In lieu of an abstract, here is a brief excerpt of the content:A Trial of PatienceChristopher LewisIt seemed like after two weeks, my “flu” symptoms should have resolved. I was not eating, could not hold anything down, and had no energy. It was easy enough for my pediatrician at the time to attribute this to a common virus. This was not sitting well with my parents, however. My mother decided to take me to the emergency room and get me evaluated (...) there. The doctors there assessed me and sent me back home with a medication to help with the nausea. Later that evening, my mom gave me that medication, and it caused a seizure. She called 911, and I was brought by ambulance to the hospital. After an extensive workup, it was determined I was in liver failure related to an aneurysm in my hepatic artery. I was going to require a liver transplant if I were to live. I had to be transferred to another hospital in New York from the hospital near our home in Connecticut. I do not remember any of the details leading up to this after the seizure. I do not remember being told I needed a liver transplant and I do not remember going into surgery.My memories of these events start after the surgery. What I remember is being in the pediatric ICU and being told my mother was able to donate part of her liver to me. I had quite a lengthy recovery after this point. I spent about two months in the hospital and then went to a rehab facility where I would have to learn how to walk again and regain my strength.By the time I was discharged from the rehab facility, I had missed the last half of my 5th-grade year. By the time I was able to return to school, it was already several months into 6th grade. Slowly but surely, life was returning to normal. I was able to get back to doing the things an eleven-year-old should be doing. For twelve years after this initial transplant, I was in great health, my transplant team was happy with how I was doing, and I just required annual checkups after a while. Unfortunately, I saw as a child how fast things can change. This was once again the case. [End Page 126]I was in my last week of college classes, just about to finish my Bachelor’s degree in nursing and looking forward to starting my career as a nurse in the neuro ICU. However, I once again became acutely ill with seemingly flu-like symptoms. After a few days of dealing with these symptoms, my mother brought me to the emergency room. When we got to the emergency room, they did some initial testing and told me I would need to be admitted for antibiotic therapy. The first thought that came to my mind was, “Would I be able to be discharged in time to take my final exams next week?”Once I arrived in my hospital room, I met with my transplant team. They delivered the grave news. The imaging they had done showed that the graft artery from my original liver transplant as a child had failed. The graft had thrombosed and I had infected bilomas in my liver. Now, twelve years later, I would need to be re-listed for another transplant. I was devastated and in disbelief. I recall telling my mother, who was with me at the time, that we should hold off on telling my dad, thinking this could not be possible, and we shouldn’t worry him over something that was not necessarily true. Unfortunately, however, this was my reality. I would go on to wait a little over two years for the perfect liver from a deceased donor.The road to being listed and ultimately having a repeat transplant was not without its challenges and bumps in the road. About three months into my two-year wait for a liver transplant, I received my first offer for a liver. I went through all of the pre-op preparation and the next morning went into the OR and underwent anesthesia. However, I... (shrink)

Objective: Parental influence during children’s “everyday” pain events is under-explored, compared to clinical or experimental pains. We trialed two digital reporting methods for parents to record the real-world context surrounding their child’s everyday pain events within the family home.Methods: Parents completed a structured e-diary for 14 days, reporting on one pain event experienced by their child each day, and describing child pain responses, parental supervision, parental estimates of pain severity and intensity, and parental catastrophizing, distress, and behavioral responses. During (...) the same 2-week period, a subsample of parent-child pairs completed digital ecological momentary assessments, immediately after any chosen pain event. Children reported their current pain while parents estimated the child’s pain and indicated their own distress.Results: “Everyday” pain events frequently featured minor injuries to the child’s head, hands or knees, and child responses included crying and non-verbal comments. Pain events occurred less frequently when parents had been supervising their child, and supervising parents reported lower levels of worry and anxiety than non-supervising parents. Child sex was significantly associated with parental estimates of pain intensity, with parents of girls giving higher estimates than parents of boys. Child age was significantly associated with both the number of pain events and with parental estimates of pain intensity and child distress: the youngest children experienced the fewest pain events but received higher pain and distress estimates from parents than older children. Hierarchal Linear Modeling revealed that parental estimates of pain severity were significant positive predictors of parental distress and catastrophizing in response to a specific pain event. Furthermore, higher levels of parental catastrophic thinking in response to a specific pain event resulted in increased distress, solicitousness, and coping-promoting behaviors in parents. The EMA data revealed that children reported significantly higher pain intensity than their parents.Conclusion: The electronic pain diary provided a key insight into the nature of “everyday” pain experiences around the family home. Digital daily reporting of how the family copes with “everyday” events represents a viable means to explore a child’s everyday pains without disrupting their home environment. (shrink)

Emergency care providers regularly deal with ethical dilemmas that must be addressed. In comparison with in-hospital nurses, emergency medical service personnel are faced with more problems such as distance to resources including personnel, medico-technical aids, and information; the unpredictable atmosphere at the scene; arriving at the crime scene and providing emergency care for accident victims and patients at home. As a result of stressfulness, unpredictability, and often the life threatening nature of tasks that ambulance professionals have to deal with (...) every day, ethical decision-making has become an inevitable challenge. The content analysis approach was used to conduct the present qualitative study in Iran. The participants consisted of 14 EMS personnel selected through purposive sampling, which continued until the data became saturated. Data were collected using semi-structured interviews and analyzed concurrently with their collection through the constant comparison method. The process of data analysis resulted in the emergence of 3 main categories “respecting client’s values”, “performing tasks within the professional manner”, “personal characteristic”, and the emergence of eight sub-categories signifying participants’ experiences with regard to EDM. According to the results, when EMS personnel are faced with ethical dilemmas, they consider the client’s values and professional dignity, and perform the assigned tasks within the framework of the regulation. The findings also suggest that pre-hospital care providers assess legal consequences before making any decision. Further studies should be conducted regarding the experiences of the subordinates and other related parties. (shrink)

ObjectiveTo assess the impact of the closure of group-based cardiac rehabilitation training during the first COVID-19 lockdown in spring 2020 on patients’ physical activity, cardiorespiratory fitness, and cardiovascular risk, and to describe the patient experience of lockdown and home-based exercise training during lockdown.DesignMixed methods study. Prospectively collected post-lockdown measurements were compared to pre-lockdown medical record data. Quantitative measurements were supplemented with qualitative interviews about the patient experience during lockdown.SettingOutpatient CR centre in Salzburg, Austria.ParticipantsTwenty-seven patients [six female, mean age 69 (...) years] who attended weekly CR training sessions until the first COVID-19 lockdown in March 2020.Outcome MeasureQuantitative: exercise capacity, cardiovascular risk. Qualitative: individual semi-structured interviews.ResultsExercise capacity had significantly reduced from pre- to post-lockdown: mean power in maximal ergometry 165 vs. 151, p < 0.001; submaximal ergometer training 99 vs. 97, p = 0.038. There was no significant difference in Framingham risk score and other cardiovascular risk factors. Qualitative data showed that almost all patients had kept physically active during lockdown, but 17 said they had been unable to maintain their exercise levels, and 15 felt their cardiorespiratory fitness had deteriorated. Many patients missed the weekly CR training and the motivation and sense of community from training together with others. Several patients stated that without professional supervision they had felt less confident to carry out home-based exercise training at high intensity.ConclusionThis study highlights the importance of group-based supervised exercise training for patients who engage well in such a setting, and the detrimental impact of disruption to this type of CR service on physical activity levels and exercise capacity. Additionally, learning from the COVID-19 pandemic may inform the development and implementation of remote CR modalities going forward. (shrink)

