How is death and dying addressed in introductory psychology textbooks?

Although psychologists have conducted a great deal of research on death and dying, little is known about how topics related to death and dying are introduced in psychology courses. We analyzed the amount and breadth of coverage given to topics related to death and dying in 28 introductory psychology textbooks published between 1995 and 2000. We coded for number of words included, the types of topics discussed, and authors cited. All textbooks included some information about death and dying, most frequently, suicide. Little consistency was found in references cited. We recommend that future textbooks include information to help students explore their own death attitudes, as well as providing more theory and empirical research findings on aspects of death and dying.

Gender differences in older adults' preferences for life-sustaining medical treatments and end-of-life values.

In the present study, we examined gender differences in preferences for life sustaining treatments in response to various health state scenarios and the endorsement of end-of-life values in 99 older adults. Men preferred life-sustaining treatments more than women overall, for specific treatments (i.e., CPR, surgery, and artificial feeding), and in response to specific health scenarios (i.e., current health, Alzheimer's disease, coma with a slight chance of recovery). In terms of values, women indicated a greater desire for a dignified death than men.

Advance directives as acts of communication: a randomized controlled trial.

BACKGROUND: Instructional advance directives are widely advocated as a means of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-sustaining treatment wishes. However, no research has examined whether instructional directives are effective in improving the accuracy of surrogate decisions. PARTICIPANTS AND METHODS: A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% children) were randomized to 1 of 5 experimental conditions. In the control condition, surrogates predicted patients' preferences for 4 life-sustaining medical treatments in 9 illness scenarios without the benefit of a patient-completed advance directive. Accuracy in this condition was compared with that in 4 intervention conditions in which surrogates made predictions after reviewing either a scenario-based or a value-based directive completed by the patient and either discussing or not discussing the contents of the directive with the patient. Perceived benefits of advance directive completion were also measured. RESULTS: None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogate understanding and comfort for patient-surrogate pairs in which the patient had not completed an advance directive prior to study participation. CONCLUSIONS: Our results challenge current policy and law advocating instructional advance directives as a means of honoring specific patient wishes at the end of life. Future research should explore other methods of improving surrogate decision making and consider the value of other outcomes in evaluating the effectiveness of advance care planning.

Accuracy of primary care and hospital-based physicians' predictions of elderly outpatients' treatment preferences with and without advance directives.

BACKGROUND: Past research has documented that primary care physicians and family members are often inaccurate when making substituted judgments for patients without advance directives (ADs). This study compared the accuracy of substituted judgments made by primary care physicians, hospital-based physicians, and family surrogates on behalf of elderly outpatients and examined the effectiveness of ADs in improving the accuracy of these judgments. PARTICIPANTS AND METHODS: Participants were 24 primary care physicians of 82 elderly outpatients, 17 emergency and critical care physicians who had no prior experience with the patients, and a baseline comparison group of family surrogates. The primary outcome was accuracy of physicians' predictions of patients' preferences for 4 life-sustaining treatments in 9 hypothetical illness scenarios. Physicians made substituted judgments after being provided with no patient AD, patient's value-based AD, or patient's scenario-based AD. RESULTS: Family surrogates' judgments were more accurate than physicians'. Hospital-based physicians making predictions without ADs had the lowest accuracy. Primary care physicians' accuracy was not improved by either AD. Accuracy and confidence in predictions of hospital-based physicians was significantly improved for some scenarios using a scenario-based AD. CONCLUSIONS: Although ADs do not improve the accuracy of substituted judgments for primary care physicians or family surrogates, they increase the accuracy of hospital-based physicians. Primary care physicians are withdrawing from hospital-based care in growing numbers, and emergency medicine and critical care specialists most often are involved in decisions about whether to begin life-sustaining treatments. If ADs can help these physicians better understand patients' preferences, patient autonomy more likely will be preserved when patients become incapacitated.

Older adults' attitudes toward death: links to perceptions of health and concerns about end-of-life issues.

The current study had two primary goals, to determine whether: 1) self-rated mental and physical health, pain, and experience with health problems were predictors of elderly adults' attitudes toward death; and 2) death attitudes predict end-of-life medical treatment concerns. Participants were 109 adults, 65 years of age or older (M=78.74 years), recruited from the local community. Regression analysis indicated that poorer perceived physical health predicted a greater likelihood of viewing death as an escape, and poorer perceived mental health predicted a greater fear of death. Viewing death as an escape and fearing death predicted end-of-life medical treatment concerns; a greater endorsement of either attitude predicted more concern. Possible explanations for the links between perceived health, attitudes toward death, and concern about end-of-life issues are suggested.

The stability of older adults' judgments of fates better and worse than death.

