The disability paradox: high quality of life against all odds

The Use of a Comprehensive Concept of Capability for Wellbeing Assessment: A Best-Fit Framework Synthesis

Developing an instrument with the capability approach can be challenging, since the capability concept of Sen is ambiguous concerning the burdens that people experience whilst achieving their capabilities. A solution is to develop instruments with a comprehensive concept of capability, such as the concept of 'option-freedom'. This study aims to develop a theoretical framework for instrument development with the concept of option-freedom. A best-fit framework synthesis was conducted with seven qualitative papers by one researcher. Two researchers supported the synthesis by discussing interim results during the synthesis. A priori concepts of option-freedom were used to deductively code against. Themes and subthemes were developed inductively when data did not match a priori themes. Seven paper were identified that fulfilled the eligibility criteria. Four themes emerged from the synthesis. (1) Option Wellbeing represents a range of options that need to be satisfied for individuals to experience wellbeing. (2) Self-Realization represents that there are experiences in an individual's life that have value beyond realizing options. (3) Perceived Access to Options represents the perceived ability of individuals to realize freedoms. (4) Perceived Control represents the experience of having control. Developing an instrument with the proposed framework has two benefits. First, it acknowledges the importance of assessing impediments in realizing capabilities for wellbeing assessment. Secondly, the themes form a broad informational base by including themes related to subjective wellbeing. Future research should study the feasibility of implementing the framework for instrument development.

A Systematic Review of the Impact of Spinal Cord Injury on Costs and Health-Related Quality of Life

OBJECTIVE

To systematically review the health-related quality of life (HRQoL) burden and costs of spinal cord injury (SCI) on health services, patients and wider society.

METHODS

A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was conducted in March 2021 through Scopus, PubMed and Embase databases. Inclusion criteria were quantitative studies on SCI reporting healthcare costs, social costs and/or HRQoL measured with the Euroqol EQ-5D or Short-Form 36. Risk of bias was assessed using the QualSyst tool. Descriptive analyses, random-effects direct meta-analysis and random-effects meta-regression were conducted.

RESULTS

A total of 67 studies were eligible for inclusion. SCI individuals tend to report higher HRQoL in mental than physical dimensions of the Short-Form 36. Neurological level of SCI negatively affects HRQoL. Cross-sectional studies find employment is associated with better HRQoL, but the effect is not observed in longitudinal studies. The estimated lifetime expenditure per individual with SCI ranged from US$0.7 million to US$2.5 million, with greater costs associated with earlier age at injury, neurological level, United States of America healthcare setting and the inclusion of non-healthcare items in the study.

CONCLUSIONS

SCI is associated with low HRQoL on mobility and physical dimensions. Mental health scores tend to be greater than physical scores, and most dimensions of HRQoL appear to improve over time, at least over the first year. SCI is associated with high costs which vary by country.

CLINICAL TRIALS REGISTRATION

This review was registered in PROSPERO (registration number: CRD42021235801).

Unpacking the notion of "serious" genetic conditions: towards implementation in reproductive decision-making?

The notion of a "serious" genetic condition is commonly used in clinical contexts, laws, and policies to define and delineate both the permissibility of and, access to, reproductive genomic technologies. Yet, the notion lacks conceptual and operational clarity, which can lead to its inconsistent appraisal and application. A common understanding of the relevant considerations of "serious" is lacking. This article addresses this conceptual gap. We begin by outlining existing distinctions around the notion of "serious" that will factor into its appraisal and need to be navigated, in the context of prenatal testing and the use of reproductive genomic technologies. These include tensions between clinical care and population health; the impact of categorizing a condition as "serious"; and the role of perception of quality of life. We then propose a set of four core dimensions and four procedural elements that can serve as a conceptual tool to prompt a mapping of the features of seriousness in any given context. Ultimately, consideration of these core dimensions and procedural elements may lead to improvements in the quality and consistency of decision-making where the seriousness of a genetic condition is a pivotal component at both a policy and practice level.

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Ethical Implications of Cleft Lip and Palate Repair in Patients with Trisomy 13 and Trisomy 18

BACKGROUND

Children born with Trisomy 13 or 18 (T13/18) often have multiple congenital anomalies, many of which drastically shorten their lifespan. Among these defects are cleft lip and palate, the repair of which presents an ethical dilemma to the surgeon given the underlying comorbidities associated with T13/18. The authors present an ethical discussion and institutional experience in navigating this dilemma.

METHODS

The authors analyzed existing literature on T13 and T18 surgery and mortality. A retrospective study over ten years was also conducted to identify pediatric patients who underwent surgical correction of cleft lip and/or palate secondary to a confirmed diagnosis of T13/18. The authors identified two patients and examined their treatment course.

RESULTS

The authors' review of literature coupled with their institution's experience builds on the published successes of correcting cleft lip and palate in the setting of T13/18. It was found that both patients identified in the case series underwent successful correction with no surgical complications.

CONCLUSION

A careful balance must be struck between improved quality of life, benefits of treatment, and risks of surgery in children with T13/T18. Careful consideration should be given to the medical status of these complex patients. If the remaining medical comorbidities are well managed and under control, there is an ethical precedent for performing cleft lip and palate surgeries on these children. A diagnosis of T13/T18 alone is not enough to disqualify patients from cleft lip/palate surgery.

An investigation of the longitudinal trajectory patterns of health-related quality of life among Australians with disabilities: explaining disability types and properties

BACKGROUND

Research on health-related quality of life (HRQoL) trajectory patterns for people with disabilities (PwD) is scant. Understanding the HRQoL trajectory patterns for PwDs and investigating their relationship with disability types and socioeconomic factors can have important implications for Australia's welfare policy.

METHODS

We analysed data from waves 11 to 21 of the Household, Income and Labour Dynamics in Australia (HILDA) survey of respondents aged 15 + years of the PwDs. The analytic sample consists of 3724 self-reported disabled individuals and 34,539 observations in total. The SF-6D utility score is our HRQoL measure. Group-based trajectory modelling was utilised to identify trajectory groups, and multinomial logistic regression was employed to determine the baseline factors associated with trajectory group membership.

RESULTS

The study identified four distinct types of HRQoL trajectories (high, moderate improving, moderate deteriorating and low HRQoL trajectories). Psychosocial disability types followed by physical disability types had a high Relative Risk Ratio (RRR) in the low group compared with high trajectory group membership of PwDs (psychosocial: 6.090, physical: 3.524). Similar, results followed for the moderate improving group albeit with lower RRR (psychosocial: 2.868, Physical: 1.820). In the moderate deteriorating group, the disability types were not significant as this group has a similar profile to high group at the baseline. Compared with males, females had a higher RRR in low and moderate versus high improving HRQoL trajectories (low: 1.532, moderate improving: 1.237). Comparing the richest class to the poorest class, socioeconomic factors (income and education) predicted significantly lower exposure for the richer class to the low and medium HRQoL trajectories groups (RRR < 1).

CONCLUSION

Different forms of disability, demographic and socioeconomic factors have distinct effects on the HRQoL trajectories of disabled individuals. Healthcare and economic resource efficiency might be improved with targeted government policy interventions based on disability trajectories.

Exploring the relationship between condition severity and health-related quality of life in people with haemophilia A across Europe: a multivariable analysis of data from the CHESS II study

BACKGROUND

Haemophilia A (HA; Factor VIII deficiency) is a congenital X-linked bleeding disorder characterized by trauma-related or spontaneous bleeding events, most notably arising within the intraarticular space and resulting in chronic inflammation and degeneration of affected joints. Endogenous clotting factor activity relative to normal levels determines the severity of HA symptoms, as mild (> 5-40%), moderate (1-5%), or severe (< 1%). Within the current environment of rapid evolution in HA management, we seek to understand the interplay of condition severity and health-related quality of life (HRQoL) to characterise and differentiate unmet needs among people with HA (PwHA).

METHODS

A generalised linear regression model (GLM) was developed to explore the relationship between HA severity and EQ-5D-5 L index score from adult HA patients sampled in the "Cost of Haemophilia across Europe - a Socioeconomic Survey II" (CHESS II) cross-sectional, retrospective burden of illness study among adults with hereditary haemophilia A or B from eight European countries. HA patients of any severity with no active inhibitors during the 12 months prior to data capture and a completeEQ-5D-5 L response were included. A base GLM model was specified with covariates for demographic and clinical characteristics (age, body mass index, country, employment, HA severity, annual bleeding rate, problem joints, and chronic pain).

