Early maternal guidance of mother-child emotion dialogues predicts adolescents' attachment representations: a longitudinal study.

This study examined the contribution of early vs. concurrent maternal guidance of emotion dialogues with their children to the security and coherence of the children's attachment representations as adolescents. Maternal Sensitive Guidance was assessed from mother-child emotion dialogues when participants were preschoolers (approximate age 4 years) and young adolescents (approximate age 12.5 years), along with an assessment of adolescents' attachment representations using the Friends and Family Interview (FFI). Mothers' Sensitive Guidance in preschool predicted adolescents' coherence in the FFI, secure maternal (but not paternal) representations, and a positive representation of sibling relationships. In contrast, mothers' concurrent Sensitive Guidance was related only to adolescents' sibling relationships. These results highlight the significance of mothers' sensitive guidance of emotion dialogues during the early years for their children's later attachment representations, and point to the need for further examination of mothers' role when they guide emotion dialogues with their adolescents.

A shared model-based linguistic space for transmitting our thoughts from brain to brain in natural conversations.

Effective communication hinges on a mutual understanding of word meaning in different contexts. We recorded brain activity using electrocorticography during spontaneous, face-to-face conversations in five pairs of epilepsy patients. We developed a model-based coupling framework that aligns brain activity in both speaker and listener to a shared embedding space from a large language model (LLM). The context-sensitive LLM embeddings allow us to track the exchange of linguistic information, word by word, from one brain to another in natural conversations. Linguistic content emerges in the speaker's brain before word articulation and rapidly re-emerges in the listener's brain after word articulation. The contextual embeddings better capture word-by-word neural alignment between speaker and listener than syntactic and articulatory models. Our findings indicate that the contextual embeddings learned by LLMs can serve as an explicit numerical model of the shared, context-rich meaning space humans use to communicate their thoughts to one another.

Validation of a checklist to facilitate serious illness conversations in adult emergency in China: a single-centre pilot study.

BACKGROUND: Advances in emergency and critical care have improved outcomes, but gaps in communication and decision-making persist, especially in the emergency department (ED), prompting the development of a checklist to aid in serious illness conversations (SIC) in China. METHODS: This was a single-centre prospective interventional study on the quality improvement of SIC for life-sustaining treatment (LST). The study recruited patients consecutively for both its observational baseline and interventional stages until its conclusion. Eligible participants were adults over 18 years old admitted to the Emergency Intensive Care Unit (EICU) of a tertiary teaching hospital, possessing full decisional capacity or having a legal proxy. Exclusions were made for pregnant women, patients deceased upon arrival, those who refused participation, and individuals with incomplete data for analysis. First, a two-round Delphi process was organized to identify major elements and generate a standard process through a checklist. Subsequently, the efficacy of SIC in adult patients admitted to the EICU was compared using the Decisional Conflict Scale (DCS) score before (baseline group) and after (intervention group) implementing the checklist. RESULTS: The study participants presented with the most common comorbidities, such as diabetes, myocardial infarction, cerebrovascular disease, moderate-to-severe renal disease, congestive heart failure, and chronic pulmonary disease. The median Charlson Index did not differ between the baseline and intervention cohorts. The median length of hospital stay was 11.0 days, and 82.9% of patients survived until hospital discharge. The total DCS score was lower in the intervention group than in the baseline group. Three subscales, including the informed, values clarity, and support subscales, demonstrated significant differences between the intervention and baseline groups. Fewer intervention group patients agreed with and changed their minds about cardiopulmonary resuscitation (CPR) compared to the baseline group. CONCLUSION: The use of a SIC checklist in the EICU reduced the DCS score by increasing medical information disclosure, patient value awareness, and decision-making support.

Mid-Atlantic primary care providers' perception of barriers and facilitators to end-of-life conversation.

Background: Among the chronically ill, end-of-life conversations are often delayed until emergently necessary and the quality of those conversations and subsequent decision-making become compromised by critical illness, uncertainty, and anxiety. Many patients receive treatment that they would have declined if they had a better understanding of benefits and risks. Primary care providers are ideal people to facilitate end-of-life conversations, but these conversations rarely occur in the out-patient setting. Objective: To investigate the self-reported experiences of physicians and advanced practice nurses with conversational barriers and facilitators while leading end-of-life discussions in the primary care setting. Design: A qualitative descriptive study. Methods: Six physicians and eight advanced practice nurses participated in singular semi-structured interviews. Results were analyzed using a qualitative descriptive design and content analysis approach to coding. Results: Reported barriers in descending order included resistance from patients and families, insufficient time, and insufficient understanding of prognosis and associated expectations. Reported facilitators in descending order included established trusting relationship with provider, physical and/or cognitive decline and poor prognosis; and discussion standardization per Medicare guidelines. Conclusion: Recommendations for improving the end-of-life conversational process in the primary care setting include further research regarding end-of-life conversational facilitators within families, the improvement of patient/family education about hospice/palliative care resources and examining the feasibility of longer appointment allotment.1.

