Virginia P. Tilden

Family decision-making to withdraw life-sustaining treatments from hospitalized patients.

BACKGROUND With a national trend toward less aggressive treatment of hospitalized terminally ill patients, families increasingly participate in decisions to withdraw life-sustaining treatment. Although prior research indicates decision making is stressful for families, there have been no psychometric reports of actual stress levels and few discussions of the reasoning used by families compared to clinicians in reaching the decision. OBJECTIVES The purpose of this study was to assess levels of family stress associated with decisions to withdraw life-sustaining treatments, to assess factors that affected stress, and to compare families and clinicians on their reasoning about the decision. METHODS Data were collected from hospital decedent charts, family members of decedents, and clinicians who cared for decedents. Data from families were collected in individual interviews, shortly after decedent death and 6 months later, using psychometric measures and semi-structured interview questions. Clinicians were interviewed once shortly following patient death. RESULTS Family stress associated with the withdraw decision was high immediately following the death of the decedent and, while it decreased over time, remained high a half a year later. Several factors affected stress; most notably, stress was highest in the absence of patient advance directives. In reaching the decision, both families and clinicians prioritized what the patient would want, although families, more strongly than clinicians, endorsed doing everything medically possible to prolong the patients life. CONCLUSIONS Findings add compelling evidence for the power of advance directives, whether written or verbal, to reduce the stress associated with family decision-making.

Legalizing Assisted Suicide — Views of Physicians in Oregon

BACKGROUND Since the Oregon Death with Dignity Act was passed in November 1994, physicians in Oregon have faced the prospect of legalized physician-assisted suicide. We studied the attitudes and current practices of Oregon physicians in relation to assisted suicide. METHODS From March to June 1995, we conducted a cross-sectional mailed survey of all physicians who might be eligible to prescribe a lethal dose of medication if the Oregon law is upheld. Physicians were asked to complete and return a confidential 56-item questionnaire. RESULTS Of the 3944 eligible physicians who received the questionnaire, 2761 (70 percent) responded. Sixty percent of the respondents thought physician-assisted suicide should be legal in some cases, and nearly half (46 percent) might be willing to prescribe a lethal dose of medication if it were legal to do so; 31 percent of the respondents would be unwilling to do so on moral grounds. Twenty-one percent of the respondents have previously received requests for assisted suicide, and 7 percent have complied. Half the respondents were not sure what to prescribe for this purpose, and 83 percent cited financial pressure as a possible reason for such requests. The respondents also expressed concern about complications of suicide attempts and doubts about their ability to predict survival at six months accurately. CONCLUSIONS Oregon physicians have a more favorable attitude toward legalized physician-assisted suicide, are more willing to participate, and are currently participating in greater numbers than other surveyed groups of physicians in the United States. A sizable minority of physicians in Oregon objects to legalization and participation on moral grounds. Regardless of their attitudes, physicians had a number of reservations about the practical applications of the act.

The IPR inventory: development and psychometric characteristics.

The purpose of this study was to develop, validate, and norm a measure of dimensions of interpersonal relationships that are salient to nursing: social support, reciprocity, and conflict. The selection of these concepts was guided by social exchange and equity theories. In the first phase of the study, 44 respondents were interviewed to provide narrative data from which to develop items so that items would be grounded in lived experience. Content validity of items was judged by a panel of 11 experts. The revised 39-item instrument was tested in successive steps with a total of 340 students, patients, and community residents for reliability and validity, including internal consistency reliability, test-retest reliability, factor analysis, and three forms of validity assessment (theory testing, contrasted groups, and multitrait-multimethod comparison). The three subscales of social support, reciprocity, and conflict demonstrated repeated internal consistency and test-retest reliability. Strong evidence of construct validity was demonstrated for the social support and the conflict subscales; validity of the reciprocity subscale was equivocal.

Use of qualitative methods to enhance content validity

Qualitative methods to enhance the content validity of a new psychometric measure are described in this report. Qualitative data collected in interviews with respondents familiar with a concept helps to enrich and extend what is known about the concept and serves as a valuable source of items. Qualitative data were collected from 44 respondents on aspects of interpersonal relationships, including social support, reciprocity, and conflict. Data were used to generate items for the new measure, the Interpersonal Relationship Inventory. Content validity of items and of scales was judged by a panel of experts, and initial psychometric properties of items were evaluated before developing the final measure.

