Why caregivers have no autonomy-based reason to respect advance directives in dementia care.

Advance directives (ADs) have for some time been championed by ethicists and patient associations alike as a tool that people newly diagnosed with dementia, or prior to onset, may use to ensure that their future care and treatment are organized in accordance with their interests. The idea is that autonomous people, not yet neurologically affected by dementia, can design directives for their future care that caregivers are morally obligated to respect because they have been designed by autonomous individuals. In this paper, we first criticize the idea that ADs can retain moral authority in severe dementia by arguing that it is paradoxical. Second, we consider two arguments that initially seem to refute this critique of ADs, but we eventually dismiss them. The first argument states that ADs retain moral authority in severe dementia because autonomously formed interests, for example, ADs, can only be appropriately discarded by autonomous persons. This we term the historical autonomy argument. We dismiss it by demonstrating how we, in analog cases, are not obligated to continue to respect autonomously formed interests even though they have been discarded under nonappropriate conditions. The second argument is that ADs can be justified by what we term external interests. While we agree that people with severe dementia plausible can be said to have external interests, we show that ADs cannot express such interests and hence cannot be justified by them. We conclude that none of the discussed arguments support the use of ADs and because of this, the idea of ADs should be reassigned.

Digital media use and sleep in late adolescence and young adulthood: A systematic review.

Despite much attention on digital media use and young peoples' sleep, the literature on digital media and its impact on sleep in older adolescents and young adults remains to be synthesized. We conducted a systematic review of studies including young people aged 16-25 years. We searched Medline, Web of Science, and CINAHL for observational studies, identifying 60 studies. These studies were assessed for methodological quality. Only studies rated as moderate or high-quality studies were included (n = 42). A narrative synthesis summarized the impact of digital media use on eight sleep outcomes: Bedtime; Sleep onset latency or problems falling asleep; Sleep duration; Early awakening; Sleep disturbance; Daytime tiredness and function; Sleep deficits; Sleep quality. In summary, digital media use was associated to shorter sleep duration and poorer sleep quality. These associations were found for general screen use and use of mobile phone, computer, internet, and social media, but not for television, game console, and tablet use. Most studies investigating bedtime or nighttime use found associations to poor sleep outcomes. Later bedtime and daytime tiredness were associated with mobile phone use at night. Additional research is warranted to draw solid conclusions about the causal direction and to understand the underlying mechanisms.

On the definition of stigma.

BACKGROUND: There are thousands of papers about stigma, for instance about stigma's impact on wellbeing, mental or physical health. But the definition of stigma has received only modest attention. In "Conceptualizing stigma" from 2001, Link and Phelan offer a thorough and detailed definition of stigma. They suggest that there are six necessary conditions for stigma, namely labelled differences, stereotypes, separation, status loss and discrimination, power, and emotional reaction. This definition is widely applied in the literature but is left mainly uncriticized. METHOD: We submit the Link and Phelan definition of stigma to a systematic conceptual analysis. We first interpret, analyze and reconsider each of the six components in Link and Phelan's definition of stigma, and on the basis of these analyses, we secondly suggest a revised definition of stigma. RESULT: The Link and Phelan definition is thorough and detailed, but includes redundant components. These are status loss and discrimination, and emotional reaction. CONCLUSION: We suggest that groups, not individuals, are the target of stigma, though it is individuals who may be the victims of it. We suggest a revised definition of stigma that is more simple, precise, and consistent with the empirical literature on stigma; there is stigma if and only if there is labelling, negative stereotyping, linguistic separation, and power asymmetry.

Onset of workplace sexual harassment and subsequent depressive symptoms and incident depressive disorder in the Danish workforce.

BACKGROUND: We studied onset of workplace sexual harassment and subsequent risk of depressive symptoms and depressive disorder. METHODS: We examined 9,981 individuals who participated in the Work Environment and Health in Denmark survey in 2012 and 2014 and 6,647 individuals who also participated in 2016, all unexposed to sexual harassment in 2012. Depressive symptoms and disorder were assessed with the Major Depression Inventory. Using linear regression, we estimated the associations between onset of sexual harassment in the 12 months preceding the 2014 survey and depressive symptoms in 2014 and 2016, respectively. Using logistic regression, we estimated risk of incident depressive disorder in 2014. RESULTS: Onset of sexual harassment was associated with elevated depressive symptoms in 2014, both for harassment by non-workplace personnel (e.g., patients, estimate (B): 1.61, 95% CI: 0.51-2.72, p = 0.004) and workplace personnel (e.g., supervisors, B: 3.85, 95% CI: 2.51-5.20, p < 0.001), after adjustment for depressive symptoms in 2012. Harassment by workplace personnel was further associated with elevated depressive symptoms in 2016 after adjustment for symptoms in 2012, but not after adjustment for symptoms in 2014. Harassment by workplace personnel was associated with incident depressive disorder in 2014 (odds ratio: 5.26, 95% CI: 2.68-10.31, p < 0.001). LIMITATIONS: Depressive symptoms and disorder were assessed with a validated self-administered rating scale but not a clinical diagnostic interview. Participants reporting harassment in 2014 had elevated depressive symptoms already in 2012 requiring future investigation. CONCLUSIONS: Exposure to sexual harassments at the workplace may be a contributing factor in the aetiology of depressive symptoms and disorder.

Exploring Perceptions of Continuity of Care Among People With Long-Term Mental Disorders in Denmark.

