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Manevich A, Rubin SS, Katz M, Ben-Hayun R, Aharon-Peretz J. The Two-Track Model of Dementia Grief and spousal response to illness and death. DEATH STUDIES 2022; 47:592-599. [PMID: 35993431 DOI: 10.1080/07481187.2022.2113479] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This cross-sectional study examined the experiences of healthy spouses caring for their partners via the Two-Track Model of Dementia Grief thereby broadening our understanding of the functional and relational aspects of this process. The 122 participating older adults had spouses drawn from four groups: mild to moderate cognitive-impairment; advanced cognitive-impairment; deceased following dementia; and, healthy controls. They completed a battery of self-report measures. Results showed elevated scores on both tracks of the model for all affected groups. Assisting spouses of those living with cognitive-impairment begins with the earliest symptoms of decline and continues after the death of the loved one.
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Affiliation(s)
- Alexander Manevich
- International Laboratory for the Study of Loss, Bereavement and Human Resilience and the School of Psychological Sciences, University of Haifa, Haifa, Israel
- Department of Behavioral Sciences, Kinneret Academic College, Galilee, Israel
| | - Simon Shimshon Rubin
- International Laboratory for the Study of Loss, Bereavement and Human Resilience and the School of Psychological Sciences, University of Haifa, Haifa, Israel
- Department of Psychology, Max Stern Yezreel Valley College, Jezreel Valley, Israel
| | - Michael Katz
- International Laboratory for the Study of Loss, Bereavement and Human Resilience and the School of Psychological Sciences, University of Haifa, Haifa, Israel
| | - Rachel Ben-Hayun
- Cognitive Neurology Institute, Rambam Health Care Campus, Haifa, Israel
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Supporting bereavement and complicated grief in primary care: a realist review. BJGP Open 2021; 5:BJGPO.2021.0008. [PMID: 33653707 PMCID: PMC8278512 DOI: 10.3399/bjgpo.2021.0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/18/2021] [Indexed: 12/03/2022] Open
Abstract
Background Bereavement can have significant impacts on physical and mental health, and a minority of people experience complicated and prolonged grief responses. Primary care is ideally situated to offer bereavement care, yet UK provision remains variable and practitioners feel uncertain how best to support bereaved patients. Aim To identify what works, how, and for whom, in the management of complicated grief (CG) in primary care. Design & setting A review of evidence on the management of CG and bereavement in UK primary care settings. Method A realist approach was taken that aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes. Results Forty-two articles were included. Evidence on the primary care management of complicated or prolonged grief was limited. GPs and nurses view bereavement support as part of their role, yet experience uncertainty over the appropriate extent of their involvement. Patients and clinicians often have differing views on the role of primary care in bereavement. Training in bereavement, local systems for reporting deaths, practitioner time, and resources can assist or hinder bereavement care provision. Practitioners find bereavement care can be emotionally challenging. Understanding patients’ needs can encourage a proactive response and help identify appropriate support. Conclusion Bereavement care in primary care remains variable and practitioners feel unprepared to provide appropriate bereavement care. Patients at higher risk of complicated or prolonged grief may fail to receive the support they need from primary care. Further research is required to address the potential unmet needs of bereaved patients.
