Medical students and end-of-life decisions: the influence of religion.

The objective of this study was to see if medical students' attitudes about medically assisted dying were influenced by their religious background and current beliefs. A cohort study was conducted using a self-completion study questionnaire in a large UK medical school. In total, 400 out of 505 questionnaires were completed (79%). The study population's characteristics are summarised as follows: mean age 22.7 years (range 18-44); 68.5% believe in god, 31.5% have no belief in god; religious background: Christian 45%, Hindu 16.5%, Muslim 22%, Other 10% and None 7%. The majority of students did not agree with euthanasia and physician-assisted suicide in the study scenario. Those who had a belief in god were more likely to disagree with actions that hasten death. The findings show this was particularly the case with students from a Muslim background. Gender was not related to overall agreement with actions that hasten death; being older, a finalist and a graduate were weakly associated with a greater likelihood of agreeing with such acts. This is an important issue which warrants further enquiry. The demographics of the UK medical population continue to shift, containing a higher proportion of people from Asia and with Asian British backgrounds than the general population. This study provides us with a basis for further exploration of the potential for disparity between the opinions of the UK population and those of medical workers and trainees, and how that might inform decisions about patient care at the end of life.

Administering anticipatory medications in end-of-life care: a qualitative study of nursing practice in the community and in nursing homes.

BACKGROUND: In the United Kingdom, an approach to improving end-of-life care has been the introduction of 'just in case' or 'anticipatory' medications. Nurses are often responsible for deciding when to use anticipatory medications, but little is known about their experiences. AIM: To examine nurses' decisions, aims and concerns when using anticipatory medications. DESIGN: An ethnographic study in two UK regions, using observations and interviews with nurses working in community and nursing home teams (n = 8). FINDINGS: Observations (n = 83) and interviews (n = 61) with community nurses. Nurses identified four 'conditions' that needed to be established before they implemented anticipatory medications: (1) irreversibility; (2) inability to take oral medication; (3) where the patient was able, they should consent and (4) decision had to be independent of demands or requests from patient's relatives. By using anticipation medications, nurses sought to enable patients to be 'comfortable and settled' by provision of gradual relief of symptoms at the lowest dose possible. They aimed to respond quickly to needs, seeking to avoid hospital admission or medical call-out, while adhering to local prescribing policies. Worries included distinguishing between pain and agitation, balancing risks of under- and over-medication and the possibility of hastening death. CONCLUSION: Nurses take a leading role in the administration of anticipatory medications. Nurses apply consideration and caution to the administration of anticipatory medications but some experience emotional burden. Education, training and experience played a role in the nurses' confidence and should continue to be central to efforts to improving the quality of palliative care in the community and nursing homes.

The language of sedation in end-of-life care: The ethical reasoning of care providers in three countries.

The application of ethically controversial medical procedures may differ from one place to another. Drawing on a keyword and text-mining analysis of 156 interviews with doctors and nurses involved in end-of-life care ('care providers'), differences between countries in care providers' ethical rationales for the use of sedation are reported. In the United Kingdom, an emphasis on titrating doses proportionately against symptoms is more likely, maintaining consciousness where possible. The potential harms of sedation are perceived to be the potential hastening of social as well as biological death. In Belgium and the Netherlands, although there is concern to distinguish the practice from euthanasia, rapid inducement of deep unconsciousness is more acceptable to care providers. This is often perceived to be a proportionate response to unbearable suffering in a context where there is also greater pressure to hasten dying from relatives and others. This means that sedation is more likely to be organised like euthanasia, as the end 'moment' is reached, and family farewells are organised before the patient is made unconscious for ever. Medical and nursing practices are partly responses to factors outside the place of care, such as legislation and public sentiment. Dutch guidelines for sedation largely tally with the practices prevalent in the Netherlands and Belgium, in contrast with those produced by the more international European Association for Palliative Care whose authors describe an ethical framework closer to that reportedly used by UK care providers.

