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1.
CMAJ ; 194(35): E1198-E1208, 2022 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-36096505

RESUMO

BACKGROUND: The benefits and harms of anticoagulants for people near the end of life are not well understood, nor is it known what proportion of patients discontinue these medications. We aimed to characterize anticoagulant use in older recipients of home palliative care and describe patient and provider characteristics, as well as outcomes associated with anticoagulant discontinuation in this group. METHODS: Using linked administrative health databases, we conducted a population-based cohort study of patients aged 66 years and older who initiated home palliative care in Ontario from 2010 to 2018. We calculated the prevalence of anticoagulant use. We used multilevel logistic regression models to assess patient (e.g., sociodemographic, comorbidities) and physician (e.g., demographic, training, practice) factors associated with anticoagulant discontinuation after initiation of home palliative care. We defined discontinuation as either primary (no anticoagulant claim within 1.5 times the days' supply of the previous prescription) or secondary (no subsequent anticoagulant claim at any time after the index date). In secondary analyses, we used cause-specific hazards regression to explore subsequent thrombotic and bleeding events associated with anticoagulant discontinuation, and multivariable logistic regression for location of death. RESULTS: We identified 98 089 recipients of home palliative care, of whom 15.5% were taking anticoagulants at the time of the first palliative care visit. Depending on the definition of discontinuation, 18.0% to 24.4% of patients discontinued anticoagulants after the first home palliative care visit. Compared with warfarin, use of a direct oral anticoagulant (adjusted odds ratio [OR] 0.49, 95% confidence interval [CI] 0.43-0.56) and low-molecular-weight heparin (adjusted OR 0.56, 95% CI 0.47-0.66) were associated with a lower likelihood of discontinuation. Few patient or physician characteristics - and no comorbidities or indications for therapeutic anticoagulation - were associated with discontinuation. Anticoagulant discontinuation after beginning home palliative care was associated with similar rates of thrombosis (adjusted hazard ratio [HR] 1.06, 95% CI 0.81-1.39), lower rates of bleeding (adjusted HR 0.75, 95% CI 0.62-0.90) and a higher likelihood of a home death (adjusted OR 1.22, 95% CI 1.09-1.36) compared with continuing anticoagulation. INTERPRETATION: Among recipients of home palliative care in Ontario, anticoagulant use is common, and discontinuation is not influenced by comorbidities or indication for anticoagulation. Physician preference may play an important role; patients should be made aware of their options toward the end of life and supported in shared decision-making.


Assuntos
Anticoagulantes , Cuidados Paliativos , Idoso , Anticoagulantes/efeitos adversos , Estudos de Coortes , Morte , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Hemorragia/epidemiologia , Humanos , Estudos Retrospectivos
2.
Nihon Ronen Igakkai Zasshi ; 59(3): 323-330, 2022.
Artigo em Japonês | MEDLINE | ID: mdl-36070906

RESUMO

INTRODUCTION: This study explored the factors related to awareness of hope at the end of life among older adults who attend community-based preventive services for long-term care. METHODS: Hope at the end of life was determined using a six-item questionnaire inquiring about topics such as "Medical hope when oral intake is not possible" and "Where they wanted to spend the end of their lives." A multiple logistic regression analysis was performed using the six items as dependent variables and hospitalization experience, end-of-life care experience, and one's view of life and death as independent variables. RESULTS: Data from 95 retrieved questionnaires were analyzed. The range of hope at the end of life was 14.7%-71.6% for each item. "Where they wanted to spend the end of their lives" was the most frequently considered topic among the respondents. "Medical hope when oral intake was not possible" was considered by 41.1% of respondents, and this topic was related to experience with hospitalization and end-of-life care as well as interest in death. CONCLUSION: Hospitalization experience, end-of-life care, and personal views on life and death were shown to be related to awareness of hope at the end of life among community-dwelling older adults.


