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At least 1,081 records · Page 60Linked to original sources

PubMed1996

Physical restraint use and falls in nursing home residents.

OBJECTIVE: To examine the relationship between restraint use and falls while controlling for the effect of psychoactive drug use among nursing home residents, including subgroups of nursing home residents with high rates of restraint use and/or falls. DESIGN: Secondary analysis of data from a longitudinal clinical trial designed to reduce restraint use. SETTING: Three nursing homes. PARTICIPANTS: Subjects (n = 322) were either restrained (n = 119) or never restrained (n = 203) at each observation point during a 9.5-month data collection period that preceded the intervention phase of the clinical trial. MEASUREMENTS: We evaluated restraint status (independent variable) three times during the data collection period by direct observation over a 72-hour period. Incident reports documenting falls and fall-related injuries (dependent variables) were reviewed. Cognitive status was measured using the Folstein Mini-Mental State Exam and functional status (including ambulation status) by the Psychogeriatric Dependency Rating Scale. Psychoactive drug use profile was obtained through record review. MAIN RESULTS: Using multiple logistic regression, we compared the effect of restraint use on fall risk between a confused ambulatory subgroup and the remaining sample and found a significant difference in the odds ratio for falls and recurrent falls (P = .02; chi-square = 5.24, df = 1; P = .003, chi-square = 9.12, df = 1). In the confused ambulatory subgroup, restraint use was associated with increased falls (odds ratio: 1.65, 95% CI: 0.69, 3.98) as well as recurrent fall risk (odds ratio: 2.46, 95% CI: 1.03, 5.88). Increased falls and recurrent fall risk was not observed in the remaining sample (falls odds ratio: 0.49, 95% CI: 0.28, 0.87; recurrent falls odds ratio: 0.42, 95% CI: 0.20, 0.91). One subgroup, the nonconfused ambulatory residents, were never restrained; after removing this subgroup, the confused ambulatory continued to be associated, though not significantly, with a higher risk of falls and injuries. Only nonconfused nonambulatory restraints were associated with a lower risk of all three outcomes: falls (odds ratio: 0.28, 95% CI: 0.05, 1.58), recurrent falls (odds ratio: 0.48, 95% CI: 0.05, 4.72), and injurious falls (odds ratio:0.42, 95% CI: 0.04, 4.01); these results, however, were not statistically significant. There was no evidence that the effect of restraint use on fall risk depended upon the use of psychoactive drugs (chi square = 4.43; df = 2, P = .11). CONCLUSION: Restraints were not associated with a significantly lower risk of falls or injuries in subgroups of residents likely to be restrained. These findings support individualized assessment of fall risk rather than routine use of physical restraints for fall prevention. Researchers and clinicians should continue to focus efforts on developing a variety of approaches that reduce risk of falls and injuries and promote mobility rather than immobility.

Accidental Falls↗

PubMed1999

Genetic medicine: an experiment in community-expert interaction.

This project tested a two-way model of communication between lay groups and experts about genetic medicine in Perth, Western Australia. Focus group discussion with community group participants was followed by a communication workshop between community group participants and experts. Four groups of concerns or themes emerged from discussion: clinical considerations; legislative concerns; research priorities, and ethical and wider considerations. Community group concerns are not always met by the actions of "experts". This is, in part, because of the differing life-worlds of each group. However, the communication workshop showed the potential of two-way communication for both lay and expert members in understanding the others' viewpoint. Further, the approach developed here offers one possible way for community groups to participate in a substantial way in policy formulation processes.

Attitude to Health↗

PubMed1997

Durable power of attorney and informed consent with Alzheimer's disease patients: a clinical study.

