Understanding Muslim patients: cross-cultural dental hygiene care.

BACKGROUND: Healthcare providers who understand the basic pillars of Islamic beliefs and common religious practices can apply these concepts, anticipate the needs of the Muslim patient and family, and attract Muslim patients to the practice. OBJECTIVE: Cross cultural knowledge can motivate dental hygienists to adopt culturally acceptable behaviors, strengthen patient-provider relationships and optimize therapeutic outcomes. Trends in Muslim population growth, Islamic history and beliefs, modesty practices, healthcare beliefs, contraception, childbearing, childrearing, pilgrimage, dietary practices, dental care considerations and communication are explained. MATERIALS AND METHODS: This paper reviews traditional Muslim beliefs and practices regarding lifestyle, customs, healthcare and religion as derived from the literature and study abroad experiences. RESULTS AND DISCUSSION: Recommendations are offered on how to blend western healthcare with Islamic practices when making introductions, appointments, eye contact, and selecting a practitioner. The significance of fasting and how dental hygiene care can invalidate the fast are also discussed. CONCLUSION: The ultimate goal is for practitioners to be culturally competent in providing care to Muslim patients, while keeping in mind that beliefs and practices can vary widely within a culture.

Parkinson's disease: considerations for dental hygienists.

The prevalence of Parkinson's disease (PD) is expected to double over the next 20 years owing to the increase in life expectancy. This progressive disease has several implications relating to oral health, and many are manageable with proper awareness and knowledge about the disease. This article reviews the epidemiology, pathophysiology, and characteristics of PD, as well as the treatments and oral health considerations to enable dental hygienists to undertake an informed approach to patient management strategies and provide optimal care.

A novel approach to controlling bacterial contamination on toothbrushes: chlorhexidine coating.

PURPOSE: This project was conducted to determine the effectiveness of chlorhexidine-coated toothbrush filaments in reducing quantities of bacteria. MATERIALS AND METHODS: An Institutional Review Board (IRB)-approved, two-group, double-blind, randomized, post-test only study was conducted. Sixty-four individuals utilized control and experimental toothbrushes, for 30 days. At the end of the study toothbrushes were returned and transported to the laboratory for analysis. Microorganisms were detached from the filaments by sonification and vortexing then plated on Mitis Salivarius (MS) (selective) and trypticase soy agar (TSA) 5% Sheep Blood (non-selective) media. Inoculated plates were incubated aerobically for 24 h at 37 degrees C. After incubation, bacterial colony-forming units (CFU) were determined. Data were analysed using Wilcoxon and Kruskal-Wallis tests. RESULTS: Fifty-nine toothbrushes were returned for analysis; experimental (n = 31) and control (n = 28). Data from TSA media revealed a mean CFU for the control group of 5.41 x 10(5) compared with 6.28 x 10(5) for the experimental group. Data from MS agar resulted in a mean CFU for the control group of 4.32 x 10(5) compared with 4.20 x 10(5) for the experimental group. CONCLUSION: Results revealed no statistically significant difference in the quantity of bacteria surviving on toothbrush filaments between control and experimental groups, on both selective and non-selective media, after 30 days.

Scleroderma: considerations for dental hygienists.

Scleroderma, the general name of a group of progressive diseases affecting the connective tissues is the most deadly of the varying connective tissue disorders. Characterized by abnormal thickening of the skin, this collagen-vascular disease is associated with immune dysfunction. Hallmark signs of scleroderma include fibrosis, vascular instability and initial inflammation resulting from excessive collagen deposition. Oral facial involvement is considerable, necessitating adaptations in patient oral self-care and influencing oral hygiene. Appropriate dental hygiene management of patients with this autoimmune disorder requires an understanding of clinical characteristics, the recognition of oral facial involvement, treatment considerations and pharmacological interventions. With this information, dental hygienists will be better prepared to provide compassionate, safe and effective dental hygiene management and care to patients with scleroderma.

Workplace Bullying: A survey of Virginia dental hygienists.

