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Background: Family caregivers (FCGs) encounter several physical, psychosocial, and financial struggles while caring for a dying loved one. After their loved one has passed, FCGs face new difficulties as they transition out of the caregiving role and into bereavement. Recent research has focused on the positive adaptive outcomes of bereavement. Objective: This study examined the relationship between core bereavement experiences and post-traumatic growth (PTG) for bereaved hospice FCGs. Design: This is a quantitative cross-sectional mail-in survey. Settings/Subjects: A total of 395 bereaved FCGs of patients who died while under the care of a comprehensive hospice program were surveyed. Measurements: Demographics were collected. Bereavement experiences were assessed using the core bereavement items, and PTG was assessed using the Posttraumatic Growth Inventory (PTGI). Both surveys are validated measures. Results: Two-tailed bivariate correlations were used to analyze the relationships between bereavement experiences and PTG. Significant positive relationships were found between all bereavement experiences and PTG variables ( p  = <0.01-0.011, r  = 0.134-0.290), except for one variable pairing (grief × new possibilities). Participants who reported more intense bereavement experiences also reported greater PTG, especially in the areas relating to others and appreciation of life. Conclusion: FCGs who undergo more intense bereavement experiences tend to experience greater PTG. This information can be used in the future to develop a more comprehensive understanding of the multifaceted nature of grief and loss.

A systematic effort has been described to grow ternary Ge 1- x - y Si x Sn y semiconductors on silicon with high Sn concentrations spanning the 9.5-21.2% range. The ultimate goal is not only to produce direct band gap materials well into the infrared region of the spectrum but also to approach a critical concentration ( y c ) for which further additions of Si would decrease─rather than increase─the band gap. This counterintuitive behavior is expected as a result of the giant bowing parameter in the compositional dependence of the band gap associated with the presence of Si-Sn pairs. The growth approach in this study was based on a chemical vacuum deposition method that uses Si 4 H 10 , Ge 3 H 8 , and SnD 4 or SnH 4 as the sources of Si, Ge, and Sn, respectively. A fixed Si concentration near x = 0.05-0.07 was chosen to focus the exploration of the compositional space. A first family of samples was grown of Ge-buffered Si substrates. For Sn concentrations y < 0.12, it was found that the samples relaxed their mismatch strain in situ during growth, resulting in high Sn content films that had relatively low levels of strain and exhibited photoluminescence signals that demonstrated direct band gap behavior for the first time. The device potential of these materials was also demonstrated by fabricating a prototype photodiode with low dark currents. The optical studies suggest that the above-mentioned critical concentration is close to y c = 0.2. As the growth temperature was lowered in an effort to reach such values, Sn concentrations as high as y = 0.15 were obtained, but the films grew fully strained with compressive levels as high as 1.7%. To increase the Sn concentration beyond y = 0.15, a new strategy was adopted, in which the Ge buffer layer was eliminated, and the ternary alloy was grown directly on Si. The much higher lattice mismatch between the Ge 1- x - y Si x Sn y layer and the Si substrate caused strain relaxation right at the film/substrate interface, and the subsequent films grew with much lower levels of strain. This made it possible to lower the growth temperatures even further and achieve a comprehensive series of strained relaxed samples with tunable Sn concentrations as high as y = 0.21 (and beyond). The latter represent the highest Sn contents in crystalline Ge 1- x - y Si x Sn y attained to date and reach the desired y c = 0.2 range. The synthesized films exhibited significant thickness, allowing a thorough determination of composition, crystallinity, morphology, and bonding properties, indicating the formation of single-phase single-crystal alloys with random cubic structures. Further work will focus on optimizing the latter samples to explore the optical and electronic properties.

Background: End-of-life dreams and visions (ELDVs) are a common phenomenon in which dying patients experience dreams/visions often of deceased loved ones before death. Past research has highlighted the need for education and awareness to improve clinical engagement at the bedside in response to ELDVs. Objectives: To explore the perspectives of multidisciplinary hospice care providers who are ELDV subject matter experts. Design/Methods: Semi-structured interviews with 13 multidisciplinary hospice providers were conducted and analyzed using thematic qualitative analysis. Results: Analysis revealed six themes: Normalization , Rapport Building , Active Listening , Individualized Meaning Making , Barriers , and Education . A secondary thematic analysis focused on defining/describing ELDVs and resulted in two themes: Natural Part of Dying and ELDV Properties . Conclusions: Findings identified facilitators and barriers encountered when caring for a patient with ELDVs. Based on this, an initial set of recommendations for meaningful clinical engagement regarding ELDVs and initial operationalized definition has been proposed.

