Dying in hospital: the residents' viewpoint

A survey of residents'' (junior house officers'') experiences and attitudes to the terminal care part of their work in four Glasgow teaching hospitals showed that even a month after starting work one-fifth of the respondents had not actively managed a dying patient. Sixty-four per cent thought that they had received inadequate teaching in terminal care. Depression and anxiety had been the most difficult symptoms encountered. The residents thought that the ward nursing staff contributed much more than their senior medical colleagues to both the medical and psychological aspects of terminal care. The results indicate a need for more undergraduate education in the most relevant areas, such as coping with the psychological problems of dying patients and their relatives. Newly qualified residents require more support from senior medical staff in looking after the terminally ill.     

Ethical problems in feeding patients with advanced dementia.

Aged patients with dementia if not stricken by an acute disease sooner or later approach a terminal phase that is distinguished by a failure of spoon feeding. This condition induces great anxiety in the workers who care for these patients. The interaction between patient and care-worker during spoon-feeding failure is described by the psychological model of double-binding. Two serious consequences of double-binding are the distancing of the care-workers from the patient and scapegoating among the care-workers. It is essential that the pressure of double-bindings in the wards should be reduced.     

Women's access to health care in Ghana: Effects of education,residence, lineage and self‐determination

Abstract

Women's physical and psychological access to health care was analyzed using the 2003 Ghana Demographic and Health Survey (GDHS), a nationally representative study for monitoring population and health in Ghana. Female respondents from the 2133 cases in the couple's data set were used in this study. Women's level of education was positively related to physical but not to psychological access to health care. Residing in an urban area was positively related to both types of access. Matriliny consistently showed positive effects on physical access. In addition to these demographic factors, both physical and psychological access were positively related to women's self‐determination, i.e., women's right and ability to make real choices about their lives including their health, fertility, sexuality, childcare and all areas where women are denied autonomy and dignity in their identities as women. Self‐determination factors both mediated the effects of background factors on access and added explanatory power to the models.     

Feeling like a burden to others and the wish to hasten death in patients with advanced illness: A systematic review

Studies that have explored the wish to hasten death (WTHD) in patients with advanced illness have found that the feeling of being a burden may trigger WTHD. Research suggests that both the feeling and the wish are indicators of multidimensional suffering whose meaning may depend on the patient's biographical background. Therefore, we carried out a systematic review and meta‐ethnography. Fourteen qualitative studies, reported in 16 articles, met the inclusion criteria. The analysis identified two themes: the personal and social dimensions that could help to explain the feeling of being a burden in these patients. These dimensions reveal how this feeling is linked to physical, psychological/emotional, existential and social factors. The feeling of being a burden cannot be understood without considering patients’ personal interpretation of their dependency or care needs, and hence it is also necessary to understand their biographical background. Such an understanding is crucial to inform clinical policies based on the moral duty to provide all patients with humane care.     

Bereavement in the elderly: the role of primary care

Bereavement in the elderly is a concern to primary care physicians (PCPs) as it can lead to psychological illness such as depression. Most people are able to come to terms with their grief without any intervention, but some people are not. This case highlights the importance of early recognition of bereavement-related depressive illness in elderly people. PCPs need to optimise support and available resources prior to, and throughout, the bereavement period in order to reduce the family members'' burden and suffering.     

Les problemes d'erection: une souffrance encore trop souvent cachee

Many epidemiological studies have demonstrated the high prevalence of erectile dysfunction, particularly among aging males and patients with chronic diseases. Many of these studies, using an objective methodology, showed that this problem induces major suffering for the patient and his partner. This suffering results less from loss of sexual pleasure than from loss of self-esteem, humiliation or guilt of being “impotent”, and from the consequences on the relationship of the patient's modified personality and attitudes (introversion, irritability, avoidance of tenderness and intimacy). These problems are also worsened by the female partner, who questions her own femininity, related, to confusion between loss of erection and lack of desire. The impact of erectile dysfunction extends well beyond sexual function, as it constitutes a real identity problem for the man, affecting his relational and work life (loss of dynamism and self-confidence). Many objective studies have demonstrated significant improvement of various quality of life parameters after effective treatment of erectile problems with intracavernosal injections or tablets They also have shown significant improvement of global quality of life (and not only sexual quality of life) and many psychological parameters (anxiety, depression, self-confidence in sexual and marital relationships and social and work life, hostility and interrelational sensitivity). Global health indices are also improved. Despite the suffering due to erectile problems, and the fact these problems can be effectively treated, few men mention these problems to their general practitioner. Many surveys, estimate between 5 and 30% the percentage of men with erectile dysfunction seeking medical attention, although they also reveal that a higher proportion would like to be helped. Because of religious and sociocultural taboos and their shame and fear of being judged or that their problem will be revealed, men are embarrassed to raise this question. Other causes are also involved in this phenomenon: fear that their request will be rejected by the doctor, or the belief that no treatments are available for this type of problem, or that they have to accept this problem as an inevitable part of physiological aging. Surveys confirm that patients would like their doctor to question them about their sexual functioning. This appears to be all the more desirable in that erectile problems are often due to endothelial dysfunction with may also affect other vessels such as coronary arteries. The diagnosis of these disorders could help to identify and correct the risks factors responsible for both types of this disease.     

