Evaluation and ethical review of a tool to explore patient preferences for information and involvement in decision making

Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial

BACKGROUND

Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions.

METHODS

This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient's preferences for information and involvement and the clinician's perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis.

DISCUSSION

The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.

Patient preferences in geriatric wards, a survey of health care professionals' practice, experience and attitudes

PURPOSE

We aimed to identify whether health care professionals (HCP) examine their patient and next-of-kin preferences, and to study whether medical decisions follow these preferences.

METHOD

A cross-sectional web-based survey was conducted with multidisciplinary HCP from 12 geriatric wards in the South-Eastern Norway Regional Health Authority.

RESULTS

Of the 289 HCPs responding (response rate 61%), mean age 37.8 years (SD 11.3), 235 (81.3%) women, 12.4 (SD 9.6) years of experience and 67 (23.2%) medical doctors, only half report clarifying patients' preferences. The majority reported that they did not inform, involve and treat in line with such preferences. However, 53% believe that HCP, patients and next-of-kin should make clinical decisions together.

DISCUSSION

Our findings indicate a lack of engagement in conversation and inclusion of patient preferences when providing health interventions in geriatric wards. Measures for change of culture are needed.

Oncologists' Communication About Uncertain Information in Second Opinion Consultations: A Focused Qualitative Analysis

Introduction: Uncertainty is omnipresent in cancer care, including the ambiguity of diagnostic tests, efficacy and side effects of treatments, and/or patients' long-term prognosis. During second opinion consultations, uncertainty may be particularly tangible: doubts and uncertainty may drive patients to seek more information and request a second opinion, whereas the second opinion in turn may also affect patients' level of uncertainty. Providers are tasked to clearly discuss all of these uncertainties with patients who may feel overwhelmed by it. The aim of this study was to explore how oncologists communicate about uncertainty during second opinion consultations in medical oncology. Methods: We performed a secondary qualitative analysis of audio-recorded consultations collected in a prospective study among cancer patients (N = 69) who sought a second opinion in medical oncology. We purposively selected 12 audio-recorded second opinion consultations. Any communication about uncertainty by the oncologist was double coded by two researchers and an inductive analytic approach was chosen to allow for novel insights to arise. Results: Seven approaches in which oncologists conveyed or addressed uncertainty were identified: (1) specifying the degree of uncertainty, (2) explaining reasons of uncertainty, (3) providing personalized estimates of uncertainty to patients, (4) downplaying or magnifying uncertainty, (5) reducing or counterbalancing uncertainty, and (6) providing support to facilitate patients in coping with uncertainty. Moreover, oncologists varied in their (7) choice of words/language to convey uncertainty (i.e., "I" vs. "we"; level of explicitness). Discussion: This study identified various approaches of how oncologists communicated uncertain issues during second opinion consultations. These different approaches could affect patients' perception of uncertainty, emotions provoked by it, and possibly even patients' behavior. For example, by minimizing uncertainty, oncologists may (un)consciously steer patients toward specific medical decisions). Future research is needed to examine how these different ways of communicating about uncertainty affect patients. This could also facilitate a discussion about the desirability of certain communication strategies. Eventually, practical and evidence-based guidance needs to be developed for clinicians to optimally inform patients about uncertain issues and support patients in dealing with these.

Improved patient participation through advance care planning in nursing homes-A cluster randomized clinical trial

OBJECTIVE

To improve patient participation in advance care planning in nursing homes where most patients have some degree of cognitive impairment.

METHODS

This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support using a whole-ward approach where regular staff perform advance care planning and invite all patients and next of kin to participate.

RESULTS

In intervention group wards the patients participated more often in end-of-life treatment conversations (p < 0.001). Moreover, the patient's preferences, hopes AND worries (p = 0,006) were more often documented, and concordance between provided TREATMENT and patient preferences (p = 0,037) and next of kin participation in advance care planning with the patient (p = 0,056) increased.

CONCLUSION

Improved patient participation - also when cognitively impaired - is achievable through advance care planning in nursing homes using a whole-ward approach.

PRACTICE IMPLICATIONS

Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be used to implement advance care planning.

TRIAL REGISTRATION

ISRCTN registry (ID ISRCTN69571462) - retrospectively registered.

