Palliative care is increasingly confronted with cultural diversity. This can lead to various problems in practice. In this perspective article, the authors discuss in more detail which issues play a role in culture-sensitive palliative care, why naive culturalism will not solve such problems and in which direction research into this aspect of care can be further elaborated.

INTRODUCTION:After terrorist attacks, media coverage of the attacks is extensive. There are some indications that there is an association between watching the media coverage and certain health reactions, both mental and somatic. Most studies occur in the United States and often months after the initial attack. In the current study, we investigated the terrorist attacks in Belgium on 22 March 2016.METHODS:An online cross-sectional survey was conducted one week after the attacks among the general population of Belgium. We measured hours of media watching of the terrorist attacks (hereafter media watching), adjusted scales of the Patient Health Questionaire-4 (PHQ-4) to measure mental symptoms and the Patient Health Questionaire-15 (PHQ-15) to measure somatic symptoms, proximity to Brussels (home, work and overall proximity) and background factors such as gender, age and level of education. Respondents were included if they answered the survey between 29 March 2016 and 5 April 2016.RESULTS:A total of 2972 respondents were included. Overall, media watching was significantly associated with both mental symptoms (p < 0.001) and somatic symptoms (p < 0.001), while controlling for age, gender, level of education and proximity. Watching more than three hours of media was associated with more mental and somatic symptoms (p < 0.001). Compared to proximity, media watching was, in general, a better association. For geographical factors, watching more than three hours of media indicated equally high scores for mental symptoms and somatic symptoms as work proximity (p = 0.015) and overall proximity to the attacks (p = 0.024).CONCLUSION:Media-watching is associated with acute health reactions after terrorist attacks. However, the direction of the relationship is unclear, as it might also be that people with health issues seek out more media.

Little is known about the association between terrorism and suicide. This study investigates suicide numbers in Flanders, Belgium before and after the Paris-attacks (13/11/2015) and Brussels-attacks (22/03/2016). Population mortality data for suicide were gathered from the Agency for healthcare. Suicides in Flanders, Belgium, were higher after both attacks. The increase was higher after the Paris-attacks, compared to the attacks in Brussels, Belgium. The effect of a close-by, but still foreign attack (the Paris-attacks in France) on suicide numbers is larger than that of an attack inside the country (the Brussels-attacks), possibly due to a difference in threat experience and coping possibilities.

Feeling threatened by terrorism can be associated with mental health problems and behavioural changes. However, few studies look at the association in the long-term. Using a survey, the population in Brussels, Belgium was studied using a representative database delivered by the national post service. The Patient Health Questionnaire-4 (PHQ-4) assessed mental health, and self-made questions avoidance behaviour. 170 people answered: 60% women and 50% higher educated, 28.2% between 56 and 65 years and 62.4% had a partner. 43.5% felt threatened by the terrorist attacks and 45.9% experienced no mental health problems. Both terrorist threat (p < 0.001) and avoidance behaviour (p < 0.001) significantly predicted PHQ-4 scores, while controlling for gender, age, social support, education level, and traumatic events. There is a relation between terrorist threat and anxiety/depressive symptoms 2.5 years after the last study on terrorist threat in Brussels, but it has weakened. Avoidance behaviour seems to be more present than threat.

OBJECTIVE:Condom use prevents the contraction of the HIV. Research shows limited effects of education on increasing condom use. Psychological inoculation (PI) has been found to be more effective in this domain, however, its mechanism is unknown. This study examined effects of PI versus education on condom use barriers and tendencies, and its relations with cognitive dissonance, using a fully automatized online system.DESIGN:The study was a randomized controlled trial (RCT) and included 149 students from a German University randomly assigned to PI or a control condition.MAIN OUTCOME MEASURES:An indirect condom use test (I-CUTE), a condom use barriers questionnaire, self-reported condom use, and cognitive dissonance estimations were all assessed at baseline and one-month post-intervention.RESULTS:PI significantly increased I-CUTE scores when participants had sexual relations. Control participants increased in self-reported condom use and on I-CUTE scores in people without sexual relations. No changes in barriers were seen in either group. The cognitive dissonance tended to be higher in PI participants as compared to control participants.CONCLUSIONS:PI increases I-CUTE scores compared to controls (based on effect sizes), and significantly in those with sexual relations. The role of relationship status and the mechanisms of PI should be further examined.

