Cuidado de enfermagem ao potencial doador de órgãos em morte encefálica: uma reflexão sobre a prática

Despite of the technological advances that favor the transplant process, there are issues of effectiveness of care necessary for the maintenance of potential organ donors with brain death, which contribute to the no realization of transplants of organs and tissues of these patients. It is presupposed that the problems could be related to perceptions and understandings that the professionals of the units of internment have about the care required by the diagnosis of brain death. The aim of this study was to understand the meaning of the nursing care of the potential organ donor with brain death to the nursing staff. Descriptive study with qualitative approach guided by Action Science Theory and the critic-reflexive research methodology accomplished with five nurses and 19 nursing technicians from Operative Rehabilitation Center in a public hospital at Natal / RN, Brazil, between March and May 2013. Data were collected through semi-structured interviews with individual reflection about the care and through group interview, after approval by the Ethics and Research Committee, CAAE No.: 04255612.7.0000.5537. The analysis was performed in a thematic way according to Bardin. During the group meeting the participants were driven in a discussion about the need for change and how to perform them. The results indicate that the professionals actions are consistent with those required for maintenance of potential organ donors, although the material and human resources are not adequate. That situation leads the professionals to develop a meaning of care as one labor more, demanding more than they can give. They express beliefs and feelings concerning the hope that their care brings a greater good that is to save lives. The reflection for a possible change of action was difficult to accomplish due to professionals not to be able to self evaluate, what lead to direct your changes suggestions for other team members. It is concluded that the care provided to these patients is a difficult care, evidenced by suffering both death situation of the person cared and pain of their families, as the dehumanizing conditions of work, helping themselves to keep distance from patients to not suffer so much. The knowledge impregnated in their act, are scientific, ethical, aesthetic and personal kind with a predominance of the scientific followed by the personal. The study was also relevant to the practice of nursing in maintaining the potential donor, in that it allowed the identification of the knowledge used by nurses in their care practice and the meaning understanding of the professionals on the care provided, as a good action that brings satisfaction when the transplanting is executed. Other experiences are suggested with the critic-reflexive research methodology, both in research as in teaching nursing

[Ethics, empiricism and uncertainty]

Accidents can lead to difficult boundary situations. Such situations often take place in the emergency units. The medical team thus often and inevitably faces professional uncertainty in their decision-making. It is essential to communicate these uncertainties within the medical team, instead of downplaying or overriding existential hurdles in decision-making. Acknowledging uncertainties might lead to alert and prudent decisions. Thus uncertainty can have ethical value in treatment or withdrawal of treatment. It does not need to be covered in evidence-based arguments, especially as some singular situations of individual tragedies cannot be grasped in terms of evidence-based medicine.

Automatic extraction of the mid-facial plane for cranio-maxillofacial surgery planning

Recently developed computer applications provide tools for planning cranio-maxillofacial interventions based on 3-dimensional (3D) virtual models of the patient's skull obtained from computed-tomography (CT) scans. Precise knowledge of the location of the mid-facial plane is important for the assessment of deformities and for planning reconstructive procedures. In this work, a new method is presented to automatically compute the mid-facial plane on the basis of a surface model of the facial skeleton obtained from CT. The method matches homologous surface areas selected by the user on the left and right facial side using an iterative closest point optimization. The symmetry plane which best approximates this matching transformation is then computed. This new automatic method was evaluated in an experimental study. The study included experienced and inexperienced clinicians defining the symmetry plane by a selection of landmarks. This manual definition was systematically compared with the definition resulting from the new automatic method: Quality of the symmetry planes was evaluated by their ability to match homologous areas of the face. Results show that the new automatic method is reliable and leads to significantly higher accuracy than the manual method when performed by inexperienced clinicians. In addition, the method performs equally well in difficult trauma situations, where key landmarks are unreliable or absent.

