Filial obligations to elderly parents: a duty to care?

Moral aspects of filial concern for a parent living with dementia: Social imaginaries in contemporary narratives

Many adults face the difficulties of a parent living with dementia. Although not always caregiving for a parent living with dementia, they care about and are concerned for the vulnerability of their parent. This concern is invaluable but often an experience with a far-reaching impact. Qualitative research on filial concerns and experiences of caregiving has resulted in a vast body of knowledge about the experience of family carers. Far less research, however, has examined the moral concern of children. The aim of this study is to gain insight into the normative aspects of their concern. An international collection of 24 books written by adult children about their involvement with an ageing parent was analysed using the Dialogical Narrative Analysis method. Our study shows that the stories deal with children's moral questions about independence, identity, and suffering. These questions can be related to social imaginaries of individualism and progress. The two social imaginaries may have both positive and negative impacts on children's ability to cope with their concern for a parent living with dementia. The moral questions that arise from children's concern seem to originate from both the appeal of the vulnerable parent and from the social imaginaries. These moral sources may compete, resulting in moral friction. Children with a parent living with dementia deliberate upon the personal and societal held beliefs and need moral space to embody their concern.

How Do Attitudes of Adult Children Toward Long-Term Care Change with Education? International Evidence

Global demographic trends indicate that the world population is aging and education acquisition is increasing. For the first time in history, people are expected to spend more years as adults with living parents than as a parent of teenage children, and the average years of schooling have increased dramatically over the past several decades for many countries. Additionally, family-provided care is still the most important form of care to meet care demands worldwide. As strong filial norms could affect older adults' long-term care decision-making, understanding the link between filial obligations and education is critical under these trends. Using individual data from the World Values Survey and an instrumental variables strategy to account for endogeneity, this study finds that adult children with higher education levels have lower filial beliefs. Since population aging is expected to increase the demand for long-term care services, and education can reduce the supply of family-provided long-term care services, countries must start addressing this gap.

Filial piety and older adult caregiving among Chinese and Chinese-American families in the United States: a concept analysis

BACKGROUND

The culturally sensitive nursing practice has not embedded filial piety as a cultural value and stance pertaining to caregiving among aging Chinese and Chinese-American (CCA) families in the United States, yet it is critical for healthy aging among CCAs.

PURPOSE

To understand filial piety when caring for aging CCAs and conceptualize an operational definition and framework.

METHODS

A systematic search was conducted in CINAHL, PubMed, Scopus, and PsycINFO databases. Analysis of the concept of filial piety among CCAs used Walker and Avant's methods. Twenty-six studies were selected in the final full-text analysis.

FINDINGS

Synthesis of evidence identified four antecedents: (a) filial obligation as a 'cultural gene', (b) sense of altruism, (c) familial solidarity, and (d) societal expectation of 'birth right'. Attributes included familial material and emotional support, obedience, pious reverence, and societal norms. Consequences were related to caregiver burden, psychological and physical well-being, quality of life, and health equity.

CONCLUSION

Filial piety is an intrinsic desire to support aging parents and an extrinsic desire to adhere to Chinese societal moral tenets. The proposed operational framework "Caregiving for aging CCAs in the United States" merits further study.

Cohort profile: The ENTWINE iCohort study, a multinational longitudinal web-based study of informal care

