Responding to desire to die statements from patients with advanced disease:recommendations for health professionals

It is not uncommon for patients with advanced incurable disease to express a desire to hasten their death. Health professionals often have difficulty responding to such statements, and find it challenging to ascertain why these statements are made. Health professionals may struggle to determine whether a 'desire to die' statement (DTDS) is about a request for hastened death, a sign of psychosocial distress, or merely a passing comment that is not intended to be heard literally as a death wish. Given the lack of guidelines to assist health professionals with this issue, we have prepared multidisciplinary recommendations for responding to a DTDS, underpinned by key principles of therapeutic communication and a systematic review of empirical literature. Where the relevant literature was lacking, the recommendations were drafted by the authors (clinicians and/ or academics from the following disciplines: nursing, medicine, psychiatry, psychology, sociology, aged care and theology), based on their expert opinion. Multiple drafts of the recommendations were circulated to the authors for refinement until consensus was reached. Strategies for advancing the evidence base for the maturation of guidelines in this area are offered.

User perspective on palliative care services: experiences of middle-aged partners bereaved through cancer known to social work services in Northern Ireland

This qualitative research study explores experiences of partners bereaved through cancer, who were resident in an urban area of Northern Ireland and who had been service users of the social work services. Data were collected in 2004 from 10 individuals who participated in semi-structured interviews. Emergent themes were identified using thematic content analysis and findings analysed under four categories: cancer journey; impact of bereavement; process of adjustment and change; and experience of support services. Opportunities to facilitate communication were not always maximised, often resulting in poor bereavement outcomes. Although hospices undertook bereavement risk assessment, participants were unaware of its use and queried its accuracy without service user involvement. The most cited informal support was family and friends, although such help was time-limited. Service user feedback regarding social workers was generally positive; however, there was a lack of knowledge about their role in palliative care. Post-bereavement adjustment was influenced by the quality of social networks, the responsibilities of lone parenthood, and challenges to life values and core beliefs. A framework for palliative care social work has been recommended based on research findings.

How does involvement of a hospice nurse specialist impact on the experience on informal caring in palliative care? Perspectives of middle-aged partners bereaved through cancer

The aim of this study was to retrospectively explore partners' understandings and experiences in relation to caring for a loved one with a terminal illness, with a particular focus on the role of the hospice nurse specialist (HNS). Participants were purposively sampled and recruited through HNS gatekeepers. Seven middle-aged, bereaved partners participated in semi-structured, qualitative interviews. The interviews were audio recorded and transcribed verbatim and data were analysed using thematic content analysis. Five main themes emerged regarding the impact of the HNS on informal caring: ‘the ambivalence of caring’, ‘the HNS as a “confidante” in caring’, ‘the HNS as a “champion” in support’, ‘the work of the HNS – an unseen benefit’ and ‘being prepared for death and bereavement’. Findings from this study offer new insights into how involvement of a HNS impacts on the ability of carers to perform their role as an informal caregiver. Results highlight a crucial need for carers to have a clear understanding of all aspects of the HNS role so that full benefit is derived from their input. Recruitment of experienced and knowledgeable nurses is paramount, but equally important for carers is the supportive aspect of the role for which nurses need to demonstrate excellent communication skills and an intuitive, caring approach.

Substance Use among Young People Living in Residential State Care

Existing empirical evidence on substance use among young people living in residential state care during adolescence is comparatively limited. This paper reports on substance use trends of young people living in residential state care during three annual data-sweeps when aged 14, 15 and 16 years. A repeated cross-sectional research design was utilised in the research. The findings suggest some similarities for lifetime prevalence rates for tobacco and alcohol use for those living in residential state care with a group of same-age young people not living in residential state care who participated in the research. However, solvent abuse and cannabis use was higher among those living in care. More frequent substance use was reported by the residential care sample for all substances at each stage of the study. These findings suggest that young people living in state care continue to merit higher levels of vigilance from researchers and policy-makers in order to fully understand this behaviour and develop appropriate prevention initiatives to meet their needs regarding potential drug problems.

