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Céline Gélinas,1,2 Shiva Shahiri T,1,2 Melissa Richard-Lalonde,1,2 Denny Laporta,3,4 Jean-François Morin,5,6 Madalina Boitor,7 Catherine E Ferland,8,9 Patricia Bourgault,10 Philippe Richebé11 1Ingram School of Nursing, McGill University, Montreal, QC, Canada; 2Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital – CIUSSS West-Central Montreal, Montreal, QC, Canada; 3Faculty of Medicine, Respiratory Division, McGill University, Montreal, QC, Canada; 4Department of Medicine, Division of Adult Critical Care, Jewish General Hospital – CIUSSS West-Central Montreal, Montreal, QC, Canada; 5Faculty of Medicine, Department of Surgery, Division of Cardiac Surgery, McGill University, Montreal, QC, Canada; 6Department of Surgery, Cardiac Surgery, Jewish General Hospital – CIUSSS West-Central Montreal, Montreal, QC, Canada; 7Faculty of Dentistry, McGill University, Montreal, QC, Canada; 8Faculty of Medicine, Department of Anesthesia, McGill University, Montreal, QC, Canada; 9Shriners Hospitals for Children – Canada, Montreal, QC, Canada; 10Faculty of Medicine and Health Sciences, School of Nursing, Université de Sherbrooke, Sherbrooke, QC, Canada; 11Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital – CIUSSS de l’Est-de-l’Île-de-Montréal – Université de Montréal, Montreal, QC, CanadaCorrespondence: Céline GélinasIngram School of Nursing – McGill University, 680, Sherbrooke West, Suite 1800, Montreal, QC, H3A 2M7, CanadaTel +1 514 398 6157Fax +1 514 398 8455Email celine.gelinas@mcgill.caIntroduction: The aim of this study was to explore the use of a multi-parameter technology, the Nociception Level (NOL) index (Medasense Biometrics Ltd, Ramat Gan, Israel), for pain assessment in postoperative awake patients after cardiac surgery during non-nociceptive and nociceptive procedures in the intensive care unit (ICU).Materials and Methods: A prospective cohort repeated-measures design was used. Patients were included if they were in the ICU after undergoing cardiac surgery and if they could self-report their pain. A non-invasive probe was placed on the patient’s finger for the continuous monitoring of the NOL index. Patients’ self-reports of pain and anxiety (0– 10 Numeric Rating Scale or NRS), and behavioral scores with the Critical-Care Pain Observation Tool (CPOT) were obtained before and during a non-nociceptive procedure (ie, non-invasive blood pressure [NIBP] using cuff inflation), and before, during and after a nociceptive procedure (ie, chest tube removal [CTR]) for a total of five time points. Non-parametric tests were used to compare scores at different time points, and receiver operating characteristic curve analysis was performed.Results: Fifty-four patients were included in the analysis. The NOL index, pain and anxiety scores were significantly higher during CTR compared to rest and NIBP (p < 0.001). During CTR, the NOL was associated with self-reported pain intensity and unpleasantness but not with anxiety and CPOT scores. The NOL showed a modest performance in detecting pain (NRS ≥ 1 and ≥ 5) in this sample with sensitivity and specificity ranging from 61% to 85%.Conclusion: The NOL index was able to discriminate between a non-nociceptive and a nociceptive procedure and was associated with self-reported pain. Further validation testing of the NOL is necessary in a heterogeneous sample of ICU patients.Keywords: nociception, pain, pain assessment, adult, cardiac surgery, intensive care unit

Background Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients. Methods A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15). Results Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69. Conclusions The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice.

