A qualitative study exploring the factors that influence the uptake of pre-pregnancy care among women with Type 2 diabetes.

AIM: To elicit the views and experiences of women with Type 2 diabetes and healthcare professionals relating to the pregnancy and pre-pregnancy care they have received or provided. METHODS: A qualitative study using in-depth semi-structured interviews with women with Type 2 diabetes (n=30) and healthcare professionals (n=22) from primary and specialist care. Women were purposively sampled to include different experiences of pregnancy and pre-pregnancy care. Data were transcribed verbatim and analysed thematically using Framework Analysis. RESULTS: The median age of the women was 37 years, and most were obese (median BMI 34.9 kg/m2 ), of black or Asian ethnicity (n=24, 80%) and from areas of high deprivation (n=21, 70%). Participating healthcare professionals were from primary (n=14), intermediate (n=4) and secondary (n=4) care. Seven themes expressing factors that mediate reproductive behaviour and care in women with Type 2 diabetes were identified at the patient, professional and system levels. Type 2 diabetes was generally perceived negatively by the women and the healthcare professionals. There was a lack of awareness about the pre-pregnancy care needs for this population, and communication between both groups was unhelpful in eliciting the reproductive intentions of these women. The themes also reveal a lack of systemic processes to incorporate pre-pregnancy care into the care of women with Type 2 diabetes, and consequently, health professionals in primary care have limited capacity to provide such support. CONCLUSION: If the current high levels of unprepared pregnancies in women with Type 2 diabetes are to be reduced, the reproductive healthcare needs of this group need to be embedded into their mainstream diabetes management.

Recovery from postpartum psychosis: a systematic review and metasynthesis of women's and families' experiences.

Postpartum psychosis is a serious disorder that can result in adverse consequences for the mother and baby. It is important that we understand the experiences of women, to develop effective interventions during this critical period. The aim of this systematic review was to conduct a metasynthesis of qualitative research exploring women's experiences of postpartum psychosis and factors involved in recovery from the perspective of women and family members. A comprehensive literature search of five databases was conducted and the findings were appraised and synthesised, following a thematic synthesis approach. Fifteen studies, capturing the views of 103 women and 42 family members, met the inclusion criteria. Four main themes incorporating 13 subthemes were identified following synthesis: (1) Experiencing the unspeakable, (2) Loss and disruption, (3) Realigning old self and new self and the integrative theme of (4) Social context. The findings offer new insight into the unique experience of postpartum psychosis and demonstrate that recovery does not follow a linear path. To improve clinical outcomes, a more integrative and individualised approach is needed which incorporates long-term psychological and psychosocial support, and considers the needs of the family. Further areas for staff training, service development and future research are highlighted.

Psychological interventions for managing postpartum psychosis: a qualitative analysis of women's and family members' experiences and preferences.

BACKGROUND: Postpartum psychosis is a rare, yet severe disorder, in which early identification and immediate intervention are crucial. Despite recommendations for psychological input, little is known about the types of psychological intervention reported to be helpful. The aim of this study was to explore the experiences, needs and preferences for psychological intervention from the perspective of women with postpartum psychosis and from the perspective of family members. METHODS: Thirteen women and eight family members, including partners were interviewed. The data from these semi-structured interviews were audio-recorded, transcribed and inductively analysed using thematic analysis. RESULTS: Twelve subthemes were identified and then organised around three main themes: 1) Seeking safety and containment, 2) Recognising and responding to the psychological impact and 3) Planning for the future. These themes highlight the temporal element of recovery from postpartum psychosis, because women's psychological needs and preferences changed over time. Emphasis was initially placed on ensuring safety, followed by a need to connect, process and adjust to their experiences. Additional needs were reported by women and family when planning for the future, including managing the fear of relapse and help to reach a decision about future pregnancies. CONCLUSION: The results illustrate a range of areas in which psychological intervention could be delivered to facilitate and enhance recovery. Further research is needed to develop meaningful and effective psychological interventions and to investigate the most appropriate timing for this to be offered.

Pregnancy in Diabetes: challenges and opportunities for improving pregnancy outcomes.

