Patient Safety in Palliative Care at the End of Life from the Perspective of Complex Thinking.

Actions for patient safety at the end of life must be aligned with the principles of palliative care, such as promoting comfort and quality of life. Faced with this complex process, health professionals need to seek the central relationships of the concepts of safety and palliative care to the end of life, in line with the wishes and expectations of the person and family members/caregivers, as well as with available resources and the capacity of services but, above all, reinforcing the importance of a non-reductionist care approach, which encompasses the various aspects inherent to humans. Hence, we present a new vision of patient safety in palliative care at the end of life based on the complex thinking of Edgar Morin, scientific evidence, and health policies in the global context. We discuss the deficiencies and disjunctions in thought and practice of palliative care at the end of life and patient safety, as well as the challenges for the conjunction of these complex themes, to finally present potential ways to apply complex thinking in the safe care of the patient at the end of life. The problematization of different aspects for the interposition of knowledge about patient safety in palliative care at the end of life portrays the existence of intersubjective connections and the multidimensionality that permeate the guidelines, actions and relationships that sustain the disciplines.

A Qualitative Study of the Limits and Possibilities of Integrating Palliative Care in Heart Failure.

Heart failure is a progressive condition with a high burden of symptoms and clinical decompensations that causes psychological and social suffering, poor quality of life, and limited life expectancy. Therefore, it requires palliative care to control symptoms and signs, but integrating it with clinical care is complicated. We aimed to discuss the limits and possibilities of integrating palliative care in heart failure. This was a qualitative descriptive study. Semi-structured qualitative interviews were carried out between July 2020 and July 2021. We applied the thematic content analysis and the SWOT matrix. Ethical principles were respected. Ten professionals from an Institute specializing in cardiovascular diseases in Rio de Janeiro, Brazil, participated in the study, including physicians, nurses, psychologist, and occupational therapist. We identified 4 categories related to intervening factors: the patient's profile, the emotional aspects of professionals facing these patients, the challenges to integrating and sustaining palliative care in practice, and the ways for assistance planning in this context. The existence of a specialized team, the palliative care commission, and the institutional palliative care protocol, aligned with the realistic perception of the assistance, organizational, political, and social problems, may promote the advancement of palliative care in heart failure.

The Organization of Home Palliative Cancer Care by Primary Health Care: A Systematic Review Protocol.

Greater longevity and chronic diseases, such as cancer, require (re)organization of care for the sustainability of health systems and better quality of life. Palliative care organized by primary health care has positive outcomes, changing standards of care at the end of life, reducing hospitalizations and health costs and contributing to people's autonomy to stay at home with controlled symptoms. However, in many countries, this is not possible because the provision of palliative cancer care is isolated or generalized, concentrated in the hospital, and without the strategic participation of primary care. In many developed countries, where palliative care is offered in an integrated way, home care has increased the people's chances of receiving dignified care at the end of life. The aim of this review is to evaluate the organization of home palliative cancer care by primary care to improve the use of health resources and the quality of life of such patients. This systematic review protocol follows the Cochrane methodology to provide a narrative synthesis, with the resulting report guided by the Preferred Reporting Items for Systematic Reviews (PRISMA).

Antineoplastic therapy administration: Nursing intervention in the relief of suffering.

OBJECTIVE: To identify the nursing interventions with potential to act on the suffering and to evaluate the results of the nursing intervention designed. METHOD: We used a multi method study. After the identification of the scientific evidence and having found the supporting theory, the intervention process to relieve the suffering of hospitalized patients was modeled using the methodology of qualitative research. Then, training conditions were created for the implementation of the intervention Chemotherapy Administration as an Individualized Nursing Intervention, with a Quasi Experimental, longitudinal piloting study. RESULTS: The patients of the experimental group showed values of suffering lower than the control group . Having finished the pilot study, we would return to qualitative research to understand the variation of some data. FINAL CONSIDERATIONS: The use of mixed methods of investigations allowed the understanding of the different components of drug chemotherapy administration as an individualized nursing intervention.

Antineoplastic therapy administration: Nursing intervention in the relief of suffering / Administração de terapia antineoplásica: intervenção de enfermagem no alívio do sofrimento / Administración de terapia antineoplásica: Intervención de enfermería en el alivio del sufrimiento

ABSTRACT Objective: To identify the nursing interventions with potential to act on the suffering and to evaluate the results of the nursing intervention designed. Method: We used a multi method study. After the identification of the scientific evidence and having found the supporting theory, the intervention process to relieve the suffering of hospitalized patients was modeled using the methodology of qualitative research. Then, training conditions were created for the implementation of the intervention Chemotherapy Administration as an Individualized Nursing Intervention, with a Quasi Experimental, longitudinal piloting study. Results: The patients of the experimental group showed values of suffering lower than the control group . Having finished the pilot study, we would return to qualitative research to understand the variation of some data. Final Considerations: The use of mixed methods of investigations allowed the understanding of the different components of drug chemotherapy administration as an individualized nursing intervention.

