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PubMedDate not supplied

Do not attempt resuscitation decisions: the nursing role.

This exploratory study examines the roles of practice nurses with regard to do not attempt resuscitation (DNAR) decisions. The British Medical Association (BMA) and the Royal College of Nursing (RCN) have published joint DNAR guidelines. One NHS trust responded by developing a local DNAR policy written for use in hospital and general practice. The study focuses on aspects of compliance with the policy and hence DNAR decision-making, in particular, the nurse's involvement in the decision-making process. The response rate to self-administered questionnaires to practice nurses was 52% (n = 45). Hospital nurses (n = 49) were selected for interview using a quota-sampling technique. Comparisons were made of the views of acute and community staff in their use of the DNAR policy. A clear finding is that hospital nurses wish for more autonomy in DNAR decision-making and improved methods of communicating with medical colleagues when decisions are made. Practice nurses are currently not involved in DNAR decisions. The appropriateness of developing policies for such complex issues as DNAR, when compliance remains low, questions their validity. This study raises awareness, and adds to the discussion for the need for a multidisciplinary approach to DNAR policy.

Clinical Nursing Research↗
PubMed1998

Development of an approach to estimating mid- to long-term critical loads for radiocaesium contamination of cow milk in western Europe.

This paper describes the application of the critical load methodology, developed to set emission targets for atmospheric pollutants, to radioecology. The critical load can be redefined within radioecology as the radionuclide deposition at which radionuclide activity concentrations in a specified food product will exceed the maximum permitted level. An empirically based approach is described which provides estimates of critical load values for cow milk in the mid- to long-term after an accident when soil-to-plant transfer of radiocaesium is largely responsible for plant radiocaesium contamination. The areas identified as being most potentially vulnerable to radiocaesium deposition using this approach are those with extensive areas of organic soils such as western Scotland, parts of Ireland, The Netherlands and Denmark. The classification of European soil types into soil groups with significantly different soil-to-plant transfer of radiocaesium, and the allocation of a transfer value to each soil group provide the greatest uncertainties within this approach. Potential problems and deficiencies affecting the estimation of parameter values are discussed.

Animals↗
PubMed2001

The effect of explicit financial incentives on physician behavior.

Managed care organizations use explicit financial incentives to influence physicians' use of resources. This has contributed to concerns regarding conflicts of interest for physicians and adverse effects on the quality of patient care. In light of recent publicized legislative and legal battles about this issue, we reviewed the literature and analyzed studies that examine the effect of these explicit financial incentives on the behavior of physicians. The method used to undertake the literature review followed the approach set forth in the Cochrane Collaboration handbook. Our literature review revealed a paucity of data on the effect of explicit financial incentives. Based on this limited evidence, explicit incentives that place individual physicians at financial risk appear to be effective in reducing physician resource use. However, the empirical evidence regarding the effectiveness of bonus payments on physician resource use is mixed. Similarly, our review revealed mixed effects of the influence of explicit financial incentives on the quality of patient care. The effect of explicit financial incentives on physician behavior is complicated by a lack of understanding of the incentive structure by the managed care organization and the physician. The lack of a universally acceptable definition of quality renders it important that future researchers identify the term explicitly.

Attitude of Health Personnel↗
PubMed2001

Exploring caring using narrative methodology: an analysis of the approach.

The investigation of caring in nursing practice and the need to explicate what it is nurses do when they care present a challenge for nurse researchers. This is due largely to the complex and nebulous nature of caring as a concept and the contextual elements that influence its perceived meaning. Consequently, the use of qualitative methods in the exploration of caring is the method of choice, with researchers employing a variety of such approaches. In particular, the use of stories as a primary way of making sense of an experience has gained attention in the literature and the narrative method is being seen increasingly as a valid means of tapping into the patient experience. However, the use of narratives is complex with a diversity of approaches often being presented. This paper discusses the use of narratives in the exploration of caring, focusing specifically on an approach developed by Donald Polkinghorne. Issues associated with the collection and analysis of narrative data using this approach are examined.

Data Collection↗
PubMed2006

Human cell type diversity, evolution, development, and classification with special reference to cells derived from the neural crest.