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Broady TR. Carers’ Experiences of End‐of‐Life Care: A Scoping Review and Application of Personal Construct Psychology. AUSTRALIAN PSYCHOLOGIST 2020. [DOI: 10.1111/ap.12278] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ornstein KA, Aldridge M, Gillezeau C, Kristensen MS, Gazibara T, Groenvold M, Thygesen LC. New antidepressant utilization pre- and post-bereavement: a population-based study of partners and adult children. Soc Psychiatry Psychiatr Epidemiol 2020; 55:1261-1271. [PMID: 32185418 PMCID: PMC7494560 DOI: 10.1007/s00127-020-01857-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 03/03/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Bereavement is associated with increased morbidity and mortality, but few studies have examined the specific timing of depression onset. This study examines the risk of developing new-onset depression in adult children and partners by month, 1 year before and after death. METHODS Using population-based registers in Denmark, we assembled a cohort of 236,000 individuals who died a natural death (2010-2016). Partners and adult children of the deceased were identified and demographic and prescription data were collected. GEE logistic regression was used to model whether the bereaved received a new antidepressant prescription around the death of their loved one across 24 time intervals (12 months before and after death). RESULTS Male and female partners had an increase in receipt of new antidepressant prescriptions in the 11 months after the death of their partner, with a peak increase 2 or 3 months after death. Partners also increased new antidepressant prescription use 2 months before death. Characteristics of the decedents including cause of death were not associated with new antidepressant prescription in the surviving partner. Adult children did not have increased odds of being prescribed new antidepressants at any time. CONCLUSION Both male and female partners have increase in new antidepressant utilization before and after the death of their partner. Our work points to the importance of supporting partners not only after the death of their partner, but also in the period before death when families may be actively engaged in caregiving for the seriously ill.
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Affiliation(s)
- Katherine A Ornstein
- Department of Geriatric and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Melissa Aldridge
- Department of Geriatric and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Christina Gillezeau
- Department of Geriatric and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Marie S Kristensen
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Tatjana Gazibara
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Beograd, Serbia
| | | | - Lau C Thygesen
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
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Livingston G, Huntley J, Sommerlad A, Ames D, Ballard C, Banerjee S, Brayne C, Burns A, Cohen-Mansfield J, Cooper C, Costafreda SG, Dias A, Fox N, Gitlin LN, Howard R, Kales HC, Kivimäki M, Larson EB, Ogunniyi A, Orgeta V, Ritchie K, Rockwood K, Sampson EL, Samus Q, Schneider LS, Selbæk G, Teri L, Mukadam N. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet 2020; 396:413-446. [PMID: 32738937 PMCID: PMC7392084 DOI: 10.1016/s0140-6736(20)30367-6] [Citation(s) in RCA: 4208] [Impact Index Per Article: 1052.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 01/31/2020] [Accepted: 02/07/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Gill Livingston
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK.
| | - Jonathan Huntley
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Andrew Sommerlad
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - David Ames
- National Ageing Research Institute and Academic Unit for Psychiatry of Old Age, University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | | | - Sube Banerjee
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Alistair Burns
- Department of Old Age Psychiatry, University of Manchester, Manchester, UK
| | - Jiska Cohen-Mansfield
- Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Heczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel; Minerva Center for Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Sergi G Costafreda
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Amit Dias
- Department of Preventive and Social Medicine, Goa Medical College, Goa, India
| | - Nick Fox
- Dementia Research Centre, UK Dementia Research Institute, University College London, London, UK; Institute of Neurology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Laura N Gitlin
- Center for Innovative Care in Aging, Johns Hopkins University, Baltimore, MA, USA
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Helen C Kales
- Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, University of California, Sacramento, CA, USA
| | - Mika Kivimäki
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Vasiliki Orgeta
