Cancer patients have a reduced likelihood of dying in hospital with advance care planning in primary health care and a summarizing palliative plan: a prospective controlled non-randomized intervention trial.

BACKGROUND: Advance care planning (ACP) allows patients to define their goals and preferences. Spending more time at home and less time in the hospital, along with avoiding death in the hospital, are often considered desirable outcomes of palliative care (PC). In 2015, 36% of cancer patients died in the hospital and 13% died at home in Norway. METHOD: From 2015 to 2022, this prospective controlled non-randomized intervention trial observed 144 cancer patients with or without an organized ACP conversation in primary health care and a summarizing palliative plan (ClinicalTrials.gov Identifier: NCT02170168, 23 June 2014). The patients were identified through contact with the local cancer outpatient clinic or hospital-based PC team. RESULTS: A total of 128 patients died during the observation period. Of these, 67 patients had an organized ACP conversation and summarizing palliative plan (intervention (I) group) and 61 had not (control (C) group). Dying in the hospital was significantly less common for patients in the I group compared to the C group (17.9% vs. 34.4%; X2 (1, n = 128) = 4.55, p = 0.033). There were no differences between the groups in terms of where they spent their time in the last 90 days of life (home, nursing home, or hospital). Most patients (62%) preferred to die at home. The observed differences between the groups regarding preferred and actual places of death did not reach statistical significance. CONCLUSION: With organized ACP conversations in primary health care and a summarizing palliative plan, cancer patients died less often in the hospital in our observational study. A structured ACP approach integrating palliative care for cancer patients into primary health care can support patients´ preferences at the end of life.

Physicians' perceptions of patient participation and the involvement of family caregivers in the palliative care pathway.

INTRODUCTION: Patient participation is essential for quality palliative care, and physicians play a crucial role in promoting participation. This study explores physicians' perceptions of patients and family caregivers' involvement in the different phases of the palliative pathway and employs a qualitative design with thematic analysis and a hermeneutic approach. METHODS: A purposive sampling included physicians who worked in different phases of the palliative pathway. In-depth, semi-structured interviews were conducted with 13 physicians in Norway between May and June 2020. RESULTS: Three main themes illustrate physicians' perceptions of patients' and family caregivers' involvement: (1) beneficence for the patient and the family caregivers in the early phase, (2) autonomy and shared decision-making in the middle phase, and (3) family involvement in the terminal phase. CONCLUSION: The physicians perceived bereavement conversations as essential, particularly if the pathway had been challenging. They also perceived patient participation and family caregivers' involvement as contextual. The results reveal that participation differs across the different phases of the palliative pathway. This type of knowledge should be included in the education of health-care professionals. Future research should explore elements vital to successful patient participation and family involvement in the different phases of care. PATIENT OR PUBLIC CONTRIBUTIONS: Family caregivers were involved in a previous study through individual interviews. The same interview guide used for the family caregivers was used when interviewing the physicians. The family caregivers' contribution led to nuanced questions in the interviews with the physicians, questions leaning on their stories told.

Cancer patients spend more time at home and more often die at home with advance care planning conversations in primary health care: a retrospective observational cohort study.

BACKGROUND: Spending time at home and dying at home is advocated to be a desirable outcome in palliative care (PC). In Norway, home deaths among cancer patients are rare compared to other European countries. Advance care planning (ACP) conversations enable patients to define goals and preferences, reflecting a person's wishes and current medical condition. METHOD: The study included 250 cancer patients in the Romsdal region with or without an ACP conversation in primary health care who died between September 2018 and August 2020. The patients were identified through their contact with the local hospital, cancer outpatient clinic or hospital-based PC team. RESULTS: During the last 90 days of life, patients who had an ACP conversation in primary health care (N=125) were mean 9.8 more days at home, 4.5 less days in nursing home and 5.3 less days in hospital. Having an ACP conversation in primary health care, being male or having a lower age significantly predicted more days at home at the end of life (p< .001). Patients with an ACP conversation in primary health care where significantly more likely to die at home (p< .001) with a four times higher probability (RR=4.5). Contact with the hospital-based PC team was not associated with more days at home or death at home. Patients with contact with the hospital-based PC team were more likely to have an ACP conversation in primary health care. CONCLUSION: Palliative cancer patients with an ACP conversation in primary health care spent more days at home and more frequently died at home. Data suggest it is important that ACP conversations are conducted in primary health care setting.

