Discussions and Conclusion
- Ethical challenges related to elder care. High level decision-makers' experiences

The HDMs in this study, revealed both ethical dilemmas and their experiences of being in ethically difficult situations related to elder care. They were directly or indirectly involved with the dilemmas. The ethical dilemmas revealed were associated with a lack of good elder care and a lack of agreement concerning care. These issues addressed for example vulnerable patients in inappropriate care settings, weaknesses in medical support, dissimilar focuses between the caring systems as well as justness in the distribution of care and deficient information. The HDMs' experiences of being in ethically difficult situations were associated with their exposed situations, feelings of having to be strategic and having to live with divided feelings. These issues addressed aspects such as aloneness and loneliness, uncertainty, lack of confirmation, risk of being threatened or of becoming a scapegoat. Avoidance of difficult decisions and loyalty vs. own conviction was also highlighted.

Lack of good care such as inappropriate care settings for patients with dementia disease were seen as ethically problematic. Chronically ill individuals are to be met with dignity and should have priority in the health care system [20,21]. Future conflicts related to the extensive care needs of a growing older population together with decreased resources are well known [22]. Ensuring good residences for the most vulnerable patients will inevitably be one of the dilemmas on the HDMs agenda.

Weaknesses in medical support due to a continuous shortage of physicians in elder care were expressed as ethically troublesome. Unnecessary transfers of older adults to the hospital were mentioned as a result of this situation. High transfer rates among older adults living in sheltered housing facilities to the emergency departments have been reported, but more analysis was recommended [23]. The shortage of physicians in elder care and current recruiting difficulties can originate from several causes but are still problems the HDMs are obligated to resolve. Physicians have ranked caring for older patients last in the area of prestige [24]. This ranking indicates the degree of esteem the physicians, health care services and society in general seem to have towards older adults [12].

Dissimilar focuses and lack of structure and agreement between the municipalities' and the county councils' organisations responsible for elder care in Sweden were reported in our study as being a cause of ethical dilemmas. This is comparable to what Thompsen [25] called "the problem of many hands", which means that when many officials contribute to decisions and policies of government it is difficult to identify who is morally responsible for the political outcomes. A society can be referred to as being unethical if it has vague policies. An example mentioned is a health care system that lacks structure and policy [26]. In our study it was empathized that lack of structure is a factor contributing to ethical difficulties. It is reasonable to assume that the HDMs are to a large extent responsible for handling the problems related to the organisational structure deficiencies especially since a system can interfere with the understanding of what is right and fair and can thereby be a source of ethical dilemmas or can prevent them [26]. In a system lacking policy and structure, it can be difficult to act ethically even if people have the intention to do so [26].

Lack of agreement concerning care was related by the HDMs as the incongruence between health care needs and the budget. This situation has caused relatives to assume a greater amount of responsibility, which is something they question to some extent the appropriateness of. Relatives are already assuming much responsibility in elder care and many of those doing so are the spouses [27]. Additionally, the reduction of sheltered housing facilities in several municipalities has been rapid and there are few studies that investigate the consequences of these changes [28].

Dealing with the justness in the distribution of care between different groups was referred to in our study as a source of ethical dilemmas. This justness was associated with the difficulties of prioritising and fairly providing for the care needs of the different groups while still remaining within the budget. When preconditions associated with priority setting among decision-makers, physicians, private citizens and patients were studied [29], it was shown that private citizens and patients in general had high expectations regarding what should be offered by the public health care system. These expectations did not correspond with the decision-makers' and physicians' view [29]. In a study, by Hammarström [30] involving politicians, civil servants and health care professionals it was found that the medical ethical principals established by Swedish health care legislation were not much reflected in the decision making process when priorities or budget cuts were being decided upon. Instead of seeing these actors as being insensitive, these results were interpreted as being due to the vague ethical guidelines and the difficult nature of the issues being faced [30]. The justness in the distribution of care mentioned in our study was associated with the fact that the voices of some groups are stronger than others.

