bluuebunny/crossref_metadata_2025 huggingface dataset:
DOCUMENTATION OF ADVANCE END OF LIFE CARE WISHES IN TWO AUSTRALIAN RESIDENTIAL AGED CARE FACILITIES
Authors: Welz M , Gee W , Workman B , Morton J
Published: April 2013

Background

Healthcare professionals often lack awareness of patients' wishes regarding end-of-life care (EOLC). Existing data suggest low utilisation and poor application rates of advance care directives in Australian residential aged care facilities (RACF).

Southern Health RACFs use separate forms to document advance EOLC wishes, namely advance care wishes (ACW), terminal care wishes (TCW) and resuscitation status, however extent and quality of the documented information is unknown.

Aim

1. To audit the documentation rates of EOLC wishes in two low-level RACF in Victoria, Australia.

2. To assess whether documented EOLC wishes are likely to affect medical care in an emergency department (ED) presentation.

Methods

Retrospective audit of medical records (n=88). Assessment of documented EOLC wishes by a consultant physician with expertise in advance care planning.

Results

ACW including ‘particular wishes’, ‘representatives’ wishes' and ‘cultural/religious EOL needs’ were documented in 78.4, 53.4 and 69.3% respectively.

Completion of TCW (form comprising 11 questions regarding EOLC preferences) ranged between 50–65%.

Resuscitation management plans available in less than 30%. The majority were for those who did not want resuscitation (93%).

Quality of documented EOLC preferences: 66% assessed as likely to influence decisions in the ED. This includes clear wishes for all active care.

Discussion/Conclusion

This audit demonstrates poor documentation of End of Life care wishes in a RACF setting. Healthcare services should prioritise staff and consumer education in this area and improve procedures and forms that provide clear guidelines for the useful documentation of EOL care wishes.
IMPROVING HOME DEATH DOWN UNDER
Authors: Molenaar R
Published: April 2013

Background

The rate of home death of palliative care patients in a Melbourne community based palliative care service has decreased over the last few years. As a result, the service has initiated a 6 month Structured Support Programme (SSP) intervention, completed in November 2012, encompassing a three visit platform of support which will be provided by a Nurse Practitioner Candidate (NPC). Preliminary results will be discussed in this presentation.

Aim

Overall, this study aimed to determine whether a SSP provided by an advanced practice nurse can improve outcomes for patient and caregivers at home compared to regular support from the nursing team. Specific aims are to: improve symptom relief for patients, enhance psychosocial support for patient and carers, facilitate place of death according to patient and carer wishes and articulate a Nurse Practitioner (NP) model supporting complex End of Life (EOL) care.

Methods

The SSP provided by the NPC established both patient and carer needs, from which an anticipatory care plan was developed to provide a platform of future support for the patient and the carer.

Results

47% of patients who had the SSP died at home compared to 33% who did not. 60% of patients who had the SSP died where they wished compared to 33% who did not.

Discussion

This intervention was provided by a NPC, it was possible to identify where an endorsed NP would enhance access to medications

Conclusion

A SSP provided by an advanced practice nurse can improve outcomes for patient and caregivers at home.
CPR: STAT! OR STOP! THE END-OF-LIFE CARE ELECTRONIC RECORD (ELCER)
Authors: Varndell W , Mackenzie J , Sands M B
Published: April 2013

Background

Advance Care Planning is about much more than CPR and the aspiration to support care planning and symptom management to improve care at the end-of-life; empowering and supporting patients in deciding upon what care they wish to receive at the end-of-life, is not controversial. The legal and ethical imperative to abstain from needlessly causing harm and distress from medical intervention is also well established. The real-time availability of an Advance Care Plan in which clinicians and administrators can rightly place their confidence has been more elusive.

Aim

To review the evidence supporting the use of a universal electronic health record such as eHealth (National Electronic Health Transition Authority) for the documentation and communication of ACPs.

Methods

A systematic review of the evidence to support the use of electronic health records in ACP will be presented.

Results

Evidence-based and generalisable approach to documentation and communication of ACP will be presented.

Discussion

Barriers, risks and benefits will be discussed.

Conclusion

Advance Care Planning is vital to medically defensible, rational, compassionate and patient centred care at the end of life. The Australian eHealth platform provides an opportunity to achieve this across primary, secondary, rural, regional and metropolitan healthcare settings.
ENGAGEMENT IN ADVANCE CARE PLANNING: DO REGION-WIDE INTERVENTIONS WORK?
Authors: Tayler C , Hanvey L , Teixeira A A , Barwich D , Baxter S , Heyland D K
Published: April 2013

Background

Prior research suggests that only a small percentage of the general population is involved in ACP.

Aim

To compare engagement in ACP among the general population of Canadian adults with the engagement among adults in a health authority with a region-wide ACP engagement initiative (Fraser Health (FH), British Columbia).

Methods

An on-line opinion poll of a nationally representative sample of 1523 respondents including five questions regarding core ACP activities. Pearson χ2tests were used to compare the prevalence of ACP in FH and the rest of Canada.

Results

Compared to the rest of Canada, respondents from FH had higher levels of ACP awareness (20% against 15%, p=0.025) and higher rates of ACP discussions with family and friends (59% against 51%, p=0.004). However, they had lower rates of written ACPs (15% against 20%, p=0.018).

