Access to, use of, and experiences with social alarms in home-living people with dementia: results from the LIVE@Home.Path trial.

Background: Social alarms are considered an appropriate technology to ensure the safety and independence of older adults, but limited research has been conducted on their actual use. We, therefore, explored the access, experiences, and use of social alarms among home-bound people with dementia and their informal caregivers (dyads). Methods: From May 2019 to October 2021, the LIVE@Home.Path mixed-method intervention trial collected data from semi-quantitative questionnaires and qualitative interviews conducted among home-dwelling people with dementia and their informal caregivers in Norway. The study focused on data from the final assessment at 24 months. Results: A total of 278 dyads were included, and 82 participants reached the final assessment. The mean age of the patients was 83 years; 74.6% were female; 50% lived alone; and 58% had their child as a caregiver. A total of 62.2% of subjects had access to a social alarm. Caregivers were more likely to answer that the device was not in use (23.6%) compared to patients (14%). Qualitative data revealed that approximately 50% of the patients were not aware of having such an alarm. Regression analyses assessed that access to a social alarm was associated with increasing age (86-97 years, p = 0.005) and living alone (p < 0.001). Compared to their caregivers, people with dementia were more likely to answer that the device gave them a false sense of security (28% vs. 9.9%), while caregivers were more likely to answer that the social alarm was of no value (31.4% vs.14.0%). The number of social alarms installed increased from 39.5% at baseline to 68% at 24 months. The frequency of unused social alarms increased from 12 months (17.7%) to 24 months (23.5%), and patients were less likely to feel safe during this period (60.8% vs. 70%). Conclusion: Depending on their living situation, patients and family members experienced the installed social alarm differently. There is a gap between access to and the use of social alarms. The results indicate an urgent need for better routines in municipalities with regard to the provision and follow-up of existing social alarms. To meet the users' changing needs and abilities, passive monitoring may help them adapt to declining cognitive abilities and increase their safety.Clinical Trial Registration: https://ClinicalTrials.gov, NCT04043364.

The Effect of Music-Based Intervention on General Cognitive and Executive Functions, and Episodic Memory in People with Mild Cognitive Impairment and Dementia: A Systematic Review and Meta-Analysis of Recent Randomized Controlled Trials.

BACKGROUND: Music-based intervention has been used as first-line non-pharmacological treatment to improve cognitive function for people with mild cognitive impairment (MCI) or dementia in clinical practice. However, evidence regarding the effect of music-based intervention on general cognitive function as well as subdomains of cognitive functions in these individuals is scarce. OBJECTIVE: To evaluate the efficacy of music-based interventions on a wide range of cognitive functions in people with MCI or dementia. METHOD: We searched the effect of various music therapies using randomized controlled trials on cognitive function using several databases. Studies based on any type of dementia or MCI were combined. The effects of music-based intervention on each cognitive function were pooled by meta-analysis. RESULTS: A total of 19 studies involving n = 1024 participants (mean age ranged from 60 to 87 years old) were included. We found statistically significant improvements in MMSE (general cognitive function), the Frontal Assessment Battery (executive function), and the Auditory Verbal Learning Test (episodic memory). CONCLUSIONS: This study provides positive evidence to support music-based interventions for improving a wide range of cognitive functions in older adults with MCI and dementia. Therefore, we recommend increased use of music in people's homes, day care centers and nursing homes. This study was registered with PROSPERO, number 250383.

Factors associated with access to assistive technology and telecare in home-dwelling people with dementia: baseline data from the LIVE@Home.Path trial.