Metazoans are composed of a finite number of recognisable cell types. Similar to the relationship between species and ecosystems, knowledge of cell type diversity contributes to studies of complexity and evolution. However, as with other units of evolution, the cell type often resists definition. This review proposes guidelines for characterising cell types and discusses cell homology and the various developmental pathways by which cell types arise, including germ layers, blastemata (secondary development/neurulation), stem cells, and transdifferentiation. An updated list of cell types is presented for a familiar, albeit overlooked model taxon, adult Homo sapiens, with 411 cell types, including 145 types of neurons, recognised. Two methods for organising these cell types are explored. One is the artificial classification technique, clustering cells using commonly accepted criteria of similarity. The second approach, an empirical method modeled after cladistics, resolves the classification in terms of shared features rather than overall similarity. While the results of each scheme differ, both methods address important questions. The artificial classification provides compelling (and independent) support for the neural crest as the fourth germ layer, while the cladistic approach permits the evaluation of cell type evolution. Using the cladistic approach we observe a correlation between the developmental and evolutionary origin of a cell, suggesting that this method is useful for predicting which cell types share common (multipotential) progenitors. Whereas the current effort is restricted by the availability of phenotypic details for most cell types, the present study demonstrates that a comprehensive cladistic classification is practical, attainable, and warranted. The use of cell types and cell type comparative classification schemes has the potential to offer new and alternative models for therapeutic evaluation.

Evolution, Molecular↗
PubMedDate not supplied

Promoting scientific integrity in nursing research. Part I: Current approaches in doctoral programs.

Schools of nursing with doctoral programs were surveyed to determine current approaches and elicit suggestions for institutional- and professional-level strategies to promote scientific integrity. Results from 38 schools are reported in a two-part series. Part 1 reports findings concerning formal and informal instruction about responsible science and the standards, norms, and guidelines being used to direct scientific inquiry. Information on misconduct and scientific integrity was typically included in required research methods, courses, and optional workshops, but the extent and scope of the instruction was variable, and a majority of respondents judged it to be marginal or inadequate. A high value was placed on informal student-mentor interaction. Where they existed, institutional guidelines were more specific than federal guidelines, but dealt primarily with procedures for handling alleged misconduct rather than for promoting responsible science. Findings suggest the need for a more proactive and consistent approach to promoting scientific integrity in doctoral programs.

Curriculum↗
PubMedDate not supplied

Issues in Internet survey research among cancer patients.

Considering the increasing number of cancer patients who are online, it is clear that the Internet will provide an important research medium and/or setting for oncology nurses in the near future. Despite increasing Internet usage in nursing research and practice, issues in using the Internet among cancer patients as a research tool have rarely been explored and discussed. The purpose of the article is to propose future directions for Internet research among cancer patients based on discussions of practical issues raised in an Internet survey study among 40 online cancer patients. The issues raised through the research process include (a) ethical issues, (b) recruitment issues, (c) issues in Web site development and maintenance, and (d) data entry and analysis issues. On the basis of the discussions of these issues, some future directions for Internet survey studies are proposed, including dealing with ethical issues, getting computer expertise, using motivational strategies, and using national and international approaches.

Aged↗
PubMed1977

The changing attitudes of physicians toward prolonging life.

This follow-up survey of physicians' attitudes and practices reveals a changing approach toward the care of terminal patients. It shows that: 1) communication with dying patients is becoming more open, 2) support for the omission of life-prolonging treatments is increasing, and 3) opposition to the use of death-hastening measures remains strong. It indicates that the physician's experience with terminal patients and the setting of his practice influence his attitude towards these patients and the approach to treatment.

Attitude of Health Personnel↗
PubMed2000

Not if, but how: one way to talk with patients about forgoing life support.

May the common clinical conversation be used to explore whether or not seriously ill patients want to talk about possible limitations of life support? In order to answer this question, a series of 20 seriously ill patients took part in an interview. The clinical conversations were taped and transcribed, and recurrent themes were identified and organised into categories. After talking about their diagnosis and prognosis, most patients said it was natural to talk about possible limitations of life support, and a substantial number immediately indicated that they did not want any life-sustaining treatment. Although their emotional reactions were different, no one seemed to be upset by talking about such issues. Many but not all patients said that they wanted a family member and possibly also a nurse to participate in the conversation. Every doctor learns to conduct a clinical conversation and this approach may be applied when talking with seriously ill patients about difficult treatment decisions.

Attitude to Health↗
PubMedDate not supplied

The present and future state of hormonal treatment for male infertility.

