Absent Awareness Research Articles

Palliative Sedierung

Terminal illnesses can cause distressing symptoms such as severe pain, mental confusions, feelings of suffocation, and agitation. Despite skilled palliative care in some cases these symptoms may not respond to standard interventions. After all other means to provide comfort and relief to a dying patient have been tried and are unsuccessful, clinical caregivers and patients can consider palliative sedation. Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness in order to relieve the burden of otherwise refractory suffering. Palliative sedation is not intended to cause death or shorten life. The patient and family should agree with plans for palliative sedation. Because cases involving palliative sedation are emotionally stressful, the patient, family, and health care workers can all benefit from talking about the complex medical, ethical, and emotional issues they raise.

Sedation for the care of patients with advanced cancer

Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness (i.e. unconsciousness) in order to relieve the burden of otherwise intractable suffering. Sedation is used in palliative care in several settings: transient controlled sedation, sedation in the management of refractory symptoms at the end of life, emergency sedation, respite sedation, and sedation for refractory psychological or existential suffering. Sedation is controversial in that it diminishes the capacity of the patient to interact, function, and, in some cases, live. There is no distinct ethical problem in the use of sedation to relieve otherwise intolerable suffering in patients who are dying. Since all medical treatments involve risks and benefits, each potential option must be evaluated for its promise with regards to achieving the goals of care. When risks of treatment are involved, to be justified these risks must be proportionate to the gravity of the clinical indication. Some aspects of management, such as the need for hydration in patients undergoing sedation and the use of sedation in the management of psychological and spiritual suffering, remain controversial.

Protecting Patients after a Right CVA

erebrovascular accidents (CVAs) on the right side ot the brain don't usually produce speech deficits, since the left cerebral hemisphere houses the speech center in nearly all right-handed and most left-handed people. For that reason, patients with right CVAs may seem to have escaped serious impairment. But, in fact, they're often left with perceptual difficulties that severely compromise their daily living skills. They may also be at greater risk for falls and subsequent injuries than patients with left-hemisphere strokes. Decreased or absent awareness of the affected side of the body after a stroke-a syndrome referred to as hemineglectis much more prevalent among patients with right than left CVAs. This deficit, which usually accompanies left-sided weakness, can also include loss of vision in the left visual field of both eyes (homonymous hemianopia). Hemineglect puts patients at great risk for tripping over, knocking over, or bumping into objects in their vicinity. Sometimes they simply don't see them and move on as if they weren't there; other times, they aren't aware of their deficits and move as though they aren't handicapped (a condition called anosognosia). In many cases, the risk of falling is enhanced by age-related decline in balance control. Impaired judgment and impulsive behavior, both common effects of right CVA, may complicate matters further. Developing a plan of care When Sally Hanover, age 68, was admitted to a neurology ulIit after a right CVA, her primary nurse, Alice White, explained all safety precautions to her-keeping the side rails of her bed up while she was in it, locking her bed in the low position, and placing her call bell within reach. And Alice reminded her to call for assistance whenever she needed it. Because Ms. Hanover exhibited hemineglect, her plan of .are included turning her bed so that her unaffected side faced the door to her room. The funi,ture was also moved around :o her unaffected side. Since she couldn't see the left side of her food tray, all her food was placed on the right half. And she iJas taught to scan the environment by turning her head in order to see areas not within her field of vision. One day, during afternoon rounds, Alice helped Ms. Hanover out of bed to a nearby chair. She positioned everyTh ing she thought Ms. Hanover might want within her r:each-call bell, telephone, TV remote control, and water glass-and reminded her not to get up without calling for assistance. Ms. Hanover smiled and nodded, and Alice left to continue her rounds. Half an hour later, Alice found her patient lying on the tloor, with an upper arm laceration that required sutures. Ms. 1-anover was shocked that she'd fallen. Alice was dismayed, lout she knew Ms. Hanover's attempt to get up unassisted ~o:lod be the result of cognitive and personality changes associated with right CVA that aren't always immediately appar:nt. In this instance, Alice had assessed her patient to be reliable. But the accident demonstrated that she wasn't. Alice obtained an order for a vest restraint to be worn coninuously to discourage Ms. Hanover from mobilizing herself unassisted. She also reminded her once again not to get up without calling for assistance. But in spite of these interventions, Ms. Hanover eventually untied her vest restraint, tried tO get out of her chair, lost her balance, and fell to the floor. X-rays confirmed a hip fracture.

