Endstation Notfallstation: Perzeption und Rezeption des Begriffs «palliativer Patient» sowie Ansätze zur Verbesserung der interdisziplinären Zusammenarbeit – ein Survey unter notfallmedizinischem Personal auf einer Schweizer Notfallstation

Hintergrund: Wegen sich verändernder Strukturen im Spitalbereich sowie im Bereich der Hausarztabdeckung als auch infolge zunehmenden Drucks auf das Gesundheitssystem kommen mehr Patienten auf die Notfallstationen, die aufgrund ihrer Grunderkrankung und des fortgeschrittenen Krankheitsstadiums von einem palliativen Behandlungskonzept profitieren. Eine wesentliche Herausforderung ist hierbei bereits die Definition von «Palliative Care» (PC), sowie die Klärung, was genau die palliative Versorgung beinhaltet. Häufig vermischt wird der Terminus «Palliative Care» mit «End of life care». Die vorliegende Studie ist eine Standortbestimmung im Universitären Notfallzentrum des Inselspitals Bern (UNZ), das jährlich rund 32 400 Patienten versorgt. Ziel ist es, mehr über den Wissensstand und die persönliche Einstellung der Mitarbeiter zu palliativen Fragestellungen und speziell zum Begriff «Palliative Care» zu erhalten. Methodik: Die Mitarbeiter des Universitären Notfallzentrums des Inselspitals Bern (UNZ) wurden mittels einer Online-Umfrage durch eine spitalexterne Fachinstitution interviewt. Diese Befragung basiert auf einem Instrument [1], das in einer vergleichbaren Studie auf einer Notfallstation in den USA entwickelt und validiert wurde. Resultate: Von 154 Mitarbeitenden (Pflege und Ärzte) füllten 60 Mitarbeitende die Befragung vollständig aus, entsprechend einer Antwortrate von 39%. Die Definition von Palliative Care (von n=60) war sehr heterogen und konnte in sechs Themenbereiche eingeteilt werden. Bei den Fragen nach spezifischen Leistungsangeboten äusserten die Mitarbeitenden den Wunsch nach einem erleichterten Zugang zu bestehenden Patientendaten, nach einem 24-Stunden-Palliative-Care-Konsiliardienst und nach mehr Besprechungszeit für Fragestellungen der PC im klinischen Alltag. Schlussfolgerungen: Die heterogene Begriffsdefinition von «Palliative Care» bestätigt sich. Es besteht kein klares Vorgehen, und zudem lässt sich ein Zeitmangel für ausführliche Patientengespräche in palliativen Situationen im UNZ feststellen. Der Patientenwunsch oder Patientenverfügungen mit DNR/DNI-Prozedere stehen nicht im Widerspruch zu den persönlichen Wertvorstellungen der meisten Mitarbeitenden. Die 24-Stunden-Verfügbarkeit eines spezialisierten PC-Teams, das Erarbeiten von Guidelines und vermehrtes Training für PC würde von den UNZ-Mitarbeitenden begrüsst.

Phonological Development in Hearing Children of Deaf Parents

Phonological development in hearing children of deaf parents Dr. Diane Lillo-Martin 5/9/2010 The researcher wishes to determine the significance of a unique linguistic environment on the effects of phonological development. The research examines whether 3 hearing children of deaf parents, hereafter referred to as CODAs, have inconsistencies, as compared to children in a typical linguistic environment, in their syllable structure, phonological processes or phonemic inventories. More specifically, the research asks whether their speech is more consistent with children of typical environments or more similar to children with phonological delays or disorders or articulation disorders. After the examination of these three components to a child's phonological development, it can be concluded that the linguistic environment of CODA children does not negatively hinder their phonological language development.

