While Medical-Legal Partnerships (MLPs) have improved the health and well-being of the people they serve, most healthcare institutions will only invest in an MLP if they are convinced that doing so will improve its balance sheet. This article offers a detailed estimation of the cost savings that an MLP targeted toward the most acute legal needs would accrue to an academic medical center (AMC) in North Carolina.

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted involuntarily (...) under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients. (shrink)

This paper presents part of a larger study of contemporary nursing practice and the rationalisation of hospital length of stay. Informed by Michel Foucault's work on governmentality, length of hospital stay and the re-engineering of surgical services are examined, not in terms of numerical representations of hospital use, but as part of social and political processes through which certain concepts are made susceptible to measurement and practices are organised. Using data generated through fieldwork in a hospital (...) surgical division this analysis offers understandings of how social practices around length of hospital stay are translated and how they pattern contemporary hospital nursing practice. Nursing practice is explored through the reconstitution of hospital beds and the demands of local administration of hospital length of stay. (shrink)

Background: Despite a gradual shift in the focus of medical care among terminally ill patients to a palliative model, studies suggest that many children with life-limiting chronic illnesses continue to die in hospital after prolonged periods of inpatient admission and mechanical ventilation.Objectives: To examine the characteristics and location of death among hospitalised children, investigate yearwise trends in these characteristics and test the hypothesis that professional ethical guidance from the UK Royal College of Paediatrics and Child Health would lead to (...) significant changes in the characteristics of death among hospitalised children.Methods: Routine administrative data from one large tertiary-level UK children’s hospital was examined over a 7-year period for children aged 0–18 years. Demographic details, location of deaths, source of admission , length of stay and final diagnoses were studied. Statistical significance was tested by the Kruskal–Wallis analysis of ranks and median test , χ2 test and Cochran–Armitage test .Results: Of the 1127 deaths occurring in hospital over the 7-year period, the majority were among infants. The main diagnoses at death included congenital malformations , perinatal diseases , cardiovascular disorders and neoplasms . Most deaths occurred in an intensive care unit environment , with a significant increase over the years . There was a clear increase in the proportion of admissions from in-hospital among the ICU cohort . Infants with congenital malformations and perinatal conditions were more likely to die in an ICU , and older children with malignancy outside the ICU . Children stayed for a median of 13 days on a hospital ward before being admitted to an ICU where they died.Conclusions: A greater proportion of hospitalised children are dying in an ICU environment. Our experience indicates that professional ethical guidance by itself may be inadequate in reversing the trends observed in this study. (shrink)

This paper describes a practice innovation: the addition of formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers’ moral distress and decrease length of stay for patients with life-threatening illnesses. We evaluated the innovation using a pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls. Physicians and nurses on staff in our pediatric intensive care unit in a quaternary care children's hospital participated in the evaluation. There were (...) 60 patients in the interventional group and 66 patients in the historical control group. We evaluated the impact of weekly meetings to establish goals of care for patients with longer than 10 days length of stay in the ICU for a year. Moral distress was measured intermittently and reported moral distress thermometer scores fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall moral distress scores, measured on the moral distress scale revised, were lower for respondents in all categories, and on three specific items. Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS, a statistically significant increase in both code status changes DNR, and in-hospital death, with no change in patient 30 or 365 day mortality. The addition of a clinical ethicist and senior intensivist to weekly inter-professional team meetings facilitated difficult conversations regarding realistic goals of care. The study demonstrated that the PEACE intervention had a positive impact on some factors that contribute to moral distress and can shorten PICU length of stay for some patients. (shrink)

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted involuntarily (...) under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients. (shrink)

Background and PurposeMany critically ill patients in intensive care units (ICUs) are unable to communicate their wishes about goals of care, particularly about the use of life-sustaining treatments. Surrogates and clinicians struggle with medical decisions because of a lack of clarity regarding patients’ preferences, leading to prolonged hospitalizations and increased costs. This project focused on the development and implementation of a tool to facilitate a better communication process by (1) assuring the early identification of a surrogate if indicated on admission (...) and (2) clarifying the decision-making standards that the surrogate was to use when participating in decision making. Before introducing the tool into the admissions routine, the staff were educated about its use and value to the decision-making process.Project and MethodsThe study was to determine if early use of a simple method of identifying a patient’s surrogate and treatment preferences might impact length of stay (LOS) and total hospital charges. A pre- and post-intervention study design was used. Nurses completed the surrogacy information tool for all patients upon admission to the neuroscience ICU. Subjects (total N=203) were critically ill patients who had been on a mechanical ventilator for 96 hours or longer, or in the ICU for seven days or longer. The project included staff education on biomedical ethics, critical communication skills, early identification of families and staff in crisis, and use of a simple tool to document patients’ surrogates and previously expressed care wishes. Data on hospital LOS and hospital charges were collected through a retrospective review of medical records for similar four-month time frames pre- and post-implementation of the assessment tool.ResultsSignificant differences were found between pre- and post-groups in terms of hospital LOS (F=6.39, p=.01) and total hospital charges (F=7.03, p=.009).ConclusionsProject findings indicate that the use of a simple admission assessment tool, supported by staff education about its completion, use, and available resources, can decrease LOS and lower total hospital charges. The reasons for the difference between the pre- and post-intervention groups remain unclear. Further research is needed to evaluate if the quality of communications between patients, their legally authorized representatives, and clinicians—as suggested in the literature—may have played a role in decreasing LOS and total hospital charges. (shrink)

The aim of the present study is to analyze individual differences in academic self-efficacy within a population of Unaccompanied Foreign Minors from the European cities of Ceuta and Melilla. Variables describing educational level and length of stay were considered in a sample of 377 individuals being cared for in different youth centers. Of these, 63.4% belonged to the group who had stayed at the center for less than 9 months and 36.6% reported a length of stay (...) of more than 9 months. The age of participants ranged between 8 and 17 years old. Once the quality parameters of the instrument were elaborated, reliability and validity was confirmed through Confirmatory Factor Analysis using Structural Equation Modeling methodology. Data collection was then initiated. The results overall indicate that 87.6% of those who completed the questionnaire reported a higher level of self-efficacy with regards to working with any classmate, whilst at the same time seeing themselves as capable of achieving good marks. ANOVA results indicated significant differences with respect to educational level and length of stay. In this regard, students who had received professional training and had been at the Center for more than 9 months, were the ones who developed greater academic self-efficacy for spending more time working when tasks were judged to be difficult. The results obtained demonstrate that any intervention will be positive as long as it promotes different institutions to develop strategies that cater to a length of stay of more than 9 months and target education, academic self-efficacy, socialization and strengthening the future workforce. Such interventions can be directed through new European, Spanish or local level policies. It is clear that institutions still have a lot of work left to do. (shrink)

