"I don't see the whole picture of their health": a critical ethnography of constraints to interprofessional collaboration in end-of-life conversations in primary care.

CONTEXT: Interprofessional collaboration is recommended in caring for frail older adults in primary care, yet little is known about how interprofessional teams approach end-of-life (EOL) conversations with these patients. OBJECTIVE: To understand the factors shaping nurses' and allied health clinicians' involvement, or lack of involvement in EOL conversations in the primary care of frail older adults. METHODS/SETTING: A critical ethnography of a large interprofessional urban Family Health Team in Ontario, Canada. Data production included observations of clinicians in their day-to-day activities excluding direct patient care; one-to-one semi-structured interviews with clinicians; and document review. Analysis involved coding data using an interprofessional collaboration framework as well as an analysis of the normative logics influencing practice. PARTICIPANTS: Interprofessional clinicians (n = 20) who cared for mildly to severely frail patients (Clinical Frailty Scale) at the Family Health Team. RESULTS: Findings suggest primary care nurses and allied health clinicians have the knowledge, skills, and inclination to engage frail older adults in EOL conversations. However, the culture of the clinic prioritizes biomedical care, and normalizes nurses and allied health clinicians providing episodic task-based care, which limits the possibility for these clinicians' engagement in EOL conversations. The barriers to nurses' and allied health clinicians' involvement in EOL conversations are rooted in neoliberal-biomedical ideologies that shapes the way primary care is governed and practiced. CONCLUSIONS: Our findings help to explain why taking an individual-level approach to addressing the challenge of delayed or avoided EOL conversations, is unlikely to result in practice change. Instead, primary care teams can work to critique and redevelop quality indicators and funding models in ways that promote meaningful interprofessional practice that recognize the expertise of nursing and allied health clinicians in providing high quality primary care to frail older patients, including EOL conversations.

Registered Practical Nurses' Experiences of the Moral Habitability of Long-Term Care Environments during the COVID-19 Pandemic.

The COVID-19 pandemic has had a deleterious impact on the lives of nurses who work in long-term care; however, the moral conditions of their work have been largely unexamined. The purpose of this qualitative study, therefore, was to explore registered practical nurses' (RPNs) experiences of the moral habitability of long-term care environments in Ontario, Canada during the COVID-19 pandemic. Four themes were identified: (1) Striving to meet responsibilities in a failed system; (2) bearing the moral and emotional weight of residents' isolation and dying in a context of strict public health measures; (3) knowing the realities of the work, yet failing to be heard, recognized, or supported by management; and (4) struggling to find a means of preservation for themselves and the profession. Attention to the moral habitability of RPNs' work environments is necessary to achieve a high-quality, ethically attuned, and sustainable nursing workforce in long-term care.

Strategies Used by Outpatient Oncology Nurses to Introduce Early Palliative Care: A Qualitative Study.

BACKGROUND: Although early palliative care is linked to improved health-related quality of life, satisfaction with care, and symptom management, the clinical strategies that nurses use to actively initiate this care are unknown. OBJECTIVES: The aims of this study were to conceptualize the clinical strategies that outpatient oncology nurses use to introduce early palliative care and to determine how these strategies align with the framework of practice. METHODS: A constructivist-informed grounded theory study was conducted in a tertiary cancer care center in Toronto, Canada. Twenty nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) from multiple outpatient oncology clinics (ie, breast, pancreatic, hematology) completed semistructured interviews. Analysis occurred concurrently with data collection and used constant comparison until theoretical saturation was reached. RESULTS: The overarching core category, pulling it all together, outlines the strategies used by oncology nurses to support timely palliative care referral, drawing on the coordinating, collaborating, relational, and advocacy dimensions of practice. The core category incorporated 3 subcategories: (1) catalyzing and facilitating synergy among disciplines and settings, (2) promoting and considering palliative care within patients' personal narratives, and (3) widening the focus from disease-focused treatment to living well with cancer. CONCLUSION: Outpatient oncology nurses enact unique clinical strategies, which are aligned with the nursing framework and reflected multiple dimensions of practice, to introduce early palliative care. IMPLICATIONS FOR PRACTICE: Our findings have clinical, educational, and policy implications for fostering the conditions in which nurses are supported to maximize their full potential in the introduction of early palliative care.

Mental health and well-being of unpaid caregivers: a cross-sectional survey protocol.