OBJECTIVE: Experience with a new surrogate consent system for patients with Alzheimer's disease is reviewed. It was hypothesized that as patients' cognitive status deteriorated, surrogate consent through a durable power of attorney would become necessary to facilitate continued involvement in clinical research. METHOD: The authors retrospectively reviewed the charts of inpatients with Alzheimer's disease who participated in research between January 1989 and December 1994 at the Geriatric Psychiatry Unit of the National Institute of Mental Health. Seventy-nine patients were included. The main outcome measures were the Clinical Dementia Rating, Global Deterioration Scale for primary degenerative dementia, and Mini-Mental State. RESULTS: Most patients were in the mild-to-moderate stage of the illness when they chose to participate in research and assign a durable power of attorney (96% scored 2 or less on the Clinical Dementia Rating, and 92% scored 5 or less on the Global Deterioration Scale). On average, the subjects participated in 3.8 (SD = 2.6) studies. For 35 patients with multiple admissions over this period (average = 3.1 years), scores on the Clinical Dementia Rating and Global Deterioration Scale declined by 1.0 and 1.5 points, respectively. CONCLUSIONS: The durable power of attorney allows research participation for subjects with Alzheimer's disease at all stages. The linchpin is assignment of a durable power of attorney in the early-to-moderate stage of Alzheimer's disease, before subjects lose the capacity to give informed consent. This approach could also be adapted to patients with cognitive decline due to other debilitating diseases.

Advance Directives↗

PubMed2003

The value of disease severity in predicting patient readiness to address end-of-life issues.

BACKGROUND: Although patient-physician discussion is the most important tool for end-of-life planning, less than 30% of seriously ill patients have held these discussions. While physicians use objective disease severity and recent clinical events to trigger end-of-life discussions, it is not known if such findings predict patient readiness. We evaluated the ability of disease severity measures and recent clinical events to predict patient readiness for end-of-life discussions in patients with chronic lung disease. METHODS: The desire for discussion about end-of-life care was evaluated in 100 outpatients with a diagnosis of chronic lung disease presenting for pulmonary function testing. Objective disease severity was indicated by the percentage of the predicted forced expiratory volume, use of oral corticosteroids, a functional status score, frequency of recent hospitalizations, and required use of mechanical ventilation. RESULTS: In multivariate analysis, patient desire for an end-of-life discussion with the physician was not associated with percentage of predicted forced expiratory volume in 1 second (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.96-1.03), oral corticosteroid use (OR, 1.34; 95% CI, 0.40-4.54), functional status score (OR, 1.37; 95% CI, 0.34-5.56), hospitalizations in the past year (OR, 0.33; 95% CI, 0.09-1.20), or previous mechanical ventilation (OR, 1.37; 95% CI, 0.34-5.56). CONCLUSIONS: Patients appear no more or less interested in end-of-life discussions at later stages of chronic lung disease. Physicians cannot use disease severity measures or recent clinical events to accurately predict when patients desire end-of-life discussions. Focusing on physician skill in using specific communication strategies for patients at all stages of illness may be the most promising approach to increasing end-of-life discussions.

Adult↗

PubMed1985

Teaching medical students the effects of values and stereotyping on the doctor/patient relationship.

As part of an introductory course on the doctor/patient relationship, a teaching unit was designed which emphasized to students that values, biases and prejudices may affect their behaviors when interacting with patients. The unit included lectures on values, specific readings and a survey component which challenged students' value systems and provided them with the opportunity for exploration of hidden biases and prejudices. The survey component involved a series of trigger vignettes depicting five patients interacting with the same (actor) physician. On a rating instrument, students were asked to rate each patient on ten positive and ten negative characteristics, identify the characteristic which best described each patient and select the patient they would most like to treat. The survey was administered to an incoming class of medical students at the orientation session to a course on the doctor/patient relationship. Students were asked to keep a copy of their ratings and bring it to the small group discussion session on physician values. The data were collected, and a class composite developed and submitted to the course instructors prior to the discussion and processing sessions on values. Specific instructions on how to utilize the materials were provided. The class composite, which revealed that students have biases, served as a focus for discussion and facilitated students awareness that unconscious stereotypes exist in their value systems. This teaching approach provided students with a beginning insight that biases and prejudices affect the doctor/patient relationship and the quality of care patients receive.

Adult↗

PubMed1981

Justice in the distribution of health care resources. The position of physical therapists, physiatrists, and rehabilitation nurses.

Physical therapists, rehabilitation nurses, and physiatrists in the United States were surveyed to identify the interpretation(s) of justice they judged to be most appropriate as a basis for health policies. A questionnaire containing four interpretations of justice was used. Responses by the three groups according to their overall interpretation showed marked inconsistencies. To the extent that consistency was observable, they favored a "needs-based" approach over a "utilitarian," "contract," or "skeptical" approach. Individually, physical therapists favored a needs-based interpretation while rehabilitation nurses and physiatrists were divided between utilitarian and needs-based interpretations.

