Palliative psychiatry: research, clinical, and educational priorities.

BACKGROUND: Palliative psychiatry has been proposed as a new clinical construct within mental health care and aims to improve quality of life (QoL) for individuals experiencing severe and persistent mental illness (SPMI). To date, explorations of palliative psychiatry have been largely theoretical, and more work is needed to develop its approaches into tangible clinical practice. METHODS: In this paper, we synthesize existing literature with discussions held at a one-day knowledge user meeting titled "A Community of Practice for Palliative Psychiatry" to generate priorities for research, clinical practice, and education that will help advance the development of palliative psychiatry. RESULTS: Palliative psychiatry will benefit from research that is co-produced by people with lived experience (PWLE) of mental illness, that clarifies contested concepts within mental health care and wider medicine, and that adapts existing interventions that have the potential to improve the QoL of individuals experiencing SPMI into the mental health care context. Specific methods and tools might be developed for use in clinical spaces taking a palliative psychiatry approach. More work must be done to understand the populations that might benefit from palliative psychiatry, and to mitigate mental health care providers' (MHCPs') anxieties about using these approaches in their work. As palliative psychiatry is developed, current MHCPs, trainees, individuals experiencing SPMI, and their loved ones will all require education about and orientation to this novel approach within mental health care. CONCLUSIONS: There are several priorities in research, clinical practice, and education that can help advance the development of palliative psychiatry. All future work must be considered through a human rights-based, anti-oppressive lens. Research projects, clinical models, and educational initiatives should all be developed in co-production with PWLE to mitigate the epistemic injustices common in mental health care.

Perceptions of Safety of Daily Cannabis vs Tobacco Smoking and Secondhand Smoke Exposure, 2017-2021.

Importance: While rates of cigarette use are declining, more US adults are using cannabis. Perceptions of safety are important drivers of substance use and public policy; however, little is known about the comparative views of US adults on tobacco and cannabis safety. Objective: To compare public perceptions of safety of cannabis vs tobacco smoke and evaluate how perceptions may be changing over time. Design, Setting, and Participants: This longitudinal survey study was conducted using a web-based survey administered in 2017, 2020, and 2021. US adults participating in Ipsos KnowledgePanel, a nationally representative, population-based survey panel, were included. Data were analyzed from March 2021 through June 2023. Main Outcomes and Measures: Two questions directly compared the perception of safety of cannabis vs tobacco in terms of daily smoking and secondhand smoke exposure. Additional questions assessed perceptions of safety of secondhand tobacco smoke for adults, children, and pregnant women, with an analogous set of questions for secondhand cannabis smoke. Results: A total of 5035 participants (mean [SD] age, 53.4 [16.2] years; 2551 males [50.7%]) completed all 3 surveys and provided responses for tobacco and cannabis risk questions. More than one-third of participants felt that daily smoking of cannabis was safer than tobacco, and their views increasingly favored safety of cannabis vs tobacco over time (1742 participants [36.7%] in 2017 vs 2107 participants [44.3%] in 2021; P < .001). The pattern was similar for secondhand cannabis smoke, with 1668 participants (35.1%) responding that cannabis was safer than tobacco in 2017 vs 1908 participants (40.2%) in 2021 (P < .001). Participants who were younger (adjusted odds ratio [aOR] for ages 18-29 years vs ≥60 years, 1.4 [95% CI, 1.1-1.8]; P = .01) or not married (aOR, 1.2 [95% CI, 1.0-1.4]; P = .01) were more likely to move toward safer views of cannabis use over time, while those who were retired (aOR vs working, 0.8 [95% CI, 0.7-0.9]; P = .01) were less likely to move toward a safer view of cannabis. Participants were also more likely to rate secondhand smoke exposure to cannabis vs tobacco as completely or somewhat safe in adults (629 participants [12.6%] vs. 119 participants [2.4%]; P < .001), children (238 participants [4.8%] vs. 90 participants [1.8%]; P < .001), and pregnant women (264 participants [5.3%] vs. 69 participants [1.4%]; P < .001). Conclusions and Relevance: This study found that US adults increasingly perceived daily smoking and secondhand exposure to cannabis smoke as safer than tobacco smoke from 2017 to 2021. Given that these views do not reflect the existing science on cannabis and tobacco smoke, the findings may have important implications for public health and policy as the legalization and use of cannabis increase.