INTRODUCTION: Unpaid caregiving, care provided by family/friends, is a public health issue of increasing importance. COVID-19 worsened the mental health conditions of unpaid caregivers, increasing substance/drug use and early development of chronic disease. The impact of the intersections of race and ethnicity, sex, age and gender along with unpaid care work and caregivers' health and well-being is unknown. The aim of this study is to describe the inequities of caregiver well-being across the intersections of race and ethnicity, sex, age and gender using a cross-sectional survey design. METHODS AND ANALYSIS: We are collaborating with unpaid caregivers and community organisations to recruit a non-probability sample of unpaid caregivers over 18 years of age (n=525). Recruitment will focus on a target sample of 305 South Asian, Chinese and Black people living in Canada, who represent 60% of the Canadian racial and ethnic populations. The following surveys will be combined into one survey: Participant Demographic Form, Caregiver Well-Being Index, interRAI Self-report of Carer Needs and the GENESIS (GENdEr and Sex DetermInantS of Cardiovascular Disease: From Bench to Beyond-Premature Acute Coronary Syndrome) PRAXY Questionnaire. Sample characteristics will be summarised using descriptive statistics. The scores from the Caregiver Well-Being Index will be dichotomised into fair/poor and good/excellent. A two-stage analytical strategy will be undertaken using logistic regression to model fair/poor well-being and good/excellent well-being according to the following axes of difference set a priori: sex, race and ethnicity, gender identity, age, gender relations, gender roles and institutionalised gender. The first stage of analysis will model the main effects of each factor and in the second stage of analysis, interaction terms will be added to each model. ETHICS AND DISSEMINATION: The University of Toronto's Health Sciences Research Ethics Board granted approval on 9 August 2022 (protocol number: 42609). Knowledge will be disseminated in pamphlets/infographics/email listservs/newsletters and journal articles, conference presentation and public forums, social media and through the study website. TRIAL REGISTRATION NUMBER: This is registered in the Open Sciences Framework with a Registration DOI as follows: https://doi.org/10.17605/OSF.IO/PB9TD.

Education for public health 2030: transformation to meet health needs in a changing world.

Education for public health is at a critical inflection point, and either transforms for success or fails to remain relevant. In 2020, the Association for Schools and Programs of Public Health launched an initiative, Framing the Future 2030: Education for Public Health (FTF 2030) to develop a resilient educational system for public health that promotes scientific inquiry, connects research, education, and practice, eliminates inequities, incorporates anti-racism principles, creates and sustains diverse and inclusive teaching and learning communities, and optimizes systems and resources to prepare graduates who are clearly recognizable for their population health perspectives, knowledge, skills, attitudes, and practices. Three expert panels: (1) Inclusive excellence through an anti-racism lens; (2) Transformative approaches to teaching and learning; and (3) Expanding the reach, visibility, and impact of the field of academic public health are engaged in ongoing deliberations to generate recommendations to implement the necessary change. The article describes the panels' work completed thus far, a "Creating an Inclusive Workspace" guide, and work planned, including questions for self-evaluation, deliberation, and reflection toward actions that support academe in developing a resilient education system for public health, whether beginning or advancing through a process of change. The FTF 2030 steering committee asserts its strong commitment to structural and substantial change that strengthens academic public health as an essential component of a complex socio-political system. Lastly, all are called to join the effort as collaboration is essential to co-develop an educational system for public health that ensures health equity for all people, everywhere.

Nurses' Experiences of their Ethical Responsibilities during Coronavirus Outbreaks: A Scoping Review.

Globally, nurses have experienced changes to the moral conditions of their work during coronavirus outbreaks. To identify the challenges and sources of support in nurses' efforts to meet their ethical responsibilities during SARS, MERS, and COVID-19 outbreaks a scoping review design was chosen. A search was conducted for eligible studies in Ovid MEDLINE, Ovid Embase and Embase Classic, EBSCO CINAHL Plus, OVID APA PsycInfo, ProQuest ASSIA, and ProQuest Sociological Abstracts on August 19, 2020 and November 9, 2020. The PRISMA-ScR checklist was used to ensure rigor. A total of 5204 records were identified of which 41 studies were included. Three themes were identified related challenges in meeting ethical responsibilities: 1) substandard care, 2) impeded relationships, 3) organizational and system responses and six themes relating to sources of support: 1) team and supervisor relationships, 2) organizational change leading to improved patient care, 3) speaking out, 4) finding meaning, 5) responses by patients and the public, 6) self-care strategies.Our review revealed how substandard care and public health measures resulted in nurses not being fully able to meet their ethical responsibilities of care. These included the visitation policies that impeded the support of patients by nurses and families, particularly with respect to face-to-face relationships. Organizational and system responses to the evolving outbreaks, such as inadequate staffing, also contributed to these challenges. Supportive relationships with colleagues and supervisors, however, were very beneficial, along with positive responses from patients and the public.