BACKGROUND Many patients experience pain in the intensive care unit (ICU) despite receiving pain medication. Research has shown that music can help reduce pain. Music interventions studied so far have not used music streaming to generate playlists based on patient preferences while incorporating recommended tempo and duration. Previous research has focused on postoperative ICU patients able to self-report, which is underrepresentative of the ICU population that might benefit from a music intervention for pain management. We developed a new patient-oriented music intervention (POMI) that incorporates features based on theoretical, empirical, and experiential data intended to be used in the ICU. Such a music intervention should consider the expertise of ICU patients, family members, and nursing staff, as well as the practicality of the intervention when used in practice. OBJECTIVE The primary objectives of this study are to (1) evaluate the acceptability and feasibility of the POMI to reduce pain in ICU patients and (2) evaluate the feasibility of conducting a crossover pilot randomized controlled trial (RCT) for intervention testing in the ICU. A secondary objective is to examine the preliminary efficacy of the POMI to reduce pain in ICU patients. METHODS A single-blind 2×2 crossover pilot RCT will be conducted. Patients will undergo 1 sequence of 2 interventions: the POMI which delivers music based on patients’ preferences via headphones or music pillow for 20-30 minutes and the control intervention (headphones or pillow without music). The sequence of the interventions will be inverted with a 4-hour washout period. Timing of the interventions will be before a planned bed turning procedure. Each patient will undergo 1 session of music. Twenty-four patients will be recruited. Patients able to self-report (n=12), family members of patients unable to self-report (n=12), and nursing staff (n=12) involved in the bed turning procedure will be invited to complete a short questionnaire on the POMI acceptability. Data will be collected on the feasibility of the intervention delivery (ie, time spent creating a playlist, any issue related to headphones/pillow or music delivery, environmental noises, and intervention interruptions) and research methods (ie, number of patients screened, recruited, randomized, and included in the analysis). Pain scores will be obtained before and after intervention delivery. RESULTS Recruitment and data collection began in March 2022. As of July 5, 2022, in total, 22 patients, 12 family members, and 11 nurses were recruited. CONCLUSIONS Methodological limitations and strengths are discussed. Study limitations include the lack of blinding for patients able to self-report. Strengths include collecting data from various sources, getting a comprehensive evaluation of the intervention, and using a crossover pilot RCT design, where participants act as their own control, thus reducing confounding factors. CLINICALTRIAL ClinicalTrials.gov NCT05320224; https://clinicaltrials.gov/ct2/show/NCT05320224 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/40760

Introduction: The Critical-Care Pain Observation Tool-Neuro (CPOT-Neuro) was derived from the original CPOT to assess pain in brain-injured patients in the adult intensive care unit (ICU). Objective: This study aimed to describe the nurses’ evaluations of the feasibility and clinical utility of the use of the French and English versions of the CPOT-Neuro in critically ill brain-injured adults. Methods: Fifty-nine ICU nurses from two university affiliated trauma centres (Montreal, Canada) were trained to use the CPOT-Neuro. Those who used it at the bedside during the study were invited to complete a self-administered questionnaire about its feasibility and clinical utility. Results: Twenty-seven of the trained ICU nurses (46 %) used the CPOT-Neuro during the study and completed the questionnaire. Feasibility: All nurses agreed that the training duration was sufficient, that the directives of use were clear, and that the tool content was simple to understand. Some nurses disagreed that the tool was quick to use (11.1 %), and easy to complete (7.7 %). Clinical utility: The tool was found useful by most nurses, but some of them disagreed that it was helpful for practice (7.7 %), that it influenced their practice (15.4 %) and that they would recommend it routinely (11.1 %). Responses did not differ between nurses from the two trauma centres who used either the French or the English version of the CPOT-Neuro (Mann-Whitney U tests, p>.05). Discussion and conclusion: The CPOT-Neuro was found to be feasible and useful by ICU nurses. Its implementation into daily practice could optimize pain assessment in critically ill brain-injured patients., Introduction : Le Critical-Care Pain Observation Tool-Neuro (CPOT-Neuro) a été élaboré à partir du CPOT original pour évaluer la douleur chez des patients adultes cérébrolésés à l’unité de soins intensifs. Objectif : Cette étude visait à décrire les évaluations des infirmières sur la faisabilité et l’utilité clinique de l’utilisation du CPOT-Neuro pour évaluer la douleur chez les adultes cérébrolésés à l’unité de soins intensifs. Méthodes : Cinquante-neuf infirmières de deux centres universitaires de traumatologie (Montréal, Canada) ont été formées à l’utilisation du CPOT-Neuro. Les infirmières ayant utilisé l’outil lors de l’étude ont été invitées à compléter un questionnaire auto-administré sur sa faisabilité et son utilité clinique. Résultats : Vingt-sept infirmières (46 %) formées ont utilisé le CPOT-Neuro durant l’étude et complété le questionnaire. Faisabilité : Toutes les infirmières ont jugé la durée de la formation suffisante, les directives d’utilisation claires et le contenu de l’outil simple à comprendre. Toutefois certaines d’entre elles n’étaient pas d’accord que l’outil soit rapide à utiliser (11,1 %) et facile à compléter (7,7 %). Utilité clinique : La majorité des infirmières ont trouvé l’outil utile, mais certaines n’étaient pas d’accord quant à son utilité pour la pratique (7,7 %), que l’outil avait influencé leur pratique et qu’elles en recommanderaient l’utilisation systématique (11,1 %). Les réponses ne différaient pas entre les infirmières des deux centres de traumatologie utilisant la version française ou anglaise du CPOT-Neuro (tests U de Mann-Whitney, p>,05). Discussion et conclusion : La faisabilité et l’utilité clinique du CPOT-Neuro ont été évaluées positivement par les infirmières. Son implantation dans la pratique clinique pourrait optimiser l’évaluation de la douleur des patient cérébrolésés à l’unité de soins intensifs.