Background: The decision to initiate antibiotics in hospice patients that are very near end-of-life is a complex ethical and stewardship decision. Antibiotics may be ordered to improve urinary tract infection-related symptoms, such as delirium. However, infection symptoms may be managed using antipsychotics, antipyretics, antispasmodics, and analgesics instead. Currently, there are no studies that compare symptom management between those who receive antibiotics and those who do not. Methods: A retrospective chart review was conducted for patients admitted to a hospice inpatient unit. Charts were included if the patient was admitted for delirium and had a Palliative Performance Scale score ≤40%, the urine culture was positive for organism growth, and the patient died while in the HIU. Clinical and demographic data was collected. Medication use was tallied for the 5 days prior to the date of death. Results: Sixty-one charts met the inclusion criteria. Thirty-five patients received antibiotics (ABX+) and 26 did not (ABX-). There was no difference in any medication consumption between groups during the 5 days prior to death. The ABX+ group died 8.2 days after obtaining the urine sample vs 6 days ( P =0.046). The ABX+ group had more documented urinary tract-specific infection symptoms (66% vs 38%, P =0.042). More than half of antibiotic courses were discontinued prematurely. Conclusion: The results of this study do not show a difference in overall medication consumption between groups, which suggests that antibiotics may not help improve terminal delirium symptoms in those with a suspected urinary tract infection at end-of-life.

The current study examined qualitative data from hospice clinicians' perspectives on language, surrounding end-of-life (EOL), to understand challenges and opportunities for constructing a trajectory of communication leading towards a good death experience. Findings from two focus groups with nine clinicians' and 12 individual interviews, four of which were follow up interviews after the focus groups, were guided by framework analysis and revealed three themes, constructing language choices, roles and responsibilities, and socio-cultural considerations. We used the Opportunity Model for Presence during the End-of-Life Process (OMP-EOLP) to make sense of the findings and discuss implications for language use throughout the EOL process. We argue additional efforts should be made in recognizing the value of presence checks, re-constructing advance care planning, and utilizing different forms of media as an educational tool and connection mechanism for clinicians with patients and families to achieve a timely engagement of EOL conversations for all healthcare participants., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In this work, a SiGeSn/GeSn/SiGeSn single quantum well was grown and characterized. The sample has a thicker GeSn well of 22nm compared to a previously reported 9nm well configuration. The thicker well leads to: (i) lowered ground energy level in Γ valley offering more bandgap directness; (ii) increased carrier density in the well; and (iii) improved carrier collection due to increased barrier height. As a result, significantly enhanced emission from the quantum well was observed. The strong photoluminescence (PL) signal allows for the estimation of quantum efficiency (QE), which was unattainable in previous studies. Using pumping-power-dependent PL spectra at 20K, the peak spontaneous QE and external QE were measured as 37.9% and 1.45%, respectively., (© 2021 IOP Publishing Ltd.)

Background: Interpersonal hurt or offenses are common human experiences. Bereavement may be impacted for caregivers of a terminally ill loved one when these experiences occur. Objective: To determine the prevalence and impact of interpersonal hurt-based experiences for hospice caregivers and interest in forgiveness-based support. Design: Cross-sectional, mixed methods needs assessment. Settings/Subjects: Bereaved hospice caregivers ( n  = 162) and direct care hospice clinicians ( n  = 133) were surveyed through mail-in and online surveys. Measurements: Participants completed ad hoc surveys to assess prevalence and impact of interpersonal hurt experiences and interest in forgiveness-based support. Bereaved caregivers also completed the Core Bereavement Items (CBI). Results: 41.98% of the bereaved experienced an interpersonal hurt or offense during the care or passing of their loved one. Those with hurt experiences felt highly impacted (63.2%), "sometimes" or "often" revisited the experience (91.2%), felt that their bereavement was affected (61.5%), and experienced physical symptoms (46.3%). CBI scores positively correlated with the impact of the experience. Hurt caregivers had higher CBI scores compared with those who did not. Of those who had not forgiven the offender, 46.3% felt that they could benefit from forgiveness-based support services. Qualitative analysis revealed themes of Disagreements with Decisions, Lack of Support, Relational Interactions, and Impact on Bereavement. Clinician responses supported these results. Conclusions: Interpersonal hurt experiences can greatly impact the offended caregiver during caregiving and in bereavement. However, it should be noted that the decision to forgive is ultimately a personal choice and therefore forgiveness-based for forgiveness-specific interventions may not be appropriate for all individuals. Future research should assess the feasibility and usefulness of this type of support for caregivers and the bereaved.

Background: While the majority of research assesses the impact of end-of-life dreams and visions (ELDVs) on patients, more recent research has begun to explore their impact on family caregivers (FCG)., Objective: This study evaluates the relationship between general attitudes about dreams, perspectives of ELDV and their role the bereaved FCG experience., Design: Mixed-methods using a cross-sectional survey and five focus groups., Settings/subjects: A total of 500 FCGs of patients who died under hospice care were recruited for the survey. Focus group members were self-selected through identified interest from the survey., Measurements: In addition to demographics and ELDV prevalence, general attitude toward dreams, ELDV perspectives, and impact on grief were assessed using ad hoc surveys., Results: Participants reporting ELDVs were significantly more validating of everyday dreams ( p < .001). Positive attitudes toward dreams strongly correlated with comfort from ELDVs for both patients and FCGs. Openness correlated positively with comfort from the ELDV for both the patient ( r = .149, p = .038) and FCG ( r = .217, p = 0.002) and negatively with fear/anxiety ( r = -.141, p = 0.050). Negative ELDV perceptions (ex. ELDVs were caused by medications) affected grief in areas such as accepting the loss ( r = -.235, p = .010) or maintaining connection ( r = -.255, p = .010) with the deceased. Focus group discussions were thematically analyzed resulting in 4 themes: ELDV narrative , Connection , Reflection , and Other Experiences ., Conclusions: Positive general attitudes toward dreams and positive ELDV perceptions are correlated with better bereavement outcomes. Therefore, patient and family education on ELDVs that focuses on awareness and understanding of ELDVs may enhance clinical outcomes for both family and patients.

