Older people's views on loneliness during COVID-19 lockdowns

BACKGROUND AND OBJECTIVES

There have been growing concerns that social distancing and stay-at-home mandates have exacerbated loneliness for older people. Empirical evidence about older people's experiences of loneliness and COVID-19 have quantified this phenomena without considering how older people themselves define and understand loneliness. This paper explores how older New Zealanders conceptualized and experienced loneliness under 'lockdown' stay-at-home measures.

METHODS

This multi-methods qualitative study combines data from letters (n = 870) and interviews (n = 44) collected from 914 people aged over 60 and living in Aotearoa, New Zealand during the COVID-19 pandemic. We conducted a reflexive thematic analysis to conceptualise this data.

FINDINGS

We identify three interconnected ways in which older people conceptualised and experienced loneliness: (1) feeling disconnected relating to lack of emotional closeness to another often resulting from being physically separated from others and not being able to touch; (2) feeling imprisoned relating to separation from preferred identities and activities and was frequently associated with boredom and frustration; and (3) feeling neglected which often related to feeling let down by generalised and idealised forms of support, such as one's neighbourhood and health care system.

DISCUSSION

Older New Zealanders experienced lockdown loneliness in three interconnected ways rather than as a stable and homogenous experience. Māori, Pacific, Asian and New Zealand European older people often discussed loneliness in different ways; attesting to loneliness being a culturally-mediated concept shaped by expectations around desirable social interaction. We conclude the paper with implications for research and policy.

The work of palliative care from the perspectives of district nurses: A qualitative study

AIM

To explore the work of palliative care from the perspectives of district nurses with a focus on the strategies they use to achieve positive outcomes for patients.

DESIGN

An exploratory descriptive qualitative study.

METHODS

A combination of group and individual interviews using semi-structured interviewing were used to explore district nurses' views of providing palliative care across two large urban community nursing services.

RESULTS

Sixteen district nurse participants were interviewed. Three key themes were identified: "Getting what was needed" involved finding solutions, selling a story and establishing relationships. District nurses sought ways to "Stay involved" recognizing the benefit of delaying discharge for some patients. "Completing a nursing task" was a way of managing time constraints and a form of self-protection from having difficult conversations.

CONCLUSION

This study highlights the importance of understanding the contextual nature of the practice setting in relation to the provision of palliative care. In doing so, it has revealed the strategies district nurses use to overcome the challenges associated with providing palliative care within a generalist workload.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

District nurses experience a tension between managing high patient workloads and remaining patient centred in palliative care. Being task focused is a way of remaining safe while managing a high volume of work and is not always a negative factor in the care they provide. However, focusing on a task while at the same time addressing other unmet needs requires a set of skills that less experienced nurses may not have.

IMPACT

Palliative care education alone will not improve the quality of palliative care provided by generalist community district nurses. The practice context is an important factor to take into consideration when supporting the integration of palliative care in district nursing.

NO PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was made to this study.

REPORTING METHOD

We have adhered to the relevant EQUATOR guidelines and used the COREQ reporting method.

A task service and a talking service: A qualitative exploration of bereaved family perceptions of community nursing care at the end of life

BACKGROUND

Greater emphasis on community-based care at the end of life is supported by the premise that most people want to be cared for and die at home. As such, it is important to understand the current state of palliative care nursing within an integrated generalist-specialist model of care in the community.

AIM

To explore bereaved family perceptions and experiences of community nursing at the end of life, with a particular focus on service integration.

DESIGN

A qualitative study design using semi-structured telephone interviews with bereaved family. A critical realist framework was used to inform the analysis of interview data and thematic analysis of data was used to identify key themes.

SETTING/PARTICIPANTS

Participants were the family carers of patients who had died within the catchment area of two large District Health Boards in Auckland, New Zealand.

RESULTS

Twenty-three participants were interviewed. Participants described their experiences of community nursing in terms of the service they provided. Hospice nursing roles were described in terms of a "talking service" and District Nursing as a "task service." There was minimal expectation of the general practice nurse in terms of palliative care support and little evidence of service integration.

CONCLUSION

Findings from this study support the need for a new integrated model of palliative care nursing which utilizes the unique skill set of nurses working across all community care settings including general practice, hospice and district nursing services. Accommodating different models of nursing care which can be responsive to patient need rather than limited to a defined service delivery model.

'Mum, I think we might ring the ambulance, okay?' A qualitative exploration of bereaved family members' experiences of emergency ambulance care at the end of life

BACKGROUND

In the context of a sudden or unexpected event, people with a life-limiting illness and their family caregivers may be dependent on emergency ambulance services.

