It’s Yet Another Thing: Barriers to and Recommendations for Physician Referrals to Home-Based Palliative Care

To understand primary care providers’ (PCPs) experiences with referring patients to home-based palliative care (HBPC), we conducted individual, key-informant interviews with 31 PCPs. About half participants were male (54.8%), White (42.5%), US-born (58.1%), and were 57 years old (SD=9.17), on average. About one-third of participants (32.3%) indicated they refer 10+ patients annually to HBPC, while most (80.7%) reported “strong” comfort discussing palliative care with patients. Qualitative analysis revealed three prominent thematic categories, each related to barriers PCP experienced when referring patients to palliative care: (1) PCP-level (lack of knowledge and comfort); (2) perceived patient-level (culture, family disagreement, need, home-based aspect); and (3) HBPC program-level (need to close the loop with PCP, insurance coverage, program availability, and eligibility). PCP recommendations for overcoming identified barriers will be discussed. Findings hold important implications for timely patient-referrals to palliative care by PCPs and for sustaining palliative programs that rely on these referrals.

Factors Affecting Students’ Preference for Nursing Education and their Intent to Leave: A Cross-sectional Study

Introduction:Insufficient research has been conducted into the factors that prompt young students to select nursing education as a profession in Saudi Arabia.Aim:The aim of the study is to identify factors affecting students' preference for nursing education and their intent to leave.Methods:This study follows a descriptive cross-sectional research design, with data collected by adapting the Tan-Kuick questionnaire to measure second-year nursing students’ (n=162) preference for nursing education and intent to leave one academic institution in Saudi Arabia.Results:Nursing image is identified as the major factor influencing the nursing students’ preference for nursing education in Saudi Arabia (69.89 ± 16.49), and parents' image of nursing is identified as the factor with the least amount of influence (34.52 ± 22.04). Additionally, more than half of the nursing students surveyed report intending to leave the nursing profession. Regarding the reasons for their intent to leave, a total of 70% of the surveyed nursing students report having no interest in the nursing profession. Family disagreement and societal image are also identified as common prompts to leave nursing.Conclusion:The study recommends the use of media to enhance the image of the nursing profession through the presentation of role models that talk to the students and encourage and motivate them to engage in the working life of a nurse. In addition, the study suggests replicating the longitudinal study for the same group in their third and fourth year of study to see if they leave the nursing profession.

Prehospital Advanced Resuscitation with Video Direct Medical Control Using Mobile Smart Device

Introduction:The prognosis for out-of-hospital cardiac arrest (OHCA) remains controversial if a smart device or video is used. In this study, a system was used that provides advanced cardiac life support (ACLS) with direct medical control through remote video calls for OHCA patients. The study investigated how this system will improve survival.Aim:The effect of video remote direct medical control using a mobile smart device for cardiac arrest was the main objective of this research.Methods:Medical origin OHCA patients over 18 years old for one year were included in the video remote direct medical attempt. Trauma, intoxication, environmental origin, and family disagreement were excluded. The advanced field resuscitation was performed by paramedics with video communication-based medical direction, who were dispatched simultaneously by two ambulances. Video communication was performed by a mobile application or video call. The results and opinions were recorded in a mobile application and a specific website. We analyzed the general characteristics and outcomes of the prehospital ACLS using video communication.Results:A total of 11,054 consecutive out-of-hospital cardiopulmonary resuscitation cases were recorded, and 3,352 underwent prehospital ALS using video call. Prehospital ROSC was 23.3%, survival upon hospital arrival was 13.6%, survival admission was 19.5%, survival discharge was 10.6%, and survival with good neurologic outcome was 6.0%. The reasons for no prehospital ALS included no request from a provider (29.1%), cardiac arrest during transport (20.9%), communication failure (11.6%), and family refusal (11.1%).Discussion:As a result of providing prehospital ACLS with direct medical direction through remote video calls to cardiac arrest patients, the prehospital ROSC rate, survival admission, and discharge rate improved. Advantages of this type of medical control by video communication were ease of control of the patient`s family, more precise communication with paramedics, and continuous confirmation of the real patient’s status and monitoring parameters.

ROBERT MALTHUS, ROUSSEAUIST

Although the argument of theEssay on populationoriginated in a family disagreement between Malthus and his father Daniel, who idolized Rousseau, and theEssayitself attacks Condorcet and Godwin, both of whom drew on Rousseau's ideas about human perfectibility, Malthus's project can plausibly be seen as an extension of the social theory set out above all in Rousseau'sDiscourse on the origin of inequality. Malthus was animated by some of Rousseau's characteristic concerns, and he deployed recognizable versions of some of Rousseau's distinctive arguments, in particular relating to the natural sociability and natural condition of humankind, conjectural history, and political economy, especially with respect to the question of balanced growth. His arguments about ‘decent pride’, furthermore, that were emphasized in later editions of theEssaymap neatly onto what has been called ‘uninflamedamour-propre’ in the Rousseau literature. When we treat the social question as a nineteenth-century question, or when we locate its origins in the post-Revolutionary political controversies of the 1790s, we risk losing sight of the way in which what was being discussed were variations on mid-eighteenth-century themes.

The interplay of polygenic plasticity and adrenocortical activity as sources of variability in pathways among family adversity, youth emotional reactivity, and psychological problems

This study examined the interplay between a polygenic composite and cortisol activity as moderators of the mediational pathway among family adversity, youth negative emotional reactivity to family conflict, and their psychological problems. The longitudinal design contained three annual measurement occasions with 279 adolescents (Mean age = 13.0 years) and their parents. Latent difference score analyses indicated that observational ratings of adversity in interparental and parent–child interactions at Wave 1 predicted increases in a multimethod, multi-informant assessment of youth negative emotional reactivity to family conflict from Waves 1 to 2. Changes in youth negative emotional reactivity, in turn, predicted increases in a multi-informant (i.e., parents, adolescent, and teacher) assessment of psychological problems from Waves 1 to 3. Consistent with differential susceptibility theory, the association between family adversity and negative emotional reactivity was stronger for adolescents who carried more sensitivity alleles in a polygenic composite consisting of 5-HTTLPR, DRD4 VNTR, and BDNF polymorphisms. Analyses of adolescent cortisol in the period surrounding a family disagreement task at Wave 1 revealed that overall cortisol output, rather than cortisol reactivity, served as an endophenotype of the polygenic composite. Overall cortisol output was specifically associated with polygenic plasticity and moderated the association between family adversity and youth negative emotional reactivity in the same for better or for worse manner as the genetic composite. Finally, moderator-mediated-moderation analyses indicated that the moderating role of the polygenic plasticity composite was mediated by the moderating role of adolescent cortisol output in the association between family adversity and their emotional reactivity.

Terminal care in the intensive care unit

In the UK, around 10%–20% of all patients admitted to the intensive care unit (ICU) do not survive while, in the United States, it has been estimated that 22% of all deaths occur in an ICU. Therefore, terminal or palliative care is as important as any of the life-saving interventions that occur in the ICU. The goal of palliative care is to achieve a good death. In the ICU, the switch from care with curative intent to palliation occurs when it becomes obvious that the patient is not responding to treatment. Typically, this is manifest by deteriorating physiology and escalating organ support in the setting of overwhelming disease or injury. It is predominantly expert opinion (consensus amongst treating medical and nursing teams) that determines the point at which the patient is recognized as not responding to treatment and, in fact, dying. This chapter covers the ethical considerations, communication, family disagreement, organ donation, withdrawal of therapies, care after death, and diagnosing death.