The challenge to health professionals when carers resist truth telling at the end of life: a qualitative secondary analysis

Aims and objectives: To draw out the similar complexities faced by staff around
truth-telling in a children’s and adult population and to interrogate the dilemmas faced by staff when informal carers act to block truth-telling.

Background: Policy encourages normalisation of death, but carers may act to protect or prevent the patient from being told the truth. Little is known about the impact on staff.

Design: Secondary analysis of data using a supra-analysis design to identify commonality of experiences.

Methods: Secondary ‘supra-analysis’ was used to transcend the focus of two primary studies in the UK, which examined staff perspectives in a palliative children’s and a palliative adult setting, respectively. The analysis examined new theoretical questions relating to the commonality of issues independently derived in each primary study. Both primary studies used focus groups. Existing empirical data were analysed thematically and compared across the studies.

Results: Staff reported a hiding of the truth by carers and sustained use of activities aimed at prolonging life. Carers frequently ignored the advance of end of life, and divergence between staff and carer approaches to truth-telling challenged professionals. Not being truthful with patients had a deleterious effect on staff, causing anger and feelings of incompetence.

Conclusions: Both children’s and adult specialist palliative care staff found themselves caught in a dilemma, subject to policies that promoted openness in planning for death and informal carers who often prevented them from being truthful with patients about terminal prognosis. This dilemma had adverse psychological effects upon many staff.

Relevance to clinical practice: There remains a powerful death-denying culture in
many societies, and carers of dying patients may prevent staff from being truthful with their patients. The current situation is not ideal, and open discussion of this problem is the essential first step in finding a solution.

Dissolved uranium, radium and radon evolution in the Continental Intercalaire aquifer, Algeria and Tunisia

Natural, dissolved 238U-series radionuclides (U, 226Ra, 222Rn) and activity ratios (A.R.s: 234U/238U; 228Ra/226Ra) in Continental Intercalaire (CI) groundwaters and limited samples from the overlying Complexe Terminal (CT) aquifers of Algeria and Tunisia are discussed alongside core measurements for U/Th (and K) in the contexts of radiological water quality, geochemical controls in the aquifer, and water residence times. A redox barrier is characterised downgradient in the Algerian CI for which a trend of increasing 234U/238U A.R.s with decreasing U-contents due to recoil-dominated 234U solution under reducing conditions allows residence time modelling ∼500 ka for the highest enhanced A.R. = 3.17. Geochemical modelling therefore identifies waters towards the centre of the Grand Erg Oriental basin as palaeowaters in line with reported 14C and 36Cl ages. A similar 234U/238U trend is evidenced in a few of the Tunisian CI waters. The paleoage status of these waters is affirmed by both noble gas recharge temperatures and simple modelling of dissolved, radiogenic 4He-contents both for sampled Algerian and Tunisian CI and CT waters. For the regions studied these waters therefore should be regarded as “fossil” waters and treated effectively as a non-renewable resource.

Bias in research

The aim of this article is to outline types of ‘bias’ across research designs, and consider strategies to minimise bias. Evidence-based nursing, defined as the “process by which evidence, nursing theory, and clinical expertise are critically evaluated and considered, in conjunction with patient involvement, to provide the delivery of optimum nursing care,”1 is central to the continued development of the nursing professional. Implementing evidence into practice requires nurses to critically evaluate research, in particular assessing the rigour in which methods were undertaken and factors that may have biased findings.

An Appraisal of End-of-Life Care in Persons with Chronic Kidney Disease Dying in Hospital Wards

AIM: To review end-of-life care provided by renal healthcare professionals to hospital in-patients with chronic kidney disease, and their carers, over a 12-month period in Northern Ireland.

METHODS: Retrospective review of 100 patients.

