International palliative care experts' view on phenomena indicating the last hours and days of life

BACKGROUND Providing the highest quality care for dying patients should be a core clinical proficiency and an integral part of comprehensive management, as fundamental as diagnosis and treatment. The aim of this study was to provide expert consensus on phenomena for identification and prediction of the last hours or days of a patient's life. This study is part of the OPCARE9 project, funded by the European Commission's Seventh Framework Programme. METHOD The phenomena associated with approaching death were generated using Delphi technique. The Delphi process was set up in three cycles to collate a set of useful and relevant phenomena that identify and predict the last hours and days of life. Each cycle included: (1) development of the questionnaire, (2) distribution of the Delphi questionnaire and (3) review and synthesis of findings. RESULTS The first Delphi cycle of 252 participants (health care professionals, volunteers, public) generated 194 different phenomena, perceptions and observations. In the second cycle, these phenomena were checked for their specific ability to diagnose the last hours/days of life. Fifty-eight phenomena achieved more than 80% expert consensus and were grouped into nine categories. In the third cycle, these 58 phenomena were ranked by a group of palliative care experts (78 professionals, including physicians, nurses, psycho-social-spiritual support; response rate 72%, see Table 1) in terms of clinical relevance to the prediction that a person will die within the next few hours/days. Twenty-one phenomena were determined to have "high relevance" by more than 50% of the experts. Based on these findings, the changes in the following categories (each consisting of up to three phenomena) were considered highly relevant to clinicians in identifying and predicting a patient's last hours/days of life: "breathing", "general deterioration", "consciousness/cognition", "skin", "intake of fluid, food, others", "emotional state" and "non-observations/expressed opinions/other". CONCLUSION Experts from different professional backgrounds identified a set of categories describing a structure within which clinical phenomena can be clinically assessed, in order to more accurately predict whether someone will die within the next days or hours. However, these phenomena need further specification for clinical use.

A quality of life subscale for terminally ill cancer patients

A subscale was developed to assess the quality of life of cancer patients with a life expectancy of six months or less. Phase I of this study identified the major concerns of 74 terminally ill cancer patients (19 with breast cancer, 19 with lung cancer, 18 with colorectal cancer, 9 with renal cell cancer, 9 with prostate cancer), 39 family caregivers, and 20 health care professionals. Patients interviewed were being treated at the University of Texas M. D. Anderson Cancer Center or at the Hospice at the Texas Medical Center in Houston. In Phase II, 120 patients (30 with breast cancer, 30 with lung cancer, 30 with colorectal cancer, 15 with prostate cancer, and 15 with renal cell cancer) rated the importance of these concerns for quality of life. Items retained for the subscale were rated as "extremely important" or "very important" by at least 60% of the sample and were reported as being applicable by at least two-thirds of the sample. The 61 concerns that were identified were formatted as a questionnaire for Phase III. In Phase III, 356 patients (89 with breast cancer, 88 with lung cancer, 88 with colorectal cancer, 44 with prostate cancer, and 47 with renal cell cancer) were interviewed to determine the subscale's reliability and sensitivity to change in clinical status. Both factor analysis and item response theory supported the inclusion of the same 35 items for the subscale. Internal consistency reliability was moderate to high for the subscale's domains: spiritual (0.87), existential (0.76), medical care (0.68), symptoms (0.67), social/family (0.66), and emotional (0.61). Test-retest correlation coefficients also were high for the domains: social/family (0.86), emotional (0.83), medical care (0.83), spiritual (0.75), existential (0.75), and symptoms (0.81).^ In addition, concurrent validity was supported by the high correlation between the subscale's symptom domain and symptom items from the European Organization for Research and Treatment of Cancer (EORTC) scale (r = 0.74). Patients' functional status was assessed with the Eastern Cooperative Oncology Group (ECOG) Performance status rating. When ECOG categories were compared to subscale domains, patients who scored lower in functional status had lower scores in the spiritual, existential, social/family, and emotional domains. Patients who scored lower in physical well-being had higher scores in the symptom domain. Patient scores in the medical care domain were similar for each ECOG category. The results of this study support the subscale's use in assessing quality of life and the outcomes of palliative treatment for cancer patients in their last six months of life. ^

Seelsorge, Psychologie und Medizin im Gespr��ch mit Spiritual Care (Psychologische Perspektive)

Spirituality is a travelling concept among different disciplines. As for psychology, spirituality has long been a neglected topic ��� especially in the academic context. However, during the last dec-ade there has been an increase of theoretical and empirical work, mainly emerging from positive and life-span developmental psychology. This research focuses spirituality either as an element of well-being or as predictor of well-being and health (e.g. as a coping strategy), or finally as an outcome after dealing with critical life events (i.e. spiritual growth). This knowledge has an impact on spiritual care ��� and vice-versa spiritual care ��� as a growing inter- and transdisciplinary field ��� has an impact on clinical psychological practice.

