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Contents
Foreword
Preface
Acknowledgements
Chapter 1Framing Palliative Care3
Sanchia Aranda
Chapter 2Evidence-Based Practice in Palliative Care7
Alan Pearson
Chapter 3Communication Skills in Palliative Care23
Annabel Pollard and Kathleen Swift
Chapter 4Occupational Stress in Palliative Care41
Mary Vachon
Chapter 5Ethical Decision-making53
Margaret O’Connor and Sanchia Aranda
Chapter 6Spiritual Care69
Rosalie Hudson and Bruce Rumbold
Chapter 7A Framework for Symptom Assessment89
Sanchia Aranda
Chapter 8Pain Management101
Jeannine Brant
Foreword
Palliative Care Nursing: A Guide to Practice addresses palliative care from a nursing perspective, and will assist nurses in a variety of settings to care for people and their families with confidence and competence. Written in the main by nurses, the book presents the expertise that the contributing authors have gathered over many years of practical experience in clinical practice, backed by extensive research and an awareness of the relevant nursing and medical literature. The book is a tribute to all the contributing authors.
This book offers all nurses an evidence-based approach to handling the many difficult scenarios faced by nurses who care for dying people and their families. The World Health Organization definition of palliative care (WHO 2002) emphasises, for the first time, the importance of ‘impeccable assessment’ in the provision of high-quality palliative care. Each chapter of Palliative Care Nursing gives nurses detailed guidelines for making in-depth assessments to elicit the patients’ problems, followed by relevant advice to enable them to plan effective care.
Palliative care is now accepted as an important aspect of health care by an increasing number of government health departments and by health professionals all over the world. For nurses worldwide who are contributing to new palliative-care services, as well as for those working in established service settings, this book is a must. It is an authoritative text on palliative-care nursing, and will provide up-to-date knowledge and ideas for enhancing the care that nurses provide in assisting people achieve a peaceful dignified death, and in caring for their families and loved ones.
I have great pleasure in commending this excellent book.
Dr Susie Wilkinson Head of Palliative Care Research and Senior Lecturer in Palliative Care
Marie Curie Palliative Care Research & Development Unit, London, UK
Preface
Palliative care has been traditionally defined as ‘ . . . specialised health care of dying people, aiming to maximise quality of life and assist families and carers during and after death’ (PCA 1999). The long tradition of the hospice movement attests to a commitment to care for people who are dying. More recently, palliative care has developed into an active practice-based discipline aimed at improving the care of those who are facing the end of their lives. Palliative care now begins before the traditionally understood dying phase of care, and has become a multidisciplinary practice involving interactions with other relevant parts of the health-care system.
Wherever palliative care is practised, it is founded on the following values and principles (PCA 1999):
◗ the dignity of the patient and family;
◗ compassionate care of the patient and family;
◗ equity in access to palliative-care services;
◗ respect for the patient, family, and carers;
◗ advocacy on behalf of the expressed wishes of patients, families, and communities;
◗ pursuit of excellence in the provision of care and support; and
◗ accountability to patients, families, and the wider community.
The success of the first edition of Palliative Care Nursing suggests that the original goal of developing a book that would make palliative care accessible to nurses in all health settings has been realised. This second edition has been totally revised, rewritten, and redesigned to ensure that the book remains a reliable and useful practice guide for nurses, especially for those who are new to palliative care and those who work in other areas of health in which palliativecare skills are required.
Palliative Care Nursing
This complete revision and rewriting required a comprehensive re-evaluation of the first edition. Feedback from nurses revealed that the clinically focused chapters of the earlier edition were especially useful in guiding practice, and this has resulted in an increased focus on clinical issues in this second edition. The content of the new book has therefore been refocused to incorporate a wider range of clinical problems faced by nurses in their care of dying people. Each of these new chapters has been written by a nurse with recognised expertise in the topic area and a commitment to providing recommendations that are firmly evidence-based. Many of these authors are from countries other than Australia, and this reflects a widening of content and readership from a predominantly Australian focus to a wider international scope.
This book will empower nurses through the development of their clinical knowledge, and will contribute to enhanced care for people who are dying.
Acknowledgements
Radcliffe Medical Press has received much help and advice from the UK contributors to this book, and from Susie Wilkinson, who wrote the foreword. It was on Susie’s advice that we asked the following experts to review certain chapters to ensure they reflected current practice in the NHS.
Margaret Goodman, Marie Curie Palliative Care Research and Development Unit, Royal Free Hospital, London
Kath Jenkins, Marie Curie Centre, Caterham, Surrey
Carole Mula MA, Macmillan Nurse Consultant in Adult Palliative Care, Christie Hospital NHS Trust, Manchester and North Manchester Primary Care Trust
Sanchia Aranda
Sanchia Aranda is professor and director of cancer nursing research at Peter MacCallum Cancer Institute, Melbourne (Victoria, Australia). She has worked in cancer care since 1979, predominantly in the tertiary sector since 1990. Her research interests include cancer and palliative nursing in both inpatient and community settings, especially in the area of supportive care. Her research, both quantitative and qualitative, concentrates on implementing evidence into clinical practice, especially in improving the delivery of health services and the outcomes for people with cancer and their families. Current studies include workforce planning in breast care, the support needs of women with advanced cancer, symptom interventions in pain and fatigue, prevention of oral mucositis, and care of people suffering bodily decay.
Chapter 1 Framing Palliative Care
Sanchia Aranda
The purpose of this book is to disseminate knowledge of palliative-care nursing to improve the care of people at the end of their lives, and to provide care and assistance to their families, friends, and carers. It is important that knowledge of palliative care is available to nurses who care for dying people, regardless of the health-care setting or the diagnosis. Because dying people can be found in almost any setting, palliative care is increasingly a core component of all health-care roles.
Palliative care occurs at three levels (Finlay & Jones 1995):
◗ the palliative approach;
◗ specialist interventions; and
◗ specialist palliative care.
The palliative approach consists of a core set of knowledge and skills, and can be used by all health professionals who are involved in caring for people with life-threatening or terminal illnesses. At this level, all nurses can undertake basic symptom assessment and management, understand the experiences of dying people and their families, engage in communication regarding individual needs and experiences, and consult with specialist palliative-care practitioners if the needs of these people are outside the nurses’ expertise.
PALLIATIVE CARE NURSING
Specialist interventions by practitioners from disciplines outside palliative care are sometimes required to assist in the management of difficult nursing problems. Examples include the involvement of a wound nurse in the care of a malignant wound or the involvement of a radiotherapy nurse in palliative radiotherapy.