AIM

To explore bereaved family members' experiences of emergency ambulance care at the end of life.

DESIGN

A qualitative study using reflexive thematic analysis of data collected from semi-structured phone interviews.

SETTING/PARTICIPANTS

A purposive sample of 38 family caregivers identified from a database of deaths in Aotearoa, New Zealand.

RESULTS

Emergency ambulance personnel assist, inform and reassure patients and family caregivers managing distressing symptoms, falls, infections, unexpected events and death itself. Family members and patients are aware of the pressure on emergency services and sometimes hesitate to call an ambulance. Associating ambulances with unwanted transport to hospital is also a source of reluctance.

CONCLUSIONS

The generalist palliative care provided by emergency ambulance personnel is a vital service for patients in the last year of life, and their caregivers. This must be acknowledged in palliative care policy and supported with training, specialist consultation and adequate resources.

Employment and family caregiving in palliative care: An international qualitative study

BACKGROUND

Family caregivers provide the majority of palliative care. The impact of family caregiving on employment and finances has received little research attention in the field of palliative care.

AIM

The aim of this study was to explore perspectives and experiences of combining paid employment with palliative care family caregiving, and to assess the availability and suitability of employment support across three countries - the United Kingdom (UK), Aotearoa New Zealand and Canada.

DESIGN

A qualitative descriptive study design was used. Semi-structured interviews were held with 30 key informants with professional or personal experience in palliative care from the UK (n = 15), Aotearoa New Zealand (n = 6) and Canada (n = 9). Interviews were recorded, transcribed and analysed using the principles of thematic analysis.

RESULTS

Four main themes were identified: (1) significant changes to working practices are required to enable end of life family carers to remain in work; (2) the negative consequences of combining caregiving and employment are significant, for both patient and carer; (3) employer support for working end of life caregivers is crucial but variable and; (4) national, federal and government benefits for working end of life family carers are necessary.

CONCLUSION

Supporting carers to retain employment whilst providing care has potential benefits for the patient at end of life, the caregiver, and the wider economy and labour market. Employers, policymakers and governments have a role to play in developing and implementing policies to support working carers to remain in employment.

The impact of uncertainty on bereaved family's experiences of care at the end of life: a thematic analysis of free text survey data

Background

Inequities in the provision of palliative care for people with cardiac disease have been well documented in the literature. Despite experiencing significant palliative care needs, those with cardiac disease are less likely to be referred to specialist palliative care services and more likely to die in a hospital when compared to those with cancer. The unpredictable trajectory of heart failure has been identified as a key barrier to providing palliative care with many people experiencing a long period of stability with appropriate medical treatment. However, as the disease progresses and cardiac function deteriorates, exacerbations of acute decompensation can lead to what is often perceived to be ‘sudden’ death. The aim of this study is to explore the impact of uncertainty on how death is remembered by bereaved family members of people with heart disease.

Methods

Thematic analysis of free text collected during a postal survey of bereaved family’s experiences of healthcare services in the last 3 months of life using the New Zealand version of the VOICES questionnaire was undertaken. Data was analysed using a three-dimensional conceptual framework of “scientific uncertainty”.

Results

Eight hundred and twenty-seven completed questionnaires were received of which 12.6% (n = 105) indicated that they had cared for someone at the end of life with cardiac disease. Experiences of uncertainty were found to have a significant impact upon bereaved family. Four key themes were identified; distrust in healthcare professionals, stories left incomplete, loss, regret and missed opportunity and disempowerment.

Conclusions

This study highlights the ongoing impact on bereaved family when uncertainty is not made explicit in conversations regarding end of life for people with heart disease. Timely and sensitive conversations regarding the uncertainty of when death may occur is an important factor in ensuring that bereaved family are not left with unresolved narratives. Reframing how we think and talk about uncertainty in end of life care is important, as clinicians’ uncertainties may not always reflect or match up with families’ uncertainties. Being explicit about our inability to be certain about the timing of death may thus lead to a more positive and complete experience for bereaved family.