Sacred vocation program follow up evaluation at the Baylor healthcare system

Background: The Sacred Vocation Program (SVP) (Amick B, Karff S., 2003) helps workers find meaning, spirituality, and see their job as a sacred vocation. The SVP is based on Participatory Action Research (PAR) (Minkler & Wallerstein, 1997; Parker & Wall, 1998). This study aims to evaluate the SVP implemented at the Baylor Healthcare System, Dallas-Fort Worth. ^ Methods: The study design is a qualitative design. We used data from study participants who have participated in focus groups. During these focus groups specific questions and probes regarding the effectiveness of the SVP have been asked. We analyzed the focus groups and derived themes. ^ Results: Results of this study demonstrate SVP helps graduates feel valued and important. The SVP has improved meaningful work for employees and improved a sense of belonging for participants. The program has also increased participant spirituality. The coping techniques developed during a SVP class helps participants deal with stressful situations. The SVP faces challenges of implementation fidelity, poor communication, program viability in tough economic times and implementation of phase II. Another sustainability challenge for SVP is the perception of the program being a religious one versus a spiritual program. ^ Conclusion: Several aspects of the SVP work. The phase I of SVP is successful in improving meaningful work and a sense of belonging for participants. The coping techniques help participants deal with difficult work situations. The SVP can increase effectiveness through improvements in implementation fidelity, communication and leadership commitment. ^

The influence of high contrast acuity and normalised low contrast acuity upon self-reported situation avoidance and driving crashes

The aim of this study was to determine the cues used to signal avoidance of difficult driving situations and to test the hypothesis that drivers with relatively poor high contrast visual acuity (HCVA) have fewer crashes than drivers with relatively poor normalised low contrast visual acuity (NLCVA). This is because those with poorer HCVA are well aware of their difficulties and avoid dangerous driving situations while those poorer NLCVA are often unaware of the extent of their problem. Age, self-reported situation avoidance and HCVA were collected during a practice based study of 690 drivers. Screening was also carried out on 7254 drivers at various venues, mainly motorway sites, throughout the UK. Age, self-reported situation avoidance and prior crash involvement were recorded and Titmus vision screeners were used to measure HCVA and NLCVA. Situation avoidance increased in reduced visibility conditions and was influenced by age and HCVA. Only half of the drivers used visual cues to signal situation avoidance and most of these drivers used high rather than low contrast cues. A statistical model designed to remove confounding interrelationships between variables showed, for drivers that did not report situation avoidance, that crash involvement decreased for drivers with below average HCVA and increased for those with below average NLCVA. These relationships accounted for less than 1% of the crash variance, so the hypothesis was not strongly supported. © 2002 The College of Optometrists.

Achievement of generic baccalaureate student nurses using computer -assisted instruction simulations during a nursing review course

The use of computer assisted instruction (CAI) simulations as an instructional strategy provides nursing students with a critical thinking approach for evaluating risks and benefits and choosing correct alternatives in "safe" patient care situations. It was hypothesized that using CAI simulations during an upper level nursing review course would have a positive effect on the students' posttest scores. Subjects (n = 36) were senior nursing students enrolled in a nursing review course in an undergraduate baccalaureate program. A limitation of the study was the small sample size. The study employed a modified group experimental design using the t test for independent samples. The group who received the CAI simulations during the physiological system review demonstrated a significant increase (p $<$.01) in the posttest score mean when compared to the lecture-discussion group score mean. There was no significant difference between high and low clinical grade point average (GPA) students in the CAI and lecture-discussion groups and their score means on the posttest. However, score mean differences of the low clinical GPA students showed a greater increase for the CAI group than the lecture-discussion group. There was no significant difference between the groups in their system content subscore means on the exit examination completed three weeks later. It was concluded that CAI simulations are as effective as lecture-discussion in assisting upper level students to process information for clinical decision making. CAI simulations can be considered as an instructional strategy to supplement or replace lecture content during a review course, allowing more efficient use of faculty time. It is recommended that the study be repeated using a larger sample size. Further investigations are recommended in comparing the effectiveness of computer software formats and various instructional strategies for other learning situations and student populations. ^

Perinatal care at the limit of viability between 22 and 26 completed weeks of gestation in Switzerland.

