Initiating end-of-life care pathways: a discussion paper

watts t. (2012)?Initiating end-of life-care pathways: a discussion paper. Journal of Advanced Nursing68(10), 2359-2370. ABSTRACT: Aims. To discuss the intricacies of the decision-making process about initiating end-of-life care pathways. Background. Internationally, enhancing the quality of end-of-life care has become a central concern in governments' health policies. Despite limited empirical evaluation, end-of- life care pathways have been championed and widely adopted as complex interventions to enhance end-of-life care worldwide. Data sources. A literature search of established electronic databases was conducted for published articles in English addressing decision-making and end-of-life care pathways between 1997-2010. Manual searches of relevant journals and internet sites were also undertaken. Discussion. The initiation of an end-of-life care pathway marks the transition to the terminal phase of care. Although guidance for commencing these pathways exists, this may not overcome the complexities of the decision-making process, which must be viewed in context, namely: marking the transition to terminal care, dealing with ambiguity, reaching professional consensus and engaging patients and families. Implications for nursing. Nurses in all care settings have an important role in easing the transition to end-of- life care. Accordingly, nurses need not only an appreciation of end-of-life care pathways, but the complexities surrounding the decision to commence a pathway and their role within. Conclusion. The initiation of an end-of-life care pathway is contingent on the outcome of a complex decision-making process which is rarely explored and poorly understood.     

A philosophical discussion of end-of-life decision-making methods for incompetent patients

This article provides an analysis of decision-making methods that can be used with incompetent patients (patients who are unable to make decisions for themselves). It is intended as a general discussion of the relevant issues rather than an examination of legal or policy concerns. The advance directive principle (whereby a person leaves instructions for what to do if they become unable to make their own decisions) is discussed with reference to practical and philosophical issues. Substituted judgement (where surrogate decision makers make decisions that the patient who is incompetent would make if competent) is then discussed followed by the principle of best interests, which requires consideration beyond purely medical interests. The need to make patient-centred quality-of-life judgements as a component of best interests decisions is argued. Conclusions reached include the notion that the advance directive principle and the substituted judgement principle facilitate the concept of self-determination. The best interests principle helps to ensure that patients ending up in this vulnerable position are protected.     

Providing high-quality care in primary care settings: How to make trade-offs

Objective

To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care.

Design

Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices.

Setting

Three regions of Quebec.

Participants

Health care professionals and staff of 5 PC practices.

Methods

Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed.

Main findings

The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters.

Conclusion

Irrespective of their models, PC practices’ pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care.     

Dignity conserving care at end-of-life: A narrative review

Purpose of the researchThis narrative literature review uses systematic principles to define evidence regarding dignity conserving care at end-of-life from published research on dignity or distress in end-of-life care.MethodsThe Chochinov model of dignity was used as a pre-defined framework. Articles were reviewed using thematic analysis to produce a synthesis of findings. A total of 39 articles (26 qualitative and 13 quantitative) fulfilled the inclusion criteria and were found to give suggestions on care actions.Key resultsSeveral care actions were identified related to all themes contained within the Dignity Model, except aftermath concerns. Examples include: controlling symptoms; listening to the patient and taking them seriously; providing advice concerning how to cope on a daily basis; treating patients as equals and with respect, and; encouraging the family members’ presence.ConclusionsEvidence for supporting palliative care services has previously been found to be weak in determining solutions to meet individual’s important needs. Drawing together primary research, as in this study, is therefore of importance. The suggested care actions will be used to develop a dignity care pathway for end-of-life care, which is currently being evaluated by the authors. The intention is to provide more valid evidence for the effectiveness of the care actions suggested.     

Advanced practice nurses in emergency care settings: A demographic profile.

INTRODUCTION: Very little is known about clinical nurse specialists and nurse practitioners (advance practice nurses [APNs]) who practice in emergency care settings. The Advanced Practice Committee of the ENA sought to determine a profile of these individuals. METHODS: Surveys were distributed to all registrants at 2 ENA conferences and posted on the ENA Web site. This survey asked 17 questions concerning the demographic characteristics of the APN respondents (eg, education, experience, certification, state recognition, and practice area). The survey was completed by 166 APNs. RESULTS: APNs had considerable experience as ED registered nurses before becoming an APN. They obtained their APN education at the master's degree or post-master's degree level. State recognition was required for 89.2% of the APNs. The majority of APNs (61.4%) obtained their certification through the American Nurses Credentialing Center. Nurse practitioners were predominantly family nurse practitioners (43%), and clinical nurse specialists were either critical care clinical nurse specialists (8.9%) or had other certifications (5.9%). APNs provided services in both the main emergency department and the fast track (45.7%) and were relatively new to their role as an APN. DISCUSSION: Consistent with current educational and certification requirements, the vast majority of APNs held a master's degree. Although relatively new to their role as APNs in emergency care, they were nonetheless very experienced as ED registered nurses. The majority of APNs were certified, even though that is not required for practice in all states. Continued research is needed to identify the most effective utilization of APNs, document their contributions to patient care outcomes, and develop strategies to meet their educational and practice needs.