Medical students' learning experience and participation in communities of practice at municipal emergency care units in the primary health care system: a qualitative study.

BACKGROUND: Medical education has been criticised for not adapting to changes in society, health care and technology. Internationally, it is necessary to strengthen primary health care services to accommodate the growing number of patients. In Norway, emergency care patients are increasingly treated in municipal emergency care units in the primary health care system. This study explores medical students' learning experience and how they participated in communities of practice at two municipal emergency care units in the primary health care system. METHODS: In this qualitative study, we collected data from March to May 2019 using semi-structured individual interviews and systematic observations of six ninth-semester medical students undergoing two-week clerkships at municipal emergency care units. The interview transcripts were thematically analysed with a social constructivist approach. A total of 102 systematic observations were used to triangulate the findings from the thematic analysis. RESULTS: Three themes illuminated what the medical students learned and how they participated in communities of practice: (i) They took responsibility for emergency care patients while participating in the physicians' community of practice and thus received intensive training in the role of a physician. (ii) They learned the physician's role in interprofessional collaboration. Collaborating with nursing students and nurses led to training in clinical procedures and insight into the nurses' role, work tasks, and community of practice. (iii) They gained in-depth knowledge through shared reflections when time was allocated for that purpose. Ethical and medical topics were elucidated from an interprofessional perspective when nursing students, nurses, and physicians participated. CONCLUSIONS: Our findings suggest that this was a form of clerkship in which medical students learned the physician's role by taking responsibility for emergency care patients and participating in multiple work tasks and clinical procedures associated with physicians' and nurses' communities of practice. Participating in an interprofessional community of practice for professional reflections contributed to in-depth knowledge of ethical and medical topics from the medical and nursing perspectives.

Nephrologists' experiences with patient participation when long-term dialysis is required.

BACKGROUND: For individuals in need of dialysis, patient participation is important when determining care goals and in decision making regarding dialysis modality. Nephrologists hold a key role in delivering evidence-based healthcare that integrates patient preferences and values throughout the trajectory, and their experiences with patient participation are important for improving health care. The aim of this study was to explore nephrologists' experiences with patient participation in different phases of the end-stage renal disease trajectory for working-age individuals who require dialysis. METHODS: This explorative study comprised interviews with ten nephrologists from four different dialysis units in Central Norway. We analysed the interviews by applying an interpretive phenomenological approach. RESULTS: Nephrologists had varied experiences with patient participation throughout the different phases of the treatment trajectory. During decision making on the dialysis modality, nephrologists emphasised patients' choices in two approaches. In the first approach, they expected patients to choose the modality based on the provided information, which could be actively steered. In the second approach, they recognised the patients' values and lifestyle preferences through shared decision-making. Within hospital haemodialysis, nephrologists considered patients' self-care activities equivalent to patient participation, seeing self-care as a source of patient empowerment. They identified divergent patient-professional values and organisational structures as barriers to patient participation. CONCLUSION: Our study shows that nephrologists have different approaches to patient participation in different phases of the end-stage renal disease trajectory. Individual understanding as well as organisational structures are important factors to address to increase patient participation in end-stage renal disease care. Shared decision making, in which patient values are balanced against biomedical treatment targets, allows for mutual agreement between patients and healthcare professionals concerning medical plans and minimises the potential for patient-professional tensions.

Nursing qualifications needed in municipal emergency inpatient units. A qualitative study.