BACKGROUND: There is a knowledge gap regarding factors that may influence the access to different devices for home-dwelling people with dementia (PwD). The aim of this study was to identify different assistive technology and telecare (ATT) devices installed in the home and key factors associated with access to such technology. METHODS: The baseline data came from the LIVE@Home.Path trial, a 24-month multi-component intervention including PwDs and their informal caregivers (dyads) and were collected through semi-quantitative questionnaires in three Norwegian municipalities between May and November of 2019. Regression models were applied to detect demographic and clinical factors associated with access to ATT. RESULTS: Of 438 screened dyads, 276 were included at baseline. The mean ages of the PwDs and caregivers were 82 ± 7.0 and 66 ± 12 years, respectively, and 62.8% of the PwD were female and 73.5% had access to any type of ATT. The majority had traditional equipment such as stove guards (43.3%) and social alarms (39.5%) or everyday technology, e.g. calendar support and door locks (45.3%). Multivariate regression analyses revealed that access to a social alarm was more often available for females than males, at increased age, and when the PwD lived alone, while tracking devices (14.9%) were more often accessible at lower age. Everyday technology was more often available for females, at increased age of the PwD and the caregiver, higher comorbidity, and poor IADL (instrumental activities of daily living) function. For PwDs with severe dementia, access to ATT was significantly associated with poor IADL function, having their children as the main caregiver (61.3%), and having caregivers who contributed 81-100% to their care (49.5%). CONCLUSIONS: Home-dwelling PwDs mainly had access to traditional and obligated devices, followed by everyday technology. There is unmet potential for communication, tracking, and sensing technology, especially for devices not offered by the municipalities. Gender, ages of the PwD and caregiver, cohabitation status, and physical function were the main associated factors for access to ATT. TRIAL REGISTRATION: ClinicalTrials.gov NCT04043364.

Scoping Review: Intergenerational Resource Transfer and Possible Enabling Factors.

We explore the intergenerational pattern of resource transfer and possible associated factors. A scoping review was conducted of quantitative, peer-reviewed, English-language studies related to intergenerational transfer or interaction. We searched AgeLine, PsycINFO, Social Work Abstracts, and Sociological Abstracts for articles published between Jane 2008 and December 2018. Seventy-five studies from 25 countries met the inclusion criteria. The scoping review categorised resource transfers into three types: financial, instrumental, and emotional support. Using an intergenerational solidarity framework, factors associated with intergenerational transfer were placed in four categories: (1) demographic factors (e.g., age, gender, marital status, education, and ethno-cultural background); (2) needs and opportunities factors, including health, financial resources, and employment status; (3) family structures, namely, family composition, family relationship, and earlier family events; and (4) cultural-contextual structures, including state policies and social norms. Those factors were connected to the direction of resource transfer between generations. Downward transfers from senior to junior generations occur more frequently than upward transfers in many developed countries. Women dominate instrumental transfers, perhaps influenced by traditional gender roles. Overall, the pattern of resource transfer between generations is shown, and the impact of social norms and social policy on intergenerational transfers is highlighted. Policymakers should recognise the complicated interplay of each factor with different cultural contexts. The findings could inform policies that strengthen intergenerational solidarity and support.

LIVE@Home.Path-innovating the clinical pathway for home-dwelling people with dementia and their caregivers: study protocol for a mixed-method, stepped-wedge, randomized controlled trial.

BACKGROUND: The global health challenge of dementia is exceptional in size, cost and impact. It is the only top ten cause of death that cannot be prevented, cured or substantially slowed, leaving disease management, caregiver support and service innovation as the main targets for reduction of disease burden. Institutionalization of persons with dementia is common in western countries, despite patients preferring to live longer at home, supported by caregivers. Such complex health challenges warrant multicomponent interventions thoroughly implemented in daily clinical practice. This article describes the rationale, development, feasibility testing and implementation process of the LIVE@Home.Path trial. METHODS: The LIVE@Home.Path trial is a 2-year, multicenter, mixed-method, stepped-wedge randomized controlled trial, aiming to include 315 dyads of home-dwelling people with dementia and their caregivers, recruited from 3 municipalities in Norway. The stepped-wedge randomization implies that all dyads receive the intervention, but the timing is determined by randomization. The control group constitutes the dyads waiting for the intervention. The multicomponent intervention was developed in collaboration with user-representatives, researchers and stakeholders to meet the requirements from the national Dementia Plan 2020. During the 6-month intervention period, the participants will be allocated to a municipal coordinator, the core feature of the intervention, responsible for regular contact with the dyads to facilitate L: Learning, I: Innovation, V: Volunteering and E: Empowerment (LIVE). The primary outcome is resource utilization. This is measured by the Resource Utilization in Dementia (RUD) instrument and the Relative Stress Scale (RSS), reflecting that resource utilization is more than the actual time required for caring but also how burdensome the task is experienced by the caregiver. DISCUSSION: We expect the implementation of LIVE to lead to a pathway for dementia treatment and care which is cost-effective, compared to treatment as usual, and will support high-quality independent living, at home. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04043364. Registered on 15 March 2019.

