Are end-of-life practices in Norway in line with ethics and law?

BACKGROUND: End-of-life decisions, including limitation of life prolonging treatment, may be emotionally, ethically and legally challenging. Euthanasia and physician-assisted suicide (PAS) are illegal in Norway. A study from 2000 indicated that these practices occur infrequently in Norway. METHODS: In 2012, a postal questionnaire addressing experience with limitation of life-prolonging treatment for non-medical reasons was sent to a representative sample of 1792 members of the Norwegian Medical Association (7.7% of the total active doctor population of 22,500). The recipients were also asked whether they, during the last 12 months, had participated in euthanasia, PAS or the hastening of death of non-competent patients. RESULTS: Seventy-one per cent of the doctors responded. Forty-four per cent of the respondents reported that they had terminated treatment at the family's request not knowing the patient's own wish, doctors below 50 and anaesthesiologists more often. Anaesthesiologists more often reported to have terminated life-prolonging treatment because of resource considerations. Six doctors reported having hastened the death of a patient the last 12 months, one by euthanasia, one by PAS and four had hastened death without patient request. Male doctors and doctors below 50 more frequently reported having hastened the death of a patient. CONCLUSION: Forgoing life-prolonging treatment at the request of the family may be more frequent in Norway that the law permits. A very small minority of doctors has hastened the death of a patient, and most cases involved non-competent patients. Male doctors below 50 seem to have a more liberal end-of-life practice.

Moral distress among Norwegian doctors.

BACKGROUND: Medicine is full of value conflicts. Limited resources and legal regulations may place doctors in difficult ethical dilemmas and cause moral distress. Research on moral distress has so far been mainly studied in nurses. OBJECTIVE: To describe whether Norwegian doctors experience stress related to ethical dilemmas and lack of resources, and to explore whether the doctors feel that they have good strategies for the resolution of ethical dilemmas. DESIGN: Postal survey of a representative sample of 1497 Norwegian doctors in 2004, presenting statements about different ethical dilemmas, values and goals at their workplace. RESULTS: The response rate was 67%. 57% admitted that it is difficult to criticize a colleague for professional misconduct and 51% for ethical misconduct. 51% described sometimes having to act against own conscience as distressing. 66% of the doctors experienced distress related to long waiting lists for treatment and to impaired patient care due to time constraints. 55% reported that time spent on administration and documentation is distressing. Female doctors experienced more stress that their male colleagues. 44% reported that their workplace lacked strategies for dealing with ethical dilemmas. CONCLUSION: Lack of resources creates moral dilemmas for physicians. Moral distress varies with specialty and gender. Lack of strategies to solve ethical dilemmas and low tolerance for conflict and critique from colleagues may obstruct important and necessary ethical dialogues and lead to suboptimal solutions of difficult ethical problems.

Impact of feeling responsible for adverse events on doctors' personal and professional lives: the importance of being open to criticism from colleagues.

OBJECTIVE: To investigate the impact of adverse events that had caused patient injury and for which the doctor felt responsible, and the experience of acceptance of criticism among colleagues. DESIGN: Self-reports based on postal questionnaires to 1616 doctors. SETTING: Norway. PARTICIPANTS: A representative sample of 1318 active doctors. RESULTS: 368/1294 (28%) reported that they had experienced at least one adverse event with serious patient injury. Being male and working within a surgical discipline (including anaesthesiology, obstetrics and gynaecology) significantly increased the probability of such reports. 38% of the events had been reported to official authorities and, for 17% of doctors, the incident had a negative impact on their private life; 6% had needed professional help. 50% and 54%, respectively, found it difficult to criticise colleagues for their ethically or professionally unacceptable conduct. Doctors who found it easy to criticise colleagues also reported having received more support from their colleagues after a serious patient injury. CONCLUSION: Male surgeons report the highest prevalence of adverse events. Criticism for professionally and ethically unacceptable conduct is difficult to express among doctors. More acceptance of criticism of professional conduct may not only prevent patient harm, but may also give more support to colleagues who have experienced serious patient injury.

Mortality of anesthesiologists, pediatricians, and other specialists in Norway.

BACKGROUND: Following sensational media reports, particularly from Sweden, there has been discussion in Scandinavia during the last couple of years about whether anesthesiologists have shorter life spans than other medical specialists. METHODS: Survival analysis (Cox regression) from the master file of the Norwegian Medical Association was used to compare anesthesiologists with pediatricians and other specialists. Data was taken from 10367 specialists, 533 anesthesiologists, 488 pediatricians, and 9325 other specialists, with Norwegian citizenship. These comprised 574065 man-years, of which 171190 were lived after achieving specialty. CONCLUSION: No differences in mortality were found between the three groups.