BACKGROUND: Providing care to older individuals with complex needs and patients with chronic illness is a concern worldwide. In Norway, this situation led to the transfer of responsibility for care and treatment to the municipalities. Providing emergency care at the municipal level - thereby reducing the need for emergency hospital admissions - is part of the Coordination Reform in Norway. This reform from 2012 warrants a reconsideration of which nursing qualifications are needed in the municipalities. The aim of the study is to explore which professional qualifications nurses need to provide emergency care in municipal emergency inpatient units. METHOD: A qualitative design with a hermeneutic approach was employed. Interviewing physicians about nursing qualifications may be considered inappropriate. We believe that this is important for developing knowledge that can strengthen interprofessional cooperation in emergency situations. Three focus groups were conducted. Physicians with experience in municipal emergency inpatient units were interviewed. RESULTS: We synthesised three themes from the data: (1) broad medical knowledge; (2) advanced clinical skills; and (3) ethical qualifications and a holistic approach. The first theme is about knowledge, the second is about skills, and the third conveys the need for overall competence. CONCLUSIONS: Nurses working in municipal emergency inpatient units need advanced ethical qualifications, which integrate broad medical knowledge, advanced clinical skills and the ability to take a holistic approach. They have a considerable responsibility to work independently and safely in a setting where both the patient and the patient's family play important roles. Establishing arenas for collaborative practice between physicians and nurses on clinical issues may be a way of strengthening patient safety and nurses' clinical judgement.

Narratives of patient participation in haemodialysis.

AIM AND OBJECTIVE: To explore how working-age adults experience patient participation in hospital haemodialysis. BACKGROUND: End-stage kidney disease is a progressive, chronic condition imposing patients with high treatment burdens and low health-related quality of life. Patients face multiple medical decisions related to living with kidney failure. Given their frequent interaction with health services, patient participation may be of special value. DESIGN: Qualitative design with a narrative approach. METHODS: In 2018, eleven patients aged 35-64 years undergoing hospital haemodialysis participated in individual interviews. All interviews were analysed using a narrative approach. Reporting followed the Consolidated criteria for Reporting Qualitative Research guidelines. FINDINGS: The patients' narratives of participation comprised three themes following their healthcare trajectory: Informed, but not involved in treatment choices; Duality of care and control; and Frail trust reflecting collaborative deficiencies. The patients received good information about dialysis, but were not involved in choice of treatment modality. Professional work, as well as the nature of treatment, contributed to restricted patient autonomy. Patients' trust suffered from collaborative deficiency generating delays in their treatment trajectories, and patients extended their responsibility into the coordination of transitions as a way of coping with these issues. CONCLUSIONS: The study identified challenges related to patient involvement and interdisciplinary collaboration. Involving patients through dialogue and acknowledging their experiences, preferences and lifestyles may strengthen the mutual patient-professional understanding of treatment. Despite increased focus on seamless trajectories, patients face obstacles regarding interdisciplinary collaboration and coordination of health services. RELEVANCE TO CLINICAL PRACTICE: The findings indicate a want of individually customised care for people requiring dialysis. Patients need to be involved in the choice of treatment modality as well as decisions related to the current treatment. Information must include potential consequences of the different treatment modalities. Health services need to strengthen collaboration in order to secure treatment continuity and patient involvement.

Nurses' experiences of compassionate care in the palliative pathway.

AIMS AND OBJECTIVES: The aim was to explore how nurses experience compassionate care for patients with cancer and family caregivers in different phases of the palliative pathway. BACKGROUND: Compassion is fundamental to palliative care and viewed as a cornerstone of high-quality care provision. Healthcare authorities emphasize that patients should have the opportunity to stay at home for as long as possible. There are, however, care deficiencies in the palliative pathway. DESIGN: This study employed a qualitative design using focus groups and a hermeneutic approach. METHODS: Four focus groups with three to seven female nurses in each group were conducted in Mid-Norway in 2018. Nurses' ages ranged from 28-60 years (mean age = 45 years), and they were recruited through purposive sampling (N = 21). Compassionate care was chosen as the theoretical framework. Reporting followed the COREQ guidelines. RESULTS: Three themes expressing compassionate care related to different phases of the pathway were identified: (a) information and dialogue, (b) creating a space for dying and (c) family caregivers' acceptance of death. CONCLUSIONS: This study showed that it was crucial to create a space for dying, characterized by trust, collaboration, good relationships, empathy, attention, silence, caution, slowness, symptom relief and the absence of noise and conflict. RELEVANCE TO CLINICAL PRACTICE: The quality of compassion possessed by individual practitioners, as well as the overall design of the healthcare system, must be considered when creating compassionate care for patients and their family caregivers. Nursing educators and health authorities should pay attention to the development of compassion in education and practice. Further research should highlight patients' and family caregivers' experiences of compassionate care and determine how healthcare systems can support compassionate care.

