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Bruun H, Milling L, Wittrock D, Mikkelsen S, Huniche L. How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety. BMC Med Ethics 2024; 25:58. [PMID: 38762457 PMCID: PMC11102201 DOI: 10.1186/s12910-024-01061-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 05/08/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. METHODS We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. RESULTS We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. CONCLUSION Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.
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Affiliation(s)
- Henriette Bruun
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.
- Department of Regional Health Research, Faculty of Health Science, Forensic Mental Health Research Unit Middelfart (RFM), University of Southern Denmark & Psychiatric dept, Middelfart, Denmark.
| | - Louise Milling
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Daniel Wittrock
- Department of Quality and Education, Ambulance Syd, the Region of Southern Denmark, Odense, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
| | - Lotte Huniche
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Milling L, Nielsen DS, Kjær J, Binderup LG, de Muckadell CS, Christensen HC, Christensen EF, Lassen AT, Mikkelsen S. Ethical considerations in the prehospital treatment of out-of-hospital cardiac arrest: A multi-centre, qualitative study. PLoS One 2023; 18:e0284826. [PMID: 37494384 PMCID: PMC10370897 DOI: 10.1371/journal.pone.0284826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/07/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA. METHODS We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis. RESULTS All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values. CONCLUSION This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.
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Affiliation(s)
- Louise Milling
- Department of Anaesthesiology and Intensive Care, Prehospital Research Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dorthe Susanne Nielsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jeannett Kjær
- Department of Anaesthesiology and Intensive Care, Prehospital Research Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Grassmé Binderup
- Department for the Study of Culture, Philosophy, University of Southern Denmark, Odense, Denmark
| | | | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Aalborg University, Aalborg, Denmark
- Emergency Medical Services, Region North Denmark, Aalborg, Denmark
| | | | - Søren Mikkelsen
- Department of Anaesthesiology and Intensive Care, Prehospital Research Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Lauridsen S, Schou-Juul F, Folker AP, Simonsen P, Phil ME, Skov SS. Developing the CARE intervention to enhance ethical self-efficacy in dementia care through the use of literary texts. BMC Med Ethics 2023; 24:45. [PMID: 37386381 PMCID: PMC10311821 DOI: 10.1186/s12910-023-00926-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/22/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Dementia care is essential to promote the well-being of patients but remains a difficult task prone to ethical issues. These issues include questions like whether manipulating a person with dementia is ethically permissible if it promotes her best interest or how to engage with a person who is unwilling to recognize that she has dementia. To help people living with dementia and their carers manage ethical issues in dementia care, we developed the CARE intervention. This is an intervention focused on promoting the ethical self-efficacy of people living with dementia and carers, i.e., their confidence that they can manage ethical issues when they occur. The purpose of this paper is to explain and discuss how we have developed the CARE intervention to promote the ethical self-efficacy of people living with dementia, their family, and professional carers through a specific and, we believe, new use of literary texts. METHODS The CARE intervention has been developed in two phases: First, we conducted a needs assessment of the occurrence of ethical issues in dementia care and the need for an intervention to support people living with dementia and their carers in managing such issues. Second, in a design phase, we developed the CARE intervention to meet identified needs. RESULTS To address identified ethical issues in dementia care we designed the CARE intervention as a workshop format where people living with dementia and carers can meet, discuss literary texts, and deliberate on how to solve such issues. The workshop is structured by the following elements: An agenda of ethical issues, a collection of literary cases exemplifying ethical issues, a moderator with an understanding of dementia care, and an overview of the ethical principles relevant to the discussion of ethical issues. >This workshop concept is operationalized in three applications tailored to meet the specific ethical issues of each of the study´s three target groups: people living with dementia and family carers, professional and family carers, and professional carers. CONCLUSION We conclude the paper by stating that it is possible to develop an intervention that promotes the ethical self-efficacy of people living with dementia and family and professional carers.
