human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Although  family caregiving  has been intensively studied in the past decade , little attention has been paid to the impact of end-of-life care on caregivers who are family members of persons with dementia or to the caregivers ' responses to the death of the patient . METHODS Using st and ardized assessment instruments and structured questions , we assessed the type and intensity of care provided by 217 family caregivers to persons with dementia during the year before the patient 's death and assessed the caregivers '  responses to the death . RESULTS Half the caregivers reported spending at least 46 hours per week assisting patients with activities of daily living and instrumental activities of daily living . More than half the caregivers reported that they felt they were " on duty " 24 hours a day , that the patient had frequent pain , and that they had had to end or reduce employment owing to the dem and s of caregiving . Caregivers exhibited high levels of depressive symptoms while providing care to the relative with dementia , but they showed remarkable resilience after the death . Within three months of the death , caregivers had clinical ly significant declines in the level of depressive symptoms , and within one year the levels of symptoms were substantially lower than levels reported while they were acting as caregivers . Seventy-two percent of caregivers reported that the death was a relief to them , and more than 90 percent reported belief that it was a relief to the patient . CONCLUSIONS End-of-life care for patients with dementia was extremely dem and ing of family caregivers . Intervention and support services were needed most before the patient 's death . When death was preceded by a protracted and stressful period of caregiving , caregivers reported considerable relief at the death itself PURPOSE We sought to determine the effects of a communication process that was design ed to encourage the use of advanced supportive technology when it is of benefit , but to limit its burdens when it is ineffective . We compared usual care with a proactive , multidisciplinary method of communicating that prospect ively identified for patients and families the criteria that would determine whether a care plan was effective at meeting the goals of the patient . This process allowed caregivers to be informed of patient preferences about continued advanced supportive technology when its continuation would result in a compromised functional outcome or death . MATERIAL S AND METHODS We performed a before- and -after study in 530 adult medical patients who were consecutively admitted to a university tertiary care hospital for intensive care .  Multidisciplinary meetings were held within 72 hours of critical care admission . Patients , families , and the critical care team discussed the care plan and the patients ' goals and expectations for the outcome of critical care . Clinical " milestones " indicative of recovery were identified with time frames for their occurrence . Follow-up meetings were held to discuss palliative care options when continued advanced supportive technology was not achieving the patient 's goals . We measured length of stay , mortality , and provider team and family consensus in 134 patients before the intensive communication intervention and in 396 patients after the intervention . RESULTS Intensive communication significantly reduced the median length of stay from 4 days ( interquartile range , 2 to 11 days ) to 3 days ( 2 to 6 days , P = 0.01 by survival analysis ) . This reduction remained significant after adjustment for acute physiology and chronic health evaluation ( APACHE ) 3 score [ risk ratio ( RR ) = 0.81 ; 95 % confidence interval ( CI ) , 0.66 to 0.99 ; P = 0.04 ) . Subgroup analysis revealed that this reduction occurred in our target group , patients with acuity scores in the highest quartile who died ( RR = 0.60 ; 95 % CI , 0.38 to 0.92 ; P = 0.02 ) . The intervention , which allowed dying patients earlier access to palliative care , was not associated with increased mortality . CONCLUSIONS Intensive communication was associated with a reduction in critical care use by patients who died . Our multidisciplinary process targeted advanced supportive technology to patients who survived and allowed the earlier withdrawal of advanced supportive technology when it was ineffective PURPOSE The purpose of this study was to examine the joint effects of  bereavement and caregiver intervention on  caregiver depressive symptoms . DESIGN AND METHODS Alzheimer 's caregivers from a r and omized trial of an enhanced caregiver support intervention versus usual care who had experienced the death of their spouse ( n = 254 ) were repeatedly assessed with the Geriatric Depression Scale prior to and following bereavement . R and om effects