Informal care is a key pillar of long-term care provision across Europe and will likely play an even greater role in the future. Thus, research that enhances our understanding of caregiving experiences becomes increasingly relevant. The ENTWINE iCohort Study examines the personal, psychological, social, economic, and geographic factors that shape caregiving experiences. Here, we present the baseline cohort of the study and describe its design, recruitment methods, data collection procedures, measures, and early baseline findings. The study was conducted in nine countries: Germany, Greece, Ireland, Israel, Italy, the Netherlands, Poland, Sweden, and the United Kingdom. The study comprised a web-based longitudinal survey (baseline + 6-month follow-up) and optional weekly diary assessments conducted separately with caregivers and care recipients. From 14 August 2020 to 31 August 2021, 1872 caregivers and 402 care recipients were enrolled at baseline. Participants were recruited via Facebook and, to a lesser extent, via the study website or caregiver/patient organisations. Caregiver participants were predominantly female (87%) and primary caregivers (82%), with a median age of 55 years. A large proportion (80%) held at least post-secondary education, and two-thirds were married/partnered. Over half of the caregivers were employed (53%) and caring for a person with multiple chronic conditions (56%), and nearly three-quarters were caring for either a parent (42%) or a spouse/partner (32%). About three-quarters of care recipient participants were female (77%), not employed (74%), and had at least post-secondary education (77%), with a median age of 55 years. Over half of the care recipients were married/partnered (59%), receiving care primarily from their spouses/partners (61%), and diagnosed with multiple chronic conditions (57%). This study examining numerous potential influences on caregiving experiences provides an opportunity to better understand the multidimensional nature of these experiences. Such data could have implications for developing caregiving services and policies, and for future informal care research.

Unmet Needs for Support in Activities of Daily Living among Older Persons: The Effects of Family and Household Structures in a Low- and Middle-Income Context

The unmet need for assistance in activities of daily living (ADLs) accentuates older persons' risk of falls, ill health, hospitalisation, and mortality. In Nigeria, the family arrangements through which older persons derive support are changing due to modernisation, migration, and economic challenges. How the family dynamics explain the unmet needs is poorly understood. This study investigates the influence of family and household structures on older persons' unmet needs in ADLs in southwestern Nigeria. The study analysed the data of 827 older adults aged ≥65 years selected from Oyo State, southwestern Nigeria, using a multi-stage sampling design. Associations were examined using the Poisson-logit hurdle regression model. From the results, 65% of older persons with difficulties had unmet needs in instrumental ADLs and 59% in basic ADLs. Increased unmet needs were associated with older persons living with non-family members (β = 0.19; p < 0.01; 95% C.I. = 0.05-0.32) and widows (β = 0.27; p < 0.01; 95% C.I. = 0.13-0.42). Conversely, unmet needs decreased with higher family size (β = -0.06; p < 0.001; 95% C.I. = -0.08--0.03), living in rich households (β = -0.29; p < 0.001; 95% C.I. = -0.42--0.17), not being the household head (β = -0.27; p < 0.001; 95% C.I. = -0.40--0.15), close family bonds, and proximity to children/caregivers. The study recommends alternative or complementary home-based support mechanisms for seniors with vulnerable family settings in southwestern Nigeria.

Developing a scale for examining the perspective of university students on parental care

Introduction

With the declining birth rate and increasingly aging population in Japan, an increased care burden may be placed on the family and the younger generation will address challenging circumstances when they can care for their parents. This study aimed to develop a scale for examining the perspectives of Japanese university students on parental care and determines its reliability and validity.

Methods

A web-based survey on a total of 408 Japanese students was adopted. This study performed exploratory and confirmatory factor analyses to obtain the underlying factors of the scale. Reliability was verified using Cronbach's α coefficient and Spearman-Brown's split-half reliability α coefficient. Validity was verified through sample, criterion-related, and convergent and discriminant validity.

Results

In total, the study identified a three-factor 11 item-scale. Cronbach's α for the scale was 0.901, and the Cronbach's α and split-half reliability α coefficients of each factor were greater than 0.7. Three factors explained 64.6% of the total variance. The model indicators were χ2/df = 2.241, comparative fit index (CFI) = 0.951, incremental fit index (IFI) = 0.951, TLI = 0.942, root mean square error of approximation (RMSEA) = 0.078 (p < 0.001). Thus, the study confirmed that the convergent and discriminant validity is acceptable. Correlations were noted for criterion-related validity (r = 0.675, p < 0.001).

Discussion

The results show that the scale for examining the perspective of Japanese university students on parental care was confirmed with good reliability and validity.