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Affiliation(s)
- Sigurd Lauridsen
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| | - Frederik Schou-Juul
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Anna Paldam Folker
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Peter Simonsen
- Department Department of Language, Culture, History and Communication, University of Southern Denmark, Odense, Denmark
| | - Marie-Elisabeth Phil
- Department Department of Language, Culture, History and Communication, University of Southern Denmark, Odense, Denmark
| | - Sofie Smedegaard Skov
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Sato H, Takimoto Y. Clinical ethics problems in psychiatry and the need for clinical ethics consultation in Japan: A cross-sectional study. PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2023; 2:e86. [PMID: 38868145 PMCID: PMC11114266 DOI: 10.1002/pcn5.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/17/2023] [Accepted: 03/19/2023] [Indexed: 06/14/2024]
Abstract
Aim Psychiatrists often encounter ethical dilemmas in their daily clinical practice. Clinical ethics consultations (CECs) have been recently increasing, especially in general hospitals. However, the current situation in the psychiatric field is unclear. This study clarifies clinical ethics problems in psychiatry and determines the need for CECs. Methods We conducted an anonymous self-administered questionnaire survey in February 2022, which targeted directors and supervisors of psychiatric specialty training programs at 1224 psychiatry facilities. Results Responses were received from 311 facilities (response rate: 25.4%). CEC systems existed in 223 (72.2%) facilities, and medical safety committees were the most common. Clinical ethics problems occurred at 248 (80.3%) facilities; the most common method for managing the problems was discussions at case conferences without using CECs. The top four reasons for psychiatrists to solicit advice were conflicts with patients' relatives, treating a patient with cognitive impairment, discontinuation of treatment, and suicide/attempted suicide. Most respondents (89.9%) considered CECs necessary. Conclusion Although CECs exist in psychiatry, they may not meet the needs of clients. Future studies are needed to investigate client satisfaction and CEC evaluation methods in facilities where psychiatric CECs are provided.
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Affiliation(s)
- Hiroyuki Sato
- Department of Biomedical Ethics, Faculty of MedicineThe University of TokyoTokyoJapan
| | - Yoshiyuki Takimoto
- Department of Biomedical Ethics, Faculty of MedicineThe University of TokyoTokyoJapan
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Bruun H, Milling L, Mikkelsen S, Huniche L. Ethical challenges experienced by prehospital emergency personnel: a practice-based model of analysis. BMC Med Ethics 2022; 23:80. [PMID: 35962434 PMCID: PMC9373324 DOI: 10.1186/s12910-022-00821-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 08/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. In prehospital emergency medicine, decision-making commonly takes place in everyday life, under time pressure, with limited information about a patient and with few possibilities of consultation with colleagues. This paper explores the ethical challenges experienced by prehospital emergency personnel.
Methods The study was grounded in the tradition of action research related to interventions in health care. Ethical challenges were explored in three focus groups, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. The participants, 15 in total, were recruited through an internal information network of the emergency services. Focus groups were audio-recorded and transcribed verbatim. Results The participants described ethical challenges arising when clinical guidelines, legal requirements, and clinicians’ professional and personal value systems conflicted and complicated decision-making processes. The challenges centred around treatment at the end of life, intoxicated and non-compliant patients, children as patients—and their guardians, and the collaboration with relatives in various capacities. Other challenges concerned guarding the safety of oneself, colleagues and bystanders, prioritising scarce resources, and staying loyal to colleagues with different value systems. Finally, challenges arose when summoned to situations where other professionals had failed to make a decision or take action when attending to patients whose legitimate needs were not met by the appropriate medical or social services, and when working alongside representatives of authorities with different roles, responsibilities and tasks. Conclusion From the perspective of the prehospital emergency personnel, ethical challenges arise in three interrelated contexts: when caring for patients, in the prehospital emergency unit, and during external collaboration. Value conflicts may be identified within these contexts as well as across them. A proposed model of analysis integrating the above contexts can assist in shedding light on ethical challenges and value conflicts in other health care settings. The model emphasises that ethical challenges are experienced from a particular professional perspective, in the context of the task at hand, and in a particular, the organisational setting that includes work schedules, medical guidelines, legal requirements, as well as professional and personal value systems.
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Affiliation(s)
- Henriette Bruun
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark. .,Psychiatric Department Middelfart, Mental Health Services in the Region of Southern Denmark, Middelfart, Denmark.
| | - Louise Milling
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.,The Mobile Emergency Care Unit, Department Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
| | - Lotte Huniche
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.,Department of Psychology, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Schofield G, Dittborn M, Selman LE, Huxtable R. Defining ethical challenge(s) in healthcare research: a rapid review. BMC Med Ethics 2021; 22:135. [PMID: 34587950 PMCID: PMC8479723 DOI: 10.1186/s12910-021-00700-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/03/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Despite its ubiquity in academic research, the phrase 'ethical challenge(s)' appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of 'ethical challenge(s)' and closely related terms as used in current healthcare research literature. METHODS Rapid review to identify peer-reviewed reports examining 'ethical challenge(s)' in any context, extracting data on definitions of 'ethical challenge(s)' in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher's Index, EMBASE, CINAHL) were searched from April 2016 to April 2021. RESULTS 393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of 'ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to 'ethical challenge(s)' within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study. CONCLUSIONS Only 12/72 studies contained an explicit definition of 'ethical challenge(s)', with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.