Discussion

The population of adults in FH tend to talk more with their family and friends about ACP than do adults in the rest of Canada. The fact that a lower number of respondents had written ACPs in FH could be explained by the fact that while FH had engaged professionals and the public around ACP, legislation supporting ACP was only recently declared.

Conclusion

Engagement with the public by a health authority makes a difference in the levels of ACP awareness and discussions with family and friends. However, regulatory frames need to be in place in order to provide optimal support to ACP interventions.
DOES LAW HAVE A ROLE TO PLAY IN ADVANCE CARE PLANNING?
Authors: White B P
Published: April 2013

Background

The role of law in end of life care is vexed. Legal risk (or perceptions of it) can impede good end of life care through defensive medicine, and legal processes can be slow to respond to clinical need. Some also argue that legal considerations are not part of clinical decision-making at the end of life. Yet an integral part of the regulatory framework on which advance care planning is based is at least partly sourced in law.

Aim

To consider how law can support advance care planning and end of life care.

Discussion

Although there are clear limits on what law can achieve, there are good reasons to co-opt law into advance care planning in a deliberate and structured way. Principled reasons include that law is a reflection of community values. More pragmatic considerations include that the involvement of law cannot be avoided as part of advance care planning and end of life care.

Conclusion

If a role for law is inevitable in advance care planning and end of life care, we should acknowledge this and grapple with it squarely. This requires end of life policies to include legal considerations and accurately represent them, and for clinicians to be supported to know and navigate the law. Where law fails to support good end of life care, this should be addressed directly and the law reformed. Ongoing dialogue between health and legal professionals to achieve this is needed.
DECIDING FOR OTHERS: A CLINICIAN'S VIEW
Authors: Saul P
Published: April 2013

Background

The majority of people in Australia die in acute care. Up to 95% of them will lack capacity to make treatment decisions at the end of life, and these decisions will be made by uninformed family members and caring strangers.

Methods

But what do we know about deciding for others? Two sources of knowledge come to mind—empirical evidence from surveys and other scientific investigations, and philosophical explorations of advance statements, substituted judgments and best interests. The empirical evidence suggests that people differ considerably in the extent to which they wish to decide for others, that they are skeptical about the medical information they are given, that they have a low awareness of the likely preferences of the person they are deciding for, and that they do not accept the hierarchies of the various legal provisions. In legal terms, then, deciding for others rests on somewhat uncertain ground, especially when the decision to be made is about the end of life.

Discussion

Legislation about deciding for others at EOL has a number of functions—principally (and wholly in the case of NSW) to protect the vulnerable. Other functions: providing standardised forms as evidence of prior wishes, indemnifying doctors who follow these wishes, and providing some guidance about best interests decisions, are variably included in different jurisdictions.

Conclusion

But what do clinicians want? I would suggest: recognition of the need to make EOL decisions on behalf of others, of the need to protect vulnerable people from reckless overtreatment as well as undertreatment, clarification of the role of the family, regular review, transparency of decisions in tribunals, a process for establishing the validity of directives, and harmony with adjacent jurisdictions. This paper reviews current efforts from the UK and Australia, and suggests some lobbying may be required.
EXAMINING ADVANCE CARE DIRECTIVE (ACD) LAW AND POLICY FRAMEWORK FUNCTIONALITY IN THE CONTEXT OF NURSES AND AMBULANCE OFFICES/PARAMEDICS ADHERENCE TO ACD CPR REFUSALS
Authors: Seal M
Published: April 2013

Background

Australian States and Territories are called to align ACD legislation with common law principles. However, little is known about the functionality of different ACD frameworks when Nurses or Ambulance Officers/Paramedics attend a situation when an ACD CPR refusal might apply.

Aim

To construct a working picture of the different ACD legislative and policy frameworks currently operating in Australia and other countries under Westminster systems.

Methods

An ACD law, policy and outcome table was constructed summarising each jurisdictions' ACD operational parameters, who is authorised to implement ACD, and any ACD adherence research.

Results

ACD operation parameters varied from: requiring a medical condition to which the refusal related; only applying in the terminal phase, to any period of incapacity nominated by the person as under common law. Policy examples under prescriptive law usually authorised all health professionals could implement ACD. Under permissive law, even with policy support, a preference for community `Not-For-CPR' medical orders was evident. There was little empirical research about ACD adherence in the context under examination.

Discussion

Legislative and policy framework affects ACD scope and delivery. Most with broad ACD application parameters also used community `Not-For-CPR' orders, reverting to medical oversight. Others appeared effective in delivery but excluded some people from making ACD.

Conclusion

The table illustrated a large variation between jurisdictions and that research is needed to determine whether there is a relationship between adherence to ACD CPR refusals and the type of ACD framework. This knowledge could help optimise ACD adherence and application across all settings.
TO MET OR NOT TO MET: THAT IS THE QUESTION!
Authors: Sulistio M , Vo A , Franco M
Published: April 2013

Background

The Medical Emergency Team (MET) aim to identify clinically deteriorating patients to provide early intervention and prevent negative outcomes. However, for a proportion of these patients (ie, patients who are expectedly dying) continued intervention is ‘medically futile’ and unwanted by the patient and/or next-of-kin. Although diagnosing dying can be complex and challenging, it is an important step to establish appropriate goal of care, avoid futile medical intervention and allow a ‘good death’.

