Models of care in palliative medicine

© 2014 Springer-Verlag Berlin Heidelberg. All rights reserved. In resource-rich countries, chronic complex diseases have largely replaced acute causes of disability and death. There is now a need for every clinician to be able to take a palliative approach. This is defined as the ability to deal with key elements of clinical care for someone who has a progressive illness that is likely to lead to death and their caregivers. The key elements of a palliative approach are access; collaborative interdisciplinary team-based care; defining the goals of care; evaluating the net effect of any treatments or interventions addressing, where relevant, issues of withholding and withdrawing treatment; determining preferred place of care and, separately, the preferred place at the time of death; and managing care transitions. For patients, there is evidence of improved symptom control, better met needs, better satisfaction with care and better quality of dying and improved comfort in the last 2 weeks of life. Having relinquished their roles, caregivers for people at the end of life who have used specialist palliative care services had better long-term survival and were better able to adjust to their changed circumstances. Specialist palliative care services are also associated with better met caregiver needs, improved satisfaction with care and less caregiver anxiety. For health systems, benefits include reduced inpatient stays, fewer presentations to the emergency department and reduced overall costs. Patient-defined areas of importance include the ability to carry out one's affairs as the end-of-life approaches, resolving relationship issues and being involved in decision-making. Specialist supportive and palliative care has services which are charged with providing team-based clinical care to people with the most complex end-of-life care needs and their families, as well as and consultative support for colleagues providing care where the patient or family have less complex needs. Ensuring all people have access to best palliative care is dependent upon an on going committment to ensuring that: There is adequate education at an undergraduate, postgraduate and post-registration level; and high-quality research that continues to refine the evidence base for clinical care that is offered; and health services are structured to optimally deliver these services

Effects of less-invasive surfactant administration on oxygenation, pulmonary surfactant distribution, and lung compliance in spontaneously breathing preterm lambs

BACKGROUND: A new technique was proposed to administer surfactant to spontaneous breathing preterm infants by placing a thin catheter through the vocal cords. This technique was not studied with respect to oxygenation, gas exchange, surfactant distribution, and lung mechanics. We tested the technique of less-invasive surfactant administration (LISA) in a spontaneous breathing preterm lamb model. METHODS: Preterm lambs (n = 12) of 133-134 d gestational age were randomized to the following three groups: (i) continuous positive airway pressure (CPAP) only, (ii) CPAP + LISA, and (iii) intubation and mechanical ventilation with surfactant administration. Surfactant was labeled with samarium oxide. During the next 180 min, blood gas analyses were performed. Postmortem, lungs were removed and surfactant distribution was assessed, and pressure-volume curves were performed. RESULTS: Pao(2) in the LISA-treated. lambs was significantly higher than in the lambs that exclusively received CPAP. Moreover, Pao(2) values were similar between the LISA-treated and the intubated lambs. Overall, surfactant deposition was less in the LISA lambs, with significantly less surfactant distributed to the right upper lobe. Lung compliance was better in the intubated lambs compared with the LISA-treated lambs, although this did not reach significance. CONCLUSION: LISA improved oxygenation, similar to conventional surfactant application techniques, despite lower surfactant deposition and lung compliance

Lung morphometry and collagen and elastin content: Changes during normal development and after prenatal hormone exposure in sheep

This study examined whether the improvement in lung function after prenatal hormone exposure coincided with changes in lung morphometry or in collagen and elastin content. Fetal lambs received a single intramuscular injection of betamethasone (0.5 mg/kg) plus L-thyroxine (T-4) (15 mu g/kg) or vehicle control 48 h before delivery at 121, 128, or 135 d gestational age (d 121, d 128, d 135, term = 150 d). T-4 was administered in conjunction with betamethasone in an attempt to enhance the maturational response. The right-upper lobes were instillation fixed at 30 cm H2O by Karnovsky's fixative after a 40-min period of mechanical ventilation. A number of significant changes occurred between d 121 and d 135 in control animals: alveolar airspace volume increased by 270%; despite a 40% reduction in alveolar septal thickness, alveolar septal volume did not change appreciably, suggesting a "redistribution" of septal tissue into the formation of secondary alveolar septa, which doubled in number; and both parenchymal collagen and elastin volume increased significantly, whereas pleural collagen and elastin volume did not change. In contrast to the changes seen in control animals, exposure to betamethasone plus T-4 led to alveolar septal thinning at each gestational age without an associated increase in secondary septal number, a 40% decrease in alveolar septal volume, and a proportionate reduction in parenchymal elastin at d 121. Although attenuation of alveolar septa coincides with redistribution of septal tissue into the formation of secondary septa during normal maturation, exposure to betamethasone plus T-4 promotes thinning of alveolar septa in the absence of secondary septal formation, which results in a loss of alveolar septal tissue