Specialist palliative care is provided by practitioners who have specialist qualifications and experience in the care of dying people and their families. These practitioners might work in specialist community palliative-care services, in palliative consulting services in an acute hospital, or in a hospice. The involvement of such specialist services and practitioners is most relevant for patients with complex and difficult symptoms or care needs. Such specialist services might be involved in an advisory capacity, or can assume primary care of the patient.
This book provides a core set of knowledge that can be applied at each of these three levels of practice, but the focus of the book is to assist all nurses to incorporate palliative care into their work, on the premise that all nurses require access to information that will support their care of dying people and their families. The book presents palliative care as the expert, holistic, and interdisciplinary care that is offered to dying people, regardless of diagnosis or care setting. It is a continuum of practice from a generalised approach to a specialist discipline.
Even though one of the tenets of palliative care is the promotion of equitable access, there are still considerable difficulties with access to palliative care in many communities and in many settings of care, especially for people with noncancer diagnoses. In part, this is caused by the reluctance of some health professionals to involve specialist palliative-care services in the care of people who have palliative needs. In addition, there is still some ignorance in the community about the care of people facing the end of life. Public testimonials in the media about unnecessary suffering in dying are evidence that many people still do not have ready access to expert palliative care. Despite efforts to the contrary, palliative care continues to be represented in the media in the context of discussions about the active ending of life.
The artificial separation of curative care and palliative care means that people are sometimes reluctant to recommend or receive palliative care because it infers an acceptance of inevitable death. However, there is now an increasing recognition that many people actively seek life-prolonging therapy while simultaneously requiring palliative care. In the future, especially with an ageing population, palliative care will be more closely integrated into the acute care of people with chronic life-limiting illness. Nurses who work with chronic illness will therefore require an increasing level of palliative-care knowledge. The goal
FRAMING PALLIATIVE CARE
of this book is to transcend settings of care and diagnosis in setting out a knowledge base that is applicable to all.
In facing the challenges of promoting the best care for people at the end of life, and support for those who are significant to them, nurses will find this approach to palliative care useful in understanding need and in promoting palliative-care practices in all environments.
Alan Pearson
Professor Alan Pearson is head of nursing in the School of Nursing and Midwifery, La Trobe University, Melbourne (Victoria, Australia). Alan has extensive experience in nursing practice, nursing research, and academic nursing. Having qualified as a registered nurse in 1969, he has practised in a range of nursing fields in the United Kingdom, Papua New Guinea, and Australia. He has been an active researcher since 1981 and has conducted a large number of research projects in the fields of aged care, nursing history, and organ donation. Alan was instrumental in establishing the Joanna Briggs Institute for Evidence Based Nursing (of which he is currently the director) and is the foundation director of the newly established Australian Centre for Evidence Based Residential Aged Care. He has played a leading role in promoting research of evidence-based practice in Australia, New Zealand, and Hong Kong. Alan is editor of the International Journal of Nursing Practice and has published 20 books and numerous journal articles. He is active in developing and promoting nursing at the state, national, and international levels.
Chapter 2
Evidence-Based Practice in Palliative Care
Alan Pearson
Introduction
In the industrialised world, all areas of the health-care system are facing increasing demands and an escalation in costs. Governments and health-care professionals have responded to this in a variety of ways. Some responses focus on cost-cutting—by rationing services, by introducing measures to increase productivity, and by imposing cost-shifting exercises. This has involved serious ethical discussions of what can be afforded and what cannot, and the development of processes to provide essential health services to those who most need it. Some responses promote a ‘user-pays’ approach, and others simply blame others!
Another response is that of evidence-based practice (EBP). The emergence of EBP has led, in most Western countries, to a focus on best practice, based on the best available evidence.
This chapter provides an overview of the development of EBP, considers the processes of EBP, and discusses its limitations in palliative care. The view presented here is that clinical performance and professional judgment in the
PALLIATIVE CARE NURSING
‘information age’ must increasingly be based on exposure to summarised evidence and that, in the not-too-distant future, practice that is not based on a consideration of the evidence will be difficult to justify.
EBP: What is it?
Simply defined, EBP is a combination of individual clinical professional expertise with the best available external evidence to produce practice that is most likely to lead to a positive outcome for the person receiving care. Although medicine and nursing are the health-care occupations that are most advanced in the EBP movement, the ideas and arguments are common to all professionals who work in health care.
‘Professional judgment in the ‘information age’ must increasingly be based on exposure to summarised evidence ... practice that is not based on a consideration of the evidence will be difficult to justify.’
Sackett et al. (1996) have contended that evidence-based medicine (EBM) had its philosophical origins in the mid nineteenth century in Paris. They defined it as being ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (p. 71).
The establishment of the Cochrane Collaboration stemmed from the work of A.L. Cochrane. He drew attention to the lack of information about the effects of health care, with particular reference to medicine, and suggested (Cochrane 1979) that it is:
... surely a great criticism of our profession that we have not organised a critical summary by specialty or sub-specialty adapted periodically of all relevant randomised controlled trials.
Cochrane argued that, because resources for health care are limited, they should be used effectively to provide care that has been shown, in valid evaluations, to result in desirable outcomes. He emphasised the importance of randomised controlled trials in providing reliable information on the effectiveness of medical interventions.
The development of EBM has been rapid—led by Professor David Sackett, formerly of McMaster University in Canada, and now of the University of Oxford, England. EBM has been defined by Sackett and colleagues (1996, p. 71) as:
EVIDENCE-BASED PRACTICE
The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.
Sackett and Rosenberg (1995) have suggested that EBM is concerned with five linked ideas:
◗ that clinical and other health-care decisions should be based on the best patient-based, population-based, and laboratory-based evidence;
◗ that the nature and source of the evidence to be sought depends on the particular clinical question;
◗ that the identification of the best available evidence requires the application of epidemiological, economic, and biostatistical principles, together with a consideration of the relevant pathophysiology in the context of personal experience;
‘EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.’
◗ that this identification and appraisal of the evidence must be acted upon; and
◗ that there should be continuous evaluation of performance. The Cochrane Collaboration provides systematic reviews of randomised controlled trials with respect to specific medical conditions, specific client groups, and specific interventions by health professionals. Such a systematic review of any given topic involves:
◗ determining the objectives and eligibility criteria for including trials;
◗ identifying studies that are likely to meet the eligibility criteria;
◗ tabulating the characteristics of, and assessing the methodological quality of, each study identified;
◗ excluding studies that do not meet the eligibility criteria;
◗ compiling the most complete set of data feasible, involving the investigators if possible;
◗ analysing the results of eligible studies, using a meta-analysis or statistical synthesis of data if appropriate and possible;
◗ performing sensitivity analyses if appropriate and possible; and
◗ preparing a structured report of the review that states the aims of the review, describes the materials and methods used, and reports the results.