The Jewish faith: its spiritual consolation, moral guidance, and immortal hope; with a brief notice of the reasons for many of its ordinances and prohibitions; a series of letters answering the inquiries of youth.

Bound with the authors Shema�� Yi��ra��el. Philadelphia, 1864.

The ethics of Judaism, /

No more published.

A select series, biographical, narrative, epistolary, and miscellaneous; chiefly the productions of early members of the Society of Friends: intended to illustrate the spiritual character of the gospel of Christ /

The first five volumes were edited by John Barclay. After his death in 1838 volumes 6 through 8 were prepared by his brother A.R.Barclay. cf. Smith, I-172.

Self-culture : physical, intellectual, moral, and spiritual : a course of lectures, /

Mode of access: Internet.

The nature of spirit, and of man as a spiritual being.

Mode of access: Internet.

The spiritual letters of Archbishop Fe��nelon : letters to women /

Half-title: Archbishop Fe��nelon's Letters to women.

Self-culture : physical, intellectual, moral, and spiritual; a course of lectures /

Mode of access: Internet.

Ourselves and the universe : studies in life and religion /

"First edition, June, 1902 ... Sixth edition, November, 1906."

O IMAGIN��RIO DO TEMPLO CELESTE E O ATO SIMB��LICO DE JESUS EM JERUSAL��M (MC 11:15-19): A VARIA����O DE ESCALAS NA BUSCA PELO JESUS HIST��RICO

A disserta����o tem como proposta um interc��mbio entre a Nova Hist��ria Cultural e a Pesquisa pelo Jesus Hist��rico. Os problemas colocados �� historiografia atual pela p��smodernidade, a quest��o da subjetividade nos processos epistemol��gicos de constru����o hist��rica e a necessidade de reconhecimento da complexidade das a����es sociais, pedem por uma metodologia que encontre uma sa��da �� contraposi����o entre racionalismo e irracionalismo, entre o positivismo e a recusa em interpretar os objetos hist��ricos. O projeto prop��e a Micro- hist��ria italiana como tentativa de superar estas quimeras. A busca pelo Jesus de Nazar�� funcionar�� assim n��o a partir de esquemas te��ricos ge rais as estruturas permanentes do Mediterr��neo, o common judaism , ou o ethos da Baixa Galil��ia mas pelo estudo fino, detalhado de um microfen��meno bastante representativo de Jesus, a sua demonstra����o simb��lica no Templo narrada em Mc 11:15-19 e paralelos. A microan��lise tratar�� de controlar a multiplica����o da grande teia de rela����es causais da a����o simb��lica em Jerusal��m e inferir�� a partir delas que tipo de religioso foi Jesus e como se relacionou ao grande centro religioso do Santu��rio de Herodes. A varia����o entre as escalas microsc��picas e macrosc��picas de observa����o ser�� tamb��m fundamental na constru����o das imagens plaus��veis de Jesus. Infer��ncias sobre o contexto cultural e religioso da Galil��ia tamb��m ser��o experimentadas a partir da microa����o analisada o corol��rio de que os indiv��duos s��o, de uma forma ou de outra, representativos de per��odos hist��ricos e de estratos culturais ser�� levado bastante a s��rio. A hip��tese do presente trabalho �� a de que a demonstra����o de Jesus no Templo, longe de uma tentativa de purifica����o, fora a atualiza����o de um estrutura m��tica centrada em Jeremias 7 (uma mitopr��xis) orientada pelo imagin��rio plurissecular do c��u-templo, abundante nas imagens liter��rias da apocal��ptica e no misticismo incipiente que culminar�� na literatura Hekhalot. Como experimento final, propor-se-�� uma conex��o entre supostas experi��ncias vision��rias de ascens��o aos c��us de Jesus de Nazar�� e o seu imagin��rio do c��u-templo.

Economic life in the modern age

Werner Sombart (1863-1941) may well have been the most famous and controversial social scientist in Germany during the early twentieth century. Highly influential, his work and reputation have been indelibly tainted by his embrace of National Socialism in the last decade of his life. Although Sombart left an enormous opus spanning disciplinary boundaries, intellectual reaction to his work inside and outside of Germany is divided and ambivalent. Sombart consistently responded to the social and political developments that have shaped the twentieth century. Economic Life in the Modern Age provides a representative sampling of those portions of Sombart's work that have stood the test of time. The volume opens with a substantial introduction reviewing Sombart's life and career, the evolution of his major intellectual concerns, his relation to Marx and Weber, and his political affiliation with the Nazis. The editors' selection of texts emphasizes areas of Sombart's economic and cultural thought that remain relevant, particularly to those intellectual trends that seek a more broadly based, cross-disciplinary approach to culture and economics. Sombart's writings on capitalism are represented by essays on the nature and origin of the market system and the diversity of motives among the bourgeoisie and the proletariat. Also included is an excerpt from Sombart's controversial The Jews and Modern Capitalism, exploring the widely perceived relation between economic life and Judaism as a religion. In essays on the economics of cultural processes, Sombart's comprehensive and expansive idea of cultural science yields prophetic insights into the nature of urbanism, luxury consumption, fashion, and the cultural secularization of love. The volume's final section consists of Sombart's reflections on the social influences of technology, the economic life of the future, and on socialism, including the influential essay "Why is there no Socialism in the United States." Encapsulating the most valuable aspects of his work, Economic Life in the Modern Age provides clear demonstration of Sombart's sense for fine cultural distinctions and broad cultural developments and the predictive power of his analyses. It will be of interest to sociologists, economists, political scientists, and specialists in cultural studies.

