IPU or ITU? It all starts with PCT (palliative care training)

Background: Impending death is not well recognised. Due to improvements in technology and medicine, people are living longer with more complex health conditions and because of this, the death of a patient is an experience that many people entering a healthcare profession will have little of. As death occurs in any setting, at any time, it is vital that all healthcare professionals regardless of the setting they go on to work in, have adequate Palliative Care Training (PCT). / Aim: To understand what current training is available on the recognition of dying at undergraduate level. / Methods: An information gathering exercise of the following UK undergraduate courses: medicine, nursing, social work, physiotherapy, occupational therapy. All courses received an email asking what training was provided in recognising and communication of dying and what time was dedicated to this. / Results: 73/198 courses responded (37%). 18/20 medical courses provided training in recognising dying with a median of 2 hours dedicated, and 17/20 in the communication of dying with a median of 3 hours dedicated. 80% (43/54) of nursing and allied health professional courses provided some form of training in end-of-life care. Many of these courses expressed frustration at the lack of resources, funding, and time to include more training. Those with more time dedicated to PCT often had a ‘champion’ to advocate for it. / Conclusion: Training in end-of-life care was inconsistent and variable across courses and professions. Further work on how we can support the champions in progressing PCT input on the courses is needed

Palliative care training in undergraduate medical, nursing and allied health: a survey

OBJECTIVES: Impending death is poorly recognised. Many undergraduate healthcare professionals will not have experience of meeting or caring for someone who is dying. As death can occur in any setting, at any time, it is vital that all healthcare students, regardless of the setting they go on to work in, have end-of-life care (EOLC) training. The aim was to determine current palliative care training at the undergraduate level, in multiple professions, in recognising and communicating dying. METHODS: Current UK undergraduate courses in medicine, adult nursing, occupational therapy, social work and physiotherapy were included. All courses received an email asking what training is currently offered in the recognition and communication of dying, and what time was dedicated to this. RESULTS: A total of 73/198 (37%) courses responded to the request for information. 18/20 medical courses provided training in recognising when patients were dying (median 2 hours), and 17/20 provided training in the communication of dying (median 3 hours). 80% (43/54) of nursing and allied health professional courses provided some training in EOLC. Many of the course organisers expressed frustration at the lack of resources, funding and time to include more training. Those courses with more palliative care provision often had a 'champion' to advocate for it. CONCLUSIONS: Training in EOLC was inconsistent across courses and professions. Further research is needed to understand how to remove the barriers identified and to improve the consistency of current training

The (un)availability of prognostic information in the last days of life: a prospective observational study.

OBJECTIVES: The aims of this study were (1) to document the clinical condition of patients considered to be in the last 2 weeks of life and (2) to compare patients who did or did not survive for 72 hours. DESIGN: A prospective observational study. SETTING: Two sites in London, UK (a hospice and a hospital palliative care team). PARTICIPANTS: Any inpatient, over 18 years old, English speaking, who was identified by the palliative care team as at risk of dying within the next 2 weeks was eligible. OUTCOME MEASURES: Prognostic signs and symptoms were documented at a one off assessment and patients were followed up 7 days later to determine whether or not they had died. RESULTS: Fifty participants were recruited and 24/50 (48%) died within 72 hours of assessment. The most prevalent prognostic features observed were a decrease in oral food intake (60%) and a rapid decline of the participant's global health status (56%). Participants who died within 72 hours had a lower level of consciousness and had more care needs than those who lived longer. A large portion of data was unavailable, particularly that relating to the psychological and spiritual well-being of the patient, due to the decreased consciousness of the patient. CONCLUSIONS: The prevalence of prognostic signs and symptoms in the final days of life has been documented between those predicted to die and those who did not. How doctors make decisions with missing information is an area for future research, in addition to understanding the best way to use the available information to make more accurate predictions

How do palliative care doctors recognise imminently dying patients? A judgement analysis.

OBJECTIVES: To identify a group of palliative care doctors who perform well on a prognostic test and to understand how they make their survival predictions. DESIGN: Prospective observational study and two cross-sectional online studies. SETTING: Phase I: an online prognostic test, developed from a prospective observational study of patients referred to palliative care. Phase II: an online judgement task consisting of 50 hypothetical vignettes. PARTICIPANTS: All members of the Association of Palliative Medicine (APM) were eligible (n=~1100). 99 doctors completed the prognostic test and were included in the phase I analysis. The top 20% were invited to participate in phase II; 14/19 doctors completed the judgement task and were included in the phase II analysis. MEASURES: Phase I: participants were asked to give a probability of death within 72 hours (0%-100%) for all 20 cases. Accuracy on the prognostic test was measured with the Brier score which was used to identify the 'expert' group (scale range: 0 (expert)-1 (non-expert)). Phase II: participants gave a probability of death within 72 hours (0%-100%). A mixed model regression analysis was completed using the percentage estimate as the outcome and the patient information included in the vignettes as the predictors. RESULTS: The mean Brier score of all participants was 0.237 (95% CI 0.235 to 0.239). The mean Brier score of the 'experts' was 0.184 (95% CI 0.176 to 0.192). Six of the seven prognostic variables included in the hypothetical vignettes were significantly associated with clinician predictions of death. The Palliative Performance Score was identified as being the most influential in the doctors' prognostic decision making (β=0.48, p<0.001). CONCLUSIONS: This study identified six clinical signs and symptoms which influenced the judgement policies of palliative care doctors. These results may be used to teach novice doctors how to improve their prognostic skills