Development and Validation of Filial Piety Representations at Parents’ End of Life Scale

Filial piety has a long historical standing in Chinese communities. However, the filial piety practices of adult children at the end of a parent’s life are under-explored. This study aims to develop a measurement for filial piety representations of the adult children of Macao Chinese, whose parents are at the stage of end of life. By adopting a scale development and validation framework, a 19-item Filial Piety Representations at Parents’ End of Life Scale (FPR-EoL) was formulated based on a Dual Filial Piety Model and literature, through procedures of item identification, panel review, cognitive interviews, and pre-test. The FPR-EoL was examined on 274 individuals. Factor analysis showed four factors in the scale; respect and comfort, acceptance of death, spending final days, and disclosing bad news. The Cronbach’s alpha of FPR-EoL was 0.73, and the four factors were 0.73, 0.66, 0.58 and 0.77, respectively. Discriminant validity was examined between FPR-EoL, the Good Death Inventory (GDI) and the Filial Piety Scale (FPS). The results suggested that there were differences between the three scales. FPR-EoL is found to be a reliable, valid and novel measure of filial piety representations among Macao Chinese. It may be a potential tool to probe and achieve good death among older persons of Chinese ethnicity in clinical settings.

Respecting Older Adults: Lessons from the COVID-19 Pandemic

The COVID-19 pandemic has exacerbated many social problems and put the already vulnerable, such as racial minorities, low-income communities, and older individuals, at an even greater risk than before. In this paper we focus on older adults' well-being during the COVID-19 pandemic and show that the risk-mitigation measures presumed to protect them, alongside the generalization of an ageist public discourse, exacerbated the pre-existing marginalization of older adults, disproportionately affecting their well-being. This paper shows that states have duties to adopt and put into practice redress measures to compensate for the negative consequences of COVID-19 public health policies on older adults' overall well-being. These duties flow from the minimal ethical requirement of respect for persons. We show that respect is a morally basic attitude that presupposes taking the others' interests into account, with the aim of advancing their well-being. This duty is not limited to kinship, relatives, and friends but it extends to states and the rest of the civil society. In the conclusion, we draw lessons from the COVID-19 pandemic and sketch some redress measures that could compensate for the decrease in older adults' well-being as a result of the adoption of measures to contain the spread of the virus.

Normative tensions in filial caring for a mother with dementia: A narrative perspective

This article aims to gain insight in the normative struggles of adult children caring for their ageing mother living with dementia. Two Dutch autobiographical books written by siblings recording their own caregiving experience were analysed using a narrative design. Children appear to understand their normative concerns through six fields of tension. Our analysis shows that filial caregivers describe two distinct approaches to deal with these normative tensions. One approach aims to preserve the child's pre-existing personal beliefs and values, but also causes the child to demonstrate rigid and uncompromising behaviour at odds with the needs of their parent. The other approach is more reflective and flexible, prioritizing the needs of the vulnerable person over previously held values, providing an opportunity for better care. We conclude that caregiving children have to find their way between being faithful to their principles and showing moral flexibility.

What Makes Chinese Adult Children Behave Differently during Parents' End of Life: A Discriminant Analysis of Macao Chinese

The daily practice of filial piety (FP) is well prescribed under the traditional filial norms in the Chinese community. However, exploration of FP practices at the end of parents' lives is limited. The current study explored the FP representation and good death preferences of Macao Chinese. A cross-sectional web-based survey was conducted and discriminant analysis was used to identify possible predictors of FP representation in the context of parents' end of life. Results showed that Macao Chinese were inclined to perform most of the filial duties in the last journey of their parents. Among 705 participants, 150 (21.3%) tended to practice authoritarian FP, and 555 (78.7%) tended to practice reciprocal FP. Age, education, religion, and good death preferences were identified as predictors of different FP representation groups. The findings could help clinicians to obtain a preliminary perception of FP representation of Chinese patients and to determine the appropriate approach for end-of-life care from a family perspective.

