Bakgrund: Vårdandet handlar om att främja patientens hälsa trots sjukdom och inte minst blir det centralt i det palliativa vårdandet. Den palliativa vården innebär för sjuksköterskan att förebygga och lindra lidande samt att förbättra livskvaliteten. Detta kan leda till ett ökat välbefinnande och en upplevelse av hälsa trots att patienten befinner sig i livets slutskede. I det palliativa vårdandet kan sjuksköterskan använda sig av vårdmodellen ”de 6 S:n”. Syftet med vårdmodellen är att främja patientens delaktighet i livets slutskede med patientens perspektiv i fokus. Syfte: Syftet var att beskriva sjuksköterskans upplevelse av att vårda palliativt i livets slutskede. Metod: Den valda metoden var en litteraturöversikt med en innehållsanalys av nio kvalitativa vetenskapliga artiklar. Resultat: I resultatet framkommer det att sjuksköterskan upplever ett behov av att vara närvarande och finnas där för patienten. För sjuksköterskan skapas det känslor och tankar i det palliativa vårdandet som kan upplevas både som positiva och negativa. För att utföra en så god palliativ vård som möjligt upplever sjuksköterskan inte ha tillräckligt med kunskap och klinisk erfarenhet. Konklusion: Sjuksköterskan upplevde sig ha bristande kunskap och lite klinisk erfarenhet av den palliativa vården som gjorde att sjuksköterskan kände sig otillräcklig och fick svårt att hantera sina känslor / Background: Nursing is about upholding patient health despite illness and not least when it comes to palliative care. For the nurse, palliative care intend to improve quality of life and prevent and relieve suffering, which in turn can lead to increased well-being and a feeling of health even though the patient is in the end of life. The nurse can use “the 6S” care model, which aims to make the patient involved in the palliative care, focusing on the patient’s perspective. Aim: The purpose of this study is to describe the nurse’s experience of palliative care in the end of life. Method: The selected method is a literature review with a content analysis of nine qualitative scientific articles. Results: The results show that the nurse feels a need to be present and to be there for the patient. For the nurse, palliative care generates emotions and thoughts, which can be both positive and negative. The nurse experiences a lack in knowledge and clinical experience, which is an obstacle in achieving good palliative care. Conclusion: The nurse felt that insufficient knowledge combined with few clinical experiences of palliative care made the nurse feel insufficient and unable to cope with arisen emotions.

Bakgrund: Palliativ vård innebär att ge vård till patienter med en obotlig sjukdom samt tillstånd där patienten inte förväntas att överleva sjukdomen eller tillståndet. Hopp är viktigt att eftersträva inom den palliativa vården, där sjuksköterskan har en betydande roll. Det är svårt att förmedla hopp till svårt sjuka patienter, och därför är kunskapen om hur det kan förmedlas viktig. Syfte: Att beskriva hur sjuksköterskor förmedlar hopp till patienter i livets slutskede. Metod: En innehållsanalys gjordes där en kvantitativ och åtta kvalitativa vetenskapliga artiklar granskades. Resultat: De nio vetenskapliga artiklar som granskades resulterade i en kategori; kommunikation i palliativ vård med tre subkategorier; kommunikation om fokus på livet, sjuksköterskans närvaro vid kommunikation och kommunikation om döden. Slutsats: Resultatet i studien visar att kommunikation med patienter angående döden var en svårighet för sjuksköterskor. Där rädsla för att patienten skulle förlora hoppet helt är en stor del till varför sjuksköterskor valde att undvika att tala om döden. När sjuksköterskor har vågat bemöta patienten i fråga om döden påvisade detta positiva effekter hos patienten då de hade uppnått en acceptans av den obotliga sjukdomen och hade på så vis kunnat behålla hoppet. Studien påvisar vikten av att sjuksköterskor vågar kommunicera med patienten om döden. / Background: The definition of palliative care is to give treatment to patients with incurable disease when the patient is not expected to survive the disease. Hope is important to strive for in palliative care, where the nurse has a significant role. It is difficult to convey hope to critically ill patients, and therefore the knowledge of how it can be conveyed is important. Aim: To describe how nurses can convey hope to patients in palliative care. Method: A content analysis was made where nine scientific articles were audited. Results: The nine scientific articles that were audited resulted in one category; communication in palliative care with three subcategories; communication about focus in life, nurse’s presence when communicating and communication about death. Conclusion: The results of this study indicated that communication with patients about death was a difficulty for nurses. Where fear of patient losing their hope was a big part of why nurses choose to avoid talking about death. When nurses have had the courage to talk about death with the patient it has shown positive effects within the patient where they have reached an acceptance of the incurable disease and they have been able to keep their hope. The study has shown how important it is that nurses dare to communicate with patients about death.

