Surviving Family Members Research Articles

Bereavement Service Preferences of Surviving Family Members: Variation among Next of Kin with Depression and Complicated Grief.

Research indicates that bereavement services reduce distress and support adjustment in the bereaved, particularly those experiencing significant levels of depression or grief. However, the service use of bereaved individuals and whether utilization differs among those experiencing depression and complicated grief currently remain unclear. Research is needed to clarify the preferences of the bereaved, including specific bereaved subgroups. The purpose of this study was to explore the bereavement service preferences of bereaved family members whose loved one died in the hospital and identify group differences in service use among individuals with and without depression and complicated grief, considering time since the death of the patient. In this cross-sectional study, self-report data were collected from family members primarily between 3 and 18 months following the death of the patient in the hospital. Academic medical center. We explored helpfulness ratings and actual and projected service utilization of a comprehensive list of hospital and community bereavement services, and compared findings between those with and without depression and complicated grief, considering timing since patient death. Services receiving the highest helpfulness ratings by the entire sample included time alone with the deceased, a quiet room to be alone after the death, sympathy cards from hospital staff, memorial services, chaplain support before/during time of death, an educational grief booklet, grief book recommendations, a check-in phone call from hospital staff, individual counseling, and a relationship-specific support group. Individuals with depression and complicated grief reported a greater willingness to utilize specific services, including a memorial website, support groups, a holiday workshop, and individual/family psychotherapy. Findings indicate a difference in the projected service use of the bereaved experiencing depression and/or complicated grief. Follow-up screenings 6-12 months post-bereavement are recommended to identify those in need of formal psychosocial support.

Workplace Death at Sea: Chinese Surviving Families’ Experiences of Compensation Claims

Seafaring remains one of the most adventurous yet dangerous forms of work. Compared to shore-based industrial workers, seafarers suffer a risk of fatality that is up to 11 times higher. Workplace fatality is proved to be harmful to the social, financial and health conditions of surviving families. Although there has been an increase in attention given to the improvement of seafarers’ health and working conditions at sea, the effects of death at sea on surviving families has remained neglected by both researchers and policymakers.Drawing on in-depth interviews conducted with eight surviving family members in 2013 and 2014, this study investigates seafarers’ surviving families’ experiences of raising death compensation claims in China, which has the world’s largest population of seafarers. The work-related fatalities occurred between 2005 and 2013. At the time of the study, 2.4 years had elapsed on average since the deaths took place. All research participants reported considerable difficulties in communicating with crewing agencies and contacting ship owners when making compensation claims.This study shows that surviving families are in a vulnerable position when in conflict with companies. It also reveals that weak state prevention forces surviving families to defend their rights through protests. The absence of regulation over organizations involved in foreign-related employment relationships exacerbates the economic loss and mental harm suffered by surviving families following the occurrence of workplace fatalities. Furthermore, current legal and administrative procedures are unable to restore justice and provide therapeutic help for surviving families. Consequently, surviving families have suffered considerable financial loss and additional psychological harm in claim processes.

Awareness and Attitudes of Community-Dwelling Individuals in Singapore towards Participating in Advance Care Planning

Advance care planning (ACP) is an important aspect of end-of-life care that has been shown to improve patient autonomy in decision-making and reduce stress for surviving family members. Given the rapidly ageing population in Singapore, a greater emphasis on end-of-life care planning is needed. This study therefore sought to examine the awareness and attitudes of the general Singaporean community towards participating in ACP, which are not known hitherto. A 24-item interviewer-administered questionnaire was constructed and administered via door-to-door survey amongst community-dwelling residents living in Housing and Development Board (HDB) flats across Singapore, selected via a two-stage stratified random sampling. Of the 406 completed surveys, 14.4% of respondents had heard of ACP (n = 58), mostly through the media (67.9%), from family and friends (21.4%) and healthcare providers (21.4%). Only 26.8% of those who had previously heard of ACP knew how to begin an ACP discussion and 12.5% of them had a prior ACP discussion. After education, the majority of respondents were willing to begin an ACP discussion (n = 236, 60.1%). Being of an older age, having a life threatening illness, and having more knowledge about ACP were significant factors associated with willingness to have an ACP discussion. Barriers included perceiving oneself as still healthy and preferring the family to make decisions instead. There is a low awareness but high expressed willingness to engage in an ACP discussion amongst the Singaporean community. More efforts are needed to educate the public about ACP, engage the family unit and correct the present misconceptions.

