Emmanuelle Bélanger

Shared decision-making in palliative care: A systematic mixed studies review using narrative synthesis

The aim of this study is to synthesize knowledge about the process of shared decision-making (SDM) in palliative care. Medline, EMBASE, CINAHL, PsychInfo, Web of Science were searched with core concepts: shared decisions, patient participation in decision-making, and palliative care. Titles and abstracts were screened according to inclusion criteria (original research, adult patients, Western contexts, decision-making, palliative treatment or setting), yielding 37 articles for analysis. A narrative synthesis was created using the methods of thematic analysis, conceptual mapping, and critical reflection on the synthesis process. Results demonstrate that while a majority of patients want to participate in treatment decisions to some extent, most do not achieve their preferred levels of involvement because decisions are delayed and alternative treatment options are seldom discussed. The literature regarding the process of SDM itself remains scarce in palliative care. Further research is needed in order to better understand the longitudinal, interactive, and interdisciplinary process of decision-making in palliative care.

More than the sum of its parts? A qualitative research synthesis on multi-disciplinary primary care teams

This qualitative research synthesis reviews interpretive scholarly papers on multi-disciplinary primary care teams. A bibliographic search was conducted in electronic databases: Medline, Embase, and the Web of Science Citation Index, and in the references of retrieved papers. The research consists of a taxonomic analysis of 19 qualitative studies about primary care teams published in peer-reviewed journals between 2001 and July 2008 in English and French. Nineteen qualitative studies were synthesized. Two major concerns emerged: (1) strategies for organizational change toward effective co-operative practice, and (2) dimensions of team interactions and work relations. The authors conclude that qualitative results suggest common strategies to improve the development of primary care teams, while identifying dimensions of team interactions that remain problematic. A fundamental aspect of team formation appears to be overlooked, i.e., the construction of a collective identity, which would involve the whole team in a shared ideal of co-operative practice. The adoption of discourse analysis is suggested as a more sophisticated qualitative methodology to explore this issue.

Hyphenated identities and acculturation: second generation Chinese of Canada and the Netherlands

This research used a mixed-methods approach to compare the meanings of hyphenated identities in terms of acculturation attitudes across the 2nd generation Chinese of Canada and The Netherlands. The authors conducted two studies: (a) a statistical analysis of the acculturation correlates of hyphenated identity and (b) a discourse analysis of the construction of hyphenated identities in relation to contrast categories. Statistically, the hyphenated position did not correspond to an integrated acculturation profile; discursively, Canadian-Chinese and Dutch-Chinese were accountable positions constructed in relation to national categories. The civic discourse of being Canadian appeared to be more supportive of hyphenated identities. The authors concluded that research gains from combining different perspectives on identity, both as inner psychological constructs and as relational discursive positions.

Sources of social support associated with health and quality of life: a cross-sectional study among Canadian and Latin American older adults.

Objectives To examine whether the association between emotional support and indicators of health and quality of life differs between Canadian and Latin American older adults. Design Cross-sectional analysis of the International Mobility in Aging Study (IMIAS). Social support from friends, family members, children and partner was measured with a previously validated social network and support scale (IMIAS-SNSS). Low social support was defined as ranking in the lowest site-specific quartile. Prevalence ratios (PR) of good health, depression and good quality of life were estimated with Poisson regression models, adjusting for age, gender, education, income and disability in activities of daily living. Setting Kingston and Saint-Hyacinthe in Canada, Manizales in Colombia and Natal in Brazil. Participants 1600 community-dwelling adults aged 65–74 years, n=400 at each site. Outcome measures Likert scale question on self-rated health, Center for Epidemiological Studies Depression Scale and 10-point analogical quality-of-life (QoL) scale. Results Relationships between social support and study outcomes differed between Canadian and Latin American older adults. Among Canadians, those without a partner had a lower prevalence of good health (PR=0.90; 95% CI 0.82 to 0.98), and those with high support from friends had a higher prevalence of good health (PR=1.09; 95% CI 1.01 to 1.18). Among Latin Americans, depression was lower among those with high levels of support from family (PR=0.63; 95% CI 0.48 to 0.83), children (PR=0.60; 95% CI 0.45 to 0.80) and partner (PR=0.57; 95% CI 0.31 to 0.77); good QoL was associated with high levels of support from children (PR=1.54; 95% CI 1.20 to 1.99) and partner (PR=1.31; 95% CI 1.03 to 1.67). Conclusions Among older adults, different sources of support were relevant to health across societies. Support from friends and having a partner were related to good health in Canada, whereas in Latin America, support from family, children and partner were associated with less depression and better QoL.

