Do ‘no‐suicide’ contracts work?

Suicide is the main cause of premature death in mental health service users, and the prevention of suicide is a major, global concern. An intervention designed to address this concern is the 'no-suicide' contract (NSC) – an agreement, usually written, between a mental health service user and clinician, whereby the service user pledges not to harm himself or herself. Following a review of the literature on NSCs, this paper argues that there is a lack of quantitative evidence to support such contracts as clinically effective tools and that there is strong opposition to the tool, from both service users and nurses. Moreover, important ethical and conceptual issues in the use of such contracts have been identified, including the potential for coercion from the clinician for their own protection and the ethical implications of restricting a service user's choices when they may be already struggling for control. In light of these findings, the paper discusses alternative interventions aimed at preventing self-harm and suicide. Although a number of other interventions are available to clinicians, further research is required to test the effectiveness of these as viable alternatives to the NSC.     

Antiplatelet ‘resistance’ and ‘non‐responders’: what do these terms really mean?

The term ‘resistance’ should be restricted to very specialized physiologic circumstances, if not abandoned altogether. The term ‘non‐responder’ needs to be placed in the context of the question: ‘Non‐responder to what?’ Even if we would somehow magically know what an optimal response to antiplatelet therapy was, it will still be challenging to demonstrate an ‘inadequate’ response to antiplatelet therapy. At present there are two alternatives – give more drug or give additional drugs. Both strategies may work in further inhibiting platelet function, but both strategies can also be associated with an increased risk of bleeding. The trick, for the future, much as with our antihypertensive and lipid‐lowering armamentaria, will be to know in whom to do what with which drug, and why. Single isolated measurements are not useful – if you don't know where you started, how we would know that antiplatelet drug is producing an ‘adequate’ clinical effect? There is no evidence of any sort of absolute ‘threshold’ that must be exceeded for treatment to be effective, and in the absence of this, if we are to evaluate the effect of a given drug, we have to have baseline values (off drug), therapeutic values (on drug), and some sort of assessment of both resting (unstimulated) and agonist‐provoked (stimulated) platelet function. Moreover, given all of the different things that platelets do, the ideal assessment of platelet function and drug responsiveness will need to incorporate more than one agonist and some sort of assessment of both platelet activation and platelet aggregation. No one man (or test) tells us everything; it is the totality of the information that gives us the most complete picture. And, ultimately, we need to more firmly establish how the variability in platelet function and drug‐associated changes in that function correlates with long‐term, hard‐endpoint clinical events.     

‘Modern language’ or ‘spin’? Nursing, ‘newspeak’ and organizational culture: new health scriptures

A new managerial language of modernization has accompanied political restructuring of the National Health Service. Corporate goals of efficiency and audit have been integrated with the ideological manifesto of New Labour in stressing citizenship, inclusion and empowerment. Drawing on the theoretical insights of anthropology and sociology, this article critically reviews the relationship between health policy, organizational culture and nursing practise through an exploration of language in terms of "rhetoric", "jargon" and "metaphor". It is suggested that beyond the bewildering vocabulary of "buzz words" is a fundamental contradiction between the ethic of caring and the expectations of Government. Finally thought is given to the role of professional education and training where intellectual engagement with the ritual categories of "newspeak" is a subversive act.     

‘You do know he’s had a stroke,don’t you?’ Preparation for family care‐giving – the neglected dimension

? Countries throughout the developed world have introduced a policy of community care for older people to reduce costs to the state and maintain quality of life. ? In reality community care is largely family care and recognition of the need to support family carers is being promoted through the notion of partnership with professional carers. ? Such a partnership calls for a more complete understanding of how carers’ needs change over time and how professional support can be most effective. ? Support is particularly important at the start of care‐giving in order that carers can exercise free choice and be adequately prepared for their role. ? This paper provides an overview an ongoing longitudinal study and reports specifically on the findings of data from a preliminary study in which a convenience sample of seven experienced carers of stroke survivors who attended a stroke and carers club were interviewed in their own homes. ? Based on initial data from a longitudinal study of stroke victims, this paper outlines four themes: ‘What’s it all about’, ‘Going it alone’, ‘Up to the job’ and ‘What about me?’ These themes highlight the difficulties carers experience in the immediate aftermath of stroke.     

