Family caregiver descriptions of stopping chemotherapy and end-of-life transitions.

PURPOSE: The purpose of this study was to describe family caregivers' perspectives of the final month of life of patients with advanced cancer, particularly whether and how chemotherapy was discontinued and the effect of clinical decision-making on family caregivers' perceptions of the patient's experience of care at the end of life (EOL). METHODS: Qualitative descriptive design using semi-structured interviews collected from 92 family caregivers of patients with end-stage cancer enrolled in a randomized clinical trial. We used a phased approach to data analysis including open coding, focused coding, and within and across analyses. RESULTS: We identified three patterns of transitions characterizing the shift away from active cancer treatment: (1) "We Pretty Much Knew," characterized by explicit discussions about EOL care, seemingly shared understanding about prognosis and seamless transitions from disease-oriented treatment to comfort-oriented care, (2) "Beating the Odds," characterized by explicit discussions about disease-directed treatment and EOL care options, but no shared understanding about prognosis and often chaotic transitions to EOL care, and (3) "Left to Die," characterized by no recall of EOL discussions with transitions to EOL occurring in crisis. CONCLUSIONS: As communication and palliative care interventions continue to develop to improve care for patients with advanced cancer, it is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life. Our findings reveal considerable, and potentially unwarranted, variation in transitions from active treatment to death.

Somatization reconsidered: incorporating the patient's experience of illness.

The large and heterogeneous group of patients with "unexplained somatic symptoms," with or without coexisting psychiatric, "functional," or "organic" illnesses, provides continuing difficulty for clinicians. The construct of somatization artificially separates bodily and psychological symptoms that patients experience as a unified whole. Concurrent chronic illnesses make it difficult to exclude "general medical conditions." The diagnosis requires that the patient seek medical care. Conflict between patients' experiences of illness and physicians' diagnostic categories, and fear of blaming the patient, complicate naming and characterizing the illness. We recommend an approach to clinical care that involves exploring the patient's life context, finding mutually meaningful language to arrive at a name for the illness, normalizing the patient's bodily experience of distress, using a chronic disease model that attends to functioning, and addressing the physician's need for certainty and efficacy. Health systems can help coordinate care and avoid iatrogenic harm by appropriately controlling access to medical services.

Toward creating physician-healers: fostering medical students' self-awareness, personal growth, and well-being.

To restore the "humanism" in medical care, medical education needs to espouse the goal of creating physician-healers. Critical, and often neglected, factors in healing are the personal development and well-being of the healer. Unexamined attitudes and biases and personal stress can interfere with patient care. Personal awareness and well-being can contribute to physicians' using their emotional reactions to patients for their patients' benefit. The authors suggest goals and objectives for medical education that can promote trainees' self-awareness, personal growth, and well-being, and comment on how medical educators might achieve and evaluate these goals and objectives.

Pudor, honor, and autoridad: the evolving patient-physician relationship in Spain.

The expression of emotion and the sharing of information are determined by cultural factors, consultation time, and the structure of the health care system. Two emblematic situations in Spain - the expression of aggression in the patient-physician encounter, and the withholding of diagnostic information from the patient - have not been well-described in their sociocultural context. To explore these, the authors observed and participated in clinical practice and teaching in several settings throughout Spain and analyzed field notes using qualitative methods. In this paper, we explore three central constructs - modesty (pudor), dignity (honor), and authority (autoridad) - and their expressions in patient-physician encounters. We define two types of emotions in clinical settings - public, extroverted expressions of anger and exuberance; and private, deeply held feelings of fear and grief that tend to be expressed through the arts and religion. Premature reassurance and withholding of information are interpreted as attempts to reconstruct the honor and pudor of the patient. Physician authority and perceived loyalty to the government-run health care system generate conflict and aggression in the patient-physician relationship. These clinical behaviors are contextualized within cultural definitions of effective communication, an ideal patient-physician relationship, the role of the family, and ethical behavior. Despite agreement on the goals of medicine, the behavioral manifestations of empathy and caring in Spain contrast substantially with northern European and North American cultures.

Talking about AIDS.

Despite increased public and professional awareness, patients and physicians tend to avoid discussions about HIV. Empiric studies of patient-physician communication point to specific common communication breakdowns. These include lack of a good opening line, inappropriate context, awkward moments, vague language, and a physician-centered rather than a patient-centered interview style. In effective HIV-related discussions, clinicians elicit the patient's beliefs and concerns first, are organized, use empathy, provide a rationale for the discussion, persist through awkward moments, and clarify vague language. In addition to information about sexual behaviors and the number, gender, and HIV status of partners, clinicians should ask about the context and antecedents to risk behaviors, praise prior attempts to reduce risk, and assess the patient's motivation to change. Although studies indicate that experienced practitioners often do not have these skills, they can be learned.

Understanding fear of contagion among physicians who care for HIV patients.

BACKGROUND: Fear of contagion has been identified as a potential deterrent for primary care physicians who would otherwise care for HIV patients. This study examines physicians' fears of occupational HIV transmission and the ways that they cope with those fears. METHODS: Thirty community-based primary care physicians who were caring for HIV patients were interviewed about their experiences with HIV patients and the meanings they ascribe to those experiences. Qualitative content and narrative analysis were used. RESULTS: Fear of contagion was common despite the relatively low reported self-assessment of risk by primary care physicians. Most physicians considered their level of risk acceptable, but for some it seemed to take a high emotional toll. Some physicians identified their fear as "irrational." Physicians reported tension between fear of contagion and ethical responsibility to care for HIV patients. Some physicians were overattentive to infection control measures, whereas others used universal precautions inconsistently. Physicians continued to care for HIV patients despite their fears. Some physicians' family members needed information and reassurance about transmission of HIV. CONCLUSIONS: Some physicians who care for HIV patients are poorly equipped to deal with their own fears. There is a need to examine in greater depth the relationship between fear of contagion and willingness to provide care, and to examine other factors that may be contributing to the expression of these fears.