Background Current guidelines support family members' participation in care, but little is known regarding their potential contribution to pain assessment using validated behavioral pain scales. Aims This study aimed to describe family members’ observations of pain behaviors with the Critical-Care Pain Observation Tool and their evaluation of the tool and its use, and to understand their experience and perceptions of their potential role in pain management in the intensive care unit. Design A mixed methods cross-sectional explanatory design was used. Setting A medical-surgical intensive care unit in Canada. Participants/Subjects Family members were eligible if they had a loved one admitted in the intensive care unit who was unable to self-report. Methods Family members identified pain behaviors using the Critical-Care Pain Observation Tool after a brief training, completed a self-administered questionnaire, and participated in a follow-up individual interview regarding their experience and perceived potential role in pain management when their loved one is unable to self-report. Results Ten family members participated. A 15-minute training appeared sufficient for family members to be comfortable with observing pain behaviors included in the Critical-Care Pain Observation Tool. The tool allowed them to confirm their observations of pain behaviors, to focus more on the patient, and to advocate for better pain management. Conclusions Future research is needed to explore the views of more family members and to compare their Critical-Care Pain Observation Tool scores to the ones of nurses' for interrater reliability testing.

Maintaining optimum analgesia in anesthetized patients is challenging due to the inability to self-report pain or exhibit pain-related behaviours. The Analgesia Nociception Index (ANI) (based on heart rate variability [HRV]) and the Nociception Level Index (NOL) (based on HRV, photoplethysmography, skin conductance, and temperature) both include HRV and provide continuous index monitoring for nociception assessment. The research question was: "What are the validation strategies of the NOL and ANI for nociception assessment in anesthetized patients?". The objectives were to describe and analyze the validation strategies and results. A systematized review was conducted using a comprehensive search with keywords under three concepts (nociception/pain, ANI/NOL, and validity) in four databases. A quality assessment using an adapted GRADE approach for measurement tools, and a risk of bias assessment using QUADAS-2 tool were performed by two reviewers. Out of 525 results, 15 validation studies were included. Strategies included hypothesis testing, discriminative, and criterion validation. Significant changes in ANI/NOL values were found in response to nociceptive stimuli at different opioid concentrations (hypothesis testing). Higher ANI/NOL values were observed during nociceptive stimuli (discriminative). AUCs ranging from 0.83 to 0.99 were obtained to detect nociceptive stimuli (criterion). Both technologies performed superiorly in detecting nociceptive stimuli compared to individual monitoring of HR and blood pressure. Although the aforementioned validation strategies are deemed appropriate, in the absence of a gold standard, criterion validation findings should be interpreted with caution. Moreover, reliability could be examined using test-retest with consistent ANI/NOL values during a stable time-interval.

