OBJECTIVE: Collusion is a largely unconscious, dynamic bond, which may occur between patients and clinicians, between patients and family members, or between different health professionals. It is widely prevalent in the palliative care setting and provokes intense emotions, unreflective behavior, and negative impact on care. However, research on collusion is limited due to a lack of conceptual clarity and robust instruments to investigate this complex phenomenon. We have therefore developed the Collusion Classification Grid (CCG), which we aimed to evaluate with regard to its potential utility to analyze instances of collusion, be it for the purpose of supervision in the clinical setting or research.
METHOD: Situations of difficult interactions with patients with advanced disease (N = 10), presented by clinicians in supervision with a liaison psychiatrist were retrospectively analyzed by means of the CCG. Result 1) All items constituting the grid were mobilized at least once; 2) one new item had to be added; and 3) the CCG identified different types of collusion.
SIGNIFICANCE OF RESULTS : This case series of collusions assessed with the CCG is a first step before the investigation of larger samples with the CCG. Such studies could search and identify setting-dependent and recurrent types of collusions, and patterns emerging between the items of the CCG. A better grasp of collusion could ultimately lead to a better understanding of the impact of collusion on the patient encounter and clinical decision-making.
BACKGROUND: Diagnostic criteria for prolonged grief have appeared in the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5; persistent complex bereavement disorder, PCBD) and in the ICD-11 (prolonged grief disorder, PGD), and the question of which diagnosis is most clinically useful has been hotly debated. This study provides the first longitudinal comparison of PCBD and PGD in their ability to capture symptom change over time and their relation to long-term outcomes.
METHODS: A community sample was recruited consisting of 282 individuals who had recently lost a spouse. Structured clinical interviews were conducted at 3, 14, and 25 months postloss for symptoms corresponding to PCBD and PGD criteria. Outcomes at 25 months included PCBD and PGD caseness, depression, global functioning, and interviewer ratings of participant suffering.
RESULTS: PCBD and PGD trajectories determined by growth mixture modeling, each captured three primary outcomes: resilience, moderate-improving symptoms, and prolonged-stable symptoms. The PGD solution also identified trajectories of increasing and decreasing distress: prolonged-worsening and acute-recovering symptoms. Prediction of 25-month outcomes indicated differences conforming to the severity of PGD symptoms, and the prolonged-worsening trajectory was associated with the worst adjustment.
CONCLUSIONS: PGD symptoms were more differentiated, better-captured psychopathology, and other outcomes and were more sensitive to change over time compared to PCBD.
Background: A distinct grief-specific disorder is included in the ICD-11. Lack of clarity remains regarding whether different proposed diagnostic criteria capture similar or different diagnostic entities. Our aim was to examine the specificity of four proposed diagnostic criteria-sets for pathological grief in a population-based sample.
Methods: Participants were 206 conjugally bereaved elderly Danes (59% female; mean age = 72.5 years, SD = 4.2; range 65–81) who completed self-report questionnaires six months post-loss. The main measure was the Danish version of Inventory of Complicated Grief-Revised.
Results: Results indicate substantial agreement between Prolonged Grief Disorder (PGD), Persistent Complex Bereavement Disorder (PCBD) and ICD-11-PGD (kappa's = 0.69–0.84), which found 6–9% of cases tested positive for pathological grief. Complicated Grief (CG) was partly in agreement with the three other symptom-diagnostic tests (kappa's = 0.13–0.20), and the prevalence-rate of pathological grief was 48%.
Limitations: The low response-rate of 39%. The selective inclusion of data >=6 months post-loss prevents a comparison of acute and prolonged grief reactions. Using self-reported data, not diagnostic interviews, challenges the validity of our findings. Using a sample of elderly people may limit the generalizability of our results to other age groups.
Conclusion: We suggest that PGD, PCBD and ICD-11-PGD may be more discriminative in identifying a specific grief-related psychopathology, while CG may identify a broader set of grief reactions.
BACKGROUND: Patients with heart failure (HF) are at increased risk of unmet palliative care needs. The International Classification of Diseases, Ninth Revision ( ICD-9) code, V66.7, can identify palliative care services. However, code validity for specialist palliative care in the Veterans Health Administration (VHA) has not been determined.
