What Is Wrong with Monetary Sanctions? Directions for Policy, Practice, and Research.

Monetary sanctions are an integral and increasingly debated feature of the American criminal legal system. Emerging research, including that featured in this volume, offers important insight into the law governing monetary sanctions, how they are levied, and how their imposition affects inequality. Monetary sanctions are assessed for a wide range of contacts with the criminal legal system ranging from felony convictions to alleged traffic violations with important variability in law and practice across states. These differences allow for the identification of features of law, policy, and practice that differentially shape access to justice and equality before the law. Common practices undermine individuals' rights and fuel inequality in the effects of unpaid monetary sanctions. These observations lead us to offer a number of specific recommendations to improve the administration of justice, mitigate some of the most harmful effects of monetary sanctions, and advance future research.

Connecting the right to health and anti-extractivism globally / Conectando o direito à saúde e o antiextrativismo globalmente / Conectando el derecho a la salud y el anti-extractivismo a nivel mundial

ABSTRACT Natural resources are essential to health and are global commons. Recognizing the devastating damage posed by extraction to health and the environment, as well as the erosion of the sovereignty of our governments that have increasingly conceded people's health in the interest of profit and development, is important in framing our resistance. Our communities experience growing displacement, the loss of social services, of land, water and livelihood, heightened militarization, violence and repression, and increased incidence of communicable diseases and health problems resulting from exposure to toxics. All of these are linked to an extractivist project driven by global financial capital promoting an unsustainable and inequitable development model that threatens people's health and the health of the planet. Is it compatible with the right to health to finance national health systems with revenues of activities that intrinsically destroy life? The essay portrays the inconsistency of development policies that fund health/right to health with extractivism and depicts examples of resistance to extractive industries tied to the People's Health Movement (Canada,Turkey, India and Ecuador) in different types of governments. The need to strengthen the link between the right to health struggles and anti-extractive resistance is highlighted.

RESUMO Os recursos naturais são essenciais para a saúde e são bens comuns globais. Reconhecer os danos devastadores causados pelo extrativismo à saúde e ao meio ambiente, bem como a erosão da soberania de nossos governos, que cada vez mais têm subordinado a saúde das pessoas ao interesse do lucro e do desenvolvimento, é importante para enquadrar nossa resistência. Nossas comunidades sofrem deslocamentos crescentes, a perda de serviços sociais, de terra, água e meios de subsistência, militarização aumentada, violência e repressão e aumento da incidência de doenças transmissíveis e problemas de saúde resultantes da exposição a substâncias tóxicas. Tudo isso está vinculado a um projeto extrativista impulsionado pelo capital financeiro global que promove um modelo de desenvolvimento insustentável e desigual que ameaça a saúde das pessoas e a saúde do planeta. É compatível com o direito à saúde financiar sistemas nacionais de saúde com receitas de atividades que destroem intrinsecamente a vida? Este ensaio retrata a inconsistência das políticas de desenvolvimento que financiam a saúde/direito à saúde com o extrativismo e descreve exemplos de resistência às indústrias extrativas ligadas ao Movimento pela Saúde dos Povos (Canadá, Turquia, Índia e Equador) em diferentes tipos de governo. Destaca-se a necessidade de fortalecer o vínculo entre o direito à saúde e a resistência antiextrativa.

RESUMEN Los recursos naturales son bienes comunes a escala global esenciales para la salud. Reconocer la devastación que produce el extractivismo en la salud y el ambiente, así como la erosión de la soberanía de nuestros gobiernos que han cedido en favor del desarrollo y el lucro es importante para estructurar nuestras resistencias. Nuestras comunidades sufren un creciente desplazamiento, la pérdida de servicios sociales, tierras, agua, medios de subsistencia, militarización, violencia y represión. A la par vemos una mayor incidencia de enfermedades transmisibles y problemas de salud derivados de la exposición a sustancias tóxicas, todo ello vinculado a un proyecto extractivista impulsado por el capital financiero global que promueve un modelo de desarrollo insostenible e injusto, amenazando la salud de las personas y del planeta. ¿Es compatible con el derecho a la salud financiar los sistemas nacionales de salud con ingresos de actividades que destruyen la vida intrínsecamente? El ensayo reflexiona sobre la inconsistencia del modelo de desarrollo que financia el derecho a la salud con extractivismo y coloca historias de resistencia a las industrias extractivas ligadas al Movimiento para la Salud de los Pueblos (Canadá, Turquía, India, Ecuador) y en diferentes tipos de gobiernos. Destaca la necesidad de fortalecer el vínculo entre las luchas por el derecho a la salud y la resistencia contra el extractivismo.

