Differing Effects of Mass and Interpersonal Communication on Breast Cancer Risk Estimates: An Exploratory Study of College Students and Their Mothers

Communication at the end of life poses important challenges for patients, families, and caregivers. Previous research on end-of-life communication has concentrated on areas including the provision of bad news and clinical and personal decision making. In this study, we turn our attention to the processes through which caregivers provide comfort in palliative care. Our ethnographic and interview study of spiritual communication among hospice workers and their patients is guided by a dialectical framework. We find a central dialectic in which hospice workers recognize the tension between “leading” and “following” patients and families in discussions of spirituality at the end of life. Our analysis reveals that though some care providers choose one pole of this dialectic, most workers try to manage the dialectic by shifting between leading and following in different situations or different points in time or by transcending the dialectic and addressing the multiple goals of interaction.     

Communication models, professionalization, and the work of medical interpreters

A growing number of health institutions are employing medical interpreters, bilingual individuals who facilitate communication between health care providers and patients. Organizations working to establish the professional status of medical interpreting have articulated codes of ethics that prescribe a number of different roles for interpreters in their clinical work. Interviews obtained from 17 medical interpreters support the observation that the code of ethics, based primarily on a conduit model of interpreter communication, does not provide consistent guidance in clinical practice. I discuss the role of communication theory in developing improved models for interpreter practice.     

Religious advance directives: the convergence of law, religion, medicine, and public health.

Because of the deep interpersonal significance of decisions made at the end of life, it is not surprising that religion has played an important role in patient and family decision making. Specific religious concerns about death and dying have led to religious advance directives. Advance directives offer a case study of models of interaction between religious communities and secular institutions. This paper examines why such directives have been created and how they may affect health care decisions. An analysis of their strengths and weaknesses concludes that specific religious instructions are unnecessary in written directives and may undermine both the religious and health care goals of patients.     

The communication of palliative care for the elderly cancer patient

Palliative care (PC) is often recommended by physicians for their elderly patients who are terminally ill. In contrast to hospice care, which precludes the use of any curative treatment at life's end stages, PC seeks primarily to comfort patients and to keep them pain free, yet it does not necessarily preclude medical treatment. It does seek to attend to patients' physical as well as psychological, emotional, spiritual, and existential needs in an attempt to enhance overall quality of life. A review of current literature in PC for oncology patients, elderly and otherwise, reveals a curious irony: Although PC plausibly entails a holistic, patient-centered approach to health care, much of the research on PC and, apparently, many of the practices in PC focus almost exclusively on the biomedical approach to patient care, particularly in regard to pain and symptom management. Furthermore, few methods in PC research incorporate patients' narratives and lived experiences in the final stages of their lives. We argue that a holistic, patient-centered approach must guide research in PC, including the treatment of elderly patients as "active interpreters, managers, and creators of the meaning of their health and illness" (Vanderford, Jenks, & Sharf, 1997, p.14) and of the meaning of their lives.     

Creating New Normals in Cancer Care: A Review of The Art of the Possible

Palliative care (PC) is often recommended by physicians for their elderly patients who are terminally ill. In contrast to hospice care, which precludes the use of any curative treatment at life's end stages, PC seeks primarily to comfort patients and to keep them pain free, yet it does not necessarily preclude medical treatment. It does seek to attend to patients' physical as well as psychological, emotional, spiritual, and existential needs in an attempt to enhance overall quality of life.

A review of current literature in PC for oncology patients, elderly and otherwise, reveals a curious irony: Although PC plausibly entails a holistic, patient-centered approach to health care, much of the research on PC and, apparently, many of the practices in PC focus almost exclusively on the biomedical approach to patient care, particularly in regard to pain and symptom management. Furthermore, few methods in PC research incorporate patients' narratives and lived experiences in the final stages of their lives. We argue that a holistic, patient-centered approach must guide research in PC, including the treatment of elderly patients as "active interpreters, managers, and creators of the meaning of their health and illness" (Vanderford, Jenks, &; Sharf, 1997, p.14) and of the meaning of their lives.     