Purpose: Workplace bullying in health care has been identified as a problem that negatively affects career satisfaction, career longevity and patient outcomes. The purpose of this pilot study was to determine the prevalence of workplace bullying in a convenience sample of dental hygienists in the state of Virginia.Methods: Two hundred and forty Virginia dental hygienists attending a continuing education seminar were invited to participate. Using the Negative Acts Questionnaire-Revised (NAQ-R), respondents were asked to indicate how often they had experienced 22 negative acts or behaviors according to rate of occurrence (never, now and then or monthly, weekly or daily). Bullying was defined as experiencing two or more of the specified negative behaviors over the past 6 months. The negative behaviors were categorized into three subgroups: work-related bullying, personal bullying and physical intimidation.Results: The response rate was 64%. Data revealed almost one fourth (24%) of respondents experienced workplace bullying. The most frequent behaviors experienced by those being bullied were having their opinions and views ignored (73%), experiencing unmanageable workloads (68%) and having their work excessively monitored (68%), on a weekly or daily basis.Conclusions: Results from this study suggest approximately 1 out of 4 Virginia dental hygienists responding to this survey experience workplace bullying. Education and support to ensure identification of bullying may be helpful in promoting proactive awareness, prevention strategies and a healthier work environment leading to greater job satisfaction.

Discussing life-sustaining treatment. A teaching program for residents.

Ideally, physicians and patients should discuss patient preferences for life-sustaining treatment before the onset of cognitive impairment or a life-threatening illness; however, these conversations often do not occur. We developed an educational program in which residents practiced discussing advance directives with volunteer simulated outpatients and then received feedback from the patient, an observing resident, and a faculty member. Residents found the training sessions to be realistic, relevant, and useful. Resident self-ratings improved significantly on eight items representing knowledge, skills, and attitudes about discussing advance directives with patients. Resident learning occurred in four major areas: technical knowledge about advance directives; introducing the topic to patients; giving patients information; and eliciting patients' values and feelings. We conclude that residents need and want training in this area and that simulated patients act as a catalyst for their learning.

Tube feeding. Internists' attitudes regarding ethical obligations.

BACKGROUND: Little is known about the attitudes of internists regarding their ethical obligation to provide or withhold tube feeding in three clinical contexts when patient preferences are not known: acute pneumonia, severe dementia, and persistent vegetative state. METHODS: A written questionnaire with patient scenarios was mailed to a randomized national sample of 1000 internist members of the American College of Physicians. RESULTS: Response was received from 58% of our sample (n = 581). Only physicians with personal experience with tube feeding decisions were included in the subsequent analysis (n = 326). Respondents were mostly male board-certified internists active in patient care in urban/suburban settings. Physicians demonstrated a predominant attitude for each scenario: 98% favored initiation of tube feeding for the patient with acute pneumonia; 84% opposed initiation of tube feeding for the patient with advanced dementia when depicted with a mixed happy/sad affect; and 80% favored withdrawal of tube feeding for the patient with established persistent vegetative state. Sixteen percent (n = 51) described tube feeding as basic humane care, whereas 84% (n = 265) believed tube feeding is medical therapy. Physicians were more opposed to tube feeding in certain patient scenarios than the literature suggests occurs in actual practice. CONCLUSIONS: Our data suggest that when patient wishes are not known, physician decisions regarding tube feeding are strongly influenced by prognosis. State legislation that categorizes tube feedings differently from other medical treatments conflicts with the judgment of the majority of internist respondents.

Decisions about life-sustaining treatment. Impact of physicians' behaviors on the family.

BACKGROUND: Despite the growing availability of advance directives, most patients in the intensive care unit lack written directives, and, therefore, consultation with families about treatment decisions remains the rule. In the context of decision making about withdrawing life-sustaining treatments, we investigated which physician and nurse behaviors families find supportive and which behaviors increase the family's burden. METHODS: We conducted intensive 1- to 2-hour-long individual interviews using a semistructured interview protocol with 32 family members of patients without advance directives whose deaths followed a stay in the intensive care unit and withdrawal of treatment. We analyzed more than 700 pages of verbatim interview data using content analysis techniques and achieved more than 90% interrater agreement on data codes. RESULTS: Themes emerged as families identified selected physician and nursing behaviors as helpful: encouraging advanced planning, timely communication, clarification of families' roles, facilitating family consensus, and accommodating family's grief. Behaviors that made families feel excluded or increased their burden included postponing discussions about treatment withdrawal, delaying withdrawal once scheduled, placing the full burden of decision making on one person, withdrawing from the family, and defining death as a failure. CONCLUSIONS: Study findings provide an increased understanding of the unmet needs of families and serve to guide physicians and nurses in reducing actions that increase families' burdens as they participate in treatment withdrawal decisions.

A prospective study of the efficacy of the physician order form for life-sustaining treatment.