Bakgrund Det avlider cirka 15 000 personer på olika sjukhusavdelningar varje år. Som sjuksköterska inom denna verksamhet kommer du komma i kontakt med dessa patienter i slutskedet av deras liv. Det är viktigt att som sjuksköterska vara förberedd för denna vård för att kunna ge ett professionellt bemötande samt bästa möjliga omvårdnad. Syfte Syftet med denna litteraturstudie var att beskriva sjuksköterskors erfarenheter av att vårda vuxna patienter i livets slutskede inom slutenvården. Samt att undersöka de inkluderade artiklarnas datainsamlingsmetod. Metod En beskrivande litteraturstudie med kvalitativa artiklar. Artiklarna har sökts i databaserna Medline och Cinahl samt genom manuell sökning och det slutgiltiga antalet inkluderade artiklar blev 11 stycken. Artiklarna har sedan granskats av båda författarna för att se att de motsvarade föreliggande studies syfte. Huvudresultat Resultatet från artiklarna kom att lyftas fram i föreliggande studies resultatdel och beskrevs i tre huvudrubriker. Dessa visade på vikten av arbetserfarenhet bland sjuksköterskorna för att de skulle känna sig bekväma i sin arbetssituation. Hur mycket tidsaspekten påverkade vårdandets kvalitet samt vilka känslor som sjuksköterskorna förknippade med vårdandet av patienter i livets slutskede. De granskade artiklarnas datainsamlingsmetod bestod av semistrukturerade intervjuer och ostrukturerade intervjuer. Slutsats Sjuksköterskor upplever olika känslor i detta vårdande, både positiva och negativa. Vidare kämpar sjuksköterskan med att få tiden att räcka till samt att fördela tiden mellan patienter för att utifrån rådande förutsättningar skapa en bra vård i livets slutskede för dessa patienter. I detta arbete upplever sjuksköterskor att det krävs erfarenhet för att kunna hantera vården av patienter i livets slutskede. Grundutbildningen för sjuksköterskor upplevs inte förbereda sjuksköterskan för denna vård. / Background Approximately 15,000 people die in different hospital wards in Sweden each year. As a nurse, you will come in contact with and meet with these patients in the final stages of their lives. It is important as a nurse to be prepared for this care to be able to provide professional treatment and the best possible care. Aim The purpose of this study was to describe nurses' experiences of caring for adult palliative patients in hospital wards and to investigate the included articles data collection method. Method A descriptive literature study with qualitative articles. Articles have been searched in Medline and CINAHL databases and by manual search. The final number of included articles was 11. The articles were then reviewed by both authors to ensure that they correspond to the purpose of the current study. Results The result of the reviewed articles came to be highlighted in the results section of the current study and described under three mainheadings. These showed the importance of work experience among nurses that they would feel comfortable in their work situation. How much time factor affected the quality care and the emotions associated with the nurses caring for patients in the final stages of life. The reviewed articles datacollection method consisted of semi-structured interviews and unstructured interviews. Conclusion Nurses experience different feelings in this caring, both positive and negative. Further more, the nurse struggling to find enough time to and to allocate time between patients to match prevailing conditions to create a good end of life care for these patients. In this work, nurses feel that they required experience to manage the care of patients in the final stages of life. The nursing education is perceived to not adequately prepare nurses for this care.

No description available.

