Cancer Caregivers’ Prognostic and End-of-Life Communication Needs and Experiences and their Impact

ContextFamily caregivers of patients with advanced cancer are integrally involved in communications regarding prognosis and end-of-life (EOL) planning and care. Yet little research has examined caregivers’ communication experiences or the impact of these experiences on patients and caregivers at EOL.ObjectivesInvestigate cancer caregivers’ communication experiences and potential impact on patient and caregiver outcomes.MethodsSemistructured interviews with bereaved family cancer caregivers (N=19) about their communication needs and experiences as their loved one approached EOL and died. Audiotaped interviews were transcribed and thematically analyzed for communication-related themes.ResultsCaregivers described fulfilling many important communication roles including information gathering and sharing, advocating, and facilitating—often coordinating communication with multiple partners (e.g., patient, family, oncology team, hospital team). Caregivers reported that, among the many topics they communicated about, prognosis and EOL were the most consequential and challenging. These challenges arose for several reasons including caregivers’ and patients' discordant communication needs, limited opportunity for caregivers to satisfy their personal communication needs, uncertainty regarding their communication needs and responsibilities, and feeling unacknowledged by the care team. These challenges negatively impacted caregivers’ abilities to satisfy their patient-related communication responsibilities, which shaped many outcomes including end-of-life decisions, care satisfaction, and bereavement.ConclusionCaregivers often facilitate essential communication for patients with advanced cancers yet face challenges successfully fulfilling their own and patients’ communication needs, particularly surrounding prognostic and end-of-life conversations. Future research and interventions should explore strategies to help caregivers navigate uncertainty, create space to ask sensitive questions, and facilitate patient-caregiver discussions about differing informational needs.     

Relationship between abnormal blood rheology and development and recovery of hyperte nsion and cerebral infarction

Background：Increasedbloodpressureinhypertensionisrelatedtovesselsresistance，cardiacoutput，aswellasbloodviscosity．Strokeiscommonfollowinghypertension．Anumberofstudiesreportedthatabnormalbloodrheologywasfrequentinstrokesuggestingcorrelationofbloodrheologywithonset，development，recoveryofhyperten－sion．Hypertensionisthemostoneofindependentriskfactorsofstroke．Inthecurrentpaper，weinvestigatedpathogenesisanddevel－opmentofhypertensionandcerebralinfarctiontoprovideprinciplefoundationforearl…     

Of bedpans and ivory towers? Nurse academics' identities and the sacred and profane: a Bernsteinian analysis and discussion paper

Aim

In light of debates arising from recent developments in Irish nursing education, this paper analyses tensions in the positioning of nursing in academia in terms of notions of the sacred and profane, and the symbolic boundaries between them, and discusses the implications of this analysis for nurse academics’ identities.

Background

The entry of nursing education to the higher education sector has occurred against a discursive backcloth of opposition which constructs nursing work as either sacred, and under threat from the academy, or profane, and unworthy of a place in it.

Method

Conceptual resources derived from the work of Basil Bernstein are deployed to analyse the forces driving the loom weaving this discursive backcloth. These forces are conceptualised as deriving from deep-seated fears and anxieties sparked by changes in the strength of symbolically important boundaries between constructions of the sacred and profane in the fields of nursing and higher education. These constructions are explicated.

Findings

Bernstein regards secure academic identities as inhering in strong boundaries between disciplines and between the fields of education and work. The transfer of nursing education from health to the higher education sector and nurse academics’ attempts to articulate a nursing-discipline specific knowledge base can be understood in these terms. This analysis challenges nurse academics who promote disciplinary eclecticism and those who legitimate academic nursing principally in terms of the acquisition of generic and transferable lifelong learning skills.

Conclusions

To counter a discourse that constructs them as a profane presence in higher education, some nurse academics have articulated a discourse of legitimation that constructs (academic) nursing as a sacred endeavour. Whether this can provide the grounds of their legitimacy and the basis of their careers as distinctively nursing academics is unclear at this stage of nursing's development as an academic discipline.     