Objectives: To investigate whether different methods of obtaining informed consent affected recruitment to a study of delirium in older, medically ill hospital inpatients.Design: Open randomised study.Setting: Acute medical service for older people in an inner city teaching hospital.Participants: Patients 70 years or older admitted to the unit within three days of hospital admission randomised into two groups.Intervention: Attempted recruitment of subjects to a study of the natural history of delirium. This was done by either a formal test of capacity, followed (...) by either a request for consent or an attempt at obtaining assent from a proxy, or a combined informal capacity/consent process.Main outcome measures: Prevalence and severity of delirium, and, as case mix measures, length of hospital stay and destination on discharge.Results: Recruitment of subjects through establishing formal capacity and then informed consent was less successful and, compared with those recruited through the usual combined capacity/consent approach, yielded a sample with less cognitive impairment, lower severity of delirium, lower probability of case note diagnosis of delirium and lower rate of entering a care home.Conclusions: Methods of obtaining informed consent may significantly influence the case mix of subjects recruited to a study of delirium. Stringent testing of capacity may exclude patients with delirium from studies, thus rendering findings less generalisable. A different method is necessary to achieve an ethical balance between respecting autonomy through obtaining adequate informed consent and avoiding sample bias. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChua Hong Choon, Adjunct Associate ProfessorThe case for commentary describes a difficult, and yet not uncommon, clinical situation faced by clinicians at the Institute of Mental Health (IMH) in the course of their work. Based on the information provided on the case, the patient is likely to be suffering from the paranoid subtype of schizophrenia, and his illness is characterised by hostile and aggressive behaviour during episodes of (...) relapse.Although aggressive behaviour is known to be associated with young, male patients with paranoid delusions, auditory hallucinations and lack of insight,1 it is still necessary to exclude other causes of aggressive behaviour in this young man. Two causes of aggressive behaviour that are sometimes misattributed to schizophrenia are antisocial personality disorder and substance abuse. However, Mr. T did not have a history of conduct or behavioural problems prior to the onset of his psychotic illness, and he was also not reported to be violent or disruptive during the periods when he was on regular medication. There was also no history of illicit drug use.The initial onset of Mr. T’s illness while he was serving his National Service is a fairly common presentation of the first episode of schizophrenia in Singaporean males. While traits apparent prior to National Service such as his academic difficulties and inability to make friends are associated with the development of schizophrenia,2 the stress of regimented life and military drills might be more closely associated with his initial full-blown psychotic episode with prominent paranoid (and persecutory) delusions.The systematised nature of Mr. T’s delusions and the prominent threatening auditory hallucinations significantly increase his risk of [End Page 217] dangerousness,3 and when his wife became “incorporated” into his delusional beliefs, he began to threaten her physically during episodes of relapse. Despite being only 28 years old, Mr. T has already been hospitalised numerous times for inpatient treatment, due to frequent relapses of his illness. While relapses in schizophrenia may be attributed to various factors, including lack of social support, substance abuse, poor (or partial) response to medication and psychosocial stressors, Mr. T’s multiple relapses were primarily due to the stopping of his medication and his refusal to continue with any form of psychiatric treatment.The key problem to be addressed in this case is therefore the patient’s severe lack of insight which leads to recurrent episodes of treatment non-adherence and subsequent relapses.Mr. T’s wife has come to the clinic to ask for medication to secretly put into his food. Although the patient is apparently in remission of his condition (having just been treated and discharged from hospital), he has again stopped his medication, and she is justifiably afraid that he will become unwell again. Recognising that the patient’s lack of insight is the main (and possibly only) reason for his refusal to take medication, it would be prudent to first consider if all possible actions had been taken to create an awareness and to help the patient gain insight into his illness and the need to take medication. This may yet be possible in the window of opportunity that exists when the patient is in remission of his illness (and is therefore not disturbed by the symptoms of his psychotic disorder).Recent studies have demonstrated that psycho-education is able to reduce self-stigmatisation in individuals with schizophrenia, and also significantly improve insight 4 (as measured by the Birchwood’s Psychosis Insight Scale). A 2011 Cochrane Review 5 also concluded psycho-education does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stays in patients with schizophrenia. In this case, psycho-education could be given to Mr. T even after he has been discharged from hospital; he might not want to continue with medication, but he might consider seeing a trained clinician (case manager, nurse or medical social worker) to make sense of his life experiences. Engaging Mr. T through psycho-education may result in sufficient insight for him to consider resuming medication voluntarily, at least in the short term.Although there is a paucity of studies examining specific psycho-therapies (including cognitive behavioural therapy... (shrink)

The aim of this paper is to investigate among a group of non-profit organizations: a) the effect of ethical leadership on volunteers’ satisfaction, affective organizational commitment and intention to stay in the same organization; b) the role played by job satisfaction as a mediator in the relationship between ethical leadership and volunteers’ intentions to stay in the same organization, as well as between ethical leadership and affective commitment. An anonymous questionnaire was individually administered to 198 Italian volunteers of (...) different non-profit organizations. The questionnaire contained the Ethical Leadership Scale, the Volunteers Satisfaction Index, the Affective organization Scale, as well as questions regarding the participants’ age, sex, type of work, level of education, length of their volunteer works, intention to volunteer in the following months in the same organization. The construct as well the effects of EL on volunteers is approached in light of the Social Exchange Theory and the Social Learning Theory. Structural equation models were used to test hypothesized relationships. The results confirm the role of mediation of volunteer satisfaction in the relationships between the variables studied. In particular, ethical leadership was found to be positively associated both with volunteers’ intention of staying and with their affective commitment. In the first case this relationship is fully explained by the mediation of the volunteers’ satisfaction, while the latter is explained by both direct and indirect factors. To the authors’ knowledge, this the first attempt to understand the role played by ethical leadership on volunteers’ behavior and, more in general, in the management of non-profit organizations. Findings are relevant both for practitioners and managers of non-profit organization, since they suggest the relevance of the perception of ethical leadership by volunteers, as well as for scholars, since they further deepen the knowledge on EL and its effects on the followers. Limits of the study: the questionnaire was administered only among a group of non-statistical sample of volunteers. Furthermore, the study reached only volunteers from Italian non-profit organization. (shrink)

Increasing prevalence of depression poses a huge challenge to the healthcare systems, and the success rates of current standard therapies are limited. While 30% of treated patients do not experience a full remission after treatment, more than 75% of patients suffer from recurrent depressive episodes. Eye Movement Desensitization and Reprocessing therapy represents an emerging treatment option of depression, and preliminary studies show promising effects with a probably higher remission rate when compared to control-therapies such as cognitive behavioral therapy. In the (...) present study, 49 patients with severe depression were treated with an integrated systemic treatment approach including EMDR therapy that followed a specific protocol with a treatment algorithm for depression in a naturalistic hospital setting. Following their discharge from the hospital, the patients were followed up by a structured telephone interview after 3 and 12 months. 27 of the 49 patients fulfilled the Beck’s depression criteria of a full remission when they were discharged. At the follow-up interview, 12 months after discharge, 7 of the 27 patients reported a relapse, while the remaining 20 patients had stayed relapse-free. The findings of our observational study confirm reports of earlier studies in patients with depression, showing that EMDR therapy leads to a high rate of remission, and is associated with a decreased number of relapses. Patients with depression receiving EMDR treatment may be more resilient to stressors. (shrink)

As we look beyond our terrestrial boundary to a multi-planetary future for humankind, it becomes paramount to anticipate the challenges of various human factors on the most likely scenario for this future: permanent human settlement of Mars. Even if technical hurdles are circumvented to provide adequate resources for basic physiological and psychological needs, Homo sapiens will not survive on an alien planet if a dysfunctional psyche prohibits the utilization of these resources. No matter how far we soar into the stars, (...) our psychologies for future generations will be forever tethered to the totality of our surroundings. By shaping our environment toward survival and welfare during the voyage to Mars and in a Martian colony, we indirectly shape our psyches and prepare them for a mission of unprecedented alienation and duration. Once on Mars, human factors such as leadership structure, social organization and code of conduct, group size, gender balance, developmental cycle, mobility, length of stay and the ecological settings and type and manner of subsistence, will create a novel Martian culture. The degree that settlers are severed from the Earth will affect how radically foreign this culture will be when compared with cultures on Earth. (shrink)

The ongoing Coronavirus disease 2019 (COVID-19) pandemic is disrupting most specialized healthcare services worldwide, including those for high-risk newborns and their families. Due to the risk of contagion, critically ill infants, relatives and professionals attending neonatal intensive care units (NICUs) are undergoing a profound remodeling of the organization and quality of care. In particular, mitigation strategies adopted to combat the COVID-19 pandemic may hinder the implementation of family-centered care within the NICU. This may put newborns at risk for several adverse (...) effects, e.g., less weight gain, more nosocomial infections, increased length of NICU stay as well as long-term worse cognitive, emotional, and social development. This article aims to contribute to deepening the knowledge on the psychological impact of COVID-19 on parents and NICU staff members based on empirical data from the literature. We also provided evidence-based indications on how to safely empower families and support NICU staff facing such a threatening emergency, while preserving the crucial role of family-centered developmental care practices. (shrink)

The functional independence measure is a clinical scale which is used to evaluate the amount of assistance disabled persons need to conduct their daily living activities. Drawing on 65 video-recorded rehabilitation team meetings and medical records collected from a Japanese hospital, this article utilizes ethnomethodology and conversation analysis to uncover how Japanese rehabilitation team members use the FIM to track changes in the functional status of patients and decide the length of stay in ongoing interactional sequences. Analysis shows (...) that a series of the FIM scores assembled and arranged in situ provide a sequential framework for members to understand the progress of rehabilitation and predict the plateau phase. Moreover, a particular expert is asked about patients’ capacity for further improvements and his or her opinions are treated as a basis for clinical decisions. In this way, diagnostic and clinical decision-making is produced through the ongoing collaborative work of various specialists. (shrink)