Management of depression symptoms in hospice patients is complicated by the fact that an appropriate trial of antidepressant therapy requires 4-6 weeks and most hospice patients receive hospice services for less than 8 weeks. Intravenously administered ketamine has been shown to produce rapid improvement in depression symptoms but is not an ideal route for hospice patients and oral ketamine appears to have a slower onset of antidepressant activity. We present a case series that illustrates the use of a single subcutaneous dose of ketamine (0.5 mg/kg) followed by daily oral ketamine (0.5 mg/kg daily) therapy to manage depression symptoms in three hospice patients. Clinical improvement of depression symptoms occurred quickly for all patients as measured by the PHQ-4, numeric ratings, and subjective reporting. A single subcutaneous dose of ketamine followed by oral therapy presents itself as an option to quickly reduce depression symptoms in hospice patients that do not also require additional pain management. Combining the use of the subcutaneous and oral routes takes advantage of the possibly faster onset, home administration, and milder side effects than intravenous dosing. Prospective studies are needed to determine which dosing strategy would be the most beneficial for hospice patients.

Background: The ability to perceive care goals of the dying may be an indicator of future quality patient-centered care. Research conducted on end-of-life goals indicates discrepancies between patients and physicians., Objective: The aim of this study is to compare end-of-life care goals of hospice patients and medical student perceptions of patient care goals., Design: Hospice patients and medical students were surveyed on their care goals and perceptions, respectively, using an 11-item survey of goals previously identified in palliative care literature. Medical student empathy was measured using the Interpersonal Reactivity Index., Settings/participants: Eighty hospice patients and 176 medical students (97 first-year and 79 third-year) in a New York State medical school., Results: Medical students ranked 7 of the 11 care goals differently than hospice patients: not being a burden to family ( p < .001), time with family and friends ( p = .002), being at peace with God ( p < .001), dying at home ( p = .004), feeling that life was meaningful ( p < .001), living as long as possible ( p < .001), and resolving conflicts ( p < .001). Third-year students were less successful than first-year students in perceiving patient care goals of hospice patients. No significant differences in medical student empathy were found based on student year., Conclusions: Medical students, while empathetic, were generally unsuccessful in perceiving end-of-life care goals of hospice patients in the psychosocial and spiritual domains. Differences impeding the ability of medical students to understand these care goals may be generationally based. Increased age awareness and sensitivity may improve future end-of-life care discussions. Overall, there is a need to recognize the greater dimensionality of the dying in order to provide the most complete patient-centered care.

Background: End-of-life dreams and visions (ELDVs) are a recognized phenomenon that can occur as part of the normal dying process. Data suggest that ELDVs can provide comfort, foster discussion of waking life concerns, and lessen the fear of death. Current literature on ELDVs focuses on the prevalence, content, and effects of ELDVs exclusively in adult populations. Methods: We present the case of a 15-year-old girl with terminal glioblastoma who was enrolled in a pediatric palliative care program and later in hospice care. During her end-of-life trajectory, the patient experienced two distinct ELDV experiences, from which she recalled vivid details regarding the setting, characters, and content. These ELDV experiences afforded comfort and meaning to the patient and her family through her end-of-life trajectory as well as provided relief for her grieving family. Conclusion: In the case presented, ELDVs appear to show similar characteristics and impact in the adolescent population as described in the previous literature examining adult ELDVs. In addition, this case demonstrates the potential benefits of ELDV awareness for the bereaved. Clinicians working with pediatric and adolescent end-of-life populations should take note of the potential for ELDVs and the impact they can have on both patients and families.

Purpose: This study assessed the feasibility and preliminary efficacy of the Photographs of Meaning Program for Adolescent and Young Adult cancer patients and survivors (POM-AYA). Methods: POM-AYA is a structured 10-week meaning-based intervention in which participants post photographs and accompanying narratives through a social media platform. Measures of depression, overall quality of life (QoL), and spiritual well-being were assessed on consent (T1), after completing the 10-week intervention (T2) and 2 months' postintervention (T3). Participants also completed a satisfaction questionnaire and follow-up semi-structured interviews. Results: Thirty AYA cancer patients and survivors (ages 17-36) were enrolled in the study. At T2, depressive symptoms were significantly lower and QoL was significantly higher compared with T1. These gains were maintained at T3. There were no significant differences in reported spiritual well-being across the study period. Overall, participants reported high rates of study satisfaction in both the survey and qualitative feedback. Conclusion: POM-AYA appears to be a potentially beneficial, widely accessible intervention in reducing depressive symptoms and increasing QoL in AYA cancer patients and survivors.

