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PubMed2006

In search of an advance directive that works for end-stage renal disease patients.

Although loss, disability, and death are constant possibilities for any end-stage renal disease patient, very few have planned for the last of life. Currently available Advance Directives (ADs) are refusal of specific therapies in only specific but nebulous circumstances. They fail to provide positive guidance for a patient's remaining time. Without addressing goals, quality of life, reversibility of medical problems, and desired end-of-life (EOL) care, such ADs are useless. End-stage renal disease providers are generally untrained and unsupported in offering guidance. Financial, emotional, and structural factors collude to justify ignoring EOL planning. Several alternative ADs are offered, along with a goal-directed approach to EOL counseling for patients and staff.

Advance Directives↗
PubMedDate not supplied

Rx for caries prevention: time line for home care. A software aid for communication of patient instructions for management of dental caries.

Treatment of a caries active patient requires the clinician to be knowledgeable in the restorative and risk management issues with which these patients often present. Modifications of risk factors that promote dental caries play an important part in the long-term restorative success in these patients. Patient compliance to recommendations addressing modifiable caries risk factors for maintenance of oral health is important to long-term caries risk management. Effective dentist-patient or hygienist-patient communication is a first step to encouraging a proactive role by the patient. Others have reported verbal communication accompanied by written communication to result in better compliance compared to verbal communication, alone (Tagliacozzo & Ima, 1970; MacDonald, MacDonald & Phoenix, 1977; Baker & others, 1991; Harvey & Plumridge, 1991; Vukmir & others, 1993; Makoul, Arntson & Schofield, 1995). Further evidence shows that medical patients who misunderstand their treatment plans and associated instructions usually exhibit poor compliance to following directions (Cargil, 1992; Counsell, Geddis & Smith, 1993; Vukmir & others, 1993; Makoul & others, 1995; Mayeaux & others, 1996). Computer-generated (printed) instructions were shown to significantly increase compliance to emergency room instructions when compared to verbal or verbal + hand-written instructions (Vukmir & others, 1993). Written instructions for use in management of dental caries have not been widely addressed in the literature (Fuller & Harding, 1991; Benn & others, 1997). This report presents a novel computer-generated, graphic approach to written communication that recognizes the patient's need to be reminded that home care consists of daily cyclic events. The objective of this approach is to promote communication with and comprehension by a wider population range than what might be affected by text-only instructions. The software for this method is pre-loaded with recommendations that can be modified by the dentist or hygienist and can be easily adapted as part of a comprehensive disease management program used in the office.

Communication↗
PubMedDate not supplied

Pharmaceutical care and health care utilization in an HMO.

CONTEXT: The belief that expanding the role of pharmacists in patient care could improve the safety and efficacy of drug therapy is growing. Specifically, pharmaceutical care programs through which pharmacists provide direct and ongoing counseling to patients have been introduced. Whether such programs reduce medication-related problems or health care utilization is unknown. OBJECTIVE: To assess whether a pharmaceutical care program decreases health care utilization, medication use, or charges. DESIGN: Nonrandomized, controlled trial. SETTING: Staff clinic and freestanding contract pharmacies affiliated with a large HMO in greater Minneapolis-St. Paul (6 intervention pharmacies, 143 control pharmacies). STUDY POPULATION: Adult HMO enrollees (n = 921) with heart or lung disease who used one of the selected pharmacies. INTERVENTION: Patients at intervention pharmacies were invited to participate in the pharmaceutical care program. The protocol-based program consisted of scheduled meetings between trained pharmacists and patients to assess drug therapy, plan goals, and intervene through counseling and/or consultation with other health professionals. OUTCOME MEASURES: Change in number of outpatient clinic visits, unique medications dispensed, and total charges over 1 year of follow-up. RESULTS: In an intention-to-treat analysis (after adjustment for gender, age, Charlson Comorbidity Index, disease category, and the baseline value of the utilization measure), the number of unique medications for patients in the pharmaceutical care group increased more than in the usual care group (1.0 vs. 0.4 unique medications; P = 0.03). There was no difference between the two groups in the change in total number of clinic visits or total costs. In secondary adherence analyses, participants were more likely than the usual care group to increase the number of clinic visits (1.2 vs. -0.9; P = < 0.01) and number of unique medications (1.0 vs. 0.2; P = 0.02). CONCLUSION: Pharmaceutical care for patients with chronic health conditions appears to be associated with a modest increase rather than a decrease in health care utilization.

