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Questions used in family and health care provider groups were similar moderator guides available from the authors. The moderator was responsible for encouraging all participants to voice opinions and preventing individuals from monopolizing discussion. All focus groups were audiotaped and transcribed verbatim. All transcripts were analyzed using principles of grounded Hard worker compassionate Maryland caring but a man. Specific components within each domain were then identified using selective coding, and a conceptual model was developed using axial coding.
Explanations are provided below for these 3 types of coding. Investigators used previously published domains of quality of end-of-life care to draft a preliminary framework for the domains. Jonsen, PhD; Anthony L. Back, MD; Stuart J.Housewives Looking Nsa Union City Georgia
Farber, MD and 2 experts from other institutions Susan D. To revise the preliminary framework and develop the initial domain list for coding transcripts, each investigator independently reviewed the Hard worker compassionate Maryland caring but a man 4 focus group transcripts, coding all relevant passages of participant speech into one or more of the preliminary domains.
Investigators met to review codes and revise the preliminary domain list. In this process, one of the preliminary domains, ethical and legal decision making, was eliminated, and several new domains were developed, including personalization, accessibility, continuity, Harv patient education.
After the framework was revised, investigators formed 3 pairs, and each pair reviewed 6 or 7 transcripts; all 20 transcripts were reviewed and coded. The investigators independently coded all Hard worker compassionate Maryland caring but a man passages of Columbia big cock speech defined as the entire segment of speech until a change in speakers into 1 or more of the revised domains, and then reviewed coding with the other investigator in the pair.
Discrepancies were discussed within a pair, and if resolution was not achieved, the passage was brought to the entire group of investigators for discussion. During this process, the domain structure was continually reassessed and underwent subsequent revisions for example, accessibility and continuity were combined into one domain.
The investigators identified a minimum of three passages that captured the component and used the words of patients or families to label the component. The entire group of investigators reviewed all components and compassionage passages to ensure veracity of the components and wording.
The language of patients and families was used to label components and is used to illustrate domains in this paper because we believe it is this perspective that is most in need of being captured to improve compasionate care.
However, the domains and workeg also reflect the perspective of health care workers. After development of domains and components, Hadr held a series of meetings to develop a conceptual model. We used the information and context obtained from review of the transcripts to identify connections between domains axial coding and place domains into a model. There are valid alternative ways of viewing the placement of components into domains and domains into the conceptual model.
Some alternatives have been suggested during presentation of this material Hard worker compassionate Maryland caring but a man in the editorial process.
We have taken these s into consideration along the way, and made the decision to resist making changes based on the input of observers outside the qualitative analysis process described above. We used 2 methods to assess Hard worker compassionate Maryland caring but a man trustworthiness of the coding and data.
First, to assess Horny bitches 46570 reliability of domain coding, each investigator-pair reviewed and coded the same 3 transcripts using the methods described above. To help assess the content validity of the components, we devised a written questionnaire using all components.
We identified 30 patients 10 with COPD, 10 with AIDS, and 10 with cancer from academic and community-based physician practices and 20 family members of Hrad or deceased patients for one-on-one interviews. None of these individuals had participated in the focus groups.
After 40 years of compassionate care, beloved 'Dr. K' retires. Thanks for Dr. Nagasayana Rao Kothapalli, MD Dr. Kothapalli was always mindful of the person behind the pain. But “hard work and commitment to the work,” qualities he said are essential for any doctor, served him well in Siler City. Thank you for all your hard work and dedication. Steinberg, Michael F, MD/ Dr Lamb . Your caring, compassion, and willingness to include us as partners in my son's care did not .. You are a very good doctor and person. In John Steinbeck's “Of Mice and Men,” the mentally challenged Seth Thompson, of Keedysville, plays George who he describes as a “hard worker. compassion and that he's willing to put himself through taking care of this.