Decreased cerebral spinal fluid neurotransmitter levels in Smith-Lemli-Opitz syndrome

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive, multiple congenital anomaly syndrome with cognitive impairment and a distinct behavioral phenotype that includes autistic features. SLOS is caused by a defect in 3β-hydroxysterol Δ(7)-reductase which leads to decreased cholesterol levels and elevated cholesterol precursors, specifically 7- and 8-dehydrocholesterol. However, the pathological processes contributing to the neurological abnormalities in SLOS have not been defined. In view of prior data suggesting defects in SLOS in vesicular release and given the association of altered serotonin metabolism with autism, we were interested in measuring neurotransmitter metabolite levels in SLOS to assess their potential to be used as biomarkers in therapeutic trials. We measured cerebral spinal fluid levels of serotonin and dopamine metabolites, 5-hydroxyindoleacetic acid (5HIAA) and homovanillic acid (HVA) respectively, in 21 SLOS subjects. Results were correlated with the SLOS anatomical severity score, Aberrant Behavior Checklist scores and concurrent sterol biochemistry. Cerebral spinal fluid (CSF) levels of both 5HIAA and HVA were significantly reduced in SLOS subjects. In individual patients, the levels of both 5HIAA and HVA were reduced to a similar degree. CSF neurotransmitter metabolite levels did not correlate with either CSF sterols or behavioral measures. This is the first study demonstrating decreased levels of CSF neurotransmitter metabolites in SLOS. We propose that decreased levels of neurotransmitters in SLOS are caused by a sterol-related defect in synaptic vesicle formation and that CSF 5HIAA and HVA will be useful biomarkers in development of future therapeutic trials.

Risk management strategies following analysis of cataract negligence claims

INTRODUCTION

Clinical governance and risk management is very important in today's clinical practice. Cataract surgery is one of the most common procedures performed in the NHS, with around 200,000 operations per year. In order to help minimise the frequency of negligence claims, we performed a collaborative study to analyse claims relating to cataract surgery, dealt with by the defence organisations of England, Scotland, Wales, and Northern Ireland.

MATERIALS AND METHODS

All claims dealt with by the Medical Defence Union, the Medical Protection Society, and the Medical and Dental Defence Union of Scotland from January 1990 to December 1999, were analysed by three ophthalmologists with at least 5 years' speciality experience. Recurrent themes were identified and claims were grouped by major causative factor. The findings were discussed by a panel compromising the authors in conjunction with the defence unions and risk management strategies were designed.

RESULTS

There were 96 claims within the 10- year period analysed. Of these, the largest group (52) pertained to claims that related to accepted complications of cataract surgery. The remainder comprised two groups: 'Medical Errors' (anaesthetic, surgeon, and biometry) and 'Other Claims' comprising subjective complaints, pain and poor visual outcome. A total of 16 claims had been settled by May 2002, 45 are ongoing and 35 have closed without settlement.

CONCLUSIONS

The majority of claims pertained to well-recognised complications of cataract surgery. If these risks are adequately explained to the patient before surgery and if the care provided reaches a standard acceptable to a responsible body of professional opinion, all such claims should be defensible. Good visual outcome does not protect against litigation.

Abdominal ultrasound examination in pregnant blunt trauma patients

BACKGROUND

The ability of abdominal ultrasound to detect intraperitoneal fluid in the pregnant trauma patient has been questioned.

METHODS

Pregnant blunt trauma patients admitted to a Level I trauma center during an 8-year period were reviewed. Ultrasound examinations were used to detect intraperitoneal fluid and considered positive if such fluid was identified.

RESULTS

One hundred twenty-seven (61%) of 208 pregnant patients had abdominal ultrasound during initial evaluation in the emergency department. Seven patients had intra-abdominal injuries, and six had documented hemoperitoneum. Ultrasound identified intraperitoneal fluid in five of these six patients (sensitivity, 83%; 95% confidence interval, 36-100%). In the 120 patients without intra-abdominal injury, ultrasound was negative in 117 (specificity, 98%; 95% confidence interval, 93-100%). The three patients without intra-abdominal injury but with a positive ultrasound had the following: serous intraperitoneal fluid and no injuries at laparotomy (one) and uneventful clinical courses of observation (two).

CONCLUSION

The sensitivity and specificity of abdominal ultrasonography in pregnant trauma patients is similar to that seen in nonpregnant patients. Occasional false negatives occur and a negative initial examination should not be used as conclusive evidence that intra-abdominal injury is not present. Ultrasound has the advantages of no radiation exposure.

Failure to replicate association between the gene for the neuronal nicotinic acetylcholine receptor alpha 4 subunit (CHRNA4) and IGE

The gene for the neuronal nicotinic acetylcholine receptor alpha4 subunit (CHRNA4) was identified as a gene underlying a rare idiopathic partial epilepsy syndrome in humans, autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE). In a recent study, one of four silent polymorphisms (594 C/T) in CHRNA4 showed association with the common subtypes of idiopathic generalised epilepsy (IGE). In the present study, three of these polymorphisms were investigated for association in 182 Caucasian patients with IGE, but not categorised by subtype. They were compared with 178 controls in a case/control study. Further analyses were performed using a family-based design. None of the three polymorphisms exhibited any association with IGE. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:814-816, 2000.

