Awareness of dying: an experience of Chinese patients with terminal cancer

Despite the effort to provide an alternate way to dying, there seems to be little effort to examine the real situation of hospice care. For example, the patients' desired outcomes are seldom addressed. It is recently that studies began to investigate the features of "good death." However, work in eastern cultures, such as Chinese, remains scarce. The purpose of this study is to gain an understanding of what it means to die a "good death" from the perspective of Chinese patients. Thirty-three Chinese hospice patients with terminal cancer were interviewed. Grounded in the analysis of qualitative data, seven elements that contribute to dying a good death emerged. Awareness of dying was identified as the foremost essential element of a good death. From the findings of this study, most respondents considered receiving a diagnosis of cancer as one of the significant points of psychological distress in the course of their illness. Half of the patients openly talked about their cancers and more than half of them discussed various issues related to death. That means, about one-third of the respondents talked about death and cancer with openness. These preliminary findings may reflect the progress of hospice work in Hong Kong. Meanwhile, 13 respondents did not mention the word "death" and 16 of them did not mention that they had cancer. They talked about their illness and future using the expressions that they preferred. It is important that health care professionals also respect people who show awareness of dying as much as those who do not present clear evidence of this awareness. Both groups of people can have a positive experience when they die.     

Deathbed visions from India: a study of family observations in northern Kerala

This is an interview-based study of 104 families and their observations of the last weeks and days of a dying family member. Forty families reported "unusual experiences and behaviors" from the dying person in their last period of life. Thirty of these dying persons displayed behavior consistent with deathbed visions-interacting or speaking with deceased relatives, mostly their dead parents. There were six cases of reported premonitions of death and five possible confusional states with one patient reported to have had both a deathbed vision and confusional experiences. Socio-demographic factors such as gender, age, occupation, or cause and place of death were not found to be significant. Hindu patients appeared to be more likely than Muslim patients to report these experiences. Use of opiates (or not) did not appear to influence reports. The findings are discussed with reference to past studies of deathbed visions as well as their implications for the future pastoral care of dying people and their families.     

Researching "good death" in a Hong Kong palliative care program: a clinical data-mining study

This study operationalizes and assesses the percentage of "good deaths" achieved among Chinese cancer patients in a palliative care program, the profile of these patients, the relationship between patients with a good death and psychosocial factors, and the differences in background factors, and physical and psychosocial conditions between patients who experienced a good death and those who did not. Clinical data mining was the research method used. Records of deceased cancer patients between 2003 and 2005 in a palliative care unit were the sole data source. Good death was operationally defined as the patient's record indicating no pain (physical) or anxiety (psychological), and having open and honest communication with family (social) in the final assessment by the Support Team Assessment Schedule (STAS) just before death. Using these criteria, about one-fifth of patients (21.5%; 137 out of 638) experienced a good death. Those with a good death were significantly older and were in palliative care longer. Their records also indicated lower levels of constipation, insomnia, oral discomfort, and family anxiety at their first and at their final STAS assessments. Good death was positively associated with recorded indicators of fullness in life, caregivers' acceptance and support, and negatively with reported feelings of upset about changes in the course of their illness. The results heighten awareness among social workers and other healthcare professionals about the value of good death in patients in palliative care. This empirically-based awareness can foster professionals' ability to set intervention objectives to help patients in palliative care achieve this universally accepted goal.     

Quality insights of university students on dying, death, and death education--a preliminary study in Hong Kong

Death is a subject seldom studied in school and often misunderstood and feared by many people. Children often learn about death from their family and mass media. From the literature review on dying, death, and death education, it may be concluded that people are generally ignorant about the issues of death and dying. There is a need to investigate what young people, such as university students, know about death and dying, and their attitudes toward them. Eight university students were recruited for this study. Most participants have had death experiences. They seldom talked about death and loss. Some of these experiences were quite pleasant but some of them were not. Most participants addressed the need to have "life and death" education in schools at their young age. Such a need is further supported by the incidents of two participants who attempted suicide unsuccessfully when they encountered a life problem which they could not solve.     

Are we making progress? Not in haematology!

It will be shown, through the presentation of recent research findings, that haematology is a neglected area in terms of sensitive care of the dying. The Australian evidence indicates that scant progress has been made in relation to even the most basic palliative care practices such as sensitive, honest information giving or appropriate referral to the palliative system. Rather, the data show that during terminal trajectory, patients from these diagnostic groups and their families remain trapped in processes within the high-tech, curative system that are not responsive to the needs of the dying.     

