Continuous sedation until death: The everyday moral reasoning of physicians, nurses and family caregivers in the UK, The Netherlands and Belgium

Copyright © 2014 Raus et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.Background - Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress. Methods - This study is an international qualitative interview study involving interviews with physicians, nurses, and relatives of deceased patients in the UK, The Netherlands and Belgium (the UNBIASED study) about a case of continuous sedation at the end of life they were recently involved in. All interviews were transcribed verbatim and analysed by staying close to the data using open coding. Next, codes were combined into larger themes and categories of codes resulting in a four point scheme that captured all of the data. Finally, our findings were compared with others and explored in relation to theories in ethics and sociology. Results - The participants’ responses can be captured as different dimensions of ‘closeness’, i.e. the degree to which one feels connected or ‘close’ to a certain decision or event. We distinguished four types of ‘closeness’, namely emotional, physical, decisional, and causal. Using these four dimensions of ‘closeness’ it became possible to describe how physicians, nurses, and relatives experience their involvement in cases of continuous sedation until death. More specifically, it shined a light on the everyday moral reasoning employed by care providers and relatives in the context of continuous sedation, and how this affected the emotional impact of being involved in sedation, as well as the perception of their own moral responsibility. Conclusion - Findings from this study demonstrate that various factors are reported to influence the degree of closeness to continuous sedation (and thus the extent to which carers feel morally responsible), and that some of these factors help care providers and relatives to distinguish continuous sedation from euthanasia.The Economic and Social Research Council (UK), the Research Foundation Flanders (BE), the Flemish Cancer Association (BE), the Research Council of Ghent University (BE), the Netherlands Organization for Scientific Research (NL) and the Netherlands Organization for Health Research and Development (NL)

Sand dynamics along the Belgian coast based on airborne hyperspectral data and lidar data

The goal of this project was to explore the possibilities of airborne hyperspectral data and airborne lidar data to study sand dynamics on the Belgian backshore and foreshore. The Belgian coast is formed by a sandy strip at the southern edge of the North Sea Basin which is commonly known as the Southern Bight. Since the beach is prone to structural and occasional erosion, it is very important to obtain a better understanding of the processes controlling it. The combination of multi-temporal hyperspectral data and lidar data provides a suitable tool for follow-up of the Belgian coastline, and sandy coastlines in general. Hyperspectral imagery generates a reflectance spectrum for each pixel in the image. The shape of this spectrum is influenced by the composition of the topsoil of the beach, being mainly the mineralogical composition and the grain size. A Spectral Angle Mapper (SAM) algorithm was used to perform a supervised classification of the hyperspectral images in order to distinguish between different sand types. Digital terrain models (DTM’s) with a mean vertical accuracy of 5 cm were generated from lidar data. By differencing a DTM from September 2000 and one from September 2001 a map with sedimentation and erosion zones was generated. By combining the erosion/sedimentation map with the classified hyperspectral images, dating from August 2000 and August 2001, an appropriate and cost-effective method was found for studying the processes of sand transport along the Belgian coastline

Monitoring inland waters with the APEX sensor, a wavelet approach

In this study a new curve fitting approach is presented to derive TSM, CHL and CDOM concentrations in inland and coastal waters from water leaving-reflectance spectra. The approach is based on the wavelet transform and is tested on simulated water-leaving reflectance spectra. For simulations SIOPS and water concentrations, representative for the Scheldt river, were used. The results shown that the approach is less sensitive to errors in the atmospheric correction or specific sensor noise. The idea is based on the development of a new minimization criteria for curve fitting. Instead of minimizing the difference between modeled and measured spectra using a simple RMSE, the RMSE is now combined with specific wavelet features. Several types of errors and noise are added to the simulated spectra to find robust features. Two minimization criteria were found which are almost insensitive to a white error and less sensitive to adjacency effects

Hyperspectral data for coral reef monitoring. A case study: Fordate, Tanimbar, Indonesia

Coral reefs are endangered world-wide by devastating fishing methods (overfishing, dynamite and cyanide fishery), pollution, tourism, environmental changes and bleaching. The aim of this project is to monitor coral reefs and associated ecosystems (mangroves, sea-grass beds) by integrating different remote sensing data with spectral libraries and field measurements. The study area is Fordate, a small island to the northeast of Tanimbar, Indonesia. The monitoring system under development will enable not only the mapping of the coral reefs but also the localisation of those parts of the reefs that are most affected by degradation. A first test with hyperspectral data from the CHRIS/PROBA sensor shows promising results for the discrimination of different bottom-types on the Pulau Nukaha patch reef east of Fordate. Further field sampling and spectral measurements are needed to validate this preliminary classification

A SWIR based algorithm to retrieve total suspended matter in extremely turbid waters