The safety attitudes questionnaire - ambulatory version: psychometric properties of the Norwegian version for nursing homes.

BACKGROUND: Patient safety culture involves leader and staff interaction, routines, attitudes, practices and awareness that influence risks of adverse events in patient care. The Safety Attitudes Questionnaire (SAQ) is an instrument to measure safety attitudes among health care providers. The instrument aims to identify possible weaknesses in clinical settings and motivate quality improvement interventions leading to reductions in medical errors. The Ambulatory Version of the SAQ (SAQ-A) was developed to measure safety climate in the primary care setting. The original version of the SAQ includes six major patient safety factors: Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, Working conditions, and Stress recognition. Patients in nursing homes are particularly vulnerable to adverse events. We present the psychometric properties of the Norwegian translation of the SAQ-A for the nursing home setting. METHODS: The study was conducted in five nursing homes in Tønsberg, Norway, in February 2016. A total of 463 employees working more than 20% received a paper version of the translated SAQ-A adapted to the Norwegian nursing home setting and responded anonymously. Filled-in questionnaires were scanned and transferred to an SPSS file. SPSS was used to estimate Cronbach alphas, corrected item-total correlations, item-to-own and item-to-other correlations, and item-descriptive statistics. The confirmatory factor analysis was done by AMOS. RESULTS: Of the 463 health care providers, 288 (62.2%) responded to the questionnaire. The confirmatory factor analysis showed that the total model of the six factors Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, Working conditions, and Stress recognition had acceptable goodness-of-fit values in the nursing home setting. CONCLUSIONS: The results of our study indicate that the Norwegian translated version of the SAQ-A, with the confirmed six factor model, is an appropriate tool for measuring patient safety climate in the nursing home setting. Future research should study whether there is an association between patient safety climate in nursing homes and occurrence of adverse events among the patients.

Analgesic treatments in people with dementia - how safe are they? A systematic review.

INTRODUCTION: People with dementia may be unable to verbally express pain and suffer from untreated pain. Use of analgesics in people with dementia has increased during the last decade, in particular opioid analgesics with high potential for adverse effects. AREAS COVERED: This article presents a systematic review of the current evidence for safety and tolerability of analgesic drugs from randomized controlled trials in people with dementia. Relevant trials were identified by a literature search in the EMBASE, MEDLINE, and Cochrane databases from inception to November 2018. The search included the main terms 'dementia' and 'analgesic' or their subterms, and was filtered to limit results to clinical trials. EXPERT OPINION: Although pain treatment is increasingly recognized as an important clinical issue in people with advanced dementia, there is currently a lack of evidence to support safety evaluations of commonly used analgesics in this group. To inform treatment decisions and enable care providers to appropriately monitor patients at risk of adverse effects, it is necessary to conduct well-designed clinical trials to investigate the relative efficacy and safety of analgesics in people with dementia, with particular emphasis on harmful effects of long-term opioid use as well as short-term use of nonsteroidal anti-inflammatory drugs.

Comparing unplanned and potentially planned home deaths: a population-based cross-sectional study.