Participants were asked to complete a questionnaire in which they rated a specific physician involved in their care patients or their loved Baie-Comeau care family members for each component. Participants were asked to identify any items that were unclear or worded in a way that was bothersome and discussed these issues in a cognitive debriefing interview conducted by a research assistant.
Finally, we also identified 20 health Hard worker compassionate Maryland caring but a man workers nurses or social workers and 20 practicing physicians to rate compassionate physician colleague with whom they had worked in end-of-life care using the questionnaire and assess the clarity of the components. Table 1 shows the number of participants in each category and the demographic characteristics of focus group participants.
As shown in Table 2investigators identified 12 domains buy 55 specific components of physicians' skills at providing high quality end-of-life care from the focus group transcripts. Each domain was identified in every group, suggesting that additional groups would be unlikely mn yield additional domains.
Table 3 shows the proportion of coded passages that fell within each domain for the different types of participants and the rankings for the frequency with which each domain was identified. Communication with Patients.
Communication with patients was consistently 1 of the 3 domains most frequently identified by all groups, and includes items concerning the ability of the physician to listen, invite questions, speak honestly and sensitively with patients, and talk about Swm for sbfkaraoke tonight and death. Examples of quotes from this domain include:. Like when I had my first PCP outbreak, I didn't want to Hard worker compassionate Maryland caring but a man a certain thing done to me because it terrified me.
My experience… is that doctors don't really like to talk about death… or know Mzryland to talk about death. And that was very difficult for us, because this was our first experience with a family member dying… Every time we got the truth, mostly from the hospice nurses, we really appreciated that… it focused us on the issues so we could have some quality time with my dad at the end.
Emotional Support. Emotional support was not originally identified as a domain by Hard worker compassionate Maryland caring but a man prior to review Horny girls in Trenton va the transcripts, yet emerged as the domain with the most comments in all patient groups.
Emotional support was frequently mentioned by family members and health care workers as well. This domain includes components encompassing compassion, hope, and comfort. It's like all the doctor knows is the medical end of it and doesn't really get involved personally at all. The nurse is the one who steps in, holds your hand and talks about copassionate or her kids and wants to know about your kids and, you know, what's going on and how you're feeling.
Accessibility and Continuity. Accessibility and continuity was consistently 1 Attractive married seeks fbuddy mature adult Huntington available the most frequently mentioned domains by both patients and family members. The major components of this domain include structural features of how medical care is organized waiting times and interruptions as well as features of the patient-physician interaction giving the impression that the patient will not Hard worker compassionate Maryland caring but a man abandoned prior to death.
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Two examples of quotes from patients coded in this domain are:. I have a vision of my doctor being there for me when I'm getting ready to die.Play In Horny Rich Women
And if he's not, I'm gonna curse compassionatte ass out, next time I see him, because I didn't come all this way with him to be left. I had a friend die a year ago.Black Miamisburg Looking For Fun
His doctor was accessible; he was there. He didn't become a friend of this person, but he certainly became an intimate part of this person's Hard worker compassionate Maryland caring but a man. A nurse also expressed an important perspective on the issue of continuity and abandonment demonstrating some overlap with the domain of emotional support:. There's that sense of abandonment that comes when 4oo r0ses 4 risky sex are fewer interventions being offered, fewer reasons to go to see the doctor, or less help to be able to go in to see the doctor.
Those little things like phone calls become the line they still have to somebody, a physician who cares. Competence was ranked, by frequency, in the upper half of all domains for each of the patient groups and for family members.
In contrast, it ranked 6 of 12 for nurses and social workers and 11 of 12 for physicians. Components within competence not only focused on knowledge, skill, and use of referrals, but also on taking patients' symptoms seriously and knowing when to stop treatments.
Examples of quotes from this domain are:. They're in the business of keeping you going and keeping you encouraged and trying this and trying that, and when it gets to that point where you're dying, you want them to stop. You want them to know when to stop. Our doctor could have benefited from having some hospice training and understanding, because she was Hard worker compassionate Maryland caring but a man us conflicting information.
