The systemic challenges of non-palliative care professionals caring for end-of-life patients: A lived experience study.

OBJECTIVES: The aims of this study are to identify the challenges faced by non-palliative care professionals (NPCPs) in caring for end-of-life patients; determine how these challenges interact with and influence each other systemically; and advance the theories and practices for supporting NPCPs in the provision of quality end-of-life care beyond the boundaries of palliative medicine. METHODS: A constructivist phenomenological research design with an Interpretive-Systemic Framework of inquiry was adopted. Thirty-five physicians, 35 nurses, and 35 Medical Social Workers who play critical roles in caring for end-of-life patients and belonging to the 9 major medical disciplines of Cardiology, Geriatric, Intensive Care Medicine, Internal Medicine, Nephrology, Neurology, Oncology, Respiratory Medicine, and Surgery were recruited through purposive snowball sampling from 3 major public hospitals. RESULTS: Framework analysis revealed 5 themes and 17 subthemes that illuminate the individual, relational, cultural, institutional, and structural challenges that NPCPs faced in rendering end-of-life care. These challenges influence each other within the health-care ecosystem, serving to perpetuate or heighten care obstacles. SIGNIFICANCE OF RESULTS: This is the first known study exploring the systemic challenges of NPCPs spanning 9 major medical disciplines and encompassing 3 professional stakeholders responsible for the care for end-of-life patients, thus ensuring perspective inclusivity across the health-care system. Recommendations that consider the complexity of the interactions between these systemic challenges are presented in detail.

Burnout and Resilience After a Decade in Palliative Care: What Survivors Have to Teach Us. A Qualitative Study of Palliative Care Clinicians With More Than 10 Years of Experience.

CONTEXT: Burnout is common among palliative care clinicians (PCCs). Resilience helps to reduce burnout, compassion fatigue, and is associated with longevity in palliative care. OBJECTIVES: We aimed to study PCCs who have remained in the field for longer than 10 years to deepen our understanding on their views on burnout and resilience. METHODS: We conducted a qualitative study using semistructured interviews and purposive sampling on 18 PCCs - five doctors, 10 nurses, and three social workers who worked in various palliative care settings (hospital palliative care team, home hospice, and inpatient hospice). The mean age of the interviewees was 52 years, and the mean number of years practicing palliative care was 15.7 years (range 10-25). The interviews were recorded verbatim, transcribed, and analyzed using a grounded theory approach. RESULTS: Four major themes emerged from our analysis - struggling, changing mindset, adapting, and resilience. Intervening conditions, such as self-awareness, reflection, and evolution, were also important factors. The core phenomenon of our study was that of transformational growth - a process that PCCs have to go through before they achieve resilience. We also further classified resilience into both personal and collective resilience. CONCLUSION: Our findings highlight the evolving process of transformational growth that PCCs must repeatedly undergo as they strive toward sustained resilience and longevity. It also stresses the importance of taking individual and collective responsibility toward building a culture of personal and team resilience.

Measuring Filial Piety in the 21st Century: Development, Factor Structure, and Reliability of the 10-Item Contemporary Filial Piety Scale.

The experience and practice of filial piety have evolved in modern Chinese societies, and existing measures fail to capture these important changes. Based on a conceptual analysis on current literature, 42 items were initially compiled to form a Contemporary Filial Piety Scale (CFPS), and 1,080 individuals from a representative sample in Hong Kong were surveyed. Principal component analysis generated a 16-item three-factor model: Pragmatic Obligations (Factor 1; 10 items), Compassionate Reverence (Factor 2; 4 items), and Family Continuity (Factor 3; 2 items). Confirmatory factor analysis revealed strong factor loadings for Factors 1 and 2, while removing Factor 3 and conceptually duplicated items increased total variance explained from 58.02% to 60.09% and internal consistency from .84 to .88. A final 10-item two-factor structure model was adopted with a goodness of fit of 0.95. The CFPS-10 is a data-driven, simple, and efficient instrument with strong psychometric properties for assessing contemporary filial piety.

Neighborhood support network, perceived proximity to community facilities and depressive symptoms among low socioeconomic status Chinese elders.

OBJECTIVES: Depressive symptoms are common in older people; most previous research on elderly depression focused on individual-level characteristics or neighborhood socioeconomic status. Modifiable neighborhood characteristics of older people dwelling in low-income communities are under-studied. This study aims to identify potentially modifiable social and physical neighborhood characteristics that influence depressive symptoms independent of individual-level characteristics among older Chinese. METHOD: Data came from a cross-sectional survey conducted in four low-income public rental housing estates in Hong Kong in 2012. We interviewed a total of 400 elderly residents. The structured questionnaire covered demographics, activities of daily living, recent fall history, neighborhood support networks, and perceived proximity by walk to community facilities. Multiple regression was used to test whether inclusion of neighborhood factors in addition to individual characteristics increases model fit in explaining depressive symptoms in elders with low socioeconomic status. RESULTS: At individual level, activities of daily living and income significantly predicted depressive symptoms. Receiving support from friends or neighbors is associated with fewer depressive symptoms. However, participants who received organizational support had a 1.17 points of increase on the 15-item Geriatric Depression Scale (GDS-15). At-ease walkable proximity to medical facilities was positively associated with a better GDS score. CONCLUSION: Neighborhood support networks and perceived proximity by walk to community facilities contribute significantly to depressive symptoms among low-income elders. Programs and policies that facilitate neighborhood support and commuting or promote facility accessibility may help ameliorate depressive symptoms common among low-income elders.

