Yes / While death is universal, reactions to death and ways of dealing with the dead body are hugely diverse, and archaeological research reveals numerous ways of dealing with the dead through time and across the world. In this paper, findings are presented which not only demonstrate the power of archaeology to promote and aid discussion around this difficult and challenging topic, but also how our approach resulted in personal growth and professional development impacts for participants. In this interdisciplinary pilot study, archaeological case studies were used in 31 structured workshops with 187 participants from health and social care backgrounds in the UK, to explore their reactions to a diverse range of materials which documented wide and varied approaches to death and the dead. Our study supports the hypothesis that the past is a powerful instigator of conversation around challenging aspects of death, and after death care and practices: 93% of participants agreed with this. That exposure to archaeological case studies and artefacts stimulates multifaceted discourse, some of it difficult, is a theme that also emerges in our data from pre, post and follow-up questionnaires, and semi-structured interviews. The material prompted participants to reflect on their biases, expectations and norms around both treatment of the dead, and of bereavement, impacting on their values, attitudes and beliefs. Moreover, 87% of participants believed the workshop would have a personal effect through thinking differently about death and bereavement, and 57% thought it would impact on how they approached death and bereavement in their professional practice. This has huge implications today, where talk of death remains troublesome, and for some, has a near-taboo status – ‘taboo’ being a theme evident in some participants’ own words. The findings have an important role to play in facilitating and normalising discussions around dying and bereavement and in equipping professionals in their work with people with advanced illness. / The project ‘Continuing Bonds: Exploring the meaning and legacy of death through past and contemporary practice’ was funded by the Arts and Humanities Research Council, Grant Number AH/M008266/1. / Research Development Fund Publication Prize Award winner, Dec 2020.

Bakgrund: Palliativ vård i livets slutskede innebär lindring av fysiskt, psykiskt, socialt och existentiellt lidande för patienter med ett sjukdomstillstånd som inte går att bota. Här är målet att utifrån en holistisk och humanistisk människosyn främja välbefinnande och förbättra livskvalitet för den sista livstiden som patienter har kvar. Vårdformen är en avgörande del av sjuksköterskors arbetsuppgifter och det krävs att de besitter kompetens och färdigheter för vårdande av patienter och stödjande av anhöriga på bästa möjliga sätt. Patienter och anhöriga uttrycker både positiva och negativa erfarenheter av den vård som ges. Syfte: Syftet var att skapa en översikt av sjuksköterskors erfarenheter av palliativ vård i livets slutskede. Metod: En allmän litteraturöversikt, där tolv artiklar användes varav nio var kvalitativa, två var kvantitativa och en hade mixad metod. Utifrån likheter och skillnader i syften, metoder och resultat granskades och analyserades artiklarna. Resultat: Följande fyra teman identifierades efter analysen av artiklarna: Att möta patienter, Att möta anhöriga, Att förhålla sig till kunskaper och erfarenheter samt Att möta utmaningar vid vård i livets slutskede. Slutsats: Ibland erfor sjuksköterskor komplexa utmaningar gällande bland annat brist på kunskaper, erfarenheter och emotionella utmaningar. Därför krävs en förbättring av dessa för att ge patienter en högkvalitativ vård i livets slutskede. / Background: Palliative end of life care aims to alleviate physical, psychological, social, and existential suffering for patients with an incurable disease. The goal here is to offer care based on a holistic and humanistic approach, promote well-being, and improve the quality of life for the patients last days. This form of care is a crucial part of the nurses’ duty, and it is therefore required that they possess the necessary competence and skills for caring for patients and supporting relatives in the best possible way. Patients and relatives express both positive and negative experiences of the care provided. Purpose: To create an overview of nurses’ experiences of palliative care at end of life. Method: A general literature review, where twelve articles were used of which nine were qualitative, two were quantitative and one was a mixed method. Based on the similarities and differences in purpose, method and results, the articles were reviewed and analysed. Results: The following themes were identified after the analysis of the articles: To meet patients, To meet relatives, To relate to knowledge and experiences and To meet challenges in end-of-life care. Conclusion: Nurses experience complex challenges in end-of-life care such as lack of knowledge and emotional challenges. An improvement in these areas is therefore necessary to provide patients with high-quality end-of-life care.

No description available.