regression growth curve analyses examined the effects of treatment group and bereavement while controlling for other variables . RESULTS The death of the care recipient led to reductions in depressive symptoms for both caregiving groups . Enhanced support intervention led to lower depressive symptoms compared with controls both before and after bereavement . Post-bereavement group differences were stronger for caregivers of spouses who did not previously experience a nursing home placement . These caregivers maintained these differences for more than 1 year after bereavement . Caregivers who received the enhanced support intervention were more likely to show long-term patterns of fewer depressive symptoms before and after bereavement , suggesting resilience , whereas control caregivers were more likely to show chronic depressive symptoms before and after the death of their spouse . IMPLICATION S Caregiver intervention has the potential to alter the long-term course of the caregiving career . Such clinical strategies may also protect caregivers against chronic depressive symptoms that would otherwise persist long after caregiving ends OBJECTIVE The aim of family focused grief therapy is to reduce the morbid effects of grief among families at risk of poor psychosocial outcome . It commences during palliative care of terminally ill patients and continues into bereavement . The authors report a r and omized , controlled trial . METHOD Using the Family Relationships Index , the authors screened 257 families of patients dying from cancer : 183 ( 71 % ) were at risk , and 81 of those ( 44 % ) participated in the trial . They were r and omly assigned ( in a 2:1 ratio ) to family focused grief therapy ( 53 families , 233 individuals ) or a control condition ( 28 families , 130 individuals ) . Assessment s occurred at baseline and 6 and 13 months after the patient 's death . The primary outcome measures were the Brief Symptom Inventory , Beck Depression Inventory , and Social Adjustment Scale . The Family Assessment Device was a secondary outcome measure . Analyses allowed for correlated family data and employed generalized estimating equations based on intention to treat and controlling for site . RESULTS The overall impact of family focused grief therapy was modest , with a reduction in distress at 13 months . Significant improvements in distress and depression occurred among individuals with high baseline scores on the Brief Symptom Inventory and Beck Depression Inventory . Global family functioning did not change . Sullen families and those with intermediate functioning tended to improve overall , whereas depression was unchanged in hostile families . CONCLUSIONS Family focused grief therapy has the potential to prevent pathological grief . Benefit is clear for intermediate and sullen families . Care is needed to avoid increasing conflict in hostile families PURPOSE To determine whether provision of a question prompt list ( QPL ) influences advanced cancer patients ' /caregivers ' questions and discussion of topics relevant to end-of-life care during consultations with a palliative care ( PC ) physician . PATIENTS AND METHODS This r and omized controlled trial included patients r and omly assigned to st and ard consultation or provision of QPL before consultation , with endorsement of the QPL by the physician during the consultation . Consecutive eligible patients with advanced cancer referred to 15 PC physicians from nine Australian PC services were invited to participate . Consultations were audiotaped , transcribed , and analyzed by blinded coders ; patients completed question naires before , within 24 hours , and 3 weeks after the consultation . RESULTS A total of 174 patients participated ( 92 QPL , 82 control ) . Compared with controls , QPL patients and caregivers asked twice as many questions ( for patients , ratio , 2.3 ; 95 % CI , 1.7 to 3.2 ; P < .0001 ) , and patients discussed 23 % more issues covered by the QPL ( 95 % CI , 11 % to 37 % ; P < .0001 ) . QPL patients asked more prognostic questions ( ratio , 2.3 ; 95 % CI , 1.3 to 4.0 ; P = .004 ) and discussed more prognostic ( ratio , 1.43 ; 95 % CI , 1.1 to 1.8 , P = .003 ) and end-of-life issues ( 30 % v 10 % ; P = .001 ) . Fewer QPL patients had unmet information needs about the future ( 21 = 4.14 ; P = .04 ) , which was the area of greatest unmet information need . QPL consultations ( average , 38 minutes ) were longer ( P = .002 ) than controls ( average , 31 minutes ) . No differences between groups were observed in anxiety or patient/physician satisfaction . CONCLUSION Providing a QPL and physician endorsement of its use assists terminally ill cancer patients and their caregivers to ask questions and promotes discussion about prognosis and end-of-life issues , without creating patient anxiety or impairing satisfaction Despite evidence of high psychological distress and unmet needs , evaluated interventions for informal caregivers in palliative care are few . This study involved an observational outcome evaluation of attendees , and a comparison group , in specialist home palliative care .  