Questioning the value of present life: The lived experience of older people who see no future for themselves.

OBJECTIVES: To describe the lived experience of older people who see no future for oneself in the context of aging and the possible development of a wish to die. METHODS: Data were collected from 34 interviews with people of 55-92 years. A phenomenological hermeneutical analysis was performed using crafted stories as an analytical device. RESULTS: Four intertwined constituents together with the essence of the phenomenon provide a layered description of what it means to see no future for oneself. In all constituents: 1) not sharing everyday life, 2) looking for new commitments, 3) facing present losses and future fears and 4) imagining not waking up in the morning, the essence losing zest for life seeped through their daily experiences. CONCLUSIONS: As their horizon of future possibilities is shrinking, older people in our study experience a loss of zest for life and start to questioning the value of their present lives. And although a certain languishing mood can be discovered, the phenomenon 'seeing no future for oneself' does not entail a wish to die.

[Physician-assisted dying at home in the Netherlands: what do general practitioners face? An qualitative interview study]. / Euthanasie in de thuissituatie.

OBJECTIVE: To explore what Dutch general practitioners (GPs) need and what their felt responsibilities and considerations are during (decision-making for) physician assisted dying (PAD) in the context of palliative care in the home-setting. DESIGN: A qualitative interview study was performed as part of a larger interview-study exploring the experiences of patients, relatives, and other care-professionals with PAD. METHOD: Purposive sampling was adopted to select eleven GPs with experience in end-of-life decision-making and with sufficient variety on the domains of age, gender, work setting and additional expertise. Narrative interviews were conducted by a GP-researcher. Interviews were transcribed, anonymized and analyzed through narrative thematic analysis. A member check with participants was performed. RESULTS: GPs mentioned corresponding needs on the personal level, in the interaction with patients and families, and on an organizational/societal level. Similar examples of complicating family-dynamics were described. Meanwhile, different considerations emerged in relation to how to act and what to take responsibility for during PAD, such as GPs' own life views, sort/duration of treatment relationships, and care for relatives. Last, casuistry of PAD-requests of patients with metastasized cancer emerged - in theory the least controversial cases - in which specific circumstances made GPs again (re)consider their responsibilities and boundaries. CONCLUSION: This study provides new insight into what matters for Dutch GPs while trying to realize 'good euthanasia-care' in the home-setting. The study raises important questions about the position of GPs, the conditions under which they need to operate, and what reasonably may be expected of them.

Requests for euthanasia or assisted suicide of people without (severe) illness.

BACKGROUND: Some people request euthanasia or assisted suicide (EAS) even though they are not (severely) ill. In the Netherlands the presence of sufficient medical ground for the suffering is a strict prerequisite for EAS. The desirability of this 'medical ground'-boundary is currently questioned. Legislation has been proposed to facilitate EAS for older persons with "completed life" or "tiredness of life" in the absence of (severe) illness. OBJECTIVES: To describe the characteristics and motivations of persons whose requests for EAS in the absence of (severe) illness did not result in EAS and the decision-making process of medical professionals in these types of requests. METHODS: Analysis of 237 applicant records of the Dutch Euthanasia Expertise Center. We studied both the perspectives of applicants and medical professionals. FINDINGS: The majority of the applicants were women (73%) aged 75 years and older (79%). Applicants most often indicated physical suffering as element of suffering and reason for the request. Medical professionals indicated in 40% of the cases no or insufficient medical ground for the suffering. CONCLUSIONS: Physical suffering plays an important role in requests for EAS even for persons who are not (severely) ill. From the presence of physical suffering it does not necessarily follow that for medical professionals there is sufficient medical ground to comply with the 'medical ground'-boundary.

[Persons aged 75 and above who have a death wish while not being seriously ill: who are these people?] / 75-plussers met een doodswens zonder dat ze ernstig ziek zijn.

