Hastening death in end-of-life care: A survey of doctors

This is the post-print version of the final paper published in Social Science & Medicine. The published article is available from the link below. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. Copyright @ 2009 Elsevier B.V.The application of medical technology to prolong life at the expense of quality of life is widely debated in end-of-life care. A national survey of 3733 UK doctors reporting on the care of 2923 people who had died under their care is reported here. Results show that there was no time to make an 'end-of-life decision' (deciding to provide, withdraw or withhold treatment) for 8.5% of those reporting deaths. A further 55.2% reported decisions which they estimated would not hasten death and 28.9% reported decisions they had expected to hasten death. A further 7.4% reported deaths where they had to some degree intended to hasten death. Where patients or someone else had made a request for a hastened death, doctors were more likely to report expecting or at least partly intending to hasten death. Doctors usually made these decisions in consultation with colleagues, relatives and, where feasible, with patients. Intensive care specialists were particularly likely to report a degree of intention to hasten the end of life and to have treated patients lacking the capacity to discuss these decisions. Palliative medicine specialists were the least likely to report decisions they expected or at least partly intended to end life, in spite of reporting a high incidence of requests from their patients for a hastened death. Doctors with strong religious beliefs or who opposed the legalisation of assisted dying were unlikely to report such decisions. Elderly women and those with dementia are groups considered vulnerable in societies where a permissive approach is taken to hastening death in end-of-life care, but doctors describing these deaths were no more likely to report decisions which they expected or at least partly intended to end life. The survey suggests that concerns about the sanctity of life, as well as estimates of the quality of life, enter clinical decision-making. © 2009 Elsevier Ltd. All rights reserved.National Council for Palliative Care, Age Concern, the Motor Neurone Disease Association, the Multiple Sclerosis Society, Help the Hospices, Macmillan Cancer Support and Sue Ryder Care

The blue one takes a battering why do young adults with asthma overuse bronchodilator inhalers? A qualitative study

Objective: Overuse of short-acting bronchodilators is internationally recognised as a marker of poor asthma control, high healthcare use and increased risk of asthma death. Young adults with asthma commonly overuse short-acting bronchodilators. We sought to determine the reasons for overuse of bronchodilator inhalers in a sample of young adults with asthma. Design: Qualitative study using a purposive extreme case sample. Setting: A large urban UK general practice. Participants: Twenty-one adults with moderate asthma, aged 20-32 years. Twelve were high users of short-acting bronchodilators, nine were low users. Results: Asthma had a major impact on respondents' lives, disrupting their childhood, family life and career opportunities. High users of short-acting bronchodilators had adapted poorly to having asthma and expressed anger at the restrictions they experienced. Overuse made sense to them: shortacting bronchodilators were a rapid, effective, cheap 'quick-fix' for asthma symptoms. High users had poorer control of asthma and held explanatory models of asthma which emphasised short-term relief via bronchodilation over prevention. Both high and low users held strong views about having to pay for asthma medication, with costs cited as a reason for not purchasing anti-inflammatory inhalers. Conclusions: Young adults who were high users of short-acting bronchodilators had adapted poorly to having asthma and had poor asthma control. They gave coherent reasons for overuse. Strategies that might address high bronchodilator use in young adults include improving education to help young people accept and adapt to their illness, reducing stigmatisation and providing free asthma medication to encourage the use of anti-inflammatory inhalers

Recruiting ethnic minority participants to a clinical trial: a qualitative study

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non-commercial and is otherwise in compliance with the license.To compare the motives and experiences of different ethnic groups participating in a randomised double blind placebo-controlled trial of montelukast in preschool wheeze, and to assess parents' or guardians' understanding of trial procedures and their implications, including the collection of genetic material.National Institute of Health Research Efficacy and Mechanism Evaluation Stream(grant number: 08-43-03)

Anticipatory prescribing for end of life care in the community: a survey of community nurses in England

Anticipatory prescribing is increasingly common in the UK, yet little is known about nurses’ roles in the process. As part of a wider study to explore this, a postal survey of 575 community/district, nursing home and palliative care nurses was undertaken in two regions. Nurses report anticipatory prescriptions to be very common, and once in place they are normally used. Findings show that nurses report taking prominent roles throughout the anticipatory prescribing process and principal responsibility for administering and monitoring the medications. Many respondents recount good working relationships with GPs. However, some nurses report being challenged by: GPs who are reluctant to prescribe the medications, incorrectly written prescriptions, and difficulties in gaining access to the necessary medications. Qualitative comments indicated that being a nurse prescriber could enhance confidence to use anticipatory prescriptions. Importantly, nurses responding to the survey perceived that anticipatory prescriptions facilitated provision of good end of life care

News media coverage of euthanasia: A content analysis of Dutch national newspapers

