Assessing readiness for death in hospice elders and older adults

BACKGROUND

Readiness for death may affect the quality of the death experience and influence response to treatments. The psychologic vulnerability of the dying person is a major focus of palliative care. Accurate assessment of readiness for death may lead to earlier and more appropriate interventions.

OBJECTIVE

The purpose of this study was to assess the psychometric properties of the revised readiness for death instrument.

METHODS

Using a known groups technique and a cross-sectional study design, the revised instrument was administered to 52 elders in hospice care with a terminal diagnosis and 91 community dwelling adults without a terminal diagnosis.

RESULTS

Instrument content validity (Kappa = 0.96) was supported by three expert panelists who were hospice researchers. Principal components factor analysis explained 43% of the variance and partially supported the proposed four-factor structure of the revised 26-item instrument. Internal consistency was acceptable (.76). Discriminant validity was significant as assessed by an independent t-test between two contrast groups (t = 5.98, p = 0.000). The factor analysis, reliability testing, and qualitative analysis of items supported deletion of 2 items.

CONCLUSIONS

Results indicated that the revised instrument has sound psychometric properties but further testing with a larger sample of hospice subjects is needed to confirm the factor structure of the instrument.

Assessing abuse among the elderly living in public housing

Abuse and victimization among the elderly have received increased attention in the last few years from practitioners, researchers, and policymakers but remain growing problems, especially for elders who live in public housing. This study assessed the psychometric properties of an existing instrument, the Hwalek-Sengstock Elder Abuse Screening Test (HSEAST), which has been tested in only two studies. The instrument was administered to 100 African American, Hispanic, and White elders living in public housing. Study results were compared to findings from a previous study of elderly groups. A principal components factor analysis of the 15-item instrument supported the 3-factor structure for a total of 10 items (factor loadings = 0.4 or >), explaining 38% of the variance. A discriminant function analysis showed that 6 items were as effective as the 9-item model in classifying cases (71.4%) as abused.

Dyspnea assessment and management in hospice patients with pulmonary disorders

Accurate assessments and appropriate management of dyspnea are essential to provide improved quality of life for hospice patients. This study describes methods of assessing dyspnea and interventions used to manage dyspnea in 72 hospice patients with end-stage lung disease or lung cancer. The mean age of the sample was 72.46 years old and the majority was white (80 percent) and male (62 percent). Paired t-tests were used to compare mean scores on admission and near death for dyspnea severity, Karnofsky functional status, pain, and Mini-Mental Status scores. Results showed significant decline in functional and cognitive status, but no significant changes in dyspnea severity and pain. Dyspnea was often assessed subjectively with observational methods only. Use of inhalants, oxygen, positioning, steroids, and oral opioids were the most frequent therapies for dyspnea. Relaxation, guided imagery, and other complementary therapies were rarely used (five percent or less). Measurement of dyspnea needs to be done frequently by using standardized instruments to assess severity and degree of symptom distress as well as the effects of treatment. Clinical trials are needed to determine which dyspnea interventions are most effective in terminally ill patients. Guidelines such as those developed for pain management are needed for effectively managing dyspnea.

Psychophysiologic predictors of weaning from mechanical ventilation in chronic bronchitis and emphysema

This study identified psychophysiologic variables related to successful weaning in 27 ventilator-dependent patients with chronic bronchitis and emphysema (CBE) from two long-term care pulmonary-specialty hospitals in South Central Florida. Subjects were studied from admission until weaning occurred (successful weaning without mechanical ventilation) or until they were transferred without being weaned or died (unsuccessful weaning). The study subjects, 15 males and 12 females, ranged in age from 56 to 89. Baseline data on the variables (age, mastery, hope, social support, dyspnea, and rapid shallow breathing index [RSBI]) were not statistically significant by gender. The logistic regression model identified mastery and RSBI to be the best predictors of successful weaning (model chi 2 = 16.33, df = 2, and p value = .0003; prediction rate 82%).

Improving utilization of breast and cervical cancer screening in your office practice

It has been well documented that early detection and early intervention for breast and cervical cancer saves lives. However, the challenge is to ensure that physicians' practices are effective in implementing the standard guidelines for screening and that all women are screened and undergo appropriate follow-up. Early detection and intervention are imperative since African-American women are twice as likely as European-American women to die from breast cancer even though the incidence of breast cancer is lower. African-American women have fewer mammograms and are being diagnosed later after metastases have occurred. Studies also show that women are more likely to have mammograms if their physicians so advise. However, the most common reason women give for not obtaining mammograms is, "My doctor never recommended it." By using a simple critical path analysis tool to systematically evaluate an office practice and by implementing practical, simple principles, a physician can increase utilization of breast and cervical cancer screening.