Family Court Judges' Training, Background, and Child Development Knowledge: Associations with Child Custody Decision Making

Family court judges are often asked to make inferences about - or directly interview children to ascertain - children's custody preferences and their maturity to express such preferences. These estimates of children's developmental maturity are important to the judges' considerations of children's "best interests" in custody cases. The research literature describing family court judges' background, education, training, and knowledge about child development is scant. With appropriate child development knowledge, judges should be better able to identify the developmental stages at which children have the cognitive and social capabilities to communicate directly their placement wishes or concerns. The current study is the first to examine judges' estimates of - and actual tests of - their child development knowledge, their training/education, and their application of this knowledge to their decisions to involve children as participants in contested custody cases.

Attitudes toward end-of-life decision making in South Texas

Advance care planning has the potential to create positive outcomes in the realm of end-of-life health care. The completion of advance directives and living wills are vital in equipping patients with autonomy and ensuring that their end-of-life wishes are respected. However, there remains a lack of knowledge and low completion rates of advance directives despite their possible improvements and ramifications on health care at the end of life. This study seeks to determine the knowledge of and attitudes towards end-of-life decision-making in South Texas. The study is designed as a cross-sectional, exploratory survey using a descriptive survey instrument to query 71 subjects in South Texas. The setting for the study includes three distinct groups, two in San Antonio, Texas and one in Brownsville, Texas. Unique differences in demographics between the three groups, such as variability in age, ethnicity, language and religious affiliation allowed for preliminary associations to be concluded in describing the results of the survey instrument. Ultimately, this study describes the attitudes and perceptions of advance care planning in South Texas and reveals the need for further education and awareness of the topic, perhaps indicating the need for a public health initiative in this regard.^

The Elegant Simplicity of Family Preservation Practice Legecies and Lessons

An earlier version of this manuscript was prepared for the Chapin Hall invitational seminar on family preservation, The Chapin Hall Center for Children at the University of Chicago, September 16 & 17, 1999. The author wishes to acknowledge the comments and helpful suggestions of seminar participants-Jacqueline McCroskey, Martha Shirk, Fran Jacobs, John Schuerman, Lee Schorr, Charlotte Booth, Kristi Nelson, Susan Kelly, Frank Farrow, and Susan Notkin. These comments, as indeed many of their prior contributions, have had a seminal effect on my thinking about family preservation services over the years. Clark Peters and other Chapin Hall staff deserve special thanks for creating the conditions necessary to produce a lively and productive discussion. As always, Harold Richman, Executive Director of Chapin Hall, and Hermon Dunlap, Smith Professor at the School of Social Service Administration of the University of Chicago, as seminar convenor combined perfectly the skills of gracious host and incisive critic. We in the child welfare field are in his debt for continually raising the level of discourse in our field. In the end, as it should be, the thoughts and opinions in the following paper are wholly my own.

Strange bedfellows: The ethics and politics of medical futility in Texas

Background: Futile medical treatments are interventions that are not associated with a benefit to the patient. The definition and concept of medical futility are controversial. The Texas Advance Directives Act (TADA) was passed in 1999 to address medically inappropriate interventions by allowing providers to withdraw inappropriate interventions against a surrogate decision maker's wishes following a review, attempt to transfer the patient, and 10-day waiting period. The original legislation was a negotiated compromise by players across the political spectrum. However, in recent years there has been increasing controversy regarding TADA and attempts to alter its applicability in Texas. ^ Purpose: The purpose of this project was to apply Paul Sabatier's advocacy coalition framework (ACF) to gain understanding into the historical, ethical, and political basis of the initial compromise, and determine the sources of conflict that have led to increased opposition to TADA. ^ Methods: Using the ACF model, key actors within the medical futility policy debate in Texas were aggregated into coalitions based on shared beliefs. A narrative summary based analysis identified the core elements of the policy subsystem, as well as the constraints and resources of the subsystem actors. Externalities that promoted adjustments to coalition beliefs and tactics used by coalition participants were analyzed. Data sources included review of the published literature regarding medical futility, as well as analysis of published newspaper accounts and editorials regarding the medical futility issue in Texas, legislative testimony, and review of weblogs and online commentaries dealing with the issue. ^ Results: Primary coalition participants in developing compromise legislation in 1999 were the Providers and Vitalists, with Autonomists gaining a prominent role starting in 2006. Internal factors associated with the breakdown of consensus included changes to the makeup of the governing coalition and changes in individual case information available to the Vitalist coalition. Externalities related to the intertwining of the Sun Hudson case and the Terri Schiavo case generated negative publicity for the TADA from progressive and conservative viewpoints. Dissemination of information in various venues regarding contentious cases was associated with more polarization of viewpoints, and realignment of coalition alliances. ^ Conclusions: The ACF provided an outline for the initial compromise over the creation of the Texas Advance Directives Act as well as the eventual loss of consensus. The debate between the Provider, Vitalist, and Autonomist coalitions has been affected by internal policy evolution, changes in the governing coalition, and important externalities. The debate over medical futility in Texas has had much broader implications in the dispute over Health Care Reform.^

