Generation Y nurses in Quebec, faced with high levels of psychological distress because of their exposure to difficult nursing work environments, might leave the profession thereby exacerbating an already salient nursing shortage.

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Context. In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.Objectives. To review: delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium. Methods.We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO and CINAHL) to inform this narrative review.Results. The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health care staff, clear communication, education and emotional support are vital components to assist with decision making and direct the treatment care plan. Conclusion.Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement are needed in this patient population.

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Many western industrialized countries are currently suffering from a crisis in health human resources, one that involves a debate over the recruitment and licensing of foreign-trained doctors and nurses. The intense public policy interest in foreign-trained medical personnel, however, is not new. During the 1960s, western countries revised their immigration policies to focus on highly-trained professionals. During the following decade, hundreds of thousands of health care practitioners migrated from poorer jurisdictions to western industrialized countries to solve what were then deemed to be national doctor and nursing 'shortages' in the developed world. Migration plummeted in the 1980s and 1990s only to re-emerge in the last decade as an important debate in global health care policy and ethics. This paper will examine the historical antecedents to this ethical debate. It will trace the early articulation of the idea of a 'brain drain', one that emerged from the loss of NHS doctors to other western jurisdictions in the 1950s and 1960s. Only over time did the discussion turn to the 'manpower' losses of 'third world countries', but the inability to track physician migration, amongst other variables, muted any concerted ethical debate. By contrast, the last decade's literature has witnessed a dramatically different ethical framework, informed by globalization, the rise of South Africa as a source donor country, and the ongoing catastrophe of the AIDS epidemic. Unlike the literature of the early 1970s, recent scholarship has focussed on a new framework of global ethics.