A European multicenter study on systematic ethics work in nursing homes

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In elderly care and the ‘nursing home world’, many ethical challenges and dilemmas have to be faced. Both ‘everyday ethical issues’ and ‘big ethical issues’ have been described in the literature 1. The typical ethical challenges in nursing homes are lack of resources 3, resident autonomy issues, such as the use of coercion or restraints 4, and decision‐making surrounding end‐of‐life care 3.
More than 90% of the staff at a Norwegian nursing home experienced ethical problems as a burden 12. A main barrier to the use of ethics discussions and ethics committees in nursing homes seems to be a lack of awareness 9. The Norwegian Association of Local and Regional Authorities started the ‘Cooperation for building ethics competence’ in order to improve competence in ethics through ethics education and reflection on ethics in nursing homes and primary care in 2007 13. The project showed that the sustainability of ethics work depends on an assignment from the administration, ethics competence and methods for structuring ethical reflection 14.
There is a need for systematic ethics work including ethics education and ethics reflection 4, but it is not yet standard in all nursing homes. Systematic ethics work ‘includes the organisation's systematic use of different measures, tools and places to enhance ethics discussions and ways to handle ethically difficult situations and choices in nursing homes, for example ethics education, ethical deliberation, different arenas for ethics discussions, ethics consultants and ethics committees’ 12. Different approaches to discussing ethics in nursing homes have been established in the USA 9, Germany 15, Austria 16 and Norway 4. At present, theses approaches include, for example, informal discussions, reflection groups, moral case deliberation, ethics consultant, ethics committee, ethics café, ethics rounds or role play 19. Ethics support has become more diverse and adapted to local needs and everyday ethical issues are important topics 1. So far there is no international gold standard or a state of the art for systematic ethics work other than that the need to discuss and handle ethical challenges in nursing homes is widely recognised.
The theoretical background and perspective of this study are the principles of biomedical ethics as proposed by Beauchamp and Childress with autonomy as a central concept in modern bioethics 21, as well as palliative care ethics and hospice philosophy where the patients and their relatives' wishes and needs are paramount 23. Although the principlism that is based on the four moral principles respect for autonomy, nonmaleficence, beneficence and justice 21 is not a classical ethical theory, it is a frequently used ethical framework of moral norms in modern bioethics 22. The four principles approach is widely used in medical ethics to discuss ethical dilemmas in ethics committees and ethics consultations in hospitals. Due to its importance in modern bioethics, the principle of respect for autonomy has even been referred to as being ‘first among equals’ 25. In order to respect the residents' autonomy in nursing homes, the inclusion of residents and relatives in the discussion about ethical challenges and decision‐making is needed 26.
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