Dying, dependency and death: Exploring palliative care access gaps for children.

Death has become a medicalized event. As such, end-of-life care has become entrenched in an over-reliance on individual patient autonomy to guide ethical decision making. Subsequently, the process of dying and the event of death are not primarily valued as life events - that is, as life-affirming phases of living. Rather, dying and death are viewed through the lens of medical options of when and how to die versus why dying and death are meaningful. This presents a problem for addressing the pediatric palliative care access gap and the Global Common Good. Specifically, in the context of important life events, one of which is death, we need space to be dependent on our inter-personal relationships to make crucial life decisions that affect our well-being. Recognizing dependency and inter-personalism is particularly important for pediatric populations. Children are uniquely placed to draw on their families and caregivers to make affirming life decisions in end-of-life care. This is particularly challenging to do in the Canadian context when Specialized Pediatric Palliative Care is not equitably available but options such as assisted death may soon be. Importantly, the meaning of death and dying is largely unexplored for this population. To advance ethical care at the end-of-life, more emphasis needs to be placed on the meaning that end of life events hold for Canadian children. In this paper I will outline the relevance of dependency and inter-personalism to attend to dying and death as meaningful phases of living for Canadian children and in relation to the pediatric palliative care access gap, the Global Common Good and Global Health Bioethics.

Around the world children need access to pediatric palliative healthcare during and at the end of life. In both Global Health and Canadian contexts, children have yet to achieve the necessary access to this kind of healthcare. At the same time, the meaning of dying and death is not well known in healthcare contexts, and this is particularly true for Canadian children. Instead, dying and death have become medicalized events in healthcare. This means that how and when to die get more consideration in healthcare than the meaning of dying and death as life events. This paper will look at how children can start to better access the care they need at the end of life, by discussing how dying and death should be considered as life events first and in relation to children. One way to think about this is to appreciate that children are physical, psycho-social, spiritual and dependent people who require inter-personal relationships to enact their care. Dying children should also be able to flourish for the Global Common Good. To start to address the pediatric palliative care access gap, the meaning of dying and death and palliative care need to become part of mainstream healthcare.

The meaning of dying and death for children, their carers, and families: a scoping review.

BACKGROUND: The meaning of dying and death are underexplored concepts for Canadian children. Subsequently, it is unclear how children and stakeholders make meaning of children's holistic health needs at the end of life. METHODS: A scoping review of the international scholarly literature was conducted. Thirteen data sources were searched to search the scholarly literature without date limits until January 2022. Studies were included on the basis of population: children (aged 0-19 years), families and caregivers; setting (in Canada and end-of-life or dying phases of living) and concepts of interest (dying and death). RESULTS: Of the 7377 studies identified, 12 were included for data extraction and content thematic analysis. The themes and subthemes include: 1) valuing the whole person; 2) living while dying; 3) authentic death talk; 4) a supportive approach (with lack and presence of support as subthemes); and, 5) a personalist approach. CONCLUSIONS: There is a pressing need for research into the meaning of dying and death for children, their carers and families in Canada. Lack of holistic care, authentic death talk, specialized pediatric palliative care providers, a personalist approach and communities of support present major gaps in care for Canadian children. Research is urgently needed to address these knowledge gaps to generate policy and support practice for dying children in Canada.

Effectiveness of interventions on healthcare professionals' understanding and use of conscience: a systematic review protocol.

