The constraints of the ordinary: "being with" patients in a hospice in Scotland

The phenomenon 'being with', in relation to caring for patients who are close to death, is an important aspect underlying specialist palliative care. This study examines how 'being with' is constructed in day-to-day nursing practice in an inpatient hospice in Scotland.This thesis begins with a formulation of 'being with' in facing death as part of Cicely Saunders' notion of a better way of caring for dying patients. The thesis proceeds to outline my methodological and analytical approach using principles of ethnomethodology developed by Harold Garfinkel and Charles Taylor's philosophy of interpretation. Four chapters then present the analysis of data, drawing predominantly on material gathered through observation.In the beginning of this study, the nurses and nursing care assistants told me that 'being with' was part of their day-to-day care within the hospice. We seemed to share the same understanding of the phenomenon. However, I concluded during participant observation that 'being with' in facing death, as formulated by Saunders, was absent from the day-to-day care of patients in the hospice. By devising a methodology and approaches to analysis of data based on Garfinkel's and Taylor's work, I came to understand that the nurses' and nursing care assistants' perception of 'being with' was different from the way Saunders formulated 'being with'. I argue that the nurses' and nursing care assistants had constructed 'being with' when caring for patients who were close to death as providing comfort rather than dealing with the uncomfortable psychological and emotional effects of facing death. The consequence of this was that the patients were 'comforted' but they were not encouraged to face death in the way Saunders suggests, and as I had endeavoured to do in my own practice, thus leaving out an important part of specialist palliative care.In the last chapters of the thesis I discuss my findings by revisiting Saunders' notion of 'being with' as a better way of caring for dying patients, and by exploring Heidegger's ideas of how human beings can face death. Through revisiting Saunders' notion of 'being with', I came to the view that there is a tension between the 'theory' and the 'practice' of 'being with' in relation to its practical outworking. It may be that Saunders has underestimated how difficult it is for nurses and nursing care assistants to 'be with' patients in facing death due to the physical demands of caring for dying patients and secondly to facing death per se. In this discussion I compare Saunders' discussion of the phenomenon of death with that of Heidegger. There are similarities between their understandings but I also found tension between their thinking. By exploring this I conclude that the nurses and nursing care assistants had constructed 'being with' in terms of providing comfort in order to manage both their own and their patients' feelings and thoughts about death and dying. On the basis of this study I offer some important insights into the tension between the hospice ideology of a 'good death' as provided by Saunders, and the day-to-day management of care of dying patients in this hospice

Interstitial laser thermotherapy (ILT) of breast cancer - Methodology and immunological responce

Interstitial laser thermotherapy (ILT) is an attractive form of local therapy against cancer because of its anti-tumor immune activity. The aim of this work was to evaluate ILT in breast cancer with respect to technique, changes in tissue immunocompetent cells and effect on prognosis. The method is dependent on accurate assessment of the tumor, and another aim was therefore to evaluate if MRI is better than ultrasound (US) for imaging. Twenty-four patients were treated with ILT, followed by surgical resection about two weeks later. Pre-treatment US estimated the average tumor diameter to be 14 (range 5-35) mm. ILT was performed at 48Cº for 30 minutes under local anesthesia. Three patients were radically treated with ILT and the average tumor necrosis was 33% (0-100). Microscopic examination of the resected specimen showed that the average tumor diameter was 23 (range 7-55) mm. US underestimation of tumor size contributed to the rather poor local efficacy. ILT-induced changes in tissue immunocompetent cells were assessed by comparing findings in pre-treatment core biopsies and post-treatment pathologic specimens (paired comparisons). Changes in regional lymph nodes were assessed by comparison with a control group undergoing surgery only. ILT induced a significant increase of mature dendritic cells, B lymphocytes and macrophages at the tumor border and of cytotoxic T lymphocytes and macrophages within the tumor. In the lymph nodes there was a significant decrease in T regulatory cells. Most of these changes are considered to have a favorable prognostic value. Follow up after ILT was 116 (91-136) months. No patient had local recurrence of disease. Five patients developed distant metastases, and three of them have died. The number of cytotoxic T cells within the tumor was higher in patients with recurrence than in patients without recurrence. Patients with recurrent disease had a lower number of NK cells in tumor-free lymph nodes than patients without recurrence. Possible clinical benefit of ILT should be examined in a larger and less heterogenous patient population. MRI has been used preoperatively in most patients (68%) with breast cancer in Iceland during 2007-2009, in addition to mammography and US. Invasive tumor was measurable on all imaging methods in 267 patients. The study revealed that MRI and US both under- and overestimated size. Routine MRI was not shown to be a better radiological method than US for estimating tumor size in local ablative therapy

