Lesa L. Woodby

Measurements for active cigarette smoke exposure in prevalence and cessation studies: why simply asking pregnant women isn't enough.

Tobacco smoke exposure during and after pregnancy may cause maternal, fetal, and infant morbidity and mortality. The purpose of this review is to (a). describe existing methods of measuring active tobacco exposure among pregnant women and (b). illustrate the usefulness of these measures in validating self-reported smoking status among these women. Medline, PsycINFO, and Academic Search Elite were used to identify measures of cigarette smoking exposure, prevalence reports, cessation and validity studies, and research on deception about smoking during pregnancy. Review of the research on smoking cessation among pregnant women since 1966 revealed that 36% of studies (9 out of 25) located used only self-report to assess smoking status. The remaining 16 studies used either significant other reports or at least one type of biochemical test to confirm self-report. Deception rates were reported at baseline only, follow-up only, or both in 15 studies. Three federal agencies in the United States collect data on self-reported smoking during pregnancy. Smoking prevalence rates are inconsistent among these agencies. This article demonstrates that measuring smoking status during pregnancy via self-report alone leads to discrepancies in national prevalence rates, deceptions in clinical practice disclosure, and inconsistencies in research study results. Evaluation studies that confirm smoking status among pregnant women by biochemical methods provide more accurate prevalence rates and lead to the most effective behavioral interventions to achieve cessation. National statistics should carry a disclaimer indicating the likelihood of underestimation. Researchers and clinicians should be trained in best-practice, evidence-based behavioral methods to assess prenatal smoking status and to assist those who desire to quit.

Expanding the Notion of Researcher Distress: The Cumulative Effects of Coding

Qualitative researchers who explore the individual’s experience of health, illness, death, and dying often experience emotional stress in their work. In this article, we describe the emotional stress we experienced while coding semistructured, after-death interviews conducted with 38 next of kin of deceased veterans. Coding sensitive topic data required an unexpected level of emotional labor, the impact of which has not been addressed in the literature. In writing this discussion article, we stepped back from our roles as interviewers/coders and reflected on how our work affected us individually and as a team, and how a sequence of exposures could exert a cumulative effect for researchers in such a dual role. Through this article, we hope to generate an expanded discourse on how qualitative inquiry impacts the emotional well-being of researchers.

Effectiveness of Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Methods in Medicaid-Supported Prenatal Care Trial III

This two-phase evaluation documented the delivery and effectiveness of evidence-based health education methods by regular staff to pregnant smokers. During Phase 1, a total of 436 Medicaid patients were screened and 416 (95%) gave consent: 334 nonsmokers and 102 smokers. This historical Comparison (C) group was assessed to document the “normal” pretrial smoking prevalence, patient nondisclosure (deception), and cessation rates at the first prenatal visit and during care. After this study, a formative evaluation of SCRIPT methods was conducted among 139 experimental group patients and 126 control group patients. During Phase 2, a total of 6,514 patients were screened over a 36-month period: 1,736 (27%) were smokers and 1,340 (77%) gave consent. After randomization, 247 became ineligible. The remaining 1,093 smokers received brief routine advice to quit. The experimental group (n = 544) also received a Commit to Quit video, A Pregnant Woman’s Guide to Quit Smoking, and counseling. Self-reports and saliva were collected at baseline, ≥60 days, and ≤90 days postpartum for cotinine analyses to document cessation and significant reduction (SR) rates. The Phase 1 formative evaluation documented a 24% nondisclosure rate at the onset of care. It also confirmed a significantly higher experimental (17.3%) versus control group (8.8%) cessation rate and experimental versus control group SR rates of 22% and 16%. During Phase 2, unplanned policy changes, and delivery of experimental group counseling procedures to 15% to 20% of control group patients, resulted in a final experimental group cessation rate of 12% and a control group rate of 10%. The experimental group SR rate of 18%, however, was significantly higher than the control group SR rate of 13%. Effectiveness varied by the stability of clinic infrastructure, and degree of fidelity of staff performance of assessment and intervention procedures. The methods and results of this study will assist future health education programs for pregnant smokers to plan and conduct process and impact evaluations in prenatal care.

Opioid Pain Medication Orders and Administration in the Last Days of Life

CONTEXT Most patients with serious and life-limiting illness experience pain at some point in the illness trajectory. OBJECTIVES To describe baseline pain management practices for imminently dying patients in Veterans Administration Medical Centers (VAMCs) and examine factors associated with these processes, including presence of opioid orders at the time of death and medication administration in the last seven days, 48 hours, and 24 hours of life. METHODS Data on orders and administration of opioid pain medication at the end of life were abstracted from the medical records of veterans who died in six VAMC hospitals in 2005. RESULTS Of 1068 patient records, 686 (64.2%) had an active order for an opioid medication at the time of death. Of these, 69.8% of patients had received the medication at some time within the last seven days of life, 61.2% within the last 48 hours, and 47.0% within the last 24 hours. In multivariable models, presence of an order for opioid pain medication at the time of death and administration within the last 24 hours were both significantly associated with having a Do Not Resuscitate (DNR) order (P < 0.0001/0.0002), terminal condition (P < 0.0001/< 0.0001), family presence (P < 0.0001/0.0023), location of death (P = 0.003/0.0005), and having pain noted in the care plan (P = 0.0073/0.0007). CONCLUSION Findings indicate a need for improving availability of opioids for end-of-life care in the inpatient setting. Modifiable factors, such as family presence and goals-of-care discussions, suggest potential targets for intervention to improve recognition of the dying process and proactive planning for pain control.