The aim of this study was to evaluate terminal care among hospitalized children who died of HIV/AIDS. The design was a retrospective chart review of the terminal hospitalization. The setting was a public, secondary and tertiary children's hospital in Cape Town, South Africa (SA). The patients included a consecutive series of in‐patient deaths from HIV‐related causes. The main outcome measures included: documentation of do not resuscitate (DNR) orders and comfort care plans, intensity of diagnostic and therapeutic interventions in last 24 (...) hours of life, and presence of pain and distress in last 48 hours of life. The results are based on the review of 165 out of 167 in‐patient deaths. Of those, 79% of patients died in general wards. Median age and length of stay were 4 months and 6 days respectively. A total of 84% of patients had a DNR order. DNR orders appeared simultaneously in only 41% of medical and nursing notes. Only 44% of patients had a comfort care plan. Pain and distress in the last 48 hours was documented in 55% of patients who died in the general wards. Respiratory symptomatology and painful skin conditions accounted for most discomfort. Half (36/72) the patients with pain and distress, including 16 with a comfort care plan, received no analgesia. Conclusions drawn found that, despite clinical uncertainty, doctors made tough end of life decisions that included DNR orders and comfort care plans. The lower rate of comfort care plans suggests doctors had difficulty making the transition from curative to palliative care. Many comfort care plans were incoherent and included interventions unlikely to promote patients' comfort. In light of the HIV/AIDS pandemic in SA, reforms are needed to integrate palliative care within mainstream hospital medicine. However, without adequate human resources including trained interpreters, doctors and nurses will struggle to deliver optimal terminal care in acute hospitals. (shrink)

Background: Little is known about what factors may contribute to the growth of a consultation service or how a practice may change or evolve across time. Methods: This study examines data collected from a busy ethics consultation service over a period of more than two decades. Results: We report a number of longitudinal findings that represent significant growth in the volume of ethics consultation requests from 19 in 1990 to 551 in 2013, as well as important changes in the patient (...) population for which ethics help is requested. The findings include (1) a steady growth in requests from primary care providers (e.g., physicians and nurses), as well as increases in ancillary services (e.g., social workers); (2) a decrease in length of stay (days) before ethics help is requested; (3) an increase in the reasons that individuals ask for help from ethics; (4) an upsurge in consults requests from areas outside the intensive care unit (ICU); (5) a decrease in patients that died during hospitalization (e.g., live discharges); and (6) growth in the numbers of patients lacking decision-making capacity. Conclusions: We believe the increases in consult requests reflect appropriate and necessary growth because recent consultations have also been associated with consultations requiring (7) additional interventions and (8) reasonably high time intensity scores. (shrink)

With a focus on end-of-life discussion in aging and chronically ill populations, this book offers insight into the skill of communicating in complex and emotionally charged discussions. This text is written for all clinicians and professionals in the fields of healthcare and public health who are faced with questions of ethical deliberation when a patient's illness turns from chronic to terminal. This skill is required to manage care well in an age of advanced technology, and numerous autonomous choices. With a (...) palliative care and ethics focus, the manuscript provides case studies illustrating issues which occur in the acuity and chronicity of end of life. Clear tools for clinicians, such as scripting and "the advance care planning video library" are included. The book focuses on the unique concept of outpatient ethics, including readmission prevention and shortened length of stay through good communication for clinicians who will be required to conduct this discussion with patients. The ethical undertone in this text provides a perfect opening for application in healthcare ethics classes, both in fields of public health and healthcare. Medical scholars and physicians, nurse practitioners and physician's assistants, as well as social workers, both in practice and training, will benefit from this text. (shrink)

BackgroundClinical ethics case consultations (CECCs) provide a structured approach in situations of ethical uncertainty or conflicts. There have been increasing calls in recent years to assess the quality of CECCs by means of empirical research. This study provides detailed data of a descriptive quantitative and qualitative evaluation of a CECC service in a department of cardiology and intensive care at a German university hospital.MethodsSemi-structured document analysis of CECCs was conducted in the period of November 1, 2018, to May 31, 2020. (...) All documents were analysed by two researchers independently.ResultsTwenty-four CECCs were requested within the study period, of which most (n = 22; 92%) had been initiated by physicians of the department. The patients were an average of 79 years old (R: 43–96), and 14 (58%) patients were female. The median length of stay prior to request was 12.5 days (R: 1–65 days). The most frequent diagnoses (several diagnoses possible) were cardiology-related (n = 29), followed by sepsis (n = 11) and cancer (n = 6). Twenty patients lacked decisional capacity. The main reason for a CECC request was uncertainty about the balancing of potential benefit and harm related to the medically indicated treatment (n = 18). Further reasons included differing views regarding the best individual treatment option between health professionals and patients (n = 3) or between different team members (n = 3). Consensus between participants could be reached in 18 (75%) consultations. The implementation of a disease specific treatment intervention was recommended in five cases. Palliative care and limitation of further disease specific interventions was recommended in 12 cases.ConclusionsTo the best of our knowledge, this is the first in-depth evaluation of a CECC service set up for an academic department of cardiology and intensive medical care. Patient characteristics and the issues deliberated during CECC provide a starting point for the development and testing of more tailored clinical ethics support services and research on CECC outcomes. (shrink)

Little is known about how certain patient characteristics can affect the timing of an ethics consultation, which has been hypothesized to affect patient length of stay. This study assessed how specific patient characteristics affect the timing of an ethics consultation, namely, age (over 65 years), race, Medicaid status, the presence of a living will, the presence of a health care proxy, and the absence of decisional capacity. Moving beyond the typical case-series evaluation of an ethics consultation service, this (...) study used an innovative approach to model how predisposing, enabling, and need factors affect health behavior and subsequently affect health outcomes for patients who received an ethics consultation at a Catholic health care system in Oklahoma. (shrink)

Hospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial optimistic prognosis. It is (...) hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients. Among physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources. Our current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system. (shrink)

Background Hospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial optimistic prognosis. It (...) is hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients. Main body Among physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources. Conclusion Our current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system. (shrink)

ObjectiveTo provide insights on emergent ethical tensions experienced by mental health practitioners during system re-organisation, which is sufficiently grounded in empirical data at the local level to inform policy on recovery at institutional and provincial levels.MethodEthnographic methods using narrative and critical phenomenological resources over 24 months.FindingsEveryday ethical tensions emerged at the confluence of different experiences of time, for example, how a context of increasing pressure to decrease patients’ length of stay at the hospital challenged efforts to listen to (...) and advocate for what mattered to patients and maintain the integrity of interventions. In this context, practitioners drew on clinical language and that of personal recovery to strategically ‘push back’, ‘play with’ or ‘take back’ time.DiscussionExamining everyday practices through ethnographic methods can illuminate the everyday ethical tensions that arise when mental health professionals and psychiatrists grapple with, often competing, goods. Critical phenomenological resources can help expand the structural considerations in empirical ethics, excavate underground practices and raise questions about the conceptual categories undergirding normative ethics. Experiencing-with practitioners in clinical contexts as they encounter and creatively resolve ethical tensions also propose a normative ethics of possibility, to help bridge the gap between empirical and normative ethics.ConclusionFocus on the relationship between policy, temporal practices and ethics suggests a reconfiguration of time and re-imagination of ethics in institutional settings in ways that can ultimately benefit patients and professionals alike. (shrink)

