What is a good death? Health care professionals' narrations on end-of-life care

Qualitative study on the perception of good death in patients with end-stage cancer in oncology nurses

OBJECTIVE

To explore the perception of good death of patients with end-stage cancer by nurses in the oncology department.

METHOD

In the study we used a phenomenological approach and semi-structured interviews. A total of 11 nurses from the oncology department of a Grade A hospital in Taizhou were interviewed on the cognition of good death from July 1 to September 30, 2022. Colaizzi's analysis method was used to analyse the interview data. This study followed the consolidated criteria for reporting qualitative research (COREQ).

RESULT

Four themes were identified: a strong sense of responsibility and mission; To sustain hope and faith; The important role of family members; Improve patients' quality of life.

CONCLUSION

The nurses in the department of oncology have a low level of knowledge about the "good death", and the correct understanding and view of the "good death" is the premise of the realization of " good death". The ability of nursing staff to improve the "good death", attention, and meet the needs and wishes of individuals and families, is the guarantee of the realization of "good death".

Physical appearance and well-being in adults with incurable cancer: a thematic analysis

OBJECTIVES

Existing research has established the importance of appearance concerns for individuals with cancer and identified appearance as an important factor in dying with dignity. No research, however, has explored in depth the role of appearance in the experiences of individuals who have incurable cancer. This research aims to explore patients' experiences and perspectives in relation to the role of appearance issues in adults with incurable cancer.

METHODS

Semi-structured interviews were conducted with 24 adults with incurable cancer (20 women, 4 men; mean age 54.5, SD 11.32).

RESULTS

Thematic analysis generated three themes: 'Identity: Embodying Cancer', 'Communication: Wearing your illness' and 'Support: Holistic Care'. Appearance was felt to be an important element of identity, which was often dominated by cancer, leading to feelings of separation from the participant's previous self. Appearance changes also influenced the way in which individuals communicated with their external world, forcing discussion of their diagnosis, and increasing focus on their cancer, with participants having to manage the emotional impact of this on loved ones, as well as the impact on their legacy. Finally, participants highlighted the positive impact of appearance-related support in their well-being and identified peer connections and refocusing on the self as key elements of such support.

CONCLUSIONS

Appearance changes play an important role in the experiences of individuals with incurable cancer with regards to both identity and communication and challenged participants' ability to maintain normalcy. Further psychosocial support relating to appearance concerns was considered necessary to promote dignity and provide truly holistic patient care.

Opinions of Cancer Patients, Their Relatives, and Nurses on Good Death

The study sample consists of participants as the patient, patient relatives, and nurse. In our study, a significant relationship was found between the ages of patients, and fear of death, avoidance of death, accepting approach, non-acceptance, and the DAP-R scale total score. A positive moderate correlation was found between the fear of death and death avoidance among my nurses who participated in the study. The nurse, the patient, and patient relatives had a good perception of death and had a higher attitude toward death. Additionally, that found to nurses' fear of death and death avoidance behavior are higher than patients and their relatives.

Student Nurses' Perception of Good Death and Religious Coping Styles

This research aims to examine the perception of the good death and religious coping styles of student nurses. The research is a correlational descriptive study. The research was conducted with 358 nursing students at a state university in the east of Turkey. It was found in the study that students had a good perception of death (58.83 ± 6.12) and mostly used positive religious coping styles (positive/24.55 ± 3.71, negative/13.31 ± 4.21). As a result of the correlation analysis, a weakly significant positive relationship was determined between good death perception and positive religious coping (p < .001).This study observed that students' perceptions of good death increased along with their positive religious coping styles.

Negotiating the Beginning of Care: A Grounded Theory Study of Health Services for Amyotrophic Lateral Sclerosis

A range of professional figures are needed to preserve the quality of life of people with amyotrophic lateral sclerosis. This study aimed to explore the beginning of the care process as negotiated by people with amyotrophic lateral sclerosis, their caregivers, and healthcare professionals. We designed the study according to the constructivist Grounded Theory method, collecting data through open-ended, semi-structured interviews, employing theoretical sampling and constant comparison, and performing conceptual coding as data analysis. By naming the core category "off-beat interfacing", we were able to show how the demands of the professionals concerned did not correspond to the ability of people with ALS and their proxies to process information, deal with requests, and be at ease in making decisions at the beginning of the shared care pathway. Three categories were generated: (i) navigating different paths, (ii) offering and experiencing a standard, non-personalized pathway, and (iii) anticipating decisions. The network of services must be organized according to guidelines, but must also contemplate a patient-family-centered approach that permits more personalized assistance.

