A Framework for Categorizing Social Interactions Related to End-of-Life Care in Nursing Homes

Purpose: Almost half of people age 85 and older who die annually in the United States die as nursing home residents, yet because it is not always clear who is close to death, not all residents who might benefit from end-of-life care receive it. The purpose of this study is to develop a framework for organizing social interactions related to end-of-life care and to characterize the social construction of dying in two nursing homes. Design: Secondary analysis of qualitative ethnographic data collected before the death of 45 residents who were selected for the study on account of their "declining” health status. Methods: Field notes, medical chart data, and transcribed interviews corresponding to 45 residents in two nursing homes in a large Midwestern city were analyzed using qualitative descriptive methods guided by symbolic interaction and role theory. The data were also grouped by resident to facilitate the development of cases that illustrate the categories of social interactions. A second reader also categorized all the resident cases into one of five categories as a means of verifying the model. Results: A new framework of five categories to name the stance toward the possibility of dying is presented and illustrated with cases. The categories include: dying allowed, dying contested, mixed message dying, not dying, and not enough information. Cases are provided to illustrate the importance of recognizing the impact that social interactions can have on care. Over half the resident cases were classified as mixed message dying or not enough information, which speaks to the ambiguity regarding care plan goals found in the two nursing homes in the study. Implications: Social interactions related to the health care and dying status of a nursing home resident help to construct a social reality, and that social reality can affect the care the nursing home resident receives. Conversations about goals of care, and how these goals will be operationalized are important issues for discussion among residents (to the extent able), family, staff, and physicians. Social interactions, or the lack thereof, matte

Final arrangements following death: Maori indigenous decision making and tangi

Death is a universal event. It will happen to all of us, yet how we respond to death is particular and influenced by our cultural worlds. This study offers an investigation of the idiographic, of how one woman responded to, and made arrangements to, mourn and bury her mother. Specifically, we explore how she and her whanau (family) under pressure of time and grief and in the absence of clear final wishes, met to consider issues and make decisions about the situation they were confronted with. This case forms part of a much larger programme of research into Maori death rituals, change and adaption. Informing a scholarly audience unfamiliar with the Maori world requires a significant amount of contextual information. The case study is a powerful strategy to achieve this and one that draws readers into deep understanding (Willig, 2008). This case provides insight into the struggles of an indigenous fourth-world people living within the heterogeneity of Aotearoa/New Zealand society; it demonstrates how values change across generations as people live their lives increasingly away from their ancestral homelands; and how traditionally defined roles and responsibilities within the whanau (family) are challenged by members living away from each other

Decisions at the end of life: have we come of age?

Decision making is a complex process and it is particularly challenging to make decisions with, or for, patients who are near the end of their life. Some of those challenges will not be resolved - due to our human inability to foresee the future precisely and the human proclivity to change stated preferences when faced with reality. Other challenges of the decision-making process are manageable. This commentary offers a set of approaches which may lead to progress in this field

The nucleotide addition cycle of RNA polymerase is controlled by two molecular hinges in the Bridge Helix domain

Abstract Background Cellular RNA polymerases (RNAPs) are complex molecular machines that combine catalysis with concerted conformational changes in the active center. Previous work showed that kinking of a hinge region near the C-terminus of the Bridge Helix (BH-HC) plays a critical role in controlling the catalytic rate. Results Here, new evidence for the existence of an additional hinge region in the amino-terminal portion of the Bridge Helix domain (BH-HN) is presented. The nanomechanical properties of BH-HN emerge as a direct consequence of the highly conserved primary amino acid sequence. Mutations that are predicted to influence its flexibility cause corresponding changes in the rate of the nucleotide addition cycle (NAC). BH-HN displays functional properties that are distinct from BH-HC, suggesting that conformational changes in the Bridge Helix control the NAC via two independent mechanisms. Conclusions The properties of two distinct molecular hinges in the Bridge Helix of RNAP determine the functional contribution of this domain to key stages of the NAC by coordinating conformational changes in surrounding domains.</p

Older Adults More Likely to Discuss Advance Care Plans With an Attorney Than With a Physician

Adults are encouraged to discuss their end-of-life health care preferences so that their wishes will be known and hopefully honored. The purpose of this study was to determine with whom older adults had communicated their future health care wishes and the extent to which respondents themselves were serving as a surrogate decision maker. Results from the cross-sectional online survey with 294 persons aged 50 and older reveal that among the married, over 80% had a discussion with their spouse and among those with an adult child, close to two thirds (64%) had. Over a third had discussed preferences with an attorney and 23% with a physician. Close to half were currently serving as a surrogate decision maker or had been asked to and had signed papers to formalize their role. 18% did not think that they were a surrogate but were not sure. More education is needed to emphasize the importance of advance care planning with a medical professional, especially for patients with advanced chronic illness. More education and research about the role of surrogate medical decision makers is called for