Coaching doctors to improve ethical decision-making in adult hospitalised patients potentially receiving excessive treatment: Study protocol for a stepped wedge cluster randomised controlled trial.

BACKGROUND: Fast medical progress poses a significant challenge to doctors, who are asked to find the right balance between life-prolonging and palliative care. Literature indicates room for enhancing openness to discuss ethical sensitive issues within and between teams, and improving decision-making for benefit of the patient at end-of-life. METHODS: Stepped wedge cluster randomized trial design, run across 10 different departments of the Ghent University Hospital between January 2022 and January 2023. Dutch speaking adult patients and one of their relatives will be included for data collection. All 10 departments were randomly assigned to start a 4-month coaching period. Junior and senior doctors will be coached through observation and debrief by a first coach of the interdisciplinary meetings and individual coaching by the second coach to enhance self-reflection and empowering leadership and managing group dynamics with regard to ethical decision-making. Nurses, junior doctors and senior doctors anonymously report perceptions of excessive treatment via the electronic patient file. Once a patient is identified by two or more different clinicians, an email is sent to the second coach and the doctor in charge of the patient. All nurses, junior and senior doctors will be invited to fill out the ethical decision making climate questionnaire at the start and end of the 12-months study period. Primary endpoints are (1) incidence of written do-not-intubate and resuscitate orders in patients potentially receiving excessive treatment and (2) quality of ethical decision-making climate. Secondary endpoints are patient and family well-being and reports on quality of care and communication; and clinician well-being. Tertiairy endpoints are quantitative and qualitative data of doctor leadership quality. DISCUSSION: This is the first randomized control trial exploring the effects of coaching doctors in self-reflection and empowering leadership, and in the management of team dynamics, with regard to ethical decision-making about patients potentially receiving excessive treatment.

The feminine and the transgender sinthome: clinical and theoretical issues / Feminino e sintoma transgênero: questões clínicas e teóricas / Féminin et sinthome transgenre: enjeux cliniques et théoriques / Feminino y síntoma transgénero: cuestiones clínicas y teóricas

In some contemporary psychoanalytic theories, a thesis has emerged according to which gender transition can constitute a sinthome. But gender remains a much-discussed notion in Lacanian psychoanalysis, especially in France. This article contributes to the debate by questioning the notion of femininity since it seems to be an essential point in how gender studies and Lacanian sexuation theory diverge. First, we clarify the Lacanian notion of femininity and its conceptual link to the notion of sinthome. Then, we discuss the clinical case of a transgender woman for whom the question of femininity was central during her transition. Finally, we argue how gender transition might function as a sinthome and the limits to such an understanding.

Em algumas teorias psicanalíticas contemporâneas, surgiu a tese de que a transição de gênero pode constituir um sinthoma. Mas gênero continua sendo uma noção muito discutida na psicanálise lacaniana, especialmente na França. Este artigo contribui para o debate ao questionar a noção de feminilidade, pois parece ser um ponto essencial na divergência entre os estudos de gênero e a teoria lacaniana da sexuação. Primeiramente, esclarecemos a noção lacaniana de feminilidade e seu vínculo conceitual com a noção de sinthoma. Em seguida, discutimos o caso clínico de uma mulher transgênero para quem a questão da feminilidade foi central durante sua transição. Por fim, discutimos como a transição de gênero pode funcionar como um sinthoma e os limites para tal compreensão.

Dans certaines théories psychanalytiques contemporaines, une thèse a émergé selon laquelle la transition de genre peut constituer un sinthome. Mais le genre reste une notion très discutée dans la psychanalyse lacanienne, notamment en France. Cet article contribue au débat en interrogeant la notion de féminité puisqu'elle semble être un point sur lequel divergent les études de genre et la théorie lacanienne de la sexuation. Pour ce faire, nous clarifions la notion lacanienne de féminité et son lien conceptuel avec la notion de sinthome. Ensuite, nous étudions le cas clinique d'une femme transgenre pour qui la question de la féminité a été centrale lors de sa transition. Enfin, nous discutons de la manière dont la transition de genre peut fonctionner comme un sinthome et des limites de cette thèse.

En algunas teorías psicoanalíticas contemporáneas ha surgido la tesis de que la transición de género puede constituir un sinthome. Pero el género sigue siendo una noción muy discutida en el psicoanálisis lacaniano, especialmente en Francia. Este artículo contribuye al debate cuestionando la noción de feminidad ya que parece ser un punto esencial en la divergencia entre los estudios de género y la teoría lacaniana de la sexuación. Primero, aclaramos la noción lacaniana de feminidad y su vínculo conceptual con la noción de sinthome. Luego, discutimos el caso clínico de una mujer transgénero para quien la cuestión de la feminidad fue central durante su transición. Finalmente, argumentamos cómo la transición de género podría funcionar como un sinthome y los límites de tal comprensión.