Expectedly dying$Not expected to dieGOC#changedGOC#unchangedIncidents (patients)
AH^(%)
▸ Multiple/admit (%)47 (38)
31 (66%)
22 (47%)409 (318)
241 (59%)
161 (39%)104 (95)
60 (58%)
42 (40%)352 (282)
212 (60%)
141 (40%)Demographics
Age (Range)
Male%
▸ From HLC%*
72.05 (28–96)
50%
18%
66.7 (18–95)
56%
5.3%
76.9 (31–96)
61%
19%
64.7 (18–96)
51%
4%Admission (%)
Medical
▸ AH^
70%
61%
66%
54%
77%
55%
63%
54%Life-limiting illness (%)
Malignant
▸ Non-malignant
21%
47%
13%
31%
25%
49%
10.8%
33%Outcome (%)
Death
▸ Altered SOC&
74%
2.6%
20%
25.5%
53%
25%
19%
13.8%

$Patients with 2 out of 4 clinical observations prior to incident (taking sips of fluid only, unable to swallow medications, bed-bound, semi-comatose)#Goal of care ^After hours (weekend/public holiday and weekday outside of 0800–1700 h) *High level care&Site of Care (rehabilitation, residential care facility or inter-hospital transfer).

Aim

To determine the incidence of MET or Code Blues on patients who were expectedly dying.

To identify patient's, clinician's or institution's variables that result in the occurrence of such incidents

Methods

Retrospective 3 months audit of MET and code blue occurring on all Southern Health inpatients with onsite access to ICU support (Monash Medical Centre Clayton, Jessie McPherson Private Hospital, and Dandenong Hospital). Medical records were reviewed to collect patient demographics, admission and incident details, existing life limiting diagnosis, resuscitation and limitation of medical therapy status, clinical observations that may suggest terminal phase$, and documentation of communication with patient's next-of-kin.

Results

A total of 456 incidents on 351 adult patients are analysed.

Conclusion

A significant proportion of MET (10%) in a major hospital network may have been avoided if dying patients were better identified and the documentation of the goals of care was clearer. More such incidents occurred out of business hours than within hours. These results should encourage prospective study into what further measures could reduce this proportion of incidents.
THE REUNIFICATION EXPECTATIONS OF ESTRANGED ELDERS TOWARDS THE END OF LIFE
Authors: Agllias K
Published: April 2013

Background

Intergenerational estrangement is not uncommon in later life families. While the response to estrangement can range from relief to devastation, many older people feel a need to ‘make things right’ before their death.

Aim

To examine the experience of parents estranged from at least one adult child in later life, with a focus on preparations for end of life and reunification expectations.

Methods

This paper reports primarily on a qualitative study conducted between 2009 and 2010—which utilised two in-depth interviews and diaries—with 25 older people estranged from at least one adult child.

Results

The majority of participants described a desire to reunify before end of life. Indeed, later life events such as illness, the death of a friend, or one's own impending death often triggered an intense need to attend to wills, determine legacy items, write letters and maybe even reunify with an estranged child. While participants expected their estranged child to come to their bedside if they—or their spouse—became critically ill, their actual experiences of this eventuality were mostly of non-reunification and a significant grief response ensued.

Discussion

The ambiguous nature of intergenerational estrangement and its social disenfranchisement often intensifies the grief and loss associated with it. Later life is a period when ‘making sense’ or ‘meaning’ of estrangement can be particularly pertinent.

Conclusion

This study suggests a significant role for allied health and human service workers in the preparation of estranged older people for the end of life regardless of reunification possibilities.
ETHICAL AND EFFECTIVE ADVANCE CARE PLANNING
Authors: Savulescu J
Published: April 2013

I will outline the principles of ethical and effective advance care planning both for children and adults. I will outline the range of interventions which can be withheld or withdrawn, including feeding and hydration. I will outline the concept of values-based advance care planning and its relevance to context-specific medical decisions. I will show how people have a de facto right to euthanasia through the advance refusal of feeding and hydration.
IS IT ETHICAL NOT TO DO ADVANCE CARE PLANNING?
Authors:   TBC
Published: April 2013

No abstract
THE SAFETY AND QUALITY OF END OF LIFE CARE IN AUSTRALIAN ACUTE HEALTH SERVICES: A REPORT ON PRELIMINARY CONSULTATION INTERVIEWS WITH CONSUMERS, CLINICIANS, HOSPITAL EXECUTIVES AND GOVERNMENT POLICY-MAKERS
Authors: Hill J , Dunbar N
Published: April 2013

Background

During the course of the Commission's work on recognising and responding to clinical deterioration, it became clear that people who are dying in acute health services do not always receive appropriate end of life care. To scope the issues and identify where the Commission might contribute to improving the quality and safety of end of life care in acute health services, preliminary consultation was carried out.

Aim

The primary aims of the preliminary consultation were to identify and explore issues that affect the safety and quality of end of life and terminal care in acute health services in Australia and identify current approaches to improvement.

Methods

A series of focus group and individual interviews were conducted with consumers, clinicians, hospital executives and policy makers at state and commonwealth level.