Intensive care unit utilization among patients with cancer at the end of life

Over the last 2 decades, survival rates in critically ill cancer patients have improved. Despite the increase in survival, the intensive care unit (ICU) continues to be a location where end-of-life care takes place. More than 20% of deaths in the United States occur after admission to an ICU, and as baby boomers reach the seventh and eighth decades of their lives, the volume of patients in the ICU is predicted to rise. The aim of this study was to evaluate intensive care unit utilization among patients with cancer who were at the end of life. End of life was defined using decedent and high-risk cohort study designs. The decedent study evaluated characteristics and ICU utilization during the terminal hospital stay among patients who died at The University of Texas MD Anderson Cancer Center during 2003-2007. The high-risk cohort study evaluated characteristics and ICU utilization during the index hospital stay among patients admitted to MD Anderson during 2003-2007 with a high risk of in-hospital mortality. Factors associated with higher ICU utilization in the decedent study included non-local residence, hematologic and non-metastatic solid tumor malignancies, malignancy diagnosed within 2 months, and elective admission to surgical or pediatric services. Having a palliative care consultation on admission was associated with dying in the hospital without ICU services. In the cohort of patients with high risk of in-hospital mortality, patients who went to the ICU were more likely to be younger, male, with newly diagnosed non-metastatic solid tumor or hematologic malignancy, and admitted from the emergency center to one of the surgical services. A palliative care consultation on admission was associated with a decreased likelihood of having an ICU stay. There were no differences in ethnicity, marital status, comorbidities, or insurance status between patients who did and did not utilize ICU services. Inpatient mortality probability models developed for the general population are inadequate in predicting in-hospital mortality for patients with cancer. The following characteristics that differed between the decedent study and high-risk cohort study can be considered in future research to predict risk of in-hospital mortality for patients with cancer: ethnicity, type and stage of malignancy, time since diagnosis, and having advance directives. Identifying those at risk can precipitate discussions in advance to ensure care remains appropriate and in accordance with the wishes of the patient and family.^

End -of -life planning and decision -making: Implications for adults with mental retardation

