Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians

Importance: Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers.

Objective: To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process.

Design, Setting, and Participants: Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces.

Main Outcomes and Measures: Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important).

Results: Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for an overall response rate of 77.7% (512 of 646 nurses [79.3%], 484 of 634 residents [76.3%], 260 of 337 staff physicians [77.2%]). The following family member-related and patient-related factors were consistently identified by all 3 clinician groups as the most important barriers to goals of care discussions: family members' or patients' difficulty accepting a poor prognosis (mean [SD] score, 5.8 [1.2] and 5.6 [1.3], respectively), family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments (5.8 [1.2] for both groups), disagreement among family members about goals of care (5.8 [1.2]), and patients' incapacity to make goals of care decisions (5.6 [1.2]). Clinicians perceived their own skills and system factors as less important barriers. Participants viewed it as acceptable for all clinician groups to engage in goals of care discussions-including a role for advance practice nurses, nurses, and social workers to initiate goals of care discussions and be a decision coach.

Conclusions and Relevance: Hospital-based clinicians perceive family member-related and patient-related factors as the most important barriers to goals of care discussions. All health care professionals were viewed as playing important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication and decision making about goals of care.

Lung consequences in adults born prematurely

Although survival has improved significantly in recent years, prematurity remains a major cause of infant and childhood mortality and morbidity. Preterm births (<37 weeks of gestation) account for 8% of live births representing >50 000 live births each year in the UK. Preterm birth, irrespective of whether babies require neonatal intensive care, is associated with increased respiratory symptoms, partially reversible airflow obstruction and abnormal thoracic imaging in childhood and in young adulthood compared with those born at term. Having failed to reach their optimal peak lung function in early adulthood, there are as yet unsubstantiated concerns of accelerated lung function decline especially if exposed to noxious substances leading to chronic respiratory illness; even if the rate of decline in lung function is normal, the threshold for respiratory symptoms will be crossed early. Few adult respiratory physicians enquire about the neonatal period in their clinical practice. The management of these subjects in adulthood is largely evidence free. They are often labelled as asthmatic although the underlying mechanisms are likely to be very different. Smoking cessation, maintaining physical fitness, annual influenza immunisation and a general healthy lifestyle should be endorsed irrespective of any symptoms. There are a number of clinical and research priorities to maximise the quality of life and lung health in the longer term not least understanding the underlying mechanisms and optimising treatment, rather than extrapolating from other airway diseases.

Conflict and Consensus

There are widely differing conceptions as to whether healthy social relations are, in essence, conflictual or consensual; such differences give rise to different approaches to finding peace and managing power. This article outlines the two broad schools of thought from conflict theory (in which society functions through competition) and consensus theory (which sees society developing through cooperation). It outlines the middle ground between them, as found by pluralism and agonism, before considering the ways in which assumptions vis-a-vis conflict and consensus are reflected in different models of democratic system and, in particular, different priorities for post-conflict recovery.

Regional integration of biogas – developing an intersectoral research action plan for Northern Ireland

