Persistent Vegetative State: Clinical and Ethical Issues

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. The patient outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family.     

Clinical Implications for Supporting Caregivers at the End-of-Life: Findings and from a Qualitative Study

Despite families providing considerable care at end of life, there are substantial gaps in the provision of supportive care. A qualitative interview study was conducted with 17 caregivers of people supported by an adult hospice to explore the support needs of families. Family members readily identified the ways in which the diagnosis of a life-limiting illness impacted on them and the family as a whole, not just the patient. Implications for practice demonstrate the need to intervene at a family and relational level prior to bereavement, in order to mitigate complicated grief for the surviving family members. Such an approach offers a fruitful prospective alternative to supporting caregivers post-bereavement.     

Providing therapy to children and families in foster care: a systemic-relational approach

Foster care is a system created to protect children from an unsafe home environment yet multiple foster home placements, conflictual or nonexistent relationships between foster parents and birth parents, long, drawn out court battles, and living in an on-going state of not knowing when or if they will be going home are just some of the challenges many children in care are expected to manage. This paper presents a guide for therapists working with families involved in foster care. Utilizing ideas from the postmodern therapies and structural family therapy, suggestions will be provided about who needs to talk to whom about what, when to have these necessary conversations, and how to talk to people in a way that mobilizes adults to take action for the children, with the goal of minimizing postplacement trauma, strengthening and repairing relational bonds, and moving children out of foster care and into permanent homes as quickly as possible.     

Not so far from home: How family characteristics predict child care quality

This study examined the relationship between family background and child care quality for 636 children enrolled in 120 day care centres in three states in the US with widely varying regulations for child care centre quality. Family characteristics accounted for a substantial portion of the variance in day care quality. Mother' attitudes towards child-rearing and parent' education were the most potent family-level predictors of quality. State child care policy variables were also strong predictors of quality. Findings also suggest that the influence of environment on children's development cannot be partitioned simply into family and out-of-home child care effects; rather, the child care environment is an extension of the family environment, with parents determining characteristics of both.     

Ethical Issues in Family-Centered Primary Care

In 1969 a new primary care medical specialty, family practice, was formally created. One element in the development of this specialty from the roots of general practice was an understanding of the importance of family process in health and health care. Family physicians are now trained to work with families in the provision of primary medical care, and many provide some formal family counseling and therapy. The family physician who works with families faces many of the same ethical conflicts with which family therapists are confronted. The primary relationship of the family physician to his or her patients, however, as the provider of continuing health care, modifies these conflicts and creates new and vexing problems.     

Quality child care supports the achievement of low-income children: Direct and indirect pathways through caregiving and the home environment

Existing studies of child care have not been able to determine whether higher quality child care protects children from the effects of poverty, whether poverty and lower quality child care operate as dual risk factors, or whether both are true. The objective of the current study was to test two pathways through which child care may serve as a naturally occurring intervention for low-income children: a direct pathway through child care quality to child outcomes, and an indirect pathway through improvements in the home environment. Children were observed in their homes and child care settings at 6, 15, 24, and 36 months. An interaction between family income-to-needs ratio and child care quality predicted School Readiness, Receptive Language, and Expressive Language, as well as improvements in the home environment. Children from low-income families profited from observed learning supports in the form of sensitive care and stimulation of cognitive development, and their parents profited from unobserved informal and formal parent supports. Policy implications are discussed.     

Predictors of Placement Outcomes in Treatment Foster Care: Implications for Foster Parent Selection and Service Delivery

Treatment foster care (TFC) is a normalizing environment in which to treat those children whose particular needs are not addressed in traditional foster care and for whom an institutional setting is a restrictive and unnecessary alternative. However, when the foster care placements of these emotionally and behaviorally disturbed children fail, as they often do, the children are shifted from one home to another without the opportunity to experience permanence or emotional attachment, resulting in poor adjustment to foster care. Placement stability, which depends in part upon effective matching of foster children with potential foster families, is critical for achieving positive outcomes in TFC. Yet, there is a dearth of information to guide placement agencies in making decisions about matching foster children with families. Moreover, once a successful match has been made, it is equally vital that service delivery be of high quality so that permanence is maintained. We review research on the predictors of positive outcomes in foster care, focusing on studies involving emotionally or behaviorally disturbed children, and provide recommendations for selecting foster parents and for ensuring high quality foster care services and placement stability.     