Hemodialysis (HD) is the most frequently used treatment for end-stage renal disease. Despite all efforts to improve the outcomes, the mortality of patients on HD is still high, and this especially is related to cardiovascular diseases (CVD). Glucose degradation products accumulate in plasma and tissue as a result of oxidative stress in these patients. Such accumulation is strongly related to the risk of developing CVD. Tissue deposits of advanced glycation end products (AGE) can be easily assessed by a skin autofluorescence (SAF) technique. SAF is one of the strongest prognostic markers of mortality in HD patients. The aim of this thesis is to examine whether intervention on HD treatment can reduce the load of AGE of these patients. The aim of the first study was to investigate whether changes in SAF appear after a single HD session and if they might be related to changes in plasma AF. Skin and plasma AF (PAF) were measured before and after HD in 35 patients on maintenance HD therapy. Median dialysis time was 4 h (range 3-5.5). SAF was measured noninvasively with an AGE Reader, and plasma AF was measured before and after HD. The HD patients had on average a 65% higher SAF value than age-matched healthy persons (P < 0.001). PAF was reduced by 14% (P < 0.001), whereas SAF was not changed after a single HD treatment. No significant influence of the reduced PAF on SAF levels was found. This suggests that the measurement of SAF can be performed during the whole dialysis period and is not directly influenced by the changes in plasma AF during HD. In study 2 different dialysis filters were compared to clarify whether using a high-flux (HF) dialyzer favors plasma or SAF removal compared to low-flux (LF) dialyzer. Twenty-eight patients were treated with either an HF-HD or LF-HD but otherwise unchanged conditions in a cross-over design. SAF was measured non-invasively with an AGE reader before and after HD. PAF was determined as total and non-protein-bound fractions. Corrections for hemoconcentrations by volume changes were made using the change in serum albumin. Paired and non-paired statistical analyses were used. The different treatments did not change SAF after LF- and HF-dialysis. Total, free, and protein-bound PAF were reduced after a single LF-HD by 21%, 28%, and 17%, respectively (P<.001). After HF-HD total and free PAF was reduced by 5% and 15%, respectively (P<.001), while protein-bound values were unchanged. The LF-HD resulted in a more pronounced reduction of PAF than did HF-HD (P<.001). Serum albumin correlated inversely with PAF in HF-HD. There was no significant change in SAF after dialysis, either with LF or with HF dialysis. Although only limited reductions in PAF were observed, these were more pronounced when performing LF dialysis. These data are not in overwhelming support of the use of HF dialysis in the setting used in this study. In the third study the effect on SAF was investigated using either glucose-containing or glucose-free dialysate. SAF and PAF were measured in patients on HD during standard treatment with a glucose-containing dialysate (n=24). After that, the patients were switched to a glucose-free dialysate for a 2 week period, and new measurements were performed on PAF and SAF. There was an increase of pre-dialysis SAF measured at the beginning of the study compared with the values one month later (as in study 4). By comparing pre- and post-dialysis values there was a significant decrease of SAF only when using glucose-free dialysate. Free PAF decreased independently whether glucose-containing or glucose-free dialysate was used. The important finding was that increase in SAF seemed possible to slow down using glucose-free dialysate. Study 4 was performed to investigate whether there are seasonal variations in SAF on a HD population. SAF was measured non-invasively with an AGE Reader in patients on HD at different seasonal periods during one year such as February-May (N=31), May–August (N=28), August–March (N=25). SAF was measured before HD. Paired statistical analyses were performed between each two periods.  Unexpectedly there was at a median 6% increase in SAF during the winter (p=0.004) and a 11% decrease from 4.0 to 3.5 arbitrary units of the SAF during the summer (p<0.001). The study concluded that SAF shows seasonal variation. The cause of these changes could not be clarified. A beneficial effect may be due to extended exposure to sunlight during the summer and/or to different dietary intakes during the seasons. In conclusion, these interventional studies confirmed that PAF is lowered by dialysis. SAF was only decreased by HD when using glucose-free dialysate. SAF was not influenced by a single HD, with glucose-containing dialysate, independent of using HF or LF filters. These data favor glucose-free dialysate as a possible measure to slow down the progress of tissue AGE compared to glucose-containing dialysate. Longitudinal studies will help to clarify this issue further.

This thesis presents a comprehensive theory of evildoing as an attack on morality, grounded in objective morality. It introduces evildoing as a distinct category of immorality, arguing that it is the relationship of evil acts to the core of morality that distinguishes them from ordinary wrongdoing. Two projects are undertaken: to provide an account of morality that can ground a theory of evildoing that is both objective and capable of systematically accommodating the diverse phenomena and definitions of evil acts, and to articulate and defend the attack on morality theory of evildoing. The challenge of the first project is met by a minimalist account of morality, structured by what I call the fundamentals of morality. The thesis defends a particular substantive account of these fundamentals, underpinned by the idea of conatus as the end of morality. Ultimately, it is conatus as the striving to persist in existence and prosper inherent in human beings that justifies the objectivity of the fundamentals of morality and with it the objectivity of the theory of evildoing, for it is these fundamentals that are attacked when we speak of an ‘attack on morality.’ Specifying and defending the conditions necessary for such an attack is the task of the second part of the thesis. An act constitutes evildoing, or an attack on morality, when it is wrong, results in serious harm to others, originates in an intention based on the correct belief that the act will cause or risk such harm, and where the perpetrator’s mental states and/or the act’s consequences are antagonistic to the realization of morality via one or more of its fundamentals.

