A Qualitative Pilot Study of the Perceptions in Older Adults with End-Stage Kidney Disease on Hemodialysis.

BACKGROUND: Little is known about the perceptions of older adults with end-stage kidney disease (ESKD) on chronic hemodialysis (HD) even though this could potentially influence how treatment is received. This study explores the perceptions of older adults with ESKD on HD, specifically their decision to initiate HD, preconceptions and expectations of HD, perceived difficulties with HD, and coping strategies. DESIGN: Cross-sectional. SETTING: Outpatient chronic dialysis units. PARTICIPANTS: Older adults with ESKD on HD. INTERVENTION: Open-ended interviews were conducted with 15 participants. Inclusion criteria were age 60 years and older, HD duration of at least three months, and ability to consent and participate in the interview process. RESULTS: We report on four identified domains: decision to initiate HD; preconceptions and expectations of HD; drawback of HD; and coping strategies. All participants were reluctant to initiate HD, but made the decision on advice from their physicians for varying reasons. Trust in physicians' opinions also played a role for some. Some participants had positive preconceptions of HD, while a few had negative preconceptions or unrealistic expectations. Even though the majority of participants identified several difficulties with being on HD, they also had positive coping strategies, and the majority indicated that they would make the same decision to initiate HD. CONCLUSION: As clinicians are turning more to patient-centered medicine, understanding patients' perceptions of HD is of crucial importance. Our study highlights the importance of improving pre-hemodialysis education to ensure that patients' expectations are realistic, as well as identifying individualized coping strategies by patients.

Stories of Growth and Wisdom: A Mixed-Methods Study of People Living Well With Pain.

Chronic pain remains a daunting clinical challenge, affecting 30% of people in the United States and 20% of the global population. People meeting this challenge by achieving wellbeing while living with pain are a virtually untapped source of wisdom about this persistent problem. Employing a concurrent mixed-methods design, we studied 80 people living with chronic pain with "positive stories to tell" using semi-structured interviews and standardized questionnaires. In-depth interviews focused on what helped, what hindered, how they changed, and advice for others in similar circumstances. Major qualitative themes included acceptance, openness, self-efficacy, hope, perseverance, self-regulation, kinesthetic awareness, holistic approaches and integrative therapies, self-care, spirituality, social support, and therapeutic lifestyle behaviors such as music, writing, art, gardening, and spending time in nature. Themes of growth and wisdom included enhanced relationships, perspective, clarity, strength, gratitude, compassion, new directions, and spiritual change. Based on narrative analysis of the interviews and Ardelt's Three-Dimensional Wisdom Model, participants were divided into 2 groups: 59 wisdom exemplars and 21 nonexemplars. Non-exemplar themes were largely negative and in direct contrast to the exemplar themes. Quantitatively, wisdom exemplars scored significantly higher in Openness and Agreeableness and lower in Neuroticism compared to non-exemplars. Wisdom exemplars also scored higher in Wisdom, Gratitude, Forgiveness, and Posttraumatic Growth than nonexemplars, and more exemplars used integrative therapies compared to the non-exemplars. As a whole, the exemplar narratives illustrate a Positive Approach Model (PAM) for living well with pain, which allows for a more expansive pain narrative, provides positive role models for patients and clinicians, and contributes to a broader theoretical perspective on persistent pain.