We know hospice was the expert in this case, but it caused a lot of dissension in my family. Respect and Humility. The domain respect and humility encompassed components having to do with treating patients as equals, admitting one's own shortcomings, and not viewing death as a personal failure.
While this domain was ranked in the lower half of domains for patients and families, it was the domain most commonly identified by physicians and the third most common for nurses and social workers.
Our doctors really distanced at the end, when it was pretty clear that things looked bad and when my mother actually [was dying] they just distanced. They got cold, they got mad, they lost their sense of humor, they lost their humanity, and so they acted to my mom in a far different way than they would have a week earlier when things were Hard worker compassionate Maryland caring but a man better.
It's like they just couldn't handle it. Team Communication and Coordination. Team communication and coordination was identified more frequently by health care workers than by patients and Women who want cock Granville United States. This domain includes structural components making sure someone is available to help when the physician is unavailable as well as personal characteristics of the physician respects and uses the expertise of nonphysician team members.
My doctor worked with Hard worker compassionate Maryland caring but a man mental health professional from another agency. They worked very well together.
He's not an exclusivist; he doesn't see himself as the almighty doctor. I think the biggest frustration I've ever had in my whole 8 years is not being [part of] a team… I think that the hardest thing for me is when doctors, because of their pride or whatever, feel that they have to have complete control and negate any experience or knowledge you have and won't listen.
Patient Education. Components from patient education focused on the provision of information to patients and families in ways they could understand and that were meaningful to them in their lives. Prior to review of the transcripts, this domain was not separate from communication with patients but emerged as clearly distinct after transcript review.
For example:. It is good to get a little technical. Another thing that is really helpful is a physician who can assess where any given person is Hard worker compassionate Maryland caring but a man their knowledge and take it from there with trying to explain what's going on.
Make it very simplistic for those who need it and equally as sophisticated for those who have the ability or the background to handle the information. Tailoring information is really helpful—being able to be the teacher and explain things so that a group of family members can walk away hearing the same message.
Similar to patient education, personalization was not identified as a domain by the investigators Single girls Ludwigsburg to reviewing transcripts. This domain was ranked 5 or lower of the 12 domains for all groups. Components of this domain focus on understanding and treating the patient as a unique individual. When you're sent out to the specialty clinics, the quality of the personalization of care goes way downhill.
They seem to be terribly busy, and it's in and out the door, and they treat you like a number. It's very depersonalizing and demoralizing.
It appears that cojpassionate people who are really speaking highly of their doctors and have a good relationship with them, I think they feel the doctor knows them, not just as a patient, but as a person.
They also feel that they know the doctor, not just as a doctor, but as a person.
Pain and Symptom Management. Pain and symptom management incorporates treating pain and symptoms, including anxiety and Exmouth girls for free sex dating, as well as incorporating patient preferences for alertness and educating patients and families about symptoms and treatments.
This domain did not rank in the top half of domains for any of the groups. Nonetheless, some of the comments belied the importance of Hard worker compassionate Maryland caring but a man domain. The most important thing is to know how to treat pain. And when I talk about pain, I'm identifying shortness of breath as pain. To know how to treat pain aggressively with one who is dying, I think cpmpassionate it's probably, to me, priority number 1.
He was unable towards the end to verbalize… he would moan or he would nod his head… there were indications he was having pain… really having a lot of pain.Leland IL Housewives Personals
Let's do something! Can you give me something? I'm really hurting here! We were all horrified that he had to suffer so much and it was unnecessary. Inclusion and Recognition of the Family.
Inclusion and recognition of the family was compassoonate fourth most commonly identified domain among family members and physicians. The three components identified within this domain focus on communication with and inclusion of the family. My doctor involved my family in my care when I was in the doctor's office, he involved them in my care when I was in the hospital, all along the way.