BACKGROUND: There is little research on number of planned home deaths. We need information about factors associated with home deaths, but also differences between planned and unplanned home deaths to improve end-of-life-care at home and make home deaths a feasible alternative. Our aim was to investigate factors associated with home deaths, estimate number of potentially planned home deaths, and differences in individual characteristics between people with and without a potentially planned home death. METHODS: A cross-sectional study of all decedents in Norway in 2012 and 2013, using data from the Norwegian Cause of Death Registry and National registry for statistics on municipal health and care services. We defined planned home death by an indirect algorithm-based method using domiciliary care and diagnosis. We used logistic regressions models to evaluate factors associated with home death compared with nursing home and hospital; and to compare unplanned home deaths and potentially planned home deaths. RESULTS: Among 80,908 deaths, 12,156 (15.0%) were home deaths. A home death was most frequent in 'Circulatory diseases' and 'Cancer', and associated with male sex, younger age, receiving domiciliary care and living alone. Only 2.3% of home deaths were from 'Dementia'. In total, 41.9% of home deaths and 6.3% of all deaths were potentially planned home deaths. Potentially planned home deaths were associated with higher age, but declined in ages above 80 years for people who had municipal care. Living together with someone was associated with more potentially planned home deaths for people with municipal care. CONCLUSION: There are few home deaths in Norway. Our estimations indicate that even fewer people than anticipated have a potentially planned home death.

Patient safety culture in Norwegian nursing homes.

BACKGROUND: Patient safety culture concerns leader and staff interaction, attitudes, routines, awareness and practices that impinge on the risk of patient-adverse events. Due to their complex multiple diseases, nursing home patients are at particularly high risk of adverse events. Studies have found an association between patient safety culture and the risk of adverse events. This study aimed to investigate safety attitudes among healthcare providers in Norwegian nursing homes, using the Safety Attitudes Questionnaire - Ambulatory Version (SAQ-AV). We studied whether variations in safety attitudes were related to professional background, age, work experience and mother tongue. METHODS: In February 2016, 463 healthcare providers working in five nursing homes in Tønsberg, Norway, were invited to answer the SAQ-AV, translated and adapted to the Norwegian nursing home setting. Previous validation of the Norwegian SAQ-AV for nursing homes identified five patient safety factors: teamwork climate, safety climate, job satisfaction, working conditions and stress recognition. SPSS v.22 was used for statistical analysis, which included estimations of mean values, standard deviations and multiple linear regressions. P-values <0.05 were considered to be significant. RESULTS: Out of the 463 employees invited, 288 (62.2%) answered the questionnaire. Response rates varied between 56.9% and 72.2% across the five nursing homes. In multiple linear regression analysis, we found that increasing age and job position among the healthcare providers were associated with significantly increased mean scores for the patient safety factors teamwork climate, safety climate, job satisfaction and working conditions. Not being a Norwegian native speaker was associated with a significantly higher mean score for job satisfaction and a significantly lower mean score for stress recognition. Neither professional background nor work experience were significantly associated with mean scores for any patient safety factor. CONCLUSIONS: Patient safety factor scores in nursing homes were poorer than previously found in Norwegian general practices, but similar to findings in out-of-hours primary care clinics. Patient safety culture assessment may help nursing home leaders to initiate targeted quality improvement interventions. Further research should investigate associations between patient safety culture and the occurrence of adverse events in nursing homes.

Staff Distress Improves by Treating Pain in Nursing Home Patients With Dementia: Results From a Cluster-Randomized Controlled Trial.

CONTEXT: Most people with dementia develop neuropsychiatric symptoms (NPSs), which are distressing for their carers. Untreated pain may increase the prevalence and severity of NPSs and thereby staff burden. OBJECTIVES: We investigated the association between NPSs and the impact of individual pain treatment on distress in nursing home staff. METHODS: Nursing home (NH) units were cluster-randomized to an intervention group (33 NH units; n = 175) or control group (27 NH units; n = 177). Patients in the intervention group received individual pain treatment for eight weeks, followed by a four-week washout period; control groups received care as usual. Staff informants (n = 138) used the Neuropsychiatric Inventory-NH version (including caregiver distress) as primary outcome to assess their own distress. Other outcomes were pain (Mobilization-Observation-Behavior-Intensity-Dementia-2 Pain Scale) and cognitive functioning (Mini-Mental State Examination). RESULTS: Using hierarchical regression analysis, all NPS items at baseline were associated with staff distress (P < 0.01) apart from euphoria; agitation had the largest contribution (ß = 0.24). Using mixed models, we found significantly lower staff distress in the intervention group compared to the control group. Moreover, we also found significantly reduced distress in the control group, and there were still effects in both groups throughout the washout period. CONCLUSION: Individual pain treatment reduced staff distress in the intervention group compared to control group especially in regard to agitation-related symptoms and apathy. Furthermore, our results indicated a multifactorial model of staff distress, in which enhanced knowledge and understanding of NPSs and pain in people with advanced dementia may play an important role.