Dealing with ethical and existential issues at end of life through co-creation

BACKGROUND

In research on co-creation in nursing, a caring manner can be used to create opportunities for the patient to reach vital goals and thereby increase the patient's quality of life in palliative home care. This can be described as an ethical cornerstone and the goal of palliative care. Nurses must be extra sensitive to patients' and their relatives' needs with regard to ethical and existential issues and situations in home care encounters, especially at the end of life.

AIM

The aim of this study was to explore nurses' experiences of dealing with ethical and existential issues through co-creation at the end of life in palliative home care.

RESEARCH DESIGN, PARTICIPANTS, AND RESEARCH CONTEXT

The material consisted of texts from interviews with 12 nurses in a home care context. A hermeneutical approach was used, and the method was inspired by a thematic analysis.

ETHICAL CONSIDERATIONS

Informed consent was sought from the participants regarding study participation and the storage and handling of data for research purposes. Ethical permission to conduct the study was given from organizations that participated in this study.

FINDINGS

A main theme and four subthemes emerged. The main theme was "Deep co-creative relationships are needed to manage ethical and existential issues at the end of life." A model was created to display the findings and relations between ethical issues and situations and the need for a deep trustful caring relationship to solve problems in palliative home care.

DISCUSSION

Together, the themes can be considered as a tool for learning and dealing with ethical and existential issues at the end of life in home care. The themes can also be seen as a part of nurses' ethical competence within this context.

CONCLUSION

The quality of life at the end of life can be improved through co-creation, despite difficult ethical and existential issues. Future research should focus on co-creation from the patients' perspective.

Implementing advance care planning in nursing homes - study protocol of a cluster-randomized clinical trial

BACKGROUND

Close to half of all deaths in Norway occur in nursing homes, which signals a need for good communication on end-of-life care. Advance care planning (ACP) is one means to that end, but in Norwegian nursing homes, ACP is not common. This paper describes the protocol of a project evaluating an ACP-intervention in Norwegian nursing homes. The aims of this research project were to promote the possibility for conversations about the end of life with patients and relatives; promote patient autonomy; create a better foundation for important decisions in the case of medical emergencies and at the end of life; and gain experiences in order to find out what characterizes good ACP and good implementation strategies.

METHODS/DESIGN

This study was a mixed method study including a cluster-randomized clinical trial. Eight nursing home wards or "clusters" were pair-matched, and one ward from each pair was randomly selected for a 12-month intervention. The intervention consisted of implementing an ACP-guideline. Implementation strategies were training and supervision of project teams and staff in using the guideline, written information to patients and next of kin, and information meetings with nursing home staff. The project was evaluated using both quantitative and qualitative data, and both outcome and process evaluation. Quantitative data included patient chart reviews of ACP, diagnoses, patient preferences for decision-making and treatment, values and wishes that are more general, documented life-prolonging treatment and hospitalizations, and concordance between patient wishes and treatment. The primary outcome was documented ACP. Qualitative data included observations of conversations, interviews with patients, next of kin and health care personnel, logs from project coordinators and conversations, and transcripts from meetings with project teams in the intervention group.

DISCUSSION

This project attempted to increase the quality and use of ACP in Norwegian nursing homes (NH). A mixed methods approach, inclusion of patients with dementia, attempts to involve, as many patients as possible, and a sustainable implementation plan adapted to real life in nursing homes were strengths of the project.

The Trial of Ascertaining Individual Preferences for Loved Ones' Role in End-of-Life Decisions (TAILORED) Study: A Randomized Controlled Trial to Improve Surrogate Decision Making

CONTEXT

Patients with terminal illnesses often require surrogate decision makers. Prior research has demonstrated high surrogate stress, and that despite standards promoting substituted judgment, most patients do not want their surrogates to make pure substituted judgments for them. It is not known how best to help loved ones fulfill the surrogate role.

OBJECTIVES

To test the effectiveness of an intervention to help surrogate decision makers.

METHODS

One hundred sixty-six patients (41% with amyotrophic lateral sclerosis and 59% with gastrointestinal cancers) and their surrogates at two university medical centers were randomized to an intensive nurse-directed discussion of the end-of-life decision control preferences of the patient (TAILORED) or a discussion of nutrition (CONTROL); 163 completed baseline interviews and underwent the intervention.

