Context A validated 82-item Advance Care Planning (ACP) Engagement Survey measures a broad range of behaviors. However, concise surveys are needed. Objectives To validate shorter versions of the Survey. Methods The Survey included 57 process (e.g. readiness) and 25 action items (e.g. discussions). For item reduction, we systematically eliminated questions based on face validity, item non-response, redundancy, ceiling effects, and factor analysis. We assessed internal consistency (Cronbach’s alpha) and construct validity with cross-sectional correlations and the ability of the progressively shorter survey versions to detect change one week after exposure to an ACP intervention (Pearson’s correlation coefficients). Results 501 participants (4 Canadian and 3 US sites) were included in item reduction (mean age 69 years (±10), 41% non-white). Due to high correlations between readiness and action items, all action-items were removed. Due to high correlations and ceiling effects, 2 process-items were removed. Successive factor analysis then created 55, 34, 15, 9, and 4-item versions. 664 participants (from 3 US ACP clinical trials) were included in validity analysis (age 65 years (±8), 72% non-white, 34% Spanish-speaking). Cronbach’s alphas were high for all versions (4-item, 0.84–55-item, 0.97). Compared to the original survey, cross-sectional correlations were high (4-item, 0.85–55-item, 0.97) as were delta correlations (4-item, 0.68–55-item, 0.93). Conclusion Shorter versions of the ACP Engagement Survey are valid, internally consistent, and able to detect change across a broad range of ACP behaviors for English and Spanish speakers. Shorter ACP Surveys can efficiently measure broad ACP behaviors in research and clinical settings.

We surveyed 45 small lakes in central Alberta to determine if discrete, repeatable types of fish assemblages exist, to identify the main environmental and biotic processes likely responsible for assemblage-level patterns, and to compare and contrast Alberta patterns with those observed in other regions of North America. Overall, 11 species of fish were caught in 36 lakes; nine lakes were fishless. Hierarchical classification and detrended correspondence analysis of fish species presence/absence identified two main assemblage types, characterized by northern pike (Esox lucius) and yellow perch (Perca flavescens) versus brook stickleback (Culaea inconstans) and fathead minnow (Pimephales promelas). Pike/perch lakes were significantly deeper and larger than lakes of the stickleback/fathead assemblage type; however, a subset of the former group lacking yellow perch was environmentally similar to stickleback/fathead lakes. Piscivory by northern pike appears to be the dominant process maintaining nearly complete negative associations between members of the two assemblage types. Despite environmental and faunal-richness differences, our results were not unlike those from southern Ontario and northern Wisconsin. For small boreal lakes of North America, piscivory and processes related to a small number of environmental variables, such as maximum depth, surface area, and isolation, appear to be most important in structuring fish assemblages.

One way that families and individuals manage living with a chronic condition is to construct and live a story of "life as normal." The conceptualization of this process is based on constant comparative analysis of accounts of individuals and family members who are managing chronic conditions. The process begins with construction of the story of life as normal and continues as the story is lived over time. As the story is enacted, persons reauthor their lives. Thus the reciprocal nature of the process becomes evident. Specifically, how individuals and families construct and enact the story is discussed along with the role of health care professionals in the process and associated costs and benefits.

This paper examines the phenomenon of trust in health care relationships from a new perspective, that of the recipients of care for chronic illness. The authors argue that reciprocal trust is a necessary component of satisfying, effective health care relationships when the illness is of an ongoing nature. From the patient's perspective, reciprocal trust has a significant impact on the experience of being a receiver of health care and on the development of competency with illness management. Because of this, the authors claim that it is imperative for health care professionals to alter their traditional beliefs with regard to sick role and trust. With a new perspective, they may then develop the specific skills necessary to enact the caring aspect of the service they offer. The authors offer a number of suggestions for actualizing this reciprocal trust in clinical practice.

Tailored approaches to palliative care developed in conjunction with rural communities are needed in order to optimize care.

After more than a decade of concerted effort by policy‐makers in Canada and elsewhere to encourage older adults to age at home, there is recognition that the ageing‐in‐place movement has had unintended negative consequences for family members who care for seniors. This paper outlines findings of a qualitative descriptive study to investigate the health and wellness and support needs of family caregivers to persons with dementia in the Canadian policy environment. Focus groups were conducted in 2010 with 23 caregivers and the health professionals who support them in three communities in the Southern Interior of British Columbia. Thematic analysis guided by the constant comparison technique revealed two overarching themes: (1) forgotten: abandoned to care alone and indefinitely captures the perceived consequences of caregivers’ failed efforts to receive recognition and adequate services to support their care‐giving and (2) unrealistic expectations for caregiver self‐care relates to the burden of expectations for caregivers to look after themselves. Although understanding about the concepts of caregiver burden and burnout is now quite developed, the broader sociopolitical context giving rise to these negative consequences for caregivers to individuals with dementia has not improved. If anything, the Canadian homecare policy environment has placed caregivers in more desperate circumstances. A fundamental re‐orientation towards caregivers and caregiver supports is necessary, beginning with viewing caregivers as a critical health human resource in a system that depends on their contributions in order to function. This re‐orientation can create a space for providing caregivers with preventive supports, rather than resorting to costly patient care for caregivers who have reached the point of burnout and care recipients who have been institutionalised.

Most explanations of the relationships between health care providers and health care recipients reflect perspectives and belief systems peculiar to health care professionals. In contrast, this study combined data from two separate qualitative investigations to yield an analysis of these relationships from the perspective of family members involved with chronic illness. Relationships between health care providers and health care recipients are viewed as evolving over time through a process which has identifiable stages. The utility of such a process orientation for nurses and other health care professionals is the insight it provides into the possibilities for negotiating satisfying care.

There is urgent need to effectively support the well-being of rural palliative family caregivers (FCGs). A mixed method study was conducted with 23 FCGs. Data collection included completion of an assessment questionnaire and semistructured interviews. The most prevalent needs identified by questionnaire were caring for the patient's pain, fatigue, body, and nourishment; FCG's fatigue and need for respite. Yet few FCGs wanted more attention to these needs by healthcare providers. FCGs resisted considering their own personal needs. Instead, they focused on needs related to providing care including to be(come) a palliative caregiver, be skilled and know more, navigate competing wishes, needs, demands, and priorities, and for "an extra pair of hands." Gaps in rural palliative services contributed to low expectations for assistance; reluctance to seek assistance was influenced by FCGs' resourcefulness and independence. Findings suggest that supporting FCGs will most likely be successful when framed in relation to their caregiving role.