Results

Themes emerging from consultation interviews include: poor recognition of dying by clinicians, and a subsequent lack of timely and appropriate decision-making; ambiguity in the meaning assigned to terms describing end of life, palliative and terminal care; fears held by clinicians; difficulty talking about dying; tensions between paternalistic models of care and patient autonomy; and the absence of pathways for escalating concerns regarding end of life care for patients dying in hospital.

Discussion

The quality and safety of end of life care in Australian acute health services is variable and frequently sub-optimal because of multiple complex and interlinked individual and systemic factors.

Conclusion

A formal consultation paper is being developed to test the findings and recommendations of the preliminary consultation more broadly.
SHOULD ACP BE SPECIFICALLY FUNDED?
Authors: Kearney J
Published: April 2013

No abstract
LIVING WELL DYING WELL: PUTTING THESE WORDS INTO ACTION
Authors: Larpent Andrew , Davidson-Park B , McCallum S , Price K , Evans D , Ullrich S , Williamson P
Published: April 2013

Background

Providing quality end of life care in residential aged care (RAC) is influenced by multiple drivers including the workforce to deliver care. Older Australians rank palliative care and dying with dignity as major issues requiring future aged care workforce reform.

Aim

This presentation will outline the new workforce model to be developed through theLiving Well Dying Wellproject. Key objectives and examples of case studies will illustrate how:

To implement a targeted education programme that focuses on all staff at Southern Cross Care.

To create a better workforce balance.

To harness a cultural shift amongst all involved to establish a partnership approach.

To build leadership for change and sustainability of the new workforce model.

To provide quality end of life care in RAC.

Methods

Outcome Mapping is being used as a change management tool and a developmental evaluation methodology to assist Southern Cross Care to successfully implement theLiving Well Dying Wellproject. It ensures a logical, participatory and reflective set of steps so as to address the complexity of the project in the context of RAC.

Results

The project is currently in development stage therefore this presentation will focus on the change management process, the ‘End of Life’ model of service delivery that is underpinning the workforce reform and challenges along the way.

Discussion

The project is possible due to funding by Health Workforce Australia. It is ensuring positive and open attitudes towards death and dying to enable all residents and their families the choice and dignity that is integral to living well and dying well in RAC.

Conclusion

At Southern Cross Care we are thinking more systematically and pragmatically about how our workforce provide advance care planning and end of life care. We are already translating our thinking about how to do it, to bring about the desired outcomes, into action.
EMBEDDING ADVANCE CARE PLANNING (ACP) BEST PRACTICES IN LONG TERM CARE FACILITIES (LTC): GIVING ACP ITS BEST CHANCE
Authors: Iversen S , Berg B , Simon J
Published: April 2013

Background

LTC residents frequently have cognitive impairment, are at risk of intercurrent illnesses and being unable to express their preferences when medical decisions need to be made. Consequently, ACP in LTC often requires staff and family participating with/on behalf of the resident makingadvancedecisions about intent of care and use of hospital services should a sudden deterioration arise. It is not known how best to embed such ACP in the fabric of LTC delivery.

Aim

To use an Inquiry to Action project, including patient/family survey, to describe the strengths and challenges of ACP in LTC and inform best practices for embedding ACP in LTC

Methods

Using a quality improvement initiative ‘Inquiry to Action’ akin to the qualitative Action Research, a nurse educator sought to understand how ACP occurs in three urban LTC and to develop a plan of action to improve the quality and frequency of LTC ACP communication. In addition we adapted and piloted a validated survey from acute care (ACCEPT), to collect perspectives on ACP of residents and their family.

Results

The commitment to ACP from facility leaders and staff varied with local context. We will describe facility strategies and work flow processes that family, residents and staff reported as facilitative or challenging to ACP.

Conclusion

An implementation framework, adaptable to local context, was created of best practice suggestions related to organisational and business processes, resident and family member engagement, ongoing staff education and continuous quality improvement.
IMPLEMENTING A NATIONAL ADVANCE CARE PLANNING (ACP) PROGRAMME IN SINGAPORE
Authors: Chung I , Wong C , Oh C , Ho S Y
Published: April 2013

Background

Since its inception in 2011, ACP has steadily gained traction among healthcare providers in rapidly ageing Singapore. Efforts to implement ACP, beginning with public hospitals, are spearheaded by a National ACP Steering Committee, in collaboration with service providers and government agencies. However public awareness remains low. This poster examines the key thrusts, outcomes, and challenges in assimilating ACP in our system of care.

Aim

To share Singapore's experience in implementing ACP nationally, with considerations such as its diverse cultural and ethnic composition, family structures that tend to place familial harmony over autonomy, and lack of communication on end of life matters.

Methods

ACP is implemented along 3 thrusts: (i) Increasing ACP awareness among healthcare professionals, community and religious leaders, and the public; (ii) Training more ACP facilitators in health and social care organisations to assist with ACP conversations; and (iii) Building and strengthening systems to support ACP implementation, including a national ACP IT system.

Results

Over 450 facilitators have been trained. Pilots are on-going in five public hospitals, in departments such as Palliative Medicine, Cardiology, Oncology and Respiratory Medicine.