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.

The perspective of professional caregivers working in generalist palliative care on 'good dying': An integrative review

In today's industrial societies, many people die receiving professional care. Although specialist palliative and hospice care have often been identified as ideal care approaches to promote good dying, more people die receiving generalist palliative care. This integrative review examines how professional caregivers providing generalist palliative care in hospitals, nursing or private homes define good dying. Furthermore, through comparative analysis of existing empirical studies, it explores conceptual aspects in researching good dying that better reflect the social complexity of this phenomenon. Three databases (Scopus, MEDLINE, and CINAHL) were searched for peer-reviewed studies published between January 2000 and April 2020. Studies were selected if they presented original empirical findings from qualitative or quantitative studies on the perspective of professional caregivers in generalist palliative care (nurses, physicians, surgeons, clergy, and other staff) on good dying or related concepts (e.g., good death, dignity in dying, or quality of life at the end of life). 42 studies were included in the review. They identified good dying as expected, accepted and prepared dying, as free from pain and suffering, as socially embedded, as being at peace with one's life and situation, as supported with individualised and holistic care, as based upon professional cooperation and communication, and as in a peaceful and private environment. The paper concludes that the perspective of professional caregivers in generalist palliative care shares many elements of good dying with societal and specialist palliative care discourses around good dying. Through comparing the different studies, the review found that studies that explicated who benefitted from ideals and practices of good dying, questioned the dichotomous categorisation of good/bad dying, or discussed the compatibility of elements of good dying, provided more nuanced perspectives on this topic. Thus, the review calls for a more systematic analysis of these aspects in research of good dying.

A genealogy of what nurses know about 'the good death': A socio-materialist perspective

In this article, we report the outcome of a sociological inquiry into nursing knowledge of death and dying, specifically 'the good death'. A genealogical approach informed by actor-network theory and appreciative inquiry were used to compose a broad socio-material account of how nurses concern themselves with the care of the dying and end-of-life care. Our enquiry revealed similarly to other studies, that there was no shared or overarching model of care. Key themes derived from nurses' translations of 'the good death' were re-presented pictorially as six pillars and two processes to comprise a new diagram of The Personalised Ideal Death.

Embodied good deaths and disembodied bad deaths: Undergraduate nursing students narratives of experience

BACKGROUND

The concept of "good and bad deaths" has been widely addressed in the literature. However, little is known of undergraduate nursing students' experiences with death in clinical practice or how they perceive good and bad deaths.

OBJECTIVE

To explore undergraduate nursing students' personal and professional/clinical experiences of death and dying.

DESIGN

A qualitative narrative inquiry design.

SETTING AND PARTICIPANTS

Eighteen third year Bachelor of Nursing students participated in the study.

METHODS

Data was collected through individual participant interviews and analysed using Clandinin and Connelly's three dimensions of narrative inquiry (temporality, sociality and place).

RESULTS

A key finding of the study revealed that students' death experiences are shaped by the role of others, especially experienced nurses in clinical practice. Embodied good death experiences were influenced by the presence of nurses who guided students through the experience. Disembodied bad death experiences were influenced by undignified care, ritualistic post-mortem care and the physical coldness of the deceased and the environment.

CONCLUSION

Nursing students need meaningful preparation to undertake end of life care in clinical practice, including post-mortem care and the possibility of bad deaths. End of life care education and end of life care simulation play a role in preparing students for end of life care in clinical practice. End of life care education needs to be commenced early in the undergraduate degree. Furthermore, nursing clinicians need to be aware of the impact that they have in shaping good and bad death experiences for undergraduate nursing students, the Registered Nurses of the future.

Preparing for a good death? Palliative care representations in the italian public television programming

The difficulty in accepting death is a constant that transcends differences of time and place. The literature shows that the dying is often subjected to invasive procedures with significant consequences on individual wellbeing and public health. If death is hard to accept even for the practitioners, what happens in the broader population? What narratives surround the end of life? The study focuses on the Italian context and its transformations, the public's understanding of palliative care, and the television programs dealing with hospice and palliative care aired by the Italian public broadcasting company from the 1950s to the present day.

