Objective Considerable controversy over the justifications for forgoing life-sustaining treatment to patients with advanced dementia (AD) exists. Based on an ethnographic study, the decision-making practices for forgoing tube feeding and antibiotic treatment for AD patients in the U.S is examined. Methods Prospective case studies were undertaken in a dementia special care unit (BDSC) over a period of six months. Data sources included clinical observation notes from 10 patients, and interview notes from their family members and healthcare providers. Three strategies were used to manage the data: event analysis, content analysis and cross-case analysis. The American Caucasian culture and hospice care culture provided the context for analysis. Results Two patterns of decision-making were practiced in BDSC: (1) advance decision-making with respect paid to the patient's wishes, and (2) advance decision-making focused on what is best for the patient. Differences in justifications for forgoing tube feeding and forgoing antibiotic treatment were discussed. Conclusions Forgoing life-sustaining treatment decision is difficult to make within the clinical context. Underpinning these difficulties are the predominant values in current medical practice that support the biological determinants of life and medical technology for enhancing the quality of life. In resolving these difficulties, a moral paradigm shift in two respects is required for framing the care of patients dying with AD. They are a shift from the medical protraction of life and a shift towards forms of care that enhance quality of life within the natural-organic framework of emotional, relational, esthetic and spiritual well-being. In this study, a paradigm shift of values underpinning the practice of forgoing life-sustaining treatments for AD patients was observed in three aspects. First, the emphasis on prognostication based on biomedical markers in predicting the length of survival is shifted to a focus on the "diagnosis of dying". This act facilitates the transition from connecting the choice of treatment with the goal of resolving the emergent medical problem to that of the goal of comfort care. Second, the overriding concern in conventional medical practice with preserving life is shifting to an overriding concern of "what is best for the patient." Third, in the last days of life, the conventional approach of "trying to do everything for the patient" was true in BDSC, but the approach had shifted from a technological to a relational one. Providing a peaceful and dignified environment in which the patient could die in the last days are the primary concern.

Objective:under the protective medical system,health care professional incline not to disclose the medical information to vulnerable patients in order to protect them from any unpleasant stimuli which might worsen their illness condition.This study aims to understand how patients' perceived illness severity and prognostic awareness impact on their will to live and healthcare expectations.Participants & Methods:twenty newly admitted patients,6 men and 14 women,with confirmed diagnosis of metastasis cancer in a hospice ward in Shanghai participated in the study.Semi-structured interviews were used to illicit the patients' view and experience.The interview questions include the patients' understanding of their illness condition,concerns in different aspects of life and expectation on treatment and care.Audio-recorded interviews were verbatim transcribed and analyzed using vanKaam's method of controlled explication.Result:although the patients did not learn their illness directly from others,they were able to capture their illness severity by observing the reaction of doctors or family members.Among them,9 patients actively sought evidence to confirm their illness condition.Although all 20 patients considered themselves gravely ill,their will to live ranged form very strong to very weak,which can be categorized into three major kinds of responses: struggling for life,letting-it-to-happen and pleading for death.The patient's level of prognostic awareness did not have a strong association with their will to live,but the will to live was associated with their expressed quality of life concerns.The patients with more negative emotion,weaker family ties and more physical discomforts had weaker will to live.The patients who had unfinished business such as young children had the strongest will to live.The letting-it-go-happen patients were complacent that they had fulfilled their life responsibilities.Both patients who struggled for life and who pleaded for a hastened death had unrealistic healthcare expectations.The former hoped the medical staff could cure their illness whilst the latter preferred the medical staff to end their life.This is inconsistent to the concept of hospice care as dying should be treated as a natural process.Conclusion: This study shows that empathetic and open interactions with terminally cancer patients are possible.No untoward emotional reactions were noted after the interviews.The patients could receive better psychological support form the health care providers,and their needs were more realistically addressed.Furthermore,it can facilitate the family and healthcare providers to fulfill patients' last wishes and help them to pass their last days in peace,comfort and dignity.