RESULTS

Twelve patients died during follow-up and 137 dyads completed the study. Post-intervention, using all available data, TAILORED patients and surrogates became more likely to endorse mutual surrogate decision making, that is, a balance of their own wishes and what the surrogate thinks best (adjusted odds compared with baseline for patients = 1.78, P = 0.04; adjusted odds for surrogates = 2.05, P = 0.03). CONTROL patients became 40% less likely to endorse mutual surrogate decision making (P = 0.08), and CONTROL surrogates did not change significantly from baseline (adjusted odds = 1.44, P = 0.28). Stress levels decreased for TAILORED surrogates (impact of events scale = 23.1 ± 14.6 baseline, 20.8 ± 15.3 f/u, P = 0.046), but not for CONTROL (P = 0.85), and post-intervention stress was lower for TAILORED than CONTROL (P = 0.04). Surrogates' confidence was uniformly high at baseline and did not change. Caregiver burden (Zarit) increased from 12.5 ± 6.5 to 14.7 ± 8.1 for TAILORED (P < 0.01), while not changing for CONTROL, yet satisfaction with involvement in decision making was higher at follow-up for TAILORED than for CONTROL (71% vs. 52%, P = 0.03).

CONCLUSION

TAILORED patients and surrogates who completed the study adopted a more mutual decision-making style, balancing their own wishes with what the surrogate thinks would be best for them. Surrogates reported less stress and more satisfaction. Confidence was high at baseline and did not change. There was a modest increase in caregiver burden. These findings suggest that interventions like TAILORED might positively impact surrogate decision making.

End-of-life care communications and shared decision-making in Norwegian nursing homes--experiences and perspectives of patients and relatives

BACKGROUND

Involving nursing home patients and their relatives in end-of-life care conversations and treatment decisions has recently gained increased importance in several Western countries. However, there is little knowledge about how the patients themselves and their next-of-kin look upon involvement in end-of-life care decisions. The purpose of this paper is to explore nursing home patients' and next-of-kin's experiences with- and perspectives on end-of-life care conversations, information and shared decision-making.

METHODS

The study has a qualitative and explorative design, based on a combination of individual interviews with 35 patients living in six nursing homes and seven focus group interviews with 33 relatives. The data was analysed applying a "bricolage" approach". Participation was based on informed consent, and the study was approved by the Regional Committees for Medical and Health Research Ethics.

RESULTS

Few patients and relatives had participated in conversations about end-of-life care. Most relatives wanted such conversations, while the patients' opinions varied. With some exceptions, patients and relatives wanted to be informed about the patient's health condition. The majority wanted to be involved in the decision-making process, but leave the final decisions to the health professionals. Among the patients, the opinion varied; some patients wanted to leave the decisions more or less completely to the nursing home staff. Conversations about end-of-life care issues are emotionally challenging, and very few patients had discussed these questions with their family. The relatives' opinions of the patient's preferences were mainly based on assumptions; they had seldom talked about this explicitly. Both patients and relatives wanted the staff to raise these questions.

CONCLUSION

Nursing home staff should initiate conversations about preferences for end-of-life care, assisting patients and relatives in talking about these issues, while at the same time being sensitive to the diversity in opinions and the timing for such conversations. As the popularity of advance care planning increases in many Western countries, discussions of patients' and relatives' perspectives will be of great interest to a broader audience.

Advance care planning discussions with geriatric patients

BACKGROUND

Advance care planning discussions are conversations with patients about future treatment to ensure that the patients' wishes are known if their decision-making capacity fails. Many doctors fear that such conversations represent a strain on patients. We wished to test systematic advance care planning discussions on an acute geriatric ward and to investigate how patients felt about such discussions.

MATERIAL AND METHOD

All patients who were admitted were continuously assessed with regard to their capacity for reflection on their future illness. An internationally tested tool was used as a basis for discussion with willing patients.

RESULTS

Of 96 patients who were assessed, a total of 34 were found to be unsuitable and four declined. Of the 58 interviewed, 54 wanted complete transparency of information and 47 wanted their families to participate when important information was to be imparted and crucial decisions on treatment were to be made. A total of 11 wanted no involvement of their families in these processes. All of them wanted their doctor to participate in important decisions. The majority took a very positive view of an advance care planning discussion of this type. Only one had a negative attitude.