OBJECTIVE: To validate the ICD-9 code for specialist palliative care and determine common reasons for specialist palliative care consultation among VHA patients hospitalized with HF.
DESIGN: Electronic health record review of data from the Veterans Aging Cohort Study.
SETTING/PARTICIPANTS: The sample included 100 patients hospitalized with HF from 2003 to 2012.
MEASUREMENTS: Data from 50 patients with V66.7 were matched by age, race, site of care, hospital length of stay, intensive care unit admission, and fiscal year of study discharge to 50 patients with HF without V66.7 who had died within a year of hospitalization. We calculated positive and negative predictive values (PPV, NPV), sensitivity, and specificity.
RESULTS: All patients included in the sample were male, 66% black ethnicity, and mean age = 65 years (standard deviations [SD] ± 10.5 for cases; SD ± 9.8 for matches). Specialist palliative care was documented for 49 of 50 patients with V66.7 (PPV = 98%, 95% confidence interval [CI]: 88-99) and 9 of 50 patients without the code (NPV = 82%, 95% CI: 68-91). Sensitivity was 84% (95% CI: 72-92), and specificity was 98% (95% CI: 86-99). Establishing goals of care was the most frequent reason for palliative care consultation (43% of the sample).
CONCLUSION: The ICD-9 code V66.7 identifies specialist palliative care for hospitalized patients with HF in the VHA. Replication of findings in other data sources and populations is needed.
Objective:: to construct and validate nursing diagnoses for people in palliative care based on the Dignity-Conserving Care Model and the International Classification for Nursing Practice.
Method: a two-stage methodological study: 1) construction of the database of clinically and culturally relevant terms for the nursing care for people in palliative care and 2) construction of nursing diagnoses from the database of terms, based on the guidelines of the International Council of Nurses.
Results: the 262 terms validated constituted a database of terms from which 56 nursing diagnoses were developed. Of these, 33 were validated by a group of 26 experts, and classified in the three categories of the Dignity-Conserving Care Model: illness-related concerns (21); dignity-conserving repertoire (9); and social dignity inventory (3).
Conclusion: of the 33 validated diagnoses, 18 of them could be included in the update of the Catalog of the International Classification for Nursing Practice - palliative care for a dignified death. The study contributes to support the clinical reasoning and decision making of the nurse.
BACKGROUND: Palliative care patients are often described as complex but evidence on complexity is limited. We need to understand complexity, including at individual patient-level, to define specialist palliative care, characterise palliative care populations and meaningfully compare interventions/outcomes.
AIM: To explore palliative care stakeholders' views on what makes a patient more or less complex and insights on capturing complexity at patient-level.
DESIGN: In-depth qualitative interviews, analysed using Framework analysis.
PARTICIPANTS/SETTING: Semi-structured interviews across six UK centres with patients, family, professionals, managers and senior leads, purposively sampled by experience, background, location and setting (hospital, hospice and community).
RESULTS: 65 participants provided an understanding of complexity, which extended far beyond the commonly used physical, psychological, social and spiritual domains. Complexity included how patients interact with family/professionals, how services' respond to needs and societal perspectives on care. 'Pre-existing', 'cumulative' and 'invisible' complexity are further important dimensions to delivering effective palliative and end-of-life care. The dynamic nature of illness and needs over time was also profoundly influential. Adapting Bronfenbrenner's Ecological Systems Theory, we categorised findings into the microsystem (person, needs and characteristics), chronosystem (dynamic influences of time), mesosystem (interactions with family/health professionals), exosystem (palliative care services/systems) and macrosystem (societal influences). Stakeholders found it acceptable to capture complexity at the patient-level, with perceived benefits for improving palliative care resource allocation.
CONCLUSION: Our conceptual framework encompasses additional elements beyond physical, psychological, social and spiritual domains and advances systematic understanding of complexity within the context of palliative care. This framework helps capture patient-level complexity and target resource provision in specialist palliative care.