Enhancing end of life care on general internal medical wards: the 3 Wishes Project.

BACKGROUND: Initially developed in the intensive care unit (ICU) at St. Joseph's Healthcare Hamilton (SJHH) the 3 Wishes Project (3WP) provides personalized, compassionate care to dying patients and their families. The objective of this study was to develop and evaluate 3WP expansion strategies for patients cared for on General Internal Medicine (GIM) wards in our hospital. METHODS: From January 2020-November 2021, we developed a phased, multicomponent approach for program expansion. We enrolled patients on the GIM wards who had a high probability of dying in hospital, then elicited, implemented, and documented wishes for them or their families. Data were analyzed descriptively. RESULTS: From March 2020 to November 2020, we implemented staff education and engagement activities, created an Expansion Coordinator position, held strategic consultations, and offered enabling resources. From March 2020 to November 2021, we enrolled 62 patients and elicited 281 wishes (median [1st, 3rd quartiles] 4 [4, 5] wishes/patient). The most common wish categories were personalizing the environment (67 wishes, 24%), rituals and spiritual support (42 wishes, 15%), and facilitating connections (39 wishes, 14%). The median [1st, 3rd] cost/patient was $0 [0, $10.00] (range $0 to $86); 91% of wishes incurred no cost to the program. CONCLUSIONS: The formal expansion of the 3WP on GIM wards has been successful despite COVID-19 pandemic disruptions. While there is still work ahead, these data suggest that implementing the 3WP on the GIM wards is feasible and affordable. Increased engagement of the clinical team during the pandemic suggests that it is positively received.

Comparison of mental health outcomes of augmenting medications for patients with posttraumatic stress disorder: A national veterans affairs study.

RATIONALE: Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD. AIMS AND OBJECTIVES: We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication. METHOD: We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days. RESULTS: Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline. CONCLUSION: Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.

Effectiveness of synchronous action observation and mental practice on upper extremity motor recovery after stroke.

The purpose of this quasi-experimental pretest-posttest control group study was to examine the effect of group synchronous action observation/mental practice intervention compared to usual rehabilitation care on upper extremity motor recovery after stroke. The intervention group (n = 25) received usual care, consisting of a minimum of 3 hours of rehabilitation services per day, 5 days a week, plus group synchronous action observation/mental practice sessions 3 times per week and the control group (n = 26) received usual care. Outcome measures included the Kinesthetic and Visual Imagery Questionnaire Short Version (KVIQ-10), the Fugl-Meyer Assessment (FMA-UE) of affected upper extremity motor function only and The Box and Block Test (BBT). Although there were no statistically significant differences in upper extremity motor function between the two groups, a subgroup analysis of the intervention group identified statistically significant (FMA-UE: p < .001; BBT: p = .04) and Minimally Important Clinical Differences on upper extremity motor recovery between patients with behaviors demonstrating more versus less commitment to the intervention. Group synchronous action observation/mental practice is a promising intervention for patients demonstrating commitment to actively participating in the intervention to improve outcomes on upper extremity motor recovery after stroke.

Implementation of Interprofessional Meetings Preparing Caregivers of Patients With Brain Injury for Discharge: A Pilot Study.