INTERPRETATION

The patients were overwhelmingly positive with regard to advance care planning discussions. They have important messages to convey about information, the involvement of their families and the intensity of end-of-life treatment.

Values and ethics in practice-based decision making

BACKGROUND

Values are evident in health ethics literature; however, it is seldom clear how they are visible in practice.

PURPOSE

The aim of this study was to illuminate how values inform occupational therapists' decision making in practice.

METHOD

Fifteen New Zealand community occupational therapists completed this embedded experimental mixed-methods study. A pre-deliberation questionnaire was completed prior to deliberation of a case study using web-based values transparency software, the Values Exchange, followed by a post-deliberation questionnaire. Categorical data were analyzed using non-parametric statistics. Written responses to open questions were thematically analyzed.

FINDINGS

Most participants disagreed with the proposed action for the case. Degrees of divergence, concern for dignity and risk, and values-based reasoning were found, revealing how ethical deliberation was values based. IMPLICATIONSs. Recognition and transparency of the values inherent in practice-based decision making is possible and desirable in promoting sound ethical reasoning.

Do cancer-specific websites meet patient's information needs?

OBJECTIVE

To evaluate commonly used cancer websites' information provision, we developed and applied an Information Comprehensiveness Tool to breast and prostate cancer websites.

METHODS

We first collated questions from a systematic literature review on patient information needs. We then classified the questions in terms of spectrum of care, theme, and nature of question. "Breast cancer" and "prostate cancer" were typed into Google, and websites listed on the first page of results were selected. Two researchers, blind to each others' scores, assessed the same websites using the coding system. Each question was scored on a 3-point scale as not (0%), partially (50%) and fully (100%) answered by two researchers. Average scores were calculated across all questions. Inter-rater reliability was assessed.

RESULTS

We identified 79 general, 5 breast, and 5 prostate cancer questions. Inter-rater reliability was good, with an intraclass coefficient of 0.756 (95% CIs 0.729-0.781). 17 questions were not answered thoroughly by any website. Questions about "future planning", "monitoring", and "decision-making" were discussed least. Biomedical questions scored highest.

CONCLUSIONS

More comprehensive information needs to be provided on breast and prostate cancer websites.

PRACTICE IMPLICATIONS

This ICT can improve cancer information online and enable patients to engage more actively regarding their information needs.

An online survey to study the relationship between patients' health literacy and coping style and their preferences for self-management-related information

OBJECTIVE

To evaluate patients' preferences for message features and assess their relationships with health literacy, monitor-blunter coping style, and other patient-dependent characteristics.

METHODS

Patients with coronary heart disease completed an internet-based survey, which assessed health literacy and monitor-blunter coping style, as well as various other patient characteristics such as sociodemographics, disease history, and explicit information preferences. To assess preferences for message features, nine text sets differing in one of nine message features were composed, and participants were asked to state their preferences.

RESULTS

The survey was completed by 213 patients. For three of the nine text sets, a relationship was found between patient preference and health literacy or monitor-blunter coping style. Patients with low health literacy preferred the text based on patient experience. Patients with a monitoring coping style preferred information on short-term effects of their treatment and mentioning of explicit risks. Various other patient characteristics such as marital status, social support, disease history, and age also showed a strong association.

CONCLUSION

Individual differences exist in patients' preferences for message features, and these preferences relate to patient characteristics such as health literacy and monitor-blunter coping style.

Governance mechanisms in the physician-patient relationship: a literature review and conceptual framework

BACKGROUND

The physician-patient relationship is a critical component of the integrated approach to excellence in health-care delivery. Although commonly modelled within the boundaries of the agency theory and regarded as synonymous to an agent-principal interaction, there exists only a sparse understanding about the most effective ways of governing it.

OBJECTIVE

This article undertakes a selective review of the growing body of research on the governance of the physician-patient relationship to discuss the current state of the knowledge in the field and suggest promising avenues for further exploration.

FINDINGS

On the basis of an extensive analysis of the relevant literature, we identify two emerging streams of inquiry on the trust-based (i.e. trust and ethical oversight) and distrust-based (i.e. patient information-empowerment and decision-making authority) governance mechanisms of the physician-patient relationship and discuss the key findings within each stream.

