Managing risk during care transitions when approaching end of life: a qualitative study of patients' and health care professionals' decision making

BACKGROUND: Increasing importance is being placed on the coordination of services at the end of life. AIM: To describe decision-making processes that influence transitions in care when approaching the end of life. DESIGN: Qualitative study using field observations and longitudinal semi-structured interviews. SETTING/PARTICIPANTS: Field observations were undertaken in three sites: a residential care home, a medical assessment unit and a general medical unit in New Zealand. The Supportive and Palliative Care Indicators Tool was used to identify participants with advanced and progressive illness. Patients and family members were interviewed on recruitment and 3-4 months later. Four weeks of fieldwork were conducted in each site. A total of 40 interviews were conducted: 29 initial interviews and 11 follow-up interviews. Thematic analysis was undertaken. FINDINGS: Managing risk was an important factor that influenced transitions in care. Patients and health care staff held different perspectives on how such risks were managed. At home, patients tolerated increasing risk and used specific support measures to manage often escalating health and social problems. In contrast, decisions about discharge in hospital were driven by hospital staff who were risk-adverse. Availability of community and carer services supported risk management while a perceived need for early discharge decision making in hospital and making 'safe' discharge options informed hospital discharge decisions. CONCLUSION: While managing risk is an important factor during care transitions, patients should be able to make choices on how to live with risk at the end of life. This requires reconsideration of transitional care and current discharge planning processes at the end of life

Doctors' and nurses' views and experience of transferring patients from critical care home to die: a qualitative exploratory study.

BACKGROUND: Dying patients would prefer to die at home, and therefore a goal of end-of-life care is to offer choice regarding where patients die. However, whether it is feasible to offer this option to patients within critical care units and whether teams are willing to consider this option has gained limited exploration internationally. AIM: To examine current experiences of, practices in and views towards transferring patients in critical care settings home to die. DESIGN: Exploratory two-stage qualitative study SETTING/PARTICIPANTS: Six focus groups were held with doctors and nurses from four intensive care units across two large hospital sites in England, general practitioners and community nurses from one community service in the south of England and members of a Patient and Public Forum. A further 15 nurses and 6 consultants from critical care units across the United Kingdom participated in follow-on telephone interviews. FINDINGS: The practice of transferring critically ill patients home to die is a rare event in the United Kingdom, despite the positive view of health care professionals. Challenges to service provision include patient care needs, uncertain time to death and the view that transfer to community services is a complex, highly time-dependent undertaking. CONCLUSION: There are evidenced individual and policy drivers promoting high-quality care for all adults approaching the end of life encompassing preferred place of death. While there is evidence of this choice being honoured and delivered for some of the critical care population, it remains debatable whether this will become a conventional practice in end of life in this setting

Obesity, leptin and host defence of Streptococcus pneumoniae: the case for more human research

Pneumococcal pneumonia is the leading cause of community-acquired pneumonia. Obesity is a risk factor for pneumonia. Host factors play a critical role in susceptibility to pulmonary pathogens and outcome from pulmonary infections. Obesity impairs innate and adaptive immune responses, important in the host defence against pneumococcal disease. One area of emerging interest in understanding the complex relationship between obesity and pulmonary infections is the role of the hormone leptin. There is a substantive evidence base supporting the associations between obesity, leptin, pulmonary infections and host defence mechanisms. Despite this, there is a paucity of research that specifically focuses on (pneumococcal) infections, which are the leading cause of community-acquired pneumonia hospitalisations and mortality worldwide. Much of the evidence examining the role of leptin in relation to infections has used genetically mutated mice. The purpose of this mini review is to explore the role leptin plays in the host defence of in subjects with obesity and posit an argument for the need for more human research

What the curtains do not shield: A phenomenological exploration of patient?witnessed resuscitation in hospital. Part 1: patients' experiences