Patients' narratives of their patient participation in the myocardial infarction pathway.

AIM: To explore how patients in areas without local percutaneous coronary intervention (PCI) facilities experience patient participation in different phases of the myocardial infarction pathway. BACKGROUND: Acute treatment of myocardial infarction often involves PCI. In Norway, this treatment is centralized at certain hospitals; thus, patients often require long-distance transportation and experience frequent hospital transfers. Short hospital stays, transfers between hospitals and the patient's emotional state pose challenges to promoting patient participation. DESIGN: A qualitative design with a narrative approach. METHODS: Participants were recruited through purposive sampling. Eight men and two women were interviewed in 2016. FINDINGS: Four themes related to the patients' experiences at the beginning, middle and end of the pathway were identified: (a) Lack of verbal communication in the acute phase; (b) trust in healthcare professionals and treatment; (c) lack of participation and coordination at discharge; and (d) shared decision-making in rehabilitation. The findings showed how the patients moved from a low level of patient participation in the acute phase to a high level of patient participation in the rehabilitation phase. CONCLUSION: This is the first study to explore patient participation in different phases of the myocardial infarction pathway. We argue that individual plans for information and patient participation are important to improve patient involvement in an earlier stage of the pathway. Further research from a healthcare professional perspective can be valuable to understand this topic. IMPACT: This study gives new insight that can be valuable for healthcare professionals in implementing patient participation throughout the pathway.

High-Intensity Interval Training in Patients With Heart Failure With Reduced Ejection Fraction.

BACKGROUND: Small studies have suggested that high-intensity interval training (HIIT) is superior to moderate continuous training (MCT) in reversing cardiac remodeling and increasing aerobic capacity in patients with heart failure with reduced ejection fraction. The present multicenter trial compared 12 weeks of supervised interventions of HIIT, MCT, or a recommendation of regular exercise (RRE). METHODS: Two hundred sixty-one patients with left ventricular ejection fraction ≤35% and New York Heart Association class II to III were randomly assigned to HIIT at 90% to 95% of maximal heart rate, MCT at 60% to 70% of maximal heart rate, or RRE. Thereafter, patients were encouraged to continue exercising on their own. Clinical assessments were performed at baseline, after the intervention, and at follow-up after 52 weeks. Primary end point was a between-group comparison of change in left ventricular end-diastolic diameter from baseline to 12 weeks. RESULTS: Groups did not differ in age (median, 60 years), sex (19% women), ischemic pathogenesis (59%), or medication. Change in left ventricular end-diastolic diameter from baseline to 12 weeks was not different between HIIT and MCT (P=0.45); left ventricular end-diastolic diameter changes compared with RRE were -2.8 mm (-5.2 to -0.4 mm; P=0.02) in HIIT and -1.2 mm (-3.6 to 1.2 mm; P=0.34) in MCT. There was also no difference between HIIT and MCT in peak oxygen uptake (P=0.70), but both were superior to RRE. However, none of these changes was maintained at follow-up after 52 weeks. Serious adverse events were not statistically different during supervised intervention or at follow-up at 52 weeks (HIIT, 39%; MCT, 25%; RRE, 34%; P=0.16). Training records showed that 51% of patients exercised below prescribed target during supervised HIIT and 80% above target in MCT. CONCLUSIONS: HIIT was not superior to MCT in changing left ventricular remodeling or aerobic capacity, and its feasibility remains unresolved in patients with heart failure. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00917046.

Gender differences in the assessment and treatment of myocardial infarction. / Kjønnsforskjeller i utredning og behandling av hjerteinfarkt.

