Sheltered housing compared to independent housing in the community

Background:  With elderly people desiring to live independently as long as possible, traditional homes for the elderly are increasingly being transformed into sheltered accommodations. In order to assess the importance of housing for frail elderly people, elderly people at risk for institutionalization were studied in two living conditions: sheltered accommodation and living independently in the community.
Methods:  A total of 317 elderly people at risk for institutionalization [91 men and 240 women, mean age = 83.3 (SD = 6.0)] were interviewed using a structured questionnaire with questions regarding home care and social service use, quality of life, subjective well-being, life satisfaction, autonomy, functional status, feelings of insecurity and loneliness.
Results:  Exactly 56.5% of the respondents were living in sheltered accommodation (n = 179) and 43.5% (n = 138) were living in regular houses. Although both groups were similar in demographic details and functional status, those in sheltered accommodation had a higher perceived autonomy, sense of security and quality of life. No differences were found with regard to subjective well-being or feelings of loneliness. Elderly people in regular houses needed more hours of housekeeping assistance. Those in sheltered accommodation participated more frequently in services like social activities and social restaurants, but made less use of day care facilities.
Conclusions:  Affordable, decent and suitable noninstitutional housing with service provision play a vital role in the lives of elderly people. Compared with independent living in the community, sheltered accommodations provide added value. Sheltered housing should therefore be an integral part of long-term care policy.     

Early Palliative Care Initiation: Role of the Primary Care Clinician

Palliative care provided to patients with chronic life-limiting illnesses shows improvement in symptom management, quality of life, and caregiver support while reducing cost of care. Early initiation of palliative care faces a multitude of barriers in the primary care setting, including provider confidence, coordination and implementation, education, and family and patient misconceptions. A team-based approach along with additional education, clear referral triggers, and resources for advanced-care planning discussions allows providers to overcome many of these barriers. With the population’s advancing age, it is essential that primary care providers are properly prepared for early initiation of palliative care.     

Consensus of the Millennium Conference on Teaching High Value Care

Issue: Healthcare costs have spiraled out of control, yet students and residents may lack the knowledge and skills to provide high value care, which emphasizes the best possible care while reducing unnecessary costs. Evidence: Mainly national campaigns are aimed at physicians to reconsider their test ordering behaviors, identify overused diagnostics, and disseminate innovative practices. These efforts will fall short if principles of high value care are not incorporated across the spectrum of training for the next generation of physicians. Implications: Consensus findings of an invitational conference of 7 medical school teams consisting of academic leaders included strategies for institutions to meaningfully incorporate high value care into their medical school, residency, and faculty development curricula.     

The challenges in adopting care pathways for the dying for use in care homes

An increasing number of older people are requiring palliative care within the care home setting. There are currently a number of initiatives that are generally gaining approval and being implemented within health care in general with the goal of improving standards of palliative care. These are the Integrated Care Pathway for the dying person, the Gold Standards Framework and the Preferred Place of Care document. The Liverpool Care Pathway is being used across a wide range of care settings to improve care in the last 24–48 hours of life and is being implemented in care homes as part of a national rollout programme. This article aims to explore some of the issues associated with the use of the care pathways in care homes, particularly without the input of additional resources and support for the care homes. It also questions the appropriateness of the pathway in its current format without further work on the specific palliative care needs of the residents dying in care homes.     

Nurse-led inpatient care: opening the 'black box'

With recent evaluations contradicting early reports of improved outcomes from nurse-led inpatient care, the 'black box' of nurse-led care must be opened in order to examine the model of treatment. We present findings on the processes of care in one nurse-led unit (NLU), compared with an acute ward. Patterns and quality of nursing care were quantified using bar-code technology to measure type, frequency and duration of nursing activities and Quality Patient Care Scale to measure the quality of care. NLU quality matched, but did not exceed, quality on the acute ward. Patterns of care differed between wards, but activities associated with therapeutic nursing were no more frequent on the NLU. These findings support the hypothesis that disappointing outcomes in recent evaluations may be linked to failure to implement a therapeutic model of nursing.     

Obesity significantly increases the difficulty of patient management in the emergency department

Objective: To determine which aspects of ED management are adversely affected by patient obesity, to determine the level of obesity above which management is made more difficult and to make recommendations on how these effects might be mitigated. Methods: This was a cross‐sectional survey of patients and the staff caring for them in a single ED. Doctors, nurses and radiographers managing consecutive patients, during a range of enrolment periods, completed a self‐administered questionnaire. Each was asked to record how the level of their patient's obesity increased the difficulty of specific management items, using a Likert scale. Staff also provided recommendations to mitigate the effects of obesity for each patient, if applicable. For each management item, body mass index (BMI) and management difficulty were correlated (Spearman's rank correlation). Results: Seven hundred and fifty patients and their ED carers were enrolled. Patient BMI was positively correlated with all aspects of ED clinical management examined (correlation coefficient range 0.28–0.57, P < 0.001). BMI most strongly correlated with difficulty in finding anatomical landmarks, venous pressure measurement, physical examination, patient positioning and procedures generally, especially cannulation and venipuncture (coefficient > 0.5, P < 0.001). Doctors reported more difficulties than nurses and radiographers. Generally, management difficulty did not increase until the BMI was in the obese or morbidly obese range. Most staff recommendations related to issues of patient mobility including equipment, staffing and bariatric devices. Conclusion: Patient obesity significantly increases the difficulty of ED patient management. Staff recommendations to mitigate these effects were few but may inform changes in ED practice.     