Re-vaccination of 421 children with a past history of an adverse vaccine reaction in a special immunisation service

BACKGROUND

In Australia an adverse event following immunisation (AEFI), with the exception of anaphylaxis and encephalopathy, is no longer considered an absolute contraindication to continuing vaccination with the suspect vaccine. Despite these recommendations there is a paucity of information on the re-vaccination of such children.

AIMS

To describe the re-vaccination of a large number of children with a past history of an AEFI.

METHODS

A review of children attending special immunisation services in three Australian tertiary care paediatric centres.

RESULTS

During the review 970 children attended of whom 469 had experienced a past AEFI. Of these, 293 had experienced minor while 176 children had experienced significant neurological or allergic reactions. The majority (421/469) were re-vaccinated, with only one child having a significant neurological event; this was transient and resolved spontaneously.

CONCLUSIONS

Re-vaccination of children who have a past history of an AEFI appears safe. A special immunisation service should be part of a comprehensive immunisation programme.

No association found between polymorphisms in genes encoding mGluR7 and mGluR8 and idiopathic generalised epilepsy in a case control study

The genes of two group III metabotropic glutamate receptors, mGluR7 and 8, are candidate susceptibility genes for epilepsy. The Tyr433Phe polymorphism of mGluR7 and a novel polymorphism in the mGluR8 gene located 29 bp after the termination codon (2756C/T) were investigated in case control association studies performed on DNA from more than 100 patients with idiopathic generalised epilepsy (IGE). No significant association was found with IGE for either polymorphism.

Vaccination of children following a previous hypotonic-hyporesponsive episode

BACKGROUND

Hypotonic-hyporesponsive episodes (HHE) were once considered a contraindication to pertussis vaccination.

METHODOLOGY

To evaluate the safety of further vaccination, chart review was conducted of 66 children who had experienced an HHE, and who were assessed in one of three special clinics in three capital city tertiary paediatric hospitals. Immediately prior to the HHE, 63 children had received whole-cell pertussis vaccine, three had received acellular pertussis vaccine.

RESULTS

Sixty-four of the 66 children were vaccinated in the special clinic, 59 with pertussis-containing vaccines (55 acellular, four whole-cell), without serious adverse events. There were no HHE after these further vaccinations.

CONCLUSIONS

Previously healthy children who experience HHE reactions can safely continue standard vaccination schedules.

Compliance with universal precautions among pediatric residents

BACKGROUND

There are few data on the rate of compliance with universal precautions among pediatricians. We hypothesized that compliance in pediatrics would be poor because of the intrinsic difficulties in performing invasive procedures in small subjects.

DESIGN

Prospective, observational study.

SETTING

Tertiary care children's hospital.

STUDY PARTICIPANTS

A convenience sample of pediatric house staff.

MAIN OUTCOME MEASURES

Pediatric house staff members were observed while performing invasive procedures. Procedure type, number of attempts required, and patient's age and diagnosis were recorded. Degree of compliance with universal precautions was judged by means of Centers for Disease Control and Prevention guidelines. Comparisons between the compliant and noncompliant groups were analyzed by chi2 and 2-tailed t test.

RESULTS

A total of 128 procedures performed by 43 house officers, 4 advanced medical students, and 3 chief residents or fellows were observed. Sixty-nine (53.9%) of the 128 procedures were performed correctly according to universal precaution guidelines. Rate of compliance did not appear to be influenced by small patient size, as judged by the lack of association with the age of the patient (mean+/-SD, 4.8+/-5.7 years among those in whom universal precautions were properly used vs 4.9+/-5.4 years among patients in whom precaution guidelines were breached; P=.96). Moreover, the number of attempts required in compliant procedures (1.31+/-0.53) was almost identical to that in noncompliant procedures (1.28+/-0.49; P=.73). Additionally, compliance did not improve with advanced level of training.

CONCLUSIONS

Failure of compliance among pediatricians has no apparent association with procedure difficulty, and compliance rates continue to be poor through the course of pediatric training. These findings underline the need for effective education concerning universal precautions throughout pediatric residency, and they suggest that such efforts will not be precluded by obstacles intrinsic to performing invasive procedures on young subjects.

The resolution of [Tris{cis-Diydroxybisethylene Diaminecobalt(III)}cobalt(III)] Nitrate

The resolution of [tris{cis-dihydroxybisethylenediaminecobalt(II)}cobalt(III)] nitrate (hexol nitrate) into four of the eight theoretically possible optical isomers using potassium d- and l-antimonyl tartrate is described. The reactions involved in the formation of the optically active isomers of the hexol ion show less stereospecificity than those of similar complexes studied by earlier investigators.