We reflect, using a vignette, on conceptual tensions and the value judgements that lie behind difficult decisions about whether or not the older person with dementia should return home or move into long-term care following hospital admission. The paper seeks, first, to expose some of the difficulties arising from the assessment of residence capacity, particularly around the nature of evaluative judgements and conceptual tensions inherent in the legal approach to capacity. Secondly, we consider the assessment of best (...) interests around place of residence, which demonstrates significant conceptual tensions. In addition, ‘best interests’ raise issues around the perception of risk and the perceptions of the family and crucially involve the notions of autonomy and trust. Finally, we not only gesture at some practical considerations based on insights from values-based medicine, but also make the suggestion that we require tighter functional assessments of residence capacity coupled with broader judgements about best interests. (shrink)

This is the fifth of a series of case studies provided and discussed by UK clinical ethics committees. This paper summarises discussion of a case presented by the Central and North West London Foundation NHS Trust Clinical Ethics Committee. The case concerns a 55-year old woman with Alzheimer's disease admitted to a psychiatric hospital following concerns that she was not receiving adequate care at home. Issues discussed include subjective judgements of 'adequate care', deprivation of liberty and assessment of (...) 'best interests'. The case is ethically and legally complex, with multiple stakeholders and a range of options for legal intervention. The Committee's response is provided and a practical solution advised. (shrink)

Animal shelters face diverse challenges, which often necessitate making life-or-death decisions for animals in their care. One strategy used to determine whether admitting, adoption, or euthanasia is appropriate is to assess an animal’s in-shelter or pre-admission behavior to infer its “personality.” Shelters do this because potential adopters are often interested in knowing an animal’s personality as it provides information about whether the animal will fit in their home. However, shelter behavior assessments are a broad topic. To narrow focus, I (...) explore a relatively novel development: feline behavior assessments. These assessments suggest that shelter workers can make a valid inference from in-shelter behavior to long-term, consistent personality. I argue that assessments do not, and might not be able to, validly infer personality in shelters; I utilize recent philosophical work by Kaiser & Müller on personality to do so. I build on their work by showing how shelter assessments do not meet their criteria and fall victim to epistemic bias in privileging some behaviors. Because feline assessments fail to meet philosophically robust definitions of animal personality and have methodological biases, these assessments do not provide valid insight into a shelter animal’s personality and should not be used. (shrink)

Surgical Informed Consent has long been recognized as an important component of modern medicine. The ultimate goals of SIC are to improve clients’ understanding of the intended procedure, increase client satisfaction, maintain trust between clients and health providers, and ultimately minimize litigation issues related to surgical procedures. The purpose of the current study is to assess the comprehensiveness of the SIC process for women undergoing obstetric and gynecologic surgeries. A hospital-based cross-sectional study was undertaken at Hawassa University Comprehensive Specialized Hospital (...) in November and December, 2016. A total of 230 women who underwent obstetric and/or gynecologic surgeries were interviewed immediately after their hospital discharge to assess their experience of the SIC process. Thirteen components of SIC were used based on international recommendations, including the Royal College of Surgeon’s standards of informed consent practices for surgical procedures. Descriptive summaries are presented in tables and figures. Forty percent of respondents were aged between 25 and 29 years. Nearly a quarter had no formal education. More than half of respondents had undergone an emergency surgical procedure. Only 18.4% of respondents reported that the surgeon performing the operation had offered SIC, while 36.6% of respondents could not recall who had offered SIC. All except one respondent provided written consent to undergo a surgical procedure. However, 8.3% of respondents received SIC service while already on the operation table for their procedure. Only 73.9% of respondents were informed about the availability of alternative treatment options. Additionally, a majority of respondents were not informed about the type of anesthesia to be used and related complications. Only 54.2% of respondents reported that they had been offered at least six of the 13 SIC components used by the investigators. There is gap in the provision of comprehensive and standardized pre-operative counseling for obstetric and gynecologic surgeries in the study hospital. This has a detrimental effect on the overall quality of care clients receive, specifically in terms of client expectations and information needs. (shrink)