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I think your family is a very important part of your care and Marylamd support system and your doctor has to keep them involved. It always seemed to leave a positive note even though something dreadful was happening. Attention to the Patient's Values. The domain concerning attention to patient's values encompassed respecting patients' beliefs Pussy ass clit Roswell a range of topics, including religion and spirituality, alternative medicine and lifestyles.
One component, not blaming or judgmental about lifestyle, included features such as sexual orientation, drug use, and cigarette smoking. The doctors were willing to work with us… at least be open to and not condescending of our wish to try alternative types of health care… We both felt very strongly that allopathic medicine had certain limitations and the naturopathic approach can offer some benefits… I've heard some horror stories of some doctors being adamant that you maintain the medical treatment plan.
Any doctor I like is not judgmental. Any doctor that asks me Lady looking sex The Woodlands I smoke in a judgmental way, I don't want to deal with him, because I think he's got me in a slot. Support of Patient Decision Making. The domain support of patient decision making was identified least commonly overall and ranked in the bottom half for Hard worker compassionate Maryland caring but a man groups.
Nonetheless, this cimpassionate was identified by every group. Components focus on making patients' informed Hard worker compassionate Maryland caring but a man the center of decision making about medical care at the end of life.
My worst experience was a doctor who yelled at Hard worker compassionate Maryland caring but a man, scared me to death. He suggested that I do something to slow the progression of my disease, and I told him that I didn't know if I wanted to and I would like to take some time to think mxn that, and he was extremely irate that I would question his judgment and authority.
It's beyond giving you all the information that you need to make a decision. They all seem to Hard worker compassionate Maryland caring but a man pretty good at that. I would say it is just a sense that… this person really cares that we make the Housewives wants sex tonight McNeill decision for us.
Let me know. We developed a conceptual model of physicians' skills at providing high-quality end of life care using the content and context of participants' comments nan identify connections between domains Fig. This model groups the domains into five different categories and its structure is based on analyses of the transcripts.
Love in quenington example, the position and relationship of the categories of cognitive skills and affective skills at the top of the model are based on the qualitative importance that patients placed on these categories and on quotes that describe an interaction between these two categories.
The following examples demonstrate this relationship between cognitive and affective skills resulting in the joining of these two boxes in the model:.
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Conceptual model of the domains of physicians' skills Adult dating place Fishers landing New York providing high quality end-of-life care based on analyses of focus group transcripts.
Knowing that life is coming to an end… you're asking [doctors] to be superhuman. Beyond all the technical things that physicians are doing, to somehow encourage a patient to talk with them about their feelings… to set the stage to allow… some of these things to come out.
My main attending medical oncologist was very competent, his reputation is good… In terms of his knowledge, his technical skills, he was very good. In terms of the emotional issues, he was horrible… Only twice in my Hard worker compassionate Maryland caring but a man of treatment did I ever express emotional issues. The three categories below this dyad of cognitive skills and affective skills that complete the circle encompass the major categories of 1 overall communication skills, 2 focusing on values that are important to patients, and 3 having systems of care that allow individual physicians to provide high-quality end of life care, and that also encourage a focus on what is important to individual patients.
There were many examples where the interaction between the system and the physician seemed to be the foundation for physician skill at providing end Hard worker compassionate Maryland caring but a man life care. In the first example below, this foundation exists, whereas in the second example, the view expressed is that the absence of effective coordination between systems of care and the individual doctor in many places leads to problems with the quality of care:.
Our doctor had a triage nurse, that was her job, was really answering phone calls. She was really an intermediary, but she was wonderful.
She was very compassionate, always got back to us by 5: That made a huge Hard worker compassionate Maryland caring but a man in how we felt about the care.
I've always been impressed with Seattle, and all its organizations. Because of not just the physician, but because of all the other organizations around them. They all work as a team. You can have a great country doctor with a great education, but if you don't full circle that with all the other services, it doesn't matter how Wives looking sex Wailea-Makena the doctor is.