RationaleSurrogates of critically ill patients often have inaccurate expectations about prognosis. Yet there is little research on how intensive care unit clinicians should discuss prognosis, and existing expert opinion-based recommendations give only general guidance that has not been validated with surrogate decision makers.ObjectiveTo determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness.MethodsThis was a multicenter study at three academic medical centers in California, Pennsylvania, and Washington. One hundred eighteen key stakeholders completed in-depth semistructured (...) interviews. Participants included 47 surrogates of adult patients with acute respiratory distress syndrome; 45 clinicians working in study ICUs, including physicians, nurses, social workers, and spiritual care providers; and 26 experts in health communication, decision science, ethics, family-centered care, geriatrics, healthcare disparities, palliative care, psychology, psychiatry, and critical care.Measurements and main resultsThere was broad support among surrogates for existing expert recommendations, including truthful prognostic disclosure, emotional support, tailoring the disclosure strategy to each family's needs, and checking for understanding. In addition, stakeholders offered suggestions that add specificity to existing recommendations, including: In addition to conveying prognostic estimates, clinicians should help families "see the prognosis for themselves" by showing families radiographic images and explaining the clinical significance of physical manifestations of severe disease at the bedside. Many physicians did not support using numeric estimates to convey prognosis to families, whereas many surrogates, clinicians from other disciplines, and experts believed numbers could be helpful. Clinicians should conceptualize prognostic communication as an iterative process that begins with a preliminary mention of the possibility of death early in the ICU stay and becomes more detailed as the clinical situation develops. Although prognostic information should be initially disclosed by physicians, other members of the multidisciplinary team-nurses, social workers, and spiritual care providers-should be given explicit role responsibilities to reinforce physicians' prognostications and help families process a poor prognosis emotionally.ConclusionsFamily members, clinicians, and experts identified specific communication behaviors that clinicians should use to discuss prognosis in the critical care setting. These findings extend existing opinion-based recommendations and should guide interventions to improve communication about prognosis in ICUs. (shrink)

Coastal ecosystems are increasingly dominated by humans. Consequently, the human dimensions of sustainability science have become an integral part of emerging coastal governance and management practices. But if we are to avoid the harsh lessons of land management, coastal decision makers must recognize that humans are one of the more coastally dependent species in the biosphere. Management responses must therefore confront both the temporal urgency and the very real compromises and sacrifices that will be necessary to achieve a sustainable coastal (...) ecosystem, one that is economically feasible, socially just, and ecologically sound. (shrink)

Patriarchal institutions govern all aspects of women's lives: their minds, their bodies, and their souls. Additionally, they govern the ways in which women are perceived by others and the ways in which women perceive themselves. (Re) Interpretations: The Shapes of Justice in Women's Experience, is a collection of essays on language, religion, war, sex trafficking, and medicine-the patriarchal structures that form the basis of western society and, thus, are in many ways inherently unjust. The essays illustrate the multitude of ways (...) that women have found to work within and without these structures to create justice. Traditional theories of justice cast it as a cardinal virtue, unbiased and impartial. The essays in this book, however, remove justice from the abstract and return it to the specific: most of the essays use personal narratives to highlight the connections all people share. The women discussed here are challenging the authority of existing patriarchal narratives by telling their versions, and, thus, calling attention to and challenging their own political and social realities. Reflecting a focus on global connectedness and interdisciplinarity, the writers of these essays aim not only to raise questions, but also to show ways in which women are creating new pathways for themselves. Only by exploring solutions will women reclaim justice. From L.A. to Zimbwabe, women have stories to tell about their experiences of justice in the inherently patriarchal institutions of Language, Religion, War, Sex Trafficking, and Medicine. This relevant and thought-provoking collection captures the trials that women across the world face and the hope they create through their courageous actions. Through both personal narrative and factual overview, these essays emphasize that as people committed to justice, women must not simply raise the questions, but they must also explore solutions in order to reclaim justice for themselves, their daughters, their sisters, and their mothers. Contributors: Yifat Bitton, Stephany Ryan Cate, Jo Scott-Coe, Susan Dewey, Carmela Epright, Carmen Faymonville, Adam Gaynor, Pauline Greenhill, Denise Handlarski, Alison Jobe, Marc J.W. de Jong, Jodie M. Lawston, Jody Lisberger, Kristy Maher, Susan Maloney, Mickias Musiyiwa, Ruben Murillo, Annemarie Profanter, Natalie Wilson, and J. Carter Wood. (shrink)