Analgesic prescribing patterns in Norwegian nursing homes from 2000 to 2011: trend analyses of four data samples.

BACKGROUND: the analgesic drug use has been reported to increase in general in nursing home patients. However, there is insufficient evidence in terms of what agents are used, variations of use over time and to whom these drugs are prescribed. OBJECTIVE: we investigated the prescribing patterns of scheduled analgesic drugs in Norwegian nursing home patients from 2000 to 2011, with the association to age, gender, cognitive function and type of nursing home unit. DESIGN: secondary analyses of four study samples (three observational studies and one randomised controlled trial). SETTING AND SUBJECTS: nursing home patients included in study samples from 2000 (n = 1,926), 2004 (n = 1,163), 2009 (n = 850) and 2011 (n = 1,858) located in 14 Norwegian counties. METHODS: trend analyses of analgesic drug prescriptions. Percentages were described using t-test, χ(2) and Mann-Whitney U test and multivariate logistic regression. RESULTS: the odds ratio for receiving any pain medication in 2011 compared with 2000 was 2.6 (95% CI 2.23-2.91), this is corresponding to a 65% increase from 34.9 to 57.6%. The paracetamol prescription increased by 113%, from 22.7% in 2000 to 48.4% in 2011. Strong opioids (fentanyl, buprenorphine, morphine, oxycodone) increased from 1.9% in 2000 to 17.9% in 2011 (P < 0.001), whereas non-steroidal anti-inflammatory drug prescription decreased, from 6.8 to 3.2%. In 2000, 2004 and 2009, people with dementia received fewer analgesics compared with patients without dementia; no differences in analgesic drug use between the groups were found in 2011. CONCLUSIONS: the analgesic drug prescription increased significantly from 2000 to 2011, especially the use of paracetamol and strong opioids. We also highlight a possible change from under-prescription of analgesic medication in people with dementia, to an equal amount compared with patients without cognitive impairment.

[Pain assessment in dementia]. / Smerteevaluering ved demens.

BACKGROUND: Patients with dementia are often unable to describe their pain because of memory deficiency and speech problems. This may lead to under-diagnosing and suboptimal pain treatment. The article summarises a thesis on development and testing of a new instrument for pain assessment: Mobilisation-Observation-Behavior-Intensity-Dementia (MOBID-2) pain scale. MATERIAL AND METHODS: 284 nursing home patients (with and without pain), who had been diagnosed with dementia of different types in various stages, were included in the study. Behaviour and intensity of pain was assessed during video-uptakes of clinical examinations and during regular morning care. Psychometric property testing included assessments of reliability, validity and clinical usefulness for the nursing home staff. RESULTS: Observation of pain behaviour during standardised and guided movements, by using the MOBID-2 Pain Scale, provides reliable and valid estimation of intensity of pain associated with the musculoskeletal-system. Pain that is not associated with the musculoskeletal-system is frequently observed, but more challenging to assess. Patients who have severe dementia and/or a combination of Alzheimer's disease and vascular dementia, have a higher risk of suffering from severe and untreated pain than patients without dementia. INTERPRETATION: The MOBID-2 pain scale may help to ensure competent pain treatment, and should be available in all Norwegian nursing homes. A multidisciplinary approach is needed for its implementation and use. Physicians in nursing homes should reconsider the staff's observations, perform additional investigations and find the balance between effects and side effects of pain treatment.