RESULTS

Of 381 evaluable patients, 221 (58.0%) had severe HA, 96 (25.2%) had moderate HA, and 64 (16.8%) had mild HA. Among the covariates included in the GLM model and after controlling for haemophilia-related outcomes, a significant association was observed between mild HA and higher EQ-5D-5 L index score (average marginal effects, 0.084; p = 0.016) relative to severe HA. Patient country of residence and magnitude of HA-related chronic pain were also associated with significant differences in index scores, with the latter showing a negative relationship with HRQoL outcomes.

CONCLUSIONS

Condition severity and chronic pain are significant predictors of HRQoL in PwHA. Durable bleeding protection and effective management of chronic pain have the potential to address unmet treatment needs in this population.

Limitation of life sustaining therapy in disorders of consciousness: ethics and practice

Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.

Exploring health-related quality of life, exercise and alcohol use in adolescents with sickle cell disease and healthy siblings

OBJECTIVE

This study explored the health-related quality of life (HRQL) and health behaviours of adolescents with sickle cell disease (SCD) and healthy siblings, drawing on Gap theory which suggests HRQL is the discrepancy between current and ideal selves.

DESIGN

Twenty-three adolescents with SCD and 21 healthy siblings aged 13 to 17 years participated in eight focus groups.

RESULTS

Thematic analysis identified three themes: learning to accept SCD, coping with SCD and influences on health behaviours. Adolescents appear to have normalised and adapted to SCD. Adolescents with SCD have learnt effective coping strategies, such as moderating engagement in exercise. Unlike heathy siblings, they were not encouraged to exercise by parents but were content with their level of participation. Both groups were influenced to exercise by role models or wanting to socialise, and influenced to drink alcohol by peers, but there was limited understanding of the potential negative impacts of alcohol on SCD.

CONCLUSION

There does not appear to be a discrepancy between adolescents' current and ideal selves, providing optimism about their HRQL. Further consideration of engaging in healthy behaviours is needed, but it is important to strike a balance so that modifications to lifestyle do not impair HRQL.

Communication in Neuropalliative Care

Serious illness communication needs are high among patients with neurological conditions, from the time of diagnosis to the end of life. This article will highlight unique needs among these patients, strategies for optimizing communication, and techniques to learn and teach these skills along the continuum of a career in neurology.

Validation of Polish-Language Questionnaires for Assessing the Quality of Life of Patients with Primary Ciliary Dyskinesia (PCD-QOL)

In recent years, questionnaires were published in English to assess the quality of life of patients with PCD (Primary Ciliary Diskinesia) for adults, adolescents aged 13-17 years, and children aged 6-12 years and their caregivers. This study aimed to prepare Polish versions of the questionnaires and validate them in specific age groups with the participation of Polish patients with PCD. The individual questionnaires were translated and discussed with the involvement of the creator of the original questionnaire in English. Patients completed the questionnaires according to their affiliation with one of the groups. Validation was based on internal consistency analysis (Cronbach's alpha coefficient and split-half reliability) and test-retest reliability (intraclass correlation coefficient-ICC). The internal consistency of all questionnaires was from moderate to very good (Cronbach's alpha 0.67-0.91, split-half reliability 0.53-0.95). The consistency of the measurements showed excellent repeatability (ICC 0.67-0.91). The surveyed Polish PCD patients rated their quality of life quite well (63-77%). QOL questionnaires for patients with PCD can be used routinely during each medical check-up as a simple tool to provide the doctor with an indication of the effectiveness of treatment and the impact of the disease on the patient's quality of life.

Caring for people with disability and human growth: evolutionary perspectives and contribution to psychological wellbeing

From an evolutionary point of view, organisms with mutations resulting in maladaptation are an unavoidable result of genetic variability, and they do not usually survive natural selection. Thus, they do not produce benefits for the species. I contend that this is different in humans at two levels. First, the existence of people with disability has been essential for human growth as a species. Human ancestors' evolving cognitive and social abilities were boosted by caring for vulnerable members of the species, including premature offspring and people with disability. Therefore, caregiving was an essential trait of the evolution of humans, intertwined with the development of bipedalism, the hand, face, vocal apparatus, and brain. Second, caring for disability is also a source of growth at a personal level. Even though most scientific literature focuses on the stress and burden caused by caring for people with disability, there is solid evidence to accept caregiving as a source of happiness and flourishing for human beings. Hence, disability still has an essential role in improving human life nowadays. Contrary to this evidence, influential utilitarian bioethicists promote the elimination of disability from modern societies. Following the arguments presented here, this will lead to the withering of society. In conclusion, disability should be acknowledged as an essential source of growth for the human species.

Equity in Clinical Care and Research Involving Persons with Disorders of Consciousness

People with disorders of consciousness (DoC) are characteristically unable to synchronously participate in decision-making about clinical care or research. The inability to self-advocate exacerbates preexisting socioeconomic and geographic disparities, which include the wide variability observed across individuals, hospitals, and countries in access to acute care, expertise, and sophisticated diagnostic, prognostic, and therapeutic interventions. Concerns about equity for people with DoC are particularly notable when they lack a surrogate decision-maker (legally referred to as "unrepresented" or "unbefriended"). Decisions about both short-term and long-term life-sustaining treatment typically rely on neuroprognostication and individual patient preferences that carry additional ethical considerations for people with DoC, as even individuals with well thought out advance directives cannot anticipate every possible situation to guide such decisions. Further challenges exist with the inclusion of people with DoC in research because consent must be completed (in most circumstances) through a surrogate, which excludes those who are unrepresented and may discourage investigators from exploring questions related to this population. In this article, the Curing Coma Campaign Ethics Working Group reviews equity considerations in clinical care and research involving persons with DoC in the following domains: (1) access to acute care and expertise, (2) access to diagnostics and therapeutics, (3) neuroprognostication, (4) medical decision-making for unrepresented people, (5) end-of-life decision-making, (6) access to postacute rehabilitative care, (7) access to research, (8) inclusion of unrepresented people in research, and (9) remuneration and reciprocity for research participation. The goal of this discussion is to advance equitable, harmonized, guideline-directed, and goal-concordant care for people with DoC of all backgrounds worldwide, prioritizing the ethical standards of respect for autonomy, beneficence, and justice. Although the focus of this evaluation is on people with DoC, much of the discussion can be extrapolated to other critically ill persons worldwide.

Spontaneous intracerebral hemorrhage - patients retrospectively consent to fibrinolytic surgery despite poor neurological outcome and reduced health-related quality of life

Spontaneous intracerebral hemorrhage (ICH) might lead to devastating consequences. Nonetheless, subjective interpretation of life circumstances might vary. Recent data from ischemic stroke patients show that there might be a paradox between clinically rated neurological outcome and self-reported satisfaction with quality of life. Our hypothesis was that minimally invasive surgically treated ICH patients would still give their consent to stereotactic fibrinolysis despite experiencing relatively poor neurological outcome. In order to better understand the patients' perspective and to enhance insight beyond functional outcome, this is the first study assessing disease-specific health-related quality of life (hrQoL) in ICH after fibrinolytic therapy. We conducted a retrospective analysis of patients with spontaneous ICH treated minimally invasive by stereotactic fibrinolysis. Subsequently, using standardized telephone interviews, we evaluated functional outcome with the modified Rankin Scale (mRS), health-related Quality of Life with the Quality of life after Brain Injury Overall scale (QOLIBRI-OS), and assessed retrospectively if the patients would have given their consent to the treatment. To verify the primary hypothesis that fibrinolytic treated ICH patients would still retrospectively consent to fibrinolytic therapy despite a relatively poor neurological outcome, we conducted a chi-square test to compare good versus poor outcome (mRS) between consenters and non-consenters. To investigate the association between hrQoL (QOLIBRI-OS) and consent, we conducted a Mann-Whitney U-test. Moreover, we did a Spearman correlation to investigate the correlation between functional outcome (mRS) and hrQoL (QOLIBRI-OS). The analysis comprised 63 data sets (35 men, mean age: 66.9 ± 11.8 years, median Hemphill score: 3 [2-3]). Good neurological outcome (mRS 0-3) was achieved in 52% (33/63) of the patients. Patients would have given their consent to surgery retrospectively in 89.7% (52/58). These 52 consenting patients comprised all 33 patients (100%) who achieved good functional outcome and 19 of the 25 patients (76%) who achieved poor neurological outcome (mRS 4-6). The mean QOLIBRI-OS value was 49.55 ± 27.75. A significant association between hrQoL and retrospective consent was found (p = 0.004). This study supports fibrinolytic treatment of ICH even in cases when poor neurological outcome would have to be assumed since subjective perception of deficits could be in contrast with the objectively measured neurological outcome. HrQoL serves as a criterion for success of rtPa lysis therapy in ICH.