DISCUSSION

To conciliate the on-going scholarly debate concerning the efficacy of trust- and distrust-based mechanisms, we draw the foundations of a conceptual framework which might serve as a guide for more integrative research endeavours on the governance of the physician-patient relationship.

Advance Care Planning in terminally ill and frail older persons

OBJECTIVE

Advance Care Planning (ACP) - the communication process by which patients establish goals and preferences for future care - is encouraged to improve the quality of end-of-life care. Gaining insight into the views of elderly on ACP was the aim of this study, as most studies concern younger patients.

METHODS

We conducted and analysed 38 semi-structured interviews in elderly patients with limited prognosis.

RESULTS

The majority of participants were willing to talk about dying. In some elderly, however, non-acceptance of their nearing death made ACP conversations impossible. Most of the participants wanted to plan those issues of end-of-life care related to personal experiences and fears. They were less interested in planning other end-of-life situations being outside of their power of imagination. Other factors determining if patients proceed to ACP were trust in family and/or physician and the need for control.

CONCLUSIONS

ACP is considered important by most elderly. However, there is a risk of pseudo-participation in case of non-acceptance of the nearing death or planning end-of-life situations outside the patient's power of imagination. This may result in end-of-life decisions not reflecting the patient's true wishes.

PRACTICE IMPLICATIONS

Before engaging in ACP conversations, physicians should explore if the patient accepts dying as a likely outcome. Also the experiences and fears concerning death and dying, trust and the need for control should be assessed.

Perceived risks around choice and decision making at end-of-life: a literature review

BACKGROUND

the World Health Organization identifies meeting patient choice for care as central to effective palliative care delivery. Little is known about how choice, which implies an objective balancing of options and risks, is understood and enacted through decision making at end-of-life.

AIM

to explore how perceptions of 'risk' may inform decision-making processes at end-of-life.

DESIGN

an integrative literature review was conducted between January and February 2010. Papers were reviewed using Hawker et al.'s criteria and evaluated according to clarity of methods, analysis and evidence of ethical consideration. All literature was retained as background data, but given the significant international heterogeneity the final analysis specifically focused on the UK context.

DATA SOURCE

the databases Medline, PsycINFO, Assia, British Nursing Index, High Wire Press and CINAHL were explored using the search terms decision*, risk, anxiety, hospice and palliative care, end-of-life care and publication date of 1998-2010.

RESULTS

thematic analysis of 25 papers suggests that decision making at end-of-life is multifactorial, involving a balancing of risks related to caregiver support; service provider resources; health inequalities and access; challenges to information giving; and perceptions of self-identity. Overall there is a dissonance in understandings of choice and decision making between service providers and service users.

CONCLUSION

the concept of risk acknowledges the factors that shape and constrain end-of-life choices. Recognition of perceived risks as a central factor in decision making would be of value in acknowledging and supporting meaningful decision making processes for patients with palliative care needs and their families.

What are cancer patients' experiences and preferences for the provision of written information in the palliative care setting? A focus group study

BACKGROUND

Whilst there is a wide range of literature pertaining to the need for excellent verbal communication within the palliative care setting, there is a paucity of research designed to identify the written informational needs of such patients.

AIM

To identify the experiences and wishes of patients known to a specialist palliative care service in England with regards to written information. We considered both generalizable written information (such as leaflets, books and internet resources) as well as individualized information (for example, copies of letters given to patients).

DESIGN

Five focus group discussions were recorded and transcribed for analysis.

SETTING/PARTICIPANTS

The focus groups took place at one specialist palliative care unit in England. Twenty-two patients with cancer over the age of 18 years were recruited.

RESULTS

Inductive, realist thematic analysis of the data set was performed. Themes have been broadly categorized into three main areas: (i) patients' views on the role of written information, (ii) their experiences of written information in different formats, and (iii) their thoughts on what written information they would most value.

CONCLUSIONS

Written information needs for this patient group vary greatly, sometimes in ways which can be predicted. Using a patient-centred approach to elicit information around an individual's coping strategies, desire for knowledge and empowerment may be helpful. The data supports a proactive approach to making available (to those who want them) clear, concise and attractive leaflets.