BACKGROUND: Previous studies have shown that there are gender-related differences in the assessment and treatment of myocardial infarction, despite international guidelines that prescribe identical treatment for women and men. We investigated whether these differences occurred in Norway. MATERIAL AND METHOD: All patients admitted to Norwegian hospitals with myocardial infarction from 1 January 2013 to 31 December 2014 and registered in the Norwegian Myocardial Infarction Registry were included. Data from the registry were used to analyse differences in the assessment, treatment, complications and survival of women and men in different age groups. RESULTS: A total of 26 447 myocardial infarctions were registered in the Norwegian Myocardial Infarction Registry in the period 2013 ­ 2014. Fewer women than men were assessed by means of coronary angiography. Percutaneous coronary intervention (PCI) was used to virtually the same extent for both genders if coronary stenosis was found. Women were recommended secondary prophylactic medication to a lesser extent than men. There were no major differences between men and women in the incidence of complications in the course following myocardial infarction or in survival. INTERPRETATION: Fewer women than men suffering acute myocardial infarction were assessed by means of coronary angiography, and women were recommended secondary prophylactic medication less often than men. The reason for the gender differences is not known, but comorbidity and a potentially greater risk of adverse reactions in women may be contributory factors. The different views of doctors providing treatment may also play a part.

Emergency hospitalisation in six municipalities in the Sunnmøre district.

BACKGROUND: Providing better and more cost-efficient health services is a goal for health policy. It is seen as desirable to provide health services close to the patient's home. From 2016, all municipalities must provide emergency hospitalisation (EH). The objective of this study was to develop experience-based knowledge from medium-sized municipalities that operate such services without any inter-municipal collaboration. MATERIAL AND METHOD: Focus-group interviews with 25 health workers who are responsible for this service in six small and medium-sized municipalities in Western Norway were conducted in the autumn of 2013 and the spring of 2014. Additional information on bed utilisation was also collected. RESULTS: The informants reported that their municipalities had chosen emergency hospitalisation as a measure to reinforce the professional communities in the nursing homes. They described this as a patient-centred and flexible treatment option. In their opinion, the programme would help ensure competence enhancement in the municipalities. Bed utilisation increased from the introduction of EH until 31 August 2014. INTERPRETATION: The health workers reported that emergency hospitalisation in the municipality fulfilled key intentions of the Interaction Reform, in terms of providing treatment to patients locally and close to their homes.

Coronary artery occlusions diagnosed by transthoracic Doppler.

BACKGROUND: Our aim was to assess whether anterograde flow velocities in septal perforating branches could identify an occluded contralateral coronary artery, and to assess the feasibility and accuracy of diagnosing occlusions in the three main coronary arteries by the combined use of several noninvasive parameters indicating collateral flow. METHODS: A total of 108 patients scheduled for coronary angiography because of chest pain or acute coronary syndromes were studied using transthoracic Doppler echocardiography. RESULTS: Anterograde peak diastolic flow velocities (pDV) in septal perforating branches were higher in patients with angiographic occluded contralateral artery compared with corresponding velocities in patients without significant disease in the contralateral artery (0.80 ± 0.31 m/sec versus 0.37 ± 0.13 m/sec, p < 0.001). Receiver operating characteristic curve showed pDV ≥ 0.57 m/sec to be the optimal cutoff value to identify occluded contralateral artery, with a sensitivity of 79% and a specificity of 69%. Demonstration of at least one positive parameter (retrograde flow in main coronary arteries, reversed flow in septal perforating and left circumflex marginal branches, pDV ≥ 0.57 m/sec, or demonstration of other epicardial or intramyocardial collaterals) indicating collateral flow to an occluded main coronary artery had sensitivity, specificity, positive and negative predictive value of 89%, 94%, 63%, and 99%, respectively, for detection of a coronary occlusion. With this combined use of several parameters, 25 of 28 coronary occlusions were identified. CONCLUSIONS: By investigating several parameters indicating collateral flow, we were able to identify most of the main coronary occlusions in the patient cohort. Furthermore, our study demonstrated that coronary artery occlusions may result in complex and diverging coronary pathophysiology depending on which coronary artery segment is occluded and the extent of accompanying coronary artery disease. TRIAL REGISTRATION: ClinicalTrials.gov number NTC00281346.

Myocardial infarction in Norway in 2013.