End-of-life care after the legal introduction of advance directives: A qualitative study involving healthcare professionals and family caregivers of patients with amyotrophic lateral sclerosis

BACKGROUND

Advance care planning and advance directives play a key role in the care of life-threatening illnesses such as amyotrophic lateral sclerosis.

AIM

The aim of the present study is to explore how the introduction of these features by law improves the experience of end-of-life care.

DESIGN

Five focus groups were conducted in Italy 1 year after the new law on advance directives was introduced.

SETTING/PARTICIPANTS

Purposive sampling was used to recruit 24 health professionals and 23 family caregivers of patients with amyotrophic lateral sclerosis, for a total of 47 participants.

RESULTS

The thematic analysis, conducted through the use of ATLAS.ti software, identified four thematic areas: best practices, managing difficulties, care relationships and proposals. The results indicated a lack of organization, collaboration and continuity on the part of healthcare services and professionals, a lack of information on palliative care, advance care planning, and advance directives. End-of-life care is often left to the good will of the individual professional. Difficulties can also derive from ethical dilemmas concerning end-of-life decision-making and from a lack of communication and relationships between health professionals, patients and their families.

CONCLUSION

The introduction of advance directives by law has not been sufficient to improve end-of-life care. In order to make legal regulation effective, the organization of healthcare services needs to be improved and clearer procedures have to be implemented and shared with patients and families.

Dying alone and lonely dying: Media discourse and pandemic conditions

BACKGROUND AND OBJECTIVES

This paper explores current concerns and practice related to older people dying alone in Intensive Care Units, care homes, and at home through media discussions during the Covid-19 pandemic and before. It addresses the historically-situated concept of a good death and a bad death and suggests why dying alone, whether completely alone or without significant others physically present, may be considered a bad death.

METHODS

As evidence for collective fears about dying alone, we explored the treatment of these deaths in media using headline examples from the US New York Times and the English Guardian newspaper from the 19th century through Sept. 2020.

RESULTS

A search of the New York Times located 39 articles with either lonely dying or lonely death in the headline. The Guardian had 25 articles with use of the term, but unlike the New York Times, no obituaries were included. Although the deaths profiled were deemed unusual, deaths by suicide were only minimally classed as dying alone. The condition of dying alone is represented as a stigmatised death. Themes addressed: 1) dying alone is a nonnormative event; 2) this death matters; and 3) where people die alone, societies should honour the death and learn from it.

DISCUSSION AND IMPLICATIONS

Contemporary dying involves conditions for which we are unprepared as a society. We seldom address our civic obligations to each other. Few people have discussed their wishes about their preferences in dying and whether and how they want to be accompanied at their death, if possible. This is an invisible constraint of modern healthcare. Because of limited discussions and preparation, these deaths may lead to disenfranchised grief for the mourners. Cultural and societal responses to lonely dying are important in easing the emotional burden of dying alone, helping individuals prepare for this possibility and better integrating death with the life course. Recommendations include inclusion of accompaniment/nonaccompaniment at death as part of advance care planning and mitigation if this condition occurs. It is essential for individuals to find their own still point of acceptance within competing societal narratives of privileging the self in dying alone and the value of social connection.

A critical exploration of professional jurisdictions and role boundaries in inter-professional end-of-life care in the community

This article critically examines how professional boundaries and hierarchies influence how end-of-life care is managed and negotiated between health and social care professionals. Our findings suggest there is uncertainty and lack of clarity amongst health and social care professionals regarding whose responsibility it is to engage, and document, the wishes of patients who are dying, which can lead to ambiguity in treatment decisions. We go on to explore the potential role of a new electronic system, designed to facilitate information sharing across professional boundaries, in shaping and bridging professional boundaries in the delivery of end-of-life care. We highlight potential negative impacts that may arise when health and social care groups are permitted varying levels of access to the system, and how this may be seen to reflect the value placed on their role in end-of-life care.