Formal and informal care utilisation amongst elderly persons with visual impairment.

OBJECTIVE: To examine the determinants of formal and informal care utilisation amongst persons with age-related macular degeneration (AMD). DESIGN: Cross-sectional hospital-based study. SETTING: Hospital eye clinic in Northern Ireland. PARTICIPANTS: 284 persons aged >or=50 years. MAIN OUTCOME MEASURES: Participants were questioned about their care, living arrangements, eyesight-related ability to self-care, and eyesight-related need to be more careful whilst undertaking everyday tasks. RESULTS: The percentage of older persons receiving formal and informal care rose with the level of visual impairment. 34.9% and 37.3% of those with no visual impairment received formal and informal care, respectively, compared with 51.6% and 69.9% of those with moderate visual impairment and 55.6% and 88.9% of those with severe visual impairment. Three factors (age, best corrected distance visual acuity in the better eye and living alone) were significant predictors (p

An exploration of knowledge and attitudes related to pre-pregnancy care in women with diabetes

Aims: Pre-pregnancy care optimizes pregnancy outcome in women with pre-gestational diabetes, yet most women enter pregnancy unprepared. We sought to determine knowledge and attitudes of women with Type 1 and Type 2 diabetes of childbearing age towards pre-pregnancy care.

Methods: Twenty-four women (18 with Type 1 diabetes and six with Type 2 diabetes) aged 17–40 years took part in one of four focus group sessions: young nulliparous women with Type 1 diabetes (Group A), older nulliparous women with Type 1 diabetes (Group B), parous women with Type 1 diabetes (Group C) and women with Type 2 diabetes of mixed parity (Group D).

Results: Content analysis of transcribed focus groups revealed that, while women were well informed about the need to plan pregnancy, awareness of the rationale for planning was only evident in parous women or those who had actively sought pre-pregnancy advice. Within each group, there was uncertainty about what pre-pregnancy advice entailed. Despite many women reporting positive healthcare experiences, frequently cited barriers to discussing issues around family planning included unsupportive staff, busy clinics and perceived social stereotypes held by health professionals.

Conclusions: Knowledge and attitudes reported in this study highlight the need for women with diabetes, regardless of age, marital status or type of diabetes, to receive guidance about planning pregnancy in a motivating, positive and supportive manner. The important patient viewpoints expressed in this study may help health professionals determine how best to encourage women to avail of pre-pregnancy care

The perspectives of young children in care about their circumstances and implications for social work practice

Recent reviews of research regarding children in care have concluded that there remains little research which specifically focuses on young children. This paper presents the findings of research carried out with a sample of young children in care (aged 4-7 years) regarding their perspectives of their circumstances. The findings reveal that they have deeply held views regarding living with risk; removal from their families; unresolved feelings of guilt and loss; and not being listened to. This paper considers the implications of these findings for social work practice. It concludes by stressing the capacity of young children in care to express their perspectives, and the importance of practitioners seeking these views and incorporating them into assessment and decision-making processes.

A Cluster Randomized Controlled Trial of an Adapted U.S. Model of Pharmaceutical Care for Nursing Home Residents in Northern Ireland (Fleetwood Northern Ireland Study): A Cost-Effectiveness Analysis

OBJECTIVES: To evaluate the cost-effectiveness of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood NI Study).
DESIGN: Economic evaluation alongside a cluster randomized controlled trial.
SETTING: Nursing homes in NI randomized to intervention (receipt of the adapted model of care; n511) or control (usual care continued; n511).
PARTICIPANTS: Residents aged 65 and older who provided informed consent (N5253; 128 intervention, 125 control) and who had full resource use data at 12 months.
INTERVENTION: Trained pharmacists reviewed intervention home residents’ clinical and prescribing information for 12 months, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to make changes. The control homes received usual care in which there was no pharmacist intervention.
MEASUREMENTS: The proportion of residents prescribed one or more inappropriate psychoactive medications (according to standardized protocols), costs, and a cost-effectiveness acceptability curve. The latter two outcomes are the focus for this article.
RESULTS: The proportions of residents receiving inappropriate psychoactive medication at 12 months in the intervention and control group were 19.5% and 50.4%, respectively. The mean cost of healthcare resources used per resident per year was $4,923 (95% con?dence interval.