INTRODUCTION: Conscience is central to moral decision making. In the context of morally pluralistic workplaces today, healthcare professionals' conscience may prompt them to make moral decisions to refrain from providing services they morally disagree with. However, such decisions are largely viewed as contentious, giving rise to polarising arguments for and against healthcare professionals' freedom of conscience. Yet, little work has been done to understand and support healthcare professionals' conscience. Instead, the rising polarity related to healthcare professionals' freedom of conscience stems from a central lack of understanding of what conscience is and the relevance it holds for healthcare professionals' clinical practice. Therefore, the degree and extent to which healthcare professionals are supported to understand and use their conscience is unknown. The objective of this review is to critically analyse the scholarly evidence available to ascertain the effectiveness of interventions that support healthcare professionals to understand and use their conscience in care practice. METHODS AND ANALYSES: At least two reviewers will systematically review 10 interdisciplinary, scholarly databases to examine qualitative, quantitative and mixed-methods studies including clinical trials pertaining to interventions related to conscience for healthcare professionals. Databases to be searched include: the Cochrane Controlled Register of Trials, Medline, EMBASE, PsycINFO, Cumulative Index for Nursing and Allied Health Literature (CINAHL), Academic Search Complete, ATLA Religion Database, Religion and Philosophy Collection, PhilPapers and Scopus. Databases were searched in May 2021. Study screening, selection, extraction and risk of bias assessments on each study using the Mixed Methods Appraisal Tool will be independently conducted by independent reviewers. Descriptive data synthesis will be carried out. Statistical analysis and meta-analysis will be conducted as relevant, based on homogeneity of findings. The quality of the aggregate evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations criteria. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. This protocol will not involve individual patient information endangering participant rights. The results will be reported in a peer-reviewed journal and disseminated at conferences. PROSPERO REGISTRATION NUMBER: CRD42021256943.

Conscience and conscientious objection in nursing: A personalist bioethics approach.

The ability of nurses to act as moral agents in accordance with their conscience is both an essential human freedom and an important part of professional ethics. Recent developments in Canada related to Medical Assistance in Dying have revealed new and important challenges related to conscientious objection - challenges that may require rethinking of how nurses do professional ethics. Notably, the inclusion of a personalist bioethical approach is needed to introduce and explicate what conscience is for nurses to be able to apply it to nursing practice. In this article, we explore the importance of conscience and conscientious objection as ethical concepts to support nurses in addressing issues of conscience amid ethically challenging situations. We discuss how a personalist basis for conscience can support nurses to inclusively engage with one another across diverse moral perspectives.

Paediatric euthanasia in Canada: New challenges for end of life care.

Canadians are looking to expand their Medical Assistance in Dying (MAID) program to include mature minors. Yet, little evidence exists to support this expansion. The Council of Canadian Academies released a report in December 2018 indicating that little is known about how mature minors make meaning of end of life care. To address this knowledge gap, research is needed to understand how mature minors make meaning of the dying process in the first place. Since social perceptions drive Canadian health care, practice, and end of life mentalities, the question that needs to be asked is: What is the Canadian perception of a good death for mature minors? To answer this question it is first necessary to examine the meaning that death and dying hold for mature minors, as voiced by mature minors themselves.

Surfactant protein D concentrations in serum and bronchoalveolar lavage fluid from young healthy horses on pasture and in a barn environment.

OBJECTIVE: To evaluate surfactant protein D (SP-D) concentrations in serum and bronchoalveolar lavage fluid (BALF) from young healthy horses on pasture or housed in a typical barn. ANIMALS: 20 young healthy horses. PROCEDURES: Horses were randomly assigned to 1 of 2 groups (pasture, n = 10; barn, 10), and serum and BALF samples were collected for SP-D determination at baseline (all horses on pasture) and 2 weeks and 4 weeks after the barn group of horses was relocated from the pasture to the barn. Other evaluations included physical and tracheoscopic examinations. Findings were compared within and between groups. RESULTS: Physical and tracheoscopic examinations, CBC, and serum biochemical analysis did not reveal evidence of respiratory disease, and no significant differences were present within and between groups. Serum SP-D concentrations did not significantly differ within and between groups, but BALF SP-D concentrations were significantly lower for the barn group at 2 weeks but not at 4 weeks, compared with baseline. The BALF SP-D concentration-to-BALF total protein concentration ratio was < 1.5 and did not significantly differ within and between groups. CONCLUSIONS AND CLINICAL RELEVANCE: A mild decrease was evident in the concentration of SP-D in the BALF collected from young healthy horses after 2 weeks of exposure to a barn environment. The clinical importance of this finding remains to be determined.

Conscience, conscientious objection, and nursing: A concept analysis.