Bakgrund: Palliativ sedering avser en avsiktlig sänkning av medvetandegraden hos en patient som befinner sig i livets slutskede och har outhärdliga symtom. Behandlingen ges av ett multiprofessionellt team där sjuksköterskornas uppgift är att iordningställa och administrera ordinerade läkemedel samt utvärdera effekt och upplevelse av behandlingen. Förutom de praktiska kraven som ställs på sjuksköterskorna medför palliativ sedering även krav på förmåga till reflektion och kritiskt såväl som etiskt tänkande. Syfte: Syftet med denna litteraturöversikt var att undersöka sjuksköterskors erfarenheter av palliativ sedering. Metod: En litteraturöversikt genomfördes och tio vetenskapliga artiklar valdes ut till analys efter litteratursökningar i databaserna CINAHL Complete och PubMed. Resultat: Tre teman med underteman identifierades. God palliativ vård inkluderade att ge palliativ sedering för att erbjuda patient, närstående och personal ett fridfullt avslut och för att uppfylla patientens önskningar. Palliativ sedering och eutanasi kunde vara svåra att skilja från varandra och sjuksköterskorna hade en känsla av att palliativ sedering påskyndande patientens död. Att arbeta i team var en viktig faktor för hur sjuksköterskor upplevde arbetet med palliativ sedering. Det underlättade om beslut om sedering togs gemensamt och olika former av stöd från teamet var betydelsefullt för sjuksköterskor under arbetet med palliativ sedering. Diskussion: Resultaten diskuterades utifrån Jean Watsons omvårdnadsteori om mänsklig omsorg och tre av hennes caritasprocesser Ett kärleksfullt och omsorgsfullt sinnelag, Utrymme för känslor och Hjälpsamma och tillitsfulla omsorgsrelationer. / Background: Palliative sedation refers to an intentional lowering of consciousness of a patient in the end of life who is suffering from unbearable symptoms. The care is performed by a multi-professional team where the nurses’ duties are to prepare, administer and evaluate prescribed pharmaceuticals. In addition to the practical skills required by the nurses, this treatment also requires ability to reflect as well as critical and ethical thinking. Aim: The aim of this literature review was to explore nurses’ experiences of palliative sedation. Method: A literature review was conducted and ten scientific articles were chosen for analysis. Literature searches were made in the databases CINAHL Complete and PubMed. Results: Three themes with subthemes were identified. Good palliative care included giving palliative sedation to offer patients, families and the staff a peaceful ending and to meet the patient’s wishes. Palliative sedation and euthanasia could be difficult to separate and there was a sense that palliative sedation hastened the patient’s death. Teamwork was an important factor for how nurses experienced working with palliative sedation. It was easier if the decision to sedate was taken jointly and support within the team was meaningful to nurses during their work with palliative sedation. Discussion: The results were discussed in relation to Jean Watson’s Theory of Human Caring and the three caritas processes The practice of loving kindness and equanimity, Promotion and acceptance of the expression of positive and negative feelings and Developing and sustaining a helping-trusting caring relationship.

