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Advance directives are intended to extend patient autonomy by enabling patients to prospectively direct the care of their future incapacitated selves. There has been much discussion about issues such as whether the future incompetent self is identical to the agent who issues the advance directive or whether advance directives can legitimately secure patient autonomy. However, there is another important question to ask: to what extent and in what conditions is it ethically appropriate for one to limit the liberty or agency of one's future incompetent self by issuing an advance directive? In this paper, I use a virtue‐ethical approach to explore this question, focusing on the case of an advance directive for the future self with moderate dementia. First, I examine virtuous attitudes with regard to autonomy and argue that one can manifest vices or ethically undesirable character traits in trying to intervene in the future self's life. In particular, I argue that this case can manifest vices such as disdainfulness, intellectual arrogance, and self‐dictatorship, which is the vice of trying to control one's life to an excessive degree, and that a self‐dictator fails to give due moral consideration to the future self's liberty or agency. I then introduce the Daoist idea of wu‐wei, which recommends embracement of what happens in one's life, as one of the possible remedies for the overemphasis on the value of autonomy and control. [ABSTRACT FROM AUTHOR]

Despite significant efforts to improve access to medications for opioid use disorder (MOUD), uptake remains low relative to the scope of the problem in the United States. A growing body of quantitative and qualitative research has documented consistent barriers to MOUD treatment access and retention, at the level of individuals, institutions, and society at large. Stigma - surrounding both people who use opioids (PWUO) and treatment using MOUD – is among the most-cited barriers by patients and providers alike, yet few studies have examined provider-based stigma specifically, or considered its interaction with other impediments to OUD care. This paper employs a qualitative approach to the analysis of provider-based stigma among professionals involved in the treatment or supervision of individuals with OUD. We conducted and analyzed interviews with 19 professionals as part of a larger mixed methods study on stigma among substance use treatment providers and court personnel in Pennsylvania. Beyond capturing providers' perceptions of PWUO and MOUD, the authors asked participants to describe barriers to recovery, and the effective delivery of care within this population. Interviewees enumerated multiple entrenched barriers that sometimes operated at different levels, such as criminal-legal involvement, which weakened PWUO's social networks and employment prospects, while undermining providers' attempts at continuity of care; moreover, participants cited the "War on Drugs" as an overarching impediment to effective substance use treatment, not least for its role in perpetuating stigma against PWUO. Interestingly, while an overwhelming majority of participants named stigma as a barrier to treatment at every level, most also articulated stigmatizing beliefs around PWUO. Namely, providers evoked one element of stigma – blameworthiness – in their contention that many PWUO are inadequately motivated to recover. In addition to adding further complexity to MOUD barriers research, this study troubles the notion that professional training and education on the disease model of addiction serve to eradicate stigma. • Uptake of medications for opioid use disorder remains low despite efforts to expand access. • Individual, institutional, and systemic barriers to MOUD interact to reduce usage. • Treatment providers identify stigma as a primary barrier to MOUD effectiveness at all levels. • Many treatment providers also express conceptions of people who use opioids as "blameworthy." [ABSTRACT FROM AUTHOR]

This short article provides a legal analysis of the Hale et al. white paper on specific learning disabilities identification. The white paper presents a purported consensus of experts that an approach combining response to intervention with severe discrepancy is consistent with the Individuals With Disabilities Education Act (IDEA). The analysis examines the white paper position in relation to the IDEA legislation, regulations, and agency policy interpretations. The conclusions are that this position is legally flawed in terms of its reliance on the “pattern of strengths and weaknesses” provision, its failure to consider state special education laws, and its overemphasis on the processing component. As a result, the position is justifiable only as advocating revisions, rather than in finding support, in the law. [ABSTRACT FROM PUBLISHER]

Purpose/Objectives: To explore positive and negative aspects of the experiences of informal caregivers of patients with cancer and patients with other chronic medical conditions, to compare the reactions of caregivers of patients with cancer and patients with other chronic medical conditions, and to study the association of caregiver reactions with demographic factors. Design: Descriptive, correlational. Setting: A comprehensive cancer center and a community hospital, both in Philadelphia, PA. Sample: 111 informal caregivers. Methods: A survey that could be completed either in paper format or electronically was administered. Main Research Variables: Self-esteem, impact on schedule, impact on finances, impact on health, lack of family support, positive aspects of caregiving. Findings: For caregivers, offering emotional and psychological support was most challenging, whereas providing transportation was least challenging. Caregivers reported high selfesteem and moderately positive aspects of caregiving. Caregivers of patients with cancer identified more positive aspects of caregiving. Differences in the caregiving experience based on demographic factors (e.g., gender, race, ethnicity) were found. Conclusions: Caregivers reported positive and negative aspects of caregiving. Reactions of informal caregivers to the caregiving experience vary more based on individual demographic factors than on the diagnosis of the patient. Differences exist in the caregiving experience based on race and ethnicity. Implications for Nursing: Nurses need to be aware that positive and negative reactions to the caregiving experience exist. Assessment and care planning should include consideration for individual factors, such as gender, race, and ethnicity. [ABSTRACT FROM AUTHOR]