BACKGROUND: The Norwegian Myocardial Infarction Registry was established in 2012 as a national quality registry. This first report from the registry presents the number of myocardial infarctions, the treatment provided and the 30-day mortality rate for myocardial infarctions admitted to Norwegian hospitals. MATERIAL AND METHOD: All patients with myocardial infarction admitted to Norwegian hospitals in 2013 and recorded in the Norwegian Myocardial Infarction Registry are included. The number of myocardial infarctions, patient characteristics and their treatment are indicated for myocardial infarctions with and without ST-segment elevation on ECG (STEMI and nSTEMI). The 30-day mortality is calculated for each health region. RESULTS: In 2013, a total of 13,043 myocardial infarctions in 12,336 patients were recorded in the Norwegian Myocardial Infarction Registry. Altogether 3,658 (28%) of the infarctions were classified as STEMI and 9,188 (70%) as nSTEMI. The average age at the time of the infarction was 68.1 years for men and 75.9 years for women. Percutaneous coronary intervention was performed for a total of 2,798 (77%) ST-segment elevation myocardial infarctions, whereas the corresponding number for nSTEMI was 3,179 (35%). The 30-day mortality in the entire infarction population was 10% (< 60 years: 2%, 60-69 years: 4%, 70-79 years: 9%, ≥ 80 years: 20%). We found no differences in mortality between health regions or between men and women. INTERPRETATION: This first report from the Norwegian Myocardial Infarction Registry shows that the treatment service is functioning well for most patients. Secondary prophylaxis using drug therapy and increased use of invasive examination of patients with nSTEMI appear to be areas for improvement.

The Prevalence of Bradycardia 12 Years After Roux-en-Y Gastric Bypass for Severe Obesity.

PURPOSE: The aim was to describe the frequency of bradycardia 12 years after Roux-en-Y gastric bypass (RYGB), relations to weight loss, patient characteristics, and the clinical impact. MATERIALS AND METHODS: The BAROPS study is a prospective observational study of patients who had follow-up > 10 years after RYGB. Patients with heart rate (HR) ≤ 50 bpm were compared to patients with HR > 50 bpm. RESULTS: After a mean observation period of 12 years, 32 of 546 patients (6%) had a HR ≤ 50 with a mean HR of 47.0 (2.8) bpm. The comparator group (192 patients) had a mean HR of 66.4 (10.2) bpm (p < 0.001). A higher proportion of the bradycardic vs. non-bradycardic patients (18.8% vs. 7.8% at baseline (p = 0.05) and 18.8% vs. 5.2% at end of study (p = 0.006)) used beta-blockers. Both groups had a significant reduction in heart rate from pre-surgery to end of observation. Percent total weight loss from baseline was negatively related to heart rate (p < 0.001), and smoking was positively related to heart rate (p = 0.014). Change in BMI from pre-surgery (p < 0.001) and hypertension at pre-surgery (p = 0.006) were significant predictors of change in heart rate. The only predictor of HR ≤ 50 was the use of beta-blockers (p = 0.010). There were no difference in bradycardia-related symptoms. CONCLUSION: Six percent of patients had HR ≤ 50 bpm 12 years after RYGB, but there was no increased bradycardia-related symptoms in these patients. RYGB induced a significant reduction in HR, and heart rate and changes in heart rate 12 years after RYGB were related to the amount of weight loss.

Mapping interaction quality for nursing and medical students in primary care placement in municipal emergency care units: a systematic observational study.

Introduction: Primary care placement for nursing and medical students is vital for developing the competence to accommodate the increasing number of patients with multimorbid and complex conditions. Prior studies have suggested that interaction quality in primary care placement empowers learning. However, research mapping interaction quality in primary care placements in municipal emergency care units is lacking. This study aimed to systematically map interaction quality for nursing and medical students in primary care placement in two municipal emergency care units. Materials and methods: This study adopted a systematic descriptive observational design. Systematic observations (n = 201 cycles) of eight nursing students (n = 103 cycles) and six medical students (n = 98 cycles) were used to map interaction quality across six learning situations between March and May 2019. Observations were coded using the Classroom Assessment Scoring System-Secondary (CLASS-S). Data were analyzed using descriptive statistics and Spearman correlations. Results: Interaction quality is described in three domains: (I) emotional support, (II) framework for learning, and (III) instructional support, and the overall measure, student engagement. The results indicated middle-quality interactions in the emotional and instructional support domains and high quality in the framework for learning domain and student engagement. Correlations exhibited similar patterns and ranged from non-significant to strong correlations. Conclusion: The interaction qualities indicated a generally positive and supportive learning environment contributing to nursing and medical students' learning and active participation in work tasks related to their professional roles. Thus, this new form for primary care placement for nursing and medical students in the municipal emergency care units was found to be a positive learning arena. These results may enhance nursing and medical education programs in countries with similar health services and education. Health education, supervisors, peers, and others contributing to students' learning should recognize which interaction qualities may affect learning and how to improve quality, thus affecting supervisors' approach to training students. While the CLASS-S showed potential for mapping interaction qualities for nursing and medical students in primary care placement in municipal emergency care units, further studies are needed to validate the CLASS-S for use in clinical placement settings.

