Purpose: Explore if and how American Samoan cultural norms influence caregivers' knowledge, attitudes, and care choices for person's living with Alzheimer's Dementia (AD).Design: This pilot study used mixed methods.Methods: 1) Quantitative survey: measuring knowledge/attitudes towards AD (n = 80); 2) Qualitative techniques: a) Focus groups (n= 54) with caregivers; b) Semi-structured interviews (n=26) with health professionals; and c) In-depth interviews (n=3) with key informants. Emergent themes were created using data from all methods.Findings: Quantitative analyses revealed 50% of participants identified AD as normal aging, 83% as mental illness. The majority of participants believed elders with AD do not experience pain (70%) and should be cared for solely at home (74%). Qualitative evidence showed dissonance between cultural norms of respect for elders, familial caregiving duty, shame in others observing elders' dementia-related behaviours, and the current language used to describe AD.Conclusions: Our findings show a need for developing and disseminating culturally sensitive terminology for AD to destigmatize and transmute attitudes, knowledge and care choices for elders living with AD.Clinical Evidence: American Samoan terminology for dementia is discordant with its cultural norms, thus shaping caregivers' perceptions of AD and influencing care choices for managing AD symptoms.

Key Points Question Does providing a summary of geriatric assessment results and geriatric assessment–guided recommendations to oncologists improve communication about aging-related concerns? Findings In this nationwide cluster-randomized clinical trial of 31 community oncology practices that enrolled 541 older patients with advanced cancer, providing a geriatric assessment summary with recommendations to oncologists improved postvisit patient satisfaction and caregiver satisfaction and increased the number of conversations about aging-related concerns. These results were significantly different between the intervention and usual care groups. Meaning Integrating geriatric assessment into community oncology care improves patient and caregiver satisfaction and communication about aging-related concerns.

Little is known about informal caregivers' challenges in medically underserved communities. This qualitative study explores their perceptions/experiences of caregiving in a medically underserved community in Midwest United States. Two focus groups (n = 12) were conducted and themes were extracted and analyzed. Theme 1 included perceived barriers/unmet needs; most prevalent of which were lack of informational resources and support groups. A second unsolicited and unanticipated theme highlighted how caregivers constructed meaning through reappraising challenges to create enriching experiences for themselves, reinforcing their evolving dyadic relationship with care-recipient. Challenging and enriching aspects of caregiving coexisted and were rooted in caregiver-care-recipient dyad. Caregivers used meaning-making as a coping strategy for challenges. Prior research corroborates caregivers' challenges and meaning-making; this study contributes by delineating how both become interrelated. Policy makers can (a) alleviate challenges by increasing informational resources and support groups and (b) provide training to optimize caregivers' meaning-making, thus enhancing their positive experiences.

Background. Physician gender bias in surgical treatment recommendations is recognized but not well understood. This study hypothesized that gender differences may exist in interpretation of patients' physical behaviors and that these differences may be associated with decision making by providers and surrogate decision makers. Methods. A pool of Amazon Mechanical Turk workers was solicited to participate in an online assessment. Workers viewed 3 short videos of standardized patients (SPs) trained to exhibit physical characteristics of vigorous, frail, and neither vigorous nor frail (average) behavior and then answered survey questions related to video characteristics and whether they would support the SP's decision to undergo an indicated major lung resection. Results. There were 724 participating workers; their mean age was 42.6 +/- 11.8 years, and 386 were women. Men judged the average SP to be younger (P = .025), and women were more likely to recognize weight loss in the frail SP (P = .009). Overall, men and women were equally supportive of lung resection when indicated. The likelihood of supporting a decision to proceed with resection was inversely related to SP distress (P < .001) and was directly related to increasing gait speed (P < .001), energy (P < .001), and strength (P < .001). Male participants were less likely to support resection related to higher energy (P = .02) and strength levels (P = .016). Conclusions. Gender differences exist in how video portrayal of patient frailty is perceived and affects surgical recommendations. Understanding such differences may aid in educational efforts directed at reducing gender-based biases in treatment recommendations by physicians and surrogate decision makers. (C) 2020 by The Society of Thoracic Surgeons