Background: Research has established End-of-Life Dreams and Visions (ELDVs) as prevalent, meaningful valid experiences that may help patients cope with illness and approaching death. However, no inductive qualitative analysis has explored the phenomenology of ELDVs from the perspective of hospice homecare patients. Objective: The purpose of this study is to evaluate the content of ELDVs by using a rigorous qualitative approach. Design: Five hundred forty-eight ELDVs were collected from weekly interviews of hospice homecare patients and analyzed by using Consensual Qualitative Research Methodology. Settings/Subject: Participants were enrolled in a county-wide hospice homecare program between January 2013-March 2015. Results: The following domains emerged: (1) Interpersonal, (2) Affective Experience and Reflection, (3) Activities, and (4) Setting/Location. Conclusions: This study suggests that ELDV content may include a broader spectrum of experiences that reflect waking life than previously believed. Clinical implications suggest that it may be important for providers to engage with ELDVs, as they are psychologically significant experiences that may be a source of clinical insight., Competing Interests: No competing financial interests exist., (© Rachel M. Depner et al., 2020; Published by Mary Ann Liebert, Inc.)

Background: Caring for a child or adolescent with palliative care needs can significantly influence the physical, mental, financial, and social well-being of caregivers. Due to this multifaceted impact, there is a demand for evidence-based support that meets the distinct needs of this population. Objective: This study aims to evaluate the effect the Photographs of Meaning Program (POM) has on meaning and purpose, well-being, and perceived social support of pediatric palliative caregivers (PPCGs). Design: Over an eight-week period, participants followed a meaning-making curriculum via social media. Following the social media portion of the intervention, a reflection and closure event and a community photograph exhibit were held. Participants completed pre- and post-test measures. Setting/Subjects: Eighteen PPCGs participated in POM. Settings included participant homes, the medical campus of the palliative care program, and a community art gallery. Measurements: Participant meaning and purpose were assessed through the Meaning in Life Questionnaire. The Flourishing Scale measured PPCG well-being, while the Social Provisions Scale assessed perceived social support. Participants were also given a satisfaction survey at study closure. Results: Presence ( p  = 0.003) and search ( p  = 0.023) for meaning were both positively impacted at post-test. Participants' ratings of well-being ( p  = 0.037), overall social support ( p  = 0.004), areas of attachment ( p  = 0.003), social integration ( p  = 0.026), reassurance of worth ( p  = 0.002), and guidance ( p  = 0.014) significantly increased from pre- to post-test. Conclusions: POM is an effective social media-based intervention for PPCGs. Future research should assess the effectiveness of this intervention in populations with differing demographics and its effect on other psychosocial indicators., Competing Interests: No competing financial interests exist., (© Kathryn Levy et al., 2020; Published by Mary Ann Liebert, Inc.)

The Photographs of Meaning Program for pediatric palliative caregivers (POM-PPCG) is an innovative, meaning-based intervention utilizing photovoice and social media components. In 2017, 9 pediatric palliative caregivers participated in this intervention. During the social media portion of the POM-PPCG, participants were presented with weekly themes based on a meaning-making curriculum. In response, they took photographs, applied either audio or typed narratives, and shared them via social media. Ninety-five photographs with narratives were produced during the intervention. Through thematic qualitative analysis with consensual qualitative research components, 5 themes were identified: Love , Challenges , Loss , Coping , and The New Normal . This study adds to existing literature by shedding light on the experiences of caregivers of children with palliative care needs. Findings from this research contribute not only to the innovative use of qualitative methods but also to the clinical knowledge and practice regarding the pediatric palliative caregiver experience.

Background: End-of-life dreams and visions (ELDVs) can provide both meaning and comfort to individuals nearing death. While research has examined the prevalence and content of ELDVs, little is known on how dreaming at end of life may affect psychological processes. Objective: This study aimed to explore differences in posttraumatic growth (PTG) between hospice patients who experience ELDVs and hospice patients who do not experience this phenomenon. Design: This is a multimethod cross-sectional comparison study. Settings/Subjects: 70 hospice patients (35 with ELDV experiences and 35 without ELDV experiences) were recruited after being admitted to a hospice inpatient unit. Measurements: PTG was assessed using a modified version of the Posttraumatic Growth Inventory (PTGI). Demographic information, ELDV occurrence, and a brief description of ELDVs were also collected. Results: Significant differences emerged between groups in terms of personal strength ( p  = 0.012), spiritual change ( p  = 0.002), and overall PTG ( p  = 0.019). Patients with ELDV experiences had higher scores on all subscales as well as overall PTG compared to nondreaming patients. Conclusions: Dreams and visions at the end of life affect PTG of dying individuals in hospice care. Further research should be conducted between groups to examine the effects ELDVs may have on other psychological processes.