The Effects of Exposure to "Synthetic" Chemicals on Human Health: A Review

This article examines how scientists use human, animal, and bacterial evidence to develop policy recommendations about the health consequences of human exposure to modern chemicals. Human evidence is limited because many epidemiological studies are contaminated with selection effects or unobserved heterogeneity. Changes in the aggregate incidence of morbidity (such as cancer) in the population over time are not a substitute for the lack of good individual-level data because incidence data are contaminated by the medicalization of cancer. Animal tests are also problematic because the expense of conducting experiments leads researchers to use only enough animals to allow detection of large differences in cancer incidence between controls and experimental animals that can only arise if the exposure doses are large. Predictions about the cancer incidence that would result in humans at much lower exposure levels, thus, require statistical inferences that implicitly make choices between false positive and false negative inference errors. Policy recommendations about carcinogens, therefore, are as much the product of value choices as "scientific" knowledge.     

Deathbed visions from the Republic of Moldova: a content analysis of family observations

This is an interview-based study of 102 families and their observations of the last weeks and days of a dying family member. Forty-one families reported hearing about "visions," "hallucinations," or "dreams" from their dying loved one before their death. Of these 41 mixed cases, 37 cases demonstrated classic features of deathbed visions-reports of seeing dead relatives or friends communicating to the dying person. This article reports a content analysis of these 37 cases in order to identify the major psychosocial themes that seem to be conveyed by these kinds of experiences. Six major themes are identified. These themes are: support, comfort, companionship, reunion, prognosis, and choice and control. Implications of these themes are discussed in relation to their role in providing significant support for the psychological morale and social well being of dying people.     

Heaping in anniversary reaction studies: a cautionary note

Several studies have reported evidence that death is often associated with significant ceremonial events like holidays and birthdays, a phenomenon variously called the "anniversary reaction," "holiday effect," "birthday blues," etc. This article, using data from the social security death index (SSDI), shows how evidence for this phenomenon can arise from an artifact in death records called "death heaping" in which certain dates, usually the 1st or the 15th, are systematically entered for missing data. In this study, each calendar birthday for the year 2003 in the SSDI was paired with either the 14th or 15th calendar day of death. For each pairing, there were more deaths for the 15th than the 14th. A second analysis compared the correspondence between dying on the same day of the month as one's birthday for the first 28 days of the month. A significantly greater number of birth-death combinations occurred for the 1st and 15th day of the month. These results suggest that studies of "anniversary reactions" should conduct preliminary evaluations to consider the possibility that statistically significant relationships do not arise from "death heaping."     

"The wholeness of things": infusing diversity and social justice into death education

This article presents resources and strategies for the infusion of diversity and social justice themes into an undergraduate death and dying course. The intent is not to replace or dismiss existing thanatological insights and debates, but rather to widen the cultural perspective to bring these insights and debates into conversation with multiple ways of perceiving and understanding. The article covers definitions, goals and rationales, challenges in identifying and developing appropriate resources, and overall course design. It also explores readings, audiovisual materials, class activities, and pedagogical approaches to foster: student engagement with diverse world-views and experiences; understanding of "cultural competence" in various fields; awareness of the impact of race, class, gender, etc., on access to resources and care; commitment to activism for social justice; and exposure to many forms of resilience, meaning-making, and creative healing.     

Death: the ultimate social construction of reality

Using Berger and Luckmann's thesis (1966) on the social construction of reality as rationale, this research analyzes the death drawings of 946 university students enrolled in a Death and Dying course between 1985 and 2004 to investigate the basic constructs elicited by the word "death": dying, moment of death, after death, after life, and bereavement. Consistent with earlier research, gender, race, religion, and religiosity proved to be significant factors. As expected, personal experience with grief was strongly correlated with drawings focused on bereavement. In contrast to earlier studies, fear of death was not significantly related to a particular construct. Implications for research, education, and counseling are discussed.     

Images of heaven and the spiritual afterlife: Qualitative analysis of children's storybooks about death, dying, grief, and bereavement

Many parents turn to picture books and storybooks to help explain issues surrounding death and dying to their young children. In addition to dealing with topics such as death, funerals, memories, and grief, a number of the books also mention the concept of heaven and what our loved ones might experience after they die. This article uses qualitative research methods to analyze 49 children's storybooks that touch on the existence of heaven or a spiritual afterlife. Results show that heaven is portrayed in a simplistic fashion, as a place high in the sky with bright lights, angels, and clouds. Even as heaven is presented in a relatively simple way, there are also patterned differences in depictions of the spiritual afterlife depending upon whether the decedent in the book was a family pet, a child, a parent, or a grandparent. The article concludes with a discussion of how these depictions of heaven and the afterlife might help young children cope with death-related grief.     

