Patterns of religious practice and belief in the last year of life.

OBJECTIVES: Although it is frequently assumed that issues of religious faith become more salient at the end of life, there is little or no population-based empirical evidence testing this assumption. METHODS: Using data from the New Haven site of the Established Populations for Epidemiologic Studies of the Elderly (N = 2,812), the authors examined self-reports of attendance at services, self-ratings of religiousness, and strength and comfort felt from religion for respondents who did and did not die within 12 months following an interview. Religiousness was assessed at baseline (1982) and in follow-up interviews in 1985, 1988, and 1994. Cross-sectional comparisons of levels of religiousness were made among persons in their last 6 months of life, persons in their last 12 months of life, and persons who survived 12 months, and longitudinal comparisons were made with religiousness at the previous wave. RESULTS: After adjusting for age, sex, education, marital status, religious affiliation, and a set of health status measures, the authors found that although attendance at religious services declined among the near-deceased, this group showed either stability or a small increase in feelings of religiousness and strength/comfort received from religion. Overall levels of attendance and religious feelings were high for this religiously diverse sample. DISCUSSION: Community studies of respondents in their last year of life are rare. In this sample, religious involvement appears to continue throughout the last months of life.     

33例HIV/AIDS病人的生活质量与影响因素

目的了解艾滋病病毒（HIV）感染者/艾滋病（AIDS）病人（简称HIV/AIDS病人）的生活质量及其影响因素,为社会支持提供依据。方法选择陕西省山阳县、武功县HIV/AIDS病人33例,采用世界卫生组织生活质量量表（WHOQOL-BREF）对其进行调查,对相关数据进行描述性统计和多重线性回归分析。结果超过半数调查对象感染HIV后感到羞愧、自责、痛苦、恐惧、绝望,且山阳县HIV/AIDS病人感到羞愧和自责的比例显著高于武功县。一半以上的HIV/AIDS病人认为自己的生活质量一般。约1/3的HIV/AIDS病人对自身的健康状况满意。健康状况的主观感受、心理领域得分和参加活动3个因素影响HIV/AIDS病人的生活质量,并且3个因素均为正向影响因素。结论鼓励与支持HIV/AIDS病人积极参加社会活动,提高其对健康状况的主观感受,促进心理健康,均能提高他们的生活质量。     

Advanced dementia: opinions of physicians and nurses about antibiotic therapy,artificial hydration and nutrition in patients with different life expectancies

Aim: The aim of the present study was to investigate the proportion of physicians and nurses who agree with the administration of antibiotic therapy (AT), artificial hydration (AH), and artificial nutrition (AN) in patients with advanced dementia and different life expectancies. Furthermore, we aimed at analyzing the correlates of the opinion according to which medical treatments should no longer be given to advanced dementia patients once their life expectancy falls. Methods: End‐of‐life decisions and opinions were measured with a questionnaire that was sent to geriatric units, hospices and nursing homes in three different regions of Italy. Multivariate logistic regressions were carried out to ascertain the correlates of the agreement with the administration of AH, AT or AN. Results: When the patient's life expectancy was 1–6 months, 83% of respondents agreed with AH, 79% with AT and 71% with AN. When the life expectancy was less than 1 month, a large proportion of respondents still agreed with AH and AT (73% and 61%), whereas less than one in two respondents (48%) agreed with AN. Conclusions: The findings of the present study showed that AN creates more ethical dilemmas in the clinical management of end of life than other treatments, such as AH or AT. Opinions on whether or not these practices are appropriate at the end of life were related with feelings, thoughts and ethical issues that played a different part for physicians and nurses. Geriatr Gerontol Int 2017; 17: 487–493.     