This paper examines the ethical conundrum between a hospital's ethos of relieving distress, investigation and treatment, and its concurrent duties under English law to administer tests of decision-making capacity and safeguarding protection where it believes the patient may lack this capacity. Delirium, characterised by a precipitous decline in mental functioning exhibiting the shared symptomology of recoverable depressive disorders and terminal dementia, is not uncommon after emergency admission of elderly patients into acute medical hospital wards. The use of functional capacity testing (...) as a benchmark for decision-making capacity for post-discharge residence has been criticised as outdated, conceptually floored, subjective, lacking central guidance, transparent process, and accountability. A study of patient experience demonstrates the potential for hospital misuse of capacity testing, the failure of functional testing to differentiate decision making capacity from the disability of partial cognitive impairment, and how hospital capacity processes can interact and amplify patient pathology thereby decreasing recovery prospects. Prioritisation of mental capacity obligations above thorough investigation of emergent mental pathology and relief of patient anguish, results in extended detention in medical wards lacking bespoke facilities. Further understanding of patient experience is needed to inform policy with interventions tailored to avoid harm and increase wellbeing. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Disability Embodied: Narrative Exploration of the Lives of Two Brothers Living with Traumatic Brain InjuryDouglas E. KiddAny discussion of personal experiences with disability, inevitably lead me to recall the experiences of my brother, Richard Kidd. An examination of our journeys clearly illustrates the term disability. More so, our stories reveal the outcome of severe physical impairment dictates the limits of personal agency and autonomy. Perhaps an obvious conclusion, but (...) exploration of our experience is useful as we provide living testimony to eventualities that could similarly occur to others. In order to provide context for discussion of our disabilities, I will briefly recall how we acquired our traumatic brain injuries (TBI), as well as how our brain injuries are expressed. The article will demonstrate that due to the severity of the brain damage he acquired, Richard is entirely subject to the whim of the society he encounters, and thus disabled. The article will also discuss how the disabling attitudes I have encountered sought to diminish my humanity.Richard KiddRichard’s descent into impairment began in the early evening hours of December 31, 1987. As a pedestrian, Richard attempted to cross a street in Indianapolis, when a car without using headlights, slammed into him. In addition, the driver fled the scene of the accident. After stabilizing from the initial trauma—multiple compound fractures to both legs and severe brain injury—Richard spent approximately ten months in coma. After emerging from coma, Richard underwent months of therapy. Albeit with consistent direction from others, therapy enhanced Richard’s ability to hold a cup and use a spoon. These were significant victories for Richard and signaled the beginning of his recovery. However, within two years of his accident, monies ended for rehabilitation and Richard entered into custodial care at his first nursing facility. As time passed, his daily interactions with poorly supervised, unskilled, and underpaid nursing facility employees with little time to work with Richard meant it was more cost efficient for staff to simply spoon–feed Richard. Consequently, Richard lost the ability to participate in an aspect of his self–care. Richard’s humanity took years to gradually erode, but due to the severity of his impairments, he became viewed by those he encountered as an object of treatment, or reservoir of pain and pity, rather than an individual worthy of respect. Accordingly, [End Page 199] Richard became viewed as other. Thus began Richard’s descent into disability.A complete lack of dental care for decades provides a good example of Richard’s treatment as other. Richard’s experience also demonstrates that desensitized members of the medical, dental, and long–term care professions sometimes precipitate grave circumstances. The combination of an inattention to his needs and his limited ability to participate with his self–care meant that Richard typically went without dental treatment. His quality of life diminished further when aides at a nursing facility dropped him. During the fall, Richard’s face smashed into the floor and several teeth were shattered. More than a decade passed before Richard finally received follow–up dental treatment—that day nearly cost him his life. Due to prolonged neglect, all of Richard’s teeth required extraction. I do not question the dental surgeon’s assessment of Richard’s teeth. I am certain that all of his teeth needed to be removed; but Richard’s sedentary lifestyle meant that he had limited ability to cope with the trauma associated with having 24 teeth removed in one session. I feel certain the dental surgeon assumed Richard was like most other patients and could handle the stress associated with the procedures. However, Richard could not cope with trauma and blood loss the extractions produced. What is worse than the dental surgeon’s assessment of Richard’s ability to withstand surgery is the post–op personnel decision to discharge him to home, shortly after surgery. The nursing facility was ill–equipped to cope with the extent of the blood loss that ensued and soon Richard began to aspirate on his own blood. Accordingly, Richard was sent to the hospital where he proceeded to slip into coma. Richard remained in a coma for approximately four days and in hospital... (shrink)

ObjectiveThe aim of this study was to test the feasibility of telepsychology support for patients with severe cardiorespiratory disease and their caregivers. A secondary objective was to explore pre-post relationships between patients' and caregivers' clinical measures.MethodsA telehealth program incorporating telepsychology support, i.e., an “on-demand” phone service with a psychologist, was provided to consecutive cardiorespiratory patients at discharge from inpatient rehabilitation and to their caregivers. At the start and end of the 1-year program, participants were interviewed “face-to-face,” and their anxiety/depression level, (...) patients' quality of life, and caregivers' family strain and needs were assessed: we analyzed the correlations and evaluated customer satisfaction.ResultsOf 80 eligible individuals, 40 took part in this study: 22 patients and 18 caregivers. Eleven requested tele-psychological support, resulting in 51 consultations focused on anxiety, difficulty in patient management, worry about the patient's emotional state, and need for emotional support; 3 participants underwent a tailored psychotherapy program. All participants expressed high satisfaction with the service. At enrolment, anxiety was less evident in patients than in caregivers, while depressive symptoms were more evident, and correlated with MRF-28 and MQOL. Caregivers' FSQ showed a “strongly recommended” need for support; at enrolment, high levels of anxiety/depression were correlated with high FSQ ; depressive symptoms correlated negatively with age and positively with emotional needs ; anxiety was positively correlated with education level. At follow-up, patients' perception of support tended to increase, while caregivers' strain tended to decline. At enrolment, caregivers' anxiety/depression and strain correlated with patients' quality of life. At follow-up, caregivers' strain correlated with patients' quality of life and cognitive performance.ConclusionTelepsychology support associated with a telehealth service is feasible and satisfying for both participants and psychological management. A suitable support program can benefit both patients and caregivers, particularly those at higher risk of depressive symptoms and anxiety. (shrink)

How should we assess programs dedicated to education in virtue? One influential answer draws on quantitative research designs. By measuring the inputs and processes that produce the highest levels of virtue among participants according to some reasonable criterion, in this view, we can determine which programs engender the most desired results. Although many outcomes of character education can undoubtedly be assessed in this way, taken on its own, this approach may support favorable judgments about programs that indoctrinate rather than educate, (...) because education in character entails teleological thinking that is volitional not merely determined. I argue instead that proper assessment of virtue requires an expansive view of character education in both particular and common goods that avoids the tendency to indoctrinate and an inclusive conception of measurement that takes into account qualitative in addition to quantitative methodologies. (shrink)

Advance directives are written documents that give patients the opportunity to communicate their preferences regarding treatments they do or do not want to receive in case they become unable to make decisions. Commonly used pre-printed forms have different formats. Some offer space for patients to appoint a surrogate decision maker, and/or to determine future medical treatments and/or give a statement of personal values. So far it is unknown which forms GPs preferably use and why they decide to do so. 23 (...) semi-structured interviews with GPs were analysed using content analysis. Interviewees mainly use short templates and medium length templates with checkboxes to indicate patients’ preferences in regards to life prolonging measures. Especially when patients faced the progression of a disease, participants use the latter version. Only then, the interviewees remarked, patients are capable to rate concrete situations reliably. GPs also realize the importance of the verbal assessment of patients’ preferences; however they rarely keep a written form of the conversation. Some GPs hand out one or more templates and ask their patients to read and think about them at home with the option to talk to them about it later on, while others prefer their patients to fill them out alone at home. Regardless of template usage, most GPs emphasize that ADs require regular updates. GPs tend to see standardized advance directives mainly as a tool to start a conversation with their patients and to identify their real preferences and values. When the patient is still not facing the progression of an already existing disease it could be sufficient to only appoint a surrogate decision maker instead of creating a full AD. However, in all other situations, appointing a surrogate decision maker should be backed up by a written statement of a patient’s general values. Patients and their relatives should always have the opportunity to ask their GP for medical advice when drafting an AD. It is crucial to regularly verify and update existing ADs within the course of a disease. (shrink)