A systematic review and meta-synthesis of the impact of low back pain on people's lives.

BACKGROUND: Low back pain (LBP) is a common and costly problem that many interpret within a biopsychosocial model. There is renewed concern that core-sets of outcome measures do not capture what is important. To inform debate about the coverage of back pain outcome measure core-sets, and to suggest areas worthy of exploration within healthcare consultations, we have synthesised the qualitative literature on the impact of low back pain on people's lives. METHODS: Two reviewers searched CINAHL, Embase, PsycINFO, PEDro, and Medline, identifying qualitative studies of people's experiences of non-specific LBP. Abstracted data were thematic coded and synthesised using a meta-ethnographic, and a meta-narrative approach. RESULTS: We included 49 papers describing 42 studies. Patients are concerned with engagement in meaningful activities; but they also want to be believed and have their experiences and identity, as someone 'doing battle' with pain, validated. Patients seek diagnosis, treatment, and cure, but also reassurance of the absence of pathology. Some struggle to meet social expectations and obligations. When these are achieved, the credibility of their pain/disability claims can be jeopardised. Others withdraw, fearful of disapproval, or unable or unwilling to accommodate social demands. Patients generally seek to regain their pre-pain levels of health, and physical and emotional stability. After time, this can be perceived to become unrealistic and some adjust their expectations accordingly. CONCLUSIONS: The social component of the biopsychosocial model is not well represented in current core-sets of outcome measures. Clinicians should appreciate that the broader impact of low back pain includes social factors; this may be crucial to improving patients' experiences of health care. Researchers should consider social factors to help develop a portfolio of more relevant outcome measures.

Continuous sedation until death: the everyday moral reasoning of physicians, nurses and family caregivers in the UK, The Netherlands and Belgium.

BACKGROUND: Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress. METHODS: This study is an international qualitative interview study involving interviews with physicians, nurses, and relatives of deceased patients in the UK, The Netherlands and Belgium (the UNBIASED study) about a case of continuous sedation at the end of life they were recently involved in. All interviews were transcribed verbatim and analysed by staying close to the data using open coding. Next, codes were combined into larger themes and categories of codes resulting in a four point scheme that captured all of the data. Finally, our findings were compared with others and explored in relation to theories in ethics and sociology. RESULTS: The participants' responses can be captured as different dimensions of 'closeness', i.e. the degree to which one feels connected or 'close' to a certain decision or event. We distinguished four types of 'closeness', namely emotional, physical, decisional, and causal. Using these four dimensions of 'closeness' it became possible to describe how physicians, nurses, and relatives experience their involvement in cases of continuous sedation until death. More specifically, it shined a light on the everyday moral reasoning employed by care providers and relatives in the context of continuous sedation, and how this affected the emotional impact of being involved in sedation, as well as the perception of their own moral responsibility. CONCLUSION: Findings from this study demonstrate that various factors are reported to influence the degree of closeness to continuous sedation (and thus the extent to which carers feel morally responsible), and that some of these factors help care providers and relatives to distinguish continuous sedation from euthanasia.

Whole home exercise intervention for depression in older care home residents (the OPERA study): a process evaluation.

BACKGROUND: The 'Older People's Exercise intervention in Residential and nursing Accommodation' (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect. METHODS: The OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known. RESULTS: Homes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises. CONCLUSIONS: The intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms.

Moral mediation in interpreted health care consultations.

