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The rate of fragile elderly patients affected by chronic kidney disease stage 5-5D is rapidly increasing. The decision making process regarding the start and the withdrawal of dialysis is often difficult for all those involved: patients, relatives, nephrologists and renal nurses. Therefore nephrologists and renal nurses are called to rapidly improve their theoretical and practical competence about the end-of-life care. The quality of clinical intervention and management requires a sound expertise in the ethical, legal, organizational and therapeutic aspects, not trivial nor even deductible from purely private and individual opinions nor from traditional medical practice. The present paper discusses the ethical and legal implications related to the start rather than to withdrawn from dialysis, preferring a non-dialysis medical treatment and / or palliative care. Operational aspects regarding the regional network of palliative care, the path of shared decision making process and a systematic approach to optimize medical and nursing interventions through the Liverpool Care Pathway program are discussed thereafter.

Objective: To assess the effectiveness of a nurse-led class with phone follow-up, to help patients achieve lifestyle changes after an acute coronary syndrome (ACS)., Methods: Each patient < or = 75 years, admitted to a intensive cardiac care unit (ICCU) for ACS from September 2003 to December 2004, who attended the education class (case) was matched with two patients paired for age, sex and admission time, admitted for ACS to ICCUs in the other hospitals in the same area (controls). One year later the two groups were blindly interviewed on the phone, using a structured questionnaire about their lifestyles., Results: One-hundred-nineteen cases and 238 controls were phoned and 84% cases and 61% controls completed the interview. Cases reported a more correct lifestyle: they ate > or = 4 portions/day of fruit or vegetables (55% vs. 36%, p = 0.003) and > or = 2 portions/week of fish (48% vs. 32%, p = 0.010), reported > or = 30 min/day of physical activity (67% vs. 59%, p = 0.262) and stopped smoking (82% vs. 71% of previous smokers, p = 0.264)., Conclusion: An educational intervention led by cardiology nurses, with a group meeting and personal phone follow-up, improved lifestyle habits one year after an ACS.

Background: Most patients discharged after an acute coronary event or a coronary revascularization do not have adequate knowledge of the nature of their disease and of the importance of a correct lifestyle. The aim of this study was to assess the effectiveness of an educational intervention led by nurses for patients admitted to hospital for coronary heart disease (CHD)., Methods: Since May 2003, regular health education meetings for inpatients with CHD and their relatives have been held by the nurses of the Cardiology Division of the Desio hospital. The topics covered are the nature of CHD, its risk factors and the prevention of recurrences. Before and after the meeting, a questionnaire is administered to explore patients' level of knowledge., Results: From May 2003 to September 2004, 201 patients attended the meetings (151 men and 50 women, aged from 37 to 89 years). The majority (n=152, 76%) were admitted for an acute coronary syndrome. Attendance at the meeting significantly increased the patients' understanding of atherosclerosis (from 44 to 85%, p < 0.0001), coronary vessel function (from 56 to 92%, p < 0.0001) and the causes of cardiac necrosis or ischemia (from 58 to 88%, p < 0.0001). Their awareness of the importance of correct lifestyles increased, especially the number of patients willing to increase fruit and vegetable consumption (from 56 to 77%, p < 0.0001) or to increase physical activity (from 51 to 69%, p < 0.0001) to avoid a recurrence., Conclusions: A health education meeting organized by nurses for patients admitted for CHD improves their knowledge of their illness and awareness of the benefits of correct lifestyles to prevent worsening of their disease.

Aim and Methods: The lifestyles before hospital admission, knowledge on their illness and lifestyles after the acute coronary event were analysed with questionnaires, in three different samples of patients: a. all the patients admitted for acute coronary event from may 2003 to may 2005 to explore lifestyles before acute coronary event (416 patients) b. all the patients admitted from may 2003 to april 2004 (before the start of health information meetings organised by nurses), to explore the knowledge of the illness and its causes (132 patients) c. a sample of 83 patients followed in day hospital, to explore the lifestyles after the acute coronary event., Results: Lifestyles before the event. Most patients have incorrect lifestyles: 50% eat cheese every day and never exercise for at least 30 minutes everyday. Even after the acute coronary event, some incorrect lifestyles are still present. Seventy-five percent of patients have incorrect or insufficient knowledge on illness and risk factors at discharge and only 50% is willing to increase the amount of fruit and vegetables in their diet., Conclusions: Although confirmed by other studies, these results are worrying and call for the systematic adoption of secondary prevention strategies with effective interventions aimed at increasing knowledge and modifying lifestyles.

Unlabelled: In spite of the broad recognition of the importance of health education, time for structured one-to -one initiatives of health education during the hospital stay is limited. The organization of an health education meeting for patients admitted to CCU for an acute coronary event is described., Methods: The planning and implementation of the initiative lasted two years and involved 7 nurses and one doctor. The organization required efforts related to the event itself (preparation of training aids, identification or contents and methods for delivery) but also organizative changes. Dietitians in fact had to be involved because the healthy diet recommended was different from the hospital diet. The assessment of the effectiveness of the health education was also planned: administration of a questionnaire to explore lifestyles and knowledge of the illness before and after the meeting; phone interviews after 3, 6 and 12 months from the meeting., Results: Since may 2003, in the first 3 years 74 meetings have been organised, involving 507 patients and 329 relatives. Each meeting lasts 2 hours and contents delivered encompass the coronary event, risk factors and their modification, healthy lifestyles. Initial preliminary results on the impact of the meeting on lifestyle changes are promising. Initiatives are ongoing to include this activity among officially recognised nursing activities.