Health Promotion



Health Promotion


Alicia Huckstadt



INTRODUCTION

Health-promoting behaviors strongly influence whether one prematurely succumbs to disease or whether one postpones and possibly avoids many major diseases. Yet, health promotion is often viewed as insignificant as healthcare systems scramble to treat heart disease, cancer, and other diseases that are often in advanced stages. Only recently has national attention been directed toward understanding the underlying cause of disease and how health promotion may have changed the course of the disease. The once believed single causation theory of morbidity has now been largely replaced by multifactorial causation theories and chronicity of conditions. Improved recognition and management of disease processes, better sanitation, immunizations, and other health measures have increased the longevity of Americans. The life expectancy in the early 1900s was the late 40s; it has now increased to the upper 70s for both genders. Diseases that once brought sudden death have been surpassed by chronic disease. Americans are living longer but not necessarily healthier. Seven out of 10 deaths among Americans each year are from chronic diseases and one out of two Americans has at least one chronic illness (Centers for Disease Control and Prevention [CDC], 2010).

Societal influences and individual lifestyle choices have negatively influenced health. In two important research articles describing the actual causes of death (nongenetic), smoking has remained the leading cause of death in the United States since 1990 (McGinnis & Foege, 1993; Mokdad, Marks, Stroup, & Gerberding, 2004). Poor diet, physical inactivity, alcohol consumption, microbial agents, toxic agents, motor vehicle crashes, incidents involving firearms, sexual behaviors, and illicit use of drugs follow smoking as actual causes of death. Cigarette smoking remains the nation’s leading cause of death with almost 450,000 deaths in the United States each year attributed to this cause (CDC, 2009). Smoking causes deaths from lung and other cancers, chronic lung disease, heart disease, and stroke. Exposure to secondhand smoke causes premature death and disease in others who do not smoke themselves. Other smokeless tobacco use also causes cancer and other conditions.

Following closely behind tobacco use as a major health risk is obesity. The prevalence of obesity among adults shows upward trends and there have been increases in overweight children (CDC, 2009). One of every three adults and almost one in five children are obese (CDC, 2010). As researchers study the condition, longterm obesity has been associated with avoidable
hospitalizations and substantial risk for health complications (Schafer & Ferraro, 2007). Obesity is associated with increased risk of diabetes, stroke, heart disease, some cancers, hypertension, osteoarthritis, gallbladder disease, and disability (CDC, 2009).

The CDC (2010) has maintained that four modifiable health-risk behaviors—smoking, poor diet, physical inactivity, and excessive alcohol consumption—are the major underlying causes of much of the illness, suffering, and early death related to chronic illness. These factors and the other modifiable behavioral risk factors listed previously are believed to be the genesis of heart disease, malignant neoplasm, cerebrovascular disease, diabetes mellitus, and other chronic diseases. One half of all deaths in the United States could be attributed to a limited number of largely preventable health behaviors and exposures (Mokdad et al., 2004). The U.S. spends more on health care than any other nation, yet the average life expectancy is far below many other developed countries that spend less on health care each year (CDC, 2009). The escalating healthcare costs, disease, and deaths associated with these factors make health promotion essential for all.


Defining Health Promotion in Chronic Illness

Health promotion is a multidimensional concept and focuses on maintaining or improving the health of individuals, families, and communities. Minimizing preventable health risk factors such as tobacco use, inadequate diets, and physical inactivity would substantially decrease the development and severity of many chronic diseases and conditions (Cory et al., 2010).

Health promotion for individuals with chronic or disabling conditions is commonly defined as efforts to create healthy lifestyles and a healthy environment to prevent secondary conditions, such as teaching people how to address their healthcare needs and increasing opportunities to participate in usual life activities. These secondary conditions can be the medical, social, emotional, mental, family, or community problems that an individual with a chronic or disabling condition likely experiences. Environmental factors that encompass healthy living include the policies, systems, social contexts, and physical surroundings that facilitate a person’s participation in activities, including work, school, leisure, and community events (Healthy People 2020).