AimsThe aim of the study was to explore the experiences of hospital patients who witnessed resuscitation of a fellow patient.DesignDescriptive phenomenology.MethodsPatients who witnessed resuscitation were recruited from nine clinical wards in a university hospital in England. Data were collected through face-to-face individual interviews. Participants were interviewed twice,in 1 week and 4 to 6 weeks after the resuscitation event. Data were collected between August 2018 and March 2019. Interviews were analysed using Giorgi's phenomenological analysis.ResultsSixteen patients participated in the first interview and two patients completed follow-up interviews. Three themes were developed from the patients' interviews. (1) Exposure to witnessing resuscitation: patients who witness resuscitation felt exposed to a distressing event and not shielded by bed-space curtains, but after the resuscitation attempt, they also felt reassured and safe in witnessing staff's response. (2) Perceived emotional impact: patients perceived an emotional impact from witnessing resuscitation and responded with different coping mechanisms. (3) Patients' support needs: patients needed information about the resuscitation event and emotional reassurance from nursing staff to feel supported, but this was not consistently provided.ConclusionThe presence of other patients during resuscitation events must be acknowledged by healthcare professionals, and sufficient information and emotional support must be provided to patients witnessing such events. This study generates new evidence to improve patients' experience and healthcare professionals' support practices.ImpactThe phenomenon of patient-witnessed resuscitation requires the attention of healthcare professionals, resuscitation officers and policymakers. Study findings indicate that witnessing resuscitation has an emotional impact on patients. Strategies to support them must be improved and integrated into the management of in-hospital resuscitation. These should include providing patients with comprehensive information and opportunities to speak about their experience; evacuating mobile patients when possible; and a dedicated nurse to look after patients witnessing resuscitation events

What the curtains do not shield: A phenomenological exploration of patient?witnessed resuscitation in hospital. Part 2: Healthcare professionals' experiences

AimsTo explore healthcare professionals' experiences of patient-witnessed resuscitation in hospital.DesignDescriptive phenomenology.MethodsHealthcare professionals involved in hospital resuscitation activities were recruited from medical, intensive care, resuscitation and education departments in a university hospital in England. Data were collected through face-to-face and focus group interviews, between August 2018 and January 2019. Data were analysed using Giorgi's phenomenological approach.ResultsNine registered nurses, four healthcare assistants and seven doctors participated in four individual interviews and three focus groups. Findings were related to three themes: (1) Protecting patients from witnessing resuscitation: healthcare professionals used curtains to shield patients during resuscitation, but this was ineffective. Thus, they experienced challenges in explaining resuscitation events to the other patients and communicating sensitively. (2) Emotional impact of resuscitation: healthcare professionals recognized that witnessing resuscitation impacted patients, but they also felt emotionally affected from performing resuscitation and needed coping strategies and support. (3) Supporting patients who witnessed resuscitation: healthcare professionals recognized the importance of patients' well-being, but they felt unable to provide effective and timely support while providing life-saving care.ConclusionHealthcare professionals involved in hospital resuscitation require specific support, guidance and education to care effectively for patients witnessing resuscitation. Improving communication, implementing regular debriefing for staff, and allocating a dedicated professional to support patients witnessing resuscitation must be addressed to improve clinical practice.ImpactThe WATCH study uncovers patients' and healthcare professionals' experiences of patient-witnessed resuscitation, a phenomenon still overlooked in nursing research and practice. The main findings highlight that, in common with patients, healthcare professionals are subject to the emotional impact of resuscitation events and encounter challenges in supporting patients who witness resuscitation. Embedding the recommendations from this research into clinical guidelines will impact the clinical practice of healthcare professionals involved in hospital resuscitation and the quality and timeliness of care delivered to patients

What the curtains do not shield: A phenomenological exploration of patient‐witnessed resuscitation in hospital. Part 1: patients' experiences

AimsThe aim of the study was to explore the experiences of hospital patients who witnessed resuscitation of a fellow patient.DesignDescriptive phenomenology.MethodsPatients who witnessed resuscitation were recruited from nine clinical wards in a university hospital in England. Data were collected through face-to-face individual interviews. Participants were interviewed twice,in 1 week and 4 to 6 weeks after the resuscitation event. Data were collected between August 2018 and March 2019. Interviews were analysed using Giorgi's phenomenological analysis.ResultsSixteen patients participated in the first interview and two patients completed follow-up interviews. Three themes were developed from the patients' interviews. (1) Exposure to witnessing resuscitation: patients who witness resuscitation felt exposed to a distressing event and not shielded by bed-space curtains, but after the resuscitation attempt, they also felt reassured and safe in witnessing staff's response. (2) Perceived emotional impact: patients perceived an emotional impact from witnessing resuscitation and responded with different coping mechanisms. (3) Patients' support needs: patients needed information about the resuscitation event and emotional reassurance from nursing staff to feel supported, but this was not consistently provided.ConclusionThe presence of other patients during resuscitation events must be acknowledged by healthcare professionals, and sufficient information and emotional support must be provided to patients witnessing such events. This study generates new evidence to improve patients' experience and healthcare professionals' support practices.ImpactThe phenomenon of patient-witnessed resuscitation requires the attention of healthcare professionals, resuscitation officers and policymakers. Study findings indicate that witnessing resuscitation has an emotional impact on patients. Strategies to support them must be improved and integrated into the management of in-hospital resuscitation. These should include providing patients with comprehensive information and opportunities to speak about their experience; evacuating mobile patients when possible; and a dedicated nurse to look after patients witnessing resuscitation events