Perspectives on patient-doctor communication.

Until recently, the content, structure, and function of communication between doctors and patients has received little attention and has been excluded from the realm of scientific inquiry; as a result, most clinicians have had little formal training in communication skills. In this paper leaders in doctor-patient communication present four approaches that are currently used as the basis for clinical training and research, summarize the progress made in forming a consensus, and outline the implications of these perceptions for practicing physicians.

Communication between primary care physicians and consultants.

Optimal communication between primary care physicians and consultants includes transfer of relevant clinical information, including the patient's perspectives and values, and provides a means of collaboration to provide meaningful and health-promoting interventions. Communication difficulties arise because of lack of time, lack of clarity about the reason for referral, patient self-referral, and unclear follow-up plans. Also, primary care physicians and consultants may have different core values and may have little day-to-day contact with each other. Poor communication leads to disruptions in continuity of care, delayed diagnoses, unnecessary testing, and iatrogenic complications. Changes in the health care system offer the opportunity for improved collaboration between physicians by creating smaller administrative units within large health care systems that facilitate contact between primary care physicians and consultants; incorporation of discussions of uncertainty, patient preferences, and values into referral letters; adoption of a friendlier consultant letter format; and the improvement of the transfer of clinical data.

Morbidity and mortality from anesthesia: a continuing problem.

PIP: Anesthetic exposure is usually necessary but rarely sufficient to the conduct of therapy. Consequently, there is a natural abhorrence of any worsening of a patient's condition secondary to the administration of anesthesia, which offers the patient no direct benefit. Highly safe anesthesia is a necessary precondition for the application of most surgical treatment, and the diversity of modern surgery provides support for the relative safety of contemporary anesthetic practice. The question arises as to whether this general sense of confidence is illusory. If current estimates are accurate, mortality rates associated with anesthesia may be 2000 patients each year in the United States alone. One assumes the correctness of the premise that errors of performance or malfunction of the anesthetic human-machine "system," rather than ignorance of the relevant biology, account for the great majority of untoward outcomes. If this is the case, examination of the critical incidents involved in anesthesia should provide some helpful guidance. The data of Cooper et al. show that the maintenance period of anesthesia is the time of the largest single number of critical incidents.^ieng

Mindful practice.

Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight. Mindfulness informs all types of professionally relevant knowledge, including propositional facts, personal experiences, processes, and know-how, each of which may be tacit or explicit. Explicit knowledge is readily taught, accessible to awareness, quantifiable and easily translated into evidence-based guidelines. Tacit knowledge is usually learned during observation and practice, includes prior experiences, theories-in-action, and deeply held values, and is usually applied more inductively. Mindful practitioners use a variety of means to enhance their ability to engage in moment-to-moment self-monitoring, bring to consciousness their tacit personal knowledge and deeply held values, use peripheral vision and subsidiary awareness to become aware of new information and perspectives, and adopt curiosity in both ordinary and novel situations. In contrast, mindlessness may account for some deviations from professionalism and errors in judgment and technique. Although mindfulness cannot be taught explicitly, it can be modeled by mentors and cultivated in learners. As a link between relationship-centered care and evidence-based medicine, mindfulness should be considered a characteristic of good clinical practice.

Resonance Raman studies on protocatechuate 3,4-dioxygenase-inhibitor complexes.

Resonance Raman spectra of a number of protocatechuate 3,4-dioxygenase-inhibitor complexes were studied by use of the available lines of an argon and a krypton laser. Three types of inhibitors were investigated-hydroxybenzoates, dicarboxylates, and 4-nitrocatechol. The hydroxybenzoate study shows that the hydroxy group in 3-hydroxybenzoate does not coordinate to the active site iron, in agreement with earlier suggestions, and confirms the coordination of the hydroxy group in the isomeric 4-hydroxybenzoate. The dicarboxylate study demonstrates that both glutarate and terephthalate perturb the active-site environment, shifting the charge-transfer interaction to lower energy. The pH dependence of terephthalate binding as well as the spectral similarities of the dicarboxylate complexes to the ESO2 intermediate provides further evidence for the suggestion that this intermediate is a tightly bound enzyme-product complex. The 4-nitrocatechol study indicates that, unlike the substrate catechols, 4-nitrocatechol does not bind to the iron; a binding configuration wherein the acidic phenolate group interacts with the carboxylate binding site has been suggested by others. Finally the spectra of the 4-hydroxybenzoate and terephthalate complexes demonstrate the presence of two tyrosines coordinated to the active-site iron as suggested by others; these tyrosines have different vCO's and excitation profiles.

Respiratory factors in the uptake and excretion of anesthetics. 1965.

We have considered some of the ways in which respiration can affect the gas exchange process. The simplest relationships are purely physical and relate to the speed with which the lung and tissues can be filled or emptied. More complex relationships involve a consideration of the interplay between blood and gas in the lung and the effects of gas exchange on respiratory volumes themselves. Finally, some examples of the importance of physiologic alteration produced by, and producing respiratory shifts during, gas uptake processes were presented briefly. The detailed interpretation of gas exchange phenomena demands more quantitative information of this sort, concerning not only the respiratory but the circulatory and tissue level variations affecting uptake during anesthesia. Nevertheless, understanding of the principles and application of such data as are available can go far toward removing the handicaps of empirical practice from the day-to-day administration of anesthetic agents to human beings.