Revisiting antithrombin in health and disease,congenital deficiencies and genetic variants,and laboratory studies on α and β forms

Antithrombin [AT] is the main inhibitor for activated plasma coagulation serine esterases, inhibiting thrombin, Factors Xa and IXa, but also Factors XIIa, XIa, VIIa, kallicrein, and plasmin. Its activity is highly enhanced by heparin, through binding to the pentasaccharide sequences, for inhibition of all coagulation proteases, except thrombin, which inhibition requires its additional binding to the heparin polysaccharide chain. However, AT is the major inhibitor of thrombin in the blood circulation. Congenital or acquired deficiencies of AT expose affected patients to an increased risk of developing unprovoked and recurrent thrombo-embolic diseases. Antithrombin can be measured with various laboratory techniques, by either immunological or functional methods. Earlier, a radial immunodiffusion immunoassay allowed measurement of the protein antigenic content. Functional assays are mainly designed with Anti-Thrombin or Anti-Factor Xa chromogenic methods and are useful for detecting genetic molecular mutations with decreased inhibitory activity and contributed to study the conformational changes of antithrombin and its variants, which potentially regulate the activity of this serine protease inhibitor. These assays are not equivalent in terms of diagnosing protein abnormalities, associated with increased thrombotic incidence, and they have variable performance for reflecting impaired antithrombin binding capacity for heparin, reduced progressive inhibition of serine proteases, or accelerated switch rates to the latent and less active forms. A small proportion of AT (<10%) is present in blood in the β-form, with a lower oligosaccharide content, a lower Molecular Weight, a higher binding rate to endothelial glycosaminoglycans, and a higher anticoagulant activity, hence requiring specific laboratory methods for its measurement. The β-AT form is then of critical importance for controlling blood activation by tissue injury and preventing development of thrombo-embolic diseases. This article reviews the performance characteristics of the currently available assays, and their usefulness for monitoring the use of AT concentrates in intensive care units, disseminated intravascular coagulation or severe infections, to restore the anticoagulant protective effect of heparin by supplementing the requested AT concentration. The issues of automation, harmonization and standardization are also revisited and discussed.     

Chemosensitization and chemoprotection

Cancer gene therapy over the past several yearshas involved the introduction of genes intohematopoietic cells for: (1) protecting the normalcells from the side effects of chemotherapy; (2)introduction of genes into the neoplastic cells for the     

Manipulators and integrated OR systems – requirements and solutions

Videoendoscopic (laparoscopic and thoracoscopic) surgery is characterized by challenges for the whole OR team. Additional equipment must be monitored and managed by the surgeon and the nurses in a rather dark environment. The surgeon is using long‐shafted instruments that reduce the degrees of freedom of the possible instrument movements, thus limiting the dexterity for the surgeon. The use of trocars results in a pivot point effect when moving the instruments, which needs some experience on the surgeon's side to move the instruments adequately and into the right direction. Finally the hand‐eye‐coordination is dependent on the camera position relative to the instruments and a stable image of the situs shown at the monitor. To overcome these challenges, several new technologies have been developed and introduced into the OR by the industry, also using robotics to help the surgeon perform the procedure. Integrated OR systems enable the OR team to control virtually all devices in the OR from a centralized panel; scope‐positioning systems provide the surgeon with a stable image under his own control and manipulators for the instruments allow fine movements with additional degrees of freedom. This article gives a short overview of currently available technologies, describing the design requirements and the functionality of the different systems     

Patient blood management and blood conservation – Complimentary concepts and solutions for blood establishments and clinical services in South Africa and beyond

