Against all odds: positive life experiences of people with advanced amyotrophic lateral sclerosis

Coping and end-of-life decision-making in ALS: A qualitative interview study

How do people with amyotrophic lateral sclerosis (PALS) deal with their diagnosis and engage in end-of-life decision-making? What informational or supportive needs do they have for counselling about life-sustaining treatment and end-of-life care? Which correlating conditions and influences relate to these needs and how do they connect to the wish to die or wish to live? We conducted a qualitative interview study with 13 people with ALS in Germany from March 2019 to April 2021. Data collection and analysis followed a grounded theory-based approach and revealed close relationships between coping, informational needs and the preparedness for decision-making. We identified the coping strategies 'avoid thinking about end-of-life' and its counterpart, 'planning ahead to be well-prepared,' and differentiated the latter into the patterns 'withdrawing from life and taking precautions against life-prolongation' and 'searching for a new meaning in life and preparing for life-sustaining treatment'. The approaches are based on individual perceptions, attitudes and motives and can be positively/negatively reinforced by healthcare professionals (HCP), family and other interpersonal networks, but also by disease progression and in reaction to health care services. Type and degree of needs concerning information and counselling differed according to coping strategies. These strategies may vary over time, resulting in different support needs. Our findings signify that deep insight is needed into PALS' coping processes to understand their decision-making about life-sustaining treatment. Healthcare professionals should be sensitive to illness experiences beyond medical aspects and foster coping as a biographical process to better support people with ALS.

Flexibility to manage and enhance quality of life among people with motor neurone disease

OBJECTIVES

To identify influential factors for quality of life (QoL) among individuals with motor neurone disease (MND) and explore how regulatory flexibility and psychological flexibility may contribute towards maintaining and improving QoL.

METHODS

Semi-structured interviews were conducted with 26 individuals with MND. Thematic analysis, using both inductive and deductive analyses, was employed to examine subjective QoL in view of previous understanding of QoL.

RESULTS

Four factors were important for the QoL of participants: perceived illness prognosis, sense of self, concerns for significant others, and life to enjoy. These factors reflected psychological stress caused by MND, the participant's value system, and their beliefs about life. In optimising QoL, both regulatory flexibility and psychological flexibility were essential to maintain and enhance QoL. Often, regulatory flexibility was perceived among those employing a mindful approach, and psychological flexibility was found to involve savouring positive experiences.

CONCLUSIONS

People with MND reported that seeking ways to both maintain and enhance their QoL is crucial, and that this may be accomplished by increasing flexibility through mindfulness and savouring. (171/200 words)Implications for rehabilitationPeople with motor neurone disease (MND) seek to maintain quality of life (QoL) following changes caused by the condition, whilst attempting to enhance QoL by maximising their positive experiences.Regulatory flexibility is essential to maintain QoL and it was closely associated with mindful approach so that MND is not perceived as an inevitable threat to QoL.Psychological flexibility was found to enhance QoL and it involves savouring positive experiences, while abandoning fault-finding of the current situation.Positive inter-personal interactions can encourage people with MND to engage with mindfulness and savouring for favourable outcomes in terms of QoL; current support services should orient towards both mindfulness and savouring.

Refining items for a preference-based, amyotrophic lateral sclerosis specific, health-related quality of life scale

Objective: The aim of this study was to refine the items of a preference-based amyotrophic lateral sclerosis health-related quality of life scale (PB-ALS HRQL scale) based on domains generated in a previous study. Methods: Survey methodology was used to assess item importance rating (IR) and independence. Median importance was calculated for each item and a rating of "very important" was required for the item to remain. Correlations were used to examine item independence. Highly correlated items (r_s > 0.7) were considered for removal. Cognitive debriefing (CD) interviews, conducted by Zoom, telephone, or email based on participant preference and communication needs, were used to identify potential issues. Participants provided feedback about wording, clarity, response options, and recall period on randomly selected items. Items were considered finalized when three sequential CD participants approved the item with no revisions. Results: Thirty-four people with ALS (PALS, n = 16 females; age range 44-78 years; ALS Functional Rating Scale-Revised [ALSFRS-R] range 0-48) in Canada completed the survey; a subset of 18 PALS completed CD interviews (n = 8 female; age range 44-71 years; ALSFRS-R range 0-48). Four items were highly correlated with one or more items, were not rated as very important, or were not approved via CD and were removed. Conclusions: The final four-response option PB-ALS Scale includes eight items: recreation and leisure, mobility, interpersonal interactions and relationships, eating and swallowing, handling objects, communicating, routine activities, and mood. The next step is to translate the PB-ALS Scale into French and develop a scoring algorithm based on PALS' preferences.