PURPOSE OF STUDY: Caregivers are often unprepared to care for patients discharged with brain injury. Interprofessional team meetings with the caregiver used in some specialties improve discharge planning. The purpose of this study was to evaluate the effect of a standardized interprofessional caregiver meeting on caregiver readiness for caregiving. PRIMARY PRACTICE SETTING: The study was implemented on an eight-bed brain injury unit within a 73-bed Magnet-designated surgery and rehabilitation hospital in south central Pennsylvania. METHODOLOGY AND SAMPLE: This study used a pre-/post-quasi-experimental retrospective design. Caregivers of patients admitted to the brain injury unit completed the Preparedness for Caregiving Scale at admission and discharge. The intervention group received an interprofessional team meeting focused on the needs of the caregiver in preparation for caregiving within 3-4 days of admission compared with unscheduled meetings as needed. RESULTS: Scores improved significantly from admission to discharge in usual care and intervention groups. Sample size was insufficient to detect differences between groups. Health care providers and caregivers expressed improvement in communication and readiness for discharge. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Early interprofessional meetings with the purpose of getting to know and understanding the needs of caregivers of patients with brain injury could guide us to better prepare the caregiver for caregiving at home. The Preparedness for Caregiving Scale can be useful to assess multiple domains of caregiving. This proactive approach may improve communication and discharge readiness for patients with brain injury.

Trends in Medication Prescribing in Patients With PTSD From 2009 to 2018: A National Veterans Administration Study.

OBJECTIVE: To evaluate longitudinal prescription practice trends for patients diagnosed with posttraumatic stress disorder (PTSD) using a national cohort of veterans who engaged in Veterans Health Administration (VHA) care from 2009 to 2018. METHODS: Using ICD-9 and ICD-10 codes to determine diagnoses, 1,353,416 patients diagnosed with PTSD in VHA care were retrospectively identified who were not diagnosed with bipolar or psychotic spectrum disorder. Veterans were included in the analytic sample starting in the year of their first PTSD diagnosis for each year that they were active in VHA care. Outpatient prescription records were examined from 2009 to 2018 for medications that are commonly used as recommended (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) or second-line/adjunctive (atypical antipsychotics [AAPs], mirtazapine, prazosin, trazodone, tricyclic antidepressants, and non-benzodiazepine hypnotics) medications for PTSD. Benzodiazepine prescriptions were also examined. RESULTS: From 2009 to 2018, the percentage of patients active in VHA care who received at least one of the examined recommended or second-line/adjunctive medications for PTSD in a calendar year declined by 9.0% (absolute change). The largest absolute change in rates of prescribing for medication classes over the last decade were observed among SSRIs (-12.3%) and SNRIs (+6.4%). AAP use decreased 5.4% from 2009 to 2018, with most of this change (-4.3%) occurring from 2009 to 2013. CONCLUSIONS: Consistent with clinical practice guidelines, SSRIs/SNRIs were the most common prescriptions for patients in the current study. Reductions in the percentage of patients receiving PTSD medications may reflect concerns regarding effectiveness, adverse side effects, increases in access to evidence-based psychotherapy for PTSD, and/or symptom improvement such that medication was no longer needed.

Scale-up and sustainability of a personalized end-of-life care intervention: a longitudinal mixed-methods study.

BACKGROUND: Scaling-up and sustaining healthcare interventions can be challenging. Our objective was to describe how the 3 Wishes Project (3WP), a personalized end-of-life intervention, was scaled-up and sustained in an intensive care unit (ICU). METHODS: In a longitudinal mixed-methods study from January 12,013 - December 31, 2018, dying patients and families were invited to participate if the probability of patient death was > 95% or after a decision to withdraw life support. A research team member or bedside clinician learned more about each of the patients and their family, then elicited and implemented at least 3 personalized wishes for patients and/or family members. We used a qualitative descriptive approach to analyze interviews and focus groups conducted with 25 clinicians who cared for the enrolled patients. We used descriptive statistics to summarize patient, wish, and clinician characteristics, and analyzed outcome data in quarters using Statistical Process Control charts. The primary outcome was enrollment of terminally ill patients and respective families; the secondary outcome was the number of wishes per patient; tertiary outcomes included wish features and stakeholder involvement. RESULTS: Both qualitative and quantitative analyses suggested a three-phase approach to the scale-up of this intervention during which 369 dying patients were enrolled, having 2039 terminal wishes implemented. From a research project to clinical program to an approach to practice, we documented a three-fold increase in enrolment with a five-fold increase in total wishes implemented, without a change in cost. Beginning as a study, the protocol provided structure; starting gradually enabled frontline staff to experience and recognize the value of acts of compassion for patients, families, and clinicians. The transition to a clinical program was marked by handover from the research staff to bedside staff, whereby project catalysts mentored project champions to create staff partnerships, and family engagement became more intentional. The final transition involved empowering staff to integrate the program as an approach to care, expanding it within and beyond the organization. CONCLUSIONS: The 3WP is an end-of-life intervention which was implemented as a study, scaled-up into a clinical program, and sustained by becoming integrated into practice as an approach to care.