Blood transfusions come with risks and high costs, and should be utilized only when clinically indicated. Decisions to transfuse are however not always well informed, and lack of clinician knowledge and education on good clinical transfusion practices contribute to the inappropriate use of blood. Low and middle-income countries in particular take much strain in their efforts to address blood safety challenges, demand-supply imbalances, high blood costs as well as high disease burdens, all of which impact blood usage and blood collections. Patient blood management (PBM), which is a patient-focused approach aimed at improving patient outcomes by preemptively diagnosing and correcting anaemia and limiting blood loss by cell salvage, coagulation optimization and other measures, has become a major approach to addressing many of the challenges mentioned. The associated decrease in the use of blood and blood products may be perceived as being in competition with blood conservation measures, which is the more traditional, but primarily product-focused approach. In this article, we hope to convey the message that PBM and blood conservation should not be seen as competing concepts, but rather complimentary strategies with the common goal of improving patient care. This offers opportunity to improve the culture of transfusion practices with relief to blood establishments and clinical services, not only in South Africa and LMICs, but everywhere. With the COVID-19 pandemic impacting blood supplies worldwide, this is an ideal time to call for educational interventions and awareness as an active strategy to improve transfusion practices, immediately and beyond.     

Understanding treatment adherence in affective disorders: a qualitative study

The objective of this study was to explore the perspective of depressed patients, their family and mental health professionals from their community mental health centre (CMHC) on factors related to treatment adherence. We conducted eight separate focus groups involving patients, their families and their therapists from three CMHCs. A total of 52 persons were involved. The groups explored patients' and family's explanatory model of depression, perceptions about the course of the disease, the role of medication and other treatments, the main causes of non-adherence, and interventions which would help increase it. Patients and families had a complex cognitive model of depression, which combined intrinsic vulnerability, psychological suffering during childhood and adolescence, and adverse life events. Drugs as well as other treatments were considered helpful, more so by patients than by family members. Denial of the disease and need to test its continuing presence were the main causes of non-adherence for patients, while adverse reactions did not play a relevant role. Mental health professionals tended to underestimate non-adherence in depressed patients, and did not question their patients about medication adherence. Family members needed more information on depression, on how to manage their relatives, as well as psychological and social support for themselves. The study allowed for the identification of a number of specific interventions aimed at facilitating treatment adherence, such as providing more information to patients and families, and training doctors and nurses in effective prevention and management of non-adherence.     

Effect of mental health nurses' beliefs and knowledge of medication on their use of strategies to improve medication adherence

Despite the proven efficiency of medication for mental illness, research indicates low patient adherence to medication. Nonetheless, only few studies have directly examined the relationship between nurse beliefs and knowledge, and their use of strategies to improve patient adherence to psychiatric medication. Therefore, the aim of the present study was to clarify nurses' views, beliefs about, and knowledge of psychiatric medication affect their inclination to implement various strategies to improve patient adherence. One hundred nurses working at an Israeli psychiatric hospital participated in the study. Self‐completed questionnaires were distributed. The research findings showed that nurses' levels of knowledge of psychiatric medication were moderate, but their beliefs of taking psychiatric medication were positive. The findings also showed that the higher the nurses' age and seniority, as well as their positive beliefs about taking medication, the higher their probability of implementing strategies to improve patient adherence to medication. Additionally, there was a positive correlation between positive beliefs about the nursing staff on taking medication and the staff's utilization of strategies to improve patient adherence to medication. The current study shows that nurses' traits and beliefs affect their use of strategies promoting mental health patient adherence to medication and the enhancement of these strategies.     

Motivational interviewing: addressing ambivalence to improve medication adherence in patients with bipolar disorder

Poor adherence to psychotropic medication is a significant issue for patients with bipolar disorder. The effectiveness of medication treatment is limited by high rates of medication non-adherence among this population. Motivational Interviewing is an evidence-based intervention that has been efficacious in promoting behavioral health regimens and treatment recommendations, including medication adherence. By using a patient-centered approach, Motivational Interviewing has been shown to enhance patients' insight and attitudes toward treatment. This article aims to describe to mental health nurses how to use Motivational Interviewing with bipolar patients to address ambivalence and improve adherence to psychotropic medication regimens.     

Motivational Interviewing: Addressing Ambivalence to Improve Medication Adherence in Patients with Bipolar Disorder

Poor adherence to psychotropic medication is a significant issue for patients with bipolar disorder. The effectiveness of medication treatment is limited by high rates of medication non-adherence among this population. Motivational Interviewing is an evidence-based intervention that has been efficacious in promoting behavioral health regimens and treatment recommendations, including medication adherence. By using a patient-centered approach, Motivational Interviewing has been shown to enhance patients’ insight and attitudes toward treatment. This article aims to describe to mental health nurses how to use Motivational Interviewing with bipolar patients to address ambivalence and improve adherence to psychotropic medication regimens.     