Foster Families: A Systematic Review of Intention and Retention Factors

Background: Compared to residential care, family foster care is the preferable type of alternative care for neglected or abused children as it provides a familiar context that supports children’s developmental needs. New foster families are needed to care for these children. Objective: This systematic review aims to provide a critical analysis of the literature, identifying factors that explain the intention to become and to continue as a foster family. This review was performed following the PRISMA checklist and guidelines, through a search conducted in the following databases (no restrictions were made): PsycArticles, PsycInfo, Psychology and Behavioral Sciences Collection, Academic Search Complete, ERIC, Scopus, and Web of Science. Study eligibility: The review includes empirical quantitative and/or qualitative studies in English, Portuguese, and Spanish, with community and/or foster parents’ samples and explores the factors for becoming and/or retention of foster parents. Results: Forty-nine studies were included. The results revealed that the intention to become a foster parent is largely influenced by motivational factors, personal and family characteristics, individual values and beliefs, social context influences, and perceived familiarity with the child protection system. The retention of foster families is closely related to factors within the child protection system, personal or family characteristics, foster child characteristics, and placement challenges. The relationship with agencies and professional support stands out as the most important factors. Limitations and Implications: This review did not include studies focused on children with specific needs and characteristics, and future research should consider the particular challenges of fostering this group. Practice implications of these findings for the recruitment, selection, and retention of foster families will be discussed.

     

Psychosocial management of glioma patients treated with combined therapy

Based on an empirical study it is pointed out that psychosocial care of patients with glioma differs in some points from that of other cancer patients. The first essential difference is that the emotional involvement of the care staff is not as intensive as those of other cancer patients. Other differences concern some illness- and therapy related effects such as family problems or monotony problems resulting from the longterm therapy. These specific problems are described in detail.     

What Spirituality Means for Patients and Families in Health Care

This research focuses on the spiritual care experiences of patients and families at a hospital in Australia. Twenty-four patients and 10 family members were interviewed. Results indicate the importance of relatedness: being treated as a person, reminded of your capabilities and conversations about what matters. Maintaining contact with friends and family, sustaining religious and spiritual practices, music therapy and pet therapy were also significant and contact with the natural world and shared activities. The results indicate the importance of spirituality offered through pastoral care, and that all those involved in health care can contribute to the spiritually nurturing environment that reinforces healing.

     

The Results of Family Therapy Revisited: The Nonbehavioral Methods

Studies from 1971 to 1976 reporting on the outcome of the nonbehavioral family therapies are analyzed and critically reviewed. Such research has increased in both quality and quantity since 1970 and, broadly speaking, has legitimized the status of family therapy as a viable mode of helping. Particularly potent effects were noted for family therapy as an alternative to psychiatric hospitalization, with psychosomatic problems in children and adolescents, and in certain applications with parent-child and parent-adolescent relationships. However, a number of studies comparing family therapy with no formal treatment or an alternative treatment found little difference in outcome. Problems in family therapy outcome research are discussed and some future directions suggested.     

Interpersonal Skills Training to Reduce Aggressive and Delinquent Behavior: Limited Evidence and the Need for an Evidence-Based System of Care

The prevention of aggressive and delinquent behavior during childhood and adolescence is one of the highest priorities for public health and crime prevention. The most common approach to preventing or treating these conduct problems has been to provide interpersonal skills training to the affected youth. This paper reviews all randomized controlled trials evaluating interpersonal skills training programs as an intervention to reduce conduct problems. Research shows that such programs have weak empirical support as isolated interventions. An alternative evidence-based system of care is described. Such a system would include behavioral parent training and behavioral classroom-based interventions for young children at risk of developing problems, as well as multisystemic family therapy or multidimensional treatment foster care for chronic delinquents. Within such a network of services, interpersonal skills training could play an important supportive role. Such a system holds the greatest promise for reducing the prevalence of aggressive and delinquent behavior in communities.     

Primary Care Providers’ Responses to Patient-Generated Family History

Family health history is one of the best predictors of an individual’s risk for common disease, yet it is underutilized in routine care. Although the Surgeon General has recommended consumers record their family health history and share it with their health care provider, providers’ perceptions of patient-generated family histories are unknown. To learn more about providers’ experience with and perceptions about patient-generated family histories, we mailed surveys to 301 providers and had a response rate of 24% (n = 68). Seventy-three percent felt a patient-generated computer pedigree would improve their ability to assess risk as compared to their current methods. Seventy percent felt a patient-generated computer pedigree would either have no effect on or would increase the number of patients that could be seen in a day. Results suggest that providers appreciate the potential benefits of patient-generated family histories. Genetic counselors and nurses are in a prime position to promote and facilitate the use of patient-generated family health histories in routine care.     

Integrated,Family‐based,Partial Hospital Treatment for Complex Pediatric Illness

This paper describes a unique treatment program for complex pediatric illness. The Hasbro Children's Partial Hospital Program uses a family systems orientation, integrated care, and a partial hospital setting to treat children with a wide range of pediatric illnesses that have failed outpatient and inpatient treatments. We have treated more than 2000 children with at least 80 different ICD‐9 diagnoses. The multidisciplinary treatment team functions as a meta‐family for children and their families who present with illness and family beliefs that impede successful outcomes with standard care. The three features: family systems orientation, integrated care, and partial hospital setting, hopefully interact to create an environment that helps families expand and modify their explanatory models regarding participating in effective medical care. The goal of treatment is for both children and their parents to feel empowered to take control of the illness. Parents completing standardized measures at intake describe their children and families as experiencing significant emotional distress, low levels of general family functioning, and poor quality of life. Although the children are described as having distinct behavioral differences, the families are described as responding to the experience of a seriously ill child in similar ways. A treatment program that addresses the noncategorical aspects of how families respond to illness while addressing the specific diseases of the children can allow children and their families to respond favorably to treatment.     