Our aim was to review the data from the National Pregnancy in Diabetes (NPID) audit, and to identify the challenges and opportunities for improving pregnancy outcomes in women with diabetes. We reviewed three years of NPID data and relevant diabetes and obstetric literature, and found that there has been little change in pregnancy preparation or outcomes over the past 3 years, with substantial clinic-to clinic variations in care. Women with Type 2 diabetes remain less likely to take 5 mg preconception folic acid (22.8% vs. 41.8%; P < 0.05), and more likely to take potentially harmful medications (statin and/or ACE inhibitor 13.0% vs. 1.8%; P < 0.05) than women with Type 1 diabetes. However, women with Type 1 diabetes are less likely to achieve the recommended glucose control target of HbA1c < 48 mmol/mol (6.5%) (14.9% vs. 38.1%; P < 0.05). The following opportunities for improvement were identified. First, the need to integrate reproductive health into the diabetes care plans of all women with diabetes aged 15-50 years. Second, to develop more innovative approaches to improve uptake of pre-pregnancy care in women with Type 2 diabetes in primary care settings. Third, to integrate insulin pump, continuous glucose monitoring and automated insulin delivery technologies into the pre-pregnancy and antenatal care of women with Type 1 diabetes. Fourth, to improve postnatal care with personalized approaches targeting women with previous pregnancy loss, congenital anomaly and perinatal mortality. A nationwide commitment to delivering integrated reproductive and diabetes healthcare interventions is needed to improve the health outcomes of women with diabetes.

Are end-of-life practices in Norway in line with ethics and law?

BACKGROUND: End-of-life decisions, including limitation of life prolonging treatment, may be emotionally, ethically and legally challenging. Euthanasia and physician-assisted suicide (PAS) are illegal in Norway. A study from 2000 indicated that these practices occur infrequently in Norway. METHODS: In 2012, a postal questionnaire addressing experience with limitation of life-prolonging treatment for non-medical reasons was sent to a representative sample of 1792 members of the Norwegian Medical Association (7.7% of the total active doctor population of 22,500). The recipients were also asked whether they, during the last 12 months, had participated in euthanasia, PAS or the hastening of death of non-competent patients. RESULTS: Seventy-one per cent of the doctors responded. Forty-four per cent of the respondents reported that they had terminated treatment at the family's request not knowing the patient's own wish, doctors below 50 and anaesthesiologists more often. Anaesthesiologists more often reported to have terminated life-prolonging treatment because of resource considerations. Six doctors reported having hastened the death of a patient the last 12 months, one by euthanasia, one by PAS and four had hastened death without patient request. Male doctors and doctors below 50 more frequently reported having hastened the death of a patient. CONCLUSION: Forgoing life-prolonging treatment at the request of the family may be more frequent in Norway that the law permits. A very small minority of doctors has hastened the death of a patient, and most cases involved non-competent patients. Male doctors below 50 seem to have a more liberal end-of-life practice.

Life-prolonging treatment in nursing homes: how do physicians and nurses describe and justify their own practice?

BACKGROUND: Making the right decisions, while simultaneously showing respect for patient autonomy, represents a great challenge to nursing home staff in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation to dying patents in end-of-life. OBJECTIVES: To study how physicians and nurses protect nursing home patients' autonomy in end-of-life decisions, and how they justify their practice. DESIGN: A qualitative descriptive design with analysis of the content of transcribed in-depth interviews with physicians and nurses. PARTICIPANTS: Nine physicians and ten nurses in 10 nursing homes in Norway. RESULTS AND INTERPRETATIONS: Assessment of the patient's competence to consent to treatment is almost absent. The physicians build their practice on the principles of beneficence and nonmaleficence. Nurses tend to trust the patients' rejection of life support, even when the patients have difficulty speaking or suffer from dementia. Relatives were, according to the health personnel, included in decision-making processes to a very limited extent. However, futile life support is sometimes provided contrary to the physicians' judgement of what constitutes the patient's best interest on occasions when they are pressurised by next of kin. CONCLUSIONS: The study reveals a need to improve decision-making routines according to ethical ideals and legislation. Conflicts between relatives and healthcare professionals in the decision-making process deflect the focus from searching for the best possible treatment for the terminal patient. Further discussion is required as to whether the concept of autonomy is applicable in situations in which the patient is impaired and dying.