A critical view on using "life not worth living" in the bioethics of assisted reproduction

This paper critically engages with how life not worth living (LNWL) and cognate concepts are used in the field of beginning-of-life bioethics as the basis of arguments for morally requiring the application of preimplantation genetic diagnosis (PGD) and/or germline genome editing (GGE). It is argued that an objective conceptualization of LNWL is largely too unreliable in beginning-of-life cases for deriving decisive normative reasons that would constitute a moral duty on the part of intending parents. Subjective frameworks are found to be more suitable to determine LNWL, but they are not accessible in beginning-of-life cases because there is no subject yet. Conceptual and sociopolitical problems are additionally pointed out regarding the common usage of clear case exemplars. The paper concludes that a moral requirement for the usage of PGD and GGE cannot be derived from the conceptual base of LNWL, as strong reasons that can be reliably determined are required to limit reproductive freedom on moral grounds. Educated predictions on prospective well-being might still be useful regarding the determination of moral permissibility of PGD and/or GGE. It is suggested that due to the high significance of subjective experience in the normativity of beginning-of-life bioethics, the discipline is called to more actively realize the inclusion of people with disabilities. This regards for instance research design, citation practices, and language choices to increase the accessibility of societal debates on the reproductive ethics of genetic technologies.

Should genes for non-syndromic hearing loss be included in reproductive genetic carrier screening: Views of people with a personal or family experience of deafness

Many commercial reproductive genetic carrier screening (RGCS) panels include genes associated with non-syndromic hearing loss (NSHL), however little is known about the general acceptability of their inclusion. Although some couples wish to avoid having a deaf child, there are effective interventions and supports available for deafness, and no consensus on whether it is appropriate to reproductively screen NSHL genes. This study explored views of people with personal experience of deafness regarding carrier screening for genes associated with NSHL. We interviewed 27 participants; 14 who identified as deaf and 13 hearing parents of a deaf child. Thematic analysis was undertaken on transcripts of interviews. The findings reveal the complexity of attitudes within these groups. Some vacillated between the wish to support prospective parents' reproductive autonomy and concerns about potential harms, especially the expression of negative messages about deafness and the potential loss of acceptance in society. While some participants felt carrier screening could help prospective parents to prepare for a deaf child, there was little support for reproductive screening and termination of pregnancy. Participants emphasized the need for accurate information about the lived experience of deafness. The majority felt deafness is not as severe as other conditions included in RGCS, and most do not consider deafness as a disability. People with personal experience of deafness have diverse attitudes towards RGCS for deafness informed by their own identify and experience, and many have concerns about how it should be discussed and implemented in a population wide RGCS program.

Differences in health utilities between cancer patients and the general population: The case of Quebec using the SF-6Dv2

A considerable debate persists in the literature about whose preferences should be considered in the calculation of quality-adjusted life-years. Some suggest considering only the preferences of the general population, while others advocate for the consideration of those of patients or a combination of both. This study aims to inform and measure the differences in health preferences between cancer patients and the general population in Quebec. A total of 60,976 observations representing the preferences of the general population for various health states were collected and used to develop a new value set using the SF-6Dv2. This value set was generated by combining 34,299 observations with time trade-off (TTO) and 26,677 observations with discrete choice experiment (DCE). Utility scores derived from this value set were compared to those of patients' preferences from a new value set in breast and colorectal patients for the SF-6Dv2. For both patients and the general population, the 'Pain' dimension was the highest contributor to the utility score. However, noticeable differences were observed in the estimates. Estimates of levels 2 and 3 were generally lower for cancer patients, while they were more likely to have greater estimates in severe levels. Significant differences in utility scores were also noticed with the general population showing higher mean utility scores for the same health states. These differences increased as the health states worsened. This study sheds light on the existing differences in preferences between cancer patients and the general population of Quebec for a better consideration in healthcare decision-making.

Operationalizing the Intolerable Suffering Criterion in Advance Requests for Medical Assistance in Dying for People Living with Dementia in Canada

In Canada, there is interest in expanding medical assistance in dying (MAID) to include advance requests (AR) for people living with dementia (PLWD). However, operationalizing the intolerable suffering criterion for MAID in ARs for PLWD is complicated by the Canadian legal context-in which MAID is understood as a medical intervention and suffering is conceptualized as subjective-and the degenerative nature of dementia. ARs that express a wish to receive MAID when the PLWD develops pre-specified impairments are problematic because people are unlikely to accurately predict the conditions that will cause intolerable suffering. ARs that express a wish to receive MAID when the PLWD exhibits pre-specified behaviors that likely represent suffering are problematic because they are inconsistent with the subjective conceptualization of suffering. Further research is required to determine whether adopting an objective conceptualization of suffering is justified in these cases and, if so, how to reliably identify intolerable suffering in PLWD.

A 360-degree perspective on adeno-associated virus (AAV)-based gene therapy for haemophilia: Insights from the physician, the nurse and the patient

BACKGROUND

Adeno-associated virus (AAV)-based gene therapy for haemophilia has advanced substantially in the last 13 years; recently, three products have received approvals from regulatory authorities. Although the impact on quality of life seems promising, some limitations remain, such as the presence of pre-existing anti-AAV neutralising antibodies and the occurrence of hepatotoxicity. This review follows the CSL Behring-sponsored symposium at the 27th Congress of the European Hematology Association (EHA) 2022 that examined the haemophilia gene therapy process from a 360-degree multidisciplinary perspective. Here, the faculty (haematologist, nurse and haemophilia patient) summarised their own viewpoints from the symposium, with the aim of highlighting the key considerations required to engage with gene therapy effectively, for both patients and providers, as well as the importance of multidisciplinary collaboration, including with industry.

RESULTS

When considering these new therapies, patients face a complex decision-making process, which includes whether gene therapy is right for them at their current stage of life. The authors agreed that collaboration and tailored education across the multidisciplinary team (including patients and their carers/families), starting early in the process and continuing throughout the long-term follow-up period, is key for the success of gene therapy. Additionally, patient expectations, which may surround eligibility, follow-up requirements and treatment outcomes, should be continually explored. During these ongoing discussions, transparent communication of the unknown factors, such as anticipated clotting factor levels, long-term factor expression and safety, and psychological changes, is critical. To ensure efficiency and comprehensiveness, clearly‑defined protocols should outline the whole process, which should include the recording and management of long-term effects.

CONCLUSION

In order to engage effectively, both patients and providers should be familiar with these key considerations prior to their involvement with the haemophilia gene therapy process. The future after the approval of haemophilia gene therapies remains to be seen and real-world evidence is eagerly awaited.

Health utilities in adults with hemophilia A: A retrospective cohort study

INTRODUCTION

Haemophilia A negatively affects a patient's quality of life. There is a limited amount of health utility data (a measure of health-related quality of life) available for patients with haemophilia A. This information is crucial for cost-effectiveness analysis for haemophilia A treatment.

OBJECTIVES

The goal of this project is to elicit the health utilities and factors impacting utility values for haemophilia A patients in Canada.

METHODS

This is a population-based, cross-sectional, retrospective study of health utilities in patients with haemophilia A using Patient Report Outcomes Burdens and Experiences (PROBE) components from the Canadian Bleeding Disorders Registry (CBDR). A review of the mean utilities for three severity states, defined by clotting factor VIII level, was completed. A multiple linear regression analysis was completed to examine the determinants of health utilities including age, treatment type, chronic pain status, number of limited joints, and bleed rate.