Although male factors contribute to over half of all cases of infertility, most infertile men are described as 'idiopathic oligo/asthenozoospermic' rather than diagnosed precisely; hence, specific medical treatment is not possible. One uncommon but treatable cause of male infertility is gonadotrophin deficiency in which gonadotrophin replacement therapy is highly effective at inducing spermatogenesis and fertility. Hormonal therapy is a logical approach for empirical drug therapy given the fundamental role of hormonal regulation in spermatogenesis. However, treatment with GnRH analogues, gonadotrophins, androgens, anti-estrogens, aromatase inhibitors, growth hormone- and prolactin-suppressing drugs is ineffective in unselected infertile men. Prolonged high-dose glucocorticoid therapy for sperm autoimmunity may improve pregnancy rates modestly, but the risks are generally unacceptable compared with IVF or ICSI. For these reasons, modern reproductive technologies, notably ICSI/IVF, have become the de-facto standard empirical treatment of male infertility, despite involving significant though infrequent risks to the fetus and mother. There remains a potential for hormonal methods to improve sperm quality or ultrastructure in subgroups of infertile men more responsive to hormonal manipulation or using novel protein or gene-targeted therapies or biochemical approaches based on post-hormonal receptor mechanisms that stimulate spermatogenesis. How such novel hormonal methods will develop in conjunction with improved ICSI/IVF or cloning technologies, and the potential role of adjunctive hormonal therapy remains to be clarified.

Androgens↗
PubMed1994

New approaches to the prophylaxis and treatment of bacterial and fungal infections in allogeneic marrow transplant recipients.

Bacterial and fungal infections continue to be a major threat to bone marrow transplant recipients. While standardized approaches to empiric therapy with early inclusion of antibiotics active against Gram-positive organisms and against fungi may have improved the outcome of these patients during the past decade, other developments (e.g. increasing number of patients in older age groups, unrelated donors, mismatch transplants) may even have increased the problem. Current approaches to the prophylaxis and treatment of these infections are discussed. Concerning fungal infections especially the new azoles and new approaches of amphotericin B administration are of interest.

Anti-Infective Agents↗
PubMed1992

Italian neurologists and euthanasia: a poll.

We have tried to sound out Italian neurologists regarding their attitude to euthanasia, a very controversial issue today. We gave a short multiple-choice questionnaire to neurologists attending a national conference, asking their opinion on some issues related to euthanasia. 75 (25%) of the 300 doctors polled completed the questionnaire. Answers were often contradictory. A trend in favor of passive euthanasia among the respondents and a strong demand for guidelines are evident. Emotional rather than professional or rational factors seem to play a major role in the approach to this dilemma.

Attitude of Health Personnel↗
PubMedDate not supplied

Physicians' experiences with prehospital do-not-resuscitate orders in North Carolina.

INTRODUCTION: Many states are implementing prehospital do-not-resuscitate (DNR) programs through legislation or by state or local protocol. There are no outcome studies in the literature regarding the utilization of, access to, or barriers to prehospital DNR programs, nor are there studies that evaluated whether they meet the patients' needs. STUDY OBJECTIVE: To explore physicians' perceptions of the utilization of, access to, and barriers to a southeastern state's prehospital DNR program, and to identify key professional groups needing information about prehospital DNR issues. METHODS: A convenience sample survey and a descriptive review using retrospective, self-report questionnaires sent to all physicians who requested and obtained a supply of the state's out-of-facility DNR forms in 1993. RESULTS: Respondents reported that the most common terminal conditions for patients with prehospital DNR orders are cancer and multiple chronic diseases in elderly patients. More than half of the physicians recalled that enrolled patients had engaged the services of emergency medical services (EMS), most often because the patients' conditions worsened, and the families were uncertain about what to do. Most of the enrolled patients have at least one other DNR order in another health-care setting, and are at home with hospice care or home-health care at the time of the prehospital DNR order implementation. The most frequent barrier to honoring dying patients' wishes in the prehospital environment is a lack of knowledge of prehospital issues by patients, families, primary care physicians, and nursing home staff. Ninety-eight percent of the respondents support a single, universal DNR order that would apply across all health-care settings. CONCLUSIONS: Patients, families, and key health-care professional groups need to be targeted with educational programs regarding prehospital DNR issues. Primary care physicians, using the current prehospital DNR program, support more comprehensive approaches to DNR orders across health-care settings.

Advance Directives↗
PubMed2004

The impact of a modern medical curriculum on students' proposed behaviour on meeting ethical dilemmas.