Deficient information due to the poor reporting systems were experienced by the HDMs as problematic as it could lead them to make incorrect decisions. One of the purposes of the "Swedish National Study on Aging and Care" [31] was to develop useful descriptions of the older patients needs in the health care system. A study by Mamhidir et al. [32] was conducted in which one of the previously developed systems was applied. Reporting systems can help reduce the problems that lead to ethical difficulties or as mentioned by HDMs, increase them. When referring to the idea of Heidegger, Sartre and Buber regarding the authentic existence, Nerheim [33] wrote about the blindness related to our own inauthentic understanding that focuses on the theories and the moral systems. It is necessary to set our inauthentic understanding within parentheses since theories and moral principles can be misleading. The inauthentic understanding will tell us what the "fact" is, and that might be risky, as it does not include our "life" and could therefore become a hindrance to what can be sensed and understood. In our study it was noticed that the HDMs seemed to externalize the poor reporting systems and refer to them as something out of their control. Sorlie et al. [18,8] have reported on externalization of ethical dilemmas among enrolled nurses and registered nurses working in acute care settings. The enrolled nurses in contrast placed the responsibility for their failure to achieve a good caring standard on the authorities, administrators and health care system and cited in particular a lack of resources [18]. Registered nurses tended to externalise less and seemed to focus more on the responsibility at hand instead of faulting someone else for the shortcomings [8]. With these results in mind, a necessary dialogue between the different levels might reduce the "finger pointing" and improve the elder care system. External placing of responsibility is known to protect against experiences of stress, which could be caused by qualms of conscience [18].

The HDMs' experiences of being in ethically difficult situations were associated with aspects such as their high and exposed position. They felt that the higher up in the hierarchy they were, the more alone they became, especially when situations got difficult. They also expressed feelings of uncertainty. Loneliness and uncertainty are fundamental conditions of life [34], and as such are therefore unavoidable, and it is these states of existence that make a person vulnerable. Henriksen & Vetlesen [35] empathize that when a person assumes heavy responsibility the unpleasant feelings associated with it can be their conscience striving to influence their ethical integrity. The HDMs in our study realized that these feelings were something they had to learn to live with or quit their jobs since they are required to make final decisions and stand by them. They saw their salary as somewhat of a compensation for the unpleasantness. Professionals in the different health care fields of surgery [14] paediatrics [36] and geriatrics [19] are reported to have accepted the inevitability of uncertainty.

It is obvious that the HDMs were experiencing a lack of confirmation, which is in contrast to what some others working in the health care system have experienced [14,37]. Lack of confirmation can negatively affect a person's identity. Social confirmation and recognition from others is needed for the construction of ones identity [38]. Our self image is formed by social confirmation and the lack of it could lead to a breakdown of ones self image and contribute to mistrust [34], which can negatively affect how well we act with others. The risk of becoming scapegoats or being threatened was mentioned in our study as contributing to emotional strain. The occurrences of threats and violence against elected officials have been reported to be 16% at the municipal level and 20% at the county council level [39]. Included in these threats considered to be serious not only against the individual but against the democracy as well were: assault and battery, unlawful threat, slander and insult [39]. Facing these risks expressed the sense of vulnerability.

Living with divided feelings proved ethically challenging when the HDMs' loyalty to their jobs came into conflict with their convictions. Decisions they thought could be detrimental to the older adults gave them a felling of failure. Guilt can be felt if a person does not meet what they feel is required of them in a situation or deny something valuable in their own life [34]. In our study it seems that the HDMs remembered their fallibility in their dealings with other difficult situations. This indicates what Ricoeur [40] calls the memory of ethics, which means that people never can or will forget situations in which they failed to do right or something good. The HDMs felt a loyalty to their job because of the responsibility they had assumed, even when uncomfortable decisions had to be made. This is in line with the reasoning that Lundqvist [41] presented where in some situations an ethical demand confronting an administration can be made less important if a legitimate authority had given directives concerning it. Individuals that are attended to in a system can feel a strong commitment to it and the authority represented in it causes a willingness to obey [42]. However, it is important to not blindly obey others but base actions on ones own ethical judgements [35]. Possible motives behind the HDMs loyalty to their positions could be the desire to bring about good elder care or to benefit their own self-interests.