Health-promoting activities can be implemented at the public level or the personal level, and involve passive or active strategies (Greiner & Edelman, 2010). Passive strategies, such as those used in food industry sanitation, decrease infectious agents in foods and improve public health. National, state, and local public and private agencies are given the responsibility to provide passive strategies to promote health for their constituents. Active strategies, such as engaging in better personal nutrition or activity regimens, are dependent on the individual and/or family becoming involved (Edelman & Mandle, 2006). Although both strategies are essential, this chapter focuses primarily on active strategies for individuals with chronic illness and their families.

Health promotion applies to all individuals regardless of age or disability. The goal of health promotion is to increase the involved person’s control over their health and to improve it. Leddy (2006) adds that health promotion is
mobilizing strengths to enhance health, wellness, and well-being.

Health promotion in chronic illness involves individual behavioral change for positive lifestyle activities, accepting one’s condition and making the necessary adjustments, decreasing the risk of secondary disabilities and preventing further disease, and striving for optimal health. Behavioral change becomes possible when environmental and political policies support the resources (Aro & Absetz, 2009).

Health promotion in chronic illness is important in maintaining and enhancing the function of the individual. It is also critical to prevent recurrence of some conditions. Often families direct their energies toward the illness rather than health. The illness and its cascade of effects alter family dynamics, usual roles, and patterns of life (Heinzer, 1998). Managing medicines, conserving physical and mental energy, keeping appointments with healthcare professionals, adjusting finances, and learning new resources will likely require substantial effort. These new stressors often overtax the individual, and activities to maintain a healthy lifestyle are often ignored. Preventive health screening for other conditions may be forgotten by the client and healthcare professional. Yet, health-promoting behaviors are crucial in the management of chronic conditions and are often the essential aspect in successful management. Individuals with chronic illness may develop comorbidities that could be avoided or minimized with early detection. Disease-specific preventive care needs and related physical, social, emotional, and spiritual well-being encompass health promotion for those with and without chronic illness. McWilliam, Stewart, Brown, Desai, and Coderre (1996) found in their phenomenological study exploring health and health promotion of 13 sample participants with chronic illness, “a dynamically changing and evolving endeavor that encompassed four components: fighting and struggling, resigning oneself, creatively balancing resources, and accepting” (p. 5).

Undoubtedly, chronic illness presents numerous challenges to health promotion. The potential for these activities and overall health remains largely untapped in many individuals with chronic illness. Creating new ways of accomplishing health promotion often remains an unfilled goal for nurses and their clients with chronic illness. Efforts must go beyond the individual’s chronic illness and limitations to include holistic health that focuses on personal goals, evidence-based care tailored to the person, and a willingness to adjust the plan as needed. Determining individuals’ perceptions of their condition, their aspirations, and their available resources, and supporting their efforts to achieve health promotion is an ongoing process. Leddy (2006) emphasizes that health promotion develops the individual strengths and environmental resources to find solutions rather than focusing solely on illness repair. Chronicity presents challenges to all those involved and can take precedence over other health considerations.

Nurses are ideally suited to promote the health of all individuals and their families. The holistic, caring perspective held by nurses provides opportunities to promote strengths at a time when others may perceive only threats to health. The consequences of failure to promote health are devastating. Additional morbidity, deaths, and financial strain for individuals, families, and society weigh heavy on the healthcare system. The rising healthcare costs and an aging population compound the problem. Sustained
increases in out-of-pocket healthcare spending for Medicare recipients could make health care less affordable for all but the highest income individuals (Neuman, Cubanski, Desmond, & Rice, 2007).


ISSUES AND IMPACT


National Documents

One of the issues surrounding health promotion and disease prevention is compliance with national documents. Initiated almost 30 years ago with the publication of Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (1979), and subsequent publications Healthy People: Objectives for the Nation (1980), Healthy People 2000: National Health Promotion and Disease Prevention Objectives, Healthy People 2010, and Healthy People 2020, Healthy People national documents build on one another and address select areas of health promotion with a vision for achieving improved health for all Americans. Each document was developed through a broad consultative process, made use of the best scientific knowledge available, and was designed to measure progress over time.


Healthy People 2010 and 2020

The Healthy People documents identify a comprehensive set of 10-year health objectives focusing on disease prevention and health promotion to achieve as a nation. Healthy People 2010 remains as Healthy People 2020 emerges. Many of the 2010 objectives have been retained or modified for the 2020 publication. The vision for Healthy People 2020 is a society in which all people live long, healthy lives. The mission is to: 1) identify nationwide health improvement priorities; 2) increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress; 3) provide measurable objectives and goals that are applicable at the national, state, and local levels; 4) engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge; and 5) identify critical research, evaluation, and data collection needs.