Disenfranchised grief and nonfinite loss as experienced by the families of death row inmates

The families of death row inmates experience grief and loss issues that have been neglected by scholars and clinicians alike. The issues found in this population are unique and require our understanding. The present study uses the concepts of disenfranchised grief and nonfinite loss to uncover the pain experienced by the children and other family members who have a loved one on death row. Kenneth Doka's (1989) concept of disenfranchised grief is utilized to bring attention to the ways in which the circumstances surrounding an execution leave the family members of those condemned to death outside of the "grieving rules" that exist in the United States. Family members are disenfranchised from their grief, as society does not socially validate their pain. The loss that they feel is also nonfinite (Bruce & Schultz, 2001) in that it is continuous and denies the families all of the hopes, dreams, and expectations that they had for their loved one who now sits on death row. The qualitative interview method was utilized by the authors of this study to gather data from 26 family members of death row inmates who are incarcerated along the East Coast of the United States. The reactions of this group of family members are varied and complex, yet they include the following common responses: social isolation due to stigma and their own feelings of criminalization, intensified family conflict between family members who grieve differently from one another, diminished self-esteem, shame, diffused and specific feelings of guilt, and a chronic state of despair. This study explores virtually untapped terrain. An examination of the microlevel effects of the death penalty on families provides insight in to the area of death and dying, especially as it is related to disenfranchised loss and nonfinite grief. In addition, this study provides insight into the death penalty and its effects.     

The development of the physicians' end-of-life care attitude scale

The Physicians' End-of-Life Care Attitude Scale (PEAS) was developed as an outcome measure for palliative care education. PEAS assesses the willingness of medical trainees to care for dying patients. Sixty-four Likert-type questions were created on the basis of discussions with focus groups of medical trainees, then administered to sixty-two medical students and residents. Total PEAS scores as well as personal preparation and professional role subscales (where higher scores indicated greater concern) possessed excellent internal consistency and reliability. In addition, there were substantial correlations between PEAS scores and the CA-Dying scale, a measurement of laypersons' fears about interacting with dying persons. Thus, PEAS adequately assesses the unique communication concerns of physicians in training regarding working with dying persons and their families. Correlations between PEAS scores and age were negative, while those who had experienced the death of a loved one had higher PEAS scores than those who did not. This suggests that for some persons, life experiences may lessen difficulties in dealing with dying persons, while for others, personal losses may exacerbate such concerns. The utility of PEAS in evaluating the efficacy of palliative care education as well as its potential to measure medical trainee's willingness to care for the terminally ill is discussed.     

所有权控制与家族企业成长——基于日本三井的案例分析

针对家族企业代际传承中的成长难题,基于所有权控制视角,深入考察了日本三井从其创业到财阀生成这段时间内的成长历程。研究表明,三井财阀从创业到发展,得益于对所有权控制上3个层面问题的有效解决,即通过“总有制”实现了“分家不分业”,确保了三井公司在资金短缺情况下的健康发展;将所有权制衡理念植入家族成员的所有权分配之中,抑制了家族领导人可能的“私人利益”动机过强,或者“经营短视”所造成的企业经营风险;基于信任的充分授权和作为“家族治理结构”的“大元方”的建立,为协调家族所有者和职业经理人之间关系建立了保障。从中得到的启示是,所有权控制创新是解决家族企业的所有权归属及分配、所有权结构以及两权分离下代理问题的有效途径。但同时也应看到,所有权控制创新在理论上还面临着家族企业与职业经理人之间信任机制构建等诸多课题。     

IRS proposed "physician recruitment" revenue ruling offers few kernels in search for

Not to sound corny, but things have really been popping since the Internal Revenue Service (IRS) recently released a proposed revenue ruling regarding the scope of recruitment incentives that may be offered to nonemployee physician members of tax-exempt hospital medical staffs. Commentators have criticized the proposed revenue ruling, however, because it offers little in the way of guidance in all but the most obvious cases of recruitment violations. Nonetheless, the proposed ruling may provide insight that may assist hospitals to prepare permissible recruitment incentives for physicians. The IRS provided a public comment period within which individuals and groups could submit proposals to improve or revise the proposed ruling. However, with or without such comments, clarification of the ruling is called for. "Health Law" is a regular feature of Physician Executive from the Washington, D.C., law firm Epstein Becker & Green. Mark Lutes of the law firm serves as editor of the column.     