Transforming the discharge conversation through support and structure: A scoping review.

Background: System level demands and interpersonal barriers can disrupt nurse delivery of high-quality information at discharge, which can contribute to a lack of caregiver preparedness to manage care of the patient and ultimately affect patient health. Objective: To synthesize evidence on effective nurse communication with informal caregivers during hospital discharge of adult patients with cognitive decline or Alzheimer's disease and related dementia. Design: A scoping review of inpatient nurse communication with informal caregivers. Methods: Collected research (published between 2011 and 2023) from three databases (MEDLINE, PsycINFO, and CINAHL), along with a separate search for gray literature (N = 18), to extract and synthesize recommended communication practices evidenced to improve the nurse care experience and support caregiver activation and preparedness. Results: Extraction synthesis of strategies resulted in two themes with corresponding sub-themes: Support (Information exchange, Space and time to determine preparedness, and Positive reinforcement of caregiver efforts) and Structure (Setting shared expectations, Informational resources, and Standardization). Conclusions: We offer practical recommendations for both interpersonal and policy level facilitation of nurse delivery of high-quality information at discharge to caregivers of patients with serious illness.

It Starts With a Story: A Four-Step Narrative-Based Framework for Serious Illness Conversations.

Background: As a key component of advance care planning, serious illness conversations form a core intervention in palliative care. To achieve effective serious illness conversations, acknowledgment and inclusion of patient sense of self and identity are critical. However, no framework exists to describe how goals, values, and choices relate to patient identity. This conceptual gap hinders the advancement of palliative care education and practice. Objective: This philosophical investigation aimed to explicate two items: first, a novel conceptual framework for serious illness conversations; second, a structured approach to optimize these conversations within the palliative care clinical context. Methods: A philosophical and theoretical analysis was performed within an interdisciplinary context, by scholars in palliative care, medical humanities, philosophy, and bioethics. Key literature in psychology, qualitative research on the experience of serious illness, medical ethics, and choice architecture in medical decision-making were reviewed, and a structured conceptual and narrative analysis was performed. Results: An original and innovative identity-centered conceptual framework for serious illness conversations was developed. The framework consists of a four-step, reproducible approach: (1) attend to patient narrative identity, (2) identify values, (3) cocreate goals, and (4) actively promote choices. In short: attend, identify, create, and promote (AICP). Discussion: By using this conceptual framework and four-step approach, clinicians can accomplish goal-concordant serious illness care and build rich clinical relationships that foster trust and goodwill.

Do parents engage in weight- and health-focused conversations with their emerging adult children and are there cross-sectional associations with weight and well-being outcomes?

BACKGROUND: Research indicates harmful associations between parental weight-focused conversations and markers of pediatric health and well-being. However, little is known about the prevalence and consequences of parent conversations focused on weight or health behaviors (i.e., physical activity or nutrition) with emerging adult children. METHODS: Data are from the 2018 follow-up survey of the population-based EAT 2010-2018 (Eating and Activity over Time) in cohort from Minneapolis-St. Paul, MN. Participants were emerging adults at follow-up with ages 18-26. Regression models adjusted for sociodemographic characteristics were conducted. RESULTS: Over two-thirds (68%) of mothers and 44% of fathers engaged in weight-focused conversations with their emerging adult children; 25% of both parents reported engaging in conversations focused only on health behaviors; and 8% of mothers and 26% of fathers reported not engaging in either type of conversation. Health-focused conversations by both parents were associated with lower body mass index (BMI) and disordered eating behaviors, higher intake of fruit and vegetables, and psychosocial well-being in emerging adult children. Weight-focused conversations with both parents were associated with higher BMI and disordered eating behaviors in emerging adults. There were gender moderated associations of paternal conversations about weight and health with vegetable intake, binge eating, and depressive symptoms. DISCUSSION: The high prevalence and negative health outcomes associated with weight-focused conversations coupled with the low prevalence and positive health outcomes associated with health-focused conversations by parents suggests the need for public health messaging and intervention development aimed at reducing parental weight talk with emerging adult children.