Continuity of mental health care is central to improve the treatment and rehabilitation of people with mental disorders. While most studies on continuity of care fail to take the perspectives of service users into account, the aim of this study was to explore the perceived meanings of continuity of care among people with long-term mental disorders. Fifteen service users participated in semi-structured in-depth interviews. We used template analysis to guide the analysis. The main transversal themes of continuity were "Navigating the system" and "Connecting to people and everyday life." While the first theme related to the participants' experiences of their interaction with the mental health care system, the latter related to their hopes and perceived opportunities for a good life as desired outcomes of mental health care. We conclude that efforts to improve continuity of mental health care should be tailored to the priorities of service users.

Workplace sexual harassment and depressive symptoms: a cross-sectional multilevel analysis comparing harassment from clients or customers to harassment from other employees amongst 7603 Danish employees from 1041 organizations.

BACKGROUND: Previous research has reported that sexual harassment can lead to reduced mental health. Few studies have focused on sexual harassment conducted by clients or customers, which might occur in person-related occupations such as eldercare work, social work or customer service work. This study examined the cross-sectional association between sexual harassment by clients or customers and depressive symptoms. We also examined if this association was different compared to sexual harassment conducted by a colleague, supervisor or subordinate. Further, we investigated if psychosocial workplace initiatives modified the association between sexual harassment by clients or customers and level of depressive symptoms. METHODS: We used data from the Work Environment and Health in Denmark cohort study (WEHD) and the Work Environment Activities in Danish Workplaces Study (WEADW) collected in 2012. WEHD is based on a random sample of employed individuals aged 18-64. In WEADW, organizational supervisors or employee representatives provided information on workplace characteristics. By combining WEHD and WEADW we included self-reported information on working conditions and health from 7603 employees and supervisors in 1041 organizations within 5 occupations. Data were analyzed using multilevel regression and analyses adjusted for gender, age, occupation and socioeconomic position. RESULTS: Exposure to workplace sexual harassment from clients or customers was statistically significantly associated with a higher level of depressive symptoms (2.05; 95% CI: 0.98-3.12) compared to no exposure. Employees harassed by colleagues, supervisors or subordinates had a higher mean level of depressive symptoms (2.45; 95% CI: 0.57-4.34) than employees harassed by clients or customers. We observed no statistically significant interactions between harassment from clients and customers and any of the examined psychosocial workplace initiatives (all p > 0.05). CONCLUSIONS: The association between sexual harassment and depressive symptoms differed for employees harassed by clients or customers and those harassed by colleagues, supervisors or subordinates. The results underline the importance of investigating sexual harassment from clients or customers and sexual harassment by colleagues, supervisors or subordinates as distinct types of harassment. We found no modification of the association between sexual harassment by clients or customers and depressive symptoms by any of the examined psychosocial workplace initiatives.

Sexual harassment in care work - Dilemmas and consequences: A qualitative investigation.

BACKGROUND: Care workers are often exposed to sexual harassment from patients. Research shows that such exposure may have detrimental effects on mental health of the care workers. Inappropriate sexual behaviour from patients is a particular challenge for formal and informal care workers alike. There is a scarceness of studies investigating the experience and the handling of sexual harassment from patients. OBJECTIVES: To investigate the experience and handling of sexual harassment from patients in care work. DESIGN: The study follows an explorative qualitative approach based on group interviews (n=19) with 39 care workers. SETTINGS: Ten workplaces participated in the study, including hospitals, nursing homes, community health centres, rehabilitations care centres, and psychiatric residential facilities. PARTICIPANTS: We conducted group interviews with care workers (employees), managers, shop stewards and/or safety representatives. The majority of the interviewees were trained nurses. RESULTS: The interviews revealed that sexual harassment is a complex and multifaceted phenomenon. The care workers often separated between intentional and unintentional behaviours initiated by cognitively impaired patients. Thus, they often refrain from using the term harassment, because it implies that the actions were intentional. However, the interviews revealed that, in practice, this separation was very difficult, and that sexual harassment often creates a range of dilemmas in the daily work. At the same time, sexual harassment is a taboo. The managers, shop stewards and safety representatives in this study were often not aware of the frequency and the impact of the episodes had on the care workers. The workplaces participating in this study, rarely had guidelines or policies for managing and/or preventing sexual harassment or inappropriate sexual behaviours, but often responded to episodes in an ad hoc and case-by-case manner. CONCLUSION: The term sexual harassment might not be appropriate in the context of care work, because many patients who display inappropriate behaviours are cognitively impaired. While the interviews revealed that there is no universally accepted term, it might be more prudent to avoid the term harassment and refer it to as sexual behaviours. Considering the demographic development with a rising number of elderly and the increase in various forms of dementia, the management of inappropriate sexual behaviour by patients will be even more pressing in the future. It is time to address the prevention of sexual harassment and the management of patients' sexuality as an explicit part of the professional organisational culture of care work.

Experiences and attitudes towards end-of-life decisions amongst Danish physicians.

In this survey we have investigated the experiences and attitudes of Danish physicians regarding end-of-life decisions. Most respondents have made decisions that involve hastening the death of a patient, and almost all find it acceptable to do so. Such decisions are made more often, and considered ethically more acceptable, with the informed consent of the patient than without. But both non-resuscitation decisions, and decisions to provide pain relief in doses that will shorten the patient's life, have been made and found acceptable by at least 50% of the respondents, even when there is no informed consent. Furthermore, 12% have doubled morphine dosages with fixed intervals, thus providing doses substantially higher than that necessary to control pain, without the informed consent of the patient. Two percent have helped in assisted suicide, and 5% have administered a lethal injection at the patient's request. Respectively 37% and 34% find these last two practices ethically acceptable. Amongst those that do not find them acceptable, the most important reasons to be opposed are, the doctrine of double effect, the doctrine of doing and allowing, and the view that human life is sacred. Amongst supporters, the most important reasons mentioned are, that the patient's right to self-determination should be respected, the view that a patient should not be forced to suffer, and the view that the patient has a right to be helped to a dignified death.