This paper reports on the moral work done in routine diabetes review consultations in primary care with nurses. Consultations with fluent English speakers are compared with consultations where an interpreter was present, largely involving patients of Bangladeshi origin. The study setting was Tower Hamlets in London, where type 2 diabetes is particularly common. Existing research has shown some dissatisfaction with diabetes care amongst Bangladeshi patients, and studies of care providers in other locations suggest that they at times experience the care of this group as particularly challenging. Through analysis of video-recorded consultations recorded in 2010-2011 we shed light on possible reasons for these difficulties. The 12 non-English speakers often experienced difficulties in raising issues that concerned them, particularly if their interpreter did not translate their utterance because it was deemed to be unrelated to diabetes. These difficulties were not shared by the 24 fluent English speakers, who also found it easier to convey a positive moral reputation and to excuse behaviour that deviated from recommended self-management practices. Interpreters at times also acted as moral mediators. For example, where a participant in the consultation made statements that appeared to convey a negative moral judgement of an other participant, these would often go untranslated. Probably, neither health care providers nor patients are fully aware of the nature of their communication difficulties. Given this, interpreters possess considerable power to influence matters. Understanding the moral work of consultations is important in explaining the findings of other studies showing difficulties in the provision of diabetes care to people with limited English language skills.

The challenge of communication in interpreted consultations in diabetes care: a mixed methods study.

BACKGROUND: The experience of diabetes care for individuals from minority ethnic groups, particularly individuals of Bangladeshi origin, shows they are at a significant disadvantage. AIM: To identify the challenges of interpreted consultations for healthcare providers and to explain the disadvantage experienced by patients from minority groups who have diabetes. DESIGN AND SETTING: Comparison of 12 interpreted consultations with 24 consultations involving fluent English speakers in four primary healthcare centres in Tower Hamlets, east London, UK. METHOD: Content analysis of video recordings of routine diabetes review consultations in primary care, involving 36 patients, nine nurses or healthcare assistants, and six interpreters. RESULT: Interpreted consultations were as long as same-language consultations but patients said less. The incidence of misunderstandings was similar but patients in interpreted consultations asked fewer questions. Indicators of social distance in interpreted consultations included less humour and less discussion of the patient's feelings or personal circumstances. Patients in interpreted consultations were less likely to raise issues unrelated to diabetes, to discuss their own ideas about health, or to talk about clinical parameters. Providers commonly addressed English-speaking patients directly but usually addressed patients through interpreters using the third person. Interpreters sometimes changed the meaning or did not translate speech, and they added their own comments. CONCLUSION: The findings explain some of the known problems of diabetes care for individuals from ethnic minorities. Effective training for interpreters and care providers is needed to reduce social distance and to facilitate patients' involvement in self-management.

Recruiting ethnic minority participants to a clinical trial: a qualitative study.

OBJECTIVES: To compare the motives and experiences of different ethnic groups participating in a randomised double blind placebo-controlled trial of montelukast in preschool wheeze, and to assess parents' or guardians' understanding of trial procedures and their implications, including the collection of genetic material. DESIGN: Qualitative interviews with parents or guardians. SETTING: Interviews occurred in the homes of London children recruited to a national multicentre clinical trial following primary and secondary care attendance with wheeze. PARTICIPANTS: 42 parents (20 of Bangladeshi origin, 10 white UK, 12 other ethnicities) of preschool children enrolled in a clinical trial. RESULTS: Bangladeshi families were relatively reluctant to participate in the qualitative study, despite strong engagement with the parent study. Anxiety related to wheezing was a common primary motive for trial enrolment. Parents viewed the trial as a route to improved treatment. Verbal delivery of trial information appeared more effective than study literature, especially for Bangladeshi families, with low parental literacy and high levels of trust in medical professionals potential contributors to this effect. All ethnic groups expressed a low understanding and/or retention of essential study concepts such as randomisation and genetic testing. CONCLUSIONS: Bangladeshi families are particularly motivated to participate in clinical trials despite variable comprehension of study concepts. This motivation is more strongly contingent on strong researcher-subject rapport than on the quality of study literature. Trial teams seeking to recruit from South Asian populations should emphasise face-to-face verbal explanation of trial concepts and procedures and consider modified trial literature.

News media coverage of euthanasia: a content analysis of Dutch national newspapers.