A Study of the Structure of Japanese University Students' Awareness of Long-Term Care Socialization

This study aimed to examine the structure of the awareness of long-term care socialization by focusing on the younger generation's awareness in order to improve a sustainable long-term care system. A questionnaire that assessed personal attributes and awareness of long-term care socialization was administered. In total, the answers of 209 students (48.4%) were collected for factors related to the awareness of long-term care socialization extracted through exploratory factor analysis. Additionally, the responses 149 students (56.7%) were collected for the construct validity verified through confirmatory factor analysis. According to the exploratory factor analysis, awareness of long-term care socialization included 10 items and three factors: "care burden when caring for family", "feelings about leaving family care to society", and "sense of responsibility to care for family as a member of the family". The goodness-of-fit model in the confirmatory factor analysis proved the awareness of long-term care socialization scale's construct validity. The structure of the awareness of long-term care socialization included three factors: "care burden when caring for family", "sense of responsibility to care for family as a member of the family", and "feelings about leaving family care to society". This study demonstrated the scale's good reliability and validity.

Lived experiences of older adults living in the community during the COVID-19 lockdown - The case of mauritius

Adoption of strict social distancing and sanitary measures were inevitable in the attempt to thwart the spread of the Covid-19 virus. These measures, however, came at a cost for older adults who faced major mental health issues because of social isolation. The impact of social isolation remains well documented in the wake of the pandemic. This paper explored the lived experiences of older adults living in the community during the Covid-19 sanitary lockdown in the small-island state of Mauritius. As a small-island state with family structures that still skew towards extended or modified extended families, it was interesting to explore whether older adults would be reporting feelings of social isolation as was being reported elsewhere. This study utilized a qualitative approach using a lifeworld hermeneutical approach with 15 older adult participants, recruited through convenience and snowball sampling, in the community. Data were collected using a narrative approach supplemented by an interview guide. Thematic analysis was used to identify themes from transcribed and translated data. Six themes were discovered: Fears of the virus and fear of deprivation; Reliving and recreating bonds; Active contribution to family life; Being and feeling valued within the family; Rediscovering family time and family moments; and Fear of going back to 'normal'. The study revealed positive experiences of the lockdown period characterised by an increase bonding in the family, deepening of familial bond, and increased value despite an initial apprehension of the lockdown. A renewed sense of purpose as well as deepening of bonds was reported by older adults. Some limitations in relation to data trustworthiness and respondents bias, however, could not be avoided since the study was carried out during sanitary lockdown period. The feelings of social isolation and depression reported by older adults who lived alone were not seen in this study, suggesting that the family structure may have a role to play in mitigating these effects. There would also be a need to explore similar small-island states or similar cultures where the effects of sanitary lockdowns may be different from current literature.

Epistemic Violence in Research on Eldercare

Decolonial perspectives challenge the notion that standard knowledge in hegemonic psychology is productive of progress and enlightenment. They instead emphasise its association with the colonial violence that constitutes the darker underside of modern development. Our contribution to the special issue applies a decolonial perspective to theory and research on obligation to an elderly parent. Thinking from the standpoint of West African epistemic locations not only illuminates the culture-bound character of standard models but also reveals their foundations in modern individualist selfways. Although modern individualist selfways can liberate well-endowed people to pursue fulfilling relationships and avoid unsatisfying connections with burdensome obligations, these ways of being pose risks of abandonment for people—like many elders—whose requirements for care might constitute a constraint on others’ satisfaction. In contrast, the cultural ecologies of embedded interdependence that inform everyday life in many West African settings afford selfways that emphasise careful maintenance of existing connections. Although these selfways may place constraints on the self-expansive pursuit of satisfying relationships, they provide elders and other vulnerable people with some assurance of support.

Caring responsibility from the perspectives of older persons whose adult children are their caregivers

AIM

To describe lifeworld insights into the phenomenon of caring responsibility from the perspectives of persons aged 80+ years living alone with chronic illness, physical frailty and dependency on adult children.

DESIGN

A phenomenological inquiry inspired by Reflective Lifeworld Research.

METHOD

Semi-structured lifeworld interviews with 11 persons aged 80+ years were conducted following their discharge. The interviews lasted 35-83 min, were audio-recorded and transcribed verbatim. Both interviews and the analysis followed the epistemological and methodological principles of Reflective Lifeworld Research.

FINDINGS

We identified the essential meaning 'It means everything' and four constituents illuminating different aspects inherent in the complex phenomenon of caring responsibility; 'A life-constraining transition,' 'Trusting the children to fill the gaps and be the glue,' 'Tacit responsibility, agreement and acceptance' and 'Depending on the children and knowing they are burdened by you.'