Counseling↗
PubMed2004

Growth characteristics of renal cortical tumors in patients managed by watchful waiting.

OBJECTIVE: To characterize tumor growth of patients managed conservatively for renal cell carcinoma. METHODS: Patients electing conservative management of radiographically determined renal cell carcinomas were referred to a surveillance database. Exclusion criteria consisted of locally advanced disease (>T2) and those with metastatic disease. Clinical follow-up included renal imaging with ultrasound or computed tomography at least every 6 months. RESULTS: Twenty-two patients were originally managed conservatively, two of whom subsequently underwent nephrectomy because of rapid tumor growth. Mean follow-up was 26 months. Mean tumor volume and diameter at presentation was 62.4 cc and 4.08 cm respectively. Overall tumor growth was 24 cc/year by volume or .86 cm/year diameter. CONCLUSIONS: Given the stage migration of incidentally detected renal masses, the natural history of these tumors remains incomplete. Overall tumor growth in selected populations appear to be slow even in those diagnosed with larger masses. These data may be useful in counseling patients and directing further trials on conservative therapy for renal cell carcinoma.

Aged↗
PubMed1992

Different risks in two familial translocations t(9;12) with similar breakpoints.

The risk of offspring with unbalanced karyotypes born to carriers of reciprocal chromosomal translocation (RCT) is important to evaluate for further family planning and prenatal diagnosis. The authors describe two families with carriers of similar RCT concerning breakpoint positions and discuss the different individual risks for abnormal progeny. These translocations were studied by GTG, RBG and CBG banding. They have the same breakpoint on 9p, i.e. 9p22, and a different one on 12p, i.e. terminal (pter----p13) and intermediate (p11.2), respectively. The risk value of 27% for family 1 was obtained directly from the large enough pedigree (high risk) a risk value of about 5% was estimated for family 2, according to the guidelines of Stene and Stengel-Rutkowski (1988). The data show that similar translocations with only slight differences in the breakpoints position have different risks for unbalanced progeny. Results of these empiric findings may be used directly in genetic counselling of a family with RCT leading to a single imbalance of the same segment.

Adolescent↗
PubMed1983

Causes of binocular legal blindness in an australian metropolitan community.

Australian legal blindness is defined as bilateral corrected visual acuity less than 6/60; if visual acuity is better than this, collateral visual impairments may be included. Persons thus affected qualify for the Invalid Pension (Blindness). From October 1975 to June 1982, I studied clinical data of 311 persons assessed as legally blind, and recorded diagnoses. I personally examined 259 of these persons and a medical colleague examined 52. Examinees were resident in Brisbane (or environs), Australia. Eleven persons had asymmetrical conditions (analysed separately), and 300 had symmetrical conditions. Causes of the latter were genetically transmissible (20.3%), adult maculopathy (18%), congenital (12.7%), vascular (non-diabetic) (8.7%), adult glaucoma (8.3%), diabetes (7.3%), trauma (6%), and others (18.7%). Of 61 symmetrical genetic cases causes were retinitis pigmentosa (34.4%), congenital cataracts (16.4%), retinal dystrophy and maculopathy (13.1%), Leber's optic atrophy (9.8%), and others (26.3%). These results suggest that more attention should be directed to genetic counselling.

Adolescent↗
PubMed1994

Maslow's Hierarchy of Needs and the individual with chronic vestibular dysfunction.

Individuals with chronic vestibular dysfunction may have unmet physiological or safety needs on a chronic basis. Their inability to fulfill the basic needs and progress to higher needs can lead to a patient population with many psychosocial problems. Very often such problems are ignored or unrecognized or are misdiagnosed, and treated inappropriately. This disruption in the individual's life can lead to an inability to progress as a human being. Nursing assessment and appropriate interventions should be developed to treat psychosocial problems in this patient population. The nursing profession should serve patients with vestibular dysfunction through direct care, teaching, counseling, support group facilitation, and research into appropriate interventions.

Chronic Disease↗
PubMed1998

Considering advance directives for oncology patients.