Are You Prepared for End-of-Life Care? A Content Review of Canadian End-of-Life Care Standards and Competencies for Saskatchewan

BACKGROUND

The provision of end-of-life care is receiving attention locally, provincially, and nationally in Canada. It is important to ensure that interprofessional standards and competencies are in place to provide quality end-of-life care that meets the needs of patients and their families. The purpose of this content review was to identify core standards and competencies essential to an interprofessional team providing end-of-life care.

METHODS

The researchers conducted a review of health professional associations and registration bodies that support professionals providing end-of-life care to identify existing standards and competencies. Key concepts were reviewed and organized using thematic analysis; relationships were developed; and core themes for interprofessional end-of-life care were identified.

RESULTS

Four themes essential to the provision of end-of-life care were common across all health professions: (1) access to care, (2) professional practice, (3) person-centered care, and (4) the process and delivery of care.

CONCLUSIONS

Health professional associations need to ensure end-of-life care standards and competencies are in place for the provision of appropriate and holistic care. Aligning standards and competencies across professions improves the preparedness of health professionals to provide interprofessional end-of-life care.

A Time to Live and a Time to Die: Heterotopian Spatialities and Temporalities in a Pediatric Palliative Care Team

The death of a child creates especially poignant feelings and extreme stress, distress, and devastation for family members and healthcare providers. In addition, serious or long-term illness forces a reconstruction of our experiences with time and space. In this paper, we report on a long-term ethnographic study of a Pediatric Palliative Care Team (PPCT). Using the concepts of spatiality and temporality; Deleuze's concepts of smooth and striated spaces; Innis's concepts of space and time biases; Foucault's concept of heterotopian space-places with multiple layers of meaning; and a related concept of heterokairoi-moments in time with multiple possibilities-we consider how the PPCT constructs and reconstructs meaning in the midst of chaos, ethical dilemmas, and heartbreaking choices.

Thematic Analysis of Interprofessional Provider Perceptions of Pediatric Death

PURPOSE

Though provider and patient perceptions of death are characterized in the adult population literature, there is limited information related to providers' perceptions in pediatric and neonatal patients. The purpose of this study was to better understand how interprofessional care team members perceive and experience neonatal and pediatric end-of-life situations.

DESIGN AND METHODS

This survey questionnaire was administered to interprofessional providers following their participation in an institutional workshop, as part of an ongoing institutional effort to improve end-of-life experiences for patients/family and providers. Interprofessional care providers completed an electronic survey consisting of closed-ended and one open-ended question to elicit their perceptions of their participation in end of life care for a recent neonatal/pediatric patient in the period before the child's death.

RESULTS

The qualitative analysis of 306 free-text responses commenting on the deaths of 138 patients, contained within 880 completed mixed-method surveys, is described. Thematic analysis of the free text discovered three primary themes from the data: favorable aspects of the death experience, unfavorable aspects of the experience, and combined favorable and unfavorable aspects. Four subthemes contributed to the themes; namely, language, parental presence, trust/rapport in provider relationships and inclusion in decision-making, communication, and culture.

CONCLUSIONS

Multiple factors contribute to how interprofessional care providers perceive end-of-life care experiences for neonatal/pediatric patients. The same death may be perceived differently by different providers.

PRACTICE IMPLICATIONS

Understanding favorable and unfavorable aspects of providing end-of-life care will support strategies to provide resources, education and support to facilitate coping and resiliency in care providers.

Are Television Deaths Good Deaths? A Narrative Analysis of Hospital Death and Dying in Popular Medical Dramas

This study explores death narratives in the popular international medical dramas Grey's Anatomy (USA), Casualty (UK), All Saints (Australia), and E.R. (USA). Using narrative analysis, we characterize death portrayals in terms of the number and causes of the deaths, the types of characters who die, the narrative structures of the deaths, and themes found within the death stories. We then compare characteristics actual patients, physicians, and caregivers identify as important in a death experience with the characteristics of deaths portrayed in medical dramas. Our narrative analysis shows that death narratives in medical dramas lack narrative fidelity with the characteristics of "good" death experiences described in the literature.

The care of dying people in 16th- and 17th-century England

Between the years 1500 and 1700, mortality was higher and exposure to death is greater than in the modern day. Through analysis of primary texts from the chosen period, we explored the principles behind the care of the dying in the context of medicine, spirituality, and society. Results showed that a "holy death" was a cultural norm and medicine was subsidiary: hope was for the salvation of the soul, not the body. This was part of an approach that focused on symptom relief, irrespective of disease classification, demonstrating an early holistic approach to death and dying.