The psychological and social effects of myocardial infarction on wives.

Eighty-two wives of men suffering a first myocardial infarction were interviewed while their husbands were in hospital, and again two months and a year after they went home. The wives had substantial and persistent psychological symptoms, and the husbands'' illness had continuing effects on their work, leisure and social activities, and family life and marriage, their psychosocial disability being comparable to that of the patients. Measures of psychosocial adjustment before the illness and the quality of the marriage and of family life were good predictors of outcome for the wives. The women had a major role in the patients'' readjustment during convalescence, and their attitudes and behaviour as well as the general quality of family life were important determinants of the rate and extent of the patients'' recovery. The wives of patients with myocardial infarction should have more practical help and advice during the hospital period, and the whole family should be given advice and help throughout the convalescence.     

Medicine and the Gulag.

The nature of the medical treatment of prisoners in the Gulag has emerged from accounts published by survivors. Over a period of 70 years some doctors entrusted with the medical care of prisoners failed to discharge their ethical duties, contributing to the prisoners'' neglect and suffering. The medical profession must carefully examine what occurred and properly assign responsibility for ethical as well as unethical medical acts. Understanding the history of these ominous events will alert doctors worldwide to the importance of medical autonomy in the support of imprisoned patients.     

Youth outcomes of psychological distress of Albanian adolescents in Albania

Albania is a country of transition facing many challenges including the development and support of health and social services that will enhance the well-being of its population. Albania has one of the youngest populations in Europe and the young people face difficulties with lack of recognition and care of mental disorders, as well as violent and antisocial behaviours that may reflect violent environmental conditions and nutritional deficiencies leading to developmental problems. In this paper the behaviour of some Albanian adolescents was examined; it is probable that they are more at risk from psychological stress. For many of them the need to make a new start at a point in life at which all resources should be committed to distancing the world of childhood and starting to create a position, means a process of inevitable recession.     

Die „Pathologische Realangst“ am Beispiel kardiovaskulärer Erkrankungen

Fears of patients suffering from chronic or life threatening diseases are frequently observed as adjustment reactions. Left untreated they may lead to an unfavorable course of the disease and a generally poor outcome. Difficulties in diagnostic standard procedures arise from the question whether the anxiety symptoms are an expression of physical illness, or an independent anxiety disorder of clinical significance. The concept of Pathological Realistic Fear derives from these considerations, and describes the fear of a real threat, particularly in patients with chronic disease, especially those suffering from life threatening illnesses. Distorted perceptions of the primary disease, caused by subjective ideas about disease mechanisms often lead to misguided assumptions and frequently result in a distorted interpretation of the physical symptoms of illness. As a result a fearful attention focus evolves, which triggers the ultimate development of a Pathological Realistic Fear as. The following article is a first attempt to elaborate on the concept of Pathological Realistic Fear as a pathology and to describe its clinical relevance. The concept contributes to a more precise diagnosis of anxiety and could stimulate an interdisciplinary patient care.     

Between Difference and Belonging: Configuring Self and Others in Inpatient Treatment for Eating Disorders

Dedicated inpatient care for eating disorders has profound impact on patients'' embodied practices and lived realities. Analyses of inpatients'' accounts have shown that participants endorse complex and conflicting attitudes toward their experiences in eating disorders wards, yet the apparent ambivalence that characterizes inpatient experiences has not been subject to critical examination. This paper examines the narrated experiences of 13 participants (12 women and one man; age 18–38 years at first interview) with past or present anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified, who had been hospitalized in an inpatient eating disorders ward for adults in central Israel. The interviews, which took place in 2005–2006, and again in 2011, were part of a larger longitudinal study exploring the subjective experiences of eating disorders and recovery among Israeli adults. Employing qualitative analysis, this study finds that the participants'' accounts were concerned with dynamics of difference and belonging, as they played out in various aspects of inpatient care, including diagnosis, treatment, relationships with fellow patients and staff, and everyday life in hospital. Notably, participants simultaneously defined themselves as connected to, but also distinct from, the eating disordered others who formed their reference group at the ward. Through negotiating a protectively ambivalent positioning, participants recognized their eating disordered identities and connected with others on the ward, while also asserting their non-disordered individuality and distancing themselves from the potential dangers posed by ‘excessive’ belonging. The paper suggests that this ambivalent positioning can usefully be understood through the anthropological concept of liminality: being both a part of and apart from one''s community.     