Development and Pilot Evaluation of a Novel Dignity-Conserving End-of-Life (EoL) Care Model for Nursing Homes in Chinese Societies.

PURPOSE OF THE STUDY: The provision of end-of-life (EoL) care in long-term-care settings remains largely underdeveloped in most Chinese societies, and nursing home residents often fail to obtain good care as they approach death. This paper systematically describes the development and implementation mechanisms of a novel Dignity-Conserving EoL Care model that has been successfully adopted by three nursing homes in Hong Kong and presents preliminary evidence of its effectiveness on enhancing dignity and quality of life (QoL) of terminally ill residents. DESIGN AND METHODS: Nine terminally ill nursing home residents completed the McGill Quality of Life Questionnaire and the Nursing Facilities Quality of Life Questionnaire at baseline and 6 months post-EoL program enrollment. Wilcoxon signed rank test was used to detect significance changes in each QoL domains across time. RESULTS: Although significant deterioration was recorded for physical QoL, significant improvement was observed for social QoL. Moreover, a clear trend toward significant improvements was identified for the QoL domains of individuality and relationships. IMPLICATIONS: A holistic and compassionate caring environment, together with the core principles of family-centered care, interagency and interdisciplinary teamwork, as well as cultural-specific psycho-socio-spiritual support, are all essential elements for optimizing QoL and promoting death with dignity for nursing home residents facing morality. This study provides a useful framework to facilitate the future development of EoL care in long-term-care settings in the Chinese context.

Psychometric properties of a Chinese version of the Stigma Scale: examining the complex experience of stigma and its relationship with self-esteem and depression among people living with mental illness in Hong Kong.

BACKGROUND: Stigma of mental illness is a global public health concern, but there lacks a standardized and cross-culturally validated instrument for assessing the complex experience of stigma among people living with mental illness (PLMI) in the Chinese context. AIM: This study examines the psychometric properties of a Chinese version of the Stigma Scale (CSS), and explores the relationships between stigma, self-esteem and depression. METHODS: A cross-sectional survey was conducted with a community sample of 114 Chinese PLMI in Hong Kong. Participants completed the CSS, the Chinese Self-Stigma of Mental Illness Scale, the Chinese Rosenberg Self-Esteem Scale, and the Chinese Patient Health Questionnaire-9. An exploratory factor analysis was conducted to identify the underlying factors of the CSS; concurrent validity assessment was performed via correlation analysis. RESULTS: The original 28-item three-factor structure of the Stigma Scale was found to be a poor fit to the data, whereas a revised 14-item three-factor model provided a good fit with all 14 items loaded significantly onto the original factors: discrimination, disclosure and positive aspects of mental illness. The revised model also displayed moderate to good internal consistency and good construct validity. Further findings revealed that the total stigma scale score and all three of its subscale scores correlated negatively with self-esteem; but only total stigma, discrimination and disclosure correlated positively with depression. CONCLUSION: The CSS is a short and user-friendly self-administrated questionnaire that proves valuable for understanding the multifaceted stigma experiences among PLMI as well as their impact on psychiatric recovery and community integration in Chinese communities.

A Model for Art Therapy-Based Supervision for End-of-Life Care Workers in Hong Kong.

End-of-life care workers and volunteers are particularly prone to burnout given the intense emotional and existential nature of their work. Supervision is one important way to provide adequate support that focuses on both professional and personal competencies. The inclusion of art therapy principles and practices within supervision further creates a dynamic platform for sustained self-reflection. A 6-week art therapy-based supervision group provided opportunities for developing emotional awareness, recognizing professional strengths, securing collegial relationships, and reflecting on death-related memories. The structure, rationale, and feedback are discussed.

Prevalence and determinants of depression among survivors 8 months after the Wenchuan earthquake.

The current study assessed the estimated rate of depression and associated risk factors among survivors 8 months after the 2008 Wenchuan earthquake in China. A stratified random sample of 1514 participants was recruited from all temporary camp communities in a county town 45 km away from the epicenter. The estimated rate of depression was 35.7%. The severity of depressive symptoms was significantly associated with female sex, perceived livelihood security, loss of a family member, residential house damage or collapse, and not living in an urban area, whereas married status is a protector against depressive symptoms. The results suggest that community-based effective, sustainable, and culturally sensitive interventions and services are warranted and should be directed to the groups at high risk for mental health problems.

The effect of t'ai chi exercise on immunity and infections: a systematic review of controlled trials.