Different effects of infrared and one-half hot blade beak trimming on beak topography and growth.

This study examined the effects of infrared beak treatment (IR-BT) and hot blade beak trimming (HB-BT) on beak length and production in laying hen pullets. Seventy-two 1-d-old birds were randomly assigned to the HB-BT, IR-BT, or control group. Birds were pair housed by treatment, and beak images and production indices were obtained posttreatment at fixed intervals for 10 wk. Immediately after treatment, HB-BT beaks were shorter than control or IR-BT beaks (P < 0.01), whereas control and IR-BT beaks remained comparable in length until the onset of tissue degeneration and erosion of the IR-BT beaks at 1 to 2 wk posttreatment. At wk 2 posttreatment, beaks were longest in control birds, intermediate in IR-BT birds, and shortest in HB-BT birds (P < 0.01). Thereafter, an increase in beak length in all treatments was observed over time (P < 0.01), but HB-BT beaks had the greatest regrowth. The beak length of birds in the HB-BT group was similar to that of birds in the IR-BT group from wk 3 to 8, and then grew longer at wk 9 and 10 posttreatment (P < 0.01). The effects of treatments on BW emerged at d 5 posttreatment. The BW of birds in the HB-BT group was suppressed up to and including wk 9 posttreatment compared with that of control birds (P < 0.05) and was significantly lower than that of birds in the IR-BT group between 2 and 4 wk posttreatment (P < 0.05). Birds in the IR-BT group did not differ from control birds after wk 3 posttreatment (P < 0.05). By the final week of the study, differences in BW across treatments were no longer apparent (P > 0.05). For the most part, feed intake was higher in control birds, intermediate in birds in the IR-BT group, and lowest in birds in the HB-BT group until wk 9 posttreatment (P < 0.05). Similarly, feed waste was generally higher in control birds and least in birds in the HB-BT group (P < 0.05). The IR-BT treatment appeared to be more effective at inhibiting beak regrowth, with a less pronounced effect on feed intake than the HB-BT treatment in laying hen pullets.

Value choices and considerations when limiting intensive care treatment: a qualitative study.

BACKGROUND: To shed light on the values and considerations that affect the decision-making processes and the decisions to limit intensive care treatment. METHOD: Qualitative methodology with participant observation and in-depth interviews, with an emphasis on eliciting the underlying rationale of the clinicians' actions and choices when limiting treatment. RESULTS: Informants perceived over-treatment in intensive care medicine as a dilemma. One explanation was that the decision-making base was somewhat uncertain, complex and difficult. The informants claimed that those responsible for taking decisions from the admitting ward prolonged futile treatment because they may bear guilt or responsibility for something that had gone wrong during the course of treatment. The assessments of the patient's situation made by physicians from the admitting ward were often more organ-oriented and the expectations were less realistic than those of clinicians in the intensive care unit who frequently had a more balanced and overall perspective. Aspects such as the personality and the speciality of those involved, the culture of the unit and the degree of interdisciplinary cooperation were important issues in the decision-making processes. CONCLUSION: Under-communicated considerations jeopardise the principle of equal treatment. If intensive care patients are to be ensured equal treatment, strategies for interdisciplinary, transparent and appropriate decision-making processes must be developed in which open and hidden values are rendered visible, power structures disclosed, employees respected and the various perspectives of the treatment given their legitimate place.

Autonomy at the end of life: life-prolonging treatment in nursing homes--relatives' role in the decision-making process.

