"The communication and support from the health professional is incredibly important": A qualitative study exploring the processes and practices that support parental decision-making about postmortem examination

Background Consent rates for postmortem (PM) examination in the perinatal and paediatric setting have dropped significantly in the United Kingdom, the United States, and the Western Europe. We explored the factors that act as facilitators or barriers to consent and identified processes and practices that support parental decision‐making. Methods A qualitative study conducted with bereaved parents, parent advocates, and health care professionals in the United Kingdom. Analysis was conducted on 439 free‐tect comments within a cross‐sectional survey, interviews with a subset of 20 survey respondents and 25 health professionals, and a focus group with five parent advocates. Results Three broad parental decision‐making groups were identified: 1, “Not open to postmortem examination”; 2, “Consent regardless of concerns”; and 3, “Initially undecided.” Decisional drivers that were particularly important for this “undecided” group were “the initial approach,” “adjustment and deliberation,” “detailed discussion about the procedure,” and “formal consent.” The way in which these were managed by health care staff significantly impacted whether those parents' consented to PM, particularly for those who are ambivalent about the procedure. Conclusions We propose a set of recommendations to improve the way PM counselling and consent is managed. Adopting such measures is likely to lead to improved family experience and more consistent and high‐quality discussion regarding PM

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis

OBJECTIVES: Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. DESIGN: Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). SETTING: One hundred-fifty-three ICUs in 13 countries. PATIENTS: Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007). CONCLUSIONS: Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions

The aesthetic dimension of the psychoanalytic process

This paper brings out one perspective on the experiences of the analytic couple, and transposes it into a general perspective on the analytic process: its aesthetic dimension. It is a combined epistemological and emotional perspective that is open to both participants. By an intense preoccupation with and distance to the object, the subject tries to reconcile the object's exterior form with its imagined content. This perspective offers itself most advantageously in highly emotional situations, in which analyst and analysand feel the pain of being outsiders to each other. They are thrown back on making guesses about the other's intimations. It can bring them into indifference or despair—or it can bring out an aesthetic experience. A situation, until now unbearable, suddenly reveals its surprising potential. The theoretical discussion will be illustrated by a discussion taken from the Talmud and by two clinical examples: one from the psychoanalysis with an infant and her mother, the other with a latency girl. The paper also accounts for the aesthetic as a philosophical and psychoanalytic concept. Some recurrent topics, especially those of form and content, reflect the aesthetic experience as our continuous struggle to reconcile outward form with interior content. This struggle will be formulated as a continuation of the infantile aesthetic conflict, following Meitzer

On approaching schizophrenia via Wittgenstein

Louis Sass disputes that schizophrenia can be understood successfully according to the hitherto dominant models--for much of what schizophrenics say and do is neither regressive (as psychoanalysis claims) nor just faulty reasoning (as "cognitivists" claim). Sass argues instead that schizophrenics frequently exhibit hyper-rationality, much as philosophers do. He holds that schizophrenic language can after all be interpreted--if we hear it as Wittgenstein hears solipsistic language. I counter first that broadly Winchian considerations undermine both the hermeneutic conception of interpreting other humans in general and Sass's hope of interpreting schizophrenics in particular. I then go on to argue that even if these Winchian considerations are not accepted, Sass in any case doesn't take sufficiently seriously Wittgenstein's use of nonsense as a term of criticism. Solipsism is not something we can understand so as to be able to understand analogically the schizophrenic's "world"--for there is no such thing as understanding it. Solipsism is nonsense, is nothing--there is no "world" there, in solipsists (as I show by reference to Cora Diamond's reading of Wittgenstein). Nor in any actually analogous cases of schizophrenia. Their "alienness" is the alienness of nothingness; roughly, of the fantasy of "logically alien thought"