Après avoir abordé le codage Z51.5 (Classification Internationale des Maladies pour les soins palliatifs) depuis sa création, les auteurs posent la question suivante "Les soins palliatifs sont-ils solubles dans le code Z51.5 et le PMSI ?".
Prolonged grief disorder (PGD), characterized by severe, persistent and disabling grief, is being considered for inclusion in the International Classification of Diseases' 11 (ICD-11) and a related disorder, Persistent Complex Bereavement Disorder (PCBD), is included for further investigation in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). Establishing diagnoses for pathological grief may lead to stigmatization. Additionally, it has been argued that people experiencing severe grief responses after loss of non-family members (i.e., disenfranchised grief) may experience more stigmatizing reactions. Yet, no research to date has investigated this. To fill this gap in knowledge, 379 adults from the general population were randomly allocated to read one of 4 different vignettes of a person with and without a grief disorder diagnosis who had lost a friend or a spouse. After reading the vignettes, we assessed: 1) characteristics ascribed to the person, 2) emotional reactions to the person, and 3) desire for social distance. Notably, people with a diagnosis were attributed relatively more negative characteristics, and elicited more anger, anxiety and pro-social emotions and a stronger desire for social distance. Stigmatization and its negative consequences appear a valid concern to the establishment of pathological grief disorders in diagnostic manuals.
Social support is one of the strongest determinants of bereavement outcomes, yet little is understood about the community’s recognition of grief and intentions to provide social support to grieving persons. A total of 476 adults responded to an online vignette and questionnaire measuring grief norms and supportive intentions. Respondent gender, age, and bereavement status all had some association with expectations of grief, intentions to support, perceived helpfulness of support attempts, and opinions toward the diagnostic classification of grief. Given that most bereavement support is informal, this study informs the development of community capacity to provide constructive, timely bereavement support.
BACKGROUND: For the next edition of the International Statistical Classification of Diseases (ICD-11) it is proposed to include prolonged grief disorder as a new diagnosis. The diagnosis describes persistent intensive and disabling grief reactions to bereavement (WHO, 2016b). The aim of the present survey was to determine the extent to which the diagnosis is accepted by practitioners in the healthcare and psychosocial field.
METHODS: A total of 2088 German-speaking professionals in the fields of psychotherapy, psychology, counselling, medicine and palliative care completed the online survey.
RESULTS: 42.4% of the participants felt that the advantages of including the diagnosis outweigh the disadvantages, 32.9% came to the conclusion that there are more disadvantages. The remaining 24.7% stated that advantages and disadvantages are balanced. The proposed classification as separate diagnosis was supported by 24.8%, while 60.0% preferred alternatives (e.g. as subtype of adjustment disorder). Furthermore, a time criterion of at least 12 months was voted for considerably more frequently (49.2%) than the proposed 6 months (11.3%). Objections were predominantly expressed with regard to pathologization of normal grief and to the difficulty of adequate crosscultural application of the diagnosis.
LIMITATIONS: Results are limited to predominantly German health-care professionals. The items did not undergo psychometric analyses.
CONCLUSIONS: The disagreement about the diagnosis found in specialist literature is also reflected in the responses by the participants. The present results provide stimulation for future questions and validation studies carried out as part of the ICD revision.
Persistent complex bereavement disorder (PCBD) is a condition for further study in the Diagnostic and Statistical Manual of Mental Disorders-5. Prolonged grief disorder (PGD) will likely be included in the International Classification of Diseases’-11. While it has been argued that PCBD and PGD cover the same diagnostic entity, their symptom count differs. A higher symptom count may increase the complexity of diagnostic algorithm and thereby the symptom profile heterogeneity of a disorder. Using binomial equations, a nearly thousand-fold difference in possible symptom profiles to meet PGD versus PCBD criteria was demonstrated, showing both disorders may differ more than just semantically.
BACKGROUND: Cachexia is a multifactorial syndrome that is highly prevalent in advanced cancer patients and leads to progressive functional impairments. The classification of cachexia stages is essential for diagnosing and treating cachexia. However, there is a lack of simple tools with good discrimination for classifying cachexia stages. Therefore, our study aimed to develop a clinically applicable cachexia staging score (CSS) and validate its discrimination of clinical outcomes for different cachexia stages.