ObjectiveTo investigate the association of pre-existing migraine in patients hospitalised and who recovered from severe acute respiratory syndrome coronavirus 2 infection with the presence of post-coronavirus disease symptoms.BackgroundNo study has investigated the role of migraine as a risk factor for development of post-COVID symptoms.MethodsA case-control study including individuals hospitalised during the first wave of the pandemic was conducted. Patients with confirmed previous diagnosis of migraine were considered cases. Two age- and sex-matched individuals without a history of headache per case were (...) also recruited as controls. Hospitalisation/clinical data were collected from hospital medical records. Patients were scheduled for a telephone interview. A list of post-COVID symptoms was systematically evaluated, but participants were invited to freely report any symptom. The Hospital Anxiety and Depression Scale and the Pittsburgh Sleep Quality Index were used to assess anxiety/depressive symptoms and sleep quality. Multivariable conditional logistic regression models were constructed.ResultsOverall, 57 patients with confirmed diagnosis of migraine and 144 non-migraine controls who had recovered from COVID-19 were assessed at 7.3 months after hospital discharge. The number of post-COVID symptoms in the migraine group was significantly greater than in the non-migraine group. Fatigue was significantly more prevalent in the migraine group. However, no between-groups difference in the prevalence of headache as a post-COVID symptom was detected.ConclusionPatients with a history of migraine who recovered from COVID-19 exhibited more long-term fatigue as post-COVID sequelae than those without migraine. Some of the pathophysiological changes associated with migraine could predispose to the occurrence of post-COVID symptoms. (shrink)

A core feature of drug-resistant epilepsy is hyperexcitability in the motor cortex, and low-frequency repetitive transcranial magnetic stimulation is a suitable treatment for seizures. However, the antiepileptic effect causing network reorganization has rarely been studied. Here, we assessed the impact of rTMS on functional network connectivity in resting functional networks and their relation to treatment response. Fourteen patients with medically intractable epilepsy received inhibitive rTMS with a figure-of-eight coil over the vertex for 10 days spread across two weeks. We designed (...) a 6-week follow-up phase divided into four time points to investigate FNC and rTMS-induced timing-dependent plasticity, such as seizure frequency and abnormal interictal discharges on electroencephalography. For psychiatric comorbidities, the Hamilton Depression Scale and the Hamilton Anxiety Scale were applied to measure depression and anxiety before and after rTMS. FNC was also compared to that of a cohort of 17 healthy control subjects. The after-effects of rTMS included all subjects that achieved the significant decrease rate of more than 50% in interictal epileptiform discharges and seizure frequency, 12 patients with the reduction rate above 50% compared to the baseline, as well as emotional improvements in depression and anxiety. In the analysis of RSNs, we found a higher synchronization between the sensorimotor network and posterior default-mode network in epileptic patients than in healthy controls. In contrast to pre-rTMS, the results demonstrated a weaker FNC between the anterior DMN and SMN after rTMS, while the FNC between the aDMN and dorsal attention network was greater. Importantly, the depressive score was anticorrelated with the FNC of the aDMN-SMN, which was markedly different in the good and bad response groups treated with rTMS. Based on the vertex suppression by rTMS, it is possible to achieve temporary clinical efficacy by modulating network reorganization in the DMN and SMN for patients with refractory epilepsy. (shrink)