OBJECTIVE: To evaluate the impact of a modern medical curriculum on students' proposed behaviour on encountering ethical dilemmas. DESIGN: Cohort design. SETTING: University of Glasgow Medical School. SUBJECTS: The first intake of students into Glasgow's new curriculum (n = 238). Main outcome measure Student answers consistent with consensus professional judgement on the ethical dilemmas posed by the vignettes of the Ethics and Health Care Survey Instrument. RESULTS: The probability of giving a consensus answer was lowest pre-Year 1 and highest post-Year 1. It reduced slightly post-Years 3 and 5, but remained significantly higher than at pre-Year 1. The performance of students undertaking a 1-year intercalated BSc, however, appeared to regress on testing post-Year 4. CONCLUSIONS: While the first year of the curriculum had a positive impact on students, the remainder of the curriculum did not impact to the same extent. These findings support the recommendation that small group teaching, the predominant teaching method in Year 1, should be preferred to lecture and large group teaching, the predominant method of the remaining curricular years. Full integration of ethics and law teaching within the rest of the curriculum is recommended, particularly during the clinical years. This has training implications for all medical teachers involved in the curriculum. The assessment of ethics should be incorporated into all formal examinations. It is recommended that ethics be addressed as part of a wider approach to professionalism in order to promote integration.

Cohort Studies↗
PubMed1999

The meaning of hope in health and illness.

Hope plays an important role in the illness experience, yet it is a difficult concept to articulate, given its complex intangible nature. To develop a model for capturing the personal meaning of hope in health and illness, I developed a questionnaire and distributed it to 550 healthy adults, adults with illness experience, and nurses. Major findings from this study suggest that people experience hope within three interconnected realms: personal spirit, risk, and authentic caring. This multidimensional framework provides a novel approach for understanding the complex experience of hope in health and illness.

Adult↗
PubMed2005

Concordant spiritual orientations as a factor in physician-patient spiritual discussions: a qualitative study.

OBJECTIVES: To understand the impact of physicians' and patients' religious/spiritual orientation on discussions of spiritual issues. METHODS: We performed semi-structured interviews of 10 Missouri family physicians and 10 patients of these physicians, selecting subjects nonrandomly to represent a range of demographic factors, practice types, and chronic or terminal illness. We coded and evaluated transcribed interviews for themes. RESULTS: Respondents expressed that similar belief systems facilitate patient-physician spiritual interactions and bring confidence to their relationships. Those holding dissimilar faiths noted limited ability to address spiritual questions directly. They cited significant barriers to spiritual interaction but considered that ecumenism, use of patient-centered care, and negotiation skills lessen these barriers. CONCLUSIONS: Our respondents view spirituality similarly to other aspects of the physician-patient relationship involving differing viewpoints. Where discordance exists, cross-cultural, patient-centered, diplomatic approaches facilitate spiritual discussions.

Communication Barriers↗
PubMed1999

Will to live in the terminally ill.

BACKGROUND: Complex biomedical and psychosocial considerations figure prominently in the debate about euthanasia and assisted suicide. No study to date, however, has examined the extent to which a dying patient's will to live fluctuates as death approaches. METHODS: This study examined patients with cancer in palliative care. Will to live was measured twice daily throughout the hospital stay on a self-report 100 mm visual analogue scale. This scale was incorporated into the Edmonton symptom assessment system, a series of visual analogue scales measuring pain, nausea, shortness of breath, appetite, drowsiness, depression, sense of well-being, anxiety, and activity. Maximum and median fluctuations in will-to-live ratings, separated by 12 h, 24 h, 7 days, and 30 days, were calculated for each patient. FINDINGS: Of 585 patients admitted to palliative care during the study period (November, 1993, to May, 1995), 168 (29%; aged 31-89 years) met criteria of cognitive and physical fitness and agreed to take part. The pattern of median changes in will-to-live score suggested that will to live was stable (median changes <10 mm on 100 mm scale for all time intervals). By contrast, the average maximum changes in will-to-live score were substantial (12 h 33.1 mm, 24 h 35.8 mm, 7 days 48.8 mm, 30 days 68.0 mm). In a series of stepwise regression models carried out at 12 h, 24 h, and 1-4 weeks after admission, the four main predictor variables of will to live were depression, anxiety, shortness of breath, and sense of well-being, with the prominence of these variables changing over time. INTERPRETATION: Among dying patients, will to live shows substantial fluctuation, with the explanation for these changes shifting as death approaches.

Aged↗