[Discontinuation of potentially inappropriate medications at the end of life: perspectives from patients, their relatives, and physicians]. / Overbodige medicatie stoppen vlak voor overlijden.

OBJECTIVE: To obtain insight into the perspectives of patients, relatives and physicians towards potentially inappropriate medications (PIMs) at the end of life. DESIGN: Qualitative interview study. METHOD: An analysis of in-depth interviews with 17 patients who were diagnosed as having a life expectancy of less than three months, 12 patient relatives, and 20 medical specialists and 12 general practitioners who cared for them. For analysis we applied the constant comparative method, which forms part of the grounded theory approach. RESULTS: Patients and their relatives are prepared to discontinue PIMs. Still, some patients reported that stopping might give them the feeling that their attending physician has already thrown in the towel. Physicians mentioned several reasons for not ceasing PIMs: cessation not considered, low priority, and unknown consequences of discontinuation. Some physicians were concerned that discussing the discontinuation of PIMs with patients could make patients acutely aware of the approach of death, and give patients the impression that they are receiving inferior medical care. If physicians communicate with patients the possibility of discontinuing medications, they seem to emphasize the clinical futility of continuing PIMs in light of the patient's limited life expectancy. CONCLUSION: Patients with a limited life expectancy and their relatives may be open to discontinue PIMs; however, in reality this happens rarely. When a physician is of the opinion that it would be of benefit to discontinue certain medications, then the advantages of cessation should be highlighted more in discussions with the patient.

Validation of the Hester Davis Scale for fall risk assessment in a neurosciences population.

BACKGROUND AND PURPOSE: Fall risk assessment is a necessary component of fall prevention programs. Accurate instruments to predict the risk of falling are paramount in identifying the correct patients in need of fall prevention measures. The purpose of this study was to prospectively validate the Hester Davis Scale (HDS) for fall risk assessment in an acute care setting in the South Central United States. METHODS: The HDS was prospectively validated in 1,904 patients on a neurosciences unit. RESULTS: Using an initial cut score of 7 produced a sensitivity of 100% and specificity of 24.9%. Receiver Operating Characteristic Analysis evidenced a cut score of 10 that would produce a more desirable sensitivity and specificity of 90.9% and 47.1%, respectively. CONCLUSION: The results of the psychometric evaluation and validation of the HDS support its use in clinical practice.

The Texas Medication Algorithm Project Patient and Family Education Program: a consumer-guided initiative.

Educating patients with mental illness and their families about the illness and its treatment is essential to successful medication (disease) management. Specifically, education provides patients and families with the background they need to participate in treatment planning and implementation as full "partners" with clinicians. Thus, education increases the probability that appropriate and accurate treatment decisions will be made and that a treatment regimen will be followed. The Texas Medication Algorithm Project (TMAP) has incorporated these concepts into its philosophy of care and accordingly created a Patient and Family Education Program (PFEP) to complement the utilization of medication algorithms for the treatment of schizophrenic, bipolar, and major depressive disorders. This article describes how a team of mental health consumers, advocates, and professionals developed and implemented the PFEP. In keeping with the TMAP philosophy of care, consumers were true partners in the program's development and implementation. They not only created several components of the program and incorporated the consumer perspective, but they also served as program trainers and advocates. Initially, PFEP provides basic and subsequently more in-depth information about the illness and its treatment, including such topics as symptom monitoring and management and self-advocacy with one's treatment team. It includes written, pictorial, videotaped, and other media used in a phased manner by clinicians and consumer educators, in either individual or group formats.

Environmental Protection in the Tomsk Region of the Russian Federation: A Case Study.

/ Implementation of environmental management in Russia is undergoing rapid changes. Federal responsibility rests with the Russian Federation State Committee for Environmental Protection (RFSCEP) and is delegated at regional level to local State Committees for Environmental Protection (SCEPs). This paper focuses on the functioning of the SCEP for Tomsk oblast' (region) in Siberia, which is strongly committed to forging constructive links with regional government, academia, industry, and environmental NGOs. Considerable difficulties exist for SCEPs in Russia, however, and prominent among these are (1) a rigidly vertical civil service structure, with separate organs having responsibility for different natural resources, persisting from Soviet times, which hinders effective intergrated and holistic environmental management; and (2) a lack of open access to environmental information from military and quasi-military sites.

Teaching a functional leisure skill cluster to rehabilitation clients: the art of macrame.

Disabled people often do not use leisure time productively. Past research has focused on teaching specific recreational activities isolated from related skills that would provide subjects a functional independent living repertoire. In the present study disabled subjects were taught the art of macrame. Additionally, they role-played related shopping skills such as buying materials, engaging in appropriate social-interpersonal skills, making monetary transactions, and securing their own transportation to and from the store. Subjects were taught six basic macrame knots using an instructional manual, series of error-correction procedures, and social reinforcement. After mastering those basic knots they independently used the instructional materials to make three complete macrame projects without direct instruction on the projects themselves. Subjects also demonstrated skill maintenance and generalization by making a novel project after independently engaging in all relevant shopping behavior. Two varieties of the multiple baseline design were employed. The importance of teaching a leisure skill cluster and adapting instructional materials were emphasized.