RESUMO Objetivo: Identificar intervenções de enfermagem com o potencial de atuar sobre o sofrimento e avaliar os resultados da intervenção de enfermagem criada. Método: Uma abordagem de estudo multimétodo foi utilizada. Após identificar as evidências científicas e encontrar a teoria de apoio, o processo de intervenção para aliviar o sofrimento de pacientes hospitalizados foi modelado utilizando a metodologia da pesquisa qualitativa. Em seguida, foram criadas as condições de treinamento para a implementação da intervenção Administração da Quimioterapia como Intervenção de Enfermagem Individualizada, com estudo piloto quase experimental, longitudinal. Resultados: Os pacientes do grupo experimental apresentaram valores de sofrimento inferiores ao grupo controle. Após o término do estudo piloto, retornaríamos à pesquisa qualitativa para entender a variação de alguns dados. Considerações finais: O uso de métodos mistos de pesquisa permitiu a compreensão dos diferentes componentes da administração da quimioterapia medicamentosa como uma intervenção de enfermagem individualizada.

RESUMEN Objetivo: Identificar las intervenciones de enfermería con potencial para actuar sobre el sufrimiento y evaluar los resultados de la intervención de enfermería diseñada. Método: Utilizamos un estudio de varios métodos. Tras identificarse la evidencia científica y determinarse su fundamentación teórica, se modeló el proceso de intervención para aliviar el sufrimiento de los pacientes hospitalizados, aplicándose metodología cuantitativa. Posteriormente, se crearon las condiciones de capacitación para implementar la intervención Administración de Quimioterapia como una Intervención de Enfermería Individualizada, con un estudio piloto longitudinal cuasi -experimental. Resultados: Los pacientes del grupo experimental mostraron valores de sufrimiento inferiores a los del grupo control. Habiendo finalizado la prueba piloto, habríamos de retomar la investigación cualitativa para comprender la variación de algunos datos. Consideraciones finales: La aplicación de métodos mixtos de investigación permitió comprender los diferentes componentes de la administración de la quimioterapia farmacológica como una intervención de enfermería individualizada.

Opposite effects of fasting on TGF-beta3 and TbetaRI distribution in the gastric mucosa of suckling and early weanling rats.

OBJECTIVE: Our aim was to evaluate the effects of a dietary regimen (suckling or early weaning) and feeding status (fed or fasted) on the distribution of transforming growth factor-beta3 (TGF-beta3) and TGF receptor-I (TbetaRI) in the gastric epithelium of pups. METHODS: Wistar rats were used. At 15 d, half of the pups were separated from dams and fed with hydrated powered chow. On day 17, suckling and early weanling rats were subjected to fasting (17h). Four different conditions were established: suckling fed and fasted and early weanling fed and fasted. At 18 d stomachs were collected under anesthesia and were fixed in 4% formaldehyde for immunohistochemistry. The number of immunostained epithelial cells per microscopic field was determined for TGF-beta3 and TbetaRI in longitudinal sections from the gastric mucosa. RESULTS: We found that during suckling, fasting reduced the number of immunolabeled cells per field of both molecules when compared with the fed group (P<0.05), whereas in early weaning, food restriction increased TGF-beta3 and TbetaRI distributions (P<0.05). We also observed that TGF-beta3 and TbetaRI were more concentrated in parietal cells in the upper gland in suckling pups, whereas after early weaning these were displaced to parietal and chief cells at the bottom of the gland. CONCLUSION: Suckling and early weaning directly influence TGF-beta3 and TbetaRI distributions in the gastric epithelium in response to fasting, such that early weaning anticipates the effects observed in adult rats. Furthermore, the differential concentrations of TGF-beta3 and TbetaRI indicate that they might be important for cell proliferation events in growth control.

Fasting differentially regulates plasma corticosterone-binding globulin, glucocorticoid receptor, and cell cycle in the gastric mucosa of pups and adult rats.