"Imagine You Have ALS": Death Education to Prepare for Advance Treatment Directives

The study presents the results of qualitative research carried out within a death education project dedicated to advance treatment directives (ATDs) in which it was proposed to participants to empathize with people who had received a diagnosis of Amyotrophic Lateral Sclerosis (ALS). The study involved 104 people who discussed and reflected on issues related to the knowledge of having to die, palliative care and ATDs, investigating what choices they would have made if they had received such a diagnosis. Finally, they were asked to write a paper describing their impressions and hypothetical choices. Qualitative analysis has elucidated among fundamental themes. Four thematic areas emerged from the data analysis: (1) ATDs and the family; (2) the importance of reducing pain and suffering; (3) emotions and considerations regarding death, illness and spirituality; and (4) opinions on the DeEd course. It has emerged that some people are unfamiliar with palliative care or the right to self-determination and that addressing these issues helps manage the thought of the future with less terror. The experience of death education has therefore proven to be very positive in dealing with complex and often censored issues, allowing thinking about death in a less distressing way.

Measuring coping in people with amyotrophic lateral sclerosis using the Coping Index-ALS: A patient derived, Rasch compliant scale

OBJECTIVE

The progressively disabling and terminal nature of ALS/MND imposes major coping demands on patients. We wished to improve the psychometric properties of our previously published MND-Coping Scale, so that parametric analyses were valid, and to make it simpler for patients to complete and clinicians to score.

METHODS

After a new qualitative analysis of 26 patients with ALS/MND, the draft Coping Index-ALS (CI-ALS) was administered to 465 additional patients, alongside COPE-60, General Perceived Self Efficacy scale, and WHOQOL-BREF. Validity of the CI-ALS was assessed using the Rasch model. External validity was checked against comparator measures.

RESULTS

Thirteen centres contributed 465 patients, mean age 64.9 years (SD 10.8), mean disease duration 28.4 months (SD 37.5). The CI-ALS-Self and CI-ALS-Others both satisfied Rasch model expectations and showed invariance across age, gender, marital status and type of onset. Expected correlations were observed with comparator scales. A nomogram is available to convert the raw scores to interval level measures suitable for parametric analysis.

CONCLUSIONS

Coping abilities in ALS/MND can now be measured using a simple 21 item self-report measure, offering two subscales with a focus of 'coping by self ' and 'coping with others'. This allows clinicians to identify individuals with poor coping and facilitates research on interventions that may improve coping skills.

Transitions in Amyotrophic Lateral Sclerosis: Patient and Caregiver Experiences

BACKGROUND

Amyotrophic lateral sclerosis (ALS) presents many transitions for persons/people with ALS (PwALS) and their caregivers. Transitions are passages from one life phase, condition, or status to another. We used qualitative methods to understand how PwALS and caregivers experience transitions throughout their ALS journey.

METHODS

PwALS and their caregivers were recruited from a multidisciplinary ALS clinic in Edmonton, Canada. We recruited patients at the stage of ALS that home mechanical ventilation, a feeding tube, and/or assistive communication technology had been offered. Semi-structured interviews were audio-recorded, transcribed, and analyzed using qualitative thematic analysis.

RESULTS

We interviewed 14 PwALS and 15 caregivers and identified 5 recurring themes. The importance of community was identified by many PwALS and caregivers who expressed feelings of loneliness and isolation. Most caregivers were spouses and couples navigated a change in their relationship roles as one spouse transitioned to becoming a caregiver while the other transitioned to dependency. The caregiver spouses reported a sense of "total responsibility" that encompassed continual vigilance for the PwALS's well-being, managing their household and finances. PwALS and caregivers reported transitioning to reliance on life-sustaining medical devices; early adoption and information on these devices increased their quality of life. Participants also wanted more and earlier information on advanced care planning. PwALS and caregivers identified adapting to new forms of communication as a necessity.

CONCLUSION

ALS presents many transitions for PwALS and caregivers. Understanding these transitions is important for ALS healthcare professionals who seek to implement best care practices.

The double sides of hope: The meaning of hope among amyotrophic lateral sclerosis (ALS) patients

Hope is an important factor in coping and adjusting to life-threatening disease. In this study, we examined the meaning of hope among people with amyotrophic lateral sclerosis (ALS). Semi-structured interviews with 12 people revealed that hope had two contradictory meanings. For some, hope was considered an obstacle to achieving control and to actively cope with the disease. Alternatively, other people with ALS regarded hope as a crucial resource, which empowered their coping and control. These findings are discussed in the context of research and theoretical literature about hope and coping processes.