Privacy-solidarity conflict: the communication with the support group

Actually guidelines require that patient must be informed about his condition so that he can choose the persons he wants to share these information with. Nonetheless, the caregiver usually gets an intermediary role in doctor-patient communication thus becoming the doctor's main conversation partner and claiming to be given more information than the patient himself. A more complex situation is about brain tumours patients sometimes affected by cognitive deficiencies, compromising their comprehension skills or their capability of keeping the information they are being given. A preliminary study allowed to submit separately to brain tumour patients and their family members a semi-structured interview. Although doctors communicate diagnosis and therapeutic plans, patients and their family members often do not seem to remember the information they are given. An important percentage of patients and their carers cannot tell correctly what they was said by the doctors. Only a minor percentage of patients do not want to know all details of their disease. Instead, most of the family members, would rather their beloved were given just partial information on their conditions or even not given information at all. Communication with patients and their carers requires careful re-negotiation in a multiple time-points, rather than a one-off communication episode.

Patient preferences for shared decisions: a systematic review

OBJECTIVES

Empirical literature on patient decision role preferences regarding treatment and screening was reviewed to summarize patients' role preferences across measures, time and patient population.

METHODS

Five databases were searched from January 1980 to December 2007 (1980-2007 Ovid MEDLINE, Cochrane Database of Systematic Reviews, PsychInfo, Web of Science and PubMed (2005-2007)). Eligible studies measured patient decision role preferences, described measures, presented findings as percentages or mean scores and were published in English from any country. Studies were compared by patient population, time of publication, and measure.

RESULTS

115 studies were eligible. The majority of patients preferred sharing decisions with physicians in 63% of the studies. A time trend appeared. The majority of respondents preferred sharing decision roles in 71% of the studies from 2000 and later, compared to 50% of studies before 2000. Measures themselves, in addition to patient population, influenced the preferred decision roles reported.

CONCLUSION

Findings appear to vary with the measure of preferred decision making used, time of the publication and characteristics of the population.

PRACTICE IMPLICATIONS

The role preference measure itself must be considered when interpreting patient responses to a measure or question about a patient's preference for decision roles.

Preferences for end of life: views of hospice patients, family carers, and community nurse specialists

An exploratory qualitative study was undertaken with the aim of identifying issues around discussing and recording preferences on place of death from the perspective of hospice patients, carers, and hospice community nurses. A purposive sample was selected from three hospices in the south east of England of six community nurse specialists (CNSs), five patients, five carers, and five bereaved carers. The patients and carers said it was important to them to discuss their preferences, but they acknowledged that discussing dying was difficult. The CNSs stated that there were several barriers that inhibited end-of-life discussions and that discussing preferences was not always a primary goal of care planning. It was felt among the service users, particularly the bereaved carers, that having more knowledge about what to expect of the dying process, knowing their relative's wishes, and understanding the role of hospice and palliative care could improve the experience of events leading up to death.

Ethical and legal issues in end-of-life care

The doctor has a responsibility to develop and maintain an effective approach to ethical decision making and the skills to implement the correct moral action. At the heart of this process is the experience and knowledge of particular conditions and their outcomes, alongside excellence in communication skills and working with colleagues.

Pain management in recovery

Recovery room practitioners lay the corner stone for postoperative recuperation in patients undergoing surgical procedures. This article highlights how some aspects of the role, such as pain assessment, commencement of the prescribed analgesic regimen and pain control can be very challenging, for a variety of reasons. The aim, therefore, is to follow a typical patient journey in a structured manner, beginning with a demonstration of how provision of information empowers patients during the key phase of postoperative recovery. This is followed by a description of some assessment tools best suited to patients recovering from anaesthesia who are experiencing acute, postoperative pain. Consequences of under-treated pain are discussed and treatment modalities are described.

Principles of acute pain management

Acute pain is a predominant feature of the perioperative experience for the majority of patients. This paper aims to describe the adverse effects of poorly controlled acute, postoperative pain and provides an overview of the organisational aspects involved in pain management in hospitals. Following this there will be an examination of the role information giving has in improving the patient's perioperative experience. Pharmacological and non-pharmacological interventions to prevent or reduce pain will also be described and because of its importance in setting the standard for logical prescribing in pain, the Analgesic Ladder, devised by the World Health Organisation (WHO 1986) will be given special consideration. Finally, the importance of pain assessment and re-assessment will be discussed.