Communication is an important cornerstone to the physician-patient relationship when considering advance directives. Discussing advance directives with patients is a process best initiated in routine, well-adult care that can be made more daunting when the patient is critically ill; yet, when patients are afflicted with cancer, communication on advance directives can be optimized when the primary care physician and oncologist together work with the patient. The need to counsel patients on advance directives regardless of the venue (whether inpatient or outpatient) highlights that an ongoing alliance between the oncologist and the primary care physician can help facilitate consent to, and allow periodic review of, advance directives by cancer patients. This process ensures that the patient's preferences are respected at life's end.

Advance Directives↗
PubMed1994

Proceed with care: direct predictive testing for Huntington disease.

The cloning of the Huntington disease (HD) gene allows highly accurate predictive testing using direct analysis of the CAG repeat. This new test provides results with almost complete certainty but poses unique counseling issues related to direct testing for an adult-onset disease. These include testing individuals who are at 25% risk, without the need for blood from a 50% at risk relative; the assessment of symptomatic individuals; the need for ongoing counseling despite simplification of laboratory procedures; and counseling of persons from families who represent a new mutation for HD. This paper describes protocols for direct predictive testing for adult and prenatal assessment, on the basis of the experience of the Canadian Collaborative Study on Predictive Testing (CCSPT). Over the past 8 years, we have provided > 400 results by using linked markers and, more recently, 416 results by using direct assessment of CAG expansion in the HD gene. The vast majority (86%) of requests for direct predictive testing have been from persons who have not previously received results by using linked markers. Despite the ability to now directly assess for the mutation associated with HD, we still recommend assessment of DNA from an affected relative, as this may significantly enhance the accuracy of information to be provided to the at-risk individual. Distance from a genetics center has previously limited the availability of testing, and therefore we have developed approaches to providing predictive testing in the patient's own community.

Adult↗
PubMed2005

Counselling quality in community pharmacies: implementation of the pseudo customer methodology in Germany.

OBJECTIVES: To investigate a new method for evaluating counselling performance of staff in community pharmacies and to assess the quality of patient counselling. METHOD: Trained pseudo customers, instructed to play their role according to two different self-medication scenarios, visited voluntarily participating community pharmacies in Berlin. After documenting the counselling process, immediately after each visit, outside the pharmacy on an assessment form, the pseudo customer re-entered the pharmacy and gave detailed performance feedback to the counsellor and the pharmacist in charge in order to provide support for improving counselling skills and practice behaviour, when appropriate. This was followed with a written summary of the general performance of all participating pharmacies and additional individual feedback and suggestions for improvement. Educational needs were identified for subsequent performance-based educational strategies such as group-workshops, team-training and on-site team-coaching. RESULTS: Forty-nine community pharmacies in Berlin volunteered to participate in this pilot study. Ninety-eight per cent of the participating pharmacies offered advice. However, in 36% of the cases, advice was only given on request. The different types of scenarios--presentation of a symptom or request for a specific product--made a great difference to the spontaneity of questions and advice. At least one question to check on accuracy of self-diagnosis was asked in 95% of the cases of symptom presentation but in only 47% of the cases of specific product request. Information on appropriate self-medication was provided on at least one item in 74% of pseudo customer visits, but most of the time the information was not sufficient. Communication skills (nonverbal elements, comprehensibility etc.) were very good or good in 54% of the visits. Potential for improvement was mainly in relation to the use of open-ended questions to gain more information and on counselling about appropriate self-medication. Direct feedback was given in 96% of the pharmacies (one person refused to accept feedback and one feedback had to be postponed because of time shortage). All of the participants regarded counselling as an important subject in pharmacy practice. CONCLUSION: The pseudo customer method was successfully used in this study of German community pharmacies. It was shown that pseudo customer visits and performance feedback following the counselling process, were feasible in daily practice and well accepted by the participants. A training program, focussing on areas in most need of improvement, has been developed. The promising results have led to the Federal Chamber of Pharmacists in Germany adopting this method as part of a continuous quality improvement program in community pharmacies.

Community Pharmacy Services↗
PubMed1988

Counselling for prenatal diagnosis of sickle cell disease and beta thalassaemia major: a four year experience.