The four overarching goals are to: attain high quality, longer lives free of preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all groups; create social and physical environments that promote good health for all; and promote quality of life, healthy development, and healthy behaviors across all stages (Healthy People 2020). Topic areas for Healthy People 2020 objectives are identified in Table 16-1. Each area has specific goals and potential relevance for individuals with chronic illness and their families.

One example of relevance for these individuals and families is disability and health. The specific goal for this focus area from Healthy People 2020 is to promote the health and wellbeing of people with disabilities. People with disabilities are more likely to experience delays and other difficulties in receiving health screening and other health care, more likely to experience chronic diseases, use tobacco, not engage in fitness and other healthy activities, experience symptoms of psychological distress, and receive less social-emotional support. The Healthy People 2020 objectives reinforce that people can have a disabling impairment or chronic condition at any point in life but these conditions do not define individuals, their health, or their
talents and abilities. The objectives highlight that people with chronic conditions: 1) be included in public health activities; 2) receive well timed interventions and services; 3) interact with their environment without barriers; and 4) participate in everyday life activities. Without these opportunities, people with disabilities and chronic conditions will continue to experience health disparities compared to the general population. Health promotion activities are relevant for all individuals and may decrease or eliminate further decline in health.








Table 16-1 Topic Areas for Healthy People 2020





1. Access to Health Services


2. Adolescent Health


3. Arthritis, Osteoporosis, and Chronic Back Conditions


4. Blood Disorders and Blood Safety


5. Cancer


6. Chronic Kidney Disease


7. Dementias, including Alzheimer’s disease


8. Diabetes


9. Disability and Health


10. Early and Middle Childhood


11. Educational and Community-based Programs


12. Environmental Health


13. Family Planning


14. Food Safety


15. Genomics


16. Global Health


17. Healthcare-Associated Infections


18. Health Communication and Health IT


19. Health-Related Quality of Life and Well-Being


20. Hearing and Other Sensory or Communication Disorders


21. Heart Disease and Stroke


22. HIV


23. Immunization and Infectious Diseases


24. Injury and Violence Prevention


25. Lesbian, Gay, Bisexual, and Transgender Health


26. Maternal, Infant, and Child Health


27. Medical Product Safety


28. Mental Health and Mental Disorders


29. Nutrition and Weight Status


30. Occupational Safety and Health


31. Older Adults


32. Oral Health


33. Physical Activity


34. Preparedness


35. Public Health Infrastructure


36. Respiratory Diseases


37. Sexually Transmitted Infections


38. Sleep Health


39. Social Determinants of Health


40. Substance Abuse


41. Tobacco Use


42. Vision


Another relevant Healthy People 2020 topic is nutrition and weight status. The goal of this topic is to promote health and reduce chronic disease risk through the consumption of healthful diets and achievement and maintenance of healthy body weights. Individual behaviors, policies, and environments such as schools, worksites, healthcare organizations, and communities must work together to accomplish this goal.

Health promotion activities are relevant to all individuals, groups, communities, and to our nation as a whole. Healthy People documents emphasize the many similarities among individuals with disabilities as opposed to the differences among clinical diagnoses.

Developers of the documents have also considered caregiver issues as well as environmental barriers. Environmental factors affect the health and well-being of individuals with disabilities in many ways. For example, weather can hamper wheelchair mobility, medical offices and equipment may not be accessible, and shelters or
fitness centers may not be staffed or equipped for people with disabilities. Compliance with the Americans with Disabilities Act (ADA) helps overcome some of these barriers.

Throughout the Healthy People documents, the U.S. Department of Health and Human Services (USDHHS) identifies objectives, such as the previous example of areas to address improvements in health status, risk reduction, public and professional awareness of prevention, delivery of health services, protective measures, surveillance, and evaluation, expressed in terms of measurable targets to be achieved by the targeted year. Full achievement of the goals and objectives of the Healthy People documents depends on a healthcare system reaching all Americans and integrating personal health care and population-based public health. The vision of Healthy People in healthy communities involves broad-based prevention efforts and moves beyond what happens in physicians’ offices, clinics, and hospitals to environments in which a large portion of prevention occurs: to the neighborhoods, schools, workplaces, and families in which people live their daily lives.