RESULTS

The average utility values (and standard deviations) for patients with haemophilia A in Canada are .79(.17), .76(.20), and .77(.19) for patients with severe, moderate, and mild haemophilia. The regression showed chronic pain status and the number of additional comorbidities as major significant factors (p-value < .001) in haemophilia A utility. Haemophilia severity was shown to be a major factor with smaller p-value (p-value < .05).

CONCLUSIONS

Haemophilia A patients have lower utility than the general population. Chronic pain was shown to be a significant, major factor in health-related quality of life. Our study is essential for valuing health outcomes in haemophilia A-related cost-effectiveness analysis.

Quality of life and support needs in children, adolescents, and young adults with facioscapulohumeral dystrophy, a mixed-method study

BACKGROUND AND OBJECTIVES

Quality of life (QoL) in children with facioscapulohumeral dystrophy (FSHD) seems plausible decreased. Little is known about factors influencing QoL in children with FSHD. Our objective is to explore factors contributing to the QoL of children, adolescents, and young adults with FSHD, to describe how they experience life with FSHD, and to report their support needs.

METHODS

We performed a mixed-method study with individual age-appropriate semi-structured interviews assessing QoL in children, adolescents, and young adults with FSHD and their parents. To characterize the sample, quantitative data on QoL, pain, fatigue, and participation were collected. Interview data was analyzed using a thematic analysis.

RESULTS

Fourteen patients participated (age between 9 and 26 years old, eight males and six females). The degree of FSHD severity, as indicated by the FSHD-score, did not correlate with QoL. Older children had a lower QoL than younger children. Children and adolescents strived for normality regardless of physical discomfort. Phenotypical features of FSHD led to insecurity aggravated by hurtful comments of others. The unpredictability of disease progression and its implications for career and parenthood choices led to a generalized feeling of uncertainty about the future. Support was found within family and friends. Participants expressed a need for peer support and psychological support as well as recommending it to others.

DISCUSSION

Quality of life in childhood FSHD is diminished caused by their physical limitations, altered appearance, fear of social rejection, and uncertainty of the disease progression in the future. A fear of social rejection most likely contributes to striving for normality regardless of physical discomfort. Support should be focused on acceptance and coping with hurtful comments. It should preferably be individualized, easily accessible and not offered as therapy but rather as tutoring for children.

First-in-Human Whole-Eye Transplantation: Ensuring an Ethical Approach to Surgical Innovation

As innovations in the field of vascular composite allotransplantation (VCA) progress, whole-eye transplantation (WET) is poised to transition from non-human mammalian models to living human recipients. Present treatment options for vision loss are generally considered suboptimal, and attendant concerns ranging from aesthetics and prosthesis maintenance to social stigma may be mitigated by WET. Potential benefits to WET recipients may also include partial vision restoration, psychosocial benefits related to identity and social integration, improvements in physical comfort and function, and reduced surgical risk associated with a biologic eye compared to a prosthesis. Perioperative and postoperative risks of WET are expected to be comparable to those of facial transplantation (FT), and may be similarly mitigated by immunosuppressive protocols, adequate psychosocial support, and a thorough selection process for both the recipient and donor. To minimize the risks associated with immunosuppressive medications, the first attempts in human recipients will likely be performed in conjunction with a FT. If first-in-human attempts at combined FT-WET prove successful and the biologic eye survives, this opens the door for further advancement in the field of vision restoration by means of a viable surgical option. This analysis integrates recent innovations in WET research with the existing discourse on the ethics of surgical innovation and offers preliminary guidance to VCA programs considering undertaking WET in human recipients.

Effect of etranacogene dezaparvovec on quality of life for severe and moderately severe haemophilia B participants: Results from the phase III HOPE-B trial 2 years after gene therapy

INTRODUCTION

For people with haemophilia B (PwHB), bleeding may occur despite prophylaxis, negatively affecting health-related quality of life (HRQoL). The pivotal phase 3 HOPE-B trial investigating the adeno-associated virus gene transfer product, etranacogene dezaparvovec (EDZ), demonstrated sustained factor IX (FIX) activity and bleed protection in PwHB with baseline FIX levels ≤2%.

AIM

Assess how EDZ affects HRQoL in HOPE-B trial participants.

METHODS

HRQoL was evaluated using generic and disease-specific patient reported outcomes (PROs) including the EQ-5D-5L and the Hem-A-QoL questionnaires. Mean domain and total scores were compared 6 months pre- and the first 2 years post-EDZ administration using repeated measures linear mixed models. The percentage of participants with minimal clinically important improvements in HRQoL was also evaluated.

RESULTS

Two years post-EDZ, there were nominally significant increases in the least squares (LS) mean score for the EQ-5D-5L Index Value (.04; p = .0129), reflecting better HRQoL. Nominally significant decreases in the LS mean scores, reflecting better HRQoL, were also found for the Hem-A-QoL total score (-6.0; p < .0001) and the Treatment (-13.94; p < .0001), Feelings (-9.01; p < .0001), Future (-6.45; p = .0004) and Work/School (-5.21; p = .0098) domains. The percentage of participants with ≥15-point improvement ranged from 45.83% (95% CI: 31.37%, 60.83%) for Treatment to 13.89% (95% CI: 4.67%, 29.50%) for Family Planning. Results were similar for Year 1.

CONCLUSION

In conclusion, gene therapy with EDZ improved HRQoL in the first and second years in several Hem-A-QoL domains, including Treatment, Feelings, Work/School and Future domains, whereas improvement in other aspects of HRQoL were not demonstrated.

Sleep problems in a population-based cohort of primary school age children with Cerebral Palsy

AIMS

To examine sleep problems in a population-based sample of school-aged children (8-12yo) with Cerebral Palsy (CP) METHOD: Eighty-six children (mean 9 years, 5 months, SD = 1 year, 6 months; male = 60) with CP (Gross Motor Function Classification System; GMFCS I=46; II=21; III=9; IV=6; V=6) participated. Classifications/assessments included: Sleep Disturbance Scale for Children (SDSC), Gross Motor Function Measure (GMFM-66), Manual Ability Classification System (MACS), Communication Function Classification System (CFCS), Strengths and Difficulties Questionnaire (SDQ) and the Cerebral Palsy- Quality of Life (CP-QOL) Pain Impact subscale. Analysis included linear and logistic regression.

RESULTS

38 (44 %) children were within the clinical range for sleep problems. Sleep problems were significantly associated with epilepsy, (95 % CI) = 14.48 (7.95 to 21.01), gross motor function, -0.13 (-0.26 to -0.01), manual ability, 7.26 (0.82 to 13.69), communication, 10.01 (2.21 to 17.80), child behaviour, 1.134 (0.74 to 1.53), and pain related QOL, 0.33 (0.12 to 0.53). For the multivariable model, sleep problems remained significantly associated with epilepsy, b (95 % CI) = 11.72 (4.88 to 18.57), child behaviour, 1.03 (0.65 to 1.41) and pain-related QOL, 0.21 (0.29 to 0.38).

CONCLUSIONS

Sleep problems are common and associated with epilepsy, child behaviour and pain related QOL.

Quality of life-related and non-quality of life-related issues in ICU survivors and non-ICU-treated controls: a multi-group exploratory factor analysis

BACKGROUND

Quality of life (QoL) is a key outcome measure in healthcare. However, the heterogeneity in its definitions presents challenges in the objective evaluation of improvement. Universal questionnaires, tailored for a broad demographic group, inadequately represent the unique experiences of intensive care unit (ICU) survivors, including a lack of ability to discriminate issues related to QoL from issues that do not.

METHODS

Using a 218-item, 13-domain provisional questionnaire, we assessed 395 adult ICU survivors, with a minimum 72-h stay at one of three Swedish university hospital ICUs, at 6 months to three years post-discharge. Their responses were compared to those of 195 controls, matched for age and sex and randomly recruited from the Swedish Population Registry. By multi-group exploratory factor analysis, we compared dimensionality in QoL perceptions between the two groups, emphasising patterns of correlation to 13 domain-specific QoL questions. Model fit was assessed using information criteria. Internal consistency reliability for each scale was determined using McDonald's omega or Cronbach's alpha. All analyses were conducted using Mplus, applying full information maximum likelihood to handle missing data.