BACKGROUND: The increasing number of elderly people in nursing homes with failing competence to give consent represents a great challenge to healthcare staff's protection of patient autonomy in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation. The lack of national guidelines and internal routines can threaten the protection of patient autonomy. OBJECTIVES: To place focus on protecting patient autonomy in the decision-making process by studying how relatives experience their role as substitute decision-makers. DESIGN: A qualitative descriptive design with analysis of the contents of transcribed in-depth interviews with relatives. PARTICIPANTS: Fifteen relatives of 20 patients in 10 nursing homes in Norway. RESULTS AND INTERPRETATIONS: The main findings reveal deficient procedures for including relatives in decision-making processes. Relatives have poor knowledge about the end of life, and there is little discussion about their role as substitute decision-makers for patients who are not competent to give consent. Few relatives understand the concept of patient autonomy. In Norway the treating physician is responsible for patient treatment. When relatives are included in discussions on treatment, they perceive themselves as responsible for the decision, which is a burden for them afterwards. This qualitative study describes relatives' experiences, thus providing important information on the improvement potential with the main objective of safeguarding patient autonomy and caring for relatives. CONCLUSION: The study reveals failing procedures and thus a great potential for improvement. Both ethical and legal aspects must be addressed when considering patient autonomy.

What is happening during case deliberations in clinical ethics committees? A pilot study.

BACKGROUND: Clinical ethics consultation services have been established in many countries during recent decades. An important task is to discuss concrete clinical cases. However, empirical research observing what is happening during such deliberations is scarce. OBJECTIVES: To explore clinical ethics committees' deliberations and to identify areas for improvement. DESIGN: A pilot study including observations of committees deliberating a paper case, semistructured group interviews, and qualitative analysis of the data. PARTICIPANTS: Nine hospital ethics committees in Norway. RESULTS AND INTERPRETATIONS: Key elements of the deliberations included identifying the ethical problems; exploring moral values and principles; clarifying key concepts and relevant legal regulation; exploring medical facts, the patient's situation, the therapists' perspective, analogous clinical situations, professional uncertainties, the patient's and relatives' perspective, and clinical communication; identifying the involved parties and how to involve them; identifying possible courses of action, and possible conclusion and follow-up. The various elements were closely interwoven. The content and conclusions varied and seemed to be contingent on the committee members' interpretations, experience and knowledge. Important aspects of a clinical ethics deliberation were sometimes neglected. When the committees used a deliberation procedure and a blackboard, the deliberations tended to become more systematic and transparent. Many of the committees were insecure about how to include the involved parties and how to document the deliberations. CONCLUSION: Clinical ethics committees may provide an important arena for multidisciplinary discussions of complex clinical ethics challenges. However, this seems to require adequate composition, adoption of transparent deliberation procedures, and targeted training.

The principle of justice in patient priorities in the intensive care unit: the role of significant others.

BACKGROUND: Theoretically, the principle of justice is strong in healthcare priorities both nationally and internationally. Research, however, has indicated that questions can be raised as to how this principle is dealt with in clinical intensive care. OBJECTIVE: The objective of this article is to examine how significant others may affect the principle of justice in the medical treatment and nursing care of intensive care patients. METHOD: Field observations and in-depth interviews with physicians and nurses in intensive care units (ICU). Emphasis was placed on eliciting the underlying rationale for prioritisations in clinical intensive care with particular focus on clinicians' considerations when limiting ICU treatment. RESULTS: Significant others could induce an unintentional discrimination of ICU patients. Family members who were demanding received more time and attention for both the patient and themselves. Patients' and families' status and position and/or an interesting medical diagnosis seemed to govern the clinicians' priorities of patients and families-consciously as well as unconsciously. The clinicians emphasised that patient information given through families was important. However, patients' preferences and values conveyed to clinicians through their families were not always taken seriously. This even applied in cases with very serious prognoses and an explicit patient wish to forego life-prolonging treatment. CONCLUSION: The principle of justice was violated when qualified attention was given to significant others, and through this also to patients. Attention given to significant others was influenced by the healthcare workers' professional and personal values, attitudes and interests.

"Two per cent isn't a lot, but when it comes to death it seems quite a lot anyway": patients' perception of risk and willingness to accept risks associated with thrombolytic drug treatment for acute stroke.

