European journal of anaesthesiology. Supplement
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Eur J Anaesthesiol Suppl · Jan 2008
ReviewEffects of catecholamines on cerebral blood vessels in patients with traumatic brain injury.
Data on the cerebrovascular effects of catecholamines after head injury are difficult both to interpret and to compare. Diverse parameters with regard to brain trauma animal models, methods of determining the effects on the cerebral blood flow and metabolism and choice of end-points have been used. Many studies investigate the cerebrovascular effects of catecholamines over a range of cerebral perfusion pressures above the range recommended by current guidelines. ⋯ For all other catecholamines and related substances there are insufficient data on the cerebrovascular effects after head injury. This suggests that norepinephrine may be the catecholamine that is the most suitable substance to maintain or restore adequate cerebral perfusion. The data, however, are insufficient to formulate a guideline.
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Decision-making at the end-of-life in the United States has evolved over the last 50 yr, beginning with the development of the concept of brain death as a criterion for permitting patients who are in a state of 'irreversible coma' to be considered as 'dead' for purposes of ventilator withdrawal and organ transplantation. Since then, a firm consensus has emerged in American law and ethics that 'Patients have a virtually unlimited right to refuse any unwanted medical treatment, even if necessary for life itself.' With regard to patients who are unable to make decisions for themselves, both Europe and the United States are converging toward a view that respects a role for surrogates in decision-making while recognizing the need to limit their authority. Beyond decisions to withdraw and withhold treatments, both the United States and Europe are experimenting with active hastening of the dying process through euthanasia and physician-assisted suicide. In the author's opinion, the next big question to be addressed in end-of-life decision-making is 'Just how bad does the neurological condition and prognosis need to be before it is acceptable to allow a decision to withdraw life support'? Although the practices described here have wide acceptance throughout the United States and Europe, the worldwide emergence of religious fundamentalism and the associated vitalistic view about the sanctity of life may result in significant changes over the next few decades.
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Eur J Anaesthesiol Suppl · Jan 2008
Role of the specialized neuro intensive care nurse in neuroscience research.
It is widely acknowledged that the quality of research is greatly improved when nurses are involved at the investigators' site. Many papers highlight the knowledge, skills and expertise required by nurses for the conduct of trials. The known skills include reliability, organization, communication, motivation, self-discipline and critical thought. ⋯ The rise in popularity of the role and the publication of an employment brief for clinical research nurses by the Royal College of Nursing (RCN) and the UK Clinical Research Collaboration (UKCRC) publication on 'Developing the best research professionals' has readdressed this prior imbalance; recognizing in detail their role, knowledge, skills, expertise with appropriate grading and remuneration. The role of the clinical research nurse in the neuroscience setting is equally as diverse with the added requirement of a higher level of knowledge and understanding of the pathophysiology of neurological diseases and specific skills required to work in the intensive care environment. This paper will attempt to explore the role of the specialized neurosciences intensive care nurse and the relationship with high-quality neuroscience research.
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Managing end-of-life care can be difficult because of the particular nature of intensive care support, which can separate the biological and the biographical aspects of life. Artificial organ support can temporarily delay death but, at the same time, may fail to restore a quality of life that the patient judges acceptable. ⋯ Unfortunately, neither the rule of the five Cs nor the careful use of moral principles in order to promote the patients' dignity can assure a universally acceptable decision. A reasonable level of 'moral certainty', however, might be achieved using a deliberative approach, which provides for the inclusion of all the different subjects involved in the decision-making process (patient, family, doctors, nurses and other carers), in order to reach the best possible decision in a specific situation.
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Eur J Anaesthesiol Suppl · Jan 2008
Legal aspects of end-of-life decisions in Italy: the penal relevance of the limitation of treatment in the terminally ill and the problem of causality by omission. The legal puzzle of end-of-life care in Italy: is therapeutic limitation in the terminally ill patients a crime of omission liable to prosecution?
The interruption of life support poses different problems for he who interrogates himself regarding the possible juridical role of omissible behaviour or activities by part of the physician when dealing with end-of-life interventions within the boundary of life and death. The present contribution proposes to trace the coordinates necessary to answer the main query regarding the obligations which may be incumbent on the physician. ⋯ The laws that discipline crimes against life and individual integrity must be interpreted while keeping in mind that the objective of maintaining the patient in life must be integrated with the control of suffering and the guarantee of a dignified death. When identifying the principles which have to inspire the decisions during 'borderline or boundary situations', it is highlighted the way the physician has to resort to a just equilibrium between benefit, which can be reasonably expected, and sacrifice, which should be imposed, taking into consideration the criteria of good clinical practice, among which attention to the patient's will must be taken into consideration.