Enhancing medication adherence in people with schizophrenia: An international programme of research

This paper describes the development of an adherence therapy intervention in schizophrenia and synthesizes the results to date of a collaborative international programme of research. Sticking to treatment is essential to control symptoms and prevent relapse, but as with other long‐term conditions, medication adherence is poor. Adherence therapy seeks to facilitate a process of shared decision making, where both parties work towards agreed goals. Central is the theory that when patients make shared choices with a professional they are more likely to stick with them because they are personally owned and meaningful. The results of adherence therapy trials that seek to test this theory are mixed. Outcomes of trials might have been be affected by the point in the patient's illness cycle when therapy was delivered and by sampling bias. Authors of trials of medication management and alliance training packages that aim to equip mental health workers with adherence therapy competencies show considerable promise in improving clinical outcomes. Helping patients manage their medication is central to the work of mental health nurses. We argue that the potential benefits to patients are such that there is sufficient evidence to recommend that all mental health nurses receive medication management training.     

The role of the inpatient mental health nurse in facilitating patient adherence to medication regimes

Non-adherence to antipsychotic medication is associated with relapse of psychiatric symptoms and readmission to inpatient mental health services. The important role of the mental health nurse in facilitating adherence has been acknowledged, however, there has been little exploration of how nurses themselves perceive this aspect of their role. A qualitative study was conducted to explore the perceptions of mental health nurses employed in inpatient settings regarding their role in facilitating medication adherence. Focus groups were conducted with 22 nurses from three inpatient settings in metropolitan Melbourne. The main themes to emerge from the data were: nurses' responsibilities in medication management; ways in which nurses are educated about antipsychotic medication; barriers to the provision of medication management, and barriers to effective patient adherence. Recommendations for more effective practice are discussed.     

Preliminary reliability of an observer rating scale for assessing medication adherence on psychiatric wards

Objectives  Medication non-adherence is a major contributor to poor outcomes following discharge from psychiatric hospitals. It is therefore imperative that staff are able to accurately assess the extent to which patients have engaged with treatment. This study presents data on a new observer rating instrument of patient medication adherence.
Methods  Staff participating in a medication adherence training programme ('Medication Alliance') were given a brief overview of the Observer Rating of Medication Taking (ORMT) scale. Participants then watched six video vignettes of patient adherence behaviour and provided a rating on their scale for each vignette. Participant ratings were then compared with 'expert' ratings.
Results  Percentage agreement between 'experts' and participants ranged from a low of 68% through to 98% agreement. Only one vignette was rated significantly differently [ Mdiff  = 0.33, t (49) = 2.08, P  = 0.007], with 32% of people falling outside the expert rating range (all of those ratings being higher). This difference was attributed to between group differences, [ F (2,47) = 3.49, P  < 0.05] and post hoc assessment suggested that the differences between expert and trainee ratings for the vignette may be explained by trainee characteristics, as distinct from inherent characteristics of the rating scale.
Conclusion  The ORMT can help mental health professionals identify particular non-adherent behaviours thus facilitating identification and treatment of likely non-adherence before discharge. The scale appears to be accessible to a variety of professions with a range of experience and requires minimum training in order to be used reliably.     

Nurses' attitudes toward their role in patient discharge medication education and toward collaboration with hospital pharmacists: a staff development issue.

This qualitative pilot study explored nurses' attitudes toward their role in patients' discharge medication education and collaboration with pharmacists. Purposive sampling was used, and data were collected by a focus group interview. The findings give a clear indication of the need for extensive staff development. It is unfortunate that nurses in this study appeared not to value their role in educating patients on medications prior to discharge. They were somewhat resistant to collaboration with pharmacists, and they tended to accept limited responsibility for improving patient discharge medication adherence or compliance. Although the findings are of concern, they do provide clear evidence of the need for intensive staff development.