Adult↗

PubMed2001

Communicating with dying patients within the spectrum of medical care from terminal diagnosis to death.

BACKGROUND: Efforts to improve communication between physicians and dying patients have been unsuccessful, and guidelines for improving patient-physician communication about end-of-life care are based primarily on expert opinion. This study assessed which aspects of communication between patients and physicians are important in end-of-life care. METHODS: Twenty focus groups were held with 137 individuals, including patients with chronic and terminal illnesses, family members, health care professionals from hospice or acute care settings, and physicians with expertise in end-of-life care. Focus group analyses determined domains of physician skill at end-of-life care. Communication with patients was identified as one of the most important domains. Analyses of components important in communicating with dying patients and their families were performed. RESULTS: The following 6 areas were of central importance in communicating with dying patients: talking with patients in an honest and straightforward way, being willing to talk about dying, giving bad news in a sensitive way, listening to patients, encouraging questions from patients, and being sensitive to when patients are ready to talk about death. Within these components, subthemes emerged that provide guidelines for physicians and educators. Dying patients also identified the need to achieve a balance between being honest and straightforward and not discouraging hope. CONCLUSIONS: Several areas emerged for physicians to focus their attention on when communicating with dying patients. These findings provide guidance in how to improve this communication. They also highlight the need to approach communication about end-of-life care as a spectrum that requires attention from the time of a terminal diagnosis through death.

Clinical Competence↗

PubMed2003

Student nurses' attitudes towards working with older patients.

BACKGROUND: The ageing of the United Kingdom (UK) population means that the care of older people will become an increasingly important part of nurses' remit. However, employment statistics suggest that this is an unpopular nursing specialism. This may be due to a number of factors, one of which may be nurses' negative attitudes towards working with older people. This constitutes a potential problem, especially if such attitudes have an impact on the quality of care provided. AIM: To examine the attitudes held by student nurses towards working with older patients. METHODS: Questionnaires incorporating Likert-type scales, two vignettes and demographic questions were designed using the theory of planned behaviour. These were distributed to 172 student nurses undertaking preregistration nursing courses in the UK during the academic session 2000-2001. RESULTS: Student nurses displayed positive intentions towards working with older patients. These were based on their own attitudes and beliefs about what others would wish them to do. Participants believed that their behaviour towards older patients was to a large extent under volitional control. Analysis of the beliefs underlying student nurses' views showed that they differentiated between those participants who had a relatively positive approach to their work with older patients and those with a less positive approach. In addition, the results offered mixed support for the view that more knowledgeable or experienced nurses hold more positive views towards older people. CONCLUSIONS: The findings offer some support for previous studies that have looked at the more general issue of attitudes towards older people. However, the results also indicate that a more rigorous and more highly focused approach to the study of such attitudes is required if the research is to be relevant to the issue of working with older patients. The theoretical, methodological and practical implications of the findings are discussed.

Adult↗

PubMed1989

Developing standards in animal research review.

Thirty-two institutional animal care and use committees reviewed 4 hypothetic protocols involving experimental procedures frequently conducted on animals. Committees were in general agreement on the need to refine hypothetic protocols to minimize pain, distress, and other harm to laboratory animals. All but 2 committees sought modifications in each protocol, and in numerous instances, committees would not approve a protocol without major modifications. The committee responses delineated emerging standards governing specific areas of animal use, such as antibody production, induced disease, surgery, physical restraint, and behavioral conditioning. Committees had less consensus in their approach to assessing the justification for laboratory animal use. Apparently, this component of committee responsibilities presented the major conceptual and practical difficulties for committees engaged in animal research review.

Animal Care Committees↗

PubMed1994

Case managers discuss ethics: dilemmas of an emerging occupation in long-term care in the United States.

As case management programs mature, ethical questions undoubtedly arise. Yet there are few, if any, standards by which case managers can guide their actions and decisions. In this article, the authors present the results of a survey of 251 frontline case managers in 10 states who were asked to describe the ethical challenges they face. The respondents were conscious of struggling with difficult, even life-and-death decisions involving important choices in their clients' lives. Generally, the case managers were committed to the ideology of respect for client autonomy but found themselves making uneasy compromises with the concept at every turn. Ethical issues arose not only with the client but also with the client's family, colleagues, and providers. Case managers, long-term care providers, and governmental policymakers could all benefit from both theoretical and practical explorations of desirable approaches to individual and societal long-term care decisions.