OBJECTIVES: The Physician Orders for Life-Sustaining Treatment (POLST), a comprehensive, one-page order form, was developed to convey preferences for life-sustaining treatments during transfer from one care site to another. This study examined the extent to which the POLST form ensured that nursing home residents' wishes were honored for Do Not Resuscitate (DNR) and requests for transfer only if comfort measures fail. DESIGN: The study used chart record data to follow prospectively a sample of nursing home residents with the POLST. SETTING: Eight geographically diverse, long-term, adult-care facilities in Oregon in which the POLST was in use. PARTICIPANTS: Nursing home residents (n = 180), who had a POLST recording DNR designation and who indicated a desire for transfer only if comfort measures failed, were followed for 1 year. MEASUREMENTS: For all subjects: treatment and disposition after significant health status changes; orders for narcotics and for provision or limitation of aggressive interventions. For hospitalized subjects: diagnosis, medical interventions, and DNR orders. For those who died: cause and location of death, life-sustaining treatments attempted, and comfort measures provided. RESULTS: No study subject received CPR, ICU care, or ventilator support, and only 2% were hospitalized to extend life. Of the 38 subjects who died during the study year, 63% had an order for narcotics, and only two (5%) died in an acute care hospital. A total of 24 subjects (13%) were hospitalized during the year. Hospitalized subjects' mean length of stay was 4.9 days, and the mean rate of hospitalizations for all subjects was 174 per 1000 resident years. In 85% of all hospitalizations, patients were transferred because the nursing home could not control suffering. In 15% of hospitalizations (n = 4), the transfer was to extend life, overriding POLST orders. CONCLUSIONS: POLST orders regarding CPR in nursing home residents in this study were universally respected. Study subjects received remarkably high levels of comfort care and low rates of transfer for aggressive life-extending treatments.

Family reports of dying patients' distress: the adaptation of a research tool to assess global symptom distress in the last week of life.

Understanding dying patients' symptom distress is an important component of efforts to improve care at the end of life. It can, however, be problematic to conduct research with dying patients. Family members can serve as sources of information about decedents' last days of life. In order to assess family reports of decedents' global symptom distress in the last week of life, we adapted the Memorial Symptom Assessment Scale Global Distress Index (MSAS-GDI), a brief measure of patient global symptom distress, for use in a retrospective study of family reports about end-of-life care. It was administered to a sample of 103 family members to assess the psychometric properties of the instrument in bereaved family members. The Family MSAS-GDI consists of questions about 11 psychological and physical symptoms commonly experienced by dying patients. The majority of family members were able to respond to the scale items. The mean Family MSAS-GDI score was 1.14 (SD = 0.87) with a range of 0 to 3.73. The scale demonstrated good internal consistency (alpha = 0.82). The average item-total correlation was r = 0.49 and the average inter-item correlation was r= 0.30, suggesting items were moderately correlated with the overall total scale and with each other. The Family MSAS-GDI could prove to be a useful tool in assessing and tracking global symptom distress in dying patients.

Internal medicine residents' preferences regarding medical ethics education.

Three hundred and twenty-three residents in six internal medicine programs in three states were surveyed concerning what they wanted to learn about medical ethics and how they would prefer to learn it; they were also asked to indicate what medical ethics education they had already received. Specifically, the residents were given a list of 35 medical ethics topics and asked to indicate whether they would like more attention to a topic, or whether it had received enough or too much attention. (They could also indicate that they though the topic was inappropriate for attention during residency.) The residents were also given a list of 17 teaching methods for medical ethics and asked to indicate whether each method was very useful, somewhat useful, or not useful. Sixty-one percent of the residents responded. Approximately three-fourths of these had had some formal teaching about medical ethics in both medical school and residency, and nearly all indicated that they wanted more ethics training on specific topics. Certain topics were chosen as particularly suitable or unsuitable for such training; many of those judged as deserving more attention concerned legal issues and end-of-life issues. Most of the responding residents regarded standard clinical teaching formats as very useful for learning about medical ethics but regarded several other methods are not useful. The authors discuss the implications of these and related findings.

Physicochemical and solubilization properties of N, N-dimethyl-N-(3-dodecylcarbonyloxypropyl)amineoxide: a biodegradable nonionic surfactant.