Aim: The overall aim of the thesis was to explore and describe the concepts of guilt and shame and gain a greater understanding of the next-of-kin’s experiences of guilt and shame in end-of-life care. Methods: Study I was a qualitative secondary analysis of 47 interviews with next-of-kin searching for experiences of guilt and shame. In study II a semantic concept analysis of the two concepts guilt and shame was performed. In studies III and IV a hermeneutic approach inspired by Gadamer was used to analyze next-of-kin’s experiences of guilt (Study III), and shame (Study IV) in end-of-life care. Main findings: The concept of guilt focus on behaviour and the concept of shame on the influence on the self.  The situation of being next-of-kin in end-of-life care involves a commitment to make the remaining time for the loved one as good as possible. When, for some reason, the commitment cannot be accomplished there is a risk that the next-of-kin experience guilt such as not having done enough, not having been together during important events, not having talked enough to each other, or not having done the right things. Aspects such as not having fulfilled a commitment, omission, and being the cause of can be present in these experiences. The guilt experience has a focus on what the next-of-kin has, or has not done. The experiences of shame are also linked to a perception that the remaining time for the loved one should be as good as possible. Shame can occur when the next-of-kin is involved and actually causes harm to the loved one as well as in situations that are beyond their control. Shame that the next-of-kin experience can also emanate from being put in situations by other people. Feelings of inferiority and powerlessness, second order shame, and family conflicts that are brought into the open are experiences of shame found in the studies as well as ignominy, humiliation, and disgrace. The shame experience has a focus on the next-of-kin’s self. Conclusion: The situation of being next-of-kin in end-of-life care is complex and demanding, something that health professionals should be aware of. Acknowledgement of experiences of guilt and shame can help the next-of-kin in their adaptation to the end-of-life situation as a whole and maybe also give useful tools to support next-of-kin during bereavement.

What does it mean to occupy the other side of what is - to “be” the nothing that lies beyond being? Or, in other words: Where yonder the End of Philosophy? Thus reads the first and final line of inquiry that we, the philosophers of this age, are impelled to pursue. Such is the case, I contend, in light of the fact that our time quite simply is that of the eschatological aftermath, the “postmodern” era where the purportedly “greatest” thinkers of our immediate past, Martin Heidegger and Ludwig Wittgenstein, have, each in his own way, already declared philosophical moratorium. Yet it seems to me there is curious and vital affinity to the philosophical legacy these thinkers, whose mark on history is, paradoxically, so wide and so deep as to be at once indelible and invisible. Accordingly, this thesis seeks to render Heidegger and Wittgenstein, each a formidable critic of the philosophical tradition, as mutually complementary voices, speaking not of an end-to-be, but on the way beyond the end-that-is-past. In writing on the disjunctive parallelism evident in their famed non-encounter, I hope to clarify the nature and purpose of contemporary philosophical practice. My principal argument is that, in locating philosophy, conceived as a thematic study of the being of what is, within language, Wittgenstein and Heidegger both came to view language itself as the pre-philosophical nothing, which, in its wordless non-identity or self-difference, presents a way beyond the word and world of traditional philosophical thinking. It is my hope that, in outlying the shared strains of their respective critical disclosures of the relation between language and philosophy, I will be able to say not the same, but something yet unsaid, addressing our time, the time after the end, as a period of continued, self-critical thinking and speaking about that which, as the difference between the spoken word and that which is, prepares the way towards an experience of the hitherto “impossible” meaning of non-being.

Hospital-based specialist palliative care services are designed to address the needs of critically ill patients by psychosocial and spiritual support, improving symptoms management, and offering discussions on goals of care. Integrating palliative care upstream in the care continuum for patients who eventually die in the hospital will help to address the many individualistic needs of the critically ill patient. The diffusion of specialist hospital-based palliative care services requires an understanding of patterns of utilization by patients. The purpose of this study was to examine the population characteristics of decedents who may or may not have utilized specialist palliative care services in a hospital setting in order to develop a model of predictors of access to specialist palliative care services. The basic constructs of this study are grounded in the Behavioral Model of Health Services Use. Potential access is measured in terms of population characteristics, which include predisposing characteristics, enabling resources, and evaluated need. Building on this theoretical model, the study sought to better understand equitable and inequitable access to specialized palliative care services and to define which predictors of realized access were dominant. The research question asked was: What are predictors of access to specialized palliative care within a large urban public teaching hospital? A model of access to a palliative consult and a predictor of access to a palliative care unit were explored. Findings from this study revealed that factors encouraging access to a palliative care consult include older age, White non-Hispanic ethnic membership, a diagnosis with solid cancer and insurance. Factors encouraging access to a palliative care unit include older age, gender (female), insurance, and either a solid cancer or hematologic malignancy diagnosis.

Nurses perform a vital role in the care of dying patients and their families. Hence, experiences of nurses are a meaningful source from which to advance holistic end-of-life care. In this study, a hermeneutic phenomenological perspective was used to explore the phenomenon of end-of-life nursing care. Details derived from a scientific exploration into the experiences of 13 registered nurses who provided care for patients and families at end-of-life in the inpatient hospital setting offer understandings regarding this important phenomenon. The hermeneutic phenomenological methods of Max van Manen guided data collection and analysis. Three main themes described the participants’ experience of nursing care at end-of-life: “Confronting Challenges,” “Coming to Understand End-of-Life Care,” and “Transforming the Understanding of End-of-Life Care into Nursing Practice.” Recommendations for nursing education, practice, and research were derived.