The Cochrane Collaboration caters for other interests, including nonmedical groups. In the health-care field, it assists certain categories of healthservice users, different groups of health professionals, various health-care settings, and certain classes of intervention. The involvement of nurses is, however, just beginning to occur in most Western countries.
There is a small but growing body of literature on EBP in nursing. Much of the work has originated in the United Kingdom (UK), but there is a growing awareness of the importance of the subject in the United States of America (USA). In Australia, there has been considerable development of infrastructure underpinning evidence-based nursing, and there is an increasing amount of work on EBP in nursing, emanating largely from the Joanna Briggs Institute for Evidence Based Nursing & Midwifery (JBI) and its collaborating centres in Adelaide, Perth, Darwin, Toowoomba, Brisbane, Sydney, and Melbourne (where there are two centres). The institute also has collaborating centres in Auckland (New Zealand) and Hong Kong (China).
EBP in palliative care
Because the EBP movement has, in the past, focused on effectiveness, and because it has elevated the randomised controlled trial as the ‘best’ generator of evidence, many practitioners are critical of the wide application of evidence-based approaches to palliative care. As Higginson (1999, p. 462) has asserted, palliative care is essentially focused on ‘a person centered approach ... It focuses on both the quality of life remaining to patients and supporting their families and those close to them’. Keeley (1999, p. 1448) has criticised the current overemphasis on the use of evidence, and has asked:
... if our loved one is dying and wishes to die at home, how much evidence do we need that skilled home nursing available around the clock would be a good idea?
Although it is true that the randomised trial is frequently an inappropriate method for the study of palliative-care interventions, it remains useful for many. Grande et al. (1999) reported on a randomised controlled trial designed to establish the relationship between the utilisation of a ‘hospital-at-home’ service and the place of death. Their findings suggested that there is no difference in the place of death between patients admitted to hospital and those who participate in a hospital-at-home program. They noted, however, that the randomised controlled trial is problematic in palliative care in terms of: (i) sample recruitment; (ii) the ethical difficulties associated with randomisation;
(iii) the complexities of collecting data from palliative-care patients and their significant others; and (iv) the difficulties of standardising intervention and control conditions.
Fitch et al. (1995) have argued for the adoption of evidence-based approaches to those areas of palliative-care nursing that require an evidence base, and have argued that these approaches be drawn from international research to work towards ‘best practice’. They have suggested that there is a wide range of interventions for which such good evidence exists to inform the decision-making of palliative-care practitioners. For example, Gerson and Triadafilopoulos (2000) reviewed the care of people requiring palliative care for pain control, for the management of oral and skin ulcerations, for the control of nausea and vomiting, and for the treatment of psychological problems associated with inflammatory bowel disease. The review took an evidence-based approach and ranked the evidence to support various care interventions. The study included evidencebased algorithms for the management of pain and nausea in patients with inflammatory bowel disease.
Although there are large areas of palliative-care practice that will always rely on the professional judgment of the practitioner, this professional judgment will increasingly need to be seen to be informed by the best available evidence. Although the best available evidence might be a distillation of the practical experience of expert practitioners, some interventions will increasingly have a strong evidence base upon which to draw.
‘Care decisions ultimately balance the needs and desires of individual patients and their families with the judgment of the caring practitioners in the light of the best available evidence.’
EBP does not imply that practitioners should slavishly follow the recommendations of a systematic review or those of an evidence-based set of guidelines. Care decisions ultimately balance the needs and desires of individual patients and their families with the judgment of the caring practitioners in the light of the best available evidence.
Health care practices and evidence-based guidelines
In response to high-profile initiatives of governments and provider agencies, health professions are increasingly embracing the use of evidence-based guidelines to inform (rather than direct) practice.
In the USA, considerable resources have been invested in high-quality, high-cost research and development programs with a view to developing appropriate clinical guidelines. The US National Institutes of Health now have a well-established strategy for reviewing international literature, and conduct meta-analyses to generate clinical guidelines based on best available evidence.
In the UK, recent policy initiatives have directed health-care provider agencies to develop research and development (R&D) strategies, to establish R&D units, and to promote practices based on the best available knowledge. The British government has also established a number of centres for EBP, supported by health research centres such as the Kings Fund.
At an international level, the Cochrane Collaboration has linked R&D sites across the world to review and analyse randomised clinical trials from an international perspective. The Cochrane Collaboration also generates reports to inform practitioners and influence practice, and acts as a resource in the development of consensus guidelines.
As a result of these and other developments, the practical application of rigorously reviewed evidence is now promoted through the development and dissemination of practice guidelines in most developed health-care systems. Clinical practice guidelines, systematically developed on the basis of consensus within expert groups, consist of statements to assist the decisions of practitioners and patients regarding appropriate health care in specific clinical circumstances. An increasing number of well-constructed, practical, evidence-based guidelines is being developed, with most of this activity emanating from the USA.
EBP is now almost institutionalised in most industrialised countries, especially in Europe, the UK, North America, and Australasia. Many of these regions have established centres for evidence-based health care, medicine, and nursing. There are, for example, Cochrane centres in all of these regions. In addition, specific centres exist for evidence-based nursing in the UK, North America, and Australia. The JBI, based in Australia, has collaborating centres in China and New Zealand.
Evidence-based practice in Australia and New Zealand
Policy-makers and health services in Australia began to focus on EBP some years ago and several developments have occurred in this area.
The Health Advisory Committee of the National Health and Medical Research Council (NH&MRC) funds the Australasian Cochrane Centre. The
EVIDENCE-BASED PRACTICE
centre draws on the methodology and findings of the international Cochrane Collaboration to promote EBM in Australia and New Zealand. Drawing on this work, the translation of reviews into clinical practice guidelines has developed rapidly in Australia. The establishment of a national guidelines development program was first proposed by the National Health Strategy, as one of five major activities of a national focus on quality and effectiveness. This followed an earlier survey of health professional organisations in Australia by the National Health Strategy to determine whether guidelines were being developed and, if so, for which purposes. In its interim report, the Professional Indemnity Review noted that clinical practice guidelines have potential to improve the quality of services and set standards (DHHCS 1992).
In 1992, the Australian Health Ministers’ Advisory Council agreed to work with the NH&MRC to develop a process for promoting best practice linked to outcomes and effective cost-management, including the development of clinical practice guidelines. In the 1995/96 Commonwealth budget, funding for clinical practice guideline development was built into the National Hospitals Outcomes Program.