Nursing, psychotherapy and advanced cancer: A scoping review.

PURPOSE: Many individuals with advanced cancer have unmet psychological needs and often lack access to supportive care. Psychotherapy for adults with advanced cancer is a promising way to address some of the challenges in meeting these care needs. Nurses are the largest cohort of healthcare workers who can practice as psychotherapists and are positioned ideally to integrate these interventions as part of routine care. The purpose of this scoping review is to map the literature on psychotherapeutic interventions among adults with advanced cancer and to explore the nursing role in this body of evidence. METHODS: We conducted a scoping review for relevant quantitative, qualitative, and mixed methods studies. The content of included studies was analyzed and grouped based on two broad categories that describe how nursing's role was mentioned, described, and utilized: 1. Nurses are not the interventionist/psychotherapist and, 2. Nurses are mentioned as the interventionist/psychotherapist. RESULTS: Eighty-six studies were included. Overall, majority of studies did not mention a role for nursing in any capacity. Some studies mentioned a non-interventionist role for nursing in the research study. Fourteen studies mentioned nurses as interventionists/psychotherapists. These studies focused on feasibility, acceptability and patient related outcomes of brief psychotherapies. Dignity therapy was the most common psychotherapy in studies where nurses were utilized as interventionists, followed by life review and supportive expressive therapies. Very few studies discussed nursing's role in this area and nursing's capacity to deliver this form of care. CONCLUSION: There is paucity in nursing research focused on psychotherapy for adults with advanced cancer. It is feasible and acceptable for nurses to deliver brief psychotherapies to adults with advanced cancer, and the integration of these techniques in everyday practice has great potential that must be explored. The development of this knowledge base is needed to support future education, research, and practice policy agendas.

Nurses' experiences of ethical responsibilities of care during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has forced rapid and widespread change to standards of patient care and nursing practice, inevitably leading to unprecedented shifts in the moral conditions of nursing work. Less is known about how these challenges have affected nurses' capacity to meet their ethical responsibilities and what has helped to sustain their efforts to continue to care. RESEARCH OBJECTIVES: 1) To explore nurses' experiences of striving to fulfill their ethical responsibilities of care during the COVID-19 pandemic and 2) to explore what has fostered nurses' capacity to fulfill these responsibilities. RESEARCH DESIGN: A generic qualitative approach was used incorporating concepts coming from fundamental features of care. PARTICIPANTS: Twenty-four Canadian Registered Nurses from a variety of practice settings were interviewed. ETHICAL CONSIDERATIONS: After receiving ethics approval, signed informed consent was obtained before participants were interviewed. FINDINGS: Four themes were identified. 1) Challenges providing good care in response to sudden changes in practice. 2) Tensions in juggling the responsibility to prevent COVID-19 infections with other competing moral responsibilities. 3) Supports to foster nurses' capacity to meet their caring responsibilities. 4) The preservation of nurses' moral identity through expressions of gratitude and health improvement. DISCUSSION: Infection control measures and priorities set in response to the pandemic made at distant population and organizational levels impacted nurses who continued to try to meet the ideals of care in close proximity to patients and their families. Despite the challenges that nurses encountered, the care they received themselves enabled them to continue to care for others. Nurses benefited most from the moral communities they had with their colleagues and occasionally nurse leaders, especially when they were supported in a face-to-face manner.Conclusion: Moral community can only be sustained if nurses are afforded the working conditions that make it possible for them to support each other.

Biomedicalization of end-of-life conversations with medically frail older adults - Malleable and senescent bodies.

The common practice of delaying and/or avoiding end-of-life conversations with medically frail older adults is an important clinical issue. Most research investigating this practice focuses on clinician training and developing conversation skills. Little is known about the socio-political factors shaping the phenomenon of end-of-life conversations between clinicians and medically frail older patients. Using the critical lens of biomedicalization we consider how two dominant discourses, successful aging and frailty, and subsequent constructions of bodies as malleable or senescent, shape patient subjectivities and influence normative expectations about appropriate healthcare conversations and the consumption of biomedicine for medically frail adults. We highlight the uneven ways medically frail older adults are clinically positioned as successful or frail agers and briefly discuss how gender, class, and race may impact this tension and ambiguity. We conclude by arguing that end-of-life conversations with medically frail older adults is constrained by the pervasiveness of the successful aging discourse and the tendency within medical institutions to construct older bodies as malleable and in need of medical intervention to promote health and longevity.

