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PubMed1991

Thoughts and feelings and things: a new psychiatric epistemology.

Epistemology--the study of knowledge--is a philosophical discipline with close ties to psychiatry. When epistemologists address specific questions about how knowledge is actually realized by human beings, their philosophy must be informed by empirical studies of the sort psychiatrists now take up in a variety of forms. As this paper describes, psychiatrists can likewise improve their understanding of human psychology through a deeper appreciation of philosophical analysis in epistemology. The aim of this article is to introduce a unifying framework within which the experience from different approaches to psychiatry--(1) the conceptual schemas of cognitive psychiatry, (2) the mental structures of psychoanalytic psychiatry, (3) the categorical forms of existential psychiatry, and (4) the neural pathways of biological psychiatry--can all be applied productively to the central question of epistemology. By establishing a broad understanding of the problem of knowledge, this new view of epistemology is developed within the idiom of each psychiatric approach. In addressing themselves to a unitary problem, these diverse psychiatric approaches are themselves revealed, not as competing points of view, but as complementary views of a single subject. The result is a new epistemology that can not only bring the insights of psychiatry to philosophy, but can also contribute to the care of patients when psychiatrists bring this broader view to their clinical work.

Humans↗
PubMed1991

Some philosophical directions towards a simple theory of the self.

In the act of self-observation, an individual becomes simultaneously observer and observed, subject and object. While some philosophical psychologists have dismissed this reflexivity, the present author proposes that it is the essential feature of the self, making it the basis of a new, conceptually simple, structural and dynamic theory of the self. Drawing from psychopathology, poetry and literature, the author portrays normal and disordered psychological states as disturbances in reflexivity. Qualitative and quantitative variations in this core function are proposed to define discreet spectra of psychological situations. The author briefly examines the theories and practices of psychoanalytic and existential psychology, and proposes clinical applications of the new views here depicted. He attempts to show that inherent limits to our simultaneous knowledge of both aspects of the reflexive duality limit the precision and validity of all psychological theorization.

Ego↗
PubMed2005

[End-of-life dilemmas].

Cancer patients need continuous care from the time of diagnosis until the final phase of life. Comfort for the patients becomes the predominant goal as the disease progresses. Cancer patients often die with serious, unrelieved, symptoms that cause a distressing death and tremendous suffering for their families. Many physicians have not been trained to care for the dying patient. The symptoms associated with the dying process are so characteristic that all physicians should be able to recognise them, be skilled in providing appropriate care, and be prepared for problems that may arise. As the disease progresses, it may become necessary in some cases for the patient and his/ her family to consider sedation as an alternative to alertness accompanied by intolerable physical and existential disease. This article reviews the common symptoms in the final phase of life and describes the methods to manage the symptoms while supporting the patient and family through this difficult period.

Aged↗
PubMed2007

[Consultation. Considerations on the practice of medical consultation].

On the theme of Linus Geisler's nine steps for a successful consultation between doctor and patient, the ability for self-criticism, the ability to be able to listen to oneself and the value of the doctor-patient relationship in the context of medical practice will be discussed. Subsequently, the framework of the consultation, the consulting room atmosphere and the complete setting of the consultation will be dealt with. The importance of active listening and the recognition of all messages, both verbal and from body language, will be particularly emphasized. The capability for empathy is presented as the necessary bridge to recognition of the feelings and inner world of the patient. Because one only sees what one is looking for and only recognizes what one knows, the recognition of typical complaints presented by patients in a consultation represents the "something" which must be specifically elucidated. The problems and symptoms which the patient brings to the doctor are surrounded by a ring of fears and apprehensions. For this reason it is decisive to uncover the accompanying cloud of fears and apprehensions with appropriate questions, to correctly assign the unsettling symptoms of the patient and to be able to correctly interpret them. As illustrated by the language of nature - the translation of deoxyribonucleic acid (DNA) triplets into amino acids - the translation of biological, psychological and social aspects of the complaints symptomatic into the level of diagnosis and the translation of the referential, social and affective meaning of the expressions used by the patient, into the level of the significance will be discussed. The role of the doctor here is that of a producer of context and a skilled translator. In the management of functional disorders and chronic diseases the construction of a shared reality is important. The therapeutic function of consultations is due to an introduction of metaphors as bridges - bridges to an improved understanding of the body, the self and the world. The role of the physician here is that of a moderator, motivator an accompanying person. Finally, Jaspers levels of good doctoring (natural science or causal level, nursing level, communicative-existential level) are stressed and the importance of a good patient-physician relationship for a patient-centered medicine is underlined.

