Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.     

The Beneficial Role of Spiritual Counseling in Heart Failure Patients

To ascertain the beneficial role of spiritual counseling in patients with chronic heart failure. This is a pilot study evaluating the effects of adjunct spiritual counseling on quality of life (QoL) outcomes in patients with heart failure. Patients were assigned to “religious” or “non-religious” counseling services based strictly on their personal preferences and subsequently administered standardized QoL questionnaires. A member of the chaplaincy or in-house volunteer organization visited the patient either daily or once every 2 days throughout the duration of their hospitalization. All patients completed questionnaires at baseline, at 2 weeks, and at 3 months. Each of the questionnaires was totaled, with higher scores representing positive response, except for one survey measure where lower scores represent improvement (QIDS-SR16). Twenty-three patients (n = 23, age 57 ± 11, 11 (48 %) male, 12 (52 %) female, mean duration of hospital stay 20 ± 15 days) completed the study. Total mean scores were assessed on admission, at 2 weeks and at 3 months. For all patients in the study, the mean QIDS-SR16 scores were 8.5 (n = 23, SD = 3.3) versus 6.3 (n = 18, SD = 3.5) versus 7.3 (n = 7, SD = 2.6). Mean FACIT-Sp-Ex (version 4) scores were 71.1 (n = 23, SD = 15.1) versus 74.7 (n = 18, SD = 20.9) versus 81.4 (n = 7, SD = 8.8). The mean MSAS scores were 2.0 (n = 21, SD = 0.6) versus 1.8 (n = 15, SD = 0.7) versus 2.5 (n = 4, SD = 0.7). Mean QoL Enjoyment and Satisfaction scores were 47.2 % (n = 23, SD = 15.0 %) versus 53.6 % (n = 18, SD = 16.4 %) versus 72.42 % (n = 7, SD = 22 %). The addition of spiritual counseling to standard medical management for patients with chronic heart failure patients appears to have a positive impact on QoL.     

The Living Fossil of Human Judgment

Although the biases and anomalies characterizing psychometric data should serve as conclusive evidence of systematic flaws in scientific methodology, these problems are usually ignored, which reduces empirical psychology to the closed system of its error theory. However, psychometric scores are ambiguous, and response-shifts and fluctuating validities point to fundamental differences in what the measuring-apparatus questionnaire records and how the measuring-apparatus person judges. Therefore, empirical methods fail when psychology requires evidence-based knowledge about cognitive processes and phenomena. Correcting these flaws requires a reassessment of basic scientific premises and careful consideration of Homo sapiens’ biosemiotic heuristics. Based on comprehensive biopsychosocial, data, the author reconstructs the evolutionary axioms of self-referenced cognitions and reveals what is usually obscured by the axioms of normal science. He substantiates the need for a paradigm shift toward basic bio–cultural principles and an evolutionary understanding of human thinking and behavior.     

MLK Day and Racial Attitudes: Liking the Group More but Its Members Less

Intuition suggests that the Martin Luther King holiday (MLK Day) should improve racial attitudes toward African Americans. However, its influence may depend on whether African Americans are evaluated as a group or individually. In two studies, we assessed racial attitudes either on MLK Day or on a control day. As might be expected, participants had more sympathetic attitudes towards African Americans as a group on MLK Day compared to control days; however, they evaluated individual African American exemplars more negatively on MLK Day compared to control days, who presumably seemed worse by comparison to the eminent political figure.     

Spatial associations in number-related tasks: A comparison of manual and pedal responses

Bimanual parity judgments of numerically small (large) digits are faster with the left (right) hand (the SNARC effect; Dehaene, Bossini, & Giraux, 1993). According to one explanation, this effect is culturally derived and reflects ontogenetic influences such as the direction of written language; it might therefore be limited to, or at least be larger with, pairs of lateralized effectors which are instrumental to the production and comprehension of written language. We report two experiments which test for SNARC effects with pedal responses, and compare these effects to manual results. Pedal responses yielded highly systematic SNARC effects; furthermore, these effects did not differ from manual SNARC effects. These results argue against accounts in which the SNARC effect is specific for effectors that are habitually associated with the production or comprehension of written language.     

