Planning end-of-life care for patients with dementia: roles of families and health professionals

We examined families' end-of-life decision making and their interactions with health professionals. Twenty-eight family members of institutionalized dementia patients participated in four focus groups. We found that participating family members were not well prepared for their decision-making roles, and that they: 1) experienced substantial burdens and loss in caring for institutionalized elders; 2) had limited understanding of the natural progression of dementing conditions; 3) were uncomfortable in setting goals for their relatives' end-of-life care; 4) had little experience with death, and were ambivalent about the anticipated death of their relative; and (5) reported that they had little substantive communication with health professionals regarding end-of-life care planning. We concluded that many of the needs of such families could be addressed through improved application of the principles of advance care planning, including regular structured discussions, involvement of surrogate decision-makers, and anticipation of clinical decisions. Health professionals should take the lead in 'normalizing' the discussion of death.     

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.     

Spirituality and the physician executive

The "s" word can now be spoken without flinching in health care organizations. Spirituality is becoming a common topic in management conferences around the world. Many U.S. corporations are recognizing the role of spirituality in creating a new humanistic capitalism that manages beyond the bottom line. Spirituality refers to a broad set of principles that transcend all religions. It is the relationship between yourself and something larger, such as the good of your patient or the welfare of the community. Spirituality means being in right relationship to all that is and understanding the mutual interdependence of all living beings. Physician executives should be primary proponents of spirituality in their organizations by: Modeling the power of spirituality in their own lives; integrating spiritual methodologies into clinical practice; fostering an integrative approach to patient care; encouraging the organization to tithe its profits for unmet community health needs; supporting collaborative efforts to improve the health of the community; and creating healing environments.     

The importance of end-of-life care in nursing home settings is not diminished by a disaster

The emphasis in disaster situations is on preserving life, and this goal is both appropriate and laudable. There is a risk, however, that the needs of people who are dying can become lost when there is a sudden surge of people needing acute intervention. There are significant ethical considerations inherent in society's prioritization of care needs across the acute, rehabilitative, and palliative spectrum in general, let alone in a disaster situation. These ethical conundrums are not the focus of this article. Rather, we anchor our discussion on the assumption that care needs are equally valid, and our purpose is to explore the issues that impact the provision of quality end-of-life care in nursing home settings for those who require this care when a disaster occurs. Nursing home residents, in particular, are at heightened risk for experiencing negative disaster-related outcomes due to compromised physical or mental health that requires skilled nursing care. Moreover, within the already vulnerable nursing home population are many people who are receiving palliative end-of-life services when a disaster strikes. Education and training in end-of-life services for nursing home staff, disaster emergency responders, and other lay people is vital to build capacity for adapting the delivery of these services in disaster situations in the interest of equity and human rights. Given the present lack of guidance in the literature as to what end-of-life care looks like when adapted to the context of disaster response, there is also a pressing need for research to inform this discussion. The purpose of this article is to draw attention to this topic and highlight some of the critical issues, gaps, and opportunities.     

“中魂西制”——中国式管理的核心问题

作为一种"式"的中国式管理不单纯是管理哲学或管理方法问题,还是贯通、跨越了从管理哲学到管理方法诸层次的,体现为一种与文明类型相伴的管理类型。在一体化组织理论框架的范畴体系中,中国式管理就是在中国组织中通行的目标整合、制度规范内在逻辑支配下,包含了部分相容的西方现代管理体系和方法在内的,体现了至今仍有现实价值的中国传统观念和意义的管理类型,即"中魂西制"。当前阶段,致力于探究中国改革以来成功企业管理经验,并在此基础上做理论总结和提炼,才可能形成能反映中国经验的管理学理论和体系。     

Health care reform. Four variables and a theory: an equation for health care

Writings about health care reform currently appearing in all manner of publications often can confuse, rather than clarify, both problems and solutions. One of the strengths of the study of economics is the ability to summarize complex situations in graphic form, and one of the benefits of management theory is to visualize approaches to problems in a broad and well-organized manner. Three recent articles, when combined, suggest a fresh analysis of the problems demanding health care reform in this nation. They are reviewed here and synthesized into a philosophical view that encourages a more positive approach to solutions for the problems. The first article considers an economic theory with striking applications to health care. The second article suggests one management approach for the future for both for-profit and not-for-profit organizations. The third article takes a fresh approach to competition in health care. This review will discuss the economic theory and then apply the management principles to the problem of health care reform confronting the profession and the nation today.     

Transformational leadership and leader moral orientation: Contrasting an ethic of justice and an ethic of care

Previous research on the moral foundations of transformational leadership has focused on a Kohlbergian (1969, 1976) ethic of justice. However, proposed associations between level of justice reasoning and transformational leadership have received only partial support. We reasoned that an ethic of care would be more consistent with the nature of transformational leadership than would be an ethic of justice. Multilevel regression analyses on data obtained from a sample of leaders (N = 55) and followers (N = 391) at a Canadian university supported our predictions. Specifically, leader propensity toward using an ethic of care was significantly, positively related to follower perceptions of transformational (but not transactional) leadership. Leader propensity toward an ethic of justice was significantly, positively related to follower perceptions of transactional (but not transformational) leadership. Conceptual, research, and practical implications are discussed.     