The Sudden Death in the Young Case Registry: Collaborating to Understand and Reduce Mortality.

Knowledge gaps persist about the incidence of and risk factors for sudden death in the young (SDY). The SDY Case Registry is a collaborative effort between the National Institutes of Health, the Centers for Disease Control and Prevention, and the Michigan Public Health Institute. Its goals are to: (1) describe the incidence of SDY in the United States by using population-based surveillance; (2) compile data from SDY cases to create a resource of information and DNA samples for research; (3) encourage standardized approaches to investigation, autopsy, and categorization of SDY cases; (4) develop partnerships between local, state, and federal stakeholders toward a common goal of understanding and preventing SDY; and (5) support families who have lost loved ones to SDY by providing resources on bereavement and medical evaluation of surviving family members. Built on existing Child Death Review programs and as an expansion of the Sudden Unexpected Infant Death Case Registry, the SDY Case Registry achieves its goals by identifying SDY cases, providing guidance to medical examiners/coroners in conducting comprehensive autopsies, evaluating cases through child death review and an advanced review by clinical specialists, and classifying cases according to a standardized algorithm. The SDY Case Registry also includes a process to obtain informed consent from next-of-kin to save DNA for research, banking, and, in some cases, diagnostic genetic testing. The SDY Case Registry will provide valuable incidence data and will enhance understanding of the characteristics of SDY cases to inform the development of targeted prevention efforts.

Bereaved Military Dependent Spouses and Children: Those Left Behind in a Decade of War (2001–2011)

U.S. military service members die from a variety of causes (i.e., accidents, combat, illnesses, homicide, suicide, and terrorism) while on duty and in greater numbers during times of war, leaving behind bereaved dependent family members. Identifying characteristics of these dependent families improves our understanding of their unique needs, helps educate service providers who offer assistance to these surviving family members, and better informs policy addressing their health and well-being. This study describes deceased U.S. military service members (DSMs) who died on active duty between September 11, 2001 and September 11, 2011 and their surviving dependent spouses and children. Characteristics of DSMs (service branch, rank, and cause of death) and characteristics of spouse-with-children and spouse-only families (ages of dependents, time since loss, and distance from a military installation) were examined. 15,938 DSMs died from a variety of causes (e.g., accidents, combat, and illnesses). 55% of DSMs had dependent spouses and 56% of those spouses had children. Most surviving dependent spouses and children were young (mean ages = 32.8, 10.3 years; SD = 9.3, 7.3 years, respectively) at the time of DSM death. Many of these young dependents were related to a DSM who experienced a sudden and violent death. 60% of spouse-with-children families and 58% of spouse-only families lived farther than 60 miles from a military installation. Time since loss (range = 1.3-11.3 years) did not predict distance to installation. Findings characterize surviving spouses and their children, suggest potential risk for problematic grief outcomes, and underscore the importance of educating service providers about how to support military survivor family health and resilience.

In search for the grave of 100 Poles executed on March 20, 1942 in Zgierz, Poland - research by SIGO (Network for Genetic Identification of Victims).

It can be reasonably assumed that remains exhumed in 2012 and 2013 during archaeological explorations conducted in the Lućmierz Forest, an important area on the map of the German Nazi terror in the region of Lodz (Poland), are in fact the remains of a hundred Poles murdered by the Nazis in Zgierz on March 20, 1942. By virtue of a decision of the Polish Institute of National Remembrance's Commission for the Prosecution of Crimes Against the Polish Nation, the verification of this research hypothesis was entrusted to SIGO (Network for Genetic Identification of Victims) Consortium appointed by virtue of an agreement of December 11, 2015. The Consortium is an extension of the PBGOT (Polish Genetic Database of Totalitarianisms Victims). So far, the researchers have retrieved 14 DNA profiles from among the examined remains, including 12 male and 2 female profiles. Furthermore, 12 DNA profiles of the victims' family members have been collected. Due to the fact that next-of-kin relatives of the victims of the Zgierz massacre are of advanced age, it is of key importance to collect genetic material as soon as possible from the other surviving family members, identified on the basis of a list of victims that has been nearly completely compiled by the Polish Institute of National Remembrance (IPN) and is presented in this paper.