Heterogeneous Response of Chemotherapy-Related Cognitive Decline in Patients with Breast Cancer: A Prospective Study.

OBJECTIVE: A significant proportion of adjuvant-treated breast cancer patients experience cognitive decline, challenging the person's ability to return to normal activities after treatment. However, not every patient experiences cognitive problems, and even in patients with impairments, determining clinically important cognitive decline remains challenging. Our objective was to explore differences in neuropsychological performance following adjuvant chemotherapy (CT) in patients with breast cancer. METHOD: We conducted a prospective observational study in an Oncology Breast Clinic and assessed neuropsychological performance before and after adjuvant CT and in non-CT-treated women with breast cancer and healthy controls (HCs). Standardised between-group differences and regression-based change scores were calculated. RESULTS: CT-treated patients (n = 66) performed significantly different from non-CT-treated patients (n = 39) and HCs (n = 56). There was a significant effect on verbal fluency (p = .0013). CT performed significantly worse than non-CT and HC [effect size (ES) = .89, p < .001 and ES = .61, p ≤ .001, respectively] and from HCs with regard to proactive interference (ES = .62, p ≤ .001). Regression-based scores revealed more severe cognitive decline in the CT-treated group [24.24% (16/66)] than in the non-CT-treated group [15.20% (6/39)] and HC group [7.14% (4/56)]. Patients who underwent CT and showed cognitive decline were less educated and older, with significantly lower baseline scores. CONCLUSIONS: CT-treated patients showed more vulnerability on cognitive control and monitoring than non-CT-treated breast cancer patients and HCs. Older patients with less education and lower baseline cognitive performance represent a group at risk for cognitive decline following CT. Identification of patients at risk for decline could improve targeted support and rehabilitation.

Coping With Moral Distress in Oncology Practice: Nurse and Physician Strategies.

PURPOSE/OBJECTIVES: To explore variations in coping with moral distress among physicians and nurses in a university hospital oncology setting.
. RESEARCH APPROACH: Qualitative interview study.
. SETTING: Internal medicine (gastroenterology and medical oncology), gastrointestinal surgery, and day clinic chemotherapy at Ghent University Hospital in Belgium.
. PARTICIPANTS: 17 doctors and 18 nurses with varying experience levels, working in three different oncology hospital settings. 
. METHODOLOGIC APPROACH: Patients with cancer were interviewed based on the critical incident technique. Analyses were performed using thematic analysis.
. FINDINGS: Moral distress lingered if it was accompanied by emotional distress. Four dominant ways of coping (thoroughness, autonomy, compromise, and intuition) emerged, which could be mapped on two perpendicular continuous axes. CONCLUSIONS: Moral distress is a challenging phenomenon in oncology. However, when managed well, it can lead to more introspection and team reflection, resulting in a better interpersonal understanding.
. INTERPRETATION: Team leaders should recognize their own and their team members' preferred method of coping and tailored support should be offered to ease emotional distress.

Tinnitus, anxiety and automatic processing of affective information: an explorative study.

Anxiety is found to play an important role in the severity complaint of tinnitus patients. However, when investigating anxiety in tinnitus patients, most studies make use of verbal reports of affect (e.g., self-report questionnaires and/or interviews). These methods reflect conscious appraisals of anxiety, but do not map underlying processing mechanisms. Nonetheless, such mechanisms, like the automatic processing of affective information, are important as they modulate emotional experience and emotion-related behaviour. Research showed that highly anxious people process threatening information (e.g., fearful and angry faces) faster than non-anxious people. Therefore, this study investigates whether tinnitus patients process affective stimuli (happy, sad, fearful, and angry faces) in the same way as highly anxious people do. Our sample consisted out of 67 consecutive tinnitus patients. Relationships between tinnitus severity, pitch, loudness, hearing loss, and the automatic processing of affective information were explored. Results indicate that especially in severely distressed tinnitus patients, the severity complaint is highly related to the automatic processing of fearful (r = 0.37, p < 0.05), angry (r = 0.44, p < 0.00) and happy (r = -0.44, p < 0.00) faces, and these relationships became even stronger after controlling for hearing loss. Furthermore, in contrast with findings on the relation between audiological characteristics (pitch and loudness) and conscious report of anxiety, we did find that the audiological characteristic, loudness, tends to be in some degree related to the automatic processing of fearful faces (r = 0.25, p = 0.08). We conclude that tinnitus is an anxiety-related problem on an automatic processing level.