What accounts for differences or disparities in pediatric palliative and end-of-life care? A systematic review focusing on possible multilevel mechanisms

OBJECTIVE

The goal was to clarify potential mechanisms underlying differences/disparities in pediatric palliative and end-of-life care.

METHODS

We systematically searched online databases to identify articles relating to differences/disparities in pediatric palliative and end-of-life care, retaining 19 studies for evaluation. We then augmented this search with a broader review of the literature on the mechanisms of differences/disparities in adult palliative and end-of-life care, general pediatrics, adult medicine, and pain.

RESULTS

The concept of reciprocal interaction can organize and illuminate interacting mechanisms across 3 levels of human organization, namely, broader contextual influences on patients and clinicians, specific patient-provider engagements, and specific patients. By using this rubric, we identified 10 distinct mechanisms proposed in the literature. Broader contextual influences include health care system structures; access to care; and poverty, socioeconomic status, social class, and family structure. Patient-clinician engagements encompass clinician bias, prejudice, and stereotypes; concordance of race; quality of information exchange; and trust. Patient-specific features include perceptions of control; religion and spirituality; and medical conditions.

CONCLUSIONS

Differences and disparities in pediatric palliative and end-of-life care can be understood as arising from various mechanisms that interact across different levels of human organization, and this interactive multilevel model should be considered in designing studies or planning interventions to understand differences and to ameliorate disparities.

Patients' Experiences of Being a Burden on Family in Terminal Illness

Studies of persons with chronic and life-threatening illness have revealed a fear of being a burden on family. The purpose of this case study was to explore that concern in-depth in three persons with different terminal illnesses. Participants were part of a larger study of end-of-life decision making and were selected for this study because their illnesses are characterized by a steady decline in health (amyotrophic lateral sclerosis), a rapid decline (stage IV lung cancer), or an uncertain trajectory of decline (advanced heart failure). Content analysis of their interviews resulted in four themes: managing the burden, spirituality, supportive relationships, and planning for the future. Themes contained specific categories of thoughts, feelings, and actions related to fear of being a burden. These themes should be explored in greater depth in future larger studies of persons with terminal illness.

Evidence-based practice in clinical psychology: What it is, why it matters; what you need to know

The history and meaning of evidence-based practice (EBP) in the health disciplines was described to the Council of University Directors of Clinical Psychology (CUDCP) training programs. Evidence-based practice designates a process of clinical decision-making that integrates research evidence, clinical expertise, and patient preferences and characteristics. Evidence-based practice is a transdisciplinary, idiographic approach that promotes lifelong learning. Empirically supported treatments (ESTs) are an important component of EBP, but EBP cannot be reduced to ESTs. Psychologists need additional skills to act as creators, synthesizers, and consumers of research evidence, who act within their scope of clinical expertise and engage patients in shared decision-making. Training needs are identified in the areas of clinical trial methodology and reporting, systematic reviews, search strategies, measuring patient preferences, and acquisition of clinical skills to perform ESTs.

[Combined use of bucolome and pyrazolone derivatives (II). Complex formation due to interaction between bucolome and pyrazolones]

We have already reported that bucolome (BCP), a non-steroidal anti-inflammatory agent, potentiates significantly the analgesic and antipyretic effects of pyrazolones which are substituted by alkylamino group at 4-position of the pyrazolone ring. Physical and quantum chemistry were applied to the mechanism of this synergistic action. The solubility of BCP was markedly increased in proportion to elevation of aminopyrine (AM) concentration, but not by a combination with isopropylantipyrine (IP). The binding of BCP to bovine serum albumin was slightly inhibited by AM, but not by IP. The mixture of AM and BCP in aqueous media generated optical absorption in the ultraviolet differential spectrum, due to the charge transfer interaction. The results of the infrared or NMR spectrum demonstrated the formation of a hydrogen binding in non-aqueous media between BCP and AM. From the calculation of the charge on an atom, the energy of the highest occupied molecular orbital and the frontier electron density, BCP is considered to be a good electron acceptor. The beta-units of Mho of pyrazolones were found to correlate with the potentiation coefficient of analgesic activity in combination drugs. These results suggest that the complex formation between BCP and pyrazolones is an important factor for the synergism of action and is due to the charge transfer interaction and the hydrogen binding of both molecules.