The physicochemical characteristics of N,N-dimethyl-N-(3-dodecylcar- bonyloxypropyl)amineoxide (DDCPNO), a biodegradable analogue of a N, N-dimethylalkylamine-N-oxide, are compared with those of N, N-dimethyldodecylamine-N-oxide (DDNO) to establish the effect on the properties of DDNO of inserting a propoxy linker between the hydrophobic tail and hydrophilic head region. Surface tension measurements gave a critical micelle concentration of 0.33 mM for DDCPNO compared with a value of 1.57 mM for DDNO, suggesting that the former was the more hydrophobic surfactant. This result was confirmed by laser light scattering studies in which total intensity light scattering indicated the presence of DDCPNO micelles of aggregation number 85.0. Photon correlation spectroscopy studies yielded a limiting hydrodynamic diameter of 4.0 nm in comparison with values of 57.5 and 3.3 nm obtained for the aggregation number and the limiting hydrodynamic size, respectively, of DDNO micelles. Studies demonstrated that neither a dilute aqueous solution of DDCPNO or DDNO exhibited a cloud point within the temperature range 293-373 K. Solubilization studies showed that the capacity of DDCPNO micelles for a range of drugs of varying size and polarity was less than that observed with DDNO micelles at an equivalent surfactant concentration. As a further measure of solubilization, the ability of DDCPNO to form oil-in-water microemulsions with a range of ethyl ester oils was investigated and found to be slightly higher than that achieved with DDNO. Together these studies suggest that the presence of the semipolar linker significantly alters the properties of this low molecular weight surfactant.

Oregon emergency physicians' experiences with, attitudes toward, and concerns about physician-assisted suicide.

OBJECTIVE: To determine emergency physicians' (EPs') attitudes toward physician-assisted suicide (PAS), factors associated with those attitudes, current experiences with attempted suicides in terminally ill persons, and concerns about the impact of legalizing PAS on emergency medicine practice. METHODS: A cross-sectional, anonymous mailed survey was taken of EPs in the state of Oregon. RESULTS: Of 356 eligible physicians, 248 (70%) returned the survey. Of the respondents, 69% indicated that PAS should be legal, 65% considered PAS consistent with the physician's role, and 19% believed that it is immoral. The respondents were concerned that patients might feel pressure if they perceived themselves to be either a care burden on others (82%) or a financial stress to others (69%). Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons. Support for legalization was not associated with gender, age, or practice location. Respondents with no religious affiliation were most supportive of PAS (p < 0.001), and Catholic respondents were least suppportive (p = 0.03). A majority (58%) had treated at least 1 terminally ill patient after an apparent overdose. Most respondents (97%) indicated at least 1 circumstance for which they would sometimes be willing to let a terminally ill patient die without resuscitation after PAS if the Oregon initiative becomes law: if verified with an advance directive from the patient (81%), with documentation in writing from the physician (73%), after speaking to the primary physician (64%), if a competent patient verbally confirmed intent (60%), or if the family verbally confirmed intent (52%). CONCLUSIONS: Although the majority of Oregon EPs favor the concept of legalization of PAS, most have concerns that safeguards in the Oregon initiative are inadequate to protect vulnerable patients. These physicians would consider not resuscitating terminally ill patients who have attempted suicide under the law's provisions, only in the setting of documentation of the patient's intent.

Tube-feeding decisions in the elderly.

Tube-feeding decisions in the elderly can be most challenging. We begin our decision making with the premise that artificial nutrition is a medical therapy and therefore that its prescription is based on a calculation of net benefits over burdens for the patient to whom it is given. When the burdens of this therapy outweigh the benefits of prolonged life, tube feeding may be ethically withheld or withdrawn. For the cognitively impaired and in the absence of known patient preferences, the ratio of benefits to burdens may best be figured after a time trial of therapy. If restraints are needed to keep the tube in place, or if significant medical complications ensue, the burdens of the therapy have outweighed its potential benefits, and the therapy may be ethically withdrawn. State statutes and institutional policies are often confusing and at times in conflict with the ethical choice made by families and health care providers for their loved ones and patients. The options--starting a court battle (Cruzan7), moving the patient to a different state (Busalacchi), or committing civil disobedience--are not best for the welfare of the patient, family, or health care team. We well recognize that what is legal is not always what is ethical. Ethics should lead the law as we consider how to use new health care technologies wisely. We hope that the state legislatures will work to minimize future conflicts by acknowledging that (1) artificial nutrition is a life-sustaining therapy that should not have special status distinct from other life-sustaining therapies and (2) artificial nutrition and hydration are medical therapies that can and should be ethically withdrawn or withheld when their burdens outweigh their benefits.

Physicians' and nurses' perspectives on increased family reports of pain in dying hospitalized patients.