Bioenergy is a key component of the European Union long term energy strategy across all sectors, with a target contribution of up to 14% of the energy mix by 2020. It is estimated that there is the potential for 1TWh of primary energy from biogas per million persons in Europe, derived from agricultural by-products and waste. With an agricultural sector that accounts for 75% of land area and a large number of advanced engineering firms, Northern Ireland is a region with considerable potential for an integrated biogas industry. Northern Ireland is also heavily reliant on imported fossil fuels. Despite this, the industry is underdeveloped and there is a need for a collaborative approach from research, business and policy-makers across all sectors to optimise Northern Ireland’s abundant natural resources. ‘Developing Opportunities in Bio-Energy’ (i.e. Do Bioenergy) is a recently completed project that involved both academic and specialist industrial partners. The aim was to develop a biogas research action plan for 2020 to define priorities for intersectoral regional development, co-operation and knowledge transfer in the field of production and use of biogas. Consultations were held with regional stakeholders and working groups were established to compile supporting data, decide key objectives and implementation activities. Within the context of this study it was found that biogas from feedstocks including grass, agricultural slurry, household and industrial waste have the potential to contribute from 2.5% to 11% of Northern Ireland’s total energy consumption. The economics of on-farm production were assessed, along with potential markets and alternative uses for biogas in sectors such as transport, heat and electricity. Arising from this baseline data, a Do Bioenergy was developed. The plan sets out a strategic research agenda, and details priorities and targets for 2020. The challenge for Northern Ireland is how best to utilise the biogas – as electricity, heat or vehicle fuel and in what proportions. The research areas identified were: development of small scale solutions for biogas production and use; solutions for improved nutrient management; knowledge supporting and developing the integration of biogas into the rural economy; and future crops and bio-based products. The human resources and costs for the implementation were estimated as 80 person-years and £25 million respectively. It is also clear that the development of a robust bio-gas sector requires some reform of the regulatory regime, including a planning policy framework and a need to address social acceptance issues. The Action Plan was developed from a regional perspective but the results may be applicable to other regions in Europe and elsewhere. This paper presents the methodology, results and analysis, and discussion and key findings of the Do Bioenergy report for Northern Ireland.

‘Plugging the Gap’: Shared Education and the promotion of community relations through schools in Northern Ireland

Although there is no consensus amongst educationalists as to the role schools play as drivers of hostilities in divided societies, there is broad agreement that they can facilitate more positive intergroup relations. In Northern Ireland the promotion of school based inter-group contact has been offered as a means through which this can happen. Until 2007, the approach was twofold, reflected on the one hand in short-term contact opportunities for pupils in predominantly Catholic and Protestant schools, and on the other, in support for integrated schools which educate Catholics and Protestants together. In 2007 the Shared Education Programme was introduced to ‘bridge the gap’ between short-term opportunities for contact, and ‘full immersion’ integrated schools. Informed by contact theory, shared education offers curriculum based interaction between pupils attending all school types, aimed at promoting the type of contact likely to reduce negative social attitudes and ultimately contribute to social harmony. In this paper, we examine the impact of shared education thus far. Our analysis suggests that whilst shared education is generally effective in promoting positive assessments of other group members, there is a danger that programme impact may be inhibited by the foregrounding of educational over reconciliation priorities. Appreciating that the downplaying reconciliation objectives may have been necessary when the programme was established in order to maximize recruitment to it, we argue that if the full potential of shared education is to be realized, moving forward, it is important for schools to engage with issues of group differences.

Cancer and serious mental illness – patient, caregiver and professional perspectives: study protocol

Aim: To explore the experience of serious mental illness and cancer from the perspective of patients, significant others and healthcare professionals involved in their care. Background: Serious mental illness is associated with poorer cancer outcomes. Those suffering from this comorbidity receive fewer specialist interventions and die earlier than the general population. Prior qualitative research in this area has comprised of a single study focussing on healthcare professionals and there is little evidence regarding the experiences of patients and caregivers.Design: A qualitative exploration using approximately 36 semi-structured interviews.Methods: Semi-structured digitally recorded interviews conducted with: adults living with serious mental illness and diagnosed with cancer; those providing them with informal support and care; and healthcare professionals. Questions will focus on the experience of having cancer and serious mental illness or caring for someone with this comorbidity, experiences of healthcare and priorities for patients and carers. Framework analysis will be used. Research Ethics Committee and Trust Research & Development approval was obtained. A steering group comprising six people with experience of either cancer or mental illness provided feedback and ratified the patient information sheets and interview schedules. Discussion: There is a paucity of research addressing stakeholder perspectives on the experience of cancer and of cancer services for people with serious mental illness. Dissemination of findings will inform practice relating to the care of an often neglected population, informing better support for their significant others and the professionals involved in their care.