Terminal lucidity in the teaching hospital setting

Terminal lucidity is an unpredictable end-of-life experience that has invaluable implications in preparation for death. We retrospectively evaluated terminal lucidity at a university teaching hospital. Of 338 deaths that occurred during the study period (187 in the ICU and 151 in general wards), terminal lucidity was identified in 6 cases in general wards. Periods of lucidity ranged from several hours to 4 days. After experiencing terminal lucidity, half of the patients died within a week, and the remainder died within 9 days. More attention should be directed toward understanding terminal lucidity to improve end-of-life care in a meaningful way.

"Violence" in medicine: necessary and unnecessary, intentional and unintentional

We are more used to thinking of medicine in relation to the ways that it alleviates the effects of violence. Yet an important thread in the academic literature acknowledges that medicine can also be responsible for perpetuating violence, albeit unintentionally, against the very individuals it intends to help. In this essay, I discuss definitions of violence, emphasizing the importance of understanding the term not only as a physical perpetration but as an act of power of one person over another. I next explore the paradox of a healing profession that is permeated with violence sometimes necessary, often unintentional, and almost always unrecognized. Identifying the construct of "physician arrogance" as contributory to violence, I go on to identify different manifestations of violence in a medical context, including violence to the body; structural violence; metaphoric violence; and the practice of speaking to or about patients (and others in the healthcare system in ways that minimize or disrespect their full humanity. I further suggest possible explanations for the origins of these kinds of violence in physicians, including the fear of suffering and death in relation to vicarious trauma and the consequent concept of "killing suffering"; as well as why patients might be willing to accept such violence directed toward them. I conclude with brief recommendations for attending to root causes of violence, both within societal and institutional structures, and within ourselves, offering the model of the wounded healer.

Concept analysis of good death in long term care residents

The purpose of this concept analysis paper is to delineate the meaning of good death in long term care (LTC) settings and examine its implications for nursing. The Walker and Avant (2011) method was chosen for this analysis. An in depth literature review identifies uses of the concept and determines the defining attributes of the good death. This paper also illustrates case presentations, antecedents, consequences, empirical referents and implications for clinical practice to clarify the concept of 'good death' in this population. In LTC, death is experienced frequently and is considered the ultimate outcome for most admissions. Much of the existing research on end-of-life care has focused on community dwelling cancer patients whose death trajectory is predictable and who may remain cognitively intact until actively dying. In contrast, the LTC population is older and more likely to suffer from dementia and experience chronic illness for long periods prior to death, and they follow a less predictable death trajectory. In this century, death became the province of older people and the assurance of a good death became the responsibility of those caring for them.

Still Searching: A Meta-Synthesis of a Good Death from the Bereaved Family Member Perspective

The concept of a good death continues to receive attention in end-of-life (EOL) scholarship. We sought to continue this line of inquiry related to a good death by conducting a meta-synthesis of published qualitative research studies that examined a good death from the bereaved family member's perspective. Results of the meta-synthesis included 14 articles with 368 participants. Based on analysis, we present a conceptual model called The Opportunity Model for Presence during the EOL Process. The model is framed in socio-cultural factors, and major themes include EOL process engagement with categories of healthcare participants, communication and practical issues. The second theme, (dis)continuity of care, includes categories of place of care, knowledge of family member dying and moment of death. Both of these themes lead to perceptions of either a good or bad death, which influences the bereavement process. We argue the main contribution of the model is the ability to identify moments throughout the interaction where family members can be present to the EOL process. Recommendations for healthcare participants, including patients, family members and clinical care providers are offered to improve the quality of experience throughout the EOL process and limitations of the study are discussed.

When the woman gets violent: the construction of domestic abuse experience from heterosexual men's perspective

AIMS AND OBJECTIVES

To promote a critical approach on the conceptualisation of domestic violence by investigating the experience of abuse on the part of men who are victims of domestic violence by their female partners.