Relationship effects in psychological explanations of nonhuman behavior

Abstract

Research suggests that close relationships with animals encourage psychological explanations of their behavior. To determine the causal effect of ownership on psychological explanations, we conducted experiments in which we manipulated participants' ownership of a target imagined dog (experiment 1), animated object (experiment 2), and real pet fish (experiment 3). Adapting scales used in previous research, we obtained ratings of how intentional the target's behavior was, the target's reasons (rather than causes), and references to complex human-like emotions, motives or characteristics. In experiment 1, 26 volunteers and staff at an animal shelter imagined scenarios involving their dog, a neighbor's dog, their friend, or a visitor. Participants' intentionality ratings and the target's reasons were similar for a friend, a visitor, and their dog. In experiment 2, 36 participants watched a film of three moving objects. Half of the participants were told the small triangle was theirs. In the ownership condition, participants vilified the “aggressive” big triangle more, gave more causal history for reasons, and gave more social, humanlike narratives. In experiment 3, 82 university students and staff were given a Betta fish either to own or to care for temporarily, and they were to report daily or weekly on the fish's behavior. Ownership and reporting frequency did not directly influence outcomes. Rather, ownership predicted commitment to, and affection for, the fish. Affection, in turn, significantly predicted participants' psychological explanations including how smart the fish was, how much the fish liked the participant, how similar the fish was to the participant, and psychological explanations of social behavior such as turning toward a visitor. Automated analyses of participants' language showed that affection also predicted their use of social psychological and emotion words to describe the fish. We discuss alternative processes whereby social relationships give rise to psychological explanations of behavior.     

Psychological and social problems in HIV infection: interviews with general practitioners in London.

OBJECTIVE--To assess current practice and opinions of general practitioners in London about managing psychological and social problems relating to HIV infection. DESIGN--A stratified random sample of general practitioners, including those with a range of experience of people with HIV infection, were interviewed by medically trained interviewers. SETTING--Doctor''s surgeries. PARTICIPANTS--270 General practitioners working within the area covered by London postcodes. RESULTS--Two thirds of doctors had treated at least one patient with HIV infection and described their work with these patients. General practitioners were counselling and educating many of their patients about AIDS and associated risk behaviours and were aware of the need for careful attention to confidentiality. Doctors with no experience of patients with HIV infection were often older, in singlehanded practice, less inclined to deal with drug abusers or to counsel their patients on risk behaviours, and more in favour of insurance companies'' policies towards people with HIV infection. CONCLUSIONS--General practitioners in London are quickly becoming involved in the care of patients with HIV infection and their relatives and friends. Many are counselling patients and testing for antibodies themselves and regard this as an integral part of their work. A considerable workload in primary care comprised patients who obsessively fear contracting HIV infection.     

MDs must help eliminate 911 calls after "expected" home deaths,medical examiner advises

More and more Canadians are choosing to die at home. Unfortunately, family members may not know how to respond when death does occur. Some call 911 seeking advice, and soon find police, ambulance and fire services arriving at their door. If calls are made before terminal patients die, they may even be rushed to hospital for emergency care. The wasted energy wastes money and creates additional stress. Dr. John Butt, Nova Scotia''s chief medical examiner, says physicians must help educate the public and emergency services about how to respond after an expected death occurs at home.     

Coevolution of female fidelity and male help in populations with alternative reproductive tactics

In socially monogamous species, pair-bonded males often continue to provide care to all offspring in their nests despite some degree of paternity loss due to female extra-pair copulation. Previous theoretical models suggested that females can use their within-pair offspring as ‘hostages'' to blackmail their social mates, so that they continue to provide care to the brood at low levels of cuckoldry. These models, however, rely on the assumption of sufficiently accurate male detection of cuckoldry and the reduction of parental effort in case of suspicion. Therefore, they cannot explain the abundant cases where cuckolded males continue to provide extensive care to the brood. Here we use an analytical population genetics model and an individual-based simulation model to explore the coevolution of female fidelity and male help in populations with two genetically determined alternative reproductive tactics (ARTs): sneakers that achieve paternity solely via extra-pair copulations and bourgeois that form a mating pair and spend some efforts in brood care. We show that when the efficiency of mate guarding is intermediate, the bourgeois males can evolve to ‘specialize'' in providing care by spending more than 90% of time in helping their females while guarding them as much as possible, despite frequent cuckoldry by the sneakers. We also show that when sneakers have tactic-specific adaptations and thus are more competitive than the bourgeois in gaining extra-pair fertilizations, the frequency of sneakers and the degrees of female fidelity and male help can fluctuate in evolutionary cycles. Our theoretical predictions highlight the need for further empirical tests in species with ARTs.     