Four foundational health measures will be used to monitor progress toward promoting health, preventing disease and disability, eliminating disparities, and improving quality of life. These measures include: 1) general health status such as life expectancy, healthy life expectancy, years of potential life lost, physically and mentally unhealthy days, self-assessed health status, limitation of activity, and chronic disease prevalence; 2) health-related quality of life and wellbeing, including physical, mental, and social health-related quality of life, well-being/satisfaction, and participation in common activities; 3) determinants of health including personal, economic, social, and environmental factors that influence health status; and 4) disparities including measures of disparities and inequity based on race/ethnicity, gender, physical and mental ability, and geography. These determinants include biology, genetics, individual behavior, access to health services, and the environment. The Healthy People documents can be accessed at healthypeople.gov/.


Where Does the United States Stand?

The CDC (2010) reinforces that chronic diseases are among the most common, costly, and preventable of all health problems in the nation. Diseases such as heart disease, cancer, stroke, diabetes, and arthritis are the leading causes of death and disability. Seven out of 10 deaths among Americans each year are from chronic diseases. Almost one out of every two American adults has at least one chronic illness. Health disparities in chronic disease incidence and mortality are widespread among members of racial and ethnic minority populations.

Four modifiable health-risk behaviors— lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption—are responsible for much of the morbidity and mortality. More than one-third of all adults do not meet recommendations for aerobic physical activity based on the 2008 Physical Activity Guidelines for Americans, and 23% report no leisure-time physical activity at all in the preceding month (USDHHS, 2009). In 2007, less than 22% of high school students and only 24% of adults reported eating five or more servings of fruits and vegetables per day. More than 43 million American adults smoke and 20% of
high school students were current smokers in 2007 (CDC, 2011a). The 2005-2010 National Health Inter-view Surveys estimated that 45.3 million of U.S. adults were current cigarette smokers and 78.2% of these adults smoked every day. Non-Hispanic American Indians/Alaska Natives continued to have higher prevalence of smoking compared with other racial/ethnic groups. Smoking also continues to be higher in those with lower educational and income levels (CDC, 2011). The U.S. Surgeon General has issued a report on how tobacco smoke causes disease and the specific pathways by which tobacco smoke damages the human body (USDHHS, Office of the Surgeon General, 2010). The CDC National Center for Chronic Diseases and Health Promotion (2011a) emphasizes that lung cancer is the leading cause of cancer death, and cigarette smoking is related in almost all cases. Smoking causes about 90% of lung cancer deaths in men and almost 80% in women. Smoking also causes cancer of the larynx, mouth and throat, esophagus, bladder, kidney, pancreas, and others. Nearly 45% of high school students report consuming alcohol in the past 30 days, and more than 60% of those who drink report binge drinking within the past 30 days.

The CDC National Centers for Chronic Disease Prevention and Health Promotion (NCCDPHP) vision is that all people live healthy lives free from the devastation of chronic diseases (2011). The center’s mission is to lead efforts that promote health and well-being through prevention and control of chronic diseases. The NCCDPHP strategic priorities are to:



  • Focus on well-being: Increase emphasis on promoting health and preventing risk factors, thereby reducing the onset of chronic health conditions.


  • Health equity: Leverage program and policy activities, build partner capacities, and establish tailored interventions to help eliminate health disparities.


  • Research translation: Accelerate the translation of scientific findings into community practice to protect the health of people where they live, work, learn, and play.


  • Policy promotion: Promote social, environmental, policy, and systems approaches that support healthy living for individuals, families, and communities.


  • Workforce development: Develop a skilled, diverse, and dynamic public health workforce and network of partners to promote health and prevent chronic disease at the national, state, and local levels.

The NCCDPHP (2009) provides important health promotion and chronic disease information including statistics, state profiles, tools and resources. Its publication, The Power of Prevention: Chronic Disease … the Public Health Challenge of the 21st Century, is helpful in recognizing that chronic disease prevention must occur in multiple sectors and across individuals’ entire lifespan.