ContextAssessing consciousness and pain during continuous sedation until death (CSD) by behavior-based observational scales alone has recently been put into question. Instead, the use of monitoring technology has been suggested to make more objective and reliable assessments. Insights into which factors influence attitudes toward using these monitoring devices in a context of CSD is a first step in formulating recommendations to inform future practice.ObjectivesThe aim of this study was to find out what influences professional caregivers' and family members' (FMs) attitudes regarding the use of monitors during CSD.MethodsWe conducted semistructured face-to-face interviews with 20 professional caregivers and 15 FMs, who cared for a patient or had an FM, respectively, who took part in a study using monitoring devices. Recruitment took place in an academic hospital, a locoregional hospital, and two nursing homes, all located in Belgium. Two researchers independently analyzed the data, using grounded theory to inductively develop a model that represents the emerging attitude toward use of monitors during CSD.ResultsOur model shows that the emerging attitudes toward using monitors during CSD is determined by view on CSD, desire for peace of mind, emotional valence attached to using monitors, and the realization that the sole use of behavior-based observational measures could be unreliable in a CSD context. We identified several facilitators and barriers to inform future implementation strategies.ConclusionMost participants had no objections, and all participants found the use of monitoring devices during CSD feasible and acceptable. We identified a number of facilitators and barriers and suggested that being aware that care can be improved, good communication, shared decision making, and continuing professional education can overcome the identified barriers. We suggest future research would focus on developing implementation strategies and guidelines for introducing objective monitoring devices in diverse palliative care settings.

Introduction: Little is known about how to avoid intercultural nurse-family conflicts in critical care settings. In this article, strategies are discussed that may be useful to prevent or mitigate intercultural nurse-family conflicts during critical medical situations in hospital. Method: Strategies are based on an ethnographic study by Van Keer et al., other literature, and expert opinion. Results: Sufficient structural measures are needed. First, institutions must create appropriate ward policies, such as including nurses in end-of-life communication. Second, nurses should be coached in the workplace. Third, institutions must provide adapted, visual, ward information to families. Additionally, education and research are needed. These measures should be actively stimulated by nurse managers and reflect a multicultural program supported by the hospital. Discussion: Intercultural nurse-family conflict prevention or mitigation should take into account organizational aspects, on hospital units and in hospital as a whole, and the crucial role of education and research.

In case of untreatable suffering at the end of life, continuous sedation until death (CSD) may be the only treatment option left. Because these patients cannot communicate anymore, caregivers have to rely on behavioral observation to assess the patient’s comfort. Recently, however, a number of studies from the neurosciences have shown that sometimes consciousness and pain are undetectable with these traditional behavioral methods. The aim of this study was to find out if subjective caregiver assessments of consciousness and pain would be confirmed by objective neurophysiological measures. In this prospective observational study, we observed patients from the start of palliative sedation until death. Subjective caregiver assessments of level of consciousness and pain based on behavioral observations were compared with objective measures from neurophysiological monitoring devices. We collected and analyzed 108 subjective caregiver assessments in a sample of 12 patients and 32 assessments by traditionally used observational scales. We compared these with objective neurophysiological measures. Sensitivity and specificity of caregivers’ subjective assessments of consciousness was 23.6 and 91.1% respectively, with an accuracy of 54.0% and interrater reliability (κ) of 0.13. For pain, this was 0 and 94.79%, respectively, an accuracy of 88%, and an inter-rater reliability (κ) of − 0.063. Agreement between caregivers’ subjective assessments and objective neurophysiological measures of consciousness and pain was very poor. Caregivers’ subjective assessment of level of consciousness and pain during CSD is unreliable compared with objective neurophysiological monitoring. Our results suggest that assessments of patient comfort during CSD could have been improved substantially by including objective monitoring of level of consciousness and pain. The protocol for this observational study has been registered retrospectively at Clinical-Trials.gov (ID NCT03273244).

Background: Critical care physicians often have to make challenging decisions to withhold/withdraw life-sustaining treatments. As a result of society's increasingly cultural diversity such decision making often involves patients from ethnic minority groups, which might pose extra challenges. Objective: To investigate withholding/withdrawing life-sustaining treatments with patients from ethnic minority groups and their families during critical care. Design: Ethnographic fieldwork (observations, in-depth interviews and reading patients' medical files). Setting/Subjects: Eighteen patients from ethnic minority groups, their relatives, physicians and nurses were studied in one intensive care unit of a multi-ethnic urban hospital (Belgium). Results: During decision making physicians had a very central role. The contribution of patients and nurses was limited, while families' input was more noticeable. Decision making was hampered by communication difficulties between: (1) staff and relative(s), (2) relatives, and (3) patient and relative(s). Different approaches were used by physicians to overcome difficulties, which often reflected their tendency to control decision making, for example, stressing their central role. At times their approaches reflected their inability to align families' wishes with their own, for example, when making decisions without explicitly informing relatives. Conclusions: Withholding/withdrawing life-sustaining treatments in a multi-ethnic critic care context has a number of alarming difficulties, such as how to take families' input correctly into account. It is important that decision making happens in a cultural sensitive way and with involvement tailored to patients' and relatives' needs and in close consultation with interprofessional health care workers/other services.