The influence of academic discourses on medical students' identification with the discipline of family medicine.

Purpose To understand the influence of academic discourses about family medicine on medical students’ professional identity construction during undergraduate training. Method The authors used a multiple case study research design involving international medical schools, one each from Canada, France, Spain, and the United Kingdom (UK). The authors completed the fieldwork between 2007 and 2009 by conducting 18 focus groups (with 132 students) and 67 semistructured interviews with educators and by gathering pertinent institutional documents. They carried out discursive thematic analyses of the verbatim transcripts and then performed within- and cross-case analyses. Results The most striking finding was the diverging responses between those at the UK school and those at the other schools. In the UK case, family medicine was recognized as a prestigious academic discipline; students and faculty praised the knowledge and skills of family physicians, and students more often indicated their intent to pursue family medicine. In the other cases, family medicine was not well regarded by students or faculty. This was expressed overtly or through a paradoxical academic discourse that stressed the importance of family medicine to the health care system while decrying its lack of innovative technology and the large workload-to-income ratio. Students at these schools were less likely to consider family medicine. Conclusions These results stress the influence of academic discourses on medical students’ ability to identify with the practice of family medicine. Educators must consider processes of professional identity formation during undergraduate medical training as they develop and reform medical education.

Initiating decision-making conversations in palliative care: an ethnographic discourse analysis.

BackgroundConversations about end-of-life care remain challenging for health care providers. The tendency to delay conversations about care options represents a barrier that impedes the ability of terminally-ill patients to participate in decision-making. Family physicians with a palliative care practice are often responsible for discussing end-of-life care preferences with patients, yet there is a paucity of research directly observing these interactions. In this study, we sought to explore how patients and family physicians initiated decision-making conversations in the context of a community hospital-based palliative care service.MethodsThis qualitative study combined discourse analysis with ethnographic methods. The field research lasted one year, and data were generated through participant observation and audio-recordings of consultations. A total of 101 consultations were observed longitudinally between 18 patients, 6 family physicians and 2 pivot nurses. Data analysis consisted in exploring the different types of discourses initiating decision-making conversations and how these discourses were affected by the organizational context in which they took place.ResultsThe organization of care had an impact on decision-making conversations. The timing and origin of referrals to palliative care shaped whether patients were still able to participate in decision-making, and the decisions that remained to be made. The type of decisions to be made also shaped how conversations were initiated. Family physicians introduced decision-making conversations about issues needing immediate attention, such as symptom management, by directly addressing or eliciting patients’ complaints. When decisions involved discussing impending death, decision-making conversations were initiated either indirectly, by prompting the patients to express their understanding of the disease and its progression, or directly, by providing a justification for broaching a difficult topic.ConclusionsDecision-making conversations and the initiation thereof were framed by the organization of care and the referral process prior to initial encounters. While symptom management was taken for granted as part of health care professionals’ expected role, engaging in decisions regarding preparation for death implicitly remained under patients’ control. This work makes important clinical contributions by exposing the rhetorical function of family physicians’ discourse when introducing palliative care decisions.

Improving undergraduate medical education about pain assessment and management: A qualitative descriptive study of stakeholders’ perceptions

BACKGROUND Pain is one of the most common reasons for individuals to seek medical advice, yet it remains poorly managed. One of the main reasons that poor pain management persists is the lack of adequate knowledge and skills of practicing clinicians, which stems from a perceived lack of pain education during the training of undergraduate medical students. OBJECTIVE To identify gaps in knowledge with respect to pain management as perceived by students, patients and educators. METHODS A qualitative descriptive study was conducted. Data were generated through six focus groups with second- and fourth-year medical students, four focus groups with patients and individual semistructured interviews with nine educators. All interviews were audiotaped and an inductive thematic analysis was performed. RESULTS A total of 70 individuals participated in the present study. Five main themes were identified: assessment of physical and psychosocial aspects of pain; clinical management of pain with pharmacology and alternative therapies; communication and the development of a good therapeutic relationship; ethical considerations surrounding pain; and institutional context of medical education about pain. CONCLUSION Participating patients, students and pain experts recognized a need for additional medical education about pain assessment and management. Educational approaches need to teach students to gather appropriate information about pain, to acquire knowledge of a broad spectrum of therapeutic options, to develop a mutual, trusting relationship with patients and to become aware of their own biases and prejudice toward patients with pain. The results of the present study should be used to develop and enhance existing pain curricula content.