PURPOSE: The aim of this review is to summarize and assess critically clinical trial evidence of the effect of t'ai chi (TC) exercise on immunity and TC efficacy for treating infectious diseases. METHODS: Fourteen databases were searched from their respective inceptions through January 2011. No language restrictions were imposed. Quality and validity of the included clinical trials were evaluated using standard scales. RESULTS: Sixteen (16) studies, including 7 randomized controlled trials, 4 controlled clinical trials, and 5 retrospective case-control studies, met the inclusion criteria for this review. One (1) study examined clinical symptoms, 3 studies tested functional measures of immunity (antigen-induced immunity), and the other studies tested enumerative parameters of immunity. such as lymphocytes, immunoglobulins, complements, natural-killer cells, and myeloid dendritic cells. Overall, these studies suggested favorable effects of TC exercise. CONCLUSIONS: TC exercise appears to improve both cell-mediated immunity and antibody response in immune system, but it remains debatable whether or not the changes in immune parameters are sufficient to provide protection from infections.

Dignity amidst liminality: healing within suffering among Chinese terminal cancer patients.

This study critically examines the concepts of dignity and liminality at the end-of life, in an effort to better understand the processes of healing within suffering among Chinese terminal cancer patients receiving palliative care services in Hong Kong. Meaning-oriented interviews were conducted with 18 Chinese terminal patients, aged 44 to 98, to elicit the narratives and stories of their illness experience. All interviews were analyzed using grounded theory and supplemented by ethnographic observations and field notes. Two major themes and eight subprocesses of healing adopted by patients to achieve and maintain dignity were identified: (a) personal autonomy, which encompasses the need to (i) regain control over living environments, (ii) maintain self-sufficiency despite institutional care, (ii) make informed care decisions to reduce sense of burden, and (iv) engage in future planning to create a lasting legacy; and (b) family connectedness, which encompasses the need to (i) maintain close ties with family members to express appreciation, (ii) achieve reconciliation, (iii) fulfill family obligations, and (iv) establish a continuing bond that transcends generations. Implications of these themes for advanced care planning and life review interventions were discussed with the goal of enhancing patient autonomy and family connectedness, and thereby providing structure and meaning for Chinese terminal patients and their families at the end of life.

Symptoms of posttraumatic stress disorder and depression among bereaved and non-bereaved survivors following the 2008 Sichuan earthquake.

Many studies have suggested that unexpected death of a loved one is an important risk factor of posttraumatic stress disorder (PTSD) and depression among disaster survivors, but few have examined the magnitude of psychiatric morbidities among bereaved survivors. This study examined the prevalence rates of clinically significant PTSD and depressive symptoms and their associated risk factors among Chinese adult survivors following the 2008 Sichuan earthquake. Two hundred and fifty-one bereaved adults were compared with 1474 non-bereaved adult survivors. The estimated rates of PTSD and depressive symptoms were 65.6% and 64.8% for those who lost first-degree family members, 34.1% and 45.5% for those who lost second-degree relatives, and 27.1% and 37.5% for non-bereaved survivors respectively. Loss of a child was a significant predictor of psychopathological symptoms. The results suggested that effective and sustainable mental health services were required, especially for bereaved single-child parents.

Social networks and health-related quality of life among Chinese older adults with vision impairment.

OBJECTIVE: This study examines the associations between social networks and vision-specific health-related quality of life (HRQOL) among Chinese older adults. METHOD: Urban older adults with visual problems (N = 167) were interviewed using a structured questionnaire to assess self-reported visual functioning, general health, social networks, and vision-specific HRQOL. Objective visual function was clinically measured by ophthalmologists in terms of distance visual acuity. RESULTS: Findings indicate that age-related vision loss is significantly associated with older adults' social networks. Multiple regression analyses show that social networks are mildly related to vision-specific HRQOL even after controlling for other variables, and that friendship network was a significant predictor, independent of family network, of vision-specific HRQOL. DISCUSSION: Previous studies have emphasized the importance of family network, whereas this study finds that friendship network correlates more strongly with HRQOL measures among Chinese visually impaired older adults. This suggests a need to expand intervention beyond the family system.

Does mood state change risk taking tendency in older adults?

No study has been conducted to evaluate the influences of age differences on specific moods for risk taking tendencies. This study examined the patterns of risk taking tendencies among younger and older persons in 3 transient affective states: positive, neutral, and negative moods. By means of viewing happy, neutral, or sad movie clips, participants were induced to the respective mood. Risk taking tendencies were measured with decision tasks modified from the Choice Dilemmas Questionnaire (N. Kogan & M. A. Wallach, 1964). Consistent with the affect infusion model (J. P. Forgas, 1995), risk taking tendency was greater for those individuals who were in a happy mood than for those who were in a sad mood, for both young and older participants. However, an asymmetrical effect of positive and negative mood on risk taking tendency was identified among both the young and older participants, but in opposite directions. These results are consistent with the predictions of the negativity bias and the positivity effect found in young and older adults, respectively, and are interpreted via information processing and motivation effects of mood on the decision maker.