Care of the dying: a Catholic perspective. Part II: Social and political context--Catholic providers must exemplify a caring community. Catholic Health Association

Fears of abandonment and isolation in an institution have increased the public demand for euthanasia and assisted suicide. To quell this movement, Catholic healthcare providers must provide a caring community where patients and care givers enable each other to confront the fear of death and find support in living with human limitation. To begin to address the social and political dimensions of issues about the end of life, Catholic healthcare providers must use clear and consistent definitions of the terms used to describe these issues, such as death with dignity, right to die, euthanasia, allowing to die, and assisted suicide. By acknowledging the influence of the media in forming attitudes and opinions, healthcare institutions can seize opportunities for public education on fundamental human and religious values. The first effort has to be directed toward educating members of the media. The Catholic Church supports the concept of advance directives, which provide an opportunity for people to express their values and the ways they would expect those values to be honored in decisions about medical treatment. Courts' role in resolving decisions about treatment should be limited. Patient self-determination is best exercised when a patient (or surrogate), in consultation with a physician, decides what is best. Catholic healthcare institutions should advocate for legislation that fosters an appropriate balance between protecting a patient's right to self-determination and the state's interests to protect life. At the same time, institutions' advocacy efforts should demand sufficient resources for holistic care for the dying.     

Fostering Connections Among Diverse Individuals Through Multi-Sensorial Storytelling

A growing number of health institutions are employing medical interpreters, bilingual individuals who facilitate communication between health care providers and patients. Organizations working to establish the professional status of medical interpreting have articulated codes of ethics that prescribe a number of different roles for interpreters in their clinical work. Interviews obtained from 17 medical interpreters support the observation that the code of ethics, based primarily on a conduit model of interpreter communication, does not provide consistent guidance in clinical practice. I discuss the role of communication theory in developing improved models for interpreter practice.     

Antemortem care in an afternoon: a successful four-hour curriculum for third-year medical students

Numerous well-designed studies have shown that patients near the end of life often receive substandard palliative care. Medical students have expressed a strong interest in antemortem care; however, palliative medicine education remains poorly integrated into the overall curriculum at most medical institutions in the United States. In response to this need, a palliative medicine curriculum has been developed for medical students in the required third-year clerkship in family medicine at the University of Tennessee Health Sciences Center The implementation of this curriculum resulted in a statistically significant increase in student competence (as measured by a standardized pretest and post-test) and a significant trend in student confidence (as measured by a single-item Likert scale). The curriculum was popular with students, and encouraged many of them to request hospice clinical experiences during their family medicine clerkship, or to register for the elective fourth-year clerkship in palliative medicine.     

The Imperative to Reimagine Assisted Living

Assisted living (AL) has existed in the United States for decades, evolving in response to older adults’ need for supportive care and distaste for nursing homes and older models of congregate care. AL is state-regulated, provides at least 2 meals a day, around-the-clock supervision, and help with personal care, but is not licensed as a nursing home.The key constructs of AL as originally conceived were to provide person-centered care and promote quality of life through supportive and responsive services to meet scheduled and unscheduled needs for assistance, an operating philosophy emphasizing resident choice, and a residential environment with homelike features. As AL has expanded to constitute half of all long-term care beds, the increasing involvement of the real estate, hospitality, and health care sectors has raised concerns about the variability of AL, the quality of AL, and standards for AL. Although the intent to promote person-centered care and quality of life has remained, those key constructs have become mired under tensions related to models of AL, regulation, financing, resident acuity, and the workforce.These tensions have resulted in a model of care that is not as intended, and which must be reimagined if it is to be an affordable care option truly providing quality, person-centered care in a suitable environment. Toward that end, 25 stakeholders representing diverse perspectives conferred during 2 half-day retreats to identify the key tensions in AL and discuss potential solutions. This article presents the background regarding those tensions, as well as potential solutions that have been borne out, paving the path to a better future of assisted living.     

分级诊疗背景下吉林省慢性非传染性疾病治疗费用研究

目的:综合分析吉林省慢性非传染性疾病治疗费用现状和特征,为卫生政策制定提供数据支持和建议。方法:基于"卫生费用核算体系2011",核算分析吉林省慢性非传染性疾病治疗费用总量及构成。结果:2014年吉林省慢性非传染性疾病治疗费用总量为320.22亿元,占全省治疗费用的65.51%。从疾病角度,心血管疾病和恶性肿瘤等居于治疗费用消耗前五位疾病类型,其治疗费用占全部慢性病治疗费用的66.22%;从服务角度,除口腔疾病的治疗费用大部分消耗在门诊服务外,其他系统慢性病的治疗费用则主要消耗在住院服务;从机构角度,其治疗费用中65.83%的费用发生在省市级医疗卫生机构。从筹资角度,吉林省慢性病治疗费用中家庭卫生支出占比为41.77%;结论:吉林省慢性病治疗费用规模庞大,机构分布呈"倒三角"现象,筹资结构需要优化。     