Context There exists a disparity between the views of physicians and the views of their patients on end-of-life decisions. However, the timing of when the end-of-life preferences of physicians and non-medically-trained individuals diverge is currently unknown. The objective of this paper is to characterise how preferences for medical interventions change throughout medical education and residency or fellowship training when confronted with scenarios of critical or terminal illness. Methods This is a single-centre cross-sectional study that enrolled medical students at Sidney Kimmel Medical College and residents and fellows at Thomas Jefferson University Hospital. Through an online survey we determined the preferences of medical trainees for specific interventions throughout medical training when presented with different clinical scenarios. Interventions were organised into three categories: standard, intermediate and aggressive. We analysed responses to questions regarding different scenarios in separate repeated measures logistic regression models. The probability of declining medical interventions was modelled, and significant predictors of refusal of interventions were identified. Results Years of training was a significant predictor of declining interventions for several scenarios. When faced with permanent physical disability, increased years of training led to a higher rate of refusal of intermediate ( OR = 1.14 [1.02-1.28], p = 0.02) and aggressive interventions ( OR = 1.15 [1.03-1.28], p = 0.01). For the scenario of terminal illness with associated physical disability, years of training significantly influenced refusal of intermediate ( OR = 1.14 [1.04-1.26], p = 0.006) and aggressive ( OR = 1.20 [1.08-1.34], p = 0.001) interventions. For the scenario of permanent cognitive impairment, increased years of training led to a higher rate of refusal of standard ( OR = 1.14 [1.01-1.29], p = 0.03), intermediate ( OR = 1.30 [1.13-1.50], p < 0.001) and aggressive ( OR = 1.38 [1.14-1.66], p = 0.001) interventions. Conclusion Changes in end-of-life preferences occur throughout medical training. Years of training influenced the likelihood of declining medical interventions when faced with scenarios of terminal illness and physical or cognitive disability. [ABSTRACT FROM AUTHOR]

As interest in comparative effectiveness research grows, questions have emerged regarding whether it is ever acceptable to alter informed consent requirements for research when patients are randomly assigned to widely-used therapies. This paper reports on interviews with Institutional Review Board members and researchers and on focus groups with patients from Geisinger and Johns Hopkins health systems. The objective was to elicit participants' views of the acceptability of four different disclosure and authorization models for low-risk pragmatic comparative effectiveness trials of widely-used therapies. Results suggest that although participants valued autonomous choice, many also believed that it was acceptable to streamline information disclosure and to use an opt-out process for eligible individuals who would prefer not to participate. This provides some preliminary evidence that relevant stakeholders find alternatives to traditional informed consent acceptable for low-risk pragmatic comparative effectiveness trials of widely-used therapies as long as a sufficient amount of choice is preserved. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate the views of special education directors toward communitybased vocational instruction (CBVI). Participants included a non-proportional random sample of 47 directors from one state who completed an online or paper-based survey. Independent variables were directors' years of experience, geographic location, whether the district provided CBVI in the summer, and the curriculum of students who participated in CBVI. Data were analyzed using descriptive and inferential statistics along with a content analysis of open-ended questions. Results indicate that respondents support the use of CBVI and experience few barriers to implementation. Insufficient staff and inadequate public transportation were the highest rated barriers. Views regarding the intensity with which CBVI should be provided and the age and types of students who should receive CBVI differed from practices recommended in the field. Significant group findings were evident for the variables of years of experience and curriculum of students who participated in CBVI. [ABSTRACT FROM AUTHOR]

State officials responsible for the regulation of hydraulic fracturing (fracking) operations used in the production of oil and gas resources will inevitably confront a key policy issue; that is, to what extent can statewide regulations be developed without reducing land use autonomy typically exercised by local officials? Most state regulators have historically recognized the economic importance of industry jobs and favor the adoption of uniform regulatory requirements even if these rules preempt local policymaking authority. Conversely, many local officials seek to preserve land use autonomy to provide a greater measure of protection for public health and environmental quality goals. This paper examines how public officials in three states--Colorado, Pennsylvania, and Texas--address the question of state control versus local autonomy through their efforts to shape fracking policy decisions. While local officials within Texas have succeeded in developing fracking ordinances with relatively little interference from state regulators, Colorado and Pennsylvania have adopted a tougher policy stance favoring the retention of preemptive oil and gas statutes. Key factors that account for between state differences in fracking policy decisions include the strength of home rule provisions, gubernatorial involvement, and the degree of local experience with industrial economic activities. [ABSTRACT FROM AUTHOR]

This study reports a comparison of demographics, outdoor recreation activity patterns, and attitudes toward conservation issues collected via mail and online survey methods within a mixed-mode survey. Pennsylvania residents, randomly sampled by Survey Sampling, Inc., were invited in a pre-survey letter to complete the survey online, or through a paper survey mailed to their homes. Differences in outdoor recreation participation were generally small for wildlife-related activities, and were greater among non-wildlife-related outdoor recreation activities, with the Internet respondents generally reporting higher rates of participation. Analyses controlling for demographic variables showed a confounding influence on the relationships examined. Internet respondents tended to be younger, better educated, and more affluent. Conservation- related attitudes did not differ between the mail and online survey respondents and were more weakly related to demographic factors. Results suggest that online surveys can yield valid results when using appropriate sampling designs and implementing quality control procedures. [ABSTRACT FROM AUTHOR]