Age determination in refugee children: A narrative history tool for use in holistic age assessment.

AIM: To present the rationale for using a narrative history tool as part of a holistic age assessment of accompanied refugee children with age uncertainty by exploring cultural narratives of age. METHODS: Seven small group, semi-structured interviews with 24 humanitarian entrants (10 male, 14 female) recruited from Afghan, Bhutanese and Burundian communities in Adelaide, Australia were conducted. Interviews were performed with interpreters present, audio-recorded, transcribed verbatim and thematically analysed. RESULTS: Four themes emerged: the significance of age; ways of remembering age; the refugee experience and its effect on age recall; and the reliability and permissibility of documentation. Age was significant, but understood and remembered differently with knowledge of an exact date of birth not required for functioning in participants' home societies. Information regarding age was embedded in narrative accounts, related to events and other people. Birth was not always registered, with birth and age-containing documentation obtained later in life. These documents often reflected cultural ideas regarding age, rather than recording true chronological age. The refugee experience profoundly affected the ability of people to remember their age by disrupting methods used to recall specific events, including birth. CONCLUSION: Narrative history provides valuable information regarding age in accompanied refugee children with age uncertainty, and allows for age to be located within a range that approximates true chronological age when age documentation is absent or clearly erroneous. The Age Assessment Tool questionnaire provides health professionals with a framework for conducting age assessment interviews.

Why is Pain Still Under-Treated in the Emergency Department? Two New Hypotheses.

Across the world, pain is under-treated in emergency departments (EDs). We canvass the literature testifying to this problem, the reasons why this problem is so important, and then some of the main hypotheses that have been advanced in explanation of the problem. We then argue for the plausibility of two new hypotheses: pain's under-treatment in the ED is due partly to (1) an epistemic preference for signs over symptoms on the part of some practitioners, and (2) some ED practices that themselves worsen pain by increasing patients' anxiety and fear. Our argument includes the following logic. Some ED practitioners depart from formal guidance in basing their acute pain assessments on observable features rather than on patient reports of pain. This is potentially due to an epistemic preference for signs over symptoms which aims to circumvent intentional and/or unintentional misrepresentation on the part of patients. However, conducting pain assessments in line with this epistemic preference contributes to the under-treatment of pain in at least three respects, which we detail. Moreover, it may do little to help the practitioner circumvent any intentional misrepresentation on the part of the patient, as we explain. Second, we examine at least four ED practices that may be contributing to the under-treatment of pain by increasing patient anxiety and fear, which can worsen pain. These practices include failing to provide orienting information and partially objectifying patients so as to problem-solve along lines pre-established by modern medical science. We conclude by touching on some potential solutions for ED practice.

Australian men with cancer practice complementary therapies (CTs) as a coping strategy.

OBJECTIVE: The aim of this study was to explore how and why Australian men with cancer practice complementary therapies (CTs) and how their significant others (SOs) contribute to the regular uptake of CTs. METHODS: This qualitative study employed semi-structured interviews with 26 male cancer patients and 24 SOs. Participants were purposefully sampled from a preceding Australian survey investigating the use of CTs in men with cancer (94% response rate and 86% consent rate for follow-up interview). Interviews were conducted in a metropolitan location, and the 43 interview transcripts were analyzed thematically. RESULTS: Three core themes were identified: men used CTs as (a) problem-focused coping (e.g., diet modification), (b) emotion-focused coping (e.g., meditation), and (c) meaning-based coping (e.g., prayer). Practicing CTs helped men to cope with physical, emotional, and spiritual concerns, although some men spoke of difficulties with practicing meditation to regulate their emotions. SOs were supportive of men's coping strategies but were only rarely involved in men's emotion-focused coping. CONCLUSIONS: Complementary therapies have the potential to facilitate coping with cancer, independent of any measurable physiological benefit. Our findings suggest that when clinicians engage in conversations about CTs use, they should consider the type of coping strategy employed by their patient. Such information may enhance the efficacy of some interventions (e.g., meditation) and also provide for an opportunity to discuss patients' expectations concerning CTs.

A qualitative study investigating chemotherapy-induced nausea as a symptom cluster.