End-of-Life Skills and Professionalism for Critical Care Residents in Training: The ESPRIT Survey.

End-of-life (EOL) care is a key aspect of critical care medicine (CCM) training. The goal of this study was to survey CCM residents and program directors (PDs) across Canada to describe current EOL care education. Using a literature review, we created a self-administered survey encompassing 10 CCM national objectives of training to address: (1) curricular content and evaluation methods, (2) residents' preparedness to meet these objectives, and (3) opportunities for educational improvement. We performed pilot testing and clinical sensibility testing, then distributed it to all residents and PDs across the 13 Canadian CCM programs. Our response rate was 84.3% overall (77 [81.1%] for residents and 13 [100%] for PDs). Residents rated direct observation, informal advice, and self-reflection as both the top 3 most utilized and perceived most effective teaching modalities. Residents most commonly reported comfort with skills related to pain and symptom management (n = 67, 94.3%; score > 3 on 5-point Likert scale), and least commonly reported comfort with donation after cardiac death skills (n = 26-38; 44.8%-65.5%). Base specialty and time in CCM training were independently associated with comfort ratings for some, but not all, EOL skills. With respect to family meetings, residents infrequently received feedback; however, most PDs believed feedback on 6 to 10 meetings is required for competence. When PD perceptions of teaching effectiveness were compared with resident comfort ratings, differences were most apparent for skills related to pain and symptom management, cultural awareness, and ethical principles. By the end of their first subspecialty training year, PDs expect residents to be competent at most, but not all, EOL skills. In summary, trainees and programs rely on clinical activities to develop competency in EOL care, resulting in some educational gaps. Transitioning to competency-based medical education presents an opportunity to address some of these gaps, while other gaps will require more specific curricular intervention.

Experiences of Bereaved Family Members Receiving Commemorative Paintings: A Qualitative Study.

Importance: Although family members of patients who die in the intensive care unit commonly experience long-term psychological distress, end-of-life bereavement support programs for such relatives are uncommon. Whether art influences the grief experience of families is largely unexplored. Objective: To explore the influence of personalized paintings created to honor deceased critically ill patients on family members' bereavement experience. Design, Setting, and Participants: A qualitative descriptive analysis was conducted of semistructured interviews of grieving relatives who received a painting after the death of their loved one. The deceased patients were from a 21-bed medical-surgical intensive care unit. Eleven families were invited to receive a painting, of whom 1 family declined. A total of 22 family members of 10 patients who died in the intensive care unit were interviewed in the study between July 11, 2017, and May 19, 2019. Interventions: Patients were enrolled in an end-of-life care program that elicits and implements wishes of patients and their families to bring peace during the dying process. Selected families of 10 decedents were invited to receive a painting to honor their loved one 1 to 10 months after the patient's death. Using details about the patient's life story, the artist created individualized paintings to commemorate each patient. Main Outcomes and Measures: The experiences of family members receiving a personalized painting and its reported influence on their grieving experience. Results: The family members of 10 decedents (mean [SD] age, 60 [14] years; 5 women [50%]; 8 White patients [80%]) were interviewed. The central theme of art to facilitate healing was illustrated through the following domains: the cocreation process, painting narratives, postmortem connections, and legacy. The process of cocreating the paintings with the artist and family members involved reminiscing, storytelling, and creativity. Family members emphasized the role of art to facilitate healing, exemplified through connections with images portrayed that deeply resonated with memories of their loved one. Participants indicated that the paintings validated that the patient was remembered, helped families feel less alone during a time of grief, honored the loved one's life, and enhanced connections between family members and clinicians. Conclusions and Relevance: This qualitative study's findings suggest that the creation of personalized paintings commemorating the lives of patients may help foster legacy and postmortem connections with clinicians and may help family members in their healing process.

