Background: The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a ´maelstrom´ of ethical dilemmas. How ethically demanding situations are handled affects employees’ moral stress and job satisfaction. Aim: Describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway. Research design: A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020. Ethical considerations: Ethical approval granted by the Regional Research Ethics Committee in Western Norway (131421). Findings: Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0–10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful. Discussion: By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreak-affected patients, those redeployed or those most impacted by mitigation strategies must be a priority. Conclusion: Empirical research of healthcare workers experiences under a pandemic are important to identify groups at risks and useful support mechanisms.

High-quality end-of-life care in nursing homes relies on organization, funding and skilled staff, including available doctors who are able to recognize illness trajectories and perform individualized Advance Care Planning.

Objective. To examine drug treatment in nursing home patients at the end of life, and identify predictors of palliative drug therapy. Design. A historical cohort study. Setting. Three urban nursing homes in Norway. Subjects. All patients admitted from January 2008 and deceased before February 2013. Main outcome measures. Drug prescriptions, diagnoses, and demographic data were collected from electronic patient records. Palliative end-of-life drug treatment was defined on the basis of indication, drug, and formulation. Results. 524 patients were included, median (range) age at death 86 (19–104) years, 59% women. On the day of death, 99.4% of the study population had active prescriptions; 74.2% had palliative drugs either alone (26.9%) or concomitantly with curative/preventive drugs (47.3%). Palliative drugs were associated with nursing home, length of stay > 16 months (AOR 2.10, 95% CI 1.12–3.94), age (1.03, 1.005–1.05), and a diagnosis of cancer (2.12, 1.19–3.76). Most initiations of palliative drugs and withdrawals of curative/preventive drugs took place on the day of death. Conclusion. Palliative drug therapy and drug therapy changes are common for nursing home patients on the last day of life. Improvements in end-of-life care in nursing homes imply addressing prognostication and earlier response to palliative needs.

Objective: To explore doctor-patient interactions and decision-making processes before high-risk cardiac surgery or intervention with special attention to existential challenges. Design, setting and participants: We conducted a qualitative study with data drawn from doctor-patient dialogues preceding high-risk procedures. The study setting was the cardiac department of a university hospital with 24-hour emergency service. We recruited a purposive sample of 10 patients and eight doctors. The patients were categorised as high-risk patients in accordance with EuroSCORE and established angiographic procedural high-risk criteria. Transcripts from the dialogues were analysed with systematic text condensation, inspired by discourse analysis. Main outcome measure: Accounts of doctor-patient interaction reflecting existential aspects of the decisionmaking process.

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A novel 8-element GA frailty score identified gradations in survival in patients declined for open heart surgery. Patients with higher GA frailty scores had significantly higher two-year mortality after TAVI.

Suicide risk assessments based on verbal reports from individuals with psychotic depression may not always be valid due to potential impulsivity and underreporting of suicidal ideation. It may be important for clinicians to explore the delusional content of such patients' experiences to assess the possibility of suicide as a result of shame, guilt, remorse, or altruistic intentions to save others from harm.

Coping with existential challenges is important when struck by serious disease, but apart from cancer and palliative care little is known about how patients deal with such issues and maintain hope. To explore how patients with life-threatening heart disease experience hope when coping with mortality and other existential challenges, we conducted a qualitative study with semi-structured interviews. We made a purposive sample of 11 participants (26–88 years) who had experienced life-threatening disease: eight participants with serious heart disease, two with cancer, and one with severe chronic obstructive pulmonary disease. Analysis was by systematic text condensation. The findings showed that hope could enhance coping and diminish existential distress when patients were confronted with mortality and other existential challenges. Hope was observed as three types of dynamic work: to shift perception of mortality from overwhelming horror toward suppression or peaceful acceptance, to foster reconciliation instead of uncertainty when adapting to the new phase of life, and to establish go-ahead spirit instead of resignation as their identity. Meaning of life could, hence, be sustained in spite of serious threats to the persons' future, everyday life, and self-conception. The work of hoping could be supported or disturbed by relationships with family, friends, and health care professionals. Hope can be regarded as an active, dynamic state of existential coping among patients with life-threatening disease. Physicians may support this coping and thereby provide personal growth and alleviation of existential distress by skillfully identifying, acknowledging, and participating in the work of hoping performed by the patient.