Effects of guided imagery in patients with chronic bronchitis and emphysema

Together, chronic bronchitis and emphysema (CBE) ranks as one of the top five leading health problems in the United States. Few nursing interventions have been tested that improve symptom management, functional status, and quality of life. This study tested the effects of guided imagery and maximal inspiratory muscle training (MITT) in a group of 10 males and 9 females, 56-75 years old, with moderate CBE. The research tested whether the independent variables, guided imagery and MITT, have significant independent and/or interaction effects on the dependent variables functional status, fatigue, dyspnea, depression, mastery, quality of life, perceived health status, and inspiratory muscle strength. Results showed that the psychologic intervention of guided imagery significantly improved subjects' perceived quality of life. The physiologic intervention of MITT could not be tolerated by subjects, which precluded testing the effects on the dependent variables. Application of study findings to clinical practice and the need for further research are discussed.

A study of the public's knowledge regarding advance directives

Advance directives are legal documents used to indicate individuals' wishes concerning medical care and treatment in the event that they are no longer able to do so. This study assessed the level of knowledge of 157 adults concerning advance directives and other medical terminology related to end-of-life events. Results indicated that 57% to 79% of respondents demonstrated an understanding of four to five major elements related to advance directives. There were no significant differences in level of understanding among groups of differing ethnicity, religion, and gender. Nor were there significant correlations found between level of understanding and the respondents' age and years of education.

The Soviet health care system: Glasnost, Perestroika, and health problems of the 1990s

Worsening economic conditions and political turmoil in the Soviet Union have led to significant health care problems in the 90s. The Soviet people are calling for reforms of education and the health care system that extend beyond the unsuccessful program of glasnost and perestroika. The purposes of this article are to (a) describe the health care system in the Soviet Union, (b) highlight health issues and concerns of the Soviet people, (c) describe the education of physicians and nurses, and (d) compare and contrast common and unique factors about Soviet health care with health care in the West. The data base for the article was collected from observational site visits, on-site focused interviews with key informants in Kiev and Moscow, and extensive computerized and manual literature searches. Data were also gathered from questionnaires distributed to a convenience sample of 17 nurses in Moscow. Study results include demographic information and the state of nursing education and research, including availability and access to resources to conduct nursing research in Moscow.

Analysis of a decade of critical care nursing practice research: 1979 to 1988

The purpose of this study was to analyze critical care nursing practice research published in leading refereed nursing research journals during the period from 1979 to 1988 to identify knowledge-building methods and research outcomes in critical care nursing. Findings indicate a significant increase in the number of nursing practice research studies published as well as a high percentage of intervention-oriented studies. The results of the study reflect the interest that critical care nurses have in identifying a research-based practice.

The crisis of the health care nonsystem

Far from being the best in the world, the United States' cure-oriented patchwork of fee-for-service service medical care has left 37 million American citizens without access to health care. The new public debate on health care reform gives nurses an opportunity to transform this ineffective market-oriented medical model into a universal, true health care system.

Analysis of a decade of nursing practice research: 1977-1986

The purpose of this study was to analyze the research focus, theoretical bases, research designs, statistical methods, and research findings of nursing practice research, 1977-1986. A secondary purpose was to assess the fit of nursing practice research topics within the North American Nursing Diagnosis Association's (NANDA) taxonomy. The sample consisted of 720 articles that met the definitional criteria of nursing practice research from six major refereed journals in nursing that primarily publish nursing research. Findings showed that 95% of research in nursing in the last decade was conducted by nurses as first authors, over half with doctoral degrees. Funded research increased as well as the trend toward multidisciplinary research and multisite studies. One-third of the studies focused on nursing intervention, and two-thirds were assessment-oriented. Although use of nursing conceptual models increased over the decade, theories or models from psychology, physiology, and sociology were used most often. There was an increase in use of sophisticated research methods and better reporting of reliability and validity. The use of NANDA as a taxonomy for classifying nursing practice research was assessed.