Not all cost conversations are the same: An exploration of potential value in cost conversations during Atrial fibrillation treatment decision making.

OBJECTIVES: To explore the cost conversations taking place when patients with atrial fibrillation and their clinicians decide on whether and how to use anticoagulation to prevent strokes. METHODS: Secondary qualitative thematic analysis of conversations from 476 clinical encounters in three sites of a multicenter randomized trial comparing usual care with and without a shared decision-making tool. RESULTS: We identified three themes with subthemes: (1) What was discussed: conversation content (2) How content was transmitted: communication patterns and (3) Implicit conversation drivers. Due to each patient's unique circumstances, bi-directional conversations focused on relationship- and solution-based content enabled better cost burden discovery. Conversation drivers included affordability, comorbidities, preferences, and uncertainty about future costs. CONCLUSIONS: Cost conversations were often initiated by clinicians, and if they did not invite a response, patients passively received information without understanding or weighing cost burden. When clinicians discussed cost information using relational or solution-focused content and bi-directional communication patients were more likely to engage in discussion including their unique situation. PRACTICE IMPLICATIONS: Solution-focused cost conversations can reduce financial treatment burden, but require estimates of out-of-pocket costs, insurance coverage, and long-term financial effects of various options. Conversation tools and information on financial resources are valuable to patients and clinicians.

A model of marmoset monkey vocal turn-taking.

Vocal turn-taking has been described in a diversity of species. Yet, a model that is able to capture the various processes underlying this social behaviour across species has not been developed. To this end, here we recorded a large and diverse dataset of marmoset monkey vocal behaviour in social contexts comprising one, two and three callers and developed a model to determine the keystone factors that affect the dynamics of these natural communicative interactions. Notably, marmoset turn-taking did not abide by coupled-oscillator dynamics, but rather call timing was overwhelmingly stochastic in these exchanges. Our features-based model revealed four key factors that encapsulate the majority of patterns evident in the behaviour, ranging from internal processes, such as particular states of the individual driving increased calling, to social context-driven suppression of calling. These findings indicate that marmoset vocal turn-taking is affected by a broader suite of mechanisms than previously considered and that our model provides a predictive framework with which to further explicate this natural behaviour at both the behavioural and neurobiological levels, and for direct comparisons with the analogous behaviour in other species.

Increasing goals of care conversations in primary care: Study protocol for a cluster randomized, pragmatic, sequential multiple assignment randomized trial.

BACKGROUND: Goals of care conversations explore seriously ill patients' values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations. METHODS: We plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders. CONCLUSION: This study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings.

Promoting serious illness conversations in primary care through telehealth among persons living with cognitive impairment.

BACKGROUND: serious illness conversations (SIC), particularly for persons living with cognitive impairment (PLCI), inconsistently happen in primary care. Pragmatic, scalable strategies are needed to promote SIC for PLCI. DESIGN: Pragmatic, prospective single-arm pilot study that occurred between July 1, 2021 and May 30, 2022 across seven primary care practices in North Carolina. PARTICIPANTS: Community-dwelling patients aged 65 and older with known or probable mild cognitive impairment or dementia (with decision-making capacity) and their care partners (if available). INTERVENTION: SIC telehealth intervention (TeleVoice) via video or telephone to assist PLCI in discussing their current goals, values, and future medical preferences, while facilitating documentation within the EHR. MAIN OUTCOMES: Main feasibility outcomes included reach/enrollment, intervention completion, and adoption rates at the clinic and provider level. Primary effectiveness outcomes included SIC documentation and quality within the EHR and usage of advance care planning billing (ACP) codes. RESULTS: Of the 163 eligible PLCI approached, 107 (66%) enrolled (mean age 83.7 years, 68.2% female, 16.8% Black, 22% living in a geographic area of high socioeconomic disadvantage) and 81 (76%) completed the SIC telehealth intervention; 45 care partners agreed to participate (mean age 71.5 years, 80% female). Adoption at clinic level was 50%, while 75% of providers within these clinics participated. Among PLCI that completed the intervention, SIC documentation and usage of ACP billing codes was 100% and 96%, respectively, with 96% (n = 78) having high-quality SIC documentation. No significant differences were observed between telephone and video visits. CONCLUSION: These findings provide preliminary evidence to support the feasibility of conducting SICs through telehealth to specifically meet the needs of community-dwelling PLCI. Further investigation of the sustainability of the intervention and its long-term impact on patient and caregiver outcomes is needed.

