Death does not deal – nurses' experiences of transition to terminal care

BAKGRUND: Ökad ålder innebär att livet närmar sig sitt slut och har ett starkt samband med sjuklighet. Palliativ vård syftar till att lindra lidande och främja livskvalitet för patienter som har en livshotande sjukdom eller skada. Alla som är i behov av palliativ vård ska erbjudas den, oavsett ålder och sjukdom. Startpunkten för palliativ vård är ett brytpunktssamtal. Hos den äldre patienten är det palliativa stadiet längre och identifikation av brytpunkt kan därmed försvåras. En teori om vårdens övergångar kan ge en ökad förståelse för sjuksköterskors upplevelser av övergången till vård i livets slutskede SYFTE: Att beskriva sjuksköterskors upplevelser av övergången från kurativ eller palliativ vård till vård i livets slutskede. METOD: En kvalitativ studie med semistrukturerade intervjuer av fyra sjuksköterskor med erfarenhet av geriatrisk akutsjukvård. RESULTAT: Resultatet presenteras i fyra kategorier: 1.ingen delaktighet, 2.symtomlindring och omvårdnad, 3.kunskap, tid, rutiner, direktiv och reflektion samt 4.närståendes betydelse. Studiens resultat belyser sjuksköterskors upplevelser och erfarenheter av att vårda äldre sköra patienter i livets slut. De ansåg sig ha för lite kunskaper och tid för att ge en god palliativ vård. Samtliga sjuksköterskor upplevde att bristen på brytpunktssamtal och sent beslut om övergång till vård i livets slut var en central del i problematiken kring vården av den äldre patienten. KONKLUSION: Resultatet visar att sjuksköterskor upplever att de har för lite kunskap i att ge palliativ vård till äldre personer. Bristen på brytpunktssamtal gör att patientens och dennes närståendes delaktighet i vården minskar och ibland uteblir helt. Dessutom tas beslutet om vård i livets slut ofta under patientens sista levnadsdygn, vilket inte ger denne möjlighet till delaktighet i beslut kring sin egen död.BACKGROUND: Increased age means life is coming to an end and is highly connected with illness. Palliative care aims to relieve suffering and to promote quality of life to patients who suffers from a life threatening disease or injury. All who is in need of palliative care shall be offered it, regardless of age or disease. Palliative care comprises multidisciplinary teamwork and the starting point of this work is the palliative turning point. The dying processes of older patients are usually longer than that of younger patients, making the identification of the palliative turning point difficult. A theory about health transition could be useful when describing nurses’ experiences of the transition to end of life care in older patients. AIM: To describe nurses’ experiences of the transition to end of life care. METHOD: A qualitative approach with semi structured interviews with four nurses who had experience of geriatric acute care. RESULTS: The result is summarized in four categories; no participation, symptomatic relief and nursing, knowledge, time, routines, directions & reflection and relatives. The nurses felt they had too little knowledge and time to provide good palliative care, and that the lack of a documented palliative turning point and late decisions on the transition to terminal care was a central part of the problems surrounding the care of the older patient. DISCUSSION: The study highlights the nurse's perceptions of the shortcomings of the current terminal care for the elderly frail patients. Where the lack of breakpoint call causes the patient and his related parties' participation in care reduces or sometimes absent. Moreover the decision about terminal care often during the patient's last days of life, which does not give him an opportunity to make decisions about his death

Death does not deal – nurses' experiences of transition to terminal care

Ökad ålder innebär att livet närmar sig sitt slut och har ett starkt samband med sjuklighet. Palliativ vård syftar till att lindra lidande och främja livskvalitet för patienter som har en livshotande sjukdom eller skada. Alla som är i behov av palliativ vård ska erbjudas den, oavsett ålder och sjukdom. Startpunkten för palliativ vård är ett brytpunktssamtal. Hos den äldre patienten är det palliativa stadiet längre och identifikation av brytpunkt kan därmed försvåras. En teori om vårdens övergångar kan ge en ökad förståelse för sjuksköterskors upplevelser av övergången till vård i livets slutskede SYFTE: Att beskriva sjuksköterskors upplevelser av övergången från kurativ eller palliativ vård till vård i livets slutskede. METOD: En kvalitativ studie med semistrukturerade intervjuer av fyra sjuksköterskor med erfarenhet av geriatrisk akutsjukvård. RESULTAT: Resultatet presenteras i fyra kategorier: 1.ingen delaktighet, 2.symtomlindring och omvårdnad, 3.kunskap, tid, rutiner, direktiv och reflektion samt 4.närståendes betydelse. Studiens resultat belyser sjuksköterskors upplevelser och erfarenheter av att vårda äldre sköra patienter i livets slut. De ansåg sig ha för lite kunskaper och tid för att ge en god palliativ vård. Samtliga sjuksköterskor upplevde att bristen på brytpunktssamtal och sent beslut om övergång till vård i livets slut var en central del i problematiken kring vården av den äldre patienten. KONKLUSION: Resultatet visar att sjuksköterskor upplever att de har för lite kunskap i att ge palliativ vård till äldre personer. Bristen på brytpunktssamtal gör att patientens och dennes närståendes delaktighet i vården minskar och ibland uteblir helt. Dessutom tas beslutet om vård i livets slut ofta under patientens sista levnadsdygn, vilket inte ger denne möjlighet till delaktighet i beslut kring sin egen död. Increased age means life is coming to an end and is highly connected with illness. Palliative care aims to relieve suffering and to promote quality of life to patients who suffers from a life threatening disease or injury. All who is in need of palliative care shall be offered it, regardless of age or disease. Palliative care comprises multidisciplinary teamwork and the starting point of this work is the palliative turning point. The dying processes of older patients are usually longer than that of younger patients, making the identification of the palliative turning point difficult. A theory about health transition could be useful when describing nurses’ experiences of the transition to end of life care in older patients. AIM: To describe nurses’ experiences of the transition to end of life care. METHOD: A qualitative approach with semi structured interviews with four nurses who had experience of geriatric acute care. RESULTS: The result is summarized in four categories; no participation, symptomatic relief and nursing, knowledge, time, routines, directions & reflection and relatives. The nurses felt they had too little knowledge and time to provide good palliative care, and that the lack of a documented palliative turning point and late decisions on the transition to terminal care was a central part of the problems surrounding the care of the older patient. DISCUSSION: The study highlights the nurse's perceptions of the shortcomings of the current terminal care for the elderly frail patients. Where the lack of breakpoint call causes the patient and his related parties' participation in care reduces or sometimes absent. Moreover the decision about terminal care often during the patient's last days of life, which does not give him an opportunity to make decisions about his death