[On-call physicians in nursing homes]. / Vakttjeneste for leger på sykehjem.

BACKGROUND: Patients in Norwegian nursing homes are old and multimorbid; they often need emergency treatment and regular medical follow-up is a must. The aim of the study was to investigate reasons for contacting a physician and to find out if unnecessary hospitalization can be reduced. MATERIAL AND METHODS: The study took place at Bergen Red Cross Nursing home, which has 174 patients in long-term wards, dementia wards, a short-term ward and a palliative care ward. Contacts to on-call nursing home physicians were recorded (time, ward, problem and measures taken) and assessed in a prospective study of 4 months duration. RESULTS: 319 calls were registered during the 107-day study period, and these resulted in 187 active working hours (92.5 hours for the palliative care unit). Active working hours per patient/week by ward were 0.32 hours for the palliative care unit, 0.07 hours for the short-term ward and 0.03 hours for the long-term wards. Frequent problems were counselling/information (24 %), the abdomen (14 %), the nervous system (13 %), airways (12 %), pain (11 %) and cardiovascular disease (7 %). Admission to a hospital could have been prevented for nine patients. INTERPRETATION: All wards at Bergen Red Cross Nursing home use the 24-hour on-call service frequently. Nursing homes should offer such services to ensure acute and competent treatment and avoid unnecessary transport and hospitalisation.

Who suffers most? Dementia and pain in nursing home patients: a cross-sectional study.

OBJECTIVES: To explore the relationship between nursing home patients with different stages of dementia and different dementia diagnoses and use of pain medication according to pain intensity. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: Participants included 181 consecutive, long-term stay patients, 43 primary caregivers, 1 geriatric study nurse, and 4 physicians of a Norwegian nursing home. MEASUREMENTS: Admission records, prescription lists, care plans, Mini-Mental State Examination, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), International Classification of Diseases (ICD-10), cerebral computed tomography, pain diagnoses and pain locations by physicians' examinations, and pain intensity by MOBID-2 (Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale), a novel staff-administered pain tool in dementia. RESULTS: Patients with severe dementia do not experience less pain intensity (P = .079), numbers of pain diagnoses (P = .172), and pain locations (P = .202) compared to other stages of dementia. Severely demented patients receiving opioids demonstrated higher pain intensity (mean 4.4, SD 1.7) than nondemented patients (mean 2.9, SD 1.8), and received less pain treatment (P = .018). Pain intensity did not differ between diagnostic groups of dementia (P = .439). Patients with mixed dementia receiving opioids had more pain (mean 5.3, SD 1.5, range 4-7) than mentally healthy controls and received less pain treatment (P < .005). CONCLUSION: Patients with severe dementia and mixed dementia are at high risk to suffer from severe pain. More research and quality improvement programs are needed to increase the knowledge in pain treatment by staff, which requires competence in both pain assessment and dementia.

Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale (MOBID): development and validation of a nurse-administered pain assessment tool for use in dementia.

Pain assessment in older persons with severe cognitive impairment (SCI) is a challenge due to reduced self-report capacity and lack of movement-related pain assessment instruments. The purpose of this article was to describe the development of the Mobilization-Observation-Behaviour-Intensity-Dementia Pain Scale (MOBID) and to investigate aspects of reliability and validity. MOBID is a nurse-administered instrument developed for use in patients with SCI, where presence of pain behavior indicators (pain noises, facial expression, and defense) may be observed during standardized active, guided movements, and then inferred to represent pain intensity. Initially, the MOBID contained seven items (observing at rest, mobilization of the hands, arms, legs, turn over in bed, sitting on bedside, and teeth/mouth care). This was tested in 26 nursing home patients with SCI. Their primary caregivers, five registered nurses and six licensed practical nurses (LPNs), rated the patients' pain intensity during regular morning care, and by MOBID, both at bedside and from video uptakes. Three external raters (LPNs), not knowing the patients, also completed the MOBID by rating the videos. Internal consistency of the MOBID indicated high Cronbach's alpha (alpha=0.90) after deleting the items for observation at rest and observation of teeth/mouth care. MOBID disclosed significantly more pain than did pain scorings during regular morning care, and video observation demonstrated higher pain intensity than bedside scoring. Intertester reliability for inferred pain intensity was high to excellent (intraclass correlation coefficient=0.70-0.96), but varied between poor and excellent for pain behavior indicators (kappa=0.05-0.84). These results suggest that registration of pain behavior indicators during active, guided movements, as performed by the MOBID procedure, is useful to disclose reliable and valid pain intensity scores in patients with SCI.