Connecting the right to health and anti-extractivism globally / Conectando o direito à saúde e o antiextrativismo globalmente / Conectando el derecho a la salud y el anti-extractivismo a nivel mundial

ABSTRACT Natural resources are essential to health and are global commons. Recognizing the devastating damage posed by extraction to health and the environment, as well as the erosion of the sovereignty of our governments that have increasingly conceded people's health in the interest of profit and development, is important in framing our resistance. Our communities experience growing displacement, the loss of social services, of land, water and livelihood, heightened militarization, violence and repression, and increased incidence of communicable diseases and health problems resulting from exposure to toxics. All of these are linked to an extractivist project driven by global financial capital promoting an unsustainable and inequitable development model that threatens people's health and the health of the planet. Is it compatible with the right to health to finance national health systems with revenues of activities that intrinsically destroy life? The essay portrays the inconsistency of development policies that fund health/right to health with extractivism and depicts examples of resistance to extractive industries tied to the People's Health Movement (Canada,Turkey, India and Ecuador) in different types of governments. The need to strengthen the link between the right to health struggles and anti-extractive resistance is highlighted.

RESUMO Os recursos naturais são essenciais para a saúde e são bens comuns globais. Reconhecer os danos devastadores causados pelo extrativismo à saúde e ao meio ambiente, bem como a erosão da soberania de nossos governos, que cada vez mais têm subordinado a saúde das pessoas ao interesse do lucro e do desenvolvimento, é importante para enquadrar nossa resistência. Nossas comunidades sofrem deslocamentos crescentes, a perda de serviços sociais, de terra, água e meios de subsistência, militarização aumentada, violência e repressão e aumento da incidência de doenças transmissíveis e problemas de saúde resultantes da exposição a substâncias tóxicas. Tudo isso está vinculado a um projeto extrativista impulsionado pelo capital financeiro global que promove um modelo de desenvolvimento insustentável e desigual que ameaça a saúde das pessoas e a saúde do planeta. É compatível com o direito à saúde financiar sistemas nacionais de saúde com receitas de atividades que destroem intrinsecamente a vida? Este ensaio retrata a inconsistência das políticas de desenvolvimento que financiam a saúde/direito à saúde com o extrativismo e descreve exemplos de resistência às indústrias extrativas ligadas ao Movimento pela Saúde dos Povos (Canadá, Turquia, Índia e Equador) em diferentes tipos de governo. Destaca-se a necessidade de fortalecer o vínculo entre o direito à saúde e a resistência antiextrativa.

RESUMEN Los recursos naturales son bienes comunes a escala global esenciales para la salud. Reconocer la devastación que produce el extractivismo en la salud y el ambiente, así como la erosión de la soberanía de nuestros gobiernos que han cedido en favor del desarrollo y el lucro es importante para estructurar nuestras resistencias. Nuestras comunidades sufren un creciente desplazamiento, la pérdida de servicios sociales, tierras, agua, medios de subsistencia, militarización, violencia y represión. A la par vemos una mayor incidencia de enfermedades transmisibles y problemas de salud derivados de la exposición a sustancias tóxicas, todo ello vinculado a un proyecto extractivista impulsado por el capital financiero global que promueve un modelo de desarrollo insostenible e injusto, amenazando la salud de las personas y del planeta. ¿Es compatible con el derecho a la salud financiar los sistemas nacionales de salud con ingresos de actividades que destruyen la vida intrínsecamente? El ensayo reflexiona sobre la inconsistencia del modelo de desarrollo que financia el derecho a la salud con extractivismo y coloca historias de resistencia a las industrias extractivas ligadas al Movimiento para la Salud de los Pueblos (Canadá, Turquía, India, Ecuador) y en diferentes tipos de gobiernos. Destaca la necesidad de fortalecer el vínculo entre las luchas por el derecho a la salud y la resistencia contra el extractivismo.

Forensic Medical Examinations: Imagining Justice.