RESULTS: Mean age at death was 72 years (19-95) and 56% were male. Eighty three percent of patients had a 'Not For Attempted Resuscitation' order during their last admission and this was implemented in 42%. Less than 20% of all patients died in a hospital ward. No patients had an advanced care plan, although 42% had commenced the Liverpool Care Pathway for the Dying Patient. Patients suffered excessive end-of-life symptoms. In addition, there was limited documentation of carer involvement and carer needs were not formally assessed.

CONCLUSION: End-of-life care for patients with advanced chronic renal disease can be enhanced. There is significant variation in the recording of discussions regarding impending death and little preparation. There is poor recording of the patients' wishes regarding death. Those with declining functional status, including those frequently admitted to hospital require holistic assessment regarding end-of-life needs. More effective communication between the patient, family and multi-professional team is required for patients who are dying and those caring for them.

Fluence dependence of the surface roughness of InP after N2 + bombardment

InP(1 0 0) surfaces were sputtered under ultrahigh vacuum conditions by 5 keV N2+ ions at an angle of incidence of 41° to the sample normal. The fluence, φ, used in this study, varied from 1 × 10¹⁴ to 5 × 10¹⁸ N2+ cm^-2. The surface topography was investigated using field emission scanning electron microscopy (FE-SEM) and atomic force microscopy (AFM). At the lower fluences (φ ≤ 5 × 10¹⁶ N2+ cm^-2) only conelike features appeared, similar in shape as was found for noble gas ion bombardment of InP. At the higher fluences, ripples also appeared on the surface. The bombardment-induced topography was quantified using the rms roughness. This parameter showed a linear relationship with the logarithm of the fluence. A model is presented to explain this relationship. The ripple wavelength was also determined using a Fourier transform method. These measurements as a function of fluence do not agree with the predictions of the Bradley-Harper theory. © 2004 Elsevier B.V. All rights reserved.

Stable Isolated Metal Atoms as Active Sites for Photocatalytic Hydrogen Evolution

The process of using solar energy to split water to produce hydrogen assisted by an inorganic semiconductor is crucial for solving our energy crisis and environmental problems in the future. However, most semiconductor photocatalysts would not exhibit excellent photocatalytic activity without loading suitable co-catalysts. Generally, the noble metals have been widely applied as co-catalysts, but always agglomerate during the loading process or photocatalytic reaction. Therefore, the utilization efficiency of the noble co-catalysts is still very low on a per metal atom basis if no obvious size effect exists, because heterogeneous catalytic reactions occur on the surface active atoms. Here, for the first time, we have synthesized isolated metal atoms (Pt, Pd, Rh, or Ru) stably by anchoring on TiO2, a model photocatalystic system, by a facile one-step method. The isolated metal atom based photocatalysts show excellent stability for H-2 evolution and can lead to a 6-13-fold increase in photocatalytic activity over the metal clusters loaded on TiO2 by the traditional method. Furthermore, the configurations of isolated atoms as well as the originality of their unusual stability were analyzed by a collaborative work from both experiments and theoretical calculations.

Type 2 diabetes: a case study

Increased prevalence of diabetes in the community has been accompanied by an increase in diabetes in hospitalised patients. About a quarter of these patients experience a hypoglycaemic episode during their admission, which is associated with increased risk of mortality and length of stay. This article examines the aetiology, pathophysiology, diagnosis and treatment of type 2 diabetes using a case study approach. The psychosocial implications for the patient are also discussed. The case study is based on a patient with diabetes who was admitted to hospital following a hypoglycaemic episode and cared for during a practice placement. The importance of early diagnosis of diabetes and the adverse effects of delayed diagnosis are discussed.

Current treatments for renal cell carcinoma

Renal cell carcinoma (RCC), also known as kidney cancer, renal adenocarcinoma or hypernephroma, and metastatic renal cell carcinoma is a global burden. This article aims to provide a brief overview of RCC. It outlines epidemiology and presentation; invesitgation and staging; treatments and prognosis. The article also includes a focus on currently available drug treatments, and serves as an introduction to the topic.