Double-blind crossover comparison of human and porcine insulins in patients reporting lack of hypoglycaemia awareness

There has been much debate about reports that some insulin-treated diabetic patients lose awareness of hypoglycaemic symptoms on changing from porcine to human insulin. In a double-blind, crossover study, we sought differences between porcine and human insulin in the frequency and characteristics of hypoglycaemic episodes among patients who reported a reduction of awareness of hypoglycaemia after changing treatment. We studied 50 patients referred by their physicians because of complaints of lack of awareness of hypoglycaemia on human insulin. They had had diabetes for a mean of 20 (SD 12) years and 70% had good or acceptable glycaemic control. Each patient was treated in a double-blind manner for four 1-month periods, two with human and two with porcine insulin, in random order. Only 2 patients correctly identified the sequence of insulin treatments used; 8 or 9 would have been expected to do so by chance alone. The mean percentage of hypoglycaemic episodes associated with reduced or absent awareness was 64% (SD 30%) for human insulin and 69% (31%) for porcine insulin. We could find no statistically significant differences between the insulin species with respect to glycaemic control or the frequency, timing, severity, or awareness of hypoglycaemia. Reduced hypoglycaemia awareness is common with both human and porcine insulins.

Classification of Symptoms of Hypoglycaemia in Insulin‐treated Diabetic Patients Using Factor Analysis: Relationship to Hypoglycaemia Unawareness

The allocation of some symptoms of acute hypoglycaemia to autonomic and neuroglycopenic groups has proved problematical, with possible misinterpretation of studies which depend upon the use of diverse symptom questionnaires. Two hundred and ninety-five randomly selected insulin-treated diabetic patients were asked to report the symptoms which they usually experienced and believed to be caused by hypoglycaemia. Sweating, trembling, inability to concentrate, weakness, hunger and blurred vision were the most frequently reported symptoms. To classify symptoms of hypoglycaemia objectively, Factor Analysis was used to identify related symptoms which grouped together. This resulted in five groups or clusters of symptoms, four of which could be denominated as groups with a presumed common aetiology, and were labelled: 'neuroglycopenic', 'general malaise', 'autonomic', 'motor dysfunction', and 'sensory dysfunction'. The groups of symptoms derived by Factor Analysis were assessed in relation to partial or absent symptomatic awareness of hypoglycaemia based on historical evidence from the 295 insulin-treated diabetic patients. Neuroglycopenic symptoms were reported more commonly by the patients who had reported partial awareness of hypoglycaemia (number of symptoms 2.6 +/- 1.8 (mean +/- SD] than by the patients who had reported normal hypoglycaemia awareness (1.4 +/- 1.5 symptoms) (p less than 0.05). By contrast autonomic symptoms were reported less frequently by the patients who had reported absent hypoglycaemia awareness (1.3 +/- 1.4 symptoms) than by those with normal awareness (2.2 +/- 1.4 symptoms) (p less than 0.05), which was similar to the number of autonomic symptoms reported by the patients who had partial hypoglycaemia awareness (2.1 +/- 1.3 symptoms).

Unawareness of Hypoglycaemia in Insulin‐treated Diabetic Patients: Prevalence and Relationship to Autonomic Neuropathy

Three-hundred and two insulin-treated diabetic patients were questioned about hypoglycaemia using a structured questionnaire interview. Two-hundred and twenty-six patients (75%) had normal symptomatic awareness, 48 (16%) had partial awareness, 21 (7%) had absent awareness of hypoglycaemia, and 7 (2%) denied ever experiencing hypoglycaemia. Patients with complete loss of awareness of hypoglycaemia had diabetes of longer duration; none had a HbA1 concentration within the non-diabetic range. Loss of awareness of hypoglycaemia was associated with an increased incidence of severe hypoglycaemia, 19 (91%) of the patients with absent awareness, and 33 (69%) with partial awareness of hypoglycaemia experiencing severe hypoglycaemia over 1 year compared with only 41 (18%) of patients with normal awareness of hypoglycaemia (p less than 0.001). Cardiovascular autonomic function tests were performed in 226 (75% of the whole group). Of the patients who had diabetes for more than 15 years, 54% (n = 39) with normal awareness of hypoglycaemia, compared with 59% (n = 10) with absent awareness of hypoglycaemia, had evidence of cardiovascular autonomic impairment (NS). Seven (41%) of the 17 patients with absent awareness of hypoglycaemia and diabetes of greater than 15 years duration had no evidence of autonomic dysfunction. Loss of hypoglycaemia awareness is a common problem in patients with insulin-treated diabetes of long duration, is associated with an increased incidence of severe hypoglycaemia, but is not invariably associated with abnormal cardiovascular autonomic function tests.