Depending on the type of physical contact involved during a sexual assault offense, samples collected from a suspect's body may carry greater probative value than samples collected from a victim's body. However, unlike forensic medical examinations for persons identified as victims of a sexual assault, no professional consensus exists for what constitutes a high-quality forensic medical examination standard for persons identified as suspects, or the accused. The purpose of this article is to explore underlying assumptions that may contribute to disparate practices and inequalities in the provision of forensic medical examinations for persons suspected of committing a sexual offense and persons identified as victims of a sexual offense.

The mobility of food retailers: How proximity to SNAP authorized food retailers changed in Atlanta during the Great Recession.

Retailer mobility, defined as the shifting geographic patterns of retail locations over time, is a significant but understudied factor shaping neighborhood food environments. Our research addresses this gap by analyzing changes in proximity to SNAP authorized chain retailers in the Atlanta urban area using yearly data from 2008 to 2013. We identify six demographically similar geographic clusters of census tracts in our study area based on race and economic variables. We use these clusters in exploratory data analysis to identify how proximity to the twenty largest retail food chains changed during this period. We then use fixed effects models to assess how changing store proximity is associated with race, income, participation in SNAP, and population density. Our results show clear differences in geographic distribution between store categories, but also notable variation within each category. Increasing SNAP enrollment predicted decreased distances to almost all small retailers but increased distances to many large retailers. Our chain-focused analysis underscores the responsiveness of small retailers to changes in neighborhood SNAP participation and the value of tracking chain expansion and contraction in markets across time. Better understanding of retailer mobility and the forces that drive it can be a productive avenue for future research.

The Cost of Being Cool: How Adolescent Pseudomature Behavior Maps onto Adult Adjustment.

During adolescence, one's status among peers is a major concern. Such status is often largely a function of popularity and establishing oneself as "cool." While there are conventional avenues to achieving status among adolescents, engaging in adult-like, or pseudomature, behaviors such as substance use or sexual activity is a frequent occurrence. Although past research has examined the consequences of adolescent delinquency, what remains unclear is the long-term fate of adolescents who are both popular and antisocial. Using data from a sample of African American males (N = 339) we employ latent class analysis to examine the adult consequences of achieving popularity during adolescence by engaging in pseudomature behavior. Our results identified four classes of adolescents: the conventionals, the pseudomatures, the delinquents, and the detached. The conventionals were low on popularity, pseudomature behavior, and affiliation with deviant peers but high on academic commitment. The pseudomatures were high on popularity, adult-like behavior, and academic commitment but low on affiliation with delinquent peers. The delinquents were low on popularity and school achievement but high on pseudomature behavior and affiliations with delinquent peers. Finally, the detached were low on school commitment, popularity and pseudomature behavior but they report high involvement with a delinquent peer group. By early adulthood, the costs of adolescent adult-like behavior were evident. Early popularity and academic commitment did not portend later social competence or college completion for the pseudomatures. Instead, they frequently experienced an early transition to parenthood, a likely consequence of precocious sexual activity. These findings suggest that interventions should not focus only on the most delinquent adolescents but also need to attend to the pseudomature students who are brimming with promise but are flirting with behaviors that may subvert realization of this potential.

Monetary Sanctions: Legal Financial Obligations in US Systems of Justice.

This review assesses the current state of knowledge about monetary sanctions, e.g., fines, fees, surcharges, restitution, and any other financial liability related to contact with systems of justice, which are used more widely than prison, jail, probation, or parole in the United States. The review describes the most important consequences of the punishment of monetary sanctions in the United States, which include a significant capacity for exacerbating economic inequality by race, prolonged contact and involvement with the criminal justice system, driver's license suspension, voting restrictions, damaged credit, and incarceration. Given the lack of consistent laws and policies that govern monetary sanctions, jurisdictions vary greatly in their imposition, enforcement, and collection practices of fines, fees, court costs, and restitution. A review of federally collected data on monetary sanctions reveals that a lack of consistent and exhaustive measures of monetary sanctions presents a unique problem for tracking both the prevalence and amount of legal financial obligations (LFOs) over time. We conclude with promising directions for future research and policy on monetary sanctions.

Self-Assessment Scores Improve After Simulation-Based Palliative Care Communication Skill Workshops.