Multiple frame rate integration

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/76755/1/AIAA-1988-4579-400.pd

Evaluating family support needs of people using Strathcarron Hospice services

Executive summary: - Over two-thirds of cancer patients are cared for by two or more close relatives (1998), however, there are substantial gaps in the provision of supportive care. - An interview study with 16 family members of people supported by Strathcarron Hospice was conducted to identify the support needs of families when someone is receiving palliative care from Strathcarron Hospice. - Participants described the demanding role of being the main family carer and how this can at times be overwhelming and stressful. - Many interviewees were not provided the information they needed to help them to cope with the responsibility and new experiences which come about in their role as a carer prior to accessing Strathcarron Hospice services. - Relationships with healthcare professionals within the general healthcare system were often difficult and family members often felt taken for granted. Those interviewees who were also trained as nurses or worked in healthcare felt considerable role conflict from this duality. - Healthcare professionals were not thought to provide adequate support, on the whole, for family members. Strathcarron Hospice's services, however, were considered to stand out somewhat from this pattern and participants reported feeling supported by the Hospice. - Out of hours support was considered inadequate, with difficulties in accessing specialist support from NHS24, and limited knowledge of the role that the Hospice could have out of office hours. - Family members readily identified the ways in which a palliative diagnosis impacted on them, not just the patient. Thus, there is a need to understand the entire context in which people experience and make sense of their illness, and particularly their interconnectedness and interrelationships with others. - For many interviewees, there was a sense of a growing difficulty in relationships as a consequence of the multitude of changes which had occurred as a consequence of the illness. - Unpaid carers were drawn into supporting a range of other family members. However, families often experienced considerable difficulties in communicating with each other, and received no support to facilitate this. - Despite participants all having a relative who had been diagnosed with a life limiting condition, very little mention was made by interviewees of death or dying. Key recommendations include the following points of action for Strathcarron: 1. Continue to adopt a systematic approach to assessing the needs of family members in relation to both practical and psychosocial support. 2. Facilitate access to external agencies which can provide specialist family therapy support to ensure that families are supported in processing the wider implications of the disease, and prevent complicated grief reactions in the future. 3. Offer education to healthcare professionals which draw on this study's findings regarding the impact of a life-limiting diagnosis on the wider family system. 4. Support primary care services to stay involved with families who are accessing specialist palliative care, and ensure that family members are informed of the likely disease progression and how to access out-of-hours support. 5. Conduct further research regarding the ways families talk about death and dying

Relational ethics in palliative care research: Including a person-centred approach

The traditional approach to research ethics is to ensure that all ethical issues are adhered to through the scrutiny of research proposals by research ethics committees, themselves sitting within national research governance frameworks. The current approach implies that all potential ethical issues can be considered and mitigated prior to the research. This article is a perspective piece whereby we consider how this approach, on its own, is not enough to ensure ethical practice. We draw attention to the limitations of current ethical procedures in the inherent detachment between the researcher and research participants. We argue that applying a person-centred approach to research ethics allows for contextual and situational factors and places the relationship between research participants and researcher as central.https://doi.org/10.1177/263235241988538413pubpu

Supporting the provision of palliative care in the home environment: a proof-of-concept single-arm trial of a PalliativE Carers Education Package (PrECEPt)

Introduction Practical educational interventions for palliative carers are needed. Current supports frequently rely on carers travelling to a central venue to receive education. A substantial gap therefore exists around determining how high-quality relevant information can be delivered nationally, with limited cost implications, using educational methods that are acceptable to carers in palliative care. This study seeks to design and assess feasibility and acceptability of a distance-learning approach to educating carers. Methods This is an embedded mixed-method feasibility and acceptability study. It embeds an unblinded 1-arm pilot test, with subsequent qualitative interviews which will be used to inform the assessment of the intervention's acceptability and feasibility. The theoretical framework is self-efficacy theory, whereby we seek to impact carers' beliefs in their ability to carry out and succeed in caring tasks and situations. The educational materials focused on pain and nutrition/hydration will be developed in phase 1 with former carers (n=8) providing input into the content and style of materials. The educational package privileges adult-learning styles, recognising and responding to the learner's context including their learning needs, prior knowledge and motivations for engaging in education. The materials will be tested with up to 24 current carers. Analysis Analysis will focus on determining recruitment processes for a full-scale study, data collection procedures/completion rates, queries directed to the hospice from carers involved in the feasibility work, mode of delivery and content of the materials. The primary outcome measure is self-efficacy, with other measures focused on caregiver preparedness and caregiving tasks, consequences and needs questionnaire. Adherence to educational components will also be collected and reported. Ethics and dissemination Ethical approval has been provided by the participating site, Calvary Healthcare, Canberra, reference 02–2016, and the Australian Catholic University. Results will be published in peer-reviewed journals, presented at conferences and a lay summary sent to participants. Trial registration number ACTRN12616000601437; Pre-results

