Health care quality in end-of-life care: promoting palliative care in the intensive care unit

Seminal articles published in the late 1990s instigated not only an intense interest in health care quality but also a new era of research into quality end-of-life care, particularly in intensive care units (ICUs). ICUs can improve health care quality at the end of life by better using palliative care services and palliative care-related principles. This article details how the interest in health care quality has spurred a similar interest in end-of-life and palliative care in ICUs, defines palliative care and describes how it improves health care quality, and highlights barriers to the incorporation of palliative care in ICUs.     

End-of-life care in the intensive care unit

End-of-life care in the intensive care unit (ICU) is an oxymoron. Intensive care units appeared in the 1980s only admitting patients for ‘intensive care’. Nowadays the ICU has become one of the few places in the hospital that can provide comfort care to the dying patient. For many doctors on ICU it remains a difficult and problematic area. Yet it is conceptually simple. The difficulty for the doctor is making the decision, for the patient and family, coming to terms with it. This article will focus on how this decision should be made and then on the care that should be provided for the patient. Many of the considerations in decision making are in the General Medical Council guidelines, Treatment and Care Towards the End of Life and this is essential reading before embarking of the process.     

End-of-life care in the intensive care unit

The transition from active, invasive interventions to comfort care for critical care patients is often fraught with misunderstandings, conflict and moral distress. The most common issues that arise are ethical dilemmas around the equivalence of withholding and withdrawing life-sustaining treatment; the doctrine of double effect; the balance between paternalism and shared decision-making; legal challenges around best-interest decisions for patients that lack capacity; conflict resolution; and practical issues during the limitation of treatment. The aim of this article is to address commonly posed questions on these aspects of end-of-life care in the intensive care unit, using best available evidence, and provide practical guidance to critical care clinicians in the UK. With the help of case vignettes, we clarify the disassociation of withdrawing and/or withholding treatment from euthanasia; offer practical suggestions for the use of sedation and analgesia around the end of life, dissipating concerns about hastening death; and advocate for the inclusion of family in decision-making, when the patient does not have capacity. We propose a step-escalation approach in cases of family conflict and advocate for incorporation of communication skills during medical and nursing training.     

Is chiropractic care primary health care?

The following paper sets out to examine three issues: primary health care, chiropractic care, and the challenges to both in the next decade. The current crisis of primary health within the health care system provides chiropractic with an opportunity to choose between functioning as primary care or primary contact care. Chiropractic has seldom met its potential, or its own rhetoric, with regard to holistic health care which would make the case for being primary health care much stronger. There have been numerous social and political factors that have influenced this but part of the problem is that chiropractic has failed to clearly articulate itself as primary health care, and in some instances, has denied that it was. New opportunities and challenges will force chiropractors to resolve the issue of whether chiropractic is a general model of health care, or a form of health specialty (the neuromusculoskeletal practitioner verses the primary health practitioner).     

不准肌肤“胡思乱相”

好痛!娇嫩的皮肤好像还有点不适应这春暖花开的季节，踏青回来脸上居然出现一些淡红色斑疹，又痛又痒随着天气转暖，许多皮肤问题接踵而至，敏感成了春日肌肤的神秘杀手。[编者按]