In ocean colour remote sensing, the use of Near Infra Red (NIR) spectral bands for the retrieval of Total Suspended Matter (TSM) concentration in turbid and highly turbid waters has proven to be successful. In extremely turbid waters (TSMN 100 mgL−1) however, these bands are less sensitive to increases in TSM. Here it is proposed to use Short Wave Infra Red (SWIR) spectral bands between 1000 and 1300 nm for these extreme cases. This SWIR spectral region is subdivided into two regions, SWIR-I (1000 nm to 1200 nm) and SWIR-II (1200 nm to 1300 nm) which correspond to local minima in the pure water absorption spectrum. For both spectral regions the water reflectance signal was measured in situ with an ASD spectrometer in three different extremely turbid estuarine sites: Scheldt (Belgium), Gironde (France), and Río de la Plata (Argentina), along with the TSMconcentration.A measurable water reflectance was observed for all sites in SWIR-I, while in the SWIR-II region the signal was not significant compared to the Signal-to-Noise Ratio (SNR) of current Ocean Colour (OC) sensors. For the spectral band at 1020 nm (present in Ocean and Land Colour Instrument ? OLCI, onboard Sentinel-3) and at 1071 nm, an empirical single band TSM algorithm is defined which is valid for both the Gironde and Scheldt estuarine sites. This means that a single algorithm can be applied for both sites without expensive recalibration.The relationship between TSM and SWIR reflectance at 1020 and 1071 nm is linear and did not show any saturation for the concentrations measured here (up to 1400 mg L−1), while saturation was observed for the NIR wavelengths, as expected. Hence, for extremely turbid waters it is advised to switch from NIR to SWIR-I wavelengths to estimate TSM concentration. This was demonstrated for an airborne hyperspectral dataset (Airborne Prism Experiment, APEX) from the Gironde estuary having several spectral bands in the SWIR-I. The empirical single band SWIR TSM algorithm was applied to the atmospherically corrected scene providing a TSM concentration map of the Gironde from mouth to more upstream with concentrations expected in this region ranging from a few to several hundreds mg L−1. These results, i.e. the existence of a single relationship for the Scheldt and Gironde, not showing any decrease of sensitivity, highlights the importance of having SWIR bands in future ocean colour sensors for studying extremely turbid rivers, coastal areas and estuaries in the world. A further implication of these results is that there is a TSMlimit for application of atmospheric correction algorithms which assume zero SWIR marine reflectance. That limit is defined here as function of wavelength and sensor noise level.Fil: Knaeps, E.. Flemish Institute for Technological Research (VITO); BélgicaFil: Ruddick, K. G.. Flemish Institute for Technological Research ; BélgicaFil: Doxaran, D.. Laboratoire d; FranciaFil: Dogliotti, Ana Inés. Consejo Nacional de Investigaciónes Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Instituto de Astronomía y Física del Espacio. - Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Instituto de Astronomía y Física del Espacio; ArgentinaFil: Nechad, B.. Royal Belgian Institute for Natural Sciences (RBINS); BélgicaFil: Raymaekers, D.. Flemish Institute for Technological Research; BélgicaFil: Sterckx, S.. Flemish Institute for Technological Research; Bélgic

The perspectives of clinical staff and bereaved informal care-givers on the use of continuous sedation until death for cancer patients: The study protocol of the UNBIASED study

Background: A significant minority of dying people experience refractory symptoms or extreme distress unresponsive to conventional therapies. In such circumstances, sedation may be used to decrease or remove consciousness until death occurs. This practice is described in a variety of ways, including: ‘palliative sedation’, ‘terminal sedation’, ‘continuous deep sedation until death’, ‘proportionate sedation’ or ‘palliative sedation to unconsciousness’. Surveys show large unexplained variation in incidence of sedation at the end of life across countries and care settings and there are ethical concerns about the use, intentions, risks and significance of the practice in palliative care. There are also questions about how to explain international variation in the use of the practice. This protocol relates to the UNBIASED study (UK Netherlands Belgium International Sedation Study), which comprises three linked studies with separate funding sources in the UK, Belgium and the Netherlands. The aims of the study are to explore decision-making surrounding the application of continuous sedation until death in contemporary clinical practice, and to understand the experiences of clinical staff and decedents’ informal caregivers of the use of continuous sedation until death and their perceptions of its contribution to the dying process. The UNBIASED study is part of the European Association for Palliative Care Research Network. Methods/Design: To realize the study aims, a two-phase study has been designed. The study settings include: the domestic home, hospital and expert palliative care sites. Phase 1 consists of: a) focus groups with health care staff and bereaved informal care-givers; and b) a preliminary case notes review to study the range of sedation therapy provided at the end of life to cancer patients who died within a 12 week period. Phase 2 employs qualitative methods to develop 30 patient-centred case studies in each country. These involve interviews with staff and informal care-givers closely involved in the care of cancer patients who received continuous sedation until death. Discussion: To our knowledge, this is one of the few studies which seek to take a qualitative perspective on clinical decision making surrounding the use of continuous sedation until death and the only one which includes the perspectives of nurses, physicians, as well as bereaved informal care-givers. It has several potential strengths, weaknesses, opportunities and threats associated with the specific design of the study, as well as with the sensitive nature of the topic and the different frameworks for ethical review in the participating countries