The COVID-19 pandemic is a health issue leading older adults to an increased vulnerability to unfavorable outcomes. Indeed, the presence of physical frailty has recently led to higher mortality due to SARS-CoV-2 infection. However, no longitudinal studies have investigated the role of neuropsychogeriatric factors associated with lockdown fatigue in healthy cognitive aging. Eighty-one healthy older adults were evaluated for their neuropsychological characteristics, including physical frailty, before the pandemic. Subsequently, 50 of them agreed to be interviewed and neuropsychologically re-assessed during the (...) lockdown and immediately after it. Moreover, during another home confinement, they performed a psychological screening to evaluate possible mood changes and fatigue. According to Fried's frailty criteria, at T0, 63% of the sample was robust, 34.5% pre-frail, and only 2.5% frail. Significantly, these subjects presented a decrease in handgrip strength and walking speed. Results from Principal Component Analyses and multiple regression models highlighted the contribution of “cognitive” and “psychological” factors in explaining handgrip strength and gait speed. At T3, lockdown fatigue was explained by higher scores on the Beck Depression Inventory and lower scores on the Trail Making Test part A. Results from a moderated-mediation model showed that the effect of psychomotor speed on lockdown fatigue was mediated by depression, with a moderating effect of gait speed. Our findings highlight the complex interrelationship between cognitive, psychological, and physical factors in the emergence of pandemic fatigue in a carefully selected older population. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vertical Transmission:The Patient, the Student, the TeacherMiguel PaniaguaHe did not ask for this fate, nor did he deserve it, particularly considering the tragic circumstances. Lì presented to the campus health provider one month prior with fatigue, abdominal pain, and jaundice. He and his parents immigrated to the United States from China when he was a child. He was well aware that he had hepatitis B from what is termed (...) "vertical transmission." His mom unknowingly passed on this virus to him during her pregnancy. In most countries with a high prevalence of the virus, prenatal screening is routinely undertaken, and prophylaxis administered. I am not certain this occurred in Lì's case and at this point it did not matter. Lì knew he would live with this for the duration of his life. In fact, he told me he had gone his whole life to this point without any symptoms whatsoever. What is known about chronic hepatitis B infection is that in most people affected, it can be considered a chronic disease where most live a long full life. The risk of advancing to liver cirrhosis or cancer in general is low. This unfortunately was not the case with Lì.What transpired was what they most feared. As he was studying for his final exams, Lì endured days of worsening fatigue, malaise, and nausea. He noticed his skin was a tinge of yellow and he was having some itching that was unusual. He noticed his clothes fitting more loosely and found he had unintentionally lost twenty pounds. He visited the campus health center and after a series of tests and imaging studies, Lì was diagnosed with advanced hepatocellular carcinoma, an unfortunate sequela of this chronic infection. It was then that he put school on hold and returned home to get further care.I first met Lì in the hospital as a consultant for the palliative medicine service. "He won't listen." "He is so difficult." "He is in denial." These were examples of some of the care team's exasperated assessments of his demeanor as a patient. What I did not realize prior to visiting him the first time was that Lì was a pre-clinical medical student. When I first met him, he did not want to talk very much; he was preoccupied and distant. In retrospect, I can see that he was suffering on so many levels. His appearance was gaunt and cachectic. The lights in the room cast shadows in the concave areas of his temples and his collarbones were the most prominent feature of his torso through his hospital gown. He glowed yellow from jaundice. When I examined him on this first visit, I noticed that his liver, a now grossly enlarged hard and nodular structure, occupied most of his abdomen. I found that speaking to him as a colleague, even calling him "doctor," helped him feel respected and enabled me to build rapport with him. At one point, I described to him the findings I felt in his abdomen. "I can palpate the edge of your liver here, what seems to be eight centimeters below your costal margin. There are many palpable nodularities on the ventral surface." It was at this point I invited him to palpate what I was feeling. I gently guided his own hand over his abdomen and noticed him studying the features as if they were not his own, like a skilled diagnostician.Over the course of three weeks, I visited with Lì when I was on service. The last time I saw him, he had declined rapidly, his disease progressing [End Page 17] cruelly, and he was very short of breath and becoming more somnolent. I noticed his mother in the room, standing by his bed, and crying inconsolably as he lay suffering. I felt deep anguish and remorse, wondering if she said these words to herself "It is all my fault," considering the source of his initial illness. I cannot even imagine.As I assisted the team in titrating his comfort medications, I sat with him. He shook my hand with all the strength left that he could muster and said, "you are a good doctor." I... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hume Contra Spinoza? Wim Klever In Book 1 ofthe TreatiseofHumanNature1 Spinoza enjoys thehonour ofbeing the only figure from the history of philosophy and science to be explicitly and extensively discussed by Hume. This honour is, however, a dubious one as the treatment he gets is not so friendly. The passage (T 232-51) is full of insults and denunciations: Spinoza is referred to as "that famous atheist" (T 241), and (...) characterized as "universally infamous" (T 240). His doctrine contains "a true atheism" (T 240). His theory about the thinking substance is an "hideous hypothesis" (T 241); Hume does not want to enter "farther into these gloomy and obscure regions" (T 241), although he spends ten pages on the subject. Richard Popkin2 suggests on account ofthis not too well studied section: "In introducing Spinoza into the discussion of the immateriality ofthe soul, Hume follows what was common practice in his day." This statement, if true, raises the question whether Hume was sincere in writing these 'satanicverses'. Does he, after all, hide the backside of his tongue? This would bring him pretty well in line with two of his English forerunners; with Hobbes about whom Aubrey recorded: "He toldme he [Spinoza]had outthrown him [Hobbes] a bar's length, for he [Hobbes] durst not write so boldly," and with Locke, who possessedinhis privatelibraryall Spinoza's worksbutnonetheless, for one reason or another, refused to assess the theories of "those decried names," saying "I am not so well read in Hobbes or Spinoza as to be able to say what were their opinions in this matter" (namely the pre-existence ofthe soul).4 One commentator, named Gilbert Boss, wrote a two volume dissertation in order to argue for the fundamental opposition between the philosophical systems of both thinkers. In this paper I wish to propose another view and to defend their overall agreement. I will not do so with regard to their thought on religion (as this is already done byPopkin), but I shall more specificallyfocuson the theoretical (mainly epistemological) part oftheir work. Coming to Hume's text the reader of Spinoza's work who is, moreover, convinced by his geometrical demonstration of the propositions, does feel himself quite well at home chez Hume. Hume's is not another world for him. Apart from the question who is the real first modern thinker, Descartes, Hobbes, Spinoza or Hume, there is much common in their treatises on man and world, not only methodologically. Hume's rejection of "the antient philosophy," in Volume XVI Number 2 89 WIM KLEVER which he criticizes the "fictions... concerning substances, and substantial forms, and accidents, and occult qualities" (T 219), "sympathies, antipathies, and horrors ofa vacuum" (T 224) could have been written by the three other candidates as well. In fact every one of thoseitems maybe tracedoutin Spinoza's work; compare, for instance, JSp 136 ("doctrinam illam puerilem et nugatoriam de formis substantialibus, qualitatibus etc.") or 2 PPC 8s ("Quare omnia ilia figmenta de sympathie et antipathie ut falsa sunt reicienda... Nunquam dicendum erit, quod corpus aliquod movetur, ne detur vacuum; sed tantum ex alterius impulsu"). But let us go to the main theme in Book 1 ofthe Treatise, already present in Part 1, Section 1, "Ofthe Origin ofour Ideas." All our ideas result from impressions, themselves also being ideas or perceptions, though withmoreforce andliveliness. The original perceptions aresaid to be "the causes of our ideas" (T 5). We find the impressions in our mind and their effects, our ideas. Hume does not explain the cognitive status ofthe impressions by reducing them to non-cognitive processes. The "universe of the imagination" (T 68) is a world apart, irreducible to matter; we can't step out ofit, "since nothing is ever present to the mind but perceptions, and since all ideas are deriv'd from something antecedently present to the mind" (T 67). Ideas, whatever their character (about external existences or not), can only be explained by other ideas. Hume carefully avoids the category mistake of transcending the border from mental to material things and keeps consequently, at least methodologically, to the absolute caesura between mind and body. The Spinozistic reader must necessarily feel sympathy for this position. The attributes of... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Republicanism, Religion, and Machiavelli’s Savonarolan MomentMarcia L. ColishMachiavelli’s readers often take at face value his claim that Christianity has weakened Italy’s civic spirit and martial valor, leaving it open to priestcraft and foreign invasion. Some scholars see this critique of Christianity as an expression of the irreligious, immoral, neopagan, or scientific Machiavelli, making it the chief index of his modernity. 1 One subset within this group treats Machiavelli’s [End (...) Page 597] anthropology as a secularized version of Augustine on original sin, absent an Eden behind it and a redemption before it. 2 Another view of Machiavelli on religion sees him as treating religion, whatever its teachings, functionally, as an instrument promoting desirable political behavior. 3 This is why they regard [End Page 598] Machiavelli as original and modern; although Maury D. Feld notes rightly that Machiavelli is here simply imitating the ancient Roman historians, who all treat religion in just this way. 4 For some proponents of the functionalist interpretation, it does not preclude Christian belief on Machiavelli’s part. For them his brief is not against Christianity itself but against clericalism, the papacy, and Christianity as it is currently interpreted. 5 Still others recognize Machiavelli’s acceptance of signs and portents, saintly behavior and miracles, and other indices of God’s existence and action in human history. They also note Machiavelli’s praise of biblical leaders seen as divinely inspired and his inclusion of them among the founders of religions and states who head his list of heroes. 6 Going farther, some scholars argue that Machiavelli was a conventional, if not an ardent or impeccable, Christian, who joined a religious confraternity before which he preached his Exhortation to Penitence, and the apparent recipient of the last rites of his church after a deathbed confession. 7 [End Page 599]Can these conflicting assessments of Machiavelli and religion be integrated? To some extent, yes. Once, that is, we consider a number of issues not always brought to bear on this question. Machiavelli recognizes that the foreigners who have overrun Italy and deprived Florence of the republic he had served are as Christian as the Italians. At home and abroad, their Christianity has not undermined their military strength or the civic virtue Machiavelli associates with republics. Within contemporary Florence there were three kinds of republicanism on offer, for those unhappy with the Medici restoration of 1512. One group sought to restore the pre-Medici governo stretto constitution dominated by the ottimati. Their opponents defended governo largo republicanism. Machiavelli advocated this type of polity, informed by his reading of ancient history and his assessment of human nature. But another, competing version of governo largo was put forth by Girolamo Savonarola during the Dominican friar’s stormy career as de facto head of the Florentine state from 1494 to 1498. Savonarola’s republican theory combined a number of ideas that Machiavelli loathed: the appeal to the Venetian Great Council as a model, the wish to purge Florence of her sins so that she could serve as the New Jerusalem in the coming apocalypse, and the notion that governo largo was a means to these religious ends, since the more broad-based the government, the more readily could it legislate and enforce moral reform. And, far from self-destructing after the friar’s ashes had been strewn on the Arno, Savonarolan republicanism continued to draw support from a diverse and substantial group of Florentines. Equally alarming, the agents [End Page 600] of this protracted Savonarolan moment seemed to have preempted Machiavelli’s own anticlerical, antipapal, antioligarchic, and antiMedicean positions, as well as a theory of governo largo. If we foreground Machiavelli’s desire to defend his own version of republicanism by undermining the Savonarolan alternative and if we recall that he treats Christianity positively in other contexts, it becomes possible to read those passages where he criticizes Christianity as practiced in Italy as texts with an antiSavonarolan subtext. Read this way, they are not incompatible with his acceptance of Christianity as true or as politically constructive elsewhere. In approaching this topic, we should also remember the longstanding associations that bound Christianity to politics and warfare.Addressing this last point... (shrink)

