Several ethical dilemmas and ethical challenges confronted the HDMs
associated with elder care. No differences could be seen between the
politicians and the civil servants or between the municipality and
county council levels, with the method used, regarding the phenomenon
of ethical dilemma or the meaning of their experiences of being in
ethically difficult situations.
Ethical dilemmas
The themes and sub-themes developed are presented in Table 1. Quotations that illuminate the themes and sub-themes are included in the text.
Lack of good care
Vulnerable patients in inappropriate care settings
The
HDMs reflected on how the governments good intentions which are aimed
at helping older adults remain in their private residences as long as
possible have led to a lack of care and ethical dilemmas. They felt
many of the older adults being cared for at home have illnesses that
require extensive and at times advanced care that can be difficult to
provide for there. According to them, ethical dilemmas have been
accentuated with last decade's economic reductions and the decreased
number of beds in sheltered housing facilities. An ethical dilemma that
was mentioned was the lack of available residences causing patients
with dementia to be placed in inappropriate settings. "It is difficult
when persons with dementia disease live in mixed care settings with
others that don't have it. It is difficult for everyone, but especially
for those with dementia since they are so vulnerable".
Poor care and disrespectful interactions
The HDMs
told of the ethical dilemmas associated with the strained conditions in
elder care. They said that caregivers working in the homes worked in a
hurried task oriented manner that did not address the individual
patient's needs. According to them, the caregivers have been reported
as being in such a hurry that they put meals in the refrigirator
without noticing there were several still in there uneaten. Receiving
information from mass media or upset relatives of insufficinet care due
to poor and sometimes disrespectful interactions on the part of the
caregivers, was also highlighted. This was distrubing since the HDMs
expected health care professionals to know how to interact with
patients.
Weaknesses in medical support
Ethical dilemmas
related to the lack of good medical care was said to occur when the ill
patients were poorly assessed or received poor medical service due to a
continuous shortage of physicians. They spoke of the physician shortage
in elder care causing unnecessary referrals of older adult patients to
the hospitals and felt that daily caregivers often lacked the
competence to make referral decisions. The Elder-reform of 1992 with
its strong emphasis on the social aspects resulted in a weakening of
the medical priorities in elder care, according to the HDMs.
Lack of agreement concerning care
Abandoned ideals vs. budget realities
The
HDMs told of the ethical dilemmas related to the demands of maintaining
a balanced budget with the ever-increasing needs in elder care.
Short-term budget solutions, downsizing of sheltered housing facilities
and relatives having to assume more responsibility, were named in
association with such dilemmas. The HDMs experienced ethical dilemmas
when they felt forced to abandon their vision of ideal elder care to
budget realities.
Dissimilar focuses between the caring systems
The
HDMs spoke of the ethical dilemmas associated with a care system they
felt did not always meet the patients' needs. "We have built up a
system that seems to mostly benefit the system itself, the employees or
possibly those in power". They also said that the dissimilar focuses
regarding elder care between the county council and municipal health
care systems contributed to ethical dilemmas. "The needs of the whole
person are not looked after, it's about all the levels of elder care
focusing on the older adults' possibilities and strengthening them. If
we all had the same focus we could get over a few of the hurdles. The
established structure can contribute to ethical problems". They thought
that a change would not occur until a new generation assumed its place
in the profession, in politics, and in the administration.
Justness in the distribution of care and deficient information
Ethical
dilemmas associated with the problems within the system that made it
difficult to distribute resources in a just manner were described. The
HDMs told of the old and chronically ill that should have priority, but
as there are others i.e. the younger and less ill that also need access
to health care, there were often conflicts and strong voices involved.
HDMs found it difficult with incomplete information and a poor
reporting system that did not give them a clear description of
individual or organisational needs. They spoke of the ethical dilemmas
encountered with a system that allows for insufficient input and
inexplicit guidelines.
The meaning of being in ethically difficult situations
The themes and sub-themes developed are presented in Table 2. Quotations that illuminate the themes and sub-themes are included in the text.
To be in a high position
Aloneness and Loneliness
HDMs
in their high positions with heavy responsibility experienced emotional
distress especially in situations associated with budget cuts. "I have
assumed the responsibility; that is part of the job. I get paid for it,
but it still feels heavy. I often lay sleepless, I get frustrated, I
feel alone, and we don't talk with each other that much about our
frustrations. But this is a job that has to be done, if not by myself
by someone else." They felt that aloneness is something that goes with
the job. A lack of support could intensify their feeling of loneliness
since they could not depend on anyone else when things got tough. "It's
lonely at the top but that's how it is with the ultimate
responsibility."
Uncertainty
The HDMs stated that it was ethically
challenging when they had to make decisions they were not certain of or
when the consequences for the older patients were unforeseeable and
unclear. Living with uncertainty was something they felt they could not
escape from. "If I'm unable, then I have to resign". Receiving reports
of insufficient patient care was also challenging since the HDMs felt
uncertain they could actually trust the system.
Lack of confirmation
HDMs felt ethically challenged
when there was a lack of confirmation and that their health pays a high
price for it. They found it difficult when they often heard that things
were not working out well and seldom received any positive feedback.
The HDMs told of how they could get some confirmation at home but there
were limits to that.
Scapegoat
In their top positions where difficult
decisions had to be made, the HDMs said they felt vulnerable and were
easily targeted as a scapegoat. They told how many persons quit or got
fired. Preserving a good relationship with the media was mentioned as
being important but they found it difficult when they were hunted down
by the mass media.
To be in an exposed position
Bombarded
The
HDMs often felt exposed and bombarded by many different factions and
found dealing with them all to be ethically challenging. They felt
pressure from all sides, from the public, from the different health
care professionals and the rules and regulations that have to be
followed. The personal demands they place on themselves also bombarded
them at times, they said. The HDMs felt that these ethical challenges
could be met by finding positive aspects in their work. "The job gives
me satisfaction and a person feels important. The driving force is that
you want to improve health care".
Threats
The HDMs spoke of threats made by the
public, which became most acute when they had made decisions that
called for the closing of healthcare facilities. "Threats, in fact it's
unpleasant being in this position, just standing there and taking it".
To be strategic
Avoiding difficult decisions
"It
won't be long before the national politicians will be forced to take a
stand on where the lines for elder care are to be drawn. A dialogue has
been going on for a while with the professionals in which they have
asked us to tell them what they should and should not do, but we
haven't done that yet. This is a difficult area to address and it's
only human to take up the most difficult issues last". According to the
HDMs, the national allocation of resources between the different groups
in the health care system has not been discussed in an open public
debate. They said it was important to understand the processes involved
when working in a socialised health care system.
Handling different opinions
The HDMs stated that
they constantly had to deal with different opinions. Opinions could
come from the different public interest groups or from different
administrative entities within the health care system.
To live with divided feelings
Loyalty vs. own conviction
Making
decisions that would have negative consequences for elder care were
mentioned as being ethically challenging since it left them with
divided feelings. The HDMs felt they had failed in their mission to
provide good health care when their loyalty to their job forced them to
make reductions. They also said that their position steers their
actions since that is what is expected of them and that they are a part
of a system with many actors involved.
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