Medical futility at the end of life: the perspectives of intensive care and palliative care clinicians.

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital in Germany. The transcripts were subjected to qualitative content analysis. Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment.

Between pluralism and majoritarianism: the European Court of Human Rights on religious symbols and education

How is it possible to square the development of a consistent Europeanapproach to religious diversity with the recognition of the sometimes-conflictiveplurality of state-religion models? The Court´s support of the liberalprinciples of separation and neutrality have either been deplored by Christianconservatives as the result of European Christophobia, or celebratedby secularists as contributing to the formation of a Europe free of religion.In contrast, the present chapter argues for a differentiated approach toEuropean jurisprudence, outlining how the Court has been oscillating betweenan appealing liberal-pluralist perspective or framework, and a questionablemajoritarian one. Both perspectives are illustrated by focusing onrepresentative decisions in the area of religious education and symbols.

Argumentation and education. Theoretical foundations and practices

During the last decade, argumentation has attracted growing attention as a means to elicit processes (linguistic, logical, dialogical, psychological, etc.) that can sustain or provoke reasoning and learning. Constituting an important dimension of daily life and of professional activities, argumentation plays a special role in democracies and is at the heart of philosophical reasoning and scientific inquiry. Argumentation, as such, requires specific intellectual and social skills. Hence, argumentation will have an increasing importance in education, both because it is a critical competence that has to be learned, and because argumentation can be used to foster learning in philosophy, history, sciences and in many other domains. Argumentation and Education answers these and other questions by providing both theoretical backgrounds, in psychology, education and theory of argumentation, and concrete examples of experiments and results in school contexts in a range of domains. It reports on existing innovative practices in education settings at various levels.

Health Care and Public Transit; Your Ticket to Health Care Access, 2005

Transportation is an important health care issue. The majority of the population here in Iowa have ready access and typically use private automobiles to access health care and other community services. There is also a significant segment of the population that either does not have access to a personal automobile or is not currently capable of driving. This can potentially limit their access to health care, but it has greater health implications because it can also limit access to nutrition and other community services, as well as involvement in social activities. For people unable to drive themselves, the alternatives generally include reliance on family, friends, volunteer groups, and public transit. Many choose transit because it gives them a degree of independence. Public transit is often used to supplement other options even when they are available. It becomes critical in circumstances where the other options don’t exist. In many cases there may be no family available or they may not always be able to get off work when travel needs arise during the workday. Friends may be in similar circumstances and volunteer groups may be either unavailable or overwhelmed. The fact that many patients depend on public transit to get to and from health care appointments makes it beneficial for health care professionals to get to know more about public transit and how it operates here in Iowa.

Child care and health rights: perspectives of adolescent mothers

AbstractOBJECTIVETo analyze child health care and the defense of their rights from the perspective of adolescent mothers.METHODSAn exploratory study with qualitative thematic analysis of data, based on conceptual aspects of care and the right to health, from semi-structured interviews with 20 adolescent mothers ascribed by Family Health teams.RESULTSMaternal reports indicate that child health care requires responsibility and protection, with health practices that promote child advocacy. Gaps in assistance which preclude the full guarantee of the right to child health care were also highlighted.CONCLUSIONThe right to health care assumed different meanings, and the forms to guarantee them were linked to individual behavior in detriment to broader actions that consider health as a social product, connected to the guarantee of other fundamental rights.

Caution, children crossing: Heterogeneity of victim's cost of care and negligence rule

The paper deals with a bilateral accident situation in which victims haveheterogeneous costs of care. With perfect information,efficient care bythe injurer raises with the victim's cost. When the injurer cannot observeat all the victim's type, and this fact can be verified by Courts, first-bestcannot be implemented with the use of a negligence rule based on thefirst-best levels of care. Second-best leads the injurer to intermediate care,and the two types of victims to choose the best response to it. This second-bestsolution can be easily implemented by a negligence rule with second-best as duecare. We explore imperfect observation of the victim's type, characterizing theoptimal solution and examining the different legal alternatives when Courts cannotverify the injurers' statements. Counterintuitively, we show that there is nodifference at all between the use by Courts of a rule of complete trust and arule of complete distrust towards the injurers' statements. We then relate thefindings of the model to existing rules and doctrines in Common Law and Civil Lawlegal systems.

Consumer Advisory Bulletin, How to Find Reputable In-Home Health Care and Service Plans, January 2008

The Attorney General’s Consumer Protection Division receives hundreds of calls and consumer complaints every year. Follow these tips to avoid unexpected expense and disappointments. This record is about: How to Find Reputable In-Home Health Care and Service Plans

Informal care and labour force participation among middle-aged women in Spain

Informal care is today the form of support most commonly used by those who need other peoplein order to carry out certain activities that are considered basic (eating, dressing, taking a shower,etc.), in Spain and in most other countries in the region. The possible labour opportunity costsincurred by these informal carers, the vast majority of whom are middle-aged women, have not asyet been properly quantified in Spain. It is, however, crucially important to know these quantities ata time when public authorities appear to be determined to extend the coverage offered up to nowas regards long-term care.In this context, we use the Spanish subsample of the European Community Household Panel (1994-2001) to estimate a dynamic ordered probit and so attempt to examine the effects of various typesof informal care on labour behaviour. The results obtained indicate the existence of labouropportunity costs for those women who live with the dependent person they care for, but not forthose who care for someone outside the household. Furthermore, whereas caregiving for morethan a year has negative effects on labour force participation, the same cannot be said of those who start caregiving and stop caregiving .

No consistent association between processes-of-care and health-related quality of life among patients with diabetes : a missing link?

