Health professional attitudes about end-of-life care depend in part on the providers role in the care team. Physicians generally have favorable attitudes towards Advance Directives, which are a key facet of end-of-life care. Medical doctors who have more experience and training in end-of-life care are more likely to cite comfort in having end-of-life-care discussions with patients. Those physicians who have more exposure to end-of-life care also have a higher likelihood of involving nurses in their decision-making process.A systematic review assessing end-of-life conversations between heart failure patients and healthcare professionals evaluated physician attitudes and preferences towards end-of-life care conversations. The study found that physicians found difficulty initiating end-of-life conversations with their heart failure patients, due to physician apprehension over inducing anxiety in patients, the uncertainty in a patients prognosis, and physicians awaiting patient cues to initiate end-of-life care conversations.Although physicians make official decisions about end-of-life care, nurses spend more time with patients and often know more about patient desires and concerns. In a Dutch national survey study of attitudes of nursing staff about involvement in medical end-of-life decisions, 64% of respondents thought patients preferred talking with nurses than physicians and 75% desired to be involved in end-of-life decision making. End-of-life care around the globe
Canada
In 2012, Statistics Canadas General Social Survey on Caregiving and care receiving found that 13% of Canadians (3.7 million) aged 15 and older reported that at some point in their lives they had provided end-of-life or palliative care to a family member or friend.
Causes
Vitamin B12 deficiency:
Achlorhydria-induced malabsorption
Deficient intake
Deficient intrinsic factor, a molecule produced by cells in the stomach that is required for B12 absorption (pernicious anemia or gastrectomy)
Coeliac disease
Biological competition for vitamin B12 by diverticulosis, fistula, intestinal anastomosis, or infection by the marine parasite Diphyllobothrium latum (fish tapeworm)
Selective vitamin B12 malabsorption (congenital—juvenile megaloblastic anemia 1—and drug-induced)
Chronic pancreatitis
Ileal resection and bypass
Nitrous oxide anesthesia (usually requires repeated instances). Folate deficiency:
Alcoholism
Deficient intake
Increased needs: pregnancy, infant, rapid cellular proliferation, and cirrhosis
Malabsorption (congenital and drug-induced)
Intestinal and jejunal resection
(indirect) Deficient thiamine and factors (e.g., enzymes) responsible for abnormal folate metabolism. Combined Deficiency: vitamin B12 & folate. Inherited Pyrimidine Synthesis Disorders: Orotic aciduria
Inherited DNA Synthesis Disorders
Toxins and Drugs:
Folic acid antagonists (methotrexate)
Purine synthesis antagonists (6-mercaptopurine, azathioprine)
Pyrimidine antagonists (cytarabine)
Phenytoin
Nitrous Oxide
Erythroleukemia
Inborn genetic mutations of the Methionine synthase gene
Di Guglielmos syndrome
Congenital dyserythropoietic anemia
Copper deficiency resulting from an excess of zinc from unusually high oral consumption of zinc-containing denture-fixation creams has been found to be a cause. Pathophysiology
There is a defect in DNA synthesis in the rapidly dividing cells and to a lesser extent, RNA and protein synthesis are also impaired. Therefore, unbalanced cell proliferation and impaired cell division occur as a result of arrested nuclear maturation so the cells show nuclear-cytoplasmic asynchrony. In the bone marrow, most megaloblasts are destroyed prior to entering the peripheral blood (intramedullary hemolysis). Some can escape the bone marrow (macrocytes) to peripheral blood but they are destroyed by the reticulo-endothelial system (extramedullary hemolysis). Diagnosis
The gold standard for the diagnosis of Vitamin B12 deficiency is a low blood level of Vitamin B12.