1
Q
What are Parkes’ 4 Phase of Grief?
A
- numbness
- yearning/pining and anger
- disorganisation and despair
- reorganisation
2
Q
What are the 6 aspects of acute grief (according to Lindemann)?
A
- somatic or bodily distress
- preoccupation with the image of the deceased
- guilt relating to the deceased or circumstances of the death
- hostile reactions
- inability to function as one had before the loss
- development of traits of the deceased in own behaviour
3
Q
What are Worden’s 4 Tasks of Mourning?
A
- accept the reality of the loss
- work through the pain of grief
- adjust to an environment in which the deceased is missing
- emotionally relocate the deceased and move on with life
4
Q
What factors affect grief severity?
A
- closeness of relationship
- meaningfulness of relationship
- nature of relationship prior to death
- expectedness and manner of death
- age and developmental stage of griever
- individual resilience (function of: neuroticism, introversion, childhood trauma, parenting)
- attachment and dependency
- religious / spiritual beliefs
- social support
5
Q
What are the 4 types of infant attachment described by Ainsworth?
A
- secure attachment
- anxious ambivalent/resistant attachment
- anxious avoidant attachment
- disorganised attachment
6
Q
How can religious belief impact on bereavement?
A
- belief in an afterlife
- continued attachment beyond death (e.g. through prayer)
- a defence against fear of personal death
- funeral rituals aid and progress grief
- funeral rituals recruit social support
7
Q
What is palliative care?
A
- active, holistic care of patient with advanced, progressive illness
- management of pain and other symptoms and provision of psychological, social and spiritual support
- goal is to achieve best quality of life for patients and their families
8
Q
What types of services contribute to generalist palliative care?
A
- primary care
- nursing home
- secondary care
- social services
9
Q
What types of services contribute to specialist palliative care?
A
- clinical nurse specialists (in hospital and community)
- specialist physicians in palliative care
- hospices
- marie curie nurses
10
Q
Who provides and funds palliative care?
A
NHS
- specialist nurses
- some consultants
- some in-patient units
- macmillan nurses
Voluntary sector
- hospices
- marie curie nurses
- macmillan nurses
11
Q
What services do hospices provide?
A
- in-patient beds
- day hospice
- medical clinics
- complementary therapies
- education
- bereavement services
- out-of-hours advice
- hospice at home
- benefits advice
12
Q
What types of nurses may be involved in palliative care and what are their roles?
A
- district nurses (generalist palliative skills, “hands on” nursing skills, work in the community)
- practice nurses (practice based, generalist palliative skills, “hands on” nursing skills)
- marie curie nurses (community based, arranged by district nurses, specialist palliative care skills and “hands on” nursing skills)
- macmillan nurses (community or hospital based, specialist palliative care, advice, support, signposting)
13
Q
More people die globally of _____ than any other cause.
A
CVD
14
Q
> 75% of CVD deaths are in…
A
low and middle income countries
15
Q
What two factors affect PARP?
A
- RR
- prevalence
16
Q
What is PARP?
A
- population attributable risk proportion
- the proportion of disease in a population which is attributable to a particular exposure
17
Q
What is the prevention paradox?
A
A preventative measure that brings large benefit to the community offers little to each participating individual
18
Q
What are the pros of aiming risk reducing interventions at high risk individuals?
A
- intervention is appropriate to the individual
- they are likely a motivated participant
- the clinician will be motivated
- cost-effective resource use
- benefit:risk is high
19
Q
What are the cons of aiming risk reducing interventions at high risk individuals?
A
- screening is difficult
- benefits may only be palliative or temporary
- limited potential gains
- labelling/stigma to high risk individuals
20
Q
What are the pros of aiming risk reducing interventions at low risk individuals?
A
- large potential gains
21
Q
What are the cons of aiming risk reducing interventions at low risk individuals?
A
- population paradox (small individual benefit)
- poor motivation from individuals and potentially from clinicians
- benefit:risk is low
22
Q
What is decision analysis based on?
A
A normative theory of decision making: subjective expected utility theory (SEUT)
23
Q
What are the assumptions of decision analysis?
A
- decision process is logical and rational
- a rational decision maker will choose the option to maximise utility (the desirability or value attached to a decision outcome)
24
Q
What is decision analysis?
A
- a systematic, explicit, quantitative way of making decisions in healthcare that can lead to both enhanced communication about clinical controversies and better decisions
25
What does decision analysis do?
- assists in understanding of a decision task
- divides decision task into components
- uses decision trees to structure the task:
- uses evidence in the form of probabilities so we can examine the risks associated with each option
- examines the utility or cost associated with each option and gives it an actual value
- suggests the most appropriate decision option for that particular situation using calculations
26
What are the components of an evidence based decision?
- evidence from research
- patient preferences
- available resources
- clinical expertise
27
How does decision analysis align with evidence-based decision making?
Aligns well:
- decisions are based on empirical evidence about effectiveness and prognosis from RCTs and cohort studies
- it also draws on values attached to the outcomes which are derived from the patient(s) or health economics
28
What are the stages in a decision analysis?
1. structure the problem as a decision tree - identifying choices, information, and preferences
2. assess the probability of every choice in the tree
3. assess numerically the utility of every outcome state
4. identify the option that maximised expected utility
5. conduct a sensitivity analysis to explore the effect of varying judgements
29
What do the different symbols mean on a decision tree?
- square - a decision, a choice between two actions
- circle - chance, uncertainty, potential outcomes of each decision
- triangle - value of outcome state (higher is better)
30
Each time the decision tree branches the values must equal...
1
31
How might you measure patient experience / acceptability of treatment for consideration in a decision analysis? What is another name for these measures?
- EQ5D questionnaire
- visual analogue scale
- QALYs
AKA utility measures
32
How do you calculate from a decision tree?
- work right to left
33
What is a sensitivity analysis? Why would you do it?
- necessary if numbers are uncertain
- calculate the effect different values would have on the outcome
- you vary the uncertain variables over a plausible range and calculate the effect of uncertainty on the decision
34
What are the benefits of decision analysis?
- makes all assumptions in a decision explicit
- allows examination of the decision making process
- integrates research evidence into the decision process
- insight gained during process may be more important than the numbers generated
- can be used for individual decisions, population level decisions and for cost-effectiveness analysis
35
What are the limitations of decision analysis?
Probability estimates:
- data required to estimate probabilities may not exist
- subjective probability estimates could build bias into the decision
Utility measures:
- individuals may be asked to rate a state of health they have not yet experienced
- different techniques will result in different numbers (not reliable)
- subject to presentation framing effects (e.g. survival, death)
- reductionist approach (takes complex health states and assigns numbers to them - must be oversimplification)
Phase I: H&S
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