BACKGROUND:: Ethical nursing practice is increasingly challenging, and strategies for addressing ethical dilemmas are needed to support nurses' ethical care provision. Conscientious objection is one such strategy for addressing nurses' personal, ethical conflicts, at times associated with conscience. Exploring both conscience and conscientious objection provides understanding regarding their implications for ethical nursing practice, research, and education. RESEARCH AIM:: To analyze the concepts of conscience and conscientious objection in the context of nurses. DESIGN:: Concept analysis using the method by Walker and Avant. RESEARCH CONTEXT:: Data were retrieved from Philosopher's Index, PubMed, and CINAHL with no date restrictions. ETHICAL CONSIDERATION:: This analysis was carried out per established, scientific guidelines. FINDINGS:: Ethical concepts are integral to nursing ethics, yet little is known about conscientious objection in relation to conscience for nurses. Of note, both concepts are well established in ethics literature, addressed in various nursing codes of ethics and regulatory bodies, but the meaning they hold for nurses and the impact they have on nursing education and practice remain unclear. DISCUSSION AND CONCLUSION:: This article discusses the relevance of conscience and conscientious objection to ethical nursing practice and proposes a model case to show how they can be appreciated in the context of nurses. Conscientious objection is an option for ethical transparency for nurses but is situated in contentious discussions over its use and has yet to be fully understood for nursing practice. Conscience is an element in need of more exploration in the context of conscientious objection. Further research is warranted to understand how nurses respond to conscience concerns in morally, pluralistic nursing contexts.

Conscientious objection and nurses: Results of an interpretive phenomenological study.

BACKGROUND: While conscientious objection is a well-known phenomenon in normative and bioethical literature, there is a lack of evidence to support an understanding of what it is like for nurses to make a conscientious objection in clinical practice including the meaning this holds for them and the nursing profession. RESEARCH QUESTION: The question guiding this research was: what is the lived experience of conscientious objection for Registered Nurses in Ontario? RESEARCH DESIGN: Interpretive phenomenological methodology was used to gain an in-depth understanding of what it means to be a nurse making a conscientious objection. Purposive sampling with in-depth interview methods was used to collect and then analyze data through an iterative process. PARTICIPANTS AND RESEARCH CONTEXT: Eight nurse participants were interviewed from across practice settings in Ontario, Canada. Each participant was interviewed twice over 9 months. ETHICAL CONSIDERATIONS: This study was conducted in accordance with Health Science Research Ethics Board approval and all participants gave consent. FINDINGS: Six themes emerged from data analysis: encountering the problem, knowing oneself, taking a stand, alone and uncertain, caring for others, and perceptions of support. DISCUSSION: This study offers an initial understanding of what it is like to be a nurse making a conscientious objection in clinical practice. Implications for nursing practice, education, policy, and further research are discussed. CONCLUSION: Addressing ethical issues in nursing practice is complex. The need for education across nursing, healthcare disciplines and socio-political sectors is essential to respond to nurses' ethical concerns giving rise to objections. Conscience emerged as an informant to nurses' conscientious objections. The need for morally inclusive environments and addressing challenging ethical questions as well as the concept of conscience are relevant to advancing nursing ethics and ethical nursing practice.

Nurses' use of conscientious objection and the implications for conscience.

AIMS: To explore the meaning of conscience for nurses in the context of conscientious objection (CO) in clinical practice. DESIGN: Interpretive phenomenology was used to guide this study. DATA SOURCES: Data were collected from 2016 - 2017 through one-on-one interviews from eight nurses in Ontario. Iterative analysis was conducted consistent with interpretive phenomenology and resulted in thematic findings. REVIEW METHODS: Iterative, phased analysis using line-by-line and sentence highlighting identified key words and phrases. Cumulative summaries of narratives thematic analysis revealed how nurses made meaning of conscience in the context of making a CO. RESULTS: Conscience issues and CO are current, critical issues for nurses. For Canadian nurses this need has been recently heightened by the national legalization of euthanasia, known as Medical Assistance in Dying in Canada. Ethics education, awareness, and respect for nurses' conscience are needed in Canada and across the profession to support nurses to address their issues of conscience in professional practice. CONCLUSION: Ethical meaning emerges for nurses in their lived experiences of encountering serious ethical issues that they need to professionally address, by way of conscience-based COs. IMPACT: This is the first study to explore what conscience means to nurses, as shared by nurses themselves and in the context of CO. Nurse participants expressed that support from leadership, regulatory bodies, and policy for nurses' conscience rights are indicated to address nurses' conscience issues in practice settings.