Assuntos
Assistência de Longa Duração , Assistência Terminal , Idoso , Serviços de Saúde Comunitária , Morte , Humanos , Inquéritos e Questionários
3.
BMC Palliat Care ; 21(1): 156, 2022 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-36071421

RESUMO

BACKGROUND/PURPOSE: The purpose of this secondary-analysis study was to identify never-before-examined factors associated with distinct depressive-symptom trajectories among family caregivers from end-of-life caregiving through the first 2 bereavement years. PARTICIPANTS/METHODS: Participants (N=661) were family caregivers who provided end-of-life caregiving for terminally ill cancer patients. Multinomial logistic regressions were conducted to identify modifiable factors associated with caregivers' seven previously identified depressive-symptom trajectories: minimal-impact resilience, recovery, preloss-depressive-only, delayed symptomatic, relief, prolonged symptomatic, and chronically persistent distressed. Drawing from the stress-appraisal-coping model, modifiable time-varying factors associated with distinct depressive-symptom trajectories were examined in three domains: (1) stressors, (2) stress appraisal, and (3) available resources (internal coping capacity and external social support). RESULTS: Profound objective caregiving demands were associated with caregivers' increased likelihood of belonging to more distressing depressive-symptom trajectories than to the minimal-impact-resilience trajectory. But, stronger negative appraisal of end-of-life caregiving increased odds of caregiver membership in preloss-depressive-only and relief trajectories over the recovery, delayed, and prolonged-symptomatic trajectories. Stronger internal coping capacity and perceived social support buffered the tremendous stress of end-of-life caregiving and permanent loss of a relative, as evidenced by higher odds of being in the minimal-impact-resilience and recovery trajectories. CONCLUSION: Family caregivers' distinct depressive-symptom trajectories were linked to their preloss caregiving demands, appraisal of negative caregiving impact, personal coping capacity, and perceived social support. Our results highlight actionable opportunities to improve end-of-life-care quality by boosting family caregivers' coping capacity and enhancing their social support to help them adequately manage daily caregiving loads/burdens thus relieving the emotional toll before patient death and throughout bereavement.


Assuntos
Luto , Depressão , Cuidadores/psicologia , Morte , Depressão/etiologia , Depressão/psicologia , Pesar , Humanos
4.
Vet Rec ; 191(5): 187, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36083094
5.
PLoS One ; 17(9): e0274201, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36084060

RESUMO

OBJECTIVES: To explore patients' experiences and recommendations for discussions about their prognosis and end of life with their physicians. METHODS: Patients with advanced cancer or advanced chronic obstructive pulmonary disease (COPD) were enrolled in qualitative interviews, which were analyzed with a phenomenological and thematic approach. RESULTS: During interviews with fourteen patients (median age 64 years), we identified the following themes for discussion about prognosis and the end of life: topics discussed, the timing, the setting, physician-patient relationship, responsibilities for clinicians, and recommendations. Patients preferred the physician to initiate such discussion, but wanted to decide about its continuation and content. The discussions were facilitated by an established physician-patient relationship or attendance of relatives. Patients with cancer had had discussions about prognosis at rather clear-cut moments of deterioration than patients with COPD. Patients with COPD did not consider end-of-life discussions a responsibility of the pulmonologist. Patients recommended an understandable message, involvement of relatives or other clinicians, sufficient time, and sensitive non-verbal communication. CONCLUSIONS: Patients appreciated open, sensitive, and negotiable discussions about prognosis and the end of life. PRACTICE IMPLICATIONS: Patients' recommendations could be used for communication training. Possible differences in the need for such discussions between patients with cancer or COPD warrant further research.


Assuntos
Neoplasias , Doença Pulmonar Obstrutiva Crônica , Assistência Terminal , Comunicação , Morte , Humanos , Pessoa de Meia-Idade , Relações Médico-Paciente , Prognóstico , Pesquisa Qualitativa
6.
Handb Clin Neurol ; 190: 195-215, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36055716

RESUMO

Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.


