Nurse managers play an important role in the working environment in home health care [1] . They have great responsibility for determining and planning their subordinates’ work [2] [3] [4] . According to Anthony et al. [5] , nurse managers have the most demanding work schedules in the community healthcare services. Changes in the role have affected their subordinates’ work, as it has become increasingly difficult to provide the previous level of support [1] [6] . Nurse managers are expected to act as representatives of their organization and an ethical conflicts occurs when they are told to do something that is contrary to their ethical values and principles [7] . Ethical conflicts can also arise when nursing and organizational values differ and where competition is highlighted [8] . The complexity of the healthcare organization with emphasis on efficiency and productivity has led to an increase in value conflicts as well as moral and ethical challenges [8] .

Nurse managers are responsible for the community healthcare of older patients who are tired of living and wish to die. Such death wish can be complex and is not always articulated. Sometimes such wishes can be seen as death ideation related to suicide or physician-assisted suicide. Optimal home healthcare cannot always prevent many older patients from becoming tired of living and developing the wish to die, which is sometimes due to the fact that aging leads to a reduced sense of meaning in life. Previous studies have revealed this phenomenon in 5% - 25% of older persons [9] [10] [11] [12] . Death wishes can be related to physical and mental health problems and sometimes to loneliness, a small social network, lack of control and living in residential care [9] [13] [14] . However, it has been shown that despite having a death wish older people do not necessarily want to fulfill it. In home healthcare, deciding what to do for patients who are tired of living and want to die can be an impossible task, leading to ethical conflicts for nurse managers as well as for home healthcare professionals as it is impossible to know whether the older patient will actively attempt to fulfil her/his death wish. Scocco and De Leo [11] make a distinction between passive and active death ideation. Passive death ideation means that a person wants to die but does not pursue this wish, while active death ideation implies that a person seriously considers taking her/his own life. The estimated prevalence of active death ideation among older persons is 1% - 9% [11] [12] . In contrast to the Netherlands, physicians in Norway have no legal right to participate in assisted suicide and no care criteria exist [15] . The decision to stop eating and drinking is legal throughout the United States for competent patients and does not necessarily require the participation of a physician [16] [17] . Pasman et al. [18] explored the views of patients and physicians in the context of suffering patients who requested euthanasia and whose request was either not granted or granted but not performed. The results showed that not all patients who requested euthanasia considered their suffering unbearable, although they had a strong wish to die [18] .

The debate on how to determine the time and manner of death has become more common, as these aspects are considered important indicators of a “good death” in western countries [19] . Many factors need to be considered and the complexity of this concept must be recognized. In addition to a growing awareness of death and dying, values such as self-determination, autonomy and individualism have become more dominant [19] . Lloyd [20] has described how the emphasis on autonomy and independence in Western cultures can result in older people becoming marginalised because of their dependency and vulnerability. There is a risk that the needs of older people will not be met [21] Franklin et al. [22] found that the attitudes of those around older people could both promote and hinder their dignity of identity. Several years ago MacKenzie [23] stated that ethical conflict can be related to an individual’s consciousness, which can be difficult to understand because several views are present in her/him at the same time [23] . An ethical conflict can be seen as an inner struggle within the individual. Ethical conflicts in home healthcare can be considered part of an effort to increase the quality of important professional initiatives by exploring what home health care managers and workers consider difficult ethical conflicts and challenges [24] . They are often related to the needs of the patient and the ethical standards of the profession on the one hand, and economic and organizational conditions on the other [24] .

It can be difficult to gain a sufficient overview of the needs of older patients who have expressed that they are tired of living.

The aim of this study was to explore nurse managers’ perceptions of ethical conflicts when caring for older patients who wish to die.

The results revealed one theme; A struggle due to responsibility for decision making and four sub-themes; Understanding the meaning of free will, Wondering about how serious the death wish is, Providing more worthy elder care and Lack of competent healthcare professionals to provide safe care.