RESULTS

All domains except Cognition had a subset of questions correlating to the domain-specific QoL question in at least the ICU survivor group. The similarity between the two groups varied, with Physical health, Sexual health and Gastrointestinal (GI) functions mainly correlating the same issues to QoL in the two groups. In contrast, Fatigue, Pain, Mental health, activities of daily living, Sleep, Sensory functions and Work life showed considerable differences. In all, about one-fourth of the issues correlated to QoL in the ICU survivor group and about one-tenth of the issues in the control group.

CONCLUSIONS

We found most issues experienced by ICU survivors to be unrelated to quality of life. Our findings indicate that the consequences of post-ICU issues may play a more significant role in affecting QoL than the issues themselves; issues restricting and affecting social life and work life were more related to QoL in ICU survivors than in non-ICU-treated controls. Caution is advised before associating all post-ICU problems with an effect on quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov Ref# NCT02767180; Registered 28 April 2016.

Experiencing the unreal. Mapping patient journeys from injury towards rehabilitation for a life with tetraplegia

When patients are brought to the emergency room with a traumatic injury to the spinal cord, the road to recovery is long and uncertain. In minutes, their lives have been irreversibly altered. Time will tell if the paralysis to the limbs is permanent or if some degree of mobility or sensation can be reacquired. To many patients, the first weeks feel almost unreal. They find themselves in a state of shock, and feelings of uncertainty and loss of control are dominating. Spinal cord injuries are treated in multiple specialized hospital units. Each unit is accountable for providing the best possible treatment within their area of expertise. While continuity in care has been a hot research topic for the past 20 years, few studies provide empirical data on patients' perspectives on long-term hospital treatments. This study examines how patients with tetraplegia experience continuity in care when they journey across multiple hospital units over the course of several months. This paper is based on a study of patient pathways for patients with tetraplegia caused by high spinal cord injuries. Semi-structured interviews were conducted with nine patients, seven next of kin and thirteen healthcare professionals in Copenhagen University Hospital. Data from the interviews were analyzed using patient journey mapping, to uncover variations in patients' experience during various stages of their admission. The study finds that patients are struggling to maintain a sense of control over their life as they continuously engage in negotiations of perceptions of their body, of the physical surroundings and of their perception of time and the future. The study concludes that health care professionals should be mindful of these key themes to support the patients' empowerment and active participation during recovery.

Divergent Views and Experiences Regarding 'Completed Life' and Euthanasia in the Netherlands

A small proportion of older people in the Netherlands want to end their lives because they feel their lives to be 'completed' and no longer worth living. Currently, there is heated debate over whether or not these people should have the right to euthanasia. Drawing on previous research, we conduct a heuristic analysis of views and experiences of three different 'parties' involved in this debate, namely, the older people, their relatives and friends and medical professionals. The views of these three groups tend to be divergent and conflicting, posing a difficult dilemma to decision-makers.

Assessing the Effectiveness of Rehabilitation Interventions through the World Health Organization Disability Assessment Schedule 2.0 on Disability-A Systematic Review

(1) Background: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a tool designed to measure disability in accordance with the International Classification of Functioning, Disability and Health. Measuring disability is becoming increasingly important due to its high prevalence, which continues to rise. Rehabilitation interventions can reduce disability and enhance functioning. (2) Objective: The present study aims to assess the impact of rehabilitation interventions on reducing disability, as measured by the WHODAS 2.0 questionnaire. It also seeks to identify which specific rehabilitation interventions are more effective and to explore other disability assessment questionnaires. (3) Methods: Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a systematic review, with the protocol registered with the identifier CRD42023495309, focused on "WHODAS" and "rehabilitation" using PubMed and Web of Science electronic databases. (4) Results: We identified 18 articles from various regions encompassing patients with various health conditions, related to stroke, the cardiovascular system (cardiovascular disease, chronic heart failure), the pulmonary system (chronic obstructive pulmonary disease), the neurologic system (Parkinson's disease, cerebral palsy, neurodegenerative disease), the musculoskeletal system (orthopaedic surgery), cancer, and chronic pain, and among frail elderly. These patients have received a wide range of rehabilitation interventions: from conventional therapy to virtual reality, robot-assisted arm training, exergaming, and telerehabilitation. (5) Discussion and Conclusions: A wide range of rehabilitation techniques can effectively improve disability with various comorbidities, offering numerous benefits. The WHODAS 2.0 questionnaire proves to be an efficient and reliable tool for measuring disability, and scores have a tendency to decrease after rehabilitation.

Child disability as a family issue: a study on mothers' and fathers' health in Italy

BACKGROUND

Disability does not simply affect the health status of the individual who directly experiences that condition, but it has important consequences on the health and well-being of the other family members as well. Focusing on Italy, an extremely interesting test-bed due to its strong familialist welfare regime, we show significant spillover effects of children's disability on parental health and well-being.

METHODS

We use data from a nationally representative household survey on almost 13 000 mothers and fathers and adopt a multivariate regression setting providing evidence that the disability of a child is negatively associated with parents' health and life satisfaction.

RESULTS

Parents of a disabled child report lower levels of general and mental health, as well as lower levels of well-being compared with parents with a healthy child. Strong heterogeneity by gender and socio-economic characteristics is observed, with mothers being more affected by the disability status of the child than fathers. The estimated coefficients suggest that education remains an important protective factor even for parents of a disabled child.

CONCLUSION

This study claims and documents that child disability is an overlooked source of health disadvantage for parents. Such disadvantage is especially relevant for mothers and lower-educated parents, evidence that suggests the importance of taking an intersectional approach to study health disparities.

Revisiting the meaning and the source of health-related constructs and their applications in neurodisability

The aim of this review is to revisit the meaning of common concepts and frameworks promoted to capture subjective outcomes of patients, the content of their corresponding measurements, and the preferred sources of the information of interest. This is important because conceptualizations of 'health' and the subject evaluations thereof continue to evolve. Related but distinct concepts like quality of life (QoL), health-related QoL (HRQoL), functional status, health status, and well-being are often used indiscriminately to assess clinical impacts of interventions and to influence decisions about patient care and policymaking. The discussion addresses and illustrates the following issues: (1) the required features of effective and valid health-related concepts; (2) understanding underlying factors that often create confusion about QoL and HRQoL; and (3) how these concepts provide insight into, and promote, health in the context of populations with neurodisability. The hope is to illustrate how a combination of a clear research question, a hypothesis, conceptualization of the required outcomes, and operational definitions of the domains and items of interest, including item mapping, can help to achieve robust methodology and valid findings beyond the required psychometric properties. WHAT THIS PAPER ADDS: The language, content, and the source of perceived health and life issues are clarified. Using the same terms for different constructs, or different terms for the same constructs, creates confusion and hinders outcome research. The challenges of using patient-reported outcomes in neurodisability are addressed.

Subjective quality of life and schizophrenia: results from a large cohort study based in Chinese primary care

INTRODUCTION

Much confusion exists between health-related QoL (HRQoL) scales and subjective QoL (SQoL) scales. One method to avoid confusion is use of a single question that asks What is your quality of life? or similar. This study explored the relationship between biopsychosocial factors and high SQoL, SQoL stability, and factors associated with improving SQoL.

METHOD

We conducted a large cohort study of community-dwelling Chinese adults with schizophrenia, with two data points (2015-2016 (N = 742), 2017-2018 (N = 491)). Demographic and clinically related items and a comprehensive suite of published measures were collected. Direct logistic regressions were used to explore links between biopsychosocial factors and high SQoL and Improvement in SQoL across time.

RESULTS

Sample at Baseline: Male = 62.3%; Med age = 38.5 years; Med Age at illness onset = 24 years; SQoL Mode = neither poor nor good. Three independent variables predicted high SQoL at T1. Contemporary age and the presence of clinically relevant symptoms had a negative relationship with high SQoL; insight had a positive relationship with high SQoL. SQoL changed significantly across time with a modest effect size. Age at illness onset was the single independent variable linked to improving SQoL favoring being older at the time of illness onset.

DISCUSSION/CONCLUSIONS

SQoL can be high and changeable. While symptomology and illness insight may affect SQoL self-appraisals at single points in time, only age of illness onset was connected with improving SQoL. Thus, public health measures to delay illness onset are important. In addition, care about the distinction between HRQoL and SQoL in study design and choice of measures is necessary and will depend on the purpose and context.