- Division of Psychiatry, University College London, London, UK
| | - Karen Ritchie
- Inserm, Unit 1061, Neuropsychiatry: Epidemiological and Clinical Research, La Colombière Hospital, University of Montpellier, Montpellier, France; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kenneth Rockwood
- Centre for the Health Care of Elderly People, Geriatric Medicine Dalhousie University, Halifax, NS, Canada
| | - Elizabeth L Sampson
- Division of Psychiatry, University College London, London, UK; Barnet, Enfield, and Haringey Mental Health Trust, London, UK
| | - Quincy Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MA, USA
| | - Lon S Schneider
- Department of Psychiatry and the Behavioural Sciences and Department of Neurology, Keck School of Medicine, Leonard Davis School of Gerontology of the University of Southern California, Los Angeles, CA, USA
| | - Geir Selbæk
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Geriatric Department, Oslo University Hospital, Oslo, Norway
| | - Linda Teri
- Department Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, WA, USA
| | - Naaheed Mukadam
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
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Leggett AN, Sonnega AJ, Lohman MC. Till Death Do Us Part: Intersecting Health and Spousal Dementia Caregiving on Caregiver Mortality. J Aging Health 2020; 32:871-879. [PMID: 31272269 PMCID: PMC7187632 DOI: 10.1177/0898264319860975] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We consider whether it is the healthiest dementia caregivers who experience a mortality benefit and whether a protective association is consistent for leading causes of mortality. METHOD Using the Health and Retirement study (2000-2012), Cox survival models predict time to death for dementia caregivers, including an interaction between dementia caregiver status and self-rated health. The nationally representative sample consisted of 10,650 married adults aged 51 or older (917 dementia caregivers). RESULTS A significant interaction between dementia caregiver status and self-rated health suggested that relative to noncaregivers, dementia caregivers had reduced mortality, with this effect particularly strong at lower levels of self-rated health. The protective effect of dementia caregiver status was consistent across death by heart disease, cancer, and cerebrovascular disease. DISCUSSION These findings add to a growing body of literature suggesting that caregiving may provide a mortality benefit and a reason to maintain health.
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Wilson SJ, Padin AC, Bailey BE, Laskowski B, Andridge R, Malarkey WB, Kiecolt- Glaser JK. Spousal bereavement after dementia caregiving: A turning point for immune health. Psychoneuroendocrinology 2020; 118:104717. [PMID: 32485342 PMCID: PMC7849822 DOI: 10.1016/j.psyneuen.2020.104717] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 04/24/2020] [Accepted: 05/11/2020] [Indexed: 11/25/2022]
Abstract
Losing a spouse can increase the risk for premature mortality, and declines in immune health are thought to play a role. Most of the supporting data have come from cross-sectional studies comparing already-bereaved individuals to matched controls, which provides valuable information about health disparities between groups but does not reveal health changes over time. Moreover, the health consequences of bereavement may be unique for dementia family caregivers, a large and growing segment of the population. The current study sought to evaluate the course of health around 52 dementia spousal caregivers' bereavement by capturing lymphocyte proliferation to Con A and PHA and self-rated health before and after spousal loss. To investigate the moderating role of the social environment, we examined associations between social ties and health trajectories before and after spousal loss. Using piecewise linear mixed models to allow for turning points in caregivers' trajectories, we found that, for the average caregiver, lymphocyte proliferation to both mitogens weakened as bereavement neared and continued to decline after the loss, but at a slower pace. In tandem, perceived health degraded as bereavement approached but rebounded thereafter. Further, we found that socially isolated caregivers showed marked declines in immune responses to Con A and PHA over time both before and after bereavement, whereas their socially connected counterparts had shallower declines to PHA and maintained a level immune response to Con A. In addition, socially isolated caregivers reported poorer health before and after bereavement compared to their counterparts, whose self-rated health declined as the loss neared but later recovered to exceed prior levels. These findings shed new light on the dynamics of immune function in response to spousal bereavement after dementia caregiving: longitudinal data reveal a pattern of health recovery following caregivers' loss, particularly among those with more robust social networks prior to bereavement.