Discussion

With plans to improve health and social support for aged persons in the community, greater emphasis must be placed on developing ACP services among providers of intermediate and long-term care. Community engagement, media advocacy and publicity also need to be in place to raise awareness and normalise conversations in care planning.

Conclusion

In tandem with the growth of ACP at acute and community settings, greater engagement and empowerment of providers and the public must also happen.
PRACTICE OF CONSULTATION FOR ADVANCE DIRECTIVES IN GERMANY: A PILOT STUDY OF CONSULTANTS TRAINED BY A BAVARIAN HOSPICE ACADEMY
Authors: Petri S , Marckmann G
Published: April 2013

Background

Apart from the pilot projectbeizeiten begleiten, Advance Care Planning (ACP) programmes are still not widely implemeted in Germany. There is, however, an increasing number of organisations and individuals offering consultation for advance directives (ADs). So far, there is hardly any knowledge about their consulting profile and thereby the quality of ACP in Germany.

Aim

To assess the current status of organisation, actual practice and possible improvement of AD-consultation in Germany and thereby the need for structured ACP-programmes.

Methods

A pilot study using a written questionnaire (Likert-Scale) completed by 33 consultants participating in a follow-up meeting of a Bavarian Hospice Academy.

Results

A typical consultation is initated by the consulted individual himself, often by family or friends, rarely by stationary facilities. It takes between 60–90 min (73%) and includes one meeting (61%). The age of the consults is predominately between 61–80 years. 27% of the participants have no or rarely knowledge about the health status of the consults. 97% use the same form for AD (Bavarian State Ministery of Justice), 100% inform about a proper custody. 91% suggest to invite a person of trust and report positive experiences of such an involvement. They never or rarely (64%) exchange with other care providers.

Discussion

The results of this pilot study show that these current AD consultation practices do not yet fully meet the quality criteria of international ACP-programmes (eg, initiate conversations, ACP process with several meetings, planning with health care provider).

Conclusion

It underlines the need for more comprehensive ACP-programmes.
AN EXPLORATORY STUDY ON THE VIEWS OF CANCER PATIENTS' INFORMAL CAREGIVERS ABOUT ADVANCE CARE PLANNING
Authors: Michael N , Hiscock N , Baird A , O'Callaghan C
Published: April 2013

Background

In oncology, informal caregivers often partake in patient-medical consultations and treatment decision making, yet little is known about their views on advance care planning (ACP). Understanding what caregivers want to communicate with cancer patients and health workers, regarding advance care wishes and goals, may complement and potentially further advance the development of an appropriate ACP framework in an integrative cancer centre.

Aim

To understand caregivers' perspectives about ACP in relation to potential limitations, barriers, and facilitators of communication that may exist between patients and themselves.

Methods

Constructivist approach with grounded theory design. Participants participated in either focus groups (13) or semi-structured interviews (5), assisted by the vignette technique. Qualitative inter-rater reliability was integrated.

Results

Eighteen caregivers (13 female; mean 49.1 years) of 17 patients from lung (5) and gastro-intestinal (12) tumour streams participated. 24 declined participation. Caregivers' difficulties in approaching ACP can relate to information access, mismatched desires with patients for conversations, competing care roles, and its confrontational nature. Caregivers may also have a role in supporting patients through careful initiation of discussions and/or their own ‘provisional ACPs’. Many participants requested caregiver specific ACP information and recommended support to help them assist patients with ACP, or their caring when patients decline ACP.

Discussion

Caregivers can be conduits through which hospitals can assist oncology patients to approach ACP.

Conclusion

This study supports development of an ACP framework which recognises opportunities for caregiver involvement through providing information and support which helps them to sensitively initiate ACP discussions with patients.
DESIGNING FOR DEMENTIA AND PALLIATIVE CARE: A REVIEW
Authors: O'Brien D
Published: April 2013

Background

With a global shift towards the concept ofAging in Place,aged care facilities will increasingly be occupied by the physically frail, those suffering from late stage dementia and those seeking palliative care outside of the home. We ask what role the built environment will play in this context and how useful are current Australian design guidelines?

Aims

Review current Australian design guidelines.

Review global research literature and design precedents.

Develop a strategy for integration of ongoing research into the design process.

Methods

We assessed available design guidelines in Victoria, NSW and South Australia against 312 peer reviewed papers from the fields of sociology, gerontology and neurophysiology and architecture.

Results

A growing body of evidence supports the hypothesis that the design of aged care environments has a direct impact on the experience and treatment of dementia patients and also on the well-being of staff. Australian design guidelines however are aspirational, problem-focussed and lack detailed reference to this evidence-base.

Discussion

Available evidence can radically improve current design guidelines; however it must be recognised that the data has primarily come from non-randomised, short-term research projects.

Conclusion

Co-ordinated, longitudinal and randomised research is required to continuously improve the evidence base. We contend that this paradigm shift can only occur if stimulated by aged care providers and integrated into architectural practice.
QUALITY OF END-OF-LIFE CARE
Authors: Hussin E , Omar E , Subramanian P , Wong L P
Published: April 2013

Background

Critical care units (ICU) have been designed to provide highly skilled, lifesaving care for patients with acute illnesses or injuries. The mortality rate in the ICU still remains as a high rate comparing to the general word (Steinhauseret al., 2002). Having a good quality of end of life care (EOLC) is a common wish for patients who dying in the ICU. Quality of EOLC is the most popular measure to evaluate the quality of care provided to critically ill patients in the critical care units.