BACKGROUND: We conducted a randomized trial of a simulation-based multisession workshop to improve palliative care communication skills (Codetalk). Standardized patient assessments demonstrated improved communication skills for trainees receiving the intervention; however, patient and family assessments failed to demonstrate improvement. This article reports findings from trainees' self-assessments. AIM: To examine whether Codetalk resulted in improved self-assessed communication competence by trainees. DESIGN: Trainees were recruited from the University of Washington and the Medical University of South Carolina. Internal medicine residents, medicine subspecialty fellows, nurse practitioner students, or community-based advanced practice nurses were randomized to Codetalk, a simulation-based workshop, or usual education. The outcome measure was self-assessed competence discussing palliative care needs with patients and was assessed at the start and end of the academic year. We used robust linear regression models to predict self-assessed competency, both as a latent construct and as individual indicators, including randomization status and baseline self-assessed competency. RESULTS: We randomized 472 trainees to the intervention (n = 232) or usual education (n = 240). The intervention was associated with an improvement in trainee's overall self-assessment of competence in communication skills ( P < .001). The intervention was also associated with an improvement in trainee self-assessments of 3 of the 4 skill-specific indicators-expressing empathy, discussing spiritual issues, and eliciting goals of care. CONCLUSION: Simulation-based communication training was associated with improved self-assessed competency in overall and specific communication skills in this randomized trial. Further research is needed to fully understand the importance and limitations of self-assessed competence in relation to other outcomes of improved communication skill.

The Growth, Scope, and Spatial Distribution of People With Felony Records in the United States, 1948-2010.

The steep rise in U.S. criminal punishment in recent decades has spurred scholarship on the collateral consequences of imprisonment for individuals, families, and communities. Several excellent studies have estimated the number of people who have been incarcerated and the collateral consequences they face, but far less is known about the size and scope of the total U.S. population with felony convictions beyond prison walls, including those who serve their sentences on probation or in jail. This article develops state-level estimates based on demographic life tables and extends previous national estimates of the number of people with felony convictions to 2010. We estimate that 3 % of the total U.S. adult population and 15 % of the African American adult male population has ever been to prison; people with felony convictions account for 8 % of all adults and 33 % of the African American adult male population. We discuss the far-reaching consequences of the spatial concentration and immense growth of these groups since 1980.

Growth In SNAP Retailers Was Associated With Increased Client Enrollment In Georgia During The Great Recession.

Policies to improve food accessibility in underserved areas often use direct financial incentives to attract new food retailers. Our analysis of data on the Supplemental Nutrition Assistance Program (SNAP) in Georgia before and after the Great Recession suggests that increased program enrollment improves access to food for SNAP beneficiaries by acting as an indirect subsidy to retailers. We divided food stores into four categories: large, midsize, small, and specialty retailers. Between 2008 and 2011 the number of SNAP enrollees increased by 87 percent, and between 2007 and 2014 the number of SNAP retailers in Georgia increased by 82 percent, primarily because of growth in the number of authorized small retailers. Inside metropolitan Atlanta, changes in the numbers of SNAP enrollees and authorized retailers were positively and significantly associated for small retailers. For the areas outside of metropolitan Atlanta, the association between changes in numbers of enrollees and authorized retailers was strongest for small retailers; more modest associations were also seen for large and specialty retailers. Policy makers should consider how retailers' sensitivity to and reliance on SNAP funding can be leveraged to improve not only food availability, but also access to healthy foods.

The experiences of risk managers in providing emotional support for health care workers after adverse events.

Risk managers often meet with health care workers who are emotionally traumatized following adverse events. We surveyed members of the American Society for Health care Risk Management (ASHRM) about their training, experience, competence, and comfort with providing emotional support to health care workers. Although risk managers reported feeling comfortable and competent in providing support, nearly all respondents prefer to receive additional training. Risk managers who were comfortable listening to and supporting health care workers were more likely to report prior training. Health care organizations implementing second victim support programs should not rely solely on risk managers to provide support, rather engage and train interested risk managers and provide them with opportunities to practice.

Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-Life Care.