Additional file 1. Supplemental Material: French-Canadian and English versions of the CPOT-Neuro and Directives of Use

This review describes family member involvement in intensive care unit pain assessment and management and generates implications for clinical practice, education, and future research. A literature review was performed in MEDLINE, PubMed, EMBASE, Cochrane, and CINAHL databases from their inception until April 30, 2019. Only 11 studies addressing the topic were identified, and the current quality of evidence is low. Family members can be involved in pain assessment by describing patients’ pain behaviors and in pain management by selecting and delivering nonpharmacological interventions tailored to patients’ needs, if the family members feel comfortable with this role. More-rigorous research is required to describe the role of family members in patients’ pain assessment and management. Advancing knowledge in this field could improve patients’ and family members’ experiences with pain assessment and management in the intensive care unit.

Context Multimodal analgesic approaches are recommended for intensive care unit (ICU) pain management. Although music is known to reduce pain in acute and chronic care settings, less is known about its effectiveness in the adult ICU. Objectives Determine the effects of music interventions on pain in the adult ICU, compared with standard care or noise reduction. Methods This review was registered on PROSPERO (CRD42018106889). Databases were searched for randomized controlled trials of music interventions in the adult ICU, with the search terms ["music*" and ("critical care" or "intensive care")]. Pain scores (i.e., self-report rating scales or behavioral scores) were the main outcomes of this review. Data were analyzed using a DerSimonian-Laird random-effects method with standardized mean difference (SMD) of pain scores. Statistical heterogeneity was determined as I2 > 50% and explored via subgroup analyses and meta-regression. Results Eighteen randomized controlled trials with a total of 1173 participants (60% males; mean age 60 years) were identified. Ten of these studies were included in the meta-analysis based on risk of bias assessment (n = 706). Music was efficacious in reducing pain (SMD −0.63 [95% CI −1.02, −0.24; n = 10]; I2 = 87%). Music interventions of 20–30 minutes were associated with a larger decrease in pain scores (SMD −0.66 [95% CI −0.94, −0.37; n = 5]; I2 = 30%) compared with interventions of less than 20 minutes (SMD 0.10 [95% CI −0.10, 0.29; n = 4]; I2 = 0%). On a 0–10 scale, 20–30 minutes of music resulted in an average decrease in pain scores of 1.06 points (95% CI −1.56, −0.56). Conclusion Music interventions of 20–30 minutes are efficacious to reduce pain in adult ICU patients able to self-report.

Many patients in the intensive care unit (ICU) suffer from pain and are non-communicative. Therefore, alternative pain measures are necessary. Although behavioral pain measures are available, physiological measures are lacking. The Nociception Level index (NOL™) provides a value from combination of multiple physiological parameters to measure pain and its use in the ICU is new.To explore the use of a multiple physiological parameter measure for pain assessment, the NOL™ index, in mechanically ventilated patients able to self-report pain in the ICU.A prospective cohort study was performed. Data were collected before, during, and 15 minutes after a non-nociceptive procedure (noninvasive blood pressure using cuff inflation) and a nociceptive procedure (endotracheal suctioning). NOL index, 0 to 10 pain intensity, and Critical-Care Pain Observation Tool (CPOT) scores were also obtained. Data were analyzed using Friedman and Mann-Whitney tests. Feasibility of study procedures was described.Out of 28 patients who consented, 17 remained eligible and data were analyzed for 15. Technical issues prevented obtaining a NOL signal in 2 patients. NOL values were higher during endotracheal suctioning (median = 41.6) compared with before (median = 11.2) and after the procedure (median = 11.8) and compared with cuff inflation (median = 15.1; Friedman test, p .001). NOL values were associated with pain intensity and CPOT scores (Mann-Whitney tests, p .05).The study procedures with the NOL were found feasible; NOL values could discriminate between nociceptive and non-nociceptive procedures, and values were associated with reference pain measures. Further NOL testing is required in other ICU patient groups and procedures.