The Quality of Care and Health Outcomes Committee (QCHOC) of the NH&MRC encourages and facilitates clinical colleges and other groups to develop guidelines and outcome measures. The QCHOC has stated that the development of clinical practice guidelines should be carried out within a context of worldwide concerns about:
◗ documented and unjustifiable variations in practice for similar conditions;
◗ increasing availability of new treatments and technology;
◗ lack of knowledge about effectiveness of interventions in terms of patient health outcomes; and
◗ the rising cost of health care.
‘Development of clinical practice guidelines should be carried out within a context of worldwide concerns.’
Several guidelines have been developed on the basis that the health system should focus on the outcomes of patient care. The NH&MRC has recommended that clinical practice guidelines be developed through a multidisciplinary approach that includes contributions from all relevant clinicians, representatives of consumers, and other key groups and disciplines. Guidelines should provide information on the best investment for the best health outcomes, and should include an economic appraisal. They should identify known exceptions or risks,
and identify the specific patient populations to which they apply. They must be comprehensive and flexible enough to apply to diverse settings and circumstances.
The multidisciplinary development process should define and recommend processes to encourage adoption of the guidelines. Implementation strategies could use the education and communication links of appropriate colleges, professional organisations, and consumer groups, and should seek to be incorporated into quality-assurance processes. They should include consideration of confidentiality and privacy (which might otherwise inhibit implementation), identify other barriers to implementation, and ensure that incentives and support for dissemination and implementation are linked to accountability.
The systematic review
The core of EBP is a systematic review of the literature on a particular condition, intervention, or issue. Such a systematic review is essentially an analysis of all of the available evidence in the literature, together with a judgment of the effectiveness of a practice. The process developed by the Cochrane Collaboration involves three steps:
◗ planning the review;
◗ the review protocol; and
◗ assessing the quality of a research report.
Planning the review
Planning of the review begins with an initial search of the Cochrane Library, especially the Database of Abstracts of Reviews of Effectiveness (DARE), to establish whether or not a recent review report exists. If this is the case, permission is sought from the originators of the existing review to use it to develop a practice information sheet. If the topic has not been the subject of a systematic review, a review protocol is developed.
The review protocol
As in any research endeavour, the development of a rigorous research proposal or protocol is vital for a high-quality systematic review, and a similar approach is required for a focused reading program. The review protocol provides a predetermined plan to ensure scientific rigour and minimise potential bias. It also allows for periodic updating of the review if necessary. Figure 2.1 (page 17) shows the format of the JBI review protocol described here. Protocol development involves:
◗ a background review;
◗ objectives;
◗ inclusion criteria;
◗ search strategy;
◗ assessment criteria;
◗ data extraction; and
◗ data synthesis. Each of these is considered below.
Background review
The initial step is to undertake a quick, general evaluation of the literature to determine the scope and quantity of the primary research, to search for any existing reviews, and to identify issues of importance.
Objectives
As with any research, it is important to have a clear question. The protocol should state in detail the questions or hypotheses that will be pursued in the review. Questions should be specific regarding the patients, setting, interventions, and outcomes to be investigated.
Inclusion criteria
‘As with any research, it is important to have a clear question ... regarding the patients, setting, interventions, and outcomes to be investigated.’
The protocol must describe the criteria that will be used to select the literature. The inclusion criteria should address the participants of the primary studies, the intervention, and the outcomes. In addition to this, it should also specify the research methodologies that will be considered for inclusion in the review (for example, randomised controlled trials, clinical trials, case studies, and so on).
Search strategy
The protocol should provide a detailed strategy that will be used to identify all relevant literature within an agreed timeframe. This should include databases and bibliographies that will be searched, and the search terms that will be used.
Assessment criteria
It is important to assess the quality of the research to minimise the risk of an inconclusive review resulting from excessive variation in the quality of the
PALLIATIVE CARE NURSING
studies. The protocol must therefore describe how the validity of primary studies will be assessed and any exclusion criteria based on quality considerations.
Data extraction
It is necessary to extract data from the primary research regarding the participants, the intervention, the outcome measures, and the results. Examples of sheets developed for this purpose are shown in Figure 2.2 (page 18) and Figure 2.3 (page 19) and should be included as part of the protocol.
Data synthesis
It is important to combine the literature in an appropriate manner when producing a report. Statistical analysis (meta-analysis) might or might not be used, depending on the nature and quality of studies included in the review. Although it might not be possible to state exactly what analysis will be undertaken, the general approach should be included in the protocol. The approach might be a statistical analysis. However, for some reviews, a narrative summary will suffice.
The format of the JBI review protocol is reproduced in Figure 2.1 (page 17).
Assessing the quality of a research report
A structured assessment process is used to evaluate the quality of the literature. The structured format used by the JBI is shown in Figures 2.2 (page 18) and 2.3 (page 19). There is one format for research (which follows a randomised control design) and one for research (which is observational in nature).
Effectiveness, appropriateness, and feasibility
To date, the EBP movement has focused on evidence of effectiveness. Although agreeing that EBP includes such an interest in research into effectiveness, Pearson (1998, pp 25–6) has argued that it is not confined to this:
... evidence-based practice is not exclusively about effectiveness; it is about basing practice on the best available evidence ... randomised trials are the gold standard for phenomena that we are interested in studying from a cause-and-effect perspective, but clearly they are not the gold standard if we are interested in how patients and nurses relate to each other, or if we are interested in how patients live through the experience of radiotherapy when they have a life-threatening illness. We have yet to
THE JOANNA BRIGGS INSTITUTE FOR EVIDENCE BASED NURSING
Review Protocol
TITLE: BACKGROUND:
OBJECTIVES:
CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW:
Types of Participants:
Types of Intervention:
Types of Outcome Measures:
SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES: METHODS OF THE REVIEW: Selecting Studies for Inclusion:
Assessment of Quality:
Methods Used to Collect Data From Included Studies:
Methods Used to Synthesise Data:
Date Review to Commence: Date Review to Complete:
Figure 2.1
JBI review protocol Courtesy Joanna Briggs Institute
work out how to assess the quality of alternative approaches to research other than the RCT [randomised control trial].
The diverse nature of problems in palliative care means that a diversity of research methodologies is required. Methodological approaches need to be eclectic enough to incorporate both the classical medical and scientific designs and the emerging qualitative action-oriented approaches from the humanities
Checklist for Assessing Validity of Experimental Studies
Ref No. ..........