A rapid scoping review of end-of-life conversations with frail older adults in Canada.

OBJECTIVE: To explore what is known about end-of-life (EOL) conversations with frail older adults across all settings including primary care in Canada, and to understand the barriers to, and recommendations for, EOL conversations. DATA SOURCES: Comprehensive searches were conducted in CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), AgeLine (EBSCO), Sociological Abstracts (ProQuest), and Applied Social Sciences Index and Abstracts (ProQuest). Searches used text words and subject headings (eg, MeSH, Emtree) related to 3 concepts: frailty, Canada, and EOL conversations. STUDY SELECTION: Twenty-one English-language articles were selected (ie, 4 reviews, 10 commentaries, 3 quantitative studies, 3 qualitative studies, 1 mixed-methods study) that included information about EOL conversations with frail older adults in the Canadian health care context. SYNTHESIS: In terms of having EOL conversations with frail older adults, this study found that many clinicians do not often and adequately discuss frailty and impending death with their older patients. Moreover, patients and their care partners do not have enough knowledge about frailty and death to make informed EOL decisions, leading to patients choosing more aggressive therapies instead of care focused on symptom management. In terms of barriers to EOL discussions, common barriers included a lack of trust between clinician and patient, inadequate EOL training for clinicians, and ineffective clinician communication with patients and families. Recommendations for improving EOL conversations include regular screening for frailty to prompt conversations about care and the use of an interprofessional approach. CONCLUSION: More empirical research is needed that uses exploratory methods to shed light on the contextual factors that may act as a barrier to EOL conversations. More research is also needed on the roles and responsibilities of interprofessional teams in screening for frailty and engaging in EOL conversations. Moreover, there is a need to better understand how frail older patients and their families want EOL conversations to unfold and what best facilitates these conversations.

The "nurse as hero" discourse in the COVID-19 pandemic: A poststructural discourse analysis.

BACKGROUND: Nurses have been labelled "heroes" by politicians, the mass media, and the general public to describe their commitment to providing front-line care to people with COVID-19, despite the risks of exposure and lack of clinical resources. Few studies have examined the implications of the hero discourse to nurses' professional, social, and political identities. OBJECTIVE: To critically examine the effects of the hero discourse on nurses who are contending with the ongoing COVID-19 crisis and to consider the political, social, cultural, and professional impact of this discourse on nursing work. METHODS: A poststructural discourse analysis, employing the theoretical ideas of truth, power, knowledge, subjectivity, and normalization, was conducted to explore the mass media's constructions of nurse as hero in the contexts of COVID-19. Media electronic databases were searched between March 1, 2020 to August 1, 2020 to locate newspaper and magazine articles, corporate advertisements, videos, social media postings, and institutional/corporate websites. SETTING: Data sources included English language media accounts that originated from Canada, the USA, and the UK. RESULTS: Three main elements of the hero discourse include: 1. Nurses as a "necessary sacrifice" - portraying nurses as selfless, sacrificing, and outstanding moral subjects for practicing on the front-line without adequate protective gear and other clinical resources; 2. Nurses as "model citizens" - positioning nurses as compliant, hardworking, and obedient subjects in contrast to harmful individuals and groups that ignore or resist COVID-19 public health measures. 3. Heroism itself as the reward for nurses - characterizing hero worship as a fitting reward for nurses who were unappreciated pre-pandemic, as opposed to supporting long-term policy change, and highlighting how heroism reconfigures nursing work from the mundane and ordinary to the exciting and impactful. CONCLUSIONS: The hero discourse is not a neutral expression of appreciation and sentimentality, but rather a tool employed to accomplish multiple aims such as the normalization of nurses' exposure to risk, the enforcement of model citizenship, and the preservation of existing power relationships that limit the ability of front-line nurses to determine the conditions of their work. Our study has implications for approaching the collective political response of nursing in the ongoing COVID-19 crisis and formalizing the ongoing emotional, psychological, ethical, and practice supports of nurses as the pandemic continues.

Advance care planning with chronically ill patients: A relational autonomy approach.

