Palliative care by family physicians in the 1990s. Resilience amid reform.
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OBJECTIVE: To explore issues family physicians face in providing community-based palliative care to their patients in the context of a changing health care system. DESIGN: Focus groups. SETTING: Small (< 10,000 population), medium-sized (10,000 to 50,000), and large (> 50,000) communities in Nova Scotia. PARTICIPANTS: Twenty-five men and women physicians with varying years of practice experience in both solo and group practices. METHOD: A semistructured approach was used, asking physicians to reflect on recent palliative care experiences in order to explore issues of care. MAIN FINDINGS: Five themes emerged from the discussions: resources needed, availability of family support, time and money supporting physicians' activities, symptom control for patients, and physicians' emotional reactions to caring for dying patients. CONCLUSION: With downsizing of hospitals and greater emphasis on community-based care, the issues identified in this study will need attention, particularly in designing an integrated service delivery model for palliative care. (+info)
Introducing death: a 15th century Croatian Glagolitic literary text.
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We explored the notions of life and death as perceived and presented in a 15th century Croatian literary text, Slovo Mestra Polikarpa, in which master Polikarp, a well-learned man of medieval times, engages in a lengthy dialogue with Death itself. This contrast/debate is a rare piece of medieval literature, not only by its Old Croatian language, but also by the angular Glagolitic script in which it was written. As a part of Croatian cultural heritage, it is deeply rooted in and clearly belongs to the common context of Western European medieval views on life, health, ailing, and death. A medieval perspective on such issues might be interesting to broad readership and, in many aspects, to medical professionals, whose everyday practice necessarily involves not only practical and scientific, but also moral, philosophical, and religious deliberations about life and death. (+info)
Facilitating end-of-life decision-making: strategies for communicating and assessing.
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End-of-life decision-making is often a difficult process and one that many elderly patients and their families will undergo. The grounded theory study of nurses, physicians, and family members (n = 20) reported in this article examined provider behaviors that facilitated the process of decision-making near the end of patients' lives. According to participants, providers who are experienced and comfortable are more likely to engage in communication and assessment strategies that facilitate end-of-life decision-making. Communication strategies included: being clear, avoiding euphemisms, spelling out the goals and expectations of treatment, using words such as "death" and "dying," and being specific when using such words as "hope" and "better." Assessment strategies included: assessing patients' physical conditions and end-of-life wishes, patients' and family members' understandings of the disease and prognosis, and their expectations and goals. An important first step for improved care is making explicit the provider's communicating and assessing strategies that facilitate end-of-life decision-making. (+info)
The human cadaver in the age of biomedical informatics.
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Major national and international critiques of the medical curriculum in the 1980s noted the following significant flaws: (1) over-reliance on learning by rote memory, (2) insufficient exercise in analysis and synthesis/conceptualization, and (3) failure to connect the basic and clinical aspects of training. It was argued that the invention of computers and related imaging techniques called to question the traditional instruction based on the faculty-centered didactic lecture. In the ensuing reform, which adopted case-based, small group, problem-based learning, time allotted to anatomical instruction was severely truncated. Many programs replaced dissection with prosections and computer-based learning. We argue that cadaver dissection is still necessary for (1) establishing the primacy of the patient, (2) apprehension of the multidimensional body, (3) touch-mediated perception of the cadaver/patient, (4) anatomical variability, (5) learning the basic language of medicine, (6) competence in diagnostic imaging, (7) cadaver/patient-centered computer-assisted learning, (8) peer group learning, (9) training for the medical specialties. Cadaver-based anatomical education is a prerequisite of optimal training for the use of biomedical informatics. When connected to dissection, medical informatics can expedite and enhance preparation for a patient-based medical profession. Actual dissection is equally necessary for acquisition of scientific skills and for a communicative, moral, ethical, and humanistic approach to patient care. Anat Rec (New Anat) 269:20-32, 2002. (+info)
Identifying and managing preparatory grief and depression at the end of life.
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Grief and depression present similarly in patients who are dying. Conventional symptoms (e.g., frequent crying, weight loss, thoughts of death) used to assess for depression in these patients may be imprecise because these symptoms are also present in preparatory grief and as a part of the normal dying process. Preparatory grief is experienced by virtually all patients who are dying and can be facilitated with psychosocial support and counseling. Ongoing pharmacotherapy is generally not beneficial and may even be harmful to patients who are grieving. Evidence of disturbed self-esteem, hopelessness, an active desire to die and ruminative thoughts about death and suicide are indicative of depression in patients who are dying. Physicians should have a low threshold for treating depression in patients nearing the end of life because depression is associated with tremendous suffering and poor quality of life. (+info)
Cross-cultural similarities and differences in attitudes about advance care planning.