METHODS: Advanced cancer patients were enrolled in our study. A CSS comprising the following five components was developed: weight loss, a simple questionnaire of sarcopenia (SARC-F), Eastern Cooperative Oncology Group, appetite loss, and abnormal biochemistry. According to the CSS, patients were classified into non-cachexia, pre-cachexia, cachexia, and refractory cachexia stages, and clinical outcomes were compared among the four groups.
RESULTS: Of the 297 participating patients, data from 259 patients were ultimately included. Based on the CSS, patients were classified into non-cachexia (n = 69), pre-cachexia (n = 68), cachexia (n = 103), and refractory cachexia (n = 19) stages. Patients with more severe cachexia stages had lower skeletal muscle indexes (P = 0.002 and P = 0.004 in male and female patients, respectively), higher prevalence of sarcopenia (P = 0.017 and P = 0.027 in male and female patients, respectively), more severe symptom burden (P < 0.001), poorer quality of life (P < 0.001 for all subscales except social well-being), and shorter survival times (P < 0.001).
CONCLUSIONS: The CSS is a simple and clinically applicable tool with excellent discrimination for classifying cachexia stages. This score is extremely useful for the clinical treatment and prognosis of cachexia and for designing clinical trials.
Individuals suffering from prolonged grief disorder (PGD) show severe grief reactions after the death of a significant other, even beyond a period of grieving that is within a person's cultural and religious context. In addition to this core element, PGD can manifest in various ways. Symptoms may include persistent preoccupation, intense emotional pain, or impairment in important life domains. The symptoms, furthermore, have to be of culturally or religiously inappropriate extent or severity, taking into account different norms of grieving. PGD is discussed as a distinct diagnostic category in the revision of the International Classification of Diseases (ICD-11). Nosology of PGD has been highly debated surrounding the suggested inclusion in the DSM-5, which had been declined due to insufficient evidence. This paper addresses the latent nature of PGD. Using a short form of the Inventory of Complicated Grief-Revised (ICG-R), we applied three popular taxometric methods: MAXEIG, MAMBAC and L-Mode. Data stemmed from a subsample of N = 1,445 bereaved individuals that participated in a large representative German population survey (N = 2,520). The analysis strongly indicated a dimensional latent structure of PGD. Implications of the conceptualization of PGD on a continuum are discussed, regarding measurement, diagnosis, etiology and future research.
Introduction: Code Z515, which indicates palliative care, is a part of the International Classification of Diseases and Related Health Problems (ICD). At present, this diagnostic code is still rarely used although the number of patients requiring palliative care is increasing. So many patients forfeit their right to access the best palliative care and all that it entails. Objectives: To determine the prevalence of the code Z515 diagnostis according to ICD-10 in patients diagnosed with cancer as well as the relationship between treatment and costs in Songklanagarind Hospital. Methods: A retrospective descriptive study on patients diagnosed with code Z515 in Songklanagarind Hospital between 2012 and 2016 was conducted. We collected data from our hospital information system (HIS) and divided into 2 groups, In and outpatients department. Then we recorded data using extraction forms. We analyzed the data using percentages, 95% CI and odds ratios.
Results: Prevalence of diagnosis with code Z515 in cancer patients was 1.7 × 10-3 for both in- and outpatients. For outpatients, patients who received radiation and combined treatment were 9.4 and 26.5 times, respectively, to incur medical costs in the range of 4,001 to 6,000 THB (118-177 USD) compared with patients who received supportive treatment or had no cost. The results shows no relationship between the number of medications taken and cost among inpatients, there was no observable difference in statistical significance The same was true for the relationship between treatment and costs as well.
Conclusion: Study found a very low prevalence of coding Z515 use. Although we know that all cancer patients should receive the best palliative care, the greater their benefit from this type of treatment, the Z515 diagnosis remains less pervasive than it should be.