BACKGROUND

Media attention and prevention programmes relating to domestic violence have mainly focused on women as the victims and men as the perpetrators. The underlying idea is that violence is predominantly physical and a prerogative of men. This conceptualisation of violence reduces the opportunities for the consideration of different modalities of abuse.

DESIGN

Discourse analysis within a qualitative approach.

METHODS

Semistructured interviews with 20 Italian men who claimed to have been abused by their female partners were conducted via Skype and analysed with the software atlas.ti. The grounded theory methodology was used to avoid imposing external points of view. Personal data were collected; in particular, their occupational level was compared to their partners' to assess the social power within the couple.

RESULTS

Because of their strong endorsement of social and cultural values, participants showed a protective attitude towards their partners and imputed their violent acts to fragility or an external condition. Emotional distress emerged due to the isolation and subsequent inability to seek help. Although the physical violence reported is severe, the psychological violence was indicated as more damaging.

CONCLUSION

Gaining an understanding of how men experience domestic abuse offers an opportunity to provide better prevention and intervention for them and other family members at risk of abuse.

RELEVANCE TO CLINICAL PRACTICE

The study identifies gaps in service provision generated by a lack of information or perceived prejudice towards abused men. The role of the nurse in supporting male victims is discussed, and future applications for treatments and prevention plans are proposed.

"Doing death": Reflecting on the researcher's subjectivity and emotions

Given that death is a universal concept, the idea that a researcher must be objective when studying this topic is common place and problematic. Thus, this article adds to the literature by discussing the complexity of subjectivity within death studies. Three key elements of subjectivity form the basis of this discussion: (a) the researcher's cultural background, (b) the researcher's personal experiences, and (c) the emotional impact of research on the researcher. It is argued that transparency about the subjective nature of death studies research can be fruitful in understanding the research process before, during, and after fieldwork.

Quality of death among hospice decedents: Proxy observations from a survey of community-dwelling adults in the contiguous United States

This study examines hospice service experience and quality of death. A survey of 123 community-dwelling adults in the United States found that physical comfort, pain-free, and spiritual peace were more important to respondents reporting a personal experience with hospice. A "good death" was associated with older patients who died at home, and respondent satisfaction with hospice service. A "good death" was mapped as 29 nodes and 79 links using semantic network analysis. Three subjects (patient, family, hospice), three timeframes (end-of-life, moment of dying, death), and four central causes (home, peaceful, pain-free, and expected) were identified.

Metaphors for ‘good’ and ‘bad’ deaths

This paper discusses the metaphors used by sixteen palliative healthcare professionals from around the United Kingdom in semi-structured interviews to describe what they see as ‘good’ and ‘bad’ deaths. The interviews, conducted for the large-scale “Metaphor in End-of-Life Care” project, are set against the background of contemporary practices and discourses around end-of-life care, dying and quality of death. To date, the use of metaphor in descriptions of different types of deaths has not received much attention. Applying the Metaphor Identification Procedure (Pragglejaz Group, 2007) we find that the difference between good and bad deaths is partly expressed via different frequencies of contrasting metaphors, such as ‘peacefulness’ and ‘openness’ as opposed to ‘struggle’ and ‘pushing away’ professional help. We show how metaphors are used to: evaluate deaths and the dying; justify those evaluations; present a remarkably consistent view of different types of deaths; and promote a particular ‘framing’ of a good death, which is closely linked with the dominant sociocultural and professional contexts of our interviewees. We discuss the implications of these consistent evaluations and framings in broader end-of-life care contexts, and reflect on the significance of our findings for the role of metaphor in communication about sensitive experiences.

Family Functioning as a Constituent Aspect of a Child's Chronic Illness

This study explored how family functioning may contribute to trace a child's illness trajectory. We conducted semi-structured interviews with 33 parents of children in care at a hospice in northern Italy. We also examined the medical records of the children, and interviewed the physician who cared for them. Data analysis was based on the grounded theory approach. Different illness progressions corresponded to the different ways with which families experienced the illness: possibility, focus on illness, denial, and anger. Clinical interventions should involve the whole family and take into account their role in the construction of illness trajectories.

Hypnosis-based psychodynamic treatment in ALS: a longitudinal study on patients and their caregivers

Background: Evidence of psychological treatment efficacy is strongly needed in ALS, particularly regarding long-term effects.

