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At first glance, continuity and closure may seem mutually exclusive, but these elements reflect different needs occurring at different times in the dying process. Early on, patients and family caregivers fear that their physician, whose expertise and caring they have come to depend on, will become unavailable. Physicians are aware of this fear and attempt to address it with reassurance or continuity strategies. Yet, as death approaches, some patients and families may feel abandoned nonetheless because they lose the continuity of their physician's expertise or their relationship with that physician.

Near death or afterward, they may also experience a lack of closure of that relationship. Most of these physicians are not consciously aware of having abandoned their patients. Instead, they report lack of closure or a feeling of unfinished business. This study builds on prior work on nonabandonment and ties together other existing work on physician practices at the end of life.


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Our study provides empirical verification of continuity in 2 dimensions: the perceived need for access to physician expertise as well as the importance of continuity in a therapeutic relationship. In addition, our study adds another dimension to nonabandonment: the need for closure of the patient-family caregiver—physician relationship near or after the patient's death. This finding ties nonabandonment to limited literature that describes expert practices for physicians experiencing the loss of an important relationship with a patient.

These practices include personal reflection, 21 saying goodbye, 22 writing a condolence letter, 23 and attending a funeral. Few other empirical studies of nonabandonment exist. The significance of our study is that it provides empirical grounding for a central professional value. Our empirical findings enrich and extend these concepts in ways that we did not expect. Specifically, our findings identify aspects of nonabandonment—continuity and closure—that can be acted on Table 3. Reducing system barriers to continuity, for example, with nonhospice palliative care services may foster nonabandonment.

Physician or interdisciplinary team communication involving nurses and other health care providers that facilitates continuity and closure may improve patient and family caregiver experiences.

Caring for Children and Families | Nursing General | Subjects | Wiley

Finally, physicians can develop reflective skills that enable them to deal with loss and grief. This study has limitations worth noting. First, the generalizability of our findings is limited for several reasons. The study occurred in one state and involved older patients with 1 of 2 life-limiting diagnoses who were treated mostly as outpatients. In addition, most patients had a family or friend caregiver, were living at home, and had a preexisting relationship with a physician. Furthermore, none of our patients was seen by a palliative care consultation service, although some of the patients who died during follow-up were seen by hospice before death.

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These are all characteristics that may limit generalizability to other groups of patients. Second, because the study was designed to understand patient-physician communication, we were unable to investigate the issue of closure for patient-nurse relationships. Because the vast majority of the physicians were men and nearly all the nurses are women, we are unable to comment on sex effects.

Finally, our study was not originally designed to study nonabandonment so could have missed findings possibly observed if the study had focused specifically on this issue. On the other hand, asking participants to consent to a study about nonabandonment may have resulted in bias resulting from selective participation of patients willing to discuss the topic. In summary, we found that the professional value of nonabandonment at the end of life consists of providing continuity of expertise and a therapeutic relationship as well as facilitating closure of that therapeutic relationship.

Our aim in establishing an empirical frame for nonabandonment was to enable the development of interventions designed to improve this aspect of end-of-life care. Future studies are needed to determine whether intervention with clinicians, patients, or family members can prevent or address abandonment. Correspondence: Anthony L. Author Contributions: Drs Back and Curtis and Ms McCown had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drafting of the manuscript : Back, Young, and Reinke. Statistical analysis : Engelberg and Reinke.

Obtained funding : Engelberg, Wenrich, and Curtis. Administrative, technical, and material support : Young and McCown.

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All Rights Reserved. Table 1. View Large Download. Characteristics of Physicians and Nurses a. Characteristics of Patients and Family Caregivers a. The physician's responsibility toward hopelessly ill patients: a second look. Family perspectives on end-of-life care at the last place of care. An approach to understanding the interaction of hope and desire for explicit prognostic information among individuals with severe chronic obstructive pulmonary disease or advanced cancer. Transitions regarding palliative and end-of-life care in severe chronic obstructive pulmonary disease or advanced cancer: themes identified by patients, families, and clinicians.

Somerset, NJ Aldine Transaction;. Accessed January 14, Google Scholar Crossref. Save Preferences. Privacy Policy Terms of Use. This Issue. Citations View Metrics.

Bulgaria's Abandoned Children (Amazing People Documentary) - Real Stories

Original Investigation. Anthony L. Back, MD ; Jessica P. Engelberg, PhD ; Elizabeth K.

Vig, MD ; Lynn F. Reinke, PhD ; Marjorie D. McGrath, PhD ; J. Participant recruitment. Data collection. Qualitative analyses. Questions Used to Investigate Nonabandonment a Patients and Family Caregivers What do you need from [physician] now that there aren't any treatments available?

Physicians What strategies do you use in transitioning patients from active treatment? Before death, abandonment worries related to loss of continuity. Patients and Caregivers. Physicians and Nurses. At the time of death or after, feelings of abandonment resulted from lack of closure for patients and families.

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Caring for Children with Complex Needs in the Community

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Parenting Matters: Supporting Parents of Children Ages 0-8.

Page Updated: Tuesday 4 September Contact page owner: Maternity, Child and Family. Referrals to West Wyalong. Please contact the central referral number. Bemboka Primary School, referrals to Bega Valley. All new to area clients need to register with Central Intake Service on prior to attending a clinic. Phone: 02 Mon — Fri to make appointments. For appointments please call the central intake line. Contact Inverell CHC. Bungendore Community Centre, referrals to Queanbeyan.