RATIONALE: Communication with family of critically ill patients is often poor and associated with family distress. OBJECTIVES: To determine if an intensive care unit (ICU) communication facilitator reduces family distress and intensity of end-of-life care. METHODS: We conducted a randomized trial at two hospitals. Eligible patients had a predicted mortality greater than or equal to 30% and a surrogate decision maker. Facilitators supported communication between clinicians and families, adapted communication to family needs, and mediated conflict. MEASUREMENTS AND MAIN RESULTS: Outcomes included depression, anxiety, and post-traumatic stress disorder (PTSD) among family 3 and 6 months after ICU and resource use. We identified 488 eligible patients and randomized 168. Of 352 eligible family members, 268 participated (76%). Family follow-up at 3 and 6 months ranged from 42 to 47%. The intervention was associated with decreased depressive symptoms at 6 months (P = 0.017), but there were no significant differences in psychological symptoms at 3 months or anxiety or PTSD at 6 months. The intervention was not associated with ICU mortality (25% control vs. 21% intervention; P = 0.615) but decreased ICU costs among all patients (per patient: $75,850 control, $51,060 intervention; P = 0.042) and particularly among decedents ($98,220 control, $22,690 intervention; P = 0.028). Among decedents, the intervention reduced ICU and hospital length of stay (28.5 vs. 7.7 d and 31.8 vs. 8.0 d, respectively; P < 0.001). CONCLUSIONS: Communication facilitators may be associated with decreased family depressive symptoms at 6 months, but we found no significant difference at 3 months or in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. This is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress. Clinical trial registered with www.clinicaltrials.gov (NCT 00720200).

The Institutional Effects of Incarceration: Spillovers From Criminal Justice to Health Care.

POLICY POINTS: The steady increase in incarceration is related to the quality and functioning of the health care system. US states that incarcerate a larger number of people show declines in overall access to and quality of care, rooted in high levels of uninsurance and relatively poor health of former inmates. Providing health care to former inmates would ease the difficulties of inmates and their families. It might also prevent broader adverse spillovers to the health care system. The health care system and the criminal justice system are related in real but underappreciated ways. CONTEXT: This study examines the spillover effects of growth in state-level incarceration rates on the functioning and quality of the US health care system. METHODS: Our multilevel approach first explored cross-sectional individual-level data on health care behavior merged to aggregate state-level data regarding incarceration. We then conducted an entirely aggregate-level analysis to address between-state heterogeneity and trends over time in health care access and utilization. FINDINGS: We found that individuals residing in states with a larger number of former prison inmates have diminished access to care, less access to specialists, less trust in physicians, and less satisfaction with the care they receive. These spillover effects are deep in that they affect even those least likely to be personally affected by incarceration, including the insured, those over 50, women, non-Hispanic whites, and those with incomes far exceeding the federal poverty threshold. These patterns likely reflect the burden of uncompensated care among former inmates, who have both a greater than average need for care and higher than average levels of uninsurance. State-level analyses solidify these claims. Increases in the number of former inmates are associated simultaneously with increases in the percentage of uninsured within a state and increases in emergency room use per capita, both net of controls for between-state heterogeneity. CONCLUSIONS: Our analyses establish an intersection between systems of care and corrections, linked by inadequate financial and administrative mechanisms for delivering services to former inmates.

Risk managers' descriptions of programs to support second victims after adverse events.

Guidelines call for healthcare organizations to provide emotional support for clinicians involved in adverse events, but little is known about how these organizations seek to meet this need. We surveyed US members of the American Society for Healthcare Risk Management (ASHRM) about the presence, features, and perceived efficacy of their organization's provider support program. The majority reported that their organization had a support program, but features varied widely and there are substantial opportunities to improve services. Provider support programs should enhance referral mechanisms and peer support, critically appraise the role of employee assistance programs, and demonstrate their value to institutional leaders.

Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU.

The intensive care unit (ICU), where death is common and even survivors of an ICU stay face the risk of long-term morbidity and re-admissions to the ICU, represents an important setting for improving communication about palliative and end-of-life care. Communication about the goals of care in this setting should be a high priority since studies suggest that the current quality of ICU communication is often poor and is associated with psychological distress among family members of critically ill patients. This paper describes the development and evaluation of an intervention designed to improve the quality of care in the ICU by improving communication among the ICU team and with family members of critically ill patients. We developed a multi-faceted, interprofessional intervention based on self-efficacy theory. The intervention involves a "communication facilitator" - a nurse or social worker - trained to facilitate communication among the interprofessional ICU team and with the critically ill patient's family. The facilitators are trained using three specific content areas: a) evidence-based approaches to improving clinician-family communication in the ICU, b) attachment theory allowing clinicians to adapt communication to meet individual family member's communication needs, and c) mediation to facilitate identification and resolution of conflict including clinician-family, clinician-clinician, and intra-family conflict. The outcomes assessed in this randomized trial focus on psychological distress among family members including anxiety, depression, and post-traumatic stress disorder at 3 and 6 months after the ICU stay. This manuscript also reports some of the lessons that we have learned early in this study.