Advance care planning is a process that encourages people to identify their values, to reflect upon the meanings and consequences of serious illness, to define goals and preferences for future medical treatment and care, and to discuss these goals with family and health-care providers. Advance care planning is especially important for those who are chronically ill, as patients and their families face a variety of complex healthcare decisions. Participating in advance care planning has been associated with improved outcomes; yet, despite over 25 years of public awareness campaigns, research, and interventions developed to increase participation, advance care planning completion rates for people with chronic illnesses are no different than those in the general public (approximately 25%). Advance care planning has traditionally used an individualistic approach to autonomy, which puts forward an understanding of agents as independent, rational and self-interested persons. Because this individualistic approach has been largely unsuccessful in improving advance care planning uptake, a re-examination of the philosophical underpinnings of this practice and an exploration of alternative frameworks is warranted. In offering this exploration, we briefly outline two current perspectives on autonomy: the individualistic view and the relational view as articulated by feminist philosophers. Using a critical examination of the theoretical and empirical work on this topic, we argue that the individualistic view of autonomy does not sufficiently capture the relational and social complexities of the decision-making process of advance care planning. To offer a counterpoint, we examine the relational view of autonomy and suggest that this perspective is better aligned with the process of advance care planning. Specifically, we demonstrate that a relational model of autonomy is well suited to exploring advance care planning for four main reasons: (1) it recognizes the importance of relationships, (2) it reflects the fluctuating nature of autonomy in chronic illness, (3) it recognizes vulnerability, and (4) it is consonant with empirical work examining the advance care planning process.

The medicalisation of the dying self: The search for life extension in advanced cancer.

Although many studies have previously examined medicalisation, we add a new dimension to the concept as we explore how contemporary oncological medicine shapes the dying self as predominantly medical. Through an analysis of multiple case studies collected within a comprehensive cancer centre in Ontario, Canada, we examine how people with late-stage cancer and their healthcare providers enacted the process of medicalisation through engaging in the search for oncological treatments, such as experimental drug trials, despite the incurability of their disease. The seven cases included 20 interviews with patients, family, physicians and nurses, the analysis of 30 documents and 5 hr of field observation. A poststructural perspective informed our study. We propose that searching for life extension enacts medicalisation by shaping the dying person afflicted with terminal cancer into new medical subjectivities that are knowledgeable, active, entrepreneurial and curative. Participants initially took up medical thinking from the formal oncology system, but then began to apply and internalise medical rationalities to alter their personhood, thereby generating new curative possibilities for themselves. For people seeking life extension, the embodied and day-to-day experiences of suffering and being close to death became expressed and moderated in fundamentally medicalised terms.

"I'm going to push this door open. You can close it": A qualitative study of the brokering work of oncology clinic nurses in introducing early palliative care.

BACKGROUND: Early palliative care improves quality of life during life-prolonging treatment for patients with cancer, but the role of nurses in facilitating the early involvement of palliative care is unclear. AIM: To conceptualize the psychosocial processes involved in the introduction and provision of palliative care by oncology nurses. DESIGN: A constructivist qualitative grounded theory study was conducted. SETTING/PARTICIPANTS: A total of 20 nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) completed semi-structured interviews. Participants were from multiple ambulatory care oncology clinics (i.e. breast, pancreatic, hematology) in a comprehensive cancer center. RESULTS: The core category, brokering palliative care, represented the overarching concept of the study that linked other subcategories. The other subcategories were as follows: opening the door-creating the possibility of discussing early palliative care at a time when patients show signs of being receptive to this discussion; building trust-establishing relationships with patients as a starting point for open discussions about palliative care; tackling misconceptions-addressing patients' assumptions about palliative care as signifying death; and advocating with oncologists-seeding the process of referral by bringing patients' concerns forward. CONCLUSION: Oncology nurses play a central role in "brokering" the introduction of early palliative care; this process is supported by their relational proximity to patients and their location "in between" the patient and the oncologist. Training all nurses in palliative care and empowering them to have proactive discussions in a collaborative practice context would allow greater access to early palliative care.

Experiences and Expectations of Bereavement Contact among Caregivers of Patients with Advanced Cancer.