Communication↗
PubMed2006

[Meaning and spirituality in patients with chronic somatic illness].

Issues of the meaning of life and spirituality are particularly important subjects given the threat of a serious illness and the confrontation with the finiteness of one's own life. Thus, addressing questions of meaning and spiritual domains of supportive care has been identified as essential by patients as well as by health care professionals. In recent years more research has focussed on theoretical conceptualization, empirical examination as well as on the development of meaning-centred interventions in somatically ill patients. Theoretical models for the understanding, development and adaptation of concepts and interventions addressing meaning and spirituality in the chronically ill are offered by the philosophical tradition of existentialism, logotherapy as well as by cognitive and developmental psychology, in particular studies on autobiographical memory and life story. However, the current state of empirical research focussing on the association between meaning, spirituality and physical as well as mental health and underlying mechanisms is not sufficient to draw reliable conclusions. With regard to psychosocial care, meaning-centred interventions have been developed in recent years primarily within the context of palliative care. These interventions are intended to support patients to find meaning in life in the face of a serious illness and to experience their life as fulfilled.

Attitude to Death↗
PubMed2006

[Doctor's role and communication with the dying].

In palliative medicine, the doctor's role towards the patient changes from curing to looking after and depends on the different organizational forms. A key topic for the doctor remains the decision, how far medical treatment should be extended - according to patient's will. Studies for palliative medicine have also showed considerable communication deficits. This leads to the following aims of communication with the dying: Recording of somatic, psychic, social and spiritual problems of the patients, informing about illness and prognosis, responding to the patient's emotional situation and to the existential dimension of dying as well as involving relatives in communication. "Active listening" is proposed as a communication form to be learned by doctors. Training programs and possibilities of improving the emotional situation of doctors are described.

Attitude to Death↗
PubMed2003

[A long life--a wish and its limits. Aging with dignity and meaning].

In the journal "Gerontologie" (1991, Oswald WD et al. Eds.), the article on "Langlebigkeit" (longevity) is followed by the article on "Lebenszufriedenheit" (satisfaction in life) for purely alphabetical reasons. However, there is a deeper meaning in this order which refers to a connection that should not be neglected. "The number of our days is 70 years. Or maybe 80 years if..." To have a long and satisfying life is a deeply rooted wish in the human mind. Medicine and modern, improved conditions of living let this come true for many. However, what undoubtedly is a value by itself and has been praised as success until recently, now causes personal and social problems. We are dealing with a covert problem in particular: Which decisions that concern us and are likely not to please us, are others going to take when we are old? "I need a coat already. For me the sun is already declining". The wish to live as long as possible is always connected with hope, that is hope to have a fulfilling life. However, there are limits to that hope due to the constancy of maximal life expectation, multiple morbidity related with old age and consequent shortening of life. At the same time basic existential experiences as uniqueness, loneliness and the limits of the human mind increase with age. So what does it mean to fill life in old age with meaning and dignity? Nowadays dignity is constantly talked about. That is possibly why it is on the retreat. Dignity is understood as something that can be ascribed and if that is so, we can simply abandon it since theology is not a known discipline any more. Theology and religion in general could bring about a new understanding of the meaning of life as it could relate something incomprehensible with a potential interpretation. Life in old age also comprises the personal and private wherein the memories of the personal life attain a particularly important function.

Aged↗
PubMed2003

Next of kin's experience of powerlessness and helplessness in palliative home care.