Astrophysical and Astrobiological Implications of Gamma-Ray Burst Properties

Combining results for the local cosmic rate and mean peak luminosity of GRBs with the cosmic history of the star formation rate, we provide estimates for the local GRB rate per unit blue luminosity in galaxies. We find a typical GRB rate per unit B luminosity of 2.4x10^-17 h_{70}^2/Lsun/yr. The corresponding mean rate in the Milky Way is 5.5x10^-7 h_{70}^2/yr. We conclude: 1) the ratio of supernova rate to isotropic equivalent GRB rate is large: more than 6000 SNIbc per GRB or 30,000 SNII per GRB. GRBs could arise in a large fraction of black hole-forming events only with collimation in the range 0.01 - 0.001 and a steep enough slope of the IMF; 2) GRBs cannot account for the majority of large HI holes observed in galaxies; 3) the probability that the solar system was exposed to a fluence large enough to melt the chondrules during the first 10^7 yr of solar system history is negligibly small; 4) Even for very opaque atmospheres, a significant fraction of the GRB energy is transmitted as UV lines due to excitation by secondary electrons. For eukaryotic-like organisms in thin atmospheres (e.g. contemporary Mars), or for UV line exposure in thick atmospheres (e.g. Earth), biologically significant events occur at a rate of about 100--500 /Gyr. The direct contribution of these "jolts" to mutational evolution may, however, be negligible because of the short duration of the GRBs. Evolutionary effects due to partial sterilizations and to longer-lived disruptions of atmospheric chemistry should be more important. (Abridged)Comment: 36 pages, no figures Accepted by Astrophysical Journal Oct. 2001. First submitted December,1999. Substantially rewritten discussion of burst source count distributions and of biological implication

Depletion forces near curved surfaces

Based on density functional theory the influence of curvature on the depletion potential of a single big hard sphere immersed in a fluid of small hard spheres with packing fraction \eta_s either inside or outside of a hard spherical cavity of radius R_c is calculated. The relevant features of this potential are analyzed as function of \eta_s and R_c. There is a very slow convergence towards the flat wall limit R_c \to \infty. Our results allow us to discuss the strength of depletion forces acting near membranes both in normal and lateral directions and to make contact with recent experimental results

Hard Spheres in Vesicles: Curvature-Induced Forces and Particle-Induced Curvature

We explore the interplay of membrane curvature and nonspecific binding due to excluded-volume effects among colloidal particles inside lipid bilayer vesicles. We trapped submicron spheres of two different sizes inside a pear-shaped, multilamellar vesicle and found the larger spheres to be pinned to the vesicle's surface and pushed in the direction of increasing curvature. A simple model predicts that hard spheres can induce shape changes in flexible vesicles. The results demonstrate an important relationship between the shape of a vesicle or pore and the arrangement of particles within it.Comment: LaTeX with epsfig; ps available at http://dept.physics.upenn.edu/~nelson/index.shtml Phys Rev Lett in press (1997

A systematic review of using virtual reality technology in palliative care

Background: Virtual Reality (VR) has the potential to ease patient symptomatology but its efficacy is not known. Aim: A systematic review on the feasibility and effectiveness of VR intervention in a palliative care setting. Methods: Medline, Embase, AMED, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science were searched from inception up to March 2021. Studies that reported on the use of VR in an adult (over 18 years) palliative population were included. The ROB-2 (for RCTs) and ROBINS tools (for non-RCTs) were used to assess risk of bias. The GRADE tool assessed the quality of the evidence. The standardised mean differences were calculated from the pre- and post- data of the Edmonton Symptom Assessment System-revised (ESAS-r). A DerSimonian-Laird random effects model meta-analysis was conducted. Registered: PROSPERO (CRD42021240395, 03/03/2021) Results: 8 studies were included, 3 were included in the meta-analysis. All studies had at least some concern for risk of bias. 225 patients used the VR technology. Patient diagnoses included cancer (3/8; 37.5%), multiple (3/8; 37.5%), advanced heart disease (1/8; 12.5%), and dementia (1/8; 12.5%). 44% (97/219) were male; the mean age ranged from 47 to 85 (years). Recruitment was feasible and retention rates ranged between 55% and 100%. Overall, participants reported a positive experience with using VR and were happy to repeat the experience. Discomfort and technical issues were recorded in 4/7 studies (57%). The meta-analysis showed limited evidence for VR across the domains of the ESAS-r. The quality of the evidence was rated as low to very low. Conclusions: VR in palliative care is feasible and has varying acceptability. Limited sample sizes and low-quality studies mean that the efficacy of VR is difficult to draw definitive conclusions on. Existing studies provide valuable insights and guidance into how to set up VR in clinical practice settings and the challenges to expect

A coil-globule transition of a semiflexible polymer driven by the addition of spherical particles

The phase behaviour of a single large semiflexible polymer immersed in a suspension of spherical particles is studied. All interactions are simple excluded volume interactions and the diameter of the spherical particles is an order of magnitude larger than the diameter of the polymer. The spherical particles induce a quite long ranged depletion attraction between the segments of the polymer and this induces a continuous coil-globule transition in the polymer. This behaviour gives an indication of the condensing effect of macromolecular crowding on DNA.Comment: 12 pages, 4 figure