Adult↗

PubMed2001

Mentoring and the impact of the research climate.

In this article, we focus on the mentoring process, and we argue that the internal and external pressures extant at research universities may create a research culture that may be antithetical to appropriate mentoring. We developed a scale based on motivation theory to determine the perceived research culture in departments and research laboratories, and a mentoring scale to determine approaches to mentoring graduate students. Participants were 610 faculty members across 49 departments at a research oriented university. The findings were that a mastery-oriented research climate and an outcome-oriented research climate were manifested at the university. More importantly, each research climate had its own unique impact on how the faculty approached mentoring graduate students. A mastery research climate was related to a more supportive approach to mentoring than the outcome research climate. We concluded by suggesting that the outcome research climate may have an adverse effect on effective mentoring and on maintaining research ethics.

Analysis of Variance↗

PubMed2004

Preferences of older African-Americans for long-term tube feeding at the end of life.

The purpose of this study was to elicit preferences and reasons behind preferences for percutaneous endoscopic gastrostomy (PEG) tube placement in an older African-American sample. Five focus groups were conducted with subjects invited from the Geriatric Clinic of an urban tertiary care hospital. Thematic and latent content analyses were used. Five broad themes emerged as reasons behind the acceptance or rejection of a PEG tube, namely: the nature of the illness; the quality of life at the time of the decision; the concern about dependency; experiences; and religion (including issues of death). The issue of proxy also arose and contained three themes: fear of loss of decision-making ability; trust in family or caregivers as proxy even when the proxy choices differed from their own choices; and trust in the doctor and family to respect personal decisions. Use of a qualitative approach enabled potentially sensitive issues to be discussed. Preferences and the reasons behind these preferences may not always be anticipated by clinicians.

Black or African American↗

PubMed1992

The organ donor family members' perception of stressful situations during the organ donation experience.

The purpose of this study was to determine what the individual organ/tissue donor family members appraised as most stressful during the anticipation, confrontation and post-confrontation stages of the organ-donation process. The Lazarus and Folkman stress and coping theory guided the development and interpretation of the study. Family members who had lost a loved one suddenly and consented to donation in 1988 were interviewed. Data were analysed by means of content analysis. Findings showed that family members appraised different types of stressful situations during the three stages. The most frequently reported stressful situations centred around the threat of losing a loved one, confirmation of brain death, failure of the health professionals to identify the loved one as a potential donor and to approach the family regarding organ donation, and adjusting to the many changes associated with the loss. Significantly, five families requested donation, while two readily consented when approached. All family members reported that organ donation had helped with their grief. The findings of this study contribute to the development of knowledge required to guide nursing interventions to provide sensitive care to donors and their families.

Adaptation, Psychological↗

PubMedDate not supplied

How managed care can be ethical.

The growth of managed care in the United States has been paralleled by a rising tide of anti-managed care sentiment. The "managed care problem" is understood generally as the need to protect individuals against large companies that care more about their bottom line than about people. The premise of the BEST (Best Ethical Strategies for Managed Care) project is that the "managed care problem" is best understood as an ethical problem--a conflict of values that arises as the country changes from a patient-centered to a population-centered approach to health care. The BEST project team worked with nine managed care organizations to identify their most intractable problems. The team redefined these problems in terms of ethical dilemmas, then studied each organization in search of innovative, exemplary approaches. These exemplary approaches are being shared publicly with the aim that they be adapted and adopted by other organizations facing similar difficulties and by regulators and legislators hoping to improve the health care system.

Benchmarking↗

PubMed1999

Prediction of hepatic metabolic clearance based on interspecies allometric scaling techniques and in vitro-in vivo correlations.