Background: End-of-life dreams and visions (ELDVs) are prevalent experiences that provide comfort and meaning to dying individuals. Limited research has examined the impact of ELDVs on the bereaved. Objective: This study aimed to explore differences in self-reported grief for people whose loved ones shared ELDVs and those who did not, and to describe the role of ELDVs in the grieving process. Design: Mixed-methods cross-sectional survey. Settings/Subjects: A total of 228 bereaved family caregivers (FCGs) of patients who died while under the care of a comprehensive hospice program were recruited. Measurements: Demographics and ELDV prevalence were collected. Bereavement was assessed using the Core Bereavement Items (CBI) a validated measure. Impact on grief was also evaluated using an ad hoc tool. Results: Comfort from dreams significantly related to total CBI score ( r  = 0.224, p  = 0.047) as well as the images and thoughts ( r  = 0.258, p  = 0.025) and acute separation subscales ( r  = 0.224, p  = 0.047). Comfort from dreams had a positive relationship with accepting the reality of loss ( r  = -0.511, p  < 0.001), working through the pain of grief ( r  = -0.556, p  < 0.001), adjusting to the new environment ( r  = -0.405, p  = 0.001), and continuing bonds ( r  = -0.538, p  < 0.001). CBI scores were not significantly different between caregivers who reported loved ones with ELDVs and others. Open-ended responses were thematically analyzed resulting in three emergent themes: comfort , reflection and emotions , and sense-making . Conclusions: ELDVs' impact extends beyond those experiencing them to bereaved loved ones. Bereaved FCGs report that comforting ELDVs experienced by their dying loved ones influenced their grief process in terms of the Worden's tasks of mourning.

Background: Research indicates that informal caregiving can have intense physical and mental impact on the individual. Relative to caregivers of adults, pediatric palliative caregivers appear less in literature despite experiencing greater mental, physical, financial, and social strain. There is limited research on the creation and evaluation of interventions specifically for this population despite clear need., Objective: This study aims to evaluate the feasibility and engagement of the Photographs of Meaning Program, a modified meaning-making intervention for pediatric palliative caregivers., Design: Participants completed a pre-post intervention meaning-in-life measure. Over a 9-week period, participants followed a meaning-making curriculum whereby they created and shared photo narratives via social media. As part of the intervention, a community photo exhibition was held featuring these photo narratives. Exit interviews were also conducted at study close., Setting/participants: Nine individuals providing informal care to children in a pediatric palliative care program participated in the intervention. All participants were female and are older than 18 years. Settings for research include participant homes and at The Center for Hospice and Palliative Care in Cheektowaga, New York., Results: Participants posted 95 photographs and 96 narratives during the intervention, posting on average once each week. Statistical analysis within the small sample indicated an increased presence of meaning in the lives of participants ( P = .022). Exit interviews conveyed satisfaction with the intervention., Conclusions: Findings suggest that the Photographs of Meaning Program is a practical intervention with life-enhancing potential for pediatric palliative. Future research should aim to collect additional evidence of the intervention's effectiveness.

The GeSn-based quantum wells (QWs) have been investigated recently for the development of efficient GeSn emitters. Although our previous study indicated that the direct bandgap well with type-I band alignment was achieved, the demonstrated QW still has insufficient carrier confinement. In this work, we report the systematic study of light emission from the Ge 0.91 Sn 0.09 /Ge 0.85 Sn 0.15 /Ge 0.91 Sn 0.09 double QW structure. Two double QW samples, with the thicknesses of Ge 0.85 Sn 0.15 well of 6 and 19 nm, were investigated. Band structure calculations revealed that both samples feature type-I band alignment. Compared with our previous study, by increasing the Sn composition in GeSn barrier and well, the QW layer featured increased energy separation between the indirect and direct bandgaps towards a better direct gap semiconductor. Moreover, the thicker well sample exhibited improved carrier confinement compared to the thinner well sample due to lowered first quantized energy level in the Γ valley. To identify the optical transition characteristics, photoluminescence (PL) study using three pump lasers with different penetration depths and photon energies was performed. The PL spectra confirmed the direct bandgap well feature and the improved carrier confinement, as significantly enhanced QW emission from the thicker well sample was observed.

Background: Delirium is a challenging occurrence among people at end of life. It can be difficult to detect and treat because of its episodic nature. The Buffalo Delirium Scale (BDS) was designed to identify risk factors for hospice patients in the prodromal stage of delirium., Objective: This study evaluated the psychometric properties of items assessing delirium risk factors related to cognitive problems, psychological distress, and sleep problems., Methods: Hospice nursing staff assessed patients with the 11-item BDS over a 6-month period as part of standard weekly visits to monitor for emerging signs of delirium, for example, sleep patterns, cognition, and behavior., Setting/participants: The rating period produced 4992 assessments from 817 hospice home care patients., Results: Factor analysis of nurses' ratings identified 3 factors: (1) cognitive problems, (2) distress, and (3) sleep problems. Coefficient αs for these factors and total score were moderate to high (range = .66-.82). Nurses' ratings of presence of delirium highly correlated with scores on distress ( r = .40, P < .01), while dementia highly correlated with cognitive problems ( r = .50, P < .01). Analysis of at-risk cases with high BDS total scores where no delirium was assessed indicated that quality sleep may mitigate delirium onset., Conclusion: Preliminary psychometric testing suggests BDS to be a valid and appropriate measure for hospice patients. Use of BDS may help differentiate individuals in prodromal stage of delirium versus dementia. Examination of BDS scores may help identify patients for whom sleep interventions may delay onset of or reduce the frequency of delirium.