•Make attendees aware of the impact of American Samoan (AS) culture on caregivers attitudes and knowledge about AD.•Increase understanding of the importance of developing resources for dementia education in the American Samoan culture. Despite modernization, AS culture has retained norms/practices, including respect toward elders, familial protection and shame of elders’ behavioral symptoms, and caregiving as solely a family responsibility. Such ties to their cultural identity can impact the care AS healthcare providers give elders with AD. There is a dearth of research on AS culture and its relationship to caregiving for AD elders. The present research seeks a fuller understanding of how AS cultural practices shape caregivers’ awareness, attitudes/knowledge about AD in AS. Understand impact of American Samoan (AS) culture on caregivers’ attitudes/knowledge about Advanced Dementia (AD). Determine resources for dementia education and care supports for AS culture. 1) Focus Groups, (n=54): Four, 1-hour sessions conducted with community-based caregivers/advocates, using a semi-structured Moderator Guide. 2) Semi-structured Interviews (n=26) conducted with physicians. 3) Key Informant interviews (n= 3). 4) Ten-item Survey asking about knowledge/attitudes towards AD, administered to all participants prior to focus groups/interviews (n=80). Emergent themes were analyzed using Dedoose web-based qualitative software. Survey indicates 50% of sample conceptualized AD as a normal part of aging and a terminal illness, and 83% conceived it as mental illness. Further, 70% believed it was not painful, and people with AD should be cared for at home (74%). Focus groups/interviews corroborated these findings, showing AS lack knowledge about AD that is based in: 1) nuances of AS language, conceptualizing AD as a mental and terminal illness; 2) respect for elders, making it shameful for others to see their elders' behavioral symptoms, and, 3) caring for elders with AD as responsibility of family. AS cultural norms embedded in language play a role in shaping attitudes/ knowledge of healthcare providers about AD.

Objectives: 1) Identify themes arising from nurses' perceptions of assessing older-patients' pain; 2) use themes to guide development of optimal interventions to improve quality of pain assessment in the emergency department (ED).Methods: Nurse interviews (n = 20) were conducted until theme saturation. They were transcribed, coded, and analyzed using qualitative methodology.Results: Two major themes-nurse 'challenges' and 'strategies' to overcome challenges, and their subthemes - classified as 'patient-related' or 'system-related,' were salient in nurses' perceptions. Strategies nurses reported for managing challenges were based in their own professional lived experiences.Discussion and conclusion: A 2 x 2 framework was developed to conceptualize challenges, strategies, subthemes and their classifications, yielding 4 typologies comprising challenge types matched with appropriate strategy types. While emergent challenges and strategies are corroborated in the literature, the present study is the first to develop a scheme of typologies beneficial for guiding the development of optimal interventions to improve the quality of assessing pain in older-patients.Practice implications: The typology framework can guide the development of pain assessment tools and the needed combinations for assessing multidimensional pain in older-patients. Using the present findings, a new clinical intervention was shown to significantly improve pain management for olderpatients in the ED. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Objectives: Explore physicians' verbal and nonverbal responses to cues/concerns in consultations with older-patients.Methods: Two teams independently coded a sample of Norwegian consultations (n = 24) on verbal and nonverbal dimensions of communication using VR-CoDES and NDEPT instruments. Consultations exploring older-patients' verbal emotional expressions were labeled 'Acknowledging of patients' emotional expressions', and 'Distancing from patients' emotional expressions.' Based on type and extent of nonverbal expressiveness, consultations were labeled 'Affective' and 'Prescriptive.' Congruency of verbal and nonverbal communication was assessed and categorized into four types. Incongruent consultations were qualitatively analyzed.Results: Types 1 and 2 consultations were described as 'Congruent,' i.e. both verbal and nonverbal behaviors facilitate or inhibit emotional expressions. Types 3 and 4 were considered 'Incongruent,' i.e. verbal inhibits, but nonverbal facilitates emotional expressions or vice versa. Type 3 incongruent encounters occurred most often when it was challenging to meet patients' needs.Conclusions: Frequently physicians' display incongruent behavior in challenging situations. Older patients' may perceive this as either alleviating or increasing distress, depending on their needs.Practice implications: Type 3 consultations may shed light on reasons for physicians' incongruent behavior; therefore, independent measurement and analyses of verbal and nonverbal communication are recommended. Older-patients' perceptions of incongruent communication should be further explored. (C) 2017 Elsevier B.V. All rights reserved.