"A balancing act": parents' longitudinal perspectives of weight-related discussions with their children following obesity treatment.

Weight-related discussions during childhood may have long-lasting effects on children's body image and well-being. However, little is known about how parents frame these discussions with children who have undergone treatment for obesity. Our study aimed to explore how parents perceive weight-related discussions, several years after their children started obesity treatment. This qualitative study is part of the 4-year follow-up of the More and Less study, a randomized controlled trial examining the effectiveness of a parental support program as part of obesity treatment for preschool-aged children in Stockholm, Sweden. Semi-structured interviews were conducted with 33 parents (79% mothers, 48% with a university degree, 47% with foreign background) of 33 children (mean age 9.3 years (SD 0.7), 46% girls), transcribed and analyzed using realist informed thematic analysis. Three main themes, encompassing three subthemes were developed. Under the first theme, Parental attitudes and concerns, parents emphasized the importance of discussing weight and health behaviors with their children, yet found it challenging due to uncertainties about how to approach it safely and sensitively. A few parents found the conversation manageable, citing their own experiences of having overweight or their style of communication with the child as facilitating the conversation. Under the second theme, The significance of time and context, parents said they engaged in weight-related conversations with their children more frequently as the children matured, driven by their growing self-awareness. Parents also expressed how contextual factors, such as gender and the presence of others, shaped conversations. Parents perceived boys as more resilient, thus exposing them to more negative weight talk. The third theme, Navigating weight stigma, revealed how parents employed strategies such as nurturing their children's self-confidence, downplaying the significance of appearance and emphasizing health when discussing weight to shield their children from weight stigma. Taken together, we found that many parents need support to navigate weight-related discussions. Addressing weight stigma is part of children's obesity management process, as children may be bullied, teased, or experience discrimination in different social settings. More research is needed to explore how young children undergoing obesity treatment experience weight stigma and to understand gendered differences in these experiences.

Feasibility and Effectiveness of Virtual Group Advance Care Planning Visits During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic necessitated the transition from in person to virtual advance care planning (ACP) engagement efforts. This pilot initiative evaluated virtual group visits (GVs) and in-person GVs for ACP to determine their feasibility and effectiveness. METHODS: Participants included patients in a Geriatric Medicine clinic who were referred by their primary care physician to an ACP GVs intervention. The ACP GVs had 2 sessions, led by clinicians with ACP expertise who facilitated a discussion on patients' values, goals, and preferences. Participants were provided with technical assistance to support use of the virtual platform. Evaluation included an ACP readiness survey, post-session feedback, GV observations, and electronic health record review at baseline and a 6 month follow-up for goals of care documentation and advance directives. RESULTS: Seventy patients attended 46 ACP GVs from August 2019 to February 2022, including 16 in-person GVs and 54 virtual GVs. At a 6 month follow-up, for virtual GVs participants (n = 54), goals of care documentation increased from 31% to 93%, and advance directives increased from 22% to 30%. For in-person GVs participants (n = 16), goals of care documentation increased from 25% to 100%, and advance directives increased from 69% to 75%. All surveyed patients in both formats would recommend ACP GVs. CONCLUSION: ACP GVs are feasible and effective for supporting ACP, demonstrating an increase in both goals of care conversations and advance directives completion.

Adapting the serious illness conversation guide for unhoused older adults: a rapid qualitative study.

BACKGROUND: Older adults experiencing homelessness (OAEH) age quickly and die earlier than their housed counterparts. Illness-related decisions are best guided by patients' values, but healthcare and homelessness service providers need support in facilitating these discussions. The Serious Illness Conversation Guide (SICG) is a communication tool to guide discussions but has not yet been adapted for OAEH. METHODS: We aimed to adapt the SICG for use with OAEH by nurses, social workers, and other homelessness service providers. We conducted semi-structured interviews with homelessness service providers and cognitive interviews with OAEH using the SICG. Service providers included nurses, social workers, or others working in homeless settings. OAEH were at least 50 years old and diagnosed with a serious illness. Interviews were conducted and audio recorded in shelters, transitional housing, a hospital, public spaces, and over Zoom. The research team reviewed transcripts, identifying common themes across transcripts and applying analytic notetaking. We summarized transcripts from each participant group, applying rapid qualitative analysis. For OAEH, data that referenced proposed adaptations or feedback about the SICG tool were grouped into two domains: "SICG interpretation" and "SICG feedback". For providers, we used domains from the Toolkit of Adaptation Approaches: "collaborative working", "team", "endorsement", "materials", "messages", and "delivery". Summaries were grouped into matrices to help visualize themes to inform adaptations. The adapted guide was then reviewed by expert palliative care clinicians for further refinement. RESULTS: The final sample included 11 OAEH (45% Black, 61 ± 7 years old) and 10 providers (80% White, 8.9 ± years practice). Adaptation themes included changing words and phrases to (1) increase transparency about the purpose of the conversation, (2) promote OAEH autonomy and empowerment, (3) align with nurses' and social workers' scope of practice regarding facilitating diagnostic and prognostic awareness, and (4) be sensitive to the realities of fragmented healthcare. Responses also revealed training and implementation considerations. CONCLUSIONS: The adapted SICG is a promising clinical tool to aid in the delivery of serious illness conversations with OAEH. Future research should use this updated guide for implementation planning. Additional adaptations may be dependent on specific settings where the SICG will be delivered.