This article reviews the methods available for predicting hepatic metabolic clearance in humans, and discusses their application to the processes of drug discovery and development. The application of these techniques has increased markedly during the past few years because of the improved availability of human liver samples, which has increased the opportunities to use in vitro studies to predict human clearance. The techniques available involve both empirical and physiologically based approaches. Allometric scaling using in vitro data from animals and humans combines certain aspects of both approaches. An evaluation of data retrieved from the literature indicates that, together with in vitro human data, allometric scaling based on a combination of in vitro and in vivo preclinical data can accurately predict clearance in humans. With this approach, 80% of the predictions were within a 2-fold factor of actual human clearance values, with an overall accuracy of 1.6-fold. The uncertainties and inaccuracies in predicting human clearance are related to: (i) the specific method that is used to make the prediction; (ii) the experimental design and the model used to determine the in vitro clearance; (iii) protein binding within the in vitro test system; and (iv) various in vivo factors such as the involvement of extrahepatic metabolism and active transport processes, interindividual variability and nonlinearity in pharmacokinetics. In contrast to purely empirical approaches, the physiological approach to predicting clearance gives an opportunity to integrate some of these complexities and, therefore, should provide more confidence in the prediction of clearance in humans.

Animals↗

PubMed1988

Human immunodeficiency virus antibody testing. A description of practices and policies at US infectious disease-teaching hospitals and Minnesota hospitals.

A questionnaire that asked about policies concerning the use of human immunodeficiency virus (HIV) antibody tests was sent in January 1987 to the 200 hospitals in the United States that conduct infectious disease (ID) fellowship training (US ID hospitals) and to all 171 short-term-care Minnesota hospitals. Information was received from 189 of the US ID hospitals (94.5%) and from 160 (94%) of the Minnesota hospitals. Only 49% of the US ID hospitals and 37% of the Minnesota hospitals had an HIV antibody test-ordering policy; 47% of the US ID hospitals and 39% of the Minnesota hospitals had a specific educational program for physicians about the HIV antibody test; and 62% of the US ID hospitals and 41% of the Minnesota hospitals had an HIV autopsy policy. Marked variety existed in approaches to handling test results, obtaining patient consent, and providing risk-reduction information among the hospitals surveyed. These data suggest the need for a consensus on optimal use of HIV antibody testing at hospitals.

Acquired Immunodeficiency Syndrome↗

PubMed1992

Cancer diagnosis disclosure in a Spanish hospital.

At the Clinic Hospital in Barcelona, Spain, 167 cancer patients and 380 hospital health care workers were interviewed about cancer diagnosis disclosure. Only 25 patients (15%) were correctly informed of their diagnoses. Breast cancer patients were significantly more often informed than patients with other malignancies (p less than 0.05). Two hundred seventy-two of 380 hospital health workers interviewed (71%, p = 0.00) would want to know their own diagnoses should they suffer from cancer in the future, but only 19% (p = 0.00) would want such a diagnosis revealed to their similarly afflicted relatives. This information model, based on cancer taboo, is largely preferred by these healthy people and is followed by doctors, patients and family members. To inform our patients better, the mandatory uniform disclosure of the true diagnosis is not likely to be constructive at present. In our opinion a pragmatic approach is more realistic and humane. Nevertheless, we must hope that more modern cancer education will lead to the gradual elimination of this taboo in our society.

Aged↗

PubMed2003

Do they understand? (part II): assent of children participating in clinical anesthesia and surgery research.

BACKGROUND: Participation of children in clinical research requires not only parental permission but also the assent of the child. Although there is no fixed age at which assent should be sought, investigators should obtain assent from children considered able to provide it. This study was designed to determine children's understanding of the elements of disclosure for studies in which they had assented to participate. METHODS: The study population included 102 children aged 7-18 yr who had given their assent to participate in a clinical anesthesia or surgical study. Children were interviewed using a semistructured format to determine their understanding of eight core elements of disclosure for the study to which they had agreed to participate. Two independent assessors scored the children's levels of understanding of these elements. RESULTS: The children's perceived level of understanding of the elements of disclosure was significantly greater than their measured understanding (7.0 +/- 2.4 vs 5.3 +/- 2.7, 0-10 scale; P< 0.0001). Complete understanding of the elements of disclosure for all children ranged from 30.4 to 89.4%. Children aged more than 11 yr had significantly greater understanding compared with younger children, particularly with respect to understanding of the study protocol, the benefits, and the freedom to withdraw. CONCLUSIONS: Children approached for their assent to participate in a clinical anesthesia or surgery study have limited understanding of the elements of disclosure and their role as a research participant, particularly if they are aged less than 11 yr.

Adolescent↗