Dysphagia and its consequences in the elderly

This investigation was designed to study to what extent dysphagia in the elderly is accompanied by other chest symptoms and if it leads to a reduction in body weight and quality of life. To this end 796 persons, randomly taken from a population register, replied to a questionnaire concerning swallowing difficulties and other chest symptoms. Chest pain, heartburn, and regurgitation occurred significantly more frequently in subjects who admitted feelings of obstruction in the throat or chest during the ingestion of food (p<0.001) than in the rest, as did so-called heart problems (p<0.05). People with dysphagia had more often gained weight over the last 5 years than people without dysphagia (p<0.05). Psychosocial problems in those with dysphagia were given as anxiety at mealtimes and the wish to eat alone. Of those with dysphagia, 40% had consulted a physician, but despite this these patients had as many problems as those who had not seen a doctor. It is apparent that difficulty in swallowing in the elderly leads to physical and psychosocial problems that may reduce their quality of life.     

End-of-life and other ethical issues related to pacemaker and defibrillator use in the elderly

In the past decade, the rate of implantation of pacemakers and cardioverter-defibrillators in the elderly with cardiac impairment has soared. As patients near the end of life, interventions become more complicated and expensive, and less effective. In this context, "informed consent" requires consideration of issues different from those faced in more routine settings. Informed consent requires full disclosure, patient competence, and free exercise of will-but in practice, few patients or their families are in a position to make fully informed decisions about highly complex treatments at the end of life. Physicians continue to bear the responsibility of advising patients about sophisticated interventions or, alternatively, palliative care. Physician training, with its narrow focus on the treatment of disease with drugs and technology, has not prepared physicians to advise patients on issues arising from the availability of multiple interventions at the end of life. Professional societies can fill a gap by developing programs and materials to help physicians treat their dying patients in a high-technology era.     

Beclomethasone dipropionate and salbutamol by metered dose inhaler in infants and small children with recurrent wheezing

The efficacy of beclomethasone dipropionate (BDP) to control respiratory symptoms was evaluated in 31 children under age 2 years with recurrent wheezing. The study was conducted in a double-blind, parallel, and placebo-controlled fashion. The two study groups received either salbutamol plus BDP 200 microg bid by metered dose inhaler (MDI) with a spacer, or salbutamol MDI plus a placebo. Inhaled corticosteroid (IC) and placebo were administered for 8 weeks. Patients were seen every 2 weeks as outpatients, and their progress was evaluated by clinical examination and a daily symptom score card.At the end of the study, patients in both groups had significantly decreased symptoms. No significant difference was found between BDP and placebo groups regarding clinical score, number of salbutamol doses, sleep disturbances, number of symptom-free days, feelings of insecurity of mothers regarding the infants' life due to wheezing, and mothers' perceptions of progress in their infants' respiratory symptoms.We conclude that salbutamol plus 200 microg bid of BDP inhaled from an MDI with a spacer for 8 weeks is no better than salbutamol alone for decreasing recurrent wheezing in small children under age 24 months.     

Physician-older patient communication at the end of life

Communication with dying patients and their families requires special skills to assist them in this extremely stressful period. This article begins with a case that illustrates many of the challenges of communicating with the dying. It then reviews the literature about communication with older patients at the end of life, focusing on physician-patient discussions, decision-making, advance directives, and cultural factors. The article concludes with a practical discussion of problems that physicians may encounter when working with older patients at the end of life and their families and recommendations to improve communication.     

The psycho-social impact of a liver transplant programme

Through in-depth interviews, an inventory has been made of the experiences of 18 liver patients who have been considered for or undergone a liver transplant. Interviews were also held with the patients' relatives. Chronic patients especially seem to regard a transplant as their last chance, and all their hopes become based on it. The strict selection procedure is distressing, and being turned down causes negative feelings. As far as the operation itself is concerned, patients are inclined to create high success rates for themselves in relation to their survival chances and the expectations of quality of life. For some patients a transplant means a marked improvement in the various aspects of their functioning. Others are not so fortunate, but do not give up hope of improvement. From the relatives of the patients who had died post-operatively, no negative feelings were encountered over the 'failure' of the technology'.     