Assessing the Validity of Self-Rated Health with the Short Physical Performance Battery: A Cross-Sectional Analysis of the International Mobility in Aging Study

Objective The aim of this study was to explore the validity of self-rated health across different populations of older adults, when compared to the Short Physical Performance Battery. Design Cross-sectional analysis of the International Mobility in Aging Study. Setting Five locations: Saint-Hyacinthe and Kingston (Canada), Tirana (Albania), Manizales (Colombia), and Natal (Brazil). Participants Older adults between 65 and 74 years old (n = 1,995). Methods The Short Physical Performance Battery (SPPB) was used to measure physical performance. Self-rated health was assessed with one single five-point question. Linear trends between SPPB scores and self-rated health were tested separately for men and women at each of the five international study sites. Poor physical performance (independent variable) (SPPB less than 8) was used in logistic regression models of self-rated health (dependent variable), adjusting for potential covariates. All analyses were stratified by gender and site of origin. Results A significant linear association was found between the mean scores of the Short Physical Performance Battery and ordinal categories of self-rated health across research sites and gender groups. After extensive control for objective physical and mental health indicators and socio-demographic variables, these graded associations became non-significant in some research sites. Conclusion These findings further confirm the validity of SRH as a measure of overall health status in older adults.

An Empirical Comparison of Different Models of Active Aging in Canada: The International Mobility in Aging Study

Purpose Active aging is a concept that lacks consensus. The WHO defines it as a holistic concept that encompasses the overall health, participation, and security of older adults. Fernández-Ballesteros and colleagues propose a similar concept but omit security and include mood and cognitive function. To date, researchers attempting to validate conceptual models of active aging have obtained mixed results. The goal of this study was to examine the validity of existing models of active aging with epidemiological data from Canada. Methods The WHO model of active aging and the psychological model of active aging developed by Fernández-Ballesteros and colleagues were tested with confirmatory factor analysis. The data used included 799 community-dwelling older adults between 65 and 74 years old, recruited from the patient lists of family physicians in Saint-Hyacinthe, Quebec and Kingston, Ontario. Results Neither model could be validated in the sample of Canadian older adults. Although a concept of healthy aging can be modeled adequately, social participation and security did not fit a latent factor model. A simple binary index indicated that 27% of older adults in the sample did not meet the active aging criteria proposed by the WHO. Implications Our results suggest that active aging might represent a human rights policy orientation rather than an empirical measurement tool to guide research among older adult populations. Binary indexes of active aging may serve to highlight what remains to be improved about the health, participation, and security of growing populations of older adults.

Life-course social and economic circumstances, gender, and resilience in older adults: The longitudinal International Mobility in Aging Study (IMIAS)

Although early socioeconomic adversity is associated with poorer function and health in adulthood, those who are able to adapt positively to such risks and threats develop a resilience that may ameliorate harm. Predictors of resilience have been examined in children, however exploring the relationship between life-course events, lived environments and current resilience among older adults across countries is novel. We specifically studied how childhood social and/or economic adversity and current socioeconomic resources were associated with resilience in 2000 community dwelling older men and women in Canada, Colombia, Brazil and Albania. The longitudinal International Mobility in Aging Study (IMIAS) collected information in 2012 and 2014 on childhood adversity, current income sufficiency social support and social engagement, and resilience (Wagnild Resilience Scale RS-14). Resilience levels were moderately high, and similar among women and men. Early social adversity predicted later resilience for some, with women but not men adapting positively. In contrast there was no bouncing back from early economic adversity. Current social engagement aligned with resilience (women only) as did social support from children (for women) and friends (for men). Partner support was of no advantage to either. Among men economic circumstances were stronger correlates of resilience while for women social circumstances were primary. The impact of site on resilience suggested that cultural norms and values have an independent effect on resilience of their populations, with strong and positive social ties more typical of Latin America than Canada appearing to offset lower absolute incomes. These findings are of importance because resilience is dynamic, can be fostered across the lifespan and is generally associated with greater health. Understanding which social assets and resources can be reinforced to build individual resilience offers a means for decreasing the harms of social and economic adversity.