Neurocritical care: a distinct discipline?

PURPOSE OF REVIEW: We sought to review the evidence supporting neurocritical care as a distinct specialty of medicine. RECENT FINDINGS: Over the past 20 years, neuro-intensive care units have evolved from neurosurgical units focused primarily on postoperative monitoring to units that provide comprehensive medical and specialized neurological support for patients with life-threatening neurological diseases. In addition to standard interventions, areas of expertise unique to neurocritical care include management of intracranial pressure, hemodynamic augmentation to improve cerebral blood flow, therapeutic hypothermia, and advanced neuromonitoring (i.e. continuous electroencephalography, brain-tissue oxygen, and microdialysis). Neurointensivists defragment care by focusing on the interplay between the brain and other systems, and by integrating all aspects of neurological and medical management into a single care plan. Outcomes research has established that victims of traumatic brain injury and hemorrhagic stroke experience reduced mortality, better functional outcomes, and reduced length of stay when cared for by neurointensivists in a dedicated neuro-intensive care unit. In the US a national system for accrediting training programs and certifying intensivists with special qualifications in neurocritical care is currently being established by the United Council of Neurologic Subspecialties. SUMMARY: Neurocritical care is one of the newest subspecialties of medicine and is at the forefront of bringing effective new therapies to patients with life-threatening neurological diseases.     

Is there a distinctive care ethics?

Is it true that an ethics of care offers something distinct from other approaches to ethical problems in nursing, especially principlism? In this article an attempt is made to clarify an ethics of care and then to argue that there need be no substantial difference between principlism and an ethics of care when the latter is considered in the context of nursing. The article begins by considering the question of how one could in fact differentiate moral theories. As is explained, this cannot be done merely in light of the moral judgements they defend, nor their ontological commitments (e.g. their view of the nature of persons). Following these methodological beginnings, care-based ethics is described and critically discussed. It is shown that ontological commitments embraced within care ethics do not themselves show that care ethics is distinct from other approaches. The idea of 'psychological care' is also discussed, which stems from the work of Margaret Little. Her claim that the 'gestalts' of justice and care cannot be combined is rejected in favour of an approach that does just that and which has been developed by Joan Tronto. It is then claimed that the moral commitments of principlism are certainly not incompatible with those of an ethics of care in the nursing context. A challenge to the idea that principlism and ethics of care might be compatible is anticipated in the work of Eva Feder Kittay. This challenge is responded to and it is concluded that care considered as a moral orientation and the moral values embedded in principlism are best combined in the nursing context. Care provides a moral orientation over which the obligations referred to in principlism can be laid.     

Implementing multimodal pain rehabilitation in primary care – a health care professional perspective

Purpose: To explore professional perspectives on how to start and work with multimodal pain rehabilitation within primary healthcare.

Methods: Fourteen healthcare professionals (11 women, 3 men) were individually interviewed about their experiences of starting and working with multimodal pain. Interviews were transcribed and analyzed by qualitative content analysis. This study was part of a larger project, which aimed at evaluating multimodal pain rehabilitation in primary care.

Results: The analysis resulted in six categories. Two categories were about management engagement: putting the focus on rehabilitation and creating appropriate conditions. Three were about professional engagement: importance of driving spirits, creating a program – a process, and good teamwork – not a coincidence. The last category was about professional gain from multimodal rehabilitation (MMR): team work is enriching.

Conclusions: To enable implementation of MMR in primary care, managers on all organizational levels must take responsibility for allowing rehabilitation to be a priority. A driving spirit among the professionals facilitates the start, but the entire team is important when processing a program. Creating good teamwork requires hard work, e.g., negotiations for consensus about rehabilitation, and assumption of responsibility by each team member. Collaboration between professionals was perceived to strengthen and enhance knowledge about the patients.

• Implications for rehabilitation

• Much can be gained from conducting multimodal pain rehabilitation in primary care.

• Front line managers and those at other organizational levels must prioritize and create appropriate conditions to facilitate multimodal pain rehabilitation in primary care.

• Creation of an effective multimodal rehabilitation team requires that each team member takes responsibility, drops the focus on individual rehabilitation, seek member consensus about the content of the rehabilitation, and confer equal worth to each team member.

• The process of creating a program can be facilitated, especially at the beginning, if the team is supported by speciality pain clinics or more experienced teams.

     

End-of-life care in acute care hospitals in Canada: a quality finish?

Understanding patients' and family members' perspectives on the relative importance of elements of end-of-life (EOL) care and their satisfaction with those elements will help prioritize quality improvement initiatives. We administered a face-to-face questionnaire containing a selection of 28 elements of care to eligible inpatients with advanced lung, heart, or liver disease, or metastatic cancer, and available family caregivers (FCGs) in five tertiary care hospitals across Canada. 440 of 569 (78%) eligible patients and 160 of 176 (91%) FCGs participated. No respondent reported complete satisfaction with all elements of care. The average satisfaction score was 4.6 on a 26 point scale. Medical patients reported lower levels of satisfaction than cancer patients. Elements rated as "extremely important" and anything other than "completely satisfied" most frequently by respondents related to discharge planning, availability of home health services, symptom relief, not being a burden, physician trust, and communication. In conclusion, most patients and their family members in our survey were not completely satisfied with EOL care. Improvement initiatives to target key elements identified by patients and FCGs have the potential to improve satisfaction with EOL care across care settings.     

Is the complexity of care a paradox?

This paper looks at the phenomenon known as care and the medium through which it is expressed - caring. It explores some of the meanings of these terms but focuses particularly on nursing care. Superficially, nurses and society have a broad understanding of what 'care' means but common usage of the word belies its complexity. When examined alongside the writings of scholars the inconsistent nature of care and caring emerges. We reflect on the difficulties this presents for both the nurse and the cared for when, on the one hand care is promoted as the essence of nursing, while on the other there is no acceptable definition of care on which to base this claim. Encompassed within our discussion is the underlying theme that although care is an appropriate ideal for nursing it does not capture all of the day-to-day realities and hence it is not an overriding ideal. Care in nursing in this sense is contradictory and we describe it as paradoxical.