Stable long-term BCI-enabled communication in ALS and locked-in syndrome using LFP signals

Restoring communication for people with locked-in syndrome remains a challenging clinical problem without a reliable solution. Recent studies have shown that people with paralysis can use brain-computer interfaces (BCIs) based on intracortical spiking activity to efficiently type messages. However, due to neuronal signal instability, most intracortical BCIs have required frequent calibration and continuous assistance of skilled engineers to maintain performance. Here, an individual with locked-in syndrome due to brain stem stroke and an individual with tetraplegia secondary to amyotrophic lateral sclerosis (ALS) used a simple communication BCI based on intracortical local field potentials (LFPs) for 76 and 138 days, respectively, without recalibration and without significant loss of performance. BCI spelling rates of 3.07 and 6.88 correct characters/minute allowed the participants to type messages and write emails. Our results indicate that people with locked-in syndrome could soon use a slow but reliable LFP-based BCI for everyday communication without ongoing intervention from a technician or caregiver. NEW & NOTEWORTHY This study demonstrates, for the first time, stable repeated use of an intracortical brain-computer interface by people with tetraplegia over up to four and a half months. The approach uses local field potentials (LFPs), signals that may be more stable than neuronal action potentials, to decode participants' commands. Throughout the several months of evaluation, the decoder remained unchanged; thus no technical interventions were required to maintain consistent brain-computer interface operation.

Quality of Life for People with Motor Neurone Disease: A Consideration for Occupational Therapists

Motor neurone disease (MND) is a rapidly progressive neurological disease of unknown cause, which results in relentless loss of function and, conversely, high levels of disability. There has been a significant increase in quality of life (QoL) literature in recent years and the philosophy of the occupational therapy process may be considered consistent with the QoL construct. However, little is documented in occupational therapy literature that promotes consideration of the QoL construct in practice. This may be explained by the profession's adherence to the medical model of health care intervention.

Expectations and desires continually shift for people with MND and individual-perceived QoL is determined by a continuous process of adjustment to increasing disability. In order to promote wellbeing, occupational therapists must identify what people with MND consider important in their lives.

Occupational Disruption: Living with Motor Neurone Disease

Little is known of the day-to-day experience of living with motor neurone disease from the perspective of those who have it, apart from what can be found in personal accounts such as those published on web pages. In this study, which was informed by phenomenology, seven people living in an urban setting in New Zealand were asked to describe their experiences.

This report focuses on the study findings that related specifically to disruption to occupation. It describes how early changes in occupational performance alerted the participants to the fact that something was wrong. The findings also showed the pervasive impact of an awkward and unreliable body on participation in occupations that gave meaning to life, expressed identity and filled time. Issues of how the family's world was changed, the introduction of assistive devices into their homes and the betrayal of trust were also powerfully evident in participants' stories.

Although the findings are broadly consistent with those of previous studies, the disruption to occupation and the consequent role losses are new findings. Further research into the impact of the loss of participation in occupation, the ways in which people are perceived when occupations are disrupted and the experience of having occupations taken away prematurely is recommended.

What are the Care Needs for People with Motor Neurone Disease and How Can Occupational Therapists Respond to Meet These Needs?

Motor neurone disease is a fatal neurodegenerative disorder and from disease onset health care intervention is palliative in nature. Numerous studies on wellbeing in motor neurone disease are consistent with the palliative care literature, where the values assigned to non-physical life domains increase with disease progression. Occupational therapists should consider all components of wellbeing for people with motor neurone disease and not physical disability alone. A better understanding of motor neurone disease and an awareness of the service needs important to this client group are necessary to improve the quality of care and to assist occupational therapists in meeting care needs.

Population screening for spinal muscular atrophy: A mixed methods study of the views of affected families

Autosomal recessive conditions are a significant health burden with few treatments. Population carrier screening has been suggested as a means to tackle them. Little is known about the views of affected families despite the potential for direct impacts on them. Data are presented on attitudes among families affected by Spinal Muscular Atrophy (SMA) toward two population screening programs, pre-conception, and prenatal. Data were gathered through qualitative interviews (n = 36) and a survey (n = 337). Eighty-two survey participants had SMA and 255 were family members. The majority were in favor of screening (75%). Reasons for supporting pre-conception screening support were a belief that it would reduce SMA-related terminations and raise awareness of SMA in the population. For prenatal screening, reasons for support included a belief in the importance of informed decision-making and the need to reduce suffering. Key reasons for non-support of pre-conception screening included concerns about carrier stigmatization and social engineering. For prenatal screening, concerns focused on the collateral loss of high quality of life lives affected by SMA. This study highlights that those affected by SMA are predominantly in favor of screening, although pre-conception screening is most favored. While family members and adults with SMA had largely consistent views, perceptions varied according to the severity (type) of SMA, with those affected by SMA type II the least likely to support screening. These findings suggest that screening for SMA is a complex issue for affected families, underscoring the need to consider and include their views when planning and implementing screening programs. © 2016 Wiley Periodicals, Inc.

A Comparative Study of Variables That Have an Impact on Noncancer End-of-Life Diagnoses

By way of analysis of variance, this secondary analysis compared three groups of noncancer home hospice patients (AIDS, amyotrophic lateral sclerosis [ALS],and other) for psychological correlates of adaptation and well-being, pain, and physical function, as measured by the Life Closure Scale (LCS), the Affect Balance Scale, the McGill-Melzack Pain Questionnaire Part I, and the Karnofsky Performance Status Scale. The sample included 10 AIDS patients (Group 1), 6 ALS patients (Group 2), and 5 patients with other noncancer, end-stage diseases (Group 3). A significant difference was found between Group 2 (ALS) and Group 3 (other) on the LCS, F(2, 18) = 4.3, p = .03. Scheffe and Duncan range post hoc tests and at test at the p≤.05 level (t9 = 4.1, p = .003) confirmed the finding. No significant group differences were found among the ALS, AIDS, and other groups in measures of psychological well-being, pain, and physical function.