The purpose of this study was to investigate the process used by Haitians and Haitian Americans who must make healthcare decisions for a terminally ill family member. There is a large population of Haitians and Haitian Americans in South Florida and there has been no research regarding their decision-making process about end-of-life healthcare. The study design was descriptive, applying constructivist grounded theory methodology. Data were collected using semi-structured, face-to-face qualitative interviews. Data analysis and collection occurred simultaneously. Participants (n=12) were purposefully recruited, with 11 from a single, faith-based community. The findings resulted in six concepts: (1) imminent or actual death, (2) disrupted unity, (3) managing disrupted unity, (4) consequences, (5) restoring unity, and (6) creating memories you can live with. These six concepts, elaborated by an additional 17 dimensions, were incorporated into a process model relating to the cultural value of communal unity to the end-of-life decision-making process. The implications of this study include a need to improve the congruence between the nursing care provided at this vulnerable time and the cultural values of this population. Successful access to this population through the structure of the faith-based community points the way to increasing access to appropriate end-of-life healthcare. Practice implications informed by caring science include the importance of nurses’ coming to know the family and listening to the unique care needs. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2015. / FAU Electronic Theses and Dissertations Collection

The course of endstage renal disease (ESRD) and receiving hemodialysis (HD) treatment is complex and filled with uncertainty. Part of this illness experience includes making end-of-life (EOL) care decisions. Many families are unprepared to make such decisions. Advance care planning (ACP) creates an excellent context for laying the groundwork for these emotionally charged conversations. Hemodialysis patients, their families and healthcare providers (HCPs) are in a unique position to begin the ACP process early in the illness trajectory, revisiting it when the patient’s health status, prognosis and treatment modality changes. To date, little research has focused directly on how families experience ACP conversations in the context of ESRD or HD. The purpose of this study was to explore family members’ experiences of participating in a facilitated ACP conversation with the HD patient. This approach recognizes and privileges the family’s role in the illness trajectory of ESRD and validates that they too are HCPs’ clients. Five families, consisting of the HD patient and one family member, who went through the ACP process were interviewed along with an ACP facilitator from the nephrology program. This focused ethnographic study applied the theoretical perspective of postmodernist critical theory to derive and analyze data from in-depth semi-structured interviews. Findings revealed a detailed description of the ACP process that included timing, readiness to acknowledge the potentiality of death, facing mortality, and finding meaning in the illness experience. As families started to deconstruct their experiences, they shared stories of communication breakdown, highlighting the complexities of their relationships with HCPs. Understanding the factors that potentially contribute to HD patients’, their families’ and the renal staff’s discomfort with death were analyzed. The study findings provide important direction for HCPs about how families make ACP decisions, how they perceive the ACP process, and what they identify as their EOL care needs and wishes. Failure to implement ACP as part of an EOL care program means that death will continue to be denied and clients’ EOL care needs will remain un-addressed. In order for ACP to be effective on HD units, sustainable resources are essential for patients, their families and HCPs.

The course of endstage renal disease (ESRD) and receiving hemodialysis (HD) treatment is complex and filled with uncertainty. Part of this illness experience includes making end-of-life (EOL) care decisions. Many families are unprepared to make such decisions. Advance care planning (ACP) creates an excellent context for laying the groundwork for these emotionally charged conversations. Hemodialysis patients, their families and healthcare providers (HCPs) are in a unique position to begin the ACP process early in the illness trajectory, revisiting it when the patient’s health status, prognosis and treatment modality changes. To date, little research has focused directly on how families experience ACP conversations in the context of ESRD or HD. The purpose of this study was to explore family members’ experiences of participating in a facilitated ACP conversation with the HD patient. This approach recognizes and privileges the family’s role in the illness trajectory of ESRD and validates that they too are HCPs’ clients. Five families, consisting of the HD patient and one family member, who went through the ACP process were interviewed along with an ACP facilitator from the nephrology program. This focused ethnographic study applied the theoretical perspective of postmodernist critical theory to derive and analyze data from in-depth semi-structured interviews. Findings revealed a detailed description of the ACP process that included timing, readiness to acknowledge the potentiality of death, facing mortality, and finding meaning in the illness experience. As families started to deconstruct their experiences, they shared stories of communication breakdown, highlighting the complexities of their relationships with HCPs. Understanding the factors that potentially contribute to HD patients’, their families’ and the renal staff’s discomfort with death were analyzed. The study findings provide important direction for HCPs about how families make ACP decisions, how they perceive the ACP process, and what they identify as their EOL care needs and wishes. Failure to implement ACP as part of an EOL care program means that death will continue to be denied and clients’ EOL care needs will remain un-addressed. In order for ACP to be effective on HD units, sustainable resources are essential for patients, their families and HCPs.

