ABSTRACT
The end of life is a period of intensive care. It is imperative that physicians have training and skills in the care of dying patients. Understanding the process of dying and recognizing physical changes aids in prognostication. Skills in facilitating family coping, treating pain, respiratory distress and delirium are critical.
Subject(s)
Critical Care/methods , Physician's Role , Terminal Care/methods , Adaptation, Psychological , Anger , Attitude of Health Personnel , Attitude to Health , Critical Care/psychology , Delirium/etiology , Delirium/prevention & control , Dyspnea/etiology , Dyspnea/prevention & control , Family/psychology , Humans , Pain/etiology , Pain/prevention & control , Philosophy, Medical , Physician-Patient Relations , Professional-Family Relations , Prognosis , Resuscitation Orders , Terminal Care/psychologyABSTRACT
Many healthcare professionals already in practice have identified their need to pursue further practical training in the provision of hospice and palliative care. We began offering a 1-week clinical experience to physicians, nurses, pharmacists, social workers, and chaplains in the summer of 1995. As of October 1,1997, there have been 190 requests for application materials from individuals in more than 22 states, as well as from Singapore and Uganda. Thirty-five individuals completed visits by October 31,1997; 17 nurses, 16 physicians, 1 psychologist, and 1 chaplain. Although all are working in areas related to palliative care, 57% (20 of 35) were not currently working for a hospice program. A 25-question examination was administered as a needs-assessment test. Overall they scored 75% correct. They did especially poorly on questions related to dosing of opioids, assessment of pain, and prognosis in AIDS. They completed a videotaped interview with a standardized patient focusing on skills in discussing a terminal prognosis, "do not resuscitate" (DNR) status, and hospice referral. They evaluated the entire educational experience with a self-report at the end of their visit using a Likert Scale with values of 1 to 5. To the statement "I achieved the specific goals which I set for myself," the average score was 4.6 (range 1-5). To the statement "The experience was worth the time and effort," the average score was 4.9. To the statement "I would recommend this experience to others," the average score was 4.9. The evaluation was repeated 6 months after the visit with similar scores. In addition, to the statement "My current efforts are helping to change the way dying patients and their families are cared for in the broader environment in which I work," the average score was 4.9 (range 4-5). We conclude that this is a successful program of clinical exposure to hospice and palliative medicine for clinicians in practice.
ABSTRACT
The hospice approach to terminal care will benefit patients with advanced chronic illnesses other than cancer. This article describes general criteria that will help clinicians assess when patients may be appropriately referred for hospice care. Common illnesses, such as dementia, heart disease, lung disease, and renal failure for which terminal care in advanced stages is appropriate, are discussed. Specific palliative management issues regarding these advanced disease states also are addressed.
Subject(s)
Terminal Care/methods , Dementia/therapy , Heart Failure/therapy , Hospice Care/methods , Humans , Karnofsky Performance Status , Lung Diseases, Obstructive/therapy , Palliative Care/methods , PrognosisABSTRACT
Vesicles containing single lipoprotein particles are found in the perisinusoidal cytoplasm of rat hepatocytes in the proximity of particle-containing rough-smooth endoplasmic reticulum transition elements. these lipoprotein particle-containing smooth endoplasmic reticulum elements provide an alternative to Golgi apparatus as a supplier of very low density lipoprotein particles to the circulation. To test this possibility, the kinetics of appearance of lipoprotein particles in these elements was determined for isolated rat livers first depleted of particles and then perfused with free fatty acid to restore particles. The results show that elements of the smooth endoplasmic reticulum in the perisinusoidal cytoplasm acquire lipoprotein particles in advance of elements of the conventional Golgi apparatus and that the particles contained within the perisinusoidal elements of smooth endoplasmic reticulum are not products of endocytotic uptake of particles from the circulation.