ObjectiveThis study aims to investigate anxiety and its influencing factors in patients with drug-induced liver injury (DILI).Materials and MethodsNinety-four patients with DILI were enrolled and evaluated with a self-rating anxiety scale (SAS). According to the anxiety score, they were divided into four groups: the non-anxiety, mild anxiety, moderate anxiety, or severe anxiety groups, and the scores were analyzed based on demographic and biochemical indicators.ResultsOf the 94 patients with DILI, 63 did not have anxiety and 31 had anxiety (32.9%), of which (...) 27 had mild, 3 had moderate, and 1 had severe anxiety. There were no statistically significant differences in gender, age, occupation, and level of education between the groups (F= 1.42,H= 2.361,H= 6.751,H= 1.796, andP> 0.05); anxiety score and degree of anxiety between the types of drugs that led to the liver injury (H= 0.812,H= 1.712, andP> 0.05); anxiety score between the different degrees of liver injury (H= 2.836,H= 4.957,P> 0.05); or length of hospital stay or prognosis between the degrees of anxiety (F= 1.487,H= 0.761,P> 0.05). However, there were statistically significant differences in the degree of anxiety between different degree and types of liver injury (H= 7.981,H= 8.208,P< 0.05).ConclusionPatients with DILI may have anxiety, especially mild anxiety. The occurrence of anxiety in patients with DILI is not related to gender, age, occupation, or level of education but may be related to the degree and type of liver injury. Anxiety has no impact on the length of stay in hospital or the prognosis of the DILI. These findings may contribute to the development of management strategies for patients with DILI. (shrink)

The EU's Farm to Fork strategy (European Commission European Commission. 2020. Farm to Fork strategy. https://food.ec.europa.eu/horizontal-topics/farm-fork-strategy_en. Accessed 31 August 2023.) highlights the need for a resilient food system capable of providing affordable food to citizens in all circumstances. Behind the provision of affordable food for EU citizens there is the effort of many migrant and seasonal food workers (MSFWs). In Almería, Spain, the area with the biggest concentration of greenhouses in the world, MSFWs face vulnerability in the form of physical (...) and institutional invisibility despite performing the essential task of providing affordable food for the EU’s food system. This paper aims to move on from structuralist concerns and place MSFWs’ lived experiences at the center, including the (in)formal nature of their food practices, to understand how the people that feed Europe feed themselves. A combination of social practice theories and diverse economies is used to explore MFSWs’ daily food routines. These theories are used as lenses that inform the data collection process, performed through semi-structured interviews, photography, and observations. The findings of the study reflect a dynamic portfolio of (in)formal practices that evolve based on the length of stay in the county. These practices demonstrate how the EU food system resilience relies on the diverse economies of migrant settlements. We conclude that informality is a reality in the EU food system, and that shedding light on previously hidden food practices and their structures can help us envision food security interventions that are inclusive for all actors involved. (shrink)

In recent years, the concept ‘post‐feminism’ and its links to neoliberal economic structures and to the extreme reinforcement of individualization as raison d'etre of Western civilization have been discussed at length by numerous distinguished scholars in feminist cultural studies and feminist philosophy. This article takes its point of departure in this discussion. Drawing on Wendy Brown, Elizabeth Grosz, Angela McRobbie, Wendy Larner, and others, the text is examining the discourse of post‐feminism and neoliberalism, and its effects on overarching political (...) scenarios, as well as on everyday life: What happens to feminist politics when the collective, both as figuration and as virtual political platform, is deemed to be something situated in the discursive outskirts? By drawing on examples form the contemporary cultural imaginaries, from popular culture, economic structures, and public debate, and by pointing out the links between the micro‐perspective of our everyday living and overarching political structures, this article aims at bringing to the fore and critically discuss these issues, and the ways in which they intersect with contemporary Western feminism. The article ends with a discussion of possible points of exit or paths to follow in order to find alternatives. (shrink)

The current Medicare prospective payment system has many positive incentives for hospitals to control costs. Hospitals are increasing outpatient surgery, decreasing admissions, decreasing length of stay, and decreasing use of ancillary services. These are just the effects that Congress and the Health Care Financing Administration hoped for to save the Medicare trust fund. However, there has been evidence of some adverse outcomes including premature discharge, “dumping” sicker patients and patients without insurance, and adverse impact on hospitals with specialty (...) centers. We examine these issues and present a possible solution based on a new Computerized Severity Index. (shrink)

BackgroundThe Life Extension Medical Decision law enacted on February 4, 2018 in South Korea was the first to consider the suspension of futile life-sustaining treatment, and its enactment caused a big controversy in Korean society. However, no study has evaluated whether the actual implementation of life-sustaining treatment has decreased after the enforcement of this law. This study aimed to compare the provision of patient consent before and after the enforcement of this law among cancer patients who visited a tertiary university (...) hospital's emergency room to understand the effects of this law on the clinical care of cancer patients.MethodsThis retrospective single cohort study included advanced cancer patients aged over 19 years who visited the emergency room of a tertiary university hospital. The two study periods were as follows: from February 2017 to January 2018 (before) and from May 2018 to April 2019 (after). The primary outcome was the length of hospital stay. The consent rates to perform cardiopulmonary resuscitation (CPR), intubation, continuous renal replacement therapy (CRRT), and intensive care unit (ICU) admission were the secondary outcomes.ResultsThe length of hospital stay decreased after the law was enforced from 4 to 2 days (p = 0.001). The rates of direct transfers to secondary hospitals and nursing hospitals increased from 8.2 to 21.2% (p = 0.001) and from 1.0 to 9.7%, respectively (p < 0.001). The consent rate for admission to the ICU decreased from 6.7 to 2.3% (p = 0.032). For CPR and CRRT, the consent rates decreased from 1.0 to 0.0% and from 13.9 to 8.8%, respectively, but the differences were not significant (p = 0.226 and p = 0.109, respectively).ConclusionAfter the enforcement of the Life Extension Medical Decision law, the length of stay in the tertiary university hospital decreased in patients who established their life-sustaining treatment plans in the emergency room. Moreover, the rate of consent for ICU admission decreased. (shrink)

This paper investigates the structure and composition of the social network formed on the campus of the Faculty of Economics and Business of Diego Portales University, Chile, exposing a series of characteristics that are aligned with similar research in the field of networks. We use a model of social networks formation in order to understand socioeconomic and academic factors that predict the formation of friendship between two students. Specifically, we test empirically our model, using students' administrative information. Of special interest (...) is the impact of the length of stay of the students in the university, with which we refer to the years completed in the degree course, in the probability of establishing friendship ties where being socioeconomically different is a condition. The mechanism behind a result like this is the sense of belongingness that being part of the same institution may induce amongst students. By means of counterfactual simulations we found evidence in favor that passing through the university increases the probability of forming friendship networks, which can mean a kind of social capital, thus reducing socioeconomic segregation from the Chilean school system. Given the importance of this finding, we believe that policies that increase the sense of belongingness such as cultural events, leaderships programs, and community should be implemented on university campuses. (shrink)

Focusing on Hangzhou, a famous tourist city in China, in this study, four regression models were constructed through four items of tourist loyalty to investigate the influence of tourist perceptions and characteristics on male and female tourist loyalty to shared bicycles. A questionnaire survey and ordered logistic regression model techniques were used. Survey data from 467 tourists indicated that there were significant differences between male and female tourists. For male tourists, their willingness to reuse shared bicycles was positively correlated with (...) ease of access to cycles, environmental awareness, psychological benefit, and management provision; however, their willingness to recommend shared bicycles was only affected by environmental awareness, psychological benefit, and management provision. Among female tourists, willingness to reuse shared bicycles was affected by ease of access to cycles, environmental awareness, and rule adherence, while their willingness to recommend shared bicycles was affected by ease of access to cycles, environmental awareness, psychological benefit, and managerial provision. In addition, female tourists’ socio-demographic and behavioral characteristics had a significant impact on their loyalty, among which length of stay in Hangzhou and education were significant in the four regression models, and number of visits to Hangzhou had a positive impact on female tourists’ willingness to reuse. In addition, female tourists who used Hellobike had higher willingness to reuse and recommend than those who used Mobike. For male tourists, only length of stay in Hangzhou had a significant impact on their reuse intention. The current study extends the theory of attribution to explore the factors which may affect tourist’s loyalty to bicycle-sharing from the perspectives of tourists’ perceptions. It will provide further support to decision makers in the development of new shared-bicycle systems at Chinese tourist destinations, with the aim of strengthening tourist loyalty to shared-bicycle programs. (shrink)

Suppose one accepts the argument that past infinity is not acceptable. This does not eliminate the possibility that the beginning of time is not equivalent across objects. Along with breakdown of absolute simultaneity of events in relativity, there may even be no agreement on whether an event existed. There may be no consistent way to totally order events. In such a case, despite every object, conscious or not, having finite lifetime, there may be no single point called “the beginning,” and (...) the universe stays as it is without requiring a cause of existence. (shrink)

