning persons living with dementia were identified. In 61 (6%) of these reports, the missing person was harmed. The level of harm varied from lacerations to death. Male sex, no prior missing incidents, cold season, time since last contact, delayed reporting, and prolonged duration of police search effort were significantly associated with an increased probability of harm. CONCLUSIONS:Persons living with dementia constituted a substantial proportion of all missing persons case reports submitted to the Swedish Police during the study period. Persons living with dementia were also at considerable risk of harm when missing, as even minor injuries can lead to substantial consequences. Furthermore, time was a critical factor, emerging as the strongest predictor of harm in the study. This calls for the development of collaborative routines between the police and professional caregivers caring for persons living with dementia.

Background Ambulance clinicians regularly encounter medical, caring, existential and ethical challenges. Meeting patients with complex medical presentations underscore the need for holistic decision-making and actions as ambulance clinicians struggle to strike a balance between addressing medical and caring needs.Aim This study aimed to explore action alternatives considered and discussed during ethics case reflections in response to care-related challenges in ambulance services.Research design A qualitative descriptive study design was applied. Data were analyzed using conventional and summative content analysis.Participants and research context Ethics case reflections were performed with 14 groups comprising a total of 78 ambulance clinicians. Prior to the reflections, a video depicting the encounter between two ambulance clinicians and an older patient and his spouse was viewed.Ethical considerations The principles of the Declaration of Helsinki were applied throughout the research process, and an advisory statement was obtained from the Swedish Ethical Review Authority (No. 2019-02127 and 2021-03490).Findings The ethics case reflections generated a variety and breadth of action alternatives to manage challenges in caring, suggesting that this format is suitable for discussing ethical issues in clinical cases that depart from standard medical emergencies. Furthermore, the breadth of the results reveals the wide professional discretion afforded to ambulance clinicians and suggest the presence of tacit competences embedded in professional practice.Conclusions Ethics case reflection has a potential to enhance ambulance clinicians' ethical decision-making by deepening reflections about patient autonomy as well as highlighting the potential for a caring approach and promoting holistic care. By generating a breadth of specific action alternatives, many possible ways forward even in situations with complex care-related challenges are illustrated. Further investigation regarding the role of ethics case reflections to articulate implicit attitudes and tacit competencies is warranted.

Introduction Making decisions about the appropriate level of care is a significant challenge for healthcare professionals, especially when older patients present with diffuse symptoms. Collaboration between ambulance services and primary care may promote a comprehensive understanding of patient needs. However, such collaboration remains limited, potentially leading to lower care quality and higher costs. There is a need to understand how collaboration can be effectively implemented. This scoping review aims to explore existing models of collaboration between ambulance services and primary care, identifying their characteristics, outcomes and current research gaps.Methods and analysis This scoping review will follow the methodological framework proposed by Arksey and O’Malley, supplemented with recommendations from the Joanna Briggs Institute Handbook for Scoping Reviews. A comprehensive literature search will be conducted in PubMed, CINAHL, Web of Science and Scopus. In addition, Google Scholar, Overton, SwePub and the Swedish national library database Libris will be searched for relevant grey literature. The review will include studies published from January 2014 to the present. Data will be analysed descriptively, with findings categorised by collaboration models and patterns identified through inductive analysis to address the research questions. The review will apply the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews to present the results.Ethics and dissemination This review is the first stage of an overarching research study to develop a model for extended collaboration between ambulance services and primary care (the ECAP project). Results will be disseminated through peer-reviewed publications, conference presentations and sharing with ambulance services and primary care stakeholders to inform practice and policy. This scoping review protocol has been registered on the Open Science Framework (https://osf.io/nrkm5/). No participants will be involved at this stage, and the selected literature is publicly available, so no ethical approval will be required for this scoping review.

Forest fires, or wildfires, are expected to increase due to warmer and drier summers caused by climate change. When the forest is on fire, all forest owners are by law responsible to assist the fire and rescue services. Hence, the aim of this study was to describe private forest owners’ experiences of forest fires on their property. In-depth interviews were conducted and analyzed by using qualitative content analysis to describe 20 private forest owners’ experiences of forest fires. The result merged in the overarching theme: “Powerlessness in fighting the forest fire alleviates by togetherness in a desire to help and to be helped”. Meaning, a forest fire is a disaster both in economical and emotional terms, causing destruction to the forest that has been in the private forest owners’ care for generations. The forest owner feels responsibility and expresses an unquestionable will to act. The invaluable support from the local community helps the forest owner to manage this difficult. However, the forest owner expects to be allowed to contribute, therefore, the fire and rescue services need a proactive plan that involves private forest owners to ensure a safe work environment for all involved. In addition, the strong and differentiated network of family and neighbors that mobilize brings strength and local knowledge important to the operation. Though worrying of new forest fires will remain, it is a burden that needs to be taken seriously. A positive outcome is that through collaboration, security and resilience enhances in the local community.