Assuntos
Cuidados Paliativos na Terminalidade da Vida , Hospitais para Doentes Terminais , Assistência Terminal , Morte , Humanos , Qualidade de Vida
7.
Psychodyn Psychiatry ; 50(3): 435-443, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36047795

RESUMO

As a result of end-of-life movements in a number of states, psychiatrists may be drawn into the capacity assessment of patients requesting assistance to end their lives. Such assessments cannot follow the mere technicalities of common clinical interviews, not simply because of the finality of the choice, but also because of the limitations of common cognitive assessments. The Committee on Professionalism and Ethics of the Group for the Advancement of Psychiatry consequently proposes an interview for such purposes that explores a patient's emotional capacity through a narrative inquiry about the patient's life, past coping, and reversible emotional states. It is a neutral approach that seeks to understand the patient rather than judge the appropriateness of an end-of-life request.


Assuntos
Tomada de Decisões , Psiquiatria , Morte , Humanos , Inquéritos e Questionários
8.
Hu Li Za Zhi ; 69(5): 111-119, 2022 Oct.
Artigo em Chinês | MEDLINE | ID: mdl-36127764

RESUMO

Respect for autonomy is an important principle of medical ethics. Individuals exist within socially embedded networks that include many people, and develop their sense of self and decision-making capacity through network relationships. The concept of relational autonomy has been proposed as a feasible alternative to individual autonomy. Within the framework of relational autonomy, an individual builds up their decision-making capacities through continuous interaction, delivering information and knowledge to the medical team, family, and other important relations while considering their own social and cultural backgrounds within the contexts of trust, caring, and sincere collaboration. The authors of this study integrated the concept of relational autonomy and analyzed the decision-making autonomy of critical patients. When a patient has decision-making capacity, health professionals must provide a trusting, open, and caring communication environment for all important stakeholders to interact, discuss, and assist patients to demonstrate their autonomy. If a patient is unconscious or unable to make decisions, their wishes need to be respected. However, if this patient has not signed a document of intent, the legal representative must respect patient autonomy in accordance with their previous wishes and values. However, the disease prognosis is not easy to predict, the public and health professionals lack knowledge of advance directives, and it is considered taboo to talk about death. Advance directives remain unpopular. Therefore, we hope this article may assist health professionals to demonstrate patient relational autonomy in medical decision situations.


Assuntos
Tomada de Decisões , Autonomia Relacional , Comunicação , Cultura , Morte , Humanos
9.
Rev Bras Enferm ; 75(2): e20210684, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36134812

RESUMO

OBJECTIVES: to analyze the modes of subjectification of health professionals towards end of life and death in a home care service. METHODS: this is qualitative research carried out in a home care service at a teaching hospital in southern Brazil, with 12 health professionals. Participant observation and semi-structured interviews were used for data collection, from April to September 2018. Data were analyzed based on Foucault's concept of power and subjectivation. RESULTS: professionals are sensitized by moral, spiritual and palliative care discourses, as well as experiences that constitute them subjects who modify their ways of life and professional practice based on the relation with death. FINAL CONSIDERATIONS: the discursive network of palliative care is internalized by professionals, who carry out their practices with behaviors aimed at promoting "a good death".


Assuntos
Serviços de Assistência Domiciliar , Assistência Terminal , Morte , Pessoal de Saúde , Humanos , Cuidados Paliativos , Pesquisa Qualitativa
10.
JACC Cardiovasc Imaging ; 15(9): 1635-1644, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36075625