Aim

This paper aimed to systematically review original studies of quality of EOLC and appraise their quality.

Method

Only the original Studies that concerned on the quality of EOLC were included. Words like quality of EOLC, quality of dying and death were used to search in Midline and Ovid online data bases.

Result

Forty-nine studies met the selection criteria. These 31 quantitative, 16 qualitative and 2 mixed method studies identified different level of satisfaction to the quality of EOLC.

Discussion

The quality of EOLC still need to improve and barriers such as communication, lack of education and experiences, pain management, high expectations of families and environmental circumstances stile hindered the quality of EOLC.

Conclusion

different studies were conducted using different measures and methods to understand the quality of EOLC; however, further studies to identify the best strategies to improve EOLC are needed.
QUALITY OF END OF LIFE FOR LONG- TERM VENTILATED ADULTS WITH TRACHEOSTOMY AND THEIR FAMILIES- A PRACTICAL SOLUTION AND PRACTICAL INTRODUCTION
Authors: Hutzel P
Published: April 2013

Background

Based on clinical experience in Intensive Care, as well as experience in the Intensive Home Care setting in Germany, a number of long-term ventilated Adults with Tracheostomy can be provided with Quality of end of Life at Home rather than in ICU.

Aim

The provision of Intensive Home Care Nursing services for Patients and Families who wish to die at Home, with a holistic focus on Patients and Families needs. Furthermore, Intensive Home Care is a cost effective model compared to the provision of Hospital ICU services

Methods

The provision of Intensive Home Care Nursing services for long-term ventilated Patients with Tracheostomy and their Families as a genuine alternative to ICU. This model is based on the service provision of an accredited Australian Intensive Home Care service provider. The service model is based on successful Home Intensive Care services in Germany.

Results

Quality of end of Life for Patients and their Families in their own home as a genuine alternative to ICU, as well as cost effectiveness and effective resource management for ICU's

Discussion

Using a dedicated and accredited Intensive Home Care Service provides Patients and their Families with a genuine alternative to Intensive Care whilst also freeing up expensive and scarce ICU beds.

Conclusion

Considering more people want to die at home if given the choice, in combination with the continued high demand for scarce and expensive ICU beds, Intensive Home Care services are a genuine alternative for the provision of Quality of end of Life services for long term ventilated Patients and their Families.
‘WE ALL NEED SOMEBODY TO LEAN ON’: SUPPORTED DECISION-MAKING, LAW REFORM AND MENTAL HEALTH CARE
Authors: McSherry B
Published: April 2013

When faced with significant life decisions most people will consult with and seek the support of others. Yet laws relating to decision-making in health care are generally couched in terms of individual rights to consent to or refuse treatment with no mention of the involvement of carers, friends, partners or family members. In relation to individuals with severe mental health problems, laws enabling involuntary detention and treatment are usually based on a model of substituted decision-making whereby psychiatrists make decisions about treatment providing certain criteria are met. The advent of the United Nations Convention on the Rights of Persons with Disabilities has provided the impetus for the exploration of supported decision-making models in mental health care including psychiatric advance directives. This presentation looks at recent law reform endeavours to take into account the preferences of those with severe mental health problems and to provide for supported rather than substituted decision-making wherever possible.
Republished: Managing the after effects of serious patient safety incidents in the NHS: an online survey study
Authors: Pinto Anna , Faiz Omar , Vincent Charles
Published: April 2013

Objective

To examine the current state of practice in English NHS Trusts in relation to the communication of serious patient safety incidents to patients and families and support for all parties involved.

Design

Cross-sectional design using online surveys.

Participants

209 patient safety managers, responsible for the ‘Being Open’ policy (54% response rate).

Setting

English NHS Trusts.

Results

98% of the participants reported that they are familiar with the National Patient Safety Agency Being Open guidance and 82% that they implement it more than half the time when incidents occur. However, provision of timely information was not reported as routine, with two-thirds of the discussions taking place 3–6 weeks after the investigation. The frequency of taking responsibility for harm was low for incidents of different severity levels but significantly lower for less serious ones (p<0.001). Follow-ups of patients in the long term and ex gratia payments were provided less than half the time. The most highly rated barriers to being open were clinical staff's fear of negative reactions from patients or their families and anxiety about litigation. Support practices for staff, such as debriefing and training on being open, were acknowledged as highly important but not always available.