Transient Flow Stabilization of an Hydraulic Servomechanism

Mechanical Engineerin

A Prospective Analysis on Functional Outcomes Following Extended Latissimus Dorsi Flap Breast Reconstruction.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked FilesTo prospectively assess the functional effect of using the extended latissimus dorsi flap in immediate breast reconstructions.A total of 15 consecutive patients undergoing breast reconstruction with extended latissimus dorsi flap participated. Shoulder range of motion, muscle strength, lateral flexion of the torso, and position of scapula were measured pre-operatively and 1, 6, and 12 months post-operatively, in addition to donor-site post-operative complications.At 12 months post-operatively, patients had achieved full range of shoulder movement, when compared to pre-operative values. Lateral flexion of the torso was, however, significantly reduced bilaterally at 1 and 6 months post-operatively (p = 0.001, p = 0.01) and to the not operated side at 12 months (p = 0.01). Muscle strength in flexion-extension-internal rotation was significantly (p = 0.01) reduced on the operated side 12 months post-operatively. All but one patient had numbness around the donor-site scar 12 months post-operatively, 33% had slight adhesions but all were pain free.Although invariably, patients having extended latissimus dorsi flap may expect to achieve full range of shoulder movement, they should be informed of possible functional consequences and the time and effort it takes to recover. Further research is needed to investigate the potential long-term functional implications that extended latissimus dorsi flap may have as a result of changes in the lateral flexion of the torso and scapula position

Consistent Estimation of Gibbs Energy Using Component Contributions

Standard Gibbs energies of reactions are increasingly being used in metabolic modeling for applying thermodynamic constraints on reaction rates, metabolite concentrations and kinetic parameters. The increasing scope and diversity of metabolic models has led scientists to look for genome-scale solutions that can estimate the standard Gibbs energy of all the reactions in metabolism. Group contribution methods greatly increase coverage, albeit at the price of decreased precision. We present here a way to combine the estimations of group contribution with the more accurate reactant contributions by decomposing each reaction into two parts and applying one of the methods on each of them. This method gives priority to the reactant contributions over group contributions while guaranteeing that all estimations will be consistent, i.e. will not violate the first law of thermodynamics. We show that there is a significant increase in the accuracy of our estimations compared to standard group contribution. Specifically, our cross-validation results show an 80% reduction in the median absolute residual for reactions that can be derived by reactant contributions only. We provide the full framework and source code for deriving estimates of standard reaction Gibbs energy, as well as confidence intervals, and believe this will facilitate the wide use of thermodynamic data for a better understanding of metabolism

Reaching for the rainbow: Person-centred practice in palliative care

Erna Haraldsdottir - ORCID 0000-0003-4891-0743 https://orcid.org/0000-0003-4891-0743Brendan McCormack - ORCID 0000-0001-8525-8905 https://orcid.org/0000-0001-8525-8905Background: Person-centred practice is inherently integrated in palliative care. However, it cannot be assumed that its underpinning values are lived out in day-to-day practice in a hospice. At St Columba’s Hospice, Edinburgh, the five-year strategy demonstrated commitment to person-centredness and this prompted an 18-month project focusing on the evaluation and development of a person-centred culture, taking a practice development approach.Aim: To implement a person-centred practice development research project to assess, evaluate and enhance person-centred culture within St Columba’s Hospice.Methods: The theoretical underpinnings of the programme were based on the Person-centred Practice Framework. A transformative practice development approach was employed to bring about change in individuals and teams. Twelve multidisciplinary team members from different departments across the hospice formed a core research project group, which was allocated 10 protected learning and development days over the 18-month period. To assess the existing culture, data were collected at the beginning of the practice development programme, including observation in practice and real-time interviews with patients and staff. The data were analysed using a participatory approach, with group members mapping the data collected against the Person-centred Practice Framework and undertaking creative hermeneutic analysis.Discussion: The project created and sustained a space to explore and expose person-centredness within the hospice and raised awareness of what person-centred culture means in day-to-day practice. Fourth-generation evaluation highlighted further areas for action, with teams developing their own action plans aimed at enhancing person-centred culture.Conclusion and implications for practice: The context of day-to-day practice in a hospice setting is complex, and developing person-centred culture is an ongoing process. Hospices can help their staff to flourish by providing the necessary space to reflect and for critical awareness of own practices to be heightened. This could encourage staff to embrace the contradictions inherent in the work they undertake and to learn from it in order to improve their own wellbeing.https://doi.org/10.19043/ipdj.101.00510pubpub