Lewis X antigen mediates adhesion of human breast carcinoma cells to activated endothelium. Possible involvement of the endothelial scavenger receptor C-Type lectin

Lewis x (Lex, CD15), also known as SSEA-1 (stage specific embryonic antigen-1), is a trisaccharide with the structure Galβ(1–4)Fucα(1–3)GlcNAc, which is expressed on glycoconjugates in human polymorphonuclear granulocytes and various tumors such as colon and breast carcinoma. We have investigated the role of Lex in the adhesion of MCF-7 human breast cancer cells and PMN to human umbilical endothelial cells (HUVEC) and the effects of two different anti-Lex mAbs (FC-2.15 and MCS-1) on this adhesion. We also analyzed the cytolysis of Lex+-cells induced by anti-Lex mAbs and complement when cells were adhered to the endothelium, and the effect of these antibodies on HUVEC. The results indicate that MCF-7 cells can bind to HUVEC, and that MCS-1 but not FC-2.15 mAb inhibit this interaction. Both mAbs can efficiently lyse MCF-7 cells bound to HUVEC in the presence of complement without damaging endothelial cells. We also found a Lex-dependent PMN interaction with HUVEC. Although both anti-Lex mAbs lysed PMN in suspension and adhered to HUVEC, PMN aggregation was only induced by mAb FC-2.15. Blotting studies revealed that the endothelial scavenger receptor C-type lectin (SRCL), which binds Lex-trisaccharide, interacts with specific glycoproteins of Mr␣∼␣28 kD and 10 kD from MCF-7 cells. The interaction between Lex+-cancer cells and vascular endothelium is a potential target for cancer treatment.Fil: Elola, Maria Teresa. Fundación Instituto Leloir; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Capurro, Mariana Isabel. University of Toronto; CanadáFil: Barrio, Maria Marcela. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Fundación para la Investigación, Docencia y Prevención del Cáncer; ArgentinaFil: Coombs, Peter J.. Imperial College London; Reino UnidoFil: Taylor, Maureen E.. Imperial College London; Reino UnidoFil: Drickamer, Kurt. Imperial College London; Reino UnidoFil: Mordoh, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Fundación para la Investigación, Docencia y Prevención del Cáncer; Argentin

Targeted glycoproteomic identification of cancer cell glycosylation

GalMBP is a fragment of serum mannose-binding protein that has been modified to create a probe for galactose-containing ligands. Glycan array screening demonstrated that the carbohydrate-recognition domain of GalMBP selectively binds common groups of tumor-associated glycans, including Lewis-type structures and T antigen, suggesting that engineered glycan-binding proteins such as GalMBP represent novel tools for the characterization of glycoproteins bearing tumor-associated glycans. Blotting of cell extracts and membranes from MCF7 breast cancer cells with radiolabeled GalMBP was used to demonstrate that it binds to a selected set of high molecular weight glycoproteins that could be purified from MCF7 cells on an affinity column constructed with GalMBP. Proteomic and glycomic analysis of these glycoproteins by mass spectrometry showed that they are forms of CD98hc that bear glycans displaying heavily fucosylated termini, including Lewisx and Lewisy structures. The pool of ligands was found to include the target ligands for anti-CD15 antibodies, which are commonly used to detect Lewisx antigen on tumors, and for the endothelial scavenger receptor C-type lectin, which may be involved in tumor metastasis through interactions with this antigen. A survey of additional breast cancer cell lines reveals that there is wide variation in the types of glycosylation that lead to binding of GalMBP. Higher levels of binding are associated either with the presence of outer-arm fucosylated structures carried on a variety of different cell surface glycoproteins or with the presence of high levels of the mucin MUC1 bearing T antigen