PURPOSE: The prevention of chemotherapy-induced vomiting has been improved by antiemetics, but nausea remains problematic. This study explores the concept that this is partly because patients use the term nausea to describe a cluster of symptoms. METHODS: A total of 42 cancer patients currently being treated (n = 21) or at least 6 months of past treatment (median 3.5 years; n = 21) with experience of chemotherapy-induced nausea consented to semi-structured interviews about nausea, which were transcribed and analysed. There were 24 females and 18 males. RESULTS: The nature, number, location, duration and intensity of experiences described as nausea varied. Physical and psychological symptoms included dry retching, vomiting, anorexia, indigestion, change of taste, dizziness, bloating, reflux, inability to concentrate, fatigue and restlessness. Patients located nausea in sites ranging from the head/neck, sternum and mid and lower abdomen to the whole body. Some patients identified symptoms as part of the experience of nausea, and others described symptoms associated with nausea but separate from it. For most, distinguishing features of chemotherapy-induced (as opposed to other) nausea were its constant presence over time, fatigue and emotional associations with the cancer diagnosis. Triggers varied and included food (smells), negative emotions including anxiety, movement, smells (e.g., hand cream, cleaning products), treatment-related events, tooth brushing and mentioning nausea. Prescribed antiemetics were consistently noted as reducing the intensity of, but for many, not completely alleviating, nausea. Distraction and relaxation were preferred management techniques. CONCLUSION: Control of nausea will require treating the particular cluster of symptoms which a patient is experiencing as nausea.

The role of complementary and alternative medicine (CAM) routines and rituals in men with cancer and their significant others (SOs): a qualitative investigation.

PURPOSE: Complementary and alternative medicine (CAM) is frequently used in cancer patients, often with contribution of the significant others (SOs), but without consultation of healthcare professionals. This research explored how cancer patients integrate and maintain CAM use in their everyday life, and how SOs are involved in it. METHODS: In this qualitative study, male participants were selected from a preceding Australian survey on CAM use in men with cancer (94 % response rate and 86 % consent rate for follow-up interview). Semistructured interviews were conducted with 26 men and 24 SOs until data saturation was reached. Interview transcripts were coded and analyzed thematically, thereby paying close attention to participants' language in use. RESULTS: A major theme associated with high CAM use was "CAM routines and rituals," as it was identified that men with cancer practiced CAM as (1) functional routines, (2) meaningful rituals, and (3) mental/spiritual routines or/and rituals. Regular CAM use was associated with intrapersonal and interpersonal benefits: CAM routines provided men with certainty and control, and CAM rituals functioned for cancer patients and their SOs as a means to create meaning, thereby working to counter fear and uncertainty consequent upon a diagnosis of cancer. SOs contributed most to men's uptake and maintenance of dietary-based CAM in ritualistic form resulting in interpersonal bonding and enhanced closeness. CONCLUSIONS: CAM routines and rituals constitute key elements in cancer patients' regular and satisfied CAM use, and they promote familial strengthening. Clinicians and physicians can convey these benefits to patient consultations, further promoting the safe and effective use of CAM.

Clinician acceptance is the key factor for sustainable telehealth services.

Telehealth, the delivery of health care services at a distance using information and communications technology, has been slow to be adopted and difficult to sustain. Researchers developing theories concerning the introduction of complex change into health care usually take a multifactorial approach; we intentionally sought a single point of intervention that would have maximum impact on implementation. We conducted a qualitative interview study of 36 Australian telehealth services, sampled for maximum variation, and used grounded theory methods to develop a model from which we chose the most important factor affecting the success of telehealth. We propose that clinician acceptance explains much of the variation in the uptake, expansion, and sustainability of Australian telehealth services, and that clinician acceptance could, in most circumstances, overcome low demand, technology problems, workforce pressure, and lack of resourcing. We conclude that our model offers practical advice to those seeking to implement change with limited resources.

The impact of receiving treatment for cancer at a large metropolitan teaching hospital as recorded by patients using unstructured journals.