Par une approche analytique, cette étude en éthique clinique a examiné la problématique de la demande d’assistance médicalisée pour mourir formulée dans le cadre des soins de fin de vie. Partant du fait que cette demande sollicite les soignants dans leur savoir et leur savoir-faire, surtout dans leur savoir-être, cette étude rend d’abord compte d’un fait : bon gré mal gré l’interdit de l’euthanasie par la loi et la déontologie médicale, ainsi que le débat contradictoire à son sujet qui dure déjà voici quelques décennies, il arrive de temps à autres que les soignants œuvrant en soins de fin de vie, soient confrontés à une demande d’assistance médicalisée pour mourir. Cette demande qui émane de certaines personnes en fin de vie et / ou de leurs proches, est souvent source de malaise pour les soignants à l’endroit de qui elle crée des défis majeurs et fait naître des dilemmes éthiques importants. Plus particulièrement, cette demande interroge toujours la finalité même des soins de fin de vie : est-ce que l’aide pour mourir fait partie de ces soins ? En réponse à cette question difficile, cette démarche réflexive de soignant chercheur en éthique montre qu’il est difficile de donner une réponse binaire en forme de oui / non ; il est difficile de donner une réponse d’application universalisable, et de définir une généralisable conduite à tenir devant une telle demande, car chaque cas est singulier et unique à son genre. Cette étude montre prioritairement que l’humanisation de la mort est à la fois un enjeu éthique important et un défi majeur pour notre société où la vie des individus est médicalisée de la naissance à la mort. En conséquence, parce que la demande d’assistance médicalisée pour mourir sollicite les soignants dans leur savoir et leur savoir-faire, cette étude montre toute l’importance de la réflexivité et de la créativité que doivent développer les soignants pour apporter une réponse constructive à chaque demande : une réponse humanisant le mourir et la mort elle-même, c’est-à-dire une réponse qui soit, sur le plan éthique, raisonnable et cohérente, une réponse qui soit sur le plan humain, porteuse de sens. D’où, outre l’axiologie, cette démarche réflexive montre que l’interdisciplinarité, la sémantique, l’herméneutique et les grilles d’analyse en éthique, constituent des outils réflexifs efficaces pouvant mieux aider les soignants dans leur démarche. Sur quelles bases éthiques, les soignants doivent-ils examiner une demande d’assistance médicalisée pour mourir, demande qui se présente toujours sous la forme d’un dilemme éthique? Cette question renvoie entre autre au fait que cette demande sollicite profondément les soignants dans leur savoir-être en relation des soins de fin de vie. Aussi bonnes les unes que les autres, qu’on soit pour ou contre l’euthanasie, plusieurs stratégies et méthodes d’analyse sont proposées aux soignants pour la résolution des conflits des valeurs et des dilemmes éthiques. Mais, ce n’est pas sur cette voie-là que cette étude invite les soignants. C’est plutôt par leur réflexivité et leur créativité, enrichies principalement par leur humanisme, leur expérience de vie, leur intuition, et secondairement par les différentes méthodes d’analyse, que selon chaque contexte, les soignants par le souci permanent de bien faire qui les caractérisent, trouveront toujours par eux-mêmes ce qui convient de faire dans l’ici et maintenant de chaque demande. C’est pourquoi, devant une demande d’assistance médicalisée pour mourir qui leur est adressée dans le cadre des soins de fin de vie, cette démarche éthique invite donc les soignants à être « des cliniciens créatifs, des praticiens réflexifs» . C’est pour cette raison, sur le plan proprement dit de la réflexion éthique, cette étude fait apparaître les repères de l’éthique humaniste de fin de vie comme bases axiologiques sur lesquels les soignants peuvent construire une démarche crédible pour répondre au mieux à cette demande. L’éthique humaniste de fin de vie située dans le sillage de l’humanisme médical , où l’humain précède le médical, renvoie au fait qu’en soins de fin de vie où émerge une demande d’aide à la mort, entre le demandeur de cette aide et le soignant, tout doit être basé sur une confiante relation d’homme à homme, même si du côté du soignant, son savoir être dans cette relation est aussi enrichi par sa compétence, ses connaissances et son expérience ou son savoir-faire. Basée sur l’humanité du soignant dans la démarche de soins, l’éthique humaniste de fin de vie en tant que pratique réflexive émerge de la créativité éthique du soignant lui-même et de l’équipe autour de lui ; et cette éthique se situe entre interrogation et transgression, et se définit comme une éthique « du vide-de-sens-à-remplir » dans un profond souci humain de bien faire. Car, exclue l’indifférence à la demande de l’assistance médicalisée pour mourir, son acceptation ou son refus par le soignant, doit porter sur l’humanisation de la mort. Cette dernière étant fondamentalement définie par rapport à ce qui déshumanise la fin de vie. / In an analytical approach, this clinical ethics study analyzes the issue of medical assistance request in dying in the context of end-of-life care. Runner of the fact that this request seeks the healthcare professionals in their knowledge and their know-how as well as in their knowledge-being in relation of the end-of-life care, this study gives first account of a fact: like it or not the prohibition of voluntary euthanasia by law and ethics, and the controversial debate about it in the last few decades, healthcare professionals involved in end-of-life care every so often are faced with a request of medical assistance to die. The request from some dying patients and / or their relatives often causes discomfort for the healthcare professionals to the point that