Background: Numerous studies demonstrate benefits of using advance care planning (ACP) in the general practice setting. Despite this, providers do not regularly initiate ACP and only one third of Americans have completed an advance directive (AD). This number is even lower among ethnic and minority groups. Community health center (CHC) providers have the opportunity to improve the quality of end-of-life (EOL) care and reduce healthcare disparities affecting medically underserved populations, yet no research has been conducted to identify CHC providers' practices, knowledge and attitudes towards ACP. Addressing this query may assist researchers in identifying optimal strategies for improving ACP delivery in this setting, ultimately leading to improved quality of EOL care for the populations served. Purpose: The study purpose was to assess Arizona CHC providers' practices, knowledge and attitudes towards ACP. Setting: The study setting was federally qualified community health centers located in urban and rural sites throughout Arizona. Participants: Study participants (N = 38) were predominantly middle-aged females practicing for an average of 13 years. 60% of providers were Master's or Doctor of Nursing Practice (DNP) prepared providers while 40% were Doctor of Medicine (MD) or Doctor of Osteopathy (MD). Methods: This study used a descriptive correlational quantitative research design. The "EOL Decision Making Survey" instrument was adapted into an electronic survey and distributed to 514 physician and non-physician CHC providers. Data analysis was performed using PASS and SPSS statistical software. Results: This sample of Arizona CHC providers was reasonably knowledgeable about Arizona state law and clinical application of ACP. Physician providers had greater knowledge and greater confidence in their answers related to Arizona state law compared to non-physician providers. Participants were largely comfortable with counseling patients in ACP and exhibited mostly positive attitudes toward ACP. Older respondents with greater years' experience tended to have greater knowledge of the clinical application of ACP as well as greater positive attitudes towards ACP. Providers with greater years' experience tended to have greater comfort in counseling patients in ACP. Despite these positive findings, routine initiation of ACP in this setting was low (44%). Conclusions: Though Arizona CHC providers have reasonable knowledge related to ACP, are comfortable with counseling patients in ACP and have positive attitudes towards ACP, less than half routinely initiate ACP conversations with their patients. Though more research is needed to validate these findings, targeted educational interventions and process changes may help improve ACP delivery rates in this setting.

As diretivas antecipadas de vontade para o fim da vida são documentos que expressam os desejos da pessoa relacionados aos procedimentos que podem ser aplicados a ela em uma situação de assistência médica no fim da vida. Nesse sentido, as diretivas são úteis para informar as equipes de assistência médica a respeito dos tipos específicos de tratamento que o paciente permite, ou não permite, quando não estiver apto a manifestar suas vontades em uma hipotética situação futura de incapacidade. Este tipo de documento foi elaborado nos Estados Unidos na década de 1970, e foi introduzido no ordenamento ético brasileiro pela Resolução 1995/2012 do Conselho Federal de Medicina. O objetivo desta dissertação é estudar essa norma ética sob o enfoque do direito penal, uma vez que as diretivas antecipadas de vontade para o fim da vida possuem uma íntima relação com a ortotanásia e a eutanásia, que são passíveis de sanção penal no Brasil. Assim, é fundamental analisar as diretivas antecipadas utilizando as ferramentas da doutrina penal, e princípios como os da dignidade humana e razoabilidade. O objetivo é pesquisar as qualidades, imperfeições e limites das diretivas antecipadas sob o ordenamento jurídico nacional, e também compreender as bases legais das diretivas antecipadas, que são os institutos da autonomia e do consentimento. Concluímos que, ainda que as diretivas antecipadas de vontade sejam uma norma ética bem-vinda, demandam algumas melhorias e refinamentos, que poderiam ser representados pelos planejamentos antecipados de tratamentos, um tipo de documento direcionado aos valores de vida das pessoas. Além disso, uma mudança de paradigma relacionada à eutanásia, particularmente a eutanásia passiva e a ortotanásia, no sentido de descriminalizá-las, seria importante para que as diretivas antecipadas tenham eficácia no Brasil. / Advance directives for dying patients are documents which express personal desires related to procedures that may be applied to people in a situation of medical assistance in the end of life. In this sense, they are useful to make health assistance teams know about what kind of specific treatment the patients permit, or do not permit, when they are not able to communicate their wishes in a hypothetical and future situation of disability. This kind of document was created in the United States in the seventies, and entered Brazilian ethical law by Resolution 1995/2012 of the Federal Council of Medicine. The aim of this dissertation is to study this ethical rule by means of the criminal law, because advance directives have a close relation to euthanasia and ortothanasia, which are prone to criminal sanction in Brazil. Therefore, it is paramount to analyze the advance directives using the doctrinal tools of criminal law and principles like human dignity and reasonability. The goal is surveying the qualities, inadequacies and limits of advance directives under Brazilian law, and also to understand the legal basis of the advance directives, which are the institutes of autonomy and consent. We concluded that, although advance directives for dying patients are a welcome ethical law, it demands some improvement and refinement, which could be represented by the advance care planning, a kind of document that is focused on the life values of people. Furthermore, a change of paradigm related to euthanasia, particularly passive euthanasia and ortothanasia, in the direction of making them apart of criminalization, would be vital to promote the adequate efficacy of the advance directives in Brazil.