This research focused on the topic of end-of-life planning and decision-making for adults affected by mental retardation. Adults with mental retardation have unique challenges in this regard, including difficulty communicating their wishes without assistance and diminished decision-making skills. The primary research objective was to identify factors that can affect opportunities for adults with mental retardation in community-based services settings (and their advocates) to be involved in planning and deciding about their own end-of-life experience. ^ A descriptive qualitative inquiry was designed to explore issues related to death and dying, and the notion of end-of-life planning, from the perspective of adults with mental retardation who receive publicly-funded community services ("clients") and family members of individuals who receive such services. Study participants were recruited from a single mental retardation service provider in a large urban setting (the "Agency"). Sixteen clients and 14 families of Agency clients took part. Client data collection was accomplished through face-to-face interviews, focus group meetings, and record reviews; family members were involved in a face-to-face interview only. ^ An initial coding scheme was developed based upon literature and policy reviews, and themes related to the research questions. Analysis involved extracting data from transcripts and records and placing it into appropriate thematic categories, building support for each theme with the accumulated data. Coding themes were modified to accommodate new data when it challenged existing themes. ^ Findings suggest that adults with mental retardation do have the requisite knowledge, interest, and ability to participate in decisions about their end-of-life experience and handling of affairs. Siblings are overwhelmingly the chosen future surrogates and they (or their children) will likely be the end-of-life advocates for their brothers and sisters affected by mental retardation. Findings further point to a need for increased awareness, accurate information, and improved communication about end-of-life issues, both in general and particular to adults affected by mental retardation. Also suggested by the findings is a need to focus on creating accommodations and adaptations that can best uncover a person's authentic views on life and death and related end-of-life preferences. Practical implications and suggestions for further research are also discussed. ^

Diagnosis del hombre moderno en Minotauroamor de Abelardo Arias

El análisis del discurso en Minotauroamor de Abelardo Arias, permite al lector acceder a una serie de conceptos acerca del hombre y de las realidades que le conciernen: el amor, la amistad, la belleza, el arte, el poder, entre otros. Si bien estos planteos alcanzan a todos los personajes, los mismos son focalizados, especialmente, en relación con los dos protagonistas: el Minotauro y Teseo. De hecho, Abelardo Arias ha declarado que lo que le impulsó a escribir esta novela fue, precisamente, un interrogante vital que lo asediaba: cuál era la verdadera condición del hombre moderno. El escritor mendocino parecía advertir, ya en ese entonces, una marcada degradación de los valores que han sido sostén de nuestra cultura e intenta despertar la conciencia de sus coetáneos a través de estas magníficas páginas. Es por ello que, en el presente trabajo, no sólo nos proponemos demostrar el enorme valor literario de la novela abelardariana y la riqueza de su contenido sino también señalar el vínculo que se establece entre los personajes con el concepto subyacente de “hombre normal". De este modo tratamos de dilucidar de qué modo, en este espacio literario, se proyectan las ideas sustentadas por el reconocido escritor mendocino. Con tal finalidad, se señalan, sucintamente, las coincidencias y modulaciones que se dan entre el mito original y la recreación que de él hace el autor mendocino para centrarnos en el análisis de los fragmentos que tienen como tema sustancial la “diagnosis" del hombre. Para este enfoque tomo en consideración un estudio de Alfonso López Quintás -Diagnosis del hombre actual-, publicado el mismo año de la obra que nos ocupa, y que plantea -desde otro lenguaje-, las mismas inquietudes que advertimos en el autor mendocino.

El principio de contradicción o el estado de cosas en cuanto estado de cosas

El principio de contradicción tiene su lugar propio en la filosofía griega, concretamente en la Filosofía Primera o Teología de Aristóteles. No es ni un precepto ni una prohibición sobre el ente, abstraído de diversos estados de cosas, sino él mismo un estado de cosas, mejor dicho: el estado de cosas primero para todo el que quiera conocer algo. Su universalidad consiste en que presenta el estado de cosas en cuanto estado de cosas y se expresa en la decisividad de lo que constata: es imposible – que lo es el caso no sea el caso.

Materialidad del texto, textualidad del libro

Este texto quisiera mostrar, a partir del caso del Quijote, que no se pueden separar el estudio de las condiciones de publicacin de los textos y la interpretacin de su sentido. El entrecruzamiento entre la historia del libro (y la imprenta) y la sociologa de los textos tal como la defini D. F. McKenzie, procura la posibilidad de superar la divisin duradera y mutiladora entre hermenutica y bibliografa.