Overall Survival in Patients with Stage IV Pan-NET Eligible for Liver Transplantation

BACKGROUND: The use of liver transplantation (LT) in patients with stage IV neuroendocrine pancreatic tumors (pan-NET) is under debate. Previous studies report a 5-year survival of 27-53% after LT in pan-NET and up to 92.7% in patients with mixed NETs. This study aimed to determine survival rates of patients with stage IV pan-NET meeting criteria for LT while only subjected to multimodal treatment. METHODS: Medical records of patients with pan-NET diagnosed from 2000 to 2021 at a tertiary referral center were evaluated for eligibility. Patients without liver metastases, who did not undergo primary tumor surgery, age > 75 years and with grade 3 tumors were excluded. The patients were divided into groups; all included patients, patients meeting the Milan, the United Network for Organ Sharing (UNOS) or the European Neuroendocrine Tumor Society (ENETS) criteria for LT. Kaplan-Meier survival analysis was used to calculate overall survival. RESULTS: Out of 519 patients with pan-NET, 41 patients were included. Mean follow-up time was 5.4 years. Overall survival was 9.3 years (95% Cl 6.8-11.7), and 5-year survival was 64.7% (95% CI 48.2-81.2). Patients meeting the Milan, ENETS and UNOS criteria for LT had a 5-year survival of 64.9% (95% CI 32.2-97.6), 85.7% (95% CI 59.8-100.0) and 55.4% (95% CI 26.0-84.8), respectively. CONCLUSIONS: In patients with stage IV pan-NET, grade 1 and 2, with no extra abdominal disease, 5-year survival was 64.7% (95% CI 48.2-81.2). As these survival rates exceed previously published series of LT for pan-NET, the evidence base for this treatment is very weak

Benefit of Primary Tumor Resection in Stage IV, Grade 1 and 2, Pancreatic Neuroendocrine Tumors

Objective:. To determine the association of primary tumor resection in stage IV pancreatic neuroendocrine tumors (Pan-NET) and survival in a propensity-score matched study. Background:. Pan-NET are often diagnosed with stage IV disease. The oncologic benefit from primary tumor resection in this scenario is debated and previous studies show contradictory results. Methods:. Patients from 3 tertiary referral centers from January 1, 1985, through December 31, 2019: Uppsala University Hospital (Uppsala, Sweden), Sahlgrenska University Hospital (Gothenburg, Sweden), and Brigham and Women’s Hospital/Dana-Farber Cancer Institute (Boston, USA) were assessed for eligibility. Patients with sporadic, grade 1 and 2, stage IV pan-NET, with baseline 2000–2019 were divided between those undergoing primary tumor resection combined with oncologic treatment (surgery group [SG]), and those who received oncologic treatment without primary tumor resection (non-SG). A propensity-score matching was performed to account for the variability in the extent of metastatic disease and comorbidity. Primary outcome was overall survival. Results:. Patients with stage IV Pan-NET (n = 733) were assessed for eligibility, 194 were included. Patients were divided into a SG (n = 65) and a non-SG (n = 129). Two isonumerical groups with 50 patients in each group remained after propensity-score matching. The 5-year survival was 65.4% (95% CI, 51.5-79.3) in the matched SG and 47.8% (95% CI, 30.6-65.0) in the matched non-SG (log-rank, P = 0.043). Conclusions:. Resection of the primary tumor in patients with stage IV Pan-NET and G1/G2 grade was associated with prolonged overall survival compared to nonoperative management. A surgically aggressive regime should be considered where resection is not contraindicated