BACKGROUND: The Netherlands is one of the few countries where euthanasia is legal under strict conditions. This study investigates whether Dutch newspaper articles use the term 'euthanasia' according to the legal definition and determines what arguments for and against euthanasia they contain. METHODS: We did an electronic search of seven Dutch national newspapers between January 2009 and May 2010 and conducted a content analysis. RESULTS: Of the 284 articles containing the term 'euthanasia', 24% referred to practices outside the scope of the law, mostly relating to the forgoing of life-prolonging treatments and assistance in suicide by others than physicians. Of the articles with euthanasia as the main topic, 36% described euthanasia in the context of a terminally ill patient, 24% for older persons, 16% for persons with dementia, and 9% for persons with a psychiatric disorder. The most frequent arguments for euthanasia included the importance of self-determination and the fact that euthanasia contributes to a good death. The most frequent arguments opposing euthanasia were that suffering should instead be alleviated by better care, that providing euthanasia can be disturbing, and that society should protect the vulnerable. CONCLUSIONS: Of the newspaper articles, 24% uses the term 'euthanasia' for practices that are outside the scope of the euthanasia law. Typically, the more unusual cases are discussed. This might lead to misunderstandings between citizens and physicians. Despite the Dutch legalisation of euthanasia, the debate about its acceptability and boundaries is ongoing and both sides of the debate are clearly represented.

'The blue one takes a battering' why do young adults with asthma overuse bronchodilator inhalers? A qualitative study.

OBJECTIVE: Overuse of short-acting bronchodilators is internationally recognised as a marker of poor asthma control, high healthcare use and increased risk of asthma death. Young adults with asthma commonly overuse short-acting bronchodilators. We sought to determine the reasons for overuse of bronchodilator inhalers in a sample of young adults with asthma. DESIGN: Qualitative study using a purposive extreme case sample. SETTING: A large urban UK general practice. PARTICIPANTS: Twenty-one adults with moderate asthma, aged 20-32 years. Twelve were high users of short-acting bronchodilators, nine were low users. RESULTS: Asthma had a major impact on respondents' lives, disrupting their childhood, family life and career opportunities. High users of short-acting bronchodilators had adapted poorly to having asthma and expressed anger at the restrictions they experienced. Overuse made sense to them: short-acting bronchodilators were a rapid, effective, cheap 'quick-fix' for asthma symptoms. High users had poorer control of asthma and held explanatory models of asthma which emphasised short-term relief via bronchodilation over prevention. Both high and low users held strong views about having to pay for asthma medication, with costs cited as a reason for not purchasing anti-inflammatory inhalers. CONCLUSIONS: Young adults who were high users of short-acting bronchodilators had adapted poorly to having asthma and had poor asthma control. They gave coherent reasons for overuse. Strategies that might address high bronchodilator use in young adults include improving education to help young people accept and adapt to their illness, reducing stigmatisation and providing free asthma medication to encourage the use of anti-inflammatory inhalers.

Communication about adherence to long-term antipsychotic prescribing: an observational study of psychiatric practice.

PURPOSE: Partial or non-adherence is common in people taking antipsychotic medication. A good therapeutic alliance is thought by psychiatrists to encourage engagement with a service and improve adherence. This paper aims to examine how psychiatrists and patients communicate in outpatient consultations about partial or non-adherence to antipsychotic prescribing. METHODS: Ninety-two outpatient consultations involving patients prescribed antipsychotic medication and their psychiatrists were tape recorded. Parts of consultations where partial/non-adherence to antipsychotic medication was discussed were analysed using conversation analysis. RESULTS: In 22 (24 %) consultations, partial/non-adherence was disclosed. Most commonly, it was volunteered without prompting and was more likely to be presented as a deliberate choice than omission by the patient. Psychiatrists responded to all but one disclosure, and patients delivered their reports in ways that minimised the prospect of this response being disciplinary. The most common outcome was a change in prescribing: a medication omission, swap or dosage reduction. CONCLUSIONS: Patients and psychiatrists work together to create a safe conversational environment in which to discuss this potentially difficult issue. Unlike previous studies of patient reports of psychotic symptoms and side effects of drowsiness being ignored, psychiatrists nearly always respond to disclosures of partial/non-adherence. Psychiatrists should apply the same listening skills to patients' disclosures of troubling side effects and psychotic symptoms.