Older widows and the transference of home

A relocation pattern, as indicated by a sample of older widows as they relocated from homes previously shared with their husbands to a metropolitan Phoenix life care facility, is presented. The suggested pattern is illuminated with quotes at each identified stage, revealing the individuals' inner feelings and motivations at those times. Characterized by relatively high income and educational levels, personal independence and prior careers, the sample is more representative of future women than those of their own age cohort. It is felt that these attributes were conducive to their apparently successful relocation.     

Advance Directives: theoretical concept and practical significance in the USA

The article examines on the basic of empirical data the discrepancy between the theoretical demand and the practical role of advance directives. Often advance directives have no influence on medical decision-making in clinical care of critically ill patients. The vague language of the widely used standard living wills and the lack of physician-patient communication in the process of delivering an advance directives are contributing factors. However, many physicians even disregard patients' preferences in concrete and meaningful living wills at the end of life. Besides the lack of information many even seriously ill patients do not deliver an advance because they misjudge their medical prognosis and life expectancy. Often the communication between patients and doctors are blocked because they expect from the each other the first step to talk about end of life decisions and advance directives. In this context physicians claim lack of time, training in communication skills and their discomfort in talking about death and dying with their patients.     

‘Finishing up’ on country: challenges and compromises

A core consideration in the care of Indigenous patients at the end of life is their place of death. Dying in community can be of paramount importance to Indigenous people. This paper reports the experiences of the Top End Palliative Care Service with respect to the barriers and solutions in the return of Indigenous patients to community for end‐of‐life care. These barriers include not only those associated with the significant distances and remoteness in the Northern Territory but, also, spiritual and cultural factors, which often influence healthcare delivery.     

The relationship between life goals at thirty and perceptions of goal attainment and life satisfaction at seventy for gifted men and women

This article examines the relationship between life goals at thirty and perceptions of goal attainment, happiness, and life satisfaction at seventy for gifted men and women. Respondents were members of the Terman Study of the Gifted. Men and women differed in life goals at age thirty, with men predominantly oriented toward occupational pursuit, and women predominantly oriented toward home and family life. Results showed a significant sex difference in feelings of goal attainment at age seventy, with men reporting greater attainment. Women with occupational goals at age thirty reported lower feelings of goal attainment at age seventy than women without such goals. For men, a positive relationship was found between satisfaction and happiness at age seventy and feelings of goal attainment. For women, these relationships varied according to life goals at age thirty. The implications of these results are discussed.     

The caring physician: a journey in self-exploration and self-care

Caring for patients involves empathic listening and awareness of the needs and feelings of the patient as well as our own; the acceptance of the fallibilities of medicine and ourselves. Too often we lead unbalanced lives in terms of work, relationships, play and personal time. We frequently strive for perfection, deny our needs and feelings, assume total responsibility for the patient, and are altruistic to the point of self-denial. Caring for patients without adequately caring for ourselves is frequently associated with subconscious needs for external validation. The hidden agenda may be harmful to the patient and the physician. Change requires self-awareness and recognition of the overt and covert benefits and risk of our current work patterns. Often there is a need to reexamine our life priorities, set limits at work, admit vulnerability, share our emotional lives, and appreciate the small things in our daily life that give us meaning and purpose.     

Caring for patients at the end of life: reflections after 12 years of practice

Physicians have the privilege and authority to assist patients and their families at the end of life. Regardless of diagnosis, commonalities occur in the dying process, and palliative care benefits patients and families. This perspective chronicles my experience over 12 years caring for 95 patients at the end of life, illustrated in part with six vignettes. I describe interactions with families, discuss logistic issues around dying, examine the do-not-resuscitate issue, and highlight experiences with home visits. I also touch on how I communicate with the family after a death. I hope to express the significance of what I have learned while assisting patients and families at this critical juncture.     