El dolor crónico sigue siendo un desafío clínico abrumador, que afecta al 30 % de las personas de los Estados Unidos y al 20 % de la población mundial. Las personas que se enfrentan a este reto logrando bienestar mientras conviven con el dolor son una fuente prácticamente sin explotar de sabiduría sobre este persistente problema. Empleando un diseño concurrente de métodos mixtos, hemos estudiado a 80 personas que viven con dolor crónico con "historias positivas que contar" usando entrevistas semiestructuradas y cuestionarios estándar. Las entrevistas en profundidad se centraron en qué les ayudó, qué les ocasionó dificultades, cómo han cambiado y en consejo para otras personas en circunstancias similares. Los principales temas cualitativos incluían la aceptación, la apertura, la confianza en sus capacidades, la esperanza, la perseverancia, la autorregulación, la conciencia propioceptiva, los enfoques psicosomáticos y los tratamientos integrales, el cuidado propio, la espiritualidad, el apoyo social y los comportamientos del estilo de vida terapéutico como la música, la escritura, el arte, la jardinería y pasar tiempo en la naturaleza. Los temas de crecimiento y sabiduría incluían relaciones más estrechas, perspectiva, claridad, fuerza, gratitud, compasión, nuevos rumbos y cambio espiritual. Basándonos en el análisis de los informes de las entrevistas y en el paradigma de sabiduría de tres dimensiones de Ardelt, se dividieron a los participantes en 2 grupos: 59 modelos de sabiduría y 21 no modelos de sabiduría. Los temas no modelo eran mucho más negativos y estaban en directo contraste con los temas modelo. Cuantitativamente, los modelos de sabiduría obtuvieron una puntuación significativamente más alta en apertura y amabilidad y más baja en neuroticismo en comparación con los no modelo. Los modelos de sabiduría también puntuaron más alto en sabiduría, gratitud, perdón y crecimiento postraumático que los no modelos y más modelos usaron tratamientos integrales en comparación con los no modelos. En conjunto, los informes de los modelos ilustran un modelo de enfoque positivo para vivir bien con el dolor, que permite informes de dolor más comunicativos, proporciona modelos de rol positivos para los pacientes y médicos y contribuye a una perspectiva teorética más amplia acerca del dolor persistente.

Wisdom in Medicine: What Helps Physicians After a Medical Error?

PURPOSE: Confronting medical error openly is critical to organizational learning, but less is known about what helps individual clinicians learn and adapt positively after making a harmful mistake. Understanding what factors help doctors gain wisdom can inform educational and peer support programs, and may facilitate the development of specific tools to assist doctors after harmful errors occur. METHOD: Using "posttraumatic growth" as a model, the authors conducted semistructured interviews (2009-2011) with 61 physicians who had made a serious medical error. Interviews were recorded, professionally transcribed, and coded by two study team members (kappa 0.8) using principles of grounded theory and NVivo software. Coders also scored interviewees as wisdom exemplars or nonexemplars based on Ardelt's three-dimensional wisdom model. RESULTS: Of the 61 physicians interviewed, 33 (54%) were male, and on average, eight years had elapsed since the error. Wisdom exemplars were more likely to report disclosing the error to the patient/family (69%) than nonexemplars (38%); P < .03. Fewer than 10% of all participants reported receiving disclosure training. Investigators identified eight themes reflecting what helped physician wisdom exemplars cope positively: talking about it, disclosure and apology, forgiveness, a moral context, dealing with imperfection, learning/becoming an expert, preventing recurrences/improving teamwork, and helping others/teaching. CONCLUSIONS: The path forged by doctors who coped well with medical error highlights specific ways to help clinicians move through this difficult experience so that they avoid devastating professional outcomes and have the best chance of not just recovery but positive growth.

Screening for substance abuse risk in cancer patients using the Opioid Risk Tool and urine drug screen.

PURPOSE: The use of opioids for management of cancer-related pain has increased significantly and has been associated with a substantial rise in rates of substance abuse and diversion. There is a paucity of data not only on the prevalence of substance abuse in cancer patients, but also for issues of drug use and diversion in family caregivers. This study aimed to evaluate the frequency of risk factors for substance abuse and diversion, and abnormal urine drug screens in cancer patients receiving palliative care. METHODS: A retrospective chart review was performed for patients with cancer who were seen in the University of Virginia Palliative Care Clinic during the month of September 2012. We evaluated Opioid Risk Tool variables and total scores, insurance status, and urine drug screen results. RESULTS: Of the 114 cancer patients seen in September 2012, the mean Opioid Risk Tool score was 3.79, with 43% of patients defined as medium to high risk. Age (16-45 years old, 23%) and a personal history of alcohol (23%) or illicit drugs (21%) were the most common risk factors identified. We obtained a urine drug screen on 40% of patients, noting abnormal findings in 45.65%. CONCLUSIONS: Opioids are an effective treatment for cancer-related pain, yet substantial risk for substance abuse exits in the cancer population. Screening tools, such as the Opioid Risk Tool, should be used as part of a complete patient assessment to balance risk with appropriate relief of suffering.