¿El museo como forma de "conocer la Historia"? El público interpreta la inmigración

El trabajo analiza cómo la exposición presentada en el Museo Nacional de la Inmigración fue aprehendida e interpretada por su público visitante. Dependiente de la Dirección Nacional de Migraciones, el Museo funcionó entre los años 2001 y 2009 en el edificio del antiguo Hotel de Inmigrantes (en Retiro). Para este estudio utilizamos más de 700 mensajes registrados en el Libro de Visitas del Museo, que fueron clasificados en nueve categorías, de acuerdo a los aspectos comunes que expresaban. A lo largo del análisis, el concepto de memoria se volvió fundamental para comprender los sentimientos y deseos expresados por el público que visitó la institución. Dentro de los temas que aparecieron en los mensajes, pudimos verificar la importancia que le atribuían los visitantes al Estado argentino por la construcción del Hotel, la recepción de los inmigrantes y, actualmente, por la preservación de su memoria y patrimonio; también se evidenció un agradecimiento a los inmigrantes, cuya "fuerza" y "esperanza" contribuyeron al desarrollo del país

Intervención y organización campesina : El caso de Copacabana en la provincia de Córdoba (Argentina)

La mayoría de los autores que trabajan la temática del desarrollo rural coinciden en que la organización de los productores es imprescindible para que los pobladores rurales puedan convertirse en actores de su propio desarrollo. Dado que la organización es una condición necesaria para el desarrollo rural, el problema consiste en establecer los caminos metodológicos más adecuados para promoverla. Situándonos en Copacabana, localidad rural serrana ubicada en el norte de la provincia de Córdoba, nos preguntamos: ¿cómo manejan las familias campesinas la tensión entre la estrategia individual y la acción colectiva para resolver sus problemas? Concluimos que, no resulta fácil que las familias campesinas realicen las inversiones sociales necesarias para establecer una organización duradera. El solo deseo por obtener los beneficios derivados de la organización no es suficiente. Se requiere además un adecuado balance entre las tendencias individualistas de sus miembros y las necesidades colectivas. Para resolver esta tensión a favor de una organización estable, se requiere generar un proceso de construcción participativa, que permita (a) que el grupo se comprometa con los objetivos inicialmente propuestos y que tenga capacidad para modificarlos; y (b) establecer reglas de acceso y mecanismos de control social claras, aceptadas y compartidas por sus integrantes. En muchos casos, este proceso puede ser favorecido por el acompañamiento de actores sociales externos

Materialidad del texto, textualidad del libro

Este texto quisiera mostrar, a partir del caso del Quijote, que no se pueden separar el estudio de las condiciones de publicacin de los textos y la interpretacin de su sentido. El entrecruzamiento entre la historia del libro (y la imprenta) y la sociologa de los textos tal como la defini D. F. McKenzie, procura la posibilidad de superar la divisin duradera y mutiladora entre hermenutica y bibliografa.

¿El museo como forma de "conocer la Historia"? El público interpreta la inmigración

El trabajo analiza cómo la exposición presentada en el Museo Nacional de la Inmigración fue aprehendida e interpretada por su público visitante. Dependiente de la Dirección Nacional de Migraciones, el Museo funcionó entre los años 2001 y 2009 en el edificio del antiguo Hotel de Inmigrantes (en Retiro). Para este estudio utilizamos más de 700 mensajes registrados en el Libro de Visitas del Museo, que fueron clasificados en nueve categorías, de acuerdo a los aspectos comunes que expresaban. A lo largo del análisis, el concepto de memoria se volvió fundamental para comprender los sentimientos y deseos expresados por el público que visitó la institución. Dentro de los temas que aparecieron en los mensajes, pudimos verificar la importancia que le atribuían los visitantes al Estado argentino por la construcción del Hotel, la recepción de los inmigrantes y, actualmente, por la preservación de su memoria y patrimonio; también se evidenció un agradecimiento a los inmigrantes, cuya "fuerza" y "esperanza" contribuyeron al desarrollo del país