Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues – missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care (...) left undone – suggesting that nurses, in certain contexts, are actively engaged in rationing care – in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care – despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource. (shrink)

As the pressure on available health care resources grows, an increasing moral challenge in intensive care is to secure a fair distribution of nursing care and medical treatment. The aim of this article is to explore how limited resources influence nursing care and medical treatment in intensive care, and to explore whether intensive care unit clinicians use national prioritization criteria in clinical deliberations. The study used a qualitative approach including participant observation and in-depth interviews with intensive care unit physicians and (...) nurses working at the bedside. Scarcity of resources regularly led to suboptimal professional standards of medical treatment and nursing care. The clinicians experienced a rising dilemma in that very ill patients with a low likelihood of survival were given advanced and expensive treatment. The clinicians rarely referred to national priority criteria as a rationale for bedside priorities. Because prioritization was carried out implicitly, and most likely partly without the clinician's conscious awareness, central patient rights such as justice and equality could be at risk. (shrink)

Background: Theoretically, the principle of justice is strong in healthcare priorities both nationally and internationally. Research, however, has indicated that questions can be raised as to how this principle is dealt with in clinical intensive care. Objective: The objective of this article is to examine how significant others may affect the principle of justice in the medical treatment and nursing care of intensive care patients. Method: Field observations and in-depth interviews with physicians and nurses in intensive care units (ICU). Emphasis (...) was placed on eliciting the underlying rationale for prioritisations in clinical intensive care with particular focus on clinicians’ considerations when limiting ICU treatment. Results: Significant others could induce an unintentional discrimination of ICU patients. Family members who were demanding received more time and attention for both the patient and themselves. Patients’ and families’ status and position and/or an interesting medical diagnosis seemed to govern the clinicians’ priorities of patients and families—consciously as well as unconsciously. The clinicians emphasised that patient information given through families was important. However, patients’ preferences and values conveyed to clinicians through their families were not always taken seriously. This even applied in cases with very serious prognoses and an explicit patient wish to forego life-prolonging treatment. Conclusion: The principle of justice was violated when qualified attention was given to significant others, and through this also to patients. Attention given to significant others was influenced by the healthcare workers’ professional and personal values, attitudes and interests. (shrink)

Aim: This study explores priority dilemmas in dialysis treatment and care offered elderly patients within the Norwegian public healthcare system.Background: Inadequate healthcare due to advanced age is frequently reported in Norway. The Norwegian guidelines for healthcare priorities state that age alone is not a relevant criterion. However, chronological age, if it affects the risk or effect of medical treatment, can be a legitimate criterion.Method: A qualitative approach is used. Data were collected through semistructured interviews and analysed through hermeneutical content analysis. (...) The informants were five physicians and four nurses from dialysis wards.Findings: Pressing priority dilemmas centre around decision-making concerning withholding and withdrawal of dialysis treatment. Advanced age is rarely an absolute or sole priority criterion. It seems, however, that advanced age appears to be a more subtle criterion in relation with, for example, comorbidity, functional status and cognitive impairment. Nurses primarily prioritise specialised dialysis care and not comprehensive nursing care. The complex needs of elderly patients are therefore often not always met.Conclusions: Clinical priorities should be made more transparent in order to secure legitimate and fair resource allocation in dialysis treatment and care. Difficult decisions concerning withholding or withdrawal of dialysis ought to be openly discussed within the healthcare team as well as with patients and significant others. The biomedical focus and limitations on comprehensive care during dialysis should be debated. (shrink)

Among the thousands who arrive in Europe to seek asylum each year, a significant number are children traveling on their own. Like adults, they are fleeing from war and armed conflict situations, persecution, severe poverty, and deprivation. Some arrive because they have been trafficked and some are fleeing for reasons specifically related to their status as children. They need special attention, not only in terms of specialized care and assistance, but also in terms of the refugee status determination procedure. When (...) they arrive in a country of asylum they risk further violations of their rights. This paper intends to outline the rignts of these children under international law; to highlight key protection concerns facing them, particularly in the European context; to summarize ways of how a UN/ngo program has attempted to address these problems; and to make some specific recommendations. (shrink)