Objective: To compare patients' attitudes towards recurrent prostate cancer (PCa) and starting hormone therapy (HT) treatment in two groups Decision-Aid (DA) (intervention) and Standard-of-care (SoC) (Control).Methods: The present research was conducted at three academic clinics-two in the Midwest and one in the Northeast U.S. Patients with biochemical recurrence of PCa (n = 26) and follow-up oncology visits meeting inclusion criteria were randomized to either the SoC or DA intervention group prior to their consultation. Analysts were blinded to group assignment. Semi-structured phone interviews with patients were conducted 1-week post consultation. Interviews were audio-taped and transcribed. Qualitative analytic techniques were used to extract salient themes and conduct a comparative analysis of the two groups.Results: Four salient themes emerged-1) knowledge acquisition, 2) decision-making style, 3) decision-making about timing of HT, and 4) anxiety-coping mechanisms. A comparative analysis showed that patients receiving the DA intervention had a better comprehension of Prostate-specific antigen (PSA), an improved understanding of HT treatment implications, an external locus-of-control, participation in shared decision-making and, support seeking for anxiety reduction. In contrast, SoC patients displayed worse comprehension of PSA testing and HT treatment implications, internal locus-of-control, unilateral involvement in knowledge-seeking and decision making, and no support-seeking for anxiety-coping.Conclusions: The DA was more effective than the SoC group in helping PCa patients understand the full implications of PSA testing and treatment; motivating shared decision-making, and support-seeldng for anxiety relief. DA DVD interventions can be a useful patient education tool for bringing higher quality decision-making to prostate cancer care. (C) 2017 Elsevier Ltd. All rights reserved.

BACKGROUND:Structured care processes that provide a framework for how oncologists can incorporate geriatric assessment (GA) into clinical practice could improve outcomes for vulnerable older adults with cancer, a growing population at high risk of toxicity from cancer treatment. We sought to obtain consensus from an expert panel on the use of GA in clinical practice and to develop algorithms of GA-guided care processes.METHODS:The Delphi technique, a well-recognized structured and reiterative process to reach consensus, was used. Participants were geriatric oncology experts who attended NIH-funded U13 or Cancer and Aging Research Group conferences. Consensus was defined as an interquartile range of 2 or more units, or 66.7% or greater, selecting a utility/helpfulness rating of 7 or greater on a 10-point Likert scale. For nominal data, consensus was defined as agreement among 66.7% or more of the group.RESULTS:From 33 invited, 30 participants completed all 3 rounds. Most experts (75%) used GA in clinical care, and the remainder were involved in geriatric oncology research. The panel met consensus that "all patients aged 75 years or older and those who are younger with age-related health concerns" should undergo GA and that all domains (function, physical performance, comorbidity/polypharmacy, cognition, nutrition, psychological status, and social support) should be included. Consensus was met for how GA could guide nononcologic interventions and cancer treatment decisions. Algorithms for GA-guided care processes were developed.CONCLUSIONS:This Delphi investigation of geriatric oncology experts demonstrated that GA should be performed for older patients with cancer to guide care processes.

The aging of the U.S. population continues to highlight emerging issues in providing care generally for older adults and specifically for older adults with cancer. The majority of patients with cancer in the U.S. are currently 65 years of age or older; therefore, training and research in geriatrics and geriatric oncology are viewed to be integral in meeting the needs of this vulnerable population. Yet, the ways to develop and integrate best geriatrics training within the context of hematology/oncology fellowship remain unclear. Toward this end, the current study seeks to evaluate the prior and current geriatric experiences and perspectives of hematology/oncology fellows. To gain insight into these experiences, focus groups of hematology/oncology fellows were conducted. Emergent themes included: 1) perceived lack of formal geriatric oncology didactics among fellows; 2) a considerable amount of variability exists in pre-fellowship geriatric experiences; 3) shared desire to participate in a geriatric oncology-based clinic; 4) differences across training levels in confidence in managing older adults with cancer; and 5) identification of specific criteria on how best to approach older adults with cancer in a particular clinical scenario. The present findings will help guide future studies in evaluating geriatrics among hematology/oncology fellows across institutions. They will also have implications in the development of geriatrics curricula and competencies specific to hematology/oncology training.