Experimental Studies YesNo (if no use other checklist)
Was the assignment to treatment groups really random? YesNo
Were participants blinded to treatment allocation? YesNo
Was allocation to treatment groups concealed from allocator? YesNo
Were the outcomes of people who withdrew described and included in the analysis (i.e. was the analysis by intention to treat)? YesNo
Were those assessing outcomes blind to the treatment allocation? YesNo
Were the control and treatment groups comparable at entry? YesNo
Were groups treated identically other than for the named interventions? YesNo
Were outcomes measured in the same way for all groups? YesNo
Were outcomes measured in reliable way? YesNo
Was an appropriate statistical analysis used? YesNo
Summary TOTAL Yes ______ No ______ ?
COMMENTS
Figure 2.2
JBI checklist for assessing validity of experimental studies
Courtesy Joanna Briggs Institute
and the social and behavioural sciences. The development of interdisciplinary research and greater understanding of the relationships among medical, nursing, and allied health interventions are also fundamental to the emergence of research methodologies that are relevant and sensitive to the health needs of the community.
There is a small, although growing, body of literature on the role of qualitative research in EBP, and there is an emerging recognition of a need to move beyond the effectiveness of interventions. Their appropriateness and practical feasibility also need to be considered.
Checklist for Assessing the Validity of Observational Studies
Ref No. ..........
Observational Studies YesNo (if no use other checklist)
Is the study based on a random or pseudo-random sample? YesNon/a
Are the criteria for inclusion in the sample clearly defined? YesNon/a
Were outcomes assessed using objective criteria? YesNon/a
If comparisons are being made, was there sufficient description of the groups? YesNon/a
Was an appropriate statistical analysis used? YesNon/a
Summary
COMMENTS
Figure 2.3
JBI checklist for assessing the validity of observational studies
Courtesy Joanna Briggs
Institute
Lemmer, Grellier and Steven (1999), in conducting a systematic review in the area of health visiting, focused on the assumption that the randomised controlled trial (RCT) should be taken as the ‘gold standard’. They reported a paucity of such trials in the field under study, and argued that clinical complexity demands the integration of qualitative methods into systematic reviews. They argued (1999, p. 323) that the ‘comprehensiveness and synthesis of a systematic review are more important to emphasise than whether the literature is outside the clinical remit of an RCT’.
The need to integrate the results of qualitative research more fully into the systematic process was well argued by Popay (1998, p. 32), who asserted that ‘there are many proponents of evidence-based decision making within health care who cannot and/or will not accept that qualitative research has an important part to play’. She went on to insist that qualitative research does more
PALLIATIVE CARE NURSING
than simply enhance quantitative studies, and stated that qualitative research is capable of generating evidence that:
◗ explores practices that are taken for granted;
◗ increases understanding of consumer and clinical behaviour;
◗ develops interventions;
◗ illuminates patients’ perceptions of quality and appropriateness;
◗ gives guidance to understanding organisational culture and change management; and
◗ evaluates complex policy initiatives.
In the same vein, Green and Britten (1998, p. 1230) have noted that qualitative studies might appear to be:
... unscientific and anecdotal to many medical scientists. However, as the critics of evidence-based medicine are quick to point out, medicine is more than the application of scientific rules.
Green and Britten (1998, p. 1231) went on to argue that qualitative research provides rigorous accounts of treatment regimens in everyday contexts and that there is an increasing need within EBP for an awareness that different research questions require different kinds of research. They were unequivocal in asserting that ‘ ... “good” evidence goes further than the results of meta-analysis of randomised controlled trials’.
‘Medicine is more than the application of scientific rules.’
The Cochrane Qualitative Methods Network, established in 1998, is currently exploring the scope for incorporating qualitative research into Cochrane reviews, and a number of protocols and checklists has been developed by the group (Qualitative Methods Network 1999).
However, there are still no internationally reviewed approaches to assessing the quality of specific qualitative methods, and no accepted method of rating or ranking qualitative research findings reported in the literature. Nevertheless, there have been several attempts to synthesise the results of similar qualitative studies (as a form of meta-analysis), and these have been well described by Sandelowski, Docherty and Emden (1997). These authors have also developed an indepth theoretical approach to the systematic metasynthesis of qualitative findings, while maintaining the integrity of individual studies. Drawing on this work, together with that of the Cochrane Qualitative Methods Network and that of Popay (1998) and Lemmer, Grellier and Steven (1999), an approach to qualitative research could be developed that takes account of qualitative metaanalysis, quality assessment, and the development of a quality rating scale. This
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Again he raised his impassioned voice. Lepraylya, however, turned upon him fiercely.
"Peace!" she cried. "I bid you, peace—yes, even you, O Brendaldoombro, High Priest of Drome though you are!
"What! You would still make of this room a shambles, stain the very throne of your queen with human blood!"
"They are not human!" he shrieked. "They are demons that have assumed the bodies of men!"
A murmur of superstitious horror arose.
"Ho, guard!" cried the queen. "Guard, ho!"
It is my belief that some cool-headed gentleman had bethought himself of the guard before ever the queen, for it was only a few moments before a score or so of armed men had entered the room and taken a position, in the form of a semicircle, before the throne.
The eyes of Lathendra Lepraylya were blazing like that great jewel on her brow. Those eyes were fixed upon Brendaldoombro, and I actually thought that the old raptor quailed a little under that look of outraged majesty. If this was indeed so, it was for an instant or two only. His look, one of baffled fury, then became fixed and defiant.
"So!" said Lathendra Lepraylya. "What madness is this that I see? What blood-howl is this that I hear? No woman or man in Drome may be deprived of liberty or life without a fair trial; and yet you, yes, even you, O Brendaldoombro, are here striving to make a shambles of the very throne itself."
She raised her hand and pointed toward us.
"If these men are indeed—"
"They are not men!" the old villain shouted. "They are demons who have taken the human shape, to attain here in Drome some fell purpose. Death, I say! Death to these masqueraded devils! Let death be swift and—"
"Peace, I say!" exclaimed Lepraylya, stamping her sandaled foot. "And, if these men from the World Above are indeed but devils
counterfeit, could we kill them, O Brendaldoombro? Since when can mere man kill a devil?"
"When they are in the human shape, he can! Death! Death to these fiends who—"
"One can kill their bodies only," interrupted the queen, "and it may be that he can not do even that much."
"Their bodies only? What more," demanded Brendaldoombro, "can one do to any woman or man? Death! Death to these demons!"
"Their spirits would be but loosed from the body, O Brendaldoombro, to move unseen in the air about us, and they could then—if, that is, they really are devils—the more easily achieve their nefarious designs."