ECMO survivors' quality of life and needs after discharge: A descriptive, comparative cross-sectional pilot study.

OBJECTIVES: To describe gender differences in health-related quality of life and characterise discharged patients' perceptions of follow-up needs after extracorporeal membrane oxygenation. RESEARCH METHODOLOGY/DESIGN: A descriptive, comparative cross-sectional pilot design was used. Adult patients receiving extracorporeal membrane oxygenation discharged between January 1, 2016 and March 31, 2018 participated in telephone interviews. SETTING: A 580-bed community teaching hospital in south central Pennsylvania. MAIN OUTCOME MEASURES: Health-related quality of life was measured with the Rand 36-item Short Form Health Survey. Open-ended questions identified post-discharge healthcare services and perceived follow-up needs. RESULTS: Of 30 eligible patients, 24 completed a telephone interview. All health-related quality of life dimensions, except for role-emotional and mental health, were lower in post- extracorporeal membrane oxygenation patients at follow-up compared to national norms. Women scored lower than men in all health-related quality of life dimensions. The most frequent post-discharge services used were physical therapy (66.7%), rehabilitation (62.5%) and occupational therapy (54.2%). The need for coordination of care post-discharge was identified. CONCLUSIONS: Given long-term sequelae of extracorporeal membrane oxygenation on health-related quality of life and gender differences in health-related quality of life outcomes, ongoing interdisciplinary follow-up is imperative to ensure comprehensive patient management across the continuum of care.

Effect of a Scheduled Nurse Intervention on Thirst and Dry Mouth in Intensive Care Patients.

BACKGROUND: Thirst is a common, intense symptom reported by hospitalized patients. No studies indicate frequency of use of ice water and lip moisturizer with menthol to ameliorate thirst and dry mouth. In an audit of 30 intensive care unit patients at a 580-bed community teaching hospital, 66% reported dry mouth with higher thirst distress and intensity scores than in published studies. OBJECTIVES: To evaluate the effectiveness of scheduled use of ice water oral swabs and lip moisturizer with menthol compared with unscheduled use in relieving thirst and dry mouth for intensive care unit patients. METHODS: In a quasi-experimental design, adult patients admitted to 2 intensive care units at a community hospital were provided with ice water oral swabs and lip moisturizer with menthol upon request. The intervention was unscheduled in 1 unit and scheduled in the other unit. The scheduled intervention was provided hourly during a 7-hour period (n = 62 participants). The unscheduled intervention consisted of usual care (n = 41 participants). A numeric rating scale (0-10) was used to measure thirst intensity, thirst distress, and dry mouth before and after 7 hours in both groups. RESULTS: The scheduled-use group had significant lessening of thirst intensity (P = .02) and dry mouth (P = .008). Thirst distress in the scheduled-use group did not differ from that in the unscheduled-use group (P = .07). CONCLUSION: Scheduled use of ice water oral swabs and lip moisturizer with menthol may lessen thirst intensity and dry mouth in critical care patients.

Proteoglycan Isolation and Analysis.

Proteoglycans can be difficult molecules to isolate and analyze due to large mass, charge, and tendency to aggregate or form macromolecular complexes. This unit describes detailed methods for purification of matrix, cell surface, and cytoskeleton-linked proteoglycans. Methods for analysis of glycoaminoglycan size and type and of core protein species are described. © 2018 by John Wiley & Sons, Inc.

Effect of the Salary Model on Sustainability of a Professional Practice Environment.