Exploring the association between exposure to suicide and suicide risk among military service members and veterans

BackgroundPast research suggests that suicide has a profound impact on surviving family members and friends; yet, little is known about experiences with suicide bereavement among military populations. This study aimed to characterize experiences with suicide exposure and their associations with lifetime and current psychiatric symptoms among military service members and veterans. MethodsA sample of 1753 United States military service members and veterans completed self-report questionnaires assessing experiences with suicide exposure, lifetime history of suicidal thoughts and behaviors, current suicidal symptoms, and perceived likelihood of making a future suicide attempt. ResultsThe majority of participants (57.3%) reported knowing someone who had died by suicide, and of these individuals, most (53.1%) reported having lost a friend to suicide. Chi-square tests, one-way ANOVAs, and logistic regression analyses revealed that those who reported knowing a suicide decedent were more likely to report more severe current suicidal symptoms and a history of suicidal thoughts and behaviors compared to those who did not know a suicide decedent. Hierarchical linear regression analyses indicated that greater self-reported interpersonal closeness to a suicide decedent predicted greater self-reported likelihood of a future suicide attempt, even after controlling for current suicidal symptoms and prior suicidal thoughts and behaviors. LimitationsThis study utilized cross-sectional data, and information regarding degree of exposure to suicide was not collected. ConclusionsMilitary personnel and veterans who have been bereaved by suicide may themselves be at elevated risk for suicidal thoughts and behaviors. Additional work is needed to delineate the relationship between these experiences.

Responding to Homicide

After a homicide, family members of the victim must cope with their loss and find ways to continue on with their lives. Research suggests that as “secondary victims,” this group may experience grief and cope in ways unique from other victims. Using focus group data, this article examines the impact of homicide on surviving family members. Our findings highlight the divergent ways in which individuals respond to homicide as well as the varying coping strategies families implement. Practical applications of these findings are discussed.

The Effect of Maternal Death on the Health of the Husband and Children in a Rural Area of China: A Prospective Cohort Study.

ObjectiveTo examine the effects of maternal death on the health of the index child, the health and educational attainment of the older children, and the mental health and quality of life of the surviving husband.MethodsA cohort study including 183 households that experienced a maternal death matched to 346 households that experienced childbirth but not a maternal death was conducted prospectively between June 2009 and October 2011 in rural China. Data on household sociodemographic characteristics, physical and mental health were collected using a quantitative questionnaire and medical examination at baseline and follow-up surveys. Multivariate linear regression, logistic regression models and difference-in-difference (DID) were used to compare differences of outcomes between two groups.FindingsThe index children who experienced the loss of a mother had a significantly higher likelihood of dying, abandonment and malnutrition compared to children whose mothers survived at the follow-up survey. The risk of not attending school on time and dropping out of school among older children in the affected group was higher than those in the control group during the follow-up. Husbands whose wife died had significantly lower EQ-5D index and EQ-VAS both at baseline and at follow-up surveys compared to those without experiencing a wife’s death, suggesting an immediate and sustained poorer mental health quality of life among the surviving husbands. Also the prevalence of posttraumatic stress disorder (PTSD) was 72.6% at baseline and 56.2% at follow-up among husbands whose wife died.ConclusionsMaternal death has multifaceted and spillover effects on the physical and mental health of family members that are sustained over time. Programmes that reduce maternal mortality will mitigate repercussions on surviving family members are critical and needed.

Premature, Untimely, and Traumatic Death of Family Members, and Mental Health Disorders Among Inpatient Substance Users

Premature, untimely, or traumatic death of a family member has been shown to be related to later substance use issues among some surviving family members. However, research on these deaths has been limited in that no studies to date have explored associations between these deaths and other mental health disorders co-occurring with substance use. Therefore, this study examined the relationships between premature, untimely, and traumatic deaths of family members (parents, grand- and great grandparents, other family members, and pets) and comorbid psychopathology among a convenience sample of 104 individuals attending treatment for substance use issues. Results indicated that these kinds of death are commonly found within the families of the respondents. In addition, it showed that these deaths were significantly related to higher levels of comorbid anxiety, mood, and personality disorder symptoms. Of particular interest was the finding that these symptoms were significantly related to death among respondents’ grand- and great grandparents rather than among their nuclear families. Further research is needed to assess what kinds of family dysfunction related to death are present in this population and what kinds of interventions may be effective in treating them.