Methods: Fifteen patients participated in a hypnosis treatment and self-hypnosis training protocol after an in-depth psychological and neurological evaluation. Patients' primary caregivers and 15 one-by-one matched control patients were considered in the study. Measurements of anxiety, depression and quality of life (QoL) were collected at the baseline, post-treatment, and after 3 and 6 months from the intervention. Bayesian linear mixed-models were used to evaluate the impact of treatment and defense style on patients' anxiety, depression, QoL, and functional impairment (ALSFRS-r), as well as on caregivers' anxiety and depression.

Results: The statistical analyses revealed an improvement in psychological variables' scores immediately after the treatment. Amelioration in patients' and caregivers' anxiety as well as caregivers' depression, were found to persist at 3 and 6 months follow-ups. The observed massive use of primitive defense mechanisms was found to have a reliable and constant buffer effect on psychopathological symptoms in both patients and caregivers. Notably, treated patients decline in ALSFRS-r score was observed to be slower than that of control group's patients.

Discussion: Our brief psychodynamic hypnosis-based treatment showed efficacy both at psychological and physical levels in patients with ALS, and was indirectly associated to long-lasting benefits in caregivers. The implications of peculiar psychodynamic factors and mind-body techniques are discussed. Future directions should be oriented toward a convergence of our results and further psychological interventions, in order to delineate clinical best practices for ALS.

Living with and treating rare diseases: experiences of patients and professional health care providers

We explored the experiences of illness of patients suffering from rare diseases and of the health professionals who care for them at the Center for the Interregional Coordination of Rare Diseases of Piedmont and Valle d'Aosta in Italy. The research was carried out between 2010 and 2011. We collected qualitative data from 22 patients and 12 health professional health care providers. The interviews were analyzed using the Colaizzi phenomenological approach. We identified five themes from the narratives of the patient participants--dealing with disease development, living with the disease, everyday living, relating to others, and relations with health care providers--and four themes from the professional health care participants--dealing with the disease, dealing with expectations, building relationships, and being operators in the context. The study has raised awareness about the issue of rare diseases and it provides some useful considerations for improving services.

Vita tua, mors mea: The experience of family caregivers of patients in a vegetative state

This study aims to understand whether, and possibly how, caregivers of patients in a vegetative state experience an emotional paradox between life and death. Individual semi-structured interviews were conducted with 24 (19 females and 5 males) caregivers of vegetative state patients living in northern Italy. Data were analysed using interpretative phenomenological analysis. Caregivers felt they were the only ones able to understand and give answer to patients' needs, but neglected their own lives in their total commitment to the patient. The findings highlight the importance for vegetative state caregivers in considering new possibilities of life that go beyond the assistance of vegetative state patients.

The family experience of living with a person with amyotrophic lateral sclerosis: a qualitative study

Living with a person with amyotrophic lateral sclerosis (ALS) is a complex and difficult experience. Most research involves only the primary caregiver and uses a quantitative approach. The aim of this study was to explore the experience of family members who live with ALS patients until their death. In-depth, semi-structured interviews were conducted with 13 family members of ALS patients now deceased. Transcripts were analysed using interpretative phenomenological analysis. Three main themes were identified: "Meaning of ALS," including the peculiarity of ALS and its comparison with other illnesses, the explanation of ALS, emotions, coping strategies, personal change and difficult choices; "Family relationships," including centripetal vs. centrifugal forces, role changes, ALS as a family disease, ALS as a family solution, openness towards the outside world; and "Healthcare context," including access to services, information and humanization. One finding was that families of a person with ALS need more supportive interaction and information during the patients' illness and their end-of-life. This study is an invitation to understand families' experience and subsequently help them to find new ways to cope with the situation.

Changes over time in the quality of life, prolonged grief and family strain of family caregivers of patients in vegetative state: A pilot study

This study explored changes over time and in the internal standards of the quality of life, prolonged grief and family strain of informal caregivers of patients in vegetative state. Data obtained from 52 caregivers showed high levels of prolonged grief and family strain, and low quality of life. A decrease of caregivers’ quality of life and an increase of family strain were found by adopting a response shift procedure. Only prolonged grief did not change during time. Clinical intervention with the caregivers of vegetative state patients should be differentiated on the basis of the duration of the caring experience.