Perinatal care of pregnant women at high risk for preterm delivery and of preterm infants born at the limit of viability (22-26 completed weeks of gestation) requires a multidisciplinary approach by an experienced perinatal team. Limited precision in the determination of both gestational age and foetal weight, as well as biological variability may significantly affect the course of action chosen in individual cases. The decisions that must be taken with the pregnant women and on behalf of the preterm infant in this context are complex and have far-reaching consequences. When counselling pregnant women and their partners, neonatologists and obstetricians should provide them with comprehensive information in a sensitive and supportive way to build a basis of trust. The decisions are developed in a continuing dialogue between all parties involved (physicians, midwives, nursing staff and parents) with the principal aim to find solutions that are in the infant's and pregnant woman's best interest. Knowledge of current gestational age-specific mortality and morbidity rates and how they are modified by prenatally known prognostic factors (estimated foetal weight, sex, exposure or nonexposure to antenatal corticosteroids, single or multiple births) as well as the application of accepted ethical principles form the basis for responsible decision-making. Communication between all parties involved plays a central role. The members of the interdisciplinary working group suggest that the care of preterm infants with a gestational age between 22 0/7 and 23 6/7 weeks should generally be limited to palliative care. Obstetric interventions for foetal indications such as Caesarean section delivery are usually not indicated. In selected cases, for example, after 23 weeks of pregnancy have been completed and several of the above mentioned prenatally known prognostic factors are favourable or well informed parents insist on the initiation of life-sustaining therapies, active obstetric interventions for foetal indications and provisional intensive care of the neonate may be reasonable. In preterm infants with a gestational age between 24 0/7 and 24 6/7 weeks, it can be difficult to determine whether the burden of obstetric interventions and neonatal intensive care is justified given the limited chances of success of such a therapy. In such cases, the individual constellation of prenatally known factors which impact on prognosis can be helpful in the decision making process with the parents. In preterm infants with a gestational age between 25 0/7 and 25 6/7 weeks, foetal surveillance, obstetric interventions for foetal indications and neonatal intensive care measures are generally indicated. However, if several prenatally known prognostic factors are unfavourable and the parents agree, primary non-intervention and neonatal palliative care can be considered. All pregnant women with threatening preterm delivery or premature rupture of membranes at the limit of viability must be transferred to a perinatal centre with a level III neonatal intensive care unit no later than 23 0/7 weeks of gestation, unless emergency delivery is indicated. An experienced neonatology team should be involved in all deliveries that take place after 23 0/7 weeks of gestation to help to decide together with the parents if the initiation of intensive care measures appears to be appropriate or if preference should be given to palliative care (i.e., primary non-intervention). In doubtful situations, it can be reasonable to initiate intensive care and to admit the preterm infant to a neonatal intensive care unit (i.e., provisional intensive care). The infant's clinical evolution and additional discussions with the parents will help to clarify whether the life-sustaining therapies should be continued or withdrawn. Life support is continued as long as there is reasonable hope for survival and the infant's burden of intensive care is acceptable. If, on the other hand, the health care team and the parents have to recognise that in the light of a very poor prognosis the burden of the currently used therapies has become disproportionate, intensive care measures are no longer justified and other aspects of care (e.g., relief of pain and suffering) are the new priorities (i.e., redirection of care). If a decision is made to withhold or withdraw life-sustaining therapies, the health care team should focus on comfort care for the dying infant and support for the parents.