RESUMO

BACKGROUND: Coronary vasomotor dysfunction (defined by reduced myocardial blood flow reserve [MBFR]) is associated with high cardiac risk in both men and women in absence of significant coexisting epicardial disease. Whether there is a sex-specific difference in prognostic value of reduced MBFR in patients with a greater burden of coexisting epicardial atherosclerotic disease is not well understood. OBJECTIVES: The purpose of this study was to examine the association of sex, MBFR, and mortality in consecutive patients with suspected or known coronary artery disease undergoing positron emission tomography myocardial perfusion imaging. METHODS: Unique consecutive patients undergoing rubidium (Rb)-82 rest/stress positron emission tomography myocardial perfusion imaging from 2010-2016 were followed for a median of 3.2 years. Multivariable Cox models were built to describe the interaction of sex and MBFR on all-cause and cardiac death for the overall population and stratified by extent of calcified atherosclerosis (none: coronary artery calcium score = 0, subclinical: coronary artery calcium >0, clinical: prior myocardial infarction/percutaneous coronary intervention) and abnormal perfusion (no significant obstructive disease: summed stress score = 0, 1%-9.9%, and ≥10%) at baseline. RESULTS: Among 12,594 patients, 52.8% were women. Compared with men, women had a lower prevalence of known coronary artery disease (16.5% vs 29.5%; P < 0.001) and were less likely to undergo revascularization after myocardial perfusion imaging (4.9% vs 9.7%; P < 0.001), but were more likely to have a reduced MBFR of <2 (56.2% vs 50.6%; P < 0.001). There were 1,699 (13.5%) all-cause and 490 (3.9%) cardiac deaths. In fully adjusted Cox models, reduced MBFR was independently associated with higher risk of death (HR per 0.1-U decrease: 1.09 [95% CI: 1.08-1.10]; P < 0.001), but female sex was not (HR: 0.95 [95% CI: 0.85-1.05]; P = 0.27). There was no significant interaction between sex and MBFR on death (P = 0.22) and cardiac death (P = 0.35) overall or in subgroups of patients with clinical, subclinical, and no atherosclerosis or across categories of perfusion abnormality at baseline. CONCLUSIONS: The association between reduced MBFR and higher risk of all-cause and cardiac death did not differ by sex, regardless of extent of coexisting atherosclerosis or perfusion abnormality.


Assuntos
Aterosclerose , Doença da Artéria Coronariana , Imagem de Perfusão do Miocárdio , Cálcio , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Morte , Feminino , Humanos , Masculino , Imagem de Perfusão do Miocárdio/métodos , Tomografia por Emissão de Pósitrons/métodos , Valor Preditivo dos Testes
11.
Medicine (Baltimore) ; 101(37): e30524, 2022 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-36123841

RESUMO

Interstitial lung disease (ILD) is widely known to be associated with high mortality and poor prognosis, especially in patients admitted to the intensive care unit (ICU). The objective of this study was to investigate clinical predictors for assisting relatively early decision of treatment level in the ICU. We retrospectively investigated patients with ILD who were admitted to the ICU between January 1, 2014, and September 30, 2019. A total of 64 patients were analyzed. We found the ICU and hospital mortality rates to be 67.2% and 69.8%, respectively. Nonsurvivors had a higher fraction of inspired oxygen (FiO2) on days 1 (79 ±â€…21 vs 60% ±â€…21%, P = .001) and 3 (61 ±â€…31 vs 46% ±â€…19%, P = .004). They showed lower partial pressure of oxygen/FiO2 (PF) ratio on days 1 (134 ±â€…80 vs 173 ±â€…102, P = .049) and 3 (147 ±â€…74 vs 235 ±â€…124, P = .003) than the survivor group. The lactic acid levels obtained on day 1 and PF ratio measured on day 3 were associated with mortality (odds ratio, 1.89; 95% confidence interval 1.03-3.47 and odds ratio, 0.99; 95% confidence interval 0.98-1.00, respectively). Among the 31 ICU survivors, 10 patients died in the general ward, 12 patients died after hospital discharge; only 9 patients survived after 1 year. We suggest that these clinical predictors could be used to determine the level of further treatment or withdrawal on day 3 of admission in patients with ILD admitted to the ICU to minimize the prolonged suffering in a relatively early period.


Assuntos
Unidades de Terapia Intensiva , Doenças Pulmonares Intersticiais , Morte , Humanos , Ácido Láctico , Doenças Pulmonares Intersticiais/terapia , Oxigênio , Estudos Retrospectivos
12.
F1000Res ; 11: 268, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35967972