“Don't Get Weak in Your Compassion”: Bereaved Next of Kin's Suggestions for Improving End‐of‐Life Care in Veterans Affairs Medical Centers

To analyze bereaved next of kins suggestions for improving end‐of‐life (EOL) care in Veterans Affairs (VA) Medical Centers (VAMCs).

“A Room Full of Chairs around His Bed”: Being Present at the Death of a Loved One in Veterans Affairs Medical Centers

Historically, death took place at home where family held vigil around the dying patient. Today, family presence is an important feature of death and dying in hospital settings. We used hermeneutic phenomenology to explore experiences of being present at the hospital death of a loved one. We conducted in-depth, face-to-face interviews with 78 recently bereaved next-of-kin of veterans who died in 6 Veterans Affairs (VA) Medical Centers in the Southeast United States. Two major themes emerged: 1) “settling in,” characteristic of the experiences of wives and daughters in the initial phase of the patients hospitalization; and 2) “gathering around,” characteristic of the experiences of a wider array of family members as the patient neared death. An in-depth understanding of experiences of next-of-kin present at the hospital death of a loved one can increase staff awareness of familys needs and empower staff to develop policies and procedures for supporting family members.

The Experience of Older Patients With Cancer in Phase 1 Clinical Trials: A Qualitative Case Series

This article explores the experiences of older patients with cancer in phase 1 clinical trials. Conducting a case series of face-to-face, in-depth, open-ended interviews and using qualitative methods of analysis, we find that the psychosocial process of social comparison is relevant for understanding older adults’ phase 1 clinical trial participation. Social comparison influences decisions to enroll in a phase 1 clinical trial, shapes perceptions of supportive care needs, and encourages the utilization of hope. Additional research should develop strategies for addressing supportive care needs among this patient cohort whose use of social comparison can inhibit articulation of pain, suffering, and symptom burden as well as use of informal support systems.

Formative Evaluation of a Multi-Component, Education-Based Intervention to Improve Processes of End-of-Life Care

A multicomponent, palliative care, education-based intervention was implemented in six Veterans Affairs Medical Centers in the southeast United States. The intervention comprised onsite staff training plus supporting written materials, installation of an electronic order set, and follow-up consultations. Training included large-group didactic presentations, small-group clinical demonstrations, and one-on-one consultations. The intervention strategy was targeted broadly to hundreds of hospital providers, including physician, nursing, and ancillary staff. The purpose was to train staff in identifying actively dying patients and implementing best practices of home-based hospice care. A formative evaluation was conducted utilizing semistructured telephone interviews with key informants from each site. Qualitative data analysis revealed processes that facilitated or impeded uptake of the intervention. Results will be used to inform ongoing and future clinical initiatives and optimize future implementation of education-based interventions to improve adoption of best practices for end-of-life care within acute care settings.

“I Was Ready to Take Him Home”: Next-of-Kin's Accounts of Loved One's Death During Hospice and Palliative Care Discussions in Veterans Affairs Medical Centers

This study explored next-of-kins retrospective accounts of hospice and palliative care discussions for hospitalized veterans. In-depth, face-to-face interviews were used to generate narrative accounts of 78 next-of-kins experience of their loved ones hospital care during the last days of the patients life. One-third of participants reported taking part in a hospice or palliative care discussion during the patients final hospitalization. In over one-half of those cases, the patients died before discharge or transfer to hospice or palliative care was accomplished. Hospice and palliative care discussions in the hospital setting shaped family perceptions of the patients’ care, directed family efforts in the days prior to death, and engendered anticipation of remaining quality time with the patient. Discussions about hospice or palliative care have meaning, emotional impact, practical effects, and unintended consequences for next-of-kin. Social workers in hospital settings can play a critical role in supporting family members through the hospice and palliative care discussion process and facilitate timely care transitions. They also can attend to the psychosocial concerns of family members, particularly when death occurs prior to discharge to hospice or transfer to an inpatient palliative care service.

Exploring the affective dimension of the life review process: Facilitators’ interactional strategies for fostering personhood and social value among older adults with early dementia

We employed an auto-ethnography approach to explore the affective dimension of life review sessions with community-dwelling older military veterans with minor cognitive impairment (MCI) and early dementia. Using researchers’ analytic memos, we identified facilitators’ interactional strategies that fostered the participant’s sense of personal identity, dignity and social self-worth. Interaction among participant, caregiver, and facilitators evoked a range of emotional responses, offering a window into the affective world of MCI and early dementia. Positive emotional responses outnumbered negative emotional responses by a ratio of two-to-one in the life review sessions; however, negative emotions were more revelatory of current struggles with declines in health and function. Facilitators utilized two interactional strategies, in particular, to foster personhood and social value of participants: focusing on the participant and creating an empathic connection with the participant. Further work is needed to understand the role of emotions in research interactions and to examine the psychosocial mechanisms through which positive affect functions in promoting identity, personhood and social value among persons with MCI and early dementia.