Financial incentives to encourage healthy behaviour: an analysis of U.K. media coverage.

BACKGROUND: Policies to use financial incentives to encourage healthy behaviour are controversial. Much of this controversy is played out in the mass media, both reflecting and shaping public opinion. OBJECTIVE: To describe U.K. mass media coverage of incentive schemes, comparing schemes targeted at different client groups and assessing the relative prominence of the views of different interest groups. DESIGN: Thematic content analysis. SUBJECTS: National and local news coverage in newspapers, news media targeted at health-care providers and popular websites between January 2005 and February 2010. SETTING: U.K. mass media. RESULTS: The study included 210 articles. Fifteen separate arguments favourable towards schemes, and 19 unfavourable, were identified. Overall, coverage was more favourable than unfavourable, although most articles reported a mix of views. Arguments about the prevalence and seriousness of the health problems targeted by incentive schemes were uncontested. Moral and ethical objections to such schemes were common, focused in particular on recipients such as drug users or the overweight who were already stereotyped as morally deficient, and these arguments were largely uncontested. Arguments about the effectiveness of schemes and their potential for benefit or harm were areas of greater contestation. Government, public health and other health-care provider interests dominated favourable coverage; opposition came from rival politicians, taxpayers' representatives, certain charities and from some journalists themselves. CONCLUSIONS: Those promoting incentive schemes for people who might be regarded as 'undeserving' should plan a media strategy that anticipates their public reception.

Altruism and participation in longitudinal health research? Insights from the Whitehall II Study.

Research that follows people over a period of time (longitudinal or panel studies) is important in understanding the ageing process and changes over time in the lives of older people. Older people may choose to leave studies due to frailty, or illness and this may diminish the value of the study. However, people also drop out of studies for other reasons and understanding the motivation behind participation or drop out may prevent further loss of valuable longitudinal information and assist the continuation of longitudinal studies. This paper examines qualitative data from interviews and focus groups in 2003/2008 with participants of the Whitehall II Study (based at UCL), and investigates reasons participants give for participating in longitudinal health studies, and recommendations they give for encouraging continued participation as they grow older. A total of 28 participants and 14 staff were interviewed, and 17 participants took part in focus groups. Our findings are discussed in the light of the debate between of altruism and reciprocity. Rather than being wholly motivated by altruism, as research staff had assumed, participants were motivated by the benefits they perceived, particularly the information and care received during the medical examinations and the sense of loyalty and membership associated with being part of the study. Our findings support the view that far from being primarily motivated by altruism, research participation in studies such as this may also involve a degree of implicit and explicit reciprocity. However, participants disliked the obligation to complete the study questionnaires--which may have influenced the expectation of payment or reciprocation, as participation was not wholly pleasing. To try and maintain participation in longitudinal health studies this project recommended gathering information from exit interviews as a way of preventing further withdrawals and closer involvement of participants through a user panel.

Predictors of two forms of attrition in a longitudinal health study involving ageing participants: an analysis based on the Whitehall II study.