RESUMO

Background: Racial and ethnic disparities in end-of-life healthcare can be reduced by showing physicians how to best respond to a documented underlying cause: African American families' hopes for a miracle via divine intervention influence their end-of-life medical decisions, like, for example, making them not want to withdraw ventilatory support in cases of poor neurologic prognosis because they are still hoping for God to intervene.  Methods: Autoethnographic research probing the author's Spiritual Care experience in this context yields a nuanced, 90-second point-of-care spiritual intervention physicians can use to address the religious aspect of African American families who base end-of-life medical decisions on their hopes for a miracle via divine intervention. Autoethnographic analysis is framed by physician-author, Dr. Jessica Zitter's documented journey of grappling with this context. The evolution of Dr. Zitter's responses to miracle-hoping African American families provides a framework for applying autoethnographic analysis to a critical appropriation of the Johns Hopkins "AMEN" communication protocol for families hoping for a miracle.  Results: The common instinct of white physicians to remain neutral, holding miracle-hoping African American families at arm's length, rather than supportively engaging their hopes, is shown to be an intellectual ruse for emotional avoidance. A novel, counterintuitive spiritual intervention for the religious aspect of miracle-hoping African American families is integrated into an existing physician communication protocol for responding to families hoping for a miracle with recommendations for utilization of existing communication technology when necessary.  Conclusion: Properly addressing the religious dimension of African American families hoping for a miracle may help physicians to increase their therapeutic connection with families, decrease their own stress/burnout levels, and eliminate racial and ethnic disparities in end-of-life healthcare. .


Assuntos
Médicos , Espiritualidade , Afro-Americanos , Comunicação , Morte , Humanos
13.
Age Ageing ; 51(8)2022 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-36001482

RESUMO

BACKGROUND: understanding end-of-life preferences in the general population and how they are structured in people's minds is essential to inform how to better shape healthcare services in accordance with population expectations for their end of life and optimise communication on end-of-life care issues. OBJECTIVE: explore key dimensions underlying end-of-life preferences in a nationally representative sample of adults aged 55 and over in Switzerland. METHODS: respondents (n = 2,514) to the Swiss version of the Survey of Health, Ageing and Retirement in Europe assessed the importance of 23 end-of-life items on a 4-point Likert scale. The factorial structure of the underlying end-of-life preferences was examined using exploratory structural equation modelling. RESULTS: four dimensions underlying end-of-life preferences were identified: a medical dimension including aspects related to pain management and the maintenance of physical and cognitive abilities; a psychosocial dimension encompassing aspects related to social and spiritual support; a control dimension addressing the need to achieve some control and to put things in order before death; and a burden dimension reflecting wishes not to be a burden to others and to feel useful to others. CONCLUSION: highlighting the multi-dimensionality of end-of-life preferences, our results reaffirm the importance of a holistic and comprehensive approach to the end of life. Our results also provide a general framework that may guide the development of information and awareness campaigns on end-of-life care issues in the general population, informational materials and guidelines to support healthy individuals in end-of-life thinking and planning, and advance directive templates appropriate for healthy individuals.


Assuntos
Diretivas Antecipadas , Assistência Terminal , Comunicação , Morte , Humanos , Inquéritos e Questionários , Suíça , Assistência Terminal/métodos
14.
PLoS One ; 17(8): e0272436, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35925996

RESUMO

BACKGROUND: End-of-life decision-making tools are used to establish a shared understanding among patients, families and healthcare providers about medical treatment and goals of care. This systematic review aimed to understand the availability and effect of end-of-life decision-making tools on: (i) goals of care and advance care planning; (ii) patient and/or family satisfaction and well-being; and (iii) healthcare utilization among racial/ethnic, cultural, and religious minorities. METHODS: A search was conducted in four electronic databases (inception to June 2021). Articles were screened for eligibility using pre-specified criteria. We focused on adult patients (aged ≥18 years) and included primary research articles that used quantitative, qualitative, and mixed-methods designs. Complementary quality assessment tools were used to generate quality scores for individual studies. Extracted data were synthesized by outcome measure for each type of tool, and an overall description of findings showed the range of effects. RESULTS: Among 14,316 retrieved articles, 37 articles were eligible. We found that advance care planning programs (eleven studies), healthcare provider-led interventions (four studies), and linguistically-tailored decision aids (three studies) increased the proportion of patients documenting advance care plans. Educational tools (three studies) strongly reduced patient preferences for life-prolonging care. Palliative care consultations (three studies) were strongly associated with do-not-resuscitate orders. Advance care planning programs (three studies) significantly influenced the quality of patient-clinician communication and healthcare provider-led interventions (two studies) significantly influenced perceived patient quality of life. CONCLUSION: This review identified several end-of-life decision-making tools with impact on patient and family-related outcomes of care among ethnocultural minorities. Advance care planning programs, healthcare provider-led interventions and decision aids increased documentation of end-of-life care plans and do-not-resuscitate orders, and educational tools reduced preferences for life-prolonging care. Further research is needed to investigate the effect of tools on healthcare utilization, and with specific patient population subgroups across different illness trajectories and healthcare settings.