CONCLUSIONS

Caring responsibility is based on a trusting relationship and tacit agreements indicating an understanding of interdependence and acceptance of dependence on adult children. However, a paradox appears when older persons express a deep-rooted perception of autonomy and independence as they have difficulties with their growing dependency and feelings of being burdensome. Older persons try to balance the continuum of autonomy, their existential self-image and actual capability. The practical part of caring responsibility seems to dominate and strongly affect the parent-child relationship because the child needs to take care of practical issues related to healthcare management and instrumental activities of daily living, leaving less time for meaningful togetherness.

IMPLICATIONS FOR PRACTICE

Older persons want their adult children to be involved and acknowledged when planning care and treatment because they often seem to serve as the 'glue' that makes it possible for the parent to remain in his/her own home.

A phenomenological-hermeneutic study exploring caring responsibility for a chronically ill, older parent with frailty

Aim

To provide lifeworld insights into experiences of adult children with caring responsibility for an 80+-year-old chronically ill parent with frailty.

Background

Informal care is common in Nordic welfare countries; however, little is known about adult children's experience of caring responsibility in this setting.

Design

A phenomenological-hermeneutic study based on Reflective Lifeworld Research.

Methods

Diaries and semi-structured interviews with 12 adult children.

Results

Caring responsibility is identified as "a condition of life, filled with uncertainty." Three constituents contribute to this phenomenon: (a) balancing love, duty and reciprocity; (b) being the parent's advocate and manager; and (c) experiencing concerns and bodily strain.

Conclusion

Adult children work hard to provide care and enhance the well-being of their parent. Heidegger's concept 'Fürsorge' may help us understand how by showing how caring responsibility means balancing different roles vis-à-vis the parent, one's own life and the health and social systems. Caring responsibility changes the relationship between parent and child.

The effects of obligation on relationships and well-being over time in middle adulthood

Previous research has offered mixed evidence on whether obligation in relationships benefits or harms individuals and their relationships. Given that few studies are prospective and consider multiple close relationships, we used 18-year longitudinal data to model whether obligation is associated with differences in relational and individual well-being over time. Because prior mixed findings may be attributed to differential influences of obligation across development, we also considered age. Light obligation predicted higher levels of relational and individual well-being; substantive obligation sometimes predicted lower levels of well-being. Both types of obligation mostly did not predict changes in relationships and well-being over time except substantive obligation predicted slower increases in friend support. The associations between light and substantive obligation were largely uniform across age. The only exception was for substantive obligation and friend support; substantive obligation was associated with a slower increase in friend support only for younger adults (<39 years old). This study extends previous research by examining obligation among middle-aged adults, addressing a critical developmental gap in this literature. Findings suggest that understanding people’s obligations toward close others is important not only for their own well-being but also their relationships in adulthood.

Caregiving for ageing parents: A literature review on the experience of adult children

BACKGROUND

More and more adults in their fifties and sixties are confronted with the need to support their ageing parents. Although many aspects of filial caregiving have been researched, a well-documented and comprehensive overview of the caregiving experience is lacking.

AIM

This study aims for a better understanding of the caregiving experience of adult children by generating an overview of main themes in international research.

METHOD

A literature review of qualitative studies, focusing on the experiences of adult children caring for their ageing parents, was performed. The electronic EBSCO databases Academic Search Premier, CINAHL and PsycINFO, and Google Scholar were searched to identify relevant qualitative studies published between 2000 and 2017. The 'SPIDER' eligibility criteria directed the approach. The quality of studies included was screened with the assessment sheet designed by Hawker and colleagues. The experiences reported were analysed and themes were synthesized.

ETHICAL CONSIDERATION

Ethical requirements were respected in every phase of the research process.

FINDINGS

Nineteen qualitative studies met the inclusion criteria. The quality of the relationship with the parent appears to be an important determinant of the children's caregiving experience. Within this context, three themes were found: caregiving as an emotional rollercoaster, a normatively demanding experience and an opportunity for personal development.

DISCUSSION

Children caring for their ageing parents have to deal with a wide range of contradicting and conflicting norms and values. Implications for healthcare professionals and future research have been discussed.

