Palliative sedation and moral distress: A qualitative study of nurses.

BACKGROUND: Clinical nursing practice may involve moral distress, which has been reported to occur frequently when nurses care for dying patients. Palliative sedation is a practice that is used to alleviate unbearable and refractory suffering in the last phase of life and has been linked to distress in nurses. AIM: The aim of this study was to explore nurses' reports on the practice of palliative sedation focusing on their experiences with pressure, dilemmas and morally distressing situations. METHODS: In-depth interviews with 36 nurses working in hospital, nursing home or primary care. RESULTS: Several nurses described situations in which they felt that administration of palliative sedation was in the patient's best interest, but where they were constrained from taking action. Nurses also reported on situations where they experienced pressure to be actively involved in the provision of palliative sedation, while they felt this was not in the patient's best interest. The latter situation related to (1) starting palliative sedation when the nurse felt not all options to relieve suffering had been explored yet; (2) family requesting an increase of the sedation level where the nurse felt that this may involve unjustified hastening of death; (3) a decision by the physician to start palliative sedation where the patient had previously expressed an explicit wish for euthanasia. CONCLUSIONS: Nurses experienced moral distress in situations where they were not able to act in what they believed is the patient's best interest. Situations involving moral distress require nurses to be well informed and able to adequately communicate with suffering patients, distressed family and physicians.

[Practicing medicine at the end of life: use clear language]. / Dokteren aan het levenseinde: gebruik heldere taal.

Up to thirty years ago, in the Netherlands the word 'stervensbegeleiding' [literally, dying-guidance] was used to refer to care for people in the last days of life. After Cicely Saunders had developed a multidisciplinary and multidimensional approach for care for the dying, the wording changed, until the word 'palliative care' was adopted. This care gradually developed from care for the dying to care for all people with life-threatening illness, as illustrated in the WHO definition. This shift in focus of care raises the question of when palliative care starts. The surprise question is regarded as a useful tool for marking this shift in focus of care. However, answering the surprise question does not inform us about palliative care needs. Nevertheless, when people enter the dying phase, a fundamental change in the nature of care is needed. The word 'stervensbegeleiding' marks this change of care.

[Palliative sedation, the sympathetic alternative for euthanasia?]. / Palliatieve sedatie, het sympathieke alternatiefvoor euthanasie?

Palliative sedation is given to relieve refractory discomfort (pain, shortness of breath, agitation) during the phase when life expectancy is estimated to be a week or less. It is a medical intervention which, although not expressly meant to shorten life, may well do so. There is an inherent uncertainty here which is the cause of considerable ethical unease. Figures show that in a limited number of cases palliative sedation is actually applied with the intention to hasten death. It may well be impossible to rid ourselves ofthis uncertainty conclusively.

Lymphoid tissue in rat oral mucosa: structure and function.

Lymphocyte and macrophage/dendritic cell populations in the oral cavity of the rat were studied by immunohistochemistry. Furthermore, the reactivity of the oral mucosa towards antigen and its position in the mucosal immune system was investigated by staining antibody-forming cells and comparing serum and saliva antibody titres. Although numerous lymphocytes and non-lymphoid cells were present in the oral mucosa, organized lymphoid tissue could not be found. The majority of the lymphocytes are T cells, particularly of the T-helper phenotype. Macrophages were found only in the connective tissue, whereas dendritic cells also occurred in the epithelium. The possible functions of the cells in the different sites of the oral mucosa are discussed. Antibody-forming cells were mainly detected in the draining superficial and posterior cervical lymph nodes and in the submandibular glands. The roles of the various compartments of the oral mucosal immune system are discussed with particular reference to the epithelium and connective tissue as induction sites, the draining lymph nodes as sites of proliferation and differentiation, and the submandibular glands as effector sites.

Immunoglobulin concentrations in nasal secretions differ between patients with an IgE-mediated rhinopathy and a non-IgE-mediated rhinopathy.

Nasal secretions from patients with an IgE-mediated rhinopathy, patients with a non-IgE-mediated rhinopathy, and healthy control subjects were collected with a newly developed direct aspiration system. Total protein, albumin, secretory IgA (sIgA), IgE, IgG, and IgM concentrations were measured in the nasal secretions to detect whether the nasal pathology is reflected in nasal secretion protein concentrations. It was found that protein and immunoglobulin concentrations in nasal secretions were inversely related to amount of secretion in the nasal cavity. Both patients' groups had a significantly higher sIgA to protein ratio than the healthy control subjects. Furthermore, patients with an IgE-mediated rhinopathy had significantly higher sIgA and IgM to total protein ratios in their nasal secretions than patients with a non-IgE-mediated rhinopathy. Probably these differences are due to changes in immunoregulation.

Nasal secretions from patients with polyps and healthy individuals, collected with a new aspiration system: evaluation of total protein and immunoglobulin concentrations.

This study was designed, first, to test a new system for aspiration of human nasal secretions and, secondly, to evaluate protein and immunoglobulin concentrations in these secretions at different levels of secretory activity. The direct aspiration system combines the advantages of minimal irritation of the nasal mucosa with the facility to determine concentrations per gram of secretion. The total protein and immunoglobulin concentrations were inversely related to the amount of secretion obtained. Variations in fluid secretion throughout the day may be responsible for this relationship. The inverse relationship was much more significant in patients with nasal polyps, in which much higher concentrations were found, than in healthy subjects. Ratios of immunoglobulin to total protein were independent of the amount of secretion obtained. Compared to the controls, the ratios of IgM and IgG to protein in the secretions of the patients were significantly increased. The secretory immunoglobulin A to total protein ratios were only slightly higher in the patients' secretions.