ObjectiveDignified care protects the patient’s rights and provides appropriate ethical care while improving the quality of nursing care. In this context, the opinions of nurses and patients who receive nursing care about dignified care are important. The aim of this study was to explore the opinions and experiences of Turkish patients and nurses about respectful care of human dignity.MethodsThis descriptive cross-sectional study was conducted in Turkey. Participants were inpatients at cardiology, neurology and neurosurgery clinics and nurses working in these clinics. (...) The data for the study were collected from face-to-face interviews using questionnaires. The percentages of characteristics and preferences of the participants were calculated, and the results were analysed using statistical tests.ResultsA total of 150 patients and 78 nurses participated in the study. The patients stated that the protection of their rights was the most important factor for dignified nursing care. The nurses stated that being careful to not expose the patients’ body and being respectful of the patients’ privacy were important in dignified nursing care. The age of the patient, duration of the disease, number of hospitalisations and length of time the nurses had been working at the clinic caused significant changes in the factors considered important in dignified care.ConclusionsOur findings provide a perspective on dignified care in the Turkish healthcare setting. There were some differences between patients and nurses in the factors considered important for dignified care. The discussion with patients and nurses related to care and practices that protect or detract from human dignity can provide insights to ethics. (shrink)

The music of Christoph Willibald von Gluck was a revolution for Paris operagoers when his work premiered there in 1774. In a setting known for its restive and often rowdy spectators, Alceste, Iphigénie en Aulide, and Orpheé et Eurydice seized audiences with unprecedented force. They shed silent tears or sobbed openly, and some cried out in sympathy with the sufferers onstage. “Oh Mama! This is too painful!” three girls called out as Charon led Alcestis to the underworld, and a boy (...) pleaded with his father to take him home. A woman who watched the same performance described falling on her knees in her opera-box as the march of the priests of Apollo began, staying in this position “suppliant and with my hands clasped until the end of the piece.”Gluck's streamlined musical language was one reason for these emotional responses. He and his librettist Ranieri de’ Calzabigi simplified the conventions by eliminating extraneous subplots, abandoning the repetitive da capo form, and replacing trills and runs with simpler melodies meant to convey passion. Another reason was the widespread culture of sentimentalism, which equated virtue with sincerity and judged tears to be the natural sign of an open heart. Painters depicted tender and tumultuous family scenes, and friends pledged trembling vows of fidelity. Listeners were also readers, and many described similar tearful responses when they read the century's bestseller, Rousseau's novel Julie; or, The New Heloise.Everist, a musicologist, takes up the story of Gluck in France in the nineteenth century, when the German composer remained a presence in repertoires. No longer prone to tears, the public was often indifferent and sometimes hostile to his works. Conductors and composers nevertheless persisted in promoting Gluck's music. Between 1828 and 1870, operatic excerpts appeared roughly twice a year in performances of the prestigious Société des Concerts, and the charismatic conductor Jules Pasdeloup regularly programmed his music. Many listeners remained unconvinced. A writer in 1861 described the “sepulchral boredom that reigned the length of all five acts” of Alceste. The periodical Monde dramatique used the same language to characterize Gluck's music: it was “profoundly boring.” After a high point of performances in the middle of Napoleon III's reign, Gluck disappeared from the Paris opera and concert stage for some thirty years.Everist's aim in this slim book is to isolate the “agents” involved in the French reception of Gluck. Traditional reception histories might begin with Gluck and his aims, identifying musical features, particular responses of audiences, critics’ accounts, and perhaps the more elusive temper of the times. Everist focuses instead on less conspicuous networks of impresarios, theater directors, and publishers. In his telling, such agents also include journalists and writers of fiction. The avowed effort is to decenter the artist and his art to emphasize the limited role that composers and librettists play in the performance of an opera. A quoted passage in the book reminds us that without parking attendants, stagehands, and ticket sellers the show could not go on. True enough. Genealogies of Music and Memory therefore provides tables listing Gluck arias in anthologies, particular singers’ performances, works by composers other than Gluck who also drew themes from classical antiquity, and works by other foreign-born composers. A section on “material culture” lists paintings and sculptures of Gluck in Paris theaters and museums.As a “genealogy,” the book is a salutary reminder of the web of amateurs and professionals who discuss, promote, and perform works that others have created. Writers such as E. T. A. Hoffmann, Mme de Staël, and Hippolyte Taine held up Gluck as the embodiment of German music. Hector Berlioz wrote frequently and enthusiastically about Gluck, although he was less keen to program his music. The singers François Delsarte and Pauline Viardot aroused temporary interest in Gluck by regularly including his arias in their recitals. Musical anthologies for the bourgeois household included piano arrangements of his best-known arias. Some nineteenth-century adaptations of his works were scored for the military band.Genealogies of Music and Memory is musicology with very little music. Everist's reliance on networks of actors, agents, publishers, pedagogical practices, and archival environments leads him to assert that “multiple agency is endemic in the story told here.” Unfortunately, it is often unclear just what the story is. Carelessness in writing and editing throughout—including a subject-verb clash in the book's final sentence—has rendered key passages obscure. Everist describes Delsarte's voice as feeble, broken, veiled, and ready to be extinguished twice in the same paragraph, first as a paraphrase and again in a quotation (with a misplaced comma).Decentering artists and their work to elevate others responsible for its reception brings attention to the unseen and often unsung. In the absence of particular performance histories, musical analyses and description, or sustained accounts of shared tastes or critical responses, however, conclusions remain piecemeal. Everist claims to have revealed a “Geertzian web of culture” in his study. A more modest account would describe it as an enumeration of references, revivals, editions, excerpts, and arrangements. (shrink)

The philosophical debate on the freedom of movement focuses almost exclusively on long-term migration, what I call, migration as settlement. The normative justifications defending border controls assume that the movement of people across political borders, independent of its purpose and the length of stay, refers to migration as settlement. “Global mobility,” “international movement,” and “immigration” are oftenused interchangeably. However, global mobility also refers to the movements of people across international borders for a short length of time such (...) as travel, short-term and circular migration. While most scholarly attention has focused on long-term migration, the vast majority of cross-border movement of people (approximately 85% of all cross-border movements in 2019) is short-term. The existing literature offers normative arguments for border controls, which are grounded on states’ right to self-determination, the freedom of (dis)association, the welfare state, the duty to compatriots, and brain drain. In this paper, I argue that these arguments do not justify excluding travelers, short-term and circular migrants from the territory. (shrink)

The need for a shift toward healthier and more sustainable diets is evident and is supported by universalized standards for a “planetary health diet” as recommended in the recent EAT-Lancet report. At the same time, differences exist in tastes, preferences and food practices among diverse ethnic groups, which becomes progressively relevant in light of Europe’s increasingly multi-ethnic cities. There is a growing tension between current sustainable diets standards and how diverse ethnic resident groups relate to it within their ‘culturally appropriate’ (...) foodways, raising questions around inclusion. What are dynamics of inclusiveness in migrant food practices? And what does this mean towards the transition to healthy and sustainable food? We study this question among Syrian migrants with different lengths of stay in the Netherlands. Our theoretical framework is based on practice theories, which emphasize the importance of socio-material context and of bodily routines and competences. We use qualitative methods, combining in-depth semi-structured life-history interviews with participant observation. Our findings indicate that inclusiveness takes different forms as migrants’ food practices and the food environment change. Regarding health and sustainability in food practices, understandings and competences around particularly fresh food change over time among both short- and long-term migrants, replacing making things from scratch with seasonal products with buying more processed products and out-of-season vegetables and fruits. We conclude that the performances of food practices and their configurations in food environments and lifestyles are dynamic and cannot unequivocally be interpreted as in- or exclusive, but that a more nuanced understanding is required. (shrink)

KJORVEN M, RUSH K and HOLE R. Nursing Inquiry 2011; 18: 325–335 A discursive exploration of the practices that shape and discipline nurses’ responses to postoperative deliriumAlthough delirium is classified as a medical emergency, it is often not treated as such by health care providers. The aim of this study was to critically examine, through a poststructural, Foucauldian concept of discourse, the language practices and discourses that shape and discipline nurses' care of older adults with postoperative delirium (POD) with a (...) purpose to question accepted nursing practice. The study was based on data collected from face‐to‐face, in‐depth, personal interviews with six nurses who work on an acute postoperative patient care unit. Five analytic readings of the data identified two prominent discourses at work in nursing practice which influenced the care of patients with POD. These were identified as discourses of legitimacy/illegitimacy and discourses of nursing work. Through the process of poststructural analysis it became evident that one overriding discourse – the biomedical/scientific discourse – served to direct, legitimize and govern all other discourses. The findings of this study have implications for nursing knowledge and practice, length of hospital stay and improved patient outcomes. This study builds on previous work and is the first study to conduct a discourse analysis illuminating nurses’ responses to POD through comparison with other acute medical emergencies from a poststructural perspective. (shrink)