BACKGROUND: Longitudinal studies are crucial providers of information about the needs of an ageing population, but their external validity is affected if partipants drop out. Previous research has identified older age, impaired cognitive function, lower educational level, living alone, fewer social activities, and lower socio-economic status as predictors of attrition. METHODS: This project examined attrition in participants of the Whitehall II study aged between 51-71 years, using data from questionnaires participants have completed biennially since 1985 when the study began. We examine the possibility of two distinct forms of attrition--non-response and formally requesting to withdraw--and whether they have different predictors. Potential predictors were age, gender, marital status, occupational grade, retirement, home ownership, presence of longstanding illness, SF-36 quality of life scores, social participation and educational level comparing participants and those who had withdrawn from the study. RESULTS: The two forms of attrition share many predictors and are associated but remain distinct. Being older, male, having a lower job grade, not being a home owner, not having a long standing illness, having higher levels of education, and not having retired, were all associated with a greater probability of non-response; being married was associated with higher probability in women and lower in men. Being older, male, having a lower job grade, not being a home owner, having lower SF-36 scores, taking part in fewer social activities, and not having a long standing illness, were all associated with greater probability of withdrawal. CONCLUSIONS: The results suggest a strong gender effect on both routes not previously considered in analyses of attrition. Investigators of longitudinal studies should take measures to retain older participants and lower level socio-economic participants, who are more likely to cease participating. Recognition should be given to the tendency for people with health problems to be more diligent participants in studies with a medical screening aspect, and for those with lower socio-economic status (including home ownership), quality of life and social participation, to be more likely to request withdrawal. Without taking these features into account, bias and loss of power could affect statistical analyses.

The practice of continuous deep sedation until death in Flanders (Belgium), the Netherlands, and the U.K.: a comparative study.

CONTEXT: Existing empirical evidence shows that continuous deep sedation until death is given in about 15% of all deaths in Flanders, Belgium (BE), 8% in The Netherlands (NL), and 17% in the U.K. OBJECTIVES: This study compares characteristics of continuous deep sedation to explain these varying frequencies. METHODS: In Flanders, BE (2007) and NL (2005), death certificate studies were conducted. Questionnaires about continuous deep sedation and other decisions were sent to the certifying physicians of each death from a stratified sample (Flanders, BE: n=6927; NL: n=6860). In the U.K. in 2007-2008, questionnaires were sent to 8857 randomly sampled physicians asking them about the last death attended. RESULTS: The total number of deaths studied was 11,704 of which 1517 involved continuous deep sedation. In Dutch hospitals, continuous deep sedation was significantly less often provided (11%) compared with hospitals in Flanders, BE (20%) and the U.K. (17%). In U.K. home settings, continuous deep sedation was more common (19%) than in Flanders, BE (10%) or NL (8%). In NL in both settings, continuous deep sedation more often involved benzodiazepines and lasted less than 24 hours. Physicians in Flanders combined continuous deep sedation with a decision to provide physician-assisted death more often. Overall, men, younger patients, and patients with malignancies were more likely to receive continuous deep sedation, although this was not always significant within each country. CONCLUSION: Differences in the prevalence of continuous deep sedation appear to reflect complex legal, cultural, and organizational factors more than differences in patients' characteristics or clinical profiles. Further in-depth studies should explore whether these differences also reflect differences between countries in the quality of end-of-life care.

Learning to manage COPD: a qualitative study of reasons for attending and not attending a COPD-specific self-management programme.

The aim of this article is to understand the reasons for attending a chronic obstructive pulmonary disease (COPD)-specific self-management (SM) programme and how attendance at such programmes might be improved. A total of 20 qualitative semistructured interviews were carried out with patients and with lay programme tutors involved in the Better Living with Long term Airways disease (BELLA) pilot trial. Thematic framework data analysis was used. Common reasons for participant attendance arising from patients and tutors include (1) desire to learn about SM, (2) social benefits of meeting others with COPD and (3) altruism. Patients' reasons for poor attendance include (1) being too ill or not feeling ill enough and (2) practical, physical and emotional barriers. Tutor's explanations for patients' poor attendance were (1) failure to accept their condition, (2) fear of making a change, (3) lack of adequate support, (4) guilt about smoking and (5) the 'scripted' nature of the course. Suggestions for improving programme participation included (1) having choice of several start dates, (2) minimal delay inviting participant onto courses, (3) planning for 'special needs'. Participation may be better amongst those who have accepted their condition or who are motivated towards improving their condition or to help others. Providing solutions for practical barriers may improve participation. However, alternatives to group-based interventions need to be developed for people with functional and emotional barriers to attendance.