The aim was to obtain patients' experiences of the cancer treatment pathway at a tertiary teaching hospital using unstructured journals to enable health care professionals to be educated on how to improve patient care. Most of 38 patients (22 females and 16 males), average age of 58 (range 29-80), who returned diaries were starting chemotherapy for a range of cancers. Data entries were transcribed and entered into the NVIVO software to facilitate thematic analysis. Women wrote more, and more often than men, and disclosed more. For most, physical side effects dominated, comprising 25-75 % of diary entries. The most commonly mentioned were fatigue (74 %), pain (63 %), sleep disturbances (50 %), nausea (45 %) and changes in appetite (45 %). Collectively, 22 patients reported 261 separate emotional reactions including depression, anger, guilt, shame, grief, panic and confusion. The treatment environment, including personnel, impacted upon patients. Where survival is unpredictable, evidence of consistency of practitioners' approaches attains heightened significance.

Dying cancer patients talk about physician and patient roles in DNR decision making.

BACKGROUND: Within medical and bioethical discourse, there are many models depicting the relationships between, and roles of, physician and patient in medical decision making. Contestation similarly exists over the roles of physician and patient with regard to the decision not to provide cardiopulmonary resuscitation (CPR) following cardiac arrest [the do-not-resuscitate or do-not-resuscitate (DNR) decision], but there is little analysis of patient perspectives. OBJECTIVE: Analyse what patients with cancer within weeks before dying say about the decision to forego CPR and the roles of patient and physician in this decision. DESIGN AND PARTICIPANTS: Discursive analysis of qualitative data gathered during semi-structured interviews with 28 adult cancer patients close to death and attending palliative or oncology clinics of an Australian teaching hospital. RESULTS: Participants' descriptions of appropriate patient or physician roles in decisions about CPR appeared related to how they conceptualized the decision: as a personal or a medical issue, with patient and doctor respectively identified as appropriate decision makers; or alternatively, both medical and personal, with various roles assigned embodying different versions of a shared decision-making process. Participants' endorsement of physicians as decision makers rested upon physicians' enactment of the rational, knowledgeable and compassionate expert, which legitimized entrusting them to make the DNR decision. Where this was called into question, physicians were positioned as inappropriate decision makers. CONCLUSION: When patients' and physicians' understandings of the best decision, or of the preferred role of either party, diverge, conflict may ensue. In order to elicit and negotiate with patient preferences, flexibility is required during clinical interactions about decision making.

Individuate and separate: Values and identity re-development during rehabilitation and transition in the Australian Army.

Many health behaviours and outcomes in veterans can be attributed to issues of identity. Identity is informed by core values, which are critical to service organisations that demand unity, including the military, but the intersection between values, identity, and adaptation to serious wounds, injuries, and illnesses remains relatively unexplored. This article elucidates the relationship between values, identity, and adaptation during rehabilitation in high-risk military personnel through examination of the experiences of 13 Australian combat soldiers undergoing rehabilitation for serious wounds, injuries, and mental health conditions. Each participated in two semi-structured, in-depth interviews which were conducted between March and December 2014. Data were thematically analysed using a qualitative approach dialectically positioned between social constructionism and critical realism. Results demonstrate those primarily with physical limitations sequentially drew on five sets of values that underscored four sequential stages of adaptation that collectively reflect the psychosocial task of adolescence, namely identity development. Those primarily with mental health conditions did not share such a clear trajectory. This insight may inform overarching primary healthcare strategies in clinical and community settings, as well as a transition research agenda.

Macrozoobenthos in the Adriatic Sea ports: Soft-bottom communities with an overview of non-indigenous species.

The present paper is a contribution to the first initiative of the Port Baseline Survey (PBS) for Non-indigenous species (NIS) in the Mediterranean Sea. It presents a report on the soft-bottom macrobenthos from the five Adriatic ports: Bari, Ancona (Italy), Koper (Slovenia), Pula, Rijeka (Croatia), with a focus on the presence and contribution of NIS to native assemblages. Out of 451 species identified, only four were common to all ports. A total of eight NIS were recorded, five in surveyed ports and three in the lagoon connected to the Port of Koper. The highest number of NIS was recorded in Bari, and the highest abundance in Ancona and Bari. Generally, the number, abundance and contribution of NIS seems too low to cause a substantial impact on native communities in surveyed ports. The suitability of methods adopted for PBS for soft-bottom NIS was discussed and suggestion for methodological improvement is provided.