Our current LTC system is burdensome to state and federal governments, to family members, and to individuals’ pocket books; it is not expected to endure the weight of the baby boom generation. Total national spending for long-term care in 2005 was $207 billion and is only expected to rise. This study examined the LTC planning behavior of individuals of baby boom birth years (1946 to 1964), focusing on the influence of individuals’ views about whose responsibility is the provision of LTC on planning behavior. Specifically, the study has three aims: to 1) to describe the LTC planning behavior among baby boom aged adults; 2) examine baby-boom aged adults’ views on whose responsibility is the planning/provision/cost of LTC (location of responsibility); and 3) examine the influence of potential predictors of individuals’ LTC planning with specific focus on the influence of location of responsibility (LOR). Data was collected between May and August of 2009 using a mixed modes self-administered 80-item original survey via the internet and regular mail (study sample = 1,066; 1,166 responding; response rate 58%). The study population consists of benefit-eligible Black, Hispanic/Latino, and Non-Hispanic White faculty/staff born in or between the years of 1946 and 1964 from a large southwestern university. This study found overall low levels of LTC planning; however, with regard to LTCI purchase, the participation rate is good relative to the national coverage rate. The study informs us that baby-boom aged individuals as a whole believe themselves (individuals) to have a high level of responsibility for their own potential LTC needs, but also that responsibility lies with the government, employers, and adult children as well. Consistent with hypotheses, LTC awareness/avoidance predicted a higher level of extent of planning (gathering, deciding, and concretizing); worthwhileness and self-efficacy predicted LTCI purchase; and awareness, subjective norm, worthwhileness, and self-efficacy predicted LTC specific savings. Additionally, individual responsibility (negatively), female (positively), income (positively), experience (self and other; positively), LTC knowledge (positively), and Hispanic (negatively) all predicted extent of planning. Employer responsibility (positively), faculty (negatively), marital status (married; negatively), Black (positively), and medical diagnoses all predicted LTCI purchase. And, employer responsibility (positively), government responsibility (negatively), income (positively), experience-other (positively), and knowledge (positively) all predicted LTC-specific savings. Implications for practitioners, employers, program planners, and policy-makers are presented. / text

Amyotrophic lateral sclerosis (ALS) is a progressive neurological disease that leads to respiratory compromise and eventually death within two to five years. Even though people with ALS must make many treatment decisions, none has such a significant impact on quality of life and survival as the one pertaining to assisted ventilation. A qualitative research study was undertaken to elicit factors that are pertinent to this decision-making process. Ten individual, semi-structured interviews were conducted with individuals with ALS. Six main themes emerged from the interviews. These are: meaning of the intervention, the importance of context, values, and fears in decision-making, the need for information, and adaptation/acceptance of the intervention. Based on these findings, it is argued that a pluralistic conception of autonomy as well as a shared decision-making model is better suited to give high priority to patient autonomy in this context. Some recommendations to improve clinical practice are proposed.

