Surrogate decision makers' understanding of dementia patients' prior wishes for end-of-life care.

OBJECTIVE: This study examines how surrogate decision makers for dementia patients developed an understanding of patient preferences about end-of-life (EOL) care and patient wishes. METHODS: Semistructured interviews were conducted with 34 surrogate decision makers for hospice-eligible nursing home patients with dementia. The data were content analyzed. RESULTS: Most surrogates reported that patients had previously completed an advance directive (59%), discussed preferences for EOL care (56%), or done both (38%). Catalysts for and barriers to completing an advance directive or having EOL care discussions included factors that were both intrinsic and extrinsic to the patient. The most commonly reported wish for EOL care was to not be kept alive by "machines" or "extraordinary measures." DISCUSSION: Health care providers may be able to assist patients and families by normalizing discussions of dying, encouraging advance care planning, helping them identify goals for EOL care, and providing information to support treatment decisions consistent with patients' wishes.

The role of physician characteristics in clinical trial acceptance: testing pathways of influence.

Eight videotaped vignettes were developed that assessed the effects of three physician-related experimental variables (in a 2 x 2 x 2 factorial design) on clinical trial (CT) knowledge, video knowledge, information processing, CT beliefs, affective evaluations (attitudes), and CT acceptance. It was hypothesized that the physician variables (community versus academic-based affiliation, enthusiastic versus neutral presentation of the trial, and new versus previous relationship with the patient) would serve as communication cues that would interrupt message processing, leading to lower knowledge gain but more positive beliefs, attitudes, and CT acceptance. A total of 262 women (161 survivors and 101 controls) participated in the study. The manipulated variables primarily influenced the intermediary variables of post-test CT beliefs and satisfaction with information rather than knowledge or information processing. Multiple regression results indicated that CT acceptance was associated with positive post-CT beliefs, a lower level of information processing, satisfaction with information, and control status. Based on these results, CT acceptance does not appear to be based on a rational decision-making model; this has implications for both the ethics of informed consent and research conceptual models.

Active management of third stage of labour saves facility costs in Guatemala and Zambia.

This study calculated the net benefit of using active management of the third stage of labour (AMTSL) rather than expectant management of the third stage of labour (EMTSL) for mothers in Guatemala and Zambia. Probabilities of events were derived from opinions of experts, publicly available data, and published literature. Costs of clinical events were calculated based on national price lists, observation of resources used in AMTSL and EMTSL, and expert estimates of resources used in managing postpartum haemorrhage and its complications, including transfusion. A decision tree was used for modelling expected costs associated with AMTSL or EMTSL. The base case analysis suggested a positive net benefit from AMTSL, with a net cost-saving of US $18,000 in Guatemala (with 100 lives saved) and US $145,000 in Zambia (with 467 lives saved) for 100,000 births. Facilities have strong economic incentives to adopt AMTSL if uterotonics are available.

Can a brief video intervention improve breast cancer clinical trial knowledge and beliefs?

A total of 262 women in the USA (161 breast cancer survivors and 101 controls) were exposed to a video vignette using modeling in which a physician discussed the concept of a clinical trial (CT) with a woman who was in the process of making a treatment decision. A pretest-post-test design was used and improvements in clinical trial knowledge and beliefs were assessed. Results indicate that video modeling is a powerful tool for increasing CT knowledge (pretest mean=41.5% correct, post-test mean=77.5% correct) but not for improving CT beliefs. Increased clinical trial knowledge, as measured by change scores, was associated with white race, lower levels of education and pretest breast cancer knowledge, more negative pretest CT beliefs, and a higher estimate of the lifetime probability that a woman will have breast cancer. When pretest CT knowledge was added to the analysis using hierarchical multiple regression, all variables except white race became nonsignificant; an increase in CT knowledge was associated with having lower pretest CT knowledge. Results indicate that the effects of low education, low breast cancer knowledge, and biased probability assessment were mediated through the pretest score. An increase in post-test positive CT beliefs was associated with older age, thinking about breast cancer less often, and having lower pretest CT knowledge in the total sample. When pretest CT beliefs was added to the analysis using hierarchical multiple regression, all other variables became nonsignificant; an increase in CT beliefs was associated with having lower pretest CT beliefs, again indicating mediation of the effects of other variables.

Incontinence after prostatectomy: coping with incontinence after prostate cancer surgery.

PURPOSE/OBJECTIVES: To describe the nature of postprostatectomy urinary incontinence, determine how men manage postsurgery urinary incontinence, identify men's perceptions of adequacy of preoperative counseling, and identify men's expectations regarding the probability of postsurgery incontinence. DESIGN: Survey. SETTING: United States. SAMPLE: Members of US TOO International, who experienced urinary incontinence after surgery. METHODS: Copies of the survey (N = 370) were mailed to all chapters of US TOO International, a prostate cancer support group, for distribution to members. A letter of invitation also was posted on the US TOO International Web site and in the monthly newsletter. Men who desired to complete the survey (N = 130) called the researcher's office, and a copy of the survey and a stamped return envelope was mailed to them. Surveys returned to the researchers from June 1998 to January 1999 were included in the analyses. MAIN RESEARCH VARIABLES: Urinary incontinence, management of urinary incontinence, and coping. FINDINGS: 166 men returned surveys. The majority was Caucasian (95%) and married (83%). The median age was 67 years, 87% of the men rated their health as good or excellent, and 114 men (69%) reported becoming incontinent after surgery. Most men experienced stress incontinence symptoms. The majority (89 of 111 men) reported that they were told preoperatively that urinary incontinence was a possible complication. Overall, regardless of length of time since surgery, men (74%) thought that incontinence was an important problem to resolve. Men used containment devices such as pads, special undergarments, and even sanitary napkins as management strategies. The majority of men (54%) used pelvic muscle exercises, especially those who were fewer than two years postsurgery (72%). CONCLUSIONS: Urinary incontinence is a prevalent postoperative complication for men, even up to five years after surgery, and a source of great distress for some. Men reported stress and urge incontinence symptoms and used an array of strategies to contain their urine. Finding effective treatments for postprostatectomy urinary incontinence and receiving adequate information before surgery is important to these men. IMPLICATIONS FOR NURSING: As the number of men who undergo surgical treatment for prostate cancer increases, nurses need to be equipped with the necessary knowledge and information to answer preoperative concerns and provide effective strategies for managing postoperative urinary incontinence.