The theme, A struggle due to responsibility for decision making, concerned the fact that the participants seem to experience ethical conflicts in decision making on a daily basis in home healthcare in Norwegian communities. Ethical conflicts can be seen as dilemmas and have been described as uncertainty about making the right decision in different situations and justifying such decisions [35] . Ethical conflicts can be related to conflicting inner values, norms and interests knowing the right thing to do, but institutional or other constraints making it difficult to pursue the desired action [36] [37] . Thus, nurse managers’ can be stressed by their awareness of competing or contradictory ethical imperatives. [38] According to MacKenzie, [23] an individual may be influenced by considerations drawn from reflections based on personal ambition, the welfare of her/his family, duty to the world, or religious beliefs. Such views may arise in one’s mind and some can conflict with others, after which it becomes a question of which of these views the individual finally chooses [23] . Different factors can contribute to uncertainty pertaining to ethical conflicts in decision making, causing feelings of frustration about which actions are consistent with one’s conscience [39] . One important issue for nurse managers is to do what is right and good in their work [40] . However, studies have revealed that nurse managers generally feel uncertain about how to manage their subordinates with regard to ethical conflicts and dilemmas [41] .

Responsibility can be seen as a relational way of being that involves being guided by one’s inner ideals, values and knowledge, in addition to struggling to do good. Ethical conflicts seem to arise when one experiences being unable to act in a good enough way. Nurse managers’ ethical conflicts appear to be related to a sense of failure to assume responsibility [42] . They seem to struggle with responsibility because they are not quite sure how to act. Redman [43] stated that a professional’s responsibility for achieving patient goals must be based on the notion that human beings are moral agents with their own values.

The demand for ethical conflicts in decision making in community healthcare is increasing [44] . However, nurse managers seem to lack commitment to ethics and have few ethical support groups to ensure trusting relationships [44] . Lack of reflection on and discussions of ethical problems and/or conflicts can lead to moral distress [45] . Thus, nurse managers can become distressed by their reactions, as well as by their awareness of competing or contradictory ethical imperatives

Understanding the meaning of free will can be related to autonomy, which involves independence, self-determination and self-care. It is a balancing act, as an ethical problem can arise because of the vulnerability of the elderly patients, often related to their experience of emotional pain and suffering. Ethical conflict can also occur when nurse managers have used force or pressure in response to a situation. Autonomy is central to the notion of independence [46] . The word “autonomy” comes from the Greek words “autos” meaning “self” and “nomos” meaning “rule”, which can be translated into the term “self-rule” [47] . The concept can thus be seen as exercising individual choice, freedom, free will and assuming responsibility for one’s own behaviour and/or self [46] . Autonomy can refer to what makes a life one’s own based on personal preferences and choices [48] . Beauchamp and Childress [48] have outlined four points that characterise a person’s autonomy; Being free from the controlling influence of others; Being free from limitations that prevent meaningful choice; Being free from inadequate understanding and Being able to freely act in accordance with a self-chosen plan. Based on these four points, liberty and agency appear to be two conditions for autonomy [46] . Negative and stereotypic bias results in elderly people experiencing how society views old age. These biased attitudes can reinforce discriminatory practices, such as dependency and infantilisation of the elderly [46] and what Butler [49] called ageism. Ageing is thus seen as a social problem and not a natural process. A consequence of ageism is that elderly people experience social death as a result of paternalistic and infantilising practices, in addition to loss of the right to autonomous behaviour. Ageism can be seen through the attitudes and actions of homecare nurse and healthcare professionals, causing them to overlook older patients’ symptoms or misinterpret them as illness instead of a natural process of aging. Wondering about how serious the death wish is seems to be related to whether or not the older patient is suicidal. If the patient trusts the healthcare professional, she/he will tell about the plan to take an overdose of tablets or similar. The homecare professional is responsible for immediately contacting the GP or nurse manager, as such messages can be serious. Sometimes it can be sufficient to devote more time to the elderly patient and encourage her/him to talk about the emotional pain and suffering. However, research has revealed negative attitudes towards suicide among nurses [50] . The belief that a person does not have the right to commit suicide was stronger among older nurses, those who had never taken care of suicidal patients, had a family history of suicide, who were Protestants and attended church services more frequently. Greater professional capacity was reported by nursing assistants and nurses who had already taken care of suicidal patients [50] . Such negative attitudes can be sensed by the older patients, causing them to conceal their serious suicidal plans.

