High Death Anxiety and Ambiguous Loss: Lessons Learned From Teaching Through the COVID-19 Pandemic

For gerontological educators, topics such as mortality, loss, and end-of-life issues often emerge or are central in their courses. However, the COVID-19 pandemic has raised our awareness of loss and death on a global scale and teaching during the pandemic has raised questions about how educators, communities, or systems of higher education can support students’ learning while simultaneously experiencing losses during intense times of uncertainty. In this mixed-method study of 246 students enrolled in undergraduate thanatology courses, we explored their levels of death anxiety and their experiences with pandemic-related losses. We found that students’ death anxiety increased significantly during the pandemic, in comparison to the years prior (p < .001). We also conducted a content analysis in a subset of students’ written narratives (n = 44) regarding their pandemic experiences. We identified three themes. Participants desired: (a) more flexibility from instructors, no questions asked; (b) more compassion and understanding; and (c) specific, targeted support resources. The voices of students were filtered through the authors’ interpretation as educators to provide several teaching recommendations that support student learning during challenging times. The recommendations align with a trauma-informed approach, given the high rates of death anxiety and ambiguous loss among students, and have immediate implications for educators teaching during the pandemic, and for years to come. Finally, we also advocate for more university and community-based thanatology, and gerontology education offerings in general, to help normalize conversations about death, loss, and bereavement.

Systemic Factors Impacting Mortality and End-of-Life Issues in Critical Care

This chapter reviews issues related to mortality in the intensive care setting. Relevant literature is summarized and emphasizes the common need patients have for more frequent assessment, dependency on technology support, and psychosocial intervention. The authors stress the importance of interdisciplinary teams and the unique staffing and workforce challenges they encounter. Despite agreement on its importance, the authors maintain that end-of-life care is associated with a lack of consensus around its implementation at the bedside. The diversity within patient groups, diseases and conditions, and health care providers results in an environment in which the interplay of a growing number of variables influences the engagement of patients and families in discussions about end-of-life planning and care, futility, palliation, or withdrawal of support.

Barriers to completing the 4AT for delirium and its clinical implementation in two hospitals: a mixed-methods study

Purpose To assess the clinical implementation and barriers to completing the 4AT for delirium in general medical and geriatric patients over 75 years upon admission to Wellington and Kenepuru Hospitals during the first eight months of 2017, 2018 and 2019. Methods Retrospective data from electronic health records were analysed using an explanatory-sequential mixed-methods approach. The initial quantitative phase measured doctors’ adherence to the 4AT and the rate of positive 4ATs (≥ 4). The subsequent qualitative phase identified doctors’ main reasons for omitting the 4AT through conventional content analysis. Results The quantitative population included 7799 acute admissions (mean age 84, 58.2% female). There was good clinical implementation of the 4AT, evidenced by an overall adherence rate of 83.2% and a rate of positive 4ATs of 14.8% that is in keeping with expected delirium rates in similar settings. The qualitative sample consisted of 875 acute admissions (mean age 84, 56.3% female) with documented reasons for omitting the 4AT. The main barriers to completing the 4AT were: reduced patient alertness, communication barriers (language, deafness, aphasia and dysarthria), prioritising patients’ wellness and comfort (addressing critical illnesses, symptoms, end-of-life issues and promoting sleep), pre-existing cognitive disorders, and unstructured delirium assessments. Conclusion Adherence to the 4AT was high and sustainable in both hospitals. Most barriers to completing the 4AT were potentially avoidable. Education about the 4AT in relation to these barriers may improve its implementation.

Good surgical practice

This chapter discusses the duties of a doctor, which are outlined in the General Medical Council (GMC)’s Good medical practice. These have been adapted by the Royal College of Surgeons of England for surgical practice. The four domains of good medical practice include: knowledge, skills, and performance; safety and quality; communication, partnership, and teamwork; and maintaining trust. Clinical governance is a quality assurance process through which a health service is accountable for maintaining and improving the quality of care. In practice, it involves setting standards, performance monitoring, and reporting medical errors and is commonly said to be held up by ‘seven pillars’: clinical effectiveness; audit; risk management; education and training; patient and public involvement; using information and information technology; and staffing and staff management. The chapter then looks at the legal aspects concerning informed consent for a surgical procedure and end-of-life issues. It also outlines the principles of good prescribing in surgery.

Along the Italian route of End-of-life: the latest judicial evolution on assisted suicide

In the last three decades, the dilemma of End-of-Life is one of the most disputed bio-juridical questions Italy is confronting with. By raising highly sensitive ethical, legal and political dilemmas, it has deeply divided the Italian society, the scientific community and the political arena. In the context of a raging controversy, the Italian Parliament has opted for silence. Thus, an evolutive, judicial route has marked the legal frame in response to numerous, concrete demands of recognition of the freedom of self-determination and value of dignity in the final phase of life. In this review article, an overview of the judicial evolution of the complex mosaic of end-of-life issues will be firstly offered through three cases, pillars on which the latest judicial evolution on assisted suicide lays its foundations. Secondly, the issue of assisted suicide will be singularly addressed through the examination of the Cappato case which has outlined the path for the historical ruling of the Italian Constitutional Court, no'242 of 2019 on the constitutional illegitimacy of the crime of assistance to suicide under article 580 of the Italian Criminal Code. Precisely, the Court has pointed out several, concurrent requirements in presence of which an active conduct directly connected with suicide is not criminally relevant: the autonomous and free formation of the individual will, the irreversible nature of the disease, the ongoing practice of a life-saving treatment, the intolerability of the physical or psychological sufferings and the mental capacity to self-determination. Among the numerous, emerging, interpretative questions, the latest Trentini case, in which the requirement of life-saving treatment has been interpreted as inclusive of pharmacological therapy and of every material, sanitary life-saving assistance, will be further evaluated. Conclusively, a cross section of the fragile interplay between the legislative power and the judiciary power will be depicted in reference to the main open interpretative questions related to the enforcement of the constitutional ruling and a portrait of the upcoming scenerios, as the existing legislative drafts and the prepositive referendum question, will be concisely examined.

Addressing the disparities and the factors related to prolonged inpatient length of stay for solid tumor oncology patients during the COVID-19 pandemic: A narrative review

Solid tumor oncology treatments are primarily performed in the outpatient setting. However, hospitalizations are inevitable due to complications of cancer and treatment-related toxicities. With rising health care spending, the length of hospital stay (LOS) is increasingly considered a proxy for healthcare costs. There are several ongoing eff orts to abbreviate the inpatient LOS and ensure a safe and timely discharge to the outpatient setting. In addition to the acute illness and the associated comorbidities, various factors aff ect the LOS: social determinants of health (SDOH), nutritional status in cancer patients, and end-of-life issues. Furthermore, it is unclear how the institutional policies on social distancing and visitation during the current coronavirus disease (COVID-19) pandemic may impact the LOS. The purpose of this article is to review various factors and barriers that lead to longer LOS for solid tumor patients during the COVID-19 pandemic, and identify the critical areas of quality improvement.