Towards a sociology of disease

We argue for a sociology of health, illness, and disease. Under the influence of Talcott Parsons, the social study of health began as medical sociology and then morphed into sociology of health and illness, focusing largely on the social aspects of health-related topics. Social scientists have been reluctant to tackle disease in its physiological and biological manifestations. The result is an impoverishment of sociological analysis on at least three levels: social scientists have rarely made diseases central to their inquiries; they have been reluctant to include clinical endpoints in their analysis; and they have largely bracketed the normative purpose of health interventions. Consequently, social scientists tend to ignore what often matters most to patients and health care providers, and the social processes social scientists describe remain clinically unanchored. A sociology of disease explores the dialectic between social life and disease; aiming to examine whether and how social life matters for morbidity and mortality and vice versa. Drawing from specific advances in science and technology studies and social epidemiology, we point to ways that sociologists can participate as health researchers.     

广西两县卫生服务整合及其影响因素研究

目的从医疗卫生服务提供者视角对两县的医疗卫生服务体系县域内整合现状进行评价和分析并提出相应的政策建议。方法以卫生服务整合理论为基础、选取彩虹模型作为分析框架,将彩虹模型量表得分进行百分制转化进行描述性分析和回归分析。结果两试点县在以人和社区为中心和机构文化两个维度得分较高,其次是服务整合和技术能力,在组织整合维度得分较低,专业整合维度得分最低。其中,县医院在以人和社区为中心、服务整合、专业整合和机构文化四个维度得分最高,公共卫生机构在这四个维度得分最低;基层医疗机构在技术能力维度得分最高。医疗机构的各维度的整合服务评分与医务人员的学历、是否全科医生和职工满意度有关。结论县域医疗机构要以政府为主导,完善基层人才培养体系,从而落实县域医共体建设,推动医防融合,以进一步提高医疗机构服务整合程度,增强医务人员满意度。     

医患间的人际冲突与冲突管理策略

医患间人际冲突和管理策略是影响医患关系的重要因素，它不仅能够产生消极的结果。还能够产生建设性的结果。本文通过分析医患间人际冲突的来源、性质和影响以及冲突管理策略，旨在促使人们透彻理解冲突产生的原因，实行有效的冲突管理方式，促使冲突得到建设性解决，从而促进良好医患关系的建立。     

Hais cuaj txub kaum txub—To Speak of All Things: A Hmong Cross-cultural Case Study

Cross-cultural medicine is a field that describes how disparate value and belief systems concerning health and disease affect the delivery of health care. This report describes the conflict between a Hmong immigrant family and the Western medical establishment over the care of their child with end stage renal disease [ESRD]. The health care providers, social service agencies and medical center failed to adequately respond to the needs of the family. The medical staff [nephrologist, nurse coordinator, dietician, social worker, and CPS worker] worked with a transcultural nurse, Hmong community health worker and the family, to design and negotiate a treatment plan that would be acceptable to the family and the health care team. Trust was reestablished between the family and the healthcare providers and the medical outcome for the child improved.     

The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease: a review.

The use of proxy raters of patients' quality of life has been suggested as a means of facilitating the factoring of quality-of-life considerations explicitly into the medical decision-making process and of resolving the problem of missing data in longitudinal quality-of-life investigations. This review addresses two questions related to the potential role of such proxy raters in clinical research and practice: (1) to what extent are health care providers and lay individuals involved in the care of patients ("significant others") able to assess accurately the quality of life of patients with chronic disease? and (2) under what conditions, if any, is inclusion of such proxy ratings in quality-of-life investigations warranted? Although the extant literature yields few unequivocal findings, a number of clear trends can be identified: (i) health care providers and significant others tend, in general, to underestimate patients' quality of life; (ii) health care providers and significant others appear to evaluate patients' quality of life with a comparable degree of (in)accuracy; (iii) health care providers tend to underrate the pain intensity of their patients; (iv) proxy ratings appear to be more accurate when the information sought is concrete and observable; and (v) while significant others' ratings tend to be more accurate when they live in close proximity to the patient, they can also be biased by the caregiving function of the rater. There is need for more methodologically sound studies that: (a) incorporate head-to-head comparisons of health care providers and significant others as proxy raters; (b) employ well-validated quality-of-life measures; and (3) employ a longitudinal design in order to examine the effect of changes in patients' health status over time on the ability of proxies to provide valid quality-of-life assessments.     