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Affiliation(s)
| | - Avelina C. Padin
- Institute for Behavioral Medicine Research, The Ohio State University College of Medicine,Department of Psychology, The Ohio State University
| | | | - Bryon Laskowski
- Institute for Behavioral Medicine Research, The Ohio State University College of Medicine
| | - Rebecca Andridge
- College of Public Health, Division of Biostatistics, The Ohio State University
| | - William B. Malarkey
- Institute for Behavioral Medicine Research, The Ohio State University College of Medicine,Department of Internal Medicine, The Ohio State University College of Medicine
| | - Janice K. Kiecolt- Glaser
- Institute for Behavioral Medicine Research, The Ohio State University College of Medicine,Department of Psychiatry and Behavioral Health, The Ohio State University College of Medicine
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Rubin SS, Manevich A, Doron II. The Two-Track Model of Dementia Grief (TTM-DG): The theoretical and clinical significance of the continuing bond in sickness and in death. DEATH STUDIES 2019; 45:755-771. [PMID: 31713463 DOI: 10.1080/07481187.2019.1688014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Grief and mourning for family members caring for a dementia patient begin with the initial changes in the person's cognitive abilities, and intensify with the worsening of his or her condition. The aim of this article is to propose a Two-Track Model of Dementia Grief (TTM-DG). This model enlarges the theoretical, research and clinical lenses for dementia, and explores how the illness process as well as the bereavement responses after death stimulate the reworking of grief and mourning over the beloved family member. Based on the insights derived from the Two-Track Model of Loss and Bereavement and the Continuing Bonds paradigm, we propose that the clinical and research examination of dementia grief begin in life and continue after the death. The TTM - DG's Track I focuses on bio-psycho-social functioning and Track II focuses on the internalized psychological representation of the patient, the ongoing relational bond and the illness and death story. A case study illustrates how this combined perspective provides a comprehensive picture of the experience of grief for persons afflicted with dementia over the course of the disease trajectory. Future clinical and empirical research has an important role to play in the further development of this model.
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Affiliation(s)
- Simon Shimshon Rubin
- International Center for the Study of Loss, Bereavement and Human Resilience and the School of Psychological Sciences, University of Haifa, Haifa, Israel
- Department of Psychology, Max Stern Yezreel Valley College, Israel
| | - Alexander Manevich
- International Center for the Study of Loss, Bereavement and Human Resilience and the School of Psychological Sciences, University of Haifa, Haifa, Israel
| | - Israel Issi Doron
- Department of Gerontology and the Center for Research and Study of Ageing, University of Haifa, Haifa, Israel
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Ennis J, Majid U. "Death from a broken heart": A systematic review of the relationship between spousal bereavement and physical and physiological health outcomes. DEATH STUDIES 2019; 45:538-551. [PMID: 31535594 DOI: 10.1080/07481187.2019.1661884] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The loss of a loved one is often associated with "death from a broken heart" for the survivor, and there is evidence that shows that widowers and widows are at risk for higher morbidity and mortality than the general population. This systematic review will summarize the physical and physiological health outcomes of spousal bereavement. A systematic database search was conducted, and 38 studies were analyzed. The majority of studies found a statistically significant and positive association between spousal bereavement and adverse physical and physiological health outcomes such as inflammation, cardiovascular risk, chronic pain, and mortality.
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Affiliation(s)
- Jeffrey Ennis
- Ennis Centre for Pain Management, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Umair Majid
- Ennis Centre for Pain Management, Hamilton, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Division of Clinical Decision-Making and Healthcare, University Health Network, Toronto, Canada
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Broady TR, Saich F, Hinton T. Caring for a family member or friend with dementia at the end of life: A scoping review and implications for palliative care practice. Palliat Med 2018; 32:643-656. [PMID: 29343195 DOI: 10.1177/0269216317748844] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although people with dementia receive substantial care from informal sources, there is limited research available that investigates how these carers experience end-of-life care. AIM This review aimed to identify what is currently known about carers' experiences of providing end-of-life care to a family member or friend with dementia and draw implications for palliative care policy and service provision. DESIGN A scoping literature review was conducted, first using a targeted key word search, followed by assessments of eligibility based on title and then abstract content. DATA SOURCES Records were sourced through PsycINFO, PubMed and CINAHL databases. Peer-reviewed papers published between 2000 and 2016, reporting on data collected directly from carers, were included for review. RESULTS Carers' experience centred on relationships (with care recipients, family and friends and health care professionals) and the specific context of caring for someone with dementia. These broad categories of carers' experiences had clear influences on them personally, particularly in relation to their sense of self and their wellbeing. CONCLUSION Palliative care services would benefit from ensuring holistic approaches to supporting people with dementia, their carers and wider family networks. Tailoring services to the specific context of dementia would enable effective, personalised support throughout extended periods leading up to care recipient death as well as through the challenges faced beyond bereavement.