Incidence of Type 1 Diabetes in Sweden Among Individuals Aged 0–34 Years, 1983–2007:An analysis of time trends

OBJECTIVE: To clarify whether the increase in childhood type 1 diabetes is mirrored by a decrease in older age-groups, resulting in younger age at diagnosis.
RESEARCH DESIGN AND METHODS: We used data from two prospective research registers, the Swedish Childhood Diabetes Register, which included case subjects aged 0-14.9 years at diagnosis, and the Diabetes in Sweden Study, which included case subjects aged 15-34.9 years at diagnosis, covering birth cohorts between 1948 and 2007. The total database included 20,249 individuals with diabetes diagnosed between 1983 and 2007. Incidence rates over time were analyzed using Poisson regression models.
RESULTS: The overall yearly incidence rose to a peak of 42.3 per 100,000 person-years in male subjects aged 10-14 years and to a peak of 37.1 per 100,000 person-years in female subjects aged 5-9 years and decreased thereafter. There was a significant increase by calendar year in both sexes in the three age-groups <15 years; however, there were significant decreases in the older age-groups (25- to 29-years and 30- to 34-years age-groups). Poisson regression analyses showed that a cohort effect seemed to dominate over a time-period effect.
CONCLUSIONS: Twenty-five years of prospective nationwide incidence registration demonstrates a clear shift to younger age at onset rather than a uniform increase in incidence rates across all age-groups. The dominance of cohort effects over period effects suggests that exposures affecting young children may be responsible for the increasing incidence in the younger age-groups.

An evaluation of an adapted United States model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood NI Study).

OBJECTIVES: To test the effect of an adapted U.S. model of pharmaceutical care on prescribing of inappropriate psychoactive (anxiolytic, hypnotic, and antipsychotic) medications and falls in nursing homes for older people in Northern Ireland (NI).

DESIGN: Cluster randomized controlled trial.

SETTING: Nursing homes randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11).

PARTICIPANTS: Residents aged 65 and older who provided informed consent (N=334; 173 intervention, 161 control).

INTERVENTION: Specially trained pharmacists visited intervention homes monthly for 12 months and reviewed residents' clinical and prescribing information, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to improve the prescribing of these drugs. The control homes received usual care.

MEASUREMENTS: The primary end point was the proportion of residents prescribed one or more inappropriate psychoactive medicine according to standardized protocols; falls were evaluated using routinely collected falls data mandated by the regulatory body for nursing homes in NI.

RESULTS: The proportion of residents taking inappropriate psychoactive medications at 12 months in the intervention homes (25/128, 19.5%) was much lower than in the control homes (62/124, 50.0%) (odds ratio=0.26, 95% confidence interval=0.14–0.49) after adjustment for clustering within homes. No differences were observed at 12 months in the falls rate between the intervention and control groups.

CONCLUSION: Marked reductions in inappropriate psychoactive medication prescribing in residents resulted from pharmacist review of targeted medications, but there was no effect on falls.

Restorative justice conferencing for reducing recidivism in young offenders (aged 7 to 21)

Background
Restorative justice is “a process whereby parties with a stake in a specific offence resolve collectively how to deal with the aftermath of the offence and its implications for the future” (Marshall 2003). Despite the increasing use of restorative justice programmes as an alternative to court proceedings, no systematic review has been undertaken of the available evidence on the effectiveness of these programmes with young offenders. Recidivism in young offenders is a particularly worrying problem, as recent surveys have indicated
the frequency of re-offences for young offenders has ranged from 40.2% in 2000 to 37.8% in 2007 (Ministry of Justice 2009)

Objectives
To evaluate the effects of restorative justice conferencing programmes for reducing recidivism in young offenders.