Measures of social support: Assessment of validity

The evidence of construct validity that resulted from conjoint testing of two measures of social support, the Personal Resource Questionnaire (PRQ85) and the Cost and Reciprocity Index (CRI) is presented. Both instruments were used with two samples of adults, 333 who were part of a large health project and 99 who participated in a methodological study. The PRQ85 and CRI appear to tap the construct of support yet are not highly redundant. Both tools demonstrated similar curves of relationships to external criteria. Dissimilar patterns of relationships with negative mood states indicated an area of need for future study.

Out-of-Hospital Death: Advance Care Planning, Decedent Symptoms, and Caregiver Burden

Objectives: To examine the end‐of‐life experiences of elderly decedents dying out of the hospital and their family caregivers in a state in which the vast majority of Medicare deaths occur in community settings.

Oregon's low in-hospital death rates: what determines where people die and satisfaction with decisions on place of death?

The dancing neurologist pleases me He sails the calm Aegean every Spring Like Sophocles, he contemplates the sea And treats our cares as a diminished thing. Such fancy footwork is a gracious gift To shift attentions locus to the feet And let the minds free concentration drift To this rhythmic swaying Ionic beat. In such a state, what relics from the past, What precious driftwood casually afloat Might rise to fevered consciousness at last Or slip into the gently rocking boat? What jealous gods or goddesses might seize The dancing neurologists reveries?Use and availability of beds in acute care hospitals have been confirmed to be the principal determining factors in location of death. Within that constraint, however, the availability of other res...

There is no "i" in teamwork in the patient-centered medical home: defining teamwork competencies for academic practice.

Evidence suggests that teamwork is essential for safe, reliable practice. Creating health care teams able to function effectively in patient-centered medical homes (PCMHs), practices that organize care around the patient and demonstrate achievement of defined quality care standards, remains challenging. Preparing trainees for practice in interprofessional teams is particularly challenging in academic health centers where health professions curricula are largely siloed. Here, the authors review a well-delineated set of teamwork competencies that are important for high-functioning teams and suggest how these competencies might be useful for interprofessional team training and achievement of PCMH standards. The five competencies are (1) team leadership, the ability to coordinate team members’ activities, ensure appropriate task distribution, evaluate effectiveness, and inspire high-level performance, (2) mutual performance monitoring, the ability to develop a shared understanding among team members regarding intentions, roles, and responsibilities so as to accurately monitor one another’s performance for collective success, (3) backup behavior, the ability to anticipate the needs of other team members and shift responsibilities during times of variable workload, (4) adaptability, the capability of team members to adjust their strategy for completing tasks on the basis of feedback from the work environment, and (5) team orientation, the tendency to prioritize team goals over individual goals, encourage alternative perspectives, and show respect and regard for each team member. Relating each competency to a vignette from an academic primary care clinic, the authors describe potential strategies for improving teamwork learning and applying the teamwork competences to academic PCMH practices.

Family Decision Making in Foregoing Life-Extending Treatments:

Families generally serve as surrogate decision makers for hospitalized dying patients who are unable to express their own decisions regarding life-prolonging treatments. The authors interviewed family members whose relatives died in the hospital following the withdrawal of aggressive medical treatments. Interviews were at two time periods: at 1 and 6 months post-patient death. Study data indicated a core set of phases which family members experienced in the process of arriving at the decision to withdraw treatment: recognition of futility, coming to terms, shouldering the surrogate role, and facing the question. At 6 months post decision, families reflected on the need for corroborating evidence that they had made the right decision, which the authors term seeking a triangulation of certainty. Advance directives and forthright communication from clinicians were two factors that most helped family members feel more positive about events.

The Interpersonal Relationship Inventory: continued psychometric evaluation.

For norm-referenced measures to be useful in social-behavioral research, investigators who develop measures face several psychometric challenges, including: (a) adequate domain specification; (b) adequate initial evidence of reliability and validity; and (c) ongoing evidence of psychometric quality. The Interpersonal Relationship Inventory (IPRI) was developed in response to gaps in measurement of social relationships, and contributed scales for reciprocity and conflict to a measure of social support. For the IPRI, the first two points were addressed during the period of instrument development. The measure now has been in use for 4 years. This article reports evidence addressing the third challenge: ongoing evidence of psychometric quality. Findings from 19 studies using the IPRI provide compelling evidence for internal consistency reliability and construct validity of the scales.