"They would be harmless then!" came the ready answer. "They are helpless save when they are in the human form."
"Since when?" queried Lepraylya, her eyes widening in surprise. "Since when did the minions of the Evil One become helpless unless in human shape?"
"You misapprehend, O Lathendra Lepraylya. These belong to a most peculiar order, to a most rare species of bad angel. And," cried Brendaldoombro, "they are the worst devils of all! Death to them before it is too late! Let us—"
"Have justice," said Lepraylya, "as we hope for mercy and justice in that dread day when every human soul—even yours, O Brendaldoombro—must stand and be judged for the sins it has done in the flesh. No human being may be condemned in Drome without trial; and I believe that Lord Milton and Lord Bill are true men, O Brendaldoombro, and no demons. And you would slay them, murder them, these the first men from the World Above, as you would slay a gogrugron—if you did not fear it, O Brendaldoombro. Who knows what message they bring to us? Now they stand silent; but, when they will have learned our language, then we shall learn that which is now so dark and so mysterious."
"Dark and mysterious indeed!" cried the high priest. "Signs and portents have been given us, warning us of what is to follow if we harbor these demons amongst us. And I tell you, O Lathendra Lepraylya, you and all Drome shall rue this day if you heed not the dread warnings of the wrath Divine. Darkness I see! Yes, I see, darkness! And earth-shocks! The roof of our world crashing down! Calamities that will overwhelm all Drome and—" "Silence!" Lepraylya commanded. "Silence, croaker of evil! One would almost think, O Brendaldoombro, that you know more about the angels of the Evil One than you do about God's own. Hear now my word:
"When Lord Bill and Lord Milton can answer the charge that they are demons masquerading in the shapes of men, then, O Brendaldoombro, and not before, shall they be brought to trial—if, indeed, you will prefer that charge against them then.
"Such is my word to you, O Brendaldoombro, and to you, ladies and lords all, and on the majesty of the Droman law and of the dread law of God it stands."
Chapter 43
DRORATHUSA
And so it was that we reached, there in the palace of the Droman queen, our journey's and—certainly a stranger journey than any I ever have heard of and one that ought to prove of even greater interest to scientists than to the world in general.
If, however, what they tell of the region is true, an expedition to the mysterious land that the Dromans call Grawngrograr would make our journey to Drome look like a promenade to fairyland.
But our journey ended there in the palace, and now it is that my story rapidly draws to a close.
Probably you will think that, there under the aegis of Lathendra Lepraylya, we found ourselves in clover. And, in a way, this was undoubtedly so. We were given each a splendid suite of rooms in the palace itself, and our lives were as the lives of princes, save that the close protective guard always kept over us was a reminder that there was such a personage in the world as one Brendaldoombro.
If it had not been for that vulture-shadow, how wonderful those days would have been!
But that shadow was there, and it never lifted. And the worst of it was that everything was involved in the deepest gloom and mystery, what with our ignorance of the Droman language. Forsooth, however, had we been masters of that language, we could not have known the plots that were hatching in the dark skull of Brendaldoombro.
As for the language, we were studying it with diligence, and we really had cause to be astonished at the rapidity of our progress.
As to the high priest, crafty and consummate villain though he was, that worthy found that Lathendra Lepraylya was quite his match and more than his match, as, indeed, was Drorathusa. Against the queen he was, of course, powerless to take any repressive measure; but the case was very different with regard to Drorathusa. He could act in this way, and he did.
She was sent to a distant, lonely, forsaken place on the very outskirts of the kingdom, or, to be precise, queendom. According to all accounts, that spot is really a terrible one. Drorathusa was, in fact, in exile, though Brendaldoombro did not like to hear any one call it that. But almost everybody did or regarded it as such, and there were murmurs, not only amongst the Droman people, but even amongst those priestesses and priests whom the old villain had counted upon to applaud his every word and act.
Nor did time still those murmurs. On the contrary, they grew louder, more persistent. Brendaldoombro was learning that it is one thing to send a person into exile and quite another to banish that person from the popular esteem. Nor did he stop at banishment; he had recourse to the assassin's dagger and the arts of the poisoner But, in all these attempts upon the life of Drorathusa, he was thwarted by the agents of the queen. Lepraylya knew her opponent, and had at once taken measures to safeguard the life of the exiled priestess, who held as high a place in the esteem of her sovereign as she did in the hearts of the people.
How strange it seems to be writing of things like these in this the Twentieth Century, the Golden Age of Science! But, as I believe I have already remarked, Science hasn't discovered everything yet. This is a stranger, a more wonderful, a more mysterious old globe than even Science herself dreams it to be.
When our acquisition of the language became a real one, we began to learn something of the science of Drome and to impart a knowledge of the wonderful science of our own world. Never shall I forget the amazement of the queen and those learned men of Drome when Rhodes brought his mathematics into play. Problems that only a Droman Archimedes could solve and that only after much labor
(what with their awful notation) Rhodes solved, presto—just like that! So unwieldly was the system of notation employed by these Hypogeans that even their greatest mathematicians had been able to do no more than roughly approximate pi.
When Rhodes proceed to the solution of trigonometrical problems, their amazement knew no bounds. And, when he explained to them that all they had to do to become masters of such problems was to discard their cumbersome notation and adopt the simple numerals used by ourselves—well, I do actually believe that that was the straw that broke the back of Brendaldoombro's power! For (strange though it may seem to a world that is more interested in any kind of abracahokum, and especially any kind of political jiggumbob, than it is in science) that brought over to our side virtually every learned man in Drome and a majority of the people themselves. Nor should I forget the priestesses and the priests. Your average Droman is much interested in all things of a scientific nature, and no one more so than the true priestess or priest, though there are, of course, some lamentable exceptions.
Yes, clearly we were men and not demons, else never would we have brought such wonders as these to offer them as gifts to the Dromans.
But old Brendaldoombro had his answer ready. "Instead," said he, "that proves that they are not men; only devils could be such wizards!"
I have often wondered what dark thoughts would have passed through that dark brain of his had he been there the day that Milton Rhodes showed Lathendra Lepraylya, all those learned men and all those grand lords and ladies (ladies and lords, a Droman would say) the marvels of a steam-engine. Yes, there the little thing was, only two feet or so high but perfect in all its parts, puffing away merrily, and puffing and puffing, and all those Dromans looking on in wonder and delight.
Even as we sat there, came word that Brendaldoombro was dead. He had died suddenly and painlessly just after placing his hand in
blessing on the head of a little child.
Well, they gave him a magnificent funeral.