[Care at the end of life or active euthanasia?]. / Omsorg ved livets slutt eller aktiv dødshjelp?

Estimates for the next 50 years indicate that the number of European citizens above 65 will increase from today's 15 - 20 % to 30 - 40 %. In the same period the number of patients suffering from dementia wills more than double. Norway has the largest percentage of beds in nursing facilities per capita in Europe, more than twice that of most European countries. The dramatic decrease in birth rates in most European countries, with women seeking education and employment, will make proper care for the majority of the weakest elderly a major European challenge. Painful and unnecessary treatments violating basic human rights for weak elderly people suffering from dementia are widespread. The unnecessary life-prolonging medical treatment of the dying in acute wards incurs enormous costs. Options for euthanasia or palliative care are much debated poles regarding the terminally ill in Europe. If a European aim is to guarantee the frail old, that means us, dignity in their last years of life, several needs must be met. Resources now used on acute medicine must be shared with long-term care. These necessary changes will require strong medical and ethical involvement from all physicians.

[Nursing homes as arenas of terminal care--how do we do in practice?]. / Sykehjemmene som arena for terminal omsorg--hvordan gjør vi det i praksis?

40% of all deaths in Norway take place in nursing homes, more than in any other European country. The nursing homes are suitable places for the terminally ill old, provided that they are met by caregivers with the necessary skills in and resources for palliative care. A recently published study from Bergen Red Cross Nursing Home showed that the vast majority of the old in their final days or hours of life need palliative treatment with morphine and other symptom-relieving drugs. 85% of the deaths were expected, a fact that facilitates preparation, communication, ethical decisions and pain control. The most frequent symptoms are dyspnoea and death rattle. Dyspnoea based on terminal heart failure is relieved with subcutaneous application of morphine. The secretions of death rattle are best reduced with hyoscine hydrobromide (scopolamine). In the patient's terminal phase, the crucial factor for proper palliative care is the doctor's skills and commitment. Avoiding the strains associated with unnecessarily prolonging the death process, adequate symptom relief and prevention of unnecessary and strongly annoying transfer of the dying old to hospitals should be aimed for in Norwegian nursing homes.

[Ethical end-of-life decision making in nursing homes]. / Etiske avgjørelser ved livets slutt i sykehjem.

BACKGROUND: A recent publication from Norwegian health authorities describes necessary routines for end-of-life decisions in hospitals. There are no comparable national recommendations regarding patients in nursing homes. 40% of deaths in Norway occur in nursing homes. METHODS: All nursing home physicians in Bergen received an open questionnaire on the practice of ethics, end-of-life-decisions, and palliative care. RESULTS: 15 of the nursing homes physicians responded to the questionnaire, representing three quarters of the nursing homes and 1483 out of 1782 nursing home patients in Bergen (83%). Only two of institutions had written instructions for end-of-life decisions. Two thirds of the physicians considered use of morphine for the dying. Only a minority treated death rattle with scopolamine. 12 out of the 15 physicians administered life prolonging treatment with diuretics facing terminal pulmonary oedema, and 5 out of 15 administered antibiotics to those dying with pneumonia. 0.9% of the patients had a feeding tube. DISCUSSION: A majority of nursing home physicians have a high awareness of and willingness to give priority to end-of-life decisions, communication and palliative care. They ask for national recommendations in this challenging area. Unnecessary life-prolonging treatment and lack of palliative care are still major problems in Norwegian nursing homes.