In our study, different ethical dilemmas and the meaning of being in ethically difficult situations related to elder care have been revealed by the HDMs. This confirms the idea of Lindseth [9] that both an action and relational ethics perspective persists simultaneously and are closely related. This is so even though the HDMs are not directly involved with the patients or the professionals. As leaders it disturbs them when they receive reports or hear of not only bad incidents occurring in elder care but also of bad relationships. When this occurs these issues are up close and personal, they are touched by them, their feelings are moved and they become directly involved. They also expressed feeling uncertain as to whether their decisions would lead to good care. It is therefore understandable that the HDMs deal with questions that reflect both perspectives such as "What should I do" as well as "How do I fulfil my role [9]. This ethical theory [9] is useful for illustrating the complexity of the ethical challenges and that ethics concerns everyone, caregivers as well as HDMs.

Health administrators and politicians have been viewed as having little understanding for the demands expressed by staff in acute care [18] and have been reported as probably cold and cynical [12]. In our study, it is reasonable to believe that the HDMs' experiences of being ethically challenged concerns their feelings that important issues and needs are at stake in elder care as well as for themselves.

The crux of the ethical challenges seems to be related to the HDMs having a covenant with older patients and society to provide good care and that this care is governed by the limited budgets of the different health care organisations. Bakken et al. [43] stressed that the rhetoric regarding the welfare state at the national level, including the health care sector can be experienced as being almost unlimited. The welfare state ambitions are executed at the local political level and the disparity between the ambitions and available recourses systematically creates ethical dilemmas [43]. The HDMs, in our study requested a public debate addressing what can be expected from and offered by the national public health care systems. This underlines their uncertainty about how to deal with troublesome situations including reports of problems in elder care. A wish for some support for making decisions or maybe some relief by sharing these difficult issues with others might be sought. It might also reflect what Thompson [25] calls restoring responsibility in health care. The fundamental key issue of trust between individuals must be transferable into the character of the health care system or organisations. Studies have addressed the concept called "organisational ethics" in which, for example, the issues related to ethical conflicts at different levels and by different professionals in the organisation are revealed. The management is required to make sure that the necessary prerequisites are provided to ensure that the structures and processes enable dialogues concerning ethical issues and behaviours within a health care organisation [44-46].

Our paper provides further insight into the ethical dilemmas and ethical challenges met at the HDM level, which is important since their decisions affect many stakeholders in elder care. According to our results it seems that ethical discussions do not have a high priority on the HDMs agenda. The distance between the patients, professionals and HDMs may affect that situation. Our results can be used to stimulate discussions between HDMs and health care professionals concerning ways of dealing with ethical issues and the necessity of structures that facilitate dealing with them. Ethical reflections will probably have an impact on the trust in the caring system. Future research is suggested that studies how situations affect people when loyalties to a position come into conflict with personal convictions. Since ethical dilemmas that confront all levels of health care organisation will persist, the concept of organisational ethics also needs further research. Our paper provides further insight into the ethical dilemmas and ethical challenges met by high level decision-makers', which is important since the overall responsibility for elder care that is also ethically defensible rests with them. They have power and their decisions affect many stakeholders in elder care. Our results can lead to stimulating discussions between high level decision-makers and health care professionals concerning ways of dealing with ethical issues and the necessity of structures that facilitate it. Even if the high level decision-makers have learned to live with the ethical challenges that confronted them, it was obvious that they were not free from feelings of uncertainty, frustration and loneliness. Vulnerability was revealed regarding themselves and others. Their feelings of failure indicated that they felt something was at stake for the older adults in elder care and for themselves as well, in that there was the risk that important needs would go unmet.

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