OBJECTIVE: To provide insight into the prevalence of persistent death wishes without being severely ill among Dutch older persons aged 75 and above; to describe the characteristics and circumstances of this group; to improve knowledge on the nature of their death wishes. DESIGN: Cross-sectional study. METHOD: In 2019 we conducted a large survey among a representative sample of 32,477 Dutch citizens aged 55 and above from the TNS-NIPObase. The questionnaire was completed by 21,294 respondents in April 2019 (response rate 65.6%). This article comprises a subanalysis of the respondents aged 75 and above. RESULTS: Of all 3,141 respondents aged 75 and above, 56 were identified as having a persistent death wish and no severe illness (PDW-NSI). The weighted percentage representing the Dutch population indicates PDW-NSI among 2.07% of all older persons aged 75 and above in the Netherlands. Respondents with PDW-NSI had a lower level of education, were of lower social class and lived in highly urbanized areas more often. Important aspects enhancing the death wish were dependence on others, worrying, physical or mental deterioration, health problems and loneliness. The death wish was subject to change and the intensity varied over time. CONCLUSION: Of older persons aged 75 and above with PDW-NSI, a considerable part stays out of sight of healthcare professionals because they do not communicate about their death wish. This may challenge timely support. Carefully questioning the meaning and nature of the death wish is essential to understand the background and underlying needs of the persons concerned.

Still ready to give up on life? A longitudinal phenomenological study into wishes to die among older adults.

RATIONALE: There is a paucity of empirical studies exploring wishes to die (WTD) in older adults without a life-threatening disease or psychiatric disorder, especially on how these WTD evolve over time. OBJECTIVE: This study aims to deepen our understanding of living with a WTD by elucidating multifaceted trajectories of death wishes in older adults without a life-threatening disease or psychiatric disorder. METHODS: Interviews were conducted between 2013 and 2019 with Dutch men and women aged 70 and older who expressed a WTD (preferably at a self-chosen moment). Using a phenomenological, longitudinal analysis approach, 35 serial interviews were analyzed. RESULTS: This resulted in four thematic meanings following four trajectories, namely: 1) a realized WTD, facing the ultimate decision with both freedom and a sense of fate; 2) an intensifying WTD, reaching a deadlock; 3) a diminishing WTD, experiencing tentative space for new possibilities; and 4) a vanishing WTD, being surprised by an unexpected turn. In the cases examined, the individuals' WTD was characterized by ambivalence and subject to change over time. Fluctuating, often asynchronous patterns of physical, social, psychological, and existential distress were lived intertwined. The WTD should thus be understood as dynamic and unpredictable, often impacted by external circumstances. CONCLUSIONS: An important clinically relevant finding is that even persons with a pronounced WTD can experience openness to new possibilities, leading to a diminished or vanished WTD and/or desire to act on their WTD. Often such changes were related to (re-)establishment of connections with other people and/or society or with themselves. Since most research in this area is cross-sectional, the current longitudinal findings of this study are unique in providing insight into changes over time, thus contributing to the fields of death and suicide studies.

Euthanasia and Physician-Assisted Suicide in Patients With Multiple Geriatric Syndromes.

Importance: The Dutch Regional Euthanasia Review Committees (RTEs) reviewed and reported an increasing number of cases of euthanasia and physician-assisted suicide (EAS) requested by older people with multiple geriatric syndromes (MGS). Knowledge of the characteristics of cases of EAS for MGS is important to facilitate societal debate and to monitor EAS practice. Objective: To examine the accumulation of patient characteristics, geriatric syndromes, and other circumstances as reported in the case summaries of the RTEs that led to unbearable suffering associated with a request for EAS and to analyze the RTEs' assessments of these cases of EAS. Design, Setting, and Participants: A qualitative content analysis was conducted of all case summaries filed from January 1, 2013, to December 31, 2019, under the category MGS and published in a national open access database. These case summaries were selected by the RTEs from the total of 1605 reported cases of EAS in the category MGS. Results: The RTEs published 53 cases (41 [77%] female) under the category MGS. A total of 28 patients (53%) had always perceived themselves as independent, active, and socially involved. None of the patients suffered from life-threatening conditions. Multiple geriatric syndromes, such as visual impairment (34 cases [64%]), hearing loss (28 cases [53%]), pain (25 cases [47%]), and chronic tiredness (22 cases [42%]), were common. The request for EAS was often preceded by a sequence of events, especially recurrent falls (33 cases [62%]). Although physical suffering could be determined in all cases, the case descriptions found that suffering occurred on multiple dimensions, such as the loss of mobility (44 [83%]), fears (21 [40%]), dependence (23 [43%]), and social isolation (19 [36%]). Conclusions and Relevance: This qualitative study suggests that an accumulation of geriatric syndromes leading to a request for EAS is often intertwined with the social and existential dimension of suffering. This leads to a complex interplay of physical, psychological, and existential suffering that changes over time.