GOALS OF WORK: Powerlessness and helplessness have been very little studied. The aims of this study were (1) to describe what characterise such experiences and the meaning of them to next of kin of cancer patients in advanced palliative home care and (2) to make quantifications. PATIENTS AND METHODS: The study design was cross-sectional and targeted next of kin during ongoing palliative home care and next of kin of patients who had died 3-9 months earlier; 233 next of kin responded (response rate 72%) to a postal questionnaire with both Likert-type and open-ended questions. The text responses were analysed with a combined qualitative and quantitative content analysis. MAIN RESULTS: Thirty-six percent of respondents stated that they had experienced powerlessness and/or helplessness every day or several times per week, whereas 33% had never had this experience during the palliative home care period. Powerlessness and helplessness concerned next of kin's perception of the patient's suffering, of the patient's fading away and the next of kin's own feelings of insufficiency and resulted in both physical and psychological symptoms, such as muscle tension, headache, loss of appetite, anxiety and depression. In addition, powerlessness and helplessness concerned also a deeper meaning with existential and social aspects, such as feelings of guilt, anger and loneliness. CONCLUSIONS: The main findings provide tools for the practitioner to identify situations contributing to next of kin's sense of powerlessness and helplessness. The findings are discussed in relation to the concepts of symptom control, communication of awareness and humans' search for action.

Adult↗
PubMed2005

Discussing end-of-life issues with terminally ill cancer patients and their carers: a qualitative study.

GOALS OF WORK: Discussing end-of-life issues is of key importance to terminally ill cancer patients and their families, and a challenging topic for both health professionals and patients/carers. There is a lack of research evidence in the literature to guide clinical practice. The objective of this study was to explore the optimal content and phrasing of information when discussing the dying process and end-of-life issues with terminally ill cancer patients and their carers. SUBJECTS AND METHODS: We conducted focus groups and individual interviews with 19 palliative care patients and 24 carers from three palliative care services in Sydney, and 22 palliative care health professionals from around Australia. The focus groups and individual interviews were audiotaped and fully transcribed. Further focus groups and/or individual interviews were conducted until no additional topics were raised. Participants' narratives were analysed using qualitative methodology. MAIN RESULTS: Distinct content areas emerged for discussing end-of-life issues: treatment decisions at the end-of-life; potential future symptoms; preferences for place of death; the process of dying; what needs to be done immediately after death; and existential issues. When discussing the process of dying participants recommended: exploring the persons' fears about dying and dispelling myths; describing the final days and the likely unconscious period; and the reduced need for food and fluids. Many participants identified the dilemma regarding whether to discuss potential complications around the time of death. CONCLUSIONS: This paper provides strategies, words and phrases which may inform discussions about the process of dying and end-of-life issues. Further research is needed to determine the generalizability of these findings.

Adult↗
PubMed2005

Experience in the use of the palliative care outcome scale.

GOALS OF WORK: The objective of the study is to assess the Palliative Care Outcome Scale (POS) as a potential audit tool within a specialist cancer centre. It also aims to answer the following questions: does the tool identify problem areas and demonstrate changes in quality of life over time? How well do staff and patient ratings correlate? PATIENTS AND METHODS: The POS questionnaire was piloted at a specialist cancer centre. Thirty consecutive patients admitted to the palliative care wards and ward staff completed questionnaires on admission and twice weekly until discharge or death. A further questionnaire assessed staff attitudes. RESULTS: There was a significant improvement in overall patient POS score at 1 week (days 5-9). Four "symptoms" or issues were scored as being important for our patients: pain, other symptoms, anxiety and patient's perception of family anxiety. These all significantly improved within the first week. At the initial assessment, staff underestimated patients' pain and overestimated problems relating to information giving and patients' ability to share their feelings. There was no significant difference between staff and patient scores after 1 week. The other six areas covered by the tool were less important; this may reflect the patient population seen at our centre. Use of the tool identified areas for staff training and effectively demonstrated improvement in patient care. CONCLUSION: The POS is an outcome measure tool designed to assess physical, psychological, practical and existential aspects of quality of life. It may be useful in identifying problems in individual patients and directing care to address these needs.