Non-indigenous macrozoobenthic species on hard substrata of selected harbours in the Adriatic Sea.

The intense shipping traffic characterising the Adriatic Sea favours the spread of marine organisms. Yet, a study of 12 Adriatic ports (4 on the western side and 8 on the eastern side of the basin) found that non-indigenous species (NIS) accounted for only 4% of the benthic communities settled on hard substrates. The cirripeds Amphibalanus amphitrite and Balanus trigonus, found in 8 harbours, were the most common invaders followed by Amphibalanus eburneus, the ascidian Styela plicata, and the bivalve Magallana gigas. The highest percentage of NIS was recorded in Venice and Ploce, the harbours with the least rich native communities; the lowest percentage was retrieved in Trieste, Koper, Pula, and Rijeka, the harbours hosting the highest species diversity. In contrast, the ports of Bari and Ancona showed both high NIS percentages and highly diversified communities.

The perceptions of do-not-resuscitate policies of dying patients with cancer.

Patients in hospitals must authorize do-not-resuscitate (DNR) orders or the default cardiopulmonary resuscitation (CPR) occurs. Using discursive analysis, we examined the speech of 28 cancer patients, judged as within 3 months of death, to determine how they justified preferences for DNR orders. Most saw these as a positive outcome of not interfering with a natural death with the decision being personal and the legal right of a competent autonomous person. If surrogates were required, they needed knowledge of the medical facts and the patient's wishes. The doctor was crucial, while family although likely to be supportive may be burdened by the responsibility. Some favored an early DNR discussion, but the majority favored a later discussion when it was applicable. At interview, 58% patients had a DNR order, rising to 82% by the time of death. Written orders were favored, yet 9 of 21 who did not want CPR had no DNR order. Hope was mentioned spontaneously by 25 patients, both as a thing over which patients had little control and as the desire of a positive future outcome. If doctors' and patients' assessments of eligibility for DNR orders do not coincide, the process and documentation of decision-making needs revision.

Dying cancer patients talk about euthanasia.

Within developed nations, there is increasing public debate about and apparent endorsement of the appropriateness of euthanasia as an autonomous choice to die in the face of intolerable suffering. Surveys report socio-demographic differences in rates of acceptance of euthanasia, but there is little in-depth analysis of how euthanasia is understood and positioned within the social and moral lives of individuals, particularly those who might be considered suitable candidates-for example, terminally-ill cancer patients. During discussions with 28 such patients in Australia regarding medical decisions at the end of life, euthanasia was raised by 13 patients, with the others specifically asked about it. Twenty-four patients spoke positively of euthanasia, 19 of these voicing some concerns. None identified euthanasia as a currently favoured option. Four were completely against it. Endorsement for euthanasia was in the context of a hypothetical future or for a hypothetical other person, or temporally associated with acute pain. Arguments supporting euthanasia framed the issue as a matter of freedom of choice, as preserving dignity in death, and as curbing intolerable pain and suffering, both of the patient and of those around them. A common analogy featured was that of euthanising a dog. These arguments were typically presented as self-evident justification for euthanasia, construed as an appropriate choice to die, with opposers positioned as morally inferior or ignorant. The difficulties of ensuring 'choice' and the moral connotations of 'choosing to die,' however, worked to problematise the appropriateness of euthanising specific individuals. We recommend further empirical investigation of the moral and social meanings associated with euthanasia.

(Using) complementary and alternative medicine: the perceptions of palliative patients with cancer.