Reproduced with the kind permission of the author. Currently available in the collection I Looked Alive . © 2010 The Brooklyn Rail/Black Square Editions | ISBN 978-1934029-07-7 Originally published 2003 Four Walls Eight Windows. continent. 1.1 (2011): 43-51. Introduction Ben Segal What interests me is instigated language, language dishabituated from its ordinary doings, language startled by itself. I don't know where that sort of interest locates me, or leaves me, but a lot of the books I see in the stores (...) seem to lack language entirely. Gary Lutz (2006). This issue of continent.'s fiction section features a reprint of “This Is Nice of You” from the first edition of Gary Lutz's collection I Looked Alive . That book was originally released by Four Walls Eight Windows in 2003 and has since been reissued in 2010 by The Brooklyn Rail/Black Square Editions. Calamari Press has also reissued Lutz's Stories in the Worst Way (originally published by Knopf, largely forgotten and dismissed, and then re-issued by the too-short-lived 3rd Bed). “This Is Nice of You” was edited for the re-issue of I Looked Alive and, as the original book is out of print, the earlier version of the story has been hard to come by for some time. This initial version is a bit longer than the new version—Lutz is a master of tightening down his texts to their most linguistically intensified cores—but it is in no way sloppy. It is a great privilege for continent. to be able to make available rare texts of (first) aesthetic and (second) scholarly value. For those readers unfamiliar with Gary Lutz, I believe this story will serve as a worthy introduction. Like Raymond Carver, Diane Williams, Christine Schutt, and so many other important twentieth century and contemporary short story writers, Lutz studied with and was edited by Gordon Lish. This connection is apparent in his attention to sound and the sentence as compositional unit, but Lutz's is a unique voice. “This Is Nice of You” bears Lutz's trademark torqued and turning syntax, his sexed-but-nameless characters, his rendering of the human body and its emissions as utterly discomfiting. Lutz's preoccupations with the mundane raise ordinariness, via startling language and observation, to grandiosity and grotesquery. In the fall of 2008, Lutz delivered a lecture entitled “The Sentence is a Lonely Place” to writing students at Columbia University. The lecture was later printed in The Believer (and is linked below). In it, he spoke about the importance of the sentence as a compositional unit, as even the distinguishing formal characteristic of prose. Specifically, Lutz explained that, from Lish, he had developed a "poetics of the sentence." Accordingly, Lutz constructs his stories at the level of the sentence, paying extreme attention to the material of words- their letters and their sounds- and the way they abut one another and interact on this material level even before they are employed in the service of traditional aims of fiction like meaning or story. Lutz often uses a(n almost constraint-related) technique called consecution. Letters or sounds from one word are carried forward into the following, producing drama and movement in the language itself at a level entirely apart from that of plot. For example, you can see how the 't's in the first sentence of “This Is Nice of You” repeat fast and hard through met and then soften into the 'th's of brothers and they. This close attention to the specific material and characteristic conditions of prose means that Gary Lutz's work always involves both a happening in language and of language. “This Is Nice of You” has a richness and depth that is hidden not in symbolism or obscure reference but on the surface of the page, in the language of every sentence. FURTHER READING Lutz, Gary. “ The Sentence Is a Lonely Place. ” The Believer January, 2009. Web. Short stories and excerpts at Web del Sol . Web. Taylor, Justin. “ An Interview with Gary Lutz .” Bookslut. July, 2006. Web. THIS IS NICE OF YOU [156] [1] I was a man dropping already well through my forties, filthy with myself, when, taking a turn at the toilets one afternoon, I met two brothers-they said they were brothers-who swore they had a sister, a schoolteacher, an officer of instruction at the county college, a whirlwind midlife turmoil of everything already put to ruin, who had gone off from a new marriage in an old car, an upkept and ennobling sedan, but had returned now to the apartment and [157] was living there alone with the little runoff there was from the marriage-some outcurved appliances, apparently, and low-posted furniture promoting its own mystery but becoming figurable in certain concentrations of TV light-and, above all, a telephone (on a pedestal, they insisted), the handpiece of which she gripped in lieu of exercise, or in fury, and I thus let out my little, reliable cry that I was in fact a student of the telephone, that it was a debasing apparatus in the main, with its meager economy of bells and tones, and the intimacy of the mouthpiece that sent your breath, tiny aftervapors of it, back toward your lips, so that regardless of the party accepting the outgoing products of your voice, you were, at most, in a further, rivaling exchange with yourself alone, and this is what must have brought the two of them around, the men who proclaimed brotherhood with the woman, because they offered me her phone number, put it at my disposal on a piece of paper one of them had already committed it to, a tearing from a menu, and the looks the men were now giving me had deletions in them, already, of my exact, beanpole shape and size. So off I went to a pay phone, the nearest canopied one I could find. The woman answered after the second ring and said she needed a lift right that very moment into the little, unlevel city close by. She was idling in the doorway of the building when I pulled up in front, and I helped her into the car, then got back in myself. I had always had a way of not having to look at people that nonetheless brought them to me in full, and so I still am certain of the susceptive and impressible comp-[158]lexion, the shimmer on the mouth, a lipstick of low brilliance, a difficulty around the eyes, the hair short and rayed out exclamation ally, skin bagged up over the elbow bone, conflict even in how her arms stayed at her sides—in sum, a spinal loveliness for me, an off-blonde quantity with shadowed, thumbworn hollows that put me out of as much as I might have ever known of women before. I set the two of us into the narrow traffic, and I remember telling her, by way of explaining the little burden which I had shifted, by now, from the shelf of the dashboard and onto my lap, that when you lived in filth, as I then did, a daily newspaper came to count for a lot, although instead of the thick-supplemented local paper I bought a trimmer one from a backlying town—not, of course, for any affluences of native data it carried, but as an article of house ware: a rough immaculacy in four lank sections, a set of fresh, hygienic surfaces to come between the table, say, and whatever I had going for me at the table, if the table was where I was going forward—because what else so cheap comes so clean and far-spreading? The woman told me that her own trouble with paper was that through a modest hole, no larger than a quarter, that had been drilled a foot or so above the floor (the standard height, she had reasoned, of legitimate electrical outlets), and by means of which her faculty office had at last gained communication with the roomier but unoccupied office next door, more and more often shot a single sheet of paper, plain copier paper she had rolled just barely into a tube, [159] so that after landing on the floor of the neighboring office the paper would preserve little if any of the curl, and there would be nothing written or typed on it, of course, and it was always a blank sheet that had been ageing on her desk for some time and had already been moved around, or advanced, from station to station on the desktop, coming into further creaselets and crimps and other infirmities—paper, in short, still too bare and unfraught to be thrown responsibly and forgettably away, and yet too seasoned and beset with irritations of the surface (a molelike blemish, say, or what looked like a tiny hair, an eyelash, sunk into it, or frecklings, or notational pressings of a fingernail), too wrought, in sum, for the paper to be appointed to any secure curricular purpose. Her office, she claimed, was in fact full of such paper, much-handled and singularized sheets of it by the loose, functionless hundred. I had to get it across to the woman that I myself no longer had an office, or any other place to divide me reliably from everybody else, and that for much of the daylight I thus appeared to be among people because I kept putting myself where people came together into even closer-fitting assortments, the viewing areas and showrooms and rotundas and such: I took in the lean-to look of the women, the tongues coming and going in what the men kept thinking of to say—whole families of low knees for me to bark my shins against during the crowded and involving way out. At home afterward, in the one room where my life was packed down, I would keep my nose stuck in the safehold of the phone [160] book, where the names of people suffered reduction to mere episodes of the alphabet and underwent humbling declensions down every column (Lail, Lain, Laine, Lainerd), and he names of streets, of the towns and townships, got docked in crude, heedless abbreviations (the vowels almost always the first to get poked out), and I would run my eyes over the telephone numbers themselves, each sequence of digits another fallible run of the infinite. I thus corrected my feelings for people and assembled myself emotionally into whatever else I had at hand—the obligating arms of the clothes hangers, usually, or the keen-angled understructure, the guardian legginess, of the ironing board. The woman said that in her case, though, it was more a matter of making slow circuits of the classroom where she had to put across the Emporial Sciences, retail theory and methods, to heat-giving and suggestive young women, some