A Murder in the Grove: Conceptions of Justice in an Early Zionist Colony

This article offers a localized perspective on early Zionist settlers’ evolving responses to interethnic violence in late Ottoman Palestine. It takes as its subject the first instance of murder in the early Zionist colony of Rishon LeZion, the death of Yaakov Abramovich in 1902, presumed to have been committed by the Palestinian notable Alfred Rock from Jaffa. Drawing from local archival records and the periodical press of the Palestine Jewish community and influenced by scholarship in legal and microhistory, the article resituates this community in the context of its relations with Ottoman authorities, Arab notables and peasants, as well as its European Jewish benefactors. It argues that the community’s behavior and reactions were period and context-specific, consequences of legal assumptions about the workings of the Ottoman court system and the traditional confliction resolution mechanism of sulh but also products of evolving economic motives around land purchase and sale, and particular social dynamics among surviving family members in the colony, namely the deceased man’s widow, his father, and his brothers. It emphasizes the contingent, local nature of communal interactions with the larger, overlapping social and legal structures of Late Ottoman Palestine.

An assessment of disaster-related mortality post-Haiyan in Tacloban City.

Tacloban City was seriously affected by Typhoon Haiyan with 2321 deaths distributed across its 138 villages and subvillages. In January 2014, a team from the Department of Health conducted a mortality assessment to identify risk factors for deaths that occurred during Typhoon Haiyan. A retrospective case-control study was conducted in the four coastal villages in Tacloban City with the highest numbers of typhoon-associated deaths. A case was defined as a person who died in Tacloban City during Typhoon Haiyan and whose body was recovered and identified. Controls were selected from surviving family members of cases. Information about typhoon-related knowledge, attitudes and practices of the cases was collected using a standardized questionnaire. There were 100 cases and 100 controls included in the study. The cause of death for all cases was drowning, and all bodies were found inside or near their house. Multivariate analysis identified that the significant risk factors for mortality due to Haiyan were not evacuating before the storm hit (odds ratio [OR] = 10.0; 95% confidence interval [CI]: 3.8-29.1) and exiting their house during the storm (OR = 3.6; 95% CI: 1.9-7.1). Proxies reported that all cases had heard about the coming typhoon, but that 88% did not understand the message about the storm surge. Ninety-five per cent of cases did not evacuate because they did not expect the magnitude of storm. Warning messages delivered before and during emergencies should be conveyed in terms understood by the population at risk. We recommend that the results from this study be used to develop more effective messages to be used before future disasters.

The Homicide-Suicide Phenomenon: Findings of Psychological Autopsies.

Homicide-suicide represents a single episode of violence which may decimate an entire family. This study aimed to further describe motives and context of these tragedies. Psychological autopsies were completed for 18 homicide-suicide cases in Dallas, Texas. This included postevent interviews with surviving family members and review of police and coroner records. Two-thirds of perpetrators had made either verbal or written threats prior to the homicide-suicide. A simplified typology describing victim-perpetrator relationship and motive type is suggested for future studies and clinical ease. Two-thirds of perpetrators fell into the category of Intimate-Possessive, most of whom were depressed men who were abusing substances and undergoing separation. Additional categories included Intimate-Ailing, Filial-Revenge, Familial-Psychotic, and Friend-Psychotic. Further, implications from this psychological autopsy study regarding risk assessment include use of collateral interviews regarding threats and past violence.

The Antidepressant Effect of Hospice: Need for a More Potent Prescription.

The Antidepressant Effect of Hospice: Need for a More Potent Prescription.