Developing brain-computer interfaces from a user-centered perspective: Assessing the needs of persons with amyotrophic lateral sclerosis, caregivers, and professionals

By focus group methodology, we examined the opinions and requirements of persons with ALS, their caregivers, and health care assistants with regard to developing a brain-computer interface (BCI) system that fulfills the user's needs. Four overarching topics emerged from this analysis: 1) lack of information on BCI and its everyday applications; 2) importance of a customizable system that supports individuals throughout the various stages of the disease; 3) relationship between affectivity and technology use; and 4) importance of individuals retaining a sense of agency. These findings should be considered when developing new assistive technology. Moreover, the BCI community should acknowledge the need to bridge experimental results and its everyday application.

Patients experiences of maintaining mental well-being and hope within motor neuron disease: a thematic synthesis

Research is required that can synthesize the experiences of patients with Motor Neuron Disease (MND). One value of being able to do this is to understand the psychological experiences and processes involved in maintaining mental well-being and hope. A qualitative thematic synthesis of studies was undertaken. Studies were electronically searched from inception until June 2014. Twenty-nine studies with 342 (175 male) unique individuals with MND were identified. Five themes were identified: (1)The effects of the disease on interactions, relationships, roles and meaningful activities, (2) Responses that relate to the expression of hope, (3) Factors which disable hope, (4) Factors which enable hope, and (5) Cognitive and Practical adaptation that enabled hope, control and coping. Finally, a model of hope enablement was identified that considers the psychological pathways undertaken by a patient which influence mental well-being and hope. Within this review article evidence is provided which illustrates the central importance of relationships and social support for individuals with MND. Further, it has been identified that periods of coping are possible and are likely associated with greater mental well-being for patients with MND.

Spirituality and/or religious faith: A means for coping with the effects of amyotrophic lateral sclerosis/motor neuron disease?

OBJECTIVE

The notion of spirituality/religious belief is recognized internationally as a domain within end-of-life care and is important in patients' and carers' quality-of-life. When faced with incurable illness, patients often become more philosophical about their life; many seek comfort in spiritual or religious philosophies. Our intention was to understand how personal spirituality and religious faith might help those living with amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) cope with their impending death.

METHOD

Unsolicited narratives (internet and print-published) written by individuals diagnosed with the terminal condition of ALS/MND were analyzed thematically. Narratives from 161 individuals diagnosed with ALS/MND written over a period of 37 years (from 1968 to 2005) were included.

RESULTS

Our findings reveal that religious faith sustains and helps people to avoid despair, and personal spirituality helps them make sense of what is happening to them.

SIGNIFICANCE OF RESULTS

The use of personal narratives by people with ALS/MND has provided a vehicle for sharing their deepest spiritual and religious thoughts with others. The place of spirituality and religious faith within ALS/MND care should not be underestimated. Assessment of religious or spiritual needs should become a routine part of practice and is the responsibility of all members of the multidisciplinary team.

A systematic review of qualitative studies on adjusting after stroke: lessons for the study of resilience

PURPOSE

To synthesize qualitative studies on adjusting after stroke, from stroke survivors' and carers' perspectives, and to outline their potential contribution to an understanding of resilience.

METHODS

A systematic review of qualitative studies in peer reviewed journals from 1990 to 2011 was undertaken. Findings from selected studies were summarized and synthesized and then considered alongside studies of resilience.

RESULTS

Forty studies were identified as suitable. These suggested that the impact of stroke was felt on many dimensions of experience, and that the boundaries between these were permeable. Nor was stroke as an adverse "event" temporally bounded. Adjustment was often marked by setbacks and new challenges over time. Participants identified personal characteristics as key, but also employed practical and mental strategies in their efforts to adjust. Relationships and structural factors also influenced adjustment after stroke.

CONCLUSIONS

The impacts of stroke and the processes of adjusting to it unfold over time. This presents a new challenge for resilience research. Processes of adjustment, like resilience, draw on personal, inter-personal and structural resources. But the reviewed studies point to the importance of an emic perspective on adversity, social support, and what constitutes a "good" outcome when researching resilience, and to a greater focus on embodiment. Implications for Rehabilitation Stroke is a sudden onset condition which for around a third of people has long-term consequences. Stroke can cause a variety of physical and cognitive impairments, some of which may not be obvious to an outsider. As well as physical functioning, stroke can have a profound effect on survivors' sense of self and on their relationships. Stroke survivors' accounts suggest that relationships (including relationships with health care professionals) and structural factors (such as access to health services, employment possibilities and welfare systems) mediate efforts to adjust after stroke. While there is considerable overlap between notions of adjustment and resilience, the experiences of stroke survivors suggest further issues that need to be addressed in order to gain a more comprehensive understanding of resilience.

