Dying and death in the electronic patient record. A qualitative analysis of textual practices

All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission.In Norway, over one in four deaths occur in hospitals, places that operate primarily according to curative logic. One aim of the Norwegian health care system is that patients, at the end of life, should receive high-quality palliative care as defined by the World Health Organization, independent of whether they are dying at home or in a nursing home, hospice or hospital. Against this potentially challenging background, this project investigates the role of the texts about such patients written into the electronic patient record (EPR). Starting from the view of (EPR) texts as active contributors to the whereabouts of (dying) patients, the EPR can be seen as an essential communication and coordination tool contributing to the types of knowledge that circulate about the dying patient and their treatment. This thesis aims to provide insights into how and what knowledge the EPR proposes as relevant by asking: What kind of textual practices of dying and death in medical wards are present in the EPR, and what do these practices achieve? The selected methods were a qualitative document analysis combining elements from the fields of linguistics, literary criticism and science and technology studies. This effort resulted in three articles elaborating different aspects of how dying and death are documented in the EPR. The first article investigated the negotiations of the transition from curative to palliative care. It argued that the text often changes from being technical and conclusive to being uncertain and open to negotiations as a need to align the involved parties in the decision. The second article explored which aspects of dying the text is attuned to in patients’ last 24 hours of life. It argued that the text has three hegemonic modes of ordering – numbering, timing, and classifying – which perform a dominant narrative in which dying is concealed. Yet, in between, there are traces of caring attention to and compassion for the dying patient. The third article considered how the moment of death is documented. It argued for what seem to be established ways of recording this moment as being manageable and portraying it as uneventful or good. This exploration of textual practices suggests that, first, the EPR treats dying and death as observations and tasks to be solved in general biomedical terms, rather than probing the needs of the individual patient. Second, the EPR seems to avoid difficult topics, deliberations, and disagreements, and it never admits to failure. Finally, the EPR sometimes shows professionals’ attempts to reveal individual patients’ needs and suffering and the troubles of dying in a curative context. Paper I: Hov, L., Synnes, O., & Aarseth, G. (2020). Negotiating the turning point in the transition from curative to palliative treatment: A linguistic analysis of medical records of dying patients. BMC Palliative Care, 19 (1), 1–13. https://doi.org/10.1186/s12904-020-00602-4 Paper II: Hov, L., Pasveer, B., & Synnes, O. (2020). Modes of dying in the electronic patient record, Mortality, https://doi.org/10.1080/13576275.2020.1865294 Paper III: Hov, L., Tveit, B., & Synnes O. (2021, May). Nobody dies alone in the electronic patient record – A qualitative analysis of the textual practices of documenting dying and death. OMEGA-Journal of Death and Dying. https://doi.org/10.1177/00302228211019197publishedVersio

Interdisciplinary teams in primary care: a systematic scoping review

Rapporten kan lastes ned gratis fra Folkehelseinstituttets nettsider : www.fhi.noI Stortingsmelding 26 om primærhelsetjenesten (2014-2015) foreslås det å opprette tverrfaglige team i den kommunale helse- og omsorgstjenesten. Teamarbeid er en økende benyttet arbeidsform i organiseringen av helsevesenet i mange land, men det er fortsatt mange ubesvarte spørsmål knyttet til en slik organiseringsmodell. Formålet med denne kartleggingsoversikten var å identifisere og beskrive forskningslitteratur om tverrfaglige team i primærhelsetjenesten. En kartleggingsoversikt over forskningskunnskapen viser først og fremst hva slags type forskning som er gjort. Kartleggingen kan bygges videre på for utvikling av prosjektplaner, etablering av tverrfaglige team, evalueringer av eksisterende og nye team og til bruk i den videre diskusjonen om tverrfaglige primærhelseteam i Norge.publishedVersio

Very early mobilization of patients with stroke: a systematic review

Rapporten kan lastes ned gratis fra Folkehelseinstituttets nettsider : www.fhi.noI 2014 ble 9600 personer lagt inn i sykehus med akutt hjerneslag i Norge. Dødeligheten som følge av hjerneslag er betydelig redusert de siste ti-årene, men mange pasienter med hjerneslag får varige nevrologiske funksjonsnedsettelser. Et viktig element i behandlingen av pasienter med akutt hjerneslag er at pasienten mobiliseres tidlig, men det er uklart om det er mest effektivt om dette skjer innen 24 timer eller mellom 24 - 48 timer etter symptomdebut. Vårt mandat var å identifisere og oppsummere studier som hadde belyst dette.publishedVersio