OBJECTIVE：To s tudy improvement effect and mech anism of ilicifoliosids alkaloid A （HBOA）on non-alcoholic fatty liver disease in rats. METHODS ：SD rats were randomly divided into blank control group ，model group ，Silybin capsule group（positive control ，26.25 mg/kg），HBOA high-dose ，medium-dose and low-dose groups （100，50，25 mg/kg），with 10 rats in each group. Except that blank control group fed normal feed ，the other groups were continuously fed with high-fat diet for 8 weeks to induce non-alcoholic fatty liver disease model. Form the 9th week ，blank control group and model group were given constant volume of 0.6％ CMC-Na solution ，and administration groups were given corresponding drugs by intragastric admini- stration，once a day ，for consecutive 4 weeks. The general information of rats were observed and the body weight increase ，organ （liver，kidney and spleen ）indexes were calculated ；the contents of AST ，ALT，TC，TG and NEFA in liver tissue were detected ， and SOD，GSH-Px activities and MDA content in the serum were also determined. The protein expression of PPARα in liver tissue was detected by immunohistochemistry. RESULTS ：Compared with blank control group ，the body mass increase and liver index of rats in model group were increased significantly （P＜0.01）；fat deposition could be observed in the liver ；the activities of SOD and GSH-Px in serum were reduced significantly ，and the contents of MDA ，the contents of AST ，ALT，TC，TG and NEFA in liver tissue were significantly increased ，and the protein expression of PPARα was decreased significantly（P＜0.01）. Compared with model group ，the body mass increase and liver index of the rats were decreased significantly in administration groups （P＜0.05 or P＜0.01），liver fat deposition was improved ，the activity of SOD and GSH-Px in serum （except for HBOA low-dose group ）were increased significantly while MDA content ，the contents of AST ，ALT，TC（except for HBOA low-dose group ），TG（except for HBOA low-dose group ） and NEFA in liver tissue were decreased significantl y，while protein expression of PPAR α 15177460685@163.com was increased significantly （P＜0.05 or P＜0.01）. Some of the above indexes of HBOA high-dose group were 电话：0771-5302433。E-mail：junlin898@126.com significantly better than HBOA medium- and low-dose group（P＜0.05）. CONCLUSIONS ：HBOA has a certain improvement effect on non-alcoholic fatty liver disease in rats caused by high-fat diet ，and its mechanism may be related to improving lipid metabolism disorders ，anti-oxidative stress and up-regulating the expression of PPARα.

OBJECTIVE：To inv estigate the effects of 4-hydroxy-2（3H）-benzoxazolone on inflammatory and apoptosis signaling pathways in non-alcoholic fatty liver disease （NAFLD）model rats. METHODS ：SD rats were divided into normal control group（10 rats）and modeling group （50 rats）. Normal control group was given basic diet ，and modeling group were given high-fat diet to induce NAFLD model. After modeling ，the rats were divided into normal control group ，model group ，silibinin group （26.25 mg/kg），and 4-hydroxy-2（3H）-benzoxazolone high-dose ，medium-dose and low-dose groups （100，50，25 mg/kg），with 8 rats in each group. Normal control group and modeling group were given 0.6％ CMC-Na intragastrically ，and other groups were given relevant medicine 10 mL/kg intragastrically ，once a day ，for consecutive 4 weeks. After last medication ，the serum levels of albumin（ALB），total protein （TP），globulin（GLB），ALB/GLB and free fatty acid （FFA）were detected ；TUNEL staining was used to observe the apoptosis of rat hepatocytes. Western blot assay was used to detect the protein expression and phosphorylation level of inflammatory signaling pathway related proteins [Toll-like receptor 4（TLR4），myeloid differentiation factor 88（MyD88）， nuclear factor-κB p65（NF-κB p65），NF-κB inhibitor protein（IκBα）] in liver tissue as well as the expression of apoptosis signaling pathway related proteins [B cell lymphoma 2（Bcl-2），Bax，caspase-3]. RESULTS ：Compared with model group ，serum levels of TP （except for low-dose group ），GLB and FFA ，the protein expression of TLR 4（except for low-dose group ），MyD88 （except for medium-dose group ）and caspase- 3，the phosphorylation levels of NF-κB p65 and IκBα protein were decreased significantly（P＜0.05 or P＜0.01）. The ratio of A LB/GLB in serum and the ratio of Bcl- 2/Bax in liver tissue were significantly increased（P＜0.05 or P＜0.01），and the phenomenon of hepatocyte apoptosis was improved. CONCLUSIONS ：4-hydroxy-2 （3H）-benzoxazolone can ameliorate NAFLD in rats ，and the mechanism may be associated with inhibiting the expression TLR 4/ MyD88/NF-κB signaling pathway-related proteins and apoptosis-related proteins in liver tissues.