Decision-making capacity in elderly, terminally ill patients with cancer

Despite the importance and complexity of evaluating decision-making capacity at the end of life, little research has focused on terminally ill patients' decision-making ability. The purpose of this study was to explore the decision-making capacity of elderly, terminally ill patients and the psychological and physical factors that affect decision making. Decision-making capacity and cognitive abilities were assessed using four measures: the Hopkins Competency Assessment Kit, the Bechara Gambling Task, the Concept Assessment Kit, and the Mini Mental Status Exam. In addition, symptoms of depression, level of physical functioning, and extent of physical symptoms were evaluated in order to identify correlates of decision-making ability. Two samples were compared: elderly, terminally ill patients with cancer (n = 43) and elderly, physically healthy adults living in supportive community residence (n = 35). Results revealed significantly poorer decision-making abilities among the terminal ill sample compared with healthy comparisons, but no association between demographic variables (e.g., age, race, or education) or clinical variables (depression or physical symptoms) and decision making. Implications for evaluating decision-making capacity are addressed.     

Assessing hopelessness in terminally ill cancer patients: development of the Hopelessness Assessment in Illness Questionnaire

Hopelessness has become an increasingly important construct in palliative care research, yet concerns exist regarding the utility of existing measures when applied to patients with a terminal illness. This article describes a series of studies focused on the exploration, development, and analysis of a measure of hopelessness specifically intended for use with terminally ill cancer patients. The 1st stage of measure development involved interviews with 13 palliative care experts and 30 terminally ill patients. Qualitative analysis of the patient interviews culminated in the development of a set of potential questionnaire items. In the 2nd study phase, we evaluated these preliminary items with a sample of 314 participants, using item response theory and classical test theory to identify optimal items and response format. These analyses generated an 8-item measure that we tested in a final study phase, using a 3rd sample (n = 228) to assess reliability and concurrent validity. These analyses demonstrated strong support for the Hopelessness Assessment in Illness Questionnaire providing greater explanatory power than existing measures of hopelessness and found little evidence that this assessment was confounded by illness-related variables (e.g., prognosis). In summary, these 3 studies suggest that this brief measure of hopelessness is particularly useful for palliative care settings. Further research is needed to assess the applicability of the measure to other populations and contexts.     

Daily variation of multiple behaviors in Aplysia fasciata: integration of feeding, reproduction, and locomotion

Daily variations in feeding, reproductive behaviors, and activity level were examined under three conditions: (1) animals had access to food and mates; (2) there was access only to food; (3) neither food nor mates were present. Behaviors differed in amplitude of variations from their daily mean value. Egg-laying had the strongest tendency to be clustered. Amplitude of variations in courtship and swimming was larger than those of immobility, crawling, and feeding, while moving in place was the least clustered behavior. Changes in state affected the tendency to be clustered. When food and mates were present, amplitude of variations became progressively larger for immobility, moving in place, crawling, and swimming. Behaviors differed in the degree to which variations were patterned as a 1/day oscillation. Relatively little of the variability in crawling, moving in place, courtship, and egg-laying was due to a 1/day oscillation under any condition. By contrast, a large proportion of the variability of immobility, swimming, mating, and eating was modulated by a 1/day oscillation in at least one condition. The contribution of a 1/day oscillation to variability differed in the conditions examined. For immobility and swimming, when food and mates were present, the 1/day component of variability became smaller. By contrast, presence of mates led to an increase in the 1/day component of variability modulating feeding. Daily peaks of swimming and feeding were in phase with one another, and out of phase with mating and feeding. The ratio of locomotion to inactivity is constant, independent of change in external conditions. However, this ratio varied throughout the day. When food and mates were absent, variations of immobility and swimming were strongly related to variations in the inactivity ratio. When food and mates were added, this tendency decreased. The data suggest that daily variations in occurrence of behaviors can be accounted for by interactions between oscillators affecting Aplysia behavior and motivational variables. A 1/day oscillator has strong effects on mating, swimming, and immobility. The effect of the oscillator is modified by changes in motivational state.     

Preferences for body type and body characteristics associated with attractive and unattractive bodies: Jackson and McGill revisited

The present investigation replicates Jackson and McGill's study (1996) and extends it by considering the effects of respondents' own height, weight, and body mass on perceptions of attractiveness. Results, although generally supportive of those found by Jackson and McGill, point to the influence of respondents' own physical characteristics in the process of perceptions of attractiveness: only 1 of Jackson and McGill's 3 (of a possible 19) differences between responses of African- and Euro-American women was corroborated (the importance of silky hair for Euro-American women), whereas a second difference (the importance of round buttocks for African-American women) disappeared when controlling for respondents' weight, height, and body mass. Although differences between the two investigations may be attributed to regional differences in the surveyed students (Michigan and North Carolina), the small effect of one's own weight, height, and body mass in assessing an other-sex person's attractiveness may reflect adherence to norms learned very early in life that are subject to regional variations.     

Measuring depression at the end of life: is the Hamilton Depression Rating Scale a valid instrument?

Depression at the end of life is a common mental health issue with serious implications for quality of life and decision making. This study investigated the reliability and validity of one of the most frequently used measures of depression, the Hamilton Depression Rating Scale (HAM-D) in 422 patients with terminal cancer admitted to a palliative care hospital. The HAM-D demonstrated high reliability and concurrent validity with depression diagnosis, based on Structured Clinical Interview for DSM-IV Axis I Disorders, non-patient research version (SCID-I/NP Depression Module). Receiver Operating Characteristic (ROC) analyses generated an area under the curve of .91, indicating high sensitivity and specificity. The HAM-D strongly correlated with several measures of distress (e.g., hopelessness, desire for hastened death, and suicidal ideation). Factor analysis generated 4 factors (anxiety, depressed mood, insomnia, and somatic symptoms), accounting for 42% of the variance. Implications for assessing depression in this population are discussed.     

The effects of torture-related injuries on long-term psychological distress in a Punjabi Sikh sample

Torture survivors often report chronic debilitating physical and psychological distress. Prior research on the relationship between physical and psychological trauma suggests that the 2 are not independent. Injury sustained during torture may increase the likelihood of subsequent distress as either a moderator or mediator. For long-term psychopathology in a sample of Punjabi Sikh survivors of human rights violations (N = 116), chronic injuries mediated the path between torture and posttraumatic stress disorder, specifically the severity of numbing symptoms. Although injuries were associated with major depression, torture was not, and injuries did not moderate the relationship between major depression and torture. Chronic injuries may represent trauma severity or persistent traumatic cues. These findings emphasize connections between physical and psychological trauma and the importance of an interdisciplinary approach to torture treatment.