What is the role of the coronary care nurse? A review of the literature.

BACKGROUND: The role of the coronary care nurse has often been described based on anecdotal evidence. However in a research conscious society it is vital that this important role is able to be defined using research findings. This paper explores the literature in order to describe this role in a research context. AIM: To review the literature to establish the contemporary role of the coronary care nurse. METHODS: An electronic search of three healthcare databases to identify all journal articles published between 1990 and 2006. The review was focussed on all primary research or audit articles that discussed the roles of nurses working in coronary care units. RESULTS: Coronary care nurses are responsible for patient assessment and symptom management often using technology to achieve these goals. In addition they are able to develop therapeutic relationships with their patients and are in a prime position to provide vital physical and psychological care in both the critical and palliative stages of illness. CONCLUSION: Whilst no study has investigated the coronary care nursing role in its entirety the themes identified within many of the studies were consistent. Therefore the findings of this review are considered to be an accurate reflection of this role.     

Teleological care and the last years of life

The final years of life present challenges for care. In middle‐/high‐income countries, the percentage of people of advanced age in the population is growing, and the dying process continues to become more complex and protracted. We propose that a new understanding of care, ‘teleological care’, be considered as an important response to the contemporary challenges of the final years of life. Teleological care is a philosophy of care built around the root idea of a telos (i.e. end) in three senses: (1) the end of life as a temporal limit; (2) the ends of life as the individual's purpose and meaning; (3) the end of life as the meaning of life as a whole. In its practice, teleological care adheres to principles of (1) fidelity of practitioner to patient; (2) generalism of practitioners; and (3) coordination of care within existing services. With this philosophy and practice, care is administered by generalist health care professionals arranging for flow between care that attempts to reverse, stop or slow the disease process when appropriate, with care to address symptoms, and with care that responds to the difficulties of dying. Teleological care involves already existing programmes in roughly their present forms, serving as an overarching layer of organization added to the existing systems. Teleological care refocuses the concept of care to the patient's perspective with emotional, spiritual and practical support for facing the end of life, and a space for narrative and reflection within a wider circle of care.     

End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom

Objective To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences.Design and setting Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001.Patients 118,199 adult admissions to ICUs.Measurements and results The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7–96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions.Conclusions Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.All work was completed at the Intensive Care National Audit & Research Centre, which also provided financial support     

Homecare at the end of life. A study of fifteen patients

The study is a part of a research project on death in a sector of a large city, involved cooperation with the Franciscan Aid "home care team". The purpose was to study death in the home setting. Fifteen deaths were registered. Participant observation in the care of 14 patients were made--a total of 83 visits to homes, 2-15 visits per patient. In one case the author had contact with the relatives, after the death had occurred. Most of the patients had cancer. Their age varied from 28 to 80 years. The observations were recorded immediately after each visit. After the death of a patient a structured interview with the closest relatives and the nurse responsible were made. Their statements were used as a basis for formulating problems for the further study and the clarification of quantitative data. Results showed that the patients who chose to leave the hospital and remain at home often had negative experiences in hospital. All the patients in this study received good palliative treatment at home. All patients were also informed about their condition. One-third of the patients were readmitted to hospital during the final days.     

“Acute caring” in the emergency department

The aim of this essay was to discuss the ways in which the dynamics of interprofessional communication and collaboration among healthcare providers ultimately affect patient quality of care in the acute setting. Interprofessionalism describes a care model whereby health providers use complementary skills, knowledge and competencies to provide quality care to a group of patients. These interactions are characterized by trust, respect and an understanding of each other's skill and knowledge. At its best, the interprofessional care model has made great strides in the amelioration of patient outcomes, including reduction in negative outcomes, decreased health access needs and increased patient satisfaction. However, challenges with regard to communication and implementation have translated to a steep learning curve for healthcare providers. As such, a new-found emphasis has been placed on interprofessional education for today's healthcare students with the goal of promoting a more efficient and collaborative philosophy for tomorrow's healthcare teams.     

运用Delphi法构建姑息照护培训的核心知识体系

目的构建适合于我国护理人员的姑息照护培训内容体系。方法采用Delphi法,通过两轮咨询集中专家意见确定培训内容。结果确立了6个模块共计67个知识点的培训内容体系,涉及医学、护理、心理、伦理学等多个学科。结论Delphi法所确定的内容体系能为开展姑息照护培训提供科学的依据。     

产前/后社区综合护理对预防产后抑郁症的效果分析

目的探讨妇保人员在社区妇保工作中,运用心理干预等综合护理方法,对预防产妇产后抑郁发生的作用。方法选取2009年5月至2010年5月在本院保健科管辖的两个社区分娩的200例产妇作为研究对象:实验组(100例),实施综合、全面的护理干预,同时进行心理护理;对照组(100例),进行常规护理。应用汉密顿抑郁量表(HAMD)和产后抑郁量表(EPDS)法,分别于产前、产后对两组产妇的焦虑、抑郁情绪进行评分。结果产妇产前HAMD评分、产后EPDS评分以及随访结果表明,综合护理的产妇抑郁症发生率和对照组相比明显降低(P0.05)。结论临床综合护理对预防以及提高产后抑郁症疗效有较好的效果。