The nutritional status influences gastric growth, and interestingly, whereas cell proliferation is stimulated by fasting in suckling rats, it is inhibited in adult animals. Corticosterone takes part in the mechanisms that govern development, and its effects are regulated in particular by corticosterone-binding globulin (CBG) and glucocorticoid receptor (GR). To investigate whether corticosterone activity responds to fasting and how possible changes might control gastric epithelial cell cycle, we evaluated different parameters during the progression of fasting in 18- and 40-day-old rats. Food restriction induced higher corticosterone plasma concentration at both ages, but only in pups did CBG binding increase after short- and long-term treatments. Fasting also increased gastric GR at transcriptional and protein levels, but the effect was more pronounced in 40-day-old animals. Moreover, in pups, GR was observed in the cytoplasm, whereas, in adults, it accumulated in the nucleus after the onset of fasting. Heat shock protein (HSP) 70 and HSP 90 were differentially regulated and might contribute to the stability of GR and to the high cytoplasmic levels in pups and elevated shuttling in adult rats. As for gastric epithelial cell cycle, whereas cyclin D1 and p21 increased during fasting in pups, in adults, cyclin E slowly decreased, concomitant with higher p27. In summary, we demonstrated that corticosterone function is differentially regulated by fasting in 18- and 40-day-old rats, and such variation might attenuate any possible suppressive effects during postnatal development. We suggest that this mechanism could ultimately increase cell proliferation and allow regular gastric growth during adverse nutritional conditions.

In vivo effects of TGFbeta1 on the growth of gastric epithelium in suckling rats.

As the content of Transforming Growth Factor-beta (TGFbeta) wanes in the milk of lactating rat, an increase in TGFbeta is observed in the gastric epithelia concomitant with differentiation of the glands upon weaning. Whereas TGFbeta has been shown to inhibit the proliferation of gastrointestinal cells in vitro, its functional significance and mechanisms of action have not been studied in vivo. Therefore, we administered TGFbeta1 (1 ng/g body wt.) to 14-day-old rats in which the gastric epithelium was induced to proliferate by fasting, and determined the involvement of signaling through Smads and the impact on epithelial cell proliferation and apoptosis. After the gavage, we observed the progressive increase of active TGFbeta1 while TbetaRII-receptor remained constant in the gastric mucosa. By immunohistochemistry, we showed Smad2/3 increase at 60 min (p<0.05) and Smad2 phosphorylation/activation and translocation to the nucleus most prominently between 0 and 30 min after treatment (p<0.05). Importantly, TGFbeta1 inhibited cell proliferation (p<0.05), which was estimated by BrDU pulse-labeling 12 h after gavage. Lower proliferation was reflected by increased p27(kip1) at 2 h (p<0.05). Also, TGFbeta1 increased apoptosis as measured by M30 labeling at 60 and 180 min (p<0.001), and by morphological features at 12 h (p<0.05). In addition, we observed higher levels of activated caspase 3 (17 kDa) from 0 to 30 min. Altogether, these data indicate a direct effect of TGFbeta1 signaling through Smads on both inhibiting proliferation, through alteration of cycle proteins, and inducing apoptosis of gastric epithelial cells in vivo. Further, the studies suggest a potential role for both milk and tissue-expressed TGFbeta1 in gastric growth during postnatal development.

Ontogenic expression of TGFbeta 1, 2, and 3 and its receptors in the rat gastric mucosa.

The stomach of the rat undergoes extensive changes during the formation and maturation of gastric glands. The presence of transforming growth factor beta (TGFbeta) in rat milk and in the gastrointestinal tract of pups may suggest its role in this process. The current study evaluated the in vivo dynamic expression and distribution of TGFbeta1, beta2, beta3 and their receptors TbetaRI and TbetaRII in the gastric epithelium of 20-day fetal rats and 1-, 14-, 21-, and 30-day-old pups. Immunohistochemistry was used to detect the proteins, and staining was classified according to intensity and cell type. The results showed that the gastric epithelium expresses TGFbeta isoforms and receptors throughout development. We found that immunoreactivity paralleled the appearance of differentiated cells, such that surface mucous cells were the first to be immunostained and chief cells were the last. The intensity of reactions followed this same pattern, showing that the expression of TGFbeta isoforms spread along the gland with growth. Of interest, the highest apparent activity of TGFbeta was observed from 21 days onward, a period that is concomitant with weaning and maturation of most gastric cell types. In addition, surface mucous cells were strongly labeled at the basal cytoplasm at 14 days, suggesting an interaction with the connective tissue. In conclusion, the dynamic expression of TGFbeta1, beta2, beta3, and TbetaRI and TbetaRII through stomach development suggests significant paracrine and autocrine roles for this growth factor. We propose that temporal and spatial differences may be regulated by dietary changes, which in turn control cell proliferation and differentiation in the gastric epithelium.