Peace to his soul.
On the death of the Droman high priest (or priestess) a successor is chosen, in the great temple in the Golden City, by a synod composed of exactly five hundred, the majority of whom are usually priestesses. On the very first ballot, Drorathusa (who was already on her way back from her lonely place of exile) was chosen.
Priestesses and priests, I should perhaps remark, are free to marry, unless they have taken the vow of celibacy. This (voluntarily, of course) many of them do. Drorathusa, by the way, had not done so.
Came, at last, the day when Milton Rhodes told me that he was going to be married—to Lathendra Lepraylya herself. The news, however, was not wholly unexpected.
Well, every man of us can't marry a queen—though of queans there are plenty.
I take the following from my journal:
"They were married today, about ten o'clock, in the great temple; and a very grand wedding it was, too. Drorathusa herself spoke the words that made them man and wife, for the sovereign of Drome can be married by the high priestess or priest only.
"Now, as she proceeded with the ceremony, which was a very long one, I thought that that pale face of Drorathusa's grew paler still and that a distraught look was coming into her eyes. Then I told myself that it was only a fancy. But it was not fancy. For of a sudden her lip began to tremble, her voice faltered, the look in her eyes suddenly became wild and helpless—and she broke down.
"A moment or two, however, and that extraordinary woman had got control over herself again.
"She motioned the attendant priestesses and priests aside; a wan smile touched her lips as she pressed a hand to her side and said:
"'It was just my heart—but I am better now.'
"She at once proceeded with the ceremony, voice and features under absolute control. Again she was Drorathusa the Sibylline.
"And so they were married And may they live happy and very happily ever after!"
And then, after the great nuptial banquet in the palace, off went the happy pair in the queen's barge for Lella Nuramanistherom, a lovely royal seat some thirty miles down the river; whilst I betook myself to the solitude of my rooms, there to ponder on the glad-sad lot of man, to hear over and over, and over again, those low tragic words:
"It was just my heart—but I am better now."
"Amor," says Saint Jerome, "ordinem nescit."
Beautiful, Sibylline, noble, poor Drorathusa!
Chapter 44
WE SEE THE STARS
When facing the dangers, mysteries, horrors (and other things) of our descent to this strange and wonderful subterranean land of Drome, how often did I say to myself:
"If ever I get out of this, never anything like it again!"
And I truly believed it at the time, though I should have known better I should have known—I did know that adventure and mystery have inexplicable and most dreadful charms. Indeed, the more fearful the Unknown, the more eager a man (one who has heard the Siren song which adventure and mystery sing) is to penetrate to its secret places—unless, indeed, the charms of some Lepraylya or Drorathusa entwine themselves about the heart. In my case—well, Amor ordinem nescit.
Here was I in the Golden City; here was everything, it would seem to another, that could conduce to contentment, to that peace of mind which is dearer that all. And yet I was restless and very unhappy.
And the Unknown was calling, calling and calling for me to come. To what? Perhaps to wonders the like of which Science never has dreamed. Perhaps to horrors and mysteries from which the imagination of even a Dante or a Doré would shrink, would flee in mad terror—things nameless, worse than any seen in a horrible dream.
But I wanted to go. Yes, I would go. I would go into that fearful land of Grawngrograr—discover its mysteries or perish in the attempt.
And I am going, too. That journey has not been abandoned, only delayed. It was like this.
I was drawing up, in my mind, tentative plans (my purpose was yet a secret) when one day Milton Rhodes came in, and, after smiling in somewhat enigmatic fashion for some moments, he suddenly asked:
"I say, Bill, how would you like to see the stars, the sun again?"
"The sun? Milton, what do you mean?"
"That I am going back to the surface, out onto the snow and ice of Rainier, back to Seattle. I thought that you would want to go along."
"What in the world," I exclaimed, "are you going back for?"
"There are many things that we ought to have here in Drome; a book of logarithms, the best that I can get, is one of them. We'll get those things, or as many as we can, for it would, of course, be impossible to bring them all. We'll wind up our sublunary affairs, and, hurrah, then back to Drome! What do you say to that, old tillicum?"
"What does Lepraylya say?"
"That I may go; otherwise, of course, there would be no going. At first she wouldn't even hear of it. She feared that it might be impossible for us to maintain secrecy—that some of our precious politicians might get down into Drome. I am sure she believes that the kingdom would have more to fear from half a dozen of those sons of Proteus than from an army of sixty thousand men. And, bless her heart, when I think of some of their blunders, asininity, hypocrisy, lying, stupidity, coat-turning and sheer insanity, I am of opinion that there is not much exaggeration, if any, in that idea of hers.
"But I have at last gained her consent. With our large party, there can not be any danger."
I was not sure of that, but I kept those thoughts to myself.
"Of course, I want to go," I told him. "But I want to come back to Drome."
"Most assuredly, Bill, we'll come back to Drome."
"But," said I, "there is something that I don't understand."
"Which is what?"
"We can't keep our great discovery a secret. And, as soon as our world has it, adventurers, spoilers, crooks, thieves and worse will come swarming down that passage. We'll loose upon our poor Dromans a horde of Pizarros."
"Did I think for one single moment that what you say, or anything like it, would follow, never one step would I take towards the sun. You say that we can not keep the discovery of Drome a secret; we can, and we will—until such time as it will not matter. We will come out onto the glacier in the nighttime. Our ways of egress—I suppose we'll have to tunnel our way out through the ice, that there will not be any accommodating crevasse—will be most carefully concealed. No one will see us come out. No one will know of our journeys to and from the Tamahnowis Rocks, for they will be made under cover of darkness. No one will know
"Fortunately, by the way, as it now turns out," he added, "when we adopted the Droman dress, we did not throw away our pants et cetera, and so, though those clothes are somewhat the worse for wear, our appearance up there on Mount Rainier will cause no remark."
"But our showing up at home," I said, "after so long an absence will cause plenty of remarks and more than remarks. How will we answer all the questions that they will surely ask us?"
"Tut, tut!" smiled Milton. "If all our difficulties could be so easily resolved as that!"
"But how will we do it?"
"We won't answer them, Bill; we'll keep them guessing."
"But suppose we find that Scranton has let out something that will give them a pretty good idea as to what has happened?"
"That might be bad," answered Rhodes. "But I have every confidence in Scranton's discretion. He will, I feel sure, maintain that utter silence which I requested, until the period designated expires. Possibly he may never tell what he knows.
"I believe, however," he went on, "that we ought to leave the world, our world, a record of the discovery. I will set down to the extent that time permits those things which, in my opinion, will interest the scientific world. As for the discovery itself, the journey and our adventures, yours, Bill, is the hand to record that."