A non-directive programme of prenatal counselling was used during a four year period. Forty-three couples at risk for having a baby with a haemoglobinopathy were identified. Prenatal diagnosis was offered in 19 pregnancies to 14 couples at risk of having a baby with sickle cell anaemia and in two pregnancies in two couples at risk of a baby with beta thalassaemia major, who presented before the 18th week of pregnancy. Six couples at risk for sickle cell anaemia accepted prenatal diagnosis in 10 pregnancies, as did both couples at risk for thalassaemia. Couples who were eligible for prenatal diagnosis but refused it tended not to have been informed about sickle cell disease before counselling, one partner was more frequently absent at the time of the initial counselling session, or they either had no children with sickle cell disease or the children were not severely affected. Other factors influencing their decision included a poor obstetric history and rejection of abortion, mainly on moral grounds. The approximately 50% uptake of prenatal diagnosis in this initial study highlights the complex issues involved. Our experience indicates that with systematic screening and counselling in the antenatal clinic, and with increased awareness of the haemoglobinopathies, couples at risk will be in a better position to make informed decisions.

Anemia, Sickle Cell↗
PubMed1998

[Effects of PAC (personal attitude construct) analysis in counseling].

The aim of the present study is to prove that the use of PAC Analysis will enhance and facilitate counseling effects. Eleven functions were hypothetically presented: (1a) Intake Facilitation Function, (1b) Self-Disclosure Facilitation Function, (1c) Trust Formation Function, (1d) Dialogue Development Function, (2a) Mutual Understanding Function, (2b) Clarification Function, (2c) Self-Understanding Facilitation Function, (2d) Counselor's Awareness Function, (3a) Descriptive Documentation Function, (3b) Practical Explanation Function, and (3c) Evaluation-Assessment Function. By examining two case studies of international students' counseling process, these functions were analyzed. Results showed that all the functions were confirmed. Introducing PAC Analysis into counseling is proved to be effective in the direct intermental function field in counseling process (1a to 1d), the intramental function field between a client and a counselor (2a to 2d), and the indirect intermental function field including description, explanation, and assessment (3a to 3c). It is discussed that PAC Analysis is expected to take an important role in counseling in general.

Adult↗
PubMedDate not supplied

Postpartum counseling perceptions and practices: what's new?

BACKGROUND: The in-hospital postpartum period is a critical opportunity for health care providers to enhance maternal understanding of newborn care, yet few studies have determined whether health care providers' educational priorities match those of new mothers. OBJECTIVE: To document how well pediatricians' perceptions of educational priorities for counseling about care of the newborn match those of new mothers during the postpartum hospitalization, and to determine whether pediatricians' actual counseling practices reflected maternal priorities. DESIGN: Cross-sectional study of perceived educational needs with direct observation of pediatrician counseling practices. SETTING: A suburban Washington, DC, community hospital. PARTICIPANTS AND INTERVENTION: All pediatricians on staff and a convenience sample of postpartum mothers were asked to rate the importance of newborn counseling issues using lists generated from focus groups and interviews. Pediatricians were observed while counseling mothers, and their postpartum counseling practices were scored using a template derived from the rating procedure. MAIN OUTCOME MEASURES: Comparison of pediatricians' and mothers' perceptions of educational priorities and the description of pediatricians' actual counseling practice. RESULTS: Mothers listed 9 issues as "very important" and expected the pediatrician to address health problems, especially jaundice, feeding, testing, pain medications for circumcision, behavior, and when to call the pediatrician for concerns or to schedule well-child care. Pediatricians and mothers agreed on 6 out of 11 very important issues. Pediatricians were observed to discuss an average of 8 issues per session, especially those they rated as very important, but they frequently failed to mention safety, sleep position, when to call for advice, testing, infant behavior, or circumcision issues. CONCLUSION: Mothers desire to learn a significant amount of information regarding the care of their newborn before hospital discharge. Although pediatricians discussed more issues than in a previously reported study of postpartum counseling, they still fell short of maternal expectations. Pediatricians must ensure that other sources of information, such as nurses, media, and reinforcement at postpartum well-child visits, supplement the information they provide in their in-hospital counseling sessions.

Adult↗
PubMed1991

[Questions directed to the open-line telephone sex counseling service].

Inquiries to the open telephone-counselling service of the sexological clinic were registered from January 1st 1988 to January 1st 1990; a total of 168 calls, 29 of which were from professional therapists. The P-LI-SS-IT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) model can be used to classify the calls, which fall within the first three categories of this model. Examples of these are given. The pattern and complaints in the inquiries are, by and large, identical with those in a Swedish sexological telephone-counselling. Contrary to a Dutch counselling service only a few telephonesex calls were registered. The use of resources is minimal and the capacity is estimated to fulfil the need. The inquiries correspond entirely to the original intentions of a telephone-counselling service.