Patients’ Views of Treatment-Focused Genetic Testing (TFGT): Some Lessons for the Mainstreaming of <Emphasis Type="Italic">BRCA1</Emphasis> and <Emphasis Type="Italic">BRCA2</Emphasis> Testing

This paper explores patients’ views and experiences of undergoing treatment-focused BRCA1 and BRCA2 genetic testing (TFGT), either offered following triaging to clinical genetics (breast cancer) or as part of a mainstreamed care pathway in oncology (ovarian cancer). Drawing on 26 in-depth interviews with patients with breast or ovarian cancer who had undergone TFGT, this retrospective study examines patients’ views of genetic testing at this point in their care pathway, focusing on issues, such as initial response to the offer of testing, motivations for undergoing testing, and views on care pathways. Patients were amenable to the incorporation of TFGT at an early stage in their cancer care irrespective of (any) prior anticipation of having a genetic test or family history. While patients were glad to have been offered TFGT as part of their care, some questioned the logic of the test’s timing in relation to their cancer treatment. Crucially, patients appeared unable to disentangle the treatment role of TFGT from its preventative function for self and other family members, suggesting that some may undergo TFGT to obtain information for others rather than for self.     

Les unités de soins intensifs psychiatriques (USIP) : expériences françaises et internationales

Psychiatric Intensive Care Units (PICU) propose a secure setting for patients with acute behavior disturbances who can not be managed in psychiatric general wards. Physical violence acts against patients or hospital staff, substance abuse, non-compliance for care and treatment, intensity of symptoms or absconding are frequent motives for admission. Patients are compulsorily detained in secure conditions. They are admitted from psychiatric facilities of a health area or by agreement between hospitals. Multidisciplinary working in psychiatric intensive care is essential, delivered by qualified staff. Care and treatment must be centered on the patient, multidisciplinary, intensive, comprehensive with an immediacy of response to critical situations. As length of stay should not exceed 2 months in duration, interface and liaison with original services of patients are important issues. In France, PICU exist notably at Cadillac, Lyon, Paris, Nice, Eygurande, Montpellier, Pau and Prémontré. These facilities appear as a missing level, an interesting alternative in mental health care system, between psychiatric general wards and maximum security hospitals. This paper reports the creation of a National Association of PICU in France, the existence of national minimum standards and international experiences.     

Faith-to-faith at the bedside: theological and ethical issues in ecumenical clinical chaplaincy.

Chaplains who serve in a clinical context often minister to patients representing a wide variety of faiths. In order to offer the best pastoral care possible, the chaplain should first possess a set of personal theological convictions as a foundation for ministry. Second, he or she needs to be sensitive to the beliefs and practices of the patients. Third, it is vital to develop a relationship of acceptance and trust not only with patients under their care, but also with family members and caregivers as well. At times, situations will arise that are purely religious or theological. In a clinical setting, however, the questions and problems that arise more often are both theological and ethical. It is beneficial for the chaplain to be involved in an ethics committee, where the specifics of each case can be discussed, and staff can offer counsel to patients and their families. This study examines issues that chaplains face at the bedside, such as terminal care, life-prolonging treatments, dementia, persistent vegetative state, and euthanasia-assisted suicide. We will discover that those who are involved in clinical pastoral ministry will be called upon to be a comforter, mediator, educator, ethicist, and counselor.     

Predicting individual differences in attention, memory, and planning in first graders from experiences at home, child care, and school

This study adds to the growing literature linking children's experiences in the environment to individual differences in their developing skills in attention, memory, and planning. The authors asked about the extent to which stimulating and sensitive care in the family and in the child-care or school environments would predict these cognitive outcomes. The authors also questioned the primacy of experiences in the first 3 years of life. Data from a sample of 700 first graders whose experiences in the home and in child care or school were evaluated since early infancy revealed that the cumulative quality of the child-rearing environment was related to attention and memory but not to planning and that the quality of the family environment was more strongly associated with outcomes than was the quality of child care and of school. The quality of both children's early (6 through 36 months) and later (54 months and first grade) environments predicted performance on the attention and memory tasks.     

The patient in the family and the family in the patient

The notion that the family is “the unit of care” for family doctors has been enigmatic and controversial. Yet systems theory and the biopsychosocial model that results when it is imported into medicine make the family system an indispensable and important component of family medicine. The challenge, therefore, is to provide a coherent, plausible account of the role of the family in family practice. Through an extended case presentation and commentary, we elaborate two views of the family in family medicine — treating the patient in the family and treating the family in the patient — and defend both as appropriate foci for care by family doctors. The practical problem that arises when the family is introduced into health care is deciding when to concentrate on the family system. The moral problems that arise concern how extensively doctors may become involved in the personal lives of their patients and families. The patient-centered clinical method provides a strategy for handling both problems. Thus, making the family a focus of care in family medicine can be justified on theoretical, practical, and moral grounds.