BACKGROUND: Contact with bereaved caregivers is not standard practice among cancer physicians, and little is known about its impact on caregivers. OBJECTIVE: Our aim was to describe the experiences and opinions of caregivers regarding bereavement contact from healthcare providers (HCP). DESIGN: Semistructured qualitative interviews were conducted with 61 bereaved caregivers. SUBJECTS: Bereaved caregivers of advanced cancer patients who had completed a randomized controlled trial of an early palliative care intervention were approached one to five years after the patient's death. Caregivers completed qualitative interviews from April 2012 to March 2015 after completion of quantitative measures. APPROACH: In semistructured interviews, bereaved caregivers were asked to describe the contact they received from HCP after the patient's death and their opinions about bereavement contact. We used thematic analysis informed by grounded theory to code and analyze the data. RESULTS: Of 60 caregivers included in the study, 30 (50%) received bereavement contact. There were no thematic differences between trial arms. The themes "contact reflects caring," "contact offers support," and "contact facilitates closure" were prominent among those who were contacted. "Contact is a courtesy," "contact is not always necessary," and "caregiver-initiated contact" were most evident among those who were not contacted. Overall, contact was appreciated by those who received it; for those who did not, reactions included rationalization, ambivalence, and regret. No negative consequences of contact were reported. CONCLUSIONS: Bereavement contact is well received and may be missed if not provided. These data support integration of bereavement contact into routine supportive care for caregivers.

"I didn't want to be in charge and yet I was": Bereaved caregivers' accounts of providing home care for family members with advanced cancer.

OBJECTIVE: To describe bereaved caregivers' experiences of providing care at home for patients with advanced cancer, while interacting with home care services. METHODS: Caregivers of patients who had completed a 4-month randomized controlled trial of early palliative care versus standard oncology care were recruited 6 months to 5 years after the patient's death. All patients except one (control) had eventually received palliative care. In semi-structured interviews, participants were asked about their experiences of caregiving. Grounded theory guided all aspects of the study. RESULTS: Sixty-one bereaved caregivers (30 intervention, 31 control) were interviewed, including spouses (33), adult children (19), and other family (9). There were no differences in themes between control and intervention groups. The core category of Taking charge encompassed caregivers' assumption of active roles in care, often in the face of inadequate formal support. There were 4 interrelated subcategories: (1) Navigating the system-navigating the complexities of the home care system to access resources and supports; (2) Engaging with professional caregivers-interacting with visiting personnel to advocate for consistency and quality of care; (3) Preparing for death-seeking out information about what to expect at the end of life; and (4) Managing after death-managing multiple administrative responsibilities in the emotionally charged period following death. CONCLUSIONS: Caregivers were often thrust into assuming control in order to compensate for deficiencies in formal palliative home care services. Policies, quality indicators, and guidelines are needed to ensure the provision of comprehensive, interdisciplinary home palliative care.

Development and Testing of a Conceptual Model Regarding Men's Access to Health Care.

Epidemiologic data suggest men often experience excessive morbidity and early mortality, possibly compromising family and community health over the lifespan. Moreover, the negative financial/economic consequences affected by poor male health outcomes also has been of great concern in the United States and abroad. Early and consistent access to preventative health care may improve health outcomes; however, men are far less likely to access these services. The purpose of this study was to understand what factors preclude men from accessing health care. We surveyed 485 participants using a 58-item online survey built from a conceptual model previously developed by the researchers using hegemonic masculinity theory, the theory of normative contentment, and the health belief model. For men, three items significantly ( ps < .05) predicted whether they had seen a health care provider in the past year: "I/Men do not access healthcare because I do not think there is anything wrong with me," "My health is only about me," and "I/Men do not access healthcare because most men in my family do not access healthcare." Other correlations of practical significance also were noted. Results suggest gender norms and masculine ideals may play a primary role in how men access preventative health care. Future programming targeting males should consider barriers and plan programs that are gender-sensitive in addition to being gender-specific. Clinical implications are discussed.

The "Conflicted Dying": The Active Search for Life Extension in Advanced Cancer Through Biomedical Treatment.

Using a poststructural perspective, we examine the subjectivities that are produced when advanced cancer patients seek life extension through biomedical treatments. Seven case studies were developed that included 20 interviews with patients, family, nurses, and physicians recruited from a tertiary hospital in Canada, 30 documents, and 5 hours of participant observation. We identify seven types of subjectivity: (a) the Desperate Subject, (b) the Cancer Expert Subject, (c) the Proactive Subject, (d) the Productive Subject, (e) the Mistrusting Subject, (f) the Model Patient Subject, and (g) the Suffering Subject. We characterize the "conflicted dying," a contemporary figure who holds multiple perspectives about seeking curative treatment despite the acknowledgment of death. Using active strategies to gain access to treatment, this figure resists traditional arrangements of power/knowledge established by health care providers. We suggest that the search for life extension is a process of shaping the self to fit certain aesthetical traits associated with surviving cancer.