Feelings of guilt and shame in patients with rheumatoid arthritis

This study aims to determine whether patients with rheumatoid arthritis (RA) experience more general feelings of guilt and shame than their peers without RA and to examine possible correlates of guilt and shame in RA. In a cross-sectional survey study, 85 out-patients with RA (77 % female; median disease duration, 11 years) and 59 peer controls completed the Experience of Shame Scale (ESS) and the Test of Self-Conscious Affect (TOSCA). Patients additionally completed measures of health status, self-efficacy, cognitive emotion regulation, and numerical rating scales for life satisfaction and happiness. Patients and peer controls were well matched for sociodemographic characteristics. No significant differences between patients and controls were found for guilt or different types of shame as measured with the TOSCA or ESS. In multivariate analyses, female patients reported more feelings of bodily shame and higher guilt proneness, while younger patients reported more character and bodily shame. Worse social functioning and more self-blaming coping strategies were the strongest independent correlates of shame. Shame proneness was only independently associated with more self-blame, whereas guilt proneness was only associated with female sex. None of the physical aspects of the disease, including pain and physical functioning, correlated with feelings of guilt and shame. Patients with longstanding RA do not experience more general feelings of shame or guilt than their peers without RA. Shame and guilt in RA is primarily associated with demographic and psychosocial characteristics and not with physical severity of the disease.     

Quality‐of‐Life Trajectories at the End of Life: Assessments over Time by Patients with and without Cancer

OBJECTIVES: To compare quality‐of‐life (QOL) ratings of terminally ill patients with and without cancer over time. DESIGN: Secondary analysis of prospective data from a randomized clinical trial. SETTING: Trial conducted with terminally ill patients in Seattle, Washington, testing the efficacy of massage and guided meditation in improving patients' QOL. PARTICIPANTS: One hundred sixty‐seven trial participants, of whom 127 provided follow‐up data and died before data analysis. MEASUREMENTS: At enrollment, participants reported demographic characteristics, symptom distress, QOL, and primary life‐limiting diagnosis. At enrollment and at follow‐up interviews after every two study‐provided treatment sessions, participants rated their perceived quality of life on a scale from 0 (no quality of life) to 10 (perfect quality). At the end of the study, the investigators added measures of patient's survival status, number of days between study enrollment and death, and receipt of hospice services to the data set. RESULTS: Multilevel models showed significantly steeper QOL declines for patients with cancer than for those without after adjustment for time between study enrollment and death. Over a 4‐month before‐death period, the average patient without cancer was estimated to experience a QOL decline of approximately 0.6 on a scale from 0 to 10, compared with a 1.2‐point decline for patients with cancer. CONCLUSION: Patients with cancer face more‐precipitous end‐of‐life challenges to quality of life than do other terminally ill persons. Therefore, clinicians must address QOL issues—not just symptom burden and distress. By introducing and discussing expected QOL declines at the end of life, clinicians may help to prepare, support, and reassure patients and their families.     

Psychic reactions to long-term hemodialysis: evaluation in the elderly by means of the Draw-A-Person Test.

Twelve patients who attended a daytime session in a hemodialysis unit were studied. Most were older than patients whose adaptation has been the subject of previous reports. Problems of life satisfaction for these elderly patients often are different from those for younger persons. Most of the group showed maladaptive reactions which interfered with their activities when away from the unit. The Draw-A-Person test was a useful tool in pinpointing these reactions, which can lead to feelings of helplessness and depression. Factors which encourage good adaptation to long-term hemodialysis are discussed.     

Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians

RECOMMENDATION 1: In patients with serious illness at the end of life, clinicians should regularly assess patients for pain, dyspnea, and depression. (Grade: strong recommendation, moderate quality of evidence.) RECOMMENDATION 2: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage pain. For patients with cancer, this includes nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates. (Grade: strong recommendation, moderate quality of evidence.) RECOMMENDATION 3: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage dyspnea, which include opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia. (Grade: strong recommendation, moderate quality of evidence.) RECOMMENDATION 4: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage depression. For patients with cancer, this includes tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial intervention. (Grade: strong recommendation, moderate quality of evidence.) RECOMMENDATION 5: Clinicians should ensure that advance care planning, including completion of advance directives, occurs for all patients with serious illness. (Grade: strong recommendation, low quality of evidence.).