A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients.

The issue of symptom management at the end of life and the need to use sedation has become a controversial topic. This debate has been intensified by the suggestion that sedation may correlate with 'slow euthanasia'. The need to have more facts and less anecdote was a motivating factor in this multicentre study. Four palliative care programmes in Israel, South Africa, and Spain agreed to participate. The target population was palliative care patients in an inpatient setting. Information was collected on demographics, major symptom distress, and intent and need to use sedatives in the last week of life. Further data on level of consciousness, adequacy of symptom control, and opioids and psychotropic agents used during the final week of life was recorded. As the final week of life can be difficult to predict, treating physicians were asked to complete the data at the time of death. The data available for analysis included 100 patients each from Israel and Madrid, 94 patients from Durban, and 93 patients from Cape Town. More than 90% of patients required medical management for pain, dyspnoea, delirium and/or nausea in the final week of life. The intent to sedate varied from 15% to 36%, with delirium being the most common problem requiring sedation. There were variations in the need to sedate patients for dyspnoea, and existential and family distress. Midazolam was the most common medication prescribed to achieve sedation. The diversity in symptom distress, intent to sedate and use of sedatives, provides further knowledge in characterizing and describing the use of deliberate pharmacological sedation for problematic symptoms at the end of life. The international nature of the patient population studied enhances our understanding of potential differences in definition of symptom issues, variation of clinical practice, and cultural and psychosocial influences.

Home versus hospice inpatient care: discharge characteristics of palliative care patients in an acute care hospital.

This prospective survey was initiated to identify factors that helped and hindered home discharge for 100 consecutive patients who did not require further specialist palliative or acute care. Information was collected on demographics, functional ability (using the Palliative Performance Scale [PPS] and Karnofsky Performance Scale [KPS]), cognitive function at discharge as measured by the Mini-Mental State Examination (MMSE), home support circumstances, and patient and family preference for discharge. 59 patients were discharged home and 41 were transferred to a hospice. Younger patients with younger caregivers were discharged home more often. Patients with better MMSE and better functional ability (PPS and KPS) were also more likely to go home. Patients going home were more likely to be married. Preference for site of discharge was met for 76% of patients and 90% of families. Of the patients going to a hospice, 24% of patients and 7% of families preferred a home discharge. More physical support at home could have facilitated a home discharge for 13 patients. Functionally dependent and cognitively impaired patients were generally unable to return home. To support patients and their families in an environment of their choice, access to increased physical support in the home must be addressed.

Changing i.v. administration sets: is 48 versus 24 hours safe for neutropenic patients with cancer?

PURPOSE/OBJECTIVES: To examine the effects of changing i.v. administration sets at 48 versus 24 hours on the incidence of infusion-related septicemia in neutropenic patients with cancer. DESIGN: Prospective, randomized clinical trial with repeated measures. SETTING: Large urban cancer center. SAMPLE: 50 adult inpatients with a primary diagnosis of hematologic malignancy, breast cancer, or testicular cancer or who were receiving a stem cell transplant. METHOD: Subjects were assigned randomly to have their i.v. sets changed every 48 or 24 hours. Subjects continued in the study for a maximum of five measurements, until they were no longer neutropenic, or until transferred or discharged from the hospital. MAIN RESEARCH VARIABLES: Rates of infusate colonization, microorganisms identified, incidence of infusion-related septicemia. FINDINGS: Colonized infusate was detected in 18 (5%) of 413 i.v. sets; 9 (5%) of 177 sets were changed at 48 hours, and 9 (4%) of 236 sets were changed at 24 hours (p > 0.05). A trend toward increased colonization of i.v. sets used to administer parenteral nutrition (19%) and, to a lesser extent, electrolytes (9%) was identified in the 48-hour group. Coagulase-negative staphylococci were the most frequently isolated microorganisms in the i.v. infusate. Similar organisms were isolated from blood cultures and administration sets, however, no subject had identical organisms isolated from both i.v. infusate and blood cultures. No subject with colonized infusate developed infusion-related septicemia. CONCLUSIONS: No difference existed in the incidence of colonization or infusion-related septicemia between subjects whose i.v. administration sets were changed at 48 versus 24 hours. IMPLICATIONS FOR NURSING PRACTICE: Changing i.v. administration sets every 48 hours is recommended. Exceptions to this include i.v. administration sets used to administer blood products and total parenteral nutrition.

The evolution of caring within bioethics: provision for relationship and context.

Given the complexity of modern health care, there exists an urgent need to discover how best to resolve complex bioethical issues. Traditionally, principle based ethics provided the benchmark for guiding ethical decision-making. More recently, however, it has become apparent that this traditional approach is often inadequate in dealing with current health care dilemmas. The notion of caring was advanced initially as an alternative to, then as a complement to, principle based ethics. In this article, caring is conceptualized as an attitude and is viewed as integral to the advancement of a coherent and integrated moral approach to ethical decision-making. First, a brief historical description of bioethics is presented. Next, an evolutionary account of caring within bioethics is described. Four fundamental problems associated with the use of caring within bioethics are then outlined. Finally, caring as an attitude is delineated and a case study is used to illustrate the proposed conceptualization of caring. The case study demonstrates that a caring attitude provides for relationship and context, which are elements often neglected by traditional approaches.