Conclusions

Awareness of the importance of being open is high among patient safety managers in English NHS Trusts, but there is still considerable scope for improvement in the management of the after effects of patient safety incidents. More research is needed on patients' and healthcare professionals' preferences for support after patient safety incidents.
PRIVACY-PRESERVING RANDOM PROJECTION-BASED RECOMMENDATIONS BASED ON DISTRIBUTED DATA
Authors: KALELI CIHAN , POLAT HUSEYIN
Published: April 2013

Providing recommendations based on distributed data has received an increasing amount of attention because it offers several advantages. Online vendors who face problems caused by a limited amount of available data want to offer predictions based on distributed data collaboratively because they can surmount problems such as cold start, limited coverage, and unsatisfactory accuracy through partnerships. It is relatively easy to produce referrals based on distributed data when privacy is not a concern. However, concerns regarding the protection of private data, financial fears due to revealing valuable assets, and legal regulations imposed by various organizations prevent companies from forming collaborations. In this study, we propose to use random projection to protect online vendors' privacy while still providing accurate predictions from distributed data without sacrificing online performance. We utilize random projection to eliminate the aforementioned issues so vendors can work in partnerships. We suggest privacy-preserving schemes to offer recommendations based on vertically or horizontally partitioned data among multiple companies. The recommended methods are analyzed in terms of confidentiality. We also analyze the superfluous loads caused by privacy concerns. Finally, we perform real data-based trials to evaluate the accuracy of the proposed schemes. The results of our analyses show that our methods preserve privacy, cause insignificant overheads, and offer accurate predictions.
Acute peripheral tissue effects of ghrelin on interstitial levels of glucose, glycerol, and lactate: a microdialysis study in healthy human subjects
Authors: Vestergaard Esben Thyssen , Møller Niels , Jørgensen Jens Otto Lunde
Published: April 2013

Ghrelin is a gut-derived peptide and an endogenous ligand for the ghrelin receptor. Intravenous infusion of ghrelin induces insulin resistance and hyperglycemia and increases circulating levels of nonesterified free fatty acids. Our objective was to investigate whether the metabolic effects are mediated directly by ghrelin in skeletal muscle and adipose (peripheral and central) tissues. Ten healthy men (24.9 ± 1.3 yr) received 300 min of supraphysiological ghrelin administration by microdialysis catheters in skeletal muscle and adipose tissues in a randomized, single-blind, and placebo-controlled study. Microdialysis perfusates were analyzed every 30 min for glucose, glycerol, and lactate during both a basal period and a hyperinsulinemic euglycemic clamp. The primary outcome measures were interstitial concentrations of glucose, glycerol, and lactate in skeletal muscle and adipose tissues. Interstitial concentrations of glucose were similar in skeletal muscle, peripheral, and central adipose tissue in the basal period. During hyperinsulinemia, interstitial concentrations of glucose in skeletal muscle decreased in response to ghrelin exposure [2.84 ± 0.25 (ghrelin) vs. 3.06 ± 0.26 mmol/l (placebo), P = 0.04]. Ghrelin exposure did not impact on interstitial concentrations of glycerol and lactate. We conclude that ghrelin administration into skeletal muscle decreases interstitial concentrations of glucose during euglycemic hyperinsulinemia, which is indicative of increased insulin sensitivity without any effects on interstitial glycerol levels in either muscle or adipose tissue. These data contrast with the metabolic effects of ghrelin observed after systemic exposure and suggest the existence of a second messenger that remains to be identified.
Upregulation of p21 activates the intrinsic apoptotic pathway in β-cells
Authors: Hernandez Angelina M. , Colvin E. Scott , Chen Yi-Chun , Geiss Steven L. , Eller Lindsay E. , Fueger Patrick T.
Published: April 2013

Diabetes manifests from a loss in functional β-cell mass, which is regulated by a dynamic balance of various cellular processes, including β-cell growth, proliferation, and death as well as secretory function. The cell cycle machinery comprised of cyclins, kinases, and inhibitors regulates proliferation. However, their involvement during β-cell stress during the development of diabetes is not well understood. Interestingly, in a screen of multiple cell cycle inhibitors, p21 was dramatically upregulated in INS-1-derived 832/13 cells and rodent islets by two pharmacological inducers of β-cell stress, dexamethasone and thapsigargin. We hypothesized that β-cell stress upregulates p21 to activate the apoptotic pathway and suppress cell survival signaling. To this end, p21 was adenovirally overexpressed in pancreatic rat islets and 832/13 cells. As expected, p21 overexpression resulted in decreased [3H]thymidine incorporation. Flow cytometry analysis in p21-transduced 832/13 cells verified lower replication, as indicated by a decreased cell population in the S phase and a block in G2/M transition. The sub-G0 cell population was higher with p21 overexpression and was attributable to apoptosis, as demonstrated by increased annexin-positive stained cells and cleaved caspase-3 protein. p21-mediated caspase-3 cleavage was inhibited by either overexpression of the antiapoptotic mitochondrial protein Bcl-2 or siRNA-mediated suppression of the proapoptotic proteins Bax and Bak. Therefore, an intact intrinsic apoptotic pathway is central for p21-mediated cell death. In summary, our findings indicate that β-cell apoptosis can be triggered by p21 during stress and is thus a potential target to inhibit for protection of functional β-cell mass.
Responses of MST neurons to plaid stimuli
Authors: Khawaja Farhan A. , Liu Liu D. , Pack Christopher C.
Published: April 2013

