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The Gerasim model of caregiving: reflections on Tolstoy's novella, The Death of Ivan Ilyich.

Count Leo Tolstoy's classic novella The Death of Ivan Ilyich (1886/1981) is examined from the perspective of a health care professional for its portrayal of a helping relationship between the central character and his servant Gerasim. The purpose of the article is to extrapolate helping behaviors depicted in the story and construct a caregiving model. Tolstoy's work, literary critiques of the novel, biographies of Tolstoy, and principles from feminist ethics are used as sources. The model will be of assistance to those who care for the terminally ill.

Caregivers

Evolutionary theory and the human family.

Emlen's (1995) paper "An evolutionary theory of the family" reviewed existing ideas about the nature of family systems and the reasons why they have evolved in certain animal species. His theorizing led him to propose 15 predictions about how family systems function, based on favorable evidence from various species, mostly birds. While he suggested that these predictions can be applied to the human case, he himself did not attempt to do so. We consider the applicability of Emlen's 15 predictions to the study of human family systems, and find that several aspects of the life history and ecology of Homo sapiens require that they be modified. These considerations include: (1) the importance of intragroup solidarity in the context of intergroup competition: unlike in many other species where dispersal constraints arise from food or breeding site shortages, the primary pressure driving human sociality seems to be competition from other human groups; (2) the complex nature of exchange and reciprocity in human society: reciprocal altruism in particular is integral to human social interaction and leads to a particularly high degree of non-nepotistic helping behavior; and (3) the implications of menopause and the existence of potentially dominant, postreproductive helpers: helpers of this sort have little incentive to disperse or to encourage offspring to disperse, thus greatly increasing family stability.

Animals

Selection of children to provide care: the effect of earlier parental transfers.

We use the first wave of data from the Asset and Health Dynamics Among the Oldest Old (AHEAD) study to examine the effects of past parent-to-child financial transfers on selection of a child to provide assistance with basic personal care for unmarried parents. We estimate a fixed-effects conditional logit model and find a positive and significant association between past financial transfers and a child's current helping behavior. The coefficient of past financial transfers is in the direction hypothesized, and its magnitude is 80% as large as that of gender, a well-documented powerful predictor of parental caregiving. There appears to be substantial evidence that earlier parent-to-child financial gifts play a role in determining which child in the family will provide assistance.

Aged

Measurement theory.

The usefulness and truthfulness of assessments, whether performed in the clinic on one patient or in the research laboratory on many subjects, depends on valid measurements. Measurement theory is the thought process and interrelated body of knowledge that form the basis of valid measurements. Translation of measurement theory to behaviors helps to ensure the integrity and relevancy of tests and the data that result from them. In the final analysis, useful and truthful data depend for their existence on scalable and detectable events being translated into pertinent, valid, and reliable measurements. The rules by which numbers are assigned to events form the basis of measurements theory.

Humans

Social supports, social networks, and schizophrenia.

This article considers the meaning of "social support" and its relationship to social networks, and discusses a structural approach to analysis of social connections in the study of schizophrenia. The concept of social supports is seen as methodologically more problematic and less strategic than the more structurally oriented concepts of social networks and social connections. It is argued that in terms of research strategy, if social connections are studied structurally as they change and develop over time, the impact of the specifically social processes can be better separated from that of the personal characteristics of the focal individual than seems possible with other approaches. Analysis of the properties of the networks around the focal individual, independently of that individual's own social behavior, can help to disentangle the interwoven complex of causes, characteristics, and consequences of schizophrenia.

Dependency, Psychological

The relations of dispositional regulation and emotionally to elder's empathy-related responding and affect while volunteering.

Researchers recently have proposed that various empathy-related reactions are differentially related to individual differences in emotional intensity and regulation. This idea was tested with a sample of elderly hospital volunteers. As predicted, dispositional sympathy was associated with high levels of both dispositional regulation and negative emotional intensity. Personal distress was linked with low regulation and high negative emotional intensity, and cognitive perspective taking was associated with high regulation. Perspective taking moderated the relation of emotional intensity to sympathy and personal distress. In addition, elders' negative affect when volunteering at a hospital was correlated with low regulation and high levels of regulation and dispositional sympathy. The results demonstrate the findings pertaining to vicarious emotional responding are generalizable to nonstudent populations engaged in planned, sustained helping behavior.