Background: The age demographic of the incarcerated is quickly shifting from young to old. Correctional facilities are responsible for navigating inmate access to healthcare; currently, there is no standardization for access to end-of-life care. There is growing research support for prison-based end-of-life care programs that incorporate inmate peer caregivers as a way to meet the needs of the elderly and dying who are incarcerated., Aim: This project aims to (a) describe a prison-based end-of-life program utilizing inmate peer caregivers, (b) identify inmate-caregiver motivations for participation, and (c) analyze the role of building trust and meaningful relationships within the correctional end-of-life care setting., Design: A total of 22 semi-structured interviews were conducted with inmate-caregivers. Data were analyzed using Consensual Qualitative Research methodology., Setting/participants: All inmate-caregivers currently participating in the end-of-life peer care program at Briarcliff Correctional Facility were given the opportunity to participate. All participants were male, over the age of 18, and also incarcerated at Briarcliff Correctional Facility, a maximum security, state-level correctional facility., Results: In total, five over-arching and distinct domains emerged; this manuscript focuses on the following three: (a) program description, (b) motivation, and (c) connections with others., Conclusion: Findings suggest that inmate-caregivers believe they provide a unique and necessary adaptation to prison-based end-of-life care resulting in multilevel benefits. These additional perceived benefits go beyond a marginalized group gaining access to patient-centered end-of-life care and include potential inmate-caregiver rehabilitation, correctional medical staff feeling supported, and correctional facilities meeting end-of-life care mandates. Additional research is imperative to work toward greater standardization of and access to end-of-life care for the incarcerated.

Objective: Longitudinal assessment of patient-caregiver relationships will determine whether caregiver self-esteem determines patient relationship satisfaction at end of life., Background: Research on close relationships and caregiving supports the idea that informal caregivers' self-esteem may influence their relationships with their terminally ill loved ones. However, this connection has not yet been investigated longitudinally, nor has it been applied specifically to care recipients' relationship satisfaction., Methods: A sample of 24 caregivers and 24 patients in a hospice home care program were recruited. Multiple patient and caregiver interviews were used to conduct a longitudinal study to measure fluctuations in patient health, changes in patient and caregiver relationship satisfaction, and self-esteem over a three-month period., Results: An interaction between caregiver self-esteem and patient relationship satisfaction demonstrated the role that self-esteem plays between caregivers and patients enrolled in hospice care. Specifically, for patients with caregivers with low self-esteem, patient relationship satisfaction significantly decreased as the patient's physical health decreased, whereas for patients whose caregivers had high self-esteem, patient relationship satisfaction marginally increased during poorer physical health., Discussion: High self-esteem may allow caregivers to overcome feelings of burden and maladaptive anticipatory grief to remain satisfied in their relationship with the patient. Caregiver self-esteem appears to play a role in fostering patient relationship satisfaction at the end of life.

A growing number of correctional facilities train inmates to provide end-of-life care for dying inmates. This study explores the phenomenological perspective of inmate-caregivers participating in an inmate-facilitated hospice program (IFHP) with regard to meaning and purpose in life, attitudes on death and dying, and perceived personal impact of participation. Twenty-two inmate-caregivers were interviewed at a maximum-security state correctional facility in the United States. The interviews were transcribed verbatim and analyzed using the Consensual Qualitative Research Methodology. Results suggest that participating in an IFHP may facilitate personal growth and transformation that mirrors the tenets of posttraumatic growth.

In this study we report in-plane nanotracks produced by molecular-beam-epitaxy (MBE) exhibiting lateral self-assembly and unusual periodic and out-of-phase height variations across their growth axes. The nanotracks are synthesized using bismuth segregation on the GaAsBi epitaxial surface, which results in metallic liquid droplets capable of catalyzing GaAsBi nanotrack growth via the vapor-liquid-solid (VLS) mechanism. A detailed examination of the nanotrack morphologies is carried out employing a combination of scanning electron and atomic force microscopy and, based on the findings, a geometric model of nanotrack growth during MBE is developed. Our results indicate diffusion and shadowing effects play significant roles in defining the interesting nanotrack shape. The unique periodicity of our lateral nanotracks originates from a rotating nucleation "hot spot" at the edge of the liquid-solid interface, a feature caused by the relative periodic circling of the non-normal ion beam flux incident on the sample surface, inside the MBE chamber. We point out that such a concept is divergent from current models of crawling mode growth kinetics and conclude that these effects may be utilized in the design and assembly of planar nanostructures with controlled non-monotonous structure.