The objective of this thesis is to formalize, model, align and operationalize the evidence-based clinical algorithms of co-morbid chronic heart failure (CHF) and atrial fibrillation (AF) in order to provide clinical recommendations, care coordination and decision support to general practitioners (GPs). This thesis addresses following healthcare knowledge modeling issues: (a) modeling of healthcare knowledge, especially in terms of clinical guidelines and clinical pathways, to develop an ontology-based knowledge model for handling co-morbid diseases; (b) computerization of clinical pathways to offer point-of-care decision support; (c) alignment of ontologically-modeled disease-specific clinical pathways to handle co-morbid diseases; and (d) the provision of computerized decision support to GPs, based on modeled clinical guidelines and pathways, to assist them in handling co-morbid diseases. An elaborate OWL CP ontology for co-morbid CHF and AF was developed that can be executed to support the diagnosis and management of co-morbid CHF and AF in a general practice setting. / In this thesis we present an ontology based decision-support framework for handling co-morbidities by the alignment of ontologically modeled clinical practice guidelines (CPGs). The objective of this thesis is to formalize, model, align and operationalize the evidence-based clinical algorithms of co-morbid chronic heart failure (CHF) and atrial fibrillation (AF) in order to provide evidence-based clinical recommendations, care coordination and decision support to general practitioners (GPs) for effective management of CHF and AF. In this regard, the thesis addresses the following healthcare knowledge modeling issues: (a) modeling of healthcare knowledge, especially in terms of clinical guidelines and clinical pathways, to develop an ontology-based healthcare knowledge model for handling co-morbid diseases; (b) computerization of clinical pathways to offer point-of-care decision support; (c) alignment of ontologically-modeled disease-specific clinical pathways to handle co-morbid diseases; and (d) the provision of computerized decision support to general practitioners, based on modeled clinical guidelines and pathways, to assist them in handling chronic and co-morbid diseases. An elaborate OWL CP ontology for co-morbid CHF and AF—the CP ontology was developed that can be executed to support the diagnosis and management of co-morbid CHF and AF in a general practice setting. We have developed a decision support framework termed COMET (Co-morbidity Ontological Modeling & ExecuTion) that can handle three patient care scenarios, (i) patient has CHF; (ii) patient has AF; and (iii) patient develops a co-morbidity of both AF and CHF. COMET is accessible by web and is designed for GPs. COMET has been evaluated, both by simulated cases and by health professionals (GP and specialist), for its ability to handle single disease and comorbid care scenarios based on patient data and related constraints. The output at every phase is compared with the expected output as per single disease or comorbid management. Our results show that the resultant sequence of plans and their outcomes are comparable to the CP knowledge. Also, our ontology was able to handle any updates in the CP knowledge as advised by the domain experts

At the Primary Health Care Centre in Vännäs (VPHCC), northern Sweden, a development work was implemented in 1976-1980. The overall purpose was to enhance primary health care planning. In trying to improve health care delivery cooperation with community members was initiated and some organizational changes like a new appointment system, a new medical record and local care programs for some common diseases were introduced. Official statistics were also used for comparative purposes. The aims of the work were postulated (increased accessibility, higher continuity, more equitable distribution and enhanced cooperation) and suitable methods were designed. From postal surveys, chartreviews and administrative data (from hospitals, out-patient clinics and health centres) figures and information were collected. Accessibility was studied by waiting room time which was reduced and continuity, analyzed with a new concept - visit based provider continuity - was improved. The question of equitable distribution was studied by the consultation rates at different out-patient clinics. It seemed as if the local development work changed the patterns of utilization but some important issues were not decisively answered. Repeated postal surveys reflected the question of equitable distribution and the cooperation between the VPHCC and the community members. Positive responses were recorded in aspects like telephone accessibility and health care information. In a tracer study of diabetes the quality of care was studied. The local care program was actually implemented in the daily practice but the question of care quality needs further penetration. Within the frames of the development work new methods in the health care planning were introduced. Our work started from the prerequisits of the VPHCC and other health centres might find other ways of planning for care provision. On a general level, however, the structure of our work - defining aims, means and evaluation methods - can be used by others. / <p>Diss. (sammanfattning) Umeå : Umeå universitet, 1986, härtill 6 uppsatser.</p> / digitalisering@umu

Diss. (sammanfattning) Stockholm : Karol. inst., 2002. / Härtill 4 uppsatser.

Thesis--University of Oklahoma. / Bibliography: leaves 77-85.