Many indicators suggest that care of the dying in Oregon has been improving over the past decade. However, results from a recent study suggest that one aspect of care of the dying, pain management, may be worsening. In late 1997, family reports of moderate and severe pain in dying hospitalized patients increased from 33% to 57%. This occurred during a volatile time in the Oregon political climate associated with events surrounding a second vote on physician-assisted suicide. In order to better understand the observed increase better, a statewide sample of physicians and nurses was surveyed to obtain their opinions about factors that may have contributed to the increased family reports of moderate and severe pain in dying hospitalized patients. Seventy-nine percent of respondents endorsed two or more factors as partial explanations. These factors include an increase in family expectations about pain management (endorsed by 96%), decreased physician prescribing (endorsed by 66%), and reduced nurse administration of pain medication (endorsed by 59%). Physicians who thought reduced physician prescribing was a partial factor rated fears of the Board of Medical Examiners and the Drug Enforcement Administration as the most likely explanations for decreased prescribing. More research is needed to better understand family expectations for end-of-life care, fears of investigation, and pain medication practices.

Sudden death in the ED: educating residents to compassionately inform families.

We describe a program used in our emergency medicine residency to help teach residents new skills in interacting with survivors following a patient's sudden death in the emergency department. This teaching module requires about two and a half hours to complete. It includes a brief presentation of new skills, videotapes of family notification, resident role play experiences, and a summary. Trained volunteers are used as simulated survivors in the role plays. Although labor intensive and time consuming, the program offers educational advantages. The residents have an opportunity to practice their communication skills in a protected setting. In addition, they receive immediate and specific feedback from the faculty facilitator, fellow residents, and, most importantly, the simulated survivor. Following the role play sessions, residents feel they are more skillful in meeting survivors' needs.

Preparing the medically compromised patient for surgery.

Preparing the medically compromised patient for surgery requires identifying and treating preoperative risk factors and anticipating postoperative complications. Preoperative evaluation of all patients should include careful screening for bleeding disorders and prior anesthetic complications and assessment of nutritional status. In addition, patients with preexisting cardiac, pulmonary, and endocrine problems must be identified, since these problems represent the greatest risk factors for postoperative complications. Perioperative care is more effective when directed at specific organ systems. Communication among internists, anesthesiologists, and surgeons promotes optimal treatment for surgical patients with medical illness.

Sexual advances by patients in dental practice: implications for the dental and dental hygiene curricula.

The occurrence of patient initiated sexual advances toward dental health professionals has not previously been examined. Information from other health care specialties and reports from dental and dental hygiene students indicate that such advances do occur and that providers are rarely educated to deal effectively with them. Utilizing an anonymous survey of 300 Oregon dentists and 300 dental hygienists, this study sought to quantify the frequency of patient initiated sexual advances toward dental professionals and to survey practitioners as to their reactions to and methods of dealing with such advances. The information provided by the 483 (81 percent) respondents indicates that up to 44 percent of providers experience one or more patient verbal advances and up to 23 percent of providers experience one or more patient physical advances during a five year period. These advances are a significant source of concern for many dental professionals. Based upon this information, implications for the dental and dental hygiene curricula are considered.

Patient death and bereavement: what is the dentist's role?

The dentist's role following a patient's death has not been examined to date; neither has the attrition rate of a dental practice because of deaths of patients belonging to that practice. This topic was explored through a survey of 400 Oregon dentists. Seventy-two percent of dentists in active practice who participated in the survey had at least one patient death each year; the mean number of patient deaths per year was five. Following these deaths, most dentists reported providing some type of emotional support to the bereaved survivors. Dentists send sympathy cards 72% of the time and attend funerals 27% of the time; 55% of dentists regard the majority of their patient deaths as unexpected. These deaths are a source of emotional stress for dentists, as are subsequent discussions with survivors. Only 3% of the respondents reported having received formal education in death and bereavement, and 66% of dentists believe that some type of education in dying and bereavement should be included in dental school.

Ethical duties when patients make suspicious narcotic requests.

Practicing dentists are likely to be familiar with the prospect of patients who request controlled substances for doubtful indications. Torn between ethical obligations of beneficence and nonmaleficence, the dentist may be uncertain whether to prescribe a medication with the intention of alleviating pain or to refuse the prescription due to concerns related to chemical dependency, underlying emotional illness, or ulterior motives on the part of the patient. Pharmaceutical choices often do not provide a mechanism for sidestepping this dilemma as chemically dependent patients may be quite sophisticated in their knowledge of drugs and the ways in which to couch their requests. Dentists have an ethical obligation to move beyond simply refusing prescriptions for patients suspected to be chemically dependent; they should sensitively discuss the issue with these patients and be prepared to offer referral for intervention. However, dentists must always be open to the possibility that a particular patient's assertion of chronic physical pain may be of complex origin. When this is the case, appropriate treatment is essential and may involve referring the patient to others with specialized skills. Dentists should not withhold pain medication from patients with uncontrolled pain in the final stages of life.