Beyond Advance Directives: Addressing Communication Gaps and Caregiving Challenges at Life's End.

Context: The premise of advance directives and care planning is to help people articulate and document their wishes so surrogate decision-makers and providers can honor them. However, beyond the completion of such a document, underlying challenges are often unaddressed OBJECTIVES: The overall purpose of the study was to investigate how communication, including but not limited to the completion of advance directives, and caregiving influenced family caregivers' experiences. Communication gaps and caregiving challenges that were unaddressed by advance directives are presented.

Prehospital Providers' Perspectives about Online Medical Direction in Emergency End-of-Life Decision-Making.

End-of-life treatment decisions present special challenges for prehospital emergency providers. Paramedics regularly make value-laden choices that transcend technical judgment and professional skill, affecting the type of care, how and to whom it is provided. Changes in prehospital emergency care over the last decade have created new moral challenges for prehospital emergency providers; these changes have also accentuated the need for paramedics to make rapid and reasoned ethical judgments.

Navigating the Transition from Advanced Illness to Bereavement: How Provider Communication Informs Family-related Roles and Needs.

Person-centered, family-oriented services are integral to palliative and end-of-life care. Effective communication with providers informs the quality of the dying experience for patients and how families fare in bereavement. This paper reports findings from a study exploring how communication and care in the later stages of an advanced illness influence family caregivers' well-being in bereavement.

Managing Death in the Field: Prehospital End-of-Life Care.

Context: Historically, the focus of prehospital care has been life-saving treatment. In the absence of a nonhospital do-not-resuscitate (DNR) order, prehospital providers have been compelled to begin and continue resuscitation unless or until it was certain that the situation was futile; they have faced conflict when caregivers objected.

Objectives: The purpose of the study was to explore prehospital providers' perspectives on how legally binding documents (nonhospital DNR order/medical orders for life-sustaining treatment) informed end-of-life decision making and care.

"I want to go home": How location at death influences caregiver well-being in bereavement.

Objectives: Goal concordant or congruent care involves having expressed wishes upheld. Yet, the preferred location for end-of-life care may be unaddressed. Caregiver-patient congruence between preferred and actual locations of care may influence the quality of life in bereavement.

Transport Home and Terminal Extubation by Emergency Medical Services: An Example of Innovation in End-of-Life Care.

For most terminally ill patients, the preferred place of death is home. Previous literature has demonstrated the feasibility of at-home terminal extubation performed by critical care and hospice physicians. This case report describes a terminal extubation performed by a paramedic under the direct supervision of an Emergency Medical Services physician in the patient's home.

Defining Core Competencies for Generalist-Level Palliative Social Work.

Context: Care provided to seriously ill patients by frontline social workers is a component of generalist-level palliative care. The core competencies for high-quality generalist-level palliative social work are necessary to promote training curricula and best practices but have not yet been defined in the U.S.

Decision-Making in the Moments Before Death: Challenges in Prehospital Care.

Background: The primary charge of Emergency Medical Services (EMS) is to save lives. However, EMS personnel are frequently called to scenes where prolonging life may not be the primary goal. When someone is nearing death, family members may feel compelled to call 9-1-1 because they are feeling uncertain about how to manage symptoms at the end of life.

Mediating Systems of Care: Emergency Calls to Long-Term Care Facilities at Life's End.

Background: Nursing home (NH) residents account for over 2.2 million emergency department visits yearly; the majority are cared for and transported by prehospital providers (emergency medical technicians and paramedics).

Objective: The purpose of this study was to investigate prehospital providers' perceptions of emergency calls at life's end.

Changing Focus: End-of-Life Care in a New York State Managed Long-Term Care Program.

In the United States, managed long-term care programs offer a noninstitutional approach to meeting the needs of increasing numbers of frail elders. Providing services that support both quality of life and quality of dying poses unique challenges. Using a qualitative descriptive design, we explored these challenges from the perspectives of care providers.

The Nexus Between the Documentation of End-of-Life Wishes and Awareness of Dying: A Model for Research, Education and Care.

The convergence of medical treatment that can extend life with written medical orders that make it possible to refuse such treatment brings the differential dynamics of contemporary end-of-life decision making into sharp focus. Communication between families and clinicians can be confusing, uncertain, and pressured when death is imminent. These situations create distress that ultimately influences the end-of-life experience for people who are dying and those who care for them.

Emergency medical services providers' perspective of end-of-life decision making for people with intellectual disabilities.

Background: Emergency medical services (EMS) providers are often called to rapidly determine and act upon patients' wishes for end-of-life care. People with intellectual disabilities are living increasingly longer with complex conditions leading to international calls for person-centred advance care planning. Yet, best estimates suggest that very few people with intellectual disabilities document their wishes.

Empathy in Dentistry: How Attitudes and Interaction With Older Adults Make a Difference.