BACKGROUND: Thrombolytic drugs to treat an acute ischaemic stroke reduce the risk of death or major disability. The treatment is, however, also associated with an increased risk of potentially fatal intracranial bleeding. This confronts the patient with the dilemma of whether or not to take a risk of a serious side effect in order to increase the likelihood of a favourable outcome. OBJECTIVE: To explore acute stroke patients' perception of risk and willingness to accept risks associated with thrombolytic drug treatment. DESIGN: Eleven patients who had been informed about thrombolytic drug treatment and had been through the process of deciding whether or not to participate in a thrombolytic drug trial went through repeated qualitative, semistructured interviews. RESULTS: Many patients showed a limited perception of the risks connected with thrombolytic drug treatment. Some perceived the risk as not relevant to them and were reluctant to accept that treatment could cause harm. Others seemed to be aware that treatment would mean exposure to risk. The patients' willingness to take a risk also varied substantially. Several statements revealed ambiguity and confusion about being involved in a decision about treatment. The patients' reasoning about risk was put into the context of their health-related experiences and life histories. Several patients wanted the doctor to be responsible for the decisions. CONCLUSION: Acute stroke patients' difficulties in perceiving and processing information about risk may reduce their ability to be involved in clinical decisions where risks are involved.

Moral distress among Norwegian doctors.

BACKGROUND: Medicine is full of value conflicts. Limited resources and legal regulations may place doctors in difficult ethical dilemmas and cause moral distress. Research on moral distress has so far been mainly studied in nurses. OBJECTIVE: To describe whether Norwegian doctors experience stress related to ethical dilemmas and lack of resources, and to explore whether the doctors feel that they have good strategies for the resolution of ethical dilemmas. DESIGN: Postal survey of a representative sample of 1497 Norwegian doctors in 2004, presenting statements about different ethical dilemmas, values and goals at their workplace. RESULTS: The response rate was 67%. 57% admitted that it is difficult to criticize a colleague for professional misconduct and 51% for ethical misconduct. 51% described sometimes having to act against own conscience as distressing. 66% of the doctors experienced distress related to long waiting lists for treatment and to impaired patient care due to time constraints. 55% reported that time spent on administration and documentation is distressing. Female doctors experienced more stress that their male colleagues. 44% reported that their workplace lacked strategies for dealing with ethical dilemmas. CONCLUSION: Lack of resources creates moral dilemmas for physicians. Moral distress varies with specialty and gender. Lack of strategies to solve ethical dilemmas and low tolerance for conflict and critique from colleagues may obstruct important and necessary ethical dialogues and lead to suboptimal solutions of difficult ethical problems.

I don't like that, it's tricking people too much...: acute informed consent to participation in a trial of thrombolysis for stroke.

BACKGROUND: Informed consent is regarded as a contract between autonomous and equal parties and requires the elements of information disclosure, understanding, voluntariness and consent. The validity of informed consent for critically ill patients has been questioned. Little is known about how these patients experience the process of consent. OBJECTIVE: The aim of this study was to explore critically ill patients' experience with the principle of informed consent in a clinical trial and their ability to give valid informed consent. DESIGN: 11 stroke patients who had been informed about thrombolytic treatment and had been through the process of deciding whether or not to participate in a thrombolysis trial went through repeated qualitative semistructured interviews. RESULTS: None of the patients had any clear understanding of the purpose of the trial. Neither did they understand the principles of randomisation and voluntariness. Reasons for giving or not giving consent were trust, conceptions of benefits and risks and altruism. Several patients found it immoral to involve patients in the consent procedure and argued that this was the doctors' responsibility. Others argued that it is a duty to question patients and perceived it as a sign of being treated with respect and dignity. A majority of the patients found the consent process vague and ambiguous. CONCLUSIONS: The results indicate that the principle of informed consent from critically ill patients cannot be seen as a contract between equal and autonomous parties. Further studies are needed to explore critically ill patients' experiences with the process of informed consent.

Should ethics consultants help clinicians face scarcity in their practice?

In an international survey of rationing we have found that European physicians encounter scarcity-related ethical difficulties, and are dissatified with the resolution of many of these cases. Here we further examine survey results to explore whether ethics support services would be potentially useful in addressing scarcity related ethical dilemmas. Results indicate that while the type of help offered by ethics support services was considered helpful by physicians, they rarely referred difficulties regarding scarcity to ethics consultation. We propose that ethics consultants could assist physicians by making the process less difficult, and by contributing to decisions being more ethically justifiable. Expertise in bringing considerations of justice to bear on real cases could also be useful in recognising an unjust limit, as opposed to a merely frustrating limit. Though these situations are unlikely to be among the most frequently referred to ethics support services, ethics consultants should be prepared to address them.