Journal of Palliative MedicineVol. 23, No. 4 Letters to the EditorA Reflection on Using Observational Measures for the Assessment and/or Monitoring of Level of Consciousness in Palliatively Sedated PatientsStefaan Six, Johan Bilsen, Steven Laureys, Jan Poelaert, Peter Theuns, and Reginald DeschepperStefaan SixAddress correspondence to: Stefaan Six, MSc, Mental Health and Wellbeing Research Group, Department of Public Health, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, Brussel 1090, Belgium E-mail Address: stefaan.six@vub.beMental Health and Wellbeing Research Group, Department of Public Health, Vrije Universiteit Brussel, Brussel, Belgium.Search for more papers by this author, Johan BilsenMental Health and Wellbeing Research Group, Department of Public Health, Vrije Universiteit Brussel, Brussel, Belgium.Search for more papers by this author, Steven LaureysComa Science Group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, Liège, Belgium.Search for more papers by this author, Jan PoelaertDepartment of Anesthesiology & Perioperative Medicine, Vrije Universiteit Brussel, Brussel, Belgium.Search for more papers by this author, Peter TheunsMental Health and Wellbeing Research Group, Department of Public Health, Vrije Universiteit Brussel, Brussel, Belgium.Search for more papers by this author, and Reginald DeschepperMental Health and Wellbeing Research Group, Department of Public Health, Vrije Universiteit Brussel, Brussel, Belgium.Search for more papers by this authorPublished Online:25 Mar 2020https://doi.org/10.1089/jpm.2019.0574AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"A Reflection on Using Observational Measures for the Assessment and/or Monitoring of Level of Consciousness in Palliatively Sedated Patients." Journal of Palliative Medicine, 23(4), pp. 442–443FiguresReferencesRelatedDetails Volume 23Issue 4Apr 2020 InformationCopyright 2020, Mary Ann Liebert, Inc., publishersTo cite this article:Stefaan Six, Johan Bilsen, Steven Laureys, Jan Poelaert, Peter Theuns, and Reginald Deschepper.A Reflection on Using Observational Measures for the Assessment and/or Monitoring of Level of Consciousness in Palliatively Sedated Patients.Journal of Palliative Medicine.Apr 2020.442-443.http://doi.org/10.1089/jpm.2019.0574Published in Volume: 23 Issue 4: March 25, 2020PDF download

Objective: During critical care, physicians are frequently confronted with bad-news communication because of patients' frail conditions. Delivering bad news is not easy, certainly not when patients from ethnic minority groups are involved. In this study we investigate the delivery of bad news in a multi-ethnic critical care context. Methods: Ethnographic fieldwork in one intensive care unit of a multi-ethnic urban hospital in Belgium. Data were collected through negotiated interactive observation, in-depth interviews and from reading patients' medical records. Data were thematically analysed. Results: Bad-news communication was primarily dominated by physicians. Patients' and relatives' input and other professionals' involvement in the communication was limited. Staff encountered ethno-cultural related difficulties, firstly, in choosing suitable conversation partner(s); secondly, in choosing the place of conversations and thirdly, in the information exchange. Staff usually tried to address these problems themselves on the spot in a quick, pragmatic way. Sometimes their approaches seemed to be more emotion-driven than well thought-out. Conclusion: Delivering bad news in a multi-ethnic intensive care unit has a number of specific difficulties. These can have negative consequences for parties involved. Practice implications: The challenges of an adequate delivery of bad news need a team-approach and a well thought-out protocol. (c) 2019 Elsevier B.V. All rights reserved.

Until now, there is little research on the experiences of indirectly exposed minors after terrorist attacks. This study sheds light on the emotions and questions of such indirectly exposed minors. A qualitative content analysis of secondary data gained from Awel, a youth-helpline, was performed until saturation. Data contained emotions and questions in chat conversations, with 30 minors (8–18 years old). Emotions included guilt, sadness, and especially fear of attacks on themselves, their family, or at school. Questions mostly focused on making sense of the attacks, and how to distinguish fantasy from reality. After an attack children and adolescents experienced a wide range of emotions, and seem to have difficulty to make sense of what happened. Teachers and parents can play an important role in buffering fears, and in offering contextual information and concrete answers.