of them world cruelties already. There was the cooing of empty stomachs in the hour just before lunch, and the braying and fizzle of loaded stomachs in the low hours of the afternoon. She would recite her notes in a voice barely loyal to anyone octave, a tiny alluvium of slaver hardening at the corners of her mouth on the days she gave the glassy lozenges a slow, warming suck, and she would take lowering notice of how whatever she said succumbed at once to freak spellings and razzing paraphrase in the big, dividered notebooks; and because in midafternoon light the world looked as thorough, as filled in, as it was ever going to get, a better way to set about ruining her eyes was to review how hair had [161] established itself on the arms of the young women, because almost every arm had brought across itself a welcome and diversifying shadow. On one girl it would be a fine, driftless haze afloat above the white of the arm, never seeming to touch down on the skin itself. (An atmosphere, at most, of chestnut brown.) On another, it was as if copper wire, the narrowmost lengthlets of it, had been stuck into the fleshy batter of the thick, freckled forearms. On a third: a field of it–wheat-colored, thin-spun. On a fourth; a differencing, darkish updrift that shaded off as it approached the inner bend of the elbow, then re-emerged at the base of the upper arm as whiskery fringe. On others it was a brassy or rust-colored frizz, or it was as coarse as cornsilk, or it looked fussed on, as if the arm had been slowly stroked with charcoal. But here the woman broke off, or I may well have made an interruption of my own—I think I must have asked whether she was hungry, and she said if I was, and so on one of the lesser streets I parked the car and led her down into a belowstairs eating house I still remembered. Sandwiches were presently lowered in front of us. I watched her remove the festooned toothpick from hers and then play her fingers over the toasted planes before she took a fond first bite. "This is nice of you," she said. I must have looked at her in the way I then had of getting people to speak so they would not seem to be dwelling any longer on my features, because if on the well-set face the mouth and eyes are said to seem frozen in elegant orbit about the til) of the nose, then mine was a face that behold-[162]ers, regarders, could not help trying to round off with greater success, to goad the particulars of it back into the arcs they had wandered away from—the mouth, for instance, having been pursed and pinched suchwise that it seemed resident more on one side of the face than the other—and there were other signs of original strife to be busied with (slapdash eyebrows unbunched, it appeared, from reserves of hair elsewhere on my person; a showing of adult acne, a shrivelly little relevance of it, confined to the declivity of my nose); and so to be polite, the woman thus sank her gaze into her sandwich, and told me, in a voice lowered accordingly, that, one late-childhood summer, she had devoted herself to collecting postage stamps: it was a tongue-involving sideline to early-arriving puberty, and she liked having to lick the pale, gummed hinges instead of the sticky backs of the stamps themselves before entering everything into the hosting album; and once, during some foul weather between her and a brother (the older, thrown-over one, who had already made a habit of fooling the underside of his arm across the top of hers and calling her "pussified"), she reached for the shoe box in which she had let duplicate stamps accumulate—Spanish ones, mostly, of a fading orange—and sent the box slooshing through the lower air so that the stamps showered onto the brother's bare legs with a full, delicate harm. The woman was now touching up the surface of her iced tea with tiny activities, initiatives, of the longspun spoon. I myself was good at getting my touch onto things, although in a way that seemed to mix up the motive atoms inside [163] them, but I was satisfied that for the moment my sandwich, the unbitten-at half of it, was displayable and fit and local to my plate. The woman went on to say that, as a child, she had been bundled off, many an afternoon, to the slope-ceilinged quarters of a bachelor uncle who, when speaking of anybody not immediately present, could not bring himself to use the person's name but instead would say "an acquaintance of mine in ..." and then mention the name of some lapsed homeland, or little-loved rural orchestra, or backset building about to come down; and it was never a riddle, this device of his (not once could the girl have been expected to identify any of the subjects), and no matter how often and aloud he insisted that particularizing persons any further—bringing even a first name down upon anyone of them—would have been indecent, he claimed, much like doing things to people while they slept, the girl accepted all of the uncle's prim and extravagant evasion for what he surely must have intended it to be: a neat, protective trick to space the world out a little further in her favor, to scatter the population so that wherever her hand might at last come down, it would have to be on herself alone. And here I could sense that the woman wanted from my mouth an account of as much as I myself might have ever managed of attachment, so I told her I had once owned a house (a rising, really, of much-fingered, handwrought architecture that amounted to a little family of rooms above garages: a boxlike building with a rattly thorax of downspouts [164] and drainpipes and an unfolded but full-toned fire escape), and I had had for a time a boarder, a student, a high-colored, loose-packed representative of declining girlhood, hung with necklaces and barrettes, a girl of precise but shifting leanings and inclinations; and the afternoon she had come round to ask after the room, I stood in the entranceway, handshaken and asweat, and from what would later be my memory of the girl, I made off with, first, how every pore of her nose seemed to be sheltering within itself a tiny dark seedlet, a grain of something immediately, enormously valuable. And an almost lipless mouth (just a slit, practically), the teeth inside looking wet, watered-it was my life's chore, at that instant, to keep from sending the back of my thumb blotterlike across the line of them (I was later to learn she drank everything cold and through the narrowest of straws). And her hair: it was tea-colored hair she had, long and reachful, an unstopped downcome of it. Tall for a girl, but she managed to stay out of much of her height and put herself across as somebody backward, or behind. I must have told the girl, as best I could, that I of course had a wife, a full-faced, imperishable partner, though for the moment she was gone otherwhere in the marriage, and here the woman, my present companion, my tablemate, whose feet were now parked, in parallel, on the grade of my upper leg, interrupted to say that her husband, too, had been such a liar, and what could I bring up by way of reply other than that a lie is a truth struck through with other, further truth, or that a lie is the present multiplied by the past or that a lie [165] is an outcry of borrowed hope? The woman gave me an allowed look of disgust, her eyes lowered but still popular with me, and on I went with what had now become the girl of my story. For there had been a great, gainful carpet in the room I put the girl into, a matty expanse of coarse, grabby piles, an engrossing affair that took things into itself and held them tight, misered them, and I of course insisted that the girl not bother herself with its upkeep, that I enjoyed weekly access to a prestigious, upstanding vacuum cleaner; but no sooner was the girl out of the house each morning than I would withdraw from my room, where time was unportionable, and loose myself into the ticktock impertinence of the girl's room and get down on my knees, and, going after the carpet first with my fingers, then with a forceps, and finally by unspooling lengths of clear package-sealing tape and pressing them against the tufts in neat rectangles to catch what I might have missed, I brought vast tracts of the carpet to depletion, recovering not simply the girlinesses, the girleries, one would expect (buttons, straight pins, downed jewelry), but flirtier personalia in the form, say, of a stray confetto brought into the world when a page had been wrung with out caution from a spiral-bound notebook, or some pleated paper shells of the chocolates she required, or one of the bargain antihistamines she took to get her naps going, or a trash-bag tie ragged enough to show the kinked line of the wire within (this I would get wound around my finger), or a cough drop enwrapped like a bonbon (I would undo the [166] wings of the wrapper and have to decide whether to suck the drop all down or begin chewing it midway)—I became the following, the public, that these things, these off-faIlings, had come to have; but mostly there was hair, afloat above the uppermost pushings of the fabric of the carpet an almost continuous haziness of loose hairs of all lengths and sources, and I would have to set them out on a fresh sheet of paper and assort them according to the regions of the body they had taken their departure from, and in no time I had nest-like filiations of broken filaments and smaller involvements of the hairs that made me think of hooks, of barbs, of treble clefs, and each pile required a separate envelope, to be filed in a separate shoe box for every sector of the body until, I hoped, the boxes themselves would no longer be enough and I would have raised something semblable, brought up something equal in volume to the comprehensive girl herself. And her wastebasket! For every bit of rubbish, every dreariment she tossed into the thing, I would, in secret, deposit a reciprocal discard of my own, matching a spotted, confessory tissue of hers with a lurid throwaway after my own heart–the cardboard substructions of a fresh parcel of underwear, maybe, or tearings from pantyhose I now and again pressed against a span of my forearm to work onto it the complications of female shading I otherwise made do, choosily, without. I thus