A Race to the End: Family Caregivers' Experience of Medical Assistance in Dying (MAiD)-a Qualitative Study

BACKGROUND

The June 2016 legalization of medical assistance in dying (MAiD) provided an added layer of choice to end-of-life care in Canada. Family caregivers play an important role in patient end-of-life decision-making. They may experience unique psychological burden or distress associated with their role. However, we know little about the caregiver experience associated with patient MAiD requests and the nature of psychosocial supports caregivers require before, during, and following MAiD intervention.

OBJECTIVE

The objective of this study is to better understand the caregiver experience of MAiD within the Canadian legal landscape following Bill C-14.

DESIGN

Caregiver experience was examined based on qualitative, semi-structured interviews.

PARTICIPANTS

A total of 22 caregivers of patients who had requested MAiD were interviewed.

APPROACH

Transcripts were recorded, transcribed, and analyzed based on grounded theory methodology.

KEY RESULTS

The caregiver experience of MAiD within the legal framework was found to be understood as a "race to the end," with the ultimate goal of creating an ideal dying experience for the patient while balancing a threat to capacity that would undermine their access to MAiD. Caregivers can be described within the overarching framework as either co-runners or onlookers. Sources of caregiver distress were linked to these roles.

CONCLUSIONS

The "race to the end" theoretical model contributes new knowledge and understanding that can inform the development of tailored support services for caregivers, the impact of legislative changes on this population, and future research examining decision-making near end of life and the caregiver experience.

The MADD-3 LAMMER Kinase Interacts with a p38 MAP Kinase Pathway to Regulate the Display of the EVA-1 Guidance Receptor in Caenorhabditis elegans

The proper display of transmembrane receptors on the leading edge of migrating cells and cell extensions is essential for their response to guidance cues. We previously discovered that MADD-4, which is an ADAMTSL secreted by motor neurons in Caenorhabditis elegans, interacts with an UNC-40/EVA-1 co-receptor complex on muscles to attract plasma membrane extensions called muscle arms. In nematodes, the muscle arm termini harbor the post-synaptic elements of the neuromuscular junction. Through a forward genetic screen for mutants with disrupted muscle arm extension, we discovered that a LAMMER kinase, which we call MADD-3, is required for the proper display of the EVA-1 receptor on the muscle’s plasma membrane. Without MADD-3, EVA-1 levels decrease concomitantly with a reduction of the late-endosomal marker RAB-7. Through a genetic suppressor screen, we found that the levels of EVA-1 and RAB-7 can be restored in madd-3 mutants by eliminating the function of a p38 MAP kinase pathway. We also found that EVA-1 and RAB-7 will accumulate in madd-3 mutants upon disrupting CUP-5, which is a mucolipin ortholog required for proper lysosome function. Together, our data suggests that the MADD-3 LAMMER kinase antagonizes the p38-mediated endosomal trafficking of EVA-1 to the lysosome. In this way, MADD-3 ensures that sufficient levels of EVA-1 are present to guide muscle arm extension towards the source of the MADD-4 guidance cue.

In most animals, the physical meeting of the pre- and post-synaptic membranes of the neuromuscular junction occurs via axonal extension towards the muscle. In nematodes, however, motor axons do not extend towards the muscle and instead form a dorsal and ventral cord with relatively few branches. To make the physical connection, the body wall muscles extend membrane projections called muscle arms to the motor axons within the dorsal and ventral cords. Through previous genetic and biochemical analyses with the nematode C. elegans, we identified a neuronally-expressed muscle arm chemoattractant (MADD-4) and its muscle-expressed co-receptor complex (UNC-40/EVA-1). Here, we report our discovery of madd-3, which encodes a LAMMER kinase that is expressed in muscles to regulate muscle arm extension. Genetic analyses revealed that MADD-3 may inhibit a p38 MAP kinase pathway whose normal function is to decrease the abundance of the EVA-1 receptor. In the presence of MADD-3, the activity of the p38 pathway is relatively low, and EVA-1 levels are consequently relatively high. Without MADD-3, the p38 pathway is freed to decrease the abundance of EVA-1. The relationships that we have uncovered between MADD-3, the p38 Map Kinase pathway, and the EVA-1 receptor provide one explanation for the muscle arm defects observed in madd-3 mutants.

The ACT-i-Pass study protocol: How does free access to recreation opportunities impact children's physical activity levels?

BACKGROUND

Physical activity during childhood is associated with a multitude of physical, behavioural, and psychological health benefits. Identification of effective population level strategies for increasing children's physical activity levels is critical for improving the overall health of Canadians. The overall objective of this study is to assess how a naturally-occurring, community-level intervention which offers Grade 5 children in London, Canada a free access pass to physical activity opportunities (facilities and programs) for an entire school year can lead to increased physical activity among recipients.

METHODS/DESIGN

This study adopts a longitudinal cohort study design to assess the effectiveness of improving children's access to physical activity opportunities for increasing their physical activity levels. To meet our overall objective we have three aims: (1) to assess whether the provision of free access increases children's physical activity levels during and after the intervention compared to a control group; (2) to assess how and why child-specific trajectories of physical activity (between-children differences in level of physical activity measured across time) in the intervention group differ according to children's individual and household characteristics; and (3) to explore additional factors that are unaccounted for in the theoretical model to gain a further understanding of why the free access intervention had varying effects on changing physical activity levels. We will be addressing these aims using a mixed methods approach, including: a series of youth surveys conducted before, during, immediately after, and 4-months after the intervention; parent surveys before, during, and post-intervention; real-time tracking of the access pass use during the intervention; and focus groups at the conclusion of the intervention. Data compiled from the youth surveys will provide a subjective measure of physical activity to be used as our outcome measure to address our primary aims.

DISCUSSION

The results of this study can inform policy- and decision-makers about the sub-groups of the population that benefitted the most (or least) from the intervention to provide more specific information on how to develop and target future interventions to have a greater impact on the physical activity levels and overall health of children.