Prevalence and characteristics of older adults with a persistent death wish without severe illness: a large cross-sectional survey.

BACKGROUND: Some older persons develop a persistent death wish without being severely ill, often referred to as "completed life" or "tiredness of life". In the Netherlands and Belgium, the question whether these persons should have legal options for euthanasia or physician-assisted suicide (EAS) is intensely debated. Our main aim was to investigate the prevalence and characteristics of older adults with a persistent death wish without severe illness, as the lack of this knowledge is a crucial problem in de debate. METHODS: We conducted a survey among a representative sample of 32,477 Dutch citizens aged 55+, comprising questions about health, existential issues and the nature of the death wish. Descriptive statistics were used to describe the group with a persistent death wish and no severe illness (PDW-NSI) and several subgroups. RESULTS: A total of 21,294 respondents completed the questionnaire (response rate 65.6%). We identified 267 respondents (1.25%) as having a persistent death wish and no severe illness (PDW-NSI). PDW-NSI did not only occur among the oldest old. Although qualifying themselves as "not severely ill", those with PDW-NSI reported considerable health problems. A substantial minority of the PDW-NSI-group reported having had a death wish their whole lives. Within the group PDW-NSI 155 (0.73%) respondents had an active death wish, of which 36 (0.17% of the total response) reported a wish to actually end their lives. Thus, a death wish did not always equal a wish to actually end one's life. Moreover, the death wishes were often ambiguous. For example, almost half of the PDW-NSI-group (49.1%) indicated finding life worthwhile at this moment. CONCLUSIONS: The identified characteristics challenge the dominant "completed life" or "tiredness of life" image of healthy persons over the age of 75 who, overseeing their lives, reasonably decide they would prefer to die. The results also show that death wishes without severe illness are often ambiguous and do not necessarily signify a wish to end one's life. It is of great importance to acknowledge these nuances and variety in the debate and in clinical practice, to be able to adequately recognize the persons involved and tailor to their needs.

Integrating Juggling with Math Lessons: A Randomized Controlled Trial Assessing Effects of Physically Active Learning on Maths Performance and Enjoyment in Primary School Children.

There are tentative indications that physical activity (PA) during school time can be beneficial for children's academic performance. So far, most studies have focused on the effects of moderate-to-vigorous PA, for example, in the form of energizers or extra physical education lessons. Little is known about the effects of physically active learning, in which PA is integrated with the academic content of the lessons, especially in preadolescent children. Moreover, there is a lack of knowledge regarding the enjoyment of physically active learning in this age group. Therefore, the aim of the current study was to assess the effects of integrating juggling with math practice in primary school children, on (1) multiplication memorization performance and (2) enjoyment during the math lessons. We conducted a cluster randomized controlled trial, in which 312 children (mean age 10.4 years) from nine Dutch primary schools participated. Fourteen classes were randomly assigned to either a group that learned juggling whilst practicing multiplication tables (intervention group), or to a group that practiced the same multiplication tables while sedentary (control group). Both interventions had a duration of 5 weeks and consisted of 20 short lessons (4 lessons per week, 5 to 8 min). We used mixed-model analyses to examine the effect of the intervention on multiplication memorization performance. Group (control or intervention) was used as the fixed factor, and class and school as random intercepts. Analyses were adjusted for pretest multiplication performance, age, gender, general motor skill level, physical activity behavior (PAQ-C), and academic math performance. No significant intervention effect on multiplication performance were observed. However, the math-juggling program significantly increased enjoyment of children during the math lessons. We can conclude that the intervention did not improve, but neither deteriorated children's math performance. The increased enjoyment in the math-juggling group can serve as an important starting point for structurally incorporating physical activities in the classroom setting.

Improving Cognitive Performance of 9-12 Years Old Children: Just Dance? A Randomized Controlled Trial.