Psychiatric illness in inpatients with neurological disorders: patients' views on discussion of emotional problems with neurologists.

The prevalence of psychiatric morbidity in inpatients with neurological disorders and the extent to which it is detected by neurologists were measured by using a two stage model of psychiatric assessment and from information recorded in the patients'' medical notes. The prevalence of psychiatric morbidity was estimated as 39%, of which 72% was unrecognised by the neurologists. Only a minority of patients with an uncertain physical diagnosis had a psychiatric illness, showing the error in assuming that a patient''s physical symptoms arise from a psychological disturbance if an organic aetiology cannot be determined. When the patients were interviewed on their discharge from hospital they were divided on whether they had wished to discuss their mood with neurologists while they were in hospital. The reasons that they gave suggested that interactions between patients and doctors and the lack of ward facilities for private consultations with doctors are important determinants of hidden psychiatric morbidity in medical inpatients.     

Care of dying patients in hospital.

OBJECTIVE--To study the process of care of dying patients in general hospitals. DESIGN--Non-participant observer (MM) carried out regular periods of continuous comprehensive observation in wards where there were dying patients, recording the quantity and quality of care given. Observations were made in 1983. SETTING--13 wards (six surgical, six medical, and one specialist unit) in four large teaching hospitals (bed capacity 504-796) in west of Scotland. SUBJECTS--50 dying patients (29 female, 21 male) with mean age of 66 (range 40-89); 29 were dying from cancer and 21 from non-malignant disease. RESULTS--Final period of hospitalisation ranged from 6 hours to 24 weeks. More than half of all patients retained consciousness until shortly before death. Basic interventions to maintain patients'' comfort were often not provided: oral hygiene was often poor, thirst remained unquenched, and little assistance was given to encourage eating. Contact between nurses and the dying patients was minimal; distancing and isolation of patients by most medical and nursing staff were evident; this isolation increased as death approached. CONCLUSIONS--Care of many of the dying patients observed in these hospitals was poor. We need to identify and implement practical steps to facilitate high quality care of the dying. Much can be learned from the hospice movement, but such knowledge and skills must be replicated in all settings.     

Evaluación del sufrimiento en la demencia avanzada

Introduction

At the end stage of life of dementia, medical comorbidities are associated with a high degree of patient suffering. The aim of this study was to assess the relationship between the lack of symptoms of discomfort and the level of patient suffering. The relationship with psychological distress and caregiver burden was also clarified.

Material and methods

This study included patients with advanced dementia according to the criteria of the Hospice Enrolment Criteria for End-stage Dementia patients. Patient suffering was assessed with Mini-Suffering State Examination (MSSE). The caregivers were scored by Zarit caregiver burden scale (ZR), and the General Health Questionnaire of Goldberg (GHQ-28). Central tendency and correlation tests were used in the statistical analysis.

Results

The study recorded data from 71 patients. In the comorbidity of medical symptoms associated with advanced dementia, pneumonia (Spearman's rho: −0.29; P=.01), and malnutrition (Spearman's rho: −0.25; P=.03), showed a significant association with the total scale score of MSSE. There were no significant correlations between patient suffering and caregiver psychological distress (r: 0.11; P=.37), or caregiver burden (r: 0.13; P=.32).

Conclusions

The identification of suffering in patients with advanced dementia is recognised by specific symptoms, such as pneumonia and malnutrition. The caregiver’ psychological distress of the caregiver was shown to be unrelated to patient suffering as measured by MSSE.     

Use of APACHE II classification to evaluate outcome of patients receiving hemodialysis in an intensive care unit.

We retrospectively reviewed the medical records of all patients who were admitted to the medical and surgical intensive care units of a university center (N = 100) and its affiliated veterans'' hospital (N = 46) between 1982 and 1986 to receive dialysis. The APACHE II severity-of-disease classification was used to identify the cases in which the prognosis was so poor that no long-term benefit would accrue from hemodialysis treatment. A "risk of death" was calculated for each patient. At a risk of death of 70% or greater, the system correctly predicted the demise of patients with 100% specificity regardless of what interventions were carried out. Sensitivity and predicted negative value were low in all cases, however, indicating a poor predictability of those who will survive. Withholding the average of 6 dialysis treatments that this group of patients received would probably have reduced patient suffering during a lingering terminal illness and led to a savings of about $4,500 per patient.