Normality and compassionate care: experiences from advanced cancer patients in their last time at home.

BACKGROUND: Many cancer patients prefer to receive palliative treatment at home, as it allows them to be in a familiar and comfortable environment. Integrating Advance Care Planning (ACP) into routine practice in primary healthcare helps patients and their relatives prepare for end-of-life (EoL) care in accordance with patients' preferences. This includes the option to spend their final days at home if desired. The aim of this study was to gain insights from experiences of advanced seriously ill cancer patients at home while receiving palliative treatment and being engaged in ACP within primary healthcare settings. METHOD: This study employed a qualitative design, utilizing individual, semi-structured interviews that were analysed through reflexive thematic analysis, employing an abductive approach with a latent-level focus. The study included interviews with 12 participants with cancer who were receiving palliative care, had an estimated lifetime under 3 months, and had undergone an organized ACP approach in primary healthcare, documented with a palliative plan. RESULTS: Participants emphasized the importance of (1) Preserving normality at home, maintaining a sense of routine, comfort, and familiarity in the face of present and future challenges. The top obstacles for success identified by participants included (1a) The challenge of deterioration and the dual aspects of (1b) The value and burden of family caregivers. Cancer treatment placed a significant demand on patients due to side effects. Family caregivers played a crucial role for participants, providing support in daily life and serving as a key factor in the overall decision to which extend they are able to involve in support and care at home in the future. (2) Compassionate health care personnel (HCP) made a difference by fostering a culture of understanding participants' concerns, fears, and preferences, which was a key element that built and maintained trust for the participants. (3) Preparing for the future, especially EoL discussions initiated by healthcare personnel, was deemed important but, at times, uncomfortable for participants as it confronted them with reality. Guidance from ACP provided them with a sense of certainty and control. CONCLUSION: Preserving normality at home, along with the desire to stay at home for as long as possible, is a crucial goal for advanced cancer patients. Consistent professional communication and care in primary healthcare play a key role in building and maintaining trust, as well as fostering a sense of certainty and control for the participants.

Exercise training and high-sensitivity cardiac troponin-I in patients with heart failure with reduced ejection fraction.

AIMS: The aims of this sub-study of the SMARTEX trial were (1) to evaluate the effects of a 12-week exercise training programme on serum levels of high sensitivity cardiac troponin I (hs-cTnI) in patients with moderate chronic heart failure (CHF), in New York Heart Association class II-III with reduced ejection fraction (HFrEF) and (2) to explore the associations with left ventricular remodelling, functional capacity and filling pressures measured with N-terminal pro brain natriuretic peptide (NT-proBNP). METHODS AND RESULTS: In this sub-study, 196 patients were randomly assigned to high intensity interval training (HIIT, n = 70), moderate continuous training (MCT, n = 59) or recommendation of regular exercise (RRE), (n = 67) for 12 weeks. To reveal potential difference between structured intervention and control, HIIT and MCT groups were merged and named supervised exercise training (SET) group. The RRE group constituted the control group (CG). To avoid contributing factors to myocardial injury, we also evaluated changes in patients without additional co-morbidities (atrial fibrillation, hypertension, diabetes mellitus, and chronic obstructive pulmonary disease). The relationship between hs-cTnI and left ventricular end-diastolic diameter (LVEDD), VO2peak, and NT-proBNP was analysed by linear mixed models. At 12 weeks, Hs-cTnI levels were modestly but significantly reduced in the SET group from median 11.9 ng/L (interquartile ratio, IQR 7.1-21.8) to 11.5 ng/L (IQR 7.0-20.7), P = 0.030. There was no between-group difference (SET vs. CG, P = 0.116). There was a numerical but not significant reduction in hs-cTnI for the whole population (P = 0.067) after 12 weeks. For the sub-group of patients without additional co-morbidities, there was a significant between-group difference: SET group (delta -1.2 ng/L, IQR -2.7 to 0.1) versus CG (delta -0.1 ng/L, IQR -0.4 to 0.7), P = 0.007. In the SET group, hs-cTnI changed from 10.9 ng/L (IQR 6.0-22.7) to 9.2 ng/L (IQR 5.2-20.5) (P = 0.002), whereas there was no change in the CG (6.4 to 5.8 ng/L, P = 0.64). Changes in hs-cTnI (all patients) were significantly associated with changes in; LVEDD, VO2peak, and NT-proBNP, respectively. CONCLUSIONS: In patients with stable HFrEF, 12 weeks of structured exercise intervention was associated with a modest, but significant reduction of hs-cTnI. There was no significant difference between intervention group and control group. In the sub-group of patients without additional co-morbidities, this difference was highly significant. The alterations in hs-cTnI were associated with reduction of LVEDD and natriuretic peptide concentrations as well as improved functional capacity.