Affect

Geriatric rigidity and its psychotherapeutic implications.

The elderly tend to be more rigid than younger adults in their attitudes and personalities, and such rigidity is correlated with poor adjustment. However, the rigidity is not the cause of the poor adjustment; rather, it is an attempted solution. One of the patterns of rigidity is an outgrowth of the lifestyle of pessimism, suspicion, self-reliance, self-discipline, determination, and endurance. Two case studies are presented illustrating how rigidity can channel thoughts and prevent the brooding which works itself into depression or anxiety, while simultaneously reinforcing self-help behavior. Geriatric psychotherapy should be problem-centered and should not launch a frontal assault on rigidity or attempt to reconstruct the patient's personality. Behavioral modification, authority, and motivation slogans can be used in conjunction with the rigidity to improve the patient's coping ability.

Adaptation, Psychological

Response of patients to participation in psychiatry board examinations.

The patient who volunteers to be a subject for Part II of the certifying examination in psychiatry and neurology is an indispensable but surprisingly invisible participant in a highly controversial process. A survey of the attitudes of 78 patients toward this experience revealed that although they experienced a significant degree of stress, the overwhelming majority viewed their participation in strongly positive terms. The patient's loyalty to the host institution and the manner in which the patient is prepared for the experience appear to be the major factors in determining a positive outcome.

Adult

Facilitating diabetes self-management.

The purpose of this study was to enhance sensitivity to and understanding of the perceptions of persons with diabetes by analyzing these individuals' unsolicited comments on structured questionnaires. Twenty of 66 adults with non-insulin-dependent diabetes mellitus (NIDDM) who participated in a study to modify their eating habits wrote a total of 122 unsolicited comments on three different questionnaires. A systematic analysis of the content of these comments resulted in seven coding categories: personal philosophy; knowledge deficit; weight or blood sugar problems; diet, exercise, or medication problems; self-care activity; stress; and success. Further analysis resulted in a trilevel schema (survival, regulation, success) depicting how individuals learn to manage their diabetes. The problem-identification and seeking-help behaviors identified in the survival level gradually changed to learning to live with the regimen in the regulation level. Respondents whose activities were in the success level demonstrated more autonomy than persons in the other two levels. A health orientation rather than a problem orientation also was seen in the success level. Consequently, teaching strategies should be tailored to the client's level of self-care, with an emphasis on assisting them toward the success level.

Adult

Friendship patterns among older women.

This study examined the friendship patterns of older women. The participants in the study were white, middle-class, urban women, sixty-five years of age or older. Results indicated the older widowed women received more help from their friends than did married older women. In addition, significant differences in the morale of the older women were found according to the equity of helping behaviors with friends. Specifically, those equitably benefited women had a higher mean morale score than over benefited women. The under benefited women also had a higher mean morale score than the over benefited women. Discussion centered on the importance of friends in the lives of older women as well as on implications for friendship support systems in late life.

Aged

Intimacy: factors affecting its development among members of a home for the aged.

The purpose of this research was to explore the extent and nature of intimate interaction in an unGoffmanesque home for the aged. Interviews with all elderly residents and the staff who served them revealed that the residents' intimate relationships were primarily with others outside the home and never with staff members. Moreover, the residents and, more particularly, the staff viewed the residents in negative ways and reported more negative than positive affectivity within the home. Factors impeding intimate interactions were related to the widely shared negative stereotype of the aged residents, the manner in which staff perceived their role, and the absence of mutual aid or helping behaviors among the residents.

Aged

Rural/urban elderly and siblings: their value consensus.