Conscientious Objection: Understanding the Right of Conscience in Health and Healthcare Practice.

In situations of moral gravitas, healthcare professionals are largely protected in the Western world to invoke their right to conscientiously object to providing care that conflicts with their personal, moral, and religious beliefs. However, making a conscientious objection needs to be predicated by an understanding of conscience, and knowledge of conscience is largely absent in definition as well as discourse surrounding conscientious objection in healthcare practice. Moreover, current definitions of health do not place emphasis on the ethical well-being of patients as well as care providers. Exploring health as an ethical condition of wellness in the light of conscientious healthcare provision will be addressed in my paper. I will also discuss how a distance from conscience in conscientious objection could compromise a healthcare professional's right to conscientious objection, if the fundamental, human right to conscience is not protected in the first place, supported by a focus on the importance of health as a state of ethical well-being.

Dobutamine "stress" test and latent cardiac susceptibility to inhaled diesel exhaust in normal and hypertensive rats.

BACKGROUND: Exercise "stress" testing is a screening tool used to determine the amount of stress for which the heart can compensate before developing abnormal rhythm or ischemia, particularly in susceptible persons. Although this approach has been used to assess risk in humans exposed to air pollution, it has never been applied to rodent studies. OBJECTIVE: We hypothesized that a single exposure to diesel exhaust (DE) would increase the risk of adverse cardiac events such as arrhythmia and myocardial ischemia in rats undergoing a dobutamine challenge test, which can be used to mimic exercise-like stress. METHODS: Wistar-Kyoto normotensive (WKY) and spontaneously hypertensive (SH) rats implanted with radiotelemeters and a chronic intravenous catheter were whole-body exposed to 150 µg/m3 DE for 4 hr. Increasing doses of dobutamine, a ß1-adrenergic agonist, were administered to conscious unrestrained rats 24 hr later to elicit the cardiac response observed during exercise while heart rate (HR) and electrocardiogram (ECG) were monitored. RESULTS: A single exposure to DE potentiated the HR response of WKY and SH rats during dobutamine challenge and prevented HR recovery at rest. During peak challenge, DE-exposed SH rats had lower overall HR variability when compared with controls, in addition to transient ST depression. All DE-exposed animals also had increased arrhythmias. CONCLUSIONS: These results are the first evidence that rats exhibit stress-induced cardiac dysrhythmia and ischemia sensitivity comparable to humans after a single exposure to a toxic air pollutant, particularly when in the presence of underlying cardiovascular disease. Thus, exposure to low concentrations of air pollution can impair the heart's ability to respond to stress and increase the risk of subsequent triggered dysfunction.

Overt and latent cardiac effects of ozone inhalation in rats: evidence for autonomic modulation and increased myocardial vulnerability.

BACKGROUND: Ozone (O3) is a well-documented respiratory oxidant, but increasing epidemiological evidence points to extrapulmonary effects, including positive associations between ambient O3 concentrations and cardiovascular morbidity and mortality. OBJECTIVE: With preliminary reports linking O3 exposure with changes in heart rate (HR), we investigated the hypothesis that a single inhalation exposure to O3 will cause concentration-dependent autonomic modulation of cardiac function in rats. METHODS: Rats implanted with telemeters to monitor HR and cardiac electrophysiology [electrocardiography (ECG)] were exposed once by whole-body inhalation for 4 hr to 0.2 or 0.8 ppm O3 or filtered air. A separate cohort was tested for vulnerability to aconitine-induced arrhythmia 24 hr after exposure. RESULTS: Exposure to 0.8 ppm O3 caused bradycardia, PR prolongation, ST depression, and substantial increases in atrial premature beats, sinoatrial block, and atrioventricular block, accompanied by concurrent increases in several HR variability parameters that were suggestive of increased parasympathetic tone. Low-O3 exposure failed to elicit any overt changes in autonomic tone, heart rhythm, or ECG. However, both 0.2 and 0.8 ppm O3 increased sensitivity to aconitine-induced arrhythmia formation, suggesting a latent O3-induced alteration in myocardial excitability. CONCLUSIONS: O3 exposure causes several alterations in cardiac electrophysiology that are likely mediated by modulation of autonomic input to the heart. Moreover, exposure to low O3 concentrations may cause subclinical effects that manifest only when triggered by a stressor, suggesting that the adverse health effects of ambient levels of air pollutants may be insidious and potentially underestimated.