In God we trust: Faith-based development, spiritual transformation, and economic change in southern Andean indigenous communities

In communities throughout the developing world, faith-based organizations (FBOs) focus on goals such as eradicating poverty, bolstering local economies, and fostering community development, while premising their activities and interaction with local communities on theological and religious understandings. Due to their pervasive interaction with participants, the religious ideologies of these FBOs impact the religious, economic, and social realities of communities. This study investigates the relationship between the international FBO, World Vision International (WVI), and changes to religious, economic, and social ideologies and practices in Andean indigenous communities in southern Peruvian. This study aims to contribute to the greater knowledge and understanding of (1) institutionalized development strategies, (2) faith-based development, and (3) how institutionalized development interacts with processes of socio-cultural change. Based on fifteen months of field research, this study involved qualitative and quantitative methods of participant-observation, interviews, surveys, and document analysis. Data were primarily collected from households from a sample of eight communities in the Pitumarca and Combapata districts, department of Canchis, province of Cusco, Peru where two WVI Area Development Programs were operating. Research findings reveal that there is a relationship between WVI���s intervention and some changes to religious, economic, and social structure (values, ideologies, and norms) and practices, demonstrating that structure and practices change when social systems are altered by new social actors. Findings also revealed that the impacts of WVI���s intervention greatly increased over the course of several years, demonstrating that changes in structure and practice occur gradually and need a period of time to take root. Finally, results showed that the impacts of WVI���s intervention were primarily limited to those most closely involved with the organization, revealing that the ability of one social actor to incite changes in the structure and practice of another actor is associated with the intensity of the relationship between the social actors. The findings of this study should be useful in ascertaining deductions and strengthening understandings of how faith-based development organizations impact aspects of religious, economic, and social life in the areas where they work.

The spiritual and professional impact of stillbirth

Stillbirth is without question one of the most devastating experiences of grief for parents and families. The death of a baby is also a distressing experience for healthcare professionals who share hopes of a live healthy baby at the end of pregnancy. It is a sad reality however, that in Ireland one in 238 babies will die before birth. The creation and nurture of new life in pregnancy is a spiritual experience as a new baby is at the same time experienced and anticipated. There is little in the published literature concerning the spiritual impact of stillbirth on healthcare chaplains who are the main providers of spiritual care for parents and staff colleagues in Irish maternity units. In addition there are few qualitative studies that explore the impact of stillbirth on consultant obstetricians and no published studies on the spiritual impact of stillbirth on bereaved parents. This study explored the spiritual and professional impact of stillbirth on Irish maternity healthcare chaplains, consultant obstetricians and bereaved parents. Following an overall review of spiritual care provision following stillbirth in the Irish maternity services, thematic analysis was used in the first phase of the study following in-depth interviews with maternity healthcare chaplains. Interpretative Phenomenological Analysis was used in the second and third phases with consultant obstetricians and bereaved parents respectively. The data from both maternity healthcare chaplains and consultant obstetricians revealed that stillbirth posed immense personal, spiritual and professional challenges. Chaplains expressed the spiritual and professional impact of stillbirth in terms of perception of their role, suffering, doubt and presence as they provided care for bereaved parents. A review of spiritual care provision in the Irish maternity services revealed a diversity of practice. The data from consultant obstetricians identified considerable personal, professional and spiritual impact following stillbirth that was identified in superordinate themes of human response to stillbirth, weight of professional responsibility, conflict of personal faith and incongruence between personal faith and professional practice. Data from bereaved parents revealed that stillbirth was spiritually challenging and all parents expressed that stillbirth posed considerable challenge to their faith/ belief structure. The parents of only three babies felt that their spiritual needs were adequately addressed while in hospital. The data had six superordinate themes of searching for meaning, maintaining hope, importance of personhood, protective care, questioning core beliefs and relationships. Other findings from the data from bereaved parents outlined the importance of environment of care and communication. This study has revealed the immense impact of stillbirth on healthcare chaplains, consultant obstetricians and most especially the spiritual impact for bereaved parents. Recommendations are made for improvements in clinical and spiritual care for bereaved parents following stillbirth and for staff wellbeing and support initiatives. Further research areas are recommended in the areas of spiritual care, theological reflection, bereavement care, post-mortem consent procedures and staff wellbeing.