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Affiliation(s)
| | | | - Tom Hinton
- Carers NSW, North Sydney, NSW, Australia
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Stajduhar K, Sawatzky R, Robin Cohen S, Heyland DK, Allan D, Bidgood D, Norgrove L, Gadermann AM. Bereaved family members' perceptions of the quality of end-of-life care across four types of inpatient care settings. BMC Palliat Care 2017; 16:59. [PMID: 29178901 PMCID: PMC5702136 DOI: 10.1186/s12904-017-0237-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 11/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aims of this study were to gain a better understanding of how bereaved family members perceive the quality of EOL care by comparing their satisfaction with quality of end-of-life care across four different settings and by additionally examining the extent to which demographic characteristics and psychological variables (resilience, optimism, grief) explain variation in satisfaction. METHODS A cross-sectional mail-out survey was conducted of bereaved family members of patients who had died in extended care units (n = 63), intensive care units (n = 30), medical care units (n = 140) and palliative care units (n = 155). 1254 death records were screened and 712 bereaved family caregivers were identified as eligible, of which 558 (who were initially contacted by mail and then followed up by phone) agreed to receive a questionnaire and 388 returned a completed questionnaire (response rate of 70%). Measures included satisfaction with end-of-life care (CANHELP- Canadian Health Care Evaluation Project - family caregiver bereavement version; scores range from 0 = not at all satisfied to 5 = completely satisfied), grief (Texas Revised Inventory of Grief (TRIG)), optimism (Life Orientation Test - Revised) and resilience (The Resilience Scale). ANCOVA and multivariate linear regression were used to analyze the data. RESULTS Family members experienced significantly lower satisfaction in MCU (mean = 3.69) relative to other settings (means of 3.90 [MCU], 4.14 [ICU], and 4.00 [PCU]; F (3371) = 8.30, p = .000). Statistically significant differences were also observed for CANHELP subscales of "doctor and nurse care", "illness management", "health services" and "communication". The regression model explained 18.9% of the variance in the CANHELP total scale, and between 11.8% and 27.8% of the variance in the subscales. Explained variance in the CANHELP total score was attributable to the setting of care and psychological characteristics of family members (44%), in particular resilience. CONCLUSION Findings suggest room for improvement across all settings of care, but improving quality in acute care and palliative care should be a priority. Resiliency appears to be an important psychological characteristic in influencing how family members appraise care quality and point to possible sites for targeted intervention.
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Affiliation(s)
- Kelli Stajduhar
- School of Nursing and Institute on Aging and Lifelong Health, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2 Canada
| | - Richard Sawatzky
- School of Nursing, Trinity Western University, 7600 Glover Road, Langley, BC V2Y 1Y1 Canada
| | - S. Robin Cohen
- Oncology and Medicine, McGill University, Lady Davis Research Institute, Jewish General Hospital, 845 Sherbrooke Street West, Montreal, QC H3A 0G4 Canada
| | - Daren K. Heyland
- Critical Care Medicine, Queen’s University, 76 Stuart Street, Kingston, ON K7L 2V7 Canada
| | - Diane Allan
- College of Nursing, University of Saskatchewan, 104 Clinic Place, Saskatoon, SASK S7N 2Z4 Canada
| | - Darcee Bidgood
- Institute on Aging and Lifelong Health, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2 Canada
| | - Leah Norgrove
- Palliative Care, Saanich Peninsula Hospital, Island Health, 2166 Mt. Newton X Road, Saanichton, BC V8M 2B2 Canada
| | - Anne M. Gadermann
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3 Canada
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