Assuntos
Planejamento Antecipado de Cuidados , Qualidade de Vida , Adolescente , Adulto , Comunicação , Morte , Tomada de Decisões , Humanos
15.
BMC Med Ethics ; 23(1): 80, 2022 08 12.
Artigo em Inglês | MEDLINE | ID: mdl-35962434

RESUMO

BACKGROUND: Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. In prehospital emergency medicine, decision-making commonly takes place in everyday life, under time pressure, with limited information about a patient and with few possibilities of consultation with colleagues. This paper explores the ethical challenges experienced by prehospital emergency personnel. METHODS: The study was grounded in the tradition of action research related to interventions in health care. Ethical challenges were explored in three focus groups, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. The participants, 15 in total, were recruited through an internal information network of the emergency services. Focus groups were audio-recorded and transcribed verbatim. RESULTS: The participants described ethical challenges arising when clinical guidelines, legal requirements, and clinicians' professional and personal value systems conflicted and complicated decision-making processes. The challenges centred around treatment at the end of life, intoxicated and non-compliant patients, children as patients-and their guardians, and the collaboration with relatives in various capacities. Other challenges concerned guarding the safety of oneself, colleagues and bystanders, prioritising scarce resources, and staying loyal to colleagues with different value systems. Finally, challenges arose when summoned to situations where other professionals had failed to make a decision or take action when attending to patients whose legitimate needs were not met by the appropriate medical or social services, and when working alongside representatives of authorities with different roles, responsibilities and tasks. CONCLUSION: From the perspective of the prehospital emergency personnel, ethical challenges arise in three interrelated contexts: when caring for patients, in the prehospital emergency unit, and during external collaboration. Value conflicts may be identified within these contexts as well as across them. A proposed model of analysis integrating the above contexts can assist in shedding light on ethical challenges and value conflicts in other health care settings. The model emphasises that ethical challenges are experienced from a particular professional perspective, in the context of the task at hand, and in a particular, the organisational setting that includes work schedules, medical guidelines, legal requirements, as well as professional and personal value systems.


Assuntos
Pessoal Técnico de Saúde , Serviços Médicos de Emergência , Criança , Morte , Grupos Focais , Humanos , Princípios Morais
16.
Proc Natl Acad Sci U S A ; 119(35): e2119513119, 2022 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-35994663

RESUMO

In a striking result, Louca and Pennell [S. Louca, M. W. Pennell, Nature 580, 502-505 (2020)] recently proved that a large class of phylogenetic birth-death models is statistically unidentifiable from lineage-through-time (LTT) data: Any pair of sufficiently smooth birth and death rate functions is "congruent" to an infinite collection of other rate functions, all of which have the same likelihood for any LTT vector of any dimension. As Louca and Pennell argue, this fact has distressing implications for the thousands of studies that have utilized birth-death models to study evolution. In this paper, we qualify their finding by proving that an alternative and widely used class of birth-death models is indeed identifiable. Specifically, we show that piecewise constant birth-death models can, in principle, be consistently estimated and distinguished from one another, given a sufficiently large extant timetree and some knowledge of the present-day population. Subject to mild regularity conditions, we further show that any unidentifiable birth-death model class can be arbitrarily closely approximated by a class of identifiable models. The sampling requirements needed for our results to hold are explicit and are expected to be satisfied in many contexts such as the phylodynamic analysis of a global pandemic.