Decisions about specific life-sustaining medical treatments have been found to be only moderately stable over time. This study examined whether more general judgments, such as whether a particular health condition is better or worse than death, would exhibit greater stability. Fifty adults (aged 65 yrs and older) made judgments about the perceived quality of life (QOL) possible in a number of hypothetical states of impaired health and their desire to live or die (LOD) in each state. Judgments were made twice from 5 to 16 months apart (M = 10.7 mo). Both QOL and LOD judgments demonstrated only moderate stability regardless of the method of analysis used. Judgments about states characterized by severe impairment became more moderate over time with a substantial minority of participants viewing the states as worse than death at the initial interview viewing them as better than death at follow-up. Participants who did not have a living will, did not have children, had a lower perceived QOL at the follow-up interview, and had a longer time between interviews had more unstable judgments. The implications of these findings for the use of instructional advance directives are discussed.

Modal preferences predict elderly patients' life-sustaining treatment choices as well as patients' chosen surrogates do.

The purpose of this study was to compare the accuracy of an actuarial method of predicting patients' preferences for life-sustaining treatment with the accuracy of surrogate decision makers. 401 outpatients 65 years old or older (mean = 73 years) and their self-designated surrogate decision makers recorded preferences for four life-sustaining medical treatments in nine hypothetical illness scenarios. The surrogates did not predict the patients' preferences more accurately than did an actuarial model using modal preferences. Surrogates' accuracy was not influenced by the use of an advance directive (AD) or discussion of life-sustaining treatment choices. In clinical practice, an actuarial model could assist surrogate decision makers when a patient has no AD, an AD is unavailable, a patient's AD is vague or describes treatment choices for only extreme or unlikely disease states, no proxy decision maker has been designated, or a patient was never competent.

For every numerator, you need a denominator: a simple statement but key to measuring the quality of care of the "dying".

A mathematical rate is composed of a numerator, denominator, and time period of observation. Deciding who is in the denominator is a key, yet difficult task given the blurred boundaries of chronic illness, in examining the quality of care for dying patients. We propose two potential solutions. First, one could prospectively define the outcome state of "living with life-threatening" illness, where there is life expectancy of 1 or 2 years. Second, retrospective interviews could be used with family members or other loved ones about their perceptions of the quality of care in the last weeks of life. Improving the quality of care for dying patients and their families requires attention to this matter.

Methodological challenges for measuring quality of care at the end of life.

Measurement is a fundamental step in improving the quality of care for dying patients and their families. Yet, there are important methodological challenges to be addressed. In conducting surveys about the patient and family experience, research is needed regarding the relative merits and cost-effectiveness of prospective or retrospective surveys after the patient's death. Proxies are an important source of information given that the majority of patients can not be interviewed in the last week of life. Research is needed to understand who is best able to serve as a proxy and the validity of their reports. The cost-effectiveness and comparability of alternative data collection strategies need to be examined. These and other important issues need to be addressed in designing reliable, valid, and clinically manageable measures.

Elderly adults' preferences for life-sustaining treatments: the role of impairment, prognosis, and pain.

Elderly adults' preferences for life-sustaining treatment are known to vary by type of medical condition and treatment. Less is known about how treatment preferences vary based on underlying health dimensions, such as the nature of the impairment, prognostic information, and the experience of pain. Fifty elderly adults stated preferences for 4 life-sustaining treatments in response to 4 pairs of health state scenarios. Overall, life-sustaining treatments were preferred less in response to (a) cognitive versus physical impairment, (b) when the prognosis described no chance versus a very slight chance of recovery/improvement, and (c) if pain was present. These findings have implications for the way in which preferences for life-sustaining treatments are recorded in advance directives. Historically, advance directives have been limited by overly broad or overly specific statements about treatment preferences. Recording underlying health dimensions that guide treatment decisions may allow decision makers to generalize and apply patient preferences to novel health conditions.

The Medicare hospice benefit's influence on dying in nursing homes.

For dying nursing home residents, the prevalence of symptoms and care utilization prior to death has yet to be empirically described for a population-based sample. Yet, related work has suggested that the quality of care for dying nursing home residents is less optimal. The provision of Medicare hospice care in nursing homes offers a means for improving terminal care in nursing homes. However, other than controversial findings emanating from the U.S. Office of Inspector General's (OIG's) hospice studies, there is a dearth of evaluative research on the comparative costs and the benefits of Medicare hospice care in nursing homes. In this article, we discuss current knowledge concerning the dying experience of nursing home residents and of the influence of the Medicare hospice benefit in nursing homes. In doing so, we critique the OIG's study of hospice care in nursing homes and we raise concerns regarding access to the Medicare hospice benefit in nursing homes. We conclude by delineating the research needed to more fully understand the dying experience of nursing home residents and the influence of Medicare hospice care provision on this experience.