it creates challenges and raises significant ethical dilemmas. Specifically, this request always challenges the very purpose of end-of-life care: Is medical assistance to dying part of the end-of-life care? In response to this difficult question, my reflexive ethics as medical researcher shows that: it is difficult to give a binary response yes / no. It is difficult to answer by a universalized application and define a generalized course of action, because each case is singular and unique to its kind. Accordingly, this study demonstrates the importance of reflexivity and creativity to be developed by the healthcare professionals to respond constructively to every request: a response humanizing dying and death itself. Hence, because the request of the assistance provided with medical care to die seeks the healthcare professionals in their knowledge and their know-how, in addition to axiology, this reflexive approach shows that interdisciplinarity, semantics, hermeneutics and analysis grids in ethics are effective reflexive tools that can better assist healthcare professionals in their approach. On what ethical basis, the healthcare professionals have to consider a request of medical assistance to dying, request that always presents itself as an ethical dilemma? This question sends back among others to the fact that this request seeks the healthcare professionals in their knowledge-being in relation of the end of life care. Several strategies and analysis methods, all equally good, are available to healthcare professionals for the resolution of ethical dilemmas. However, this is not the perspective this study invites healthcare professionals to discuss. Rather, it is through their reflexivity and creativity, enriched mainly by their humanity, life experience, intuition, and secondly helped by the different methods, that, according to each context, healthcare professionals in their ongoing effort to do right, that characterizes them, always find by themselves what is best to do here and now for each request. That is why, in front of a request of the assistance provided with medical care to die which is sent to them within the framework of the care of the end of life, this ethical approach thus invites the healthcare professionals to be “creative clinicians, reflexive practitioners " . Also, that is why, in terms of ethical reflection, this study exposes the framework of the humanistic ethics in end-of-life issues as axiological foundations on which health care providers can build their approach to best meet the request of medical assistance to die that they may receive in the context of end-of-life care. The humanistic ethics in end-of-life issues studied in the context of medical humanism , in which human precedes medical, refers to the fact that end-of-life care from which emerges a request for assisted death, between the one requesting such an assistance and the healthcare professional, everything must be based on a trusting human relationship between two persons, even if on the healthcare professional’s side, his personal and practical skills in this relationship are also enriched by his competence, knowledge and experience. Based on the humanity of the healthcare professionals in the medical process, humanistic ethics of end of life as a reflexive practice emerges from the ethical creativity of the healthcare professional himself and the team around him. This ethics is between query and transgression, and is defined as an ethics "vide-de-sens-à-remplir" in a deep human desire to do right. For, excluding indifference towards the request of medical assistance to dying, its acceptance or its rejection by the healthcare professionals must be a reasoned response and meaningful to the person who makes the request, whoever he may be, the dying patient or his relatives, and for the caregiver himself.

Over the last few years, policies have been introduced in the UK which aim to improve organ transplantation rates by changing the way that potential organ donors are treated before death. Patients incapacitated due to catastrophic brain injury may now undergo ante-mortem donor optimisation procedures to facilitate deceased organ donation. As I identify in this thesis, the most significant ethical and legal problem with these policies is that they are not based on what the patient would have chosen for themselves in the specific circumstances. The policies identify and treat patients meeting certain clinical criteria as a group rather than the individuals, with their own viewpoints, that the law on best interests requires. They equate registration on the Organ Donation Register with ante-mortem donor optimisation procedures being in their best interests, despite registrants having neither been informed about nor given consent to ante-mortem interventions. The overarching claim I make in this thesis is that a system of specific advance consent is needed to provide a clear and unequivocal legal justification for ante-mortem donor optimisation procedures. The ethical foundation for this claim is autonomy, and this is the central theme running through all six chapters. I argue that autonomy should be incorporated into donor optimisation policy to promote the dignity and integrity of potential organ donors and to safeguard trust in the organ donation programme. I argue that a system of specific advance consent is needed as part of the duty of care owed to registrants on the Organ Donor Register and to facilitate the determination of the best interests of the potential organ donor. I argue that the state has not established the necessity of the current policy of non-consensual donor optimisation procedures and that they are under an ethical and legal obligation to introduce an autonomy-based framework for ante-mortem interventions to facilitate organ donation.