Stretching after treatment with botulinum toxin for adult patients with spasticity; A sys‐ tematic mapping review

Rapporten lastes ned gratis fra: Folkehelseinstituttets nettsider www.fhi.noNasjonalt kunnskapssenter for helsetjenesten i Folkehelseinstituttet fikk en forespørsel fra Irene Krystad ved fysioterapitjenesten i Tysvær kommune om å finne forskning om effekt av tøyning etter behandling med botulinumtoksin av voksne pasienter med spastisitet. De hadde funnet begrenset dokumentasjon etter egne søk etter litteratur, og så behovet for å finne fram til denne på en systematisk måte. Vi utførte en kartleggingsoversikt der vi søkte etter systematiske oversikter og randomiserte kontrollerte studier på effekten av tøyning etter behandling med botulinumtoksin versus behandling med botulinumtoksin alene på voksne pasienter med spastisitet. Søket etter systematiske oversikter resulterte i 1109 referanser. Av disse inkluderte vi fire systematiske oversikter. Disse inkluderte til sammen fem randomiserte studier med totalt 119 pasienter på den aktuelle problemstillingen. Den ene primærstudien som var inkludert i oversiktene vurderte vi til at ikke å omfatte tøyning og vi inkluderte derfor ikke denne studien blant de randomiserte kontrollerte studiene. Søket etter randomiserte kontrollerte studier resulterte i 2617 referanser, hvorav vi inkluderte fem randomiserte kontrollerte studier med totalt 138 pasienter. Fire av disse primærstudiene var allerede inkludert i de systematiske oversiktene. Vi avdekket kunnskapshull når det gjelder primærforskning på effekten av tøyning etter behandling med botulinumtoksin versus botulinumtoksin alene.publishedVersio

Nobody dies alone in the electronic patient record—A qualitative analysis of the textual practices of documenting dying and death

In this study, we analyse the electronic patient record (EPR) as a genre and investigate how a death is documented as part of the EPR, that is, what kind of textual practices can be found, and how they can be understood based on extracts from 42 EPRs from medical wards in Norwegian hospitals. Following from our analysis, we see four distinct patterns in the documentation of patient death: a) registering the bare minimum of information, b) registering a body stopped working, c) documenting dying quietly and placing it in peaceful surroundings, and d) highlighting the accompanied death. The textual practices of documenting the transition to death in the EPR make death appear manageable and sanitised, depicting death as either uneventful or good. While the EPR genre is steeped in biomedical language, other discourses relating to death can be seen as ways to accommodate the ideal of a dignified death

Modes of dying in the electronic patient record

To die in a medical ward is to die in a context aimed at saving lives and ensuring an efficient patient turnover. At the centre of securing treatment and care for patients is the electronic patient record (EPR). In this study, we will argue that the EPR is not only a container of relevant information about a patient and a record of past events but that it also performs how to go about dying, thereby also actively contributing to orderings of dying. Based on excerpts from 42 EPRs from the last 24 hours of life, we distinguish and analyse three hegemonic modes of ordering - numbering, timing and classifying. These modes primarily perform a 'master narrative' loyal to a heroic curative medicine wherein dying is cloaked, in the sense of being sequestered, and is made invisible. But zooming in on the gaps and cracks of the EPR notes, we argue that here we find traces of a different kind of cloaking attentive to palliative care of the dying process

The effects of concurrent prescription of benzodiazepines for people undergoing opioid maintenance treatment. Systematic review