What influences patient decision-making in amyotrophic lateral sclerosis multidisciplinary care? A study of patient perspectives

BACKGROUND

Patients with amyotrophic lateral sclerosis (ALS) are required to make decisions concerning quality of life and symptom management over the course of their disease. Clinicians perceive that patients' ability to engage in timely decision-making is extremely challenging. However, we lack patient perspectives on this issue. This study aimed to explore patient experiences of ALS, and to identify factors influencing their decision-making in the specialized multidisciplinary care of ALS.

METHODS

An exploratory study was conducted. Fourteen patients from two specialized ALS multidisciplinary clinics participated in semistructured interviews that were audio recorded and transcribed. Data were analyzed for emergent themes.

RESULTS

Decision-making was influenced by three levels of factors, ie, structural, interactional, and personal. The structural factor was the decision-making environment of specialized multidisciplinary ALS clinics, which supported decision-making by providing patients with disease-specific information and specialized care planning. Interactional factors were the patient experiences of ALS, including patients' reaction to the diagnosis, response to deterioration, and engagement with the multidisciplinary ALS team. Personal factors were patients' personal philosophies, including their outlook on life, perceptions of control, and planning for the future. Patient approaches to decision-making reflected a focus on the present, rather than anticipating future progression of the disease and potential care needs.

CONCLUSION

Decision-making for symptom management and quality of life in ALS care is enhanced when the patient's personal philosophy is supported by collaborative relationships between the patient and the multidisciplinary ALS team. Patients valued the support provided by the multidisciplinary team; however, their focus on living in the present diverged from the efforts of health professionals to prepare patients and their carers for the future. The challenge facing health professionals is how best to engage each patient in decision-making for their future needs, to bridge this gap.

Sense making and benefit finding among patients with amyotrophic lateral sclerosis and their primary caregivers

The associations of sense making and benefit finding with depressive symptoms were examined among patient and caregiver pairs coping with Amyotrophic Lateral Sclerosis. Benefit finding, but not sense making, was associated with fewer depressive symptoms for both patients and caregivers. Patient and caregiver pairs where neither found benefit had more depressive symptoms compared to pairs where at least one member found benefit. Patients cited benefits related to relationships and caregivers were more likely to cite finding personal strength as a benefit. Results suggest situational constraints to making sense and on the kinds of benefit that can be found.

Psychopathology in amyotrophic lateral sclerosis: A preliminary study with 27 ALS patients

Considering the few studies published on the psychopathology of ALS patients, we carried out a preliminary study evaluating depression, anxiety, emotional reactions and coping strategies in such patients. Twenty-seven ALS patients were included and evaluated using a semi-structured interview, after which they were asked to complete a questionnaire. The rater asessed the DSM-IV criteria for a major depressive episode, dysthymia and generalized anxiety, using the MADRS scale for depression, the Covi anxiety scale and the Depressive Mood scale. Subsequently, patients completed the Ways of Coping checklist. Patients were neither anxious nor depressed. Patients whose diagnosis was recent (less than six months) presented greater emotional deficit. Patients younger than 50 years of age used problem focused strategies more frequently. Those having received the diagnosis in the preceeding six months used emotion focused strategies significantly more often.The absence of characterized depression and anxiety confirmed results of the literature. The significance of this study is found in the observation of specific emotional reactions present in the first six months following diagnosis disclosure. The results show that it is useful to continue the affective evaluation of these patients and to undertake longitudinal studies starting at the time of diagnosis disclosure.

The role of mindfulness in positive reappraisal

Mindfulness meditation is increasingly well known for therapeutic efficacy in a variety of illnesses and conditions, but its mechanism of action is still under debate in scientific circles. In this paper, we propose a hypothetical causal model that argues for the role of mindfulness in positive reappraisal coping. Positive reappraisal is a critical component of meaning-based coping that enables individuals to adapt successfully to stressful life events. Mindfulness, as a metacognitive form of awareness, involves the process of decentering, a shifting of cognitive sets that enables alternate appraisals of life events. We review the concept of positive reappraisal in transactional stress and coping theory, then describe research and traditional literature related to mindfulness and positive reappraisal, and detail the central role of mindfulness in the reappraisal process. With this understanding, we present a causal model explicating the proposed mechanism. The discussion has implications for clinical practice, suggesting how mindfulness-based integrative medicine interventions can be designed to support adaptive coping processes.

[The lived experience of struggling against illness for patients with amyotrophic lateral sclerosis]

PURPOSE

The purpose of this study was to identify and describe phenomenological structures of the lived experience of struggling against an illness for patients with Amyotrophic Lateral Sclerosis (ALS).

METHODS

The participants were 7 patients with ALS recruited by snowball sampling who agreed to participate in this research and could verbally communicated with the researcher. Data were collected by long term-repeated interviews with participants in their own homes. Data were analyzed using Colaizzi's method of phenomenology.