© 2013 Rietjens et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background: The Netherlands is one of the few countries where euthanasia is legal under strict conditions. This study investigates whether Dutch newspaper articles use the term ‘euthanasia’ according to the legal definition and determines what arguments for and against euthanasia they contain. Methods: We did an electronic search of seven Dutch national newspapers between January 2009 and May 2010 and conducted a content analysis. Results: Of the 284 articles containing the term ‘euthanasia’, 24% referred to practices outside the scope of the law, mostly relating to the forgoing of life-prolonging treatments and assistance in suicide by others than physicians. Of the articles with euthanasia as the main topic, 36% described euthanasia in the context of a terminally ill patient, 24% for older persons, 16% for persons with dementia, and 9% for persons with a psychiatric disorder. The most frequent arguments for euthanasia included the importance of self-determination and the fact that euthanasia contributes to a good death. The most frequent arguments opposing euthanasia were that suffering should instead be alleviated by better care, that providing euthanasia can be disturbing, and that society should protect the vulnerable. Conclusions: Of the newspaper articles, 24% uses the term ‘euthanasia’ for practices that are outside the scope of the euthanasia law. Typically, the more unusual cases are discussed. This might lead to misunderstandings between citizens and physicians. Despite the Dutch legalisation of euthanasia, the debate about its acceptability and boundaries is ongoing and both sides of the debate are clearly represented

Derived Demand for Food Nutrients as Welfare Indicator of Biofortified Crops: High-Iron Rice in the Philippines

The study estimates potential consumer gains from the introduction of High-Iron Rice in the Philippines. By deriving the demand for dietary iron from a national survey on household food consumption and expenditure, we project consumer welfare implications under both non-market and market analytical frameworks.Crop Production/Industries,

Men’s strategies for preserving emotional well-being in advanced prostate cancer: an interpretative phenomenological analysis

Objective This study explores men with advanced prostate cancers’ own practices for promoting and maintaining emotional well-being using Interpretative Phenomenological Analysis. Design Five men with advanced prostate cancer participated in face-to-face, semi-structured, in-depth interviews. Results Within rich narratives of lost and regained well-being, two super-ordinate themes emerged – ‘living with an imminent and uncertain death’ and ‘holding on to life.’ Well-being was threatened by reduced sense of the future, isolation and uncertainty. Yet, the men pursued well-being by managing their emotions, striving for the future whilst enjoying life in the present, taking care of their families and renegotiating purpose. Running through participant’s accounts was a preference for taking action and problem-solving. Sense of purpose, social connectedness and life-engagement were revealed as concepts central to improving well-being, indicating areas which practitioners could explore with men to help them re-establish personal goals and life-purpose. Conclusions The findings also add weight to the evidence base for the potential value of psychological interventions such as cognitive behaviour therapy and mindfulness in men with prostate cancer

Spitzer View of Massive Star Formation in the Tidally Stripped Magellanic Bridge

The Magellanic Bridge is the nearest low-metallicity, tidally stripped environment, offering a unique high-resolution view of physical conditions in merging and forming galaxies. In this paper we present analysis of candidate massive young stellar objects (YSOs), i.e., {\it in situ, current} massive star formation (MSF) in the Bridge using {\it Spitzer} mid-IR and complementary optical and near-IR photometry. While we definitely find YSOs in the Bridge, the most massive are $\sim10 M_\odot$, $\ll45 M_\odot$ found in the Large Magellanic Cloud (LMC). The intensity of MSF in the Bridge also appears decreasing, as the most massive YSOs are less massive than those formed in the past. To investigate environmental effects on MSF, we have compared properties of massive YSOs in the Bridge to those in the LMC. First, YSOs in the Bridge are apparently less embedded than in the LMC: 81% of Bridge YSOs show optical counterparts, compared to only 56% of LMC sources with the same range of mass, circumstellar dust mass, and line-of-sight extinction. Circumstellar envelopes are evidently more porous or clumpy in the Bridge's low-metallicity environment. Second, we have used whole samples of YSOs in the LMC and the Bridge to estimate the probability of finding YSOs at a given \hi\ column density, N(HI). We found that the LMC has $\sim3\times$ higher probability than the Bridge for N(HI) $>10\times10^{20}$ cm$^{-2}$, but the trend reverses at lower N(HI). Investigating whether this lower efficiency relative to HI is due to less efficient molecular cloud formation, or less efficient cloud collapse, or both, will require sensitive molecular gas observations.Comment: 41 pages, 20 figures, 6 tables; accepted for publication in ApJ; several figures are in low resolution due to the size limit here and a high resolution version can be downloaded via http://www.astro.virginia.edu/~cc5ye/ms_bridge20140215.pd

The transition to ‘patienthood’, the contribution of the nursing assistant: a grounded theory study

The face of nursing is changing, as health-care organizations are looking to new assistant roles to support the registered nurse and potentially provide a source for apprenticeship toward registration. These developments are within a context of an existing assistant staff group, delivering much of the bedside care. Few studies have explored the dyadic relationship between nursing assistant and patient, despite the potential for their interactions to contribute to the patient experience. This study aimed to gain an understanding of patients’ perceptions of the nursing assistant role using constructivist grounded theory. Constant comparison guided data collection and analysis, and 4 core categories emerged: expectation, observation, meaningful connections, and adaptation. Within these core categories, we suggest the assistant plays a part in how participants adapt from the known self to a self of patienthood and the overall patient experience. We conclude that there is a necessity to understand more fully the dyadic relationship between patients and nursing assistants