Evolution of a Molecular Autopsy Program from within a Death Investigation System

The molecular autopsy has become an important adjunct to investigation of sudden cardiac deaths in individuals under 40 years of age. Consequently, this evolution in molecular medicine has led to significant changes in the evaluation of sudden cardiac deaths and vascular catastrophe in medicolegal death investigation systems. There is a recognition that increasingly detailed pathological examinations of the heart and vasculature are necessary, which must also be accompanied by retention of deoxyribonucleic acid (DNA) for possible genetic testing and communication that a possible heritable disease may be responsible for the unexpected death. Forensic pathologists are at the forefront of identifying possible cases of heritable disease and unless properly managed, surviving family members may not receive the opportunity for subsequent clinical evaluation or the diagnosis provided may be erroneous, with inappropriate labels placed on families. More than ever, forensic pathologists must be aware of the spectrum of heritable conditions that may contribute to death. This is necessary not only for natural deaths, but also in areas of classical forensic interest where a death has occurred under criminally suspicious means or following interaction with police involving struggle or restraint. Some genetic conditions are also recognized to cause changes that mimic inflicted trauma. This review outlines many of the issues we have considered in developing a molecular autopsy program and how processes developed at the time of postmortem examinations may be optimized to facilitate evaluation and treatment of surviving family members as well as enhance information provided to the courts.

The Importance of Genetic Testing in a Case of Sudden Death in Hypertrophic Cardiomyopathy due to Troponin I Mutation

Sudden death due to hypertrophic cardiomyopathy (HCM) is uncommon. Most cases of HCM are due to mutations in sarcomeric proteins. Mutations of the cardiac troponin I gene TNNI3 are rare. Over 15 mutations of the TNNI3 gene have been identified; the clinical, imaging and pathologic findings within the small subcategory are very diverse. While asymptomatic patients do not generally receive therapy, the entire group may be at risk of sudden death. Thus, affected individuals and their family members may require heightened surveillance. As such, accurate diagnosis at postmortem examination is important as it may have a direct impact on the health and well-being of surviving family members. We present the case of a 36-year-old man who collapsed and died while jogging. His sister had been recently diagnosed with hypertrophic cardiomyopathy. Consequently, the decedent had undergone transthoracic echocardiography that demonstrated only mild features suggestive of hypertrophic cardiomyopathy including non-obstructive asymmetric septal wall thickening of less than 30 mm in the absence of systolic anterior motion of the mitral valve or cardiomegaly. The autopsy confirmed the presence of mild septal hypertrophy (maximum 23 mm thickness) in the absence of cardiomegaly. Histologic features were typical of hypertrophic cardiomyopathy including septal myofiber disarray and nuclear enlargement. Mutational analysis of frozen myocardium demonstrated an Arg162Gln substitution in the cardiac troponin I gene (TNNI3) involving exon 7. This case highlights the importance of molecular/genetic analysis in the setting of sudden natural death, from both diagnostic and public health perspectives.

Making Relations, Managing Grief: The Expression and Control of Emotions in Japanese Death Rituals

Despite a great deal of work on death and mortuary rituals in Japan, scant attention has been paid to the importance of emotional responses to death and their social and cultural implications. In this article based on extensive ethnographic fieldwork in a Japanese rural town, I examine the ways in which grief is experienced and perceived by the surviving family members, specifically how it is expressed and controlled and under what circumstances, by focusing on their emotional condition, grieving demeanour, mortuary practices, ritual process, gender roles and pollution. I found that the emotional response to death is closely related to social relationships between the bereaved and the non-bereaved as well as the proximity of bonds between the living and the dead. Thus, the analysis as a whole seeks to elucidate why the Japanese notion of grief and the process of mourning must be understood, first and foremost, in terms of these interpersonal relationships.

Decriminalization of attempted suicide law: Journey of Fifteen Decades.