Cardiovascular risk of high- versus moderate-intensity aerobic exercise in coronary heart disease patients.

BACKGROUND: Exercise performed at higher relative intensities has been found to elicit a greater increase in aerobic capacity and greater cardioprotective effects than exercise at moderate intensities. An inverse association has also been detected between the relative intensity of physical activity and the risk of developing coronary heart disease, independent of the total volume of physical activity. Despite that higher levels of physical activity are effective in reducing cardiovascular events, it is also advocated that vigorous exercise could acutely and transiently increase the risk of sudden cardiac death and myocardial infarction in susceptible persons. This issue may affect cardiac rehabilitation. METHODS AND RESULTS: We examined the risk of cardiovascular events during organized high-intensity interval exercise training and moderate-intensity training among 4846 patients with coronary heart disease in 3 Norwegian cardiac rehabilitation centers. In a total of 175 820 exercise training hours during which all patients performed both types of training, we found 1 fatal cardiac arrest during moderate-intensity exercise (129 456 exercise hours) and 2 nonfatal cardiac arrests during high-intensity interval exercise (46 364 exercise hours). There were no myocardial infarctions in the data material. Because the number of high-intensity training hours was 36% of the number of moderate-intensity hours, the rates of complications to the number of patient-exercise hours were 1 per 129 456 hours of moderate-intensity exercise and 1 per 23 182 hours of high-intensity exercise. CONCLUSIONS: The results of the current study indicate that the risk of a cardiovascular event is low after both high-intensity exercise and moderate-intensity exercise in a cardiovascular rehabilitation setting. Considering the significant cardiovascular adaptations associated with high-intensity exercise, such exercise should be considered among patients with coronary heart disease.

Intensive care unit nurses' perceptions of patient participation in the acute phase of chronic obstructive pulmonary disease exacerbation: an interview study.

AIM: To report a study conducted to explore intensive care unit nurses' perceptions of patient participation in the acute phase of chronic obstructive pulmonary disease exacerbation. BACKGROUND: An acute exacerbation is a life-threatening situation, which patients often consider to be extremely frightening. Healthcare personnel exercise considerable power in this situation, which challenges general professional notions of patient participation. DESIGN: Critical discourse analysis. METHODS: In the autumn of 2009, three focus group interviews with experienced intensive care nurses were conducted at two hospitals in western Norway. Two groups had six participants each, and one group had five (N = 17). The transcribed interviews were analysed by means of critical discourse analysis. FINDINGS: The intensive care nurses said that an exacerbation is often an extreme situation in which healthcare personnel are exercising a high degree of control and power over patients. Patient participation during exacerbation often takes the form of non-involvement. The participating nurses attached great importance to taking a sensitive approach when meeting patients. The nurses experienced challenging ethical dilemmas. CONCLUSION: This study shows that patient participation should not be understood in universal terms, but rather in relation to a specific setting and the interactions that occur in this setting. Healthcare personnel must develop skill, understanding, and competence to meet these challenging ethical dilemmas. A collaborative inter-professional approach between physicians and nurses is needed to meet the patients' demand for involvement.