Decision-making incapacity among nursing home residents: results from the 1987 NMES survey. National Medical Expenditure Survey

Recent legislative and regulatory developments have focused attention on older adults' capacity for involvement in health care decision-making. The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) focused attention on the rights of nursing home residents to be involved in health care decision-making to the fullest extent possible. This article uses data from the 1987 National Medical Expenditure Survey (NMES) to examine rates of incapacity for health care decision-making among nursing home residents. Elements of the Oklahoma statute were used to operationalize decision-making incapacity: disability or disorder, difficulty in decision-making or communicating decisions, and functional disability. Fifty-three percent of nursing home residents had a combination of either physical or mental impairment and an impairment in either self-care or money management. The discussion focuses on the policy and practice implications of significant rates of incapacity among nursing home residents.     

Maximizing internal and external validity in MMPI malingering research: a study of a military population

The authors investigated the effectiveness of various commonly used Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943) indices of exaggeration and malingering in detecting suspected malingering in a military sample of 121 enlisted men. To maximize external validity, only men undergoing psychological evaluation were used as participants. Forty-one participants were identified as suspected malingerers through multiple criteria and were contrasted with schizophrenic-spectrum and clinic outpatient groups. To improve internal validity, the 41 suspected malingering participants were asked to retake the test without exaggerating. Results revealed that there were many false positives and fewer, but nonetheless many, false negatives with standard malingering indices. It appeared that the Gough Dissimulation scale (Gough, 1947) might hold the most promise as a measure of malingering, but other scales are also useful. Individual comparisons between different samples and implications for MMPI-2 (Butcher et al., 1989) are presented.     

Physicians' values and physician-value neutrality

For years articles have decried the lack of empathy in physicians' relationships with patients. In addition to being empathetic, physicians are called upon to assume the posture of value neutrality, i.e., not imposing one's values when dealing with patients. Empathy is clearly an expression of deeply held values; even the language used to define it is value-laden. Physicians are consistently called upon to exhibit traits which are expressions of their underlying values. However, if proponents of value-neutrality are to be taken literally one must not impose any of one's values on one's patients. But then one wonders how empathy could ever be expressed; further, it is hard to imagine what a truly value neutral physician would be like. It is time we recognize that any relationship between two persons requires the expression of values from both parties. These values help shape that relationship and define its further history. Physicians are not excluded from this process just because they consider themselves professionals. Divulging personal values to patients is both more honest and more in keeping with the concepts of justice, beneficence, non maleficence, and autonomy than to feign value-neutrality. A presentation of some type statement of values is timely and would give patients an idea of where a physician stands on a myriad of issues. Rather than being value-neutral, value non-neutrality seems a more right and reasonable posture for physicians to assume.     

Food-deprivation effects on punished schedule-induced drinking in rats.

Food-deprived rats (at 80% of their free-feeding weights) were exposed to a fixed-time 60-s schedule of food-pellet presentation and developed schedule-induced drinking. Lick-dependent signaled delays (10 s) to food presentation led to decreased drinking, which recovered when the signaled delays were discontinued. A major effect of this punishment contingency was to increase the proportion of interpellet intervals without any licks. The drinking of yoked control rats, which received food at the same times as those exposed to the signaled delay contingency (masters), was not consistently reduced. When food-deprivation level was changed to 90%, all master and yoked control rats showed decreases in punished or unpunished schedule-induced drinking. When the body weights were reduced to 70%, most master rats increased punished behavior to levels similar to those of unpunished drinking. This effect was not observed for yoked controls. Therefore, body-weight loss increased the resistance of schedule-induced drinking to reductions by punishment. Food-deprivation effects on punished schedule-induced drinking are similar to their effects on food-maintained lever pressing. This dependency of punishment on food-deprivation level supports the view that schedule-induced drinking can be modified by the same variables that affect operant behavior in general.     

Mass traumatic terror in Oklahoma City and the phases of adaptational coping,part I: Possible effects of intentional injury/harm on victims' post-traumatic responses

The bombing in Oklahoma City shook the entire nation from “sea to shining sea.” This tremendous collective sensation was made even worse when available evidence revealed that this act of terrorism had not been committed by some terrorist from the Middle East but one from Middle America. The blast stunned the nation's sense of collective safety, while it raised serious questions about our ability as a nation to manage violence, and the profound feelings of discontent and narcissistic injuries among distressed Americans. Was it this failure to address chronic discontents that led to this tragedy of mass violence? These larger sociocultural and political issues are being debated in public and private forums throughout the nation, an activity that is likely to continue for some time to come. As these issues are debated in the public arena, victims' levels of psychological distress are expected to rise, as they attempt to process the traumatic shock in their minds and bodies. Specifically, this article has two parts and focuses on acute and post-acute psychophysiological traumatic stress responses in victims, as well as issues pertaining to assessment, prevention, and treatment. Part I addresses the nature of disasters, with a special emphasis on the victim's subjective evaluation (meaning) of the reality of a catastrophe caused by intentional human strategy. The article, additionally, discusses issues of epidemiology of stress reactions, post-traumatic stress disorder, co-morbidity, risk factors, and assessment and diagnostic considerations. Part II, to be published in the next of issue of the Journal, will focus on issues of prevention as well as post-disaster intervention. Prevention of chronic post-traumatic stress disorder after the Oklahoma City bombing is a critical objective by debriefers and mental health professionals. A proposed four-phase model called “self-efficacy adaptational coping” will be presented in Phase II as well. The present article is probably the first major discussion on the traumatic effects of the blast on individuals, families, and the communities of Oklahoma City, and the first to offer some broad guidelines to intervention. Since it predates future empirical studies, the author relies on his almost 20 years of experience in the field of traumatic stress, and on a review and integration of pertinent disaster outcome studies in the national and international literature.