OBJECTIVE: This replication study examined differences in RN perception of the professional practice environment (PPE) between salary- and hourly-wage compensation models over time. BACKGROUND: A previous study demonstrated that nurses in a salary-wage model had a significantly higher perception of the PPE compared with their peers receiving hourly wages. METHODS: A descriptive, comparative design was used to examine the Revised Professional Practice Environment (RPPE) scale of nurses in the same units surveyed in the previous study 2 years later. RESULTS: Mean scores on the RPPE continued to be significantly lower for hourly-wage RNs compared with the RNs in the salary-wage model. CONCLUSIONS: Nurses in an hourly-wage unit have significantly lower perceptions of the clinical practice environment than their peers in a salary-wage unit, indicating that professional practice perceptions in a salary-wage unit were sustained for a 2-year period and may provide a more effective PPE.

Referral processes and wait times in primary care.

OBJECTIVE: To evaluate the response times to requests for consultations from FPs and the wait times for patient appointments. DESIGN: Mailed invitation to participate in a survey about non-FP specialist consultation requests from April 28 to May 9, 2014. SETTING: Hamilton, Ont. PARTICIPANTS: All active physicians with community practices from the Department of Family Medicine at St Joseph's Healthcare Hamilton and Hamilton Health Sciences. MAIN OUTCOME MEASURES: All non-FP specialist consultation requests for a 2-week period. RESULTS: Thirty-four practices (9.6% response rate) collected data on 816 consultation requests. Requests for referrals were most commonly made to the following 5 specialties: dermatology, surgery, gastroenterology, orthopedics, and obstetrics and gynecology. Overall, 36.4% of the requests for consultation received no response from the non-FP specialist's office by the end of the follow-up period. The mean wait time for a patient appointment was 60.1 days (range 23.3 to 168.5 days). Five specialties had particularly lengthy wait times of 105.9 to 168.5 days. CONCLUSION: Allowing 5 to 7 weeks for a response from a non-FP specialist, there was still a 36.4% nonresponse rate (similar to a pilot survey administered in 2010). Patient and physician frustration is certainly heightened and more office time and energy is expended when no acknowledgment of a referral is received within 7 weeks. This gives our community wait times much longer than those reported by any of the national bodies.

A trivalent, inactivated influenza vaccine (Vaxigrip®): summary of almost 50 years of experience and more than 1.8 billion doses distributed in over 120 countries.

INTRODUCTION: Vaxigrip, a trivalent split-virion, inactivated vaccine available since 1968 has been in use longer than any other influenza vaccine. It is the most widely-used influenza vaccine, with more than 1.8 billion doses distributed in more than 120 countries. Areas covered: The significant body of evidence that confirms the efficacy, effectiveness, immunogenicity, and safety of Vaxigrip in healthy individuals of all ages and at-risk populations is summarized. The results from at least 15 randomized efficacy trials and 15 other studies have demonstrated that vaccination with Vaxigrip is efficacious against various clinical endpoints. It was estimated that more than 37 million laboratory-confirmed influenza episodes, 476,000 influenza-related hospitalizations, and 67,000 influenza-related deaths have been avoided by the more than 1.8 billion doses of Vaxigrip that have been distributed, emphasizing its important public health impact. Expert commentary: This strong evidence base in favor of Vaxigrip provides a robust foundation to support the implementation of the quadrivalent formulation. This quadrivalent formulation of Vaxigrip contains two A and two B influenza strains (VaxigripTetra), and has a similar immunogenicity and safety profile to the trivalent formulation while offering broader protection due to the addition of the second influenza B strain.

Role of family physicians in an urban hospital: Tracking changes between 1977, 1997, and 2014.

