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Our commentary suggests that different materialities (fragile, enduring, and mixed) may influence cognitive evolution. Building on Stibbard-Hawkes, we propose that predictive brains minimise errors and seek information, actively structuring environments for epistemic benefits. This perspective complements Stibbard-Hawkes' view.
Motor neuron disease (MND) is a progressive, fatal, neurodegenerative condition that affects motor neurons in the brain and spinal cord, resulting in loss of the ability to move, speak, swallow and breathe. Acceptance and commitment therapy (ACT) is an acceptance-based behavioural therapy that may be particularly beneficial for people living with MND (plwMND). This qualitative study aimed to explore plwMND’s experiences of receiving adapted ACT, tailored to their specific needs, and therapists’ experiences of delivering it.
Method:
Semi-structured qualitative interviews were conducted with plwMND who had received up to eight 1:1 sessions of adapted ACT and therapists who had delivered it within an uncontrolled feasibility study. Interviews explored experiences of ACT and how it could be optimised for plwMND. Interviews were audio recorded, transcribed and analysed using framework analysis.
Results:
Participants were 14 plwMND and 11 therapists. Data were coded into four over-arching themes: (i) an appropriate tool to navigate the disease course; (ii) the value of therapy outweighing the challenges; (iii) relevance to the individual; and (iv) involving others. These themes highlighted that ACT was perceived to be acceptable by plwMND and therapists, and many participants reported or anticipated beneficial outcomes in the future, despite some therapeutic challenges. They also highlighted how individual factors can influence experiences of ACT, and the potential benefit of involving others in therapy.
Conclusions:
Qualitative data supported the acceptability of ACT for plwMND. Future research and clinical practice should address expectations and personal relevance of ACT to optimise its delivery to plwMND.
Key learning aims
(1) To understand the views of people living with motor neuron disease (plwMND) and therapists on acceptance and commitment therapy (ACT) for people living with this condition.
(2) To understand the facilitators of and barriers to ACT for plwMND.
(3) To learn whether ACT that has been tailored to meet the specific needs of plwMND needs to be further adapted to potentially increase its acceptability to this population.
Voluntary assisted dying (VAD) was legalized in Victoria, Australia, in June 2019. Victoria was the first jurisdiction in the world to require doctors to undertake training before providing VAD. This study examines data from doctors who completed the mandatory training in the first 2 years of the VAD system's operation (up to 30 June 2021). It describes the doctors who are undertaking VAD training, their post-training attitudes toward VAD participation, and their experiences of the mandatory training.
Methods
Through the online training, doctors completed a short demographic survey and undertook formal assessment of knowledge (90% pass mark). They also were invited to complete an optional survey evaluating the training.
Results
In total, 289 doctors passed the training, most commonly males (56%) aged 36–65 years (82%) from an urban location (72%). Most were more than 10 years post fellowship (68%) and practising as general practitioners (51%) or medical oncologists (16%). The training most commonly took 6 h (range 2 h to over 9 h). Most doctors passed the assessment at the first (65%) or second (19%) attempt. Almost all participants (97%) found the training helpful or very helpful and most reported being confident or very confident in their knowledge (93%) and application (88%) of the VAD legislation.
Significance of results
Doctors reported the training was helpful and improved their confidence in knowing the law and applying it in clinical practice. The profile of trained doctors (particularly their location and specialty) suggests continued growth of participating doctors is needed to facilitate patient access to VAD. It is important that this safeguard does not discourage doctors’ participation.
This chapter identifies international trends in end-of-life law reform from analysing ten case studies of reform from the United Kingdom, the United States, Canada, Australia, the Netherlands and Belgium. A key finding is that law reform is more likely to succeed when supported by ‘good process’. This includes effective consultation with key stakeholders and engaging with experts. Social science evidence is also increasingly influential in both legislative and judicial reform, particularly in relation to how assisted dying systems can operate safely in practice. Other factors contributing to reform are the support or advocacy of key individuals or groups, shifts in community sentiment, and changes in political composition of parliaments. The chapter also concludes that law reform is ultimately a political exercise. Compromise is often required for a law to pass. This has implications for designing effective end-of-life law, pointing to the need for critical evaluation of both proposed laws and how existing laws operate in practice. The chapter concludes with reflections about the future of end-of-life law.