In 2009, no state in the nation met the Healthy People 2010 obesity target of 15%, and the self-reported overall prevalence of obesity had increased 1.1% points from 2007 (Sherry, Blanck, Galuska, Pan, & Dietz, 2010). These data undoubtedly give support to the alarm echoed by health professionals. The health status of the nation is summarized by Surgeon General Regina Benjamin as she calls on all Americans to help reverse the trend of obese and
overweight adults and children in our nation. The priority should be health and wellness of our families and communities through focusing on healthy nutrition and regular physical activity and making the healthiest choices accessible to all citizens. (Further remarks may be found at www.surgeongeneral.gov/library/obesityvision/obesityvision2010.pdf.)


Online Resources

The CDC’s website (www.cdc.gov) shares the goal of helping people live longer and healthier lives; it features health and safety topics on its home page. The website provides information on numerous diseases and conditions, emergency preparedness, environmental health, traveler’s health, workplace safety, and other topics. One area, healthy living, is especially beneficial to consumers and healthcare providers for health in all life stages (further information is available at www.cdc.gov/HealthyLiving/).

The CDC has additional focus areas such as emphasizing the importance of a healthy diet and eating in moderation for the general population (www.cdc.gov/nutrition/everyone/basics/foodgroups.html); it includes further information on nutrition, which is available for healthcare providers (www.cdc.gov/nutrition/professionals/index.html). The National Physical Activity Plan (www.cdc.gov/physicalactivity/index.html) is a comprehensive set of policies, programs, and initiatives that aim to increase physical activity in all segments of the American population. The CDC encourages all people to learn how to prevent disease and improve their quality of life, helping to do so through providing this information. It recommends that people know their family history and how genes and personal history could put their health at risk.

Another website (healthfinder.gov/) provides a quick guide to healthy living, personal health tools, health news, locating health providers, and other information promoting health.

A variety of screening recommendations are provided from reputable sources such as the American Heart Association, the CDC, National Cancer Institute, National Heart Lung and Blood Institute, and the Agency for Healthcare Research and Quality (AHRQ). People can review the recommendations and share their history information with their healthcare professionals to determine what tests and screenings are appropriate for them. Healthy Men (www.ahrq.gov/healthymen/) is an AHRQ resource that helps men learn what preventive medical tests they need and when to get them. The website also provides the latest recommendations on screening for colorectal cancer, abdominal aortic aneurysms, and other conditions. It also includes information on immunizations, daily healthy choices, tips on communication with health providers, understanding prescriptions, and other sources of information for men’s health.

These websites remind people, when faced with choices that may impact their health and the lives of those they love, that it is important to remember that there are options and resources to help them make healthy decisions. Related websites such as that for the U.S. Food and Drug Administration (FDA) provide information for people to make better informed decisions, for example, in taking medications (www.fda.gov/usemedicinesafely), and the Surgeon General offers information for protecting yourself from secondhand tobacco smoke
(www.surgeongeneral.gov/library/secondhandsmoke/factsheets/factsheet3.html).

The CDC’s Healthy Communities Program called “Steps Communities” has been taking local action to reverse trends in health risk factors for obesity and chronic disease since 2003 (CDC, 2011b). Each of the Steps Communities implements chronic disease prevention and health promotion activities appropriate for the needs and context of its own community. They are showing, through effective interventions, what communities can do to reduce the burden of obesity, diabetes, and asthma, and producing local success in reducing the prevalence of three related health risk factors: physical inactivity, poor nutrition, and tobacco use and exposure. (More information about how to include communities is available at healthfinder.gov/.)