L’erreur fait partie d’une réalité en médecine. Afin d’améliorer les pratiques et la sécurité des soins, les professionnels sont amenés à s’inscrire dans une démarche de révélation de l’erreur. Toutefois, la littérature met en avant une réelle difficulté des professionnels à révéler leur erreur. Différents freins sont décrits, à la fois personnels, institutionnels et sociétaux. Mais l’erreur correspond également à une perte des repères professionnels et confronte les soignants à des émotions intenses où se mêlent honte et culpabilité. Dans le cadre de cet article, nous soulignerons les freins psychologiques à la révélation qui peuvent jouer un rôle dans la capacité du professionnel à s’inscrire dans un processus de révélation de l’erreur. Le vécu psychologique du professionnel face à l’erreur permet de dresser des pistes de réflexion sur l’accompagnement des professionnels dans le processus de révélation et du chemin qu’il reste encore à accomplir.Error disclosure is now an ethical and professional obligation for health professionals and seeks to improve quality and safety in healthcare. Literature has highlighted the numerous benefits of error disclosure and several authors have described the options for handling this situation. However, it is not quite that simple to be honest and open and follow a protocol that instructs professionals to explain, support and apologise in situations where they are subject to criticism. While the many personal, institutional and social factors that hinder open disclosure have been identified, little attention has been paid to the obstacles associated with the psychological impact of disclosure, thereby limiting the debate on how professionals might be supported in their efforts to cope with error disclosure. The psychological impact of error on professionals is a well-established fact. Physicians are “second victims” likely to be emotionally affected by medical error. Emotional distress, anger, isolation, fear, guilt and shame can be intense, suggesting that, far from being an isolated act in professional practice, a medical error is a life event that modifies the psychological balance of a professional. Studies in the humanities have shown how work shapes individuals’ identities. The choice to heal and care for is indicative of the ideals related to professionals’ life histories, cultures, family models and representations of health and disease. Work and, more specifically, recognition at work from their peers, patients and relatives enables health professionals to support their ideals and establish a coherent identity, and to belong to a workgroup. The error foreshadows a rupture which plunges the professional and the team in a state of vulnerability that rules out the professional's or the team's possibility to be part of a process of disclosing the error. In these conditions, a policy of security of care also involves a guarantee of the caregiver's and the team's psychological security. The term psychological security was developed by the psychoanalysis who emphasised the individual's need to evolve in a “sufficiently good” protective environment that allows him/her to contain his/her emotions, while giving the individual the possibility to express and discuss them. This space implies a relation of trust between individuals. Trust refers to the idea that the individual can trust someone, it is based on the capacity to create relations. It is only through trust that the professional will be able to open him/herself to others and construct a space where the errors and the doubts that he/she has in the context of work are shared. But if trust is essential, it is also dangerous because it implies accepting the risk of being dependent on those considered as trustworthy and the risk that they will not live up to the professional's expectations. As a consequence, the professional will only have trust when he/she has evaluated the possibility of cooperation and more precisely, as stated by Hardin, a cooperation in which the professional's interests are “encapsulated interests”, in other words the interests of others. Therefore, this cooperation depends on each member of the team seeing his/her interests as being partially those of the others. Cooperation within a service reveals the relations of trust between the professionals and shows the relations of dependence that each one maintains with the others for the good administration of care. Thus the creation of relations of cooperation between the team members proves to be an important indicator to determine the professional's possibility to adhere to a process of disclosing the error. This approach shows that professionals must address multiple rather than single disclosures: to the self, and to others (colleagues, hierarchy, patients and families) who will mobilise specific knowledge, emotions and psychological defences. To avoid cases where disclosure takes on dimensions as tragic as the actual errors committed, it is important to pay attention to the psychic state of healthcare professionals by offering a space of free expression that enables them to better understand their feelings and gain a sense of support in order to restore their ideals and professional identities. Finally, it's important to emphasize that disclosure also depends on the preservation or restoration of the relations of cooperation within the team. Disclosure cannot be prescribed, it must emerge within a workgroup who allows the error to be thought over, communicated and shared. In this context, disclosure becomes a group rule that is known to all. A health professional who feels sufficiently supported might, in turn, support a patient and/or his/her relatives and engage in meaningful disclosure.