The measures included  carer psychological status and patient physical status at baseline , 8 weeks , and 20 weeks . Qualitative data were collected regarding content , satisfaction with , and impact of intervention . Process data described the uptake , re sources , and group activity . The intervention combined informal multiprofessional teaching with facilitated peer exchange and support , and was delivered over 6 sessions of 90 minutes per week . The uptake rate was 25 % ; carers were less likely to accept if they were in paid employment ( OR=0.26 , P=0.06 ) , and more likely to accept if they utilized avoidance coping ( OR=1.13 , P=0.04 ) or their patient had worse physical status ( OR=2.1 , P=0.03 ) . Attendees described significant support and knowledge gains from the multiprofessional input and peer group . Most relied on social comparison processes to appraise their situation . Potential detection of significant effects on global psychological scores ( i.e. anxiety , depression , and burden ) using multivariate analysis was disallowed due to attrition . This acceptable and accessible intervention provided information and support ; further outcome studies are needed for a range of interventions . Short-term interventions are unlikely to affect global psychological scores , and future evaluations should include additional time points of data collection to demonstrate support during attendance There has been much research documenting the impact of having a loved one diagnosed with advanced cancer , but little is known about how to reduce care-giver burden . In this r and omized controlled trial , the authors examined the potential relationship of an advanced cancer patient ’s participation in an 8-session , structured , multidisciplinary intervention on the care-giver ’s burden and quality of life ( QOL ) . Although the patients r and omly assigned to the intervention ( n = 54 ) demonstrated improved QOL compared to the  control condition ( n = 49 ) participants ( P < .05 ) , there was no evidence that improving the patient ’s QOL made an impact on the caregiver ’s level of burden or the care-giver ’s QOL . Further investigation is warranted in this area , including interventions specifically design ed and targeted to both reduce caregiver burden and to improve caregiver QOL CONTEXT Ethics consultations increasingly are being used to resolve conflicts about life-sustaining interventions , but few studies have reported their outcomes . OBJECTIVE To investigate whether ethics consultations in the intensive care setting reduce the use of life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge , as well as the reactions to the consultations of physicians , nurses , and patients /surrogates . DESIGN Prospect i ve , multicenter , r and omized controlled trial from November 2000 to December 2002 . SETTING Adult intensive care units ( ICUs ) of 7 US hospitals representing a spectrum of institutional characteristics . PATIENTS Five hundred fifty-one patients in whom value-related treatment conflicts arose during the course of treatment . INTERVENTIONS Patients were r and omly assigned either to an intervention ( ethics consultation offered ) ( n = 278 ) or to usual care ( n = 273 ) . MAIN OUTCOME MEASURES The primary outcomes were ICU days and life-sustaining treatments in those patients who did not survive to hospital discharge . We examined the same measures in those who did survive to discharge and also compared the overall mortality rates of the intervention and usual care groups . We also interviewed physicians and nurses and patients /surrogates about their views of the ethics consultation . RESULTS The intervention and usual-care groups showed no difference in mortality . However , ethics consultations were associated with reductions in hospital ( -2.95 days , P = .01 ) and ICU ( -1.44 days , P = .03 ) days and life-sustaining treatments ( -1.7 days with ventilation , P = .03 ) in those patients who ultimately did not survive to discharge . The majority ( 87 % ) of physicians , nurses , and patients /surrogates agreed that ethics consultations in the ICU were helpful in addressing treatment conflicts . CONCLUSION Ethics consultations were useful in resolving conflicts that may have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU This study evaluated the impact of a Cambridge hospital at home service ( CHAH ) on  patients ' quality of care , likelihood of remaining at home in their final 2 weeks of life and general practitioner ( GP ) visits . The design was a r and omized controlled trial , comparing CHAH with st and ard care . The patient ' 