Steps Communities have formed partnerships with traditional and nontraditional partners to extend the reach of their activities and to accelerate progress toward achieving better health outcomes. In addition, interventions are integrated across the public and private sectors—including community settings, schools, work sites, and healthcare settings. The communities funded through Steps are grouped into three categories: state-coordinated small cities or rural communities, large cities or urban communities, and tribes or tribal entities (more information is available at: cdc.gov/healthycommunitiesprogram/communities/steps.htm). In a recent report of Steps Communities that were funded nationwide to address six focus areas—obesity, diabetes, asthma, physical inactivity, poor nutrition, and tobacco use and exposure—a survey of outcomes from noninstitutionalized community members aged 18 years and older revealed that none of the communities achieved the Healthy People 2010 objective of increasing to 91% the proportion of adults with diabetes who have at least an annual clinical foot examination. The majority of the communities did not meet the Healthy People objectives for annual dilated eye examinations or hemoglobin A1c. The majority of communities also did not meet the goal for asthma patients not to have had any symptoms during the preceding 30 days. However, the number of community residents who engaged in moderate or vigorous physical activity for 30 or more minutes at least five times a week or who reported vigorous physical activity for 20 or more minutes three times a week ranged from 40.6% to 69.8%, exceeding the Healthy People 2010 objective of 50%. The prevalence of consumption of fruits and vegetables at least five times per day ranged from 14.6% to 37.6%. Only two of the communities reached the Healthy People 2010 objective to reduce the proportion of adults who smoke and no communities reached the objective of increasing to 75% smoking cessation attempts by adult smokers. The findings of the report reflect considerable variation in health risk behaviors, chronic diseases, and use of preventive health screenings and other health promotion activities. The authors strongly encourage the need for preventive interventions at the community level and to design and implement policies that promote and encourage healthy behaviors (Cory et al., 2010). Decreasing smoking among adolescents and adults is a major health objective for our nation. The Institute of Medicine has issued a blueprint for further reducing tobacco use (several measures are available at www.nap.edu/catalog/11795.html). Recently, a large meta-analysis identified smoking as a risk factor for
prostate cancer, with the heaviest smokers having a 24% to 30% greater risk of death than did nonsmokers (Huncharek, Haddock, Reid, & Kupelnick, 2010).

The following guides are other national documents that serve as recommendations for screening and other preventive health care.


Guide to Clinical Preventive Services

The Guide to Clinical Preventive Services includes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening, counseling, and preventive medication topics, as well as clinical considerations for each topic. Sponsored since 1998 by the AHRQ, the USPSTF is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. The task force rigorously evaluates clinical research to assess the merits of preventive measures. The clinical categories are cancer; heart and vascular disease; injury and violence; infectious diseases; mental health conditions and substance abuse; metabolic, nutrition, and endocrine conditions; musculoskeletal conditions; obstetrics and gynecologic conditions; pediatric disorders; and vision and hearing disorders. (More information is available at www.ahrq.gov/clinic/uspstfix.htm.)


Guide to Community Preventive Services

The Guide to Community Preventive Services serves as a filter for scientific literature on specific health problems that have a large-scale impact on groups of people who share a common community setting. This guide summarizes what is known about the effectiveness, economic efficiency, and feasibility of interventions to promote community health and prevent disease. The Task Force on Community Preventive Services, an independent decision-making body convened by the USDHHS, makes recommendations for the use of various interventions based on the evidence gathered in rigorous and systematic scientific reviews of published studies conducted by review teams for the guide. The findings from the reviews are published in peer-reviewed journals and also are made available online. The task force has published more than 100 findings across 16 topic areas, including tobacco use, physical activity, cancer, oral health, diabetes, motor vehicle occupant injury, vaccine-preventable diseases, prevention of injuries due to violence, and social environment. (More information is available at www.thecommunityguide.org.)


Challenges

These documents and other resources illustrate that health promotion and disease prevention are essential for all Americans. The nation needs to continually work toward the goals; however, to do so will require changes in the healthcare system. Providing chronic health care once the disease has occurred is only a segment of the needed care. Many of the risks to health—obesity, diabetes, hypertension, heart disease, cancer, and other chronic conditions—often result from failure to engage in preventive care. More closely articulated preventive, public health, and policy programs are needed to promote a healthy life. Other factors, including genetics and environmental risks, contribute to chronic illness.

Health promotion can and should occur before the onset of chronic illness, and as early as possible. Health promotion ideally occurs throughout one’s life and in concert with
chronic conditions through the end of life. Health promotion is a lifetime activity and can include end-of-life planning for individuals and their significant others. Preparing for the physical and psychosocial changes that accompany death requires attention before crisis events. Preparation, dissemination, and discussion of advance directives with significant others can help set clear boundaries for honoring the wishes of clients (Rainer & McMurry, 2002).

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Jun 29, 2016 | Posted by in NURSING | Comments Off on Health Promotion
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