RESULTS

Four categories were extracted as follows: 'Being seized with fear of death', 'Living a marginal life', 'Accepting hard fate', and 'Clinging to faint life'. Seven theme clusters were identified as: 'Wandering to find a healing method with ominous signs in the body', 'Having a diagnosis of ALS is like a bolt from the blue and struggling against illness with faint hope', 'Being forced out to the edge of life with anguish', 'Filling one's heart with hatred and longing toward becoming estranged from the world', 'Living with stigma as a stumbling block with bitter grief in one's heart', 'Accepting every things as one's fate with self controlled fear of death', and 'Attaching to desire to live'.

CONCLUSION

The results of this study can be used to develop the programs to support patients with ALS and their family.

Experiences of loss and chronic sorrow in persons with severe chronic illness

AIMS AND OBJECTIVES

The aims of the present study were to describe losses narrated by persons afflicted with severe chronic physical illness and to identify the concomitant occurrence of chronic sorrow.

BACKGROUND

Reactions connected with repeated losses are referred to in the literature as chronic sorrow, which has recently been described in conjunction with chronic illness.

DESIGN

A qualitative study with an abductive approach of analysis, including both inductive and deductive interpretations.

METHOD

The study is based on 30 persons of working age with average disease duration of 18 years. The average age was 51 years. All of the persons had personal assistance for at least three months because of considerable need for help in daily life due to physical disability. Each person was interviewed twice. There was also an independent assessment of the deductive results concerning chronic sorrow.

RESULTS

The inductive findings show that all persons had experienced repeated physical, emotional and social losses. Most common were 'Loss of bodily function', 'Loss of relationship', 'Loss of autonomous life' and 'Loss of the life imagined'. 'Loss of identity' included the loss of human worth, dignity and a changed self-image. In addition, the deductive findings suggest that chronic sorrow exists in the study population. Sixteen of 30 participating subjects were assessed by both assessors to be in a state of chronic sorrow and there was an especially high agreement with respect to one criterion of chronic sorrow 'Loss experience, ongoing or single event' (28 of 30 subjects).

CONCLUSIONS

This study shows that persons with severe chronic illness often experience recurring losses. These experiences are consistent with the phenomenon of chronic sorrow.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of the existence of chronic sorrow in persons with chronic illness will enable nurses to support these persons in a more sensitive and appropriate way.

Measurement of quality of life of survivors of neonatal intensive care: critique and implications

In recent years, an increasing number of studies on the quality of life (QoL) of adults and children have been published, mostly describing outcomes of various medical conditions. Yet, despite the wide interest, there is no universal consensus even on the very definition of what constitutes QoL, particularly for children. Herein, we discuss the conceptual framework and operational definitions of QoL and health-related quality of life (HRQL), address some methodological issues, and review the literature on QoL studies among premature infants. We also describe areas of research that are likely to be fruitful in advancing the consideration of QoL in future studies and in clinical practice.

Neurodevelopmental and neurodegenerative diseases - is there a pathophysiological link? Attention-deficit/hyperactivity disorder and amyotrophic lateral sclerosis as examples

Attention-deficit/hyperactivity disorder (ADHD), the most common neurobehavioural disorder and amyotrophic lateral sclerosis (ALS), the most common adult motoneuron disease, may be two distinct entities on first sight. This paper aims to highlight parallels concerning clinical features and neurobiology. The presence of increased physical and psychological activity and largely non-progressive frontal dysfunction associated with impaired executive control and decreased attention are characteristic clinical features of both, ADHD and ALS. At the neurobiological level, there is evidence for hyperactivity in the glutamatergic system and a - potentially related - dopaminergic hypoactivity in ADHD and ALS. The clinical features of ALS resembling ADHD are particularly characteristic for the premorbid stage of the patient. Therefore, we hypothesize that clinical features of ADHD may be a risk factor for the development of ALS. This hypothesis is currently of unknown pathogenetic, but of potential future therapeutic relevance. Our hypothesis of a link between ADHD and ALS could also be considered as an example how research on neurodevelopmental diseases might influence the understanding and possibly the prevention and treatment of neurodegenerative diseases.

Perceptions of quality of life in people with ALS: effects of coping and health care

Few qualitative studies have explored the 'meaning' of life experiences for persons with ALS. We aimed to identify the meaning of QoL in five selected individuals, and to consider how their experience of health care affected perceived well-being, using a phenomenological approach. Four of the five participants were revisited. Themes that emerged included: importance of faith, search for control, importance of dignity, desire to maintain identity, importance of family, a sense of loss, importance of altruism and support, fighting amyotrophic lateral sclerosis, and appreciation of life. All participants felt that professional services contributed to their well-being. QoL remained individual and multi-dimensional and was defined by cognitive and behavioural strategies used to cope with ALS. Our findings highlight the need to consider how persons with ALS may adapt to progressive illness.