Intergenerational Risk Decision Making: A Practical Example

There is no such thing as intergenerational decision making, at least not yet. In fact, there is no such thing as intragenerational decision making in the context of maximizing overall social good given resource limitations, there are just decisions being made in an ad hoc fashion. Even if one assumes that there is such a thing as intragenerational decision making, no uniform standard or guidance exists to make societal decisions for the common good. Risks to society are judged unevenly within the same agency and across agencies. Decisions are made in isolation and not weighed in the societal context of what is intra or intergenerationally important. The National Academy of Public Administration (NAPA) has set forth a framework for intergenerational decision making that provides a consistent and fair basis for making tough decisions in order to address difficult issues such as the long-term disposal of nuclear wastes. NAPA recognizes that there is an intergenerational obligation that must encompass broader questions than the narrow issue of waste disposal since resources are finite and needs are great. The fundamental principles are based on sustainability with the overarching objective that "no generation should needlessly, now or in the future, deprive its successors of the opportunity to enjoy a quality of life equivalent to its own." Coupled with this objective are four supporting principles of trusteeship, sustainability, chain of obligation, and precaution. The NAPA process also recognizes that no decision can be final and that a "rolling future" view is better than making decisions for "all time." It attempts to balance the needs of the present with those of the future in an open and transparent process that is aimed at producing a decision, not just endless analysis. The U.S. Congress and president should develop a rational standard by which to judge laws that involve intra and intergenerational issues relative to the overall societal good. Present regulations need to be evaluated relative to a uniform level of risk and benefit to assess where the limited money available can do the most good for both the present and future generations in the context of NAPA sustainability principles. It is hoped that decision makers will take a serious look at this process since it can work to resolve stakeholder stalemate.     

Approximations and Heuristics for the "Cause-Modified" Life Table

Life-table analysis can help to gauge the lifetime impacts that accrue from modifications to (age-specific) baseline mortality. Modifications of interest include those stemming from risk-factor-related exposures or from interventions. The specific algorithm used in these analyses can be called a cause-modified life table (a generalization of the cause-deleted life table). The author presents an approach for approximating that algorithm and uses it to obtain remarkably simplified expressions for approximating three indices of common interest: life-years lost (LYL), excess lifetime risk ratio (ELRR), and risk of exposure-induced death (REID). These efforts are restricted to the special case of multiplicative increases to baseline mortality (modeled as an excess rate ratio, ERR). The simplified expressions effectively "break open" what is often treated as a "black-box" calculation. Several insights result. For a practical range of risk factor impacts (ERRs), each index can be related to the ERR as a function of a baseline summary statistic and a "characteristic number" specific to the population and cause of interest. Conveniently, those numbers help form "rules of thumb" for translating among the three indices and suggest heuristics for extrapolating indices across populations and causes of death.     

An Empirical Test of the Relative Validity of Expert and Lay Judgments of Risk

This article investigates how accurately experts (underwriters) and lay persons (university students) judge the risks posed by life-threatening events Only one prior study (Slovic, Fischhoff, & Lichtenstein, 1985) has previously investigated the veracity of expert versus lay judgments of the magnitude of risk. In that study, a heterogeneous grouping of 15 experts was found to judge, using marginal estimations, a variety of risks as closer to the true annual frequencies of death than convenience samples of the lay population. In this study, we use a larger, homogenous sample of experts performing an ecologically valid task. We also ask our respondents to assess frequencies and relative frequencies directly, rather than ask for a "risk" estimate--a response mode subject to possible qualitative attributions-as was done in the Slovic et al. study. Although we find that the experts outperformed lay persons on a number of measures, the differences are small, and both groups showed similar global biases in terms of: (1) overestimating the likelihood of dying from a condition (marginal probability) and of dying from a condition given that it happens to you (conditional probability), and (2) underestimating the ratios of marginal and conditional likelihoods between pairs of potentially lethal events. In spite of these scaling problems, both groups showed quite good performance in ordering the lethal events in terms of marginal and conditional likelihoods. We discuss the nature of expertise using a framework developed by Bolger and Wright (1994), and consider whether the commonsense assumption of the superiority of expert risk assessors in making magnitude judgments of risk is, in fact, sensible.     

Does the internet change how we die and mourn? Overview and analysis

The article outlines the issues that the internet presents to death studies. Part 1 describes a range of online practices that may affect dying, the funeral, grief and memorialization, inheritance and archaeology; it also summarizes the kinds of research that have been done in these fields. Part 2 argues that these new online practices have implications for, and may be illuminated by, key concepts in death studies: the sequestration (or separation from everyday life) of death and dying, disenfranchisement of grief, private grief, social death, illness and grief narratives, continuing bonds with the dead, and the presence of the dead in society. In particular, social network sites can bring dying and grieving out of both the private and public realms and into the everyday life of social networks beyond the immediate family, and provide an audience for once private communications with the dead.