The self-perceived health status of Norwegian physicians compared with a reference population and foreign physicians.

AIMS: To compare the self-perceived health status of a representative sample of Norwegian physicians with a general reference population; and to investigate differences in health status among groups of physicians. METHODS: A cross-sectional postal survey was carried out of 1,126 Norwegian physicians and 1,742 subjects in a general reference population, using the widely used general health status questionnaire--Short Form 36 (SF-36). Scores were adjusted for differences in age, gender and education where applicable. RESULTS: The health status of Norwegian physicians was better than that of subjects with a lower level of education in the four dimensions of the SF-36 related to physical health. Male physicians scored better on the physical functioning scale and lower on vitality and social functioning than comparable university graduates. Older physicians scored better than younger in dimensions related to mental health and social functioning. Norwegian general practitioners reported better health status than colleagues in Sweden and the UK. CONCLUSIONS: The self-perceived health status of Norwegian physicians was as good or better than that of the general population. The cross-national differences could be caused by cultural differences, or be related to practice style or job strain.

[Norwegian medical students abroad--background, effort and satisfaction]. / Norske medisinstudenter i utlandet--bakgrunn, studieinnsats og tilfredshet.

BACKGROUND: More than 30% of Norwegian physicians have graduated from medical schools outside Norway, and the number of Norwegian students that attend medical schools abroad is increasing, particularly in Hungary, Poland and the Czech republic. It is of interest to know more about these future Norwegian doctors: where they come from, and how they cope with studying abroad. MATERIAL AND METHODS: A postal survey was carried out among all 1,198 Norwegian medical students that were in the files of the State Education Loan Fund by August 1998. There were 756 responses (63%). The questions covered reasons for going abroad, academic and non-academic outcome, satisfaction, specialty and job preferences, possible motives for career choices, personality traits, smoking status and alcohol use. Comparable data were available from previous studies of medical students in Norway. RESULTS: The social background of students abroad is similar to that of students at home, and their high school grade level is only slightly below. The main reasons for studying abroad is that they were not admitted at a Norwegian university and have a strong wish of becoming a doctor. Language, financial situation, and a number of pragmatic reasons determine which country to go to, choice of university is often incidental. Students abroad spend more time on their studies than students at home do. They are generally satisfied with the academic quality, but satisfaction with how the study is organised is lower in Central and Eastern-European countries. INTERPRETATION: Norwegians who are highly motivated but excluded from Norwegian universities increasingly attend medical schools abroad and are by and large satisfied with the quality of the curriculum.

[Norwegian medical students abroad--career plans, personality, smoking and alcohol use]. / Norske medisinstudenter i utlandet--karriereplaner, personlighet, røyking og alkoholbruk.

BACKGROUND: More than 30% of Norwegian physicians have graduated from medical schools outside Norway, and the number of Norwegian students that attend medical schools abroad is increasing, particularly in Hungary, Poland and the Czech republic. There is a need to know more about these future Norwegian doctors, what their motives and plans are, and how they differ from students at home. MATERIAL AND METHODS: A postal survey was carried out among all 1,198 Norwegian medical students that were in the files of the State Education Loan Fund by August 1998. The questions covered reasons for going abroad, academic and non-academic outcome, satisfaction, specialty and job preferences, possible motives for career choices, personality characteristics, smoking status and alcohol use. Comparable data were available from previous studies of medical students in Norway. RESULTS: There were 756 responses (63%). Surgery, internal medicine and paediatrics were the most popular specialties. Family medicine and psychiatry seem to be less likely specialties for students abroad than for students at home. Traditional gender differences, e.g. interest in aiming for a leadership position, were present and did not differ from those seen among students in Norway. Students abroad were more oriented towards leadership and prestigious specialties, less preoccupied with the possibility of making medical mistakes, and less interested in medico-policial issues than their counterparts at home. Their personality profiles seemed more robust than those of students in Norway. On the other hand, they smoked much more frequently and had a higher risk of alcohol-related problems. INTERPRETATION: Norwegian medical students abroad do not particularly prefer specialties like general practice and psychiatry, where the demand for medical manpower is highest. They seem to have quite traditional preferences according to gender.

[Palliative sedation to dying patients in Norway]. / Lindrende sedering til døende i Norge.