A study on the impact of health shocks on subjective wellbeing of middle-aged people and older adults-Evidence from China

Introduction

The health issues that afflict middle-aged people and older individuals are a significant factor that affects their quality of life. It is crucial to investigate the impact of health shocks on the subjective wellbeing of this demographic and the mechanisms that underlie this impact to promote healthy aging.

Methods

This study utilized data from the China Family Panel Study in 2018 and 2020 to analyze the effects of HSs and their categories on the subjective wellbeing of middle-aged people and older individuals using the propensity score matching difference-in-differences method. Additionally, the study explored the mediating role of social participation.

Results

The findings indicate that health shocks, both chronic and acute, diminish the subjective wellbeing of middle-aged people and older adults. Furthermore, these shocks have a more significant negative effect on the subjective wellbeing of individuals aged 60 and above, women in the middle-aged and older demographic, individuals in rural areas who belong to the middle-aged and older age groups, and individuals possessing activities of daily living. The mechanism analysis revealed that health shocks, both chronic and acute, reduce the subjective wellbeing of middle-aged people and older individuals by disrupting partnerships.

Discussion

Lowering the possibility of health shocks, the government should build a strong health management system and improve the health insurance system to enable timely treatment for persons suffering from health shocks. Individuals and families should live healthy lives and engage in social activities to avoid health shocks and improve subjective wellbeing.

Health-Related Quality of Life in FKRP-Related Limb-Girdle Muscular Dystrophy R9

BACKGROUND

Limb-girdle muscular dystrophy R9 (LGMDR9) is a chronic progressive hereditary muscle disease, related to the Fukutin Related Protein (FKRP) gene, that may cause major disabilities, cardiomyopathy, and ventilatory failure. Knowledge of how LGMDR9 affects health-related quality of life (HRQoL) is relevant in treatment and care.

OBJECTIVE

To investigate HRQoL in the Norwegian LGMDR9 population over 14 months and relation to fatigue and sleep quality.

METHODS

Participants (16+ years) of the Norwegian LGMDR9 cohort study completed two HRQoL measures, i.e., Individualized Neuromuscular Quality of Life questionnaire (INQoL) and the 36-item Short Form (SF-36) at baseline, 8, and 14 months and measures of fatigue and sleep quality at 9 months.

RESULTS

HRQoL response rate was 84/90 (75 c.826 C > A homozygotes and nine c.826 C > A compound heterozygotes). Compared to Norwegian normative data, all SF-36 domain scores were impaired (p≤0.006) except mental health in males (p = 0.05) and pain scores. During 14 months, perceived muscle weakness and the INQoL index (disease burden) worsened in c.826 C > A homozygotes. Compound heterozygotes reported more dysphagia and physical difficulties than homozygotes and showed a tendency towards worsening in weakness over time but some improvement on the INQoL index. Homozygous females reported generally poorer HRQoL and a higher burden than males. The INQoL index was related to perceived muscle weakness and fatigue, and fatigue to myalgia and mental distress. The prevalence of fatigue and poor sleep was 40% and 49%, respectively.

CONCLUSIONS

The 14-month follow-up period shows a worsening of perceived weakness and burden in c.826 C > A homozygotes, which can then be expected. The prevalence and impact of fatigue indicate a need for awareness and treatment of fatigue. Myalgia and mental distress are potential targets in the treatment of fatigue, which future studies need to establish. Sleep issues and gender-specific care needs also require attention in LGMDR9.

Reflexive thematic analysis of a coaching-based, holistic approach to child development

BACKGROUND

The F-words Life Wheel (FWLW) approaches child development by hybridizing a holistic model in the F-words for Child Development, and a coaching model in Occupational Performance Coaching, along with a life-flow approach in the Kawa model. We report the impact of the FWLW as experienced by families.

METHODS

This was a qualitative interview study of parents of children with developmental needs and experts in child development using reflexive thematic analysis.

RESULTS

From 13 interviews, we developed three themes: 1) overwhelming, 2) power rebalance and 3) connectedness. The overwhelming theme addresses how life with developmental needs is challenging, engaging with the health and disability system is difficult and the focus on deficits can lead to a sense of being overwhelmed. The power rebalance theme addresses the transition from professionals calling the shots to giving agency to the child and family. Holistic goal setting empowers parents and children to direct and prioritize therapy, and helps shift from a deficit-focused to a 'can-do' attitude. The connectedness theme addresses the linkages between psychological health, physical health, the extended family and the planet as a whole.

CONCLUSIONS

The FWLW approach appears to be empowering and motivating for children and families.

Understanding UK public views on normative decisions made to value health-related quality of life in children: A qualitative study

Developing methodology for measuring and valuing child health-related quality of life (HRQoL) is a priority for health technology agencies. One aspect of this is normative decisions that are made in child HRQoL valuation. This qualitative study aimed to better understand adult public opinion on the normative questions of whose preferences to elicit (adults, children, or both) and from which perspective (who should be imagined living in impaired health), when valuing child HRQoL. Opinions of the adult UK public (N = 32) were solicited using online semi-structured focus groups, featuring a breadth of age, sex, ethnicities, and responsibility for children under 18 years. Participants were provided with bespoke informational material on health state valuation and were probed for their views. Arguments for and against different positions were discussed. Data was analysed using framework analysis. Participants demonstrated near-to-universal agreement that children should be involved in valuation in some form, yet this should differ depending on age or maturity. There was strong support for approaches combining involvement from children and adults (e.g., their parents), especially for younger children. There was little intuitive support for the 'taxpayer argument' for asking taxpaying adults. In the context of greater involvement of children in valuation, most participants supported using an 'own' perspective. Most participants thought that valuation study participants should know the exercise is about valuing child health states for ethical reasons. Informed views from the UK public on who should be asked and with what perspective when valuing child HRQoL appear to differ from normative positions previously advocated by some health economists, such as prioritising the preferences of taxpaying adults. In contrast, the results suggest including adults and children in valuation, with the proviso that the children are of an appropriate age and level of maturity, and that an own perspective is used wherever possible.

How strong is the will-to-live in frail older persons? A survey study in acute geriatric wards and nursing homes in Belgium

INTRODUCTION

Will-to-live is defined as the psychological expression of one's commitment to life and the desire to continue living. It is an important indicator of subjective wellbeing. This study aimed to assess the will-to-live in frail older hospitalized patients and nursing home residents as well as to evaluate its association with physical frailty, tiredness of life, depression and wish-to-die.

METHODS

Between March and September 2021, we interviewed 186 older adults in six nursing homes and two acute geriatric wards across Belgium. Will-to-live was assessed using a single-item numeric rating scale from 0 to 5. A linear regression analysis was performed to assess the association between will-to-live and frailty (Clinical Frailty Scale) with adjustment for age, gender and setting. Mann-Whitney U test was used to evaluate the association between will-to-live and depression, tiredness of life and wish-to-die.

RESULTS

Mean age was 85 (± 6.2) years. Mean score on the Clinical Frailty Scale was five (± 1.5) and four on the will-to-live (± 1.3). No statistical significant association was found between will-to-live and age (p = 0.991), gender (p = 0.272), setting (p = 0.627) and frailty (p = 0.629). Multiple linear regression showed no significant association with Clinical Frailty Scale (p = 0.660), after adjustment for age, gender and setting. Will-to-live was negatively associated with tiredness of life (p = 0.020) and wish-to-die (p < 0.001), but not with depression (p = 0.186).

DISCUSSION

Both nursing home residents and older hospitalized patients expressed a strong or very strong will-to-live. Will-to-live was not associated with physical frailty as measured by the Clinical Frailty Scale. Nursing home residents with a weak will-to-live were more likely to have depressive symptoms. Most nursing home residents with a wish-to-die had also a low will-to-live, although some residents had both a high will-to-live and wish-to-die.

Recent Trends in the Withdrawal of Life-Sustaining Treatment in Patients with Acute Cerebrovascular Disease : 2017-2021

OBJECTIVE

The Act on Life-Sustaining Treatment (LST) decisions for end-of-life patients has been effective since February 2018. An increasing number of patients and their families want to withhold or withdraw from LST when medical futility is expected. This study aimed to investigate the status of the Act on LST decisions for patients with acute cerebrovascular disease at a single hospital.

METHODS

Between January 2017 and December 2021, 227 patients with acute cerebrovascular diseases, including hemorrhagic stroke (n=184) and ischemic stroke (n=43), died at the hospital. The study period was divided into the periods before and after the Act.