Clinicians' Perspectives on the Telehealth Serious Illness Care Program for Older Adults With Myeloid Malignancies: Single-Arm Pilot Study.

BACKGROUND: Serious illness conversations may help patients avoid unwanted treatments. We previously piloted the telehealth Serious Illness Care Program (SICP) for older adults with acute myeloid leukemia and myelodysplastic syndrome. OBJECTIVE: In this study, we aimed to understand the experience of the telehealth SICP from the clinician's perspective. METHODS: We studied 10 clinicians who delivered the telehealth SICP to 20 older adults with acute myeloid leukemia or myelodysplastic syndrome. Quantitative outcomes included confidence and acceptability. Confidence was measured using a 22-item survey (range 1-7; a higher score is better). Acceptability was measured using an 11-item survey (5-point Likert scale). Hypothesis testing was performed at α=.10 (2-tailed) due to the pilot nature and small sample size. Clinicians participated in audio-recorded qualitative interviews at the end of the study to discuss their experience. RESULTS: A total of 8 clinicians completed the confidence measure and 7 clinicians completed the acceptability measure. We found a statistically significant increase in overall confidence (mean increase of 0.5, SD 0.6; P=.03). The largest increase in confidence was in helping families with reconciliation and goodbye (mean 1.4, SD 1.5; P=.04). The majority of clinicians agreed that the format was simple (6/7, 86%) and easy to use (6/7, 86%). Clinicians felt that the telehealth SICP was effective in understanding their patients' values about end-of-life care (7/7, 100%). A total of three qualitative themes emerged: (1) the telehealth SICP deepened relationships and renewed trust; (2) each telehealth SICP visit felt unique and personal in a positive way; and (3) uninterrupted, unrushed time optimized the visit experience. CONCLUSIONS: The telehealth SICP increased confidence in having serious illness conversations while deepening patient-clinician relationships. TRIAL REGISTRATION: ClinicalTrials.gov NCT04745676; https://www.clinicaltrials.gov/study/NCT04745676.

How mothers talk to their children about failure, mistakes and setbacks is related to their children's fear of failure.

BACKGROUND: Many people fear failure and making mistakes. This fear can be transmitted from parents to children, suggesting that parental communication regarding failures and setbacks may play a critical role in shaping a child's perception of mistakes. AIMS: In this study, we investigated how everyday parent-child conversations about setbacks influence children's fear of making mistakes. SAMPLE: Drawing on the large pre-birth Growing Up in New Zealand cohort, we focused on a sub-sample of 231 mother-child dyads who engaged in a recorded conversations about a "recent disappointment or setback" when the children were 8 years old. METHOD: Conversations between mothers and children about the recent disappointments were coded to identify whether parents recognised or acknowledge their child's emotional response, if action plans were discussed, and the types of resources that the child could draw on. The children also completed a questionnaire about their global self-worth and their fear of making mistakes. RESULTS AND CONCLUSIONS: The discussion of clear action plans, in the absence of a discussion about collaborative resources, was found to be associated with an increased fear of making mistakes among children. Conversely, when mothers clearly acknowledged their child's emotions and discussed ways to work collaboratively with their child on future problems, there was a notable decrease in the child's fear of mistakes. However, it is noteworthy that many mothers in our study either minimally acknowledged or dismissed their child's emotions(40%), rarely discussed action plans (55%), or collaborative resources (79%)when discussing the recent setback.

"Unless someone sees and hears you, how do you know you exist?" Meanings of confidential conversations - a hermeneutic study of the experiences of patients with palliative care needs.