To evaluate the use of vital signs for pain detection in brain-injured patients in the intensive care unit.A repeated-measures descriptive-correlational study.Two neurological intensive care units in Montréal, Canada. A total of 101 brain-injured patients were included.This study examined the fluctuations in systolic and diastolic blood pressure, heart and respiratory rates, and oxygen saturation in brain-injured critically ill patients before, during, and 15 minutes after turning and soft touch using a data collection computer. When possible, patients' pain self-reports were obtained using a 0-10 Faces Pain Thermometer.The heart and respiratory rates were higher during turning than soft touch and higher during the procedure compared to prior (p 0.05), but their fluctuation was modest. The systolic blood pressure increased during both turning and soft touch by 2 mmHg, but was 26.6 mmHg higher for those who reported pain versus no pain (Mann-Whitney = 25.00, p = 0.008, n = 28). A moderate correlation was observed between the systolic blood pressure (Spearman's rho = 0.617, p = 0.004, n = 24) and self-reported pain intensity during turning. No significant effects were observed for diastolic blood pressure and oxygen saturation.Only increases in systolic blood pressure were positively associated with pain in this sample and replication studies with larger samples is needed.

Background The evidence shows that brain-injured patients express behaviours that are related to their level of consciousness (LOC), and different from other patients in the intensive care unit (ICU). Therefore, existing behavioural scales should be revised to enhance their content and validity for use in these patients. Objectives The aim was to evaluate the content relevance of behaviours and autonomic responses for pain assessment of brain-injured ICU patients from the perspective of critical care clinicians. Methods A total of 77 clinicians from four adult neuroscience ICUs (three from Canada and one from the United States) participated in this descriptive study. A physician/nurse ratio of 21% (13/61) was reached in this quota sample, and three physiotherapists also participated. They completed a content validation questionnaire of 19 items rated on clarity and relevance based on the patient’s LOC. Item Content Validity Index (I-CVI), and modified kappa (κ*) were calculated. Values higher than 0.78 and 0.75 respectively were considered excellent. Results Regardless of the patient’s LOC, brow lowering, grimacing, and trying to reach the pain site were rated as the most relevant behaviours by clinicians, with excellent values of I-CVI > 0.78 and κ* > 0.75. Eyes tightly closed, moaning and verbal complaints of pain also obtained excellent values in altered LOC and conscious patients. Eye weeping obtained excellent values only in conscious patients. Other items showed fair (0.40–0.59) to good (0.60–0.74) values, while blinking and coughing showed poor values ( Conclusions Facial expressions, movements towards the pain site, and vocalisation of pain were the most relevant pain-related behaviours rated by critical care clinicians. The relevance of some behaviours (e.g., moaning and verbal complaints of pain) varied across LOCs, thereby calling forth adaptations of behavioural pain scales to allow for interpretation in the context of a patient’s LOC and ability to express specific behaviours.

Data collected from 224 women living with HIV were analyzed to study quality of life. Quality of life was operationalized as mental health and physical functioning. A structural equation model was tested. The final model demonstrates good fit to data (χ2 = 17.63, p = .48). Mental health was directly and positively associated with being born outside of Canada, social support, and physical functioning but negatively associated with the proportion of people aware of serostatus and experienced discrimination. Physical functioning was directly and positively associated with being born outside of Canada and social support; however, it was negatively associated with time since diagnosis. The proportion of people aware of serostatus was negatively associated with being born outside of Canada and being a mother. Social work interventions aimed at improving quality of life in women living with HIV should target contexts of serostatus disclosure to minimize HIV discrimination and to improve social support sources wi...