Consensus is the level of agreement about life felt among kin and has been identified as a dimension of family solidarity with important implications for the family network. This investigation studied the factors contributing to the consensus between older adults (age sixty-five and older) and the sibling with whom they had the most contact. Respondents (N = 275) lived in a rural/urban area. Seven independent variables were entered into a multiple-regression model to determine their relative importance to consensus of the sibling relationship. Results showed that 7 percent of the variance in consensus could be explained. Filial expectations, educational disparity, and the brother/sister link were the only variables of relative importance to older adult/sibling consensus. There was greater consensus when there were fewer expectations of the sibling, similarity of educational backgrounds, and when the respondent was male and his sibling was female. Brother/sister and brother/brother links, residential proximity, communication by mail or telephone, helping behaviors, and marital status were of no relative importance to consensus. The results suggest that factors previously found to be associated with intergenerational consensus may vary in their importance to intragenerational consensus.

Aged

Asthma mortality: another opinion--is it a matter of life and ... bread?

There is a general consensus that the mortality rates for asthma in much of the developed world have been increasing for the past 10-15 years. This has occurred despite an improved information base regarding diagnosis and management as well as the development of novel and more effective therapeutic modalities. Several explanations have been proposed for this increase, including a statistical artifact based on a change in the coding criteria for asthma from the International Classification of Diseases Version 8 (ICD-8) to ICD-9, worsened pollution, delays in seeking medical help, behavioral changes, deficits in asthma education of both patients and primary care providers, toxicity of beta agonists, and noncompliance with medications. We suggest that although all of these are potential etiological factors, there may exist still another major etiological risk. There have been dramatic changes in our eating habits and food preparation. In general, we eat less total calories, more meals outside the home, and more refined or prepared foods. With the emphasis on reducing the intake of saturated fats and cholesterol, we eat more polyunsaturated fats both by choice and secondary to manufacturers' attempts to improve the appeal of foods to health-conscious government and the public. The drive to remove animal fats and cholesterol from our diet has resulted in the replacement of animal fats with vegetable oil in food manufacture, fast-food frying, and even home preparation. One result of these dietary habits has been a doubling from 8 to 15% of the percentage of the polyunsaturated linoleic acid in body fat. We postulate that this, and other nutritional changes, will render asthma a more difficult syndrome to manage and will contribute adversely to the inflammatory abnormalities in airways.

Adrenergic beta-Agonists

Health care consolidation and the changing health care marketplace. A review of the literature and issues.

This Issue Brief examines the academic literature and issues in consolidation of the hospital sector in the context of responses to changes in the competitive environment. It analyzes the motivations for consolidation as well as its effects. Hospital merger activity has increased dramatically in recent years. The current wave of mergers is primarily a reaction to a competitive environment that is placing a greater emphasis on controlling costs and forcing high-cost providers out of the market. The growth of managed care has placed considerable pressure on providers of health care and, in particular, on hospitals. The evolution of insurance companies' behavior helps explain the recent hospital consolidation movement. As managed care has become the dominant type of coverage in the last decade, insurance companies have become more active in trying to control costs--a reversion to their previous practices before the advent of managed care. Insurance companies have placed cost constraints on providers, both in the early years of health insurance and currently, when there are strong competitive forces. Hospitals claim that their primary merger motives are improving efficiency and the quality of care. The empirical evidence on this claim is mixed. Vertical integration (between suppliers and buyers of health care services, such as between hospitals and physicians) has appealed to hospitals because of their need to obtain more patients. More research is needed to explore the effects of vertical integration in the health care sector. In one of the more significant recent legal rulings, the U.S. Justice Department lost a 1997 case challenging the merger of two hospitals in the New York City metropolitan area. This, along with other recent losses by the antitrust authorities, does not bode well for the government's ability to prevent hospital mergers in metropolitan areas. It is difficult to generalize on an appropriate antitrust policy for hospital mergers. Hospital consolidation is likely to continue at a rapid pace. Since some developments may reduce the cost of employee benefits while others may increase the cost of these benefits, the final effect on the provision of health care benefits by employers is uncertain. Employers must pay close attention to the hospital consolidation movement because it will lead to important changes in the provision of health care benefits.

Antitrust Laws

Staff skills in patient/family relations grow.

Short but cogent course on communication, attitudes, and behaviors helps staff members from many departments relate more effectively with patients, their families, and visitors.

Communication