To describe ambulance clinicians' experiences of self-determination in older patients. The study had an inductive and explorative design, guided from a life-world perspective. 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. 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. 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. 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. This study adhered to COREQ guidelines. None.

Objectives To describe nurses’ perceptions of advising parents when their child has a fever.Design/method Inductive, descriptive study with a qualitative, phenomenographic approach.Participants and setting A purposive sampling was used. To be included, the 24 online interviewed nurses had to have experience advising parents of febrile children between birth and 5 years of age. They were recruited from three different parts of the healthcare system from four regions in the south of Sweden.Results The nurses described advising parents when their child has a fever as four different kinds of balancing acts: balancing between the parents’ story and objective assessment, balancing between listening and teaching, balancing between self-confidence and trust in the expert, and balancing between independence and having someone by one’s side.Conclusions Giving advice to parents when their child has a fever is a process where the nurse needs to listen, assess and give advice based on the situation. This requires a correct assessment that depends on the parents’ story. Creating a trusting relationship is perceived as necessary for parents to assimilate the advice that is provided. What dominates are the nurses’ perceptions of the inner qualities required to achieve a balance in the process, for example, the importance of experience and security in their professional role, while it is also necessary to get support from colleagues.

Objectives The purpose of this study was to describe the experiences and actions of part-time firefighters’ family members in rural areas in Sweden.Design The study had an inductive descriptive design and used the critical incident technique.Setting Rural areas, primarily served by a part-time fire station, across Sweden.Participants The study included 25 participants (21 females and 4 males) with experiences of being a family member of a part-time firefighter. Family members who themselves served as firefighters were excluded.Results Being a part-time firefighter’s family member was described into three main areas of experiences: ‘affecting everyday life’, ‘dealing with uncertainty’ and ‘being in this together’. Actions taken were divided into two main areas: ‘pursuing adaptations’ and ‘alleviating difficulties’.Conclusions Family members of part-time firefighters faced increased responsibility at home, managing personal inconvenience and frustration. They offered emotional support for the firefighter, however, expressing a need for guidance on handling firefighters’ emotions and mental health after call-outs. Despite their crucial role, they often felt unrecognised by the fire and rescue service. Nonetheless, they took pride in their firefighter’s contribution to the community and noted positive impacts on the family.

Background Out-of-hospital cardiac arrest (OHCA) is a leading cause of death, and survival outcomes vary across countries and regions. To improve survival, the European Resuscitation Council Guidelines encourage the implementation of technologies like smartphone applications to alert voluntary first responders (VFRs) who are near a suspected OHCA. VFRs are of great importance in the ´chain of survival´, but there is still a lack of knowledge about their experiences; especially of those operating in rural areas. Understanding those experiences is crucial in developing appropriate interventions to train, encourage, and safeguard VFRs in their mission. Therefore, the aim of this study was to describe VFRs´ experiences of being dispatched to suspected OHCA in rural areas. Methods The study used an inductive design. The data were collected using individual interviews with 16 VFRs and analysed using qualitative content analysis. Results The results are presented in terms of six generic categories ‘‘Being motivated and prepared’’ , ‘‘Having strategies to undertake the mission’’ , ‘‘Collaborating with others’’ , ‘‘Being ethically aware’’ , ‘‘Supporting the family members’’ , and ‘‘Coping with the mission’’ , which formed the basis of the main category ‘ Desire to save lives and help others ’. The findings showed that VFRs had a genuine desire to contribute to save lives in this rural area. Regardless of the circumstances, they were prepared to leave everything and act to the best for the victim and their family members. In theirs’ missions they collaborated with others at the scene and were guided by ethics while they acted in complex circumstances. Conclusions VFRs dispatched in rural areas express a desire to save lives. In their missions, they acted in complex situations and experienced both emotional and ethical challenges. The design, implementation, and evaluation of support interventions directed at VFRs should be prioritised, especially in rural areas, as it can contribute to more people becoming and remaining VFRs, which in turn could contribute to sustainable development.

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 sixteen interviews 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.

Forest fires, i.e., wildfires, often cause an inevitable strain on society and human living conditions. Incident Commanders (IC) at the Fire and Rescue Services (FRS) are challenged to handle forest fires and at the same time address the forest owners’ needs; this stipulates a need for collaboration, information, and communication. Hence, the aim of this study was to explore and describe the ICs’ experiences and actions in their interactions with forest owners during forest fires on private property. Interviews were conducted and analyzed using Flanagan’s Critical Incident Technique (CIT) to describe the experiences and actions of 22 ICs. The results showed that a firefighting operation needs clarity in information exchange with the forest owner as a stakeholder, not a victim. The trust between forest owner and IC accelerated the operational phase. The ICs demonstrate more care than the law stipulates, and they worry about the forest owners. Therefore, the FRS needs to form a strategic partnership with forest owners and their network on a local level. Also, future forest fire drills should not only include emergency stakeholders (i.e., police, ambulance, etc.) but also forest owners and local volunteer organizations. For a resilient community, FRS and forest owner collaboration is vital.