Resistance to the antibiotic thiostrepton, in producing Streptomycetes, is conferred by the S-adenosyl-L-methionine (SAM)-dependent SPOUT methyltransferase Tsr. For this and related enzymes, the roles of active site amino acids have been inadequately described. Herein, we have probed SAM interactions in the Tsr active site by investigating the catalytic activity and the thermodynamics of SAM binding by site-directed Tsr mutants. Two arginine residues were demonstrated to be critical for binding, one of which appears to participate in the catalytic reaction. Additionally, evidence consistent with the involvement of an asparagine in the structural organization of the SAM binding site is presented., (Copyright © 2015 Federation of European Biochemical Societies. Published by Elsevier B.V. All rights reserved.)

Objective: Hospice patients often struggle with loss of meaning, while many experience meaningful dreams. The purpose of this study was to conduct a preliminary exploration into the process and therapeutic outcomes of meaning-centered dream work with hospice patients., Method: A meaning-centered variation of the cognitive-experiential model of dream work (Hill, 1996; 2004) was tested with participants. This variation was influenced by the tenets of meaning-centered psychotherapy (Breitbart et al., 2012). A total of 12 dream-work sessions were conducted with 7 hospice patients (5 women), and session transcripts were analyzed using the consensual qualitative research (CQR) method (Hill, 2012). Participants also completed measures of gains from dream interpretation in terms of existential well-being and quality of life., Results: Participants' dreams generally featured familiar settings and living family and friends. Reported images from dreams were usually connected to feelings, relationships, and the concerns of waking life. Participants typically interpreted their dreams as meaning that they needed to change their way of thinking, address legacy concerns, or complete unfinished business. Generally, participants developed and implemented action plans based on these interpretations, despite their physical limitations. Participants described dream-work sessions as meaningful, comforting, and helpful. High scores on a measure of gains from dream interpretation were reported, consistent with qualitative findings. No adverse effects were reported or indicated by assessments., Significance of Results: Our results provided initial support for the feasibility and helpfulness of dream work in this population. Implications for counseling with the dying and directions for future research were also explored.

End-of-life dreams and visions (ELDVs) are well documented throughout history and across cultures with impact on the dying person and their loved ones having profound meaning. Published studies on ELDVs are primarily based on surveys or interviews with clinicians or families of dead persons. This study uniquely examined patient dreams and visions from their personal perspective. This article reports the qualitative findings from dreams and visions of 63 hospice patients. Inductive content analysis was used to examine the content and subjective significance of ELDVs. Six categories emerged: comforting presence, preparing to go, watching or engaging with the deceased, loved ones waiting, distressing experiences, and unfinished business., (© The Author(s) 2014.)

Background: Metastatic breast cancer patients have many options for therapy and may be at risk for late or absent hospice referrals, which make meaningful improvements in symptoms and quality of life difficult to achieve., Objective: We aimed to examine hospice utilization, status of patients on admission, and quality of care of patients treated for metastatic breast cancer from 1999 to 2010 at a National Cancer Institute (NCI)-designated comprehensive cancer center located in Western New York., Methods: We conducted a retrospective database review that identified 182 patients with deaths resulting from breast cancer who were eligible for services through a local not-for-profit hospice. Patients with metastatic breast cancer were matched to the hospice database for information on hospice utilization and quality measures. Date of last chemotherapy, medication use, documentation of advance directive and palliative care discussions, and place of death were collected through chart abstraction., Results: One-third (33%) of metastatic breast cancer patients treated at the cancer institute during the study period died without a hospice referral. Only 7% of patients who died without a hospice referral had a documented discussion of palliative care as an option by the oncology team (p < 0.001). Those patients referred to hospice were significantly more likely to have an advance directive and to die at home. Patients with a longer duration of metastatic cancer were at risk for late referral., Conclusions: Efforts to enhance end-of-life (EOL) discussions and earlier referral to palliative care and hospice for patients with metastatic breast cancer are critical to improved patient care.

Background: In the United States, 5% of the population is responsible for nearly half of all health care expenditures, with a large concentration of spending driven by individuals with expensive chronic conditions in their last year of life. Outpatient palliative care under the Medicare Hospice Benefit excludes a large proportion of the chronically ill and there is widespread recognition that innovative strategies must be developed to meet the needs of the seriously ill while reducing costs., Objective: This study aimed to evaluate the impact of a home-based palliative care program, implemented through a hospice-private payer partnership, on health care costs and utilization., Methods: This was a prospective, observational database study where insurance enrollment and claims data were analyzed. The study population consisted of Home Connections (HC) program patients enrolled between January 1, 2010 and December 31, 2012 who subsequently expired (n=149) and who were also Independent Health members. A control group (n=537) was derived using propensity-score matching. The primary outcome variable was overall costs within the last year of life. Costs were also examined at six months, three months, one month, and two weeks. Inpatient, outpatient, ancillary, professional, and pharmacy costs were compared between the two groups. Medical service utilization and hospice enrollment and length of stay were also evaluated., Results: Cost savings were apparent in the last three months of life—$6,804 per member per month (PMPM) cost for palliative care participants versus $10,712 for usual care. During the last two weeks of life, total allowed PMPM was $6,674 versus $13,846 for usual care. Enhanced hospice entry (70% versus 25%) and longer length of stay in hospice (median 34 versus 9 days) were observed., Conclusions: Palliative care programs partnered with community hospice providers may achieve cost savings while helping provide care across the continuum.