Adult↗
PubMed2001

Prenatal diagnosis of sex chromosome aneuploidy: possible reasons for high rates of pregnancy termination.

Sex chromosome aneuploidy (SCA), when detected in amniocentesis, is usually an unexpected result of a test carried out for another purpose. For most SCAs, the prognosis is milder and less predictable than trisomy 21, and therefore parents are faced with a difficult decision regarding the option of pregnancy termination. While studies from Europe and the USA report a declining trend in termination rates for SCA, our local experience is different. During the period 1989-1998, we diagnosed 60 SCA (including mosaics) in 20 106 amniocenteses (0.29%) and 48 (80%) of these pregnancies were terminated, a significantly higher proportion than has been reported in Europe and the USA. The present study shows that the difference between our experience and others' may be related to differences in cultural norms and values. Thirty women were interviewed, of whom 23 terminated and seven continued the pregnancy. Interview analyses showed that the main reason behind the decision to terminate the pregnancy was associated with the parents' fear of non-specific abnormality of the child, and concerns about abnormal sexual development. Although genetic counseling practised in our center aims to be non-directive, 56% of the women reported that the counseling was either directive towards termination, or that they at least felt that the counselor's attitude was pro-termination. Most women (93%) reported themselves as having come to terms with their decision.

Abortion, Induced↗
PubMed1997

Determining consumer preferences for a cash option: Arkansas survey results.

As long-term care (LTC) expenditures have risen, policymakers have sought ways to control costs while maintaining consumer satisfaction. Concurrently, there is increasing interest within the aging and disability communities in consumer-directed care. The Cash and Counseling Demonstration and Evaluation (CCDE) seeks to increase consumer direction and control costs by offering a cash allowance and information services to persons with disabilities, enabling them to purchase needed assistance. The authors present results from a telephone survey conducted to assess consumer preferences for a cash option in Arkansas and describe how findings from the four-State CCDE can inform consumer information efforts and policymakers.

Arkansas↗
PubMed2001

Multicultural genetic counseling: then, now, and in the 21st century.

Scholars, educators, and practitioners have argued that racial-cultural issues are obstacles for those seeking genetic counseling. When available, cross-cultural genetic counseling has focused on simplistic knowledge of client health beliefs and cultural customs, professional cultures, and biased theoretical models as reasons for failure to create realistic knowledge of members of racial-cultural groups in the United States. Recognizing the importance of meeting the needs for all who seek genetic counseling services, genetic counselors have been providing direction in cross-cultural genetic counseling research, practice, training, and developing competency, ethical, and professional guidelines. However, emanating from a cultural pluralism perspective, cross-cultural genetic counseling has often resulted in homogenized group stereotypes without attention to intragroup variation and individual differences. A transition from cross-cultural towards multicultural genetics shifts from culture-specific group norms to an integrated social, historical, psychological, and political perspective. By valuing the process of personal and professional racial-cultural identity development, the evolution from cross-cultural to multicultural genetic counseling that has occurred within the past quarter century is discussed.

Clinical Competence↗
PubMed2004

Giving infants a great start: launching a national smoking cessation program for pregnant women.

Data suggest that 12%-22% of women smoke during pregnancy. The link between smoking during pregnancy and adverse health and reproductive outcomes has been well documented. Great Start is a public education and smoking cessation program developed especially for pregnant women. Launched in December 2001, Great Start was the first national program focused on providing free and confidential smoking cessation counseling to pregnant women through a toll-free quitline. Great Start consisted of a media campaign to raise awareness and direct women to telephone counseling tailored for the pregnant smoker, and educational materials designed to support pregnant women through cessation counseling. The program was evaluated to assess the ability of the television ads to reach pregnant smokers and the effectiveness of a quitline for increasing cessation rates among pregnant women. Great Start demonstrates that it is possible to reach pregnant smokers through television ads that provide information about the consequences of smoking while pregnant, are affirming in tone, and provide direction for women to take action. Initial response to the program indicates that pregnant women want to quit and confirms the need for programs designed specifically to address the needs of this population.

Adolescent↗