Assuntos
Morte , Cadeias de Markov , Modelos Biológicos , Parto , Filogenia , Dinâmica Populacional , Evolução Biológica , Humanos , Pandemias
17.
Nurs Manage ; 53(9): 6-11, 2022 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-36040728
18.
Int J Palliat Nurs ; 28(8): 388-395, 2022 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-36006791

RESUMO

BACKGROUND: Death can cause a great deal of anxiety in nursing students for a variety of reasons. They are expected to provide a high level of care for patients, give the family the respect and patience they deserve and contend with the associated emotional attachments. This raised the question in today's educational world-can the use of technology and simulation aid students in preparing for an end-of-life scenario as part of an undergraduate nursing programme? AIM: To explore the efficacy of the use of simulations in end-of-life care. METHOD: A small study focusing upon the evaluation of an end-of-life simulated scenario for undergraduate second year cross-field Bachelor of Nursing students in a university setting. The simulated scenario consisted of a young patient who was dying and her mother. This project used a mixed approach to address varied students' learning styles and combined the need for visualisation and more structured base-sessions on the topic of death and end-of-life care. One student from the cohort group was randomly assigned as the nurse in charge, while other students were allocated to a scenario (out of a potential four) and provided care in real time. Subsequently, the impact of the scenario was assessed and students were immediately debriefed. Students' response to the scenario was important and needed to be considered, as it directly influenced the debriefing. There were some significant differences between how the students approached the scenario and their reaction to it. RESULTS: Of the students who took part in the end-of-life simulated scenario, the majority strongly agreed that the simulation increased their clinical reasoning and learning. CONCLUSION: The end-of-life scenario was deemed beneficial, despite the emotional impact on the learners involved.


Assuntos
Bacharelado em Enfermagem , Estudantes de Enfermagem , Assistência Terminal , Morte , Feminino , Humanos , Aprendizagem , Estudantes de Enfermagem/psicologia , Assistência Terminal/psicologia
19.
Radiat Oncol ; 17(1): 143, 2022 Aug 17.
Artigo em Inglês | MEDLINE | ID: mdl-35978340

RESUMO

BACKGROUND: A previous score predicted death ≤ 2 months following radiotherapy for MSCC. For patients with a high probability of early death, best supportive care was recommended. However, some of these patients may benefit from radiotherapy regarding preservation or improvement of motor function. To identify these patients, an additional score was developed. METHODS: Pre-treatment factors plus radiotherapy regimen were retrospectively evaluated for successful treatment (improved motor function or remaining ambulatory without aid) and post-treatment ambulatory status in 545 patients who died ≤ 2 months. Factors included age, interval from tumor diagnosis until MSCC, visceral metastases, further bone metastases, primary tumor type, sex, time developing motor deficits, pre-treatment ambulatory status, and number of affected vertebrae. Factors significant on both multivariable analyses were included in the score (worse outcomes 0 points, better outcomes 1 point). RESULTS: On multivariable analyses, myeloma/lymphoma, time developing motor deficits > 14 days, and pre-treatment ambulatory status were significantly associated with both successful treatment and ambulatory status, affection of 1-2 vertebrae with successful treatment only. On univariable analyses, 1 × 8 and 5 × 4 Gy were not inferior to 5 × 5 Gy and longer-course regimens. Considering the three factors significant for both endpoints, three groups were designed (0, 1, 2-3 points) with treatment success rates of 4%, 15% and 39%, respectively (p < 0.0001), and post-treatment ambulatory rates of 4%, 43% and 86%, respectively (p < 0.0001). CONCLUSION: This score helps identify patients with MSCC who appear to benefit from palliative radiotherapy in terms of improved motor function or remaining ambulatory in spite of being near end of life.


Assuntos
Compressão da Medula Espinal , Neoplasias da Medula Espinal , Neoplasias da Coluna Vertebral , Morte , Humanos , Prognóstico , Estudos Retrospectivos , Compressão da Medula Espinal/etiologia , Compressão da Medula Espinal/radioterapia , Neoplasias da Coluna Vertebral/radioterapia , Neoplasias da Coluna Vertebral/secundário
20.
Adv Skin Wound Care ; 35(9): 515-519, 2022 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-35993861
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