Within medical education, there is an increasing need to provide ethics education for learners embarking on service learning. The concept of hospitality, as illustrated in Homer’s classic epic the Odyssey, has the potential to underpin such ethics education. This paper describes the implementation and evaluation of an ethics education session for medical students, built on the concept of hospitality, before they embark on a three-year longitudinal service-learning home visit program. In preparation for their household visits, second-year students at a (...) medical school in Miami, Florida, participate in weekly didactic sessions. One of these classes consisted of a two-hour ethics session, involving a brief introductory large-group lecture, followed by self-administered small-group discussions of a series of case scenarios. An innovative web-based platform called Rise allowed the students to run their own small group activities. To assess the impact on the students’ ability to identify, and on their confidence in handling, ethical dilemmas, we administered pre- and post-session surveys. Students indicated statistically significant improvement in median responses to all questions, for two consecutive years. Students also listed three adjectives, both before and after the session, that they associated with good and bad hosts and guests. The consistency of the terms listed suggests that hospitality is a robust concept for the learners. In our experience, the concept of hospitality provides a robust framework for the students, and the mixed large-group and self-facilitated small-group format offers a valuable tool for ethics education related to service learning in medicine. Our study supports the utility of the concept as a teaching tool, and the format facilitates a session using minimal faculty. The notion of hospitality seems particularly fruitful for various ethical considerations in medicine, even beyond those that involve home visits. (shrink)

In this case, Brian, a 42-year-old patient with decision-making capacity and a history of non-adherence to treatment, refuses to leave the hospital due to concerns about a bothersome rash on his ar...

The pandemic outbreak in March 2020 and its associated sanitary regulations and restrictions triggered an abrupt and significant change for society in general and for families’ organization in particular. In Chile, the Santiago Metropolitan District was under a strict lockdown that involved the closure of the entire educational system. From a systemic-family stress perspective, the impact of these changes might have consequences not only for each individual family member, but for the parental dynamic and, consequently, for children’s well-being. This paper (...) presents the results of a follow-up study showing changes in self-reported parental depression and the perceived home organization of mothers and fathers assessed at three different moments: before the pandemic, at the initial outbreak, and after 1 month of strict lockdown. Relevant moderators were explored using linear mixed models to understand the within-subject changes in mothers’ and fathers’ self-reports across the different assessment times. Financial strain, personality traits of self-criticism and dependency, previous parent–child quality interaction, recent major stressful events, and number of children are highlighted as relevant factors that moderate changes in home chaos and parental mental health perception. Significant risks and protective factors are described for fathers and mothers. The use of pre-pandemic measures as baseline levels enabled the identification of personal and family characteristics that were related to better outcomes. The results help increase our understanding of the sanitary regulations’ impacts on the family system and identify vulnerability indicators that should be considered. (shrink)

The COVID-19 pandemic resulted in the abrupt closure of circus schools, venues, and companies, introducing a myriad of novel stressors. Performers and students must now attempt to maintain their technical, physical, artistic, creative, and cognitive abilities without in-person support from their coaches and must manage the isolation from their training and performing spaces. For circus artists, the transposition of the work space to a home environment is not possible, which creates novel stressors that could lead to the exacerbation and (...) escalation of mental health issues. The purpose of this study is to develop, implement and evaluate a holistic interventional program based on the socio-ecological model of resilience and operationalized through physical literacy. This will be a prospective longitudinal study with a retrospective comparison to data from a similar student cohort pre-pandemic. Interventions were designed using a population-specific, participant-based developmental model within a knowledge translation framework. The interventional program includes group webinars, small group information sessions, and one-on-one Zoom meetings, in addition to the distribution of electronic educational materials. The interventions will holistically provide psychological, physical, social, technical, artistic, and creative supports. Resources will be deployed throughout the closure period and through recovery, as transitions to return to training after prolonged hiatus will magnify known psychological and physical difficulties. Repeated, longitudinal assessment of students will be utilized to track changes over time at key transitions in the pandemic and school year and will be compared to a pre-pandemic school year. The framework for this program will be translatable to other performing arts and high-performance contexts. The program has implications for the mental health and overall wellbeing of artists and for cultural and economic recovery of the industry. (shrink)

Responses to the COVID-19 pandemic globally disrupted lives and contributed to the exacerbation of pre-existing inequalities. Women in research were also affected. The prominent role that women played in professional and personal care duties had a detrimental effect on their research outputs, potentially hindering their career progression. Moreover, the challenges faced by women academics during the pandemic, including job loss, increased mental health issues, and the intersection of gender with other socio-demographic traits exacerbated existing gender disparities within academia. By systematically (...) scoping the qualitative literature on the experiences of women researchers during the pandemic, this study sought to explore how women experienced and reacted to the challenges generated by the COVID-19 pandemic. A qualitative meta synthesis of the included studies revealed three themes: gendered professional expectations, colliding identities and coping strategies. These themes show how gendered roles such as teaching and professional care work, associated with the hierarchical and gendered division of tasks both at home and in the workplace, made women feel unsupported and alienated as relevant agents in the academic context. The study reveals the importance of pastoral care, teaching and service work as the essential backbone of the academic infrastructure, especially in times of crises. It also exposes how productivity-focused researcher assessment criteria, rewarding mainly individual results and unrewarding of care and service work, can be viewed as perpetuating structural inequalities based on gender, parenting situations, contractual situations and background. In conclusion, this study exposes the need to proactively address the gendered practices and implicit biases which reproduce inequalities within academia and highlights how paying attention to the experiences and needs of women researchers is essential for improving the resilience and crises preparedness of academic the system. (shrink)