The estimation of motion information from retinal input is a fundamental function of the primate dorsal visual pathway. Previous work has shown that this function involves multiple cortical areas, with each area integrating information from its predecessors. Compared with neurons in the primary visual cortex (V1), neurons in the middle temporal (MT) area more faithfully represent the velocity of plaid stimuli, and the observation of this pattern selectivity has led to two-stage models in which MT neurons integrate the outputs of component-selective V1 neurons. Motion integration in these models is generally complemented by motion opponency, which refines velocity selectivity. Area MT projects to a third stage of motion processing, the medial superior temporal (MST) area, but surprisingly little is known about MST responses to plaid stimuli. Here we show that increased pattern selectivity in MST is associated with greater prevalence of the mechanisms implemented by two-stage MT models: Compared with MT neurons, MST neurons integrate motion components to a greater degree and exhibit evidence of stronger motion opponency. Moreover, when tested with more challenging unikinetic plaid stimuli, an appreciable percentage of MST neurons are pattern selective, while such selectivity is rare in MT. Surprisingly, increased motion integration is found in MST even for transparent plaid stimuli, which are not typically integrated perceptually. Thus the relationship between MST and MT is qualitatively similar to that between MT and V1, as repeated application of basic motion mechanisms leads to novel selectivities at each stage along the pathway.
Electroacupuncture Reduces Cocaine-Induced Seizures and Mortality in Mice
Authors: Chen Yi-Hung , Ivanic Boris , Chuang Chieh-Min , Lu Dah-Yuu , Lin Jaung-Geng
Published: April 2013

The aims of this study were to characterize the protective profile of electroacupuncture (EA) on cocaine-induced seizures and mortality in mice. Mice were treated with EA (2 Hz, 50 Hz, and 100 Hz), or they underwent needle insertion without anesthesia at the Dazhui (GV14) and Baihui (GV20) acupoints before cocaine administration. EA at 50 Hz applied to GV14 and GV20 significantly reduced the seizure severity induced by a single dose of cocaine (75 mg/kg; i.p.). Furthermore, needle insertion into GV14 and GV20 and EA at 2 Hz and 50 Hz at both acupoints significantly reduced the mortality rate induced by a single lethal dose of cocaine (125 mg/kg; i.p.). In the sham control group, EA at 50 Hz applied to bilateral Tianzong (SI11) acupoints had no protective effects against cocaine. In addition, EA at 50 Hz applied to GV14 and GV20 failed to reduce the incidence of seizures and mortality induced by the local anesthetic procaine. In an immunohistochemistry study, EA (50 Hz) pretreatment at GV14 and GV20 decreased cocaine (75 mg/kg; i.p.)-induced c-Fos expression in the paraventricular thalamus. While the dopamine D3receptor antagonist, SB-277011-A (30 mg/kg; s.c), did not by itself affect cocaine-induced seizure severity, it prevented the effects of EA on cocaine-induced seizures. These results suggest that EA alleviates cocaine-induced seizures and mortality and that the dopamine D3receptor is involved, at least in part, in the anticonvulsant effects of EA in mice.
Osteoporosis Associated with Antipsychotic Treatment in Schizophrenia
Authors: Wu Haishan , Deng Lu , Zhao Lipin , Zhao Jingping , Li Lehua , Chen Jindong
Published: April 2013

Schizophrenia is one of the most common global mental diseases, with prevalence of 1%. Patients with schizophrenia are predisposed to diabetes, coronary heart disease, hypertension, and osteoporosis, than the normal. In comparison with the metabolic syndrome, for instance, there are little reports about osteoporosis which occurs secondary to antipsychotic-induced hyperprolactinaemia. There are extensive recent works of literature indicating that osteoporosis is associated with schizophrenia particularly in patients under psychotropic medication therapy. As osteoporotic fractures cause significantly increased morbidity and mortality, it is quite necessary to raise the awareness and understanding of the impact of antipsychotic-induced hyperprolactinaemia on physical health in schizophrenia. In this paper, we will review the relationship between schizophrenia, antipsychotic medication, hyperprolactinaemia, and osteoporosis.
The Modulation of Error Processing in the Medial Frontal Cortex by Transcranial Direct Current Stimulation
Authors: Bellaïche Lisa , Asthana Manish , Ehlis Ann-Christine , Polak Thomas , Herrmann Martin J.
Published: April 2013

Background. In order to prevent future errors, we constantly control our behavior for discrepancies between the expected (i.e., intended) and the real action outcome and continuously adjust our behavior accordingly. Neurophysiological correlates of this action-monitoring process can be studied with event-related potentials (error-related negativity (ERN) and error positivity (Pe)) originating from the medial prefrontal cortex (mPFC). Patients with neuropsychiatric diseases often show performance monitoring dysfunctions potentially caused by pathological changes of cortical excitability; therefore, a modulation of the underlying neuronal activity might be a valuable therapeutic tool. One technique which allows us to explore cortical modulation of neural networks is transcranial direct current stimulation (tDCS). Therefore, we tested the effect of medial-prefrontal tDCS on error-monitoring potentials in 48 healthy subjects randomly assigned to anodal, cathodal, or sham stimulation. Results. We found that cathodal stimulation attenuated Pe amplitudes compared to both anodal and sham stimulation, but no effect for the ERN. Conclusions. Our results indicate that cathodal tDCS over the mPFC results in an attenuated cortical excitability leading to decreased Pe amplitudes. We therefore conclude that tDCS has a neuromodulatory effect on error-monitoring systems suggesting a future approach to modify the sensitivity of corresponding neural networks in patients with action-monitoring deficits.