The meaning of comfort measures only order sets for hospital-based palliative care providers.

PURPOSE: Comfort Measures Only (CMO) is a label commonly used in the USA that guides the care of a hospitalized patient who is likely to die. The CMO label has unclear and inconsistent meaning, calling to question the experiences and practices of hospital-basedalliative care providers. The purpose of this study was to understand the meaning of CMO as experienced by hospital-based palliative care providers. METHODS: Using hermeneutic phenomenological research, we investigated eight palliative care experts' common experiences and shared practices of using CMO order sets in their hospital work settings. Data were collected through individual face-to-face interviews, and were analysed by an interpretive team. RESULTS: Four related themes and one constitutive pattern of "Dealing with Dying" reflect the meaning of comfort-measures-only practices. The themes are: comfort care as morphine drip; enacting a traditional binary pattern of care: all or nothing; supporting patient and family at end of life vs. CMO; and evolving culture-a better way to care for the dying. CONCLUSION: Palliative care providers and non-palliative clinicians understood and practiced end of life care in sharply different ways with dying in hospital settings, raising new questions that analyse, modify and extend extant knowledge.

Transition to comfort-focused care: Moral agency of acute care nurses.

BACKGROUND: Moving into the last phase of life comprises a developmental transition with specific needs and risks. Facilitating transitions is an important component of the work of nurses. When curative interventions are no longer helpful, nurses enact key roles in caring for patients and families. AIM: The aim of this study was to examine the experiences of registered nurses in acute care settings as they worked with patients and families to facilitate transition to comfort-focused care. RESEARCH DESIGN: Sampling, data collection, and data analysis were guided by constructivist grounded theory, chosen because of its strength in identifying and explicating social processes. PARTICIPANTS AND CONTEXT: A purposeful sample of 26 registered nurses working in acute care hospitals in one community in the northeastern United States participated in this study through semi-structured interviews. ETHICAL CONSIDERATIONS: The study received approval from the university's Institutional Review Board for the Protection of Human Subjects. Participants provided informed consent. FINDINGS: Nurses facilitated transition to comfort-focused care by enacting their moral commitments to patients and families. They focused on building relationships, honoring patient self-determination, and maintaining respect for personhood. In this context, they discerned a need for transition, opened a discussion, and used diverse strategies to facilitate achieving consensus on the part of patients, family members, and care providers. Regardless of how the process unfolded, nurses offered support throughout. DISCUSSION: Achievement of consensus by all stakeholders is critical in the transition to comfort-focused care. This study deepens our understanding of how nurses as moral agents utilize specific strategies to assist progress toward consensus. It also offers an example of recognizing the moral agency of nurses through listening to their voices. CONCLUSION: Increased understanding of effective nursing strategies for facilitating transition to comfort-focused care is essential for developing needed evidence for excellent care and strengthening end-of-life nursing education.

Guiding the Process of Dying: The Personal Impact on Nurses.

Some of the most ethically challenging and emotionally demanding aspects of nursing occur in caring for patients and their family at the end of life. The aims of this study were to examine the views of acute care nurses caring for patients during transition to comfort care, to describe the personal impact on nurses, and to identify nurses' strategies for self-support and development of competence. Using a qualitative descriptive approach, we analyzed data from 26 semistructured interviews.Nurses experienced moral distress in situations of continuing treatment when a cure was unlikely. In managing symptoms for patients, they struggled to foster an often-tenuous balance of patient comfort and calm without oversedation. They struggled to manage the competing demands of a workload including patients receiving curative care juxtaposed with those focused on comfort care. Nurses reflected on their fears as new nurses caring for end-of-life patients, the inadequacy of their preparation for this role, and their distress when the care provided felt inadequate to them.Nurses navigated challenges through support from nurse colleagues and effective leaders. They appealed to administrators to attend to care concerns arising from time-intensive nature of care. Mentoring and education facilitated assimilation to comfort-care nursing for novice nurses.

Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline.

Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non-invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence-based physiotherapy care to people with CF in Australia and New Zealand.

Physical activity levels of patients with cystic fibrosis hospitalised with an acute respiratory exacerbation.

BACKGROUND: The physical activity levels of adult patients with cystic fibrosis hospitalised for an acute respiratory exacerbation is unknown. METHODS: A prospective observational study was undertaken. Physical activity levels were measured for a 24-h period using an activity monitor (SenseWear(®) Pro 3) during hospitalisation for an acute respiratory exacerbation and one month post-discharge. Measures of exercise tolerance and muscle strength were also recorded. RESULTS: Twenty-four patients completed the study. Most outcomes significantly increased from hospitalisation to one month post-discharge. Time spent doing physical activity (≥3 METs) increased from a mean ± SD of 95 ± 58 to 209 ± 111 min. CONCLUSIONS: Hospitalisation for an acute respiratory exacerbation was associated with less time spent performing physical activity compared to one month post-discharge. Physical activity levels were higher than anticipated, even during hospitalisation, suggesting an increased metabolic rate may have contributed to the physical activity levels documented. Activity level definitions for moderate intensity exercise that are based on higher MET levels seemed more appropriate in this patient setting. CLINICAL TRIAL REGISTRY: Australian New Zealand Clinical Trials Registry Number: ACTRN12610000595011.

Adherence of adult cystic fibrosis patients with airway clearance and exercise regimens.

BACKGROUND: Regular airway clearance and exercise form an important part of the physiotherapy management of patients with cystic fibrosis (CF). Previous research has found that adherence of these patients with physiotherapy regimens is variable and influenced by factors such as sex and disease severity. To date, the adherence of Australian patients with CF has not been investigated. The aim of this study was to measure the adherence of a sample of Australian adult patients with CF and to ascertain factors that improved or decreased their adherence with physiotherapy. METHODS: Patients attending an Australian CF Unit were surveyed by an independent physiotherapist using a questionnaire based on the Manchester Cystic Fibrosis Compliance Questionnaire. RESULTS: Fifty seven of the 84 patients registered with the Unit (67.9% response rate) completed the survey. Over the previous six months, 96.5% of patients reported doing some form of airway clearance, with 70.2% doing this daily or only occasionally missing one or two days. Regular exercise was performed by 91.2% of patients when well, with 77.8% also exercising regularly when unwell. The most common reasons for non-adherence with airway clearance regimens were being too busy and not being bothered. Being too busy and too tired were the most frequent reasons for decreased adherence with exercise. Frequency of performing airway clearance regimens significantly improved when patients felt unwell. Adherence with exercise regimens was significantly higher in those who worked or studied full time. CONCLUSION: Overall, the levels of adherence with physiotherapy regimens found in this study were considered to be satisfactory and higher than those previously reported in the literature, with time related factors being the most commonly reported reasons for decreasing adherence.