Attitudes to participation in a lung cancer screening trial: a qualitative study.

BACKGROUND: Earlier diagnosis of lung cancer is key to reducing mortality. New evidence suggests that smokers have negative attitudes to screening and participation in lung cancer screening trials is poor (<1 in 6 of those eligible). Understanding participation is important since uptake in screening trials is likely to predict uptake in screening programmes. A qualitative study of people accepting and declining participation in the Lung-SEARCH screening trial was conducted. Two questions were addressed: Are the screening methods offered acceptable to patients? Why do some people take part and others decline? METHODS: The qualitative study used semi-structured interviews with 60 respondents from three groups: (a) trial participants providing an annual sputum sample; (b) trial participants with a sputum sample showing abnormal cytology and thus undergoing annual CT scanning and bronchoscopy; and (c) those declining trial participation. RESULTS: Most respondents (48/60, 80%) viewed sputum provision, CT scanning and bronchoscopy as largely acceptable. Those declining trial participation described fear of bronchoscopy, inconvenience of travelling to hospitals for screening investigations and perceived themselves as having low susceptibility to lung cancer or being too old to benefit. Patients declining participation discounted their risk from smoking and considered negative family histories and good health to be protective. Four typological behaviours emerged within those declining: 'too old to be bothered', 'worriers', 'fatalists' and 'avoiders'. CONCLUSION: Sputum provision, CT scanning and bronchoscopy are largely acceptable to those participating in a screening trial. However, the decision to participate or decline reflects a complex balance of factors including acceptability and convenience of screening methods, risk perception, altruism and self-interest. Improving practical and changing cognitive aspects of participation will be key to improving uptake of lung cancer screening.

How pressure is applied in shared decisions about antipsychotic medication: a conversation analytic study of psychiatric outpatient consultations.

The professional identity of psychiatry depends on it being regarded as one amongst many medical specialties and sharing ideals of good practice with other specialties, an important marker of which is the achievement of shared decision-making and avoiding a reputation for being purely agents of social control. Yet the interactions involved in trying to achieve shared decision-making are relatively unexplored in psychiatry. This study analyses audiotapes of 92 outpatient consultations involving nine consultant psychiatrists focusing on how pressure is applied in shared decisions about antipsychotic medication. Detailed conversation analysis reveals that some shared decisions are considerably more pressured than others. At one end of a spectrum of pressure are pressured shared decisions, characterised by an escalating cycle of pressure and resistance from which it is difficult to exit without someone losing face. In the middle are directed decisions, where the patient cooperates with being diplomatically steered by the psychiatrist. At the other extreme are open decisions where the patient is allowed to decide, with the psychiatrist exerting little or no pressure. Directed and open decisions occurred most frequently; pressured decisions were rarer. Patient risk did not appear to influence the degree of pressure applied in these outpatient consultations.

Eating disorders in the media: The changing nature of UK newspaper reports.

OBJECTIVE: Concern has been expressed about the adequacy of media reporting about eating disorders (EDs) and the impact of this on public understanding. We analyse messages about EDs in UK newspapers, comparing these with US news reports, and show changes over time and between types of newspaper. METHOD: Three thousand five hundred and eighty-three national press news articles were analysed using content and keyword analysis. RESULTS: UK press coverage presents a more realistic clinical picture than US coverage. Profiling people with EDs, popular 'tabloid' newspapers give more details of clinical complications than serious 'broadsheet' newspapers, which focus more on research stories and public health concerns. The association of EDs with young, white, female 'celebrities' is constant over time, but medical views about causation and treatment are more prominent in later years. CONCLUSION: Popular journalists pursue an entertainment agenda for their reporting of health stories and this study shows both the constraints and public education opportunities provided by this genre.