Deoxyribonucleic acids of Corynebacterium genitalium and Corynebacterium pseudogenitalium: their genome molecular weights, base ratios, and DNA relatedness with other corynebacteria involved in urinary tract infections.

Chromosomal deoxyribonucleic acids of Corynebacterium genitalium and Corynebacterium pseudogenitalium were isolated and analysed spectrophotometrically. Their genome molecular weights ranged from 1.1 X 10(9) to 1.6 X 10(9). The guanine-plus-cytosine content of C. genitalium ranged from 60.0 to 63.3%, whereas that of C. pseudogenitalium ranged from 56.1 to 58.7%. Five strains of C. genitalium showed relatively low levels of DNA relatedness to each other ranging from 35 to 64%. In contrast, most strains of C. pseudogenitalium showed high levels of DNA relatedness to each other ranging from 71 to 89%. Selected strains of C. genitalium and C. pseudogenitalium showed low levels of DNA relatedness (49 to 60%) to other corynebacterial species involved in urinary tract infection. Data obtained in this study indicate that all strains of C. genitalium consist of genetically divergent organisms while the most strains of C. pseudogenitalium belong to a single species.

Evaluation of differential media for the identification of Corynebacterium genitalium and Corynebacterium pseudogenitalium (group JK corynebacteria).

Tween purple agar containing 1% fructose (TFP agar) differentiated Corynebacterium genitalium from C. pseudogenitalium, which respectively formed colorless and yellow colonies after 72 h incubation at 37 degrees C aerobically or in 5-10% CO2 in air. Thus TFP agar is a differential medium. Corynebacteria-like colonies grown on nonspecific urethritis (NSU) chocolate agar from urogenital material were identified as C. genitalium, C. pseudogenitalium, or commensals when subcultured on TPF agar. TFP agar was unsuitable for their primary isolation since the commensals turned the medium yellow with 24 h incubation. Gentamicin cannot be employed as a selective agent in medium for the isolation of these corynebacteria. TFP agar containing 10 micrograms/mL entamicin inhibited most strains of C. pseudogenitalium and C. genitalium isolated from urogenital infections. It did not inhibit isolates of these corynebacteria from cancer patients or suppress the normal bacterial flora of the urogenital tract. Evidence that gentamicin-resistant strains are characteristic of nosocomial infections is presented.

Relationship between group JK corynebacteria and the biotypes of Corynebacterium genitalium and Corynebacterium pseudogenitalium.

Twenty-six strains of group JK corynebacteria had the same colonial morphology and biological reactions as the biotypes of the biovars of Corynebacterium genitalium and C. pseudogenitalium. Therefore, group JK corynebacteria can be assigned to the biovars of C. genitalium or C. pseudogenitalium. Although the strains differed in sensitivity to 16 antibiotics tested by Sensi-Discs or by the Micro-Media technique, they are uniformly sensitive to 4-5 micrograms/mL of vancomycin. Medium containing 10 micrograms vancomycin/mL was bactericidal and the killing time was dependent on the concentration. The rate of mutation to resistance to 10 micrograms vancomycin was greater than 1 in 10(10) corynebacteria. Therefore, vancomycin sensitivity is a stable characteristic of these corynebacteria which also indicates that group JK corynebacteria are strains of either C. genitalium or C. pseudogenitalium. Since group JK corynebacteria are considered pathogens, this finding supports the belief that C. genitalium is a pathogen and suggests that some biotypes of the commensal C. pseudogenitalium may infect compromised hosts.

Mycoplasma hominis, Ureaplasma urealyticum, and Corynebacterium genitalium recovered from the lower genital tracts of adolescent women.

The lower genital tracts of 137 adolescent women were examined for the presence of Mycoplasma hominis, Ureaplasma urealyticum, and Corynebacterium genitalium in relation to sexual activity, previous pregnancy, presence of vaginal discharge and oral contraceptive use. None of the sexually inactive and 10% of the sexually active adolescent females were colonized with U. urealyticum. None of the sexually inactive and 4% of the sexually active adolescent females were colonized with C. genitalium. Nineteen percent of the sexually inactive and 36% of the sexually active adolescent females were colonized with M. hominis. The presence of M. hominis in the lower genital tract was not associated with any clinically identifiable vaginal discharge or inflammatory changes in exfoliated cervical and vaginal epithelial cells. The presence of M. hominis in the lower genital tract did not appear to be related to the use of oral contraceptives or antecedent pregnancy. There was no significant difference in the recovery rates of these microorganisms when we compared women who had non-specific vaginitis with those who did not. There is no evidence from this study that any of these microorganisms is responsible for non-specific vaginitis.