Nursing administration research in hospitals and schools of nursing

"Nursing service administration is in the most desperate need of research..." So said Herman Finer, well-known professor at the University of Chicago and in 1952, director of the Kellogg Nursing Service Administration Research Project. Today, 35 years later, the same need holds true. Administrators in hospitals and schools of nursing were canvassed to discover the nature of nursing administration research already in progress. Information about what is being studied, and amounts and sources of funding can be useful to nurse executives who are planning to implement research projects that build on existing knowledge. Findings from the study can also contribute to development of an overdue national research agenda for nursing administration.

Delineation of nursing administration research priorities

The purposes of this national study were to determine: (a) a definition of nursing administration research and (b) priority nursing administration research questions. Brainstorming was used initially with Council on Graduate Education for Administration in Nursing (CGEAN) members in 1984, to delineate concepts for definitions. Definitions and research questions were generated and rated in a three-round Delphi survey by 129 experts from nursing and health administration. According to the most widely supported definition, nursing administration research is concerned with establishing costs of nursing care, examining the relationships between nursing services and quality patient care, and viewing problems of nursing service delivery within the broader context of policy analysis and delivery of health services. The research question of most importance was: What are the cost-effective components of clinical nursing care that yield high patient satisfaction, decrease the number of complications, and shorten hospital stay for identified groups of patients? In a scenario exercise at the 1985 CGEAN meeting, additional priorities identified were vulnerable populations and equity.

Nursing administration in small rural hospitals

Most of the world's population is rural and 45% of all United States hospitals are small or located outside of urban centers. The interdependence of rapidly changing rural communities and hospitals is described in this study of nursing directors' jobs. Findings provide needed information about the challenges and demands of nursing administration in small organizations useful for development of curriculums sensitive to values, politics, and economies; and for all nurse executives eager to understand the complexity of decisions and actions, whether in small organizations or in large multi-institutional systems comprising hospitals of varying sizes.

Human factors design of a video monitor emulator and display (VMED) for visually impaired computer users

This paper describes research conducted by the Atlanta VA Medical Center in the area of visual impairment and computer usage--in particular, work on the design of a device that reformats computer video output for use by persons with limited usable vision. The objective of the current project is to design, build, and test a video/video control interface that can be connected to and will reformat the video data of any general-purpose computer/word processor. The objectives of this work are to complete a human factors analysis of types of tasks performed on computers/word processors, and to design and build a universal interface that implements the results of the aforementioned study.

Effect of pulmonary hygiene measures on levels of arterial oxygen saturation in adults with chronic lung disease

The purpose of this study was to determine whether adult patients with chronic obstructive pulmonary disease (COPD) can safely perform pulmonary hygiene measures without compromising their arterial oxygen saturation (SaO2) levels (less than 80 per cent). In 15 male veterans with moderate-to-severe COPD an ear oximeter was used to measure SaO2 levels while subjects completed a series of percussion, deep breathing, and coughing maneuvers in the head-down position (50 degree angle). No clinically significant changes in SaO2 levels were found in 14 subjects during pulmonary hygiene measures, but potentially dangerous symptoms were noted in two subjects. Our study supports the monitoring of objective and subjective symptoms during pulmonary hygiene and discontinuance of the procedure if tachycardia, palpitations, dyspnea, chest pain, or other distressful symptoms occur that might indicate hypoxemia.

Effect of ultrasonic nebulization on arterial oxygen saturation in chronic obstructive pulmonary disease

Twenty patients with mild to severe chronic obstructive pulmonary disease received ultrasonic nebulization to assess the danger of short-term changes in blood gas levels during this therapy. The status of arterial oxygenation was monitored during 20 minutes of therapy and for 20 minutes following therapy. In nine patients with periodic studies of arterial blood, the mean change in arterial oxygen pressure from base line was a decrease of 0.8 mm Hg at ten minutes into therapy, 2.8 mm Hg at the conclusion of therapy, and 2.9 mm Hg 20 minutes after therapy. In all 20 patients, ear oximetric studies showed only a small mean change at ten minutes into therapy, at the end of therapy, and at 20 minutes after therapy. Changes in the status of arterial oxygenation during and after therapy with ultrasonic nebulization in a group of patients with chronic obstructive pulmonary disease are generally small and of no statistical and limited clinical significance; however, alarming falls in arterial oxygenation can occur and cannot be predicted by base-line testing of pulmonary function or studies of arterial blood. It would be prudent to monitor patients with chronic obstructive pulmonary disease during therapy with ultrasonic nebulization or to withhold therapy altogether.