Opiates are the most effective analgesics available for the treatment of severe pain. However, their clinical use is restricted by unwanted side effects such as tolerance, physical dependence and respiratory depression. The strategy to develop new opiates with reduced side effects has mainly focused on the study and production of ligands that specifically bind to different opiate receptors subtypes. However, this strategy has not allowed the production of novel therapeutic ligands with a better side effects profile. Thus, other research strategies need to be explored. One which is receiving increasing attention is the possibility of exploiting ligand ability to stabilize different receptor conformations with distinct signalling profiles. This newly described property, termed functional selectivity, provides a potential means of directing the stimulus generated by an activated receptor towards a specific cellular response. Here we summarize evidence supporting the existence of ligand-specific active conformations for two opioid receptors subtypes (delta and mu), and analyze how functional selectivity may contribute in the production of longer lasting, better tolerated opiate analgesics. double dagger.

Objectives To examine the relationship between levels of the T-cell regulatory cytokine interleukin-7 (IL-7) and CD4 cell counts during immune reconstitution and to assess its prognostic value in advanced HIV-1-infected patients receiving lopinavir/ritonavir-based therapy. Methods Thirty-six HIV-1-infected adults who completed 48 weeks of follow-up visits were included in this prospective study. Patients having failed two or more antiretroviral therapy regimens were treated with lopinavir/ritonavir-based therapy. An enzyme-linked immunosorbent assay was used to determine IL-7 plasma levels, flow cytometry was used to analyse cell surface antigens, and polymerase chain reaction was used to quantify plasma HIV-1. Results Pretreatment IL-7 levels were elevated in all patients (mean 11.0 pg/mL) and were negatively correlated with CD4 cell counts and age (r=−0.59, P

Dendritic cells (DCs) modulate B-cell survival and differentiation, mainly through production of growth factors such as B lymphocyte stimulator (BLyS; also known as "B-cell factor belonging to the tumor necrosis factor family" [BAFF]). We have recently shown that, in human immunodeficiency virus (HIV)-infected individuals with rapid and those with classic disease progression, B-cell dysregulations were associated with increased BLyS expression in plasma and by blood myeloid DCs (mDCs), in contrast to aviremic HIV-infected individuals with slow disease progression (also known as "elite controllers"). In previous work with transgenic mice expressing HIV genes, B-cell dysregulations were concomitant with altered mDCs and dependent on HIV negative factor (Nef). We now report that HIV Nef is detected early after infection and despite successful therapy in plasma and BLyS-overexpressing blood mDCs of HIV-infected rapid and classic progressors, whereas it is low to undetectable in aviremic slow progressors. In vitro, HIV Nef drives monocyte-derived DCs toward BLyS overexpression through a process involving STAT1. Importantly, this is counteracted in the presence of all-trans retinoic acid. Nef thus contributes to high BLyS proinflammatory profiles in HIV-infected individuals.

Intimacy motivation, power motivation, and perceived social support were examined as predictors of psychological distress in gay men who were HIV− ( N = 38), who had AIDS ( N = 39), or who were HIV+ but did not have AIDS ( N = 48). Social motives were assessed using Emmons' (1986) personal strivings methodology. Multiple-regression analyses revealed that Intimacy Striving and Perceived Social Support were inversely related to distress, but Power Striving was positively related to distress. The effect of Power Striving was especially strong in the group of HIV+ individuals who did not have AIDS. Perceived Social Support mediated the relation of Intimacy Striving to distress; that is, gay men in the HIV+ and AIDS groups with high levels of Intimacy Striving were more likely to perceive that social support was available to them and in turn reported less psychological distress.

Self-determination theory (Deci & Ryan. 1985. 1991) was used to predict psychological well-being and distress in 48 gay men with HIV. 39 AIDS patients. and 38 HIV-negative control participants. Participants listed 10 to 15 personal strivings and identitied their reasons for engaging in each striving. Multiple regression analyses revealed that introjection (engaging in strivings because of an internal sense of obligation or necessity) was associated with increased distress. especially among HIV- and AIDS participants. Introjection also predicted decreased well-being. Integration (engaging in strivings because they are personally valued and meaningful) was positively related to well-being. Adjustment to a life-threatening illness is influenced by individuals' feelings of autonomy; that is. the extent to which they believe themselves to be the source of their actions.