Tinnitus severity and its association with cognitive and somatic anxiety: a critical study.

Tinnitus has been defined as a phantom auditory perception. Research indicates the necessity to make a distinction between the physical symptom and the subjective severity of the tinnitus symptom, since especially the latter seems to vary among patients. The relationship between tinnitus severity and psychological variables has been well established. Anxiety is considered to be an important variable for understanding the differences in the subjective tinnitus severity. Although many studies confirm the relationship between anxiety and tinnitus severity, most studies do not take the possibility of shared method variance and content overlap between questionnaires into account. Furthermore, anxiety is a broad concept and contains both a cognitive and somatic dimension. Research including both dimensions of anxiety in tinnitus population is rare. According to us two conditions must be fulfilled before theorization on the relation is useful: (1) the presence of clinically relevant cognitive and/or somatic anxiety, (2) evidence of a substantial or "real" relationship. In our sample, almost 60% reported more than average cognitive anxiety and 40.8% reported clinical relevant somatic anxiety. After controlling for content overlap between the questionnaires used, the relation between tinnitus severity and cognitive and somatic anxiety remains significant. Two hypothetical models concerning this relationship that deserve future research attention are described.

Tinnitus severity and the relation to depressive symptoms: a critical study.

OBJECTIVE: In this study, the authors investigated whether tinnitus severity is a problem related to depression. If so, the following 2 conditions should be fulfilled: first, there should be evidence for the presence of moderate to severe depressive symptomatology in a substantial group of tinnitus patients; second, there should be evidence of a substantial relationship between depressive symptoms and tinnitus severity. STUDY DESIGN: Cross-sectional. SETTING: Ear, Nose, and Throat (ENT) Department of the Ghent University Hospital. SUBJECTS AND METHODS: In total, 136 consecutive help-seeking tinnitus patients were seen by a psychologist, an audiologist, and an ENT specialist. All patients filled in the Beck Depression Inventory II (BDI-II) and the Tinnitus Handicap Inventory (THI) and underwent psychoacoustic measurement. RESULTS: Mean scores indicate the presence of no or minimal depressive symptoms. There was a positive correlation (P < .01) between the BDI-II and the THI. No correlations were found between psychoacoustic measures and the self-report questionnaires. Linear regression analysis was performed to examine the predictive role of the 3 components of depression (cognitive, somatic, and affective) in tinnitus severity. Results show that only the somatic depression subscale of the BDI-II significantly predicted tinnitus severity, which can be explained because of content overlap between the BDI-II and the THI. CONCLUSION: Tinnitus does not appear to be a problem related to depression. The authors did not find a substantial group of tinnitus patients with moderate to severe depressive symptoms. The relation between depressive symptoms and tinnitus severity seems to be an artifact of content overlap between the BDI-II and the THI.

Interpersonal problems in alexithymia: A study in three primary care groups.

OBJECTIVES: The present study investigated the relation between alexithymia and interpersonal problems in a sample of primary care patients with either chronic fatigue syndrome (CFS); a chronic cardiovascular or auto-immune disease; or a minor medical condition. It was hypothesized that the relation between cold interpersonal functioning would account for the differences in alexithymia scores between the patient groups. DESIGN AND METHODS: Participants were 155 primary care patients that were recruited through 52 general practitioners: 52 CFS patients; 52 patients with a chronic cardiovascular or auto-immune disease; 51 patients with a minor medical condition. Interpersonal problems were assessed by means of the Inventory of Interpersonal Problems and alexithymia was assessed by means of the Toronto Alexithymia Scale. RESULTS: CFS patients and patients with a chronic cardiovascular or auto-immune disease have substantially higher alexithymia scores than patients with a minor medical condition. Alexithymia is positively related to cold and distant interpersonal functioning; negatively related to self-sacrificing and overly accommodating in relation to others; and positively related to vindictiveness and self-centredness. The relation between alexithymia and these interpersonal problems accounts for the differences in alexithymia scores between the patient groups. CONCLUSIONS: Alexithymia and interpersonal problems should be considered together, in terms of one deficient affect regulatory system, and the relation between alexithymia and specific illness conditions is secondary to this. Clinical assessment of patients with problems in naming and discussing affective states should never be isolated from an examination of their interpersonal problems, and vice versa. Mentalization-based therapy is recommended for patients with problems in naming affective states, interpersonal problems, and concomitant CFS or other alexithymia-related diseases.

Unexplained chronic fatigue and interpersonal problems: a study in a primary care population.