Wisdom through adversity: learning and growing in the wake of an error.

OBJECTIVE: Medical errors are a nearly universal experience for physicians. An error that harms a patient is one of the most difficult experiences that physicians face. Difficult experiences can result in growth. This study investigates how physicians coped positively with having made a serious mistake. This paper describes common elements identified in how physicians coped positively with these difficult circumstances, and the positive ways in which they learned and changed. METHODS: Physicians were recruited nationally through advertisement and word of mouth. Researchers conducted in-depth interviews with 61 physicians who had made a serious medical error. Verbatim transcripts were analyzed using a grounded theory approach and constant comparative analysis methodology. RESULTS: Our analysis identified five major elements in the process of coping positively with the experience of a serious medical error. These elements included acceptance, stepping in, integration, new narrative and wisdom. Subthemes further detail the content within each element. CONCLUSION: This study provides evidence that the experience of coping with a serious mistake can be formative in a positive way for physicians and provides a "roadmap" for growth through this experience. PRACTICE IMPLICATIONS: The profession must now seek ways to foster the development of wisdom out of these difficult experiences.

The quantification of placebo effects within a general model of health care outcomes.

OBJECTIVES: The objective of this study was to test a model of placebo effects in the context of a general model of health care outcomes. DESIGN: The design of this study was a multisite, double-blind, placebo-controlled crossover trial. SETTINGS: The study was conducted at The University of Washington Hospital, Seattle, Washington, Cooper Hospital/University Medical Center, Camden, New Jersey, and at the Neurology Center of Fairfax, Fairfax, Virginia. SUBJECTS: One hundred and seventeen (117) patients diagnosed with Multiple Sclerosis were enrolled in the study. INTERVENTION: Subjects had daily exposure to a pulsing electromagnetic generator. OUTCOME MEASURES: The outcome measures were the average score of three quality-of-life indices: the Modified Fatigue Impact Scale, the Medical Outcomes Study Pain Effects Scale, and the Spasticity Effects Scale. RESULTS: Placebo responders scored higher in the personality trait of Absorption compared with nonresponders (p<0.01). Placebo responders were more confident that the sham device was active compared to placebo nonresponders (p<0.009). The two factors of confidence in the treatment and Absorption accurately identified 80% of placebo responders in a discriminant analysis (p<0.0004). CONCLUSIONS: Placebo effects are best understood when integrated in a general model of health care outcomes.

A pilot study of qigong practice and upper respiratory illness in elite swimmers.

Upper respiratory tract infections (URIs) are a common complaint in competitive swimmers and can adversely affect performance. No intervention has yet been shown to reduce URI incidence in intensively trained athletes. The University of Virginia varsity swim team received three weeks of training in qigong for the purpose of reducing stress and improving health. Our primary objective was to assess the relationship between qigong practice and symptoms of URI during a time when swimmers would be at high URI risk. Secondary objectives were to assess degree of compliance with a qigong practice regimen, to evaluate differences between qigong practitioners and non-practitioners, and to determine the response-rate and reliability of a newly developed internet-based, self-report survey. The design was observational, cross-sectional, and prospective. Weekly data on cold and flu symptoms, concurrent health problems and medication use, and qigong practice were gathered for seven weeks. Retrospective information on health and qigong training response was also collected. Participants were 27 of the 55 members of the University of Virginia Swim Team in the Virginia Athletic Department. Main outcomes were measures of aggregated cold/flu symptoms and Qigong practice. Survey completion was 100%, with no missing data, and reliability of the instrument was acceptable. Cold and flu symptoms showed a significant non-linear association with frequency of qigong practice (R(2) = 0.33, p < 0.01), with a strong, inverse relationship between practice frequency and symptom scores in swimmers who practised qigong at least once per week (R(2) = 0.70, p < 0.01). Qigong practitioners did not differ from non-practitioners in demographic or lifestyle characteristics, medical history, supplement or medication use, or belief in qigong. These preliminary findings suggest that qigong practice may be protective against URIs among elite swimmers who practice at least once per week.