Prospective monitoring of cefepime in intensive care unit adult patients

Rapport de synthèse :Le céfépime a été associé à un taux de mortalité supérieur à celui des autres bêta-lactamines chez les patients traités pour un sepsis sévère. Une des hypothèses avancées pour expliquer ces échecs thérapeutiques sont de possibles effets secondaires cachés (par ex. neurologiques) ou des paramètres pharmacocinétiques/pharmacodynamiques (PK/PD) inadaptés. Le présent travail a étudié cette problématique en mesurant prospectivement la pharmacocinétique du céfépime chez 21 patients consécutifs hospitalisés aux soins intensifs adultes (SIAD) pour une pneumonie nosocomiale. La population étudiée avec un âge médian 55,1 ans, a reçu par voie intraveineuse du céfépime à raison de 2 g toutes les 12 heures pour une clairance de la créatinine (Clcr)>50 mI/ min, et 2 g toutes les 24 heures ou 36 heures pour une Clcr<50 ml /min. Les taux plasmatiques de céfépime ont été mesurés à plusieurs reprises avant et après administration du médicament après la lèoe dose et à l'état d'équilibre par chromatographie en phase liquide à haute pression. Les taux plasmatiques ont considérablement varié entre les patients. Cent pour cent (21/21) des patients ont eu une durée appropriée d'antibiothérapie avec des taux plasmatiques supérieures à la CMI du céfépime (T>CMI>50%) pour les agents pathogènes retrouvés dans cette étude (CMI<4 mg/I), mais seulement 45-65% d'entre eux ont eu une couverture appropriée pour les agents pathogènes potentiels présentant une CMI> 8 mg/I pour le céfépime. Deux patients avec une insuffisance rénale (Clcr<30 ml/min) ont présenté des symptômes compatibles avec une épilepsie non-convulsive (état confusionnel et myoclonies) attribuée dans un 2ème temps à une toxicité du céfépime après que les taux plasmatiques aient été communiqués aux soignants qui ont suspendu l'antibiothérapie avec disparition des symptômes. Les résultats de cette étude empirique confirment l'existence d'effets secondaires cachés et de paramètres PK/PD inappropriés (pour les agents pathogènes ayant des CMI de limite supérieure) dans notre population de SIAD. En outre, ils mettent en évidence une fenêtre thérapeutique efficace pour une posologie de céfépime de 2 g toutes les 12 heures chez les patients ayant une Clcr>50 ml/min infectés par des pathogènes avec des CMI pour le céfépime <4 mg/I. Les échecs thérapeutiques constatés dans cette étude sont probablement liés à des taux sériques inadaptés, résultant de la difficulté de prescription dans les situations cliniques complexes. Dans ce contexte, un prompt dosage plasmatique du céfépime doit être considéré en cas de diminution de la Clcr ou en présence de CMI élevées.

Accès aux soins et maintien dans la communauté des personnes difficiles à engager dans un traitement psychiatrique [Access to care and maintenance in the community of persons who are difficult to engage in psychiatric treatment]

Psychotic patients to not access easily to psychiatric care. First, psychotic disorders are difficult to identify among a great number of non psychotic depressive and anxious disorders. Second, inpatient care has shortened and now focus on acute care rather than long stay. For some psychotic patients, desinstitutionalization means exclusion and marginalization. Intensive case management can answer these needs in collaboration with relatives and professionals of patient's social network. Results and care's steps of intensive case management as practiced in Lausanne are described and illustrated with cases vignettes.

Patients âgées vulnérables au cabinet: comment les identifier et quelles ressources mobiliser [Vulnerable older patients in primary care how to identify them? Which ressources to mobilize? ].

Trust is essential to foster and preserve a long-term relationship between primary care physicians and their patients suffering from chronic diseases. However, this relation remains insufficient to successfully manage more complex situations, such as those of older patients with multiple diseases and disability. For the primary care physician, a significant limitation is the time required to plan and coordinate interventions supplied by different health and social care providers. This article describes a structured approach to support primary care physicians in this difficult task and help them to identify vulnerable older patients requiring to mobilize and coordinate health and social care resources. Current and future resources available to family physicians to complete this challenging task are further described.

Intoxication alcoolique aux urgences : dilemmes de prise en charge. Deux situations cliniques fréquentes. [The dilemma of defining "adequate" ED care for acute alcohol intoxication. About two case reports]

L'intoxication éthylique aiguë (IEA) est un motif de recours fréquent en médecine d'urgence. Bien qu'évoluant de manière spontanément favorable dans la majorité des cas, un certain nombre de complications sont susceptibles de survenir dans ce contexte, entrainant des répercussions significatives sur le pronostic des patients. Or, les altérations neurocomportementales accompagnant classiquement ce type d'intoxication mettent régulièrement les cliniciens face à des dilemmes de prise en charge complexes à résoudre. D'autre part, si les propriétés de l'éthanol peuvent atténuer l'expression clinique de certaines pathologies, un certain nombre d'affection de nature métabolique ou neurologique sont susceptibles d'être interprétées à tort comme des IEA. La littérature médicale ne fournissant que peu d'outils d'aide à la décision dans ce domaine, il est souvent difficile de trouver un compromis acceptable entre recours excessif aux examens complémentaires et banalisation face aux patients alcoolisés. A partir de situations cliniques, le présent article propose une approche pragmatique de deux problématiques régulièrement associées à une IEA et sources d'erreur diagnostique, le traumatisme crânien et l'état d'agitation. Ainsi, une meilleure définition des conditions de recours au scanner cérébral en cas de traumatisme crânien et l'adoption d'un protocole de sédation précoce dans l'ivresse excito-motrice doivent permettre de contourner en partie les difficultés soulevées par ces patients.