AIM:To illuminate from the perspective of nurses in ambulance services the experiences of using a web-based advisory decision support system to assess care needs and refer patients. DESIGN:Inductive and descriptive approaches. METHOD:Thirteen semi-structured interviews were conducted in the spring of 2020. The data were analysed through the reflexive thematic analysis. RESULTS:The Swedish web-based advisory decision support system (ADSS) was found to strengthen nurses' feelings of security when they assess patients' care needs, promote their competence and professional pride, and help them manage stress. However, the system also generated difficulties for nurses to adjust to the dynamic ambulance team and revealed a discrepancy between their professional roles and responsibilities to refer patients and provide self-care advice. The nurses thought that the support system facilitated their increased participation and helped them understand patients and significant others by offering transparency in assessment and decision making. Thus, the support system provides nurses with an opportunity to strengthen patients' independence through information and education. However, in the care relationship, nurses worked to overcome patients' expectations. CONCLUSION:Nurses using the ADSS increased their security while performing assessments and referrals and found new opportunities to provide information and promote understanding of their decisions. However, nursing care values can be threatened when new support systems are introduced, especially as ambulance services become increasingly protocol-driven. IMPLICATIONS FOR PROFESSION AND/OR PATIENT CARE:These findings have implications for nurses' work environments and help them maintain consistency in making medical assessments and in providing equivalent self-care advice when referring patients to the different levels of care. The findings will also impact researchers and policymakers who formulate decision support systems. REPORTING METHOD:Consolidated criteria for reporting qualitative research (COREQ). PATIENT OR PUBLIC CONTRIBUTION:None.

Purpose - With aging, the risk of requiring emergency care increases. Elderly patients who need Emergency Medical Services (EMS) are often vulnerable and dependent, especially when their decision-making ability is reduced, which may intensify the risk of important ethical values being violated. Studies about paramedics' views on elderly people's self-determination within EMS settings are scarce. The aim of this study was to explore the attitudes and perceptions of paramedics in a US context regarding self-determination in elderly patients who need emergency care provided by EMS. Design/methodology/approach - The study had an exploratory design, and data were collected using a Delphi technique. A panel of experts consisting of US paramedics was recruited to answer a questionnaire sent out in three rounds. The questionnaire comprised 108 items, derived from a Swedish study on the same topic, rated with a five-point Likert scale ranging from agree to disagree with a predetermined consensus level of 70%. Findings - In total 21 experts agreed to participate, 15 completed all three rounds, leaving a total response rate of 71%. Finally, 87 out of 108 items reached consensus, of which 60 were "agree" and 27 were "disagree." Originality/value - The paramedic-patient relationship is a core in assessing and handling ethical challenges within an advanced practice influenced by the paramedics' educational level and/or the patient's physical/

Background: Older patients are often vulnerable and highly dependent on healthcare professionals' assessment in the event of acute illness. In the context of ambulance services, this poses challenges as the assessment is normally conducted with a focus on identifying life-threatening conditions. Such assessment is not fully satisfactory in a patient relationship that also aims to promote and protect patient autonomy. Aim: To describe ambulance clinicians' understanding of older patients' self-determination when the patient's decision-making ability is impaired. Research design: A qualitative design with an inductive approach, guided by descriptive phenomenology. Participants: In total, 30 ambulance clinicians, comprised of 25 prehospital emergency nurses, 1 nurse and 4 emergency medical technicians participated in 15 dyadic interviews. Ethical considerations: The research was conducted in accordance with the Declaration of Helsinki, and permission was granted by the Swedish Ethical Review Authority. Findings: The findings are presented in two themes: (1) Movement between explicit and implicit will; and (2) Contradictions about the patient's best interests. The clinicians' interpretations are based on an understanding of the patient's situation using substitute decision-making in emergency situations and conversations that reveal the patient's explicit wishes. Sometimes the clinicians collaborate to validate the patient's implicit will, while they at other times subordinate themselves to others' opinions. The clinicians find themselves in conflict between personal values and organisational values as they try to protect the patient's self-determination. Conclusion: The results indicate that older patients with an impaired decision-making ability risk losing the right to self-determination in the context of ambulance services. The clinicians face challenges that significantly affect their ability to handle the older patient's unique needs based on a holistic perspective and their ability to be autonomous.