CONCLUSION

Caring for ageing parents is a continuous quest for giving the best possible care and living up to one's personal values, within the context of the parent's declining health. Professionals who support filial caregivers should address not only practical responsibilities but also the normative questions and moral considerations caregivers are dealing with.

'Call me if you need': Social support experiences under economic and social change

Social interactions play an important role in people's life and people's health but their scope and intensity tend to decrease with age, challenging social support dynamics and increasing the risk of social isolation and helplessness. In Portugal, policymakers still seem to rely on traditional social relations in eldercare, while contextual changes and trends are redefining family roles and behaviors and defying the established social support structure. In this work, we aim to examine the scope, structure and experiences of the informal social support network available in the country for stroke patients 6 months after their discharge from the acute care unit in the context of a larger study. The results seem to confirm the importance of family as a source of social support and shed light on different bonding experiences with non-kin social groups, such as neighbors and friends. A coordinated care provision, combining formal and informal support is vital and beneficial for patients, their caregivers and the care system.

A Comprehensive Measure of the Costs of Caring for a Parent: Differences According to Functional Status

Approximately 34 million family and friends provided unpaid care to individuals aged 50 and older in 2015. It is difficult to place a value on that time, because no payment is made to the caregiver, and multiplying caregiving hours by a wage does not account for the value of lost leisure time, implications for future employability and wages, or any intrinsic benefits accrued to the care provider. This study used a dynamic discrete choice model to estimate the costs of informal care provided by a daughter to her mother, including these other costs and benefits not typically accounted for, and compared these cost estimates for 4 categories of the mother's functional status: doctor-diagnosed memory-related disease, limitations in activities of daily living (ADLs), combination of both, cannot be left alone for 1 hour or more. We studied women aged 40 to 70 with a living mother at the start of the sample period (N=3,427 adult daughters) using data from the Health and Retirement Study (1998-2012). The primary outcome was the monetized change in well-being due to caregiving, what economists call "welfare costs." We estimate that the median cost to the daughter's well-being of providing care to an elderly mother ranged from $144,302 to $201,896 over 2 years, depending on the mother's functional status. These estimates suggest that informal care cost $277 billion in 2011, 20% more than estimates that account only for current foregone wages.

Health Without Care? Vulnerability, Medical Brain Drain, and Health Worker Responsibilities in Underserved Contexts

There is a consensus that the effects of medical brain drain, especially in the Sub-Saharan African countries, ought to be perceived as more than a simple misfortune. Temporary restrictions on the emigration of health workers from the region is one of the already existing policy measures to tackle the issue—while such a restrictive measure brings about the need for quite a justificatory work. A recent normative contribution to the debate by Gillian Brock provides a fruitful starting point. In the first step of her defence of emigration restrictions, Brock provides three reasons why skilled workers themselves would hold responsibilities to assist with respect to vital needs of their compatriots. These are fair reciprocity, duty to support vital institutions, and attending to the unintended harmful consequences of one’s actions. While the first two are explained and also largely discussed in the literature, the third requires an explication on how and on which basis skilled workers would have a responsibility as such. In this article, I offer a vulnerability approach with its dependency aspect that may account for why the health workers in underserved contexts would have a responsibility to attend to the unintended side effects of their actions that may lead to a vital risk of harm for the population. I discuss HIV/AIDS care in Zimbabwe as a case in point in order to show that local health workers may have responsibilities to assist the population who are vulnerable to their mobility.

Am I My Family's Keeper? Disclosure Dilemmas in Next-Generation Sequencing

Ever since genetic testing is possible for specific mutations, ethical debate has sparked on the question of whether professionals have a duty to warn not only patients but also their relatives that might be at risk for hereditary diseases. As next-generation sequencing (NGS) swiftly finds its way into clinical practice, the question who is responsible for conveying unsolicited findings to family members becomes increasingly urgent. Traditionally, there is a strong emphasis on the duties of the professional in this debate. But what is the role of the patient and her family? In this article, we discuss the question of whose duty it is to convey relevant genetic risk information concerning hereditary diseases that can be cured or prevented to the relatives of patients undergoing NGS. We argue in favor of a shared responsibility for professionals and patients and present a strategy that reconciles these roles: a moral accountability nudge. Incorporated into informed consent and counseling services such as letters and online tools, this nudge aims to create awareness on specific patient responsibilities. Commitment of all parties is needed to ensure adequate dissemination of results in the NGS era.