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Affiliation(s)
- Guy Schofield
- Centre for Ethics in Medicine, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.
| | - Mariana Dittborn
- Paediatric Bioethics Centre, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Lucy Ellen Selman
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
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Bruun H, Huniche L, Stenager E, Mogensen CB, Pedersen R. Hospital ethics reflection groups: a learning and development resource for clinical practice. BMC Med Ethics 2019; 20:75. [PMID: 31651308 PMCID: PMC6813973 DOI: 10.1186/s12910-019-0415-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
Background An ethics reflection group (ERG) is one of a number of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the significance of ERGs in psychiatric and general hospital departments in Denmark. Methods This is a qualitative action research study, including systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Short written descriptions of the ethical challenges presented in the ERGs also informed the analysis of significance. Results A recurring ethical challenge for clinicians, in a total of 63 cases described and assessed in 3 ethical reflection groups, is to strike a balance between respect for patient autonomy, paternalistic responsibility, professional responsibilities and institutional values. Both in psychiatric and general hospital departments, the study participants report a positive impact of ERG, which can be divided into three categories: 1) Significance for patients, 2) Significance for clinicians, and 3) Significance for ward managers. In wards characterized by short-time patient admissions, the cases assessed were retrospective and the beneficiaries of improved dialogue mainly future patients rather than the patients discussed in the specific ethical challenge presented. In wards with longer admissions, the patients concerned also benefitted from the dialogue in the ERG. Conclusion This study indicates a positive significance and impact of ERGs; constituting an interdisciplinary learning resource for clinicians, creating significance for themselves, the ward managers and the organization. By introducing specific examples, this study indicates that ERGs have significance for the patients discussed in the specific ethical challenge, but mostly indirectly through learning among clinicians and development of clinical practice. More research is needed to further investigate the impact of ERGs seen from the perspectives of patients and relatives.
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Affiliation(s)
- H Bruun
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - L Huniche
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - E Stenager
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - C B Mogensen
- Focused Research Unit in Emergency Medicine, Institute for Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - R Pedersen
- Center for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Jansen TL, Hem MH, Dambolt LJ, Hanssen I. Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands. Nurs Ethics 2019; 27:1315-1326. [DOI: 10.1177/0969733019877526] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. Research design A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used. Ethical considerations Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Findings Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Conclusion Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.
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Bruun H, Pedersen R, Stenager E, Mogensen CB, Huniche L. Implementing ethics reflection groups in hospitals: an action research study evaluating barriers and promotors. BMC Med Ethics 2019; 20:49. [PMID: 31311525 PMCID: PMC6636139 DOI: 10.1186/s12910-019-0387-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022] Open
Abstract
Background An ethics reflection group (ERG) is one of a range of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the implementation process of interdisciplinary ERGs in psychiatric and general hospital departments in Denmark. To our knowledge, this is the first study of ERG implementation to include both psychiatric and general hospital departments. Methods The implementation and evaluation strategies are inspired by action research, using a qualitative approach and systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Results The implementation process was influenced by both structural factors and factors related to clinicians having different values, interests and experiences. Structural barriers and promotors in the process to implement ERG included the following sub-categories: Organizational factors, recruitment and training of ethics facilitators, the deliberation model, planning and recruitment of participants to the ERGs, the support of the ward managers and the project group. Barriers and promotors found among clinicians included the following sub-categories: Expectations and pre-understandings of ERGs, understandings of a physician’s job, challenges experienced by ethics facilitators. At the end of the study, when it was decided that the ERGs should be continued, the implementation strategies were remodeled by the participants to meet new challenges. Conclusion The study of ERG implementation identified important structural and professional barriers and promotors that are likely to be relevant to anyone wanting to implement ethics support services across various types of healthcare services.
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Affiliation(s)
- Henriette Bruun
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark.
| | - Reidar Pedersen
- Center for medical Ethics, Institute of Health and Society, University of Oslo, Kirkevejen 166, 0450, Oslo, Norway
| | - Elsebeth Stenager
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Christian Backer Mogensen
- Focused Research Unit in Emergency Medicine Institute for Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Lotte Huniche
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
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