Search methods
We searched the following databases up to May 2012: CENTRAL, 2012 Issue 5, MEDLINE (1978 to current), Bibliography of Nordic Criminology (1999 to current), Index to Theses (1716 to current), PsycINFO (1887 to current), Social Sciences Citation Index (1970 to current), Sociological Abstracts (1952 to current), Social Care Online (1985 to current), Restorative Justice Online (1975 to current), Scopus (1823 to current), Science Direct (1823 to current), LILACS (1982 to current), ERIC (1966 to current), Restorative Justice Online (4May 2012),WorldCat (9May 2012), ClinicalTrials.gov (19May 2012) and ICTRP (19May 2012). ASSIA,National Criminal Justice Reference Service and Social Services Abstracts were searched up to May 2011. Relevant bibliographies, conference programmes and journals were also searched.

Selection criteria
Randomised controlled trials (RCTs) or quasi-RCTs of restorative justice conferencing versus management as usual, in young offenders.

Data collection and analysis
Two authors independently assessed the risk of bias of included trials and extracted the data. Where necessary, original investigators were contacted to obtain missing information.

Main results
Four trials including a total of 1447 young offenders were included in the review. Results failed to find a significant effect for restorative justice conferencing over normal court procedures for any of the main analyses, including number re-arrested (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.59 to 1.71; P = 0.99), monthly rate of reoffending (standardised mean difference (SMD) -0.06, 95% CI -0.28 to 0.16; P = 0.61), young person’s remorse following conference (OR 1.73, 95% CI 0.97 to 3.10; P = 0.06), young person’s recognition of wrongdoing following conference (OR 1.97, 95% CI 0.81 to 4.80; P = 0.14), young person’s self-perception following conference (OR 0.95, 95% CI 0.55 to 1.63; P = 0.85), young person’s satisfaction following conference (OR 0.42, 95% CI 0.04 to 4.07; P = 0.45) and victim’s satisfaction following conference (OR 4.05, 95%CI 0.56 to 29.04; P = 0.16). A small number of sensitivity analyses did indicate significant effects, although all are to be interpreted with caution.

Authors’ conclusions
There is currently a lack of high quality evidence regarding the effectiveness of restorative justice conferencing for young offenders. Caution is urged in interpreting the results of this review considering the small number of included studies, subsequent low power and high risk of bias. The effects may potentially be more evident for victims than offenders. The need for further research in this area is highlighted.

Ownership type and team climate in elderly care facilities: the moderating effect of stress factors

Aims. This paper is a report of a study examining the association between ownership type and perceived team climate among older people care staff. In addition, we examined whether work stress factors (time pressure, resident-related stress, role conflicts and role ambiguity) mediated or moderated the above mentioned association. Background. There has been a trend towards contracting out in older people care facilities in Finland and the number of private for-profit firms has increased. Studies suggest that there may be differences in employee well-being and quality of care according to the ownership type of older people care. Methods. Cross-sectional survey data was collected during the autumn of 2007 from 1084 Finnish female older people care staff aged 1869 years were used. Team Climate Inventory was used to measure team climate. Ownership type was divided into four categories: for-profit sheltered homes, not-for-profit sheltered homes, public sheltered homes and not-for-profit nursing homes. Analyses of covariance were used to examine the associations. Results. Team climate dimensions participative safety, vision and support for innovation were higher in not-for-profit organizations (both sheltered homes and nursing homes) compared to for-profit sheltered homes and public sheltered homes. Stress factors did not account for these associations but acted as moderators in a way that in terms of task orientation and participative safety employees working in for-profit organizations seemed to be slightly more sensitive to work-related stress than others. Conclusion. Our results suggest that for-profit organizations and public organizations may have difficulties in maintaining their team climate. In consequence, these organizations should focus more effort on improving their team climate.