In 1995, the Northern Territory, the smallest of Australia’s states and territories, was the first jurisdiction in the world to enact operative legislation allowing voluntary euthanasia (as it was then called). This legislation was short-lived, being overturned by the Commonwealth government approximately nine months after it commenced operation. Since that time, and despite over forty attempts in all Australian states but one, voluntary assisted dying remained unlawful in Australia. But this changed when Victoria passed its Voluntary Assisted Dying Act 2017 (Vic) in November 2017, which became operative in June 2019. This chapter explores the Victorian experience as a successful model for voluntary assisted dying law reform. The reform process, led by the government with the personal support of key politicians was thorough, methodical and considered, and was undertaken in a staged way with extensive consultation. This approach may prove to be a successful formula for legislative reform in a country where ongoing and high-level public support for change has been met by equivalent ongoing political resistance to reform.
This chapter establishes why understanding end-of-life law reform is important and notes the constant agitation for legal changes in the field. It describes in broad terms the issues considered in end-of-life law. They include assisted dying (voluntary euthanasia and assisted suicide), decisions about whether to withhold and withdraw potentially life-sustaining treatment and the law that governs palliative care. There are also some ‘new’ end-of-life practices that sit across these topics such as terminal sedation and voluntarily stopping eating and drinking. The chapter also considers the challenges of law reform. Changing law is generally a difficult undertaking but there are number of features of end-of-life law that make this particularly difficult. Finally, this chapter discusses each of the case study contributions to the book and its proposed overall approach.
Much has been written about whether end-of-life law should change and what that law should be. However, the barriers and facilitators of such changes – law reform perspectives – have been virtually ignored. Why do so many attempts to change the law fail but others are successful? International Perspectives on End-of-Life Law Reform aims to address this question by drawing on ten case studies of end-of-life law reform from the United Kingdom, the United States, Canada, the Netherlands, Belgium and Australia. Written by leading end-of-life scholars, the book's chapters blend perspectives from law, medicine, bioethics and sociology to examine sustained reform efforts to permit assisted dying and change the law about withholding and withdrawing life-sustaining treatment. Findings from this book shed light not only on changing end-of-life law, but provide insight more generally into how and why law reform succeeds in complex and controversial social policy areas.
Established chronologies indicate a long-term ‘Hoabinhian’ hunter-gatherer occupation of Mainland Southeast Asia during the Terminal Pleistocene to Mid-Holocene (45 000–3000 years ago). Here, the authors re-examine the ‘Hoabinhian’ sequence from north-west Thailand using new radiocarbon and luminescence data from Spirit Cave, Steep Cliff Cave and Banyan Valley Cave. The results indicate that hunter-gatherers exploited this ecologically diverse region throughout the Terminal Pleistocene and the Pleistocene–Holocene transition, and into the period during which agricultural lifeways emerged in the Holocene. Hunter-gatherers did not abandon this highland region of Thailand during periods of environmental and socioeconomic change.
Previous research suggests that CBT focusing on worry in those with persecutory delusions reduces paranoia, severity of delusions and associated distress. This preliminary case series aimed to see whether it is feasible and acceptable to deliver worry-focused CBT in a group setting to those with psychosis. A secondary aim was to examine possible clinical changes. Two groups totalling 11 participants were run for seven sessions using the Worry Intervention Trial manual. Qualitative and quantitative data about the experience of being in the group was also collected via questionnaires, as was data on number of sessions attended. Measures were delivered pre- and post-group and at 3-month follow-up. These included a worry scale, a measure of delusional belief and associated distress and quality of life measures. Of the 11 participants who started the group, nine completed the group. Qualitative and quantitative feedback indicated that most of the participants found it acceptable and helpful, and that discussing these issues in a group setting was not only tolerable but often beneficial. Reliable Change Index indicated that 6/7 of the group members showed reliable reductions in their levels of worry post-group and 5/7 at follow-up. There were positive changes on other measures, which appeared to be more pronounced at follow-up. Delivering a worry intervention in a group format appears to be acceptable and feasible. Further research with a larger sample and control group is indicated to test the clinical effectiveness of this intervention.
Key learning aims
(1) To understand the role of worry in psychosis.
(2) To learn about the possible feasibility of working on worry in a group setting.
(3) To be aware of potential clinical changes from the group.
(4) To consider acceptability for participants of working on worries in a group setting.