Context: Outpatient programs have been traditionally offered in the U.S. under programs such as the Medicare Hospice Benefit. Recommendations now emphasize a blended model in which palliative care is offered concurrently with curative approaches at the onset of serious or life-limiting disease. The efficacy of nonhospice outpatient palliative care programs is not well understood., Objectives: The aim of the study was to evaluate the clinical impact of a home-based palliative care program, Home Connections, implemented as a partnership between a not-for-profit hospice and two private insurers., Methods: This was a prospective, observational, database study of 499 Home Connections participants enrolled between July 1, 2008, and May 31, 2013. Measured outcomes were advance directive completion, site of death, symptom severity over time, program satisfaction, and hospice referral and average length of stay., Results: Seventy-one percent of participants completed actionable advance directives after enrollment, and the site of death was home for 47% of those who died during or after participation in the program. Six of eight symptom domains (anxiety, appetite, dyspnea, well-being, depression, and nausea) showed improvement. Patients, caregivers, and physicians gave high program satisfaction scores (93%-96%). Home Connections participants who subsequently enrolled in hospice care had a longer average length of stay of 77.9 days compared with all other hospice referrals (average length of stay 56.5 days)., Conclusion: A home-based palliative care program was developed between two local commercial payers and a not-for-profit hospice. Not only did this program improve symptom management, advance directive completion, and satisfaction, but it also facilitated the transition of patients into hospice care, when appropriate., (Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Inpatient palliative care (IPC) has been associated with numerous clinical benefits. Observational and randomized studies of cost savings associated with IPC provide conflicting results, and the association with readmission is not well understood., Objective: We aimed to estimate the influence of IPC on hospitalization costs and readmission rates., Methods: We measured hospitalization costs and 30-day readmission rates among 1004 patients who received IPC at two western New York hospitals in 2012. Using propensity score matching, we compared outcomes among patients receiving palliative care with those among 1004 similar adults who were hospitalized during the same period and did not receive palliative care., Results: On average, cost per admission was $1,401 (13%) lower among patients receiving palliative care than comparison patients (p<0.05). Cost reductions were evident within intensive care and laboratory services. Readmission rates were significantly lower among palliative care patients discharged with hospice care (1.1%) than comparison patients (6.6%), but significantly higher among palliative care patients discharged to other locations (12.1%)., Conclusions: Receipt of IPC appears to reduce hospitalization costs among adult western New Yorkers. Furthermore, care coordinated with postdischarge hospice services appears to substantially reduce the likelihood of readmission.

We report room-temperature Raman scattering studies of nominally undoped (100) GaAs1−xBix epitaxial layers exhibiting Bi-induced (p-type) longitudinal-optical-plasmon-coupled (LOPC) modes for 0.018 ≤ x ≤ 0.048. Redshifts in the GaAs-like optical modes due to alloying are evaluated and are paralleled by strong damping of the LOPC. The relative integrated Raman intensities of LO(Γ) and LOPC ALO/ALOPC are characteristic of heavily doped p-GaAs, with a remarkable near total screening of the LO(Γ) phonon (ALO/ALOPC → 0) for larger Bi concentrations. A method of spectral analysis is set out which yields estimates of hole concentrations in excess of 5×1017cm−3 and correlates with the Bi molar fraction. These findings are in general agreement with recent electrical transport measurements performed on the alloy, and while the absolute size of the hole concentrations differ, likely origins for the discrepancy are discussed. We conclude that the damped LO-phonon-hole-plasmon coupling phenomena plays a dominant role in Raman scattering from unpassivated nominally undoped GaAsBi.

Background: End-of-life dreams and visions (ELDVs) have been well documented throughout history and across cultures. The impact of pre-death experiences on dying individuals and their loved ones can be profoundly meaningful., Objective: Our aim was to quantify the frequency of dreams/visions experienced by patients nearing the end of life, examine the content and subjective significance of the dreams/visions, and explore the relationship of these factors to time/proximity to death., Methods: This mixed-methods study surveyed patients in a hospice inpatient unit using a semi-structured interview. Sixty-six patients admitted to a hospice inpatient unit between January 2011 and July 2012 provided informed consent and participated in the study. The semi-structured interviews contained closed and open-ended questions regarding the content, frequency, and comfort/distress of dreams/visions., Results: Fifty-nine participants comprised the final sample. Most participants reported experiencing at least one dream/vision. Almost half of the dreams/visions occurred while asleep, and nearly all patients indicated that they felt real. The most common dreams/visions included deceased friends/relatives and living friends/relatives. Dreams/visions featuring the deceased (friends, relatives, and animals/pets) were significantly more comforting than those of the living, living and deceased combined, and other people and experiences. As participants approached death, comforting dreams/visions of the deceased became more prevalent., Conclusions: ELDVs are commonly experienced phenomena during the dying process, characterized by a consistent sense of realism and marked emotional significance. These dreams/visions may be a profound source of potential meaning and comfort for the dying, and therefore warrant clinical attention and further research.