Adult↗
PubMed2006

Breast cancer survivors' supportive care needs 2-10 years after diagnosis.

GOALS OF THE WORK: A significant proportion of breast cancer patients experience psychosocial morbidity after treatment, although their longer-term outcomes and supportive care service needs have not been comprehensively documented. The aim of this study was to identify longer-term outcomes and supportive care needs in disease-free breast cancer survivors. MATERIALS AND METHODS: One hundred seventeen patients who had been diagnosed with breast cancer 2-10 years earlier completed questionnaires to assess psychosocial outcomes including supportive care needs, psychological distress, and quality of life (QoL). MAIN RESULTS: QoL and depression scores were consistent with community rates although anxiety scores were higher. Approximately two thirds of survivors reported at least one unmet need, most frequently concerning existential survivorship issues, thereby highlighting the unique needs of survivors. Years since diagnosis was not correlated with need levels. Survivors classified as clinically anxious reported over three times as many unmet needs and survivors classified as depressed reported over two and a half times as many unmet needs. Positive outcomes were frequently reported. CONCLUSIONS: The findings have direct clinical relevance: irrespective of years since diagnosis, comprehensive and extended supportive care services are required to identify breast cancer survivors in need of supportive care interventions and remediate high levels of anxiety.

Adult↗
PubMed2001

Cancer patients hospitalised for palliative reasons. Symptoms and needs presented at a university hospital.

The aim of this study was to identify patients in need of palliative care in 11 different care units with a total of 256 beds at Linköping University Hospital and to look at their overall situation with respect to assessed symptom control and quality of life. There were 46 patients fulfilling the two criteria of incurable cancer and need for palliative care, and each was assessed with the aid of a questionnaire (five oral questions on life situation) and a single visual analogue scale (VAS) about their overall quality of life (QoL). Each patient also assessed him- or herself on the Edmonton Symptom Assessment Scale (ESAS). Total ESAS scores ranged from 20 to 639 mm (median 211). Median VAS scores (100 mm = greatest symptom severity) were as follows: nausea 6 mm, pain 9 mm, anxiety 17 mm, depression 18 mm, drowsiness 35 mm, activity 38 mm, appetite 45 mm, and sensation of well-being 46 mm. The median score for QoL was 47 and correlated well with the total ESAS score. Thirty-seven patients answered the open question "What in your current situation troubles you the most?". Seven patients answered "nothing", and 10 said "the present symptoms". Twenty patients had different concerns (existential, social, and psychological). The low number of hospitalised patients found reflects a well-functioning hospital-based home-care unit. Reduced appetite, sensation of well-being and activity were dominant, while pain and nausea were less intense. The simple QoL-VAS seemed to be comparable to ESAS, which is more useful for assessing each single symptom. The non-physical dimensions need more attention in the future in order to achieve totally satisfactory palliative care.

Adult↗
PubMed2006

[Palliative chemotherapy and CUP-syndrome: medical intentions versus patients' attitudes in decision making].

The following case report is about a 55 year old male patient with CUP-syndrome. After developing a malignant bowel obstruction he received five cycles of a palliative chemotherapy with oxaliplatin and irinotecan. The focus is on medical intentions and goals concerning palliative chemotherapy and on discussing patients' attitudes towards chemotherapy. Communication is identified as fundamental skill in shared decision making. On the one hand it improves Patients' satisfaction and palliative care and on the other hand it reduces psychological and existential suffering. In tumors of unknown primary site regimens with different combinations of Platin, Taxol, Etoposide, Irinotecan and Gemcitabine showed responses up to 46% and a survival benefit with an overall median survival up to 12 months and even long term survival.

Adenocarcinoma, Scirrhous↗
PubMed2000

Quality-of-life assessment in advanced cancer.