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OBJECTIVE: Culture may have an important impact on a patient's decision whether to perform advance care planning. But the cultural attitudes influencing such decisions are poorly defined. This hypothesis-generating study begins to characterize those attitudes in 3 American ethnic cultures. DESIGN: Structured, open-ended interviews with blinded content analysis. SETTING: Two general medicine wards in San Antonio, Texas. PATIENTS: Purposive sampling of 26 Mexican-American, 18 Euro-American, and 14 African-American inpatients. MEASUREMENTS AND MAIN RESULTS: The 3 groups shared some views, potentially reflecting elements of an American core culture. For example, majorities of all groups believed "the patient deserves a say in treatment," and "advance directives (ADs) improve the chances a patient's wishes will be followed." But the groups differed on other themes, likely reflecting specific ethnic cultures. For example, most Mexican Americans believed "the health system controls treatment," trusted the system "to serve patients well," believed ADs "help staff know or implement a patient's wishes," and wanted "to die when treatment is futile." Few Euro Americans believed "the system controls treatment," but most trusted the system "to serve patients well," had particular wishes about life support, other care, and acceptable outcomes, and believed ADs "help staff know or implement a patient's wishes." Most African Americans believed "the health system controls treatment," few trusted the system "to serve patients well," and most believed they should "wait until very sick to express treatment wishes." CONCLUSION: While grounded in values that may compose part of American core culture, advance care planning may need tailoring to a patient's specific ethnic views. (+info)
Cross sectional survey of parents' experience and views of the postmortem examination.
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OBJECTIVE: To describe parents' experience and views of the postmortem examination after the loss of a baby. DESIGN: Cross sectional survey. SETTING: Hospital with a dedicated bereavement counselling service, Newcastle upon Tyne. PARTICIPANTS: 258 women who had attended a bereavement counselling service at the Royal Victoria Infirmary, Newcastle upon Tyne, on at least one occasion after losing a baby during pregnancy or infancy, between October 1996 and October 2000. METHOD: Self completion postal questionnaire incorporating fixed choice and open ended questions. MAIN OUTCOME MEASURES: Number of respondents who were asked if they would agree to a postmortem examination of their baby, and number who agreed to a postmortem examination; reasons for agreeing and not agreeing to a postmortem examination; quality of explanation received; number who regretted their decision to give or withhold consent for a postmortem examination. RESULTS: 166 (64%) respondents completed the questionnaire. Of these, 148 (89%) had been asked to agree to a postmortem examination on their baby and 120/148 of these respondents (81%) agreed, most of whom recognised benefits resulting from the examination. 101/117 (86%) respondents believed the findings had been explained appropriately. Nine (7%) of the 120 respondents who had agreed to a postmortem examination regretted their decision. Of the respondents who refused an examination, four (14%) had regrets about their decision. DISCUSSION: Parents viewed the postmortem examination as a useful and necessary tool in helping to discover the reasons why their baby had died. Simplifying the language used to explain findings may further raise parents' understanding of the value of the postmortem examination and ensure that they are satisfied with it. Medical staff involved in consent for postmortem examinations should be fully trained in how to ask for parental consent, the postmortem examination procedure, and how to explain the findings. (+info)
Death, dying and donation: organ transplantation and the diagnosis of death.
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Refusal of organ donation is common, and becoming more frequent. In Australia refusal by families occurred in 56% of cases in 1995 in New South Wales, and had risen to 82% in 1999, becoming the most important determinant of the country's very low organ donation rate (8.9/million in 1999). Leading causes of refusal, identified in many studies, include the lack of understanding by families of brain death and its implications, and subsequent reluctance to relegate the body to purely instrumental status. It is an interesting paradox that surveys of the public continue to show considerable support for organ donation programmes--in theory we will, in practice we won't (and don't). In this paper we propose that the Australian community may, for good reason, distrust the concept of and criteria for "whole brain death", and the equation of this new concept with death of the human being. We suggest that irreversible loss of circulation should be reinstated as the major defining characteristic of death, but that brain-dead, heart-beating entities remain suitable organ donors despite being alive by this criterion. This presents a major challenge to the "dead donor rule", and would require review of current transplantation legislation. Brain dead entities are suitable donors because of irreversible loss of personhood, accurately and robustly defined by the current brain stem criteria. Even the dead are not terminally ill any more. (+info)