Do ectomycorrhizal fungi exhibit adaptive tolerance to potentially toxic metals in the environment?

The effects of potentially toxic metals on ectomycorrhizal (ECM) fungi and their higher plant hosts are examined in this review. Investigations at a species and community level have revealed wide inter- and intraspecific variation in sensitivity to metals. Adaptive and constitutive mechanisms of ECM tolerance are proposed and discussed in relation to proven tolerance mechanisms in bacteria, yeasts and plants. Problems with methodology and research priorities are highlighted. These include the need for a detailed understanding of the genetic basis of tolerance in the ECM symbiosis, and for studies of ECM community dynamics in polluted sites.

Towards a Mourne National Park?Emergent prospects and pitfalls fromarticulating needs in a local context

This paper examines the prospects for sustainable rural tourism within a rural development paradigm. Specifically, an adaptive management approach is proposed as a means of understanding and accommodating the different goals and interests that exist within multi-functional rural areas. This model allows priorities to change in line with particular situations while remaining sensitive to economic, environmental, social and cultural impacts. The proposed Mourne National Park in Northern Ireland, also designated an Area of Outstanding Natural Beauty (AONB), forms the backdrop for this study. Through a critique of a consultation process that was undertaken with the community the question is posed: can a sustainable rural tourism approach achieve meaningful community engagement and thereby reflect the needs of the community? Central to the analysis are the power differentials between the various partners participating in this model of governance. The conclusions consider implications for rural communities, revealing how trusting and meaningful relationships are central to facilitating collaboration, cooperation and adaptation.

"Should I prioritize medical problem solving or attentive listening?": the dilemmas and challenges that medical students experience when learning to conduct consultations

Objective: Communication skills can be trained alongside clinical reasoning, history taking or clinical examination skills. This is advocated as a solution to the low transfer of communication skills. Still, students have to integrate the knowledge/skills acquired during different curriculum parts in patient consultations at some point. How do medical students experience these integrated consultations within a simulated environment and in real practice when dealing with responsibility?

Methods: Six focus groups were conducted with (pre-)/clerkship students.

Results: Students were motivated to practice integrated consultations with simulated patients and felt like 'real physicians'. However, their focus on medical problem solving drew attention away from improving their communication skills. Responsibility for real patients triggered students' identity development. This identity formation guided the development of an own consultation style, a process that was hampered by conflicting demands of role models.

Conclusion: Practicing complete consultations results in the dilemma of prioritizing medical problem solving above attention for patient communication. Integrated consultation training advances this dilemma to the pre-clerkship period. During clerkships this dilemma is heightened because real patients trigger empathy and responsibility, which invites students to define their role as doctor.

Practice Implications: When training integrated consultations, educators should pay attention to students' learning priorities and support the development of students' professional identity.

Irish language education and the national ideal: The dynamics of nationalism in Northern Ireland

Since the beginning of the Northern Ireland conflict in the late 1960s, Irish nationalism has been identified as a prominent force in the political culture of the state. Recent studies have suggested, however, that the ‘Nationalist’ population has become increasingly content within the new political framework created by the peace process and the aspiration for Irish unity diminished. In placing the Northern Ireland situation within the theoretical framework of nationalism, this paper will analyse how these changing priorities have been possible. Through an analysis of Irish language study in Northern Ireland's schools, the paper will examine how the political ideals espoused by the nationalist Sinn Féin Party reflected the priorities of the ‘nationalist community’. It will be contended that the relationship between the ideology and ‘the people’ is much more complex than is often allowed for and that educational inequalities are a significant contributing factor to this.