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Although  family caregiving  has been intensively studied in the past decade , little attention has been paid to the impact of end-of-life care on caregivers who are family members of persons with dementia or to the caregivers ' responses to the death of the patient . METHODS Using st and ardized assessment instruments and structured questions , we assessed the type and intensity of care provided by 217 family caregivers to persons with dementia during the year before the patient 's death and assessed the caregivers '  responses to the death . RESULTS Half the caregivers reported spending at least 46 hours per week assisting patients with activities of daily living and instrumental activities of daily living . More than half the caregivers reported that they felt they were " on duty " 24 hours a day , that the patient had frequent pain , and that they had had to end or reduce employment owing to the dem and s of caregiving . Caregivers exhibited high levels of depressive symptoms while providing care to the relative with dementia , but they showed remarkable resilience after the death . Within three months of the death , caregivers had clinical ly significant declines in the level of depressive symptoms , and within one year the levels of symptoms were substantially lower than levels reported while they were acting as caregivers . Seventy-two percent of caregivers reported that the death was a relief to them , and more than 90 percent reported belief that it was a relief to the patient . CONCLUSIONS End-of-life care for patients with dementia was extremely dem and ing of family caregivers . Intervention and support services were needed most before the patient 's death . When death was preceded by a protracted and stressful period of caregiving , caregivers reported considerable relief at the death itself PURPOSE We sought to determine the effects of a communication process that was design ed to encourage the use of advanced supportive technology when it is of benefit , but to limit its burdens when it is ineffective . We compared usual care with a proactive , multidisciplinary method of communicating that prospect ively identified for patients and families the criteria that would determine whether a care plan was effective at meeting the goals of the patient . This process allowed caregivers to be informed of patient preferences about continued advanced supportive technology when its continuation would result in a compromised functional outcome or death . MATERIAL S AND METHODS We performed a before- and -after study in 530 adult medical patients who were consecutively admitted to a university tertiary care hospital for intensive care .  Multidisciplinary meetings were held within 72 hours of critical care admission . Patients , families , and the critical care team discussed the care plan and the patients ' goals and expectations for the outcome of critical care . Clinical " milestones " indicative of recovery were identified with time frames for their occurrence . Follow-up meetings were held to discuss palliative care options when continued advanced supportive technology was not achieving the patient 's goals . We measured length of stay , mortality , and provider team and family consensus in 134 patients before the intensive communication intervention and in 396 patients after the intervention . RESULTS Intensive communication significantly reduced the median length of stay from 4 days ( interquartile range , 2 to 11 days ) to 3 days ( 2 to 6 days , P = 0.01 by survival analysis ) . This reduction remained significant after adjustment for acute physiology and chronic health evaluation ( APACHE ) 3 score [ risk ratio ( RR ) = 0.81 ; 95 % confidence interval ( CI ) , 0.66 to 0.99 ; P = 0.04 ) . Subgroup analysis revealed that this reduction occurred in our target group , patients with acuity scores in the highest quartile who died ( RR = 0.60 ; 95 % CI , 0.38 to 0.92 ; P = 0.02 ) . The intervention , which allowed dying patients earlier access to palliative care , was not associated with increased mortality . CONCLUSIONS Intensive communication was associated with a reduction in critical care use by patients who died . Our multidisciplinary process targeted advanced supportive technology to patients who survived and allowed the earlier withdrawal of advanced supportive technology when it was ineffective PURPOSE The purpose of this study was to examine the joint effects of  bereavement and caregiver intervention on  caregiver depressive symptoms . DESIGN AND METHODS Alzheimer 's caregivers from a r and omized trial of an enhanced caregiver support intervention versus usual care who had experienced the death of their spouse ( n = 254 ) were repeatedly assessed with the Geriatric Depression Scale prior to and following bereavement . R and om effects regression