A web-based team-oriented medical error communication assessment tool: development, preliminary reliability, validity, and user ratings.

BACKGROUND: Multiple-choice exams are not well suited for assessing communication skills. Standardized patient assessments are costly and patient and peer assessments are often biased. Web-based assessment using video content offers the possibility of reliable, valid, and cost-efficient means for measuring complex communication skills, including interprofessional communication. DESCRIPTION: We report development of the Web-based Team-Oriented Medical Error Communication Assessment Tool, which uses videotaped cases for assessing skills in error disclosure and team communication. Steps in development included (a) defining communication behaviors, (b) creating scenarios, (c) developing scripts, (d) filming video with professional actors, and (e) writing assessment questions targeting team communication during planning and error disclosure. EVALUATION: Using valid data from 78 participants in the intervention group, coefficient alpha estimates of internal consistency were calculated based on the Likert-scale questions and ranged from α=.79 to α=.89 for each set of 7 Likert-type discussion/planning items and from α=.70 to α=.86 for each set of 8 Likert-type disclosure items. The preliminary test-retest Pearson correlation based on the scores of the intervention group was r=.59 for discussion/planning and r=.25 for error disclosure sections, respectively. Content validity was established through reliance on empirically driven published principles of effective disclosure as well as integration of expert views across all aspects of the development process. In addition, data from 122 medicine and surgical physicians and nurses showed high ratings for video quality (4.3 of 5.0), acting (4.3), and case content (4.5). CONCLUSIONS: Web assessment of communication skills appears promising. Physicians and nurses across specialties respond favorably to the tool.

Potential for response bias in family surveys about end-of-life care in the ICU.

BACKGROUND: After-death surveys are an important source of information about the quality of end-of-life care, but response rates generally are low. Our goal was to understand the potential for nonresponse bias in survey studies of family members after a patient's death in the hospital ICU by identifying differences in patient demographics and delivery of palliative care between patients whose families respond to a survey about end-of-life care and those whose families do not. METHODS: We performed a cohort study of patients who died in the ICU at 14 hospitals. Surveys were mailed to family members 1 to 2 months after the patient's death. Chart abstraction was completed on all patients, assessing demographic characteristics and previously validated indicators of palliative care. RESULTS: Of the 2,016 surveys sent to families, 760 were returned, for a response rate of 38%. Patients whose family members returned the surveys were more likely to be white (88% vs 74%, respectively; p < 0.001); to be older (71 years vs 69 years, respectively; p = 0.015); and to have received more indicators of palliative care, including medical record documentation of family present at death, involvement of spiritual care, and dying after a decision to limit life-sustaining therapies (p < 0.05). CONCLUSIONS: Patients whose family members responded to a survey about end-of-life care were more likely to be white, older, and have indicators of palliative care documented in the medical record. Because these patients likely received higher quality palliative care, these findings suggest that the response bias in end-of-life care research is toward overestimating the quality of palliative care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00685893.

Dying patients' need for emotional support and personalized care from physicians: perspectives of patients with terminal illness, families, and health care providers.

This study addressed the emotional and personal needs of dying patients and the ways physicians help or hinder these needs. Twenty focus groups were held with 137 individuals, including patients with chronic and terminal illnesses, family members, health care workers, and physicians. Content analyses were performed based on grounded theory. Emotional support and personalization were 2 of the 12 domains identified as important in end-of-life care. Components of emotional support were compassion, responsiveness to emotional needs, maintaining hope and a positive attitude, and providing comfort through touch. Components of personalization were treating the whole person and not just the disease, making the patient feel unique and special, and considering the patient's social situation. Although the levels of emotional support and personalization varied, there was a minimal level, defined by compassion and treating the whole person and not just the disease, that physicians should strive to meet in caring for all dying patients. Participants also identified intermediate and advanced levels of physician behavior that provide emotional and personal support.