Sustaining care for a parent with dementia: an indefinite and intertwined process

This study aimed to understand how adult children sustain caring for persons with dementia (PwDs) within their family and formal care contexts in Canada. Half-day focus groups were conducted with adult daughters and adult sons in Toronto, Canada. Using constructivist grounded theory, we examined both substantive concepts and group dynamics. Sustaining care was interpreted as an indefinite process with three intertwined themes: reproducing care demands and dependency, enacting and affirming values, and "flying blind" in how and how long to sustain caring (i.e., responding to immediate needs with limited foresight). Family values and relationships, mistrust toward the institutional and home care systems, and obscured care foresight influenced care decisions and challenged participants in balancing their parents' needs with their own. Positive and negative aspects of care were found to influence one another. The implications of these findings for research and policy are discussed.

Distancing sedation in end-of-life care from physician-assisted suicide and euthanasia

Lipuma equates continuous sedation until death (CSD) to physician-assisted suicide/euthanasia (PAS/E) based on the premise that iatrogenic unconsciousness negates social function and, thus, personhood, leaving a patient effectively 'dead'. Others have extrapolated upon this position further, to suggest that any use of sedation and/or opioids at the end of life would be analogous to CSD and thus tantamount to PAS/E. These posits sit diametrically opposite to standard end-of-life care practices. This paper will refute Lipuma's position and the posits borne from it. We first show that prevailing end-of-life care guidelines require proportional and monitored use of sedatives and/or opioids to attenuate fears that the use of such treatment could hasten death. These guidelines also classify CSD as a last resort treatment, employed only when symptoms prove intractable, and not amenable to all standard treatment options. Furthermore, CSD is applied only when deemed appropriate by a multidisciplinary palliative medicine team. We also show that empirical data based on local views of personhood will discount concerns that iatrogenic unconsciousness is tantamount to a loss of personhood and death.

Nurses and care delivery to elderly women: a social phenomenological approach

OBJECTIVE: To understand how nurses see care delivery to elderly women. METHODS: In this phenomenological study, ten nurses working at Primary Health Care Units were interviewed between September 2010 and January 2011. RESULTS: In care delivery, nurses consider the elderly women's knowledge background and biographical situation, and also value the family's participation as a care mediator. These professionals have the acuity to capture these women's specific demands, but face difficulties to deliver care to these clients. Nurses expect to deliver qualified care to these women. CONCLUSION: The theoretical and methodological approach of social phenomenology permitted revealing that the nurse designs qualified care to elderly women, considering the possibilities in the context. This includes the participation of different social actors and health sectors, assuming collective efforts in action strategies and professional training, in line with the particularities and care needs of elderly women nurses identify.

‘Returning the love’, not ‘balancing the books’: talk about delayed reciprocity in supporting ageing parents

A desire to ‘return’ or ‘pay back’ past care has been identified as a potential motivator of support provided by adult children to their ageing parents. The purpose of this study is to examine whether, how and in what ways adult children interpret and apply the concept of delayed reciprocity in filial relationships. Twenty-eight men and women supporting one or both ageing parent(s) in a Western Canadian city participated in a qualitative study of filial responsibility. Data were analysed interpretively, using thematic coding, contextualised reflection and guiding questions. Findings suggest delayed reciprocity is limited as an interpretive framework for describing parent support. Overall, comments reflected qualification or rejection of ‘paying back’ in the sense of a filial contract. Delayed reciprocity appears for most participants to symbolise imbalance, expectedness or obligation, and a lack of affection. In response, participants tended to reject delayed reciprocity in favour of interpretations emphasising mutuality, family role duties and reciprocated love. Findings are discussed in relation to interpretive purposes, symbolic meanings of parent support, participant characteristics and cultural contexts.