English summary: It seems that reason is less a universal principle than something inherently bound to the contexts in which it appears. These contributions to a conference held on the occasion of Christoph Schwobel's 60th birthday explore the character of reason's manifold contexts: the grounding of reason in the inner word of God 's Trinitarian life as well as the disclosure of reason and and its limits in human conversation. German description: Vernunft scheint in der Gegenwart weniger ein allgemeines Prinzip (...) als eine in Kontexte eingebundene Grosse zu sein. Die Beitrage einer Tagung anlasslich von Christoph Schwobels 60. Geburtstag, gehen der Frage nach dem Charakter dieser Kontextbindung nach: der Begrundung der Vernunft im trinitarischen Gesprach wie der Erschliessung und Problematisierung der Vernunft im menschlichen Gesprach. Mit Beitragen von V. Brummer, G. van den Brink, C. Drobe, H. J. Eckstein, D.-M. Grube, J. Halfwassen, S. Heine, F. Hermanni, E. Herms, W. Harle, W. Homolka, W. Jeanrond, R. W. Jenson, D. Kelsey, A. F. Koch, A. Kupsch, V. Leppin, P.-C. Lai, P. Lo, A. Min, J. Moltmann, M. Muhling, P. Peterson, M. Sarot, F. Schweitzer, A. Torrance, J. Webster, M. Welker, M. Wendte, M. Wisse, H. Wisskirchen und L. Zak. (shrink)

Schelling's first systematic attempt to articulate a complete philosophy of nature.

This report outlines the findings from a Delphi study designed to establish consensus on the definitions of cognitive style and learning style amongst an international style researcher community. The study yields long-needed definitions for each construct that reflect high levels of agreement. In a field that has been criticised for a bewildering array of definitions and a proliferation of terms and concepts, this study represents an important step to address confusion in the meaning of the two terms. New researchers interested (...) in styles are encouraged to draw on these definitions when developing new research agendas aimed at deepening our understanding of style as a core construct in educational psychology. (shrink)

Various 'nonmarket' economic valuation methods have been used to compute 'total' value of nonmarketed natural resources and related recreation. We first outline the history of these valuation techniques and use the Exxon Valdez disaster response and the valuation of whooping cranes, an endangered species, as examples of how these tools can constrain policy. We then explain how, by excluding non-economic social spheres, economic valuation techniques produce a terministic screen that deforms policy makers' vision of the ecological problems faced by society. (...) Using Luhmann's functionalist social theory, we demonstrate that when natural resource managers privilege economic motives, they trivialize other social functions such as education, politics, religion and law. This process presents a significant ethical dilemma for democracies by first naturalizing, then ethicizing, existing pattersns of domination. (shrink)

The application of hierarchy theory to ecological systems presents those who seek a radical change in human perspectives toward nature with a unique window of opportunity. Because hierarchy theory has enabled scientific ecologists to discover that the window through which one chooses to observe a system influences its reality, they may now be more amenable to including the perspectives of deep and feminist ecologists into their self-definition. A synergy between deep, feminist, and scientific ecology could improve environmental policy by encouraging (...) more ecofeminists to encompass the marginalisation of nonhuman life-forms within the ethic of care, more deep ecologists to encompass the issues of overconsumption and militarisation within the anthropocentric-biocentric polarity, and more scientific ecologists to scrutinise the politics behind their investigations. (shrink)

Background Informed consent is an integral component of good medical practice. Many researchers have investigated measures to improve the quality of informed consent, but it is not clear which techniques work best and why. To address this problem, we propose developing a core outcome set to evaluate interventions designed to improve the consent process for surgery in adult patients with capacity. Part of this process involves reviewing existing research that has reported what is important to patients and doctors in the (...) informed consent process. Methods This qualitative synthesis comprises four phases: identification of published papers and determining their relevance; appraisal of the quality of the papers; identification and summary of the key findings from each paper while determining the definitiveness of each finding against the primary data; comparison of key themes between papers such that findings are linked across studies. Results Searches of bibliographic databases returned 11,073 titles. Of these, 16 studies met the inclusion criteria. Studies were published between 1996 and 2016 and included a total of 367 patients and 74 health care providers. Thirteen studies collected data using in-depth interviews and constant comparison was the most common means of qualitative analysis. A total of 94 findings were extracted from the primary papers and divided into 17 categories and ultimately 6 synthesised findings related to: patient characteristics, knowledge, communication, the model patient, trust and decision making. Conclusions This qualitative meta-aggregation is the first to examine the issue of informed consent for surgery. It has revealed several outcomes deemed important to capture by patients and clinicians when evaluating the quality of a consent process. Some of these outcomes have not been examined previously in research comparing methods for informed consent. This review is an important step in the development of a COS to evaluate interventions designed to improve the consent process for surgery. Registration The study protocol was registered on the international prospective register for systematic reviews. (shrink)

In Wrong Medicine, Lawrence J. Schneiderman, M.D., and Nancy S. Jecker, Ph.D., address issues that have occupied the media and the courts since the time of Karen Ann Quinlan. The authors examine the ethics of cases in which medical treatment is offered--or mandated--even if a patient lacks the capacity to appreciate its benefit or if the treatment will still leave a patient totally dependent on intensive medical care. In exploring these timely issues Schneiderman and Jecker reexamine the doctor-patient relationship and (...) call for a restoration of common sense and reality to what we expect from medicine. They discuss economic, historical, and demographic factors that affect medical care and offer clear definitions of what constitutes futile medical treatment. And they address such topics as the limits on unwanted treatment, the shift from the "Age of Physician Paternalism" to the "Age of Patient Autonomy," health care rationing, and the adoption of new ethical standards. (shrink)