The development of empathy and positive attitudes are essential elements of professional education. This study explored the nature of empathy and its association with attitudes about, and exposure to older patients in a sample of dental students. Students completed an adapted version of the Jefferson Scale of Physician Empathy (JSPE), the Aging Semantic Differential (ASD) and answered questions about their exposure to older people.

Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care.

Objectives: What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms.

Procedures: MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed.

Is It the Difference a Day Makes? Bereaved Caregivers' Perceptions of Short Hospice Enrollment.

Context: Hospice enrollment for less than one month has been considered too late by some caregivers and at the right time for others. Perceptions of the appropriate time for hospice enrollment in cancer are not well understood.

Objectives: The objectives of the study were to identify contributing factors of hospice utilization in cancer for ≤7 days, to describe and compare caregivers' perceptions of this as "too late" or at the "right time.

The Developmental Transition From Living With to Dying From Cancer: Hospice Decision Making.

Despite increasing utilization of hospice care, older adults with cancer enroll in hospice for shorter periods of time than those with other life-limiting illnesses. How older adults with cancer and their family members consider hospice is unknown. The purpose of this study was to compare decision making in late-stage cancer in people who enrolled in hospice with those who declined.

"We Are Strangers Walking Into Their Life-Changing Event": How Prehospital Providers Manage Emergency Calls at the End of Life.

Context: Emergency 911 calls are often made when the end stage of an advanced illness is accompanied by alarming symptoms and substantial anxiety for family caregivers, particularly when an approaching death is not anticipated. How prehospital providers (paramedics and emergency medical technicians) manage emergency calls near death influences how and where people will die, if their end-of-life choices are upheld and how appropriately health care resources are used.

Objectives: The purpose of this study was to explore and describe how prehospital providers assess and manage end-of-life emergency calls.

Examining family meetings at end of life: The model of practice in a hospice inpatient unit.

Objective: Our purpose was to rigorously examine the nature of family meetings as conducted in an inpatient hospice care unit in order to generate an inductive theoretical model.

Method: In this two-phase project, we first interviewed eight members of the interdisciplinary care team who participated in multiple family meetings each week. Interview questions explored why and how they conducted family meetings.

Preparation for frontline end-of-life care: exploring the perspectives of paramedics and emergency medical technicians.

Background: Prehospital emergency providers (emergency medical technicians [EMTs] and paramedics) who respond to emergency calls for patients near the end of life (EOL) make critical decisions in the field about initiating care and transport to an emergency department.

Objective: To identify how a sample of prehospital providers learned about EOL care, their perceived confidence with and perspectives on improved preparation for such calls.

Design: This descriptive study used a cross-sectional survey design with mixed methods.

Prehospital providers' perceptions of emergency calls near life's end.

The nature of emergency end-of-life calls is changing as people live longer and die from chronic illnesses. This study explored prehospital providers' perceptions of (1) end-of-life 911 calls, (2) the signs and symptoms of dying, and (3) medical orders for life sustaining treatment (MOLST). The exploratory-descriptive pilot study was survey based and cross-sectional.

Contending with advanced illness: patient and caregiver perspectives.

Context: Despite improvements in end-of-life care, some unrelieved suffering persists for patients with advanced illness and their family members. Hospice and palliative care services can reduce suffering, but these services remain under-used.

Objectives: To investigate how patients with advanced illness and their primary caregivers experienced and responded to health care needs and decision making and how some dyads moved toward comfort-focused care.

Final decisions: how hospice enrollment prompts meaningful choices about life closure.

Objective: The purpose of this study was to explore and describe decisions that faced newly enrolled hospice patients and their caregivers after hospice enrollment.

Method: An exploratory, descriptive, cross-sectional design was employed using qualitative methods. In-depth in-person interviews were conducted with current hospice patients (n = 35) and caregivers (n = 45) from 53 families.

Staff perspectives on the provision of end-of-life care in a community residence for older adults with developmental disabilities.

Objective: The purpose of the study was to describe the perceptions of community residence (CR) staff who have cared for older adults with developmental disabilities (ADDs) that are at the end of life.

Design: This exploratory, descriptive study utilized qualitative methods that involved semistructured interviews with CR staff members.

Setting: The setting was a CR that was also an intermediate care facility (ICF) that provided 24-hour residential treatment for medical and/or behavioral needs.

An exploratory analysis of intimate partner violence and postpartum depression in an impoverished urban population.

Research on the relationship between intimate partner violence (IPV) and postpartum depression (PPD) is limited. Numerous antecedents and consequences of both IPV and PPD are noted in the literature; however, understanding the mechanisms by which intimate partner violence impacts the postpartum mood are not clearly understood. This study utilized retrospective chart reviews from a pediatric/perinatal social work outreach program to explore urban minority women experiences with IPV and depression both during pregnancy and after.