Comparative effects of infrared and one-third hot-blade trimming on beak topography, behavior, and growth.

This research examined the effects of infrared beak treatment on layer chicks. Seventy-two layer chicks were assigned to hot-blade trimming (HB), infrared treatment (IR), or a control treatment. Day-old chicks were pair-housed by treatment. Beak photographs, behavior, and production indices were obtained at intervals for 9 wk posttreatment. All beaks were normally shaped at the onset of the study, and no perceptible treatment-related differences in shape occurred over time (P > 0.05). Posttreatment, HB birds had shorter beaks relative to the other 2 groups (P < 0.05). Control and IR beaks remained comparable in length until tissue eroded in IR beaks at 1 to 2 wk posttreatment. Thereafter, beak length increased in all treatments over time (P < 0.01). Two weeks posttreatment, beaks were longest in control birds, intermediate in HB birds (P < 0.001), and shortest in IR birds (P < 0.001). The HB birds had abnormal deviations from a normal upper-to-lower mandible length ratio than the IR or control birds (P < 0.05). Notable effects of treatment on production emerged by +2 d and persisted for 5 wk. Growth and feed intake were lower in HB and IR birds compared with control birds (P < 0.05), with IR birds performing least well until the fourth week of the study (P < 0.05). Thereafter, they performed similarly to the HB group. Feed waste was lowest in the IR group and was generally greatest in the control group (P < 0.05). There was an overall effect of trimming, irrespective of method, on behavior, particularly eating and drinking behaviors (P < 0.05). Specifically, IR birds were less active (P < 0.01) and spent less time eating (P < 0.01) and drinking (P < 0.05) than did control birds. Behavior in HB birds often ranked intermediate in duration and incidence, but was not significantly different compared with behavior measured in the control and IR groups. Effects of treatment on behavior were not present after 1 wk posttrimming. Results indicate that acute pain occurred with both trimming methods. Although the impact of trimming appeared to be greatest in the IR birds initially, these differences disappeared relatively quickly, and subsequent performance was similar in both trimmed groups.

Relationship between body weight and beak characteristics in one-day-old white Leghorn chicks: its implications for beak trimming.

Beak trimming is a routine practice used in laying hens to prevent feather pecking and cannibalism. The effect of beak trimming on bird well-being depends on multiple factors, including the amount of beak that is trimmed and the quality of the procedure. The aim of this work was to determine if a relationship existed between BW and beak characteristics in 1-d-old chicks, with a future aim to develop an automated system for standardizing beak trimming. Three hundred forty-four 1-d-old chicks (Hy-Line W-36) were sorted into 3 categories based on their BW (heavy, intermediate, and light), and their beaks were photographed. Dimensional measures of beaks, including the lengths of the culmen, gonys, maxillary tomia, mandibular tomia, and the width of the upper mandible and lower mandible measured at 2, 3, and 4 mm from the tip of the upper and lower beaks, were calculated using imaging software. Correlations between BW and beak measures were evaluated using Pearson product-moment, Spearman rank-order, Kendall's tau, and Hoeffding's dependency tests. Results showed there were no significant correlations between beak dimensions and BW in the light BW group. In contrast, correlations were present between BW and the width of the upper mandible measured at 4 mm from the tip of the upper beak (P < 0.05) and the width of the lower mandible measured 2 to 4 mm from the tip of the lower beak (P < 0.05) in the intermediate BW group. In the heavy BW group, BW was positively correlated with mandibular tomia, gonys, and the width of the lower mandible measured at 2 mm from the tip of the lower beak (P < 0.05). However, in general, these correlations were too low (all below 0.23) to have any practical use for predicting beak size. Overall, the data indicated that BW cannot be used as a reliable predicator of beak size in 1-d-old Hy-Line W-36 chicks.