built the two of us up together in her trash! One afternoon-it was another of those lifeful, unsam-[167]pled days on which the world humors us each a little differently to keep us nicely on our last legs—I discovered in the wastebasket an inch-deep textbook of hers, a paperback with a celery-colored cover that had come partly unglued, and this dilapidation I paired off, naturally, with a name-your baby guide to whose pages, during my recurrent turnings of them, in bed or at table, I had contributed dried produces of my person, a chemical splendor entirely mine. This coupling sent a sudden spigoty thrill from me that forced an unbuckling and an unzipping and a cleanup with a handkerchief I then ventured responsively into the wastebasket as well. It was in the bathroom afterward that I found a suds-clouded puddle on the unlevel floor of the tub, a little undrained remainder, rimmed with offscum, of the girl's prolonged early-morning soak, and this was as much as I needed to get on my hands; I pressed them flat against the wet porcelain, then flapped them around in the air, and that was when I noticed it—in the amphitheater of the toilet bowl, an orange-yellow tint, or value, to the waters. When the girl arrived home that evening, I told her, of course, that I had discovered fresh, unforeseen trouble within the tank of thelet (a misalignment of the trip lever, a waywardness of the float ball, a ulation of the lift wires, kinks and defects, really, throughout the entire system) and that in fine it was an apparatus now operable only by means of advanced and strenuous equilibrial manipulations that it would be unseemly, inhospitable, of me to pre-[168]sume to burd to burden her with–so that from here on out, following any leak or evacuation she need merely lower the lid and then, before quitting the room, ring the handbell that had been placed on the would seeeverythinghing else. But the bell never rang, not even once, and from my window the next morning I watched the girl carry from the house a little plastic bag distended balloonishly, much like those bags you will remember having seen in the hands of children bearing homeward their solitary carnival-prize goldfish. In fact, I never ran across the likes of the girl again. The man who came to collect her things-not the father, apparently, but an advocate, an upholder-l found to be dull-eared and lax in his speech, and the better part of his face seemed to have already begun making tiny, rotational departures from whatever it was that the eyes, themselves impressively mobile, were just that moment having to take in. (Was there a lamp in the house that was not that night slopping its wattage over everything?) I guess I was waiting for the man to take a laggard, last-minute interest in me, and by now I was pushing everything out into the paired first person–it was, I said, “Our night shot,” and I began including the two of us in whatever it might be doing out, the expected sprinkles and such—but he was no friendship buff, and he paid no heed to my telling him that the only dress of hers I'd ever twidged myself into even part of the way had been the simplest of them all, a large-buttoned wonder of depthless blue, and then only on the principle that one naturally fits whatever one has into whatever somebody else [169] had first, or how else would the world keep getting any taller with people? The man just went about the removal of the girl's things without having to be reminded too noticeably, I guess, of how every dick hangs by a thread. My listener, though, had by this time brought about some becoming slowings of her arm—it was an arm inclinable to langorous diagonals and magicianly swoops through the air above the tabletop—but it no longer was involving itself with her plate, so I suggested we shove off, I made payment for the food, and on our way to the car, and then in the car as I took to following her pointings, the directional tilts of her head, she said that you naturally kept putting more and more of yourself into another person, at first wondering how much she can take, how much of you is accumulable and how much she can hold, and you're letting things out, disbursing yourself, and you've soon got things set up in her, and room is being made for even more of you, and if you bring this off with enough people, even two or three, what you've got is at first a comfort, because you can pass yourself along and move a little more widely through the world and leave it to these others to man your grievances, your disappointments; and what brought this to mind, the woman said, was a term of financial hardship she had contrived for herself a few years back, an unpaid leave of absence from scrupling letter grades onto quiz papers (propped-up As, and upended Bs made to look, rather, like fannies; all As and Bs, no Cs or anything lower, the difference between an A and a B having less to do with the accuracy of whatever facts might [170] have been impounded in provided for an answer than with anything recallable about the way the enrollee ad conformed her body to the confining perpendiculars of her chair and the navel-level writing surface that projected from it, or the way there might one day have been an unignorable blush on the instep of a once-moseying foot, disburdened of its shoe, that had got itself trapped in the grillwork of that cagelike involvement, intended for books, that was welded to, or otherwise schemed into, the underworks of the chair)—this had been a duration, in short, of controlled difficulty when the misexpenditure of even a twenty-dollar bill had set her thrilling, gloating, over everything she would miss out on, and one afternoon she had made an engagement for a haircut, just a trim, and very early in the session the haircutter, a woman ill-defined in the face but otherwise full of conspicuities of emotion, set down the prevailing scissors and pressed the flat of a lukewarm hand against the woman's cheek, held it there for a good minute or longer, while the other hand eventually found its way into a drawer, a shallow treasury of slender specialty scissors, one pair of which the cutter withdrew and began routing deductively through the woman's hair, the other hand staying put on the cheek, longer and longer, and the woman went home and for afterward the bathtub was now a more likely destination than any of the upright furniture, and it got easier to fill the tub with further clarifying volumes than to clear space on the difficult heights of the sofa, and she was hardly claiming to have become a cleaner [171] person in result—she in fact would often discover, voyaging about her body, a browned, fractionary detail of a larger crepe of toilet tissue that must have got itself stuck in some assy crevice and was impossible to get plucked out of the revolving suds—she was saying only that she spent more and more of her time thus immersed, ill off in water, and the haircutter had surely had a hand in it, the woman was doing some of the cutter's life now, coming into some of its wrong, because you sometimes have to look to somebody else's life to get dimensions set back even part of the way around your own, and it should not have to be any less your own life when it comes from somebody else, and you could surely fudge a society out of anyone available person and get this person doubling for the many, so that in the little run of things perpetuable from one person to the next, every loose moment stood to become a complete, active finality. But by now this was a new day, with only an hour or so off it already, and the place the woman had made me bring us to, the man's place, with a promise that the man was elsewhere—this was on a little offshoot of a street, a stewy efficiency apartment the color had long ago gone out of; and when, once in bed, still clothed, I found among the sheets and blankets a spoiling pair of the man's underpants, one of the leg openings of which was puckered into an avid, sloppy mouth, I held myself accountable for redisposing the fabric until I got a befitting featurelessness back onto it; but all the while, I am sure I had to make myself go over again in my mind that if the body is the porter of as many organs of affec-[172]tion as there might one day turn out to be, then the idea was to let the thing carry you to where you would otherwise never have any reason to arrive, because I listened for the unmelodiof the the thede ofthe woman's zipper, and then the woman made me put myself out of my own clothes, the attritional corduroys and overshirt, and got herself up at last onto the topic not of the man whose apartment it was (because his story was scarcely the story of how the boy who decides he is half a girl no sooner starts to worry about where the other half might than he gets careless with where he rests his eyes, or what he gives even the feeblest of fingerholds to, and anything, even a crumbly triangle of pie offered on a saucer instead of on a pie plate proper, comes in easy, ready, wronging answer), but of her husband, and how, no more than a couple of months into the marriage, he had begun snugging away in his undershorts a little source of chanc, reliable frictions to nudge him onward through the workday—anything company-keeping that could be counted on not to slide out of the elasticky leg holes: a half-dollar packet of chocolate tittles, maybe, that was barely noticeable in the baggy surround of the widecut trousers so popular at the time. For by now the woman had at last brought what is usually called the other mouth to within only inches of my lips, but it is not a mouth, obviously, although I let myself go along with the goodwill behind the comparison, the way I will remain loyal to anything deliberately and faithfully misunderstood, and I fussed my tongue against the vital trifles hung inside of her, as much of the curtailed finery as I could find, [173] and gave the whole insimplicity of it a slow-circling, examinational lick, until I was taking a sudden tepid downwash on the tongue. It was a familiar, latrine in dribble that must have tasted, no doubt, like trouble just starting out.p [1] Editor's Note: Original pagination from first edition print denoted with bracketed page numbers. (shrink)