OBJECTIVE: Unexplained fatigue syndromes are multidimensional phenomena that involve a constellation of symptoms. This article explores whether typical interpersonal problems are associated with self-reported and clinically-rated fatigue symptoms in chronically fatigued patients. We hypothesize that the severity of fatigue symptoms will be associated with a pattern of withdrawal from social interaction. METHOD: Interpersonal problems were assessed by means of a self-report questionnaire. Chronic fatigue was assessed with a self-report questionnaire (both self-rated and clinically-rated) in a primary care Chronic Fatigue Syndrome (CFS) group (N = 52) and compared with two other clinical populations (minor medical condition: N = 51; chronic organic disease: N = 52). RESULTS: Compared to patients with a minor medical condition, CFS patients are substantially more fatigued and more socially withdrawn. Compared to patients with a chronic organic disease, somewhat more fatigue-related disability was observed in CFS patients, but no distinct interpersonal problems came to the fore. CFS patients and physicians proved to differ in their opinion on the patient's motivation. In line with the hypothesis, self-rated and clinically-scored fatigue problems proved to be related to a pattern of withdrawal from social interaction. CONCLUSION: Differences between physicians' and patients in how symptoms are interpreted might be related to patients feeling misunderstood and result in social withdrawal.

Unexplained chronic fatigue and core conflictual relationship themes: A study in a chronically fatigued population.

OBJECTIVE: Unexplained fatigue syndromes are multidimensional phenomena that involve a constellation of symptoms. This paper explores whether typical relationship patterns are associated with self-reported and clinically rated fatigue symptoms in chronically fatigued patients. METHOD: Relationship patterns were assessed by means of the core conflictual relationship theme (CCRT) method. This method examines transference patterns, and was applied to interview data collected from chronically fatigued patients (N=30). Chronic fatigue was assessed by means of a self-report questionnaire and was also rated clinically. RESULTS: Both self-reported and clinically rated fatigue correlated with relationship themes. The intensity of fatigue related to the perception of others as not respecting and as negatively interfering. The typical reaction of the self to relationships consists of feeling disrespected, anger, passivity, and reduced feelings of self-consistency. CONCLUSION: Patients' perception of interpersonal relationships as distressing may be pivotal in understanding these results. Implications for clinical intervention and future research are indicated.

Posttraumatic distress in security guards and the various effects of social support.

This study investigates the effects of six types of social support on distress and posttraumatic stress disorders in security guards who did and did not encounter a critical incident. Three types of social support were significantly related to distress and posttraumatic stress disorder: emotional support in problem situations, instrumental support, and social companionship. Emotional support in problem situations paradoxically appeared to have an aggravating effect on distress and posttraumatic stress, whereas instrumental support and social companionship had a mitigating outcome.

Pilot study: does the Five Shot Questionnaire give an indication of the severity of alcohol use-related problems?

This study explores whether the Five Shot Questionnaire reflects the severity of alcoholic inpatients' problems, such as assessed clinically by means of the EuropASI. Data were collected from 101 patients admitted to a psychiatric hospital in Belgium for alcohol use-related problems between September 2003 and December 2004. To investigate the research question, regression analyses--linear, ordinal, and binary logistic regression--have been performed. We conclude that the Five Shot Questionnaire gives an indication of the severity of alcohol use-related problems. As such, it can be recommended in general practice and emergency departments for further evaluation and treatment planning. The article ends with a discussion of its limitations and some suggestions for future research.

Alexithymia and core conflictual relationship themes: a study in a chronically fatigued primary care population.

OBJECTIVE: Clinical studies have indicated that concomitant to problems with affect regulation interpersonal problems can be observed in alexithymic patients. We test whether this is the case, and determine a parsimonious set of typical relationship themes. METHOD: Relationship themes were assessed by means of the Core Conflictual Relationship Theme (CCRT) method. This method examines transference patterns, and was applied to clinical interview data collected from a sample (n = 30) of chronically fatigued primary care patients. Alexithymia was assessed by means of a score on the 20-item Toronto Alexithymia Scale. The data were analyzed by means of the leaps and bounds regression algorithm for selecting optimal subsets of indicators, and by bootstrapping to determine 95% confidence intervals. RESULTS: Alexithymia can be meaningfully explained by typical relationship themes. A set of two wishes and one response of the self to the other that is most representative of alexithymia was mapped. The wishes demonstrate that the more alexithymic someone is, the less likely it is that this person wishes to be helped by others and the less likely it is that he/she interacts with others in order to feel good about him/herself. The selected response of the self indicates that it is typical of alexithymia that interactions with others do not result in good or happy feelings. CONCLUSION: Linking alexithymia to typical relationship themes is valid. Limitations of the study are indicated.