RESULTS

The duration of hospitalization decreased after the Act was implemented compared to before (15.9±16.1 vs. 11.2±18.6 days, p=0.127). The rate of obtaining consent for the LST plan tended to increase after the Act (139/183 [76.0%] vs. 27/44 [61.4%], p=0.077). Notably, none of the patients made an LST decision independently. Ventilator withdrawal was more frequently performed after the Act than before (52/183 [28.4%] vs. 0/44 [0%], p<0.001). Conversely, the rate of organ donation decreased after the Act was implemented (5/183 [2.7%] vs. 6/44 [13.6%], p=0.008). Refusal to undergo surgery was more common after the Act was implemented than before (87/149 [58.4%] vs. 15/41 [36.6%], p=0.021) among the 190 patients who required surgery.

CONCLUSION

After the Act on LST decisions was implemented, the rate of LST withdrawal increased in patients with acute cerebrovascular disease. However, the decision to withdraw LST was made by the patient's family rather than the patient themselves. After the execution of the Act, we also observed an increased rate of refusal to undergo surgery and a decreased rate of organ donation. The Act on LST decisions may reduce unnecessary treatments that prolong end-of-life processes without a curative effect. However, the widespread application of this law may also reduce beneficial treatments and contribute to a decline in organ donation.

Emily's struggle for dignity: An idiographic case study of a woman with multiple sclerosis

Dignity is one of the essential values and central concepts in nursing care. Dignity can be threatened due to radical life changes; therefore, this idiographic case study aimed to explore the sense of dignity experienced by a woman with multiple sclerosis. An interpretative phenomenological analysis was adopted, using data collected through a face-to-face semistructured interview with Emily, a 45-year-old woman. The study was approved by the local ethics committee. Six personal experiential themes were identified: To be ruled by a sick body; Silent progression; Loss of independence as a burden for the family; Will to fight for the meaning of life; Maintaining dignity-in-relation; Dignified care in a period of greater vulnerability. Emily's dignity is based on the effort to fight for a meaningful life, utilization of her full potential, maintain independence in activities of daily living and support in relationships. Continuous changes in functional ability, loss of self-control and an uncertain future have a negative impact on the experience of her dignity. In the context of dignified health care, she considers individual care and maintaining autonomy important. The idiographic case study can contribute to a better understanding of the experience of a woman suffering from multiple sclerosis. It is possible to carry out interventions that aim to support her dignity, improve her quality of life and contribute to individually oriented health care.

Predictors of long-term health-related quality of life in Guillain-Barré syndrome: A hospital-based study

OBJECTIVE

This study aimed to determine the impact of patients' baseline clinical, neurophysiological data, and management plan of Guillain-Barré syndrome (GBS) on long-term quality of life (QoL) and to identify its potential predictors.

METHODS

Seventy-nine GBS patients were recruited. On admission, participants were evaluated using the Medical Research Council (MRC) sumscore, GBS disability scale (GDS), and Erasmus GBS Respiratory Insufficiency Score (EGRIS). Neurophysiological data were collected, and a management plan was devised. MRC sumscore was repeated at nadir. MRC, GDS and Short Form Survey (SF-36) were assessed at first-year follow-up.

RESULTS

The mean age was 37.84 ± 17.26 years, with 43 male patients (54.4%). QoL at one year correlated significantly with baseline clinical variables (age, number of days between weakness and admission, MRC sumscore at onset and nadir, high GDS, and EGRIS scores). Antecedent events, especially diarrhoea, neck muscle weakness, autonomic dysfunction, cranial nerve involvement, and mechanical ventilation (MV), associated with worse QoL. Axonal GBS patients had lower QoL than AIDP patients, and PE patients exhibited lower QoL than IVIG patients. Multiple regression analysis showed that older age, diarrhoea, number of days between weakness and admission, neck muscle weakness, cranial nerve involvement, autonomic dysfunction, early MV, and MRC at onset and nadir and high GDS could predict poor QoL.

CONCLUSION

Older age, more days between weakness and admission, neck muscle weakness, cranial nerve involvement, autonomic dysfunction, early MV, diarrhoea, low MRC at onset and nadir, high GDS at onset, axonal type, and PE treatment were potential predictors of poor QoL in GBS.

Sexual Health and Well-Being in Adults With Congenital Heart Disease: A International Society of Adult Congenital Heart Disease Statement

As health care outcomes improve the priority for those living with adult congenital heart disease have changed to a more holistic focus on quality of life and well-being. Although health care has embraced this, there are still areas where there is a deficit in advice, allyship, and advocacy. One of these deficits is in the area of sexual health and well-being. A healthy sexual life has a myriad of physical and psychosocial benefits. However, individuals with adult congenital heart disease may have significant barriers to achieving well-being in this aspect of their lives. These barriers and their potential solutions are outlined in this paper.

Clinical and Psychosocial Factors Considered When Deciding Whether to Offer Deep Brain Stimulation for Childhood Dystonia

INTRODUCTION

Childhood dystonia is often nonresponsive to medications, and refractory cases are increasingly being treated with deep brain stimulation (DBS). However, many have noted that there is little consensus about when DBS should be offered, and there has been little examination of clinicians' decision-making process when determining whether to offer DBS for childhood dystonia.

OBJECTIVES

This study aimed to identify and examine the factors considered by pediatric movement disorder specialists before offering DBS.

MATERIALS AND METHODS

Semistructured interviews (N = 29) with pediatric dystonia clinicians were conducted, transcribed, and coded. Using thematic content analysis, nine central themes were identified when clinicians were asked about key factors, clinical factors, and psychosocial factors considered before offering pediatric DBS.

RESULTS

Clinicians identified nine main factors. Five of these were classified primarily as clinical factors: early intervention and younger age (raised by 86% of respondents), disease progression and symptom severity (83%), etiology and genetic status (79%), clinicians' perceived risks and benefits of DBS for the patient (79%), and exhaustion of other treatment options (55%). The remaining four were classified primarily as psychosocial factors: social and family support (raised by 97% of respondents), patient and caregiver expectations about outcomes and understanding of DBS treatment (90%), impact of dystonia on quality of life (69%), and financial resources and access to care (31%).

CONCLUSIONS

Candidacy determinations, in this context, are complicated by an interrelation of clinical and psychosocial factors that contribute to the decision. There is potential for bias when considering family support and quality of life. Uncertainty of outcomes related to the etiology of dystonia makes candidacy judgments challenging. More systematic examination of the characteristics and criteria used to identify pediatric patients with dystonia who can significantly benefit from DBS is necessary to develop clear guidelines and promote the well-being of these children.

Developing Disability-Focused Pre-Health and Health Professions Curricula

People with disabilities (PWD) comprise a significant part of the population yet experience some of the most profound health disparities. Among the greatest barriers to quality care are inadequate health professions education related to caring for PWD. Drawing upon the expertise of health professions educators in medicine, public health, nursing, social work, and physician assistant programs, this forum showcases innovative methods for teaching core disability skills and concepts grounded in disability studies and the health humanities. Each of the essays offers practical guidance for developing curricular interventions appropriate for students at various levels of training and familiarity with disability to be implemented in classroom discussions, case-based learning, lectures, panels, and clinical simulations across the full spectrum of pre-health and health professions education.

Self-reported functioning among patients with ultra-rare nemaline myopathy or a related disorder in Finland: a pilot study

BACKGROUND

Nemaline myopathy (NM) and related disorders (NMr) form a heterogenous group of ultra-rare (1:50,000 live births or less) congenital muscle disorders. To elucidate the self-reported physical, psychological, and social functioning in the daily lives of adult persons with congenital muscle disorders, we designed a survey using items primarily from the Patient Reported Outcomes Measurement Information System, PROMIS®, and conducted a pilot study in patients with NM and NMr in Finland. The items were linked to International Classification of Functioning, Disability and Health (ICF) categories.

RESULTS

In total, 20 (62.5%) out of 32 invited persons resident in Finland participated in the study; 12 had NM and 8 NMr, 15 were women and 5 men aged 19-75 years. Sixteen (80%) were ambulatory and 4 (20%) NM patients used wheelchairs. The results from the PROMIS measuring system and ICF categories both indicated that non-ambulatory patients of this study faced more challenges in all areas of functioning than ambulatory ones, but the differences were smaller in the domains measuring psychological and social functioning than in physical functioning. In addition, the COVID-19 pandemic adversely affected the functioning of non-ambulatory patients more than that of ambulatory patients. The interindividual differences were, however, noticeable.