BACKGROUND: Patients with palliative care needs live with the reality of limited time due to illness or age, eliciting emotional and existential responses. A failure to address their existential needs can lead to significant suffering. A person-centred approach is paramount to effectively address these needs, emphasising holistic care and effective communication. Although existing communication models focus on predefined frameworks, a need exists to explore more spontaneous and confidential conversations between patients and nurses. Confidential conversations have the potential to build therapeutic relationships and provide vital emotional support, highlighting the need for further research and integration into palliative care practice. This study aims to more deeply understand the meaning of confidential conversations for patients with palliative care needs. METHODS: In-depth interviews were conducted with 10 patients in the context of specialised palliative care. A hermeneutic analysis was used to gain a deeper understanding of the meanings of the conversations. RESULTS: The patients had varying experiences and wishes concerning confidential conversations. They strived for self-determination in finding confidants, seeking trust and comfort in their interactions with nurses. Trust was crucial for creating a safe space where patients could express themselves authentically. In shared belonging, confidential conversations with a nurse provided validation and relief from life's challenges. Experiences of feeling unheard or rejected by a nurse could intensify loneliness, prompting individuals to withdraw and remain silent. Regardless of the motives behind their choices, it was crucial that patients felt respect and validation in their decisions. Their autonomy could thus be recognised, and they felt empowered to make decisions based on their unique preferences. CONCLUSIONS: Patients value trust and understanding, particularly in confidential conversations with nurses, which offer solace, validation and empowerment. However, indifference can increase patients' suffering, fostering self-doubt and reluctance to engage further. To address this, health care can prioritise empathic communication skills, offer ongoing support to nurses, and promote continuity in care through investment in training and resources. Additionally, adopting a person-centred approach in confidential conversations is crucial, considering patients' varying preferences.

Would you be impressed: applying principles of magic to chatbot conversations.

A magician's trick and a chatbot conversation have something in common: most of their audiences do not know how they work. Both are also constrained by their own limitations: magicians by the constraints of biology and physics, and dialogue systems by the status of current technology. Magicians and chatbot creators also share a goal: they want to engage their audience. But magicians, unlike the designers of dialogue systems, have centuries of practice in gracefully skirting limitations in order to engage their audience and enhance a sense of awe. In this paper, we look at these practices and identify several key principles of magic and psychology to apply to conversations between chatbots and humans. We formulate a model of communication centered on controlling the user's attention, expectations, decisions, and memory based on examples from the history of magic. We apply these magic principles to real-world conversations between humans and a social robot and evaluate their effectiveness in a Magical conversation setting compared to a Control conversation that does not incorporate magic principles. We find that human evaluators preferred interactions that incorporated magical principles over interactions that did not. In particular, magical interactions increased 1) the personalization of experience, 2) user engagement, and 3) character likability. Firstly, the magical experience was "personalized." According to survey results, the magical conversation demonstrated a statistically significant increase in "emotional connection" and "robot familiarity." Therefore, the personalization of the experience leads to higher levels of perceived impressiveness and emotional connection. Secondly, in the Magical conversation, we find that the human interlocutor is perceived to have statistically-significantly higher engagement levels in four of seven characteristics. Thirdly, participants judged the robot in the magical conversation to have a significantly greater degree of "energeticness,""humorousness," and "interestingness." Finally, evaluation of the conversations with questions intended to measure contribution of the magical principals showed statistically-significant differences for five out of nine principles, indicating a positive contribution of the magical principles to the perceived conversation experience. Overall, our evaluation demonstrates that the psychological principles underlying a magician's showmanship can be applied to the design of conversational systems to achieve more personalized, engaging, and fun interactions.

Money matters: a critique of 'informed financial consent'.

In recent years, concerns about the financial burdens of health care and growing recognition of the relevance of cost to decision making and patient experience have increasingly focused attention on financial 'transparency' and disclosure of costs to patients. In some jurisdictions, there have been calls not only for timely disclosure of costs information, but also for 'informed financial consent'. However, simply putting the 'financial' into 'informed consent' and invoking an informed consent standard for cost information encounters several ethical, legal, and practical difficulties. This article will examine the viability and desirability of 'informed financial consent', and whether it is possible to derive ideas from traditional informed consent that may improve decision making and the patient experience. We argue that, while there are important legal, ethical, and practical challenges to consider, some of the principles of informed consent to treatment can usefully guide financial communication. We also argue that, while medical practitioners (and their delegates) have an important role to play in bridging the gap between disclosure and enabling informed (financial) decision making, this must be part of a multi-faceted approach to financial communication that acknowledges the influence of non-clinical providers and other structural forces on discharging such obligations.