The South African government announced the much-discussed stay-at-home order between March 27 and April 30, 2020, during what was known as lockdown level 5, which meant that citizens were not allowed to leave their homes. The objective of this study is to assess the stay-at-home order against the global principles of the UDBHR. It is deducible that, in reference to the UDBHR, the government possessed the right to curtail individual liberty, thereby not infringing on Article 5 of the (...) UDBHR and therefore, in this context, passes the test of the UDBHR. However, it remains uncertain at present whether the limitation of freedom imposed by the South African stay-at-home order was successful in controlling the spread of COVID-19 and protecting individuals from harm. Initial investigations also indicate that individuals who are particularly vulnerable may not have received equitable treatment in accordance with the principle outlined in Article 10, therefore, it can be cautiously and modestly argued that the stay-at-home order does not withstand scrutiny when assessed against the UDBHR. Given the continued discussion about the efficacy of limiting freedom to control the spread of COVID-19, and the growing conviction that the advancement of justice is being called into question, the notion of least restriction ought to be considered seriously. Ten Have (2022) is correct in asserting that global bioethics should also seriously consider other principles beyond an almost exclusive focus on limiting individual freedom. The preliminary conclusion is that the potential implementation of the stay-at-home order in the future must be seriously reconsidered. (shrink)

This reflection considers recent United Nations’ normative developments in international human rights law and their potential to assess, with a gender perspective, retrogressive economic policies being promoted by International Financial Institutions in the context of the COVID-19 pandemic. Orthodox and androcentric economic policies, such as structural adjustment, austerity, privatisation and deregulation of labour and financial markets, normally have devastating effects on women’s rights. Yet, the financial responses with which IFIs are trying to help states manage the effects of the pandemic (...) seem to continue promoting those androcentric economic policies. This piece concludes that ex ante human rights and gender impact assessments of multilateral loans’ conditionalities should be conducted and that women’s participation in this process as well as access to adequate quantitative and qualitative data to understand the differentiated effects of those economic policies on gender equality, are crucial. These reflections were born out of the authors’ own family and country challenges. (shrink)

Planned home birth has been considered by some to be consistent with professional responsibility in patient care. This article critically assesses the ethical and scientific justification for this view and shows it to be unjustified. We critically assess recent statements by professional associations of obstetricians, one that sanctions and one that endorses planned home birth. We base our critical appraisal on the professional responsibility model of obstetric ethics, which is based on the ethical concept of medicine from the (...) Scottish and English Enlightenments of the 18th century. Our critical assessment supports the following conclusions. Because of its significantly increased, preventable perinatal risks, planned home birth in the United States is not clinically or ethically benign. Attending planned home birth, no matter one’s training or experience, is not acting in a professional capacity, because this role preventably results in clinically unnecessary and therefore clinically unacceptable perinatal risk. It is therefore not consistent with the ethical concept of medicine as a profession for any attendant to planned home birth to represent himself or herself as a “professional.” Obstetric healthcare associations should neither sanction nor endorse planned home birth. Instead, these associations should recommend against planned home birth. Obstetric healthcare professionals should respond to expressions of interest in planned home birth by pregnant women by informing them that it incurs significantly increased, preventable perinatal risks, by recommending strongly against planned home birth, and by recommending strongly for planned hospital birth. Obstetric healthcare professionals should routinely provide excellent obstetric care to all women transferred to the hospital from a planned home birth. The professional responsibility model of obstetric ethics requires obstetricians to address and remedy legitimate dissatisfaction with some hospital settings and address patients’ concerns about excessive interventions. Creating a sustained culture of comprehensive safety, which cannot be achieved in planned home birth, informed by compassionate and respectful treatment of pregnant women, should be a primary focus of professional obstetric responsibility. (shrink)

Research ethics committees (RECs) evaluate whether the risk-benefit ratio of a study is acceptable. Decentralized clinical trials (DCTs) are a novel approach for conducting clinical trials that potentially bring important benefits for research, including several collateral benefits. The position of collateral benefits in risk-benefit assessments is currently unclear. DCTs raise therefore questions about how these benefits should be assessed. This paper aims to reconsider the different types of research benefits, and their position in risk-benefit assessments. We first propose a categorization (...) of research benefits, based on the types of benefits that can be distinguished from the literature and ethical guidelines. Secondly, we will reconsider the position of collateral benefits. We argue that these benefits are not fundamentally different from other benefits of research and can therefore be included in risk-benefit assessments of DCTs. (shrink)

Mrs. Smith's eyes filled with tears as she said, “I feel like I've done something wrong. Are they punishing me because I've been refusing therapy and won't go to a nursing home?” She acknowledged that she hadn't always listened to her doctors but said that she knew better now and wanted to go home and see if she could make it work. Many staff members at our rehabilitation hospital had explained their safety concerns to her, and some had (...) enlisted her adult daughter, with whom she lived, to convince her too. The rehabilitation team had called on the ethics consultation service, of which I am a part, to help figure out whether Mrs. Smith had the capacity to make an informed refusal of discharge recommendations. (shrink)

The pioneering anthology Home Girls features writings by Black feminist and lesbian activists on topics both provocative and profound. Since its initial publication in 1983, it has become an essential text on Black women's lives and writings. This edition features an updated list of contributor biographies and an all-new preface that provides a fresh assessment of how Black women's lives have changed-or not-since the book was first published. Contributors are Tania Abdulahad, Donna Allegra, Barbara A. Banks, Becky Birtha, (...) Julie Carter, Cenen, Cheryl Clarke, Michelle Cliff, Michelle T. Clinton, Willie M. Coleman, Toi Derricotte, Alexis De Veaux, Jewelle L. Gomez, Akasha (Gloria) Hull, Patricia Jones, June Jordan, Audre Lorde, Raymina Y. Mays, Deidre McCalla, Chirlane McCray, Pat Parker, Linda C. Powell, Bernice Johnson Reagon, Spring Redd, Gwendolyn Rogers, Kate Rushin, Ann Allen Shockley, Barbara Smith, Beverly Smith, Shirley O. Steele, Luisah Teish, Jameelah Waheed, Alice Walker, and Renita Weems. (shrink)