Depression and anxiety in individuals with amyotrophic lateral sclerosis: epidemiology and management

Amyotrophic lateral sclerosis (ALS) is a fatal motor neuron disease with no curative treatment. Considering the devastating nature of the disease, a high prevalence of depression and anxiety in affected patients would be expected. A review of the literature shows prevalence rates for depression in ALS patients ranging from 0% to 44%, but studies using the structured interview according to DSM-IV criteria find highly consistent rates of 9-11%. Prevalence rates for anxiety in ALS range from 0% to 30%. Depression and anxiety appear to be not always properly addressed aspects of ALS, as there are only a few references in the literature about psychological and pharmacological interventions. Additionally, pharmacological antidepressant therapy is often not continuously monitored and its effectiveness remains unevaluated. A review of the literature and our own experiences show that there is a lack of psychological care and, to our knowledge, there is no specific psychological intervention method for ALS patients. Concerning pharmacological treatment of depression in patients with ALS, there is broad consensus among clinical experts that SSRIs and TCAs are helpful, but there have been no controlled clinical studies of these medications in ALS patients. TCAs can be prescribed if anticholinergic effects are desired simultaneously for treating pseudohypersalivation or insomnia. Anxiety is usually treated with anxiolytics, but again there have been no systematic studies of these drugs in patients with ALS. For psychological intervention we suggest a cognitive behavioural approach, which has to be integrated into an intervention programme that includes teaching of appropriate coping strategies and reappraisal skills and encourages engagement in activities that are still practicable and pleasant. We propose that the treatment of depression and anxiety should involve both cognitive behavioural therapy and pharmacological intervention. Pharmacological treatment should be strictly monitored for effectiveness. To date, no clinical trials are available that would allow us to recommend pharmacotherapy over psychotherapy or vice versa; however, evidence from other patient groups, such as elderly patients diagnosed with major depressive disorder, suggests that a combination of both therapies has the potential to also improve depression and anxiety in patients with ALS.

A review of psychosocial aspects of motor neurone disease

Motor neurone disease (MND) is an illness involving the progressive degeneration of upper and lower motor neurones. There is no known cause or cure. The physical aspects of MND frequently receive the majority of attention, with psychosocial aspects accorded secondary importance. We undertook a comprehensive search of the available literature published between 1966 and 2006 on the psychosocial aspects of MND, including quality of life (QoL), depression, social support, life sustaining treatment (LST), coping, spirituality and current practice. The literature identified that QoL correlated more strongly with measures of suffering, social support and hopelessness than with the physical state of the patient. Depression is relatively common (prevalence rates up to 50%), as are other forms of psychological distress in the MND population, and is not associated with illness severity and functional status. Depression strongly correlates with QoL. Social support is often limited for MND patients and this also influences QoL. Hope and hopelessness are important issues for MND patients with hopelessness contributing significantly to suffering and, for some, a desire for hastened death. Choices and decisions about life sustaining treatments pose a burden for patients and carers. Despite the physical and emotional suffering associated with MND, a significant number cope well and find positive meaning in life. Many patients opting for life sustaining treatment report a satisfactory QoL. In conclusion, psychosocial aspects of life are important for patients with MND. Depression and other expressions of distress require recognition and treatment. Issues of hope, spirituality and life and death also require attention in clinical practice. Although guidelines exist to direct physicians to attend to the physical care, there is a distinct lack of guidance to attend to the psychological state of the MND patient.

Adjustment to severe disability: constructing and examining a cognitive and occupational performance model

Ninety adults with severe physical disabilities were tested with respect to their adjustment to severe disabilities in their adapted computerized work environment 1 year following occupational therapy consultation. The research goal was to examine a model that incorporates variables from the cognitive coping model (self-esteem, appraisal and social support) and variables from the occupational performance model (engagement in activities, involvement in work/study, time of typing performance and environmental adaptations). Findings showed goodness of fit between the observed and the proposed research models, although few changes in positions and relations were found. Self-esteem and time of performance were found to be core variables connecting cognitive and functional variables. Age and activities of daily living were the only background variables that contributed to the model. Research and rehabilitation clinical implications are discussed.

Self-perceived health-related quality of life of former extremely low birth weight infants at young adulthood

OBJECTIVES

The goals were to compare the self-reported, health-related quality of life of former extremely low birth weight and normal birth weight infants at young adulthood and to determine whether there were any changes over time.

METHODS

A prospective, longitudinal, population-based study with concurrent control subjects was performed. We interviewed 143 of 166 extremely low birth weight survivors (birth weight: 501-1000 g; 1977-1982 births) and 130 of 145 sociodemographically comparable, normal birth weight, reference subjects. Neurosensory impairments were present for 27% extremely low birth weight and 2% normal birth weight young adults. Health Utilities Index 2 was used to assess health status, and standard gamble technique was used to measure directly the self-reported, health-related, quality of life and 4 hypothetical health states.