Why relatives do not donate organs for transplants: ‘sacrifice’ or ‘gift of life’?

AIM: This paper is a report of a study to explore the reasons family members declined organ donation from a deceased relative. BACKGROUND: In the United Kingdom family members' consent is usually sought before organ donation from their deceased relative can proceed. Knowledge of the concerns that may influence families' decision-making could be helpful to nurses supporting bereaved family members. METHOD: A convenience sample of 26 family members, who declined donation of their deceased relatives' (n = 23) organs, were recruited via three media campaigns in large conurbations and from four intensive care units in the United Kingdom. Data were collected in 2005 using interviews. FINDINGS: Donation decisions depended on a number of converging factors in a particular situation and not necessarily on the views of relatives about donation, or the reported wishes of the deceased in life, except if the person had stated that they did not wish to be an organ donor. Therefore, reported pro-donation views held by the family, or the deceased in life, did not guarantee donation. Protecting the dead body, which related to keeping the body whole and intact was the most frequently-recurring theme, being reported in 15 interviews. CONCLUSION: Families' wishes to protect the dead body may stimulate tension between the notions of 'gift of life' as supported by transplant policy and 'sacrifice' of the body, which must be made if organ donation is to proceed. This could account for the decision of participants to decline donation even if their deceased relative previously held positive views about organ donation.     

Is mild asthma really ‘mild’?

Current evidence suggests that patients with mild asthma are often under-recognised, and those that are diagnosed can remain with this initial classification and be treated accordingly, despite worsening of their condition. There is considerable overlap between mild and more severe asthma in terms of the underlying pathophysiology and poorly reversible airway changes, such as subepithelial fibrosis and airway wall remodelling, which are present very early in the progression of asthma in patients with normal lung function. Life-threatening exacerbations can also occur in patients with mild asthma. In view of these factors and given that asthma is a two-component disease (airway inflammation and smooth muscle dysfunction), recent studies have examined the effects of both early intervention with steroids and combination therapy comprising an inhaled steroid and a long acting beta(2)-agonist. These studies suggest that early intervention is likely to provide better asthma control and possibly prevent or delay the worsening of disease and fatalities in patients considered to be mild asthmatics.     

Biosimilars of low‐molecular‐weight heparin products: fostering competition or reducing ‘biodiversity’?

The term ‘biosimilars’ is used to qualify products developed to be similar to an original biological drug. Biosimilars are much more complicated to develop than a generic version of small‐molecule drugs and this is especially true for low‐molecular‐weight heparins (LMWHs). Evidence on the antithrombotic management of acute coronary syndromes (ACS) showed that the introduction into the market of biosimilars approved on the basis of simple biological criteria, without robust data from comparative clinical trials, may be hazardous. Moreover, the mixtures of LMWH polysaccharide chains, some immunoallergic properties and potential contamination during the extraction process raise safety concerns. As was the case for the biosimilar erythropoietin, there is the risk that only copies of the most commercially successful LMWHs will be marketed, thus jeopardizing the ‘biodiversity’ now ensured by the presence of several LMWHs, each with unique features that support the use of an individual LMWH as first‐choice therapy in certain categories of patients.     

Vitamin D and Cardiovascular disease – dilemma,delight or ‘dont know?’

The current lack of sufficient evidence of vitamin D's role in CVD calls for perspective and caution to avoid that health claims, vitamin D testing and supplementations' sales will continue to run well ahead of the scientific evidence.     

Is ‘sick-nursing’ an alternative to conversion hysteria?

• ? Freud made the interesting observation that many of his patients suffering from conversion hysteria (a psychogenically induced physical dysfunction affecting the special senses) had been engaged in ‘sick-nursing’ for a prolonged period prior to decompensation.
• ? This paper aims to explore the relationship between ‘sick-nursing’ and conversion hysteria.
• ? It will be argued that, for a select population group, the unconscious motivation for choosing nursing as a career and decompensation with conversion hysteria rest on the same fundamental factors.
• ? These factors include an unconscious sense of guilt, the need for punishment through suffering, and envy all of which corrupt normal psychosexual development.