Au sommaire de ce dossier consacré aux dons d'organes : Une démarche à accompagner - De nouvelles modalités pour le don d'organes en France - Don d'organes et de tissus après arrêt des thérapeutiques en réanimation, rôle de la coordination infirmière - Préoccupations éthiques autour des donneurs décédés après un arrêt des thérapeutiques actives - L'intervention du psychologue dans la procédure de prélèvement d'organes après arrêt cardiaque 'contrôlé' - La démarche anticipée de don d'organes à l'hôpital - Démarche d'annonce anticipée de don d'organes aux urgences, rôle de l'infirmière coordinatrice - Le patient en arrêt cardiaque réfractaire en pré-hospitalier, un donneur d'organes potentiel - La coordination de don d'organes et de tissus après un arrêt cardio-circulatoire - Prise en charge infirmière d'un donneur décédé par arrêt circulatoire réfractaire - Quel avenir pour les prélèvements d'organes après arrêt circulatoire ?
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Le regard sur le handicap a radicalement évolué depuis la première guerre mondiale. Les invalides sont devenus au fil des années des personnes en situation de handicap. La prise en charge médicale au sens large du handicap a fait un bond en avant en suivant les réflexions internationales qui ont mené à la Classification internationale du handicap dans les années 1980 puis la Classification internationale du fonctionnement humain en 2001. Les thérapeutes du handicap ont espéré faire disparaître le handicap par les adaptations architecturales et les nouvelles technologies, mais ils se retrouvent aujourd'hui face à un échec : le handicap persiste, résiste à leurs soins. [...] Pourrait-on reconnaître le handicap non comme un ennemi à combattre, ou comme l'échec du pouvoir médical mais bien comme une période de la vie où la fragilité de l'homme est reconnue et prise en compte ? Ainsi reconnaître la vulnérabilité des personnes handicapées tout en s'attachant à diminuer les situations dans lesquelles leur vulnérabilité est aggravée peut être une approche complète de la prise en charge médicale.
Ce livre traite des aspects conceptuels et théoriques en relation à la déficience intellectuelle, abordés dans une perspective expérimentale et clinique. L'ensemble des textes est le fruit d'une confrontation entre théorie et expérience clinique. Il s'agit d'une approche qui se veut pragmatique, à l'usage de professionnels de la santé mentale confrontés à des problèmes présentés par des personnes ayant de graves déficiences intellectuelles. Le corpus du livre est divisé en plusieurs chapitres, les premiers étant destinés à donner une vision de ce que sont les causes de la déficience intellectuelle, la manière de concevoir l'intelligence et de diagnostiquer le déficit intellectuel. Les chapitres suivants examinent de manière détaillée les problèmes de santé physique et mentale qui se présentent chez les personnes porteuses d'une déficience intellectuelle au cours de leur vie d'adultes. [R.A.]
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Contexte : Promouvoir la santé mentale des personnes endeuillées suite à un suicide est un but clé de la National Suicide Prevention Strategy.
Buts : Evaluer les effets des interventions de soutien aux personnes endeuillées suite à un suicide.
Méthode : Nous avons conduit une revue systématique de données provenant d'études contrôlées d'interventions auprès des personnes endeuillées suite à un suicide. Les études étaient identifiées en utilisant des recherches systématiques, la qualité méthodologique des études incluses était évaluée et une synthèse narrative était menée.
Résultats : Huit études étaient identifiées. Aucune ne provenait du Royaume-Uni et toutes sauf une avaient des limites méthodologiques substantielles. Par comparaison avec pas d'intervention, il y avait la preuve de certains bénéfices provenant des études uniques d'intervention cognitivo-comportementale familiale de quatre sessions avec une infirmière de psychiatrie ; une intervention de groupe de deuil de 10 semaines conduite par un psychologue pour les enfants ; et une thérapie de groupe de 8 semaines pour les adultes délivrée par un professionnel de la santé mentale et un bénévole. Les résultats de ces études comparant deux interventions actives ou plus étaient plus équivoques.
Conclusions : Bien qu'il existe une preuve de certains bénéfices provenant des interventions pour les personnes endeuillées suite à un suicide, ce n'est pas fiable. D'autres preuves méthodologiquement fiables sont nécessaires pour confirmer si les interventions sont aidantes et, si c'est le cas, à qui.
[Traduction du résumé fourni par le producteur]
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