Exercise is assumed to have positive effects on children's cognitive performance. However, given the inconclusive evidence for the long-term effects of exercise, it is difficult to advice schools on what specific exercise programs can improve children's cognitive performance. In particular, little is known about the effects of small exercise programs that may be feasible in daily school practice. Therefore, we assessed the effects of a 9-weeks program consisting of daily exercise breaks on children's cognitive performance, aerobic fitness and physical activity levels. We conducted a cluster-randomized controlled trial in 21 classes of eight Dutch primary schools. A total of 512 children aged 9-12 years participated. The exercise intervention had a duration of 9 weeks and consisted of a daily 10-min classroom-based exercise break of moderate to vigorous intensity. Before and after the intervention, we used four cognitive tasks (i.e., the Attention Network Test, Stroop test, d2 test of attention and Fluency task) to measure children's cognitive performance in domains of selective attention, inhibition and memory retrieval. In addition, we measured aerobic fitness with a Shuttle Run test and physical activity during school hours by accelerometers. We analyzed data using mixed models, adjusting for baseline scores, class and school. After 9 weeks, there were no intervention effects on children's cognitive performance or aerobic fitness. Children in the intervention group spent 2.9 min more of their school hours in moderate to vigorous physical activity as compared to the children in the control group. In conclusion, daily 10-min exercise breaks in the classroom did not improve, nor deteriorate cognitive performance in children. The exercise breaks had no effect on children's fitness, and resulted in 2.9 min more time spent in moderate to vigorous physical activity during school hours. Daily exercise breaks can be implemented in the classroom to promote children's physical activity during school time, without adverse effect on their cognitive performance.

Effects of physical activity interventions on cognitive and academic performance in children and adolescents: a novel combination of a systematic review and recommendations from an expert panel.

OBJECTIVE: To summarise the current evidence on the effects of physical activity (PA) interventions on cognitive and academic performance in children, and formulate research priorities and recommendations. DESIGN: Systematic review (following PRISMA guidelines) with a methodological quality assessment and an international expert panel. We based the evaluation of the consistency of the scientific evidence on the findings reported in studies rated as of high methodological quality. DATA SOURCES: PubMed, PsycINFO, Cochrane Central, Web of Science, ERIC, and SPORTDiscus. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: PA-intervention studies in children with at least one cognitive or academic performance assessment. RESULTS: Eleven (19%) of 58 included intervention studies received a high-quality rating for methodological quality: four assessed effects of PA interventions on cognitive performance, six assessed effects on academic performance, and one on both. All high-quality studies contrasted the effects of additional/adapted PA activities with regular curriculum activities. For cognitive performance 10 of 21 (48%) constructs analysed showed statistically significant beneficial intervention effects of PA, while for academic performance, 15 of 25 (60%) analyses found a significant beneficial effect of PA. Across all five studies assessing PA effects on mathematics, beneficial effects were reported in six out of seven (86%) outcomes. Experts put forward 46 research questions. The most pressing research priority cluster concerned the causality of the relationship between PA and cognitive/academic performance. The remaining clusters pertained to PA characteristics, moderators and mechanisms governing the 'PA-performance' relationship and miscellaneous topics. CONCLUSION: There is currently inconclusive evidence for the beneficial effects of PA interventions on cognitive and overall academic performance in children. We conclude that there is strong evidence for beneficial effects of PA on maths performance.The expert panel confirmed that more 'high-quality' research is warranted. By prioritising the most important research questions and formulating recommendations we aim to guide researchers in generating high-quality evidence. Our recommendations focus on adequate control groups and sample size, the use of valid and reliable measurement instruments for physical activity and cognitive performance, measurement of compliance and data analysis. PROSPERO REGISTRATION NUMBER: CRD42017082505.

Untapped Resources: 10- to 13-Year-Old Primary Schoolchildren's Views on Additional Physical Activity in the School Setting: A Focus Group Study.

Schools are considered ideal venues to promote physical activity (PA) in children. However, a knowledge gap exists on how to adequately integrate PA into the school day and in particular, on the preferences of children regarding additional PA in school. Therefore, the aim of our qualitative study was to gain comprehensive insight into 10⁻13-year-old primary schoolchildren's perspectives on how to increase PA in the school setting. We conducted nine focus groups (32 girls and 20 boys) with children attending the final two grades of primary school in the Netherlands. We used inductive thematic analysis to analyze the data. The results showed that children were enthusiastic about additional PA in school. Children suggested various ways to increase PA, including more time for PA in the existing curriculum, e.g., physical education (PE), recess, and occasional activities, such as field trips or sports days; school playground adaptation; improving the content of PE; and implementing short PA breaks and physically active academic lessons. Children emphasized variation and being given a voice in their PA participation as a prerequisite to keep PA enjoyable and interesting in the long term. Finally, children mentioned the role of the teacher and making efforts to accommodate all children and their different preferences as important. Children have concrete ideas, acknowledging the challenges that accompany integrating additional PA in school. We therefore recommend actively involving children in efforts to increase school-based PA and to make "additional PA in school" a shared project of teachers and students.