growth curve analyses examined the effects of treatment group and bereavement while controlling for other variables . RESULTS The death of the care recipient led to reductions in depressive symptoms for both caregiving groups . Enhanced support intervention led to lower depressive symptoms compared with controls both before and after bereavement . Post-bereavement group differences were stronger for caregivers of spouses who did not previously experience a nursing home placement . These caregivers maintained these differences for more than 1 year after bereavement . Caregivers who received the enhanced support intervention were more likely to show long-term patterns of fewer depressive symptoms before and after bereavement , suggesting resilience , whereas control caregivers were more likely to show chronic depressive symptoms before and after the death of their spouse . IMPLICATION S Caregiver intervention has the potential to alter the long-term course of the caregiving career . Such clinical strategies may also protect caregivers against chronic depressive symptoms that would otherwise persist long after caregiving ends OBJECTIVE The aim of family focused grief therapy is to reduce the morbid effects of grief among families at risk of poor psychosocial outcome . It commences during palliative care of terminally ill patients and continues into bereavement . The authors report a r and omized , controlled trial . METHOD Using the Family Relationships Index , the authors screened 257 families of patients dying from cancer : 183 ( 71 % ) were at risk , and 81 of those ( 44 % ) participated in the trial . They were r and omly assigned ( in a 2:1 ratio ) to family focused grief therapy ( 53 families , 233 individuals ) or a control condition ( 28 families , 130 individuals ) . Assessment s occurred at baseline and 6 and 13 months after the patient 's death . The primary outcome measures were the Brief Symptom Inventory , Beck Depression Inventory , and Social Adjustment Scale . The Family Assessment Device was a secondary outcome measure . Analyses allowed for correlated family data and employed generalized estimating equations based on intention to treat and controlling for site . RESULTS The overall impact of family focused grief therapy was modest , with a reduction in distress at 13 months . Significant improvements in distress and depression occurred among individuals with high baseline scores on the Brief Symptom Inventory and Beck Depression Inventory . Global family functioning did not change . Sullen families and those with intermediate functioning tended to improve overall , whereas depression was unchanged in hostile families . CONCLUSIONS Family focused grief therapy has the potential to prevent pathological grief . Benefit is clear for intermediate and sullen families . Care is needed to avoid increasing conflict in hostile families PURPOSE To determine whether provision of a question prompt list ( QPL ) influences advanced cancer patients ' /caregivers ' questions and discussion of topics relevant to end-of-life care during consultations with a palliative care ( PC ) physician . PATIENTS AND METHODS This r and omized controlled trial included patients r and omly assigned to st and ard consultation or provision of QPL before consultation , with endorsement of the QPL by the physician during the consultation . Consecutive eligible patients with advanced cancer referred to 15 PC physicians from nine Australian PC services were invited to participate . Consultations were audiotaped , transcribed , and analyzed by blinded coders ; patients completed question naires before , within 24 hours , and 3 weeks after the consultation . RESULTS A total of 174 patients participated ( 92 QPL , 82 control ) . Compared with controls , QPL patients and caregivers asked twice as many questions ( for patients , ratio , 2.3 ; 95 % CI , 1.7 to 3.2 ; P < .0001 ) , and patients discussed 23 % more issues covered by the QPL ( 95 % CI , 11 % to 37 % ; P < .0001 ) . QPL patients asked more prognostic questions ( ratio , 2.3 ; 95 % CI , 1.3 to 4.0 ; P = .004 ) and discussed more prognostic ( ratio , 1.43 ; 95 % CI , 1.1 to 1.8 , P = .003 ) and end-of-life issues ( 30 % v 10 % ; P = .001 ) . Fewer QPL patients had unmet information needs about the future ( 21 = 4.14 ; P = .04 ) , which was the area of greatest unmet information need . QPL consultations ( average , 38 minutes ) were longer ( P = .002 ) than controls ( average , 31 minutes ) . No differences between groups were observed in anxiety or patient/physician satisfaction . CONCLUSION Providing a QPL and physician endorsement of its use assists terminally ill cancer patients and their caregivers to ask questions and promotes discussion about prognosis and end-of-life issues , without creating patient anxiety or impairing satisfaction Despite evidence of high psychological distress and unmet needs , evaluated interventions for informal caregivers in palliative care are few . This study involved an observational outcome evaluation of attendees , and a comparison group , in specialist home palliative care .  