Integration of Indicator Alarm Signals for Ecosystem‐Based Fishery Management

We consider the problem of regulating the rate of harvesting a natural resource, taking account of the wider system represented by a set of ecological and economic indicators, given differing stakeholder priorities. This requires objective and transparent decision making to show how indicators impinge on the resulting regulation decision. We offer a new scheme for combining indicators, derived from assessing the suitability of lowering versus not lowering the harvest rate based on indicator values relative to their predefined reference levels. Using the practical example of fisheries management under an “ecosystem approach,” we demonstrate how different stakeholder views can be quantitatively represented by weighting sets applied to these comparisons. Using the scheme in an analysis of historical data from the Celtic Sea fisheries, we find great scope for negotiating agreement among disparate stakeholders.

'"To have its cake and eat it too:" US policy toward South Africa during the Kennedy administration

The assumption that US policy toward Africa was characterized by continuity during the cold war has recently been challenged by scholars who argue that President John F. Kennedy embarked on an African policy that was distinct from his predecessors. This may be true for black Africa, but Kennedy’s support for African nationalism did not extend to South Africa. This article reveals that Kennedy’s cold war priorities ensured continuity in US policy toward the apartheid state and, in some cases, additional cooperation as cold war crises increased the perceived importance of South Africa as an ideological and strategic ally and bastion against communism on a rapidly changing continent. This article also explores the role South Africa’s apartheid government played in this cold war alliance. The ruling National Party recognized its importance to US foreign policy goals and used this to stave off serious American criticism of its racial policies, deflect attention in the United Nations, and ensure continued economic and military cooperation with the United States.

Reframing EU Public Health Governance:From Risk to Citizenship and Participation

Risk is the dominant frame for the European Union’s growing albeit often overlooked public health governance. The starting point for this chapter is the distortion of public health priorities by and within this frame. I argue that existing efforts to identify, underline and tackle the distortions can be strengthened by reframing governance as a matter of citizenship so as to develop citizen participation in decision making.

Adaptable housing design for climate change adaptation

It is predicted that climate change will result in rising sea levels, more frequent and extreme weather events, hotter and drier summers and warmer and wetter winters. This will have a significant impact on the design of buildings, how they are kept cool and how they are weathered against more extreme climatic conditions. The residential sector is already a significant environmental burden with high associated operational energy. Climate change, and a growing population requiring residence, has the potential to exacerbate this problem seriously. New paradigms for residential building design are required to enable low-carbon dioxide operation to mitigate climate change. They must also face the reality of inevitable climate change and adopt climate change adaptation strategies to cope with future scenarios. However, any climate adaptation strategy for dwellings must also be cognisant of adapting occupant needs, influenced by ageing populations and new technologies. This paper presents concepts and priorities for changing how society designs residential buildings by designing for adaptation. A case study home is analysed in the context of its stated aims of low energy and adaptability. A post-occupancy evaluation of the house is presented, and future-proofing strategies are evaluated using climate projection data for future climate change scenarios.

Embracing an integromic approach to tissue biomarker research in cancer: Perspectives and lessons learned

Modern approaches to biomedical research and diagnostics targeted towards precision medicine are generating ‘big data’ across a range of high-throughput experimental and analytical platforms. Integrative analysis of this rich clinical, pathological, molecular and imaging data represents one of the greatest bottlenecks in biomarker discovery research in cancer and other diseases. Following on from the publication of our successful framework for multimodal data amalgamation and integrative analysis, Pathology Integromics in Cancer (PICan), this article will explore the essential elements of assembling an integromics framework from a more detailed perspective. PICan, built around a relational database storing curated multimodal data, is the research tool sitting at the heart of our interdisciplinary efforts to streamline biomarker discovery and validation. While recognizing that every institution has a unique set of priorities and challenges, we will use our experiences with PICan as a case study and starting point, rationalizing the design choices we made within the context of our local infrastructure and specific needs, but also highlighting alternative approaches that may better suit other programmes of research and discovery. Along the way, we stress that integromics is not just a set of tools, but rather a cohesive paradigm for how modern bioinformatics can be enhanced. Successful implementation of an integromics framework is a collaborative team effort that is built with an eye to the future and greatly accelerates the processes of biomarker discovery, validation and translation into clinical practice.