BACKGROUND: In May 2000, the Norwegian Medical Association appointed a working group to propose guidelines for the practice of palliative sedation to dying patients (terminal sedation). The present study is part of this work. The aim of the study was to register to what extent this form of palliation is used in Norwegian hospitals, on what indications, how decisions are reached, and whether the treatment is considered necessary. The definition of palliative sedation given was: induction and maintenance of sleep for the relief of pain or other types of suffering in a patient close to death. The intention is exclusively to relieve intractable pain, not to shorten the patient's life. MATERIAL AND METHODS: An anonymous questionnaire was sent to 364 Norwegian hospital departments that might have experience with palliative sedation. Results are reported partly as free text comments and partly as frequencies of predetermined response alternatives. RESULTS: 58% of the questionnaires were returned. 22% of the respondents had given palliative sedation to a dying patient during the last 12 months, and more than half of the physicians found this intervention sometimes necessary. Pain was the most frequent indication; none of the respondents claimed to haven given sedation exclusively based on depression/anxiety. Lack of resources still seems to be an obstacle to optimal palliative care in Norway. CONCLUSION: Though it has some methodological weaknesses, this study confirms the need for national guidelines.

Suicide rates from 1960 to 1989 in Norwegian physicians compared with other educational groups.

The aim of the present study is to compare suicide rates between 1960 and 1989 for Norwegian physicians with corresponding rates for other Norwegians with and without university education, by age, gender, and five-year period, based on death certificates for all Norwegians who died in the period 1960-1989. There were 82 registered physician suicides, of which 9 were female, 265 suicides by persons with other university education, and 11,165 by persons with no university education. Suicide rate is measured in number of deaths per 100,000 person years. Crude suicide rates were 47.7 (95% CI 37.7-60.4) for male physicians, 20.1 (17.7-22.9) for other male university graduates, and 22.7 (22.2-23.2) for men with no university education. The corresponding figures for females were 32.3 (15.8-63.7), 13.0 (8.4-19.8) and 7.7 (7.5-8.0). Both for males and females, suicide rates, controlled for age and period, were significantly higher for physicians than for persons with other or no university education. Poisson modelling showed that the risk of suicide for male physicians has the same age pattern as for other males with higher education. In 1985-89 the suicide rate for male physicians increased nearly linearly from about 35 at the age 35-40 to about 100 at the age 75-79, which was almost three times higher than for the other male university graduates. For the age group 50-54 the estimated rate increases from about 50 in 1960-64 to about 90 in 1985-89. For the female physicians, the low number of cases prevents reliable estimation of trends. For male physicians, the trend from 1960 to 1989 is increasing. The estimated risk for a single physician to commit suicide was almost 5 times that of a married or co-habitant colleague. For 52% of the male and 85% of the female physicians the suicide method was poisoning. This is about twice the rates in the general population.

[How do Norwegian dermatologists keep themselves professionally updated?]. / Hvordan holder norske hudleger seg faglig oppdatert?

BACKGROUND: We have explored continuing medical education among Norwegian dermatologists, especially their use of medical journals and the Internet. MATERIAL AND METHODS: In April 2001, a questionnaire was sent to 170 dermatologists, including junior doctors in specialist training. 129 questionnaires (76%) were returned, of which 16 were excluded from the analysis. RESULTS: Mean time used per week reading articles in medical journals was 149 minutes (95% confidence interval (CI) 129-168 minutes). 90% of the respondents had Internet access at work and/or at home. Hospital consultants used the Internet for medical purposes for significantly more time per week than doctors in private practice (146 minutes (CI 98-195 minutes) versus 72 minutes (CI 52-93 minutes)). More hospital doctors had difficulties in getting or taking time off to attend courses and congresses (p < 0.01) and with financial costs (p < 0.001) than those in private practice. Most dermatologists found the paper version of journals (88%) and courses and congresses (79%) to be important for their continuing medical education, while fewer found medical databases on the Internet (57%) and the Internet version of journals (35%) to be so. In a logistic regression model, fewer private practitioners than hospital doctors (p = 0.011) and more female than male doctors (p = 0.014) had a feeling of insufficiency in regard to the increasing amount of medical information. INTERPRETATION: The Internet has become part of the professional life of most Norwegian dermatologists, but has so far not replaced traditional forms of continuing medical education.

Physicians' Internet activities and their perceived coping with the medical information.