Churches provide an innovative and underutilized setting for diabetes self-management programs for Latinos. This study sought to formulate a conceptual framework for designing church-based programs that are tailored to the needs of the Latino community and that utilize church strengths and resources. To inform this model, we conducted six focus groups with mostly Mexican-American Catholic adults with diabetes and their family members (N = 37) and found that participants were interested in church-based diabetes programs that emphasized information sharing, skills building, and social networking. Our model demonstrates that many of these requested components can be integrated into the current structure and function of the church. However, additional mechanisms to facilitate access to medical care may be necessary to support community members' diabetes care.

Background: Despite an increase in the content of palliative medicine curricula in medical schools, students are rarely exposed to end-of-life (EOL) care through real-patient experiences during their preclinical education. Objective: To evaluate the utility and impact of exposure to EOL care for first year medical students (MS-1s) through a hospice volunteer experience. Methods: Patients and Families First (PFF), a hospice volunteer training program in EOL care, was piloted on three cohorts of MS-1s as an elective. Fifty-five students received 3 hours of volunteer training, and were then required to conduct at least two consecutive hospice visits on assigned patients to obtain course credit. Students' reflective essays on their experiences were analyzed using qualitative methodology and salient themes were extracted by two investigators independently and then collaboratively. Results: The following five themes were identified from students' reflective essays: perceptions regarding hospice patients; reactions regarding self; normalcy of EOL care at home; impact of witnessing death and dying; and suggestions for improving EOL care education for medical students. Conclusion: Hospice volunteering during preclinical years may provide valuable experiential training for MS-1s in caring for seriously ill patients and their families by fostering personal reflection and empathic skills, thereby providing a foundation for future patient encounters during clinical training.

OBJECTIVE:To Examine physician eye contact (EC), patient understanding and adherence. METHODS:Secondary analysis of National Institute of Aging videotapes (N=52) of physician-elder patients in two visit types: (1) routine (n=20); (2) anxiety-provoking (n=32) was conducted. Self-reports of understanding and adherence were used. History-taking segments were qualitatively and quantitatively analyzed for relationships between EC, understanding and adherence. RESULTS:Qualitative analysis showed: (1) two salient EC elements--frequency, type (brief or sustained)--and verbal synchronicity were commonly invoked; (2) conjoint unfolding of three communication elements--"looking, listening and talking"--may be salient for patient outcomes; (3) despite differing EC patterns in routine and anxiety provoking visits, statistical analyses showed patient understanding and adherence ratings were similar in the sample population comprising two visit types; no significant correlations between EC elements and understanding and adherence were found. CONCLUSIONS:Salience of EC for patient-centered communication is shown in prior research. Present findings broaden the significance of EC by including verbal synchronicity. Methodological limitations may account for no significant correlations between EC and patient outcomes. PRACTICE IMPLICATIONS:Using suggested framework for operationalizing EC elements, including verbally synchronous communication, may facilitate patient-centeredness and have positive implications for patient understanding and adherence.

This study explores patient trust in physicians and its relationship to shared decision-making (SDM) among African-Americans with diabetes (types 1 and 2). We conducted a series of focus groups (n=27) and in-depth interviews (n=24). Topic guides were developed utilizing theoretical constructs. Each interview was audiotaped and transcribed verbatim. Each transcript was independently coded by two randomly assigned members of the research team; codes and themes were identified in an iterative fashion utilizing Atlas.ti software. The mean age of study participants was 62 years and 85% were female. We found that (1) race as a social construct has the potential to influence key domains of patient trust (interpersonal/relationship aspects and medical skills/technical competence), (2) the relationship between patient trustand shared decision-making is bidirectional in nature, and (3) enhancing patient trust may potentially increase or decrease SDM among African-Americans with diabetes. Mistrust of physicians among African-Americans with diabetes may partially be addressed through (1) patient education efforts, (2) physician training in interpersonal skills and cultural competence, and (3) physician efforts to engage patients in SDM. To help enhance patient outcomes among African-Americans with diabetes, physicians might consider incorporating strategies to simultaneously engender their patients' trust and encourage shared decision-making.