Byline: Prakash. Behere, T. Sathyanarayana Rao, Akshata. Mulmule Life, as they say, is a gift from god and can be given only by him. Hence, taking away life and that too one's own, has always been forbidden. Suicide has, since times immemorial, been a topic of constant controversy and unending debate. Religion, monarchy, and colonialism all condemned and prohibited suicide. Suicide is defined as death caused by self-directed injurious behavior with any intent to die as a result of the behavior. Suicide attempt, on the other hand, is a nonfatal self-directed potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury. [sup][1] The people who committed or attempted suicide have always been the subjects of wrath of the religion bound societies in the past. Following this religious trail, lawmakers in the past, served punishments to both the bodies of the victims and the survivors of a suicide attempt. Sometimes even the surviving family members were punished for their act. But liberalization and education with the help of progress in understanding the underlying causes of suicide, has led to a change in this stance worldwide. Gravity of Problem There has been an alarming increase in suicide rates in recent years. There were 127,151 cases of suicide noted in the National Crime Records Bureau in 2009 which have increased to 134,799 in 2013. Suicide rate that is, the incidence of suicide per one lakh population, has increased from 10.9 in 2009 to 11.4 in 2010. Family problems and illness were the two major reasons for suicides, together accounting for 46% of all suicides. Drug abuse/addiction (3.3%), love affairs (3.2%), bankruptcy or sudden change in economic status (2.0%), poverty (1.9%), and dowry dispute (1.6%) were the other causes of suicides. [sup][2] Religion and Suicide Almost all the religions condemn and prohibit suicide with each having an elaborate description of the punishments incurred by the offenders in their respective hells. Hinduism believes in the individual turning into a ghost and wandering between the mortals and the heavenly till the time of their actual death as per fate, whereas Islam mentions the fate of the person who commits suicide, remains to repeat the same act by which he committed suicide till eternity in the fire of hell. Some religions, like the Jews, have discrimination against those who commit suicide in the form of separate burial away from the normal deaths and limited mourning rights to the kings. The Indian Law on Suicide and its Past The Indian penal code drafted in 1860 on the recommendations of first law commission of India established in 1834 under the Charter Act of 1833 under the chairmanship of Thomas Babington Macaulay came into force in British-ruled India in 1862. [sup][3],[4] It has substantially survived for over 150 years without major amendments in several jurisdictions. But there has been a need to rethink and amend several of its sections as per the prevailing societal beliefs from time to time. The recent amendment of the section 377 is one such example. As per the Indian penal code, 1860, chapter XVI of offences affecting the human body and of offences affecting life, section 309 deals with Attempt to commit suicide. It states that whoever attempts to commit suicide and does any act toward the commission of such offence, shall be punished with simple imprisonment for a term which may extend to 1-year. [sup][5] This law has remained untouched and not amended for the past 155 years since it came into force, thus warranting a relook and repeal as per today's scientific understanding of the subject and societal attitude. Evolving Consensus Over the Years - World View Destigmatization of the act of suicide started with the pioneering work of Durkheim. His theory that external pressures or societal stressors, can contribute to suicidal behavior, increased awareness about suicide and helped to begin destigmatization. …

Co-victims of Homicide

This systematic literature review examines the effects of homicide on surviving family members, the “co-victims” or “survivors” of homicide. A content analysis was conducted on 40 articles identified through a search of the literature. The research samples were predominately located in the United States, but included two U.K. samples, one Jamaican sample, and one sample from Israel. All articles were written in English. Three themes were identified. Nineteen articles explored the psychological, academic, social, occupational, and familial effects of homicide. Thirteen articles considered survivors’ grieving process and how it was altered by experiences with the criminal justice system as well as coping strategies used by survivors to deal with their grief. Eight articles explored treatment interventions available to help surviving family members deal with their grief. Key findings from the articles, limitations of the current research, and implications for future research, policy, and practice are included.

Enrolling Brain-Dead Humans in Medical Research: Stakeholder Opinions

Background: Brain-dead humans retain many of the physiologic functions of living humans, but they are legally dead and cannot be physically harmed by participation in research. Stakeholder opinions about enrolling brain-dead humans in medical research are largely unknown. Methods: Exploratory interviews were conducted with members of three stakeholder groups—medical researchers, intensive care clinicians, and laypeople—to gauge support for and identify barriers to the conduct of research with brain-dead humans. Thematic analysis of interview transcripts was conducted based on a priori hypotheses and content analysis of interview transcripts. Results: Twenty-three of 31 participants (7/9 researchers, 8/10 clinicians, and 8/12 laypeople) indicated that research enrolling brain-dead humans who are not eligible for organ donation should be permitted, though all cited restrictions that should apply. Reservations about research involving brain-dead humans included (1) concern about maintenance of dignity or avoidance of desecration of the subject; (2) potential for a negative impact on surviving family members; (3) potential for a negative public reaction; and (4) potential for psychological harm to participating personnel. Specific restrictions that participants felt should be in place included (1) requiring consent from surviving families; (2) that such consent should be based on the substituted judgment standard; (3) that the research must have a high significance level; and (4) that the research must not interfere with organ donation or other clinical functions in the hospital. Conclusions: We found widespread support among key stakeholders for permitting research with brain-dead humans. Serious conceptual and pragmatic concerns dictate that research involving brain-dead humans should only be conducted in the context of careful limitations and safeguards.