Bakgrund: Hälso- och sjukvården har stora utmaningar när det gäller både personella- och ekonomiska resurser. Nya arbetssätt krävs med högre grad av samverkan mellan vårdgivare. Samordnad individuell plan (SIP) är reglerat i lag och syftar till att skapa en delaktig och trygg individ samt främja samverkan. Sjuksköterskan sammankallar till SIP och är en naturlig part i teamet med ansvar för omvårdnaden.                                              Syfte: Var att undersöka erfarenheter av samordnad individuell plan (SIP), hos sjuksköterskor på vårdcentral och i hemsjukvård   Metod: Studien har en kvalitativ design med induktiv ansats. Två fokusgruppsintervjuer genomfördes med sjuksköterskor från primärvård och kommun. En manifest innehållsanalys resulterade i tre kategorier; personcentrering, samverkan och patientnytta.   Resultat: I resultatet framkom tre kategorier; personcentrering, samverkan och patientnytta.   Slutsats: Sjuksköterskan behöver vara lyhörd för individens behov av anpassad information gällande SIP, så att individens delaktighet främjas. Att sjuksköterskan på vårdcentralen är fast vårdkontakt med ansvar för att sammankalla, leda och dokumentera SIP har varit en framgångsfaktor. Men det finns utmaning i framtagande av individuell plan så att SIP blir det personcentrerade verktyg individen behöver för att vara delaktig och trygg. / Background: Healthcare has major challenges in terms of both personal and financial resources. New ways of working are required with greater cooperation between healthcare providers. Coordinated Individual Plan (CIP) is regulated by law and aims to create a participant and safe individual as well as promote collaboration. The nurse convenes CIP and is a natural party in the Nursing Team.   Purpose: Was to study experiences of coordinated individual plan (CIP), in nurses at the health center and in home care   Method: The study has a qualitative design with inductive approach. Two focus group interviews were conducted with nurses from primary care and municipalities. A manifest content analysis resulted in three categories; personal centering, collaboration and patient benefit.   Result: The result was three categories; personal centering, collaboration and patient benefit.   Conclusion: The Nurse needs to be responsive to the individual's need for custom information regarding CIP, so that the individual's participation is promoted. Nursing at the health center is a permanent care contact with responsibility for gathering, leading and documenting CIP has been a success factor. However, there is a challenge in developing individual plans so that CIP becomes the person-centered tool the individual needs to be part and safe.

Orientador: Wilson Roberto Poi / Banca: Elaine Cristina Guerbach Conte Vieira / Banca: Jorge Komatsu / Resumo: As lesões traumáticas envolvem função e estética que resultam de mínimas perdas de superfície do esmalte a fraturas complexas envolvendo polpa e até perda da coroa. O conhecimento técnico e a experiência clínica são fundamentais para a obtenção de um diagnóstico correto e para realizar uma terapia racional. É objetivo deste trabalho analisar o conhecimento dos especialistas em Dentística, titulados pela Faculdade de Odontologia de Araçatuba - UNESP, sobre fraturas coronárias e corono-radiculares. Para tanto, a partir de um questionário descritivo, foram abordadas questões referentes ao perfil dos profissionais entrevistados e procedimentos empregados na conduta frente a fraturas coronárias e corono-radiculares. Cento e cinqüenta e quatro questionários foram devidamente preenchidos, e os dados obtidos foram submetidos à análise descritiva, enquanto o teste estatístico foi aplicado para demonstrar freqüência e o nível de significância entre variáveis (teste qui-quadrado). Muito embora os entrevistados tivessem formação de especialista em Dentística, grandes dificuldades foram encontradas nos planos de tratamento propostos. Dos entrevistados, 42,8% foram incapazes de tratar todos os casos de traumatismo dentário. As fraturas de esmalte, dentina e cemento, com e sem envolvimento pulpar, foram as que apresentaram maiores dificuldades de resolução, pois necessitam de conceitos e práticas multidisciplinares para favorecer o tratamento e o prognóstico dos casos. / Abstract: Traumatic lesions involve function and aesthetics that result from a minimal loss of the surface of enamel up to complex fractures involving pulp and even the loss of a crown. Technical knowledge and clinical experience are fundamentally necessary to obtain the correct diagnostic and to perform a rational therapy. The goal of this study is to analyse the knowledge about crown and crown-root fractures obtained by specialists in Dentistry, titled from Dentistry School at UNESP - Araçatuba. For that, starting from a descriptive questionnaire, some questions regarding the profile of inquired professionals and procedures used in the performance of treatment of crown and crow-root fractures. 154 questionnaires were answered and the obtained data was submitted to a descriptive analysis, while a statistical test was applied to show the frequency and the level of the significance among variables (square test). Despite the inquired professionals having background in Dentistry, a lot of difficulties were found in the planning of the treatments. 42.8% of the interviewed professionals were unable to treat all cases of dental traumatism. Crown-root fractures, involving pulp or not, were the ones that presented major difficulties being necessary some concepts and multidisciplinary approach that favor planning and treatment. / Mestre