Unintended negative outcomes on child behavior due to lockdown and home confinement following the corona virus disease pandemic needs highlighting to effectively address these issues in the current and future health crises. In this sub-study of the ODIN-study, the objectives were to determine whether the Danish lockdown and home confinement following the COVID-19 pandemic affected changes in emotional-behavioral functioning of pre-school-aged children using the validated Strength and Difficulties Questionnaire answered by parents shortly before lockdown and 3 weeks into (...) lockdown, and moreover, to examine whether baseline family and social characteristics could predict change in child emotional-behavioral functioning during lockdown. Parents of 40 children with a mean age of 5.0 completed the baseline questionnaire and the lockdown follow-up questionnaire. The SDQ-Total difficulties score and Prosocial Behavioral score changed significantly from pre- to lockdown [SDQ-TD mean: 6.0 and 7.9; P = 0.02, respectively and PSB mean: 8.5 and 7.9; P = 0.03, respectively]. Attending leisure time activities before lockdown was a predicting factor of changes to the worse in the children’s SDQ-TD scores, with a mean difference in SDQ-TD between those with and without activities of 3.16 ; P = 0.03. In conclusion, the study showed a modest decrease in child-emotional behavioral functioning during the COVID-19 lockdown, potentially due to parental stress. Although these results might not be generalizable due to small sample size and selected population, the results point to a need of a greater awareness of child mental wellbeing during a lockdown situation. (shrink)

Ongoing changes in many Western countries have resulted in more healthcare services being transferred to municipalities and taking place in patients’ homes. This greatly impacts nurses’ work in home care, making their work increasingly diverse and demanding. In this study, we explore home‐care nursing through a critical discourse analysis of focus group interviews with home‐care nurses. Drawing on insights from positioning theory, we discuss the content and delineation of their work and the interweaving of contextual changes. Nurses (...) hold a crucial position in home healthcare, particularly in ensuring care for sicker patients with complex needs. Assessing health needs, performing advanced care, and at the same time, providing customized solutions in various homes were identified as distinctive for home‐care nurses’ work. Changes have made nurses’ work become driven by comprehensive tasks and acute medical needs that require much of their competence and time. Urgent care seems to take precedence in nurses’ work, leaving less time and attention for other tasks such as conversations and support for coping with everyday life. This underlines the need to investigate and discuss the content and scope of nurses’ work to help shape the further development of home‐care nursing. (shrink)

The discharge of older people from hospital at night is a topical and emotive issue that has recently gained media attention in New Zealand and the United Kingdom, including calls to prevent it occurring. With growing pressures on hospital capacity and ageing populations, normative aspects of hospital discharge are increasingly relevant. This paper therefore addresses the question: Should older people (say, over eighty years old) ever be discharged home from hospital during the night? Or given safety concerns, should regulation (...) against the night-time discharge of older people be put in place? Employing a principlist lens to bioethics, this paper considers key principles or values involved, including discharge safety concerns, personal preference and consent, the risk of remaining in hospital, and broader considerations around discharge policy. These points act as a possible framework for further research and discussion of normative aspects of hospital discharge. Overall, this paper argues that while discharge safety concerns must be properly acknowledged and addressed, it can still sometimes be appropriate for an older person to leave hospital at night. The option of night-time discharge should therefore remain open to people of all ages. (shrink)

‘Terminal discharges’ are carried out in Singapore for patients who wish to die at home. However, if due diligence is not exercised, parallels may be drawn with euthanasia. We present a theoretical discussion beginning with the definition of terminal discharges and the reasons why they are carried out in Singapore. By considering the intention behind terminal discharges and utilising a multidisciplinary team to deliberate on the clinical, social and ethical intricacies with a patient- and context-specific approach, euthanasia is avoided. (...) It is hoped that this will provide a platform for professionals in palliative medicine to negotiate challenging issues when arranging a terminal discharge, so as to avoid the pitfall of committing euthanasia in a country such as Singapore where euthanasia is illegal. It is hoped that a set of guidelines for terminal discharges may someday be realised to assist professionals in Singapore and around the world. (shrink)

Informal home education occurs without much that is generally considered essential for formal education—including curriculum, learning plans, assessments, age related targets or planned and deliberate teaching. Our research into families conducting this kind of education enables us to consider learning away from such imposed structures and to explore how children go about learning for themselves within the context of their own socio-cultural setting. In this paper we consider what and how children learn when no educational agenda is arranged for (...) them and we link this manner of learning to the Deweyan ideas of learning as transactional and learning-in-context. We also use our empirical evidence to explore the notion of ZPD with regard to informal learning and to consider how children, without specific guidance, go about charting a course of learning through the ZPD. We consider the quality of informal learning particularly with regard to the educational aim of developing reflective and critical thinking, showing how these are integral to informal learning. We suggest that a much wider conception of what learning is and how it happens is needed, away from the confines of formal educational structures. (shrink)

Discharge planning for vulnerable infants and children is a collaborative, inter-disciplinary, decision-making activity that is grounded in the ethical complexities of clinical practice. Although it is a psychosocial intervention that frequently causes moral distress for professionals and has the potential to inflict harm on children and their families, the process has received little attention from ethicists. An ongoing study of the transition of technology-dependent children from hospital to home suggests that the ethical issues embedded in the discharge-planning process may (...) be concealed by dominant cultural values, institutional policies, clinical standards, historical precedents, and legal regulations. (shrink)

Background: Personality pathology does not have to be a contraindication to a bariatric surgery if a proper pre-surgical assessment is done. Indicating subgroups of patients with their specific needs could help tailor interventions and improve surgical treatment outcomes.Objectives: Using the Alternative DSM-5 model for personality disorders and the ICD-11 model for PDs to detect subgroups of patients with obesity based on a specific constellation of maladaptive personality traits and the level of overall personality impairment.Methods: 272 consecutively consented patients who (...) underwent a standard pre-surgical psychological assessment. The majority were women, age range was 22–79 years. Patients’ average body mass index was 43.95 kg/m2. All participants were administered the Personality Inventory for DSM-5 from which Level of Personality Functioning Scale-Self Report and Standardized Assessment of Severity of Personality Disorder scores were gained using the “crosswalk” for common metric for self-reported severity of personality disorder. The k-means clustering method was used to define specific subgroups of patients with obesity and replicated for equality testing to the samples of non-clinical respondents and psychiatric patients.Results: The cluster analysis detected specific groups in the sample of patients with obesity, which differed quantitatively from the samples of non-clinical respondents and psychiatric patients. A vast majority of patients with obesity showed above-average values in most of the PID-5 facets compared to the United States representative general community sample. In two out of the three clusters defined, patients demonstrated moderate to severe personality psychopathology within the Detachment and Negative Affectivity domains according to PID-5, which in one of the clusters corresponded to the mild overall impairment in both, LPFS-SR and SASPD. Moreover, higher levels of psychopathology prove to be associated with higher age and use of psychiatric medication.Conclusions: The dimensional DSM-5 and ICD-11 trait models are suitable procedures for defining specific “characters” of patients in a pre-bariatric setting. As such, they help to identify subgroups of patients with obesity who are different from general population and psychiatric patients. Implications for clinical practice and further research are discussed. (shrink)