Neurocognitive Performance in Children with ADHD and OCD

Attention-deficit/hyperactivity Disorder (ADHD) and obsessive–compulsive disorder (OCD) have both been linked to dysfunction in the cortico-striato-thalamo-cortical circuitry (CSTCC). However, the exact nature of neurocognitive deficits remains to be investigated in both disorders. We applied two neuropsychological tasks that tap into different functions associated with the CSTCC, namely a serial reaction time (SRT) task, developed to assess implicit sequence learning, and a delay aversion (DA) task in order to assess abnormal motivational processes. The performance data of boys with ADHD (n = 20), OCD (n = 20) and healthy controls (n = 25), all aged 10–18 years, were compared. Subjects with ADHD less frequently chose the larger, more delayed reward compared to those with OCD and controls, while subjects with OCD showed impaired implicit learning. In contrast, the ADHD group was unimpaired in their implicit learning behavior and the OCD group was not characterized by a DA style. Within the OCD-group, severity of obsessions was associated with implicit learning deficits and impulsive symptoms with DA in the ADHD-group. This double dissociation highlights the distinct cognitive dysfunctions associated with ADHD and OCD and might possibly point to different neural abnormalities in both disorders.     

Dependency Conflict,Marital Threat,and Alcohol Consumption in a Middle-Aged Sample

The hypothesis that dependency conflict is associated with higher levels of alcohol consumption when dependency needs are threatened or thwarted was tested with a sample of 672 middle-aged, married adults with college-age children. The subjects' current level of alcohol consumption was predicted based on the present level of threat to the marital relationship (assessed by reports from several family members) and on indices of dependency need and inhibition of dependent behavior estimated from sibship size, sibship density, and sibling position. A multiple regression analysis yielded a significant two-way interaction (p < .05) between marital threat and subject sex, and a significant three-way interaction of dependency heed, inhibition of dependent behavior, and marital threat. High marital threat was associated with higher levels of alcohol consumption in men and slightly lower levels of alcohol consumption in women. Additionally, when dependency need was high, alcohol consumption was generally low, except when both inhibition of dependent behavior and marital threat were high. However, when dependency need was low, the highest alcohol consumption score occurred when marital threat was low and inhibition was high.     

Enhancing the Learning of Sport Skills Through External-Focus Feedback

The authors examined how the effectiveness of feedback for the learning of complex motor skills is affected by the focus of attention it induces. The feedback referred specifically either to body movements (internal focus) or to movement effects (external focus). In Experiment 1, groups of novices and advanced volleyball players (N = 48) practiced “tennis” serves under internal-focus or external-focus feedback conditions in a 2 (expertise) × 2 (feedback type) design. Type of feedback did not differentially affect movement quality, but external-focus feedback resulted in greater accuracy of the serves than internal-focus feedback during both practice and retention, independent of the level of expertise. In Experiment 2, the effects of relative feedback frequency as a function of attentional focus were examined. A 2 (feedback frequency: 100% vs. 33%) × 2 (feedback type) design was used. Experienced soccer players (N = 52) were required to shoot lofted passes at a target. External-focus feedback resulted in greater accuracy than internal-focus feedback did. In addition, reduced feedback frequency was beneficial under internal-focus feedback conditions, whereas 100% and 33% feedback were equally effective under external-focus conditions. The results demonstrate the effectiveness of effect-related, as opposed to movement-related, feedback and also suggest that there is a need to revise current views regarding the role of feedback for motor learning.     

Emotion,cognition, and decision making

We examine two explanations of the subliminal affective priming effect. The feelings-as-information model (Schwarz &; Clore, 1988) holds that judgements are based on perceptible feelings. Hence, affective influences depend on the source to which feelings are (mis)attributed. In contrast, the affective primary hypothesis (Zajonc, 1980) suggests that affective influences should resist attributional interventions. This is because the affective system responsible for preferences is separate from the cognitive system responsible for inferences; because early affective processes are automatic and therefore inaccessible to higher-order interventions; and because early affective responses are not represented as conscious feelings. We tested these explanations in two experiments that crossed subliminal affective priming with (mis)attribution manipulations. Both studies found reliable shifts in judgements of neutral stimuli as a result of primes even when subjects were aware that their feelings might not be diagnostic for the judgement at hand. Subjects did not report experiencing any feelings in response to the primes. The obtained affective priming effect was independent of response times and subjective reports of engaging in judgemental corrections. However, the priming effect did prove sensitive to the experimental instructions. We discuss the implications of these findings for the affective primacy hypothesis and the feelings-as-information model.