The ethical conflict experienced by nurse managers in meeting older patients’ need to be seen as unique seems to be associated with showing respect and viewing the individual as a human being and not just a patient. Such attitudes can be a question of professional ethical knowledge where the value of a human being is related to uniqueness and respect. Another concept in this field is expert knowledge, which can be a way to change attitudes about older individuals. Awareness of the implications of ageism can help one to understand how to strengthen an older individual’s self-determination [49] . Healthcare has been described as a moral endeavour, thus failure to do “good” can result in a troubled conscience, aggravated by the fact that professionals demand high standards from themselves in their contact with patients [51] . Feeling that one is personally responsible for the quality of care and being uncertain about one’s professional responsibility have been reported as potential stress factors [52] [53] [54] . Ethical conflicts can arise due to lack of awareness of and attention to the moral aspects, making people less attentive to their conscience. Individuals who are aware of their inner ethical conflicts can be more attentive can focus more on their own role and responsibility [54] [55] . In the context of elder care, autonomy can be defined as the extent to which healthcare professionals explore older patients’ perspectives, support their initiatives, offer a choice of caring options and provide relevant information while minimizing pressure and control [56] .

Providing more worthy elder care can be related to our finding that in other countries families take care of their elderly relatives, which could be based on cultural expectations. In Norway, families expect the community to take over the care of their elderly family member. Hearing such statements must be difficult for the older persons. Research has revealed that older persons feel they have become a burden to their families [57] , which could be due to negative attitudes to the elderly in our society. In the aforementioned study, the older persons described feeling unworthy. Worthiness can be related to dignity of identity. A sense of dignity is described as the most important sense in the context of dignity and illness as well as in the context of dignity and ageing [58] . Dignity can be taken away by the acts of other people, by injury, illness and old age. It is something that we attach to ourselves as integrated and autonomous persons with a history, a future and relationships to other human beings [58] . As Nordenfelt ( [58] p. 75) stated “this must be a dignity attached to the person’s integrity and identity as a human being”. As the participants in this study revealed, older patients who wish to die are often referred to as being “tired of living” [59] .

In a study by McDonough and Polzer [60] , in-depth interviews with 45 front line workers revealed frustration with their working conditions and relationships with management. These inner conflicts were described as a “symbolic context of restructuring: the struggle to redefine governance and public services provision in the name of greater efficiency, effectiveness and accountability” ( [60] p. 372).

Feeling safe can be seen as a basic goal in home care nursing, which is related to existential theories outlined by Eriksson [61] as fundamental in nursing care. A sense of unsafety can be associated with feeling excluded and worthless, but might also involve a real fear related to the increased risk of falls. Another aspect may be media focus on violence against elderly people. In such situations a suicide plan can emerge where older patients actually do something active about their death wishes, such as jumping from the stairs of their second floor apartment. While this may be more in the nature of a cry for help, it can also be seen as a serious illustration of their distress, fear, pain and suffering.

Research findings recommend that nurse managers need knowledge and skills to manage their subordinates in the decision-making process [56] . Several leadership styles exist [62] and nurse managers have to make decisions based on ethical problems and/or conflicts [36] [40] . Organization, culture, power relations, quality of care and experiences of safety must also be taken into account [62] [63] . Nurse managers need to clarify their own values and enhance understanding among nurses, patients and other healthcare professionals based on shared decision-making [40] [64] [65] .

Nurse managers’ have no structure for bringing ethical conflicts to the attention of their leaders or the next level of the organization. Consequently, they appear to need supervision, support and clear, flexible lines of communication with leadership. Support can help to prevent feelings of helplessness and powerlessness in situations where they experience ethical conflicts. However, it may be difficult to find one correct leadership style in the decision-making process. Such processes should be based on contextual factors where nurse managers can shape an environment together with staff that allows sufficient time to reflect on ethical conflicts in different community home healthcare contexts and situations.

The authors thank nurse managers for their valuable contribution to the study. We also thank Monique Federsel for reviewing the English.

Holm, A.L., Berland, A.K. and Severinsson, E. (2017) Norwegian Nurse Managers’ Perceptions of Ethical Conflicts in Community Healthcare When Caring for Older Persons Who Wish to Die. Open Journal of Nursing, 7, 1274-1288. https://doi.org/10.4236/ojn.2017.711092