Specialist versus primary care: not an easy question

The central focus in the debate to reform our nation's health care system is on cost, quality, and access. There is general agreement that there are too many specialists in the wrong places, which is said to contribute to the rising cost of health care. Physician profiling has supported the concept that some specialists are more costly than primary care physicians, although the severity of illness in patients treated by specialists may often be greater. Increasing the number of primary care providers may be a solution to reduce costs and will clearly improve access. The study reported in this article was carried out to examine the efficiency of primary care physicians and endocrinologists, a specialty that has been cited as one in which resource utilization is high, in caring for hospital inpatients with diabetic ketoacidosis.     

New directions for an organised health care system in Germany: The concept of managed care

Against the background of continually rising public sector health costs in Germany, Michael Müller and Klaus Uedelhofen discuss the merits of ‘Managed Care’, a philosophy of organised health care, having its origins in the US in the early 1970s. Managed care is based on networking all separate groups within the healthcare system, standardising the services and performance, and distributing or sharing risks between all parties involved. Advantages, beyond cost reductions, include quality assurance, greater transparency, the establishment of therapy standards and increased responsibility by patients. The outlook for managed care in Germany looks optimistic.     

Making sense of loss: a content analysis of end-of-life practitioners' therapeutic approaches

Clinical professionals working in end-of-life (EOL) contexts are frequently relied upon to address questions of meaning with dying and bereaved persons. Similar to the gulf between researchers and practitioners besetting the larger healthcare community, the voices of EOL practitioners are often underrepresented in the empirical literature. This study aimed to further the dialogue in the field of thanatology by surveying and describing the therapeutic approaches that EOL practitioners most commonly report using to facilitate meaning-making. A total of 119 practitioners from a range of EOL disciplines were surveyed to write about their intervention strategies for helping clients/patients make sense of loss. Overall, participants discussed using 23 different therapeutic approaches that comprised three overarching categories: 1) presence of the helping professional; 2) elements of the process; and 3) therapeutic procedures. Importantly, the results also indicated that practitioners from the different EOL occupations are converging on many of the same strategies for promoting meaning-making. Implications for future research on evaluating the effectiveness of meaning-making interventions are also discussed.     

多元视角下的职场精神性研究述评与未来展望

在呈现VUCA特征的组织环境与新生代员工管理困境下,学业两界探索通过职场精神性管理,使员工以体验终极意义和生命价值创造的方式融入组织。文章回顾了职场精神性的理论和实证进展,梳理并整合了职场精神性的概念体系,从整体(含个体一一组织交互)、个体和组织的多元视角构建了整合模型,指明了研究的挑战、局限和未来方向。     

Older adults' attitudes toward death: links to perceptions of health and concerns about end-of-life issues

The current study had two primary goals, to determine whether: 1) self-rated mental and physical health, pain, and experience with health problems were predictors of elderly adults' attitudes toward death; and 2) death attitudes predict end-of-life medical treatment concerns. Participants were 109 adults, 65 years of age or older (M=78.74 years), recruited from the local community. Regression analysis indicated that poorer perceived physical health predicted a greater likelihood of viewing death as an escape, and poorer perceived mental health predicted a greater fear of death. Viewing death as an escape and fearing death predicted end-of-life medical treatment concerns; a greater endorsement of either attitude predicted more concern. Possible explanations for the links between perceived health, attitudes toward death, and concern about end-of-life issues are suggested.     

The effects of component commonality in an infinite horizon inventory model

This paper studies the effects of component commonality in the context of an infinite horizon inventory model. Three models are proposed that are characterized by different degrees of component commonality. Assuming the three models all follow the same inventory policy, exact service level measures are derived and incorporated into cost optimization problems. With the infinite horizon assumption, potential setup cost reductions can be evaluated due to the inclusion of common components. The results indicate that, as expected, commonality incurs significant cost savings; what is new and unique is that setup cost may increase or decrease when commonality is present. In addition, when the behaviour of the optimal solutions is examined, it is found that some of the well-known properties suggested by the existing one-period models do not hold for this infinite horizon model.     

Beyond expectancy theory: an integrative motivational model from health care

Expectancy theory has been criticized for its omission of normative, habitual, and other motivational elements. This paper describes the sources and features of an integrative motivational model from the field of preventive health care that combines expectancy/valence factors with habitual, normative, and conative motivational elements. The model is viewed as having implications for work motivation as well.     

Primary care: the driver in health care reform

The changes occurring in the health care industry have resulted in a cost-quality competition that has not been present in the past. Because of this competition, managed care is a growing way of financing and providing health care to the people of the United States. Managed care depends heavily on competent primary care physicians. Because primary care physicians are in short supply, the status and financial rewards of primary care practice are increasing. The primary care physician will be the dominant force in medical practice in the immediate future. He or she is capable in a managed setting of resolving the perceived problems of the health care industry in responding to the drivers of health care reform. Costs are reduced while quality is maintained. Access to health care is improved, and fragmentation of health care is significantly lessened.