The measures included  carer psychological status and patient physical status at baseline , 8 weeks , and 20 weeks . Qualitative data were collected regarding content , satisfaction with , and impact of intervention . Process data described the uptake , re sources , and group activity . The intervention combined informal multiprofessional teaching with facilitated peer exchange and support , and was delivered over 6 sessions of 90 minutes per week . The uptake rate was 25 % ; carers were less likely to accept if they were in paid employment ( OR=0.26 , P=0.06 ) , and more likely to accept if they utilized avoidance coping ( OR=1.13 , P=0.04 ) or their patient had worse physical status ( OR=2.1 , P=0.03 ) . Attendees described significant support and knowledge gains from the multiprofessional input and peer group . Most relied on social comparison processes to appraise their situation . Potential detection of significant effects on global psychological scores ( i.e. anxiety , depression , and burden ) using multivariate analysis was disallowed due to attrition . This acceptable and accessible intervention provided information and support ; further outcome studies are needed for a range of interventions . Short-term interventions are unlikely to affect global psychological scores , and future evaluations should include additional time points of data collection to demonstrate support during attendance There has been much research documenting the impact of having a loved one diagnosed with advanced cancer , but little is known about how to reduce care-giver burden . In this r and omized controlled trial , the authors examined the potential relationship of an advanced cancer patient ’s participation in an 8-session , structured , multidisciplinary intervention on the care-giver ’s burden and quality of life ( QOL ) . Although the patients r and omly assigned to the intervention ( n = 54 ) demonstrated improved QOL compared to the  control condition ( n = 49 ) participants ( P < .05 ) , there was no evidence that improving the patient ’s QOL made an impact on the caregiver ’s level of burden or the care-giver ’s QOL . Further investigation is warranted in this area , including interventions specifically design ed and targeted to both reduce caregiver burden and to improve caregiver QOL CONTEXT Ethics consultations increasingly are being used to resolve conflicts about life-sustaining interventions , but few studies have reported their outcomes . OBJECTIVE To investigate whether ethics consultations in the intensive care setting reduce the use of life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge , as well as the reactions to the consultations of physicians , nurses , and patients /surrogates . DESIGN Prospect i ve , multicenter , r and omized controlled trial from November 2000 to December 2002 . SETTING Adult intensive care units ( ICUs ) of 7 US hospitals representing a spectrum of institutional characteristics . PATIENTS Five hundred fifty-one patients in whom value-related treatment conflicts arose during the course of treatment . INTERVENTIONS Patients were r and omly assigned either to an intervention ( ethics consultation offered ) ( n = 278 ) or to usual care ( n = 273 ) . MAIN OUTCOME MEASURES The primary outcomes were ICU days and life-sustaining treatments in those patients who did not survive to hospital discharge . We examined the same measures in those who did survive to discharge and also compared the overall mortality rates of the intervention and usual care groups . We also interviewed physicians and nurses and patients /surrogates about their views of the ethics consultation . RESULTS The intervention and usual-care groups showed no difference in mortality . However , ethics consultations were associated with reductions in hospital ( -2.95 days , P = .01 ) and ICU ( -1.44 days , P = .03 ) days and life-sustaining treatments ( -1.7 days with ventilation , P = .03 ) in those patients who ultimately did not survive to discharge . The majority ( 87 % ) of physicians , nurses , and patients /surrogates agreed that ethics consultations in the ICU were helpful in addressing treatment conflicts . CONCLUSION Ethics consultations were useful in resolving conflicts that may have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU This study evaluated the impact of a Cambridge hospital at home service ( CHAH ) on  patients ' quality of care , likelihood of remaining at home in their final 2 weeks of life and general practitioner ( GP ) visits . The design was a r and omized controlled trial , comparing CHAH with st and ard care . The patient ' 
    Output:
    