Divergent electrocardiographic responses to whole and particle-free diesel exhaust inhalation in spontaneously hypertensive rats.

Diesel exhaust (DE) is a major contributor to traffic-related fine particulate matter (PM)(2.5). Although inroads have been made in understanding the mechanisms of PM-related health effects, DE's complex mixture of PM, gases, and volatile organics makes it difficult to determine how the constituents contribute to DE's effects. We hypothesized that exposure to particle-filtered DE (fDE; gases alone) will elicit less cardiac effects than whole DE (wDE; particles plus gases). In addition, we hypothesized that spontaneously hypertensive (SH) rats will be more sensitive to the electrocardiographic effects of DE exposure than Wistar Kyoto rats (WKY; background strain with normal blood pressure). SH and WKY rats, implanted with telemeters to monitor electrocardiogram and heart rate (HR), were exposed once for 4 h to 150 µg/m(3) or 500 µg/m(3) of wDE (gases plus PM) or fDE (gases alone) DE, or filtered air. Exposure to fDE, but not wDE, caused immediate electrocardiographic alterations in cardiac repolarization (ST depression) and atrioventricular conduction block (PR prolongation) as well as bradycardia in SH rats. Exposure to wDE, but not fDE, caused postexposure ST depression and increased sensitivity to the pulmonary C fiber agonist capsaicin in SH rats. The only notable effect of DE exposure in WKY rats was a decrease in HR. Taken together, hypertension may predispose to the potential cardiac effects of DE and components of DE may have divergent effects with some eliciting immediate irritant effects (e.g., gases), whereas others (e.g., PM) trigger delayed effects potentially via separate mechanisms.

ST depression, arrhythmia, vagal dominance, and reduced cardiac micro-RNA in particulate-exposed rats.

Recently, investigators demonstrated associations between fine particulate matter (PM)-associated metals and adverse health effects. Residual oil fly ash (ROFA), a waste product of fossil fuel combustion from boilers, is rich in the transition metals Fe, Ni, and V, and when released as a fugitive particle, is an important contributor to ambient fine particulate air pollution. We hypothesized that a single-inhalation exposure to transition metal-rich PM will cause concentration-dependent cardiovascular toxicity in spontaneously hypertensive (SH) rats. Rats implanted with telemeters to monitor heart rate and electrocardiogram were exposed once by nose-only inhalation for 4 hours to 3.5 mg/m(3), 1.0 mg/m(3), or 0.45 mg/m(3) of a synthetic PM (dried salt solution), similar in composition to a well-studied ROFA sample consisting of Fe, Ni, and V. Exposure to the highest concentration of PM decreased T-wave amplitude and area, caused ST depression, reduced heart rate (HR), and increased nonconducted P-wave arrhythmias. These changes were accompanied by increased pulmonary inflammation, lung resistance, and vagal tone, as indicated by changes in markers of HR variability (increased root of the mean of squared differences of adjacent RR intervals [RMSSD], low frequency [LF], high frequency [HF], and decreased LF/HF), and attenuated myocardial micro-RNA (RNA segments that suppress translation by targeting messenger RNA) expression. The low and intermediate concentrations of PM had less effect on the inflammatory, HR variability, and micro-RNA endpoints, but still caused significant reductions in HR. In addition, the intermediate concentration caused ST depression and increased QRS area, whereas the low concentration increased the T-wave parameters. Thus, PM-induced cardiac dysfunction is mediated by multiple mechanisms that may be dependent on PM concentration and myocardial vulnerability (this abstract does not reflect the policy of the United States Environmental Protection Agency).