PURPOSE: Health-related quality of life (HRQoL) is considered a representative outcome in the evaluation of chronic disease management initiatives emphasizing patient-centered care. We evaluated the association between receipt of processes-of-care (PoC) for diabetes and HRQoL. METHODS: This cross-sectional study used self-reported data from non-institutionalized adults with diabetes in a Swiss canton. Outcomes were the physical/mental composites of the short form health survey 12 (SF-12) physical composite score, mental composite score (PCS, MCS) and the Audit of Diabetes-Dependent Quality of Life (ADDQoL). Main exposure variables were receipt of six PoC for diabetes in the past 12 months, and the Patient Assessment of Chronic Illness Care (PACIC) score. We performed linear regressions to examine the association between PoC, PACIC and the three composites of HRQoL. RESULTS: Mean age of the 519 patients was 64.5 years (SD 11.3); 60% were male, 87% reported type 2 or undetermined diabetes and 48% had diabetes for over 10 years. Mean HRQoL scores were SF-12 PCS: 43.4 (SD 10.5), SF-12 MCS: 47.0 (SD 11.2) and ADDQoL: -1.6 (SD 1.6). In adjusted models including all six PoC simultaneously, receipt of influenza vaccine was associated with lower ADDQoL (β=-0.4, p≤0.01) and foot examination was negatively associated with SF-12 PCS (β=-1.8, p≤0.05). There was no association or trend towards a negative association when these PoC were reported as combined measures. PACIC score was associated only with the SF-12 MCS (β=1.6, p≤0.05). CONCLUSIONS: PoC for diabetes did not show a consistent association with HRQoL in a cross-sectional analysis. This may represent an effect lag time between time of process received and health-related quality of life. Further research is needed to study this complex phenomenon.

Strategic behaviours in healthcare : evidence from primary care and pharmaceutical markets

We analyse the strategic behaviours of agents in a market through the appropriate¬ness of their skills to the market. If agents' skills are well adapted to market and they can reach their target, they will not need to adopt strategic behaviours. The agents will behave as selfish individuals. However, if their skills are not well adapted and they cannot attain their target alone, they will adopt strategic behaviours to reach their objectives. These behaviours will have a different impact on the utilities of other agents, depending on the skills and the objectives of the agent. If these agents need other agents to reach their objectives, they will behave as altruistic individuals who internalise the utilities of other agents in reaching their objectives and will adopt cooperative behaviours. However, if these agents fear that other agents could prevent them from reaching their target because they can foresee that the skills of other agents are better adapted than their own skills, the agents will then behave as predator individuals and will adopt destructive behaviours to attain their objective. It is in the interests of these agents to manipulate information to increase disorder and dissimulate their lack of skills. They will reproduce the strategies of animals that modify their appearance to escape predators or simulate being bait to attract their prey. These agents will seek to induce chaos into the behaviours of other agents to amplify the impact of their strategies. The appropriateness of skills to the market allows an understanding of the emer-gence of networks and associated strategies. The members of a networks are inputs who are excluded when their costs are higher than their benefits. A network simul-taneously allows cooperation and selfish, predatory behaviours among its members. A network may adopt informational strategies when seeking to become the leader in a market or when it cannot survive. The creation of networks and the manipulation of information are two overlapping evolutionary strategies, with the first strategy favouring the second. In our model, an agent does not behave like a firm that aims only to maximise the profits of the firm but rather as a member of a network who adopts strategic behaviours as a function of the interests of this network. If his skills are well adapted to the market and he can innovate, he will not invest in erroneous input; in contrast, if his skills are not adapted, the agent will invest in the erroneous input of information into the market in order to survive. Therefore, when any informational asymmetries between the agents and their principals characterise the market, the price cannot be the main element that allows equilibrium to be reached in the market; instead, the appropriateness of skills to the market enables equilibrium. We will now apply these hypotheses to explain the strategic behaviours of physicians and pharmaceutical companies.

Quality of care and survival of haemodialysed patients in western Switzerland.

BACKGROUND: Many factors affect survival in haemodialysis (HD) patients. Our aim was to study whether quality of clinical care may affect survival in this population, when adjusted for demographic characteristics and co-morbidities. METHODS: We studied survival in 553 patients treated by chronic HD during March 2001 in 21 dialysis facilities in western Switzerland. Indicators of quality of care were established for anaemia control, calcium and phosphate product, serum albumin, pre-dialysis blood pressure (BP), type of vascular access and dialysis adequacy (spKt/V) and their baseline values were related to 3-year survival. The modified Charlson co-morbidity index (including age) and transplantation status were also considered as a predictor of survival. RESULTS: Three-year survival was obtained for 96% of the patients; 39% (211/541) of these patients had died. The 3-year survival was 50, 62 and 69%, respectively, in patients who had 0-2, 3 and >or=4 fulfilled indicators of quality of care (test for linear trend, P < 0.001). In a Cox multivariate analysis model, the absence of transplantation, a higher modified Charlson's score, decreased fulfilment of indicators of good clinical care and low pre-dialysis systolic BP were independent predictors of death. CONCLUSION: Good clinical care improves survival in HD patients, even after adjustment for availability of transplantation and co-morbidities.

Parents’ Investments and Education Returns

[cat] Aquest article analitza la relació entre els ingressos dels pares i l’educació dels seus fills. En un context d’altruïsme perfecte, el model descriu les decisions dels pares sobre quant consumir i quant invertir en l’educació dels seus fills. El model prediu que els rendiments de l’educació en termes de sous haurien de ser lineals. Usant aquest model en una economia competitiva, es mostra com el resultat depèn dels subsidis o impostos del govern sobre l’educació. El compromís habitual igualtat-eficiència apareix en aquest context. Finalment, el model dóna intuïcions sobre la relació entre educació i productivitat.