In the past 5 years, quality-of-life (QOL) assessment measures such as the McGill, McMaster, Global Visual Analogue Scale, Assessment of QOL at the End of Life, Life Evaluation Questionnaire, and Hospice QOL Index have been devised specifically for patients with advanced cancer. The developers of these instruments have tried to respond to the changing needs of this specific population, taking into account characteristics including poor performance status, difficulty with longitudinal study, rapidly deteriorating physical condition, and change in relevant issues. Emphasis has been placed on patient report, ease and speed of completion, and the existential domain or meaning of life. Novel techniques in QOL measurement have also been adapted for palliative care, such as judgment analysis in the Schedule for the Evaluation of Individual Quality of Life. It is generally agreed that a single tool will not cover all QOL assessment needs.

Health Status Indicators↗
PubMed2002

Sedation for comfort at end of life.

Treatment for patients who are dying from cancer and are suffering with physiologic and existential symptoms is an important and valuable skill for health care providers. However, the treatment for suffering at the end of life and the use of sedation for comfort often are misunderstood. The following is a discussion of the clinical skills and ethical considerations that health care providers should have when treating terminal patients with cancer.

Barbiturates↗
PubMed1992

Attitudes toward reproduction in a nonpatient population.

OBJECTIVE: A basic question to be answered in an attempt to understand human reproductive behavior as it manifests itself in clinical practice is, why do people want to have children? STUDY DESIGN: A psychometric instrument for the assessment of reproductive attitudes was developed. A total of 746 men and women at 20, 30, and 40 years of age, who were randomly selected from a nonpatient population, answered. Data were analyzed by factor analysis. Reproductive profiles were constructed. RESULTS: The two most important factors in both sexes were "children as existential satisfaction" and "children as lack of freedom," indicating a basic conflict. The third most important factor in both sexes was "the importance of one's own parents as examples in parenthood," supporting earlier findings that reproductive conflicts are transmitted from one generation to another. Reproductive profiles were uniform in the different age groups. CONCLUSION: The element of ambivalence may be a clue to a deeper understanding of human reproductive behavior.

Adult↗
PubMed1989

Reasoning about conditional sentences: development of understanding of cues to quantification.

The previous literature has reported that when children are asked to judge the truth or falsity of universally quantified conditional sentences of the form If a thing is P then it is Q they typically give responses, e.g., responding "true" whenever there is a case of P and Q even if there are also cases of P and not-Q. Three experiments are reported that address possible sources of this error. Experiment 1 shows that the error survives on sentences that refer to particular things as well as to things of a particular kind, and further shows that articulating the necessity of the consequent (... then it has to be Q) eliminates the error for adults and reduces it for fifth graders, although it does not affect second grade performance. Experiment 2 shows that for second and fifth graders the error survives to problems that are not universally quantified and for second graders to problems that are not conditionals although are otherwise structurally similar. Experiment 3 compares various verbal formulations of such universally quantified conditionals: Second and fifth graders do not make the error when the quantification is expressed with the surface structure that makes its universality most explicit (all things ...); the error tendency is greatest when the indefinite article is used (if a thing ...); and formulations using any fall in between. We argue that such erroneous evaluations of universally quantified conditionals have more to do with the quantificational aspect than the conditional aspect of the problems; children interpret the indefinite article as existential, although they resist the error when the cue to universal quantification is completely clear. The error appears to result more from the surface-structure form of the stimuli than from an inability of children to appreciate the logic of universally quantified conditionals.

Adolescent↗
PubMedDate not supplied

Life events and their impact on health attitudes and health behavior.

A representative sample of non-institutionalized elderly persons between 65 and 74 years living in Stockholm county, Sweden responded to a self-report health questionnaire. Special life events and their subsequent effects were examined in the context of health attitudes and health behavior. Of the 370 respondents, 128 reported experiencing a special life event. The resulting effects of life events were categorized into one of six groups: smoking, alcohol, diet, restricted mobility, existential circumstances and a miscellaneous group. Positive associations between life events and health attitudes and health behavior were discovered. This was particularly evident in the diet and the restricted mobility group. The findings suggest that the occurrence of life events and subsequent effects can contribute to health promotive behavior despite the potential worries, poor health and diseases which may also be associated with them.

Journal Article↗