CONCLUSIONS

To our knowledge, this pilot study is the first comprehensive survey-based study of the physical, psychological, and social functioning of adult persons with nemaline myopathy or related disorders. The results indicate vulnerability of non-ambulatory patients being at higher risk to a decrease in general functioning during global or national exceptional periods. The responses also gave directions for modifying and improving the survey for future studies.

Complex lived experiences and hidden disability after spinal cord injury: a latent profile analysis of the Australian arm of the International Spinal Cord Injury (Aus-InSCI) Community Survey

PURPOSE

To identify and examine subgroups of people with spinal cord injury (SCI) with different patterns of lived experience, and examine hidden impairments and disability among functionally independent and ambulant people.

MATERIALS AND METHODS

Latent profile analysis of population-based data from the Australian arm of the International Spinal Cord Injury (InSCI) Community survey (n = 1579).

RESULTS

Latent subgroups reflected levels of functional independence and extent of problems with health, activity/participation, environmental barriers, and self-efficacy. Quality of life (QoL), psychological profiles, and activity/participation were often as good or better in participants who reported lower (vs. higher) functional independence alongside comparable burden of health problems and environmental barriers. QoL, mental health, and vitality reflected self-efficacy and problem burdens more closely than functional independence. Ambulant participants reported a substantial burden of underlying, potentially hidden impairments, with QoL and mental health similar to wheelchair users.

CONCLUSION

Hidden disability among more independent and/or ambulant people with SCI can affect well-being substantially. Early and ongoing access to support, rehabilitation, and SCI specialist services is important irrespective of cause, type, severity of injury, and level of functional independence. Improved access to SCI expertise and equity of care would help to improve early recognition and management of hidden disability.

TRIAL REGISTRATION

Not applicable.

Determinants of perceived health in university employees

Objective: Employee health plays an important role in overall campus health and wellbeing. Therefore, this research explored the physical, mental, and environmental determinants of perceived health in employees of higher education. Participants: 422 full-time employees from one university took the American College Health Association National Faculty and Staff Health Assessment (NFSHA) online in April 2021. Methods: A cross-sectional correlational design was used to explore which physical, mental, and environmental health factors influenced perceived health of employees. Results: Sleep, body mass index (BMI), flourishing, and the extent to which employees felt the university cared about their health and wellbeing were the four significant factors that increased the odds of employees reporting higher levels of perceived health. Conclusions: Using Bandura's reciprocal determinism as a theoretical lens, these results reinforce that behaviors, personal attributes, and the environment are interdependent and influence perceived health in this sample of university employees.

Leaving no one behind: successful ageing at the intersection of ageism and ableism

BACKGROUND

The concept of 'successful ageing' has been a prominent focus within the field of gerontology for several decades. However, despite the widespread attention paid to this concept, its intersectional implications have not been fully explored yet. This paper aims to address this gap by analyzing the potential ageist and ableist biases in the discourse of successful ageing through an intersectional lens.

METHOD

A critical feminist perspective is taken to examine the sensitivity of the discourse of successful ageing to diversity in societies. The paper analyzes how ageist and ableist biases can manifest in the ways we conceptualize ageing, drawing on examples in the context of mental health.

RESULTS

We argue that the conventional approach to successful ageing is limited in its ability to account for the experiences of people who have faced intersectional discrimination throughout their lives. Drawing on examples in the context of mental health, we explore among others the link between depression and disabilities. Furthermore, we shed light on the negative impact of ageist and ableist attitudes concerning the diagnosis and treatment of dementia.

DISCUSSION

We demonstrate how diversity is often overlooked in discussions of ageing well, and how ageist and ableist biases can manifest in the ways we conceptualize ageing. We argue that focusing solely on the health status as a means of achieving success fails to adequately counter ageism for all people. We further emphasize the role of structural factors, such as ageist attitudes, in shaping the experience of ageing and exacerbating health inequalities.

CONCLUSION

Overall, our findings emphasize the need for a more nuanced and inclusive understanding of ageing and therefore an intersectional approach to conceptions of ageing well that recognizes and addresses the biases and limitations of current discourses. Thereby, this paper offers valuable insights into the complex intersections between age and disabilities from a bioethical perspective, highlighting the need for a more inclusive and intersectional approach to ageing.

Individual, family, and environmental determinants of vision-related quality of life of children and young people with visual impairment

Childhood visual impairment can have a significant impact on an individual's development. To improve clinical care and develop appropriate psychosocial interventions of these patients, it is necessary to understand the contributing and modifiable factors that both identify individuals in greater need and could be targeted in interventions. Here we investigate the broader individual, family, and environmental factors associated with vision-related quality of life (VQoL) of children and young people with visual impairment (CYP-VI). Data for this cross-sectional study were collected from September 2014 to May 2017 to develop and validate two vision-specific patient-reported outcome measures (PROMs) for CYP-VI. Patients were recruited from 22 hospitals in the United Kingdom and were aged 7-18 years with visual impairment as per WHO criteria. Participants self-completed the two PROMs, VQoL and Functional Vision Questionnaires. Clinical characteristics were extracted from medical records. Their carers provided information on family sociodemographic backgrounds. Associations between the VQoL scores and other factors were examined using Spearman's correlation, Kruskal-Wallis, Wilcoxon rank-sum tests, and quantile regression models. The sample consisted of 152 CYP-VI (67 females). Better VQoL was significantly associated with better functional vision overall (rSpearman = -0.52), parent-reported absence of additional chronic conditions (dCohen = 0.46), attending mainstream (versus other) school (dCohen = 0.44), higher socio-economic status (rSpearman = 0.17) and higher parental education level (rSpearman = 0.20). No other investigated factors were significantly associated with VQoL. The final quantile regression model included functional vision scores and the presence of additional health condition. Variation in self-reported VQoL in CYP-VI can be partly accounted for by factors relating to the clinical status of the affected child and, more importantly, by non-health-related factors. This needs to be considered in clinical practice when assessing vision-specific outcomes and providing support to CYP-VI, as well as in the development of future interventions.

Operationalizing the Chronic Care Model with Goal-Oriented Care

The Chronic Care Model has guided quality improvement in health care for almost 20 years, using a patient-centered, disease management approach to systems and care teams. To further advance efforts in person-centered care, we propose strengthening the Chronic Care Model with the goal-oriented care approach. Goal-oriented care is person-centered in that it places the focus on what matters most to each person over the course of their life. The person's goals inform care decisions, which are arrived at collaboratively between clinicians and the person. In this paper, we build on each of the elements of the Chronic Care Model with person-centered, goal-oriented care and provide clinical examples on how to operationalize this approach. We discuss how this adapted approach can support our health care systems, in particular in the context of growing multi-morbidity.

Social factors of health-related quality of life in older adults: a multivariable analysis

PURPOSE

The objective of the analysis was to examine the relationships between sociodemographic, socioeconomic, psychosocial, and behavioural factors and both physical and mental health-related quality of life (HRQOL) in older adults.

METHODS

The analysis was based on recent cross-sectional data of 1687 community residents from a whole population postal survey of German adults aged 65 years and older (33% response rate, 52% female, mean age 76 years). HRQOL was assessed using the 36-Item Short Form Survey (SF-36v2). For a differentiated analysis, hierarchical multiple linear regressions were performed.

RESULTS

An internal health locus of control, physical activity, social support, and income were positively associated with physical HRQOL (Adj. R2 = 0.34; p < 0.001) and mental HRQOL (Adj. R2 = 0.18; p < 0.001), whereas an external health locus of control and age were negatively associated with both. Alcohol use and educational level were positively associated only with physical HRQOL, whilst female gender was negatively associated only with mental HRQOL.

CONCLUSION

Sociodemographic, socioeconomic, psychosocial, and behavioural factors were associated with physical and mental HRQOL. These results highlight the importance of social factors in HRQOL and provide approaches for policy and practice to develop and implement tailored health interventions for older adults. Our findings may be transferable to municipalities in metropolitan areas of high-income European countries.

CLINICAL TRIAL REGISTRATION

Not applicable.