Challenges to patient-centred care in a general internal medicine context: findings from an exploratory study

Introduction. If we are to promote more patient-centred approaches in care delivery, we have to better characterize the situations in which being patient-centred is difficult to achieve. Data from professionals in health and social care are important because they are the people charged with operationalizing patient-centred care (PCC) in their daily practice. However, empirical accounts from frontline care providers are still lacking, and it is important to gather experiences not only from doctors but also from the other care providers. Indeed, experiences from different professions can help inform our understanding of patient care, which is expected to be both patient-centred and collaborative. Methods. This study was based on the following research question: What factors make the provision of PCC difficult to achieve? Sample and setting. A purposeful sampling technique was used, allowing for a series of choices about the participants and their professional affiliation. Because patient-centredness is the focus, 3 professions appeared to be of special interest: general internists, nurses and social workers. The study was undertaken in the General Internal Medicine Division of a teaching hospital located in a North American context. Data Collection. To answer the research question, a methodological approach based on a theory called phenomenology was chosen. Accordingly, semi-structured interviews were used since they generate understanding of the meanings different individuals have of their lived world. Interviews with 8 physicians, 10 nurses and 10 social workers were eventually conducted. Data analysis. An inductive thematic analysis was employed to make sense of the interview data. Results. The thematic analysis allowed identifying various types of challenges to PCC. Although most of the challenges were perceived by all three groups of professionals, they were perceived to a different degree across the professions, which likely reflected the scope of practice of each profession. The challenges and their distribution across the professions are illustrated in Table 1. Examples of challenges are provided in Table 2. Discussion. There is a tension between what is supposed to be done - what stands in the philosophy of patient -centredness - and what is currently done - the real life with all the challenges to PCC. According to some participants' accounts, PCC clearly risks becoming a mere illusion for health care professionals on which too great pressures are imposed.

Coercion, Perceived Care and Quality of Life Among Patients in Psychiatric Hospitals

The goals of the study were to describe patients’ perceptions of care after experiencing seclusion/restraint and their quality of life. The goal was moreover to identify methodological challenges related to studies from the perspective of coerced patients. The study was conducted in three phases between September 2008 and April 2012. In the first phase, the instrument Secluded/ Restrained Patients’ Perception of their Treatment (SR-PPT) was developed and validated in Japan in cooperation with a Finnish research group (n = 56). Additional data were collected over one year from secluded/restrained patients using the instrument (n = 90). In the second phase, data were collected during the discharge process (n = 264). In the third phase, data were collected from electronic databases. Methodological and ethical issues were reviewed (n = 32) using systematic review method. Patients perceived that co-operation with the staff was poor; patients’ opinions were not taken into account, treatment targets collated and treatment methods were seen in different ways. Patients also felt that their concerns were not well enough understood. However, patients received getting nurses’ time. In particular, seclusion/restraint was considered unnecessary. The patients felt that they benefited from the isolation in treating their problems more than they needed it, even if the benefit was seen to be minor. Patients treated on forensic wards rated their treatment and care significantly lower than in general units. During hospitalization secluded/restrained patients evaluated their quality of life, however, better than did non-secluded/restrained patients. However, no conclusion is drawn to the effect that the better quality of life assessment is attributable to the seclusion/restraint because patients’ treatment period after the isolation was long and because of many other factors, as rehabilitation, medication, diagnostic differences, and adaptation. According to the systematic mixed studies review variation between study designs was found to be a methodological challenge. This makes comparison of the results more difficult. A research ethical weakness is conceded as regards descriptions of the ethical review process (44 %) and informed consent (32 %). It can be concluded that patients in psychiatric hospital care and having a voice as an equal expert require special attention to clinical nursing, decision-making and service planning. Patients and their family members will be consulted in plans of preventive and alternative methods for seclusion and restraint. The study supports the theory that in ethical decision-making situations account should be taken of medical indications, in addition to the patients’ preferences, the effect of treatment on quality of life, and this depends on other factors. The connection between treatment decisions and a patient’s quality of life should be evaluated more structurally in practice. Changing treatment culture towards patients’ involvement will support daily life in nursing and service planning taking into account improvements in patients’ quality of life.