OBJECTIVE: To investigate changes in family doctors' attitudes about and participation in hospital activities and inpatient care in an urban hospital family medicine department from 1977 to 1997 and 2014. DESIGN: Cross-sectional survey design. SETTING: The Department of Family Medicine at St Joseph's Healthcare Hamilton in Ontario. PARTICIPANTS: Family physicians affiliated with the Department of Family Medicine at St Joseph's Healthcare Hamilton were surveyed in 2014. Data were compared with findings from similar surveys administered at this institution in 1977 and 1997. MAIN OUTCOME MEASURES: Family physicians' roles in hospital activities, attitudes toward the role of the family physician in the hospital setting, and the barriers to and facilitators of maintaining this role. RESULTS: A total of 93 physicians returned completed surveys (37.3% response rate). In 2014, half of the respondents provided some inpatient care. This patient care was largely supportive and newborn care (71.7% and 67.4%, respectively). In 2014, 47.3% believed the quality of care would suffer (compared with 92.1% in 1977 and 87.5% in 1997) if they were not involved in patient care in the hospital. There was also a considerable shift away from the 1977 and 1997 perception that the family physician had a role as patient advocate: 92.0% and 95.3%, respectively, compared with only 49.5% in the 2014 survey. CONCLUSION: Family physicians' hospital activities and attitudes continued to change from 1977 to 1997 and 2014 in this urban hospital setting. Most of the respondents had stopped providing direct inpatient care, with a few continuing to provide supportive care. Despite this, most respondents still see a role for the Department of Family Medicine within the hospital as a focus for identifying with their family physician community, a place to interact with other specialist colleagues, and a source of some continuing medical education.

Experiences and Expressions of Spirituality at the End of Life in the Intensive Care Unit.

RATIONALE: The austere setting of the intensive care unit (ICU) can suppress expressions of spirituality. OBJECTIVES: To describe how family members and clinicians experience and express spirituality during the dying process in a 21-bed medical-surgical ICU. METHODS: Reflecting the care of 70 dying patients, we conducted 208 semistructured qualitative interviews with 76 family members and 150 clinicians participating in the Three Wishes Project. Interviews were recorded and transcribed verbatim. Data were analyzed by three investigators using qualitative interpretive description. MEASUREMENTS AND MAIN RESULTS: Participants characterize dying as a spiritual event. Spirituality is an integral part of the life narrative of the patient before, during, and after death. Experiences and expressions of spirituality for patients, families, and clinicians during end-of-life care in the ICU are supported by eliciting and implementing wishes in several ways. Eliciting wishes stimulates conversations for people of diverse spiritual orientations to respond to death in personally meaningful ways that facilitate continuity and closure, and ease emotional trauma. Soliciting wishes identifies positive aspirations, which provide comfort in the face of death. The act of soliciting wishes brings clinician humanity to the fore. Wishing makes individual spiritual preferences and practices more accessible. Wishes may be grounded in spiritual goals, such as peace, comfort, connections, and tributes; they may seek a spiritually enhanced environment or represent specific spiritual interventions. CONCLUSIONS: Family members and clinicians consider spirituality an important dimension of end-of-life care. The Three Wishes Project invites and supports the expression of myriad forms of spirituality during the dying process in the ICU.

Parent reported outcomes of quality care and satisfaction in the context of a life-limiting fetal diagnosis.

OBJECTIVE: To identify which quality indicators (QI) predict patient satisfaction. METHODS: A cross-sectional design using a validated tool was administered using a Web-based platform. Parents (n = 405) who experienced a life-limiting fetal diagnosis and opted to continue their pregnancy provided feedback on 37 QI and satisfaction with prenatal care. Descriptive analyses and logistic regression identified relationships among variables. RESULTS: Parental satisfaction with care was 75.6%. Statistically significant differences in mean scores were reported with satisfied patients reporting higher agreement with quality indicators. Parents who were satisfied with their care had 1.9 times the odds of reporting that consistent care was provided (CI: 1.4-2.4, p < 0.01), 1.8 times the odds of reporting compassionate care (CI: 1.4-2.5, p < 0.01) and 1.8 times the odds that they received help to cope with their emotions (CI: 1.4-2.3, p < 0.01). The model correctly predicted parent satisfaction 92% of the time. CONCLUSION: Provision of consistent prenatal care is an important quality indicator for this population of parents. The odds of securing satisfied parents increase when families are treated with compassion and given resources to help them cope with the emotionally devastating experiences associated with a life-limiting fetal diagnosis.