Exercise of Varying Durations: No Acute Effects on Cognitive Performance in Adolescents.

Participation in structured physical activity is assumed to have a positive effect on cognitive and academic performance. A single bout of moderate to vigorous exercise has been found to have a small acute positive effect on the cognitive performance of children and adolescents. However, the dose-response effects of exercise duration are largely unknown. Therefore, the current study examined the acute effects of moderate-to-vigorous exercise with a duration of either 10, 20, or 30 min on selective attention and working memory performance of young adolescents. One hundred and nineteen adolescents (11-14 years old) participated in a randomized, controlled crossover study. Adolescents were assigned to one of the three exercise durations, each paired with a sedentary control session of the same duration. Cognitive performance was measured before and immediately after the exercise and control condition. The Attention Network Test and n-back task were used to measure selective attention and working memory, respectively. There were no significant exercise effects on selective attention (i.e., alerting, orienting, or executive control) or working memory performance measured immediately after the exercise bouts. Furthermore, there were no differential effects of exercise duration. In sum, acute exercise bouts with a duration of 10, 20, or 30 min did not improve, but neither deteriorate cognitive performance of young adolescents compared to a sedentary control condition.

"It's a Battle You Want to Do It, but How Will You Get It Done?": Teachers' and Principals' Perceptions of Implementing Additional Physical activity in School for Academic Performance.

School is an ideal setting to promote and increase physical activity (PA) in children. However, implementation of school-based PA programmes seems difficult, in particular due to schools' focus on academic performance and a lack of involvement of school staff in program development. The potential cognitive and academic benefits of PA might increase chances of successful implementation. Therefore, the aim of this qualitative study was: (1) to explore the perceptions of teachers and principals with regard to implementation of additional PA aimed at improving cognitive and academic performance, and (2) to identify characteristics of PA programmes that according to them are feasible in daily school practice. Twenty-six face-to-face semi-structured interviews were conducted with primary school teachers (grades 5 and 6) and principals in The Netherlands, and analysed using inductive content analysis. Teachers and principals expressed their willingness to implement additional PA if it benefits learning. Time constraints appeared to be a major barrier, and strongly influenced participants' perceptions of feasible PA programmes. Teachers and principals emphasised that additional PA needs to be short, executed in the classroom, and provided in "ready-to-use" materials, i.e., that require no or little preparation time (e.g., a movie clip). Future research is needed to strengthen the evidence on the effects of PA for academic purposes, and should examine the forms of PA that are both effective as well as feasible in the school setting.

Physical Activity in the School Setting: Cognitive Performance Is Not Affected by Three Different Types of Acute Exercise.

Recent studies indicate that a single bout of physical exercise can have immediate positive effects on cognitive performance of children and adolescents. However, the type of exercise that affects cognitive performance the most in young adolescents is not fully understood. Therefore, this controlled study examined the acute effects of three types of 12-min classroom-based exercise sessions on information processing speed and selective attention. The three conditions consisted of aerobic, coordination, and strength exercises, respectively. In particular, this study focused on the feasibility and efficiency of introducing short bouts of exercise in the classroom. One hundred and ninety five students (5th and 6th grade; 10-13 years old) participated in a double baseline within-subjects design, with students acting as their own control. Exercise type was randomly assigned to each class and acted as between-subject factor. Before and immediately after both the control and the exercise session, students performed two cognitive tests that measured information processing speed (Letter Digit Substitution Test) and selective attention (d2 Test of Attention). The results revealed that exercising at low to moderate intensity does not have an effect on the cognitive parameters tested in young adolescents. Furthermore, there were no differential effects of exercise type. The results of this study are discussed in terms of the caution which should be taken when conducting exercise sessions in a classroom setting aimed at improving cognitive performance.