"A record?" I exclaimed. "Then why all this secrecy, this moving under cover of darkness and pussy-footing around if you are going to broadcast the discovery of Drome to the whole world?"
"Because we will then have left that world and the way to this will have been blasted up and otherwise closed."
"That," I told him, "will never keep them out."
"I believe that it will. And, if any one ever does find his way down, he'll never return to the surface; he'll spend the rest of his days here in Drome, even if he lives to be as old as Methuselah. Be sure that you put that into the record! The Dromans are human, and so they are not quite saints. But their land is never going to be infested with plunderers or any of our sons of Proteus if I can prevent it, and I feel confident that I can.
"This closing of the way will not mean complete isolation. At any rate, I hope that it will not. For I feel confident that ere very long the two worlds will
communicate with each other by radio. There is a possibility, too, though that possibility is indeed a very remote one, that each will even see, by means of television, the inhabitants and the marvels of the other."
One or two weird things befell us during our return journey, but time presses and I can not pause to record them here.
The party was composed of picked men, one of whom was Ondonarkus. We had one ape-bat.
This going up was a more difficult business, I want to tell you, than our going down had been. There was one consolation: we did not get lost.
Onward and upward we toiled, and at last, on the 28th of June, we reached the Tamahnowis Rocks. Thanks to Rhodes' chronometer-watch and the very careful record which he had kept, we knew the very hour.
This was about ten o'clock in the morning. The way out was completely blocked by the ice. Cool air, however, was flowing in through fissures and clefts in the walls and the roof of the tunnel.
We waited until along towards midnight, for fear some one might be about, that some sound might reveal the secret of the rock.
It was about ten o'clock when we began to dig our way out through the ice. The tunnel was not driven out into the glacier but up alongside the rock wall, through the edge of the ice-stream.
Hurrah! At last our passage was through!
And, as old Dante has it,
"Thence issuing we again beheld the stars."
[1] Zandara by John Martin Leahy, Fantasy Publishing Company, Inc., 1953.
[2] This surmise of Mr. Carter's is correct. The above quotation is taken from a modernized Anatomy of Melancholy. Burton, though from what Latin writer he took the words I can not say, wrote:
"Animis haec scribo, non auribus." Darwin Frontenac.
[3] Sick Moon: Old Moon in the Chinook jargon. Darwin Frontenac.
[4] "At this time (November, 1843) two of the great snowy cones, Mount Regnier and St Helens, were in action On the 23rd of the preceding November, St. Helens had scattered its ashes, like a white fall of snow,
over the Dalles of the Columbia, 50 miles distant A specimen of these ashes was given to me by Mr Brewer, one of the clergymen at the Dalles " Fremont
[5] "When the bridge at Colebrook Dale (the first iron bridge in the world) was building, a fiddler came along and said to the workmen that he could fiddle their bridge down The builders thought this boast a fiddle-de-dee, and invited the itinerant musician to fiddle away to his heart's content. One note after another was struck upon the strings until one was found with which the bridge was in sympathy. When the bridge began to shake violently, the incredulous workmen were alarmed at the unexpected result, and ordered the fiddler to stop." Prof. J. Lovering.
[6] "It has been calculated that at the depth of 35 miles, air, subjected to the pressure of a column of matter of the mean density of that at the surface of the earth, would acquire the density of water; that at the depth of 173 miles, water itself, which is eminently incompressible, would acquire the density of marble; and at the centre, marble would have a density 119 times greater than at the surface But the comparatively small mean density of the mass [of the earth] proves that none of these effects take place " Brande
[7] "The cases are certainly not numerous where marine currents are known to pour continuously into cavities beneath the surface of the earth, but there is at least one well-authenticated instance of this sort that of the mill streams at Argostoli in the island of Cephalonia It has been long observed that the sea water flowed into several rifts and cavities in the limestone rocks of the coast, but the phenomenon has excited little attention until very recently. In 1833, three of the entrances were closed, and a regular channel, sixteen feet long and three feet wide, with a fall of three feet, was cut into the mouth of a larger cavity. The sea water flowed into this canal, and could be followed eighteen or twenty feet beyond its inner terminus, when it disappeared in holes and clefts in the rock."
George P. Marsh: Man and Nature.
[8] "Considering that the mean density of the whole earth is only about five and a half times that of water, and that the materials of which the crust of the earth is composed are all compressible in a greater or less degree, so that even at no very great depth the density of the different substances must be greatly increased by the mere pressure of the superincumbent materials, some philosophers have supposed that the effects of pressure must be counterbalanced by the expansive force of a great heat subsisting in the interior of the earth; and others that the earth is not solid, but merely a hollow shell of inconsiderable thickness " Brande
[9] "One dark night, about the beginning of December, while passing along the streets of the Villa de Natividada, I observed some boys amusing themselves with some luminous object, which I at first supposed to be a kind of large fire-fly; but on making inquiry, I found it to be a
beautiful phosphorescent Fungus, belonging to the genus Agaricus The whole plant gives out at night a bright phosphorescent light, of a pale greenish hue, similar to that emitted by the larger fire-flies, or by those curious soft-bodied marine animals, the Pyrosomae From this circumstance, and from growing on a palm, it is called by the inhabitants 'Flor de Coco.' The light given out by a few of these Fungi in a dark room was sufficient to read by."—George Gardner.
[10] "The Chevalier d'Angos, a learned astronomer, carefully observed, for several days, a lizard with two heads, and assured himself that this lizard had two wills independent of each other, and possessing nearly equal power over the body, which was in one. When a piece of bread was presented to the animal, in such a manner that it could see it with one head only, that head wished to go towards the bread, while the other head wished the body to remain still " Voltaire
[11] See In Amundsen's Tent, by John Martin Leahy, in August Derleth's anthology called The Sleeping and the Dead, page 386. Darwin Frontenac
[12] "A very decided luminosity has been observed to proceed from dissecting-room subjects, the light thus evolved being sufficient to render the forms of the parts (which are peculiarly bright), almost as distinct as in the daylight Three cases are recorded by Sir H Marsh, in which an evolution of light took place from the living body The light in each case is described as playing around the face, but not as directly proceeding from the surface; and in one of these instances, which was recorded by Dr D Donovan, not only was the luminous appearance perceptible over the head of the patient's bed, but luminous vapours passed in streams through the apartment." Dr. Carpenter.
[13] "The very children, it is said, pointed to their foreheads as he passed, being taught to regard him as a kind of madman " Irving
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