RESULTS

Extremely low birth weight young adults reported more functional limitations in cognition, sensation, mobility, and self-care, compared with control subjects. There were no differences between groups in the mean self-reported, health-related, quality of life or between impaired (n = 38) and nonimpaired (n = 105) extremely low birth weight subjects. However, with a conservative approach of assigning a score of 0 for 10 severely disabled, extremely low birth weight subjects, the mean health-related quality of life was significantly lower than control values. Repeated-measures analysis of variance to compare health-related quality-of-life measurements obtained for young adults and teens showed the same decline in scores over time for both groups. There were no differences between groups in the ratings provided for the hypothetical health states.

CONCLUSIONS

At young adulthood, health-related quality of life was not related to size at birth or to the presence of disability. There was a small decrease in health-related quality-of-life scores over time for both groups.

BCI meeting 2005-workshop on signals and recording methods

This paper describes the highlights of presentations and discussions during the Third International BCI Meeting in a workshop that evaluated potential brain-computer interface (BCI) signals and currently available recording methods. It defined the main potential user populations and their needs, addressed the relative advantages and disadvantages of noninvasive and implanted (i.e., invasive) methodologies, considered ethical issues, and focused on the challenges involved in translating BCI systems from the laboratory to widespread clinical use. The workshop stressed the critical importance of developing useful applications that establish the practical value of BCI technology.

Ventilator dependence and expressions of need: A study of patients with amyotrophic lateral sclerosis in Japan

This research examined the experience of Amyotrophic Lateral Sclerosis (ALS) patients who depend on an invasive mechanical ventilator in Japan. We investigated their difficulties in expressing their needs, their desires and wishes, and their sources of support and happiness. We examined the relationship between these factors and patient demographics, and hope as an indicator of successful adaptation to the illness experience (assessed by the Herth Hope Index). Interview results guided the formation of an anonymous questionnaire distributed to patients by mail. We interviewed 27 patients and their families and surveyed 157 respondents with a questionnaire. Most patients experienced multiple categories of difficulties, which correlated with reduced hope. More severe physical symptoms correlated with more emotional and social difficulties. Notable findings included a high prevalence of unalleviated pain, fear or experience of ventilator difficulties, and fear of burdening others. Having more sources of psychosocial support and happiness was associated with greater hope. Living at home was associated with fewer social difficulties. No patients claimed additional sources of support without claiming family or professional caregiver support, suggesting their mediation may be crucial in maintaining other social connections. Users of computer communication reported more sources of support and happiness and less frustration from difficulty expressing themselves. The most common reported desires, following a cure for ALS, related to the happiness of the patients' families, and a desire not to burden them. We also found that invasive mechanical ventilation (IMV) had been initiated emergently in 30.1% of patients without patient or family consent. Our results provide an insight into the world of this challenged population, elucidating the difficulties they face, and clarifying the role of support and other factors in maintaining hope. We identify concrete areas to which increased attention should be directed in patient care.

Social aspects of caregiving for people living with motor neurone disease: Their relationships to carer well-being

Objective:To investigate social aspects of caregiving for people living with motor neurone disease (MND) and examine their relationships to carers' well-being.

Methods:A questionnaire was developed to assess carers' perceptions of their social support network (the Caregiver Network Scale, CNS), including measures of sociodemographic status and general well-being (GHQ-12), and mailed to carers of people living with MND.

Results:Seventy-five surveys were returned (response rate: 33%). In univariate analyses, relationships between well-being and carer age, time as caregiver, and four subscales of the CNS were found to be significant. However, multivariate analyses combining their effects revealed that stress on carer social networks was the best single contributor to predictions of carer well-being.

Significance of results:Results indicate that prolonged caring for others living with MND has substantial costs for the carer in terms of loss of social support, which affects carer well-being and impacts ultimately on those living with MND. The CNS offers promise as a measure for screening at-risk carers; those who are distressed become candidates for professional intervention to help them cope better. Further research, providing validation of the scale for this task, is recommended.

An exploration of health-related quality of life in adults with haemophilia--a qualitative perspective

Musculoskeletal dysfunction is a common feature of haemophilia and along with other manifestations of this condition, there is a general perception that health-related quality of life (QoL) will be affected. Previous research using standardized questionnaires has demonstrated that QoL is lower in haemophilia groups compared with normal populations. However, disability studies and interviews with disabled people suggest that many disabled people experience positive life changes as a result of their illness and an affirmative model of disability has been proposed. A qualitative study involving focus groups and interviews was undertaken to explore these issues in a group of 19 severely affected adults with haemophilia. The focus groups and interviews were tape recorded and fully transcribed and the results subjected to thematic analysis. This paper focuses specifically on key issues that impacted on perceptions of QoL. The findings suggest that the participants' perceptions of their QoL were very positive. Possible reasons for this are proposed including the benefits of factor replacement, participants' recollections of their lifestyle before factor replacement, that having haemophilia was integral to the 'self' and finding a niche where they could be successful. A more positive affirmation of haemophilia may need to be considered when developing QoL measures.