Hais cuaj txub kaum txub--to speak of all things: a Hmong cross-cultural case study

Cross-cultural medicine is a field that describes how disparate value and belief systems concerning health and disease affect the delivery of health care. This report describes the conflict between a Hmong immigrant family and the Western medical establishment over the care of their child with end stage renal disease [ESRD]. The health care providers, social service agencies and medical center failed to adequately respond to the needs of the family. The medical staff [nephrologist, nurse coordinator, dietician, social worker, and CPS worker] worked with a transcultural nurse, Hmong community health worker and the family, to design and negotiate a treatment plan that would be acceptable to the family and the health care team. Trust was reestablished between the family and the healthcare providers and the medical outcome for the child improved.     

Life, death, and liability: duties of health care providers regarding withdrawal of treatment

Many of the issues surrounding refusal and withdrawal of medical treatment are so new and complex that the U.S. society has not resolved the ethical or legal questions involved. Questions such as where life ends and death begins, how to determine the circumstances when withdrawal of treatment is appropriate, and who should make such decisions will have to be resolved before the law in this area can become settled. Naturally, society is a long way from resolving these issues, since they involve such fundamental social, moral, medical, and legal considerations. Nevertheless, a body of law has developed that increasingly recognizes the right of an individual to direct his or her own medical care. To that end, an individual's clearly expressed intention to discontinue medical treatment will generally be honored, even if death results from the withdrawal of that treatment. Legislatures and courts have also encouraged health care providers to abide by the wishes of their patients by giving immunity to health care providers who comply in good faith with the provisions of a living will. Courts have also been reluctant to impose liability on health care providers for withdrawal of treatment absent a living will if it were done in good faith (with the consent of family or guardian) and was in accordance with accepted medical practice. It would appear that as the law gives individuals increased control over the private matter of their own medical treatment, health care providers may face more civil suits for maintaining life support systems against the patient's (or family's) wishes. In any event, while society is in the process of catching up with medical technology, individuals can best protect their right to medical self-determination by expressing their wishes clearly in the form of a living will and durable power of attorney. Health care providers can best protect themselves by keeping abreast of medical and legal developments in connection with these issues and by communicating effectively with their patients as to their wishes regarding life-prolonging medical treatment.     

The proprietarization of health care and the underdevelopment of the public sector

Failure of hospitals in urban areas is a well documented, spreading phenomenon that is resulting in decreased care for the medically indigent. As financial conditions force greater closures and cutbacks among providers, this dismantling of institutions that have historically served the unfortunate deepens the crisis in access to medical care. In this article, pressure on private health care institutions to adhere to a more bottom-line approach is viewed in the light of an overall attempt by government to divert public capital into private sector coffers, a trend that is particularly significant because of the ongoing concentration and centralization within the delivery system. Set in a historical analysis of the corporatization of health care, a case is made to reveal the underdevelopment of public hospitals, certain urban voluntary institutions, and community-based clinics, i.e., those institutions left to serve the most needy, in the face of rampant financial success by proprietary providers catering to a middle-class clientele requiring less intensity of care.     

Care of the dying: a Catholic perspective. Part I, Cultural context: a CHA document challenges care givers to define appropriate care for the dying

In a society tempted to adopt legalized assisted suicide and euthanasia as appropriate responses to dying, the healthcare community is challenged to nurture positive attitudes toward death among all ages and to help those with terminal illnesses to live well while dying. Whereas family and friends were once the primary care givers, now members of the healthcare professions are. This shift has introduced tensions between medical professionals and patients, including their families, in defining appropriate behavior toward the dying. To enable the terminally ill to live well while dying, we need to allow them to retain as much control as possible within the limits of belonging to a community. Also, we need to secure their network of significant relationships so they can experience the affective bonds of trust and love that support personal dignity and enhance the meaning of life. Medical technology is to be used in service of the total good of the patient. This includes not only the relief or cure that therapy can bring, but also what the patient prefers, values about life, and regards as giving ultimate meaning to life. Catholic healthcare institutions are challenged to promote a sensitivity and respect for cultural diversity as they respond to the needs of the dying and those who care for them.