Background In Opioid Maintenance Treatment patients receive long acting opioids as a substitute for heroin and other common illegally used opioids. People with opioid dependence are likely to experience elevated levels of anxiety and sleep disturbance. Therefore, benzodiazepines are often prescribed for these patients to alleviate such problems. Meanwhile, benzodiazepines are readily available on the illicit street market and are in high risk to be misused. Several studies find that concurrent prescription of benzodiazepines during opioid maintenance treatment is associated with more drug abuse and dependence. Prolonged use of benzodiazepines may result in anxiety and mental health problems, and increased risk of personal injury. However, the evidence is mostly descriptive and does not distinguish between prescribed versus illicitly procured benzodiazepines. Objective The purpose of this systematic review is to assess the effects of concurrent benzodiazepines prescription among people who receive opioid maintenance treatment (i.e. methadone, buprenorphine or buprenorphine combined with naloxone). Method We first searched for systematic reviews that could answer our research question in the following databases: Epistemonikos, Cochrane Library (CDSR, DARE, HTA), MEDLINE (Ovid), PubMed [sb] and Embase (Ovid). Thereafter, we searched for primary studies to conduct a systematic review to summarize the available evidence. Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted time series were included as relevant study designs. The target population was people 18 years or older who received substitution treatment with methadone, buprenorphine or buprenorphine combined with naloxone for opioid dependence. Relevant intervention was prescription of benzodiazepines as compared with no prescription of benzodiazepines. The outcomes of interest were retention in treatment, patients’ satisfaction, opioid use (self report or biological test), other substance use (self report or biological test), extent of anxiety and depression, sleep disorders, mortality, side effects (overdose, injury and use of hospital emergency) and criminal offences. We carried out a systematic search for literature, with no limit of publication time or language, in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), PubMed [sb], Embase (Ovid), CINAHL (EBSCO) and PsycINFO. Three authors evaluated the references based on the title and abstract, in pairs independently of each other (Kristoffer Yunpeng Ding evaluated all, Annhild Mosdøl and Laila Hov half each). Potentially relevant references were read in full-text (Kristoffer Yunpeng Ding evaluated all, Annhild Mosdøl and Laila Hov half each). We planned to assess the risk of bias, synthesise the data if possible and use the GRADE method (Grading of Recommendation Assessment, Development and Evaluation) to assess our confidence in the estimated effects. Results The literature search for systematic reviews identified 998 titles and abstracts. No systematic reviews were relevant for this topic after screening. The search for primary studies identified 3696 references. We considered eight references as potentially relevant and read them in full text. However, none of these references met our inclusion criteria. Discussion We did not find any relevant systematic reviews, clinical trials or controlled studies meeting our inclusion criteria. Experimental studies with controlled use of benzodiazepines are needed to evaluate the effects and consequences of benzodiazepines prescription during opioid maintenance treatment. We suggest the following outcomes: drug retention rates and abuse; patient satisfaction; mental health; sleep disorders; side effects and criminal behaviours. Conclusion We found no controlled studies focusing on the effects and consequences of concurrent benzodiazepines prescription during opioid maintenance treatment

Frédéric Godet, Commentaire sur la première épître aux Corinthiens, 2e édition avec une préface du Pr Pierre Bonnard, 2 volumes, Neuchâtel, Édition de l'Imprimerie nouvelle L.-A. Monnier, 1965

Chevallier Max-Alain. Frédéric Godet, Commentaire sur la première épître aux Corinthiens, 2e édition avec une préface du Pr Pierre Bonnard, 2 volumes, Neuchâtel, Édition de l'Imprimerie nouvelle L.-A. Monnier, 1965. In: Revue d'histoire et de philosophie religieuses, 47e année n°2,1967. pp. 195-196

Tverrfaglige team i primærhelsetjenesten: en systematisk kartleggingsoversikt

I Stortingsmelding 26 om primærhelsetjenesten (2014-2015) foreslås det å opprette tverrfaglige team i den kommunale helse- og omsorgstjenesten. Teamarbeid er en økende benyttet arbeidsform i organiseringen av helsevesenet i mange land, men det er fortsatt mange ubesvarte spørsmål knyttet til en slik organiseringsmodell. Formålet med denne kartleggingsoversikten var å identifisere og beskrive forskningslitteratur om tverrfaglige team i primærhelsetjenesten. En kartleggingsoversikt over forskningskunnskapen viser først og fremst hva slags type forskning som er gjort. Kartleggingen kan bygges videre på for utvikling av prosjektplaner, etablering av tverrfaglige team, evalueringer av eksisterende og nye team og til bruk i den videre diskusjonen om tverrfaglige primærhelseteam i Norge