OBJECTIVE: To describe and analyze physicians' Internet activities and how this relates to their coping with medical information. METHODS: Postal survey among 1276 Norwegian physicians (response rate 78%). RESULTS: Seventy-two percent of all physicians had access to the Internet in 1999, up from 38% in 1997. One out of two physicians use the Internet for professional purposes. Web-based search is the dominant activity and Internet use is closely related to other ways of information-seeking (reading and attending professional meetings). A total of 70% of the respondents reported ability to obtain sufficient information for keeping updated in their daily work. "Internet-active"-physicians reported a higher rate of such ability than physicians without Internet access (74% vs 65%). CONCLUSION: The Internet plays an increasingly important role in physicians' professional updating. The impact of new information technology on the medical community should be carefully monitored in the future.

[What does affect the general practitioners' choice of contract and plans to relocate?]. / Hva påvirker allmennlegenes kontraktsvalg og flytteplaner?

BACKGROUND: The aim of this study was to examine general practitioners' choice of contract and location in Norway. GPs can choose between two types of contract: a contract by which they are paid a salary, and a contract by which they are paid on a fee-for-service basis plus a fixed grant. METHOD: The data were collected by a questionnaire sent to a representative sample of GPs in Norway (N = 1,639). RESULTS: Salaried physicians and contract physicians show different characteristics. Salaried physicians tend to be younger than contract physicians and to prefer leisure to higher income. Most salaried physicians were located in rural areas. The following tendencies were observed with respect to location: GPs wanted to move from rural to central areas. Physicians who reported that their workload was too high, wanted to move to an area where the workload was lower. Physicians who reported that they had too few patients did not want to move. Physicians who were often on duty to provide emergency services wanted to move. INTERPRETATION: According to standard market theory, physicians are expected to move to areas where demand is high when demand in their own areas falls. Our results indicate that public regulation is necessary in order to obtain an optimal distribution of physicians.

[The public's expectations of the health services]. / Befolkningens ønsker om helsetjenester.

BACKGROUND: The challenge of finding ways of allocating public health resources is much debated. Many argue that the public should play a major role in deciding what services should be delivered and paid for. The aim of this study was to collect information on the public opinion on various health policy issues. MATERIAL AND METHODS: A representative sample of 1,342 Norwegians was interviewed in 1998 about their attitudes towards various health policy issues. RESULTS: The results showed that Norwegians have great expectations of the national health services. The majority wants immediate access, free choice, and minimal out-of-pocket payments. Factor analysis yielded four latent variables in the response pattern: economic rationing, market-orientation, access and out-of-pockets payment. Women were less in favour of economic rationing, less market-oriented and wanted more influence than men. Free access to services grew more important by age. Politically conservative voters were most in favour of market-orientation. INTERPRETATION: To involve the public in priority issues is hard, as their expectations are extensive and contradicting. However, it is most important to involve them in order to establish the understanding that public health services cannot supply everything free of charge to everyone.

[Head of department--manager or physician?]. / Avdelingsoverlegen--leder eller lege?

BACKGROUND: In Norway, as in other countries, questions regarding medical leadership in hospital departments are much discussed. The purpose of this study was to determine how much time medical heads of hospital departments spend on various leadership tasks. MATERIAL AND METHODS: Information was collected by a questionnaire survey in 1996. RESULTS: 567 out of 657 (86%) completed the questionnaire. 71% shared the departmental leadership with a nurse, and 48% of these were content with such co-leadership. Nearly all the respondents were clinically active. 49% of heads of large departments used more than half their working hours on administration, compared with 7% of heads of small departments. INTERPRETATION: Selection criteria for heads of hospital departments should be adjusted to the work they actually do. Clinical competence is of importance for all heads of clinical departments; the importance of administrative competence varies with the size of the department.

[Head of department--selected and trained as a leader?]. / Avdelingsoverlegen--utvalgt og utdannet som leder?

BACKGROUND: The importance of recruitment and leadership training for heads of hospital departments has been discussed for several years. We wanted to study how these heads were recruited, and to what extent they were trained for their leadership tasks. MATERIAL AND METHODS: Information was collected by a questionnaire; 567 out of 657 (86%) responded. RESULTS: 37% of the respondents had been interviewed before being appointed. In the interviews, most of them had been asked about leadership experience and training, a larger proportion among the heads of large departments (more than 99 employees) than small (less than 30 employees). 20% of the heads of small departments and 43% of heads of large departments had undergone leadership training at university level. 25% had spent more than one week per year during the last three years on additional training in leadership and administration compared to 81% on continuing medical education. INTERPRETATION: The results indicate that employers place great importance on leadership training, whereas the heads of department appear to place more importance on continuing medical education.