Objective: An effective method for preventing the Human Immunodeficiency Virus (HIV) is condom use. Yet, research shows limited effects of education on increasing condom use. This research examined the effects of psychological inoculation (PI) versus education on condom use -barriers and –tendencies, using a fully automatized online system. Design: Two randomized controlled trials. In Study 1, 59 Sub-Saharan students were included while Study 2 20 European students were included. In both studies, participants were randomly assigned to PI or control conditions. In Study 2, we additionally matched pairs on gender and condom barriers. In the PI, participants received challenging sentences they had to refute. Main outcome measures: An indirect condom use test (I-CUTE) and a condom use barriers questionnaire, assessed at baseline and a month later. Results: In Study 1, a significant increase in I-CUTE scores and no change in barriers was found in the PI condition. Controls did not change on either outcome. In Study 2, two sub-scales of condom barriers (concerning partner and satisfaction) were significantly decreased in the PI group, while in controls, barriers significantly increased over time. In both groups, I-CUTE scores tended to increase. Conclusions: These results replicate previous studies and extend them to a fully automatized system without counselors.

Background: Awareness and pain during palliative sedation is typically assessed by observational scales, but the use of such scales has been put into question. Case presentation: A woman in her mid-80s was admitted to a palliative care unit, presenting with chronic lymphatic leukemia, depression, and a cerebrovascular accident, with right-sided hemiplegia and aphasia. The patient was unable to eat and was suffering from nausea and vomiting. Before admission, the patient had expressed her desire to discontinue treatment on several occasions. Case management: The decision was made to initiate palliative sedation. The patient consented to take part in a study to assess level of comfort and pain using two monitoring devices (NeuroSense monitor and Analgesia Nociception Index monitor). Case outcome: The patient died 90 h after initiation of palliative sedation. Titration of the medication was challenging and sedation was not deep enough during the first 2 days. Thirteen assessments made with the Ramsay Sedation Scale showed that the patient was considered to be in a deep sleep, while in fact the NeuroSense monitor indicated otherwise. Conclusion: This case demonstrates the feasibility and potential advantages of using monitoring devices to objectify assessments of pain and discomfort in palliatively sedated patients.

Background Health education alone has a limited impact on HIV prevention programs, possibly because it does not systematically target social and cognitive factors that affect condom use. Objectives To systematically evaluate the effectiveness and methodological quality of HIV prevention interventions, which targeted factors related to social cognitive models (SCM) in the Sub-Saharan context. Method Ten online databases were searched using prespecified terms. Data extraction and quality assessment (on a 0–8 scale) were carried out and study results were critically described. Results Eight studies meeting the inclusion criteria were identified and reviewed. Three interventions showed significant effects on condom use. The most targeted SCM factors were communication skills and self-efficacy. The average methodological quality score was 5.75. Conclusion There is a need to use other intervention methods targeting SCM determinants of condom use and to improve the quality of the assessment tools, to increase condom use towards HIV prevention.

Background: The wave of terrorist attacks over the past years in Europe and other regions may cause problems such as anxiety and depressive symptoms. Some studies suggest that perceived threat might also trigger physical health problems. Objective: To investigate the association between feeling threatened and subjective health during the week following a terrorist attack. Method: Online survey with a self-selected sample in the Belgian population one week after the terrorist attacks in 2016. Participants were invited through the Belgian media to fill in a questionnaire in Dutch, French or English on a website. The main outcomes were the association between ‘feeling threatened’ and subjective health problems. Perceived threat was measured with the question ‘During the week after the attacks … Did you feel threatened?’ Subjective health was measured by using standardized scales (ACSA, PHQ-4, PHQ-15). Results: A total of 2620 respondents completed the questionnaire, of whom 69.8% were female, 27.7% lived and 43.1% worked in Brussels. Gender, age, place of living and working, media exposure, religiousness and religious affiliation were associated significantly with higher perceived threat. A total of 21% of the respondents felt much or very much threatened during the week after the attacks. They reported significantly higher levels of mental and physical health problems. The most frequently reported problems were anxiety and depressive symptoms. The health problems that differentiated most markedly between those with low and high levels of perceived threat were fainting spells, chest pain and shortness of breath. Conclusion: In a self-selected sample of respondents, ‘feeling threatened’ was strongly associated with lower level of wellbeing and higher levels of mental and physical health problems. The most prevalent health problems were mental health problems but the most pronounced differences between people with low versus high levels of perceived threat were physical health problems.