University Hospital Hairmyres is a district general hospital in the Hairmyres neighbourhood of East Kilbride, South Lanarkshire, Scotland. The hospital serves one of the largest elderly populations in Scotland. It is managed by NHS Lanarkshire.
Background Empowering nurses to discuss clinical trials with patients can increase recruitment rates. Clinical trials are essential for improving lung cancer patient outcomes; in the short term, they provide individuals access to new treatments and care regimens which, longer term, have the potential to advance clinical care. However, recruitment into lung cancer clinical trials is as low as 5%, and lung cancer nurses feel ill-equipped to signpost clinical trial opportunities to patients. This study aimed to pilot and assess the acceptability and utility of the ‘Lung I-ACT tool’: a newly developed resource comprising a patient-facing leaflet and a nurse-facing poster, designed to help lung cancer nurses initiate clinical trial discussions with patients. Methods A 6-month, mixed methods, pilot study was conducted at seven NHS hospital sites in the UK; four were intervention sites, three were control sites. Data on self-efficacy, knowledge, confidence, awareness and current practice were collected using online surveys for nurses at baseline, 3 and 6 months, and online interviews with lung cancer nurses and patients from intervention sites. Survey data were analysed using descriptive and inferential statistics, and interview data were thematically analysed via Framework Method. Results Thirty-four nurse respondents were recruited to the survey. Survey findings indicated increased frequency of clinical trial discussions at the intervention sites, and increased nurse awareness, confidence and knowledge to navigate these discussions. Eleven nurses and four patients were interviewed; these data comprised five themes regarding lung cancer nurses’ and patients’ views of the Lung I-ACT tool: (1) content and format of the tool, (2) application and utility of the tool in practice, (3) perceived changes to practice, (4) knowledge, awareness and confidence to discuss clinical trials, (5) contextual and situational factors impacting the presentation of clinical trials. Conclusion The Lung I-ACT tool improves nurses’ confidence in discussing trials with patients through increasing their awareness of clinical trial opportunities and helping them to structure conversations.
Background Myocardial Infarction with No Obstructive Coronary Arteries (MINOCA) or Nonischemic Myocardial Injury affects approximately 1 in 9 patients presenting with acute coronary syndrome, yet evidence-based therapies are lacking. Coronary microvascular dysfunction is implicated in the pathogenesis of suspected MINOCA, but its prevalence, prognostic implications and treatment are uncertain.The objectives are, first, to assess the prevalence of coronary microvascular dysfunction in patients with suspected MINOCA and, second, to implement endotype-informed stratified medicine involving patients with coronary microvascular dysfunction to treatment with eplerenone, a cardio- and vasculo-protective mineralocorticoid receptor antagonist. Methods This is a prospective, registry-based, multicenter, diagnostic study and nested, randomized, controlled, open-label, blinded-endpoint (PROBE) basket trial. Up to 400 patients with clinically suspected MINOCA and one or more cardiovascular risk factors will be enrolled into a registry-based diagnostic study. Coronary microvascular function will be assessed during invasive angiography using thermodilution. Patients with an index of coronary microvascular resistance (IMR) ≥ 25 will be randomized 1:1 to eplerenone (25-50 mg daily for 6 months) or standard care without eplerenone (control group) (n = 150 randomized). Final endotypes will be centrally adjudicated by a panel of blinded cardiologists.The primary outcome of the diagnostic study is the proportion of patients with IMR ≥ 25 during index coronary angiography. Secondary outcomes include coronary flow reserve, cardiovascular MRI parameters, patient-reported outcome measures, biomarkers of myocardial fibrosis and vascular inflammation, health outcomes and health economic assessments.The primary outcome of the randomized trial is the within-individual change in NT-proBNP at baseline, 1 month, and 6 months, based on intention-to-treat. Secondary outcomes include mechanistic blood biomarkers and patient-reported outcome measures. Value This registry-based randomized trial will provide novel evidence on endotype-informed secondary prevention therapy with eplerenone for suspected MINOCA.
Escalation of medical intervention near the end of life has become increasingly common, often driven by public misperceptions of medical capabilities, cultural narratives of ‘fighting’ disease, and clinicians’ discomfort with discussing limitations of more extreme treatment regimens. The result is the high-intervention death: intensive, invasive and frequently misaligned with patient values.This article examines the dynamics underpinning these decisions from the perspectives of emergency medicine, intensive care and palliative medicine. We describe the consequences of late acceptance of dying, the absence of advance and future care planning, and societal unpreparedness for death. We propose practical strategies to support better decision-making, including early goals-of-care discussions, compassionate communication, and a cultural shift towards acknowledging death as a realistic and acceptable outcome. Restoring humane, value-aligned care which still includes a plethora of treatments, albeit less invasive ones, requires clinicians to balance medical capability with compassion, clarity and courage.
This debate article examines whether a patient dying without an anticipatory care plan (ACP) or treatment escalation plan (TEP) should be considered a ‘never event’. Writing in favour of the motion, an emergency medicine consultant argues that such omissions represent preventable harm – not born of negligence, but of system failure and cultural reluctance to plan for dying. Drawing on a 2018 BMJ Open study showing a three-fold increase in harms among patients without a TEP, he contends that anticipatory planning safeguards patients from non-beneficial interventions, reduces moral distress for staff, and restores dignity at life’s end.A palliative medicine consultant, writing against the motion, challenges the framing of care planning as a universal requirement, warning that autonomy must include the right not to engage. He argues that making ACPs a ‘never event’ risks replacing one form of paternalism with another, and that dying is often too complex and unpredictable to be captured by documentation alone.In his rebuttal, the emergency medicine doctor acknowledges these ethical concerns but counters that the duty lies not in compelling discussion, but in ensuring that every patient is offered the opportunity to plan ahead. He distinguishes system omission from patient refusal, arguing that planning enables autonomy rather than restricts it. The palliative physician’s closing response warns that the good intention to protect patients must never become coercion.Together, the debate explores the boundary between autonomy and safety, raising essential questions about how medicine can prevent avoidable harm while honouring individual choice at the end of life.