A pilot study evaluating mindfulness-based stress reduction and massage for the management of chronic pain.

BACKGROUND: Mindfulness-based stress reduction (MBSR) and massage may be useful adjunctive therapies for chronic musculoskeletal pain. OBJECTIVE: To evaluate the feasibility of studying MBSR and massage for the management of chronic pain and estimate their effects on pain and mood. DESIGN: Randomized trial comparing MBSR or massage with standard care. PARTICIPANTS: Thirty patients with chronic musculoskeletal pain. MEASUREMENTS: Pain was assessed with 0 to 10 numeric rating scales. Physical and mental health status was measured with the SF-12. RESULTS: The study completion rate was 76.7%. At week 8, the massage group had average difference scores for pain unpleasantness of 2.9 and mental health status of 13.6 compared with 0.13 (P<.05) and 3.9 (P<.04), respectively, for the standard care group. These differences were no longer significant at week 12. There were no significant differences in the pain outcomes for the MBSR group. At week 12, the mean change in mental health status for the MBSR group was 10.2 compared with -1.7 in the standard care group (P<.04). CONCLUSIONS: It is feasible to study MBSR and massage in patients with chronic musculoskeletal pain. Mindfulness-based stress reduction may be more effective and longer-lasting for mood improvement while massage may be more effective for reducing pain.

The short-term effect of interdisciplinary medication review on function and cost in ambulatory elderly people.

OBJECTIVES: To determine whether a medication review by a specialized team would promote regimen changes in elders taking multiple medications and to measure the effect of regimen changes on monthly cost and functioning. DESIGN: A randomized-controlled trial. SETTING: Health center ambulatory clinic. PARTICIPANTS: Community-dwelling older adults taking five or more medications were assessed at baseline and 6 weeks. A medication-change intervention group of 57 elders was compared with a control group of 76 elder adults. INTERVENTION: The primary intervention was a comprehensive review and recommended modification of a patient's medication regimen. Changes were endorsed by each patient's primary physician and discussed with each patient. MEASUREMENTS: Measures were the Timed Manual Performance Test, Physical Performance Test, Functional Reach Assessment, subtests from the Wechsler Adult Intelligence Scale, a modified Randt Memory Test, the Center for Epidemiological Studies-Depression Scale, the Self-Rating Anxiety Scale, and the Rand 36-item Health Survey 1.0. Comorbidity was determined using the International Classification of Diseases, Ninth Revision, Clinical Modification. Medication usage was determined using brown bag review. RESULTS: Intervention subjects decreased their medications by an average of 1.5 drugs. No differences in functioning were observed between groups. Intervention subjects saved an average $26.92 per month in wholesale medication costs; control subjects saved $6.75 per month (P<.006). CONCLUSION: Although the intervention significantly reduced the medications taken and monthly cost, most patients were resistant to reducing medications to the recommended level. Further study is needed to understand patient resistance to reducing adverse polypharmacy and to devise better strategies for addressing this important problem in geriatric health. Greater focus on prescriber behavior is recommended.

A new approach to assessing function in elderly people.

Current functional assessment methods and measures of elderly people are limited in their ability to detect small decrements in function or in discriminating between different patterns of functional loss. Nor do they directly assess function in the patient's usual environment. Recent technological advances have led to the development of small, wearable microelectronic devices that detect motion, velocity and acceleration. These devices can be used to develop new tools for more precise monitoring, assessment, and prediction of function by characterizing the 'electronic signatures' of successful or unsuccessful task-specific performance, and to allow for continuous assessment in a home environment. This presentation will summarize current efforts to translate new technologies into a clinical and research tool for improved assessment, monitoring, and prediction of function among older individuals.