Bakgrund: Vårdmiljöer sägs kunna bidra till att lindra såväl lidande som möjliggöra välbefinnande för patienter vid livets slut, och det privata hemmet kan möjliggöra livskvalitet och är föredragen vårdplats för döende och död i samhället. Arbetet som sjuksköterska i hemmet vid livets slut involverar att möta patienter och familjemedlemmar i deras egen miljö, vilket beskrivs som utmanande men också som positiva erfarenheter beroende på klinisk organisation och sjuksköterskans ansvarsområde. Ytterligare erfarenhetsbaserad omvårdnadsforskning om denna vårdmiljö är eftersträvansvärd. Syfte: Syftet med studien var att undersöka sjuksköterskors, som arbetar i specialiserad palliativ hemsjukvård, erfarenheter av det privata hemmet som vårdmiljö vid livets slut. Metod: Den här studien har kvalitativ design, guidad av forskningsapproachen tolkande beskrivning. Deltagarproducerade fotografier användes som utgångspunkt vid tio individuella intervjuer med sjuksköterskor inom specialiserad palliativ hemsjukvård. Resultat: Datanalysen resulterade i fyra teman; Komma till ett unikt privat hem förberedd på att anpassa interaktioner och handlingar beroende på miljön; Stödja patienter och familjemedlemmar att balansera egenvård, oberoende och säkerhet; Guida patienter och familjemedlemmar inför och igenom förändringar i hemmiljön för att stödja vård vid livets slut; Använda bilfärden mellan hemmen till reflektion, återhämtning och förberedelse. Diskussion och slutsats: Resultatet i denna svenskspråkiga uppsats diskuterades utifrån Liaschenkos teorier; som framhåller att omvårdnadsansvaret i hemmet innebär att bevara och skydda patientens möjlighet till autonomi och självbestämmande i deras naturligt subjektiva miljö, som påverkas av sjukdom och sjukvård. Resultatet genomsyras av sjuksköterskornas strävan att uppnå detta, något som beskrivs kräva specifik kompetens, men också innebär en rad utmaningar och ibland risker för det egna välbefinnandet. Då resultatet samtidigt antyder hemmet som plats med dubbla syften, dels som en privat plats vid livet slut och en arbetsplats. Omvårdnadsarbetet involverar en rad anpassningar i interaktion med vårdmiljön och personerna som bor där, och ett tillitsfullt samarbete mellan sjuksköterska, patient och/eller familjemedlem beskrivs möjliggöra en optimal och delad vårdmiljö vid livets slut. / Background: Care environments are shown to be a contributing factor for alleviate suffering and enhance wellbeing for dying patients, and private homes is found to benefit life quality and is a preferred place death and dying in society. Working in home care at end-of life involves meeting patients and family members in their own environment, entailing challenges and feasibilities depending on clinical organization and nursing role. Further experiential nursing research about this care environment at end-of-life is desirable. Aim: Exploring palliative care nurse’s experiences of the private home as an end-of-life-care environment. Method: The design of this study was qualitative, guided by the interpretive description approach. We used participant-produced photographs with follow-up interviews with ten nurses working in specialised palliative home care. Findings: Four themes were constructed; Entering the unique private home prepared to adjust interactions and actions depending on the environment, Supporting patients and family members to balance between self-care, independency and security, Guiding patients and family members towards and through environmental changes to support end of life care at home and Using the time driving between homes to reflect, recover and prepare. Discussion and conclusions: The findings in this Swedish written essay was discussed by using Liaschenkos theories; displaying that the nursing role in this care settings involves keeping and protecting the patients autonomy and self-determination in their own natural subjective home, which is affected by disease and health care. This findings clearly demonstrate the nurses strive for this, requiring specific competence, but also impair several challenges and sometimes risks for their own wellbeing. Thus, the private home is suggested being a space with dual purposes; an exclusive place for death and dying and a working environment. This involves a variety of adjustments in interactions with the environment and the persons living there, facilitated by a confident cooperation between the nurse, patient and/or family members for an optimal and shared care environment in end-of-life. / Plats och rum för vård i livets slutskede