Use of complementary and alternative medicine (CAM) is increasingly common within Western societies, including Australia. This parallels calls for or claims of integration of CAM into mainstream medical practice, with oncology and palliative care specifically nominated as appropriate arenas for integration. However, there is an absence of studies examining patient perceptions of both CAM and CAM users. In this study, 28 adult patients with cancer close to death were interviewed regarding treatment decisions at the end of life, including decisions about CAM. Thematic analysis of transcribed interviews found consistent differences in talk around CAM between 12 users and 16 nonusers of CAM, primarily related to the perceived value of these treatments. Drawing upon a mind-body discourse that holds individuals responsible for their health, users valued CAM for the perceived benefit to physical or psychological well-being and compatibility with a holistic approach to health care, deemed to complement or augment conventional medicine. However, some were self-critical of their failure to continue with CAM, despite practical and financial difficulties experienced. Nonusers devalued CAM as unable to cure their disease (but did not similarly devalue conventional medicine), and negatively construed CAM users as desperate, or as challenging medical wisdom. Despite increased legitimation and medicalization of CAM, patients assess CAM differently to allopathic medicine, with different (positive and negative) assessments attributable to users. The misperception by many (nonusers) that CAM are intended to cure and available negative moral and social judgments centred around CAM use may deter patient uptake of CAM in areas where they have proven efficacy in symptom control.

Hope and hoping in the talk of dying cancer patients.

Hope is the subject of increasing research and discussion within the healthcare literature. However, although deemed of vital import to patient welfare, there is little examination of how hope features within patients' speech. This qualitative study presents the discursive properties of hope as it emerged unprompted during semi-structured interviews with 28 patients in the final phase of terminal cancer recruited from the oncology clinic of the Royal Adelaide Hospital, Australia. In the context of discussions about decision-making at the end of a terminal illness, when used as a noun, hope invariably referenced the medical domain--focussing either on the objective probability of medical cure (typically taking the negative form "there is no hope"), or the subjective possession of the patient, needed to fight their disease. Positioning the patient as relatively powerless and subject to external forces, this hope was most commonly associated with absolute solutions, and life-and-death stakes. Hope as a verb emphasised the patient's active engagement in life, identifying what was good and positive for them. It was used to assign responsibility to others, to indicate and establish solidarity or agreement between the speaker and others, effectively strengthening interpersonal ties between individuals. Through hoping, patients established connection with others and with the future. In the context of interactions between patients and clinical staff, we conclude that the use of hope-as-a-verb may have benefits, enabling the patient--even when dying--to focus on the positive, to connect to others, and to continue to engage with life.

The implications of dying cancer patients' talk on cardiopulmonary resuscitation and do-not-resuscitate orders.

Current medical emphasis on autonomy requires that patients be primary in authorizing do-not-resuscitate (DNR) orders, countermanding provision of cardiopulmonary resuscitation (CPR) on terminally ill patients. The assumptions that patients make regarding CPR and DNR orders will influence their choices about them. Using discursive analysis, the authors examined the speech of 28 patients dying of cancer regarding the appropriateness of refraining from CPR or of instituting DNR orders. Most participants identified CPR as inappropriate in their circumstances, favoring institution of DNR orders. However, a minority drew on dominant construals of DNR orders and CPR to locate themselves outside the category of suitable candidates for DNR orders, thus justifying a preference for CPR--even though some had current DNR orders. Doctors' and patients' assessments of eligibility for DNR orders might not coincide, and when patient autonomy is presumed by patients to be determinant, discrepancies between patient expectations and instituted medical practice are inevitable.

Translating into Practice Cancer Patients' Views on Do-Not-Resuscitate Decision-Making.

Do-not-resuscitate (DNR) orders are necessary if resuscitation, the default option in hospitals, should be avoided because a patient is known to be dying and attempted resuscitation would be inappropriate. To avoid inappropriate resuscitation at night, if no DNR order has been recorded, after-hours medical staff are often asked to have a DNR discussion with patients whose condition is deteriorating, but with whom they are unfamiliar. Participants in two qualitative studies of cancer patients' views on how to present DNR discussions recognized that such patients are at different stages of understanding of their situation and may not be ready for a DNR discussion; therefore, a one-policy-fits-all approach was thought to be inappropriate. To formulate a policy that incorporates the patient's views, we propose that a standard form which mandates a DNR discussion is replaced by a "blank sheet" with instructions to record the progress of the discussion with the patient, and a medical recommendation for a DNR decision to guide the nursing staff in case of a cardiac arrest. Such an advance care directive would have to honor specifically expressed patient or guardian wishes whilst allowing for flexibility, yet would direct nurses or other staff so that they can avoid inappropriate cardiopulmonary resuscitation of a patient dying of cancer.